Behavioral Science Flashcards
What is the time frame for which acute stress disorder takes place?
during the first month after a traumatic event.
It cannot be diagnosed after a month has passed since traumatic event
~50% develop into PTSD
What is the time frame for which PTSD takes place?
After the first month following a traumatic event.
Cannot be diagnosed during the first month after traumatic event.
What are the clinical symptoms of Acute stress disorder and in PTSD?
What is different between the two?
Acute Stress Disorder:
- Reliving: flashbacks, nightmares, intrusive memories
- Avoidance of reminders
- Negative mood, cognition
- Dissociative: depersonalization/derealization/dissociative amnesia of part or all of event
- Hyperarousal: decreased sleep, aggression-overreacts to perceived threat, hypervigilant
In PTSD, all the same clinical symptoms EXCEPT for the dissociative symptoms and it lasts longer than 1mo
What term describes the persistent feelings of detachment or estrangement from ones own body, thoughts, perceptions, and actions or environment?
Depersonalization/derealization disorder
This is seen in acute stress disorder but NOT PTSD
Which of the following meet the “relieving” critera in the DSM-5 for PTSD in adults?
- Repeatedly talking about the trauma
- Intrusive memories
- Nightmares specifically of the trauma
- Nightmares without a necessarily specific theme
- Flashbacks
- Intrusive memories
- Nightmares specifically of the trauma
- Flashbacks
Which of the following symptom clusters would allow you to diagnose post traumatic stress disorder in a patient who is recovering from a near fatal accident at work?
a. Repeatedly speaking about the accident, Pessimistic thoughts, Sadness
b. Flashbacks of the accident, Avoidance of feelings related to the accident, Leaden paralysis
c. Nightmares of the accident, not going to work (to avoid reminders of the accident), depression, easily angered and aroused
C. Nightmares of the accident, not going to work (to avoid reminders of the accident), depression, easily angered and aroused
PTSD criteria: Reliving (nightmares), avoidance of reminders (not going to work), negative mood (depression), and hyperarousal (easily angered and aroused)
What are the three steps to coping after trauma?
- Stabilize, deal with immediate needs – distress after trauma is normal
- Grief – feel and process feelings that could not be felt at the time
- Integration, make meaning of experience new sense of self, world
T/F: Psychological debriefing after trauma (forcing people to talk about traumatic event) ultimately is a good way to helps people cope
FALSE
Note: stabilizing is an important step, AVOID “psychological debriefing”
“Psychological debriefing” after trauma (people were asked to talk about trauma to counselors for a single session) increased the likelihood of acute stress disorder/PTSD!
Tx for acute stress disorder?
Can treating acute stress disorder prevent PTSD?
cognitive behavioral therapy (CBT) with psychoeducation to normalize the distress after trauma
SSRIs are reasonable and even low dose benzodiazepines can be given for sleep but limit to short-term <2weeks
None of the Rx shown to prevent PTSD
Tx for PTSD?
CBT, mindfulness-based stress reduction, psychodynamic psychotheramy
SSRI are first line tx
Rx nightmares/flashbacks by reducing noradrenergic activity with prazosin, clonidine
Avoid long benzos
When treating PTSD, what is the Rx used for symptims of nightmares/flashbacks
Done by reducing noradrenergic activity with
- prazosin (alpha 1 blocker)
- clonidine (alpha 2 agonist)
Beta blockers do not help
Which of the following is/are an evidence-based first line treatment for acute stress disorder or PTSD?
a. Cognitive behavioral therapy
b. Sertraline
c. Debriefing therapy right after the trauma
d. Psychodynamic Psychotherapy
e. Bupropion
f. Propranolol
g. Mindfulness meditation
h. Clonidine
a. Cognitive behavioral therapy
b. Sertraline (=SSRI)
d. Psychodynamic Psychotherapy
g. Mindfulness meditation
h. Clonidine
What part of the brain does extinction learning during reconsoldation of memories depend on?
The idea is to get the Fear cue no longer associated with harm, this leads to extinction
Extinction depends on medial PFC (mPFC), ACC (ant cingulate cx)
mPFC, ACC damaged after child abuse.
Long Term Depression means
increase/decrease of synaptic weight
increase/decrease of threshold for action potential
Long Term Depression underlies extinction: True/False
Long Term Depression means
decrease of synaptic weight
increase of threshold for action potential
Long Term Depression underlies extinction: True
Long Term Potentiation means
increase/decrease of synaptic weight?
increase/decrease of threshold for action potential?
