CLINICAL CARE OF PSYCHIATRIC DISORDERS Flashcards by Tim Mackey

What is the complex somatic, cognitive, affective, and behavioral effects of psychological trauma?

PTSD

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True or False

PTSD has a strong correlation with TBI

True

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PTSD

One study of hospitalized soldiers showed an increased prevalence of ____% at one month versus _____% at 4 months of exposure

4.2%

2. 12.2%

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True or False

A study of 1648 US marines showed that experiencing a TBI during deployment was a strong predictor of PTSD symptom development

True

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PTSD

Studies using MRI have shown decreased volume in several areas of the brain such as what?

Left amygdala (fear center)
Hippocampus (memories)
Anterior cingulate cortex

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The following can be common clinical manifestations of what psychiatric disorder?

Affective dysregulation (anger common)
Cognitive impairment
Several behavior responses in response to regular stimuli:
a. flashbacks
b. severe anxiety symptoms
c. fleeing
d. combative behaviors

PTSD

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True or False

Clinical manifestations of PTSD can lead to compensatory behaviors in the individuals affected. (avoidance of triggering experiences)

True

Avoidance leads to furthering of symptoms such as emotional numbing, diminished interests in activities and detachment from others

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Symptoms of PTSD must be present for at least how many weeks following trauma for psychiatry to make the diagnosis?

Four weeks

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True or False

The focus of the IDC for PTSD is screening

True

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What are some forms of psychotherapy that are useful in the treatment of PTSD?

Exposure Therapy
CBT (cognitive behavioral therapy)
EMDR (Eye Movement Desensitization and Reprocessing)

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True or False

Since marital problems and substance abuse are commonly seen in patients with PTSD should also consider referral sources for counseling

True

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What is the first line therapy of choice for PTSD?

Antidepressant Medications (SSRIs)

Example: Sertraline

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PTSD

What adjunctive medication can be used for nightmares?

Prazosin

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PTSD

What adjunctive medication can be used for tremors and sympathetic responses?

Beta Blockers

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PTSD

What adjunctive medication can be used for comorbid psychosis if needed?

Antipsychotics

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What is a persistent disturbance of eating that impairs both health and psychological functioning?

Eating disorders

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What are some examples of eating disorders?

Anorexia nervosa
Bulimia nervosa
Binge eating disorder
Pica
Rumination disorder

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In regards to eating disorders, you should consider a broad differential when evaluating a patient for weight loss, examples include but are not limited to what?

Hyperthyroidism
Malignancy
Disease of the GI tract
Chronic Infectious Diseases
Affective disorders (depression)

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What is the estimated lifetime prevalence of Anorexia Nervosa and is likely higher due to the concealment of the illness?

0.6%

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Who is Anorexia Nervosa more common in?

Women

Ratio ranges from 10-20:1

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What is the median age of onset for Anorexia Nervosa?

18 years old

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In what psychiatric condition is there an intense fear of gaining weight or becoming fat or persistent behavior that prevents weight gain, despite being underweight?

Anorexia Nervosa

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What is the distorted perception of body weight and shape, undue influence of weight and shape on self-worth, or denial of the medical seriousness of one’s own low body weight?

Anorexia Nervosa

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These are all common physical exam findings of what psychiatric condition?

Low BMI (<17.5)
Emaciation
Hypothermia
Bradycardia
Hypotension
Hypoactive bowel sounds
Xerosis (dry and scaly skin)
Brittle hair and hair loss
Lanugo body hair
Abdominal distention

Anorexia Nervosa

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What eating disorder has an estimated lifetime prevalence of 1.0% and is three times more common in women that in men (1.5% vs 0.5%)?

Bulimia Nervosa

What is known as recurrent episodes of binging and purging and inappropriate compensatory behavior to prevent weight gain?

Bulimia Nervosa

What psychiatric disorder is characterized by the following? 1. Self-induced vomiting 2. Misuse of laxatives 3. Diuretic use 4. Enemas 5. Fasting 6. Excessive exercise * *7. Occurring on average at least once per week for three months

Bulimia Nervosa

Bulimia Nervosa There is a mild psychosocial impairment seen in about ____% and severe impairment in ___%

1. 78% | 2. 16%

Are additional psychiatric disorders common with bulimia nervosa?

Yes | Anxiety, depression, PTSD, substance abuse, ADHD, conduct disorders, personality disorders

You may see the following in what psychiatric condition? 1. Dehydration 2. Menstrual irregularities 3. Mallory-Weiss syndrome 4. Pharyngitis 5. Erosion of dental enamel 6. ECG changes may occur

Bulimia Nervosa

True or False Binge Eating Disorder Eating is associated with: uncomfortably full, eating when not hungry, feelings of embarrassment, feelings of disgust and depression

True

What psychiatric disorder is characterized by the eating of non-food substances and can be associated with iron deficiency anemia?

PICA

What eating disorder is associated with repeated regurgitation of food?

Rumination Disorder

True or False Once recognized eating disorders require referral

True

What psychiatric disorder is characterized by the following triad? 1. Psychological dependence or craving 2. Physiologic dependence 3. Tolerance

Substance Use Disorder

What psychiatric disorder has a huge impact on our society with more than 85k deaths per year directly attributable to it and an annual economic cost of $250 billion?

Alcohol Use Disorder

True or False 1 in 10 deaths in working age adults results from excessive drinking

True

What is the 3rd leading preventable cause of death in the United States?

