Anxiety Disorder Flashcards
1
Q
<p>Social anxiety disorder (social phobia)</p>
A
<p>a. characterized by a fear of one or more social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others.
<br></br>b. The individual is afraid of acting in a way that would be embarrassing.
<br></br>c. Exposure to the situation almost always causes anxiety,
<br></br>d. and the person is aware that the fear is excessive.
<br></br>e. Social anxiety disorder is characterized by a fear or anxiety surrounding social situations in which individuals are exposed to possible scrutiny by others.
<br></br>f. The criteria center around the patient's anxiety or fear in specific social situations and does not include other specific symptoms such as irritability, decreased concentration, or sleep disturbance</p>
2
Q
<p>Not a common comorbidity associated with social phobia?</p>
A
<p>a. Disorders that are frequently comorbid with social phobia
<br></br>i. other anxiety disorders,
<br></br>ii. Affective disorders,
<br></br>iii. and substance abuse disorders.
<br></br>iv. About one-third of patients with social phobia will meet criteria for MDD
<br></br>b. There is no significant comorbidity with the somatoform disorders in general and conversion disorder in particular</p>
3
Q
<p>When treating social anxiety disorder,</p>
A
<p>a. combining CBT and pharmacotherapy does not show a clear benefit over using just one or the other for most initial treatments.
<br></br>b. There is evidence, however, that there are some refractory cases that do
<br></br>respond better to a combination of both.</p>
4
Q
<p>Tend to have</p>
A
<p>a. fewer friendships,
<br></br>b. lower levels of education,
<br></br>c. higher rates of suicide,
<br></br>d. and less success in career advancement.
<br></br>e. poorer marital function.</p>
5
Q
<p>An important differential to consider would be avoidant personality disorder.</p>
A
<p>a. In this disorder there is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. It leads to the avoidance of other people unless the sufferer is sure that he or she is going to be liked.
<br></br>b. Avoidant personality disorder leads to restraint of intimate relationships for fear of being shamed or ridiculed.
<br></br>c. These patients often view themselves as socially inept or personally unappealing.
<br></br>d. They avoid jobs with significant interpersonal contact. Very importantly,
<br></br>e. they desire the closeness and warmth of relationships but avoid them for fear of rejection.</p>
6
Q
<p>Borderline personality disorder</p>
A
<p>characterized by a pattern of instability of interpersonal relationships, self-image, and affect, as well as marked impulsivity.</p>
7
Q
<p>OCD</p>
A
<p>defined by a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.</p>
8
Q
<p>Narcissistic personality disorder is</p>
A
<p>defined by a pattern of grandiosity, need for admiration, and lack of empathy.</p>
9
Q
<p>Dependent personality disorder</p>
A
<p>defined by a pervasive need to be taken care of that leads to submissive and clinging behavior and fears of separation.</p>
10
Q
Anxiety disorders: highest prevalence
A
Over 30 million people in the United States have an anxiety disorder. About 17.5 million have depression. About 2 million have schizophrenia. About 5 million have dementia. About 12.8 million use illicit drugs.
11
Q
Panic attack
A
complaints of palpitations, sweating, shortness of breath, chest pain, and nausea, trembling, choking sensations, dizziness, fear of losing control, fear of death, paresthesias, chills, or hot flushes.
12
Q
Myxedema madness
A
is a depressed and psychotic state found in some patients with hypothyroidism.
13
Q
Mad Hatter syndrome
A
presents as manic symptoms resulting from chronic mercury intoxication.
14
Q
Agoraphobia
A
feeling anxious about being in places or situations from which escape may be difficult or in which help may not be available should the patient begin to panic.
avoids various situations because of these fears
15
Q
Acute stress disorder
A
occurs after a person is exposed to a traumatic event.
2 days to 4 weeks,
Major symptom clusters for both disorders include intrusion symptoms, avoidance symptoms, negative alterations in cognition and mood, and alterations in arousal and reactivity.
patient then feels anxiety, detachment, derealization, feelings of being “in a daze,” dissociative amnesia, and numbing.
Flashbacks and avoidance of stimuli can occur.
The symptoms do not last longer than 4 weeks, and occur within 4 weeks of the traumatic event
16
Q
PTSD
A
Sx must last for 4 weeks or more
Most people do not experience PTSD symptoms, even when faced with severe trauma.
lifetime prevalence of PTSD is about 6.7%, as per the National Comorbidity Study.
As per that same study about 60% of males and 50% of females had experienced some significant trauma.
Evidence points to a “dose–response” relationship between the degree of trauma and the likelihood of symptoms. The subjective meaning of the trauma to the individual is also extremely important.
The predisposing vulnerability factors in PTSD are as follows:
Presence of childhood trauma.
Borderline, paranoid, dependent, or antisocial personality disorder traits.
Inadequate family or peer supports.
Female gender.
Genetic predisposition to mental illness.
Recent life stressors.
Perception of an external locus of control to the trauma (natural cause) as opposed to an internal one (human cause).
Recent alcohol abuse.
experienced actual or threatened death or serious injury, which leads to symptoms of intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. “Alterations in arousal and reactivity” include irritability, poor concentration, and sleep disturbance.
17
Q
Major symptom clusters for ASD and PTSD disorders include
A
intrusion symptoms, avoidance symptoms, negative alterations in cognition and mood, and alterations in arousal and reactivity.
18
Q
In dissociative amnesia
A
the patient has one or more episodes of inability to recall important personal information usually of a traumatic or stressful nature.
The patient maintains intact memory for other information.
The prepared test-taker should be able to distinguish this from TGA, which is a reversible anterograde and retrograde memory loss with retention of basic biographic information,
which usually occurs in elderly or middle-aged men,
lasting several hours,
and is likely to be related to a transient ischemic attack.
19
Q
Central serous chorioretinopathy
A
is a disease leading to detachment of the retina and has nothing to do with anxiety.
20
Q
Carcinoid syndrome
A
can mimic anxiety disorders and is accompanied by hypertension and elevated urinary 5-hydroxyindoleacetic acid (5-HIAA).
21
Q
Hyperthyroidism
A
presents with anxiety in the context of elevated T3 and T4 and exophthalmos
22
Q
Hypoglycemia
A
presents with anxiety and fasting blood sugar under 50 mg/dL.
Signs and symptoms of diabetes may also be present with hypoglycemia (polyuria, polydipsia, and polyphagia).
23
Q
Hyperventilation syndrome
A
presents with a history of rapid deep respirations, circumoral pallor, and anxiety.
It responds well to breathing into a paper bag.
24
Q
Most important step in treating separation-anxiety disorder in an 11-year-old
A
Treatment of children with separation-anxiety disorder should be multimodal.
It should involve individual therapy for the child,
medication to reduce anxiety,
family therapy and education,
and return to school,
which is graded if necessary (i.e., start with 1 hour per day, then increase to 2 hours, then to 3 hours, etc.).
The parental education should focus on giving the child consistent support but maintaining clear boundaries about the child’s avoidant behaviors toward anxiety-provoking situations
25
Most common Anxiety disorder?
Specific phobia
It is the most common mental disorder among women
and the second most common among men (after substance abuse).
This fact takes many psychiatrists by surprise, however, because most patients with specific phobia do not seek medical attention.
26
Which anxiety disorders has equal rates in both males and females?
obsessive–compulsive disorder
| most anxiety disorders the rates are higher for women than for men
27
substance-induced anxiety disorder in DSM 5 include
"with onset during intoxication,"
"with onset during withdrawal,"
and "with onset after medication use."
28
Irritability, poor concentration, and poor sleep seen in
Generalized anxiety disorder,
Sx :restlessness, fatigue, difficulty concentrating, irritability, muscle tension, or sleep disturbance
Criteria
excessive anxiety and
worry must occur more days than not,
for at least 6 months,
about a number of events or activities.
The individual finds it difficult to control the worry.
The worry is associated with symptoms such as
restlessness,
fatigue,
difficulty concentrating,
irritability,
muscle tension,
or sleep disturbance.
It causes impairment in social or occupational functioning.
It is not attributable to substance abuse or another mental disorder.
MDD,
depressed or irritable mood, decreased interest in activities, poor concentration, sleep disturbance, and changes in appetite.
premenstrual dysphoric disorder, Sx are same as MDD
depressed or irritable mood, decreased interest in activities, poor concentration, sleep disturbance, and changes in appetite.
and PTSD
29
Treatment for Panic disorder
Studies support CBT as the best therapy for panic disorder.
SSRIs are also considered first line because of their effectiveness, safety, and low side effect profile.
Studies also support the fact that CBT plus an SSRI will deliver better results than either treatment given alone
benzodiazepine to a patient on an SSRI for panic disorder will lead to a more rapid resolution of the anxiety.
The SSRI will take 2 to 4 weeks to work in most cases.
Benzodiazepine can effectively control the patient's symptoms until the SSRI is fully working.
The other choices (Buspar, Gabapentin, Topiramate) will take longer to titrate or become effective
are not good choices for rapid resolution of panic symptoms
30
DSM criteria for panic disorder
must have recurrent attacks of which at least one attack is followed by 1 month or more of persistent concern about having more attacks, or worry about the implications of the attack or its consequences, or a significant change in behavior related to the attacks.
31
Propranolol is indicated only
for performance anxiety and should not be used in other anxiety disorders.
32
Cyclothymic disorder
does not involve psychotic symptoms, although these symptoms may be found in bipolar disorder.
Cyclothymia is a less severe form of bipolar with alternation between hypomania and moderate depression.
Symptoms must exist for 2 years to make the diagnosis.
It is equally common in men and women.
Substance use often coexists.
The onset is usually insidious and occurs in late adolescence or early adulthood.
must have 2 years with periods of hypomania and depressive symptoms that do not meet criteria for major depressive disorder (MDD).
33
MDMA (ecstasy) intoxication
Ecstasy is a serotonin reuptake inhibitor that is toxic to nerve cells.
At low doses it causes feelings of closeness and empathy.
At high doses it causes anxiety and paranoia.
Other symptoms that point toward ecstasy use would be bruxism and hyperthermia.
When hyperthermia induced by ecstasy is combined with increased physical activity it can lead to death.
34
Bipolar Disorder
Agitated, acts seductively, wears colorful clothes that are bizarre in appearance, has an excessive amount of makeup on, and vacillates between being entertaining, hyperexcited, and threatening
classic description of the appearance of a patient in the manic phase of bipolar disorder.
equal prevalence of bipolar disorder in women and men.
Bipolar I disorder in women most often starts with depression.
rapid cycling specifier in bipolar disorder,
the patient must present with at least four mood episodes over the past 12 months.
The mood episodes must meet criteria for a major depressive, manic, mixed, or hypomanic episode.
Female patients are more likely than men to have rapid cycling bipolar disorder.
