adjustment disorder Flashcards
Adjustment Disorder
not fully depressive
Mood change in reaction to a stressor (job loss, illness, etc.) with mild functional impairment
Symptoms are brief in duration, less than criteria for full disorders
do not require pharmacology except for symptomatic approach (hypnotics, temporary anxiolytics, etc.)
Brief psychotherapy beneficial
Manic Episode thoughts, content, speech behavior
x7days, euphoric, “giddy, Inflated self-esteem or grandiosity
Thought processes are racing but goal-directed although tangentiality is common
pressured speech, thought content excessively focused on topics like religion, business, sexuality, “specialness”, or persecution
main thing: Excessive goal-directed activity with high risk behaviors
Impulsive, easily angered, can lash out physically (poor insight)
Significant functional impairment, causes chaos in family and workplace
pressured speech
(feel must keep talking when convo is over)
Excessive goal-directed activity with high risk behaviors associated with
Manic episode: spending, sex, business or financial misadventures, chaotic relationship disturbances)
Manic Episode can be triggered by
may be triggered by medication, stress, drug use (esp. THC or amphetamines) or may develop spontaneously
Hypomanic Episode
Symptoms similar to Manic Episode but of less intensity and duration, Minimal functional impairment (ex: manic for a few days)
hard to diagnose.
Mixed mani depressive Specifier
During either a depressive or manic episode, at least three diagnostic criteria for the opposite mood episode are also present
Increases complexity of correct diagnosis and treatment
aka mixes of manic and depressive
Bipolar I Disorder,( type 1)
one manic episode puts them in this category (at least 1) , but can spend most time in depressed state
Diagnosis may be difficult or delayed
Treatment for depression (ssri) may result in “flip” to mania
Bipolar II Disorder (type2)
At least one Major Depressive episode and at least one episode of Hypomania
No history of full Manic episodes
“tell me about your manic episode” they will say a lot
Challenges of Bipolar diagnosis
over used vernacular outside of psych increase diagnosis outside psych office
what do rule out to diagnose bipolar? what to note?
Rule out substance induced origin (can cause strange)
Rule out origin due to medical conditions
Rule out other mental disorders (psychotic disorders, depression)
Note psychotic features specifier
Note anxious distress specifier
Mood Disorder Treatment
Step one: Diagnosis, including severity
Step two: Discuss treatment modes with patient
Step three: Choose specific treatments
Step four: Follow up (very important) and monitoring
Treating Depression
First-line treatments: SSRI (seritonin reuptake inhibitor) and SNRI with therapy
Second-line treatments: Atypical antidepressants, TCAs, mood stabilizer augmentation, TMS
Third-line treatments: MAOI’s, ECT
SSRI
Selective serotonin reuptake inhibitors
SSRI specific to panic, goal and timing
Selective serotonin reuptake inhibitors, goal is to avoid future panic attacks (has to be used consistently over time), thought that body builds up over time
TCA treatment for and general effect
Tricyclic antidepressants help keep more serotonin and norepinephrine available to your brain.
TCA used for, general effect, a few names
Tricyclic antidepressants help keep more serotonin and norepinephrine available to your brain. (hits most receptors, has many uses)
Antidepressants (TCAs) - older class of AD. Imipramine, Amitryptyline, Doxepin
TMS name , effect, treatment for what and how long duration
Transcranial Magnetic Stimulation - stimulates area
of left frontal cortex associated with mood
treatment for antidepresent( stimilates current/cells to be more active, less active cells in the brain with depressed)
6-8wks treatment, 9months recommended
MAOI’s reaction with, name and diet and issues
high chance with HTN reactions with tyrosine (low tyrosine diet-in well aged cheeses and aged wine)
MAOIs - monoamine oxidase inhibitors. React with high amount of tyramine to create potentially dangerous hypertension. Require carefully controlled diet
Antidepressant Pharmacology SNRIs names
venlafaxine, duloxetine, levomilnacipran
Antidepressant Pharmacology SGA
Second GEneration act as antipsychotics
Antidepressant Pharmacology Mood Stabilizers
lithium carbonate, divalproex, carbamazepine
SSRI generally used for these reasons?
guidlines want two of theese prescribed (they are safer) before moving to second line Considered first line treatment for depression
Ease of dosing, minimal toxicity in overdose
Generally well tolerated
Patient preferences, past responses, or family responses can be considered in selection
SNRI general info: first line for what? What does NE help with? Duloxetine also indicated for?
Treatment option that some clinicians consider first line with SSRIs
NE (norepi) receptor binding can help treat anxious distress or concentration issues associated with depression
Duloxetine also indicated for anxiety and neuropathic pain disorders, increasing utility in patients with comorbid issues
Atypical Antidepressants
bupropion, mirtizapine, nefazodone, trazodone
Course of Treatment for antidepresents: how long SSRI: until effective? If respond treat for? Continuation recommended for?
