Dx And Pathology Flashcards
What are the 5 axis?
Axis I Clinical do;focus of attention Axis II mr and pd; borderline iq; traits Axis III. General medical Axis IV psychosocial and environmental problems Axis v global assessment of fx 1 to 100 (superior fx) Rating usually for current eval
Dsm IV TR is? Atheoretical Symptom based classification Underscores importance of gender, age, and culture Multiaxial assessment Categorical approach Polythetic criteria sets
Eliminated gender bias
Cultural diff explained
Glossary w cultural info
Tr…changes only to text accompanying dx
Categorical bc either meet or not meet (dimension is 1 to 10). Works best when homogeneous, clear category boundaries, mutually exclusive. So use polythetic criteria or have to meet a sunset of sx, not all.
Give the degrees of mental retardation.
Mild 50 - 70. 85 percent Discover late childhood in school 6th grade level of education Independently live in semi skilled jobs Moderate 35/40 -50/55. 10 percent 2nd grade. Un or semiskilled w supervision. Severe. 20/25 - 30/35. 3 or 4 perc Poor motor. Limited communication . Elementary hygiene skills. Close supervision in home or grp home. Profound. Below 20/25. 1 to 2 perc Constant aid
What is the most common contributing factor to mental retardation? A. Environmental influences B. pregnancy and perinatal C. Hereditary D. Embryonic development
A. 15 to 20 percent. Cultural-familial retardation; Lack nurturance; or mental do like autism
B. 10 percent. Malnutrition; HIV;premature; anoxia; injury
C. 5 percent. PKU;Tay saks; fragile x;
D. 30 percent. Downs; prenatal use of alcohol/drugs
30 to 40 percent no etiology.
What is borderline iq?
71 to 84
Mr may be appropriate at the lower end and significant deficits I’m adaptive fx.
Put under other conditions that mAy be a focus of attention.
What are the important dx criteria for autism?
By three..delayed or abnormal fx in social intx, language, or play
6 sx 2 sx re; impaired social fx 1 sx impaired communication 1 sx restricted or repetitive behavior Other: Half don't speak ; echolalia, reversals in pronouns Older more interest in others Perseveration play 4 to 5 timeshare common in males 75 percent codx of mr Distinct from schizophrenia No correlation w ses, parent characteristics, education, job, race, religion. Potential genetic (mono twins hi rate) or neuro factors, rubella, birth probs, hi SE
What is the tx for autism?
Neuroleptics, haloperidol for aggressiveness, lability, withdrawal, stereotyped behaviors. other pharmacological do not work.
Intense behavior intervention. Operant techniques . Reinforce all efforts to communicate.
Best when started very very young, involved parents, use at home, intensive, structured environment, uses contract to delineate changes and methods.
2 percent hi fx
40 percent hi fx
Best prognosis..
Early language skills, overall intellectual ability, disorder severity, usable language by age 7.
Iq alone predicts only worst outcome.
Correlation…developmental milestones, social maturity, time in school and comorbidity neuropsychiatric do
No correlation…birthwt, perinatal, age or onset, normal development before, ses, late development of seizures, type of tx, family mental illness.
What are the important criteria for retts?
Females only
Developmental regression starting at 4.
Seem normal in prenatal and perinatal pd and for last 5 mo after birth.
Usually life long communicative and behavioral problems.
Initial signs…head growth deceleration, loss hand skills, hand washing/ringing , later gait problems, language problems. Within a few years loses interest in social environment . Eventually epilepsy, mr
Cause..genetic mutation
Childhood disintegrative disorder?
Pd of normal development 2 plus yrs
After 2 and before 10
Regression in several areas. At least 2. Language, social or adaptive, bowel/bladder, play, motor
Very rare. But social and communication impairments and behavioral signs look like autism.
Difference between aspergers and autism?
No significant deficit in language, self-help, Cognitive development, or curiosity about the environment.
Better prognosis
Many jobs and self sufficient
More in males as well.
What are the two types of dyslexia?
Surface or orthogonal dyslexia
Ability to read regularly spelled words but can’t decipher words that are spelled irregularly. This limits the comprehension of written material.
Deep dyslexia…reading errors including semantic paralexia (response related to the word in meaning but not visually or phonoloically).
Differ from lack of opportunity, bad teaching, cultural factors, mr, pdd, sensory deficit.
Can have ld and mr. Must impede achievement or daily living that require the deficient skill.
Etiology..many..neuro, genetics, malnutrition, iron deficiency, allergies, otitis media , underlying cognitive deficit..
Dx of stuttering.
Usually begins between 2 and 7.