There is no evidence to suggest that rapid cycling is a heritable phenomenon in bipolar disorder.
It is therefore likely to be a result of external factors such as stress or medication.
35
Bipolar II disorder
is characterized by at least one major depressive episode and at least one hypomanic episode during the patient's lifetime.
Hypomania
DSM criteria for hypomania specifically state
no psychotic features.
If psychosis exists then the mood episode would be considered mania
There are no full manic episodes in bipolar II disorder.
If criteria for a manic episode are met then the correct diagnosis is bipolar I disorder.
Psychotic features can be found in bipolar I disorder during mania or depression
but in bipolar II will occur only associated with depression as full mania is not present in bipolar II.
EX of bipolar II disorder
describes episodes of distractibility, racing thoughts, increased goal-directed activity, and elevated mood. These episodes last for 4 days and she is having one currently. She also describes past episodes lasting 3 to 4 weeks in which her mood is depressed, and she experiences loss of appetite, fatigue, poor concentration, and suicidal thoughts.
meets criteria for hypomania as well as major depressive episodes.
To qualify for mania one needs symptoms for at least a week.
If the core symptom is euphoria, three additional symptoms are needed.
If the core symptom is irritability, four additional symptoms are needed.
Additional symptoms can include grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal-directed activity, or excessive involvement in pleasurable activities.
One must demonstrate impairment in social or occupational functioning, need for hospitalization, or presence of psychosis as part of the picture of mania.
Hypomania lasts for at least 4 days. The same criteria for symptoms apply, but the patient does not experience disturbance in social or occupational functioning, require hospitalization, or become psychotic as part of the symptom picture.
36
Bipolar I disorder
has equal prevalence for men and women
37
Major depression
is more common in women than in men.
There is no correlation between socioeconomic status and frequency of depression.
There is a correlation between hypersecretion (not hyposecretion) of cortisol and increased depression.
Only about 50% of those with major depressive disorder receive specific treatment
38
Patient comes to you and reports recurrent hypomanic episodes but denies any depressive symptoms
To meet criteria for bipolar I the patient must have at least one manic episode.
So bipolar I is out in this case.
For bipolar II, the patient must have one hypomanic episode and one episode of MDD.
So bipolar II is out in this case because we have no depressive symptoms.
To meet cyclothymic disorder one must have hypomanic symptoms as well as depressive symptoms that do not meet criteria for major depression and that go on for at least 2 years.
This patient has no depressive symptoms so cyclothymic disorder is out.
39
Other specified bipolar and related disorder,
which includes patients with clear bipolar symptoms who do not meet criteria for any specific bipolar disorder.
40
Amok
Malaysian cultural syndrome
sudden rampage including homicide and/or suicide,
which ends in exhaustion and amnesia.
41
Koro
Asian
| delusion that the penis will disappear into the abdomen and cause death.
42
the greatest comorbidity with pathological gambling?
Major Depressive Disorder
| Also: panic, OCD, and agoraphobia, but the association MDD is greater
43
Criteria for pathological gambling
a. preoccupation with gambling,
b. gambling increased sums of money to obtain excitement,
c. being unsuccessful at stopping or cutting back,
d. gambling to escape dysphoric mood,
e. lying to significant others about gambling,
f. loss of important relationships over gambling,
g. committing illegal acts to be able to gamble,
h. relying on others to pay the bills because of money lost gambling,
i. a desire to keep going back to break even.
44
Tourettes Disorder
a. involves both motor and vocal tics.
b. onset is usually around 7 years of age,
c. may come as early as 2 years.
d. Motor tics
i. usually start in the face and head and progress down the body.
e. Vocal tics
i. not done intentionally to provoke others,
ii. but are the result of sudden, intrusive thoughts and urges that the
patient cannot control.
iii. intrusive thoughts may involve socially unacceptable subject
matter or obscenity.
45
ADHD, diagnosed
a. by six or more symptoms of inattention
1. failure to pay close attention to tasks,
2. failure to sustain attention,
3. not listening,
4. not following through on tasks,
5. problems organizing tasks,
6. forgetfulness,
7. being easily distracted by extraneous stimuli.
b. or six or more symptoms of hyperactivity–impulsivity
1. fidgeting,
2. inability to remain seated when expected,
3. running or climbing excessively,
4. difficulty playing quietly,
5. acting as if driven by a motor,
6. talking excessively,
7. blurting out answers,
8. difficulty awaiting turn,
9. and interrupting others
c. that persist for 6 months or more.
d. Several inattentive or hyperactive–impulsive symptoms should be present
prior to age 12.
e. Several symptoms of impairment must be present in more than one setting to
make the diagnosis.
46
treatment of tics in Tourettes syndrome?
a. Severe motor tics in Tourette's syndrome
i. are best treated by neuroleptics,
1. haloperidol and pimozide.
2. atypical neuroleptics because of their superior safety profiles,
a. risperidone,
b. quetiapine,
c. olanzapine,
d. ziprasidone,
e. and clozapine.
3. Fluphenazine, molindone, and other conventional antipsychotics
are also acceptable treatment choices.
4. Clonidine
a. is also a frequently used and effective treatment of tics
b. is particularly favored by pediatric neurologists for its
excellent safety profile.
5. Botulinum toxin type A
a. can be effective for blepharospasm and eyelid motor tics
b. FDA-approved for this indication.
2. Protriptyline and the other antidepressants
a. may be effective for associated obsessive–compulsive symptoms,
b. not useful for treatment of tics.
47
criterion for kleptomania
a. Kleptomania is found within the larger heading of impulse control disorders.
i. increased sense of tension.
ii. repeated stealing of objects that he or she does not need, Recurrent
failure to resist stealing objects.
iii. sense of tension before the act
iv. the sense of pleasure or relief afterward
v. theft is not done to express anger
48
Pyromania
a. is included in the impulse control disorders.
b. sets fires repeatedly because of the tension before the act and the relief after.
c. There is also a fascination with fire and its various uses.
d. If the patient is setting fires for gain such as money or to make a political
statement, then it is not a case of pyromania.
e. One cannot make the diagnosis
i. in the presence of conduct disorder, mania, or antisocial personality
disorder.
49
following a fight with police. Upon examination the psychiatrist finds that the patient
has a history of several discrete assaultive acts. His aggression in these situations
was out of proportion to what one would consider normal. The patient has no other
psychiatric disorder and no history of substance abuse. He has no significant medical
history.
a. intermittent explosive disorder.
i. discrete episodes of failure to resist aggressive impulses that lead to
extreme physical aggression directed toward people and/or property.
ii. The degree of aggression is completely out of proportion to any
particular psychosocial stressor that may trigger such an episode.
iii. Episodes are unpredictable and often arise without cause or
particular trigger and remit as spontaneously as they begin.
iv. There are no signs or symptoms of aggressivity noted in
between these discrete episodes.
v. more common in men than in women.
vi. Predisposing psychosocial factors include
1. an underprivileged or tempestuous childhood,
2. childhood abuse,
3. and early frustration and deprivation.
vii. Biological predisposing factors
1. decreased cerebral serotonergic transmission,
2. low CSF levels of 5-hydroxyindoleacetic acid,
3. and high CSF levels of testosterone in men.
viii. There is strong comorbidity
1. fire setting,
2. substance use,
3. and the eating disorders.
ix. Treatment of intermittent explosive disorder
1. mood stabilizers such as lithium, carbamazepine, divalproex
sodium, and gabapentin.
2. SSRIs and tricyclic antidepressants can also be effective in
reducing aggression
2. Temporal lobe seizures
a. aggression,
i. most often interictally,
50
Conduct disorder
a. shows a pattern whereby the rights of others and societal rules are violated.
i. presents as
ii. bullying other children,
iii. using weapons,
iv. physical fighting,
v. cruelty to animals,
vi. stealing,
vii. fire setting,
viii. destroying property,
ix. truancy,
x. or running away from home.
51
Depression
a. children can become very irritable, withdraw, and not wish to socialize.
b. They may even act out as a result of how badly they are feeling.
c. However, this is different from a long-standing pattern of actively trying to
carry out violence or do property damage regardless of mood state.
52
In bipolar disorder children
a. may break rules and have behavioral difficulties during manic and depressive
episodes.
b. clear cycling pattern to their moods (and other symptoms), which
corresponds to the times when their behaviors become problematic.
53
One of the other important distinctions to make is between conduct disorder and
oppositional defiant disorder (ODD).
a. In ODD there is a pattern of
i. negativistic, hostile, or defiant behavior directed at adults or authority
figures.
ii. ODD behaviors are therefore more targeted and have less of a wide-
ranging destructive nature than those of conduct disorder.
1. may include
a. temper tantrums,
b. arguing with adults,
c. actively defying adults' requests or rules,
d. deliberately annoying people,
e. blaming others for one's own mistakes or misbehavior,
f. being easily annoyed by others,
g. being angry and resentful,
h. or being spiteful or vindictive.
54
Primary treatment for ODD is
a. therapy for the child and parental training to give
parents management skills.
i. Often behavioral therapy will be used to reinforce
good behavior while ignoring or not reinforcing
bad behavior
b. In conduct disorder
i. the negative behavior is directed at all others regardless of whether
they are authority figures or not.
55
Kleine–Levin syndrome
a. is a rare condition.
i. marked by
1. periods of hypersomnia with periods of normal sleep in
between.
a. During the periods of excessive sleep the patients wake
up
i. experience apathy, irritability, confusion,
voracious eating, loss of sexual inhibitions,
disorientation, delusions, hallucinations, memory
impairment, incoherent speech, excitation, and
depression.
ii. onset of the illness
1. 10 and 20 years of age,
a. and it goes away by the time in his/her 40s.
56
ADHD Treatment
a. Methylphenidate and amphetamine
i. preparations are dopamine agonists.
b. Methylphenidate has been shown to be effective in about 75% of all children
with ADHD.
i. Common side effects of the stimulants are headaches, GI discomfort,
nausea, and insomnia.
ii. Of course stimulants also suppress appetite and can induce weight
loss.
iii. Some children experience a rebound effect following the
wearing-off of the stimulant, during which period they become irritable
and hyperactive.
iv. Motor tics can also be exacerbated by the use of stimulants,
which warrants caution when the medications are given in this specific
population of children.
v. Methylphenidate is also associated with growth stunting or
suppression.
vi. This effect seems to be offset when children are given drug
holidays during the summer months when they are not in school.
vii. About 75% of students on stimulant medications demonstrate
improvement in attention as measured by objective tests of their
academic performance.
c. Dextroamphetamine and dextroamphetamine/amphetamine salt combinations
(Adderall)
i. are generally the second choice when methylphenidate fails.