A treatment course of 6 to 8 weeks at therapeutic dose is considered adequate to assess response
After response is determined, may proceed with dose increase, augmentation, or change to new agent
Continuation of treatment for 9 months is recommended to achieve durable remission. If respond treat for 12 months (ROSH)
Treatment of Bipolar Disorder generally, what needs to be monitored?
SGAs and divalproex are considered first line treatments
Monitor metabolic parameters due to risk of increased lipids and metabolic syndrome
Antidepressants avoided if possible, but if needed must be combined with SGA or mood stabilizer
Ongoing treatment recommended to prevent future episodes
Lithium Carbonate used for ? issues?
Classic treatment for bipolar mania*
Can be used for antidepressant supplementation
Long term risk of renal impairment (so many salts), thyroid impairment(competes with thaimine), tremor, others
Requires blood monitoring for serum levels and has “tight” therapeutic window, want level to be = 1.
Toxicity can cause disorientation, psychosis, and may be fatal
How serious is LIthium tox?
must go to ICU, Toxicity can cause disorientation, psychosis, and may be fatal
Psychotherapy includes these three
Cognitive Behavioral Therapy (CBT) , or Psychoanalytic Therapy, dialectal therapy for pedophelia
Cognitive Behavioral Therapy (CBT)
focuses on interaction between core beliefs, thoughts, and feelings and guides patient to reformulate these connections to improve mood and reduce distress
Psychoanalytic Therapy
explores childhood experiences and long-standing paradigms of thought
dysthymia
chronic persistent depression
Anxiety disorder is a state of ? and has what symptoms?
Anxiety is state of increased worry, fear, and concern, especially over future events (real or imagined)
Associated with physical symptoms of agitation, (pain in their chest etc) increased heart and respiratory rate, tension
May include avoidance behaviors and fears of “losing it” or “going crazy”
panic attack can look just like a … so must test?
heart attack. EKG, Trop.
panic attack lasts ___, and also does what to thoughts___
10 minutes or so, speeds them up
Panic Disorder: attacks are brief and ….. and may happen during day or night and patient has concern of … and may cause the patient to….
Sudden and recurrent onset of Panic Attacks
nocturnal Panic : Up to 25% of patients experience Attacks that may awaken them from sleep
patient experiences fear of recurrence and experiences increased anxiety over the possibility of further attacks: For at least one month afterwards,
Patient engages in avoidance behaviors to prevent future attacks - isolates, changes jobs or relationships, etc.
Agoraphobia specifier - “fear of the marketplace” (
Agoraphobia specifier
“fear of the marketplace” (fear of being out in public), fear of small spaces
how to know if anxiety is a disorder
if it’s effecting behavior /unable to function and affect their personal life, normal will adjust,
Generalized Anxiety Disorder: anxiety lasts (all day or brief?) and has worry about (every situations or specific?) and include
panic disorder symptoms that persist “all day” or can ramp up to seem like panic attack or say “i’m losing my mind”
excessive, intrusive worries about everyday situations that causes significant distress and functional impairment
Accompanied by physical symptoms of anxiety such as muscle tension, restlessness, insomnia, GI disturbances, chronic headaches, fatigue, and difficulty concentrating
May have episodes of increased anxiety resembling Panic Attacks
interview techniques
dig into what they are saying (from broad to small) look on first lecture for more
Selective Mutism
Other Anxiety Disorders - refusal to speak due to increased anxiety, more common in children
Social Anxiety Disorder -
Other Anxiety Disorders, - debilitating anxiety in social situations and avoidance of socialization
Specific Phobia
Other Anxiety Disorders, avoidance of a specific situation or object that causes debilitating anxiety
Treatment of Anxiety
SSRIs (takes a few weeks,), patients with anxiety more likely to respond to real or immagined effects, start low dose and titrate up
SNRIs, Buspirone, Benzodiazepines
CBT, Mindfulness
Physical Activity, Structured Social Activities
Treatment of Anxiety
SSRIs (takes a few weeks,), patients with anxiety more likely to respond to real or immagined effects, start low dose and titrate up
SNRIs, Buspirone, Benzodiazepines
CBT, Mindfulness
Physical Activity, Structured Social Activities
Anxiety Pharmacology SSRI and SNRI
SSRIs and SNRIs both effective for anxiety, but SNRIs not shown to be effective for Panic Disorder
Anxiety Pharmacology Buspirone
5-7 days usual effect
non-addictive treatment for GAD and other anxiety disorders, but ineffective for Panic Disorder
Anxiety Pharmacology
Benzodiazepines
are effective short-term (5hr 1/2life) but carry long term risks of dependence (addiction), sedation, mental clouding, increased mortality
” tranks” abusable, can be issues when mixed with opiates, popular. Better if under use and as needed.
ssri snri vs benzo
benzo don’t have to take consistently and best used as emergency rescue for panic attack , ssri and snri are daily meds with ongoing compliance needed. but ssri can have issues after being off them for a month or so.
