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Brain and Behavior > Exam 4 Deck 2 > Flashcards

Exam 4 Deck 2 Flashcards

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1
Q

What are diagnostic criteria for the trauma in PTSD?

A

Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:

  • direct experienceing the traumatic event
  • witnessing the event as it occured to others
  • learning the traumatic event occured to close family member or friend
  • experiencing the repeated or extreme exposure to aversive details of the event
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2
Q

What are intrusion symptoms of PTSD required for diagnosis??

A

One or more of:

1) Recurrent & intrusive distressing memories of event
2) Recurrent distressing dreams of event
3) Dissociative reactions (eg, flashbacks) in which

feel or act as if event were recurring

4) Intense psychological distress at exposure to cues that symbolize/resemble aspect of event
5) Physiological reactivity on exposure to cues

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3
Q

What are avoidance symptoms needed for a PTSD diagnosis?

A

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, as indicated by 1 or both of the following:

1) Avoid distressing memories, thoughts or feelings associated with trauma
2) Avoid external reminders (activities, places, people, conversations that arouse distressing memories, thoughts or feelings about the trauma

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4
Q

What are negative alterations in cognitions and mood needed for a PTSD diagnosis?

A

As evidenced by 2 (or more of the following):

1) Can’t recall important aspect of trauma
2) Negative beliefs or expectations about oneself, others or the world
3) Distorted cognitions about the cause or consequences of the trauma that lead individual to blame self or others
4) Persistent negative emotional state (fear, horror, anger, guilt, shame)
5) Decreased interest/participation in activities
6) Feel detached or estranged from others
7) Inability to experience positive emotions

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5
Q

What are alterations in arousal and reactivity needed for a PTSD diagnosis?

A

As evidenced by ≥ 2 of the following:

1) Irritability or outbursts of anger
2) Reckless or self destructive behavior
3) Hypervigilance
4) Exaggerated startle response
5) Problems with concentration
6) Sleep disturbance

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6
Q

What are diagnostic criteria for PTSD diagnosis?

A

Exposure to trauma

Intrusion symptoms

Avoidance of stimuli associated with trauma

Negative alterations in cognition or mood

Alterations in arousal or activity

> 1 month of symptoms

Impaired functioning

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7
Q

What are some common symptoms seen in PTSD (that aren’t in the diagnostic criteria)?

A

Guilt

Depression

Anxiety

Panic attacks

Shame

Rage

Substance abuse

Self injurious behavior

Suicide attempts

Impaired relationships

Explosive or impulsive behavior

Difficult with trust

Somatic complaints

Hyperadrenergic sx

Psychosis

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8
Q

What is acute stress disorder?

A

Exposure to traumatic event with presence of 9 or more symptoms from any of the following categories:

Intrusion (memories, dreams, flashbacks)

Negative mood (can’t experience positive emotions)

Dissociation (altered sense of reality, can’t recall important aspect of trauma)

Avoidance (of memories, thoughts, feelings, external reminders)

Arousal (insomnia, irritability/anger, hypervigilance, poor concentration, exaggerated startle)

Impaired function, significant distress

Duration of symptoms: 3 days-1month after trauma

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9
Q

What are common comorbid psychiatric disorders with PTSD?

A

OCD

Panic disorder

GAD

MDD

Substance use disorders

Borderline personality disorder

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10
Q

What are predictors of worse outcomes?

A

More symptoms

Comorbid medical illnesses

Childhood trauma

Additional trauma

Psychiatric history

Female

Alcohol abuse

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11
Q

More trauma is associated with a […] rate of PTSD

A

More trauma is associated with a higher rate of PTSD

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12
Q

What role does the type of trauma have in the rates of PTSD development?

A

Those that are more personal physical affronts have higher rates (physical attack, threat wiht weapon, rape, …)

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13
Q

What are important factors related to the trauma that are risk factors for PTSD development?

A

Degree of controllability, predictability, perceived threat, and extent of injury

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14
Q

What are premorbid sociodemographic risk factors for PTSD?

A

Female, younger age, minority, lower education

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15
Q

What are premorbid historical risk factors for PTSD?

A

Prior trauma

Psychiatric history

Family history of anxiety disorder

Neurological compromise

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16
Q

What are premorbid psychological risk factors for PTSD?

A

Disrupted parental attachments

Personality disorder

Self-criticism

Cognitive appraisal of trauma

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17
Q

What are premorbid characteristics of trauma exposure that are risk factors for PTSD?

A

Type

Amount/severity

Age at exposure

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18
Q

What are premorbid characteristics of the recovery environment that are risk factors for PTSD?

A

Low social support

Stressful life events

New traumas

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19
Q

What is “failure to recover” with respect to PTSD?

A

Normal stress response occurs to a trauma

Typically it shuts off, but there is a subset of people who do not recover

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20
Q

What are neurobiological models of PTSD?

A

ANS, noradrenergic system

HPA axis, cortisol

Serotonergic system

Neuroanatomy and neurocircuitry
Genetics

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21
Q

What is the role of cortisol on the fight-or-flight response?

A

Feeds back and shuts it down

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22
Q

What findings are seen in the noradrenergic system in PTSD patients?

A

Sustained hyperactivity of sympathetic nervous system (increased urinary excretion of NE, Epi and metabolites; Increased HR, BP, increased plasma NE)

Increased CNS NE activity/reactivity (Increased CSF NE levels and responses to stressors; α2 receptor antagonist causes flashbacks and increased autonomic responses)

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23
Q

What can potentially be a predictor of PTSD in trauma survivors?

A

HR at ER presentation

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24
Q

What do you see on dexamethasone suppression test in PTSD patients?

A

Exaggerated suppression of the HPA axis

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25
Q

What HPA axis findings do you see in PTSD?

A

Decreased cortisol

Increased CRF (don’t worry, its paradoxical)

Exaggerated suppression upon dexamethasone suppression test

Increased negative feedback sensitivity

Increased glucocorticoid receptor sensitivity

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26
Q

What are consequences of “low cortisol” in acute aftermath of trauma?

A

Increased catecholamines (NE) leading to overconsolidation or pairing of memories and distress

Causes traumatic reminders to be destressing, which leads to increased fear and development of maladaptive cognitive responses to the trauma

Causes failure of habituation and extinction, which induces a state of perpetual fear; PTSD symptoms and dysfunction perpetuated

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27
Q

Can glucocorticoids prevent PTSD?