Alcohol Use Disorder

What refers to the consumption of alcohol that puts a patient at risk for health consequences?

Risky Alcohol Use

What is the amount of alcohol that increases health risks in men under the age of 65?

1. More than 14 standard drinks per week on average | 2. More than 4 drinks on any day

What is considered the standard drink?

1. 5 oz of wine | 2. 12 oz beer

What is the amount of alcohol that increases health risks in women and adults 65 and older?

1. More than 7 standard drinks per week on average | 2. More than 3 drinks on any day

What are some common medical complications of alcohol use?

1. HTN 2. Cardiovascular disease 3. Liver disease 4. Pancreatitis 5. Gastritis 6. Esophagitis 7. Neuropathy

There is a strong association with what disorder and the following? 1. Depression 2. Anxiety 3. PTSD 4. Eating Disorders 5. Other substance use disorders 6. Sleep disturbances 7. Suicidal Ideations and attempt

Alcohol Use Disorder

What is the estimated lifetime rate of suicide attempts with patients suffering from alcohol use disorder?

What are some common physical exam findings you may see in a patient with alcohol use disorder?

1. May have signs of withdrawal a. tremor, agitation 2. Peripheral neuropathy 3. Features of liver disease a. hepatic/splenic enlargement b. icterus/jaundice c. spider angiomata d. Palmar erythema

What are the questions you can ask a patient with possible alcohol use disorder?

"CAGE questions" 1. Have you ever felt you should Cut down on your drinking? 2. Have people Annoyed you by criticizing your drinking? 3. Have you ever felt bad or Guilty about your drinking? 4. Have you ever taken a drink first thing in the morning (Eye opener) to steady your nerves or get rid of a hangover?

What is one complication of Alcohol use disorder that is due to a deficiency of Thiamine (Vitamin B1)?

Wernicke Korsakoff Syndrome **actually two separate syndromes**

What is direct brain damage due to a deficiency of Thiamine and is characterized by the triad of encephalopathy, disorientation, inattentiveness, and oculomotor dysfunction ?

Wernicke Encephalopathy (WE)

The following are common findings in what syndrome that is associated with alcohol use disorder? 1. Gait ataxia 2. Wide based gait 3. Most common symptom: Confusion

Wernicke Encephalopathy

What is a chronic neuro condition that is usually a consequence of Wernicke Encephalopathy?

Korsakoff Syndrome

What is a late neuropsychiatric manifestation of Wernicke's Encephalopathy?

Korsakoff Syndrome

What does Korsakoff syndrome cause?

Anterograde and retrograde amnesia

True or False Alcohol Withdrawal Potentially life threatening problem, approximately half of patient experience some form of withdrawal, usually mild but estimated 20% experience severe symptoms

True

With mild alcohol withdrawal, symptoms generally begin within 6-24 hours of the last drink and may show things such as what?

1. Anxiety 2. Minor agitation 3. Restlessness 4. Insomnia 5. Tremors 6. Diaphoresis 7. Palpitations 8. Headache 9. Alcohol craving

Mild withdrawal symptoms usually resolve in how long?

1-2 days

Can more severe symptoms of alcohol withdrawal include hallucinations and delirium?

Yes

When do hallucinations associated with alcohol withdrawal usually begin and resolve?

1. Begins within 12-24 hours | 2. Resolves in another 1-2 days

What are the seizures typically associated with alcohol withdrawal?

Tonicclonic

When do seizures associated with alcohol withdrawal typically occur?

6-48 hours after last drink

True or False 10-30% of patients with alcohol withdrawal will develop seizures

True

What is the "kindling effect" in regards to alcohol withdrawal?

Risk of seizures increases with repeated withdrawals

Delirium due to alcohol withdrawal begins within __ to ___ hours after the last drink and occurs in __% to __% of patients hospitalized with withdrawal?

1. 72-96 hours | 2. 1-4%

True or False The term "Delirium Tremens" refers to the fluctuating disturbance in attention and cognition, may include hallucinations

True

Severe forms of what with alcohol withdrawal in severe forms can include agitation and extreme autonomic hyperactivity? (fever, tachycardia, hypertension, drenching sweats)

Delirium Tremens

What is the leading preventable causes of mortality worldwide, causes an estimated 6 million deaths worldwide, and 400k deaths annually?

Tobacco Use Disorder

What are some major causes of mortality associated with Tobacco Use Disorder?

1. Cardiovascular Disease 2. Pulmonary Disease 3. Cancer

What is responsible for an estimated 33% of all cardiovascular related deaths in the US?

Tobacco Use Disorder

What is the most important risk factor for COPD?

Tobacco Use Disorder

What is the "Pre-contemplation" stage of quitting tobacco?

Not ready to quit

What is the "contemplation" stage of quitting tobacco?

Considering a quit attempt

What is the "preparation" stage of quitting tobacco?

Actively planning a quit attempt

What is the "Action" stage of quitting tobacco?

Actively involved in a quit attempt

What is the "maintenance" stage of quitting tobacco?

Achieved smoking cessation

Triggers to smoking are a huge barrier including things like smoking with the morning coffee, smoking while drinking, and around meal time; but what is perhaps the greatest barrier?

Nicotine Withdrawal

Nicotine withdrawal peaks in the first ____ days and then slowly subsides over the course of about ___ month(s)

1. 3 Days | 2. One month

What is the long acting treatment of nicotine withdrawal?

Nicotine Patch

What is the short acting treatment of nicotine withdrawal?