Long Term Potentiation means
increase of synaptic weight
decrease of threshold for action potential
The subcortical fast pathway involves synapses between which two brain structures?
Thalamus directly to amygdala to trigger the fear response
Fear extinction involves the _______ inhibiting the excitaiton of the _______, therefore no action potential elicited, resulting in long-term depression (decreased synaptic weight)
vmPFC, Amygdala
The slow polysynaptic pathway involves synapses from where to where?
thalamus then up into cortex then to amygdala to reduce output (output of amygdala is fear response)
T/F: an impaired fear extinction process is seen in many anxiety disorders (PTSD, panic, OCD, etc.)
True
What are the 4 symptom clusters of PTSD?
To diagnose, need traumatic experience
PLUS 4 symptom clusters
1. Reliving (Intrusive memories/re-experiencing) the trauma
2. Avoidance of reminders
3. Negative cognitions/negative mood/emotional numbing
4. Hyperarousal
Which of the following is/are likely to be true regarding psychotherapy for acute stress disorder or post-traumatic stress disorder?
a. Psychotherapy involves retrieving and then modifying the memory of the trauma during reconsolidation
b. Memories are most easily modified while stored without directly retrieving them
c. Regarding the fear response, psychotherapy promotes the “fast subcortical pathway” over the “slow cortical pathway”
d. Psychotherapy reduces fear by helping to bypass the amygdala
e. A large hippocampus is likely to interfere with the efficacy of psychotherapy.
f. Extinction of the fear response is believed to be from prefrontal inhibition of the activity of the amygdala, leading to long term depression of the synapse mediating the fear response.
a&f are correct
a. Psychotherapy involves retrieving and then reconsolidating the memory of the trauma.
f. Extinction of the fear response is believed to be from prefrontal inhibition of the activity of the amygdala, leading to long term depression of the synapse mediating the fear response.
Brain fear pathways for exam:
- The amygdala mediates what emotion?
- what area in the brain causes extinction?
- Fear
2. medial prefrontal cortex (PFC)
T/F: Memories are most easily modified while stored without directly retrieving them
False
memories are modified after retrieval during reconsolidation.
Psychotherapy involves retrieving and then reconsolidating the memory of the trauma.
T/F: Psychotherapy reduces fear by helping to bypass the amygdala
False.
Psychotherapy promotes nuanced response from slow polysynaptic cortical path to amygdala, but does not bypass the amygdala
T/F: A large hippocampus is likely to interfere with the efficacy of psychotherapy.
False:
Hippocampal atrophy interferes
With regard to the biological abnormalities in PTSD:
The hypothalamic pituitary adrenal axis (HPA) will show and increased/decreased CRF?
Alarm clusters will be hyper- or hypoactive?
1. Insula, amygdala
2. Frontal areas-ACC, vmPFC
3. Hippocampus
HPA Axis:
Increased CRF
Some controversy – high vs low cortisol
Alarm Centers: Insula, Amygdala – hyperactive
Frontal Areas: ACC, vmPFC – smaller, hypoactive
Hippocampus - smaller
Which is true regarding the primary function(s) of the hippocampus?
a. Short term memory storage
b. Working memory storage
c. Converts short term memory to long term memory
d. Needed for ability to remember a phone number for 30 seconds
e. Neurogenesis takes place in the hippocampus
f. Long term memory storage
a, c, e are correct
a. Short term memory storage
c. Converts short term memory to long term memory
e. Neurogenesis takes place in the hippocampus
b. Working memory storage (no, this involves prefrontal cortex)
d. Needed for ability to remember a phone number for 30 seconds
(no - this is working memory)
f. Long term memory storage (no - once memory is stored long term, hippocampus does not play a primary role in storage)
In which type of gain do you have unconscious motives and in which type of disorders is this seen?
Primary gain: unconscious motives
Seen in somatization and conversion disorder (unconscious production of symptoms), and also in factitious disorder (conscious or purposeful production of symptoms)
In which type of gain do you have conscious motives and in which type of disorders is this seen?
Secondary gain: consciously avoid work or school responsibilities, gain money from disability, etc.
This is seen in malingering (conscious production of symptoms with a conscious motive)
In which disorders do you see an unconscious production of symptoms?