Psychotherapy for anxiety disorders
very effective: CBT helps patients manage anxious thoughts, increase functionality, reduce panic and anxiety attacks
Mindfulness practices proven to help reduce clinical anxiety
Structured activities help patient gradually resume normal psychosocial functioning
“Exposure therapy” for specific phobias is effective but intensive and time consuming (face your fears)
Psychotic Disorders
Characterized by significant disorders of thought process and content
Like mood, psychosis is considered a “spectrum” of thought disorder
Psychosis 5 symptoms
Five symptoms of psychosis:
Delusions - fixed, false beliefs
Hallucinations - sensory perceptions in the absence of external stimuli
Disorganized Speech - nonsensical or severely disorganized speech
Disorganized or Catatonic Behavior - extreme movement disturbance
Negative Symptoms
Psychotic symptoms are the defining symptoms of Schizophrenia and other psychotic disorders, but can be present in other disorders
Psychosis / Delusions
Fixed, false beliefs that persist in the face of negative evidence
May be persecutory, erotomanic, paranoid, or other types “Fragmentary” (change) delusions can be seen in psychotic disorders, but some patients present with sustained, complex (usually built up over years) and organized delusional systems (also can be a part of other systems)
Resistant to pharmacology and psychotherapy
persecutory Delusions
- becomes increasingly specific over time (and tend to “grow”)
erotomanic Delusions
believed loved by someone
ex: lady sells stuff to move in with someone who has no idea and doesn’t know she’s trying to move in with all her stuff.
content of illusions is often ___ based
culturally based
ex; Americans more so with technology
Delusions are ___ to Pharmacology and psychotherapy
Resistant
psychotic Delusional content for Persecution, Erotomanic, Technological, Medical
Persecution - becomes increasingly specific over time
Erotomanic - belief that one is loved by another
Technological - invasion or control by machines, electronics, unseen forces
Medical - belief in illness not diagnosable by current techniques
Hallucinations (psychotic)
Any sensory modality - auditory, visual, olfactory, tactile, gustatory
Auditory and Visual most common in Psychotic Disorders
Patient appears distracted, not following conversation
May respond directly to unseen stimuli
these come from correct area in brain
visual hallucinations are a lot more common in __ than in __
drug use, than in other kinds.
psychotic Hallucinatory Content
Voices - single or multiple, sometimes overlapping, occasionally music or “crowd noise”
Visions - usually normally sized people in psychotic disorders, more disorganized in medication or drug induced states
Tactile - “ants crawling on skin,” body sensations misinterpreted as technological or intrusive
psychotic Disorganized Speech
Cannot stay on topic
Suddenly stops or “blocks” in mid-sentence
Non-sequitur responses
Nonsensical responses
psychotic Disorganized Behavior
Bizarre posturing
Excessive or inappropriate clothing and grooming
Lack of responsiveness to environment
Inappropriate emotional responses
psychotic Negative Symptoms
what gave psychotic it’s initial name of early dimensia, (happy to do nothing)
Monotonic speech with minimal content
Flat, unresponsive facial expressions
Slow, labored thought processes
Lack of motivation and inability to start simple projects
Lack of spontaneity
Lack of interest in social and interpersonal interactions
Schizophrenia is the ___ disorder, characterized by and symptoms.
primary psychiatric disorder
Characterized by two or more of the five psychotic symptoms
At least one of the symptoms must be delusions, hallucinations, or disorganized speech
Significant impairment in social, occupational, or self-care activities since onset of psychosis
Psychotic symptoms present for at least one month and syndrome lasts at least six months
Not better explained by mood disorder or autistic spectrum disorder
Frequent onset in late teen to early adult years
Schizophrenia is the ___ disorder, characterized by ___and symptoms.
