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
______ refers to a set of brief unconscious behaviors. These typically last for several seconds to minutes or sometimes longer, a time during which the subject is unaware of his/her actions. Repetitive movements such as lip smacking or chewing, or movement of hands
automatism
What are the clinical manifestations of severe myoclonic epilepsy of infancy (SMEI) in the 1st year of life and 2nd year of life?
1st year of life:
- seizures associated with elevated body temp (fever or bathing)
- Progressively prolonged and cluster seizures
- Later, seizures without fever
2nd year of life:
- Psychomotor delay (dev. delay)
- Ataxia (problem with coordination)
- Cognitive impairment
Describe the pathophysiology of SMEI (severe myoclonic epilepsy of infancy)
This is a channelopathy so it begins with reduction of functional Na+ channel density, then loss of high frequency action potentials, then loss of inhibitory fcn of GABAergic neurons (cortical or purkinje) leading to either seizures (cortical interneurs involved) or ataxia (cerebellar prukinje fibers involved).
What is the clinical result when SMEI involves loss of inhibitory fcn of GABAergic purkinke cells?
Ataxia
What is the clinical result when SMEI involves loss of inhibitory fcn of GABAergic cortical interneurons?
seizures
What are the two main clinical manifestations of SMEI?
Ataxia (loss of inhibitory fcn of GABAergic purkinke cells)
Seizures (loss of inhibitory fcn of GABAergic cortical interneurons)
What is Tx of SMEI?
The goal is to try and re-establish GABAergic transmission.
Tiagabine–> decreases the reuptake of GABA
Benzodiazepines (clonazepam) –> increase in respose of post-synaptic GABA receptors
What is the timeframe for diagnosing schizophrenia?
What about for schizophreniform disorder?
Symptoms for schizophrenia: lasting >6mo
schizophreniform: lastingt <1 month
Diagnositic criteria for schizophrenia?
Dx requires at least 2 of the following criteria, and at least 1 of these should included 1-3
- Delusions
- Hallucinations-often auditory
- Disorganized speech
- Disorganized or catatonic behavior
- Negative symptoms (affect flattening, avolition, anhedonia, asociality, alogia)
Symptoms for schizophrenia: lasting >6mo
T/F: Schizophrenia is associated with reduced dopaminergic activity and decreased dendritic branching?
False. Schizo is assoicated with increased dopainergic activity and decreased dendritic branching
a 57 yo male with schizophrenia with continuous symptoms for 30 years despite treatment. Which brain morphometric finding is most likely increased in size?
a. ventricles
b. hippocampus
c. cortical gray matter
d. prefrontal cortex
a. Ventricles
Ventriculomegaly on brain imaging
Interviewing a patient, he responds to your question about whether he has difficulty with train of thought by answering “the train brain rained on me”. This is an example of what?
a. echolalia
b. clanging
c. echopraxia
d. alogia
correct answer is clanging: the association of words based on sound rather than context
echolalia: repeating of someone else’s comment
echopraxia: repetition of the movement of another person
alogia: person isn’t speaking
A medical student reports that his interview of a patient with schizophrenia has been difficult bc the patient, though alert, speaks only minimally, this is an example of:
a. echolalia
b. echopraxia
c. loose associations
d. alogia
e. flight of ideas
Correct answer is alogia: person isn’t speaking
echolalia: repeating of someone else’s comment
echopraxia: repetition of the movement of another person
loose association is the changing of topics rapidly and flight of ideas is a subtype of loose associations, that is more rapid
alogia: person isn’t speaking
A patient interviewed has pressured speech that is hard to follow bc of its volume and speed. The patient says “The sky is blue. I love blue eyes. My eyes are watering. Theres water everywhere…” is an example of:
a. echolalia
b. echopraxia
c. circumstantial speech
d. alogia
e. flight of ideas
flight of ideas is the answer
loose association is the changing of topics rapidly and flight of ideas is a subtype of loose associations, that is more rapid
echolalia: repeating of someone else’s comment
echopraxia: repetition of the movement of another person
Circumstantial speech is overly detailed speech
alogia: person isn’t speaking
” twas brillig and the slithy toves did gyre and gimble in the wabe” The poem by lewis carroll has many examples of:
a. alogia
b. echopraxia
c. neologisms
Neologisms: creating new words
alogia: person isn’t speaking
echopraxia: repetition of the movement of another person
After a 24h shift with no sleep, a resident takes an evening hike and mistakes a log in the water for a crocodile. He takes a second look and realizes its really a log. This is an example of:
a. delusion
b. illusion
c. hallucination
d. confusion
illusion
delusion: this is a belief not a perception that is false
hallucination: internally generated, seeing something that is not actually there, not mistaking something that is present
confusion
You are consulted on a 46yo accountant recovering from elective hernia repair. He has visual hallucinations of glittery holiday streamers in his room and intermitted agitation. On exam he is lethargic, has psychomotor retardation, is disoriented to time and place, and intermittently mumbles:
a. schizophrenia
b. schizoaffective disorder
c. delirium
d. bipolar mania with psychosis
c. delirium
Schizophrenia is usually associated with auditory hallucinations.
