Diagnosis & Psychopathology 2 Flashcards
Priority 1
What are the ten Substance-Induced Disorders?
- Substance Intoxication
- Substance Withdrawal
- Substance Intoxication Delirium
- Substance Withdrawal Delirium
- Substance-Induced Persisting Dementia
- Substance-Induced Persisting Amnestic Disorder
- Substance-Induced Psychotic Disorder
- Substance-Induced Anxiety Disorder
- Substance-Induced Sexual Disorder
- Substance-Induced Sleep Disorder
List 8 medical conditions associated with Delirium Due to a General Medical Condition.
- infections
- metabolic disorders
- renal disease
- electrolyte and thiamine imbalances
- post-operative states
- encephalopathies
- head trauma
- brain lesions
Name four groups of people at greater risk for Delirium.
- persons experiencing drug withdrawal, esp. rapid withdrawal from alcohol or benzodiazepine
- persons < 60yo (following surgery and medical illness)
- persons with decreased “cerebral reserve,” e.g., conditions that compromise the CNS at greater risk
- postcardiotomy patients
Describe treatments for Delirium.
- usually multimodal: medical, psychological, pharmacological
- important to evaluate suicidality
- identification of cause of Delirium
- modification of environment to compensate for disorientation
- antipsychotics for minimization of psychotic disturbances (e.g., hallucinations, delusions)
Distinguish Dementia from Delirium.
Dementia:
- relative alertness
- longer-term course
- usually later in life (20% > 85yo)
Delirium:
- confusion/clouded consciousness
- shorter-term course
- may occur at any age
Describe pseudodementia and distinguish it from Dementia.
Depression in the elderly mistaken for dementia.
pseudodementia:
- symptoms generally improve as depression lifts
- specific onset date; usually relatively sudden
- memory problems transitory & primarily in procedural memory and recall (not recognition)
- person remains aware enough to be concerned about cognitive deficits
Dementia:
- cognitive deterioration tends to be progressive
- slower, less obvious onset
- memory problems more even, widespread, and progressive (Alzeimer’s may leave procedural memory intact)
- individual lacks concern about cognitive deficits
Describe prevalence rates and risk factors for Dementia of the Alzheimer’s Type.
- most common dementia type, about 1/2 of all cases
- 20% of people over age of 80 have Alzheimer’s
- more common in women because of women’s greater longevity
- first-degree relative with Alzeimer’s increases risk by three to four times
- other risk factors are head injury, toxin exposure, Down’s Syndrome, alcohol abuse, long-standing physical inactivity
Describe the three stages of Dementia of the Alzheimer’s Type.
- (2-4 years) Short-term memory loss (forgetting tasks, repeating questions, losing thread of conversation) often unnoticed by patient or others
- (2-10 years) Above deficits increase with further impairment, esp. in explicit memory, resulting in retro- and anterograde amnesia. Also, restlessness, flat or labile mood, fluent aphasia, complex task performance difficulty, apathy, getting lost in familiar places. Progresses to aphasia, apraxia, agnosia, personality changes, delusions, hallucinations. Subjective lack of awareness of these deficits is characteristic.
- (1-3 years) Serious broad impairment. Inability to speak, loss of recognition of significant others, loss of capacity for self-care. Inability to walk, incontinence, death usually from opportunistic respiratory disease.
Total duration of disease typically 8-10 years.
Describe treatment approaches for Dementia of the Alzheimer’s Type.
Behavioral:
- balancing stimulation level of patient’s environment (neither over- nor understimulating)
- structured, routinized day
- support for immediate family
Pharmacological:
- acetylcholine esterase inhibitors can improve or stabilize cognitive and memory symptoms in 30-50% of cases
- glutamate blockers may slow neuronal deterioration
Describe prevalence rates for Vascular Dementia.
- accounts for 10-20% of all dementia cases.
- second after Alzheimer’s
Describe prevalence rates and behavioral and physical symptoms associated with Dementia Due to HIV Disease.
- occurs in about 2/3 of AIDS patients
- initial symptoms:
- apathy
- social withdrawal
- depression
- muscle weakness
- loss of balance
- later symptoms (1-6 mos < death):
- severe psychiatric symptoms
- seizures
- incontinence
- partial paralysis
Describe some psychological factors in the progression of HIV disease.
- intellectual functioning
- somatic symptoms of depression
- age
What are some general treatment approaches for dementias?
- Dementia patients generally fare better living with family
- Families supporting dementia patients typically require support and family therapy
- Treatment for patients often highlights reality orientation and elicitation of memories
Define an amnestic disorder.
Significant decline and impairment of memory with no other cognitive deficits.
