2 - Psychiatry

Question 0

What are the PD clusters and their different diagnosis?

Answer 0

1) Cluster A = Eccentric/Odd (Weird): Paranoid, Schizoid, Schizotypal
2) Cluster B = Dramatic (Wild): Antisocial, Borderline, Histrionic, Narcissistic
3) Cluster C = Anxious (Worried): Avoidant, Dependent, Obsessive-Compulsive

Question 1

What are the defining characteristics of a Personality Disorder?

Answer 1

1) difficulties in multiple areas of functioning
2) pattern that is stable, enduring and has onset traceable to adolescence or early adulthood
3) creates clinically significant stress in important areas of functioning
4) not better explained by another mental disorder, general medical condition or substance abuse

Question 2

Define Paranoid PD.

Answer 2

• Pervasive distrust and suspicion of other sucha that their motives are interpreted as malevolent
• Beginning by early adulthood
• 4 or more
  1) suspicious of others w/o sufficient basis
  2) preoccupied with the doubts about the loyalty of friends/family
  3) relunctance to confide
  4) hidden meanings in benign events
  5) bears grudges
  6) perceives attacks on his character that are not there
  7) recurrent suspicion concerning the fidelity of the spouse

Question 3

Define Schizoid PD.

Answer 3

Weird Loner

• pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings
• 4 or more
  1) neither desires or enjoys close relationships
  2) almost always chooses solitary activity
  3) little/no interest in sexual experiences
  4) takes pleasure in few, if any activities
  5) no friends/confidants other than 1st order family
  6) indifferent to praise or criticism
  7) emotional coldness, detachment or flattened affect

Question 4

Define Schizotypal PD.

Answer 4

Weird Gamer

• pervasive pattern of social/interpersonal deficits; marked discomfort w/ close relationships; perceptual/cognitive distortions; eccentricities of bx; beginning by early adulthood
• five or more
  1) ideas of reference
  2) odd beliefs/magical thinking
  3) unusual perceptual experiences
  4) odd thinking or speech
  5) paranoid ideation
  6) constricted affect
  7) odd, eccentric or peculiar
  8) lack of close friends/confidants
  9) excessive social anxiety that does not diminish w/ familiarity and is based on paranoid fears vs negative impression of self

Question 5

Define Anti-Social PD.

Answer 5

Serial Killer

• pervasive disregard for and violation of rights of others
• occurring since age 15 but individual is older than 18
• evidence of Conduct Disorder <15yrs
• 3 or more
  1) failure to conform to social norms
  2) deceitfullness/chronic lying
  3) impulsivity
  4) irritability/aggressiveness
  5) disregard for safety of others/self
  6) irresponsible
  7) lack of remorse

Question 6

Define Borderline PD.

Answer 6

• instability of interpersonal relationships, self-image and affects; marked by impulsivity
• 5 or more
  1) frantic efforts to avoid real or imagined abandonment
  2) unstable/intense personal relationships; idealization/devaluation
  3) identity disturbance; unstable self-image
  4) impulsivity in two areas that are self-damaging (spending, sex, drugs, etc)
  5) suicidal bx, gestures, threats; self-mutilation
  6) reactive mood
  7) chronic feelings of emptiness
  8) inappropriate/intense anger
  9) transient, stress-related paranoid ideation/dissociative symptoms

Question 7

Define Histrionic PD.

Answer 7

• excessive emotionality and attention seeking
• 5 or more
  1) uncomfortable when not center of attention
  2) inappropriate sexually seductive
  3) rapidly shifting and shallow emotions
  4) uses physical appearance to draw attention
  5) speech impressionistic and lacking in detail
  6) dramatic/exaggerated expression of emotion
  7) suggestibility
  8) sees relationships as closer than they are

Question 8

Define Narcissistic PD.

Answer 8

• pattern or grandiosity, need for admiration and lack of empathy
• 5 or more
  1) grandiose sense of self
  2) preoccupied with fantasies of unlimited power/brilliance/beauty
  3) believes to be “special”
  4) requires excessive admiration
  5) sense of entitlement
  6) interpersonally explosive
  7) lacks empathy
  8) envious of others; believes others are envious of him
  9) arrogant, haughty

Question 9

Define Avoidant PD.

Answer 9

Nervous Recluse

• pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation; begins by early adulthood
• 4 or more
  1) avoids interpersonal contact due to fear of criticism
  2) unwilling to get involved unless certain of being liked
  3) restraint w/in intimate relationships due to fear of being shamed
  4) preoccupied with being criticized
  5) feelings of inadequacy
  6) view of self: socially inept, unappealing, inferior
  7) reluctant to take personal risks that might be embarrassing

Question 10

Define Dependent PD.