- Lethargy (implies change in alertness) is not a symptom of schizophrenia.
- Disorientation to time and place is not a symptom of schizophrenia
If a patient has visual hallucinations, you should be strongly suspicious of what mental condition?
delirum
Schizo has mostly auditory hallucinations
Choose all indications (symptoms) that a diagnosis is an organic condition and not schizo?
a. psychomotor retardation
b. new onset of psychotic symptoms at age of 46
c. lethargy
d. visual hallucinations
e. disorientation
f. agitation
a. Psychomotor retardation can be seen in a lot of psychiatric conditions
b. a new onset at 46yo should make you highly suspicious to the fact that you might be dealing with an organic condition..it is unlikely that schizophrenia or other mental disorders start that late
c. lethargy is decreased in alertness should make you suspicious to the fact that you might be dealing with an organic condition
d. Visual hallucinations is indication for organic
e. disorientation is indication for organic
f. agitation can be seen in both mental and organic
Symptoms of schizophrenia can be classified as positive or negative.
What are positive symptoms?
- Positive symptoms are things additional to expected behavior and include delusions, hallucinations, agitation, and talkativeness.
Symptoms of schizophrenia can be classified as positive or negative.
What are negative symptoms?
Negative symptoms are things missing from expected behavior and include lack of motivation, social withdrawal, flattened affect, cognitive disturbances, poor grooming, and poor (i.e., impoverished) speech content.
Symptoms of schizophrenia can be classified as positive or negative.
_________ respond well to most traditional and atypical antipsychotic agents.
Positive symptoms
Symptoms of schizophrenia can be classified as positive or negative.
___________ respond better to atypical than to traditional antipsychotics
Negative symptoms
What type of disorder and symptom does this describe?
Misperception of real external stimuli
Ex. Interpreting the appearance of a coat in a dark closet as a man
Disorder of Perception
Symptom of illusion
What type of disorder and symptom does this describe?
-False sensory perception
Ex. Hearing voices when alone in a room
Disorder of Perception
Symptom of hallucination
What type of disorder and symptom does this describe?
- False belief not shared by others.
ex. The idea of being followed by the FBI
Disorder of thought content
symptom of delusion
What type of disorder and symptom does this describe?
- False belief of being referred to by others
ex. The feeling of being discussed by someone on television
Disorder of thought content
Symptom of ideas of reference
What type of disorder and symptom does this describe?
Problems discerning the essential qualities of objects or relationships
ex. When asked what brought her to the emergency room, the patient says, “An ambulance”
Disorder of thought process
Symptoms of impaired abstraction ability
What type of disorder and symptom does this describe?
- Belief that thoughts affect the course of events
ex. Knocking on wood to prevent something bad from happening
Disorder of thought process
Symptoms of magical thinking
What type of disorder and symptom does this describe?
- Inclusion of too much detail
ex. When asked about her health, the patient explains everything that she did since getting up that day before getting to the subject of her health
Disorder of form of thought
Symptoms of Circumstantiality
What type of disorder and symptom does this describe?
- Shift of ideas from one subject to another in an unrelated way
ex. The patient begins to answer a question about her health and then shifts to a statement about baseball
Disorder of form of thought
Symptoms of Loose associations
What type of disorder and symptom does this describe?
