CHAPTER 6 PSYCH2 Flashcards
less severe than major depressive disorder,
insidious onset, chronic course, and no loss of social or
occupational function
Dysthymic Disorder
DSM IV for Dysthymia
“ACHE2S” A—appetite (increased/decreased) C—concentration down H—hopelessness E—energy down E—esteem of self down 2—2 years (more days down than not) S—sleep (increased/decreased)
___________= major depressive disorder +
dysthymia
“Double depression”
In Manic episode:
At least three (four if mood is only irritable) of the following
D—distractibility I—insomnia, decreased need for sleep G—grandiosity, inflated self-esteem F—flight of ideas A—activities or goals increased or displays psychomotor agitation S—pressured speech T—thoughtlessness, seeks pleasure without considering consequences
Treatments for acute mania
FDA-approved:
lithium, divalproex, chlorpromazine,
haloperidol, aripiprazole, olanzapine,
quetiapine, risperidone, ziprasidone, and ECT
In mixed episode
a. Criteria met for manic episode and major depressive
episode except duration is at least _______
b. Causes impairment in functioning, psychotic features
exist, or hospitalization is required to ensure safety of
patient or others
c. Not due to ______
1 week
substance use
Hypomanic episode: overview of DSM-IV-TR criteria
a. At least ______ days of persistently elevated, expansive, or irritable mood
b. At least three (four if mood is only irritable) of the following:
____________
c. Change in functioning uncharacteristic of person’s usual
behavior
d. Changes are observable by others
e. Not severe enough to cause impaired functioning, no
psychotic features exist, and no hospitalization is
required to ensure safety of the patient or others
f. Not due to substance use
4
grandiosity or inflated self-esteem, decreased
need for sleep, pressured speech, flight of ideas or racing thoughts, distractibility, increased goal-directed activity, risky behaviors
a. Only one manic episode (see manic criteria above) and
no past major depressive episode
b. Not part of schizoaffective disorder, not superimposed
on schizophrenia, schizophreniform disorder, delusional
disorder, or psychotic disorder not otherwise specified
Bipolar I disorder, single manic episode
a. Bipolar I disorder: lifetime prevalence is ___________%, M=F
1) Early onset is associated with more ______ issues
2) Peak manic episodes occur in summer
1.0
psychotic
b. Bipolar II disorder: lifetime prevalence is___%
c. Cyclothymic disorder: lifetime prevalence is___%
- 5
0. 7
a. History of at least one major depressive episode
b. History of at least one hypomanic episode
c. No history of manic episode or mixed episode
d. Not better accounted for by one of the psychotic
disorders
e. Causes marked impairment
Bipolar II Disorder (recurrent major depressive
episode with hypomanic episodes)
GAD
a. At least ________months of excessive anxiety or worry about life
circumstances
b. Difficult for patient to control worry
c. At least three of the following: ______
d. Anxiety that does not satisfy criteria for another____
e. Causes marked impairment
f. Not due to substance use or general medical condition
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restlessness, easily
fatigued, poor concentration, irritability, muscle tension,
sleep disturbance
Axis I disorder
Course of GAD: chronic with fluctuating severity, 33% develop ______
panic disorder
___________: unresolved unconscious
conflicts or separation from important objects
Psychoanalytic theory of anxiety:
__________: learned response from
exposure to situations that induce anxiety
Psychosocial theory of anxiety
Medications that induce GAD:
theophylline, caffeine, pseudoephedrine,
thyroxine
GAD tx:
a. Antidepressants:______
b. Benzodiazepines, buspirone, β-blockers
SSRIs, TCAs, mixed-mechanism
antidepressants
a. Intense fear or discomfort
b. At least four of the following: pounding heart, sweating,
trembling, shortness of breath, feelings of choking, chest
pain, nausea, dizziness, derealization, loss of control, fear
of dying, paresthesias, chills or hot flashes
Panic attack:
a. Anxiety in settings in which escape may be difficult or
help is not available
b. Those settings/situations are avoided
Agoraphobia
a. Recurrent panic attacks
b. At least 1 month of concern about having additional
attacks, worry about implications of another attack,
change in behavior related to attacks
c. Absence of agoraphobia (panic disorder without agoraphobia)
or presence of agoraphobia (panic disorder with
agoraphobia)
d. Not due to substance use or general medical condition
