Conditions Flashcards
ADHD
Inattention: Exhibits a poor/short attention span in schoolwork/play; displays poor attention to detail or careless mistakes; has difficulty following instructions or finishing tasks; is forgetful and easily distracted.
Hyperactivity/impulsivity: Fidgets; leaves seat in classroom; runs around inappropriately; cannot play quietly; talks excessively; does not wait for his or her turn; interrupts others.
Autism spectrum disorder
- Deficits in social interaction and communication: Reduced interest in socialization, reduced empathy, inability to form relationships, impaired language development, inability to understand social cues, poor eye contact.
- Prognosis is best determined by language development. - Restricted/repetitive patterns of behavior, interests, or activities: Highly fixated or restricted interests, inflexibility to change, hand flapping, increased/decreased response to sensory input
Oppositional defiant Disorder
negative, defiant, disobedient, and hostile behavior toward authority figures
Conduct disorder
violating the basic rights of others or age-appropriate societal norms/rules
Disruptive mode disregulation disorder
outbursts that are out of proportion to the situation and a persistently irritable or angry mood between outbursts;
Cause for intellectual developmental disorders
Down syndrome (Trisomy 21)
Fetal alcohol syndrome (FAS)
Fragile X syndrome
Tourette syndrome
Multiple motor tics (eg, blinking, grimacing).
■ One or more vocal tics (eg, grunting, coprolalia, echolalia, throat clearing, coughing).
Schizophrenia
positive symptoms (hallucinations, delusions, disorganized thought/behavior) and negative symptoms (flat affect, social withdrawal, apathy).
Hallucinations (most often auditory).
■ Delusions.
■ Disorganized speech.
■ Disorganized or catatonic behavior.
■ Negative symptoms: Flattened affect, social withdrawal, anhedonia, apathy, ↓ emotion. May mimic depression.
■ 5A’s: Affect (flat), avolition, asociality, anhedonia, apathy. See Table 2.14-1 for the differential diagnosis of psychosis.
Catatonia is a neurobehavioral syndrome marked by the inability to move or speak (stuporous subtype) or the inability to stop moving or speaking repetitively (excited subtype) that typically arises from an exacerbation of a psychiatric disorder such as bipolar disorder or schizophrenia. Patients with the stuporous subtype of catatonia typically present with immobility, mutism, muscle rigidity, waxy flexibility (maintaining limb position after the limb is moved by the examiner), negativism (resistance to instruction), staring, and/or posturing. Patients with the excited subtype typically demonstrate hyperactivity, purposeless movements, verbigeration (repetition of words/phrases), and echolalia (repetition of other people’s words).
Schizophreniform disorder
Schizophreniform disorder: 1–6 months
Schizoaffective disorder
Schizoaffective disorder: Psychosis + mood disorder (mania or depression)
Dissociative identity disorder (multiple personality disorder)
≥ 2 distinct personalities
Associated with history of trauma and child abuse
Depersonalization/ derealization disorder (DDD)
Feeling of detachment from one’s self; may feel like an outside observer
Derealization: Experiencing one’s surroundings as unreal
Dissociative amnesia
Inability to recall memories or important personal information, usually after a traumatic or stressful event
Characterized by sudden, unexpected travel in a dissociated state and subsequent amnesia of the travel
GAD
Excessive anxiety or worry about multiple activities, occurring on most days for ≥ 6 months.
Symptoms cause a clinically significant impairment (eg, social, occupational).
Panic disorder
recurrent, unexpected periods of intense fear that last for several minutes and causes excessive worry about having another panic attack.
History/PE ■ Recurrent episodes of intense fear and discomfort; symptoms usually last ≤ 30 minutes. ■ May lead to agoraphobia in 30–50% of cases (fear/anxiety of developing paniclike symptoms in situations where it may be difficult to escape or get help, resulting in avoidance of those situations).
