Psychiatry

A

• Acute Agitation - Deescalation and Sedation

  Use verbal deescalation and environment control first; select pharmacologic agents based on etiology and comorbidity; use the least restrictive measures and monitor closely.
• Acute Agitation in the ED — De-escalation and Medications

  Acute agitation is a behavioral emergency with many possible medical, toxicologic, neurologic, and psychiatric causes. Management begins with scene safety and verbal de-escalation, followed by targeted medication only when necessary to prevent harm or allow essential evaluation. The goal is calm, cooperative assessment rather than deep sedation, with continuous reassessment for hypoxia, hypoglycemia, hyperthermia, intoxication, withdrawal, delirium, and other life threats.
• Adult ADHD - Evaluation and Treatment

  Adult ADHD requires a persistent pattern of inattention and/or hyperactivity-impulsivity beginning in childhood, present across settings, and causing current impairment. Evaluation relies on developmental history and collateral information, with screening for mood, anxiety, sleep, substance, and medical mimics. Stimulants are often first-line; atomoxetine and selected alpha-2 agonist or other nonstimulant strategies are useful when stimulants are unsuitable.
• Alcohol Withdrawal - Severity Assessment and Benzodiazepine Protocol

  Assess severity, give symptom triggered or fixed dose benzodiazepines, and add adjuncts when indicated; admit severe cases and monitor for complications.
• Antidepressant Switching and Cross Taper Strategies

  Switching antidepressants requires balancing discontinuation symptoms, relapse risk, pharmacokinetic interactions, and serotonin toxicity. Direct switches are reasonable for some closely related agents, cross-tapers are appropriate for selected low-risk combinations, and washout periods are essential with monoamine oxidase inhibitors and other high-risk transitions. Fluoxetine requires special attention because of its long half-life.
• Antipsychotic Induced Metabolic Syndrome - Management

  Antipsychotic-associated metabolic syndrome requires planned surveillance for weight gain, central adiposity, dysglycemia, hypertension, and dyslipidemia. Prevention starts before treatment with baseline measurements and agent selection. Management includes nutrition and activity interventions, treatment of diabetes and cardiovascular risk, consideration of switching to a lower-metabolic-risk antipsychotic when psychiatrically safe, and selected use of metformin or newer weight-management therapies.
• Attention-Deficit/Hyperactivity Disorder (ADHD) — Diagnosis & Management

  Neurodevelopmental disorder characterized by developmentally inappropriate inattention, hyperactivity, and impulsivity; diagnose using DSM-5 criteria with symptoms present in ≥2 settings, impairing function, and beginning in childhood; management includes behavioral therapy, environmental supports, and stimulant or non-stimulant pharmacotherapy tailored to age, comorbidities, and functional goals.
• Autism in Adults — Diagnosis & Supports

  Adult autism assessment focuses on developmental history, current functioning, and differential diagnoses. Provide tailored supports for employment, education, and mental health; screen for co‑occurring conditions.

B

• Benzodiazepine Tapering — Outpatient Protocols

  Do not abruptly discontinue benzodiazepines in a patient who is likely physically dependent. Build a collaborative taper around the indication, dose, duration, comorbidity, concurrent opioids or alcohol, prior withdrawal, and patient goals; an initial reduction of about 5–10% every 2–4 weeks is often appropriate, generally avoiding reductions faster than 25% every 2 weeks, with slower steps or pauses when withdrawal symptoms emerge.
• Benzodiazepine Withdrawal - Inpatient and Outpatient Management

  Benzodiazepine withdrawal can cause anxiety, insomnia, tremor, autonomic hyperactivity, perceptual disturbance, seizures, and delirium. Do not abruptly stop benzodiazepines in a physically dependent patient. Assess withdrawal severity and seizure risk, stabilize severe cases in a monitored setting, and use an individualized gradual taper, sometimes after conversion to a longer-acting benzodiazepine.
• Bipolar Mania - Acute Management

  Acute mania is characterized by pathologically elevated or irritable mood with increased energy, decreased need for sleep, pressured speech, racing thoughts, distractibility, increased activity, and risky behavior. Assess immediate safety and medical or substance causes, stop destabilizing agents, use an evidence-based antimanic medication, and hospitalize severe psychotic, dangerous, or functionally incapacitating episodes.
• Borderline Personality Disorder — Psychotherapy & Meds

  Borderline personality disorder is treated primarily with a structured, evidence-based psychotherapy and a collaborative treatment plan focused on suicidality, self-injury, emotion regulation, relationships, and functional goals. Medication is adjunctive rather than a treatment for the personality disorder itself; use it only for clearly defined target symptoms or co-occurring disorders, avoid unnecessary polypharmacy, and review ongoing benefit and burden regularly.