Gum or Lozenges

What medication used for the treatment of nicotine withdrawal has the following effects? 1. Used for both depression and smoking cessation 2. Considered an atypical antidepressant 3. Inhibits reuptake of norepinephrine and dopamine as well as act as nicotinic receptor antagonist 4. Reduces nicotine cravings and withdrawal symptoms

Buproprion (Wellbutrin)

What medication is a partial nicotine agonist, stimulates dopamine activity but to a much smaller degree than nicotine, and reduces cravings and withdrawal symptoms?

Varenicline (Chantix)

Effects from marijuana occur in ____ to ___ minutes and last ___ to ___ hours

1. 10-20 minutes | 2. 2-3 hours

Marijuana is detected in most urine tests for ___ to ___ days in short term users and ___ to __ days in long term users

1. 4-6 days | 2. 20-50 days

High doses of what produce transient psychotomimetic effects?

Marijuana

True or False Marijuana frequently aggravates existing mental illness and adversely affects motor performance

True

True or False It has been demonstrated that the rate of cannabis use is highest between the ages of 18 and 25 with approximately 18.7% of that population using at least once within the past month, with use tapering off to 7% after age 26.

True

True or False In 2018, an estimated 9.9 million people (aged 12 and older) misused prescription pain relievers and 808,000 people used heroin.

True

Approximately ___% of abused opioids ae obtained from family and friends

55%

What lab should always be checked in suspected opioid intoxication?

Serum Glucose Hypoglycemia is not uncommon, rapidly correctable, and easily confused with acute opioid intoxication

Opioid Use Disorder If a patient is found down you should consider rhabdomyolysis and run what what?

Serum CPK

What is the treatment of choice in the treatment of acute opioid intoxication?

Naloxone

What are some forms of stimulant drugs that activate the CNS with resulting strong rewarding effects (euphoria, "rush" and "high") that contribute to high abuse liability?

Cocaine and amphetamines

True or False Stimulant abuse is quite common, either alone or in combination with other drugs

True

True or False Stimulants Increase synaptic levels of monoamines (dopamine, serotonin, and norepinephrine) by blocking the monoamine transporters (cocaine, methylphenidate) or releasing monoamines (methamphetamine)

True

True or False Stimulants Increased dopamine levels in the mesolimbic dopamine pathway are believed to mediate the reinforcing effects of stimulants

True

True or False Stimulants Serotonergic activation mediates stimulant effects on mood. Alternatively, Norepinephrine mediates cognitive arousal and cardiovascular activation in response to stimulants, as well as stress response including stress-induced drug use/relapse

True

True or False Stimulants Increased sociability that is associated with acute intoxication may be mediated at least in part by acute release of the neuropeptide oxytocin

True

True or False Stimulants Cocaine blocks voltage-gated sodium ion channels, which underlies its anesthetic effect

True

Moderate use of what produces hyperactivity, a sense of enhanced physical and mental capacity, and sympathomimetic effects?

Stimulants

The clinical picture of what will show the following? 1. Sweating 2. Tachycardia 3. Elevated blood pressure 4. Mydriasis 5. Hyperactivity 6. Acute brain syndrome with confusion and disorientation

Acute Stimulant Intoxication

True or False Clinicians should be alert to cocaine use in patients presenting with unexplained nasal bleeding, headaches, fatigue, insomnia, anxiety, depression, and chronic hoarseness.

True

What disorder has an estimated lifetime prevalence in the US of around 1-2% and is the 18th leading cause of disability in the US?

Bipolar Disorder

What is a mood disorder that is characterized by the following three different mood states? 1. Mania 2. Hypomania 3. Major depression

Bipolar disorder

What is a distinct period of abnormally or persistently elevated, expansive, or irritable mood and persistently increased activity or energy, lasting at least one week and present moods of the day, nearly every day?

Mania

Three or more of the following symptoms must be present to diagnose a patient as having what? 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep 3. More talkative than usual or pressured speech 4. Flight of ideas/racing thoughts 5. Distractibility 6. Increased goal directed activity 7. Involvement in activities that carry negative potential (spending sprees, sexual indiscretions)

Mania

True or False Mania can be severe enough to cause marked impairment in functioning or necessitate hospitalization to prevent harm to self or others, or there are psychotic features