- Inventing new words
ex. The patient refers to her doctor as a “medocrat”
Disorder of form of thought
Symptoms of Neologisms
What type of disorder and symptom does this describe?
- Repeating words or phrases
ex. The patient says, “I’m evil, I’m evil, I’m evil”
Disorder of form of thought
Symptoms of perseveration
What type of disorder and symptom does this describe?
- Getting further away from the point as speaking continues
ex. The patient begins to answer a question about her health and ends up talking about her sister’s abortion; she never gets back to the subject of her health
Disorder of form of thought
Symptoms of tangentiality
What are the 3 phases of schizophrenia?
Prodromal, active, and residual phases
What characterizes the prodromal phase of schizophrenia
Prodromal signs and symptoms occur prior to the first psychotic episode and include avoidance of social activities; physical complaints; and new interest in religion, the occult, or philosophy.
What characterizes the active phase of schizophrenia
In the active phase, the patient loses touch with reality. Disorders of perception, thought content, thought processes, and form of thought (Table 11.1) occur during an acute psychotic episode.
What characterizes the residual phase of schizophrenia
In the residual phase (time period between psychotic episodes), the patient is in touch with reality but does not behave normally.
a. This phase is characterized by negative symptoms.
b. In this phase the patient typically shows intact memory capacity; is oriented to person, place, and time; and has a normal level of consciousness (e.g., is alert).
Positive symptoms of schizophrenia are associated with increased dopaminergic activity in which CNS pathway?
Negative symptoms?
Positive symptoms of schizophrenia are associated with increased dopaminergic activity in the mesolimbic pathway.
Negative symptoms of schizophrenia are associated with decreased dopaminergic activity in the mesocortical pathway.
A man with no past psychiatric history experiences an episode of psychosis lasting 3 weeks. What is the most likely dx?
Brief psychotic disorder is an unprecedented episode of psychosis lasting more than a day but <1 month.
_________ disorder is an episode of psychosis lasting <6mo but >1mo
Schizophreniform disoder
_________ is characterized by social withdrawal without psychosis.
Schizoid personality disorder
What are the negative symptoms of schizophrenia
Negative symptoms of schizophrenia are “subtracted” from a normal person’s behavior. They include:
Flattening of affect
Thought blocking (sudden halt in train of thought)
Deficiencies in speech content
Cognitive disturbances
Poor grooming
Lack of motivation
Social withdrawal_________ is a disorder characterized by psychosis associated with intermittent mood disorders, such as mania or depression.
Schizoaffective disorder
How long must schizophrenia last for prior to making a dx?
Schizophrenia is a mental disorder characterized by psychotic episodes and decline in functioning that can be diagnosed after 6 months of schizophrenic symptoms.
In patients with schizophrenia, what changes are seen in dopaminergic activity and dendritic branching ?
Schizophrenia is associated with increased dopaminergic activity and decreased dendritic branching.
A man has a consistent delusion that his boss is trying to poison him but otherwise has relatively normal social functioning. What is the most likely dx?
Delusional disorder is characterized by a fixed delusional system lasting at least one month with normal social and occupational functioning.
What type of eating disorder is characterized by body dysmorphism, fear of gaining weight, restriction of energy intake and is associated with a more rigid, controlling, and high achieving personality profile?
Anorexia nervosa
Medical issues include:
Weight loss, hypothermia (low fat), electrolyte imbalance (K+), lanugo hair (fine, white hair), and organ failure in severe cases.
How do you treat anorexia nervosa?
Very difficult to treat…may require hospitalization with forced feedings.
Psychotherapy is key, since pharm meds have not shown to be effective. Psychodynamic and CBT or even family therapy (for enablers)
What type of eating disorder is characterized by eating an atypically large amount of food in a discrete period of time that is disproportionate to typical eating.
Seen with more personality disorders and substance abuse, erratic personalities and impulsiveness, dysfunctional family
Bulimia nervosa
Binges 1x week/ for 3 months
Greater prevalence than anorexia
Normal to obese premorbidly
Abraided knuckles (russell’s sign), dental cavities/enamel loss, in normal/overweight and sexually active individuals is characteristic to patients of what behavioral condition?
