Exam 2 Flashcards
1
Q
What are immature defenses?
A
acting out externalization fantasy idealization omnipotent control passive agressive projection projective identification somatization
2
Q
What are neurotic defenses?
A
Displacement Dissociation Hypochondriasis Intellectualization Isolation Rationalization Reaction Formation Regression Repression/Blocking Undoing
3
Q
What are higher order (mature) defenses?
A
Altruism Anticipation Humor Identification Introjection Sublimation Suppression
4
Q
What percentage of the US population has a personality disorder (PD)?
A
6-9%
5
Q
When is the typical onset of PDs?
A
during adolescence or in early adulthood
you can not dx before the age of 18
6
Q
Are PDs more common in Males or Females?
A
Males are more common for PPD, APD, and NPD
Females are more common for BPD
7
Q
What is personality?
A
Combination of stable, habitual patterns of behavior that are characteristic of a person and that develop over the first two decades of life and then change little
8
Q
Trait
A
personality patterns are considered traits because they are longstanding and consistent (eye color, height)
9
Q
State
A
state behavior refers to behaviors that come and go, such as a mood state and many DSM axis 1 conditions
10
Q
What types of behavioral traits have high heritability?
A
aggressiveness altruism assertivness empathy harm avoidance impulsivity leadership persistence (stubbornness) social closeness well-being
11
Q
What is the DSM criteria for Personality Disorders?
A
must be over the age of 18 to dx 2+ of the following: -cognition -affectivity -interpersonal functioning -impulse control
12
Q
Paranoid PD
A
unwarranted suspiciousness and a tendency to misinterpret the actions of others as threatening, or deliberately harmful; stereotype of militia, hate group member, isolated bomber or killer
defense mechanism: projection
13
Q
Schizoid PD
A
detachment from others, a restricted range of emotional expression and a lack of interest in activities; stereotype of socially awkward, isolated computer hacker
14
Q
Schizotypal PD
A
deficits in interpersonal relationships and distortions in both cognition and perception; the clarirvoyant mystic
defense mechanism: fantasy
15
Q
Histrionic PD
A
excessive emotional expression and attention-seeking behavior
defense mechanism: hypochondriasis, somatization, regression
16
Q
Narcissistic PD
A
grandiosity, lack of empathy and a need for admiration; wealthy real estate tycoon who enjoys firing people
defense mechanism: omnipotent control, denial, externalization
17
Q
Antisocial PD
A
guiltless, exploitative and irresponsible behavior with the hallmark being conscious deceit of others; stereotype of the cold and callus criminal
defense mechanism: acting out, denial, externalization
18
Q
Borderline PD
A
pervasive instability in moods, interpersonal relationships, self image and behavior; often disrupts family and work life, long-term planning, and the individual’s sense of identity
originally thought to be at the “borderline” of psychosis, people with BPD suffer from a disorder of emotion regulation
defense mechanism:
acting out, splitting, projective identification, dissociation
19
Q
Obsessive-compulsive PD
A
rigidity, perfectionism, orderliness, indecisiveness, interpersonal control and emotional constriction
defense mechanism: undoing
20
Q
Avoidant PD
A
inhibition, introversion and anxiety in social situations
21
Q
Dependent PD
A
Submissive behavior and excessive needs for emotional support
defense mechanism: idealization
22
Q
PD: Cluster A (weird)
A
Paranoid PD
Schizoid PD
Schizotypal PD
23
Q
PD: Cluster B (wild)
A
histrionic PD
Narcissistic PD
Antisocial PD
Borderline PD
24
Q
PD: Cluster C (wacky)
A
Obsessive-compulsive PD
Avoidant PD
Dependent PD
25
What defense mechanism is commonly seen with depression?
introjection
26
What defense mechanism is commonly seen with paranoia/psychosis?