A

Preliminary data shows that it may play a role in protection

But there are many side effects

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28
Q

What drugs are effective in the treatment of PTSD?

A

SSRIs

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29
Q

What is the role of the serotonergic system in PTSD?

A

SSRIs are effective in treatment

Modulatory effects on affective and stress responses

Coordinates with CRF and NE systems

Potential role in pathophysiology of impulsivity, hostility, aggression, depression, hypervigilence, and suicidality

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30
Q

What neuroanatomical/neurocircuitry findings do we see in PTSD?

A

Smaller hippocampus

Smaller anterior cingulate with decreased reactivity

Increased reactivity of the amygdala

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31
Q

What are the genetics of PTSD?

A

Complex with genetic and environmental risk factors

Parental PTSD appears to be a risk factor for PTSD

  • lower cortisol levels in children of PTSD patients
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32
Q

What is the cognitive model of PTSD?

A

People respond to traumatic events based on how they interpret these events

Cognitive appraisal during and after the event is critical to understanding who develops chronic symptoms

PTSD becomes persistent when individuals process the trauma in a way that leads to a sense of serious and current threat (e.g. “all men are rapists”)

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33
Q

What are individual differences in cognitive appraisal that can be linked to greater chance of PTSD?

A

Degree of perceived controllability and predictability

Feelings of shame, humiliation, guilt

Feeling that one could have prevented what happened

Subjective interpretation of event

Gender

Social support

Pre-traumatic “history”

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34
Q

How do we treat PTSD pharmacologically?

A

Antidepressants (SSRIs, Tricyclic, MAOIs, SNRIs)

Adrenergic blockers (propranolol, clonidine, prazosin)

Anticonvulsants/Mood stabilizers

Atypical antipsychotics

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35
Q

What are psychotherapies for PTSD?

A

Education, crisis intervention
Supportive counseling

Cognitive and Behavioral Therapies (exposure therapy, relaxation techniques, cognitive restructring therapy, stress management)

Group therapy

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36
Q

What defines a personality disorder in DSM V?

A

An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture

Manifested in two or more of the following areas:

Cognition

Affectivity

Interpersonal Functioning

Impulse control

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37
Q

What are FDA approved drugs for Axis II disorders?

A

NONE!

Psychotherapy most helpful

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38
Q

What are the clusters of personality disorder in DSM-5?

A

Cluster A = odd or eccentric disorders

Cluster B = dramatic, emotional, or erratic disorders

Cluster C = anxious or fearful disorders

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39
Q

What are the cluster A personality disorders??

A

Paranoid - irrational suspicions and mistrust of others

Schizoid - lack of interest in social relationships

Schizotypal - characterized by odd behavior or thinking

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40
Q

What are the cluster B personality disorders??

A

Antisocial - pervasive disregard for law and rights of others

Borderline - extreme black and white thinking. instability in relationships, self image, identity and behavior leading to self-harm and impulsivity

Histrionic - pervasive attention-seeking behavior, inappropriately seductive behavior

Narcissistic - grandiosity, need for admiration, lack of empathy

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41
Q

What are the cluster C personality disorders??

A

Avoidant - social inhibition, avoidance of social interaction

Dependent - pervasive psychological dependence on others

Obsessive-compulsive - rigid conformity to rules, moral codes, and excessive orderliness

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42
Q

What are characteristics of schizotypal personality disorder?

A

Magical thinking (aura, destiny, telepathy, …)

Disturbances in working memory

Ideas of reference

Unusual perceptual experiences

Odd thinking and speech/odd or perculiar behavior and/or appearance

Suspicious, lack of close friends, excessive social anxiety

Inappropriate or extremely reserved emotional responses

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43
Q

What treatments are available for schizotypal personality disorder?

A

Social skills training

Low dose antipsychotic medications

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44
Q

What is the neurobiological basis behind schizotypal personality disorder?

A

Runs in family with schizophrenia

Similar abnormalities in working memory and in various neurophysiological measures including eye-tracking abnormalities

Reduced volume of the superior temporal gyrus with relative preservation of frontal lobe volume

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45
Q

What are characteristics of borderline personality disorder?

A

Extreme emotional instability, especially anger

Hypersensitivity to interpersonal interactions - especially perceived rejection

Self-injury to relieve emotional pain

Dissociateive symptoms

Impulsivity; especially impulsive aggression: verbal and physical

Unstable intense interpersonal relationships

Chronic feelings of emptiness, identity disturbance

Onset in adolescence, but symptoms evident from young childhood

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46
Q

What is the heritability of borderline personality disorder?

A

~0.7 (high)

Substantial evidence for gene x environment interaction for BPD

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47
Q

What is the role of childhood trauma in borderline personality disorder?

A

High rates reported and it seems to be almost ubiquitous

Not universal

Not all abused children develop BPD; not all BPD patients have childhood trauma, etc.

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48
Q

What is a relatively objective way of measuring emotionality?

A

Startle Eye Blink Modification

Emotion can influence the intensity; negative emotion in healthy controls enhances intensity

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49
Q

What is the neurobiological basis for borderline personality disorder?

A

Amygdala hyperactivity to emotional stimuli: prefrontal amygdala imbalance

Poor self monitoring of emotion

Social cognition dysfunction

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50
Q

What happens to an individual with borderline personality disorder when they drink alcohol or take benzodiazepines?

A

Further decreased prefrontal activity - become more emotional

The tearful drunk, the sad person in the corner of the party that may be crying or suicidal

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51
Q

What are the characteristics of cluster c personality disorders?

A

Tied closely to social anxiety disorders

Longstandign feelings of inadequacy, subjective sense of being socially inept

Extreme sensitivyt to what others think about them; hypersensitivity to criticism, blushing easily

Sensitivity results in inhibition, not aggressive response as in BPD or ASPD

Behavioral avoidance of work, school, and any activities that involve socializing or interacting with others

Social isolation, w/ restricted interpersonal contacts

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52
Q

What can you see in brain imaging in avoidant personality disorder?

A

Heightened amygdala response to fear inducing stimuli, with reduced prefrontal modulation

Decreased connectivity b/w prefrontal cortex and amygdala

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53
Q

What prenatal test can help predict future avoidant personality disorder?