57
Pathological gambling,
a. neurobiological determinant in pathological gamblers' risk-taking behaviors
i. Theories have focused on both serotonergic and noradrenergic
receptor systems.
ii. Evidence supports the probability that male pathological
gamblers have low plasma MHPG concentrations,
iii. as well as increased CSF MHPG concentrations
iv. and increased urinary output of norepinephrine.
v. Chronic gamblers also have
1. decreased platelet MAO activity,
a. which is a marker of serotonergic dysfunction,
i. which is linked to difficulties with inhibition and
impulse control.
b. Epidemiologic studies point to a prevalence rate of a
i. 3% to 5% of problem gamblers in the general population
ii. 1% who meet criteria for pathological gambling.
c.
d. an individual must present with persistent and recurrent maladaptive
gambling that causes economic problems and significant disturbances in
personal, social, or occupational functioning with at least five of the following
symptoms:
1. Preoccupation: The subject has frequent thoughts about gambling
experiences, whether past, future, or fantasy.
2. Tolerance: As with drug tolerance, the subject requires larger or more
frequent wagers to experience the same "rush".
3. Withdrawal: Restlessness or irritability associated with attempts to
cease or reduce gambling.
4. Escape: The subject gambles to improve mood or escape problems.
5. Chasing: The subject tries to win back gambling losses with more
gambling.
6. Lying: The subject tries to hide the extent of his or her gambling by
lying to family, friends, or therapists.
7. Loss of control: The person has unsuccessfully attempted to reduce
gambling.
8. Illegal acts: The person has broken the law to obtain gambling money
or recover gambling losses. This may include acts of theft,
embezzlement, fraud, or forgery.
9. Risked significant relationship: The person gambles despite risking or
losing a relationship, job, or other significant opportunity.
10. Bailout: The person turns to family, friends, or another third party for
financial assistance as a result of gambling.
58
Conduct disorder
a. repetitive and persistent pattern of behavior in which the basic rights of
others or major age-appropriate societal norms or rules are violated,
i. as manifested by the presence of three (or more) of the following
criteria
ii. in the past 12 months,
iii. with at least one criterion present in the past 6 months:
1. Aggression to people and animals
a. often bullies, threatens, or intimidates others
b. often initiates physical fights
c. has used a weapon that can cause serious physical harm
to others (e.g., a bat, brick, broken bottle, knife, gun)
d. has been physically cruel to people
e. has been physically cruel to animals
f. has stolen while confronting a victim (e.g., mugging,
purse snatching, extortion, armed robbery)
g. has forced someone into sexual activity
2. Destruction of property:
a. has deliberately engaged in fire setting with the
intention of causing serious damage
b. has deliberately destroyed others' property (other than
by fire setting)
3. Deceitfulness or theft:
a. has broken into someone else's house, building, or car
b. often lies to obtain goods or favors or to avoid
obligations (i.e., "cons" others)
c. has stolen items of nontrivial value without confronting a
victim (e.g., shoplifting, but without breaking and
entering; forgery)
4. Serious violations of rules:
a. often stays out at night despite parental prohibitions,
beginning before age 13 years
b. has run away from home overnight at least twice while
living in a parental or parental surrogate home (or once
without returning for a lengthy period)
c. is often truant from school, beginning before age 13
years
a. The disturbance of behavior causes clinically significant impairment in social,
academic, or occupational functioning. Many biopsychosocial factors
contribute to the manifestation of childhood conduct disorder.
b. Some of these factors include
i. harsh, punitive parenting;
ii. family discord;
iii. low socioeconomic status;
iv. lack of proper parental supervision;
v. and lack of social competence.
c. The problems must begin to manifest before 13 years of age.
d. In some children with conduct disorder,
i. low plasma levels of dopamine-β-hydroxylase have been found.
1. supports the notion of decreased noradrenergic functioning in
conduct disorder.
2. Canadian study demonstrated greater right frontal EEG activity
at rest correlated with violent and aggressive behavior in
children.
3. There is also little doubt that children chronically exposed to
violence and abuse have a higher risk for being violent
themselves.
59
Anorexia nervosa.
a. Tests to Order
i. Electrolytes
1. one of the most important tests is the serum potassium level.
a. develop a hypokalemic hypochloremic alkalosis
i. have cardiac complications including arrhythmias
and sudden death.
ii. renal function tests,
iii. thyroid function tests,
iv. glucose,
v. amylase,
vi. complete blood count,
vii. electrocardiogram,
viii. cholesterol,
1. Cholesterol is often increased in these patients,
2. not urgent
ix. dexamethasone suppression test,
x. and carotene
b. Osteoporosis
i. can be found in anorexic patients,
1. but a bone scan is not a vital initial procedure.
c. Delayed gastric emptying
i. can occur with eating disorders,
ii. but a study to prove such is not urgent.
60
Piblokto
occurs in female Eskimos of northern Greenland.
It involves anxiety, depression, confusion, depersonalization, and derealization,
ending in stuporous sleep and amnesia.
61
Wihtigo
Native American Indians
| is a delusional fear of being turned into a cannibal through possession by a supernatural monster, the Wihtigo.
62
Mal de ojo
Mediterranean descent
is a syndrome involving vomiting, fever, and restless sleep
caused by the evil eye.
63
Ataque de nervios
```
is a culture-bound anxiety syndrome
associated with those from Latin-American cultures.
headache,
insomnia,
anorexia,
fear,
anger,
despair,
diarrhea.
```
64
Japanese culture
it is customary to minimize distress in front of an authority figure.
65
Chinese culture
often presents with more somatic complaints and less focus on mood symptoms.
Very often Chinese patients will come to the primary care physician or emergency room
with somatic symptoms that are somewhat nonspecific
are found to be driven by an underlying depressive disorder.
66
Culture
correlates most with ethnicity.
People can be of the same race, age, gender, or nationality
have very different cultures.
67
Completed suicide
is most often associated with depression,
not bipolar disorder.
Adolescents most frequently commit suicide with guns,
not by hanging.
In recent years the suicide rate has gone up dramatically among adolescents,
not among middle-aged adults.
Previous suicide attempts are the best predictor of future risk of suicide.
Men successfully commit suicide three times more often than women.
Another factor contributing to completed suicides is age.
For men, the highest risk period is after 45 years of age.
For women, the highest risk period is after 55 years of age.
Married people are less likely to commit suicide than single or widowed people.
As far as religion is concerned,
rates of suicide among Roman Catholics are less than those for Protestants or Jewish people.
With race,
whites are more likely to commit suicide than others,
especially white males.
Physical health may play a role.
Thirty-two percent of people who commit suicide have seen a doctor within the past 6 months.
With regard to occupation, the higher a person's social status, the higher the rate of suicide.
A fall in social status also increases the risk.
The best legal protection for a psychiatrist treating a suicidal patient is thorough regular documentation of a suicide assessment.
No-suicide contracts signed by the patient offer no legal protection, though they may demonstrate the existence of a therapeutic relationship between doctor and patient.
68
Children who are depressed
can often present with irritability instead of, or in addition to, depressed mood.
Prepubertal children can report somatic complaints, psychomotor agitation, and mood-congruent hallucinations.
Depressed children can also fail to make expected weight gains.
Other signs of depression that children can present with include school phobia and excessive clinging to parents.
Teens with depression
often report poor school performance, substance abuse, promiscuity, antisocial behavior, truancy, and running away from home.
They can withdraw from social activities and be grouchy and sulky.
69
SAD is a non-DSM term used to describe a seasonal pattern specifier
a depression that sets
in during the fall and winter and resolves during the spring and summer.
often characterized by hypersomnia, hyperphagia, and psychomotor slowing.
added to the diagnoses of
bipolar I and II disorders,
and major depressive disorder.
It is associated with depressive symptoms that occur at a certain time of year,
with complete remission of symptoms at other times of the year.
One must show a pattern of two episodes during the same season of the previous 2 years to make the diagnosis.
In addition, the seasonal depressive episodes must substantially outnumber any non-seasonally related depressive episodes during the patient's lifetime.
The treatment is light therapy.
Treatment involves exposure to bright artificial light for 2 to 6 hours each day during the fall and winter months.
It is thought to be related to abnormal melatonin metabolism.
often associated with carbohydrate cravings,
that light therapy is most effective in the morning,
and that light therapy can precipitate hypomania in bipolar patients.
70
Disinhibited behavior
is more characteristic of mania than it is of depression.
71
Patients with depression
have disrupted rapid eye movement (REM) sleep,
including shortened REM latency, (1 hour or less).
increased percentage of REM sleep,
and a shift in REM distribution from the last half to the first half of the night.
Acetylcholine is associated with the production of REM sleep.
most typical effect of depression on sleep is early morning awakening.
72
How long should a patient remain on antidepressant medication after having experienced four major depressive episodes in the past 5 years?
Depression tends to be a chronic, relapsing disorder.
The percentage of patients who recover following repeated episodes diminishes over time.
About one-quarter of patients have a recurrence within the first 6 months after initial treatment.
This figure rises to about 30% to 50% in the first 2 years and even higher to about 50% to 75% within 5 years.
It has been proven than ongoing antidepressant prophylaxis helps to lower relapse rates.
As a patient experiences more depressive episodes over time, the time between episodes decreases and the severity of the episodes worsens.
73
Dysthymic disorder is
characterized by decreased mood
over a period of 2 years
with poor appetite or overeating, sleep problems, fatigue, low self-esteem, poor concentration, and feelings of hopelessness.
74
Violent or aggressive behavior is associated with
Karolinska Institute has shown in numerous studies that diminished central serotonin plays a role in suicidal behavior.
low levels of CSF 5-HIAA are associated with suicidal behavior.
It has also been shown that low 5-HIAA levels predict future suicidal behavior
and that low 5-HIAA levels have been shown in the CSF of adolescents who kill themselves.
75
Keys to normal bereavement
are that suicidality is rare,
it improves with social contacts,
and it lacks global feelings of worthlessness.
76
In depression
one finds anger and ambivalence toward the deceased,
suicidality is common,
and social contacts do not help, thus the person isolates.
In addition others find the depressed person irritating or annoying,
whereas the bereavement patient evokes sympathy from others.
In depression the patient may feel that he or she is worthless,
which is not the case in bereavement
77
period of grief or mourning
typically lasts about 6 months to 1 year.
Some symptoms and signs of mourning may persist for a longer period, even up to 2 years or more.
In most cases, the acute symptoms of grief improve over a period of about 1 to 2 months, after which time the individual returns to a more normal level of functioning.
78
Suicide rate for
adolescents has quadrupled since 1950.
Suicide accounts for 12% of deaths in the adolescent age group.
The suicide rate has gone up more in this group than in any other group over the same time period.
79
Pancreatic cancer
associated with a high rate of depression.
Present with apathy, decreased energy, and anhedonia.
It should be a consideration in the clinician's mind whenever seeing middle-aged depressed patients.