Define anterograde amnesia.
Impairment of ability to learn new information.
Define retrograde amnesia.
Impairment of ability to recall learned information or events.
Describe confabulation.
The unconscious filling in of memory gaps with imaginary events.
What is the etiology of amnestic disorders?
- any medical condition affecting brain regions associated with memory: head trauma, cerebrovascular disease, hypoxia, etc.
- a range of substances affecting brain regions associated with memory: alcohol, sedatives, hypnotics, etc.
- a range of toxins affecting brain regions associated with memory: heavy metals, carbon monoxide, industrial solvents, etc.
What is Korsakoff’s Syndrome?
Alcohol-Induced Persisting Amnestic Disorder due to B-vitamin deficiencies
Describe some treatments for amnestic disorders.
- generally family and environment focused supportive approaches, plus behavioral interventions to limit acting out
- for Korsakoff’s Syndrome, thiamine treatment sometimes used
Describe the pattern of mental disturbance labeled Post-Traumatic Amnesia (PTA).
- memory failure for day-to-day events
- disorientation
- misidentification of family and friends
- impaired attention
- illusions
- aka “posttraumatic confusional state”
Describe risk factors and course of Post-Traumatic Amnesia.
- risk factors:
- female gender
- previous head trauma
- previous psychiatric or neurological issue
- course:
- variable
- duration indicative of extent of brain damage
- retrograde amnesia returns before anterograde
- symptoms typically resolve within three to six months
- moderate to severe symptoms likely to be long-term
What impairments from Alcohol Intoxication are indicated by the WAIS?
- performance scores suppressed, esp. visual-spatial skills tests (Block Design, Object Assembly, Picture Arrangement)
- verbal scores relatively unaffected
- cognitive abilities may return to baseline after drinking has stopped
Discuss some risk factors for alcoholism.
- genetic: having a first degree relative with alcoholism increases risk four to seven times
- environmental:
- multi-problem families
- childhood emotional problems
- truancy/school behavior issues
- poor health
- presence of other mental disorders
- age (onset < 30yo typical)
- sex (more common in men cross-culturally)
For which two drugs are the Intoxication and Withdrawal criteria the same in the DSM-IV?
Cocaine and Amphetamine
What is the relationship between marijuana use and aggression?
- typical marijuana users show no relationship or a negative relationship (marijuana use inhibits aggression)
- individuals with a history of aggression may experience impulse control inhibition and thus act aggressively on impulse
The DSM-IV does not have a diagnostic category for marijuana withdrawal, but evidence indicates the existence of a clinically significant syndrome. Describe its features.
- irritability/anger
- depressed mood
- headaches
- restlessness
- anorexia
- insomnia
- cravings for marijuana
- onset < 24hrs, peak intensity days two to four
- duration 7 to 10 days
Discuss typical dosages of caffeine.
- cup of coffee ~100-150 mg
- intoxication occurs ~ 250 mg dosage
- restlessness
- nervousness/excitement
- insomnia
- diuresis
- spasms
- wandering thoughts or speech
- tachycardia/arrhythmia
- psychomotor agitation
- gastrointestinal disturbance
- flushed face
Describe three pharmacological treatments for alcoholism
- Antabuse: produces severe nausea when taken with alcohol
- Naltrexone: blocks rewarding effects of alcohol
- Acamprosate: reduces withdrawal symptoms (insomnia, anxiety, dysphoria)
Define the Abstinence Violation Effect.
- guilt and feelings of failure following relapse, which in turn lead to further relapses
- can be related to internal/stable/global causal attributions (greater likelihood of relapse) vs. external/unstable/local attributions (lesser likelihood of relapse)
NOTE: This is apparently the same as Abstinence Violation Fallacy.
Discuss treatment approaches for nicotine dependence.
- most smokers stop on their own
- nicotine replacement therapy effective
- best when combined with behavioral intervention
- most effective treatments multimodal:
- social skills
- relapse prevention
- stimulus control
- rapid smoking
- tailoring can be useful, e.g.
- relaxation training for those who smoke to relax
- aversive techniques for those who enjoy smoking
Discuss success factors for quitting smoking.
- strong desire to quit
- awareness of negative health consequences
- social support for quitting
- > 35yo
- married or cohabitating
- later age of onset
- sex (male more successful than female)
Describe Marlatt & Gordon’s (1985) Relapse Prevention Therapy.
- collection of overlearned habit patterns
- eschews disease model and labels (e.g., “alcoholic”)
- 75% of relapse associated with three situations:
- negative emotional states
- interpersonal conflict
- social pressure
- treatment focuses on alternative coping skills & lifestyle modifications (e.g., meditation, exercise, spiritual practices)
List eight areas of functioning affected by Schizophrenia.