Bulimia nervosa
Also high amylase is seen due to salivary enlargement
Low PO4 and low Mg++
What is the tx for bulimia nervosa?
Individual therapy (CBT, dynamic, group, family)
SSRI use is approved (increase serotonin)
Hospitalization is rarely needed and outcomes are better than what is seen with anorexia
A 19 yo has anorexia where she solely restricts food to a severe level based upon BMI. which of the following would you NOT expect to see? A. Hypokalemia B. Lanugo hair C. Russel's sign D. Syncope
C. Russel’s sign is characteristic of bulimia nervosa, where purging is seen
St. John’s wort is sometimes used to treat what disorder?
Mechanism?
Side effects?
Drug interactions?
Depression
Modulates serotonin, NE, DA
Side effects: well tolerated, photosensitivity (sunlight may cause rash)
Drug interactions: P450 inducer causing Rx failure of concomitant drugs (e.g. coags, birthcontrols, etc.)
DO NOT combine with SSRI/SNRI due to risk of serotonin syndrome
Omega-3 fatty acid is sometimes used to treat what disorder?
Side effects?
Drug interactions?
Depression
Side effects include a bleeding tendency, advised to discontinue preoperatively due to bleeding risk.
Avoid mixing with anti-platelets or anticoags
Dehydroepiandrosterone (DHEA) is sometimes used to treat what disorder?
Side effects?
Drug interactions?
Depression
DHEA is a precursor of estrogen and testosterone
Side effects include androgenic (acne, hirsuitism, worsen prostatitis), increased risk for breast cancer, may induce mania
No listed drug interactions
S-adenylmethionine (SAM) is sometimes used to treat what?
Side effects?
Drug interactions?
Used in treatment resistant/refractory depression
Side effects are rare but may include mania
Drug interactions include serotonin syndrome if mixed with SSRIs/SNRIs
Kava, chamomile and valerian root are sometimes used to treat what?
Anxiety- though none have been shown in clinical trials to be clearly effective or ineffective.
Kava and chamomile may reduce anxiety in some people with generalized anxiety disorder (GAD) but valerian and St. John’s wort are either mixed or negative
What are side effects of using Kava to treat anxiety?
Sedation/sleepiness
Severe hepatotoxicity/liver failure
What are some side effects of using Valerian root to treat anxiety?
Respiratory depression
Drowsiness (not surprising in sedatives)
Avoid preoperatively, taper 2 weeks before surgery to avoid withdrawal
Depression is associated with an increase/decrease in what neurotransmitters?
Decrease in NE, Serotonin, DA
Mania is associated with an increase/decrease in what neurotransmitters?
Increase in DA
Decrease in GABA
Schizophrenia is associated with an increase/decrease in what neurotransmitters?
Increase in DA and serotonin
Anxiety is associated with an increase/decrease in what neurotransmitters?
Decrease in GABA and serotonin
Increase in NE
Which catecholamine is involved in the pathophysiology of the conditioned fear response, schizophrenia, and the rewarding nature of certain drugs?
Dopamine
The amino acid tyrosine is converted to dopamine
A 45 yo male patient becomes depressed following a head injury. The areas of his brain that are most likely affected is?
a. Right parietal lobe
b. basal ganglia
c. hippocampus
d. reticular system
e. amygdala
f. left frontal lobe
F. left frontal lobe
Depression is most likely to be associated with damage to the left frontal lobe
A patient shows side effects such as sedation, increased appetite, and weight gain while being treated with an antipsychotic, of the following, which is most likely associated with the symptoms:
a. blocking serotonin receptors
b. blocking DA receptors
c. blocking NE receptors
d. blocking histamine receptors
e. decreased availability of serotonin
D. blocking histamine receptors will cause these side effects, while blocking DA receptors would be associated with parkinsonism-like symptoms and elevated prolactin levels
The major NT involved in the antidepressant action of fluoxetine is what?
Serotonin
It is an SSRI
A 55 yo woman diagnosed with schizophrenia at age 22. If this is correct, the volume of the hippocampus, size of cerebral ventricles, and glucose utilization in the frontal cortex are increased/decreased?