Often tx emotional pressure bc tension may aggravate it.
60 percent of cases it remits by age 16 on its own
ADHD
Onset before age 7
6 mo
2 settings
Not due to another disorder, including mr
3 to 5 percent meet criteria 10 percent some signs Many have academic problems Often behavioral issues start by 3 Often delayed dx, when they start school due to look like normal behavior of kids and more apparent in structured setting.
4 to 9x more males
Co dx…conduct…50 percent
Emotional do…25 percent
Learning do….20 percent
Also social maladjustment, motor uncoordination and visual and auditory impairments.
70 percent show signs thruout life
Adults…childhood hx and 12 sx; often passive aggressive or narcissistic traits develop and recede once treated
Etiology and tx of ADHD?
Biological cause…abnormal frontal lobe, striatum (b ganglia), cerebellum. Part of parietal lobe has problems. Lower glucose metabolism, decrease bld flow, smaller corpus collosum, globus pallidus, caudate nucleus (this one smaller it is worse on inhibition)
Genetics..offspring of parent 57 percent.
5 to 10 percent implicated in minimal brain dysfx ..normal iq..mild to severe behavior probs, perceptual motor probs, memory probs, EEG abnormalities.
Tx...CNS stimulants Low dose..improve attention Hi dose reduce activity level, improve social (not at peer level) Cognitive and behavioral interventions Young...contingency mgmt Older ...self monitoring, self talk Parents participate..rules, structure Positive reinforcement w punishment (response cost) and tangible rewards.
What is the behavioral disinhibition hypothesis?
Barkley proposed this way of viewing ADHD that suggests the essence of ADHD is a lack of ability to adjust activity levels to the requirements of different settings , not attention deficits.
Came about because some can attend in certain situations and not others. Overall, attention problems in full, repetitious, familiar, very structured and:or irregular reinforcement situations..
Seem to have trouble reducing and increasing their activity level.
Ritalin or methyphenidate has what side effects?
Somatic sx..decrease appetite, insomnia..mild. Change does or administration
Movement abnormalities…tics
30 to 70 percent
Don’t use if have Tourette’s
Obsessive compulsive sx.
30 to 50 percent.. Reduce dose
Growth suppression
Holidays
Conduct do
3 or more signs for 12 mo
At least 1 sign in last 6 mo
1 sx before 10 yrs if childhood onset
After 10 for adolescent onset..less severe prognosis; more linked to peers
Below peers on verbal subtests not nonverbal
Associated w nicotine, drug, alcohol
Majority it remits
Others move on to antisocial pd
Related to biology…low levels of arousal; genetics; environment
Tx..multi systemic tx. Long term decrease in criminal behavior by working on social network..use family tx and parent training . Best tx before teens and includes parent education
Pica
Ingested on a persistent basis for 1 Month Onset 1 to 2 years Remits early childhood. May go to adolescence Equally Associated w mental retardation
Rumination disorder
3 to 12 mo
After period normal development
Regurgitate and rechew for at least one month after a period of normal fx
Mortality 25 percent
Feeding do of early infancy
Failure to thrive
Chronic failure to eat enough
Wt loss or failure to gain for at least one month
Onset before 6 years, usually 1st yr
Malnutrition can develop
Most eventually gain wt
General medical condition, mental do, or lack of available food are ruled out..
Tic do
Tourette’s onset in childhood. B4 age 18.
Less 10 percent vulgar
Tics must occur multiple times a day, almost daily, for at least one year.
No more than 3 mo without tics
Chronic but may remit for brief pds
Often coexist w obsessive and compulsive behaviors, ADHD, ld, depression, social probs
Most co occuring w ADHD. Even don’t meet dx often have attention and over activity that interferes w academics. Same iq range as pop
Tx..school interventions, meds (haloperidol and pimozide anyipsychotic that r fast acting; clonodine..fewer side effects; reduce ocd w antidrpressants), family tx, individual tx
Chronic motor or vocal tic
Do…one or more tic. Only 1 kind. Sx and impairment less severe.
Enuresis vs encopresis
Encopresis..feces
Age 4 plus or develop age equivalent
Voluntary or intentional
1 x per mo for 3 mo
Enuresis
Age 5 plus
2 x per week for 3 mo or marked distress or impaired fx
Most bladder fx by 3. Daytime wetting higher chance of physical problem
More in males at age 5 (7 vs 3 percent). Difference shrinks w age
Think due to late mature fx plus self esteem and motivation
Bell and pad best long term result
Meds Antidepressants. Sterm use
Hypnosis..less expensive and gives power
Diurnal or awake or nocturnal
Separation anxiety do vs reactive attachment do
Separation anxiety do
4 weeks in response to separation from home or attachment figure
Somatic complaints
Fantasies of danger
School phobia can be a sx (ESP if develops between 5 and 7; start in adolescence it is depression)
Causes..overprotection, insecurity due to trauma, dependency issues
Tx..individual, family tx; behavioral interventions
Reactive attachment do
Before 5
Inhibited…fail to initiate or respond in age expected way in most social situations
Disinhibited..indiscriminate sociability Too familiar
Pathogenic care…chronic neglect, multiple caregivers..