Panic attacks feature acute fear or anxiety that peaks within minutes and is associated with four additional physical symptoms or associated mental states. These additional symptoms may include heart palpitations or tachycardia, shortness of breath, chest pain, dizziness, the sensation of choking, gastrointestinal distress, paresthesias, sweating, chills, trembling, derealization, the fear of dying, or the fear of losing control. These episodes may occur during calm or anxious states, in the daytime or nighttime. The pathogenesis involves genetic factors, an anxious temperament, and stressful life events. In patients with an initial episode of panic symptoms, a thorough history and physical examination along with a basic laboratory workup and a potential ECG should be performed. Panic disorder is a relatively common psychiatric disorder characterized by recurrent panic attacks that are unexpected and associated with worry about future panic attacks or avoidance of panic attack triggers. Treatment of panic disorder typically includes antidepressant medication and/or cognitive behavioral therapy (CBT) with a focus on graded exposure to the feared situation.
Social phobia
Social phobia (social anxiety disorder): Presents with excessive fear of criticism, humiliation, and embarrassment in multiple situations requiring social interaction.
Specific phobia
OCD
Obsessions: Persistent, unwanted, and intrusive ideas, thoughts, impulses, or images that lead to marked anxiety or distress (eg, fear of contamination, fear of harming oneself or loved ones). ■
Compulsions (or rituals): Repeated mental acts or behaviors that neutralize anxiety from obsessions (eg, handwashing, elaborate rituals for ordinary tasks, counting, excessive checking).
Obsessive-compulsive disorder (OCD) is an anxiety disorder typically characterized by obsessions that the patient attempts to neutralize with compulsions. Obsessions are unwanted, intrusive thoughts (eg, thoughts related to violence, sex, or contamination) or urges (eg, to commit violence) that increase anxiety. Compulsions are rigidly applied repetitive behaviors (eg, checking, washing) or mental activities (eg, counting, repeating words) that relieve anxiety related to obsessions. By definition, the compulsions are excessive or do not realistically address the obsessive fears, and patients commonly recognize the irrationality of their compulsions
OCPD
Patients do not recognize their behavior as problematic (ego syntonic)
PTSD
Patients experience severe psychological distress when exposed to stimuli that remind them of the event, resulting in avoidance of situations where exposure to triggers is possible.
Intrusive symptoms: Re-experiencing the event through nightmares, flashbacks, intrusive memories.
■ Avoidance of stimuli associated with the trauma.
■ Negative alterations in mood and cognition: Numbed responsiveness (eg, detachment, anhedonia), guilt, self-blame.
■ Changes in arousal and reactivity: ↑ Arousal (eg, hypervigilance, exaggerated startle response), sleep disturbances, aggression/irritability, and poor concentration.
■ Symptoms lead to significant distress or impairment in functioning. ■ Symptoms must persist for > 1 month. ■ Acute stress disorder
Body dysmorphic disorder
Hoarding disorder
Difficulty discarding possessions,
Excoriation disorder
Skin picking
Trichotillomania
Trichotillomania (hair pulling disorder)
Common cause for dementia
Alzheimer’s
Vascular dementia
DEMENTIASS
Degenerative diseases (Parkinson, Huntington, dementia with Lewy bodies [DLB]) Endocrine (thyroid, parathyroid, pituitary, adrenal) Metabolic (alcohol, electrolytes, vitamin B12 deficiency, glucose, hepatic, renal, Wilson disease) Exogenous (heavy metals, carbon monoxide, drugs) Neoplasia Trauma (subdural hematoma) Infection (meningitis, encephalitis, endocarditis, syphilis, HIV, prion diseases, Lyme disease) Affective disorders (pseudodementia) Stroke/Structure (vascular dementia, ischemia, vasculitis, normal-pressure hydrocephalus)
Dementia
memory loss, impaired executive function, impaired function at home, but can maintain most chores. Personal hygiene may need prompting. ■ Moderate: Severe memory loss, inability to recognize friends (agnosia), impaired social judgement, requires assistance with dressing and personal hygiene.
Personality, mood, and behavior changes are common (eg, wandering and aggression).
