mental status exam - personality disorders Flashcards
First Impressions:
Personal Appearance, Restlessness, Anxiety. Speak directly to the patient, establish eye contact.
General Description:
Appearance (Disheveled, Odorous); Behavior (Agitated, Rocking); Attitude (Argumentative, Dismissing, Uncooperative).
Speech
Echolalia, Palilalia and Neologisms are signs of Autism, Schizophrenia and Alzheimer’s. Poverty of Speech suggests Schizophrenia or Depression. Be attentive for Poverty of Content, Dysprosody (alternating speech patterns), Dysarthria and Stuttering.
Mood and Affect:
Mood = Subjective. Types of Mood: Euthymic, Alexithymia (Unable to Describe), Dysphoric, Anxious, Drepressed, Melancholia, Anhedonia, Apathetic, Labile (Swings), Elevated, Euphoria, Expansive, Hypomanic, Manic. Affect = Objective. Types of Affect: Appropriate, Inappropriate (Emotion doesn’t match presentation), La Belle Indifference (Too Calm about a Bad Dx), Restricted/Constricted, Blunted, Flat, Labile.
Thought Process:
Tempo (Flight of Ideas – Mania), Poverty of Thought (Schizophrenia), Preservation (Repetitive Thoughts), Circumstantial (Vague), Loose Associations (Changes Topic Randomly), neologism.
Thought Content:
Delusions = A Fixed False Belief: Control, Nihilism, Jealousy, Guilt, Self-Reference, Erotomania, Grandiosity, Persecution, Somatic (Body is Somehow Diseased). Preoccupations = Suicide or Homicide. Perceptions: Hallucinations – Auditory (Most Common), Visual (Suspect Drugs), Olfactory, Gustatory, Tactile (Cocaine/Meth).
Impulsivity
Especially concerning in Suicidal and Homicidal ideation.
Judgment
The Ability to make Sound, Reasoned, Responsible decisions to achieve pro-social outcomes.
Insight
Does the patient understand their diagnosis? Have them explain their disorder, their treatment plan and recognize that hallucinations and delusions are pathological. Test insight by having patients interpret proverbs.
Mini-Mental State Exam:
Assesses cognitive impairment, the hallmark of dementia, score <23/30. Testing areas include Orientation and Registration, Attention, Calculation, Recall and Language.
stage I sleep
Theta waves (3-7 Hz)
stage II sleep
Sleep Spindles and K-Complexes
Stage III/IV sleep
delta waves
rem sleep
Sawtooth Waves, Nocturnal Erections/Arousal, “Saccadic” Eye Movements and Dreaming. Associated with increased Pons activity. REM is necessary to “clear out the brain” and memory consolidation
Sleep-wake Transition
Hypnagogic = Wakefulness –> Sleep. Hypnopompic = Sleep –> Wakefulless. Either state may involve hallucinatory experiences.
Sleep Deprivation
The Cerebral Cortex suffers most. Only about 1/3 of lost sleep is made up overnight. <5Hrs/Night = Impaired Functioning. Sx = Decreased WBCs, Prefrontal Cortical Activity and Glucose Tolerance, Increased Cortisol, BP, Amygdala Activation and Negative Mood. In the first 3hrs of sleep HGH, PRL and 5-HT rise and DA and TSH fall.
-Melatonin is produced by the Pineal gland and is only produced at night. This is necessary for regulation of the Circadian Rhythm.
Developmental Aspects of Sleep:
By age 1, normal EEG patterns are detectable. By age 5, children consistently sleep through the night. In adults, 20% of sleep is spent in REM w/cycles every 90 minutes. Stage III/IV sleep declines in the elderly and they complain of not feeling rested.
Insomnia Disorder:
Chief Complaint of dissatisfaction with sleep quality/quantity with Difficulty Initiating/Maintaining sleep and Early Morning awakening w/inability to return to sleep. Sleep disturbance must occur at least 3 nights/wk over 3 months and cause clinically significant distress or impairment in social, academic, occupational or behavioral function.
Hypersomnolence Disorder
Self-Reported Excessive Sleepiness despite sleeping at least 7hrs/day at least 3 times/wk over 3 months. Acute form <1mo, Subacute form 1-3mos.
Narcolepsy
Recurrent periods of an irrepressible need to sleep, lapsing into sleep or napping in the same day. Patients may experience Cataplexy w/sudden B/L loss of muscle tone precipitated by Laughter or Joking. Dx: Hypocretin deficiency in the CSF, Nocturnal Sleep Polysomnography shows REM latency <15mins.
Obstructive Sleep Apnea Hypopnea:
Most common breathing-related Sleep Disorder. At least 5 Obstructive Apneas/Hypopneas per Hour of sleep with Snoring, Snorting/Gasping, Daytime Sleepiness and Fatigue. Dx: Polysomnography.