Projection
27
What defense mechanism is commonly seen with Obsessive Compulsive PD?
undoing
28
What defense mechanism is commonly seen with Antisocial PD?
omnipotent control
29
What defense mechanism is commonly seen with borderline personality PD?
splitting and projective identification
30
What is bipolar?
a mood disorder characterized by episodes of mania, hypomania and major depression
recurrent swings between these mood states
85% of bipolar patients will have more than one episode of a full cycle swing in their lives
31
BPD ranks _____ as the world's most disabling illness
6th
32
BPDs account for ____% of all mood disorders
25%
33
Risk Factors
majority of first episode before 25 years of age
means age of onset of first episode is 18 years
mixed episodes are more common in adolescents and young adults than older adults
There is a 10-15% of adolescents with hx of recurrent major depression will develop Bipolar disorder
GENETIC
34
How do the first episodes differ between men and women?
Women - depressive
| Men - manic
35
Risk of suicide in BPD is ____X is the general population
15 times higher
36
Bipolar disorder may account for ___% of all completed suicides
25%
37
BPD are much more likely to have ____disorders than the general population
anxiety
38
BPD pts are more likely to ....
be unemployed
| risk of divorce 2-3x general population
39
If you are counseling a family with a teenage who has depression, what is the likelihood that they will develop bipolar?
10-15%
40
What is the likelihood that monozygotic twins both have BPD if one has BPD?
50%
41
Bipolar 1 vs Bipolar 2
Bipolar 1 - episodes of full blown mania and major depression. may also have hypomania
Bipolar 2 - episodes of hypomania and major depression, but not full blown mania
42
What is the DMS criteria for mania?
a distinct period of abnormally and persistently elevated or irritable mood AND persistently increased goal-direct activity or energy lasting @ least a week or requiring hospitalization
during this period 3+ of the following:
-inflated self esteem or grandiosity
-decreased need for sleep
-more talkative than usual or pressured speech
-flight of ideas or racing thoughts
-distractibility (attention drawn to unimportant stimuli)
-increased goal directed activity
-excessive involvement in risky behavior
43
What is the DSM criteria for hypomania?
essentially the same as for mania, but the required duration is 4+ days and the sxs are "not severe enough to cause marked impairment in social or occupational functioning"
difficult to diagnose retrospectively unless you have help from a family member/significant other
44
DSM criteria for major depression
5+ of the following sxs have been present for the same 2 week period and represent a change from previous functioning; at least one of the sxs is either (1) depressed mood or (2) loss of interest or pleasure
-depressed mood most of the day, nearly every day, as indicated by either subjective report of observation made by others
- markedly diminshed interest or pleasure in all, or almost all, activities most of the day, nearly every day
significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
insomnia or hypersomnia nearly every day
-psychomotor agitation or retardation nearly every day
-fatigue or loss of energy nearly every day
-feelings or worthlessness or excessive or inappropriate guilt nearly every day
- diminished ability to think or concentrate, or indecisiveness, nearly every day
-recurrent thoughts of death recurrent suicidal ideation without specific plan
45
How do you dx Bipolar 1?
one manic episode not explained by anything else
| depression not actually required
46
How do you dx Bipolar 2?
one hypomanic plus one major depressive episode
47
Cyclothymia
a chronic, bipolar-like condition characterized by numerous periods of sxs of hypomania and periods of sxs of depression that do not meet the threshold for a major depressive episode. lasts at least 2 years, sxs present most of the time, no more than 2 months sxs-free
48
What medications can cause substance induced bipolar disorder?
cocaine
corticosteroids
stimulants
this dx is NOT made if pt had sxs of bipolar disorder prior to use of medications/substance
49
What is the ratio of depressed mood to elevated mood in bipolar 1 vs 2?
Bipolar 1 - 3:1
| Bipolar 2 - 37:1
50
What is the differential dx of BPD?
```
unipolar major depressive disorder
schizoaffective disorder
schizophrenia
ADHD
borderline personality disorder
substance abuse
hypothyroidism
```
51
What is rapid cycling?
4+ episodes in a year
| more common in women
52
When is the most dangerous time for a BP pt?