Answer 10

• excessive need to be taken care or that leads to submission, clinging and fears of separation; beginning in early adulthood
• 5 or more
  1) difficulty making everyday decisions without excessive amounts of advice/reassurance
  2) needs other to assume responsibility for major areas of life
  3) difficulty expressing disagreement; dear of loss of approval
  4) difficulty initiating projects on his own
  5) excessive lengths to obtain nuturance/support from others
  6) uncomfortable/helpless when alone
  7) urgently seeks another relationship when one ends
  8) preoccupied with fears of being abandoned

Question 11

Define Obsessive-Compulsive PD.

Answer 11

• preoccupation with orderliness, perfectionism, mental/interpersonal control
• 4 or more
  1) preoccupied with rules, lists, details to the detriment of the overall goal
  2) perfectionsism interferes with task completion
  3) excessively devoted to work to exclusion of leisure
  4) overconscientious, scrupulous, and inflexible on moral issues
  5) hoarder
  6) reluctant to delegate
  7) miserly approach to money for self and others
  8) rigidity and stubbornness

Question 12

What are risk factors for suicide?

Answer 12

** lower CSF levels of 5-HIAA in completed suicides
S - sex(male)
A - age
D - depression
P - previous attempt
E - EtOH/drugs
R - rational loss
S - social support lacking
O - organized plan
N - no spouse
S - sickness

Question 13

What is the definition of psychotherapy?

Answer 13

1) verbal
2) 2 person group
3) voluntary
4) one person is labeled as expert, the other as help seeker
5) expectation of help
6) purpose of finding areas of life that are particularly troublesome

Question 14

Define Countertransference.

Answer 14

1) Complimentary: therapist experiences and empathizes with the feelings of an important person in the patient’s life
2) Concordant: therapist experiences and empathizes with the patient’s emotional position

Question 15

What is psychological first aid?

Answer 15

• mechanism for fostering resilience and recovery from psychological insult (before they are mentally ready for therapy)
  1) Safety - be safe, feel safe
  2) Calming - rest, relax, sleep
  3) Efficacy - skills and confidence
  4) Connectedness - social support; emotional and instrumental
  5) Hope - optimism

Question 16

What is the purpose of the following instruments:

1) PHQ-9
2) GAD-2
3) PC-PTSD

Answer 16

• screening instruments meant to help objectively identify the likelihood of a given dx
  1) PHQ-9: Depression screener-> cut-off score of 10 has 88% sensitivity and specificity; 15-19 = immediate therapy; >20 = high risk
  2) GAD-2: two question general anxiety disorder screener
  3) PC-PTSD

Question 17

What are the typical symptoms of Psychosis?

Answer 17

Positive: Delusion, Hallucinations, Illusions, Disorganization
Negative: Apathy, Anhedonia, Alogia, Affective flattening

Question 18

Define Schizophrenia.

Answer 18

1) 2 or more of the following symptoms for >1month: delusions, hallucinations, disorganized speech,m grossly disorganized/catatonic bx, negative symptoms (apathy, affective flattening, alogia)
2) causes a disturbance in one or more major areas of functioning
3) continuous signs of dx for 6 months(including 1 month of symptoms)
4) schizoaffective disorder, substance abuse and GMC excluded

Question 19

What is the difference between schizophrenia, schizophreniform, and brief psychotic disorder?

Answer 19

1) Schizophrenia = >6months; Schizophreniform = 1-6 months; Brief Psychotic Disorder = 1day-1month
2) Schizophrenia and Schizophreniform share most of their diagnostic criteria, other than duration
3) Brief Psychotic Disorder requires ONE of more of the characteristic symptoms vice TWO as with the other dx

Question 20

What is the current theory of the etiology of Schizophrenia?

Answer 20

1) thought to be genetic (though new evidence is pointing to genetic susceptibility vice causation)
2) due to efficacy of D2 blockade drugs, thought to be to due to Dopamine over-activity
3) Mesolimbic: increased Dopamine is associated w/ positive symptoms
4) Prefrontal Cortex: decreased Dopamine associated with negative symptoms
5) Nigrostriatal: blocking Dopamine influence on Striatum causes Parkisonian symptoms
6) Tubuloinfudibular: dysregulation of Dopamine leads to increased release of prolactin from pituitary gland (from hypothalamus)

Question 21

Define Delusional Disorder.

