ABPN Psychiatry cheat sheet

Dopamine pathways: mesolimbic (ventral tegmental area to nucleus accumbens) mediates reward and positive psychotic symptoms; mesocortical hypofunction contributes to negative and cognitive symptoms; nigrostriatal blockade causes extrapyramidal symptoms; tuberoinfundibular blockade causes hyperprolactinemia.

Serotonin receptor pharmacology: 5-HT2A antagonism reduces extrapyramidal symptoms and may improve negative symptoms; 5-HT1A partial agonism is shared by buspirone, aripiprazole, and some antidepressants.

HPA axis: hypothalamic CRH stimulates pituitary ACTH, which drives adrenal cortisol; cortisol provides negative feedback; about 50% of patients with melancholic depression show dexamethasone nonsuppression; chronic stress is associated with reduced hippocampal volume.

Sleep architecture: depression shows shortened REM latency, increased REM density, and reduced slow-wave sleep; benzodiazepines increase stage N2 and reduce REM; alcohol suppresses REM with subsequent rebound.

Heritability estimates: schizophrenia about 80%, bipolar disorder about 80-90%, major depression about 30-40%; 22q11 deletion syndrome confers roughly a 25% risk of schizophrenia.

Neuroimaging: first-episode schizophrenia shows lateral ventricular enlargement and reduced hippocampal volume; chronic depression is associated with hippocampal volume loss; OCD shows increased caudate and orbitofrontal activity.

Catecholamine metabolism: MAO-A deaminates serotonin and norepinephrine; MAO-B deaminates dopamine; COMT metabolizes dopamine and norepinephrine; CYP2D6 poor metabolizers have higher risk of toxicity from many antipsychotics and antidepressants.

Glutamate: NMDA receptor hypofunction is a model of schizophrenia; ketamine can produce positive, negative, and cognitive symptoms; memantine is an NMDA antagonist used in Alzheimer disease.

Piaget: sensorimotor (0-2 years, object permanence), preoperational (2-7 years, egocentrism, symbolic play), concrete operational (7-11 years, conservation), formal operational (11+ years, abstract reasoning).

Erikson: trust vs mistrust (0-1 year), autonomy vs shame (1-3 years), initiative vs guilt (3-6 years), industry vs inferiority (6-12 years), identity vs role confusion (adolescence), intimacy vs isolation (young adulthood), generativity vs stagnation (middle adulthood), integrity vs despair (late life).

Attachment: the Ainsworth strange situation yields secure, insecure-avoidant, insecure-resistant, and disorganized types; disorganized attachment is associated with maltreatment and later psychopathology.

Mahler separation-individuation: normal autism (0-1 month), symbiosis (1-5 months), differentiation (5-10 months), practicing (10-16 months), rapprochement (16-24 months), object constancy (24-36 months).

Defense levels: mature defenses include sublimation, humor, altruism, and suppression; neurotic defenses include repression and intellectualization; immature defenses include splitting, projective identification, acting out, and denial.

Epidemiology: major depression is about twice as common in women; schizophrenia is similar across sexes; autism is diagnosed about four times more often in males; suicide rates are highest in older men.

Psychopathology terms: delusion is a fixed false belief; hallucination is a sensory perception without an external stimulus; flight of ideas is rapid pressured speech with loose associations; thought broadcasting is a delusion that thoughts are accessible to others.

Developmental milestones: object permanence emerges around 8-12 months; theory of mind false-belief understanding emerges around 4 years; separation anxiety is normal in infancy and early childhood.

Major depressive episode: at least five symptoms for at least two weeks, with depressed mood or anhedonia required; symptoms include sleep, appetite, energy, psychomotor, concentration, worthlessness or guilt, and suicidal ideation.

Manic episode: elevated or irritable mood plus increased energy for at least one week or requiring hospitalization; at least three additional symptoms (four if mood is only irritable), such as grandiosity, decreased sleep, pressured speech, flight of ideas, distractibility, increased activity, and risky behavior.

Schizophrenia: at least two of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms for at least one month; at least one must be delusions, hallucinations, or disorganized speech; continuous disturbance for at least six months with functional decline.