Central Sleep Apnea
5 or more Central Apneas per Hour of Sleep. May be idiopathic, Cheyne-Stokes (Crescendo-Decrescendo w/frequent arousal), or Comorbid w/Opioid use.
Sleep-Related Hypoventilation:
Polysomnography demonstrates episodes of decreased Respiration with elevated CO2 levels. May be Idiopathic, assoc. w/Congenital Central Alveolar defect or due to Lung Disease, Chest Trauma, Obesity or drugs (BZ, Opiates).
Circadian Rhythm Sleep-Wake Disorders:
Persistent or recurrent pattern of sleep disruption primarily due to Dysfunctional Circadian Rhythm secondary to unconventional Social or Work schedule. Disruption leads to Excess Sleepiness or Insomnia or periods of both and causes clinically significant distress and impairment. May be Familial or associated w/Shift-Work.
Sleepwalking
Repeated episodes of rising from bed during sleep and walking about. While sleepwalking patients have a blank staring face and is unresponsive despite efforts to communicate or wake. Patients cannot recall sleepwalking. Subtype exists in which patients engage in sexual activity while sleeping.
Sleep Terrors
Recurrent episodes of Abrupt Terror arousals from sleep with screaming and ANS arousal (Mydriasis, Tachycardia, Tachypnea, Diaphoresis). Patients cannot recall dreams or the event itself.
Nightmare Disorder:
Repeated occurrences of extended, extremely dysphoric and well-remembered dreams involving efforts to avoid threats to survival, security or physical integrity. Nightmares cause clinically significant distress and impairment.
REM Sleep Behavior Disorder
Repeated episodes of Arousal from REM sleep w/Loud Profane Vocalization and/or Complex Motor Behaviors (Jumping, Running, Kicking). Events more common later into the night. Behaviors cause clinically significant distress and impairment especially if injury to self, partner or property occurs.
Restless Legs Syndrome
An urge to move the legs in response to Uncomfortable and Unpleasant sensations that worsen during periods of rest/inactivity and are worse at night. Sx must occur 3 times/wk for at least 3mos.
-Chemical and NT Effects on Sleep: DA
Promotes Wakefulness. DA blockers increase sleep.
-Chemical and NT Effects on Sleep: ACh
Higher in REM Sleep, assoc. w/nocturnal Erections.
-Chemical and NT Effects on Sleep: NE
ACh:NE ratio triggers REM initiation, so as ACh increases, NE decreases
-Chemical and NT Effects on Sleep: BZ
Mild decrease in REM and Stage IV sleep, although chronic use increases sleep latency
-Chemical and NT Effects on Sleep: ETOH
: Increases sleepiness, but also wakefulness during the 2nd half of the night.
-Chemical and NT Effects on Sleep: barbituates
Decrease REM. Patients experience “REM Rebound” with nightmares during withdrawal.
-Chemical and NT Effects on Sleep: major depression
Decreased Stage III/IV, multiple sleep periods throughout the day and Early Morning Waking. People who get a lot of REM are more susceptible to depression.
Personality Disorder
Inflexible and Maladaptive responses in which an individual would rather alter the external environment rather than change himself to suit the external environment. Suspect in up to 15% of the population, especially low SES.
Cluster A
“Weird” (Paranoid/Schizoid/Schizotypal):
Paranoid personality disorder
cluster A
Distrust and suspiciousness of others. Resist Tx by Entrenching, do not respond to Humor
Schizoid personality disorder
cluster A
Detachment from Social Relationships and reduced Emotional Range. Tx: Supportive Psychotherapy Group.
schizotypal personality disorder
cluster A
Acute Discomfort in Close Relationships, Cognitive/Perceptual Distortions and Eccentricities of Behavior. Patients tend to be drawn to Cults. Tx: Develop Ego, Group Therapy.
Cluster B disorders
“Warped/Wild” (Antisocial/Borderline/Histrionic/Narcissistic)
Antisocial personality disorder
cluster B
Disregard for and Violation of the Rights of Others.
borderline personality disorder
cluster B
Instability in Interpersonal Relationships, Self-Image and Affect w/Marked Impulsivity. Goal of Tx: Reduce Self Harm, Keep Emotion Diary.
histrionic personality disorder
cluster B
Excess Emotionality and Attention Seeking. Tx: Individual Therapy
narcissistic personality disorder
cluster B
Grandiosity, need for Admiration and lack of Empathy.
cluster C disorders
“Worried” (Avoidant/Dependent/Obsessive-Compulsive):
avoidant personality disorder
cluster C
Social Inhibition, Feelings of Inadequacy and Hypersensitivity to Negative Evaluation.
dependent personality disorder
cluster C
Submissive and Clinging behavior related to an Excessive Need to be Taken Care of. Risk Folie A Deux where the otherwise healthy partner becomes absorbed in the delusion
obsessive-compulsive personality disorder
cluster C
Preoccupation with Orderliness, Perfectionism and Control
