HB Exam I Flashcards
Name the Axis I disorders (from DSM-IV)
Schizophrenia, Major Depression, Bipolar Disorder
Name the Axis II disorders (from DSM-IV)
Disorders that appeared early in life and persisted
- Personality disorders
- Intellectual disabilities
Name the Axis III disorders (from DSM-IV)
General medical conditions
- diabetes
- htn
- epilepsy
Name the Axis IV disorders (from DSM-IV)
Psychosocial and environmental problems (main stressors)
-Problems w/ primary support, social environment, education, occupation, housing, economic, access to health care services, interactions w/ legal system and crime
Describe Axis V (from DSM-IV)
It includes the GAF (global assessment of functioning) scale. If the patient scores 30 points or less they should be hospitalized.
What is the WHODAS assessment tool now used in the DSM-V?
It is the World Health Organization Disability Assessment Schedule used to assess level of functioning across 6 domains over the past 30 days and is scored on a 1-5 scale (no disability to can’t perform)
How many people in the U.S. over age 18 have mental disorders?
43.8 million (18.5% of population)
In what age group are mental disorders most prevalent?
Ages 26-49
What race has the highest prevalence of mental disorders?
American Indian/Native Alaskan
Which state has the highest prevalence of mental disorders?
Utah
Name 3 interview techniques discussed in class.
- Normalization (reduces shame/stigma and feelings of judgement)
- Continuation (acknowledging the pt, engaging, nonverbal cues)
- Redirection (helps guide and focus interview)
What does MAPPSS-CEETO stand for?
Your psych ROS.
- Mood
- Anxiety (do you worry a lot)
- Psychosis (do you see things others don’t)
- Personality (patterns that cause you problems, relationships)
- Substance/Addiction (use substances, gamble)
- Somatic (do you worry about your physical health)
- Cognitive/Dissociation (do you forget things often)
- Eating/Feeding (do you worry about weight, eating habits, restrict foods)
- Elimination (do you soil clothing)
- Trauma (ever suffered traumatic event)
- Obsessions/Compulsions (unwanted urges, thoughts, repetitive acts)
Name the 4Ps in the 4P Model
- Predisposing (why me)
- Precipitating (why now)
- Perpetuating (why still)
- Protective (what strengths)
Describe the characteristics that fall under predisposing factors.
FHx, genetics, medical and psych hx, chronic stressors
Describe the characteristics of precipitating factors.
Inciting events, illness, social factors
Describe the characteristics of perpetuating factors.
Factors contributing to perpetuation include severity of illness, compliance, and ongoing problems
Describe characteristics of protective factors.
Support, previous positive outcomes, insight, employment, socioeconomics, access to care, faith, family, etc.
Name the components of the MSE (14)
- Appearance and attitude
- Motor activity/behavior
- Orientation
- Mood and affect
- Thought and speech
- Perception
- Memory
- General info
- Calculations
- Capacity to read/write
- Visuospatial ability
- Attention
- Abstraction
- Judgement and insight
What is echopraxia?
It is when the patient does what you do
What is echolalia?
It is when the patient repeats what you say
Explain the difference between mood and affect
Mood is usually reported by the patient (more subjective) and affect is what the patient conveys and you perceive (more objective)
Define derailment as a pattern of speech
Speech shifts from one topic to another that is completely disjointed and unrelated to the first topic
Define tangentiality as a pattern of speech
Patient gives partially relevant or irrelevant responses that don’t answer the question
Describe circumstantiality as a pattern of speech
Speech is delayed in reaching goal b/c of unnecessary detail though components are properly related and eventually reach the point.
Name the major changes to the DSM-V discussed in class (12).
- Combined autism/asperger’s to autism spectrum disorder
- Changed ADHD critera
- Changed terms (e.g. mental retardation now intellectual disabilities)
- Changed criteria for schizophrenia
- Eliminated bereavement exclusion for major depression
- Provides guidelines for evaluating suicide
- Eliminated amenorrhea in criteria for anorexia
- OCD, acute stress and PTSD no longer anxiety disorders
- Added hoarding, gender dysphoria, and disruptive mood dysregulation
- Gambling included in substance/addictive disorders
- Eliminated 5 Multi-axial diagnostic system
- Use the WHODAS assessment tool
Describe word salad/incoherence as a pattern of speech.