primary psychiatric disorder
Characterized by two or more of the five psychotic symptoms
At least one of the symptoms must be delusions, hallucinations, or disorganized speech
Significant impairment in social, occupational, or self-care activities since onset of psychosis
Psychotic symptoms present for at least one month and syndrome lasts at least six months
Not better explained by mood disorder or autistic spectrum disorder
Frequent onset in late teen to early adult years
Schizophrenia
Associated Features
Inappropriate affect
Dysphoric mood
Erratic sleep pattern
Poor insight
Anxiety and phobias, sometimes obsessive
Feelings of derealization and depersonalization
Difficulty with social “cues” and interactions
Psychosis may cause hostility and aggression
Schizophrenia
Associated Features
Inappropriate affect (flat)
Dysphoric mood
Erratic sleep pattern
Poor insight
Anxiety and phobias, sometimes obsessive
Feelings of derealization and depersonalization
Difficulty with social “cues” and interactions (weird)
Psychosis may cause hostility and aggression (especially of acting on halucination)
Delusional Disorder
Presence of persistent delusions, Other psychotic symptoms usually not present
“fixed delusions”, may be compartmentalized
Schizoaffective Disorder
intended to be combo mood and psychotic disorder
-key element, is mood and psychotic symptoms in absence of another (get better in one way but keep another disorder)
Characterized by presence of both psychotic and mood disorder symptoms
Mood symptoms and psychotic symptoms persist in the absence of the other
Mood symptoms at least 50% of the time
Psychotic symptoms in absence of mood symptoms
Brief Psychotic Disorder
resolves in one month, Presence of psychotic symptoms in previous non-psychotic patient
Resolves within one month with full return to baseline level of functioning
Not related to drug use or medical illness
Antipsychotic Treatment (schizophrenia?)
first drugs developed to treat psychosis
First Generation medications - Thorazine, Haldol, Prolixin, others (first tried from surgery)
Second Generation medications - Risperdal, Seroquel, Zyprexa, Geodon, Abilify, Latuda, others
Clozapine (gold standard for treatment resistant schitzo
___ is the gold standard for treatment resistant schizo, but has this side effect___ and this helps?
pancytopenia (can’t make blood cells) req weekly monitoring for 6months +
people who live at home with supportive parents
schizophrenia Supplementary Treatments
Antidepressants - common in schizophrenia (5% suicide rate)
Socialization - group therapy, group community living, day programs
Primary care - medical illnesses common
Case Management - assistance with access to resources, transportation, housing, daily living
schizophrenia are different than others in this way
lots of medical problems
schizophrenia Case Management
assistance with access to resources, transportation, housing, daily living
Personality Disorder, what are the patterns and how does it effect social, cultural, adaptive amount, and when develop?
Enduring patters (not short term) about environment and oneself. Trouble getting along in society, deviates significantly from cultural standards. Inflexible, flexible to change, maladaptive (make life harder aka trouble with jobs and school), functional. Develop by early childhood.
Personality disorder criteria?
enduring patterns, two or more of:
- cognition, affectivity (range, appropriateness, intensity of open expressiveness of emotion), interpersonal functioning, impulse control.
- Rule out other mental disorders and clinical causes
clinically->Personality disorder course and progression
personality changes, distress, not caused by other medical disorders
Personality disorders come in clusters , appearances
Cluster A - odd or eccentric
Cluster B - dramatic, emotional, erratic
Cluster C - anxious or fearful
cluster A: paranoid personality disorder and
different from parania of psychotic person (is in episodes and biological)
diagnosis requires 4 of these
paranoid in many areas
Pervasive mistrust and suspiciousness as represented by at least four of the following.
Suspects, without sufficient basis, others of exploiting, harming, or deceiving them
Preoccupied with unjustified doubts about the loyalty of others
Reluctant to confide in others for fear of betrayal
Reads demeaning or threatening messages into benign statements or events
Persistently bears grudges
Perceives hidden attacks and reacts angrily
Recurrent, unjustified suspicions of infidelity
Schizoid PDO
diagnosis req 4 of these 7
Detachment from social and emotional relationships, as evidenced by four of the following:
Lack of interest in close relationships
Chooses solitary activities
Little interest in sexuality
Few pleasurable activities
Lacks close friends or confidants other than family
Indifferent to praise or criticism
Emotional detachment, coldness, or flattened affect
Schizotypal PDO
variant of Schizoid, diff from psychosis because relatively well functioning and not acute psychotic symptoms. “odd eccentric thought patterns”
Discomfort with personal relationships combined with eccentricities of thought or behavior, as evidence by five or more:
Ideas of reference Magical thinking Unusual perceptive experiences Odd thinking or speech patterns Suspiciousness or paranoia Inappropriate or constricted affect Eccentric behaviors Lack of close friendships Excessive social anxiety despite familiarity
Antisocial PDO general and diagnosis
Disregard for and violation of the rights of others, evidenced by three or more: Frequent illegal acts Chronic deceitfulness (conning people) Impulsivity and failure to plan ahead Frequent physical aggressiveness Reckless disregard for the safety or self or others ( knew was bad idea but did it anyway, different than negligence) Irresponsibility Lack of remorse
