Your friendly (yet slightly

PSYCHIATRY OSCE REVIEWER 2015 insane) UNICORNS

OUTLINE MOOD AND AFFECT

I. Interview
II. Diagnosis (based on DSM V Criteria) & Management
Mood: Dysphoric, Elevated, Euthymic, Expansive, Irritable
A. Mood Disorders Ano ang pakiramdam mo noong mga nakaraang araw? Ngayon?
B. Psychotic Disorders Affect: Within normal range, Constricted, Blunted, Flat
C. Anxiety Disorders Appropriateness: assess if the affect is appropriate for a quality of
D. Obsessive-Compulsive Disorders response
o Inappropriate: Flattened affect when speaking about a murderous
NOTE 4 Stations, 4 minutes each:
intent
(2) Interview with “actual patients”, (1) Diagnosis, (1) Prescription Writing
SPEECH
*PRESCRIPTION WRITING: IMPORTANT TO KNOW THE DOSAGE, FORMAT, AND
Quantity: talkative, taciturn, responsive to cues, spontaneous or not
THE RIGHT DRUG! ALWAYS CONSIDER THE SIDE EFFECTS!
Quality: stammering, stuttering, paucity, monotonous
Rate: slow, fast, pressured, emotional, dramatic
INTERVIEW Volubility: mute, voluble, loud
Introduce yourself and tell the purpose of the interview.
Establish rapport. Show respect. THOUGHT PERCEPTION
Ask questions: line of questioning may pertain directly to the symptom Hallucinations
being elicited since there is a limited time. o Olfactory: May naaamoy po ba kayo na hindi naaamoy ng iba?
End courteously. o Auditory: May naririnig po ba kayo na hindi naririnig ng iba? saan
po ba nanggagaling yung naririnig niyo? May bumubulong po ba
HISTORY TAKING o parang naiisip niyo lang?may mga pinapagawa po ba sila sa
Identifying Data inyo?
Source & Reliability o Tactile: May nararamdaman po ba kayo na hindi nararamdaman
Chief Complaint ng iba?
History of Present Illness o Gustatory: May nalalasahan po ba kayo na nalalasahan ng iba?
Past Medical & Psychiatric History o Visual: May nakikita po ba kayo na hindi nakikita ng iba? iyong
Alcohol & Substance Abuse mga nakikita niyo po ba, nawawala kapag nakapikit kayo?
Family History & Social History o Note: Include circumstance of any hallucinatory experience
Personal History/Anamnesis Hypnagogic (As one falls asleep) or Hypnopompic (As one
o Prenatal & Perinatal History awakens)
o Early Childhood (Birth to 3 years) Awake/ dreamy/ drunk?
ask about play, feeding habits, toilet training, symptoms of Illusions
behaviour problems, recurring dreams or fantasies, Ano po sa tingin niyo itong bagay na ito (present something)?
separation anxiety, relationship with parents, siblings, Derealization
caretakers Minsan po ba pakiramdam niyo hindi totoo ang nasa paligid?
o Middle Childhood (3-11 years) Depersonalization
gender identification, source of discipline, attitude May mga pagkakataon po ban a pakiramdam niyo hindi kayo parte ng
towards school, earliest friendships katawan niyo?
o Late Childhood (Puberty to Adolescence)
THOUGHT PROCESS
social relationships, emotional & physical problems, school
Circumstantiality: beats around the bush but gets to the point
history, sexuality
o Adulthood Tangentiality: NEVER gets to the point
occupational history, marital & relationship history, Thought Blocking
educational history, religion, social activity, current living Thought Impairments: Neologisms, Clang associations, Word salad,
situation, legal history Punning, Flight of Ideas, Loose associations
SAMPLE CASE: R.S. is a 30 y/o male call center agent who has trouble sleeping. THOUGHT CONTENT
He was noted to be more talkative than usual and also has an increased Delusions remember, CHALLENGE the patient; orient to reality. But
appetite.
to a certain limit!
Gather Patient history and perform a complete MSE.
May mga paniniwala ka bang hindi pinapaniwalaan ng iba?
Ang sabi mo isa kang anghel, paano nangyari iyon? Bakit ka andito?
MENTAL STATUS EXAM
*The following parts of the MSE can only be observed so just mention them DELUSION QUESTIONS
when you report the findings to the preceptor: Appearance, Behavior,
Persecutory/ Naiisip mo ba na may gustong manakit sa’yo?
Attitude, Speech, Affect, Thought Process/ Form.
Paranoid Mayroon ka bang problema sa pakikisama sa mga tao?
GENERAL APPEARANCE Sa tingin mo ba may mga nagpplano ng masama
Appearance tungkol sayo?
o physical characteristics, clothing, posture, eye contact, etc Jealousy Iniisip mob a na pinagtataksilan ka ng iyong asawa o
Behaviour and Psychomotor activity kasintahan? Anong ebidensiya ang meron ka?
o psychomotor agitation/ retardation, emotional appearance,
Sin/ Guilt Palagay mo ba may ginawa kang hindi tama?
voice, signs of anxiety (restlessness, wringing of hands, pacing)
Mayroon bang umuusig sa konsensiya mo? Ano iyon?
Attitude towards examiner
Sa tingin mob a dapat kang maparusahan?
o cooperative, friendly, defensive, seductive, hostile, indifferent,
etc
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 Psychiatry OSCE Reviewer
Grandiose Mayroon ka bang mga ispesyal na kakayahan o
kapangyarihan
Somatic Mayroon bang mga pagbabago sa katawan mo?
Nagbago ba ang itsura mo? Anong dahilan?
Ideas/ Kapag nasa isang lugar k aba, naiisip mong pinag-
Delusions of uusapan o pinagtatawanan ka ng mga tao?
Reference Kapag nanonod k aba sa TV o nagbabasa ng magazine,
sa tingin mo ikaw ang tinutukoy sa mga balita?
Thought Minsan po ba napapatigil kayo sa gita ng pagsasalita
Blocking na para bang may kumukuha ng mg idea niyo?
Thought May mga pagkakataon ba na may nagpapasok ng mga
Insertion idea sa ulo mo?
Thought Minsan ba iniisip mong naririnig o nababasa ng ibang
Broadcasting tao ang mga iniisip mo?
Obsessions: May mga idea po ba kayo na paulit-ulit?
Compulsions: May mga ginagawa po ba kayo na paulit-ulit? Alam niyo
po ba kung bakit niyo ito ginagawa ng paulit-ulit?
Phobias: May mga kinatatakutan ka ba?Bakit ka natatakot?