Decreased Hippocampus
Increased size of ventricles (due in part to brain shrinkage)
Decreased Glucose utilization in frontal cortex
a 69 yo former bank president cannot tell you the name of the current president or identify his wife. He began having these memory problems 3 years ago.
Atrophy to which area of the brain is most likely to be seen in this patient?
The patient is showing signs of alzheimer’s, from which the hippocampus will atrophy
Amyloid plaques are seen on biopsy
The brain pathway that is most closely associated with the display of negative symptoms in schizophrenia is which pathway?
What about positive symptoms?
Dopamine hypoactivity in the mesocortical tract is associated with negative symptoms of schizophrenia
Dopamine hyperactivity is seen in mesolimbic tract
A 29-year-old man comes to the emergency department complaining of stomach cramps, agitation, severe muscle aches, and diarrhea. Physical examination reveals that the patient is sweating, has dilated pupils, a fever, and a runny nose, and shows goose bumps on his skin. Of the following, the most likely cause of this picture is? (A) alcohol use (B) alcohol withdrawal (C) heroin use (D) heroin withdrawal (E) amphetamine withdrawal
What is most effective tx?
Heroin withdrawal
Of the choices given, the most effective immediate treatment for heroin withdrawal is clonidine to stabilize the autonomic nervous system. Naloxone and naltrexone as well as stimulants will worsen rather than ameliorate the patient’s withdrawal symptoms.
A 60-year-old man is brought to the hospital after a fall outside of a neighborhood bar. Radiologic studies indicate that the patient has a fractured hip and surgery is
performed immediately. Two days later, the patient begins to show an intense hand tremor and tachycardia. He tells the doctor that he has been “shaky” ever since his admission and that the shakiness is getting worse. The patient states that while he feels frightened, he is comforted by the fact that the nurse is an old friend (he has never met the nurse before). He also reports that he
has started to see spiders crawling on the walls and can feel them crawling on his arms. The doctor notes that the patient’s speech seems to be drifting from one subject
to another. Of the following, what is the most likely cause of this picture?
(A) Alcohol use
(B) Alcohol withdrawal
(C) Heroin use
(D) Heroin withdrawal
(E) Amphetamine withdrawal
(B) Alcohol withdrawal
Heroin use and heroin and amphetamine withdrawal generally are NOT associated with psychotic symptoms
A physician discovers that his 28-year old female patient is abusing cocaine. Which of the following can the doctor expect to see in this patient?
(A) Severe physical signs of withdrawal
(B) Little psychological craving in withdrawal
(C) Euphoria lasting 3–4 days
(D) Delusions
(E) Sedation with use
Delusions and other symptoms of psychosis are seen with the use of cocaine. The intense euphoria produced by cocaine lasts only about 1 hour. Severe psychological craving for the drug peaks 2–4 days after the last dose, although there may be few physiologic signs of withdrawal. Cocaine intoxication is characterized by agitation and irritability, not sedation.
A 40-year-old female patient who has been taking a benzodiazepine daily in moderate doses over the past 5 years abruptly stops taking the drug. When a physician sees her 2 days after her last dose, she is most likely to show (A) hypersomnia (B) tremor (C) lethargy (D) respiratory depression (E) sedation
The answer is B, tremor.
Withdrawal from benzodiazepines is associated with tremor, insomnia, and anxiety. Respiratory depression and sedation are associated with the use of, not withdrawal from, sedative drugs.
A 24-year-old patient is experiencing intense hunger as well as tiredness and headache. This patient is most likely to be withdrawing from which of the following substances? (A) Alcohol (B) Amphetamines (C) Benzodiazepines (D) Phencyclidine (PCP) (E) Heroin
(B) Amphetamines
Tiredness and headache are seen with withdrawal from stimulants. While increased appetite can be seen in withdrawal from all stimulants, the most intense hunger is seen with withdrawal from amphetamines.