True

The acronym "DIGFAST" is often used to remember the symptoms of mania, what does it stand for?

``` D- Distractibility I- Indiscretions G- Grandiosity F- Flight of Ideas A- Activity increase S- Sleeplessness T- Talkativeness ```

What has similar characteristics of mania only far less severe, there is no delusional grandiosity, thought form is more organized, there is less risky behavior, no psychotic symptoms, and no hallucinations?

Hypomania

Five or more of the following symptoms present during the same two week period could mean the patient is suffering from what? 1. Depressed mood (sad, empty, hopelessness) 2. Diminished interest in pleasurable activities 3. Weight loss or weight gain 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Decreased energy 7. Guilt or feelings of worthlessness 8. Impaired concentration 9. Thoughts of death or thoughts of suicide

Major Depression

What should the IDC do for the management of Bipolar Disorder?

1. Immediately refer and manage acute symptoms while awaiting referral 2. If agitated try to talk them down or give antipsychotic medication for assistance a. Haloperidol

Maintenance therapy for Bipolar Disorder will usually be employed by a psychiatrist with a mood stabilizer or antipsychotic such as what?

1. Lithium 2. Valproic Acid 3. Lamotrigine (Lamictal) 4. Quetiapine (Seroquel)

What is the most common psychiatric disorder in the general population with a lifetime prevalence of about 16% ?

Depression

What in the United States ranks 2nd among all injuries and illnesses as causes of disability?

Depression

The presentation of depression is variable with what sort of problems being involved?

1. Changes in mood 2. Cognitive problems 3. Neuro-vegetative symptoms 4. Somatic symptoms

What is a pneumonic used by primary care clinicians to quickly screen for depression when forms such as PHQ-9 are not utilized or available?

SIGECAPS

What does SIGECAPS stand for?

S- Sleep changes: Increased during day or decreased at night I- Interest (loss): Of interest in activities that used to interest them G- Guilt (worthless): Depressed people tend to devalue themselves E- Energy (lack): Common presenting symptom is fatigue C- Concentration: Reduced concentration and cognition A- Appetite: Usually declined appetite. Sometimes increased P- Psychomotor agitation: Anxious feelings or lethargic feelings S- Suicide/death preoccupation

What is the most feared and most important complication of depression?

Suicide

What are the mainstays of therapy for depression?

Psychotherapy, pharmacotherapy, or both

What are the two classes of medications typically used in the treatment of depression?

1. SSRI: Selective Serotonin Reuptake Inhibitors a. Fluoxetine, paroxetine, sertraline, escitalopram, citalopram 2. SNRI: Serotonin-Norepinephrine Reuptake Inhibitors a. Venlafaxine, duloxetine

Side effects for the medications to treat depression ae very common are reported in up to ___% of people treated.

55%

These are all common side effects for what medications? 1. Sexual dysfunction 2. Drowsiness 3. Weight gain 4. Insomnia 5. Anxiety 6. Dizziness 7. Headache 8. Dry mouth 9. Blurred vision 10. Nausea 11. Rash 12. Tremor 13. Constipation 14. Abdominal pain/upset stomach

Medications used to treat depression

What is a mood disorder that is commonly seen in the Navy, may look similar to a major depressive disorder but does not meet the criteria, occurring in the context of a recent stressor, and resolves within six months when the stressor is removed?

Adjustment Disorder

What mood disorder is very common, occurring in the context of childbirth, usually within 12 months after delivery, has the same diagnostic criteria as depression, and is likely due to genetic susceptibility and hormonal changes in addition to increased stressor?

Post-Partum Depression

The time period for post-partum depression varies but is usually described as depression occurring within the first ___ months after delivery

12 months

Diagnostic criteria for post-partum criteria are the same as those for major depressive disorder, must have at least ___ symptoms for at least ___ weeks

1. 5 symptoms | 2. 2 weeks

What has similar symptoms to post-partum depression but does not meet the minimum criteria of symptoms; milder and self-limited; typically develops within 2-3 days of delivery and resolves within 2 weeks?

Post-partum "blues"

Is the Edinburgh Postnatal Depression Scale usually used for the assessment of post-partum depression?

Yes

What is the initial treatment for post-partum depression and is especially useful for breastfeeding moms as they won't expose the children to antidepressants?

CBT

If cognitive behavioral therapy is unsuccessful or depression is more severe what antidepressants are useful in the treatment of post-partum depression?

1. SSRI's (bupropion, (wellbutrin), Mirtazapine (remeron))

What SSRI's appear to have the lowest adverse effects on infants?

1. Paroxetine (Paxil) | 2. Sertraline (Zoloft)

Episodes of post-partum depression last at least one year in __% to __% of patients, with those who recover being at a risk for recurrences?

30-50%

What is characterized by excessive and persistent worrying that is hard to control, causes significant distress, and occurs more days than not for at least 6 months?

Generalized Anxiety Disorder (GAD) 1. Lifetime prevalence between 5.1% and 11.9% 2. Twice as common in women 3. "hand in hand" with other psychiatric conditions

The following are common clinical manifestations of what? 1. Hyperarousal and muscle tension common 2. Poor sleep 3. Fatigue 4. Difficulty relaxing 5. Headaches 6. Pain in the neck, shoulder, and back

Generalized Anxiety Disorder (GAD)

What is the treatment of Generalized Anxiety Disorder?

CBT, Medications, or both *SSRI's and SNRI's are the typical medication classes used as first line

Panic attacks are thought to occur in about ___ of people in their life time

1/3

Panic disorder is defined as what?

people who experience multiple panic attacks

What is the median age of onset for panic disorder?

24 years

Who are panic disorders more common in?

Women, twice as common

What is a spontaneous, discrete episode of intense fear that begins abruptly and lasts for several minutes to an hour, patients can have multiple recurrent episodes?

Panic attack

