Appearance/behavior · Speech · Mood (stated) & Affect (observed) · Thought process (linear, tangential, circumstantial, flight of ideas, loose associations) · Thought content (SI/HI, delusions, obsessions) · Perception (hallucinations) · Cognition (orientation, memory, attention — MMSE/MoCA) · Insight & Judgment. The MSE is the psychiatric "physical exam."
Collaborative, patient-centered method to resolve ambivalence. OARS: Open questions, Affirmations, Reflective listening, Summaries. Roll with resistance, support self-efficacy, develop discrepancy. Stages of change: precontemplation → contemplation → preparation → action → maintenance (± relapse).
Setting, Perception (ask before telling), Invitation (how much they want to know), Knowledge (warning shot, plain language), Emotions (empathic responses), Strategy/Summary. Pair with trauma-informed, culturally humble communication.
Name the emotion, set limits with empathy, avoid power struggles, screen for underlying psychiatric/substance/pain issues. The "difficult patient" is often a difficult situation — focus on the alliance.
Assume a trauma history may exist; principles: safety, trustworthiness, choice, collaboration, empowerment. Ask permission, explain procedures, minimize re-traumatization ("What happened to you?" not "What's wrong with you?").
≥5 symptoms ≥2 weeks, including depressed mood or anhedonia. Mnemonic SIG E CAPS: Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidality. Screen with PHQ-9. First-line: SSRI/SNRI + psychotherapy (CBT); allow 4–6 weeks for response. Assess suicide risk at every visit.
Persistent depressive disorder (dysthymia): depressed mood most days ≥2 years. Peripartum, seasonal patterns. Premenstrual dysphoric disorder. Disruptive mood dysregulation (children). Rule out medical causes (thyroid, anemia) and substances.
Bipolar I = ≥1 manic episode (≥1 week, or any duration if hospitalized). Mania = DIG FAST (Distractibility, Indiscretion/impulsivity, Grandiosity, Flight of ideas, ↑Activity, ↓Sleep need, Talkativeness). Bipolar II = hypomania + major depression (no full mania). Cyclothymia ≥2 years.
GAD: excessive worry most days ≥6 months + physical symptoms (GAD-7). Panic disorder: recurrent unexpected panic attacks + anticipatory worry/avoidance. Phobias & social anxiety. Tx: SSRI/SNRI + CBT first-line; benzodiazepines only short-term/PRN (dependence risk); buspirone for GAD.
OCD: obsessions (intrusive thoughts) + compulsions (rituals to reduce anxiety). Tx: SSRI (higher doses) + ERP (exposure & response prevention). Related: body dysmorphic disorder, hoarding, trichotillomania (hair-pulling), excoriation.
After exposure to trauma: intrusion (flashbacks/nightmares), avoidance, negative cognitions/mood, hyperarousal. Acute stress disorder = 3 days–1 month; PTSD = >1 month. Tx: trauma-focused CBT/EMDR; SSRIs/SNRIs; prazosin for nightmares. Avoid benzodiazepines.
Adjustment disorder: emotional/behavioral symptoms within 3 months of an identifiable stressor, resolving within 6 months of its end. Psychogenic non-epileptic seizures: seizure-like episodes without epileptiform EEG; often trauma-related; confirm with video-EEG; treat with psychotherapy, validate.
≥2 of: delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms — for ≥6 months (≥1 month active). Positive (hallucinations, delusions) respond best to antipsychotics; negative (flat affect, alogia, avolition, anhedonia) and cognitive symptoms are harder to treat. Onset: men late teens–20s, women 20s–30s. Tx: antipsychotics + psychosocial support.
| Disorder | Duration / feature |
|---|---|
| Brief psychotic disorder | <1 month, often after a stressor; full return to baseline |
| Schizophreniform | 1–6 months |
| Schizophrenia | ≥6 months |
| Schizoaffective | Mood episode + psychosis, plus ≥2 weeks of psychosis without mood symptoms |
| Delusional disorder | ≥1 month of non-bizarre delusions, otherwise functional |
| Cluster | Theme | Disorders |
|---|---|---|
| A | "Weird" — odd/eccentric | Paranoid, Schizoid (detached/solitary), Schizotypal (magical thinking) |
| B | "Wild" — dramatic/erratic | Antisocial (≥18, disregard for others, conduct disorder <15), Borderline (instability, splitting, self-harm), Histrionic (attention-seeking), Narcissistic (grandiosity) |
| C | "Worried" — anxious/fearful | Avoidant (fear of rejection), Dependent (clingy), Obsessive-compulsive personality (rigid, perfectionistic — ego-syntonic, no true obsessions) |
Affective instability, fear of abandonment, identity disturbance, impulsivity, recurrent self-harm/suicidality, splitting. Evidence-based therapy: dialectical behavior therapy (DBT). High-yield in clinical encounters.