What is the major mechanism of action of cocaine on neurotransmitter systems in the brain? (A) Blocks reuptake of dopamine (B) Blocks release of dopamine (C) Blocks reuptake of serotonin (D) Blocks release of serotonin (E) Blocks release of norepinephrine
The answer is A. The major mechanism of action of cocaine on neural systems is to block the re-uptake of dopamine, thereby increasing its availability in the synapse. Increased availability of dopamine is involved in the “reward” system of the brain and the euphoric effects of stimulants.
After 20 years of smoking, a 45-year-old female patient has decided to quit. Of the following, what physical effect is most likely to be seen as a result of this patient’s withdrawal from nicotine? (A) Weight gain (B) Euphoria (C) Excitability (D) Delirium tremens (E) Long-term abstinence
Weight gain commonly occurs following withdrawal from stimulants such as nicotine. Mild depression of mood and lethargy are also seen. Long-term abstinence is uncommon in smokers; most smokers who quit relapse within 2 years. Delirium tremens occur with withdrawal from sedatives such as alcohol.
Clonidine is used to treat heroin withdrawal, what is its mechanism of action?
alpha-2 agonist
What are the parts of the HPA axis and how does it work?
Why is this important in depressed patients?
How do you test this?
HPA axis
Hypothalamus secretes CRF –> causes pituitary to release ACTH –> causes Adrenal to secrete cortisol (glucocorticoid)
Cortisol has a negative feedback on hypothalamus and pituitary to reduce production of their secretions.
In depressed patients or those under intense stress, the negative feedback doesnt work and you get too much cortisol.
Test this with dexamethasone suppression test. Under normal conditions Dexa will decrease cortisol by acting as neg feedback, but in severely depressed/stressed patients this will not work
T/F: CRF release is increased by cortisol when the dexamethasone suppression test is positive.
False: CRF is never increased, it is simply not increased, it will remain the same.
If the HPA axis is functioning correctly, then dexa test will be negative and CRF release will be decreased
A “positive dexa suppression test” is abnormal, indicating that neg feedback is not working
Playing poker you notice that a person drums their fingers when anxious about their hand. You then use this to decide their next bet is a bluff. What is true about your decision?
A. It illustrates mentalization
B. Your decision is made with considerable help from prefrontal cortex
C. Your decision illustrates “theory of mind”
All are true.
Mentalization and theory of mind are essentially the same thing, which is the ability to understand ones own or another persons mental state (i.e. motivation, intentions, perspective, emotional state, “why do I act this way, why does person X act that way?”).
Use prefrontal cortex to help with this process
The desxamethasone suppression test is:
A. a test of hypothalamic-pituitary-thyroid function
B. Often positive in depression
C. Generally positive in cushing’s syndrome
D. Based on whether cortisol increases when dexamethasone is given
B, C.
A- no, it is a tet of the hypothalamus-pituitary-adrenal axis
D- No-cortisol will not INCREASE, but will either decrease (normal) or remain the same (+ dexa suppression test).
Considerable evidence indicates that stress and major depressive disorder are associated with (more than one may be correct)
A. increases parasympathetic activity
B. higher levels of WBCs
C. hippocampal atrophy
D. Decreased CRH release from hypothalamus
E. Increased cortisol levels in blood
C, E correct
A. decreasead parasymp, increased symp activity
B. no
D. No decrease, but increased CRH release from hypothalamus
T/F: in schizophrenia, bipolar, and depression, you see a increase in prefrontal activity
False, you see decrease
T/F: in schizophrenia, bipolar, and depression, you see a increase in hippocampal volume
False, you see atrophy
T/F: in schizophrenia, bipolar, and depression, you see an increase in theory of mind
false, you will see a reduction
Mentalization and theory of mind are essentially the same thing, which is the ability to understand ones own or another persons mental state (i.e. motivation, intentions, perspective, emotional state, “why do I act this way, why does person X act that way?”).