Speech makes no sense and the words joined don’t coney a message
Describe distractible speech as a pattern of speech.
During conversation patient changes subject to something unrelated in the environment
Describe pressured speech as a pattern of speech.
Fast and difficult to interrupt/understand, often seen in bipolar-mania/schizophrenia
Describe characteristics of preoccupation as a form of thought content.
Obsessive, phobic, suicidal, homicidal, paranoia/suspicious
Describe delusion as a form of thought content.
False, fixed personal beliefs that are not shared by others in the patient’s community (occurs in psychotic d/o)
Name some types of delusions
Persecution, grandiosity, delusion of passivity, somatic delusions, ideas and delusions of reference, thought insertion/withdrawal, broadcasting
Define alogia
Impoverished thinking, no depth, minimal responses
-Manifested as non-fluent empty speech or fluent empty speech
Define flight of ideas
Rapid, continuous, shift of ideas either unrelated or based upon minimal associations, distractions, play on words (seen in mania)
Define perseveration
Persistent repetition of specific words or ideas; and the repeated words are typically used inappropriate to their meaning
Define illusions
Misperception of real external stimuli
Define hallucinations
Abnormal perceptions; a patient hears, sees, smells, or feels things that others can’t
How can you assess a patient’s judgement?
Ask them to propose a solution to a current problem
What is the purpose of the clock-drawing exercise?
To assess visuospatial ability. Unable to do properly with dementia/alzheimers
What are the 5 sections of the MMSE?
Orientation, Immediate Recall, Attention/Calculation, Recall, and Language
How many points are on the MMSE and what are the ranges?
30 points total.
-23-30 is normal
-19-22 is borderline
-
Name the 6 steps to developing your DDx.
1- R/O malingering/factitious disorder 2- R/O substance etiology 3- R/O general medical disorders 4- Determine the DSM-V disorder 5- Differentiate adjustment d/o from specified/unspecified d/o 6- Disorder or no mental disorder
What is the leading cause of death among those with depression?
Cardiovascular disease
Name the 9 criteria for major depression (need 5)
- Sad, empty, hopeless
- loss of interest/pleasure (apathy)
- weight change
- insomnia or hypersomnia
- psychomotor slowing/agitation
- fatigue
- worthlessness, guilt
- decreased concentration
- thoughts of death or suicide
What are some features of disruptive mood dysregulation disorder?
Less ideation, emotions are more intense but less persistent and less differentiated (more often irritable than sad), can affect attention/concentration (careful not to confuse w/ ADD/ADHD and depression). *Must be >6 y.o. to dx and does NOT predispose for bipolar
How do you treat children/adolescents?
Mostly educational, reserve SSRIs for non-responders
Describe the role of gender in depressive disorders
It is twice as common in females worldwide and double the rate of onset in reproductive years
Describe the biological relationship between PMDD/PPD/perimenopause and hormones.
All are related to the fall of estrogen and progesterone (estrogen regulates serotonin). The fall of estrogen causes a serotonin deficit and symptomatic women don’t adjust
How do you treat PMDD?
Give an SSRI during period of symptomatology. Highly treatable!
For whom is marital status more protective?
For men, but not for women.
What are some common endogenous processes that lead to secondary depression?
Endocrine (e.g. thyroid), metabolic (e.g. vitamins, renal/hepatic), cancer (e.g. gut- think of this in older men depressed for the first time), neuro (e.g. MS, stroke), vascular, autoimmune (e.g. lupus, RA), iatrogenic (e.g. medications)
Describe persistent depressive disorder (dysthymic disorder)
It is relatively mild but disabling and includes 2/6 sx (low self-esteem, hopelessness, sleep, sleep, appetite, concentration, energy) for more days than not x2 years
How can you treat persistent depressive disorder?