Fetal alcohol syndrome
What structures impacted?
Basal ganglia, hippocampus, frontal lobes most effected
Also cerebellum, corpus collosum, hypothalamus
Ave iq is mild mr. 68
No effects at less than 2 drinks per day…
SIDS. Occurrence and causes
5 in 10,000 births
3rd most frequent cause of death for infants one mo and 1 yr
Constitutional factors complicated by adverse perinatal conditions
Respiratory difficulties, apnea, at birth, low birth wt, shorter body length
What criteria need to be met for mental do due to a general medical condition?
Personality change due to medical
Catatonic do due to medical
- Do due to direct physiological consequence of a general medical condition. 3 factors to consider:
Onset together in time
If signs rep primary mental do or are
atypical
If medical condition produces such sx - Mental disturbance can’t be better explained by another mental do
- Can’t occur during delirium.
Personality change.. Due to direct medical condition
Cause marked distress or impairment and depart from usual
Aggression, impulse etc out if proportion to trigger,
Different types…labile, aggressive, disinhibited, apathetic, paranoid, unspecified, combo
Causes…CNS neoplasms, cerebrovascular disease, Huntington’s, epilepsy, HIV, endocrine probs
Catatonic due to medical
Head trauma, cerebrovascular, encephalitis, metabolic
Record medical condition on axis 1 and 3.
Substance induced disorders
Can develop during intoxication, withdrawal, or long after
Substance intoxication…includes maladaptive behavioral or psychological changes and specific signs of the substance effects on the CNS.
Substance withdrawal …result of reducing or terminating use; associated distress or impairment. Develop w in few hrs or days
Usually associated w dependence
Differential dx..hx, timing of drug use and sx onset, if sx atypical
If psychotic do ruled out, dx of intox and withdrawal are sufficient to account for most presentations where sx caused by substance. If in excess of what is usually associated w intox or withdrawal then gets independent class sunstance induced psychotic do
Hallucinogen persisting do
Flashbacks. First when using then when not.
Or has Huntington’s and significant personality change. Mental do due to Huntington’s ?
A. Change just after dx
B. personality change and dx related thru physiological mechanism
C. Nature and duration do not meet personality do dx
D. No evidence use substances.
B. by definition due to direct physiological consequences of the medical condition
Signs of mania after use if cocaine. Which inclined to dx of cocaine induced mood do?
A. Sx typical during cocaine intox
B. hx of hospitalizations due bipolar
C. Used only small amt of cocaine
D. Manic sx severe enough to require hospitalization.
D. Differential of primary mood do, cocaine intox, cocaine induced mood do.
D allows for dx because the mood sx are significant enough to warrant independent clinical attention
All of the following are true about mental do due to a general medical condition except:
A. Dx whenever mental sx connected by a physical factor
B. sometimes emerge years after medical condition
C. Involve variety of diff sx
D. Name condition on axis 1 and 3
A. Need more than a physical sx. Must be evidence that they are a direct physiological consequence of medical condition.
Who is vulnerable to developing delirium and what are the differentiating criteria?
Delirium is a disturbance of consciousness. Plus
Either a change in
Cognition (memory, disoriented, language prob) or
Perceptual disturbance
Caused by direct effects of medical condition or substance.
At risk:
Old
Ppl w decreased cerebral reserve
(HIV, stroke, dementia..)
Postcardiotomy pts (ESP increasing age, time since bypass, complexity of surgery)
Pts in drug withdrawal ….ESP rapid withdrawal from alcohol or benzodiazepines.
Tx…multimodal
Eval for suicidality. Meds if needed. Underlying problem addressed, modify environment re disorientation.
Dx criteria for dementia?
Dementia is a deterioration in multiple cognitive impairments. Always memory (new and/or recall) One of: Aphasia (language) Apraxia (motor prob but is intact) Agnosia (ident obj; sensory fx intact) Executive fx
Serious enough to impede normal fx
Decline from previous fx
How is dementia different than delirium?