Panic attack: an abrupt surge reaching peak within minutes with at least four of 13 symptoms, including palpitations, sweating, trembling, dyspnea, choking, chest pain, nausea, dizziness, derealization, fear of dying, paresthesias, chills, and heat.

PTSD: exposure to trauma plus intrusion, avoidance, negative alterations in cognition and mood, and arousal or reactivity for more than one month; specifiers include dissociative symptoms and delayed expression beyond six months.

OCD: obsessions and/or compulsions that are time-consuming (more than one hour per day) or cause distress or impairment and are not attributable to a substance or another medical condition.

Delirium: acute onset and fluctuating course with inattention and disorganized thinking or altered consciousness; dementia is chronic progressive cognitive decline with preserved attention until late stages.

Serotonin syndrome vs neuroleptic malignant syndrome: serotonin syndrome shows clonus, hyperreflexia, agitation, and diarrhea after serotonergic agents; NMS shows rigidity, bradyreflexia, hyperthermia, autonomic instability, and elevated creatine kinase after dopamine antagonists.

SSRIs: first-line for depression, anxiety, OCD, and PTSD; black-box warning for increased suicidality in children and young adults; discontinuation syndrome occurs with abrupt cessation; serotonin syndrome risk increases with MAOIs, tramadol, and linezolid.

Antipsychotics: typical high-potency agents cause more extrapyramidal symptoms and hyperprolactinemia; atypical agents cause more metabolic syndrome; clozapine is superior for treatment-resistant schizophrenia but requires absolute neutrophil count monitoring.

Clozapine: absolute neutrophil count monitoring is weekly for six months, every two weeks for six months, then monthly; risks include agranulocytosis, myocarditis, seizures, sialorrhea, constipation, and metabolic syndrome.

Lithium: therapeutic range 0.6-1.2 mEq/L; toxicity risk rises above 1.5 mEq/L; renal and thyroid effects occur; Ebstein anomaly risk exists in pregnancy; NSAIDs, thiazides, and ACE inhibitors increase lithium levels.

Valproate: hepatotoxicity, pancreatitis, hyperammonemia, thrombocytopenia, and neural tube defects; avoid in pregnancy; carbamazepine causes agranulocytosis, hyponatremia, CYP induction, and HLA-B*1502-associated rash risk.

Lamotrigine: slow titration reduces Stevens-Johnson syndrome risk; risk increases with rapid dose escalation and concurrent valproate; used as maintenance treatment for bipolar depression.

ECT: effective for severe depression, catatonia, psychosis, and suicidality; an adequate generalized seizure lasts about 20-60 seconds; adverse effects include anterograde and retrograde amnesia; seizure threshold rises with age.

Psychotherapy: CBT targets maladaptive cognitions and behaviors; DBT combines skills training, mindfulness, and validation for borderline personality disorder; exposure therapy is first-line for OCD and PTSD.

Suicide risk: a prior attempt is the strongest predictor; older white men have the highest completed suicide rate; firearm access increases lethality; asking about suicide does not increase risk.

Tarasoff duty: when a patient makes a serious threat to an identifiable third party, the clinician may have a duty to protect, including warning the victim, notifying police, or hospitalizing the patient.

Informed consent: requires capacity, disclosure, understanding, voluntariness, and authorization; capacity includes communicating a choice, understanding, appreciation, and reasoning; competence is a legal determination.

Confidentiality exceptions: imminent danger to self or others, suspected child or elder abuse, court order, and certain communicable disease reporting requirements.

Ethical principles: beneficence, nonmaleficence, autonomy, and justice; conflicts may arise in involuntary treatment, research, and resource allocation.

Restraint and seclusion: last resort for imminent danger; requires a physician order, monitoring, face-to-face evaluation, and documentation; the least restrictive alternative must be attempted first.

Quality improvement: PDSA cycles, root cause analysis for sentinel events, medication reconciliation, and standardized handoffs reduce adverse events.

Professional boundaries: sexual contact is prohibited; nonsexual boundary crossings should be evaluated for benefit, harm, and context; impaired colleagues should be reported to physician health programs.