ASPD vs Psychopathy (asocial personality disorder), psycopath difference. aka psychopathy is sort of a higher level of ASPD
“Psychopathy” overlaps with DSM ASPDO
Callous, charming, manipulative
Frequently violent and impulsive
Associated with serial violence or sexual violence
May “disguise” traits with significant social success. “people are tools to be used”
Borderline PDO, between histeria and normal
antisocial
Instability in relationships (main part), self-image, affect, and impulsivity, requiring five of the following:
Frantic efforts to avoid real or imagined abandonment
Unstable and intense relationships (from love to hate)
Unstable self-image (=x know self)
Impulsivity in high-risk activities
Recurrent suicidal threats, gestures, or self mutilating behaviors
Marked mood and affect reactivity and instability
Chronic feelings of emptiness
Inappropriate and intense anger
Transient stress-related paranoia or dissociative symptoms
Histrionic PDO
antisocial
from greek word “actor/acting”
Pattern of excessive emotionality and attention seeking, requiring five of the following:
Need to be center of attention in all settings
Interactions tend to be sexualized or provocative
Rapidly shifting and shallow emotions
Draws attention by physical appearance
Impressionistic but non-detailed speech
Emotions are dramatic, theatrical, and exaggerated
Easily influenced by others or by situations
Exaggerates intimacy of relationships
NO ANGER OR DESTRUCTIVE TRAIT (THAT BORDERLINE PERSONALITY DISORDER BRINGS)
AKA ALL ABOUT THE DRAMA
Narcissistic PDO
antisocial
Pattern of grandiosity, need for admiration, and lack of empathy (of admiration for other people), requiring five of:
Exaggerated sense of self importance
Preoccupied with fantasies of success, power, ideal love, brilliance, or beauty
Belief in “specialness” and only wants to associate with those who other “special” people
Requires excessive admiration
Sense of entitlement
Exploitative in relationships
Fails to recognize the feelings of others
Often envious of others, and believes others envy them
Arrogant, haughty behaviors or attitudes
aka extreme self regard
Avoidant PDO
“pathological shyness”
Pattern of social inhibition, inadequacy, and hypersensitivity to negative evaluations, requiring four of the following:
Avoids jobs with potential for criticism or rejection
Avoids friendships unless certain of being liked
Avoids relationships with potential for shame or ridicule
Preoccupied with fear of criticism in social situations
Inhibited in new relationships due to feelings of inadequacy
Views self as unappealing, socially inept, or inferior
Reluctant to take risks or do new things due to fears of embarassment (cause don’t want to see poeple)
Dependent PDO
Pervasive and excessive need to be taken care of leading to submissive and clinging behaviors, by five of:
Needs excessive advice or encouragement for everyday decisions
Needs others to take responsibility for most major areas of life
Difficulty disagreeing with others due to fear of losing their support
Difficulty initiating projects on their own
Goes to excessive lengths to obtain nurturance and support
Uncomfortable or helpless when alone
Urgently seeks new relationships when old ones end
Preoccupied with fears of being left to take care of self
Obsessive Compulsive PDO
in cluster c
Pattern of preoccupation with orderliness, perfectionism, and interpersonal control, as evidenced by four of the following:
Preoccupied with details, rules, list, order, etc. to the point where the major point of the activity is lost
Excessively devoted to work and productivity
Perfectionism that interferes with task completion
Overconscientious, scrupulous, and inflexible about moral and ethical values
Unable to discard useless or worn out objects (hoarders) that have no sentimental value
Reluctant to delegate tasks to others
Adopts a miserly spending style
Shows rigidity and stubbornness
Impulse Control Disorders
Related to problems in self-control and behavior
Occur in children, adolescents, and adults
Intermittent Explosive DO
Recurrent behavioral outbursts representing a failure to control aggressive impulses, by either:
Verbal aggression like temper tantrums, arguments, or fighting, twice weekly on average for a 3 month period; or
Three behavioral outbursts involving damage or destruction of property or physical injury to others within a 12 month period
Magnitude of aggression is out of proportion to provocation
Not premeditated or committed to a tangible outcome
Cause marked distress, functional impairment, or legal consequences
Must be 6 years or older
Not better explained by another disorder
Intermittent Explosive DO
Recurrent behavioral outbursts representing a failure to control aggressive impulses, by either:
Verbal aggression like temper tantrums, arguments, or fighting, twice weekly on average for a 3 month period; or
Three behavioral outbursts involving damage or destruction of property or physical injury to others within a 12 month period
Magnitude of aggression is out of proportion to provocation
Not premeditated or committed to a tangible outcome
Cause marked distress, functional impairment, or legal consequences
Must be 6 years or older
Not better explained by another disorder
“patients with extremely hot tempers”
is a rule out diagnosis: if not a depressive or manic disorder or bipolar no psychosis or provocation, then this is one.
Pyromania
Deliberate and purposeful fire setting more than once
Tension or affective arousal before the act
Fascination with fire and its situations
Pleasure, gratification, or relief when setting or witnessing fires
Not done for monetary gain, political expression, or in response to a delusion
Not associated with conduct disorder, mania, or ASPDO
can be in childhood. not for arson, for internal pleasure. not a part of mania.