When they are coming out of their depressive state via medications because their energy comes back before their mood improves
53
What is the goal of BPD treatment?
monotherpy on a mood stabilizer (lithium or valproate)
54
When do we use valproate?
first line treatment for pts without psychosis
| DO NOT use in women with periods
55
DSM 5 Criteria for Manic Episode
A distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week
3+:
- inflated self-esteem or grandiosity
- decreased need for sleep
-more talkative than usual (or pressured speech)
-flight of ideas
-distractibility
- increase in goal-directed activity or psychomotor agitation
-excessive involvement in activities that have a high potential for painful consequences
56
Bipolar I disorder
Occurrence of at least one manic or mixed episode
57
Hypomanic Episode
Mood disorder syndrome similar to mania but milder and briefer
58
Obessions
recurrent and persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress
59
Compulsions
repetitive and intentional behaviors (or mental acts) performed in response to obsessions or according to certain rules that must be applied rigidly
60
What is the DSM criteria for OCD?
Obsessions, compulsions, or both
obsession or compulsion are time consuming or cause clinically significant stress or impairment
the person recognizes that the obsessions and compulsions are intrusive and unwanted
61
What are the 7 different types of obsessions?
```
aggression
contamination
symmetry
sexual
hoarding
religious
somatic
```
62
What are the subtypes of OCD?
insight (good, poor, absent)
| tic related
63
What is the best treatment for tic-related OCD?
antipsychotic + SSRI
| this subtype is highly familial with early onset and M > F
64
What is the epidemiology of OCD?
M = W (men more likely to have earlier onset)
onset typically gradual (but can be sudden)
typically onset by late teens early 20s with most having had it by their 30s
lifetime prevalence of 2-3%
65
What is the lifetime prevalence of OCD?
2-3%
66
What SSRIs are used to treat OCD?
fluoxetine
fluvoxamine
paroxetine
sertraline
67
What is the DSM criteria for body dysmorphic syndrome?
preoccupation with 1+ received defects or flaws in physical appearance that are not observable to others
at some point during the course of the disorder, the individual has performed repetitive behaviors or mental acts in response to the appearance concerns
68
What is the prevalence of body dysmorphic syndrome?
1-3% in general population
| equally common in men and women
69
When is the typical onset of body dysmorphic syndrome?
adolescence or early adulthood
70
Is body dysmorphic syndrome acute or chronic?
chronic but fluctuates in intensity and severity
71
Pts with body dysmorphic syndrome attribute their disability to ....?
the embarrassment associated with their imagined defect
72
What is the treatment for body dysmorphic syndrome?
cognitive-behavioral therapy + SSRIs
73
The addition of what drug class will help boost the SSRIs when treating pts with body dysmorphic syndrome?
second generation antipsychotics (olanzapine, risperidone)
74
What is the incidence of hoarding disorder?
5% of the general population
75
What is the DSM criteria for Hoarding Disorder?
persistent difficulty discarding or parting with possessions
perceived need to save the items
resulting in accumulation of possessions that clutters active living areas
76
What is the emotional feelings a pt with Hoarding Disorder experience when trying to get rid of an possessions?
anxiety or feeling of grief at the loss
77
What are the nonpsychiatric differential dx of a pt with hoarding disorder?
lesions in the anterior ventromedial prefrontal and cingulate cortices
Prader -Willi Syndrome (rare --pt will be of short stature, hyperphagia, food-seeking behavior)
78
What is the treatment for mild hoarding disorder?
SSRI
79
What is trichotillomania?
hair pulling disorder
| increase sense of tension before pulling out the hair and pleasure, gratification, or relief when pulling out the hair
80
What is the DSM criteria for Trichotillomania?
Recurrent pulling out of ones hair
| repeated attempts to decrease or stop hair pulling
81
Is trichotillomania acute or chronic?
chronic but tends to wax and wane in sx severity
82
Which gender is more likely to have trichotillomania?
females
83
What is the typically onset of trichotillomania?
childhood onset
| 1-4% of adolescents and college students
84
What comorbidities do you normally see in a pt with trichotillomania?
mood and anxiety disorders
85
What is the treatment for trichotillomania?
behavioral therapy (habit reversal)
SSRIs or clomipramine
cognitive behavioral psychotherapy to help boost low self esteem
86
Excoriation
skin - picking disorder
87
What is the incidence of excoriation?
| Is it considered chronic or acute?