Which do you see a conscious production of symptoms?
Unconscious: not intended by the patient, seen in somatization disorders and conversion
Conscious production of symptoms: patients are aware or feigning/inducing illness, see in malingering
In which disorder do you see a conscious production of symptoms for an unconscious gain?
Factitious disoder (primary gain)
In which condition to patients consciously feign symptoms because of an unconscious motivation?
a. Malingering
b. Factitious disorder
c. Conversion disorder
d. Somatic symptom disorder
e. Hypochondriasis
b. Factitious disorder
Which disorder is being described:
Unconscious production of symptoms, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried
Somatization disorder (somatic symptom disorder)
In which disorder do you see a sudden and dramatic loss of one or more voluntary motor and/or sensory fcn suggesting a neurologic etiology, that is preceded by psychological stress or conflict?
Conversion disorder
Unconscious, no secondary gain, patient aware of loss and symptom generation
Usually self-limited with remission in <1 month
More common in the psychiatrically unsophisticated (adolescent and young adults, rural) and those with depression or histrionic personality traits
Examples:
Seeing something violent = blindness
Shooting someone in self defense = right arm paralysis
What disorder is described:
Fear/idea of having a serious medical illness based on misinterpretation of bodily symptoms- now thought to be part of generalized anxiety disorder (GAD) spectrum…
Hypochondriasis (renamed illness anxiety disorder)
Persists despite negative findings and reassurance after medical work ups
May cause “doctor shopping” as patient believes the doctor ‘missed it’
Symptoms must persist for ≥6 months
What condition is being described:
Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried
High health anxiety without somatic symptoms (unlike somatic symptom disorder where there is worry and somatic symptoms)
Hypochondriasis (renamed illness anxiety disorder)
Persists despite negative findings and reassurance after medical work ups
What condition is being described:
Preoccupation with an imagined problem or insignificant abnormality in appearance – usually involving the face or head
Examples
Nose too big/crooked, breasts /body not symmetrical, muscles not symmetrical, too small (adonis complex)
Body Dysmorphic Disorder (BDD)
Cannot be accounted for by an eating disorder
Anorexics are body dysmorphic thinking they are overweight
Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried
What condition is being described?
Protracted pain that is severe enough to cause the patient to seek medical attention
Cannot be explained by physical causes
Acute (<6 months) or chronic (≥6 months)
Typical age of onset during 3rd or 4th decade of life
Can be disabling and cause dependence on pain meds
Pain disorder (DSMIV) Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried
What is Tx for somatoform disorders?
These disorders are largely unconscious w/o a clear secondary gain
Ex. Conversion disorder, somatization disorder, hypochondriasis, body dysmorphic disorder, pain disorder
Tx: est strong doc-pt relationship w/ regular short appointments, reassure empathy. Typically psychiatry not needed, Identify social stressors and motivations for primary gain, identify and treat comorbid conditions (depression, anxiety)
SSRI/TCAs, psychotherapy (CBT)
Which disorder was formerly known was Munchausen syndrome?
Factitious disorder
Münchausen syndrome ‘by Proxy’ if you create medical problems in others
Which disorder is being described
Conscious feigning or production of physical or mental illness in order to receive attention from medical personnel
to assume the “sick” role, a primary gain to feel safe and cared for
possible secondary gain to feel proud, an expert, able to figure things out that doctors cannot
Factitious disorder
Get angry and leave quickly when confronted
More common in people who work in the medical field
Tends to have a negative impact on work, school, and/or social functioning
What disorder is being described?
Most commonly, a parent feigns or induces illness in a child to gain attention for him or herself
Considered a form of child abuse and must be reported!
The parent may have a history of childhood abuse/neglect or serious childhood illness during which he or she felt cared for and protected by medical personnel
Or may like being the expert in his/her child’s care
What disorder is being described?
Conscious simulation or exaggeration of physical or mental illness to achieve some sort of secondary gain
Disability (ex. Drugs in the ER, Leave of absence/ AWOL)
Symptoms improve as soon as the secondary gain is obtained
Malingering
Seen more frequently in the incarcerated and people involved in lawsuits
A 20 y o nursing student is admitted with a week of episodes of hypoglycemia, documented to be as low as 20. C-peptide levels are normal, ie not consistent with an insulinoma. Counterregulatory hormones such as cortisol levels are normal. An endocrinologist concludes the symptoms are functional. The patient angrily demands further testing, stating “Noone ever listens!” To make a diagnosis, the step(s) most likely to benefit the patient would be…
a. Obtain a second endocrinologist opinion to reassure the patient
b. Order an octreotide scan
c. Clarify what the intention of the patient might be.
c. Clarify what the intention of the patient might be.