DSM-5 Diagnostic Criteria An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of the following symptoms occur is diagnostic for what? 1. Palpitations, pounding heart, or accelerated heart rate 2. Sweating 3. Trembling or shaking 4. Sensations of shortness of breath 5. Feelings of choking 6. Chest pain or discomfort 7. Nausea or abdominal distress 8. Feeling dizzy, unsteady, light-headed, or faint 9. Chills or heat sensations 10. Paresthesia 11. Derealization (feelings of unreality) or depersonalization (feeling detached from ones self) 12. Fear of losing control or "going crazy" 13. Fear of dying

Panic attacks

Development of agoraphobia is common in what?

Panic disorders

Panic attacks require what medications?

1. Anxiolytics a. benzos (tend to avoid these due to addiction risk) 2. Antihistamines may be tried (hydroxyzine)

What medications are not anxiolytics, will not break the panic attacks, but are long term treatment options that will reduce the frequency of panic attacks, severity of anxiety, and degree of phobic avoidance?

SSRIs/SNRIs

What is a thought disorder that is broadly defined as a loss of contact with reality?

Psychosis

Psychosis Its estimated that ___% to ___ % of people will experience psychotic symptoms at some point in their lives and approximately ___% to ___ % will go on to meet the criteria for a psychotic disorder

1. 12-23% | 2. 1-4%

What can present with a wide variety of signs and symptoms such as the following? 1. Delusions 2. Hallucinations 3. Thought disorganization 4. Agitation and aggression

Psychosis

What are strongly held false beliefs that are classified broadly as bizarre vs. non-bizarre?

Delusions

This is an example of what kind of delusion? Belief that one is being following or harassed by outside entity

Persecutory delusions

This is an example of what kind of delusion? Belief that one is a billionaire

Grandiose delusions

This is an example of what kind of delusion? Belief that a famous person is in love with them

Erotomanic delusions

This is an example of what kind of delusion? Believing ones sinuses have been infested with worms

Somatic delusions

This is an example of what kind of delusion? Believing a dialog on TV is directed towards you, such as the president talking on TV is talking directly to you

Delusions or reference

This is an example of what kind of delusion? Believing one's thoughts and movements are being controlled by a powerful outside source, such as planetary overlords or the government

Delusions of control

What are wakeful sensory experiences of content that is not actually present?

Hallucinations

What are misinterpretations of sensory experiences?

Illusions

True or False Psychosis and related disorders are truly disorders of thought and evidence of thought organization is derived from the patients speech pattern during the interview process

True

What speech pattern in regards to possible psychosis has very little information conveyed by speech often with very sparse replies or lack of spontaneous speech?

Alogia/poverty of content

What speech pattern in regards to possible psychosis is the sudden loss of the train of thought and is characterized by the abrupt interruptions in speech ?

Thought blocking

What speech pattern in regards to possible psychosis where the speech content has ideas presented in a sequence that is not closely related or does not make sense?

Loosening of association

What speech pattern in regards to possible psychosis are answers to interview questions diverging from the topic being asked about?

Tangentiality

What speech pattern in regards to possible psychosis is the patient using words in a sentence that are linked by rhyming or sounding similar?

Clanging or clang association

What speech pattern in regards to possible psychosis are real words linked together incoherently, they are real words but basically nonsense?

Word salad

What speech pattern in regards to possible psychosis are the patients repeating words or ideas persistently?

Perseveration

True or False Management of psychosis involves an immediate referral and you may need to treat acute agitation associated with psychosis, if present

True

True or False Psychosis In certain scenarios you may be able to simple "redirect" the patient to help them with their agitation. Offering reassurance and simply talking to them may be enough

True

What medication may be used by the IDC to treat acute psychosis or agitation?

Haloperidol

What generation of antipsychotics are also called "typical" antipsychotics?

First generation Haloperidol Older*

What generation of antipsychotics are also called "atypical antipsychotics" and have improved side effects profiles?

Second generation Aripiprazole, risperidone, quetiapine, olanzapine

What is an extrapyramidal side effect of antipsychotics that is defined as motor restlessness with the compelling urge to move and inability to sit still?

Akathisia

What are some common side effects associated with antipsychotics?

1. Parkinsonian syndrome a. mask like facies, resting tremor, cogwheel rigidity, shuffling gait, psychomotor retardation (bradykinesia) 2. Dystonia a. involuntary contractions of muscles 3. Tardive Dyskinesia

What side effects of antipsychotics is defined as the following? 1. Involuntary movements of the face 2. Sucking or smacking of the lips 3. Movements of the tongue 4. Facial grimacing 5. Odd movements of extremities 6. Usually occur after greater than 6 months of treatment on antipsychotics

Tardive Dyskinesia

What are the two distinct phases of sleep ?

1. REM (rapid eye movement) a. AKA dream sleep 2. NREM (non-REM)

True or False Depression is a common cause of sleep disturbances

True

True or False No matter the cause, poor sleep hygiene is often an underlying problem that exacerbates insomnia

True

Sleep issues can be defined as problems such as what?

1. Difficulty getting to sleep or staying asleep 2. Intermittent wakefulness 3. Early morning awakening

What are some common factors that will cause difficulty getting to sleep?

1. Stress 2. Caffeine 3. Physical discomfort 4. Daytime napping 5. Early bedtimes

What are some psychiatric disorders often associated with sleep difficulties?

1. Depression a. fragmented sleep, decreased total sleep time, earlier onset REM 2. Bipolar disorder a. insomnia sign of impending mania

True or False Alcohol has no effect on the sleep cycle

False Abuse of alcohol disrupts the sleep cycle

True or False Heavy smoking can cause difficulty falling asleep

True