Kleptomania
Recurrent failure to resist impulses to steal objects not needed for personal use or for their monetary value
Increasing sense of tension immediately before committing the theft
Pleasure, gratification, or relief afterwards
Not committed to express anger or vengeance, not in response to delusion or hallucination
Not explained by conduct disorder, mania, or ASPDO
excitement of stealing and not related to anger, just excitement to steal and get away with it.
Obsessive-(and or) Compulsive Disorder
Presence of obsessions, compulsions, or both
Time-consuming or cause significant functional impairment
Not attributable to effects of a substance or medical condition
Not better explained by another mental disorder
Specify level of insight: poor, fair, or good
Specify if related to tic disorder
treat with benzo, SSRI (higher doses and longer treatments), psychotherapy can help Can gage how meds doing if behaviors better.
Obsession
Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, and cause marked anxiety or distress
Individual attempts to ignore or suppress such thoughts, or tries to neutralize them with some other thought or action (compulsions)
more common: cleanliness (germaphobic), security.
Common Obsessive Themes
Contamination Symmetry Forbidden or taboo thoughts Harm to self or others Hoarding behaviors
common: excessive praying, washing hands many times, these relieve anxiety and aimed and making anxiety not come back.
Repetitive behaviors (hand washing, ordering, checking) or mental acts (counting, praying, repeating) that the individual feels driven to perform in response to an obsession or rigid, arbitrary rules Actions are aimed at preventing or reducing anxiety, or preventing some dreaded event. Actions may not be logical connected to what they are designed to prevent.
Body Dysmorphic DO (obsessive and compulsive disorder)
dislike their appearance
Preoccupation with one or more perceived defects in physical appearance that are not perceived or appear slight to others
At some point, individual has performed repetitive thoughts or behaviors in response to this belief
Causes significant distress or functional impairment
Not better explained as an eating disorder
NOT A PART OF EATING
Hoarding Disorder
Persistent difficulty discarding objects regardless of their actual value
Due to perceived need to save the items and distress associated with discarding them
Living areas become cluttered and their function compromised
Causes significant distress or impairment
Not associated with other psychiatric or medical disorders
Specify: Excessive acquisition of unneeded items
Specify: Level of insight (absent, poor, fair, good)
obsessive compulsive disorder vs obsessive compulsive personality disorder
personality arrange ENTIRE LIFE, where as disorder is SPECIFIC (gets in way of success)
Mind vs Body, true dichotomy?
no. Biological function of the brain =mind.
Mental Disorders vs disease
disorders may not have an explanation, different from normal & is a range and variations outside of range. Disease has known pathophysiology aka has an “explanation”
Biopsychosocial Model
Mental disorders involve a “web of causation”
Biological Factors - anatomy, genetics, cell biology, neurochemistry
Psychological Factors - development, coping skills (w/stress), belief systems
Social Factors - cultural, economic, political, financial (play into pt presentation)
Psychiatric Interview
“what’s going on in pt brain” Interaction with a patient to assess their mental state at a given time and place (is a “snapshot”)
Includes conversation, inquiry, and observation
Approaches “from the outside in” (genera to specific questioning)
4 stages of interview
Inception
Reconnaissance
Detailed Inquiry
Conclusion
Psychiatric Interview- Elements of the History
aka starts when enter the room-“snapshot”
Chief Complaint, Psychiatric History, Social History, Family Medical and Psychiatric History, Social, educational, occupational military (histories), chemical dependence, legal history.
may not have been like this before.
psych interview -Chief Complaint and HPI
Chief Complaint - what, when, why now?
HPI - duration, precipitating factors, specific symptoms, intensity of symptoms, any associated physical changes or illnesses
-“job of digging into what’s going on, most detailed part”
psych interview-Psychiatric History,Family Medical and Psychiatric History
Psychiatric History - prior episodes of similar symptoms, other types of psychiatric illness, prior treatments and outcomes (effected by culture also note depression can be caused by hypothyroidism)
Family Medical and Psychiatric History - mental disorders, chemical dependence, medical problems (aka can be genetic)
psych interview: Social History, educational, occupational
Social History - (past and current life) family composition, parents histories, family life, cultural milieu, significant or traumatic events (abuse/foster home)
during development
Educational History - academic achievement, attitudes toward school, likes/dislikes, socialization in school
(social abilities)
Occupational History - first job, duration of employments, changes in career, significant episodes of disability or unemployment
psych interview - military, chemical, legal history
Military History (if applicable) - affiliation, duration, deployments, experience during combat
Chemical Dependence - use patterns, legal involvements, treatment episodes
Legal History - arrests or convictions, lawsuits, bankruptcy
Mental Status Examination general
Psychiatric equivalent of the physical examination
Intended to describe patient’s mental state during the interview (“snapshot”)
Uses past tense verbs
mental status examining
Appearance and Behavior Relationship to the Interviewer Mood and Affect Cognition and Memory Language Disorders of Thought Physiologic Function Insight and Judgment (think this way as this is order write note in)
Mental Status Examination-Appearance and Behavior
Describes physical aspects of patient
Should include pertinent positives or negatives
Detailed but non-judgmental
ex: neat, groomed, cooperative, evasive & details give clue to pt behavior
Mental Status Examination-Stereotypical Behaviors (physical and stereotypical behaviors)
Catatonia - minimal or no movement (stiff)
Akathesia - difficulty staying still
Waxy Flexibility - “action figure” posing (catatonia like/no voluntary movements but not stiff)
Mannerisms - picking, slapping, tapping hands or feet, etc.