Of patients with cancer, 50% often have comorbid psychiatric diagnoses,
with adjustment disorder, major depressive disorder, and delirium being the most common.
80
postpartum period.
40% of mothers may experience mood or cognitive symptoms during the
Postpartum blues (or maternity blues) is a
normal state of sadness, dysphoria, tearfulness, and dependence,
which may last for several days
and is the result of hormonal changes and the stress of being a new mother.
Postpartum depression
is more severe and involves neurovegetative signs and symptoms of depression and potential suicidality.
Postpartum psychosis
can involve hallucinations and delusions,
as well as thoughts of infanticide.
81
Content of thought
```
delusions,
preoccupations,
obsessions,
compulsions,
phobias,
suicidality,
homicidality
common mistake to put hallucinations in the thought content
Hallucinations are false sensory perceptions and fall under the category of perception.
```
82
The categories of the mental status examination are
```
appearance,
psychomotor activity,
attitude,
mood,
affect,
speech,
perception,
thought content and process,
consciousness,
orientation,
memory,
concentration,
attention,
reading and writing,
visuospatial ability,
abstract thought,
information and intelligence,
impulsivity,
judgment and insight,
reliability.
```
83
Depression
increased awakening during the second half of the night
| increased length of the first REM sleep episode.
84
EEG can be used to evaluate sleep, but in clinical psychiatry,
used to separate temporal lobe seizures from pseudoseizures
| to distinguish dementia from pseudodementia caused by depression.
85
Tumor
unrelated to sleep changes and could potentially show up on an EEG as a seizure focus,
86
Petit mal epilepsy
has a classic 3-per-second spike and wave pattern,
87
Hepatic encephalopathy
would cause a delirium
EEG patterns in delirium would show generalized slow activity, that is, theta and delta waves, with possible areas of hyperactivity.
Hepatic encephalopathy often shows on EEG
as bilaterally synchronous triphasic slow waves
88
Best method to diagnose depression
is the standard psychiatric interview.
Psychiatric interviews serve two functions:
to find and classify symptoms
and to find psychological determinants of behavior.
Interviews can be either insight or symptom oriented.
89
The MMPI
is a self-report inventory used to assess personality traits
90
The dexamethasone suppression test
used to demonstrate abnormal activity of the hypothalamic–pituitary–adrenal axis,
which can be found in 50% of major depression patients.
test has limited clinical usefulness because of the frequency of false positive and negative test results.
91
Logorrhea
is uncontrollable, excessive talking.
92
Alexithymia
is a difficulty in recognizing and describing one's emotions.
93
Echolalia
is the imitative repetition of the speech of another.
94
Flight of ideas
is rapid shifting from one topic to another.
95
Stilted speech
is a formal stiff speech pattern.
96
Suicidal ideation
is part of the thought content of the depressed patient.
It is possible to find it in the manic bipolar patient,
but is more likely during the depressed phase of the illness and is not part of the thought process
97
Thought content
```
Obsessions
delusions,
ideas of reference,
phobias,
suicidal or homicidal thoughts,
depersonalization,
derealization,
neologisms,
```
98
Thought process
```
word salad,
flight of ideas,
circumstantiality,
tangentiality,
clang associations,
perseveration,
goal-directed ideas.
```
99
ECT
no absolute contraindications to ECT.
Pregnancy is not a contraindication for ECT.
Fetal monitoring is considered important only if the pregnancy is high risk or complicated.
Brain tumors increase the risk of ECT, especially of brain edema and herniation after ECT.
If the tumor is small, complications can be minimized by administration of dexamethasone prior to ECT
and close monitoring of blood pressure during the treatment.
Aneurysms, vascular malformations, or increased intracranial pressure
are at greater risk during ECT because of increased blood flow during the induction of the seizure.
This risk can be decreased by careful control of blood pressure during the seizure.
Epilepsy and prior neuroleptic malignant syndrome are not problematic with the administration of ECT.
Recent myocardial infarction is another risk factor,
but the risk decreases markedly 2 weeks after the infarction and even further 3 months after the infarction.
Hypertension, if controlled and stabilized with antihypertensive medication,
does not pose an increased risk during ECT
100
Patients at high risk during ECT include the following:
```
space-occupying lesions in the CNS,
increased intracranial pressure,
at risk for cerebral bleed,
have had a recent myocardial infarction,
with uncontrolled hypertension.
no absolute contraindications for ECT
```
101
Right unilateral placement of the electrodes in ECT
has been shown to minimize cognitive impairment and memory deficits.
If unilateral electrode placement fails to improve the patient's symptoms after four to six treatments
the placement may be switched to bilateral,
which can be more effective but carries a higher risk of side effects
102
Lithium
can prolong seizure activity during ECT
| and should be discontinued.
103
Antipsychotics
are fine during ECT,
with the exception of clozapine,
which causes late-appearing seizures during ECT.
104
Tricyclic antidepressants (TCAs) and MAOIs
re fine to continue during ECT.
require 6 to 12 ECT treatments to treat depression.
Some cases may require as many as 30 treatments,
but these are the exception rather than the rule.
105
Treatments are often given three times per week
with one seizure per treatment.
The use of more than one seizure per episode has no proven advantages.
The preference is for unilateral electrode placement
because it lessens memory impairment from the procedure.
If a patient fails to improve after six unilateral treatments
then bilateral electrode placement should be considered.
106
Cingulotomy
a surgical treatment for OCD.
successful in treating about 30% of otherwise treatment-resistant patients.
Some patients who fail medication, and then subsequently fail surgery, will respond to medication after surgery.
Complications of cingulotomy include
seizures,
managed with anticonvulsants.
107
Biofeedback
therapy in which instruments are used to measure autonomic parameters
Pt’s are provided with "real-time" feedback from the instrumentation about their bodily physiologic processes.
enables patients to control their own physiologic functions
alter them in positive ways to alleviate symptoms using operant conditioning techniques.
Feedback is provided to the patient by measuring physiologic parameters
heart rate,
blood pressure,
galvanic skin response,
and skin temperature.
The measurement is translated into a visual or auditory output signal that patients can rely on to gauge their responses.
Patients can alter the tone by using guided imagery, breathing techniques, cognitive techniques, and other relaxation techniques.
The modality is useful for
anxiety disorders,
migraine,
tension-type headache
108
Relaxation training
```
a form of behavior therapy
encompasses techniques
meditation
yoga
to help patients to dispel anxiety
by tapping into their own physiologic parameters such as heart rate and breathing rate.
```
109
Guided mental imagery
helps patients to enter a relaxed state of mind.
110
Behavior therapy
global term used to describe various therapeutic modalities
that employ either operant or classical conditioning techniques
to help patients overcome their fears, phobias, and anxieties.
Flooding,
systematic desensitization,
aversion
111
Desensitization
helps patients gradually overcome their fears, phobias, and anxieties
by graded exposure to the very stimulus that is the source of their fears.
patient is exposed to more and more anxiety-provoking stimuli,
112
Alogia
is a lack of speech that results from a mental deficiency or dementia.
113
Akinesia
Poverty of movement
114
"flat affect."
Poverty of emotion
115
26-month-old child into the doctor's office. The child has not spoken any words yet.
child who is not speaking should first have his or her hearing checked.
Phonological disorders are characterized by a child's inability to make age-appropriate speech sounds.
The child cannot be diagnosed if the deficits are being caused by a structural or neurological problem; therefore these things must first be ruled out.
Phonological disorder may present as substitutions of one sound for another or omissions such as leaving the final consonant off of words.
The treatment of choice is speech therapy,
recovery can be spontaneous in some children.
Speech therapy is indicated if the child cannot be understood,
if the child is over 8 years of age,
when self-image and peer relationships are being affected,
when many consonants are misarticulated,
and when the child is frequently omitting parts of words
116
Transcranial magnetic stimulation (TMS)
Left dorsolateral prefrontal cortex, where treatment in applied
is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain.
electromagnetic induction to induce weak electric currents using a rapidly changing magnetic field;
this can cause activity in specific or general parts of the brain with minimal discomfort,
allowing the functioning and interconnections of the brain to be studied.
117
A variant of TMS
repetitive TMS (rTMS),
has been tested as a treatment tool for various neurological and psychiatric disorders
migraines,
strokes,
PD,
dystonia,
tinnitus,
depression,
auditory hallucinations.
The treatment protocol involves the application of electromagnetic stimulation to the standardized treatment location,
over the left prefrontal cortex,
determined by moving the TMS coil 5 cm anterior to the motor threshold location along a left superior oblique plane with a rotation point about the tip of the patient's nose.
Treatment for depression involves 20 to 30 sessions of about 40 minutes each over a 4- to 6-week period
118
NeuroStar TMS Therapy
is indicated for the treatment of major depressive disorder in adult patients
who have failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode.
noninvasively stimulates the left prefrontal cortex of the brain
to treat the symptoms of major depression.
4 to 6 weeks of treatment.
is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain.
uses electromagnetic induction to induce weak electric currents using a rapidly changing magnetic field;
this can cause activity in specific or general parts of the brain with minimal discomfort,
allowing the functioning and interconnections of the brain to be studied.
In 2008 Neuronetics, Inc.,
a privately held company in the United States,
received FDA clearance for its NeuroStar TMS Therapy device for the in-office treatment of major depressive disorder.
119
SCID (Structured Clinical Interview for DSM)
```
does not include functional impairment
covers the following topics:
general overview (demographics and medical, psychiatric services, and medication use histories),
mood episodes,
psychotic symptoms,
psychotic disorders differential,
mood disorders differential,
substance use,
anxiety disorders,
somatic disorders,
eating disorders,
adjustment disorders.
```
120
SCAN (Schedule for Clinical Assessment in Neuropsychiatry)
Covers functional impairment
| give a broader assessment of psychosocial function than the SCID.
121
HAM-D (Hamilton depression rating scale)
used to evaluate depression.
122
CAPS (Clinician-Administered PTSD Scale)
includes items to help make the diagnosis of PTSD,
rate its severity,
and determine impact on social and occupational functioning.
123
PANSS (Positive and Negative Symptom Scale)
rates severity of psychosis.
124
BPRS (Brief Psychiatric Rating Scale)
rates severity of psychosis.
125
CAGE
is a questionnaire used to evaluate alcohol abuse.
126
Monoamine oxidase inhibitor (MAOI)-related hypertensive crisis
Phentolamine
is a parenteral medication usually reserved for hospital use in intensive care unit or cardiac care
primary action is vasodilation due to α1 blockade.
It also can lead to reflex tachycardia because of hypotension and α2 inhibition, which increases sympathetic tone.
primary application for phentolamine is the control of hypertensive emergencies,
most notably due to pheochromocytoma.
It also has usefulness in the treatment of cocaine-induced hypertension,
in which one would generally avoid β-blockers
in which calcium channel blockers are not effective.