The nurses find insulin in her purse. An interview with the family and the patient reveals she has no interest in obtaining disability, or avoiding school. There are no legal or financial concerns. She has had a chronically difficult relationship with her father who is obviously narcissistic on interview. This relationship worsened a week ago when he threatened to disown her for a relationship with a man he disapproved of. What is the dx?
a. Malingering
b. Conversion disorder
c. Factitious disorder
d. Somatization
c. Factitious disorder
Purposeful production of symptoms consciously giving herself insulin but unconscious motivation
which part of the brain is responsible for processing somatic pain AND social distress?
anterior cingulate cortex (ACC) and insula
Acetaminophen reduces feelings of Social Rejection and reduces activation of ACC/Insula
A 25 year old woman seeks care for recurrent headaches present for yrs. MRI brain and two neurology consults have not been able to identify a cause. She becomes quite upset as she describes being told she needs a psychiatrist by her last neurologist. Which step(s) would you take?
a. CT angiography
b. Lumbar puncture
c. Referral to mental health provider
d. Reassurance that she does not have a severe illness
e. regular visits with you
f. Ask if she wants to involve family members next time
d. Reassurance that she does not have a severe illness
e. regular visits with you
f. Ask if she wants to involve family members next time
If suspecting irritable bowel syndrome but see any of these symptoms, what do you do next?
weight loss, blood in stool, pain/diarrhea wakes pt from sleep, fevers, fam hx of celiac disease/GI cancers/Inflammatory bowel disease/ abnormal labs (high WBC, low HgB/HCT, MCV,low Fe, positive occult blood in stool)
GI referral, GI scope
These are red flags that suggest it is NOT IBS
What is tx for Irritable bowel syndrome
Reassurance
Diet changes (e.g more fiber if constipation, no beans if bloated)
Rx symptoms (eg laxatives for constipation)
SNRI can help with chronic pain
Uptodate - Refractory cases: identify and address psychosocial concerns
What condition is being described:
widespread MSK pain (muscles and joints)
Associated with fatigue, nonrestorative sleep, cognitive disturbances,mood disorders
Px:
-multiple tender points in characteristic soft tissue locations (no need to memorize where)
-otherwise wnl, no inflammation of joints
Fibromyalgia
Patient education: Reassurance dx is benign
Dx and Rx sleep disorders (eg is there sleep apnea? Optimize sleep hygiene…)
Dx and Rx mood disorders
Exercise
Medication – avoid polypharmacy, choose one
SNRI (venlafaxine, or duloxetine or milnaciprine or tricyclic antidepressant eg amitriptyline)
Or pregabalin
In general, what is the best treatment for somatic-type disorders?
a. order every possible invasive tests to rule out a bona fide medical issue
b. refer to specialists to obtain the most accurate assessment
c. simplify # of providers
d. medications and procedures
e. refer to psychiatry for intensive management
c. simplify # of providers
An elderly man presents with blindness after witnessing his house burn down. He is very calm in the Emergency Department and does not appear concerned about his condition. What is the most likely diagnosis?
Conversion disorder
A 49 y o man presents with right arm paralysis 4 days after witnessing a colleague injured at work while operating a machine. He grimaces in agony, & refuses to move the arm. His arm moves normally when he believes he is not observed. He has no interest in hospitalization or outpatient follow up. He is focused on getting morphine and a doctor’s note to skip work for a month. What is his dx?
Malingering
Among the recommendations given for the treatment of somatoform disorders, which of the following appears to be the key element for successful management of this disorder?
A. Repressing any negative countertransference
B.Providing symptomatic treatment to minimize suffering
C.Empathically reassuring rather than confronting the patient
D.Ensuring regular follow up, preferably from the primary care doctor
E.Avoiding interventions, even benign, which may reinforce illness behavior
D. Ensuring regular follow up, preferably from the primary care doctor
A male patient has a preoccupation and fear that he has a serious disease based on his misinterpretation of bodily symptoms. His concern cannot be relieved by appropriate medical· evaluation and reassurance. The most likely diagnosis is: A. major depressive episode. B. body dysmorphic disorder. C. somatization disorder. D. generalized anxiety disorder. E. hypochondriasis.