A

Non-stress test

Duration of elevation of fetal HR predicts future inhibited temperament

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54
Q

How does the mortality of a schizophrenic patient compare to that of the general population?

A

8x higher

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55
Q

What is schizophrenia?

A

In schizophrenia, all of the normal mental processes - sensation, perception, language, emotion, interpersonal relationships - appear to go completely awry. People with the disorder lose touch with the real world. They hear voices that are not there, speak a language that does not exist, laugh for no reason, or sit motionless for hours on end. The entire human personality is laid waste, and the psychological and social building blocks of every day life are crushed, often beyond recognition.

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56
Q

What are the positive symptoms of schizophrenia?

A

Hallucinations

Delusions

Formal thought disorder

Behavioral disorganization

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57
Q

What are hallucinations?

A

False perceptions through hearing, touch, taste, smell or vision

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58
Q

What are delusions?

A

False beliefs inexplicable in terms of patient’s cultural background

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59
Q

What is formal thought disorder?

A

illogical and often disjointed but fluent speech

Seen in schizophrenia

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60
Q

What is behavioral disorganization?

A

Bizarre behavior

seen in schizophrenia

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61
Q

What are the negative symptoms of schizophrenia?

A

Alogia

Affective blunting
Avolition

Anhedonia

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62
Q

What is alogia?

A

Poverty of speech per se, or of speech content

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63
Q

What is affective blunting?

A

Impairment in emotional expression reactivity and feeling

Inability to react in an appropriate way

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64
Q

What is avolition?

A

Characteristic lack of energy drive and interest

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65
Q

What is anhedonia?

A

Difficulty in experiencing interest or pleasure

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66
Q

What are cognitive symptoms of schizophrenia?

A

Difficulty paying attention

Difficulty encoding new information (working memory)

Contstructional apraxia (difficulty copying simple diagrams, intersecting pentagons)

Difficulty with verbal fluency

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67
Q

What do you need for a diagnosis of schizophrenia?

A

2 symptoms from positive and negative symptom groups

Have to interfere markedly with work, interpersonal relationships, self care

Need to be present for 6 months with 1 month of active symptoms

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68
Q

What is the natural history/progression of schizophrenia?

A
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69
Q

What happens to the positive vs negative symptoms of schizophrenia over time?

A

Negative symptoms increase

Positive symptoms decrease

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70
Q

When in the course of schizophrenia do patients respond best to pharmacotherapy?

A

Earlier (first episode)

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71
Q

What is the rate of suicide in schizophrenics?

A

4-13%

More common in men

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72
Q

Which gender commits suicide at a higher rate in schizophrenia?

A

Men

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73
Q

What factors may increase the risk of suicidality in schizophrenia?

A

Comorbid depression and alcoholism

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74
Q

Which demographic of schizophrenics tend to commit suicide?

A

Younger men with good premorbid functioning with high self-expectations for performance

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75
Q

What is the prognosis for schizophrenia compared with other psychiatric disorders?

A

Poor

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76
Q

What is the occupational status in schizophrenic compared with other psychiatric disorders?

A

Worse

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77
Q

What is the ability to hold relationships (marital status) in schizophrenics compared to other psychiatric illnesses?

A

Worse

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78
Q

What is the largest risk factor for the development of schizophrenia?

A

Positive family history

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79
Q

Is schizophrenia a mendelian disorder?

A

NO

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80
Q

What is the neurodevelopmental hypothesis for schizophrenia?

A

Suggests the etiology of schizophrenia may involve pathologic processes, caused by both genetic and environmental factors, that begin before the brain approaches its adult anatomical state in adolescence

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81
Q

What is the “two hit” hypothesis for schizophrenia?

A

Within the neurodevelopmental theory in which maldevelopment during two critical time points (early brain development and adolescence) combines to produce the sympotms associated with schizophrenia

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82
Q

What are some external factors that increase the risk of development of schizophrenia?

A

Viral infections

10-20x risk of devleoping schizophrenia following prenatal exposure to rubella

Prenatal exposure to influenza in the 1st trimester increases 7x and infection in early to midgestation increases 3x

Maternal antibodies to toxoplasma gondii lead to 2.5x risk

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83
Q

What are maternal infetions that can increase the risk of schizophrenia?

A

Rubella (10-20x)

Influenza (3-7x)

Toxoplasma gondii (2.5x)

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84
Q

Which psychiatric disorders does schizophrenia share genetic risk factors for?

A

Bipolar disorder

Autism

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85
Q

What are the shortcomings of the pathophysiologic hypothesis of schizophrenia?

A

None account for the involvement of Dopamine, Glutamate, GABA; integrate series of macro and microscopic changes, and account for genetic and environmental factors

None are all-encompassing

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86
Q

What are the two most implicated pathophysiological mechanisms of schizophrenia?

A

Stuctural brain abnormalities and abnormal brain neurochemistry

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87
Q

What are structural brain changes seen in schizophrenia?

A

Enlarged ventricles, shrunken temporal gyri, decreased coherence of white matter tracts

Hippocampal changes, increased cortial cell density

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88
Q

In these two twins, which is more likely to have schizophrenia?

A

On the right

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89
Q

In these two twins, which is more likely to have schizophrenia?

A

On the right

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90
Q

What brain region is associated with the psychotic symptomsm of schizophrenia?

A

Temporal lobe - perhaps associated with temporal lobe epilepsy

Decreased temporal cortical thickness and thought disorder and hallucinations

auditory cortex activation thought to be implicated in auditory hallucinations

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91
Q

What is the role of the prefrontal cortex in schizophrenia?

A

Hypofrontality is observed in schizophrenics

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92
Q

What is the role of dendritic spines in schizophrenia?

A

Decreased spines result in a thinner cortex that is more densely packed

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93
Q

What macroscopic changes do post-mortem studies show in schizophrenics?

A

Smaller volumes of hippocampus, parahippocampal gyrus, amygdala, and cerebellar vermis

Enlarged lateral ventricles

Lower brain weight

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94
Q

What histolocial changes are seen in schizophrenics?

A

Disarray of pyramidal cells in CA1 and CA2 of hippocampus

Increased neuronal density in PFC

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95
Q

What is the foundation of the dopamine hypothesis of schizophrenia?