OCPD = pervasive rigidity/perfectionism/control, ego-syntonic (patient sees it as correct), no true obsessions/compulsions. OCD = ego-dystonic obsessions + compulsions causing distress.
| Anorexia nervosa | Bulimia nervosa | Binge-eating | |
|---|---|---|---|
| Weight | Low (restriction) | Usually normal | Often overweight |
| Features | Fear of weight gain, distorted body image; restricting vs binge-purge | Binge + compensatory purge ≥1×/wk ×3 mo; Russell sign, parotid swelling, erosions | Binges without compensation |
| Labs/risks | Bradycardia, amenorrhea, osteoporosis; refeeding syndrome (↓phos) | Hypokalemia, metabolic alkalosis | Metabolic syndrome |
| Treatment | Nutrition/weight restoration, therapy; med stabilization first | SSRI (fluoxetine) + CBT; avoid bupropion (seizure) | CBT, SSRI, lisdexamfetamine |
Insomnia: difficulty initiating/maintaining sleep with daytime impairment. First-line: CBT-I (sleep hygiene); medications short-term. Circadian rhythm disorders (shift work, delayed phase) — light therapy, melatonin.
Narcolepsy: excessive daytime sleepiness ± cataplexy, sleep paralysis, hypnagogic hallucinations (low orexin/hypocretin); stimulants/modafinil. OSA (see pulmonary). Parasomnias: sleepwalking, night terrors (NREM); REM behavior disorder (acting out dreams → Parkinson/Lewy).
Addiction is a chronic relapsing disorder of the brain's mesolimbic dopamine reward pathway (VTA → nucleus accumbens). Repeated use drives tolerance, withdrawal, craving, and impaired control despite harm — not a moral failing. Treat with combined pharmacotherapy + behavioral therapy.
| Substance | Intoxication | Withdrawal | Treatment |
|---|---|---|---|
| Alcohol | Disinhibition, ataxia, nystagmus | Tremor/anxiety → seizures (6–48h) → delirium tremens (48–96h, can be fatal) | Benzodiazepines (CIWA-guided), thiamine before glucose; naltrexone/acamprosate/disulfiram |
| Opioids | Miosis, respiratory depression, sedation | Non-lethal: myalgia, diarrhea, mydriasis, yawning, piloerection (flu-like) | Overdose: naloxone; OUD: buprenorphine, methadone, naltrexone |
| Stimulants (cocaine/amphetamine) | Mydriasis, ↑HR/BP, agitation, psychosis; cocaine MI/stroke | "Crash" — depression, hypersomnia, hyperphagia | Supportive; benzodiazepines for agitation (avoid beta-blockers alone in cocaine) |
| Benzodiazepines | Sedation, ataxia | Like alcohol — seizures possible (taper) | Flumazenil (caution — seizures); taper |
Ask directly about ideation, plan, intent, access to means, and prior attempts. Risk factors (SAD PERSONS): Sex (male complete more), Age (older/adolescent), Depression, Previous attempt (strongest predictor), Ethanol/substances, Rational-thinking loss (psychosis), Social isolation, Organized plan, No support, Sickness. Protective: reasons for living, support, engagement in care. Reduce access to lethal means; hospitalize if high acute risk.
Ensure safety, verbal de-escalation first. Medications if needed: antipsychotic (haloperidol) ± benzodiazepine. Rule out medical causes (hypoxia, hypoglycemia, intoxication/withdrawal, infection, head injury). Consider involuntary hold if imminent danger to self/others or grave disability (criteria vary by state).
Delirium = acute, fluctuating, inattention, often with visual hallucinations and abnormal vitals — it is a medical emergency (find the cause). New "psychosis" in an older or medically ill patient is delirium until proven otherwise.
| Syndrome | Cause / features | Treatment |
|---|---|---|
| Serotonin syndrome | Serotonergic drugs; rapid onset, clonus/hyperreflexia, agitation, hyperthermia, diarrhea | Stop agent, supportive, cyproheptadine |
| Neuroleptic malignant syndrome | Antipsychotics; slow onset, "lead-pipe" rigidity, hyperthermia, ↑CK, autonomic instability | Stop agent, supportive, dantrolene/bromocriptine |
| Lithium toxicity | Tremor, ataxia, confusion, seizures; narrow therapeutic index | Stop, hydrate, hemodialysis if severe |
| TCA overdose | Anticholinergic + wide QRS, arrhythmia, seizures | Sodium bicarbonate |
This section covers a sensitive clinical topic. If you or someone you know is struggling, call or text 988 (U.S.).