Suicide: Risk, Intent,Plans,Means, Perceived consequences, History of
attempts / Family history of suicide
Naiisip mo ba na katapusan na ng mundo?
Naiisip mo ba na wakasan na ang buhay mo? Sa tingin mo ba
matatapos lahat ng problema mo kapag nagpakamatay ka?
Mayroon ka na bang naiisip na plano para wakasan ang buhay mo?
Ilang ulit ka ng nagtangkang magpakamatay? Anong ginawa mo?
Mayroon ka bang mga kamag-anak na nagpakamatay?
NOTE: SUICIDE is one of their favorite topics!
SENSORIUM AND COGNITION
Level of consciousness: Alert, Clear, Clouding, Confused, Somnolence,
Lethargy, Stupor, coma
Orientation
Anong araw ngayon? Anong petsa? Anong lugar Ito?Alam mo ba kung
sino ka? Sino ako?Sino ang nagbabantay sa’yo?  Change of>5% of body weight/month) or decrease or increase
Memory
o Immediate
Pakiulit ang mga sasabihin kong numero- 1,4,3,7,9
Sabihin mo ulit ang mga babanggitin kong mga bagay- susi,
bolpen, sapatos
o Recent
Anong kinain mo kaninang almusal?
Anong ginagawa mo bago tayo mag-usap?
o Recent Past
Nasaan ka noong pasko at bagong taon? Anong ginagawa mo?
o Long Term/ Remote
Saan ka nag-aral ng elementary? Highschool? College?
Sino ang mga pinakauna mong kaibigan?
Sino ang teacher mo noong grade 6?
Attention, Calculation, Concentration
Mula 100, magbawas ka ng pito hangga’t kaya mo.
Magbilang ka ng pabaliktad mula 20.
Baybayin ang salitang MUNDO pabaliktad
Fund of Information
Magbigay ka ng 5 presidente ng Pilipinas.
Ano ang pambansang hayop ng Pilipinas?
Sino ang mga kilala mong bayani/ artista/ singer?
Abstract Thinking
Ano ang pagkakapareho/ pagkakaiba ng mansanas at saging?
Maari mo ba itong ipaliwanag: Aanhin pa ang damo kung patay na
ang kabayo
PSYCHO WACKO |
JUDGMENT AND INSIGHT
Judgment
Ano po ang gagawin niyo kung sakaling may napulot kayong wallet?
Kung lahat ng tao sa kwartong ito ay tulog at biglang nagkaroon ng
sunog, anong gagawin mo?
Ano ang opinion mo sa same-sex marriage?
Insight
Ano po sa tingin niyo ang dahilan kung bakit kayo narito ngayon?
Sa tingin mo ba may problema ka?
Alam mo ba na kailangan mo ng professional na tulong?
DIAGNOSIS & MANAGEMENT
Note: Specifiers and Coding were intentionally not included in this reviewer since we
are only expected to know the basics. Nonetheless, this is going to be too wordy. XD
MOOD DISORDERS
SAMPLE CASE: G.Y. is a 24 y/o female who was observed by her friends to be sad
and irritable nearly every day for almost one month now. She has trouble falling
asleep and finds it difficult to concentrate. She also seemed uninterested in the
things she usually enjoys. She has significantly lost weight for the past 2 weeks.
While she was alone in her room, her mother heard banging sounds and found
her lying on the floor. Moreover, a suicide note was found among her things.
Elicit symptoms of depression and/or mania and assess suicidal risk.
What is your impression? What are your differential diagnoses?
How do you manage this patient?
MAJOR DEPRESSIVE DISORDER
A. 5 or more of the following symptoms have been present during the
same 2-week period and represent a change from previous
functioning: at least 1 symptom is either (1) depressed mood or (2)
loss of interest or pleasure
1. Depressed mood most of the day, nearly every day. (in children
or adolescents, can be irritable mood)
2. Markedly diminished interest/pleasure in (almost) all activities
most of the day, nearly every day.
3. Significant weight loss when not dieting or weight gain (eg.
in appetite nearly every day. (in children, consider failure to
make expected weight gains)
4. Insomnia or hyperinsomnia nearly every day
5. Psychomotor agitation or retardation nearly every day
(observable by others, note merely subjective feelings of
restlessness or being slowed down.
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt
(which may be delusional) nearly every day (not merely self-
reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness,
nearly every day
9. Recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation without a specific plan, or a suicide attempt
or a specific plan for committing suicide
B. Symptoms that do not meet criteria for a mixed episode
C. Symptoms cause clinically-significant distress or impairment in social,
occupational, and/or other areas of functioning
D. Symptoms are not better accounted for by bereavement, ie. after the
loss of a loved one, the symptoms persist for longer than 2 months or
are characterized by marked functional impairment, morbid
preoccupation with worthlessness, suicidal ideation, psychotic
symptoms, or psychomotor retardation.
MANAGEMENT
FIRST LINE: SSRIs
Sertraline (Zoloft): 50mg OD
Fluoxetine (Prozac): 20mg cap OD
Paroxetine (Paxil): 20mg tab OD (for panic attacks)
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 Psychiatry OSCE Reviewer
Citalopram (Celexa): 20mg tab OD
Escitalopram (Lexapro): 10mg tab OD
SECOND LINE: OTHER ANTI DEPRESSANTS
Tricyclic Antidepressants (TCA)
Ex. Imipramine, Clomipramine, Trimipramine
Monoamine Oxidase Inhibitors (MAO-I)
Ex. N/A in the Philippines
Selective Serotonin and Norepinephrine Reuptake Inhibitor (SNRI)
Ex. Duloxetine (Cymbalta), Venlafaxine (Effexor)
SIDE EFFECTS
SSRI: sexual dysfunction
TCA: Anticholinergic effects, extreme sedation, convulsions, COMA
MAO-I: reacts with tyramine-rich foods -> hypertensive crises
SNRI: headache, nausea, hypertension
PSYCHOTHERAPEUTIC MANAGEMENT
Cognitive-behavioral Therapy (CBT)
Interpersonal Therapy
Behavior Therapy
Psychoanalytically Oriented Therapy
Family Therapy
BIPOLAR DISORDER I: Manic+ Hypomanic/ MDD
For a diagnosis of bipolar I disorder, it is necessary to meet the following
criteria for a manic episode. The manic episode may have been preceded by
and may be followed by hypomanic or major depressive episodes.
Manic Episode
*at least 1 lifetime manic episode IS REQUIRED for diagnosis of Bipolar I
Disorder
A. A distinct period of abnormally and persistently elevated, expansive,
or irritable mood and abnormally and persistently increased goal-
directed activity or energy, lasting at least 1 week and present most
of the day, nearly every day (or any duration if hospitalization is
necessary).