A

All antipsychotic neuroleptic drugs block dopamine receptors

Dopaminergic drugs can mimic or worsen some schizophrenic symptoms

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96
Q

What are the dopaminergic pathways in the brain?

A

Nigrostriatal

Mesolimbic
Mesocortical

Tuberoinfundibular

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97
Q

What is the problem with the dopaminergic model of schizophrenia?

A

There is a delayed onset of activation

There is nonresponsivity in some schizophrenic patients

There are resuidual symptoms in patients on antidopaminergic drugs

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98
Q

What is the take-home message with the dopamine hypothesis of schizophrenia?

A

Dopamine alone is not the etiologic event in schizophrenia

Dopamine is a modulator of symptom severity

(we’re talking elevated dopamine here)

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99
Q

What is the basis for glutamatergic hypothesis of schizophrenia?

A

PCP and ketamine are NMDA receptor antagonists and produce similar behaviors

Also decreased CSF glutamate in schizophrenics

GWAS data

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100
Q

What is the PCP model of schzophrenia?

A

PCP blocks NMDA receptor of GABA-inhibitory interneurons

leads to decreased excitatory modulation of inhibitory GABA-R

Excessive glutamate release at initial stages

Glutamatergic excitotoxicity and neuronal damage with subsequent reduced glutamate in later stages

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101
Q

What is the activity of glutamic acid dearboxylase in schizophrenics relative to controls?

A

Lower

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102
Q

What is the role of GABA in schizophrenia?

A

Decreased GABA interneurons in PFC

Decreased glutamic acid decarboxylase activity

Decreased release of GABA by interneurons

Decreased GABA transporter

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103
Q

What non-neuron CNS cells have been implicated in schizophrenia?

A

Oligodendrocytes

Injury may affect the numerous cells for which one oligodendrocyte provides myelin

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104
Q

What are differences seen in oligodendrocytes in schizophrenics vs controls?

A

Total number of oligodendrocytes in layer III and in white matter are decreased in schizophrenics

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105
Q

What are shared characteristics of somatic symptom and related disorders?

A

Prominence of somatic symptoms associated with significant distress and impairment

Typically present medically rather than psych

Medically unexplained symptoms are present to various degrees (can accompany diagnosed medical disorders)

Have strong disease conviction

Often include affective, cognitive, behavioral

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106
Q

What was Freud’s take on somatic symptom and hysteria?

A

Traumatic experience leads to unconscious physical symptom formation

Uncovering traumatic incident is key to symptom relief

Psychoanalysis sort of grew out of this

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107
Q

What are the DSM-5 Somatic Symptom and Related Disorders?

A

Somatic Symptom disorder

Illness anxiety disorder

Conversion disorder (Functional neurological symptom disorder)

Psychological factors affecting other medical conditions

Factitious Disorder

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108
Q
A
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109
Q
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110
Q
A
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111
Q

What defines Somatic Symptom Disorder?

A

1+ somatic symptoms (including pain) that are distressign or result in significant disruption of daily life

Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns (persistent thoughts, high anxiety, fear the worst, don’t trust doctors, devote time and attention to symptoms/health concerns)

Typically more than 6 months

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112
Q

What are some common behaviors of individuals with Somatic Symptom Disorder?

A

High levels of worry about illness, even with evidence to the contrary

Health concerns assume a central role in the individual’s life

High level of medical care utilization

Often unresponsive to medical interventions, and new ones may only exacerbate symptoms

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113
Q

Who presents with Somatic Symptom Disorder more commonly?

A

Women, perhaps more common in lower socioeconomic groups

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114
Q

What typically happens to individuals with Somatization Disorder (what ist he course of the illness)?

A

Symptoms begin in adolescence, and criteria satisfied in mid 20s

Complications are common due to unnecessary medical procedures (surgeries)

May develop drug dependence, marital separation/divorce, iatrogenic disease

115
Q

What are other diseases you must think of when you are considering Somatization Disorder?

A

Multiple Sclerosis

Systemic Lupus Erythematosus

Acute Intermittent Porphyria

Hemochromatosis

Other psych disorders (mood, anxiety, schizo, factitious, personality)

Malingering

116
Q

What are some theories on the origins/etiology of Somatization Disorder?

A

Unconscious need to be ill that can be attributed to chaotic life, lesser education, history of abuse

Can be a learned behavior (used as a way to communicate, express emotion, be taken care of)

May be genetic, or have difficulty with information processing

Patients often fully believe their problems to be physical and have great faith in powers of aggressive medical intervention

117
Q

How do you treat a patient with Somatization Disorder?

A

Goal is to prevent adoption of sick role and chronic invalidism

Recognize it!

Adjust expectations of treatment

Proper workup, but don’t perform unnecessary tests/order unnecessary drugs

118
Q

What is the overall goal of Somatization Disorder?

A

To prevent the adoption of the sick role and chronic invalidism

119
Q

22 year old man who develops atypical chest pain on the anniversary of his father’s death from an MI. Admitted to CCU, where he can grieve and at same time be excused from the demands of his ongoing life. What do you think?

A

Conversion Disorder

120
Q

35 year old woman who presents with acute onset blindness after walking in on husband with another woman. What do you think?

A

Conversion disorder

121
Q

How do you diagnose Conversion Disorder?

A

One or more symptoms of altered voluntary motor or sensory function

Clinical findings provide evidence of incompatibility between the symptom and the recognized neurological or medical conditions

Symptom or deficit are not better explained by other medical/mental disorder

Symptom or deficit causes significant distress or impairment in the patient’s life

122
Q

What are typical symptoms seen in Conversion Disorder?

A

Motor weakness or paralysis, abnormal movements, gait or limb posturing abnormalities

Altered sensation, vision, or hearing

Episodes of abnormal generalized limb shaking w/ apparent loss of consciousness

Episodes of unresponsiveness

Sensation of lump in throat

May show indifference to symptoms

123
Q

Are the symptoms of conversion disorder intentionally produced?

A

No they are involuntary

124
Q

What is la belle indifference?

A

Indifference to symptoms often seen in Conversion Disorder

Patients not concered about their symptoms, fully confident doctor’s will fix it

125
Q

Who generally presents with Conversion Disorder (which populations)?

A

Females, low socioeconomic status, low education, lack of psychological sophistocation, rural setting

126
Q

What happens to patients with Conversion Disorder (what is the course of illness)?