Delirium
waxing and waning consciousness with lucid intervals and perceptual disturbances (hallucinations, illusions, delusions). ■ Patients may be combative, anxious, paranoid, or stuporous. ■ Patients have ↓ attention span and short-term memory, a reversed sleepwake
Definition and Cause for delirium
acute disturbance of consciousness with altered cognition that develops over a short period (usually hours to days). Children, the elderly, and hospitalized patients (eg, ICU psychosis) are particularly susceptible. Major causes are outlined in the mnemonic I WATCH DEATH.
Infection Withdrawal Acute metabolic/substance Abuse Trauma CNS pathology Hypoxia Deficiencies Endocrine Acute vascular/MI Toxins/drugs Heavy metals
Alcohol withdrawal
Tremor, tachycardia, hypertension, malaise, nausea, seizures, delirium tremens (DTs), agitation
Opioid withdrawal
lacrimation, diaphoresis, dilated pupils, rhinorrhea, piloerection, nausea, vomiting, stomach cramps, diarrhea, yawning Opioid withdrawal is not life-threatening, “hurts all over,”
Amphetamine intoxication
Psychomotor agitation, impaired judgment, hypertension, pupillary dilation, tachycardia, fever, diaphoresis, anxiety, angina, euphoria, prolonged wakefulness/attention, arrhythmias, delusions, seizures, hallucinations MDMA (“ecstasy”) is an amphetamine with hallucinogenic properties; popular at dance parties or “raves.” Intoxication: As above, plus hyperthermia, heat exhaustion,
Cocaine intoxication
Psychomotor agitation, euphoria, impaired judgment, tachycardia, pupillary dilation, hypertension, paranoia, hallucinations, “cocaine bugs” (the feeling of bugs crawling under one’s skin), sudden death Chronic use causes weight loss, erythema of the nasal turbinates and septum, and behavioral changes ECG changes from ischemia
PCP intoxication
Assaultive/combative, belligerence, psychosis, violence, impulsiveness, psychomotor agitation, fever, tachycardia, vertical/horizontal nystagmus, hypertension, impaired judgment, ataxia, seizures, delirium
LSD intoxication
Marked anxiety or depression, delusions, visual hallucinations, flashbacks, pupillary dilation, impaired judgment, diaphoresis, tachycardia, hypertension, heightened senses (eg, colors become more intense)
Marijuana intoxication
Euphoria, laughter, slowed sense of time, impaired judgment, social withdrawal, ↑ appetite, dry mouth, conjunctival injection, hallucinations, anxiety, paranoia, ↓ motivation
Barbiturates intoxication
respiratory depression
Benzodiazepines intoxication
Interactions with alcohol, amnesia, ataxia, somnolence, mild respiratory depression
Caffeine intoxication
Restlessness, insomnia, diuresis, muscle twitching, arrhythmias, tachycardia, flushed face, psychomotor agitation
Nicotine withdrawal
Irritability, headache, anxiety, weight gain, craving, bradycardia, difficulty concentrating, insomnia
Synthetic opioid intoxication
Parkinson-like disorder and loss of pigmented neurons in the substantia nigra
Bath salt intoxication
Stimulant drug that causes agitation, combativeness, delirium, and psychosis that may last for weeks
MDD criteria
Diagnosis requires depressed mood or anhedonia (loss of interest/pleasure) and ≥ 5 signs/symptoms from the SIG E CAPS mnemonic for ≥ 2 weeks.