B. During the period of mood disturbance and increased energy or
activity, 3 (or more) of the following symptoms (4 if the mood is only
irritable) are present to a significant degree and represent a
noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours
of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are
racing.
5. Distractibility (i.e., attention too easily drawn to unimportant
or irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or
school, or sexually) or psychomotor agitation (i.e., purposeless
non-goal-directed activity).
7. Excessive involvement in activities that have a high potential
for painful consequences (e.g., engaging in unrestrained buying
sprees, sexual indiscretions, or foolish business investments).
C. The mood disturbance is sufficiently severe to cause marked
impairment in social or occupational functioning or to necessitate
hospitalization to prevent harm to self or others, or there are
psychotic features.
D. The episode is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication, other treatment) or to
another medical condition.
Hypomanic Episode
*common but NOT required in diagnosis of Bipolar I Disorder
A. A distinct period of abnormally and persistently elevated, expansive, or
irritable mood and abnormally and persistently increased activity or
PSYCHO WACKO |
energy, lasting at least 4 consecutive days and present most of the
day, nearly every day.
B. Same with Criteria B of Manic Episode
C. The episode is associated with an unequivocal change in functioning
that is uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable
by others.
E. The episode is not severe enough to cause marked impairment in
social or occupational functioning or to necessitate hospitalization. If
there are psychotic features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication, other treatment).
Major Depressive Episode
*common but NOT required for diagnosis of Bipolar I Disorder
A. Five (or more) of the following symptoms have been present during
the same 2- week period and represent a change from previous
functioning; at least 1 of the symptoms is either (1) depressed mood
or (2) loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day, as
indicated by either subjective report (e.g., feels sad, empty, or
hopeless) or observation made by others (e.g., appears tearful).
(Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day (as indicated by
either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a
change of more than 5% of body weight in a month), or
decrease or increase in appetite nearly every day. (Note: In
children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day
(observable by others; not merely subjective feelings of
restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt
(which may be delusional) nearly every day (not merely self-
reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness,
nearly every day (either by subjective account or as observed
by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation without a specific plan, or a suicide attempt or
a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a
substance or another medical condition.
MANAGEMENT
FIRST LINE: VALPROATE
Valproate 750 - 2,500 mg per day, achieving blood levels bet. 50 and
120 ug/Ml
equal in safety and efficacy to Lithium
SE: gastrointestinal distress (e.g., anorexia, nausea, dyspepsia,
vomiting, diarrhea), benign hepatic transaminase elevations,
osteoporosis, tremor, and sedation
SECOND LINE: LITHIUM CARBONATE
Lithium Carbonate 300 mg TID
for short term and prophylactic treatment of bipolar I disorder
controls acute mania (effect in 1-3 weeks) and MDD (with
antidepressant effect)
therapeutic levels are between 0.6 and 1.2 mEq/L
Use with supplemental thyroid hormone (e.g. 25 mg Iiothyronine)
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 Psychiatry OSCE Reviewer

SE: polyuria, polydipsia, weight gain, cognitive problems (e.g., dulling, 3. Disorganized speech (e.g., frequent derailment or
impaired memory, poor concentration, confusion, mental slowness), incoherence).
tremor, sedation or lethargy, impaired coordination, gastrointestinal 4. Grossly disorganized or catatonic behavior.
distress (e.g., nausea, vomiting, dyspepsia, diarrhea), hair loss, benign **Note: Do not include a symptom if it is a culturally sanctioned response.
leukocytosis, acne, and edema B. Duration of an episode of the disturbance is at least 1 day but less
than 1month, with eventual full return to premorbid level of
OTHERS functioning.
Carbamazepine and oxcarbazepine C. The disturbance is not better explained by major depressive or bipolar
SE: diplopia, blurred vision, fatigue, nausea, and ataxia disorder with psychotic features or another psychotic disorder such as
schizophrenia or catatonia, and is not attributable to the physiological
SIDE Effects: (in general)
effects of a substance (e.g., a drug of abuse, a medication) or another
Tremor (Beta blocker: Increased urination
medical condition.
Propanolol) Kidney function impairment
GI distress Acne MANAGEMENT
Weight gain Psoriasis FIRST LINE: ANTIPSYCHOTICS
Cognitive impairment Haloperidol Moderate disease: 0.5-2 mg q8-12hr initially; Severe
Hypothyroidism (supplement thyroid; T3, because of its short half-life, disease: 3-5 mg q8-12hr initially
25 -50 microgram perday for acute and T4 for long-term maintenance) Ziprasidone 80-160mg/day (40 mg starting dose)
PSYCHOTHERAPEUTIC MANAGEMENT SECOND LINE
Hospitalization for patients with risk of suicide Benzodiazepines: can be used in the short-term treatment of
Cognitive therapy psychosis
Anxiolytics are useful during the first 2 to 3 weeks after the resolution
BIPOLAR DISORDER II: Hypomanic + MDD/ NO MANIC
of the psychotic episode
For a diagnosis of bipolar II disorder, it is necessary to meet the following
criteria for a hypomanic episode and the following criteria for a current or SIDE EFFECTS
past major depressive episode: HALOPERIDOL (1st Gen Typical Antipsychotics): extrapyramidal
1. HYPOMANIC EPISODE – same as above symptoms (EPS), tachycardia, impotence and dizziness (non-selective
2. MAJOR DEPRESSIVE EPISODE – same as above interaction  at  the  α  adrenoceptor),  sedation  and  weight  gain  (due  to 
histamine H1 receptor blockade)
MANAGEMENT
o EPS:
For acute bipolar depression:
Parkinsonism – tremors, rigidity, slowness of movement,
1ST LINE: fixed combination of olanzapine and fluoxetine for 8 weeks temporary paralysis, cogwheel rigidity, pill rolling, facial
2ND LINE: Lamotrigine or low dose ziprasidone 20 to 80 mg per day masking
3RD LINE: ECT - for those who do not respond to lithium or other Dystonia – involuntary muscle contractions
mood stabilizers and their adjuncts, particularly in those with suicidal Akathisia – inability to resist urge to move; restless
tendencies Tardive dyskinesia – involuntary movements of the mouth,
Maintenance lips, and tongue; some will have oculogyric crisis (the
Lithium, carbamazepine and valproate alone or in combination eyeballs become fixed in one position, typically upwardly
rotated, for minutes or hour)
Lamotrigine has prophylactic antidepressant and ,potentially, mood
ADMINISTER: serotonin-dopamine antagonist in patients
stabilizing properties. It appears to have superior acute and
who are at high risk for the development of
prophylactic antidepressant properties compared with antimanic
extrapyramidal adverse effects
properties
ZIPRASIDONE: (not available in the Philippines), significant QT
PSYCHOTHERAPEUTIC MANAGEMENT prolongation in susceptible patients, may cause hyperprolactinemia (<
Cognitive therapy risperidone), NOT associated with weight gain
Interpersonal Therapy BENZODIAZEPINES: Oversedation, Memory impairment, Depression,
Psychoanalytically oriented therapy emotional blunting, Floppy Infant Syndrome, paradoxical excitement
with increased anxiety, insomnia, nightmares, and hallucinations at the
PSYCHOTIC DISORDERS onset of sleep, irritability, hyperactive or aggressive behavior, and
SAMPLE CASE: C.M. is a 26 y/o male who appears disheveled. He proclaims that exacerbation of seizures in epileptics.