1-5% of the general population
often considered chronic, the disorder fluctuates in intensity and severity (few people wit this disorder seek treatment)
88
What is the DSM criteria for Excoriation?
recurrent skin picking resulting in skin lesions
| repeated attempts to decrease or stop skin picking
89
What is the treatment for excoriation?
not well established
| SSRIs + habit reversal
90
What are the type of eating disorders?
```
Anorexia Nervosa
Bulimia Nervosa
Avoidant/Restrictive Food Intake Disorder
Binge eating disorder
Pica
Rumination disorder
```
91
What are the two key disturbances of eating disorders?
Behavioral Disorder “disturbance in eating habits”
| Cognitive Disturbance “fear of being fat”
92
What factors affect the development of eating disorders in adolescence?
Pubertal changes
Interpersonal changes
Genetics
93
What is the weight cut off for anorexia nervosa?
In adolescents a BMI for age < 5th percentile
94
Which gender is more likely to get anorexia nervosa?
Females
95
Binge eating
Eating, in a discrete period of time (ex. Within any 2 hour period), an amount of food that is definietly large than what most individuals would eat
A sense of lack of control over eating during episode
96
What is the lifetime prevalence of bulimia nervosa?
2%
97
Binge eating disorder
Recurrent episodes of binge eating
May or may not have cognitive distortions (but more often they do)
The binge-eating episodes are associated with 3+ of the following:
-eating much more rapidly than normal
-eating until feeling uncomfortably full
-eating large amounts of food when not feeling physically hungry
-eating alone because of feeling embarrassed by how much one is eating
-feeling disgusted with oneself, depressed, or very guilting afterward
The bind eating occurs, at least once a week for 3 months
98
Loss of Control Eating (LOC)
A binge is hard to define in growing children of various ages
LOC: subjective experience of loss of control over eating with an objective or subjective binge episode
Associated with weight gain
Associated with impulsivity/ADHD
99
Avoidant Restrictive Food Intake Disorder
Persistent failure to meet nutritional needs with one or more of:
-sig. weight loss
-sig. nutritional deficiency
-dependence of enteral feeding or supplements
-interference with functioning
Onset in infancy or early childhood, may persist to adulthood
Insufficient evidence linking to tother eating disorders
100
What is atypical anorexia?
Weight is in the normal range despite weight loss
101
Which groups of adolescents have higher rates of eating disorders?
Those with chronic medical conditions
And
Type 1 Diabetes
102
What are the 3 components of feeding behavior leading to food consumption?
Food acquisition
Satiety
Social learning
103
What are some CV complications of eating disorders?
```
Bardycardia
Hypotension
Orthostatic blood pressure
Long QT syndrome
Loss of cardiac muscle
Mitral valve prolapse
Pericardial effusion
Reversible with weight restoration
```
104
What are the endocrine complications of AN?
Low T3
Normal T4 and TSH
Reversible with feeding
Suppression of hypothalamic-pituitary-gonadal axis leading to amenorrhea, pubertal delay
105
What is the DSM criteria for Delirium?
Disturbance in attention (ie reduced ability to direct, focus, sustain, and shift attention) and awareness
Change in cognition (eg memory deficit, disorientation, language disturbance, perceptual disturbance) that is not better explained by something else
-disturbance develops over a short period (hours to days) and tends to fluctuate during the course of the day
106
____% of elderly patients admitted for medical problem will experience delirium
30%
107
_____% of patients admitted for a surgical problem with have delirium
25-40%
108
Up to ____% of ICU pts have delirium at some point in their stay
70%
109
___% of people over 55 living at home who were randomly chosen were found to be delirious
1%
110
Mortality rates for pts with delirium are ____ as high as pts without similar conditions who do not get delirium
Twice
111
What neurotransmitter is found to be deficient in delirium pt?
Acetylcholine
Anticholinergic medications (benadryl, tricyclic antidepressants, HTN meds) are well known to cause delirium
112
What are the risk factors for delirium?