Sleep (hypersomnia or insomnia) Interest (loss of interest or pleasure in activities) Guilt (feelings of worthlessness or inappropriate guilt) Energy (↓) or fatigue Concentration (↓) Appetite (↑ or ↓) or weight (↑ or ↓) Psychomotor agitation or retardation Suicidal ideation
Mood disorder caused by a medical condition
Hypothyroidism, Parkinson disease, CNS neoplasm, other neoplasms (eg, pancreatic cancer), stroke (especially anterior cerebral artery stroke), dementias, parathyroid disorders
Substance-induced mood disorder
Illicit drugs, alcohol, antihypertensives, corticosteroids, OCPs
Adjustment disorder with depressed mood
resemble an MDE but does not meet the criteria for MDE Occurs within 3 months of an identifiable stressor
Dysthymia (persistent depressive disorder)
Milder, chronic depression with depressed mood (≥ 2 depressive symptoms) present most of the time for ≥ 2 years; often resistant to treatment
Postpartum subtype of depression
Postpartum: Occurs within 1 month postpartum;
Psychotic subtype of depression
Psychotic features: Generally mood-congruent delusions/hallucinations. Psychosis
Presentation of mania
DIG FAST outlines the clinical presentation of mania. ■ May report excessive engagement in pleasurable activities (eg, excessive spending or sexual activity), reckless behaviors,
DIG FAST Distractibility Insomnia (↓ need for sleep) Grandiosity (↑ self-esteem)/more Goal directed Flight of ideas (or racing thoughts) Activities/psychomotor Agitation Sexual indiscretions/other pleasurable activities Talkativeness/pressured speech
Hypomanic
Less severe symptoms Symptoms present for ≥ 4 days. No hospitalization is required No significant impairment in social/occupational functioning No psychotic features
Cyclothymia disorder
Alternating periods of the following symptoms for at least 2 years: ■ Hypomanic symptoms that do not meet criteria for hypomania. ■ Depressive symptoms that do not meet criteria for major depressive episode.
Paranoid personality disorder
Distrustful, suspicious; interpret others’ motives as malevolent Note: These patients will use projection as a defense mechanism
Schizoid personality disorder
Isolated, detached “loners” who prefer to be alone Restricted emotional expression
Schizotypal personality disorder
Odd behavior, perceptions, and appearance Magical thinking; ideas of reference Note: Remember, in contrast to OCD, these patients do not feel their behavior is problematic (ego syntonic). They also do not have true obsessions and compulsions.
Schizotypal personality disorder is a cluster A personality disorder, the odd or eccentric cluster. The disorder is characterized by odd behavior and thinking and a constricted affect. Patients with schizotypal personality disorder may have strange, overly metaphorical or magical thinking, though they fluctuate in the degree of their conviction about these beliefs (which differentiates these beliefs from the fixed delusions of schizophrenia). The strange beliefs may also manifest as eccentric appearance as in this patient. Patients may experience somatosensory illusions or other abnormal perceptions. Patients with schizotypal personality disorder may appear to lack interest in cultivating relationships (eg, work graveyard shifts) and, because of an inability to interpret others’ motivations, may be deeply distrustful and anxious around others. Personality disorders are persistently maladaptive ways of relating to the self and to society that typically appear by early adulthood
Borderline personality disorder
Unstable mood, relationships, and selfimage; feelings of emptiness Impulsive History of suicidal ideation or self-harm Note: These patients often employ splitting as a defense mechanism
Histrionic personality disorders
Excessively emotional and attention seeking Sexually provocative; theatrical
Narcissistic personality disorders
Grandiose; need admiration; have sense of entitlement Lack empathy
Antisocial personality disorder
Violate rights of others, social norms, and laws; impulsive; lack remorse Must be > 18 years of age Evidence of conduct disorder before 15 years of age
OCPD
Preoccupied with perfectionism, order, and control at the expense of efficiency Inflexible morals and values Note: Remember, in contrast to OCD, these patients do not feel their behavior is problematic (ego-syntonic). They also do not have true obsessions and compulsions
Avoidant personality disorders
Socially inhibited; rejection sensitive Fear of being disliked or ridiculed, yet desires to have friends and social interactions
Dependent personality disorder
Submissive, clingy; feel a need to be taken care of Have difficulty making decisions Feel helpless
Substance use disorder criteria
Impaired control: ■ Consumption of greater amounts of the substance than intended. ■ Failed attempts to cut down use or abstain from the substance. Increased amount of time spent acquiring, using, or recovering from effects. ■ Craving. ■
Social impairment: ■ Failure to fulfill responsibilities at work, school, or home. ■ Continued substance use despite recurrent social or interpersonal problems 2° to the effects of such use (eg, frequent arguments with spouse over the substance use). ■ Isolation from life activities.
■ Risky use: ■ Use of substances in physically hazardous situations (eg, driving while intoxicated). ■ Continued substance abuse despite recurrent physical or psychological problems 2° to the effect of the substance use. ■
Pharmacologic: ■ Tolerance and use of progressively larger amounts to obtain the same desired effect. ■ Withdrawal symptoms when not taking the substance.