he is Zac Efron. He said that a voice keeps telling him to look for his missing
girlfriend who has amnesia. He suddenly approached a girl in a crowd and started PSYCHOTHERAPEUTIC MANAGEMENT
shouting that he had found ‘her’. Witnesses reported that C.M. was first seen Principles of Psychotherapy of Brief Psychotic Disorder
roaming the area around 3 weeks ago. Additionally, he was often caught staring o Exploration and development of coping strategies are the
blankly and talking to the air. major topics in psychotherapy.
Elicit perceptual disturbances (hallucination) and other psychotic o Associated issues include helping patients deal with the loss of
symptoms (delusions) self-esteem and to regain self-confidence.
What is your impression? What are your differential diagnoses?
o An individualized treatment strategy based on increasing
How do you manage this patient?
problem solving skills while strengthening the ego structure
appears to be the most efficacious.
BRIEF PSYCHOTIC DISORDER o Family involvement in the treatment process may be crucial to
A. Presence of one (or more) of the following symptoms. At least one of a successful outcome.
these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
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SCHIZOPHRENIFORM DISORDER
A. Two (or more) of the following, each present for a significant portion
of time during a 1- month period (or less if successfully treated). At
least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or
incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or
avolition).
B. An episode of the disorder lasts at least 1 month but less than 6
months. When the diagnosis must be made without waiting for
recovery, it should be qualified as “provisional.” '
C. Schizoaffective disorder and depressive or bipolar disorder with
psychotic features have been ruled out because either 1) no major
depressive or manic episodes have occurred concurrently with the
active-phase symptoms, or 2) if mood episodes have occurred during
active-phase symptoms, they have been present for a minority of the
total duration of the active and residual periods of the illness.
D. The disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition.
MANAGEMENT
FIRST LINE: ANTIPSYCHOTICS
RISPERIDONE 2-8 mg/day once daily or divided q12hr
NOTES:
o The psychotic symptoms can usually be treated by a 3- to 6-
month course of antipsychotic drugs
o Lacks anticholinergic activity – makes it better for youth, elderly
o Has same good effects as haloperidol minus the side effects of
haloperidol
o If side effects seen, give Biperiden, an anticholinergic.
SECOND LINE
LITHIUM, CARBAMAZEPINE or VALPROATE may be warranted for
treatment and prophylaxis if a patient has a recurrent episode.
SIDE EFFECTS
RISPERIDONE: increases prolactin levels (shouldn’t be given to people  substance (e.g., a drug of abuse, a medication) or another medical
with breast cancer), Increases extrapyramidal side effects ( At >4 mg,
all side effects like those of typical antipsychotics are seen; lower than
4 mg, no side effects), weight gain and sedation (dosage dependent)
LITHIUM: reduced appetite, nausea, vomiting, diarrhea, thyroid
abnormalities, polyuria or polydypsia secondary to ADH antagonism,
hair loss, acne, reduces seizure threshold, cognitive slowing, intention
tremor
o Symptoms of toxic effects of lithium
Mild (1.0 - 1.5) - impaired concentration, lethargy,
irritability, weakness, nausea, tremor, fatigue
Moderate (1.6 - 2.5) - disorientation, confusion,
drowsiness, restlessness, unsteady gait, dysarthria, muscle
fasciculation, vomiting
Severe (> 2.5) - impaired consciousness, delirium,
extrapyramidal symptoms, generalized fasciculations,
convulsions
VALPROATE: thrombocytopenia and platelet dysfunction,
hepatotoxicity, nausea, vomiting, weight gain, transaminitis, sedation,
tremor, TERATOGENIC, hair loss
CARBAMAZEPINE: Rash - most common SE seen, nausea, vomiting,
diarrhea, transaminitis, sedation, dizziness, ataxia, confusion, AV
conduction delays, aplastic anemia and agranulocytosis (<0.002%),
water retention due to vasopressin-like effect which can result in
hyponatremia and edema
PSYCHO WACKO |
PSYCHOTHERAPEUTIC MANAGEMENT
Personal Therapy
Supportive Therapy
Family Therapy
*Psychotherapeutic treatments for schizophrenia may be used for
shizophreniform as well
SCHIZOPHRENIA
A. Two (or more) of the following, each present for a significant portion
of time during a 1 -month period (or less if successfully treated). At
least one of these must be (1 ), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or
incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or
avolition).
B. For a significant portion of the time since the onset of the disturbance,
level of functioning in one or more major areas, such as work,
interpersonal relations, or self-care, is markedly below the level
achieved prior to the onset (or when the onset is in childhood or
adolescence, there is failure to achieve expected level of interpersonal,
academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This
6-month period must include at least 1 month of symptoms (or less if
successfully treated) that meet Criterion A (i.e., active-phase
symptoms) and may include periods of prodromal or residual
symptoms. During these prodromal or residual periods, the signs of the
disturbance may be manifested by only negative symptoms or by two
or more symptoms listed in Criterion A present in an attenuated form
(e.g., odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with
psychotic features have been ruled out because either 1) no major
depressive or manic episodes have occurred concurrently with the
active-phase symptoms, or 2) if mood episodes have occurred during
active-phase symptoms, they have been present for a minority of the
total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a
condition.
F. If there is a history of autism spectrum disorder or a communication
disorder of child hood onset, the additional diagnosis of schizophrenia
is made only if prominent delusions or hallucinations, in addition to the
other required symptoms of schizophrenia, are also present for at least
1 month (or less if successfully treated).