E. hypochondriasis.
Hypochondriasis (illness anxiety disorder per DSM 5) focuses on PREOCCUPATION/FEAR of CONSEQUENCES of symptoms (“I have a serious disease”), while somatization focuses on distress from symptoms.
Which of the following is the principal feature that distinguishes hypochondriasis from delusional disorder, somatic type? A. Insight B. Paranoia C. Feigning illness D. Memory changes E. Disorganized thinking
A. Insight
Delusional disorder is characterized by a fixed, persistent, false belief system lasting >1mo. Functioning otherwise is not impaired
A 32-year-old patient in otherwise good health cannot move the right leg. Extensive neurological examination cannot find a physiological cause for the patient’s apparent paralysis. Several psychiatric diagnoses are considered including conversion disorder, factitious disorder and malingering. The diagnosis is most likely to be conversion disorder if evidence of which of the following can be demonstrated?
A. Symptoms not intentionally produced
B. Clear secondary gain behind the behavior
C. Primary motivation to assume the sick role
D. Evidence of a comorbid personality disorder
E. Patient relatively unconcerned about the symptoms
A. Symptoms not intentionally produced
142. Which of the following therapies for irritable bowel syndrome has demonstrated high efficacy in controlled trials? A. Hypnosis B. Surgical resection C. Tincture of morphine D. Supportive psychotherapy E. Progressive muscle relaxation
D. Supportive psychotherapy
What are the three components of the risk triad for suicide risk level?
- Ideation
- Plan
- Intention
He said he will give questions that have a patient with either all high risks factors (ideation, plan, intention) on the risk triad or all low risk- nothing in between.
What are the three most important risk factors for suicide completion?
- serious earlier attempt
- male
- substance abuse/dependance
A patient states that he has incessant thoughts that he cannot dismiss about dying, admits that he has seriously thought about driving his car into a bridge and has a plan to do this when his divorce is finalized this year. What is his risk level for suicide?
a. none
b. low
c. moderate
d. high
High risk
A patient states that she has frequent and daily thoughts about suicide. She admits she has no imminent plan, but thinks an overdose would be peaceful. She states on a few occasions over the last year that she intended to take a handful of pills but could dismiss these impulses. This has not happened in a few months. What is her suicide risk level?
a. none
b. mild
c. moderate
d. high
b. Mild
What is the name for a sensation perceived by a patient that precedes a condition affecting the brain that often occurs before a migraine or seizure.
Aura: A sensation perceived by a patient that precedes a condition affecting the brain. An aura often occurs before a migraine or seizure.
What is the difference between aura and prodrome
Aura is short and technically part of the seizure, it is the start of the seizure when there is still no impaired consciousness.
Prodrome is longer and is not technically a seizure.
What is the main event that occurs during the seizure called?
What is the phase between two seizures called?
What is the phase that occurs following a seizure?
Ictal- the main clinical presentation
Inter-ictal
Post-ictal
What are the 3 main mechanisms that account for seizures
- Change in GABA receptor-mediated inhibition
- Network reorganization (sprouting of dentate axons -mossy fibers)
- Genetic susceptibility (epileptic channelopathies)
A lowered seizure threshold based on a mutation causing changes in the current that is carried by a channel is called what?
Epileptic channelopathies
These can be either enhanced (gain of) function or reduced (loss of) function, both of which result in abnormal balance of ions across membrane
What determines the symptoms of a epileptic seizure?
The cortical areas involved, ex. if motor cortex is involved you might have motor signs (convulsions), and if sensory cortex is involved you might get sensory issues
T/F: both focal and generalized onset of epileptic seizures can result in either aware or impaired awareness and motor or non-motor
False: Focal onset can be either aware or impaired awareness with motor or non-motor
Generalized onset involves both hemispheres and is almost exclusively impaired and can be motor or non-motor
_______ is a disease of the brain defined by any pf the following:
- at least 2 unprovoked seizures more than 24h apart
- Diagnosis of an epilepsy syndrome
Epilepsy
Epilepsy syndrome, more precisely an electroclinical syndrome, is a complex of clinical features, signs and symptoms that together define a distinctive, recognizable clinical disorder