AUD
CAGE questionnaire. Monitor vital signs for evidence of withdrawal. ■ Labs may reveal ↑ LFTs (classically AST:ALT ratio > 2∶1), ↑ LDH, ↑ carbohydrate-deficient transferrin, and ↑ mean corpuscular volume.
Look for palmar erythema or telangiectasias and for other signs and symptoms of endorgan complications.
- Have you ever felt the need to Cut down on your drinking? 2. Have you ever felt Annoyed by criticism of your drinking? 3. Have you ever felt Guilty about drinking? 4. Have you ever had to take a morning Eye opener?
Complications forAUD
Gastritis (GI bleeds, ulcers), varices, or Mallory-Weiss tears. ■ Pancreatitis, liver disease, DTs, alcoholic hallucinosis (see Table 2.14-17), peripheral neuropathy, Wernicke encephalopathy, Korsakoff psychosis, fetal alcohol syndrome, cardiomyopathy, anemia, aspiration pneumonia, ↑ risk for sustaining trauma (eg, subdural hematoma).
Alcoholic hallucinosis vs. delirium tremen
12–24 hours since last drink Visual, auditory, and tactile hallucinations
48–96 hours since last drink Autonomic instability (hyperadrenergic state; ↑ BP, ↑ HR) Disorientation, agitation Hallucinations
Anorexia nervosa
Persistent restriction of caloric intake resulting in low body weight, an intense fear of gaining weight, and a distorted body image (patients perceive themselves as fat)
BMI<18.5
Patients are typically not distressed by their illness and may thus be resistant to treatment
Anorexia nervosa is characterized by an intense fear of gaining weight, decreased self-worth related to body weight, and consequent restricting (eg, fasting, exercising) or binge eating/purging behavior (eg, vomiting, laxative or diuretic misuse) leading to insufficient nutrition. Patients with anorexia nervosa often have a BMI less than 17 kg/m2, though patients with mild anorexia may demonstrate a BMI greater than 17 kg/m2(normal BMI is 18.5 to 24.9 kg/m2). Amenorrhea is common and reflects insufficient nutrition. Alternatively, patients with bulimia nervosa do not typically demonstrate severe malnutrition that leads to amenorrhea or a low BMI. Physical examination of patients with anorexia nervosa can show dry, scaly skin and fine hair or hair loss caused by decreased protein stores. Patients who vomit to purge can demonstrate parotid gland enlargement from salivary gland overstimulation, dental caries from gastric hydrochloric acid erosion of enamel, and scars on the knuckles secondary to abrasions from the incisors when inducing vomiting. The loss of gastric hydrochloric acid leads to hypochloremia and metabolic alkalosis. In severe cases, signs of hypovolemia such as tachycardia and hypotension may be present.
Bulimia nervosa
Episodes of binge eating followed by compensatory behaviors (eg, purging, fasting, excessive exercise)
Patients are of normal weight or are overweight (BMI > 18.5 kg/m2)
Patients are typically distressed about their symptoms and are thus easier to treat
Dental enamel erosion, enlarged parotid glands, scars on the dorsal hand surfaces (if there is a history of repeated induced vomiting), and BMI > 18.5 kg/m2.
Obsessive-compulsive disorder (OCD) is an anxiety disorder typically characterized by obsessions (unwanted, intrusive thoughts that produce anxiety) that the patient attempts to neutralize with compulsions (repetitive behaviors). By definition, the compulsions are excessive or do not realistically address the obsessive fears, and patients commonly recognize the irrationality of their compulsions. This patient’s worry about contamination represents an obsession, while her repeated hand washing represents a compulsion. Treatment includes high doses of selective serotonin reuptake inhibitors (SSRIs, eg, fluoxetine) or cognitive behavioral therapy (CBT) with a focus on exposure to the discomfort of suppressing the compulsion after experiencing the obsession. SSRIs have the lowest side effect burden of antidepressant medications. Clomipramine (a tricyclic antidepressant) and venlafaxine (a selective serotonin-norepinephrine reuptake inhibitor antidepressant) are effective second-line agents.