MANAGEMENT
FIRST LINE: ANTIPSYCHOTICS
OLANZAPINE - initial: 10-15mg OD; can be raised to 20mg/day after 5-
7days
ARIPIRAZOLE - 10-15mg/day OD; as an adjunctive treatment to
patients already taking antidepressants.
RISPERIDONE - 1-2mg/day, taken at night
SIDE EFFECTS
OLANZAPINE: moderate somnolence, weight gain
RISPERIDONE: EPS at high doses; somnolence, constipation,rash,
tachycardia, dizziness, anxiety
ALL 2nd gen antipsychotics:
o Neuroleptic malignant syndrome (NMS) – muscular rigidity,
fever, autonomic dysregulation
o Tardive dyskinesia
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 Psychiatry OSCE Reviewer
PSYCHOTHERAPEUTIC MANAGEMENT
Social Skills Training
Behavior therapy (Token economy procedure)
Milieu Therapy
SUBSTANCE- INDUCED PSYCHOTIC DISORDER
A. Presence of one or both of the following symptoms:
1. Delusions.
2. Hallucinations.
B. There is evidence from the history, physical examination, or laboratory
findings of both (1)and (2):
1. The symptoms in Criterion A developed during or soon after
substance intoxication or withdrawal or after exposure to a
medication.
2. The involved substance/medication is capable of producing the
symptoms in Criterion A.
C. The disturbance is not better explained by a psychotic disorder that is
not substance/medication-induced. Such evidence of an independent
psychotic disorder could include the following:
The symptoms preceded the onset of the substance/medication
use;
The symptoms persist for a substantial period of time (e.g., about
1 month) after the cessation of acute withdrawal or severe
intoxication; or,
There is other evidence of an independent non-
substance/medication induced psychotic disorder (e.g., a history
of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a
delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
**NOTE: This diagnosis should be made instead of a diagnosis of substance
intoxication or substance withdrawal only when the symptoms in Criterion A
predominate in the clinical picture and when they are sufficiently severe to
warrant clinical attention.
MANAGEMENT
FIRST LINE: ANTIPSYCHOTICS
HALOPERIDOL
o PO
Moderate disease: 0.5-2 mg q8-12hr initially
Severe disease: 3-5 mg q8-12hr initially; not to exceed 30
mg/day
o IM lactate (prompt-acting)
2-5 mg q4-8hr PRN; may require q1hr in acute agitation
o IM decanoate (depot)
Initial: IM dose 10-20 times daily PO dose administered
monthly; not to exceed 100 mg;
If conversion requires initial dose >100 mg, administer in 2
injections (eg, 100 mg initially, then remainder in 3-7 days)
Maintenance: Monthly dose 10-15 times daily PO dose
o IV (Off-label)
May be needed for ICU delirium
Use only haloperidol lactate for IV administration; do not
use haloperidol decanoate 2-10 mg initially, depending on
degree of agitation;
If response inadequate, may repeat bolus q15-30min,
sequentially doubling initial bolus dose;
When calm achieved, administer 25% of last bolus dose
q6hr; taper dose after patient is controlled
Monitor ECG and QT interval (QT prolongation may occur
with cumulative  doses  ≥35  mg;  torsades  de  pointes  1. Restlessness or feeling keyed up or on edge
reported with single doses ≥20 mg)
PSYCHO WACKO |
OLANZAPINE
o Oral:
Initial dose: 5 to 10 mg orally once a day.
Maintenance dose: 10 mg orally once a day.
Maximum dose: 20 mg orally once a day.
o Short-acting Injection (for agitation):
Initial dose: 10 mg IM once.
Subsequent IM doses up to 10 mg may be administered 2
hours after 1st dose and 4 hours after 2nd dose; not to
exceed 30 mg/day
o IM, extended-release
Recommended dosing based on oral dosing:
Oral dosage 10 mg/day: 210 mg IM every 2 weeks or
405 mg IM every 4 weeks for 1st 8 weeks, then 150
mg every 2 weeks or 300 mg every 4 weeks
Oral dosage 15 mg/day: 300 mg IM every 2 weeks for
1st 8 weeks, then 210 mg every 2 weeks or 405 mg
every 4 weeks
Oral dosage 20 mg/day: 300 mg IM every 2 weeks for
1st 8 weeks, then 300 mg every 2 weeks
**NOTE: Olanzapine is as effective as Haloperidol, but has a lower rate of
extra pyramidal side effects
SECOND LINE/OTHER APPLICABLE DRUGS
Diuretics
o Furosemide
o Sodium Bicarbonate
Ascorbic Acid: Oral, IM, IV, subcutaneously: 4 to 12 g/day in 3 to 4
divided doses (to acidify urine)
Ammonium Chloride: Recommended dose to acidify the urine is 500
mg every 2-3 hours (for Amphetamine intoxication)
o Should not be used in patients with hepatic/renal impairment
o Give via slow IV push to avoid local irritation and toxic effects,
including pallor, sweating, retching, irregular breathing,
bradycardia, cardiac arrhythmias, local and general twitching,
tonic convulsions, and coma
PSYCHOTHERAPEUTIC MANAGEMENT
Supportive psychotherapy
Coping-focused psychotherapy
Social skills/interpersonal/growth psychotherapy.
Exploratory psychotherapy
ANXIETY DISORDERS
SAMPLE CASE: S.J. is a 28 y/o female who finds it uncomfortable to be in a crowd.
She feels dizzy and nauseated whenever she sees people around her. She feels
like she is going crazy and that she is dying every time she is exposed to people.
Elicit symptoms of anxiety (cognitive, behavioural, physical components)/
panic attack.
What is your impression? What are your differential diagnoses?
How do you manage this patient?
GENERALIZED ANXIETY DISORDER
A. Excessive anxiety and worry (apprehensive expectation), occurring
more days than not for at least 6 months, about a number of events
or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the
following six symptoms (with at least some symptoms having been
present for more days than not for the past 6 months):
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
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 Psychiatry OSCE Reviewer
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling asleep or staying asleep, or
restless, unsatisfying sleep
***NOTE: Only one item is required in children.
D. The anxiety, worry, or physical symptoms cause clinically significant
distress or impairment in social, occupational or other important areas
of functioning.
E. The disturbance is not attributable to the physiologic effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition (e.g., hyperthyroidism).
F. The disturbance is not better explained by another mental disorder
(e.g., anxiety or worry about having panic attacks in panic disorder,
negative evaluation in social anxiety disorder [social phobia],
contamination or other obsessions in obsessive-compulsive disorder,
separation from attachment figures in separation anxiety disorder,
reminders of traumatic events in posttraumatic stress disorder, gaining
weight in anorexia nervosa, physical complaints in somatic symptom
disorder, perceived appearance flaws in body dysmorphic disorder,
having a serious illness in illness anxiety disorder, or the content of
delusional beliefs in schizophrenia or delusional disorder).