e. Not better accounted for by another Axis I condition
Panic disorder
Course of Panic DO
a. Usually considered chronic and ______, ______in
intensity
b. ______ of patients recover fully
c. ______ of patients have occasional symptoms but usually do well
lifelong, fluctuating
30%
50%
T or F
Females develop agoraphobia more often than males
T
Etiology and pathophysiology of Panic do
Carbon dioxide hypersensitivity: _____
“false suffocation
alarm”
_________: exaggerated fear of social
situations
Social anxiety disorder
a. Patient avoids social interactions
b. Patient is hypersensitive to criticism
c. Patient has low self-esteem, poor social skills, poor eye
contact
Social Phobia
Course of Social Phobia
a. Develops _________, _______
b. Waxes and wanes in intensity, complete remission is rare
slowly, is chronic, no precipitating stressor
Phobic disorders tend to ________; those with specific
phobias tend to have relatives with specific phobias and
not socials and vice versa
“breed true”
Tx of phobic do
a.________: first line of treatment
b. MAOIs, mixed-mechanism antidepressants,
benzodiazepines
c. _________ can help about 30 minutes before performance or test situation
d. Most effective treatment: ____ and _____
SSRIs
Propranolol
cognitive-behavioral therapy + medications
excessive, repetitive counting, checking,
cleaning; behaviors are ego dystonic
Obsessive-Compulsive Disorder
1) Recurrent or persistent thoughts, impulses, or images
felt to be intrusive or inappropriate and that cause
anxiety or distress
2) Not simply excessive “real-life” worries
3) Attempts are made to ignore and suppress or
neutralize
4) Patient recognizes these are products of his or her own
mind
Obsessions (thoughts)
1) Repetitive behaviors: counting, checking, praying,
repeating
2) Behaviors aimed at preventing or reducing stress or
preventing a perceived dreaded event from taking
place
Compulsions (behaviors)
In pts with OCD
a. Usually both _____ and ____ are present in
80% of patients
b. Consumes a great deal of time
c. ______
obsessions and compulsions
Ego-dystonic
In pts with OCD
Prognosis is worse if ______, ______, ____hospitalization is required because of severity of symptoms
yielding to compulsions, childhood
onset, obsessions and compulsions are bizarre,
Differential diagnosis for OCD:
schizophrenia, obsessivecompulsive
personality disorder
Behavioral theory: obsessive-compulsive disorder is
learned behavior ______
(classical conditioning)
In OCD
Psychoanalytic theory: OCD is caused by unconscious
conflicts (defensive, punitive) and show regression to ____
overactive superego leading to defense mechanisms such as ______, _______, ______
anal phase of development;
“undoing,” “reaction formation,”
and “displacement
OCD
Neurobiologic theory: occurs more often in patients
with _____, _______, ________
head trauma, epilepsy, Sydenham’s chorea,
Huntington’s disease
OCD is
associated with decreased size of ____
caudate nuclei
bilaterally
OCD is associated with
a. Increased blood flow to _____, _____ and _____
frontal lobes, basal ganglia, and cingulate cortex
Key feature is catastrophic traumatic event leading to
hyperarousal, withdrawal, flashbacks, survivor’s guilt,
numbing
PTSD
In PTSD
Exposure to traumatic event—must have both of the
following:
1) Experienced or confronted with actual or threatened
death or injury to self or others
2) Response involved intense _______
fear, helplessness, horror
In PTSD
Traumatic event is reexperienced in at least one of the
following:
1) Recurrent and intrusive ______
2) Recurrent and distressing ________
3) Acting or feeling as if event were recurring
4) Intense ______ at exposure to triggers or
cues related to the event
5) ________ on exposure to triggers or cues
symbolizing the event
recollections of the event
dreams of the event
psychologic distress
Physiologic reactivity
Common findings in PTSD:
“psychogenic amnesia,” “psychic numbing,” depressive symptoms, impulsivity, aggression, isolation, “survivor’s guilt,” marital strain, social and occupational difficulties
Tx for PTSD
a. Antidepressants: _____ (first line), TCAs, trazodone,
MAOIs
b. Anxiolytics: ____ and ______
c. Mood stabilizers and antipsychotics
d. Psychotherapy:_____ and _____
stress inoculation therapy, desensitization, group
therapy, family therapy, marital therapy
SSRIs
benzodiazepines, buspirone
cognitive-behavioral therapy, insight-oriented,
In acute stress disorder
During or after experiencing traumatic event, must have
at least 3 of the following:
1) Feelings of numbing, detachment, absence of emotional
response
2) Decreased awareness of surroundings
3) Derealization
4) Depersonalization
5) Dissociative amnesia (unable to recall important
aspect of the trauma)
In acute stress disorder,
Duration: at least ______
Must occur within _______
2 days and less than 4 weeks
4 weeks after the traumatic event
SUBSTANCE-RELATED DISORDERS
- Maladaptive pattern of substance use
- Leading to marked ______ and ______
- At least one of the following during a _____
a. Recurrent use leading to failure to fulfill obligations at
home, work, school
b. Recurrent use in hazardous situations (e.g., driving,
operating machinery)
c. Recurrent substance-related legal problems
d. Continued use even when causing recurrent social or
interpersonal problems
- Symptoms have not met criteria for ______
distress and impairment
12-month period:
dependence
1) Need for increased amounts to achieve intoxication or
needed effects
2) Diminished effect with same amount of substance
Tolerance
Symptoms of withdrawal for that substance
Need for same or similar substance to relieve
symptoms of withdrawal
Withdrawal
during 12 months, at least 1 of following:
Failure at social obligations due to drug use
Legal problems due to drug use
Use even in hazardous situations
Use despite having social problems
Abuse
during 12 months, at least 3 of following:
Tolerance, increased amounts needed Withdrawal Need to use more Cannot cut down or control use Much time spent obtaining the drug Social activities relinquished as direct result of drug use Persistence of use despite being aware of harmful effects
Dependence
_____________ = 2 or less drinks/day for men
younger than 65 (≤1 drink/day for nonpregnant women
and anyone >65 years
“Moderate drinking”
________ = state of an alcoholic who is uncomfortable
when not drinking
“Dry drunk”
If you can smell alcohol on the person’s breath, the likely
level is greater than _______
0.125%
_______ = state of an alcoholic who is uncomfortable
when not drinking (grandiose, impatience, overacting
“Dry drunk”
CAGE questions
Two of four answered positively: _____ indicative
of alcohol dependence
Four of four answered positively: ______ indicative of
alcohol dependence
70%-80%
100%
Withdrawal symptoms
1) Often starts with _____
2) Anxiety, agitation, aggressiveness
3) Hallucination (most often____), delusions
4) Hypertension, respiratory depression, seizures,
delirium tremens
5) Death if symptoms are severe
6) Symptoms can be reduced or cleared by alcohol or
cross-tolerant agents (________)
tremulousness
visual
benzodiazepines, barbiturates
Possible positive effects of alcohol use (red wine thought
to be best)
1) One or two drinks per day: may lower risk of
_______ and ________
(possibly by reducing platelet “stickiness”) and can
increase level of high-density lipoproteins (“good
cholesterol”)
myocardial infarction or cerebrovascular accident
Most alcoholic patients have promising prognosis: after
treatment,______ of patients have 1 year of abstinence depending on their pretreatment level of functioning
45% to 65%
1) Close relatives of alcohol-dependent persons have _______ higher risk of developing alcohol dependence
3× to 4×
Sons of severely alcoholic fathers have up to ______
chance of becoming alcohol-dependent in their lifetime
90%
90% of alcohol is metabolized by oxidation in the
_______10% is excreted unchanged in the urine, sweat,
air
liver,
_________ breaks down alcohol to
acetaldehyde, then ________ breaks
down acetaldehyde to acetic acid
Alcohol dehydrogenase
aldehyde dehydrogenase
________ blocks aldehyde dehydrogenase,
thus build up of toxic acetaldehyde
Disulfiram (Antabuse)
Disulfiram (Antabuse), _________ (ReVia, decreases
craving for alcohol
naltrexone
Common psychotic symptom of MAP use is __________________(sensation
of crawling bugs, which may lead to excessive
scratching until the skin is severely excoriated)
formication
Methylphenidate: route is_____ followed by ______
or ________
crushed, snorting, intravenous injection
_______ marked withdrawal symptoms following a
high-dose use (“speed-run”), including depression, suicidal thoughts, intense cravings, anxiety, irritability
“Crash”:
“Speed balling”: injecting combination of____ and ___
heroin and
cocaine
Short-acting drug: rapid and powerful effects on CNS
1) Instant feelings of well-being, confidence, euphoria
2) Increased levels of _____ and _____ in brain
dopamine and NE
Metabolite of cocaine _____ can be found in a urine
drug screen 1 to 3 days after a single dose or 7 to 12 days
after frequent use of high doses