What should the first line treatment of sleep disorders always be?

Sleep hygiene

What kind of medications should be used when sleep hygiene is ineffective?

1. Antihistamines a. beneficial and produce no dependency 2. Trazadone a. long term use

What is known as an enduring pattern of perceiving, relating to, and thinking about the environment and oneself, inflexible and maladaptive personality traits across a wide range of situations, and they cause significant distress and impairment in functioning in all areas of life ?

Personality disorder

True or False Personality Disorders Problems date back to childhood typically

True

What is the estimated prevalence of personality disorders in the community?

11%

What are the two personality types we should be concerned about?

1. Borderline Personality Disorder (BPD) | 2. Antisocial Personality Disorder (ASPD)

What personality disorder shows the instability of interpersonal relationships, self image, and emotions, patients with this show very impulsive behavior?

Borderline Personality Disorder (BPD)

What is the most widely studied personality disorder?

Borderline Personality Disorder (BPD)

True or False Borderline Personality Disorder (BPD) Associated with significant morbidity and increased mortality

True

True or False Borderline Personality Disorder (BPD) History if childhood trauma is common but the relationship to BPD is clear

False Relationship is unclear

Do many patients with BPD suffer from abandonment issues ?

Yes

People with what kind of personality disorder is there many interpersonal difficulties; they tend to view others as either all good or all bad, there is no "gray" area?

BPD

People with what personality disorder tend to misinterpret otherwise neutral events, words, or interactions as "negative"; minor disagreements may elicit highly emotional responses, reaction of extreme anger or self-harm threats tend to be common?

BPD

In what personality disorder may you see the following? 1. Affective instability (unstable mood) a. often triggered by stressors in the environment 2. Impulsive behaviors a. self damaging behaviors 3. Tend to have poorer cognitive function 4. Suicidal threats, gestures, and attempts are more common

BPD

What personality disorder is a pattern of socially irresponsible, exploitative, and guiltless behavior, this is a lifelong disorder with a wide range of symptoms with criminality being common?

Antisocial Personality Disorder (ASPD)

These are all common behaviors/symptoms associated with what personality disorder? 1. Disregard for and violation of the rights of others 2. Unstable work history 3. Financial dependency 4. Poor school history 5. Alcohol abuse 6. Marital difficulties 7. Impulsive behaviors 8. Homelessness

Antisocial Personality Disorder (ASPD)

These are all common behaviors/symptoms associated with what personality disorder? 1. "wild" adolescence 2. Social isolation 3. Promiscuous sexual behavior 4. Lack of remorse 5. Use of aliases 6. Poor military performance 7. Pathological lying 8. Drug use 9. Suicide attempts

Antisocial Personality Disorder (ASPD)

Treatment of Personality Disorders Is the use of social and therapeutic environments such as day hospitals, halfway houses, and self-help communities that utilize peer pressures to modify self-destructive behavior a valid option for these patients?

Yes, the use of peer relationships and the repetition possible in a structured setting of a helpful community enhances the behavioral treatment opportunities and increase learning

Treatment of Personality Disorders True or False Operant conditioning emphasizes the recognition of acceptable behavior and its reinforcement with praise or other tangible rewards is a valid behavioral treatment option for personality disorders

True

Treatment of Personality Disorders Psychological intervention is best conducted in what kind of setting?

Group setting Peer pressure in the group tends to impose restraints on rash behavior

True or False Treatment of Personality Disorders Those patients with a history of parental abuse and a family history of mood disorder tend to have the most challenging treatments

True

What is known as the marked pattern of inattention and/or hyperactivity-impulsivity that is consistent with developmental level and clearly interferes with functioning in at least 2 setting (school, home, work)?

Attention-Deficit/Hyperactivity-Disorder

ADHD Several biologic factors have been proposed as contributors (food additives/diet, lead contamination, cigarette/alcohol exposure, low birth weight) as well as psychosocial adversity, but is there a real consensus on the cause of ADHD?

Nope

True or False ADHD Data strongly suggests a neurological and genetic basis with catecholaminergic dysfunction as a central finding

True

The following are clinical findings in what? 1. Marked inattention, distractibility, organization difficulties, and poor efficiency ( academic and occupational failure) 2. Low frustration tolerance, shifting activities, difficulty organizing, and day dreaming 3. Symptoms often attenuate during late adolescence although a minority will experience full symptoms into mid-adulthood 4. More frequently occurs in males

ADHD

What is a differential of ADHD that is characterized by a pattern of negativistic, hostile, and defiant behavior; this is a more severe, less common disorder of habitual rule breaking defined by a pattern of aggression, destruction, lying, stealing, or truancy?

Oppositional Defiant Disorder/Conduct Disorder

What is found to co-occur with ADHD in 30-50% of cases?

Oppositional Defiant Disorder/Conduct Disorder

What is the mainstay of treatment for ADHD?

Medication 1. Methylphenidate (Ritalin, Concerta, Metadate) 2. Amphetamines (Adderall, Dexedrine,Vyvanse)

Majority of children with ADHD continue to exhibit deficits in attention/activity level in adulthood with only about ____% evidencing a remission of symptoms by adolescence/adulthood.

30%

Dementia due to Traumatic Brain Injury (TBI) refers to a wide range of alterations in thinking, mood, and behavior resulting from neurologic damage related to brain trauma and can result in what?

Memory loss

True or False Head trauma severe enough to cause brief loss of consciousness or post-traumatic amnesia can produce long-lasting cognitive and behavioral changes.

True

What in the brain is especially susceptible to damage due to being near the sphenoid ridge?