Sexual Changes with Aging
Men usually require ↑ stimulation of the genitalia for longer periods of time to reach orgasm; intensity of orgasm ↓, and the length of the refractory period before the next orgasm ↑. ■ In women, estrogen levels ↓ after menopause, leading to vaginal dryness and thinning, which may result in discomfort during coitus.
Paraphilic disorder
Preoccupation with or engagement in unusual sexual fantasies, urges, or behaviors for > 6 months with clinically significant impairment in one’s life. There are eight classified disorders, characterized by disordered courtship (voyeurism, exhibitionism, and frotteurism), disordered preferences (pedophilia, transvestic fetishism, fetishism), and pleasure in inflicting/ receiving pain (sadism, masochism).
Gender dysphasia
dressing like the opposite sex, taking sex hormones, or pursuing surgeries to reassign their sex.
Primary insomnia
nonrestorative sleep or difficulty initiating or maintaining sleep that is present at least three times per week for 1 month.
Primary hypersomnia
of excessive daytime sleepiness or nighttime sleep that occurs for > 1 month.
Narcolepsy
excessive daytime somnolence and ↓ REM sleep latency daily for at least 3 months. Sleep attacks are the classic symptom; patients cannot avoid falling asleep. ■ Characteristic excessive sleepiness may be associated with the following: ■ Cataplexy: Sudden loss of muscle tone that leads to collapse. ■ Hypnagogic hallucinations: Occur as the patient is falling asleep. ■ Hypnopompic hallucinations: Occur as the patient awakens. ■ Sleep paralysis: Brief paralysis upon awakening.
Central sleep apnea
airflow and respiratory effort cease. CSA is linked to morning headaches, mood changes, and repeated awakenings during the night.
OSA
obstruction along the respiratory passages. OSA is strongly associated with snoring. ■ Risk factors: Male gender, obesity,
Complication of OSA
headaches, depression, ↑ systolic BP, and pulmonary hypertension.
Circadian Rhythm Sleep Disorder
Somatic symptom disorder
excessive thoughts, anxiety, and behaviors driven by the presence of somatic symptoms that is distressing and negatively affects daily life. This may occur with or without any medical illness present. High health care utilization is often present.
Conversion disorder
deficits of voluntary motor or sensory function (eg, blindness, seizurelike movements, paralysis) incompatible with medical processes.
Symptoms unexplained by other medical or neurologic causes. ■ Physical exam signs suggesting nonorganic cause of symptoms: ■ Presence of Hoover sign (extension of affected leg when asked to raise the unaffected contralateral leg) when attempting to rule out leg paralysis.
Eyes closed and resistant to opening during seizure; negative simultaneous EEG. ■ Tremor disappears with distraction. ■ La belle indifference: Patients are strangely indifferent to their symptoms.
Fictitious disorder
fabrication of symptoms or selfinjury to assume the sick role (primary gain). ■ Factitious disorder imposed on another (formerly Munchausen by proxy): Caregiver exaggerates or falsifies medical/psychiatric symptoms or intentionally induces illness in someone else to receive benefit by taking on the role of concerned caregiver.
Malingering
Malingering: Patients intentionally cause or feign symptoms for secondary gain (eg, financial, housing, legal).
Sexual and physical abuse
Patients typically have multiple somatic complaints, frequent emergency department visits, and unexplained injuries with delayed medical treatment. They may also avoid eye contact or act afraid or hostile. ■ Children may exhibit precocious sexual behavior, genital or anal trauma, STDs, UTIs, and psychiatric/behavioral problems. ■ Other clues include a partner who answers questions for the patient or refuses to leave the exam room.
Risk factors for suicidality
SAD PERSONS). ■ Women are more likely to attempt suicide. Men use more lethal methods (eg, firearms) and are more likely to complete suicide.
Sex (male) Age (older) Depression Previous attempt Ethanol/substance abuse Rational thinking loss Sickness (chronic illness) Organized plan/access to weapons No spouse Social support lacking
