MDD (SIGECAPS)
>= 5 of 9 symptoms for >= 2 weeks; must include depressed mood or anhedonia; Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidal ideation.
Bipolar I vs. Bipolar II
Bipolar I: At least 1 manic episode (>= 7 days or hospitalization); Bipolar II: Hypomanic episode (>= 4 days, no psychosis/hospitalization) + at least 1 MDD episode.
Schizophrenia Timeline
Brief Psychotic Disorder (< 1 mo) -> Schizophreniform Disorder (1-6 mos) -> Schizophrenia (> 6 mos with social/occupational decline).
Serotonin Syndrome vs NMS
Serotonin Syndrome (hyperreflexia, clonus, tremor, GI symptoms) vs. Neuroleptic Malignant Syndrome (lead-pipe rigidity, extreme hyperthermia, high CK).
Depressive & Bipolar Disorders Diagnostic Rubric
| Disorder | Core Diagnostic Criteria | First-Line Pharmacotherapy |
|---|---|---|
| Major Depressive Disorder | ≥ 5 of 9 SIGECAPS symptoms for ≥ 2 weeks with functional impairment | SSRI (Sertraline, Escitalopram) or SNRI (Venlafaxine, Duloxetine) + CBT |
| Bipolar I Disorder | ≥ 1 manic episode (≥ 7 days of DIGFAST criteria: Distractibility, Impulsivity, Grandiosity, Flight of ideas, Activity increase, Sleep decrease, Talkativeness) | Mood Stabilizer: Lithium, Valproate, or Second-Generation Antipsychotic (Quetiapine, Aripiprazole) |
| Bipolar II Disorder | ≥ 1 hypomanic episode (≥ 4 days, noticeable change but no hospitalization or psychosis) + ≥ 1 major depressive episode | Quetiapine, Lurasidone, Lamotrigine, or Lithium |
| Persistent Depressive Disorder (Dysthymia) | Depressed mood most days for ≥ 2 years (≥ 1 yr in children) with ≥ 2 depressive symptoms | SSRIs + Psychotherapy |
Life-Threatening Psychiatric Emergencies: Serotonin Syndrome vs. NMS
| Feature | Serotonin Syndrome | Neuroleptic Malignant Syndrome (NMS) |
|---|---|---|
| Precipitating Agents | SSRIs, SNRIs, TCAs, MAOIs, Tramadol, Linezolid, MDMA (Ecstasy), St. John's Wort | D2-receptor antagonists (Haloperidol, Fluphenazine, Risperidone) or Dopamine agonist withdrawal |
| Onset Speed | Rapid (within 24 hours of initiation or dose increase) | Subacute (develops over 1-3 days to weeks) |
| Neuromuscular Tone | Hyperreflexia, spontaneous / inducible clonus, tremor, shivering | 'Lead-pipe' muscle rigidity, hyporeflexia, bradykinesia |
| Gastrointestinal | Hyperactive bowel sounds, diarrhea, nausea | Normal or hypoactive bowel sounds |
| Specific Antidote | Cyproheptadine (5-HT2A antagonist) | Dantrolene (ryanodine antagonist) or Bromocriptine (dopamine agonist) |
OMM Board Correlate: Psychosomatic Autonomic Resetting
- Autonomic Dysregulation: Severe anxiety and depression correlate with chronic sympathetic hyperactivity and decreased vagal tone. Treating thoracic paraspinal hypertonicity (T1-T5) via rib raising dampens sympathetic outflow.
- Suboccipital & Vagal Stimulation: Suboccipital release relieves tension on the occipitoatlantal junction, enhancing parasympathetic tone via CN X exiting the jugular foramen.
- CV4 (Compression of 4th Ventricle): Induces a still point, reduces sympathetic overdrive, and produces systemic somatic relaxation.
Board Traps & Common Distractors
- Never initiate antidepressant monotherapy (SSRIs/SNRIs) in a patient with undiagnosed Bipolar Disorder; unopposed antidepressants frequently trigger acute mania, psychosis, or rapid cycling.
- Clozapine carries black-box warnings for agranulocytosis (requires absolute neutrophil count monitoring), myocarditis, and severe constipation leading to bowel necrosis.
- Lithium has a narrow therapeutic window (0.6 - 1.2 mEq/L); concurrent administration with NSAIDs, ACE inhibitors, or thiazide diuretics diminishes renal clearance and induces acute lithium toxicity.