| Delirium | Dementia (major NCD) | |
|---|---|---|
| Onset | Acute, fluctuating | Gradual, progressive |
| Attention | Impaired (hallmark) | Preserved early |
| Consciousness | Altered | Clear until late |
| Reversible? | Usually (treat the cause) | Generally not |
| Dementia type | Hallmarks |
|---|---|
| Alzheimer | Most common; insidious memory loss; amyloid plaques/tau tangles; cholinesterase inhibitors, memantine |
| Vascular | Stepwise decline, focal deficits, vascular risk factors |
| Lewy body | Visual hallucinations, parkinsonism, fluctuating cognition, REM sleep behavior disorder; antipsychotic sensitivity |
| Frontotemporal | Younger onset; early personality/behavior change or aphasia, memory relatively spared |
Pseudodementia: depression mimicking dementia — cognitive complaints, "I don't know" answers, improves with depression treatment. Screen and treat; watch for late-life suicide risk (older men).
Focus on quality of life, symptom control, and goals of care at any disease stage (not just hospice). Address pain, dyspnea, anxiety, depression, and existential distress; involve family; use SPIKES for goals-of-care conversations.
Track motor, language, social, and cognitive milestones; "red flags" = loss of skills (regression), no babbling/pointing by 12 mo, no words by 16 mo, no joint attention. Screen for autism spectrum (social communication deficits + restricted/repetitive behaviors) and ADHD (inattention/hyperactivity across settings before age 12).
Erikson's psychosocial stages (trust vs mistrust → integrity vs despair), Piaget's cognitive stages. Adolescence: identity, risk-taking (prefrontal cortex still maturing). Aging: cognitive/sensory changes, grief, role transitions.
Take a non-judgmental sexual history. Distinguish sex (biology), gender identity, gender expression, and sexual orientation. Sexual dysfunction (desire, arousal, orgasm, pain) — evaluate medical, medication (SSRIs), and psychological contributors. Gender-affirming, patient-centered, confidential care.
| Class | Examples | Pearls |
|---|---|---|
| SSRIs | Fluoxetine, sertraline, escitalopram | First-line; GI/sexual dysfunction, early ↑anxiety, hyponatremia (SIADH); discontinuation syndrome (esp. paroxetine — short half-life); fluoxetine longest half-life |
| SNRIs | Venlafaxine, duloxetine | Also for neuropathic pain; ↑BP (venlafaxine) |
| Atypical | Bupropion, mirtazapine, trazodone | Bupropion: no sexual SE/weight gain, lowers seizure threshold (avoid in eating disorders); mirtazapine: appetite/sleep; trazodone: sedation/priapism |
| TCAs | Amitriptyline, nortriptyline | Lethal in overdose (wide QRS → bicarbonate); anticholinergic |
| MAOIs | Phenelzine, tranylcypromine | Tyramine (hypertensive crisis) & serotonin syndrome risk; washout periods |
| Drug class | Key points |
|---|---|
| Typical (1st-gen) haloperidol | D2 blockade → EPS (dystonia, akathisia, parkinsonism, tardive dyskinesia), hyperprolactinemia, NMS |
| Atypical (2nd-gen) risperidone, olanzapine, quetiapine, aripiprazole | Fewer EPS; metabolic syndrome (weight, glucose, lipids — monitor). Clozapine: treatment-resistant + ↓suicide, but agranulocytosis (monitor ANC), seizures, myocarditis |
| Lithium | Bipolar maintenance, ↓suicide; narrow index; monitor levels, renal, thyroid; toxicity → tremor/ataxia/confusion (dialysis). Avoid NSAIDs/thiazides/dehydration. Ebstein anomaly in pregnancy |
| Valproate | Mania/mixed; hepatotoxic, teratogenic (neural tube defects), weight gain, thrombocytopenia |
| Lamotrigine | Bipolar depression; Stevens-Johnson rash — titrate slowly |
Benzodiazepines: fast relief but dependence/sedation/withdrawal — short-term only; avoid in elderly, SUD, with opioids. Buspirone: non-addictive GAD option (delayed onset). Hydroxyzine PRN.
ECT: rapid, effective for severe/refractory depression, catatonia, pregnancy, acute suicidality; main side effect = transient memory loss. Newer: ketamine/esketamine, rTMS.