Hippocampus Frontal lobes are also susceptible to countercoup injury

True or False Memory loss Biochemical alteration can also develop, as seen in chronic traumatic encephalopathy where repeated minor head injuries lead to dementia

True

Can fatigue, headache, and/or dizziness occur shortly after trauma when concerned for memory loss?

Yes

Memory Loss After the initial onset of symptoms from a head injury, what can develop which includes slowing of information processing, impaired attention, and poor memory ?

Post-concussive Disorder

Head injuries can be rated using what scale?

Glasgow Coma Scale

What almost always involves loss of memory for the event and frequently includes loss of recall for events immediately before and after the head trauma?

Amnesia

True or False Amnesia can present itself in someone repeatedly asking a question that has already been answered

True

What screening tool is used to assess Post-Traumatic Amnesia?

MACE

What is the treatment of mild head trauma?

1. Determine the neuropsychological deficit 2. Give appropriate counseling 3. Treat symptomatically

Symptoms attributed to Post concussion Syndrome (headache, dizziness, neuropsychiatric symptoms, and cognitive impairments) are greatest within the first ___ to ___ days for the majority of patients and at one month symptoms are usually improved and often resolved.

7 to 10 days

What is known at the strong desire to be or the insistence that one is a gender other than the one assigned at birth; essential criterion is the presence of clinically significant distress or impairment of functioning in one or more important areas (social relationships, works, etc.) ?

Gender Dysphoria

People with what experience cross-gender identification, anatomic dysphoria, and the desire to undergo treatments to align their physical appearance via cross-sex hormones and/or surgical interventions?

Gender dysphoria

True or False Gender Dysphoria Key criterion of clinically significant distress can either be from the GD itself or a consequence of others stigmatizing discriminatory reactions

True

True or False Research shows that the best practice approach is to support a social gender transition and the initiation of biomedical treatments that permit an approximation of the phenotype of the desired gender

True

Gender dysphoria If a patient expresses confusion about their gender identity or are exploring how their gender identity relates to their emerging sexual orientation, what is the goal of therapy?

Help them work through these issues before making any decisions about a gender transition

What medical treatment can be given to promote sexually dimorphic characteristics with the opposite sex and eventually sex reassignment surgery?

Hormonal Therapy

What is the disturbance of processes in sexual functioning which causes clinically significant distress?

Sexual Dysfunction

These are all examples of what? 1. Delayed ejaculation 2. Erectile dysfunction 3. Female orgasmic disorder 4. Female sexual interest/arousal disorder 5. Genito-Pelvic pain 6. Penetration disorder 7. Male hypoactive sexual desire disorder 8. Premature ejaculation 9. Substance/Medication induced sexual dysfunction

Sexual dysfunctions

What is known as delayed or absent ejaculation/orgasm occurring on almost all occasions of partnered sexual activity and persists for a minimum of 6 months?

Delayed Ejaculation

What may be the cause of delayed ejaculation if the difficulty is situational?

Psychological (partner specific)

True or False The treatment of delayed ejaculation should be tailored and may include patient/couple psychoeducation

True

What is the failure to obtain erections in a situation in which they were anticipated, causing embarrassment, self-doubt, and loss of self confidence?

Erectile dysfunction

Sexual dysfunction What can be caused by increased age, depression, smoking, diabetes, HTN, nervous tissue disorders (spinal cord injury, MS), social anxiety, and PTSD ?

Erectile Dysfunction

What does the treatment for psychological and organic impotence include?

1. Avanafil (Stendra) - 50-100 mg PO before sexual activity 2. Sildenafil (Viagra) - 50-100 mg PO before sexual activity 3. Tadalafil (Cialis) - 10-20 mg PO before sexual activity 4. Vardenafil (Levitra) - 10-20 mg PO before sexual activity

What sexual dysfunction in females includes the complaint of a normal libido and sexual excitement without the capacity to reach orgasm; there is a marked delay in, marked infrequency of, or absence of orgasm OR marked reduced intensity of orgasmic sensation present on all or almost all sexual activity?

Female Orgasmic Disorder

Female Orgasmic Disorder is often related to depression and what can be an effective treatment in changing negative sexual thoughts and attitudes?

CBT

What is a lack of or significantly reduced sexual interest or arousal in females for at least 6 months?

Female Sexual Interest/Arousal Disorder

What is the non pharmaceutical treatment of Female Sexual Interest/Arousal Disorder that has been used for desire and arousal problems?

Sex therapy and cognitive interventions

Female Sexual Interest/Arousal Disorder What medication has been reported to increase various indices of sexual responsiveness in women with low sexual desire?

Bupropion (Wellbutrin)

What sexual dysfunction includes the following 4 commonly comorbid symptoms? 1. Difficulty having intercourse 2. Genito-pelvic pain 3. Fear of pain on vaginal penetration 4. Tension of the pelvic floor muscles

Genito-Pelvic Pain / Penetration Disorder

The following may be etiology associated with what sexual dysfunction? 1. Partner/relationship factors, cultural/religious factors and medical factors 2. May be a conditioned anxiety reaction that results in spasm of the entrance to the vagina 3. Certain Medical conditions 4. Sexual dysfunction 5. Inadequate sexual stimulation 6. Psychological factors (prior assault, rape, etc.)

Genito-Pelvic Pain / Penetration Disorder

True or False Treatment of Genito-Pelvic Pain / Penetration Disorder should be multidisciplinary (psychiatric, gynecological, urological) and individualized

True

What is the sexual dysfunction in men that includes the absence of desire for sexual activity and persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies for at least 6 months?

Male Hypoactive Sexual Desire Disorder