Medication has less robust effect but may help particularly if hx of major depressive disorder. Psychotherapy also useful.
What mnemonic can be used to remember major depressive disorder criteria?
SIG E CAPS
Sleep Interest Guilt Energy Concentration Appetite Pyschomotor Suicidal thoughts
*I’m adding SIG E CHAPS (h for hopeless = 9 criteria)
What are the two questions asked in screening?
- In the past 2 wks have you been sad, down, or depressed most days?
- In the past 2 wks have you noticed loss of interest or that you can’t enjoy things as much as usual?
What is the PHQ9?
A screening tool used to screen for depression (asks a question about each of the 9 criteria)
What factors go into medical screening when evaluating possible depression?
Thyroid, vitamin D, general chemistries, CBC, age appropriate sx
What are the five Koch’s posulates for believing the DSM dx?
Right patient, sx, backstory, FHx, and prior tx response
Once a drug is found effective for major depressive disorder, how long should tx last?
At least four months, maybe much longer
What prolongs remission from major depressive disorder?
Psychotherapy
What is “SAD PERSONS”?
Demographic suicide risk screening assessment.
S-sex (1 if male, 0 if female) A-age (1 if 44) D-depression (1 if present) P-previous attempt (1 if present) E-ethanol abuse (1 if present) R-rational thinking loss (1 if present) S-social support lacking (1 if present) O-organized plan (1 if plan) N-no spouse (1 if single for any reason) S-sickness (1 if chronic, debilitating, severe)
Using the SAD PERSONS tool, what are the point ranges and corresponding actions?
0-2 send home w/ follow-up
3-4 Close follow-up
5-6 Strongly consider hospitalization
7-10 Hospitalize/commit
**Not a strong predictor
What is SAFE-T?
An evaluation and triage for suicide risk that is much more useful in assessing patients
What are the five steps of SAFE-T?
1- identify risk factors (not those that can be modified to reduce risk)
2- identify protective factors (not those that can be enhanced)
3- conduct suicide inquiry (thoughts, plans, intent)
4- determine risk level/intervention
5- document assessment of risk, rationale, intervention, and follow-up
What are some of the strong predictors for suicide?
Addicted or chronically ill, planning, prior attempts, hopelessness, anxiety (panic attacks w/ depression is a malignant marker), psychotic sx
Give an example of negative reinforcement in addiction.
I continue to drink because it takes away my anxiety
Discuss incentive salience (aka craving)
Anticipation is a conditioned response and is itself reinforcing. Just anticipating reward starts dopamine cascade
Why are GABA receptors relevant when discussing alcohol?
Because polymorphisms of the GABA receptor may be responsible for variations in response to alcohol.
What does the CAGE screening tool evaluate?
Addiction. C-cut back A-annoyed G-guilty E-eye opener
What qualifies as a DSM-V disorder for addiction?
+2 or 3/11 criteria within a 12 month period
What are the focuses of an addictive disorder?
- loss of control
- adverse consequences
- physiological dependence (tolerance, withdrawal, cravings*new to DSM-V)
What role does age play in addiction?
Earlier onset of use (
Give an example of negative reinforcement in addiction.
I continue to drink because it takes away my anxiety
Discuss incentive salience (aka craving)
Anticipation is a conditioned response and is itself reinforcing. Just anticipating reward starts dopamine cascade
Why are GABA receptors relevant when discussing alcohol?
Because polymorphisms of the GABA receptor may be responsible for variations in response to alcohol.
What does the CAGE screening tool evaluate?
Addiction. C-cut back A-annoyed G-guilty E-eye opener
What qualifies as a DSM-V disorder for addiction?
+2 or 3/11 criteria within a 12 month period
What are the focuses of an addictive disorder?
- loss of control
- adverse consequences
- physiological dependence (tolerance, withdrawal, cravings*new to DSM-V)
What role does age play in addiction?
Earlier onset of use (
By what age have most individuals with bipolar disorder had their first episode?