Dementia...relatively alert Variable course Usually late in life onset 20 percent of 85 yr olds Rare in kids; due to medical
Delirium…apparent confusion and clouding of consciousness
Sx fluctuate in a day or may remit few hrs or go on for weeks
Rapid onset
Vs pseudodementia….
Retest. If dementia will see progressive decline vs improvement w better mood.
Pseudodementia …can date onset,
Concerned abt deficits….not true of dementia.
Nature of cognitive sx different
Depression..transitory; procedural memory and recall memory
Dementia…progressive memory, recall and recognition. Early sx of do is impaired declarative (semantic and episodic). Procedural intact.
Describe Alzheimer’s type of dementia.
Most common in older adults
Half of the cases
Increases w age
20 percent over 85 have it
Gradual onset and progressive decline. 3 stages. 8 to 10 yrs
Women overrepresented. Biggest risk factor..first degree relative w hx
3 to 4
Stage 1: 2 to 4 years
Short term memory loss (may notice in retrospect). Usually recent memory probs…forget tasks, repeat ?, lose tread of convo
Stage 2: 2 to 10 yrs
Increase severity
Further memory prob (mostly explicit)..result retro and anterograde amnesia
Restless, flat affect, labile, aphasia, diff w complex tasks. Apathetic and lost in familiar places.
Stage 3: 1 to 3 yrs
Serious impairment in most areas
Lose ability to speak, unable recognize, can’t care for selves
Tx.. Optimize environment Family support Train not to over or understimulate Provide structured environment Meds
Dx criteria for vascular dementia.
10 to 20 percent of cases.
Second leading cause.
Due to cerebrovascular disease..stroke or infarction that causes a decrease in blood supply to brain
Patchy cognitive impairment..some affected and not others
Abrupt onset
Stepwise and fluctuating course
Signs depend on where damage is
What are the significant factors that impact HIV progression and prognosis?
More rapid progression of HIV to aids, HIV related dementia and death:
Intellectual fx (lower iq)
Age (older)
Somatic sx
Dementia due to HIV occurs 2/3 cases First sx...loss concentration Mild memory deficits Often motor probs and behavioral probs Later seizure, paralysis, in continence, severe psychiatric sx Death 1 to 6 mo after these sx
What is dx if substance induced dementia?
Substance induced persisting dementia
Caused by effects of substance Sx continue after intox and wdrawl Persisting effects (not direct)
Define amnestic do, etiology and tx
Memory impairment and no other cognitive impairments.
Anterograde…diminished ability to learn new info
Retrograde..recall learned info or events from past
Early stages…confab, imaginary events to fill in
Apathy, bland, personality changes
Decline from previous fx
Etiology..trauma, surgery, cerebrovascular disease, hypoxia, herpes, encephalitis, seizure
Or substances…alcohol, sedatives, hypnotics, anxiolytics. Hx long term use. Korsakoffs.
Meds..anticonvulsants, mercury…
Memory loss continues after substance is gone
Tx…depends on cause
Define post traumatic amnesia
Head injury
Memory failure for day to day events, disorientation, misidentification of family and friends, impaired attention and illusions
Duration is reliable index of severity. Longer..more extensive damage.
Better name may be post traumatic confusional state.
Recovery…duration of retrograde declines while anterograde is the last to return. Mild injury improve 3 to 6 mo.
Increased risk of long term
Impairment…female, previous head trauma, hx neuro or psychiatric problem
What substance does not qualify for a dependence disorder?
What 2 substances do not qualify for an abuse disorder?
Caffeine
Caffeine and nicotine
What are the criteria for substance dependence?
3 of the following over a 12 mo pd
Tolerance
Withdrawal or keep using to avoid it
Taken in greater amts or over longer pds of time
Persistent desire or unsuccessful try to control or reduce
Lots of time getting, using, or recovering from effects.
Activities reduced or stopped due to use
Cont use despite aware of probs caused or exacerbated by use
Dx criteria for substance abuse?
One sx over 12 mo:
Repeated use results in failure to full obligations
Use in physically hazardous situations
Repeated use related legal problems
Cont use despite probs caused or intensified
Never met criteria for dependence
What are the treatments for alcoholism?
AA, Antabuse
Naltrexone..blocks rewarding effects and craving
Acamprosate..reduces withdrawal like insomnia, anxiety, restlessness, dysphoric
Individual and family tx
When there is a relapse…restructuring their thoughts and attributions from internal to external, stable to unstable, global to specific shows higher recovery rates and better coping
What is the abstinence violation effect? AVE
Initial relapse leads to feelings of guilt and failure. Leads to more relapses or slips. Called abstinence violation effect.