```
Advanced age
Serious illness
Dehydration
Polypharmacy
Pre-existing dementia
Electrolyte and metabolic problems
Sleep deprivation
Visual/hearing problems
```
113
What is the most common cause of delirium?
INFECTION
114
What are the most common causes of delirium?
Infection
- Urinary infection
- PNA
- Sepsis
- electrolyte disturbance
- metabolic disorder
- medication reactions
- dehydration
- Heart attack
- Stroke
- EtOH/drugs
- HF
- Renal Failure
115
What are the first symptoms of delirium?
```
“Grandma ain’t acting right!”
Reduced awareness of the environment
Drowsy or lethargic
Distractible
New memory impairment
Wave and wave = HALLMARK
```
116
What questions should you be asking the family when assessing a delirium patient?
How long has this been going on?
What specifically do you notice is wrong?
Any new meds or change in meds?
Alcohol/drug hx
Recent febrile illness?
Sxs of other illness (cough, strong urine, leg weakness)
Depression?
117
What PE are you going to do for a pt with delirium?
Head to toe
| Full Neurological exam
118
What labs do you order for a pt with delirium?
ALWAYS: CBC, electrolytes, renal panel, liver panel, UA with culture, CXR
- EKG (if they have CV risk)
- blood clture
- toxicology panels/drug levels
- cardiac enzymes/ Pro-BNP
- arterial blood gas (if they seem septic)
May also include:
-CT/MRI, lumbar puncture, EEG
119
What does a low temperature in an elderly patient mean?
Equivalent to a fever in an elderly pt because they are not in balance
120
What is the treatment for delirium?
Treat the CAUSE (abx, etc)
121
What are the adjunct treatments for delirium?
- gently re-orient and reassure the patient
- have family stay close by if they are helpful
- discontinue restraints and urinary catheters if possible
- try to keep the environment quiet and remove unnecessary visual stimuli
- may be gentle sedation with haloperidol (
122
What are the differences between delirium and dementia?
```
Time frame of onset
Underlying cause
Genetic predisposition
Treatment
Reversibility (waxing and waning)
```
123
What is one of the most common and most serious psychiatric emergencies?
Suicidal Ideation
124
How many people die per year from suicide in the US?
30,000
125
____% of suicide patient saw their primary care doctor within a month of their suicide
45%
126
Men are ____times more likely to complete suicide, but women are more likely to attempt
4 times
127
How do men and women differ from attempted suicide?
Men more likely to use violent means
| Women are more likely to OD
128
People who live in a house where there is a gun are ____to ____ times as likely to succeed in suicide as those whose household do not contain guns
4 to 10
129
What are the risk factors for suicide
- Major psychiatric disorder such as depression, bipolar dz, SCZ
- previous psych hospitalization
- previous suicide attempt
- substance abuse
- hopelessness
- impulsivity (especially among teens)
- living alone
- unemployed
- being an MD
- childhood physical/sexual abuse
- family hx of suicide
- chronic illness
130
What questions are you asking when assessing a suicidal pt?
Are the means of suicide available to the pt (meds, guns)?
How lethal is the plan likely to be?
What is the likelihood of rescue?
Has pt. Made preparations for suicide? (Stockpiling pills, giving away belongings)
Who does the patient have to provide support to them?
Do they have protective religious beliefs?
131
What is the hardest part of suicide pt presentation?
They present so differently
As the provider you need to just pay attention to subtle phrases or recent stories of loss or etc
Be direct
Be comfortable with talking about suicide. “Have you thought of hurting yourself or anyone else?”
132
What is inpatient management of suicidal patient?
```
Intensive therapy (individual +/- group)
Start patient on anti-depressant or change medication regimen
Assess for psychiatric and medical comorbidities
Begin discharge planning from the first day
```
133
When you start a pt with high suicidiality on anti-depressants why do you want to see this patient multiple times a week?
The first few weeks after a pt starts an antidepressant are dangerous
Since they have more energy but aren’t feeling better
134
What is a “contract for safety”?