Mental Status Examination-Relation to Interviewer
Patient’s attitude towards examiner and examination
Eye contact, body posture, facial expressions (“gestalt”) or (sad, annoyed, body posture)
Note changes during interview and possible motivations for change
Mental Status Examination-Mood and Affect (and Demeanor)
Mood is a sustained emotional quality
Affect is a variable demonstration of the patient’s internal state
Demeanor is the patient’s projection of a specific state, possibly not their true state (a type of faking it)
mood define and types
A sustained emotional state that is frequently, but not always, associated with a certain affect
Depressed - sustained sadness
Anxious - sustained worry or fear
Irritable - easily angered or upset
Euphoric - extreme elation
Labile - rapidly changes from one affect to another
Apathetic - lack of emotions
Affect define and demonstrates what
Moment to moment expression of emotions
Demonstrate the patient’s feelings about themselves, others, and situations
Mood states have “typical” affects but patients still maintain affective range
types of affect
Euthymic - “normal” range of expression based on mood and circumstances
Dysphoric - sad, emotionally numb
Histrionic - rapidly changing, superficial (dramatic)
Labile - suddenly changing without obvious provocation
Flat - little expression of emotion, monotonous
Angry - signs of hostility
Incongruent - not consistent with statements or expressed mood (smiling and says super sad)
Cognition define and what includes
Describes quality of mental functions (make decisions) Alertness (glascow coma scale) Orientation Memory Attention Concentration
Alertness define and types
Fully alert - no impairment
Coma - non-responsive to stimuli
Stupor - briefly rousable by stimuli
Torpor - restricted responses (more so than stupor)
Twilight - brief sense of confusion and disorientation (comes and goes)
Delirium define: is long or short term? may include (halucinations) T/F? and is different than psychosis (t/f)?
Waxing and waning consciousness (aware to disoriented)
Lack of awareness of surroundings, agitation, hallucinations, restlessness, insomnia, combative, visual illusions, labile affect
Frequent in ICU and post-op settings
Caused by metabolic illness, infections, medication reactions, strokes, many other medical conditions
-often from metabolic or chemistry that delays mental
-if see delirum look for something causing, different than psychosis.
Orientation
Person - rarely impaired except dissociative states
Time - day, date, month, year, hour
Place - building, city, state
Situation - clinic, hospital, home
Memory
Immediate - initial registration by the brain
Short term - maintained in hippocampus for several minutes
Long term - memory traces in temporal and parietal lobes for retrieval
Memory Impairment: retro vs antero? before injury or after injury?
Retrograde Amnesia - loss of past memories after severe injury, metabolic illness, intoxication, psychosis, severe anxiety states, dissociative states
-brain =x form new memories or blurry memory
Anterograde Amnesia - loss of ability to form new memories following head injury or illness
-remember before an event but not after
Memory Disorders: falsification vs confabulation vs perservation?
Falsification - making up new memories because your old ones suck (make up completely)
Confabulation - false memories created to fill gaps caused by illness or dementia (=x remember but some sense so make it up)
Perseveration - repeating the same information in response to different inquiries
Memory Screening
Repeat three unrelated words to test immediate recall
Ask patient to recall words a few minutes later to test short term memory
Ask about remote events - names of schools, historical events, etc. (testing long term memory)
Concentration: effect on tasks? How to test?
Ability to focus on a task
Tests include serial 7 subtractions, spelling simple words (“world”) backwards
Note distractibility during interview
Abstraction: vs concrete?
Ability to reason in abstract concepts rather than concrete concepts
Proverbs test
Humor test
pt interview-note these Language/speech/comprehension pieces
Note language functions throughout interview
Flow of speech - fluent, sparse, stilted, over inclusive
Initiation of speech - spontaneous, latency
Comprehension - patient’s understanding
Speech Disorders: aphasia vs muteness? clang vs echolalia?