Answer 21

1) non-bizarre delusions that last >1month (being followed vs alien invasion)
2) criteria for Schizophrenia has never been met
3) other than delusion, function is not significantly impaired and interactions are otherwise normal
4) if mood episodes occur, they are short compared to the duration of the delusion

Question 22

What is Shared Psychotic Disorder (folie a deux)?

Answer 22

• delusion that develops in the context of a relationship with another person that has a long standing delusion
• ie: the spouse is convinced of her husband’s delusion

Question 23

Define Schizoaffective.

Answer 23

1) during a defined period, there has been a Major Depressive Episode, Manic Episode or a Mixed episode CONCURRENT with meeting symptom criteria of Schizophrenia
2) during the same period, hallucinations or delusions must be present for 2 weeks in the abscense of prominent mood symptoms
3) mood symptoms are present for substantial portion of disease

Question 24

What are the effects of stress on the Hippocampus, Amygdala, and Prefrontal Cortex?

Answer 24

• Hippocampus: associated with memory formation
  1) sensitive to glucocorticoids, therefore is overstimulated in chronic stress
  2) overstimualtion leads to atrophy -> reduced HF volume
  3) HF also involved in regulation of the HPA axis; HF atrophy leads to underregulation of the HPA axis which in turn leads to the release of more glucocorticoids and activation of hippocampus, amygdala and PFC
  4) chronic stress can impair the hippocampus’ memory-dependent tasks OR can cause enhanced memories/associations (re-experiencing)
• Amygdala: part of limbic system and responsible for defining a stimulus and the appropriate emotional response
  1) amygdala is sensitive to glucocorticoids and becomes over activated in chronic stress
  2) this leads to structural and functional swelling of amygdala
  3) possibly related to a underactivation of the PFC due to the inhibitory connections between the two
  4) overactivation leads to increased release of monoamines throughout the brain
• PFC: executive funcitoning including waking, attention getting, and problem solving
  1) PFC is sensitive to adrenal steroids (cortisol)
  2) overactivation (lack of inhibition) of the PFC causes it to stop working (exhaustion)
  3) this leads to atrophy of the PFC and presents as lack of inhibition, concentration and excessive fatigue

Question 25

Describe some types of stress management therapy.

Answer 25

1) Meds: NOT first line; should only be given for secondary effects -> SSRI if stress has led to depression; BZ for anxiety related to stress
2) Diaphragm Breathing: reduce hyperventilation and relieve the symtoms associated w/ respiratory acidosis
3) Progressive Muscle Relaxation: reduced excitability of sympathetic system via easing of stimulation to reticular system from chronic stress/tension
4) Biofeedback: patient learns to “control” body response via visual/auditory cues
5) imagery
6) Cognitive Techniques: intended to give the patient a sense of control/predictability by reframing the cognitive framing
7) Self-Hypnosis

Question 26

Define ADHD.

Answer 26

1) 6 or more Inattentive symptoms and 6 or more Hyperactive symptoms/Impulsive symptoms
2) some of the hyperactive or inattentive symptoms have caused impairment since before child was 7
3) impairment is seen in two or more settings (home, school, work, etc)
4) clear evidence of impairment in academic, social or occupational functioning

Question 27

What is the theory of the etiology of ADHD?

Answer 27

Catacholamine Hypothesis

• dysregulation of catacholamines within the cortex are thought to cause disorder
• while Dopamine certainly has a critical role in the disease, NE, ACh and 5-HT also participate

Question 28

What are the domains assessed in a neurophychological assessment?

Answer 28

1) Cognitive: forgetfullness, distractability, word-finding
2) Somatic: headaches, sleep problems
3) Perceptual: photophobia, phonophobia, tinnitus
4) Affective: mood, irritability, PTSD

Question 29

What are the 5 categories of psychological assessment? What is an example? When would you use each?

Answer 29

1) Clinical Interview: Unstructured vs Structured; broad vs structured questions used gain a wide range of information
2) Self-Report Questionnaires: PHQ-9 screener; quick, cheap way to ask a standard set of questions w/ relatively high sensitivity;
- MMPI; Inventories are comprehensive questionnaires to assess a person’s traits and states
3) Projective Tests: Thematic Appreciation/Rorschach Inkblot Tests; therapist interprets both the assumptions made by the patient during the test and the process by which they handled the situation; very subjective
4) Developmental Tests: BSID; measure motor, social, perceptual, sensory and cognitive skills in infants and young children
5) Intelligence/Achievement Tests: WAIS (IQ) measures intelligence/aptitude; SATs/USMLE measure knowledge