MANAGEMENT
FIRST LINE: SSRI OR SNRI
SSRI: especially for patients with comorbid depression
Fluoxetine (Prozac), Sertraline (Zoloft)
SNRI: Venlafaxine (Effexor XR), Duloxetine (Cymbalta), Desvenlafaxine
(Pristiq)
SECOND LINE: BENZODIAZEPINES
**NOTE: only for short term use due to side effects (cognitive impairment,
ataxia, sedation, dependence and withdrawal)
Avoid in substance abuse and elderly
Given with first line (BZD have immediate effects whereas SSRI/SNRI
takes time)
Alprazolam (Xanax)*
o Initial dose: 0.25-0.5mg TID, increase every 3-4 days
o Maximum daily dose of 4mg in divided doses
o Discontinuation: Decrease by at most 0.5mg every 3 days
*Discontinuation syndrome seen just after 6-8 weeks of treatment
Clonazepam (Klonopin)
Diazepam (Valium)
Lorazepam (Ativan)
THIRD LINE/ ADJUNCTS
ANTIPSYCHOTICS: olanzapine, risperidone, mirtazapine
o optimal trial involves 8-12 weeks
TRICYCLICS: reduce intensity of anxiety
o not first-line due to side effect profile (anti-cholinergic effects,
cardiotoxicity, potential lethality in overdose)
o Imipramine (Tofranil), nortriptyline (Aventy)
MAOIs: effective but not first-line due to major adverse side effect
(hypertensive crisis secondary to ingestion of tyramine)
o Phenelzine (Nardil), tranylcypromine (Parnate)
BETA-BLOCKERS: acts to suppress somatic signs of anxiety (panic
attacks)
o effective in blocking anxiety in social phobia
o side effects: bradycardia, hypotension, drowsiness
o Propanolol (Inderal), Atenolol (Tenormin)
VENLAFAXINE: effective in treating the insomnia, poor concentration,
restlessness, irritability, and excessive muscle tension
o non-selective inhibitor of the re-uptake of serotonin,
norepinephrine, dopamine (lesser extent)
BUSPIRONE (BUSPAR): most effective in reducing cognitive symptoms
o effects take 2-3 weeks
PSYCHO WACKO |
Anticonvulsant anxiolytics: used when panic attacks are present
o Gabapentin (Neurontin), Tiagabine (Gabitril), Valproate
(Depakene)
**NOTE: Treatment resistant patients should be assessed for comorbidities
PSYCHOTHERAPEUTIC MANAGEMENT
Cognitive behavioral therapy
Support psychotherapy
Insight-oriented psychotherapy
Psychodynamic therapy
Group therapy
POSTTRAUMATIC STRESS DISORDER
FOR ADULTS, ADOLESCENTS and CHILDREN older than 6 years old.
A. Exposure to actual and threatened death, serious injury, or sexual
violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s)
2. Witnessing in person the event(s) as it occurred to others
3. Learning that the traumatic event(s) occurred to a close family
member or close friend. In cases of actual or a threatened
death of a family member or friend, then event(s) must have
been violent or accidental.
4. Experiencing repeated or extreme exposure to adverse details
of the traumatic events(s) (e.g., first responders collecting
human remains; police officers repeatedly exposed to details of
child abuse).
B. Presence of one or more of the following intrusion symptoms
associated with the traumatic event(s), beginning after the traumatic
event(s) occurred:
1. Recurrent, involuntary, and distressing memories of the
traumatic event(s)
2. Recurrent distressing dreams in which the content and/or
affect of the dreams are related to the traumatic events(s)
3. Dissociative reactions (e.g. flashbacks) in which the individual
feels or acts and as of the traumatic event(s) were recurring.
(Such reactions on a continuum, with the most extreme
expression being a complete loss of awareness of present
surroundings).
4. Intense or prolonged psychological distress at exposure to
internal and external cues that symbolize or resemble an aspect
of traumatic events
5. Marked physiological reactions to internal or external cues
that symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s),
beginning after the traumatic event(s) occurred as evidence by one or
both of the following:
1. Avoidance of or efforts to avoid distressing memories,
thoughts, or feelings about or closely associated with the
traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people,
places, conversation, activities, objects, situations) that arouse
distressing memories, thoughts or feelings about or closely
associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the
traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by one or more of the following:
1. Inability to remember an important aspect of the traumatic
event(s) typically due to dissociative amnesia and not to other
factors such as head injury, alcohol, drugs
2. Persistent and exaggerated negative beliefs or expectations
about oneself, others or the world ( e.g “ i am bad, No one can 
be trusted” “ the world is completely dangerous” “ my nervous 
system is permanently ruined”).
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 Psychiatry OSCE Reviewer
3. Persistent, distorted cognitions about the cause or
consequences of the traumatic event(s) and lead the individual
to blame himself/herself or others
4. Persistent negative emotional state (e/g fear, horror, anger,
guilt or shame)
5. Marked diminished interest or participation from others
6. Feelings of detachment or estranged from others
7. Persistent inability to experience positive emotions (e.g.
inability to experience happiness, satisfaction or loving feelings)
E. Marked alterations in arousal and reactivity associated with traumatic
events(s), beginning or worsening after the traumatic event(s)
occurred, as evidenced by two or more of the following:
1. Irritable behavior and angry outburts ( with little or no
provocation) typically expressed as verbal or physical agression
toward people or objects
2. Reckless or self-destructive behavior
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep disturbance (e.g. difficulty or staying asleep or restless
sleep)
F. Duration of the disturbance (B,C,D,E) is MORE than 1 MONTH
G. The disturbance causes clinically significant distress or impairment in
social, occupational or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a
substance (e.g. medication, alcohol) or other medical condition.
SPECIFY if with dissociative symptoms:
1. Depersonalization
2. Derealization
Posttraumatic Stress Disorder for Children 6 Years and Younger
A. In children 6 years and younger, exposure to actual or threatened
death, serious injury, or sexual violence in one (or more) of the
following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing*, in person, the event(s) as it occurred to others,
especially primary caregivers
3. Learning that the traumatic event(s) occurred to a parent or
caregiving figure.
*Witnessing does not include events that are witnessed only in electronic
media, television, movies, or pictures.
B. Presence of one (or more) of the following intrusion symptoms
associated with the traumatic event(s), beginning after the traumatic
event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of
the traumatic event(s).