β-Blockers (e.g., metoprolol) or combined α- and β-adrenergic blocking agents (e.g., labetalol) should be avoided in patients with a history of cocaine abuse.
They can cause an unopposed α-adrenergic-mediated coronary vasoconstriction, causing the worsening of myocardial ischemia and hypertension.
It is also used in the treatment of pheochromocytoma prior to the administration of β-blockers to avoid unopposed α-stimulation.
In this context it is probably most safely given by infusion because bolus doses have a propensity to cause precipitous falls in blood pressure.
When given by injection it causes blood vessels to expand, thereby increasing blood flow.
Phentolamine has a very short half-life
approximately 20-minute duration.
MAOI-induced hypertensive crisis
should be treated with α-adrenergic antagonists,
phentolamine or chlorpromazine.
These agents lower blood pressure within 5 minutes.
Intravenous furosemide (Lasix) can be used to reduce the fluid load
β-adrenergic receptor antagonists can be used for controlling tachycardia.
A sublingual dose of nifedipine (Procardia) can be given and repeated in 20 minutes.
MAOIs should not be taken by patients with pheochromocytoma or thyrotoxicosis.
127
Bromocriptine and dantrolene
are dopamine agonists
used in the treatment of neuroleptic malignant syndrome.
They have no place in the treatment of MAOI-induced hypertensive crisis
bromocriptine should be used with extreme caution in patients on MAOIs,
as it can interact adversely with MAOIs,
worsening hypertensive crisis.
128
Sedative–hypnotic agents,
like diazepam,
| should also be used with caution in patients taking MAOIs.
129
greatest comorbidity with pathological gambling?
Major depressive disorder
| Also: panic, OCD, and agoraphobia, but the association with MDD is greater
130
Criteria for pathological gambling
preoccupation with gambling,
gambling increased sums of money to obtain excitement,
being unsuccessful at stopping or cutting back,
gambling to escape dysphoric mood,
lying to significant others about gambling,
loss of important relationships over gambling,
committing illegal acts to be able to gamble,
relying on others to pay the bills because of money lost gambling,
a desire to keep going back to break even.
131
Tourette's disorder
involves both motor and vocal tics.
onset is usually around 7 years of age,
may come as early as 2 years.
Motor tics
usually start in the face and head and progress down the body.
Vocal tics
not done intentionally to provoke others,
but are the result of sudden, intrusive thoughts and urges that the patient cannot control.
intrusive thoughts may involve socially unacceptable subject matter or obscenity.
132
ADHD, diagnosed
```
by six or more symptoms of inattention
failure to pay close attention to tasks,
failure to sustain attention,
not listening,
not following through on tasks,
problems organizing tasks,
forgetfulness,
being easily distracted by extraneous stimuli.
or six or more symptoms of hyperactivity–impulsivity
fidgeting,
inability to remain seated when expected,
running or climbing excessively,
difficulty playing quietly,
acting as if driven by a motor,
talking excessively,
blurting out answers,
difficulty awaiting turn,
and interrupting others
```
that persist for 6 months or more.
Several inattentive or hyperactive–impulsive symptoms should be present prior to age 12.
Several symptoms of impairment must be present in more than one setting to make the diagnosis.
133
treatment of tics in Tourette's syndrome?
Severe motor tics in Tourette's syndrome
are best treated by neuroleptics,
haloperidol and pimozide.
atypical neuroleptics because of their superior safety profiles,
risperidone,
quetiapine,
olanzapine,
ziprasidone,
and clozapine.
Fluphenazine, molindone, and other conventional antipsychotics are also acceptable treatment choices.
Clonidine
is also a frequently used and effective treatment of tics
is particularly favored by pediatric neurologists for its excellent safety profile.
Botulinum toxin type A
can be effective for blepharospasm and eyelid motor tics
FDA-approved for this indication.
134
Protriptyline and the other antidepressants
may be effective for associated obsessive–compulsive symptoms,
not useful for treatment of tics.
135
criterion for kleptomania
Kleptomania is found within the larger heading of impulse control disorders.
increased sense of tension.
repeated stealing of objects that he or she does not need, Recurrent failure to resist stealing objects.
sense of tension before the act
the sense of pleasure or relief afterward
theft is not done to express anger
136
Pyromania
is included in the impulse control disorders.
sets fires repeatedly because of the tension before the act and the relief after.
There is also a fascination with fire and its various uses.
If the patient is setting fires for gain such as money or to make a political statement, then it is not a case of pyromania.
One cannot make the diagnosis
in the presence of conduct disorder, mania, or antisocial personality disorder.
137
following a fight with police. Upon examination the psychiatrist finds that the patient has a history of several discrete assaultive acts. His aggression in these situations was out of proportion to what one would consider normal. The patient has no other psychiatric disorder and no history of substance abuse. He has no significant medical history
intermittent explosive disorder.
discrete episodes of failure to resist aggressive impulses that lead to extreme physical aggression directed toward people and/or property.
The degree of aggression is completely out of proportion to any particular psychosocial stressor that may trigger such an episode.
Episodes are unpredictable and often arise without cause or particular trigger and remit as spontaneously as they begin.
There are no signs or symptoms of aggressivity noted in between these discrete episodes.
more common in men than in women.
Predisposing psychosocial factors include
an underprivileged or tempestuous childhood,
childhood abuse,
and early frustration and deprivation.
Biological predisposing factors
decreased cerebral serotonergic transmission,
low CSF levels of 5-hydroxyindoleacetic acid,
and high CSF levels of testosterone in men.
There is strong comorbidity
fire setting,
substance use,
and the eating disorders.
Treatment of intermittent explosive disorder
mood stabilizers such as lithium, carbamazepine, divalproex sodium, and gabapentin.
SSRIs and tricyclic antidepressants can also be effective in reducing aggression
138
Temporal lobe seizures
aggression,
most often interictally,
Question 8
139
Conduct disorder
```
shows a pattern whereby the rights of others and societal rules are violated.
presents as
bullying other children,
using weapons,
physical fighting,
cruelty to animals,
stealing,
fire setting,
destroying property,
truancy,
or running away from home.
```
140
Depression
children can become very irritable, withdraw, and not wish to socialize.
They may even act out as a result of how badly they are feeling.
However, this is different from a long-standing pattern of actively trying to carry out violence or do property damage regardless of mood state.
141
In bipolar disorder children
may break rules and have behavioral difficulties during manic and depressive episodes.
clear cycling pattern to their moods (and other symptoms), which corresponds to the times when their behaviors become problematic.
142
One of the other important distinctions to make is between conduct disorder and oppositional defiant disorder (ODD).
In ODD there is a pattern of
negativistic, hostile, or defiant behavior directed at adults or authority figures.
ODD behaviors are therefore more targeted and have less of a wide-ranging destructive nature than those of conduct disorder.
may include
temper tantrums,
arguing with adults,
actively defying adults' requests or rules,
deliberately annoying people,
blaming others for one's own mistakes or misbehavior,
being easily annoyed by others,
being angry and resentful,
or being spiteful or vindictive.
Primary treatment for ODD is
therapy for the child and parental training to give parents management skills.
Often behavioral therapy will be used to reinforce good behavior while ignoring or not reinforcing bad behavior
In conduct disorder
the negative behavior is directed at all others regardless of whether they are authority figures or not.
143
Kleine–Levin syndrome
is a rare condition.
marked by
periods of hypersomnia with periods of normal sleep in between.
During the periods of excessive sleep the patients wake up
experience apathy, irritability, confusion, voracious eating, loss of sexual inhibitions, disorientation, delusions, hallucinations, memory impairment, incoherent speech, excitation, and depression.
onset of the illness
10 and 20 years of age,
and it goes away by the time in his/her 40s.
144
ADHD Treatment
Methylphenidate and amphetamine
preparations are dopamine agonists.
Methylphenidate has been shown to be effective in about 75% of all children with ADHD.
Common side effects of the stimulants are headaches, GI discomfort, nausea, and insomnia.
Of course stimulants also suppress appetite and can induce weight loss.
Some children experience a rebound effect following the wearing-off of the stimulant, during which period they become irritable and hyperactive.
Motor tics can also be exacerbated by the use of stimulants, which warrants caution when the medications are given in this specific population of children.
Methylphenidate is also associated with growth stunting or suppression.
This effect seems to be offset when children are given drug holidays during the summer months when they are not in school.
About 75% of students on stimulant medications demonstrate improvement in attention as measured by objective tests of their academic performance.
Dextroamphetamine and dextroamphetamine/amphetamine salt combinations (Adderall)
are generally the second choice when methylphenidate fails.
145
Pathological gambling,
neurobiological determinant in pathological gamblers' risk-taking behaviors
Theories have focused on both serotonergic and noradrenergic receptor systems.
Evidence supports the probability that male pathological gamblers have low plasma MHPG concentrations,
as well as increased CSF MHPG concentrations
and increased urinary output of norepinephrine.
Chronic gamblers also have
decreased platelet MAO activity,
which is a marker of serotonergic dysfunction,
which is linked to difficulties with inhibition and impulse control.
Epidemiologic studies point to a prevalence rate of a
3% to 5% of problem gamblers in the general population
1% who meet criteria for pathological gambling.
an individual must present with persistent and recurrent maladaptive gambling that causes economic problems and significant disturbances in personal, social, or occupational functioning with at least five of the following symptoms:
Preoccupation: The subject has frequent thoughts about gambling experiences, whether past, future, or fantasy.
Tolerance: As with drug tolerance, the subject requires larger or more frequent wagers to experience the same "rush".
Withdrawal: Restlessness or irritability associated with attempts to cease or reduce gambling.
Escape: The subject gambles to improve mood or escape problems.
Chasing: The subject tries to win back gambling losses with more gambling.
Lying: The subject tries to hide the extent of his or her gambling by lying to family, friends, or therapists.
Loss of control: The person has unsuccessfully attempted to reduce gambling.
Illegal acts: The person has broken the law to obtain gambling money or recover gambling losses. This may include acts of theft, embezzlement, fraud, or forgery.
Risked significant relationship: The person gambles despite risking or losing a relationship, job, or other significant opportunity.
Bailout: The person turns to family, friends, or another third party for financial assistance as a result of gambling.
146
Conduct disorder
repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated,
as manifested by the presence of three (or more) of the following criteria
in the past 12 months,
with at least one criterion present in the past 6 months:
Aggression to people and animals
often bullies, threatens, or intimidates others
often initiates physical fights
has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
has been physically cruel to people
has been physically cruel to animals
has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
has forced someone into sexual activity
Destruction of property:
has deliberately engaged in fire setting with the intention of causing serious damage
has deliberately destroyed others' property (other than by fire setting)
Deceitfulness or theft:
has broken into someone else's house, building, or car
often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)
has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
Serious violations of rules:
often stays out at night despite parental prohibitions, beginning before age 13 years
has run away from home overnight at least twice while living in a parental or parental surrogate home (or once without returning for a lengthy period)
is often truant from school, beginning before age 13 years
The disturbance of behavior causes clinically significant impairment in social, academic, or occupational functioning. Many biopsychosocial factors contribute to the manifestation of childhood conduct disorder.