- thought content (e.g., delusions)
- thought form (e.g., vague, diffuse, disorganized, etc.)
- perception
- affect
- sense of self (e.g., identity, boundaries between self and the world)
- volition
- interpersonal functioning
- psychomotor behavior
Discuss prevalence and onset of Schizophrenia.
- prevalence: 1% worldwide
- equally prevalent by gender (community studies), or more prevalent in males (hospital studies)
- onset late adolescence/early adulthood
- onset prior to age 18 less common, prior to age 13 exceedingly rare
- males typical onset age 18-25, unimodal
- females typical onset bimodal: first, age 25-35; second (3%-10%) after age 40
Describe common premorbid personality styles for people later diagnosed with Schizophrenia.
- suspicious
- introverted/withdrawn
- eccentric
Also: Dx of Schizotypal Personality Disorder
Discuss prognosis factors for people with Schizophrenia.
- better prognosis associated with:
- late onset
- acute onset
- brief active phase symptoms
- precipitating event
- female gender
- good premorbid adjustment
- family Hx of mood disorders
- no family Hx of Schizophrenia
Note: people with Schizophrenia tend to die younger than overall population due to suicide, accidents, or being victims of violence
Discuss the dopamine hypothesis of Schizophrenia.
Schizophrenia may be a function of an:
- overabundance of monoamine neurotransmitters (specifically dopamine) in CNS
- oversensitivity to dopamine naturally present in CNS
This is supported by:
- antipsychotic phenothiazine drugs’ action which blocks dopamine receptors in CNS
- amphetamines’ ability to mimic Schizophrenia by stimulation of dopamine receptors in CNS
There is also evidence that the balance between dopamine and norepinephrin levels is important; drugs like clozapine that have a positive effect restore this balance.
Discuss what is known about brain structure abnormalities associated with Schizophrenia.
- few reliable differences between normal and Schizophrenic brains
- 15%-30% have enlarged lateral and third ventricles
- those with poor performance on cognitive tasks also have poor blood-flow (fMRI) to prefrontal cortex
What is the lifetime risk of Schizophrenia based on relationship to a person with the diagnosis?
- unrelated: 1%
- biological siblings: 10%
- dizygotic twins: 16%
- monozygotic twins: 48%
What are some of the cross-ethnic differences in Schizophrenia prevalence and presentation?
- presentation of Schizophrenia among European-Americans is more severely symptomatic in all categories
- higher prevalence rates for African-Americans may be due to misdiagnosis of other disorders, e.g., bipolar, depression, substance-based organic disorders, and/or to confounding of race and SES
How does degree of industrialization of a country relate to course and presentation of Schizophrenia?
Continuous or episodic course without full remission of Schizophrenia, at 5-year follow-up:
- 65% of cases in industrial countries
- 39% of cases in developing countries
Variables believed to moderate this effect:
- extended families
- social support
- tolerance & acceptance by family members
What are the first-generation antipsychotics used to treat Schizophrenia and what are some of their effects (desirable and undesirable)?
- phenothiazines (e.g., Chlorpromazine) and butyrophenones (e.g., Haloperidol) reduce positive symptoms.
- side effects can be aggravation of negative symptoms and tardive dyskinesia
What are the atypical (second-generation) antipsychotics used to treat Schizophrenia and what are some of their effects (desirable and undesirable)?
- risperidone/Risperdal, clozapine/Clozaril, and aripiprazole/Abilify reduce positive symptoms
- they also can reduce negative symptoms and have fewer side effects than first-generation antipsychotics
What are some behavioral treatment approaches for people with Schizophrenia and their families?
- social skills training appears to be beneficial across many situations
- programs that emphasize interpersonal skills and occupational therapy produce better results than those that don’t
- family education and counseling important for those living with family, especially when it reduces intrafamily conflict
Differential diagnosis: Schizophrenia, Schizoaffective Disorder, and Mood Disorder with Psychotic Features
- Schizoaffective Disorder includes a period of at least two weeks in which psychotic Sx are present but mood Sx are absent.
- Mood Sx are substantial part of presentation in Schizoaffective Disorder, but less so in Schizophrenia
Discuss risk factors associated with Substance-Induced Delirium.
- intoxication/withdrawal
- medication side effects
- toxin exposure
Discuss evidence that violence is more common among persons with Schizophrenia than overall population.
There is no evidence to support this.
Discuss relationship between degree of nicotine dependence (higher smoking volume) and success with quitting.
Greater dependence associated with greater difficulty quitting.