**NOTE: Spontaneous and intrusive memories may not necessarily
appear distressing and may be expressed as play reenactment.
2. Recurrent distressing dreams in which the content and/or
affect of the dream are related to the traumatic event(s).
**NOTE: It may not be possible to ascertain that the frightening content
is related to the traumatic event.
3. Dissociative reactions (e.g., flashbacks) in which the child feels
or acts as if the traumatic event(s) were recurring. (Such
reactions may occur on a continuum, with the most extreme
expression being a complete loss of awareness of present
surroundings.) Such trauma-specific reenactment may occur in
play.
4. Intense or prolonged psychological distress at exposure to
internal or external cues that symbolize or resemble an aspect
of the traumatic event(s).
5. Marked physiological reactions to reminders of the traumatic
event(s).
C. One (or more) of the following symptoms, representing either persistent
avoidance of stimuli associated with the traumatic event(s) or negative
PSYCHO WACKO |
alterations in cognitions and mood associated with the traumatic
event(s), must be present, beginning after the event(s) or worsening after
the event(s):
Persistent Avoidance of Stimuli
1. Avoidance of or efforts to avoid activities, places, or physical
reminders that arouse recollections of the traumatic event(s).
2. Avoidance of or efforts to avoid people, conversations, or
interpersonal situations that arouse recollections of the
traumatic event(s).
Negative Alterations in Cognitions
3. Substantially increased frequency of negative emotional states
(e.g., fear, guilt, sadness, shame, confusion).
4. Markedly diminished interest or participation in significant
activities, including constriction of play.
5. Socially withdrawn behavior.
6. Persistent reduction in expression of positive emotions.
D. Alterations in arousal and reactivity associated with the traumatic
event(s), beginning or worsening after the traumatic event(s) occurred,
as evidenced by two (or more) of the following:
1. Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects (including extreme temper
tantrums)
2. Hypervigilance
3. Exaggerated startle response
4. Problems with concentration.
5. Sleep disturbance (e.g., difficulty falling or staying asleep or
restless sleep)
E. The duration of the disturbance is more than 1 month
F. The disturbance causes clinically significant distress or impairment in
relationships with parents, siblings, peers, or other caregivers or with
school behavior.
MANAGEMENT
FIRST LINE: SSRI
NOTE: SSRI may also increase the risk of suicide among children and
adolescents. Thus, monitoring (suicide precaution risk) is needed.
Fluoxetine (Prozac) – Black Box Warning: increased risk of suicidal
thinking and behavior in children, adolescents anD young adults (<24)
Citalopram (Celexa) – 20-40mg/ day; approved for children and
adolescents
Ecitalopram – this is the most available in the country.
SECOND LINE
BETABLOCKERS
o Propanolol – decreases the hyperarousal and agitation in
children
ALPHA AGONIST
o Clonidine – for nightmares
SIDE EFFECTS
FLUOXETINE: headache, nausea, insomnia, anorexia, anxiety,
asthenia, diarrhea, nervousness, somnolence.
CITALOPRAM: 15% Insomnia, 20% nausea and dry mouth, In general:
tremor, anxiety, agitation, yawning, headaches, dizziness, restlessness
and sedation, drop in BP and inc. HR; sexual dysfunction (dec. sexual
and diff of ejaculation in men. Side effects usually diminish or
disappear after 4 weeks of use.
PSYCHOTHERAPEUTIC MANAGEMENT
Trauma-focused Cognitive- Behavior Therapy- The treatment is
generally administered over 10-16 treatment sessions.
Steps:
1. Psychoeducation 4. Cognitive Processing
2. Stress inoculation 5. Parental Treatment component
3. Gradual
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 Psychiatry OSCE Reviewer
Crisis intervention/ Psychological Debriefing
Eye movement desensitization and reprocessing (EMDR
PANIC DISORDER
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge
of intense fear or intense discomfort that reaches a peak within
minutes, and during which time four (or more) of the following
symptoms occur:
**NOTE: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed, or faint
9. Chills or heat sensations
10. Paresthesias (numbness or tingling sensations)
11. Derealization (feelings of unreality) or depersonalization (being
detached from oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.
**Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache,
uncontrollable screaming or crying) may be seen. Such symptoms should not
count as one ofthe four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of
one or both of the following:
1. Persistent concern or worry about additional panic attacks or
their consequences (e.g., losing control, having a heart attack,
“going crazy”)
2. A significant maladaptive change in behavior related to the
attacks (e.g., behaviors designed to avoid having panic attacks,
such as avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition (e.g., hyperthyroidism, cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder
(e.g., the panic attacks do not occur only in response to feared social
situations, as in social anxiety disorder; in response to circumscribed
phobic objects or situations, as in specific phobia; in response to
obsessions, as in obsessive-compulsive disorder; in response to
reminders of traumatic events, as in posttraumatic stress disorder; or
in response to separation from attachment figures, as in separation
anxiety disorder).
AGORAPHOBIA
A. Marked fear or anxiety about two (or more) of the following five
situations:
1. Using public transportation (e.g., automobiles, buses, trains,
ships, planes)
2. Being in open spaces (e.g., parking lots, marketplaces, bridges)
3. Being in enclosed places (e.g., shops, theaters, cinemas)
4. Standing in line or being in a crowd.
5. Being outside of the home alone.
B. The individual fears or avoids these situations because of thoughts that
escape might be difficult or help might not be available in the event
of developing panic-like symptoms or other incapacitating or
embarrassing symptoms (e.g., fear of falling in the elderly; fear of
incontinence).
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence
of a companion, or are endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by
the agoraphobic situations and to the sociocultural context.
PSYCHO WACKO |
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6
months or more
G. The fear, anxiety, or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
H. If another medical condition (e.g., inflammatory bowel disease,
Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly 
excessive.
I. The fear, anxiety, or avoidance is not better explained by the
symptoms of another mental disorder—for example, the symptoms
are not confined to specific phobia, situational type; do not involve
only social situations (as in social anxiety disorder); and are not related
exclusively to obsessions (as in obsessive-compulsive disorder),
perceived defects or flaws in physical appearance (as in body
dysmorphic disorder), reminders of traumatic events (as in
posttraumatic stress disorder), or fear of separation (as in separation
anxiety disorder).
**NOTE: Agoraphobia is diagnosed irrespective of the presence of panic
disorder. If an individual’s presentation meets criteria for panic disorder and
agoraphobia, both diagnoses should be assigned.