What are the factors most important to nicotine cessation?
Most stop w minimal help.
Factors…strong desire to quit, awareness of negative health consequences of smoking and social support to quit.
Rec…multimodal…social skills and relapse prevention training, stimulus control, rapid smoking
Barrier…fear of withdrawal . Use gum, patch, inhaler…this nicotine replacement helps reduce withdrawal (anxiety, irritability, depression, impatience, impaired concentration). Maximized w behavioral intervention.
Greater dependence, harder to stop Amt of smoking determines dep Other things linked to success: 35 plus Married or live w partner, later age when started, male
What is relapse prevention therapy by marlatt and Gordon?
Cognitive behavioral approach used for substance dependence. View dependence as a collection of maladaptive or over learned habit patterns (vs physiological response to substance). Doesn’t subscribe to disease model, label as alcoholics not blame them for over learned responses. Ppl viewed as responsible for learning and practicing more adaptive habits.
3 hi risk situations related to 75 percent of relapses:
Negative emotional states
Interpersonal conflict
Social pressure
Goal…build coping mechanisms or alternative habits to deal w sit
Dx criteria for schizophrenia, schizophreniform do and schozoaffective do.
Schizophrenia
Active phase for 1month
Signs rep deterioration from previous fx for 6 mo
Schizophreniform Identical to schizophrenia At least 1month Less than 6 mo Impaired fx not required
Schozoaffective do
Sx of mood do (depression, manic or mixed) and schizophrenia (active phases) but not meet criteria for either.
Psychotic features more prominent than on mood do w psychotic
Pd of 2 weeks w psychotic sx but no mood sx
What are the active sx vs the negative sx of schizophrenia?
Active/positive sx…distortions or exaggerations of normal fx include perceptions (hallucinations), inferential thinking (delusions), language and communication (disorganized speech) and behavior (catatonic or grossly bizarre).
Most common hallucinations are auditory.
Delusions are usually bizarre and persecutors. Can be referential (song is referring to me).
Negative sx include a diminished or loss of fx that are normally present. such as flat affect, alogia (poverty of speech), avolition. Anhedonia.
What is the prevalence and age of onset for schizophrenia?
Premorbid fx?
1/100 ppl world wide
Late teens or early adulthood Before 18 less common Males earlier onset 18 to 25 Females 25 to 30; after 40 Equal rates in surveys Hospital rates..more males No more aggressive than general pop Die earlier age, often unnatural..suicide, harmed, accident
Premorbid personalities.
Suspicious, introverted, withdrawn, Eccentric. Schizotypal pd.
What is associated with a better prognosis re: schizophrenia?
Late onset Female Acute onset Precipitating event Good premorbid fx Brief active phase Family hx mood do No family hx schizophrenia
What is the criteria for residual type of schizophrenia?
At least one schizophrenic episode Continue to display negative signs Or attenuated positive sx (odd beliefs, mildly disorganized speech, eccentric). Ie. circumstantial No prominent positive psychotic sx No strong affective displays
Etiology of schizophrenia
Genetic
Biological factors.
Dopamine ho…excess D or increase sensitivity to it
Neurological irregularities:
1. Structural brain abnormal..increased volume in lateral and 3rd ventricle 15-30 perct
2. Functional brain abnormal
Smaller increase bld flow to prefrontal cortex w poor performance on cognitive tasks, ESP in those w negative sx
3. Neurotransmitter imbalance
NE, (SE, and glutamate too)
4. Genetics..closer related more likely
Unrelated 1 perct, sibs. 10 perct
Fraternal 16 perct,identical. 48 perct
Psychosocial factors.
Diathesis stress or vulnerability theory …physiologically predisposed confronted w adverse and stressful environment
What are the ethnic differences in schizophrenia.
What are the differences for industrialized and non industrialized countries?
Ethnic..originally thought black higher prevalence. Confounding. Recently found white significantly more symptomatic
Third world countries…more acute onset, shorter clinical course, more often than not a complete remission. Possibly bc extended families, more support, more tolerance
What is the treatment of schizophrenia?
Meds most effective for positive sx
Antipsychotics…phenothiazines (chlorpromazine) or butyroohenonen (haloperidol). But may aggravate negative sx and serious side effects
Atypical antipsychotics. As effective but more effective at relieving negative sx. Used if newly dx Risperidone (risperdel) Clozapine (clozaril) Aripiprazole (abilify) Meds best w social skills
Day tx forstalls relapse, reduces sx, improves community fx
Best if associated w occupational tx
Family education if return home
Relapse associated w critical, hostile, overinvolved and unempathetic attitudes