(benzoylecgonine)
Physiologic changes of hallucinogens:
hypertension, tachycardia,
pupillary dilation, sweating, tremors, blurry vision,
incoordination
effects of hallucinogens
Can cause increased levels of glucose, cortisol, ACTH,
prolactin
____ is much more potent than other hallucinogens
LSD
_______ makes giving up nicotine so difficult
Craving:
Smoking increases metabolism of many prescription
medications; smoking cessation can lead to worrisome
____________
increases in blood levels of those medications
_________ dependence is the most prevalent substancerelated disorder
Nicotine
Mx of nicotine abuse
a. Nicotine patches, sprays, inhalers
b. Clonidine
c. Bupropion (Zyban
Personality disorder:
- Cluster A __________(paranoid, schizoid,
schizotypal) - Cluster B________ (antisocial,
borderline, histrionic, narcissistic) - Cluster C _________ (avoidant, dependent,
obsessive-compulsive)
“odd or eccentric”
“dramatic, emotional, erratic”
“fearful, anxious”
Patients with______ are heavy users of the health care
system
BPD
In Personality DO,
Enduring pattern of inner experience and behavior that
deviates markedly from the expectations of the person’s
culture; this pattern is manifested in two (or more) of
the following areas:
a. __________(i.e., ways of perceiving and interpreting self,
other people, events)
b. __________ (i.e., range, intensity, lability, and appropriateness
of emotional response)
c. _________
d. _________
Cognition
Affectivity
Interpersonal functioning
Impulse control
Characterized by suspiciousness, distrust; interprets
actions of others as threatening or “out to get them
Cluster A—paranoid personality disorder
DSM criteria for personality DO
a. Enduring, pervasive distrust and _____
b. Interprets intentions of others as harmful or exploitive
c. At least four of the following:
d. Not part of schizophrenia, psychotic mood disorder, or
general medical condition
suspiciousness
1.suspects others are deceiving or exploiting,
2. preoccupied with doubts regarding loyalty
or trustworthiness of others,
3. finds it difficult to confide in others,
4. reads hidden meanings into words or situations,
unforgiving and bears grudges,
5. quickly reacts angrily if perceives character has been attacked,
6. unjustified suspicions regarding fidelity of significant other
In Personality DO
increased prevalence among those with relatives
having ______ and ________disorder,
_______ type
chronic schizophrenia
delusional
paranoid
Characterized by social detachment and limited emotional reactivity
Cluster A—schizoid personality disorder
DSM IV for schizoid personality DO
a. Enduring, pervasive \_\_\_\_\_\_\_ or isolation and limited \_\_\_\_\_\_\_ b. At least four of the following: 1. 2. 3. 4. 5. 6. 7. c. Not a part of schizophrenia, psychotic mood disorder, or general medical condition
social detachment
emotional reactivity
- no desire for close relationships,
- participates in solitary activities,
- minimal interest in sexual activity with others,
- very few activities bring pleasure,
- has very few close confidants,
- indifferent to opinions of others,
- limited emotional range
schizoid personality DO
increased prevalence among relatives of
______ or those with ______personality
disorder
schizophrenics
schizotypal
Characterized by discomfort with close relationships,
cognitive and/or perceptual distortions, and eccentric
behaviors and beliefs
Cluster A—schizotypal personality disorder
Cluster A—schizotypal personality disorder
Challenge for providers is to prevent pushing too hard,
which can lead to
increased anxiety or paranoia, and to
build trust and minimize anxiety
Cluster A—schizotypal personality disorder
Social skills training can be helpful, but group ____
can be threatening to them
psychotherapies
Characterized by pervasive disregard for and violation
of the rights of others
Cluster B—antisocial personality disorder
Cluster B—antisocial personality disorder
a. Enduring and pervasive pattern of disregard for others,
violation of the rights of others and occurring since age________
b. At least three of the following:
others
c. Must be at least 18 years old
d. Previous history of conduct disorder before age 15
e. Not part of schizophrenia or a manic episode
15
unlawfulness, deceitfulness, impulsivity or failure to plan ahead, repeated physical assaults and irritability, reckless disregard for self or others, irresponsibility, indifferent to or rationalizes hurting
Key feature is instability of mood, but these patients
are also characterized by pervasive instability of affect,