Some of these factors include
harsh, punitive parenting;
family discord;
low socioeconomic status;
lack of proper parental supervision;
and lack of social competence.
The problems must begin to manifest before 13 years of age.
In some children with conduct disorder,
low plasma levels of dopamine-β-hydroxylase have been found.
supports the notion of decreased noradrenergic functioning in conduct disorder.
Canadian study demonstrated greater right frontal EEG activity at rest correlated with violent and aggressive behavior in children.
There is also little doubt that children chronically exposed to violence and abuse have a higher risk for being violent themselves.
147
Anorexia nervosa.
```
Tests to Order
Electrolytes
one of the most important tests is the serum potassium level.
develop a hypokalemic hypochloremic alkalosis
have cardiac complications including arrhythmias and sudden death.
renal function tests,
thyroid function tests,
glucose,
amylase,
complete blood count,
electrocardiogram,
cholesterol,
Cholesterol is often increased in these patients,
not urgent
dexamethasone suppression test,
and carotene
Osteoporosis
can be found in anorexic patients,
but a bone scan is not a vital initial procedure.
Delayed gastric emptying
can occur with eating disorders,
but a study to prove such is not urgent.
```
148
Avoidant/restrictive food intake disorder
is an eating disturbance characterized by a lack of interest in eating or food
patient has significant weight loss,
significant nutritional deficiency,
dependence on enteral feeding or oral nutritional supplements.
do not meet criteria for anorexia or bulimia
notably there is not a disturbance in the way their body weight or shape is experienced.
149
Anorexia nervosa
has a significantly low body weight,
which is less than minimally normal or minimally expected.
Intense fear of gaining weight or becoming fat,
Disturbance in the way one's body weight or shape is experienced.
restricting type
binge eating/purging type.
150
Bulimia nervosa (to prevent weight gain)
recurrent episodes of binge eating
followed by inappropriate compensatory behaviors
self-induced vomiting,
misuse of laxatives or diuretics,
fasting,
or excessive exercise
there is a disturbance in how body shape or weight is experienced (like Anorexia)
often develop a hypochloremic alkalosis
at risk for gastric and esophageal tears
Dehydration (hence low blood pressure)
electrolyte imbalances are likely.
female bulimic patients have menstrual disturbances.
Russell's sign
is positive when cuts or scrapes to the backs of the hands are noted,
which are a result of the teeth scraping the fingers while vomiting
151
Binge eating disorder, q 11
recurrent episodes of binge eating
consisting of eating rapidly,
eating until uncomfortably full,
eating large amounts of food when not hungry,
eating alone because of embarrassment about eating,
or feeling disgusted with oneself, depressed, or guilty after eating.
It is differentiated from bulimia nervosa by a lack of inappropriate compensatory behaviors such as vomiting, laxative use, or excessive exercise.
152
Atypical anorexia
categorized as "Other Specialized Feeding or Eating Disorder."
This descriptor is used when the patient doesn't meet full criteria for another eating disorder.
In atypical anorexia all of the criteria for anorexia are met except that,
despite significant weight loss,
the individual's weight is still within or above the normal range.
153
Enuresis
first be treated with the bell-and-pad behavioral conditioning method
The principle is simple: a bell awakens the child when the mattress becomes wet.
Medication treatment:
amitriptyline and imipramine,
can reduce the frequency of enuresis in about 60% of patients.
are to be given about 1 hour before bedtime
Desmopressin (or DDAVP)
is effective in about half of patients
administered intranasally in doses of 10 to 40 mg daily.
results are usually evident within days
respond completely to any of these pharmacological agents should continue the therapy for several months to prevent relapse.
154
Eating Disorders
```
osteoporosis.
cachexia,
loss of muscle mass,
reduced thyroid metabolism,
loss of cardiac muscle,
arrhythmias,
delayed gastric emptying,
bloating,
abdominal pain
amenorrhea,
lanugo (fine baby-like hair),
abnormal taste sensation
```
155
Purging,
```
hypokalemic, hyperchloremic alkalosis.
hypomagnesemia,
pancreatic inflammation,
increased serum amylase,
esophageal erosion,
bowel dysfunction
```
156
Ipecac abuse
```
cardiomyopathy, enlarged heart,
increased QTc interval,
increased creatine kinase–MB
decreased ejection fraction
tricuspid or mitral valve insufficiency,
dysrhythmia,
low WBC,
increased liver function tests.
One would not expect pancreatitis (leading to an increase in amylase) or infection
```
157
Eating disorders
female-to-male ratio of about 10 to 1 (occurs about 10 to 20Xs more frequently in women than in men)
Occur in about 4% of adolescents and young adults.
Anorexia nervosa
has its most common age of onset in the middle teenage years,
but up to 5% of cases begin in the 20s.
The most common age of onset is
between 14 and 18 years of age.
is estimated to occur in about 0.5 to 1% of adolescent girls.
It is most frequent in developed countries
it is seen with highest frequency in women whose profession requires thinness,
such as acting and modeling and dance.
is associated with depression in about 65% of cases.
158
Encopresis
repeated passage of feces into inappropriate places
such as clothes or the floor, whether intentionally or involuntarily.
must be 4 years of age or older.
occur at least monthly for 3 months or more.
not due to a general medical condition.
must cause the child significant distress or social or academic impairment.
Boys are found to have encopresis six times more frequently than girls.
greater frequency in children with a known history of sexual abuse.
Some studies have associated encopresis with measures of maternal hostility and punitive and harsh parenting.
159
Dissociative identity disorder (aka multiple personality disorder)
chronic dissociative disorder
disruption of identity involving two or more distinct personality states.
involves a marked discontinuity in sense of self and sense of agency,
accompanied by related alterations in
affect,
behavior,
consciousness,
memory,
perception,
cognition,
and/or sensory motor functioning.
recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
origins of the disorder
believed to stem from early childhood trauma,
most often sexual or physical.
The hallmark of the disorder is the presence of two or more distinct identities or personality states that recurrently take over the person's behavior.
also a presence of dissociative amnesia,
with a noted inability to recall important personal information that is too extensive to be explained solely by forgetfulness
cause of DID
possible connection between DID and epilepsy,
some patients having abnormal electroencephalograms.
absence of external support, particularly from parents, siblings, relatives, and significant others,
lack of stress-coping mechanisms is also a likely contributory factor.
The differential diagnosis
borderline personality disorder,
rapidly cycling bipolar disorder,
and schizophrenia.
can start at almost any age
an early age of onset is predictive of a worse prognosis.
Treatment
insight-oriented psychotherapy.
Hypnotherapy may also be helpful.
Antipsychotic medications are often unhelpful.
Antidepressant and anxiolytic medications can be useful in addition to psychotherapy.
Anticonvulsant mood stabilizers have shown some efficacy in certain studies
160
Dissociative amnesia
inability to recall important autobiographical information,
usually of a traumatic or stressful nature.
most often consists of localized or selective amnesia for a specific event or events,
but can present as generalized amnesia for identity and life history.
161
Dissociative fugue
is travel or wandering that is associated with amnesia for identity or other important biographical information.
sudden, unexpected travel away from home or one's customary place of work,
with inability to recall one's past.
also confusion about one's personal identity or the assumption of a new identity.
The symptoms must cause significant distress or impairment in social, occupational, or other important areas of functioning.
The fugue state must not occur
during a period of substance abuse
or as part of dissociative identity disorder
or as a consequence of a medical condition.
Fugue episodes
can last from minutes to months in duration.
Traumatic circumstances leading to an altered state of consciousness with a wish to flee are generally the underlying cause of most fugue states.
seen more commonly during
natural disasters,
wartime,
or times of terrorism or social upheaval.
Treated with
psychodynamic psychotherapy
attempting to help the patient recover lost memory of his or her identity and recent experiences.
Hypnotherapy
162
Depersonalization/derealization disorder
involves the persistent or recurrent experiences of depersonalization, derealization, or both.
Depersonalization
is an experience of unreality, detachment, or feeling like an outside observer with respect to one's own thoughts, feelings, sensations, body, or actions.
Derealization
is an experience of unreality or detachment with respect to one's surroundings in which individuals or objects are experienced as unreal, dream-like, foggy, lifeless, or visually distorted.
During depersonalization/derealization disorder reality testing remains intact.
Borderline personality
consists of a pervasive pattern of instability of interpersonal relationships, self-image, and affects and marked impulsivity beginning by early adulthood.
163
Fugue
involves having amnesia for your identity and assuming a new identity.
usually also involves wandering to new places.
164
Amnesia
inability to recall past experiences.
165
Anosognosia
inability to recognize a neurological deficit that is occurring to oneself.
166
Dissociation
is a disturbance in which a person fails to recall important information.
167
Dissociative disorders
dissociative fugue,
dissociative identity disorder.
patient's lack of recall is in excess of what could be explained by ordinary forgetfulness.
Used as a defense mechanism, dissociation
an unconscious process involving the segregation of mental or behavioral processes from the rest of the person's psychological activity.
It can involve the separation of an idea from its emotional tone, as one sees in conversion disorder.
168
Psychiatrists
are held to ethical principles and standards by the American Psychiatric Association that are higher than those other physicians are held to by the American Medical Association.
are permitted to share their expertise about psychiatric issues in general with the public.
unethical for psychiatrists to offer a professional opinion about a specific individual unless they have examined the individual and been granted proper authorization for such a statement.
169
Unethical
psychiatrists to participate in executions.
to accept commission for patient referrals.
to have romantic or sexual relationships with patients.
Psychiatrists are expected to report the unethical behavior of other psychiatrists.
When retiring, the psychiatrist needs to give patients sufficient notice and make an effort to find them follow-up care
to accept a patient's estate after death
considered an exploitation of the therapeutic relationship
acceptable to accept a token bequest that you were unaware was in the will when the patient was alive.
to release information about a patient to another party without the patient's permission.
to pay another doctor for sending you referrals.
"fee splitting"
cannot receive financial compensation for referring patients to other doctors,
nor can you pay for such referrals.
arrangement puts the doctor's interests (the financial incentive to refer) over the best interests of the patient
leads to inappropriate referrals
170
Beneficence
duty to do in the benefit of the the patient
| to help patients and relieve suffering
171
Autonomy
duty to protect a patient's freedom to choose.
views the relationship between patient and doctor as between two adults, not as parent and child.
Informed Consent is an example
is the belief that patients have a right to control what happens to their own bodies and make decisions freely and without coercion
172
Justice
means a fair distribution and application of services.