C

• Catatonia - Recognition, Lorazepam, and ECT

  Catatonia is a potentially life-threatening psychomotor syndrome characterized by features such as stupor, mutism, negativism, posturing, rigidity, echophenomena, or purposeless excitement. Identify and treat the underlying cause, perform a lorazepam challenge when appropriate, use benzodiazepines as first-line therapy, and escalate promptly to ECT for severe, malignant, or benzodiazepine-resistant disease.
• Catatonia — Diagnosis & Management

  Catatonia is a potentially life-threatening psychomotor syndrome marked by combinations of stupor, mutism, negativism, posturing, waxy flexibility, echophenomena, agitation, and other characteristic signs. Identify medical, neurologic, toxic, and psychiatric causes, treat dehydration and complications, perform a lorazepam challenge when appropriate, continue benzodiazepine treatment when responsive, and use ECT promptly for malignant, severe, or benzodiazepine-refractory catatonia.
• Clozapine - Initiation, Monitoring, and Side Effects

  Clozapine is the antipsychotic of choice for treatment-resistant schizophrenia and is also used when suicide risk remains substantial despite other treatment. It requires slow titration and ongoing ANC monitoring, plus active surveillance for myocarditis, cardiomyopathy, seizures, severe constipation/ileus, metabolic disease, sialorrhea, sedation, and orthostatic hypotension. The FDA removed the Clozapine REMS program, but clinical blood-count monitoring remains recommended.

D

• Delirium in Hospital - Evaluation and Management

  Delirium is an acute, fluctuating disorder of attention and cognition caused by an underlying medical, medication, substance, or environmental trigger. Diagnose clinically, search systematically for reversible causes, use multicomponent nonpharmacologic care as first-line management, and reserve short-term antipsychotic use for severe distress or dangerous behavior that persists despite de-escalation.

E

• Eating Disorder - Refeeding Risk and Inpatient Management

  Eating-disorder admission decisions are driven by medical instability, psychiatric risk, and inability to maintain nutrition rather than body weight alone. Refeeding requires structured caloric restoration with close monitoring and replacement of phosphate, potassium, and magnesium, thiamine in high-risk patients, and management of bradycardia, hypotension, dehydration, hypoglycemia, and arrhythmia.

G

• Generalized Anxiety Disorder - First Line Treatment

  Generalized anxiety disorder is persistent, difficult-to-control worry across multiple domains with associated somatic and cognitive symptoms that cause functional impairment. First-line care combines education, cognitive behavioral therapy, and an SSRI or SNRI when medication is indicated, while screening for depression, substance use, suicidality, bipolar disorder, and medical mimics.

H

• Hoarding Disorder — Assessment & Treatment

  Characterized by persistent difficulty discarding possessions leading to clutter and impairment. Treat with specialized CBT‑HD and harm‑reduction strategies; involve family/public agencies when safety risks present.

I

• Insomnia Disorder - Nonpharmacologic and Pharmacologic Care

  Chronic insomnia disorder is persistent difficulty initiating sleep, maintaining sleep, or waking too early despite adequate opportunity for sleep, with daytime impairment. Cognitive behavioral therapy for insomnia is first-line treatment. Medication can be used selectively after evaluating sleep apnea, restless legs, circadian disorders, substance use, mood disorders, and medication effects, but sedatives should not replace CBT-I.

L

• Lithium Toxicity - Acute Management

  Identify toxicity by symptoms and level, stop lithium, assess volume status and electrolytes, give fluids, and arrange hemodialysis for severe cases or renal failure.

M

• Major Depressive Disorder - Initial Pharmacotherapy

  Initial treatment of major depressive disorder begins with diagnostic confirmation, suicide-risk assessment, and exclusion of bipolar disorder, substance-induced symptoms, and relevant medical mimics. Select psychotherapy, pharmacotherapy, or both through shared decision-making, choose an antidepressant based on prior response and comorbidity, and reassess adherence, tolerability, and response after an adequate trial.

N

• Neuroleptic Malignant Syndrome - Recognition and Management

  Hyperthermia, rigidity, altered mental status, and autonomic dysfunction after dopamine blockade; stop antipsychotic, give supportive care, and consider dantrolene or bromocriptine.
• Neuroleptic Malignant Syndrome — Recognition and Treatment

  Neuroleptic malignant syndrome is a life-threatening reaction to dopamine antagonism or abrupt dopaminergic withdrawal, characterized by hyperthermia, severe generalized rigidity, altered mental status, and autonomic instability with elevated creatine kinase. Stop the offending drug, provide aggressive supportive care and cooling, treat complications, and consider benzodiazepines, dantrolene, bromocriptine, or amantadine in severe cases with specialist guidance.

O

• Obsessive Compulsive Disorder - Treatment Algorithm

  Obsessive-compulsive disorder causes intrusive unwanted obsessions and/or repetitive compulsions that are time-consuming or impairing. Exposure and response prevention is the core psychotherapy, and SSRIs are first-line medication therapy, often requiring higher doses and longer trials than depression; severe refractory illness warrants specialist augmentation strategies.
• Opioid Withdrawal - ED Buprenorphine Initiation

  Emergency-department buprenorphine initiation treats opioid withdrawal and begins evidence-based opioid use disorder care. Confirm OUD, assess objective withdrawal and recent opioid exposure, choose an induction strategy that minimizes precipitated withdrawal, titrate buprenorphine to control symptoms and craving, provide naloxone, and arrange rapid continuity of treatment.