What male sexual dysfunction may be due to the following? 1. Hypogonadism (low T) 2. Transient stress or interpersonal conflict 3. Mood disorder 4. Schizophrenia 5. Substance abuse 6. Medications 7. Normal age-related decline in sexual desire

Male Hypoactive Sexual Desire Disorder

True or False Male Hypoactive Sexual Desire Disorder Most lifelong cases will be due to earlier experiences, and will be medical in etiology

False Most lifelong cases will be due to earlier experiences, thus will be psychogenic in etiology

What is the treatment of Male Hypoactive Sexual Desire Disorder?

CBT combined with behavioral sex therapy with major goal of education to the patient on how to communicate sexual preferences to partners

What is the persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration before the individual wishes it, present for at least 6 moths, occurring all or almost all of the time and may be distressing?

Premature Ejaculation

Many hypotheses regarding the etiology of what may include things such as an unconscious anger toward women, a pattern learning in adolescence and then maintained by performance anxiety, or an abnormality in spinal or central nervous system mechanisms controlling ejaculatory threshold?

Premature Ejaculation

There is some evidence that Premature Ejaculation is more common in men with what?

Panic Disorder and Social Anxiety

What kind of drugs can be used in the treatment of premature ejaculation?

Serotonergic Drugs (Paroxetine (Paxil) and Clomipramine (Anafranil) most commonly).

What is known as a significant disturbance in sexual function which developed during or soon after substance intoxication or withdrawal or after exposure to a medication AND the involved substance/medication is capable of producing these symptoms?

Substance/Medication-Induced Sexual Dysfunction

What is the most important complication in mental health and often includes some elements of aggression?

Suicide

In 2018, suicide rates in U.S. population were 22.8 for males and 6.2 for females (per 100,000), and in individuals with the depression the lifetime risk rises to ___% to ___ %

10-15%

____ tend toward successful suicide, particularly in older age groups, whereas ____ make more attempts with lower mortality rates

1. Men | 2. Women

What is a significant factor in many suicide attempts?

Alcohol

True or False A suicide attempt may be an impulsive or aggressive act and could be a strategy for controlling or hurting others or an attempted escape

True

Suicide is ten times more prevalent in patients with what psychiatric disorder than in the general population?

Patients with schizophrenia

Suicidal/Homicidal Ideation What is the immediate goal of the psychiatric evaluation?

Assess the current suicidal risk and the need for hospitalization versus outpatient management

Alcohol, hopelessness, delusional thoughts, and complete or nearly complete loss of interest in life or ability to experience pleasure are all positively correlated with what?

Suicide attempts

What are some risk factors for Suicidal/Homicidal Ideation?

1. Previous attempts 2. Family history of suicide 3. Medical psychiatric illness 4. Male sex 5. Older age 6. Contemplation of violent methods 7 Humiliating social stressor 8 Drug use

True or False Suicidal/Homicidal Ideation The patient's current mood status is best evaluated by direct evaluation of plans and concerns about the future, personal reactions to the attempt, and thoughts about the reaction of others

True

True or False Suicidal/Homicidal Ideation Medication should be dispensed in normal amounts to at-risk patients

False Should be dispensed in small amounts

Should patients experiencing Suicidal/Homicidal Ideations drive?

no, driving should be interdicted until the patient improves

Steps for suicide prevention must include education of all personnel and Suicide Prevention Training which includes what?

1. Warning signs 2. Supervisors getting to know their personnel 3. Watching for changes in: behavior, attitude, or performance

Upon arrival of a service member with Suicidal/Homicidal Ideations the SMDR should review the health record for what?

1. Past psychiatric problems 2. Indicators for impulse control 3. Alcohol or drug dependence 4. Concurrent Medical problems

You should interview a patient with Suicidal/Homicidal Ideations for any problems regarding what?

1. Pay 2. Family 3. Social isolation 4. Helplessness or hopelessness 5. Family history if suicide or affect disorder

What scale can be used as a guide for asking questions to a patient who is suffering from Suicidal/Homicidal Ideations; answers from this will help identify whether someone is at risk for suicide, assess severity and immediacy of that risk, and gauge the level of support that person needs?

Columbia-Suicide Severity Rating Scale (C-SSRS)

What is available for structured intervention for rescuers and survivors involved in incidents likely to produce traumatic stress (fire with loss of life, suicide of shipmate, body handling duty, hostile attack, rape)?

Special Psychiatric Rapid Intervention Team (SPRINT)

DSM-5 distinguishes two proposed conditions in regards to self mutilation, what are they?

1. Suicidal Behavior Disorder | 2. Non-suicidal Self-Injury

Self mutilation A feature of what is suicide attempts defined as self-inflicted behavior done in the expectation that it will lead to death?

Suicidal Behavior Disorder

Self Mutilation In contrast to Suicidal Behavior Disorder, what consists of deliberate self-inflicted bodily damage with the expectation that the injury will not be lethal, but will lead to only mild physical harm?

Non-Suicidal Self-Injury

True or False Self Mutilation The proposed criteria also suggest the self- injurious behavior is not motivated by a wish to die, but rather to attain some positive feeling, relief from a negative state of mind, or to achieve some interpersonal end.

True

Is there a large overlap in risk factors for suicide attempts and engagement in NSSI?

Yes

The estimate of the lifetime prevalence of NSSI ranges from ___% to ___%

13.0% to 23.2%

Reasons for engaging in NSSI include to regulate emotion and to elicit attention but other correlations of NSSI can include things such as what?

1. History of sexual abuse 2. Depression 3. Anxiety 4. Alexithymia 5. Hostility 6. Smoking 7. Dissociation 8. Suicidal Ideation 9. Suicidal Behaviors

True or False By definition, the presence or absence of suicidal intent is used to distinguish between NSSI and suicide attempts

True