173
Validity
statistical word
| test measures what it claims to measure.
174
Fiduciary duty
obligation to work in the patient's best interests
175
Nonmaleficence
is the duty to do no harm.
176
Altruism
putting the needs of others before your own needs.
177
Parens patriae
A doctrine that allows the state to intervene and act as a surrogate parent for those who cannot take care of themselves.
178
If hired by an employer to evaluate an employee
it is not presumed that your evaluation will remain confidential.
It is understood that you will disclose information from the evaluation to the patient's employer.
The patient should be made aware of this at the beginning of the interview.
The patient does not have a right to expect the entire evaluation to be confidential,
but he or she does have the right to refuse to cooperate with the evaluation.
The employer does not have a right to elements of the patient's history that do not have bearing upon his or her work performance
For example,
details about the patient's sexuality that have nothing to do with his or her work performance
Medical diagnoses that have no bearing on the patient's work performance
179
Exploitation
using the therapeutic relationship for personal gain,
such as hiring a patient or going into business with a patient.
cannot have any business interactions with patients aside from their paying you for treatment.
180
Ethical
Charging for missed visits.
Releasing information to the patient's insurance company
release only as much information as is necessary to process the claim or preapprove the visit
to keep a separate set of psychotherapy notes for your therapy patients that are not part of the medical record and to which the patient is not entitled access
181
Dopamine
is associated with the induction of aggression.
182
Serotonin
is associated with decreased aggression and irritability
CSF levels of 5-hydroxyindoleacetic acid (5-HIAA),
a major serotonin metabolite,
shown to be inversely correlated with the frequency of aggression.
Low CSF serotonin has been linked to increased frequency of suicide
183
GABA
is the major inhibitory neurotransmitter of the brain
| is associated with decreased aggression.
184
Norepinephrine
is associated with decreased aggression
its functions are thought to be connected to that of serotonin,
in mood disorders.
185
Glycine
is an inhibitory neurotransmitter
| as such is not associated with increased aggression.
186
Cholinergic and catecholaminergic mechanisms
seem to be involved in the induction of aggression
187
Glutamate
major excitatory neurotransmitter in the brain
is the precursor to GABA.
three receptor types associated with
AMPA, α-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid
kainate,
NMDA.
works on the NMDA receptor
play a role in learning and memory,
allows sodium, potassium, and calcium to pass through
It opens when bound by two glutamate molecules and one glycine molecule at the same time.
blocked by physiological concentrations of magnesium
bound by PCP and PCP-like substances.
Understimulation of the NMDA receptor by glutamate
has been found to cause psychosis;
therefore glutamate is thought to play some role in schizophrenia,
as well as four types of non-NMDA receptors.
important in learning and memory.
important in the theory of excitotoxicity,
which postulates that excessive glutamate stimulation
leads to excessive intracellular calcium and nitric oxide concentrations and cell death.
Located in
cerebellar granule cells,
striatum,
hippocampus,
pyramidal cells of the cortex,
thalamocortical projections,
and corticostriatal projections.
188
2 major inhibitory neurotransmitters
GABA and glycine.
189
Neurotransmitters associated with anxiety
Norepinephrine,
Poor regulation of norepinephrine involved in anxiety disorders
Serotonin
involved in anxiety,
its role is less clear
GABA
Role in anxiety is clearly supported by the strong effect that benzodiazepines have on lessening anxiety.
Benzodiazepines
enhance the effect of GABA at the GABA receptor
thus decreasing anxiety.
190
Noradrenergic neurons
found primarily in the locus ceruleus.
Stimulation of the locus ceruleus increases anxiety,
Ablation of the locus ceruleus blocks anxiety responses.
191
Serotonergic drugs
shown clear propensity to decrease anxiety.
192
Serotonergic neurons
located primarily in the raphe nuclei in the pons.
193
Neurotransmitters not directly associated with anxiety
dopamine
glutamate
histamine
acetylcholine
194
Injection of epinephrine
would worsen anxiety
195
Frontal lobes
the seat of executive functioning.
| play a large role in the personality.
196
Orbitofrontal region
Damage to the can cause disinhibition, irritability, mood lability, euphoria, lack of remorse, poor judgment, and distractibility.
197
Dorsolateral frontal regions
Damage leads to extensive executive functioning deficits.
198
Medial frontal region
Damage leads to an apathy syndrome
| Prefrontal cortices influence mood differently.
199
If one activates the left prefrontal cortex,
mood is lifted.
200
If the right prefrontal cortex is activated,
mood is depressed
201
Lesion to the left prefrontal cortex
would cause depression
202
Lesion to the right prefrontal cortex
would cause euphoria and laughter
203
The parietal and occipital lobes
are not the predominant lobes involved in emotion
204
Raphe Nuclei of the brain stem
predominantly in the pons,
| are the major sites of serotonergic cell bodies.
205
Ventral tegmental area, substantia nigra, and nucleus accumbens
are all dopaminergic areas
| are parts of the major neuronal pathways involved in the pathophysiology of schizophren
206
Mesolimbic pathway of dopaminergic neurons
starting at the ventral tegmental area and projecting to the nucleus accumbens
is thought to be highly involved in the sense of reward one gets from cocaine use and is a major mediator of cocaine's effects.
It is very involved in amphetamine's effects as well.
207
Locus ceruleus of the brain stem
contains a high number of adrenergic neurons
mediates the effects of opiates and opioids.
Major types of receptors found on neurons
208
Ligand-gated ion channel receptor
which actually has an ion channel as part of its structure..
209
Seven-transmembrane-domain receptor
has a characteristic NH2 terminal outside the cell, several intracytoplasmic loops, and an intracellular COOH terminal
210
Tyrosine Kinase receptor
interacts with NGF and BDNF.
Through these interactions the tyrosine kinase receptor is thought to play a large role in neuronal plasticity and the remodeling of synaptic associations.
211
Hormones and Steroids
can diffuse into the neuron
bind to cytoplasmic receptors whose effects carry to the nucleus and regulate gene expression
CRH is a hormone
that may increase in major depression, anorexia, and anxiety disorders.
It is produced by the hypothalamus
212
NE
made in the locus ceruleus.
213
Serotonin
made in the dorsal raphe nuclei.
214
Dopamine
made in the substantia nigra.
215
Acetylcholine
made in the nucleus basalis of Meynert.
216
Histamine receptor
Weight gain and Sedation.
217
M1 receptor
```
associated with
constipation,
blurred vision,
dry mouth,
drowsiness.
```
218
α1 receptors
associated with
dizziness
decreased blood pressure.
219
5-HT 1A receptor
is a presynaptic autoreceptor
| involved in the response of neurons to the SSRIs.
220
5-HT 2A receptor
is one of the post-synaptic serotonin receptors involved in the neuron's response to the SSRIs.
221
Serotonin receptors
associated with modulation of depression and anxiety
222
Six biogenic amine neurotransmitters
```
dopamine,
epinephrine,
NE,
acetylcholine,
histamine,
serotonin.
```
223
Dopamine, NE, and epinephrine
are all synthesized from the precursor tyrosine
| are known as a group as the catecholamines.
224
GABA
is an amino acid neurotransmitter
225
Cocaine
works by blocking the reuptake of the biogenic amines
| more specifically serotonin, NE, and dopamine
226
Melatonin
released principally by the pineal gland
there is a feedback loop
between the pineal gland and the suprachiasmatic nucleus in the hypothalamus
that helps with sleep regulation.
secreted predominantly at night
levels peak between 3:00 am and 5:00 am
decrease to lower levels during the day.
is a modulator of human circadian rhythm for entrainment by the light–dark cycle
227
Second messengers
```
molecules that work within the cell
to carry on the message delivered by the neurotransmitter on the cell surface
Common second-messenger molecules are
IP3
major functions of IP3 is to cause the release of intracellular Ca2+ from the endoplasmic reticulum.
cGMP
Ca2+
cAMP
DAG (diacylglycerol)
NO
CO
```
228
Adenylyl cyclase
is the enzyme that makes cAMP from ATP.
is turned on or off by G proteins
depending on the need for cAMP.
229
Binding cAMP to transcription factors
regulates gene transcription,
| including the machinery to make certain neurotransmitters.
230
Calcium
number of roles within the cell,
excess Ca2+
is linked to production of NO and cell death through excitotoxicity.
231
Opioids
µ and δ receptors.
232
Acetylcholine
nicotinic and muscarinic receptors.
233
NE
α1, α2, and β receptors.
234
Serotonin
various 5-HT receptors.
235
GABA
GABA receptor
| Is a chloride ion channel
236
Dopamine
D1, D2, D3, D4, receptors
237
Excitatory neurotransmitters
open cation channels that depolarize the cell membrane
increase the likelihood of generating an action potential.
these neurotransmitters elicit excitatory postsynaptic potentials
238
Exocytosis
process by which neurotransmitter is released into the synaptic cleft
239
Neurotransmitters
```
synthesized in the presynaptic neuron
both their synthesis and their release
mediated by Ca2+ influx into the cell
Dopamine, NE, and serotonin
will remain active until they diffuse out of the cleft or are removed by reuptake mechanisms.
```
240
MAO-A
degrade NE and serotonin
241
MAO-B
degrade dopamine
242
Feedback receptors
exist on the presynaptic membranes of many cells,
Example
α2 receptor on the noradrenergic neuron
which participates in a negative feedback loop to stop the release of NE
243
Action potential,
the first ion channel to open
the Na+ channel
lets Na+ flow into the neuron.
Next Ca2+ channels open,
allowing more positively charged ions to enter and contribute to the action potential.
Once inside, Ca2+ ions act as second messengers involved in protein–protein interactions and gene regulation.
Calcium ions
critical to the release of neurotransmitter
activate the opening of potassium ion channels
this puts a stop to the action potential through the afterhyperpolarization of the membrane.
244
Inhibitory neurotransmitters
open chloride channels
that hyperpolarize the membrane
decrease the likelihood of an action potential being generated
cause inhibitory postsynaptic potentials
245
Glycine
synthesized from serine.
necessary adjunctive neurotransmitter at the NMDA receptor that binds with glutamate.
also an independent inhibitory neurotransmitter
with its own receptors
that open chloride ion channels.
The activity of glycine on the NMDA receptor is an area of research for schizophrenia,
with some studies showing improvement in negative symptoms with the use of glycine or glycine analogues.
highest concentrations of glycine receptors
found in the spinal cord.
Mutations of this receptor lead to
a rare condition called hyperekplexia,
main symptom is an exaggerated startle response.
246
Caudate nucleus
neurons have many D2 receptors.
regulate motor activity
by determining which motor acts get carried out.
With blockade of the caudate D2 receptors,
bradykinesia develops from excessive dampening of motor activity.