Aphasia - difficulty repeating words or phrases (often from a tumor)
Muteness - lack of speech
Paralogia - approximately correct answers (constantly almost right)
Echolalia - answers echo questions
Clang Speech - words chosen based on sound rather than meaning (no rhyme or reason)
Word Salad - incoherent speech
Thought Processes-IN PT INTERVIEW, what tells you about their thought process
Inferred by speech and actions
Assessed throughout interview through observation and inquiry. rapid fire/racing thoughts or pressured speech or slow tempo/retarted tempo
Tempo Abnormalities
Racing Thoughts - rapid thoughts that patient cannot slow voluntarily. Frequently accompanied by pressured speech.
Retardation - slow, laborious thoughts with speech latency and sometimes loss of thread
Thought Processes: goal directed flight of ideas? circumstantial vs tangential?
Goal-Directed - patient is able to express coherent thoughts
Circumstantial - expresses excessive detail and “side trips” but able to reach goal
Tangential - thoughts follow each other with tentative connections to previous thought (last word of sentence triggers new topic from something mentioned prior)
Flight of Ideas - thoughts skip rapidly between topics with minimal connection to previous thought (rapid fire changes, completely unrelated)
Incoherent - thoughts essentially impossible to follow
Thought Content: logical vs paranoid? Delusions vs ideas of reference? Insertion vs broadcasting?
Logical - no “abnormal” thoughts noted
Paranoid - illogical fears, suspicion
Delusions - fixed false beliefs
Ideas of Reference - belief that benign stimuli refer to patient specifically (aka radio, news, video games)
Thought Insertion - belief that others implant thoughts in patient
Thought Broadcasting - belief that other can hear the patient’s thoughts
Abnormal Perceptions: illusion vs hallucination?
Illusions - falsely interpreted sensory stimulation (thought saw something or heart something that wasnt there, brain trying to pattern match)
Hallucinations - false perception in the absence of sensory stimulation
(come from temporal lobe place as visual or auditory)
examples of illusions and who it is common in?
Shadow passing by
Someone in the room
Heard someone’s voice
Common in depression, anxiety, extreme stress, delirium
examples of Hallucinations
Auditory - hearing voices, music, etc.
Visual - simple or complex forms
Tactile - formication, touching (bugs or feels things)
Olfactory and Gustatory - smells and tastes
Somatic - physical symptoms appear to patient as stimulated by persecution/technology (ex: belief there’s an alien in my body)
-content may be cultural-
Physiologic (changes/show mental issue): effects sleep, appetite, sex, musculoskelital?
Sleep functions
Appetite and Weight Changes
Sexual Changes
Musculoskeletal Changes - agitation, retardation, ambulation
Insight and Judgment
Insight - understanding the presence of an illness and the risks and benefits of treatment
Judgment - subjective evaluation of the quality and appropriateness of a patient’s decision making capacity
Interview Process
Initiation - greet patient, establish purpose
Begin with open-ended questions
Allow free-form answer then begin detailed inquiry (outside in approach)
Focus on clinical and diagnostic symptoms (start digging)
Use judgment on when to re-direct interview
Psychiatric Disorders
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Disorder vs. Disease: which is abnormal function vs pathological?
Disorder - disruption in normal functioning of a body part or system (=x know source)
Disease - pathophysiological response to external or internal factors
Mood Disorder: persistent or transient? accompanied by?
A change in mood that is persistent
Accompanied by physical, emotional, and functional deficits
May be intrinsic or related to other factors like stressors, illness, or substance abuse
Quality of Mood
Exists on a “spectrum”
Evaluated in discrete episodes that usually represent a clear departure from “normal”
Mania > Euthymia > Depression
(euthymia is normal)
Major Depressive Episode: required? 5 of 9 other?
two of these (main ones)
Depressed or irritable mood, most days
Anhedonia - lack of pleasure in previously pleasurable activities
plus 5 of these
-Significant appetite disturbance or weight change
-Sleep disturbance
-Psychomotor agitation or retardation (cant relax and very slow)
-Loss of energy or fatigue
-Feelings of worthlessness
-Decreased concentration or cognitive abilities
-Recurrent thoughts of death or suicide
Self-rejection (“better off dead”)
Major Depressive Disorder symptoms last how long and cause what kine of issues with functioning and exclude what?
Symptoms of Major Depressive Episode for at least two weeks (not days)
Symptoms cause significant social, occupational, or interpersonal functioning
Exclude drug use, bereavement, or other primary mental disorders
Major Depressive Disorder severity, mental features to note and physical features to note: which are psychotic and which are anxious?
Rate severity - mild, moderate, severe
Note psychotic features - hallucinations, negativistic delusions or paranoia
Note anxious distress - worry, “keyed up”, restless, fear of “something awful”, fear losing control
Note peri-partum onset
Persistent Depressive Disorder
Chronic depression without complete remission for two years or more (not improving)
“Dysthymia”, “Melancholia”
Includes episodes of Major Depression with incomplete remission between episodes
