4.4 Psychiatry, Geriatrics & Behavioral Health

Psychiatry, Geriatrics & Behavioral Health

The SMLE blueprint embeds Psychiatry and Geriatrics within the Medicine domain. Psychiatry items test recognition of major mental disorders, acute behavioral emergencies, and the side-effect profiles of psychotropic medications. Geriatrics items test the candidate's ability to differentiate reversible cognitive failure (delirium) from progressive neurocognitive decline, to manage polypharmacy, and to prevent falls in older adults. Both appear as clinical vignettes set in Saudi inpatient and primary-care settings.

Adult Psychiatry

Major Depressive Disorder (MDD)

• Diagnostic criteria: ≥5 SIGECAPS symptoms for ≥2 weeks, including depressed mood or anhedonia (Sleep disturbance, loss of Interest, Guilt/worthlessness, Energy loss, Concentration impairment, Appetite change, Psychomotor changes, Suicidal ideation).
• Screening: PHQ-9 in adults. First-line treatment is a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine or sertraline; onset of benefit takes 4–6 weeks.
• SMLE trap: Differentiate MDD from bipolar depression — prescribing an SSRI alone to a bipolar patient can precipitate a manic switch.

Bipolar Disorder

• Manic episode: ≥1 week of elevated/irritable mood + ≥3 of DIGFAST (Distractibility, Impulsivity/Indiscretion, Grandiosity, Flight of ideas, Activity increase, Sleep need decreased, Talkativeness).
• Treatment: First-line for acute mania is a mood stabilizer — lithium or valproate — with or without an atypical antipsychotic. Lithium requires monitoring of serum levels (0.6–1.2 mEq/L), renal function, and thyroid function, and is teratogenic — avoid in pregnancy.

Schizophrenia

• Diagnostic criteria: ≥2 active-phase symptoms (delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behavior, negative symptoms) for ≥1 month, with continuous disturbance ≥6 months.
• Treatment: First-line is an atypical antipsychotic (e.g., risperidone, olanzapine). For acute agitation, intramuscular haloperidol ± lorazepam is used.

Substance Abuse

• High-yield in Saudi Arabia: amphetamine/captagon and khat use, alongside alcohol and opioid use disorders.
• Opioid withdrawal: lacrimation, rhinorrhea, myalgia, diarrhea, piloerection ("cold turkey"). Maintenance is methadone or buprenorphine; naloxone reverses overdose.
• Alcohol withdrawal: tremor, autonomic hyperactivity, seizures; severe form is delirium tremens (DTs). Long-acting benzodiazepines (chlordiazepoxide, diazepam) are first-line; give thiamine (vitamin B1) before glucose to prevent Wernicke encephalopathy.

Side Effects of Psychiatric Medications

NMS vs Serotonin Syndrome: NMS presents with lead-pipe rigidity, high fever, and elevated creatine kinase after antipsychotic use; treatment is dantrolene + bromocriptine. Serotonin syndrome presents with clonus, hyperreflexia, and autonomic instability after serotonergic drugs; treatment is cyproheptadine + supportive care.

Anxiety & Stress-Related Disorders

• Generalized anxiety disorder: excessive, difficult-to-control worry for ≥6 months with somatic symptoms (restlessness, fatigue, muscle tension, impaired concentration); first-line is an SSRI or SNRI plus cognitive behavioral therapy.
• Panic disorder: recurrent unexpected panic attacks with persistent anticipatory fear; SSRIs are first-line.
• Adjustment disorder: emotional or behavioral symptoms developing within 3 months of an identifiable stressor, not meeting criteria for another disorder, and resolving within 6 months of the stressor ending.

Suicide Risk Assessment

• The single strongest predictor of completed suicide is a prior attempt. Static risk factors include male sex, older age, family history, and access to lethal means. Assess current ideation, intent, plan, and protective factors (social support, responsibility, religious/moral objection).
• An acutely suicidal patient requires a safe environment, removal of lethal means, and urgent psychiatric evaluation. Avoid "no-suicide contracts" — they lack protective value and do not replace a structured risk assessment.

Alcohol Use Disorder Pharmacotherapy

• Three agents are used alongside counseling: naltrexone (an opioid antagonist that reduces craving — avoid in opioid-dependent patients or acute hepatitis), acamprosate (supports maintenance of abstinence), and disulfiram (an aversive agent causing flushing, nausea, and hypotension with alcohol intake — contraindicated in severe cardiac or psychiatric disease).

Geriatrics

Delirium vs Dementia

Delirium is an acute medical emergency; search for the precipitant (infection — UTI/pneumonia, drug toxicity, dehydration, hypoxia, metabolic disturbance). Postoperative delirium is high-yield. The Confusion Assessment Method (CAM) is the bedside screening tool.

Dementia

• Alzheimer disease (most common): progressive memory loss; first-line is a cholinesterase inhibitor (donepezil) for mild–moderate disease, memantine for moderate–severe.
• Vascular dementia follows stepwise decline with focal neurological signs.
• Lewy body dementia: visual hallucinations, parkinsonism, fluctuating cognition, and severe antipsychotic sensitivity.

Frailty, Polypharmacy & Falls

• Frailty: the frailty phenotype (unintentional weight loss, exhaustion, weakness, slow gait, low activity) predicts adverse outcomes.
• Polypharmacy: apply the STOPP/START criteria to detect inappropriate medications; anticholinergic burden worsens cognition and falls.
• Falls: annual fall-risk assessment; treat vitamin D deficiency, review sedative/antihypertensive medications, and prescribe physical therapy and home modifications. A single fall in a frail elder warrants assessment for syncope and orthostatic hypotension.

Comprehensive Geriatric Assessment

• A multidimensional evaluation of medical, psychological, functional, and social domains (including cognition, mood, gait/balance, activities of daily living, and home environment). It improves diagnostic accuracy, reduces hospitalization and institutionalization, and lowers mortality in frail older adults — higher value than an organ-by-organ assessment alone.

Advance Care Planning & Elder Mistreatment

• Advance directives and a designated proxy document the patient's preferences for future care; Saudi practice respects the family's central role in decision-making for an incapacitated elder.
• Screen for elder mistreatment (caregiver stress, unexplained bruising or pressure injuries, delayed care-seeking, inconsistent history). Physicians are expected to document findings and report suspected abuse to protective services.