MANAGEMENT (Panic Disorder & Agoraphobia)
FIRST LINE: ALPRAZOLAM & PAROXETINE
ALPRAZOLAM
o 0.5mg tab every 8 hours
PAROXETINE
o 10mg tab once a day (20mg if social phobia)
o For rapid effect: ALPRAZOLAM + SSRI
o For Panic Attack w/ depression: FLUOXETINE
o For Anticipation Anxiety: Clonazepam
PSYCHOTHERAPEUTIC MANAGEMENT
Family Therapy
Insight Oriented Psychotherapy
OBSESSIVE-COMPULSIVE DISORDER
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images that are
experienced, at some time during the disturbance, as intrusive
and unwanted, and that in most individuals cause marked
anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts,
urges, or images, or to neutralize them with some other
thought or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or
mental acts (e.g., praying, counting, repeating words silently)
that the individual feels driven to perform in response to an
obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or
reducing anxiety or distress, or preventing some dreaded event
or situation; however, these behaviors or mental acts are not
connected in a realistic way with what they are designed to
neutralize or prevent, or are clearly excessive.
**NOTE: Young children may not be able to articulate the aims of these
behaviors or mental acts.
B. The obsessions or compulsions are time-consuming (e.g., take more
than 1 hour per day) or cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
C. The obsessive-compulsive symptoms are not attributable to the
physiological effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
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 Psychiatry OSCE Reviewer
D. The disturbance is not better explained by the symptoms of another
mental disorder (e.g., excessive worries, as in generalized anxiety
disorder; preoccupation with appearance, as in body dysmorphic
disorder; difficulty discarding or parting with possessions, as in
hoarding disorder; hair pulling, as in trichotillomania [hair-pulling
disorder]; skin picking, as in excoriation [skin-picking] disorder;
stereotypies, as in stereotypic movement disorder; ritualized eating
behavior, as in eating disorders; preoccupation with substances or
gambling, as in substance-related and addictive disorders;
preoccupation with having an illness, as in illness anxiety disorder;
sexual urges or fantasies, as in paraphilic disorders; impulses, as in
disruptive, impulse-control, and conduct disorders; guilty ruminations,
as in major depressive disorder; thought insertion or delusional
preoccupations, as in schizophrenia spectrum and other psychotic
disorders; or repetitive patterns of behavior, as in autism spectrum
disorder).
MANAGEMENT
FIRST LINE: SSRI (FLUVOXAMINE)
FLUVOXAMINE
o 50mg once a day during bed time
SECOND LINE
Clomipramine, Valproate, Lithium, Carbamazepine, Clonazepam,
Risperizone
PSYCHOTHERAPEUTIC MANAGEMENT
Insight Oriented Psychotherapy
Family Therapy
ECT
Psychosurgery
SUMMARY
MOOD DISORDERS
MAJOR DEPRESSIVE DISORDER: 5/9 symptoms for 2 weeks
FLUOXETINE 20mg tablet PO once daily for 1 month (continue for 6
months if responsive)
BIPOLAR I: Manic + Hypomanic or MDD
BIPOLAR II: Hypomanic + MDD; NO MANIC EPISODE
o Manic 1 week Bipolar I
o Hypomanic 4 days Bipolar II
*2 years
o Dysthymic = Bipolar I; Cyclothymic = Bipolar II
VALPROIC ACID 250 mg capsule every 12hrs ( 1tab am/ 1 tab night)
CLONAZEPAM 0.5 mg tablet PO every 8 hrs
OLANZAPINE 5mg tab once a day ( 1tab at night)
PSYCHOTIC DISORDERS
NOTE: Elicit delusion, hallucination; Observe speech, behaviour, negative
symptoms
BRIEF PSYCHOTIC DISORDER: at least 1 day but less than 1 month
SCHIZOPHRENIFORM DISORDER: 1 month
SCHIZOPHRENIA: at least 2 symptoms for 1 month straight 6months
SUBSTANCE-INDUCED PSYCHOSIS:
OLANZAPINE 5mg tablet once a day for 1 month (if responsive, continue
for 6 months)
ALPRAZOLAM 0.5mg tablet PO every 8 hours for one day
Haloperidol 0.5 mg tablet every 8 hours for 1 month
EMERGENCY: HALOPERIDOL or ARIPIPRAZOLE (IM)
ANXIETY DISORDERS
GENERAL ANXIETY DISORDER: at least 6 months
FLUOXETINE 20mg tablet PO once daily
PSYCHO WACKO |
POSTTRAUMATIC STRESS DISORDER at least 1 month
o ACUTE: <3 months
o CHRONIC: >3 months
a. Reexperiencing/ Intrusion (at least 1)
Paulit-ulit mo bang naaalala ang mga nangyari?
Napapanaginipan mo ba?
Pakiramdam mo ba ay nangyayari ulit ang lahat?
b. Avoidance (at least 3)
Gusto mo bang hindi na naiisip ang mga nangyari?
Umiiwas ka ba sa mga gawain, lugar, o mga taong
nakakapagpaalala sa iyo nito?
Di mo na ba maalala kahit katiting?
Nawawalan ka ba ng gana sa buhay?
Pakiramdam mo ba ay gusto mong lumayo sa iba?
Pakiramdam mo ba hindi ka na magkakatrabaho, makapag-
aasawa, o magkakapamilya?
Mayroon ka bang pagmamahal sa iba?
c. Arousal ( at least 2)
Nahihirapan/ Hindi ka ba makatulog?
May poot o galit ka ba sa puso?
Di ka ba makapag-isip ng maayos?
Palagi ka bang nakabantay sa paligid mo?
Madali ka bang mabigla o magulat?
PAROXETINE 20 mg tablet once a day for 1 month
PANIC DISORDER
Panic attack 1 month PANIC DISORDER
AGORAPHOBIA
o Takot ka bang mapunta sa isang lugar na pakiramdam mo,
kung may mangyayaring masama ay hindi ka makakaligtas?
o Umiiwas ka bas a lugay na kagaya ng tulay, bus, tren, o sa
labas ng bahay lalo na kapag mag-isa ka lang?
ALPRAZOLAM 0.5mg tab every 8 hours
PAROXETINE 10mg tab once a day (20mg if social phobia)
OBSESSIVE- COMPULSIVE DISORDER
May mga bagay ka bang paulit-ulit na iniisip na hindi lamang mga
simpleng alaala, at gusto mo nang hindi isipin?
May mga bagay bang paulit-ulit mong ginagawa para mabawasan o
maibsan ang hindi magandang pakiramdam o kaba?
FLUVOXAMINE 50mg once a day at bed time
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