With caudate D2 receptor overstimulation,
tics and extraneous motor movements develop.
Thus has an important role in Parkinson's, Tourette’s and tics.
247
GABA-A
```
complex receptor with multiple binding sites
responsible for the clinical effects of
benzodiazepines,
barbiturates
alcohol
the most predominant GABA receptor
is a chloride channel.
```
248
GABA
found throughout the central and peripheral nervous systems
is the predominant inhibitory neurotransmitter in the brain.
When the GABA receptor is occupied by an agonist,
there is a rapid influx of negatively charged chloride ions through the postsynaptic cellular membrane.
This results in fast inhibitory postsynaptic potentials.
249
GABA-B receptor
```
Sodium oxybate (γ-hydroxybutyrate; Xyrem),
which is a "date-rape" drug
FDA-approved for
narcolepsy and cataplexy,
Lioresal,
a potent antispasticity agent
act in the CNS by agonism of it
```
250
Frontal lobes
determine how the brain acts on information.
executive functioning takes place
Injury of the frontal lobes
leads to impairment in motivation, attention, and sequencing of actions.
A "frontal lobe syndrome" exists,
consists of slowed thinking, poor judgment, decreased curiosity, social withdrawal, and irritability.
may have normal IQ
Parietal lobe
IQ function of this lobe for the most part
251
Mesolimbic–mesocortical pathway
projects from the ventral tegmental area to many areas of the cortex and limbic system.
the tract that is thought to mediate the antipsychotic effects of the antipsychotic medications.
252
Nigrostriatal pathway
associated with parkinsonian effects of the antipsychotics.
253
Caudate
innervated by dopaminergic neurons from the substantia nigra pars compacta
thus plays a role in Parkinson's disease as well.
254
Tuberoinfundibular pathway
associated with prolactin increase and lactation from antipsychotics
255
Central and peripheral nervous systems
```
arise from the neural tube.
Neural tube
itself becomes the CNS
gives rise to the ectoderm,
becomes the peripheral nervous system
```
256
Second trimester of gestation
is the peak of neuronal proliferation,
| 250,000 neurons born each minute.
257
Migration of neurons
guided by glial cells
| peaks during the first 6 months of gestation.
258
Synapse formation
occurs at a high rate from the second trimester through age 10
Peaks around 2 years (toddler period)
with as many as 30 million synapses forming per second
259
Nervous system
actively myelinates its axons starting prenatally
| continuing through childhood and finishing in the third decade of life.
260
Emotional Memory
Amygdala
necessary for the recall of emotional contexts of specific events and the experience of fear, pleasure, or other emotions associated with these events
leading to stronger recall of more emotionally charged memories.
Declarative or episodic memory (also known as short-term memory)
hippocampus and parahippocampal areas (nucleus basalis of Meynert)
of the medial temporal lobe
for storage and retrieval of information
hippocampus
one of the most important structures in the formation of memory.
Diencephalic nuclei and the basal forebrain
Important for memory
261
Buprenorphine
a mixed opioid agonist/antagonist.
| used for the treatment of heroin addiction as an alternative to methadone.
262
Aripiprazole
a mixed dopamine agonist/antagonist.
263
Naltrexone
an opioid antagonist.
264
Methadone
an opioid agonist.
265
Basal forebrain
the location of the nucleus basalis of Meynert,
contains a high density of cholinergic neurons.
neurons project to the limbic system and the cerebral cortex.
266
Alzheimer's disease
result of cholinergic neuronal demise
| predominantly in the nucleus basalis of Meynert.
267
Acetylcholine
made from acetyl-coenzyme A and choline
by the enzyme choline acetyltransferase
in the synaptic nerve terminal.
then stored in vesicles in the synaptic bouton.
Once released into the synapse,
it is inactivated and metabolized by acetylcholinesterase
the resultant choline is taken back up into the presynaptic terminal for reutilization.
responsible for
maintaining short-term memory,
attention,
executive functioning,
novelty seeking,
which are mediated through the nucleus basalis of Meynert.
268
Alzheimer's dementia
acetylcholine is depleted
as a result
memory and executive functioning are compromised as a result
269
Alzheimer's meds
donepezil,
rivastigmine,
galantamine
are all acetylcholinesterase inhibitors
can increase levels of circulating acetylcholine in the nucleus basalis and throughout the brain
little bit improving symptoms of dementia to a limited extent
270
Blocking the H1 receptor
leads to
weight gain
sedation.
271
Blocking acetylcholine receptors
```
leads to
dry mouth,
constipation,
blurry vision,
urinary retention,
cognitive dysfunction.
```
272
Blocking α1 adrenergic receptors
leads to
orthostatic hypotension
drowsiness
273
Blocking dopamine receptors
Can lead to
extrapyramidal syndrome (EPS)
elevated prolactin
274
Aggressive patients
```
increased dopamine
decreased serotonin
decreased GABA
increased testosterone
increased acetylcholine
```
275
Tuberoinfundibular pathway
goes from the hypothalamus to the anterior pituitary
| important in the regulation of prolactin secretion.
276
Nigrostriatal pathway
goes from the substantia nigra to the basal ganglia
| important in the development of extrapyramidal symptoms.
277
Mesocortical pathway
goes from the ventral tegmental area to the frontal cortex
| is involved in the negative symptoms of schizophrenia.
278
Mesolimbic pathway
goes from the ventral tegmental area to the nucleus accumbens
involved in positive psychotic symptoms
279
The ventral amygdalofugal
part of the limbic system
| running from the amygdala to the thalamus and hypothalamus
280
Making a Will
Psychiatrist must determine capacity
If they have these 3
ability to understand the nature and extent of one's property.
one must know that one is making a will.
one must know to whom the property will be bequeathed.
281
McGarry instrument
determines whether someone is competent to stand trial
must be able to have the ability to consult his lawyer with a reasonable degree of rational understanding
must have a reasonable and rational understanding of the proceedings against him or her
is a clinical guide that identifies 13 areas of functioning
that must be demonstrated by a criminal defendant to be declared competent to stand trial.
as well as the ability to plan legal strategy
ability to appraise the roles of participants in courtroom procedure
capacity to challenge prosecution witnesses realistically
capacity to testify relevantly
ability to appraise the likely outcome
understanding the possible penalties, among several other
Understanding of the nature of the charges against him or her
Understanding of court procedure
Helping the lawyer in his defense
Having the ability to consult a lawyer
282
Surrogate decision-maker
will make decisions based on what the patient would have wanted
implies that the decision-maker be familiar with the patient's values and attitudes
283
Best interest principle
which was the past, but not current, standard
| states that a decision-maker will decide which option would be in the patient's best interests.
284
Patients
do have the right to refuse treatment that they feel would lessen their quality of life.
285
Advanced directives and living wills
ways for patients to preserve their wishes in writing
| so that correct decisions are made for them should they become incapacitated
286
The State
will follow the course that preserves human life
| if a suitable surrogate decision-maker not be present.
287
Surrogate decision-makers
```
can be appointed by
the patient
the court
or the hospital.
moslty this person is the patient's next of kin.
```
288
Tarasoff vs Regents of the University of California
```
landmark case from 1976
California Supreme Court ruled
that any psychotherapist who believes that a patient could injure or kill someone must notify
potential victim,
victim's relatives or friends
or the authorities.
In 1982
second ruling that broadened Tarasoff
to include the duty to protect, not only to warn, the intended victim.
```
289
The Durham Rule
case of Durham vs the United States in 1954 by Judge Bazelon.
stipulates that a defendant cannot be found criminally responsible if the criminal act was the product of a mental illness or defect.
In 1972 the District of Columbia Court of Appeals, in the ruling United States vs Brawner, discarded the Durham Rule.
290
In 1976 in the ruling of O'Connor vs Donaldson
the U.S. Supreme Court ruled that harmless mentally ill patients cannot be confined involuntarily without treatment if they can survive outside an institution
291
Clites vs State
landmark case
pertaining to a ruling in favor of a patient and his family who sued for damages resulting from chronic neuroleptic exposure that resulted in tardive dyskinesia. T
he appellate court ruled that the defendants deviated from the usual standards of care by failing to conduct physical examinations and routine laboratory tests and failed to intervene at the first signs of tardive dyskinesia.
292
advanced directives be discussed with a patient
At a time when the patient is competent
293
Privilege
psychiatrist's right to maintain a patient's secrecy or confidentiality
even in the face of a subpoena.
right of privilege belongs to the patient, not the psychiatrist
therefore the patient can waive the right.
Exceptions to medical privilege
physicians
do not legally enjoy the same privilege that exists between husband and wife, priest and parishioner, and a client and an attorney.
294
Confidentiality
professional obligation of the physician to maintain secrecy regarding all information given to him or her by the patient
A psychiatrist
may be asked to testify by subpoena
thereby be forced to break a patient's confidentiality
A patient may release the clinician from the obligation of confidentiality by signing a consent to release information.
Each release pertains to a specific matter or piece of information
may need to be reobtained for subsequent disclosures
295
Communication rights
patient's right to free and open communication with the outside world by either telephone or mail, while hospitalized
296
Private rights
the patient's right to privacy. I
n a hospital setting
this applies to patients
having private toileting and bathing space
secure storage space for personal effects
adequate personal floor space per person
have the right to wear their own clothing and carry their own money
Certain restrictions to this right may apply
based on dangerousness to self or others
297
Clinical responsibility
not a forensic term
refers to the responsibility of the physician to the patient to provide the patient with the best care possible in any clinical setting, irrespective of the patient's financial, racial, or personal status.
298
Psychiatrist keeps a medical chart as well as a separate set of psychotherapy notes for one of her patients.
records are subpoenaed by a court
| only the medical chart should be turned over to the court.
299
The law treats
the medical chart separately from psychotherapy notes
The medical chart is the official record of the patient's care.
The patient has a right to see it and it can be subpoenaed into a legal proceeding.
Psychotherapy notes belong to the therapist
are the therapist's own notes to him- or herself, which serve as a reminder of the details of the sessions.
They are not considered part of the medical record
are not part of the official record of care.
As such they cannot be subpoenaed.
They should not be turned over in this situation
it is always a good idea to get signed permission from the patient to release records, when presented with a subpoena from a court you do not have the right to withhold the records from the court
should not release anything more than is specifically requested
300
The M'Naghten rule
comes from British law
stating that a patient is not guilty by reason of insanity
if he or she has a mental disease such that he or she was unaware of the nature, quality, and consequences of his or her actions
and was incapable of realizing that his or her actions were wrong.
301
Ford vs Wainwright
case that sustained the need for a patient to be competent in order to be executed.
psychiatrists are ethically bound not to participate in state-mandated executions in any way
302
Respondeat superior
legal concept
| stating that a person at the top of a hierarchy is responsible for the actions of those at the bottom of the hierarchy.