A

Manifests in late adolesence but can have onset throughout lifespan

Generally acute and self limited

May be associated with stress/trauma

20-25% relapse within 1 year

Typically include one symptom at a time

127
Q

What other things must stay on your differential for Conversion Disorder?

A

Neurological illnesses (MS, Myasthenia Gravis, Periodic Paralysis, Epileptiform Seizure, Polymyositis, Other Myopathies, Guillain-Barre)

Comorbid physical illness + conversion

Other psychiatric disorder

Factitious Disorder or Malingering

128
Q

What are psychogical factars that may explain Conversion Disorder (etiology)?

A

Occur in setting of stress

Conversion of an unconscious psychological conflict into a physical symptom that leads to a reduction of anxiety

Choice of symptom may be symbolically important

Associated w/ maladaptive personality traits

Seconary benefits: attention, avoid noxious activities

129
Q

How do you treat Conversion Disorder?

A

Exclude physical illness

Reassure, relax pt

May try hypnosis, amobarbital interview (rarely)

Behavioral therapy

Suggestion

Direct confrontation not recommended

130
Q

What are long-term management options for Conversion Disorder?

A

Support or psychotherapy

Try to gain appreciation for relationships between conflicts/stressors and symptoms

131
Q

What is Factitious Disorder?

A

Feigning or production of physical and/or psychological symptoms without underlying pathology

Motivation is presumed to be unconscious and is related to the desire to assume the sick role

132
Q

What is Malingering?

A

Feigning or production of physical and/or psychological symptoms without underlying pathology

Viewed as the intentional production or reporting of symptoms for a specific purpose associated with some secondary gain

133
Q

What distinguishes Factitious Disorder from Malingering?

A

Distinguished by motivation for symptom production

Factitious - unconcsious and related to desire to assume sick role

Malingering - viewed as intentional for specific purpose (secondary gain)

134
Q

What defines Factitious Disorder?

A

Falsification of physical or psycholigical signs or symptoms or induction of injury or disease associated with identified deception

Presents him/herself to others as ill, impaired or injured

Deceptive behaviro is evident even in absence of obvious external rewards

Not better explained

135
Q

What are these examples of?

A

Factitious Disorder

136
Q

What is Munchausen’s Syndrome?

A

Subtype of Factitious Disorder

Simulation of disease with Peregrination/Wandering

Psudologia fantastica - grandiose often

Usually male, single, 40s, antisocial PD or cluster B traits

Discharged against medical advice, or disappear when discovered.

137
Q

What is the typical course of factitious disorder?

A

Often unrecognized or untreated

Chronic with significant morbidity

Usually intermittent episodes and reject psych interventions

Some stop behaviors on their own due to lifestyle/life changes

138
Q

What are some factors that suggest a diagnosis of Factitious Disorder?

A

Discrepancies between objective findings/inconsistenceis between them and other clinical history or symptomatology

Atypical illness course

Failure to respond to usual therapies

Unusually receptive to invasive tests/treatment

Resistant to releasing medical records

Unexplained medical paraphernalia or meds in room

139
Q

What is thought to be the basis (etiology) of Factitious Disorder?

A

Motivation to assume sick role and is presumed to be unconscious

Desire to receive empathic supoprt and be subject to reduced expectations

Disturbances in self and sense of reality

Early childhood abuse, emotional deprivation

Recent stressor, loss or relationship/sexual problem

140
Q

What is Factitious Disorder Imposed on Another?

A

(Munchausen’s by Proxy)

Falsification of physical or psychological signs or symptoms or induction of injury or disease in another, associated with identified deception

Presents someone else as ill, impaired, or injured

Deceptive behavior evident even in absence of obvious external rewards

Not better explained

141
Q

How do you manage Factitious Disorder?

A

Acute - asses negative reactions, behavior towards patient; psych eval; don’t overlook comorbid illness; confirm diagnosis

Chronic - collaborative treatment, communication; pharmacotherapy for comorbid disorders; psychotherapy

142
Q

Is malingering a psychiatric disorder?

A

Technically no

143
Q

How do you evaluate Malingering patients?

A

Obtain collateral info

Obtain past Med and Psych records

Psych testing is often useful

Look for motive to malinger

Observe discrepancies and look for inconsistenceis

144
Q

What is “give away” weakness?

A

Muscle is strong and then suddenly weak (arm suddenly drops, for instance)

Typical of Functional illness (i.e. Conversion Disorder)

145
Q

What is the “Arm Drop” Test?

A

Hold patient’s affected arm above the patient’s face and the arm is dropped.

In non-organic weakness the hand always misses the face

Look for jerky descent

146
Q

What are characteristics of a dragging monoparetic gait?

A

Leg dragged like a sack of potatoes

No external rotation, circumduction

Normal reflexes, no Babinski

147
Q

What is Hoover’s Sign?

A

Based on principle that flexion at one hip is accompanied by involuntary extension of the contralateral joint

Test includes examiner testing hip extension at the heal both voluntarily and involuntarily (after asking for hip flexion). Look for discrepancy

148
Q

What do we see here?

A

Forcefully trying to close left eye - pseudoptosis

149
Q

What is a general feature of Functional (non-organic) muscle weakness/gait disturbances/ tremor/ etc?

A

Disappear with distraction

150
Q

What is a test to check if blindness is functional (non-organic)?

A

Ask to bring fingers together or to sign name (don’t really need vision for this)

Pupillary reaction

Opticokinetic nystagmus

Normal opthalmoscopy

151
Q

What can help you identify non-organic (Functional) monocular blindness?

A

Prism bar - will help you see if the ‘blind’ eye sees anything

152
Q

What is the demographic that gets psychogenic non-epiletic seizures?

A

Women more common than men

20-30 year olds most common

Sexual/physical abuse, or bereavement

Can be seen in patients with diagnosed epilepsy

153
Q

What are features of PNES (Psychogenic Non-Epileptic Seizures)?

A

Not stereotyped

Side-to-side head or body turning

Asynchronous body movements

Slow down at end

Pelvic thrusting/sexual postures often seen

Prolonged body flaccidity

EEG negative!!! Can see similar symptoms in frontal lobe seizure

154
Q

What part of the tongue is often bitten in a pseudoseizure (PNES) vs in seizures?