Use prefrontal cortex to help with this process
T/F: The lateral prefrontal cortex is more important than the medial prefrontal cortex in the reward and motivation circuits
False, it is the medial prefrontal cortex that is connected to reward and motivation, not lateral
T/F: the medial prefrontal cortex is more specialized for emotion and motivation, while the lateral prefrontal cortex is more specialized for abstraction and cognition
True
T/f: PFC activity is decreased in bipolar disorder, schizophrenia, MDD, and anxiety disorder
true
PFC mediates executive functions, including planning ahead
T/F: nucleus accumbens is important for mediating fear
False, it is important for reward and behavior
It does receive some input from amygdala (involved in fear) but it is not its primary role
T/F: MDD is associated with a reduction in HPA axis, resulting in increased CRF release and increased cortisol
False, MDD is associated with an increase in HPA, causing increased CRF and increased cortisol
Stress causes which of the following?
A. Hyperactive PFC
B. decreased parasymp activity which causes increased in inflammatory cytokine release from WBCs
C. Increased cortisol and increased inflammatory cytokines which both are neurotoxic
D. Increase in neurotrophic activity
B, C
A- no, hypoactive PFC
D. no, you will see a reduction in neurotrophic (growth promoting) activity
T/F:
Neurogenesis is promoted by serotonin, dopamine, and norepi?
True (i.e. by antidepressants)
Depression has a pos or neg effect on the following: HPA axis Sympathetic/parasympathetic activity Pro-inflammatory cytokines Apoptosis/neurogenesis Hippocampus Frontal activity
HPA axis-high CRF, +dex suppression test, high cortisol (neurotoxic)
increased Sympathetic, decreased parasympathetic activity
increase Pro-inflammatory cytokines (neurotoxic)
Increased Apoptosis, decreased neurogenesis
atrophies Hippocampus
Less Frontal activity (less cognition, less limbic modulation)
T/F: monoamine usually increase neurogenesis, which plays a role in their antidepressant properties?
true
How does minfulness-based stress reduction (meditation) affect the activation of alarm system (amygdala, insula) and PFC/ACC activity?
Decreases activity of alarm centers (amygdala, insula)
Increases PFC/ACC
It is an evidence based tx for major depression
Which of the following correlate the LEAST with functional impairment in a patient with schizophrenia?
Positive symptoms are less correlated
T/F: patients with schizophrenia often experience disorientation as a symptom
T/F: schizophrenia patients often have clouding of consciousness?
False, psychosis rarely affects orientation.
Disorientation is a sign of an organic condition
False, patients do not have clouding of consciousness (ex. no change in arousal/alertness)
Flattened affect/emotion, social withdrawal, poor grooming, lack of motivation, alogia, area all examples of which type of symptoms in schizophrenia
Negative symptoms-missing from expected behavior (decreased or loss of usual function)
Neg symptoms do not respond to antipsychotics
Delusions, hallucinations, thought disorder, grossly disorganized or catatonic behavior are examples of which type of symptoms in schizophrenia
Positive symptoms
Positive symptoms repsond to antispychotics
A high or low level of glutamate activity correlates with pos or neg symptoms in schizophrenia?
it correlates with both
NMDA receptor hypoactivity
hypoactive mesocortical pathway causes ______ symptoms in schizophrenia
negative symptoms
Glutamate (excitatory) will increase dopa activity in mesocortical normally, therefore a decrease in glutamate will result in a decrease in dopa and thus a hypoactive pathway
hyperactive mesolimbic pathway causes ______ symptoms in schizophrenia
positive symptoms
Glutamate (excitatory) will decrease dopa activity in mesolimbic normally, therefore a decrease in glutamate will result in an increase in dopa and thus a hyperactive pathway
What is the tx for schizophrenia?
Antipsychotics will treat positive symptoms via D2 receptor blockers, haloperidol (high affinity) and chloropromazine (low affinity)
2nd generation antispychotics are better because they have fewer side effects(clozapine, olanzapine) The “pines”
Psychotherapy is also good (CBT)
What are some symptoms of schizophrenia patient with catatonia. How do you treat someone with schizophrenia with catatonia?
Patients with catatonia may have hyperactivity or hypoactivity. Mutism is a very significant symptom.
Treat with high does IV lorazepam (benzo), tx with ECT if lorazepam doesnt work
DO NOT TREAT WITH ANTISPYCHOTICS-may cause malignant catatonia
T/F: there is a weak genetic component to schizophrenia?
False, strong component to the etiology of schizophrenia seen through increased rates in monozygotic vs dzygotic twins