Sitting down and expressing concern
Making a plan for the patient to call or what actions they would take if they were considering suicide
DOCUMENT that you did this
135
Which patients do you ask about homicidal ideation?
Depression
SCZ
PD
Suicidality
Make sure you ask the patient and DOCUMENT
You do NOT want to be held accountable for this
ASK!
136
What is the Tarasoff Ruling?
Health professionals have a “duty to protect” the intended victim by warning the victim, notifying the police and any other practical means
Health professionals do not have a duty only to the patient right in front of them
This is one reason you are able to break pt confidentiality
137
What do you do if a pt tells you they want to kill someone and have a plan?
1) call the PD and let them know
| 2) hospitalize this pt and start psych work up
138
Psychosis definition
A disturbance in the perception of reality, evidenced by hallucinations, delusions, or thought disorganization
Psychotic patients are at high risk for agitation, aggression, suicide, homicide and other forms of behavioral dysfunction
139
What is Rule # 1 for evaluating psychotic pts?
Make sure that you, the pt, and all staff are safe
140
What are techniques for calming a psychotic pt?
Verbal reassurance
Cooling down period
Haloperidol (Haldol)
141
What are you assessing in a psychotic pt?
```
Hallucinations
Delusions
Thought disorganizations
Difficulty maintaining daily activities
Cognitive loss
Diminished verbal communication
```
142
What is the treatment of psychosis?
Immediate, secure hospitalization to prevent harm to themselves and others g
Long term, these patients need a correct diagnosis (SZH, Bipolar) and proper treatment for these diseases
May include antipsychotic pills or depot haloperidol (once a month injection)
143
What do you do if a pt has a weapon?
NEVER ask them to hand it to you
Ask them to put it on the ground
Follow hospital protocol for what comes next
144
Substance abusers are ___times more likely than the general population to become violent
30
145
Patients with antisocial personality disorders + substance abuse are ____ times more likely than the general population to become violent
100
146
What do you have to consider when you are physically restraining a patient?
Figure out the law in your state
But make sure they are quick release (with one pull or one hand)
Because if that patient codes or vomits you need to be able to quickly role the patient
These patients need a sitter
147
What are the two main drugs for chemical restraints?
Anti-psychotics - Haldol
Start with 5 mg IM. Dose can be repeated every 20-30 minutes
Benzo - Lorazepam
-start with 1-2mg IV/IM
Dose can be repeated every 10 - 30 minutes
148
What are the only fatal withdrawal syndromes?
EtOH or Benzos
149
What is the treatment for EtOH Intoxication?
“Banana Bag” - Thiamin, Magnesium, MVI and folate in 1 L NS given IV
NEVER give sugar before thiamine because you can cause korscoff syndrome
Prevent EtOH withdrawal since it’s fatal
150
What do pinpoint pupils suggest?
Opiate intoxication
151
What is the treatment for Opiate Intoxication?
If they are breathing ok, just let them ride it out
If not, give them Naloxone (narcan) - don’t give 2mg all at once
152
At what point do cocaine pts come into the hospital?
Only if they have a complication like chest pain (vasospasm), stroke, or spontaneous abortion, asthma
153
What is the treatment for Cocaine-related Health Problems?
If HTN or tachy treat with Benzo
If having coronary vasospasm, given ASA and nitroglycerine
NEVER given Beta Blocker —> beta blockers will block beta but leaving alpha unopposed leading to stroke or HA
Always ask a pt with chest pain if they have done cocaine
154
What is cluster A and what are the diseases, and associated familial disease?
Cluster A pts seem eccentric, peculiar, or withdrawn
Family hx of psychotic disorders
Paranoid
Schizoid
Schizotypal
155
What is cluster B? What are the diseases and family correlation?
Emotional, dramatic, or inconsistent
Familial association with mood disorders
Diseases:
- antisocial
- borderline
- histrionic
- narcissistic
156
What is cluster C? What diseases are cluster C?
Cluster C: anxious or fearful
Familial association of anxiety disorders
Diseases:
- dependent
- avoidant
- Obsessive-compulsive