A

Pseudoseizures often seen with tip of tongue biting

Seizures often bite the sides of tongue

155
Q

What are ways to determine if a person is psychogenically unresponsive vs coma.

A

Eylids flutter and close actively

Pupils small and reactive

Variable tone, bizarre posturing (potentially)

Sternal rub

Opticokinetic testing positive

Oculocalorics (fast component present)

EEG!!!!

156
Q

What is the most important part of the treatment experience in psychiatric illnesses? And the part that contributes most to positive outcomes for patients?

A

Doctor-Patient relationship

157
Q

What is psychotherapy?

A

A talking- and relationship-based treatment that affects the midn and brain

Not a “hired friendship”, hand holding or babysitting.

Target organ is the BRAIN

Goal is to increase range of behaviors available to the patient, and in this way relieve symptoms and alter problematic problems

158
Q

What is psychotherapy useful for?

A

Psychiatric symptoms and/or syndromes (mood, anxiety, psychosis, etc)

Specific problems (relationships, stresses, phase of life concerns)

General problems (self-esteem, inhibitions, ..)

159
Q

How effective is psychotherapy?

A

75-80% of patients show benefit

Many maintain their gains after completion

160
Q

What factors contribute to the success of psychotherapy?

A

Patient

Psychotherapist

Treatment method

Context

Most importantly, the relationship between therapist and patient

161
Q

Is psychotherapy generally preferred to psychopharmacology?

A

Limited data to show efficacy differences, since they are often used together

But patients report 3x preference for psychotherapy

162
Q

What is psychoanalysis/psychodynamic therapy?

A

Range of methods

Process of self-reflection, self-exploration, and self-discovery that takes place in the context of relationshpi between therapist and patient

Everyone has an unconscious that largely determines behaviors, thoughts, and feelings

Make the past alive in the present

163
Q

How does psychoanalytic/psychodynamic therapy genearlly go down?

A

Frequency ranges from 1x - 5x per week

May be time limited or open ended, brief or long term

+/- the couch

164
Q

What is the general technique of psychoanalysis/psychodynamic therapy?

A

Allow pt to free associate

Interpret transference

Interpret defense mechanisms, dreams

Focus on present, but listen for past experiences

165
Q

Which patients are going to be successful in using psychoanalysis/psychodynamic therapy?

A

Patients who are able to tolerate negative emotions and the feelings they will feel towrads the therapist

Those who will be able to delineate transference reactions from reality and maintain their therapeutic alliance despite ebb and flow of transference

166
Q

What are goals of psychoanalytic/psychodynamic therapy?

A

Increase insight

Understand relationship of present symptoms to developmental antecedents

Expand conscious emotional awareness of unconscious influences so can correct maladaptive patterns and better manage reality

Resolve intrapsychic conflict

Understand “truth” about oneself and one’s motivations

Enhance feeling of meaning in one’s life

Improve capacity to seek out and maintain appropriate relationships

Minimize vulnerability for recurrence of symptoms

167
Q

What are distinguishing features of psychodynamic therapy?

A

Focus on affect and the expression of emotion

Exploration of attempts to avoid distressing thoughts and feelings

Identification of recurring themes/patterns

Discussion of past experience

Focus on interpersonal relations and on the therapy relationship

Exploration of fantasy life, unstructured

Goals include but extend beyond symptom remission

168
Q

What are cognitive and behavioral therapies based upon?

A

Learning theory

Related to stimulus-response paradigms

169
Q

What is the goal of behavioral and cognitive-behavioral therapies?

A

To unlearn maladaptive and relearn adaptive behavioral and thinking patterns

170
Q

How does behavioral and cognitive-behavioral therapies go down?

A

Structured, often manualized (with handouts, etc)

Typically short-term with “here and now” problems

Therapist is active, a directive teacher with the patient being an active student

171
Q

What is the role of the therapist in behavioral and cognitive-behavioral therapies?

A

Active teacher

172
Q

What are active ingredients in behavioral therapy?

A

Specific exposures to things the patient may be scared of

173
Q

What are targets in behavioral therapy?

A

Specific conditioned responses that are looked to be extinguished

174
Q

What is aversive conditioning?

A

Used to reduce appeal of undesired behaviors

Patient is exposed to unpleasant stimulus while engagingi n targeted behavior

To create aversion to the behavior

(useful in nail biting, sex addiction, other habits)

175
Q

What is exposure therapy used for?

A

Specific phobias and PTSD

176
Q

What is systematic desensitization?

A

Removing a negative association/irrational fear that can extinguish conditioned fear response

Slowly and gradually increase doses of the feared stimulus, with relaxing stimuli until stimulus can be tolerated

(Much slower than flooding)

177
Q

What is flooding?

A

Actual full-on exposure without negative consequences to extinguish a fear or phobia

178
Q

What is exposure with response prevention?

A

Useful treatment for OCD, phobias

Expose to anxiety producing stimulus but cannot perform associated anxiolytic ritual

Must practice at all times, not jut during session

Pavlovian extinction

179
Q

What is token economy?

A

Behavioral therapy that looks to increase target behaviors

Reinforce the good, do not punish the bad

Operant conditioning - learning based on rewarding consequences

Useful in severely ill people or children

180
Q

What is biofeedback?

A

For physical/psychosomatic disorders

Physiological parameter is measured (BP, HR, etc) in real time to allow patient to learn how to alter that by relaxation

181
Q

What are the basic concepts of cognitive behavioral therapy?

A

Directed primarily at identifying and modifying distorted or maladaptive cognitions and associated emotional reactions and behavioral dysfunction

Adapted for use in many conditions

182
Q

What is the role of a therapist in CBT?

A

Very active, teacher

Structured sessions, psychoeducation, give patient homework

183
Q

What are automatic thoughts in CBT?

A

Cognitive errors

184
Q

What are CBT schemas?

A

Adaptive or maladaptive

185
Q

What are illnesses in which CBT is useful?

A

Depression and Anxiety Disorders

186
Q

What is a thought change record/thought record?

A

Have patients write down their thoughts/emotions in response to an emotion

187
Q
A
188
Q
A
189
Q
A
190
Q
A
191
Q
A
192
Q
A
193
Q
A
194
Q
A
195
Q

What is Dialectical Behavioral Therapy (DBT)?

A

Successful therapy for borderline personality disorder

Combines CBT techniques with concepts of distress tolerance, acceptance and mindfulness derived from Buddhist meditative practice

Therapist is an ally, not adversary

Individual and group components

196
Q

What are core skills of DBT (dialectical behavioral therapy)?

A

Mindfulness

Distress tolerance

Emotion regulation

Interpersonal effectiveness

197
Q

What is group therapy?

A

One or more therapists treat a small gropu of clients together as a group

Can refer to any form of psychotherapy or helping process that occurs in a group

198
Q

What is family therapy?

A

Group therapy with a family

199
Q

What is supportive psychotherapy?

A

Goals are to ameliorate symptoms and maintain, restore, or improve self-esteem and adaptive/coping skills

Try to increase resilience and strenghten adaptive defenses

200
Q

What changes can be seen in the brain due to psychotherapy?

A

Several fMRI studies have shown that there are changes in brain activity after psychotherapy

201
Q

How does psychotherapy change brain function?

A

Don’t know exaclty how yet, but functional neuroimaging studies have shown that they do indeed change brain function

202
Q

What are the four stages of child development/

A

Infancy

Early Childhood

School-Age

Adolescence

203
Q

What are the four developmental lines?

A

Motor

Language

Cognitive

Social-emotional

204
Q

What are the motor capabilities of a newborn?

A

Basic reflexes (rooting, sucking, palmar grasp, moro)

Lifts head

Limited purposeful movements

205
Q

What are the basic reflexes of a newborn?

A

Rooting

Sucking

Palmar grasp

Moro

206
Q

What are the three types of temperament?

A

Easy

Difficult

Slow-to-warm-up

207
Q

What is the time-scale of language development in a child?

A

Newborn = minimally responsive, cannot localize sound

Baby can coo by 2-4 months

Can babble by 5-6 months

208
Q

What are the Piaget’s Stages?

A

Sensorimotor stage (0-2 y/o)

Pre-operational stage (3-6 y/o)

Concrete operations (7-12 y/o)

Formal operations (13+ y/o)

209
Q

What is Piaget’s sensorimotor stage?

A

Ages 0-2

Babies don’t have language or ability to symbolize, so intelligence consists of exploring the environment through sensing things and learning how to manipulate their bodies

Smart = being able to breastfeed, being able to suck on bottle or thumb

210
Q

What is Piaget’s pre-operational stage?

A

Ages 3-6

Preschool age

Child has language without logic, magical thinking, animism (anything that moves is alive)

No concept of real vs imaginary

211
Q

What is Piaget’s Concrete operations stage?

A

Age 7-12

Onset of logical thought

212
Q

What is Piaget’s Formal operations stage?

A

Ages 13+

Still have logic, but now capable of abstract thought and imagining possibilities

213
Q

When should a baby be able to coo?

A

2 months

214
Q

When should a baby be able to babble with consonants?

A

5-6 months

215
Q

When should a baby be able to understand words?

A

8 months

216
Q

When should a baby be forming their first words?

A

10-12 months

217
Q

What is Mahler’s stages of attachment?

A

Normal autism - first few weeks

Symbiosis - 2 months

Differentiation - 4-5 months

Practicing - 1 year

Rapprochement - 1-2 years

Object constancy - 2-5 years

218
Q

What is Mahler’s normal autism?

A

First few weeks, baby is in its own world and doesn’t interact much with outside world. This is adaptive

219
Q

What is Mahler’s symbiosis stage?

A

By 2 months, the baby is fused with mom and has no sense that the body is separate from mom

220
Q

What is Mahler’s differentiation stage?

A

4-5 months

Baby starts to seperate, discover outside world, look around, attention wanders, finds fingers and toes

More alert; mom becomes a distinct entity, different from strangers

Development of transient stranger anxiety

221
Q

What is Mahler’s practicing stage?

A

1 year

Baby can walk, now can go fast away from mom and end up alone; Hallmark of separation, which is exciting for babies, but can develop seperation anxiety

Desire to be independent and the ongoing need for mothering are conflicting

222
Q

What is Mahler’s rapproachment stage?

A

1-2 years

Child goes out to world, feels anxious, comes back to check with mom

223
Q

What is Mahler’s object constancy stage?

A

2-5 years

Child internalized mother as stable and reliable figure, so they can tolerate separation

Mother is internalized no matter where the kid goes, so they can go to school now

224
Q

What do children with secure attachment styles look like?

A

They reach object constancy, they cry when a parent leaves but are able to tolerate it and are happy to see them return

225
Q

What do children with insecure attachment styles look like?

A

They can be avoidant and disengaged and may treat the mother and strangers equally

If parents leave them in room with stranger, they show minimal distress and avoid parent upon return

226
Q

What are Freud’s psychosexual stages?

A

Oral (0-1 years)

Anal (1-3 years)

Genital (3-5 years)

227
Q

What motor tasks should a baby be able to perform by 4 months?

A

Rolls over

228
Q

What motor tasks should a baby be able to perform by 5-6 months?

A

sits unsupported

229
Q

What motor tasks should a baby be able to perform by 8-9 months?

A

crawls

230
Q

What motor tasks should a baby be able to perform by 12 months?

A

walks

231
Q

When shoud a child be able to roll over by?

A

4 months

232
Q

When should a child be able to sit unsupported by?

A

5-6 months

233
Q

When should a child be able to crawl by?

A

8-9 months

234
Q

When should a child be able to walk by?

A

12 months

235
Q

When should a child be able to deveop a social smile?

A

2 months

236
Q

When should a child develop stranger anxiety?

A

8 months

237
Q

When should a child develop seperation anxiety by?

A

10 months

238
Q

What social/emotional milestone should a child hit by 2 months?

A

social smile

239
Q

What social/emotional milestone should a child hit by 8 months?

A

stranger anxiety

240
Q

What social/emotional milestone should a child hit by 10 months?

A

seperation anxiety

241
Q

What are language milestones of toddlers 18-36 months?

A

18 months: knows one body part

24 months: two-word combinations

30 months: uses pronouns

36 months: uses grammar

242
Q

What are cognitive milestones by 24 months?

A

Preoperational thought

Can sort shapes and colors

243
Q

What are motor milestones for 18-36 months?

A

18 months: runs

24 months: climbs stairs

30 months: jumps

36 months: rides tricycle

244
Q

What are social/emotional milestones of 18-36 months?

A

18 months: rapprochement

24 months: capable of sympathy

36 months: object constancy

3-4: gender identity

245
Q

When does a child develop gender identity?

A

3-4 years

246
Q

What age do children first understand that death is irreversible?

A

7 years old

247
Q

What defines school age?

A

5-10 years

Also called “latency period”

Child enters society and starts to become contributing member of community

248
Q

What was Erikson’s theory of development?

A

People go through eight conflicts in life

Trust vs mistrust (infancy)

Autonomy vs shame and doubt (toddlers)

Initiative vs guilt (preschool)

Industry vs inferiority (school age)

Identity vs role confusion (adolescence)

Intimacy vs isolation (young adulthood)

Generativity vs stagnation (middle age)

Integrity vs despair (old age)

249
Q

What is the prevailing Eriksonian conflict of school-age children?

A

Industry vs inferiority

Child attempts to master the basics of industry in society, academic achievement and social competence

Failure to do so results in sense of inferiority

250
Q

What emotional growth occurs during school age?

A

Child should be able to evaluate him/herself by a composite of his strengths and weaknesses

“What am I good at?”, “Can I get the job done?”

Reflected appraisals - competence is determined by the child’s evaluation of themselves and others’ evaluations of them

Self evaluation

251
Q

What is ADHD?

A

Developmental disorder of inattention and hyperactivity/impulsivity

252
Q

What is a developmental disorder of inattention and hyperactivity/impulsivity?

A

ADHD

253
Q

What do you need for a diagnosis of ADHD?

A
254
Q

When do symptoms need to present for a diagnosis of ADHD?

A

Before age 7

255
Q

Where do the symptoms of ADHD have to present in order to to merit a diagnosis?

A

In 2 or more settings

256
Q

Does an individual who meets all of the critera for ADHD but is successful and has had straight A’s all through school, etc. merit a diagnosis of ADHD?

A

NO

Must have impaired function

257
Q

What brain areas are implicated in ADHD?

A

Prefrontal Cortex

Parietal Cortex (“coctail party effect” - tuning noise-to-signal ratio)

Cerebellum

Striatum

258
Q

What is suggested by the genetics of ADHD?

A

Highly heritable (0.76)

259
Q

What findings are seen in the PFC of children with ADHD?

A

Smaller PFC volume in children with ADHD

260
Q

What changes are seen in the caudate nucleus in ADHD?

A

Decreased caudate nucleus volume

261
Q

What are changes seen in the corpus callosum in ADHD?

A

Reduced corpus callosum area

262
Q

What are changes in the cerebellum seen in ADHD?

A

Reduced cerebellum volume

263
Q

What percentage of individuals with ADHD respond to treatment with stimulants?

A

70%

264
Q

What are environmental modifications that are useful in ADHD?

A

Structure the environment

Simplify communication

Use external aids

Well structured

265
Q

How do stimulants work?

A

Block reuptake of DA and NE

266
Q

What is adderall? How does it compare to Ritalin?

A

Mixed amphetamine salt

More potent in a sense, since it blocks presynaptic reuptake, and in the presynaptic vesicles

Ritalin - methylphenidate

267
Q

What is atomoxetine?

A

Non-stimulant ADHD treatment

ATX blocks the NE transporter resulting in increased NE diffusely, and increased DA in the prefrontal cortex, specifically

268
Q

How are antihypertensive drugs helpful in ADHD?

A

Decrease sympathetic activity

269
Q

What is the traditional triad of autism?

A

Language impairment - delays, non-verbal

Social impairment - difficulty interpreting world around them or emotions/POV of someone else

Restricted, repetitive behaviors

270
Q

What is the most common comorbid condition with Autism Spectrum Disorders?

A

Intellectual defecits

271
Q

What is the relationship between epilepsy/seizures and Autism spectrum disorders?

A

Big overlap. Will have EEG abnormalities often, if not frank seizures

272
Q

What are hte two best prognostic indicators for autism spectrum disorders?

A

Intellectual ability

Verbal ability

273
Q

What do you need in order to have a diagnosis of autism spectrum disorder?

A

Persistent deficits in social communication in 3 of 3 symptoms

Restricted repetitive patterns of behavior , at least 2 of 4 symptoms

Must be in early childhood

They limit and impair everyday functioning

274
Q

What are the three social communication defecits required for diagnosis of autism spectrum disorder?

A

Deficits in social-emotional reciprocity

Deficits in nonverbal communicative behaviors used for social interaction

Deficits in developing and maintaining relationships, appropriate to developmental level

275
Q

What are restricted repetitive behaviors of Austism spectrum disorder? How many do you need for a diagnosis?

A

Need 2/4 of:

276
Q

What do you find in eye gaze tracking studies of patients with autism spectrum disorders?

A

They spend more time looking at the mouth of a person than their eyes - it’s moving, it’s “where the action is”

277
Q

What changes in the neruobiological processing of language do you see in autism spectrum disorder patients?

A

Decreased activation of Broca’s and increased activation of Wernicke’s area

278
Q

What are important features of early intervention in autism spectrum disorders?

A

Intervention by age 3 improves outcome

Behavioral signs are evident by 12 months

Experienced clinicians can reliably identify ASD at 24 months

279
Q

What are some risk alerts for autism spectrum disorder?

A

Eye contact

Response to name

Joint attention (share attention with someone else)

Response to voice

Mastery motivation

Emotional tone/affection

Interest in other children

Restricted or unusual sensory interests

Expressive language

Receptive language skills

Imitation
Pretend play

Motor sterotypy

280
Q

What are reasons for increased prevalence of autism?

A

Broadening diagnostic criteria

Younger age of diagnosis

Improved efficiency of case ascertainment

Probably not increased incidence

281
Q

What is thought to be the etiology of autism?

A

Genetic is thought to be most likely cause

Increased paternal and maternal ages

Some enviornment factors - congenital infetions (rubella)

282
Q

What proportion of the causes of autism can be identified by genetic testing?

A

15-Oct

283
Q

What pathway do most of the genes implicated in Autism converge on?

A

Glutamatergic synaptic transmission

284
Q

What determines if a head injury is closed or penetrating?

A

If the dura is breached = penetrating

If the dura is intact = closed

Brain and Behavior (9 decks)

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