P

• Panic Disorder - Acute and Long Term Care

  Panic disorder consists of recurrent unexpected panic attacks followed by persistent concern or maladaptive behavior related to future attacks. Acute care first excludes dangerous cardiopulmonary, neurologic, endocrine, and toxicologic mimics; long-term treatment relies on CBT and an SSRI or SNRI, with benzodiazepines reserved for limited situations because of dependence and avoidance-reinforcement risk.
• Postpartum Psychosis - Emergency Management

  Postpartum psychosis is a psychiatric emergency, usually beginning abruptly within days to several weeks after delivery with mania, depression, confusion, delusions, hallucinations, or severe behavioral change. Protect the mother and infant, evaluate medical mimics, hospitalize when safety is uncertain, and use antipsychotic, mood-stabilizing, and ECT treatment based on the clinical syndrome and lactation goals.
• Posttraumatic Stress Disorder - Trauma Focused Therapy and Medication

  Posttraumatic stress disorder follows exposure to actual or threatened death, serious injury, or sexual violence and requires persistent intrusion, avoidance, negative mood/cognition changes, and hyperarousal with functional impairment. Trauma-focused psychotherapy is preferred when feasible; sertraline, paroxetine, or venlafaxine are evidence-supported medication options, while benzodiazepines are discouraged.
• Premenstrual Dysphoric Disorder — Diagnosis & Treatment

  Diagnose prospectively with symptom diaries. First‑line SSRIs (continuous or luteal) and combined OCPs with drospirenone; lifestyle and CBT adjuncts; second‑line GnRH analogs with add‑back.
• Psychopharmacology in Pregnancy — Risk‑Benefit Counseling

  Psychopharmacology in pregnancy is a risk-benefit decision that weighs fetal and neonatal medication effects against the substantial risks of untreated or undertreated psychiatric illness. Avoid reflexive discontinuation of an effective medication solely because of pregnancy or lactation, identify high-risk agents before conception when possible, use the medication with the best evidence for the specific disorder, and monitor both psychiatric stability and obstetric considerations.

S

• Serotonin Syndrome - Recognition and Management

  Triad of mental status change, autonomic instability, and neuromuscular hyperactivity; stop serotonergic agents, give benzodiazepines, manage hyperthermia, and consider cyproheptadine.
• Somatic Symptom Disorder - Assessment and Communication

  Somatic symptom disorder is diagnosed when distressing physical symptoms are accompanied by excessive thoughts, anxiety, or health-related behaviors, not by proving that symptoms are medically unexplained. Good care validates symptoms, completes proportionate medical evaluation, creates one coherent longitudinal plan, treats comorbid psychiatric illness, and avoids repeated low-yield testing or adversarial reassurance.
• Somatic Symptom Disorder — Management Strategies

  Emphasize regular visits with one clinician, validate symptoms, and use CBT‑informed strategies; minimize unnecessary tests and avoid reinforcing disability.
• Stimulant Use Disorder - Contingency and Pharmacotherapy Options

  Stimulant use disorder involving methamphetamine, cocaine, or other stimulants is treated primarily with behavioral interventions, especially contingency management. There is no FDA-approved medication specifically for stimulant use disorder, but selected off-label pharmacotherapies may be considered with addiction expertise. Acute care focuses on hyperthermia, agitation, chest pain, arrhythmia, hypertension, psychosis, rhabdomyolysis, and coexposure to fentanyl.
• Suicidal Ideation - ED Triage and Safety Planning

  Suicidal ideation requires immediate safety assessment, treatment of medical and psychiatric instability, and a structured evaluation of intent, plan, access to lethal means, prior behavior, acute stressors, substance use, psychosis, and protective factors. Disposition should be based on the full clinical picture, not a screening score or a promise of safety.

T

• Tardive Dyskinesia - Recognition and Treatment

  Tardive dyskinesia is a persistent hyperkinetic movement disorder associated with dopamine receptor-blocking exposure, classically involving oro-buccal-lingual movements but also affecting trunk and limbs. Prevention requires minimizing unnecessary dopamine blockade and screening with a structured exam. Clinically significant TD is treated with a VMAT2 inhibitor, while antipsychotic changes must balance movement improvement against psychiatric stability.
• Tourette Syndrome — CBIT & Pharmacologic Therapy

  CBIT is first‑line for bothersome tics; medications for impairment or when CBIT unavailable. Treat comorbid ADHD/OCD. Consider DBS for severe refractory cases.
• Treatment‑Resistant Depression — Augmentation Strategies

  For MDD not responding to ≥2 adequate trials, confirm diagnosis and adherence, address comorbidities, and use augmentation/switch strategies (atypical antipsychotics, lithium, T3, bupropion/mirtazapine) with psychotherapy; consider ECT/ketamine/esketamine when indicated.