By age 25
*Mean age of onset of first manic, hypomanic, or depressive episode is 18
Which type of episode do men and women typically have first with bipolar disorder?
Men- manic first
Women- depressive first
Which gender accounts for 80-95% of rapid cycling patients with bipolar disorder?
Almost exclusively women; they have more serious episodes
Discuss the risk of suicide in those with bipolar disorder.
They are at 15x the risk of the general population and may account for 25% of all completed suicides
When is the most dangerous window of time for suicide risk in patients with bipolar disorder?
At the beginning of treatment (esp with SSRIs) because physical energy is improving but mood is not. Prior lack of energy may have prevented them from carrying out a plan.
With which other mental disorder does bipolar disorder likely share a genetic origin?
Schizophrenia
How much risk for bipolar disorder does one have with an affected relative?
A 10-fold increased risk
Discuss the relationship between bipolar disorder and hypothyroidism.
Hypothalamo-pituitary-thyroid (HPT) axis dysfunction is related to pathophys and clinical course of BPD and HPT abnormalities are common in rapid cycling. Because of high prevalence of hypothyroidism in BPD, be sure to check thyroid levels.
Distinguish Bipolar I from Bipolar II.
Bipolar I- episodes of full blown mania and major depression (may also have hypomania).
Bipolar II- episodes of hypomania and major depression but NOT full blown mania.
What is cyclothymia?
It is a disorder involving ups and downs in mood in patients who do not meet criteria for major depression and mania but may benefit from treatment
What is the DSM-V criteria for mania?
Distinct period of abnormally and persistently elevated mood/irritability AND increased goal-directed activity/energy lasting at least a week or requiring hospitalization. 3 or more of these: -grandiosity -decreased need for sleep -more talkative/pressured speech -flight of ideas/racing thoughts -distractibility -increased goal directed activity -excessive risky behavior
What is the criteria for hypomania?
Essentially the same as mania (increased energy/goal-directed behavior and elevated/irritable mood) but must last 4 more days (11 total) and sx are not severe enough to cause marked impairment of social/occupational fxn
*hard to dx retrospectively without help of friends/family
What is the DSM-V criteria for major depression?
At least 5 of 9 sx present during the same 2-week period and represent change from previous functioning (at least one sx must be depressed mood or loss of interest/pleasure.
- depressed mood most of the day nearly every day
- loss of interest
- weight/appetite change
- insomnia/hypersomnia nearly daily
- fatigue/loss of energy nearly daily
- feelings of worthlessness
- diminished ability to concentrate
- recurrent thoughts of death
What is required to diagnose bipolar I?
Just one manic episode. Depression not required.
What is required to diagnose bipolar II?
One hypomanic plus one major depressive episode.
What is required to diagnose cyclothymia?
Chronic bipolar-like presentation w/ periods of sx of hypomania and depression that don’t meet criteria, lasting at least 2 years, with sx present most of the time without more than 2 months sx free
What substances can cause bipolar disorder?
Cocaine, corticosteroids, stimulants.
*Substance-induced BPD not correct dx if they had sx prior to use of medication/drug.
What other differentials should be considered when thinking BPD?
Unipolar major depressive disorder, schizoaffective disorder, schizophrenia, ADHD, borderline personality disorder, substance abuse
What is the lifetime prevalence of substance use and anxiety disorders in BPD?
60% substance
40% anxiety
What defines rapid cycling?
4 or more episodes in one year
What is the first line tx for patients without psychosis in BPD?
Valproate.
*avoid in women who are or may become pregnant
What is common treatment for bipolar disorder?
Lithium (if valproate isn’t an option) and short-term use of benzodiazepines for agitation
How do you treat acute mania with psychosis?
Hospitalize if patient is unsafe. Give lithium (or valproate) + an antipsychotic (olanzapine, quetiapine, risperdone)
*consider stopping or lowering dose if patient is on anti-depressant
Need to monitor patients with bipolar disorder for…?
tx failure, suicidality, incipient depression/mania, bone marrow toxicity (lithium and valproate), inadequate or excessive serum levels.