identity, marked impulsivity, chaotic interpersonal relationships, self-injurious behaviors, failed marriages, lost jobs, “black and white” thinking, “splitting” (one care
provider valued and the other one is devalued, often
causing strife among the providers)
Cluster B—borderline personality disorder
Prevalence: _______ of general population, ____ among persons seen in outpatient mental health clinics, about ______ among psychiatric inpatients, 30% to 60% of clinical
populations with personality disorders
2%
10%
20%
IN borderline personality DO,
Increased prevalence among those with early ______________ (sexual abuse, neglect, hostility, parental loss)
traumatic
experiences
Has become a standard treatment for borderline personality DO
Dialectical behavioral therapy (DBT)
Dialectical behavioral therapy (DBT) is also used in management of recurrent ____ and ____
suicidal
and parasuicidal behaviors
Characterized by excitable, emotional, colorful, flamboyant
behavior and by inability to maintain long-lasting
relationships
histrionic personality disorder
Characterized by high sense of self-importance and
uniqueness
Cluster B—narcissistic personality disorder
Cluster B—narcissistic personality disorder
a. Enduring and pervasive pattern of ______need for
admiration, and lack of empathy
b. At least five of the following:
grandiosity,
grandiose sense of selfimportance;
preoccupied with fantasies of success, power,
brilliance, beauty, or love;
believes self to be special or unique;
needs excessive admiration; has high sense of
entitlement; takes advantage of others; lacks empathy;
envious of others; behaves arrogantly or haughtily
Characterized by extreme sensitivity to rejection, shyness,
need for uncritical acceptance
Cluster C—avoidant personality disorder
In pts with avoidant personality DO
a. Infants with_______ may be prone to this
disorder
b. _____ may predispose to this disorder
timid temperament
Disfigurement
Characterized by excessive reliance on others for emotional support and decision-making
Cluster C—dependent personality disorder
Cluster C—dependent personality disorder
Predisposing factors may be ______ or
_______
chronic physical illness
separation anxiety disorder
Cluster C—dependent personality disorder
Challenge for the provider is to prevent reestablishment
of the ________ relationship that is seen in
patient’s other relationships
dominant-dependent
Characterized by preoccupation with orderliness, perfectionism, control to point of inflexibility
Cluster C—obsessive-compulsive personality disorder
Cluster C—obsessive-compulsive personality disorder
a. Predisposing factors may be linked to high central ___________
serotonergic
function
Recommended therapies for obsessive-compulsive personality disorder:
psychodynamic psychotherapy,
cognitive-behavioral therapy
Clinical uses Antidepressants : primary use is for
depression, bipolar depression, panic disorder, agoraphobia, OCD, social phobia, generalized anxiety disorder, posttraumatic stress disorder, bulimia nervosa
SSRIs inhibit _______ reuptake but
do not act on NE or dopamine
5HT
thought to be safest SSRI in pregnancy, but potentially there may be increased risk of perinatal complications (with use during third trimester
fluoxetine
mild 2D6 inhibitors
Citalopram (Celexa), Escitalopram (Lexapro)
potent 2C19 inhibitor
Fluvoxamine (Luvox):
potent 2D6 inhibitors
Fluoxetine (Prozac):Paroxetine (Paxil)
dose-dependent 2D6
inhibitor
Sertraline (Zoloft)
For anti-depressants
1) Transient dizziness and vertigo, lethargy, paresthesias
(paroxetine) , nausea, vivid dreams, irritability
2) Treat by tapering dose
Discontinuation syndrome
1) May sometimes occur months or years after successful
treatment
2) Reduced motivation, apathy, poor initiation; may be
features of recurrent depression
Apathy syndrome
Features of Serotonin syndrome
Altered mental status, agitation, fever, hypotension,
ataxia, hyperreflexia, myoclonus
longest half-life and active metabolite
with longest half-life, side effects include
reduced appetite
Fluoxetine:
best profile in
regard to sexual side effects
Fluoxetine and fluvoxamine
________worst profile in regard to sexual side
effects, most potent blocker of dopamine
transporters, has active metabolite with short
half-life
Sertraline:
___________ no active metabolites,
more likely to cause discontinuation syndrome
with abrupt withdrawal of drug
Fluvoxamine and paroxetine:
______ most selective for 5HT
Citalopram:
________most potent SSRI, side effects
include weight gain and somnolence
Paroxetine:
