Module 3: Diagnosis and Treatment Flashcards
1
Q
persistent pattern of inattention or hyperactivity, hyperactivity, impulsivity, or both, that interferes with the functioning and development.
A
ADHD
2
Q
The tendency of some regions of the brain to react to repeated low level bioelectrical stimulation by progressively boosting synaptic discharges, thereby lowering seizure thresholds.
A
Kindling
3
Q
compulsive substance use despite harmful consequences.
A
Addiction
4
Q
The amount of drug required to produce an effect of given intensity
A
Potency
5
Q
What is the basal ganglia responsible for
A
motor control, motor learning, executive functions and behaviors, and emotions
6
Q
What abnormalities in the fronto-subcortical pathways cause ADHD?
A
- frontal cortex
- basal ganglia
- abnormalities of reticular activating system
7
Q
What is the reticular activating system (RAS) responsible for?
A
ability to focus, fight-flight response, regulating arousal and sleep-wake transitions
8
Q
What neurotransmitters are responsible for ADHD?
A
** Dopamine dysfunction:* when dopamine levels are lower or dysregulated, it can affect the brain’s ability to properly modulate attention, focus, and self-control. This can contribute to the sxs associated w/ ADHD
- Norepinepherine dysfunction: norepi plays a crucial role in regulating attention, arousal, and alertness. Low levels of norepi can lead to difficulties w/ attention, focus, and impulse control, which are hallmark sxs of ADHD
-
Serotonin dysfunction: low serotonin levels have been associated w/ impulsivity, emotional dysregulation, and difficulties w/ sustained attention
Mnemonic: DNS
9
Q
What stimulant meds can you give for ADHD and what should you check before starting them on stimulants?
A
Adderall and Methylphenidate
- Assess cardiac history before placing pt on stimulants (amphetamines for example can cause elevated heart rate and bp, and increase risk of heart attack, and stroke).
10
Q
What neurotransmitters to stimulants target?
A
DA and NE
11
Q
What age are amphetamines approved for?
A
children 3 and older
12
Q
What age are methylphnidates approved for?
A
6 and older
13
Q
What non stimulants can you use for ADHD?
A
- Alpha agonist or alpha 2 adrenergic receptor agonist: Guanfacine and Clonidine is FDA approved in ages 6-17 with ADHD
- Strattera (atomoxetine) (selective norepinephrine reuptake inhibitor) is approved for children aged 6 and older with ADHD
14
Q
Signs of stimulant abuse
A
* Insomnia
* Tremors
* Increased bp and heart rate
* Heart palpitations
* Agitation
* Anxiety
* Irritability
* Mood swings
* Elevated mood
15
Q
Nonpharmacological Management of ADHD
A
o Behavioral therapy
o Patient and parent cognitive behavioral training program
o Psychoeducation
o Treatment of learning disorders
o Family therapy and education
16
Q
What screening tools can you use to monitor a patient with ADHD?
A
o Use standardized rating scales such as: Adult Self Report Scale (ASRS)
o Conner’s Parent and Teacher Rating Scales (copyrighted)
o Vanderbilt ADHD Diagnostic Parent and Teacher Rating Scales (public domain)
17
Q
If someone has ADHD + motor/vocal tics, you should avoid giving ____ and give ____ or ____
A
Avoid stimulants and wellbutrin because they can exaccerbate tics.
Give guanfacine or clonidine intstead
18
Q
What personlity disorder is characteristic of the following:
- Impulsivity, often with self-damaging behavior
- Recurrent suicidal behavior
- Pattern of unstable, intense interpersonal relationships
- Frantic efforts to avoid real or imagined abandonment
- Identify disturbances
- Chronic feelings of emptiness
- Inappropriate, intensified affective anger responses
A
Borderline Personality Disorder
Type B
19
Q
How do you nonpharmacologically treat borderlinen personality disorder?
A
DBT-helps to decrease SI
20
Q
What personlity disorder is characteristic of the following:
* Reckless disregard for the welfarere of others
* Lack of remorse; indifference to the feelings of others
* Failure to conform to social norms
* Repeated acts that are grounds for arrest
* Deceitfulness, lying, and use of aliases for profit or pleasure
* Impulsivity and failure of future planning
* Consistent irresponsibility
A
Antisocial Personality Disorder
Type B
21
Q
Nonpharmacologicaly Treatment of antisocial personality disorder
A
CBT
Behavioral therapy
22
Q
Antisocial PD is more common in ____
A
males
23
Q
True or False:
A higher frequency of APD is associated with low socioeconomic status and urban settings.
A
true
24
Q
What personlity disorder is characteristic of the following:
- Grandiose sense of self importance
- Preoccupation with fantasies of power, success, brilliance, and beauty
- Belief of self importance be being special and unique
- Excessive admiration required
- Unreasonable expectations of sense of entitlement
- Interpersonally exploitative
- Empathy lacking
- Envy of others and belief that envy him or her
- Arrogant behaviors
A
Narcissitic PD
Type B
25
What personlity disorder is characteristic of the following:
*** Voluntary social isolation**
* Indifferent to other people: shows an apparent lack of care in relation to how others perceive them.
* Shows little to no interest in sexual activity with another person.
* Derives no pleasure in social activities.
* Lacks close friends or social supports.
* Appears cold and detached.
* Exhibits affect flattening.
Schizoid PD
Type A
26
What personlity disorder is characteristic of the following:
* Delusions/hallucinations
* Have interpersonal difficulties and social anxiety
* Few or no close friends
* Odd beliefs
* Ideas of reference
* Magical thinking
* Unusual perceptual experiences
* Paranoid ideation
* Inappropriate or constricted affect
* Behavior overtly odd
Schizotypal PD
Type A
27
What do children with ASD often like to do?
**line things up, stack, or organize objects and toys in long tidy rows**
28
Risk factors for ASD
* Male gender
* Intellectual disability
* Genetic loading
29
What are some things parents of a child with ASD report
No response when called by name
Little or no eye contact
No imaginary play
Little interest in playing other children
Intense tantrum
Extremely short attention span
Self-injurious behavior
**Children with autism often like to line up, stack, or organize objects and toys in long tidy rows.**
No cooing by age 1 year, no single words by age 16 months, no two-word
phrases by age 24 months
*Fixation on single objects
*Unusually strong resistance to changes in routine
*Oversensitivity to certain sounds, textures, or smells
*Appetite or sleep–rest disturbance
30
Screening tools used for ASD
* Modified checklist for Autism Toddlers (M-CHAT)
* Autism Diagnostic Observation Schedule-Generic (ADOS-G)
* Ages and Stages Questionnaires (ASQ)
31
How do you pharmacologically and nonpharmalogically manage ASD
Pharmacological management (p.343)
* Antipsychotics are effective for symptoms such as tantrums; aggressive behavior, self-injurious behavior; hyperactivity and repetitive stereotyped behaviors
Nonpharmacological Management
* X Behavioral therapy to improve cognitive functioning and reduce inappropriate
* behavior
* X Occupational therapy to improve sensory integration and motor skills
* X Speech therapy to address communication and language barriers
* X Pivotal response training
* X Appropriate school placement with a highly structured approach
32
What are some physical findings of Rett Syndrome
* Loss of purposeful hand skills
* Stereotypic hand movements
* Deceleration of head growth
* Early loss of social engagement
* Appearance of poorly coordinated gait or trunk movements
* Severely impaired expressive and receptive language development with severe psychomotor retardation
* Seizure
* Irregular respirations
33
Rett Syndrome usually occurs in what sex
female
34
What syndrome is associated with the following development of speciic deicits following a period of normal
functioning after birth and what is a risk factor?
Rett Syndrome
RF: seizures
35
What are some symtpoms of DMDD?
* Chronic dysregulation of mood (“moody”)
* Frequent intense temper outbursts/tantrums
* Severe irritability
* Anger
36
What age is DMDD dx?
older than 6 but younger than 18
37
What medications can you give to treat DMDD?
1. stimulants - ritalin
2. antipsychotics
3. antidepressants
38
What disorder is DMDD similar to that you can't diagnose till the age of 18.
bipolar disorder
39
What disorder involves repeated, sudden episodes of impulsive, aggressive, violent behavior, or angry verbal outbursts in which the patient reacts grossly out of proportion to the situation.
INTERMITTENT EXPLOSIVE DISORDER (IED)
40
True or False:
Children and adults can be dx with IED
true
41
What are some key features of Fetal Alcohol Syndrome (FAS)
-distinctive facial features, including small eyes, and exceptionally thin upper lip, a short, upturned nose, and a smooth skin surface between the nose and upper lip (philtrum)
-deformities of joints, limbs, and fingers
-slow physical growth before and after birth
-vision difficulties or hearing problems
-small head circumference and brain size
‼️Most Structures are under developed‼️
42
How do you differentiate between fragile x syndrome and fetal alcohol syndrome (FAS) ?
Fragile X Syndrome is where the bodily structures are larger while FAS structures are smaller.
43
Mneumonic: SIGE CAPS
S - sleep disturbance
I – interest reduced
G – guilt and self blame
E – energy loss and fatigue
C – concentration problems
A – appetite changes
P – psychomotor changes
S – suicidal thoughts
44
What is pseudodementia?
‼️Cognition and memory symptoms of MDD in the older adult population that are confused with dementia related symptoms.‼️
45
‼️Differences between dementia and pseudodementia (MDD in older adults withe a cognitive deficit)‼️
| Differences
46
**What is important when differentiating between dementia and pseudodementia?**
** see if you can highlight at least 3 symptoms of depression in the question. If you can find 3 then they usually have MDD!!!
47
What medications are used as first line for MDD?
SSRI, SNRIs, Bupropion, Mirtazapine are typically used as first line meds bc their safety and tolerability may be preferable to pts and clinicians compared to TCAs and MAOIs
48
What is second line medication treatment for MDD?
TCAS
Examples:
Amitriptyline (Elavil)
Doxepin (Silenor)
Imipramine (Tofranil)
Nortriptyline (Pamelor)
49
What antidepressants are good for chronic neuropathic pain?
SNRIs
Examples:
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
Venlafaxine (Effexor XR)
50
What is the black box warning for ALL antidepressants?
suicidal thoughts behavior, agitation, aggression in children, adolescents, young adults. MONITOR CLOSELY
51
Non-pharmacological management of MDD
* Electroconvulsive Therapy (ECT)
* Cognitive Behavioral Therapy
* TMS (transcranial magnetic stimulation)
52
Adverse side effects of electroconvulsive therapy
Possible cardiovascular effects
Systemic effects (headaches, muscle aches, drowsiness)
Cognitive effects (memory disturbance and confusion)
53
What are hallmark signs of vascular dementia
– carotid bruits, fundoscopic abnormalities, enlarged cardiac chambers
54
When should you avoid prescribing TCAs or MAOIs for MDD?
Those who are high risk for SI
55
DIG FAST (mneumonic)
**D: **Distractibility – individuals experiencing mania often have difficulty concentrating and may be easily distracted by irrelevant stimuli. Their thoughts may jump from one topic to another rapidly
**I: **Indiscretion – during manic episodes, ppl may engage in impulsive and risky behaviors, such as excessive spending, reckless driving, or promiscuous sexual activity, without considering the consequences
**G:** Grandiosity – ppl in a manic state often have an inflated sense of self-esteem and may believe they have special powers, talents, or abilities. They may make grandiose claims
**F:** Flight of ideas – refers to rapid and continuous flow of thoughts that are often tangential and interconnected. Pt may speak quickly and jump from topic to topic making it challenging for other to follow their conversation
**A**: Activity Increase – increased physical and mental activity is a hallmark of mania. Individuals may have a reduced need for sleep, engage in excessive goal-directed activities, and have a heightened level of energy
**S**: Sleep Disturbance – manic episodes can lead to a decreased need for sleep, often referred to as insomnia. Despite getting very little sleep, individuals in a manic state may not feel fatigued
**T:** Talkativeness – manic individuals often speak rapidly and excessively, sometimes to the point of being difficult to interrupt. They may also be more talkative that usual
56
what is the difference between bipolar I and bipolar II?
**In Bipolar I d/o**, a person experiences a full manic episode, which causes extreme changes in mood and energy. Symptoms are severe enough that they may interfere with a person’s functioning at home, school, or work.
* During a manic episode, a person can experience symptoms for at least a week.
**In Bipolar II d/o**, less severe symptoms occur during a hypomanic episode.
* Symptoms of hypomania mirror those of mania, except they last for a shorter period, at least four days, and are less severe
57
What neurotransmitters are involved in bipolar?
GABA, Glutamate, Dopamine, Serotonin, and Norepinephrine
58
When diagnosing someone with bipolar, what disorder should you make sure to rule out first?
MDD
59
What mood stabilizers can you give for bipolar?
Lithium
Lamotrigine (Lamictal)
Lurasidone (Latuda)
Divaloprex (Depakote)
Carbamazepine (Tegretol)
Symbax (olanzapine and prozac)
60
which of the mood stabilzers are best for bipolar depression
Lamotrigine
Lurasidone
Symbax
61
Which mood stabilzers are best for bipolar acute mania?
Depakote
Carbamazepine (Tegretol)
62
What are nonpharmacological treatments for bipolar
* Cognitive behavioral therapy (CBT)
* Behavioral therapies
* Interpersonal therapies
* Supportive groups
63
63
Which thyroid hormone is used to rule out hypo or hyperthroidism?
Free thyroxine (T4)
64
Free thyroxine (T4) normal values
value 0.8 to 2.8 ng/dl
65
TSH levels
(0.5-5.0 Mu/L)
66
What medical disorder mimics depression?
Hypothyroidism
67
Symptoms of hypothyroidism (decreased T4, increased TSH)
o Confusion
o Decreased libido
o Impotence
o Decreased appetite
o Memory loss
o Lethargy
o Constipation
o Headaches
o Slow or clumsy movements
o Weight gain
**o Sensitive to cold (cold intolerance)**
68
Symptoms of hyperthyroidism (increased T4, decreased TSH)(
**o Sensitive to heat (heat intolerance)
o Irritability/agitation**
o Motor restlessness
o Emotional lability (exaggerated changes in mood e.g., uncontrollable laughing and crying)
o Short attention span
o Compulsive movement
o Fatigue
o Tremor
o Insomnia
o Impotence
o Weight loss
69
What medical disorder mimics mania?
hyperthyroidism
70
What is the time frame to dx someone with GAD?
6 months
70
71
How do you manage GAD nonpharmacologically and pharmacologically?
Nonpharmacological Mgmt
* CBT
* Relaxation therapies
* Stress management
* Supportive counseling
Pharmacological Mgmt
* SSRIs (escitalopram (Lexapro) and paroxetinen (paxil))
* Buspirone (buspar)
* Benzodiazepines (Alprazolam (Xanax), clonazepam (Klonopin))
72
What type of anxiety is a marked and persistent fear of social or performance situations in which embarrassment may occur.
Social Anxiety D/O
73
How do you manage Social Anxiety Disorder nonpharmacologically and pharmacologically?
Nonpharmacological Mgmt
* CBT
* Exposure therapy
* Relaxation therapy
Pharmacological Mgmt
* SSRIs (sertraline, paroxetine, and venlafaxine)
* Benzodiazepines, for short term use
* Betablockers
Used for discrete episode relief for example, before having to attend a scheduled function
74
What disorder is makred by an enduring pattern of angry or irritable mood and argumentative, defiant, or vindictive behavior lasting at least 6 months
Oppositional Defiant Disorder
75
Fragile X syndrome is often associated with which sex and what are some key features.
**Usually Boys
**Large head
Elongated face
Hyperextensible joints
Abnormally large testes
SHORT STATURE****
75
76
What are s/s of oppositional defiant disorder and how many of these symptoms does one have to have for 6 months to be dx with ODD
At least 4 symptoms of:
* Loses temper
* Touchy or easily annoyed
* Angry or resentful
* Argue with authority
* Actively defies or refuses to comply with requests or rules from authority figures
* Blames others
* Deliberately annoys others
* Spiteful or vindictive
77
Oppositional Defiant Disorder can lead to ________ disorder if not treated/handled.
conduct disorder
78
How do you nonpharmacologically treat ODD?
* Individual therapy
* Family therapy, with emphasis on child management skills
* Evidence-based treatment: child and parent problem-solving skills training
* Adolescent transition program
79
A repetitive and persistent pattern of behavior in which the rights of others or societal norms or rules are violated.
Conduct Disorder
80
True or False
Conduct Disorder can be dx in both children and adults.
True
81
What s/s are associated with conduct d/o and how many have to bre present in the past 12 months with one in the past 6 months.
Must have 3 of the following:
o Aggression toward people or animal-bullies, threatens, intimidates, initiates physical fights, using a weapon to cause physical harm to others, physically, cruel to people or animals, stealing while confronting a victim, forced sexual activity on someone.
o Destruction of property-engaged in fire setting, destroyed others property
o Deceit or theft-broke into house, building, or car; lies, steals items.
**o Lack of remorse
**
82
How do you manage conduct disorder?
* Family therapy
* Individual therapy
83
What is conversion disorder and when do they usually occur?
* Conversion disorder is a mental condition in which a person has blindness, mutism, paralysis, or paresthesia (glove stocking syndrome), or other nervous system (neurological) symptoms that cannot be explained by medical evaluation
* Symptoms usually begin suddenly after a stressful experience.
84
How do you manage conversion disorder?
CBT
Physical Therapy
85
What disorder is associated withh an emotional or behavioral reaction to a stressful even or change in person’s life. The reaction is considered an unhealthy or excessive response to the event or change within three months of it happening
Adjustment Disorder
86
86
What are the 5 classifications of Adjustment Disorder
* **Adjustment disorder with depressed mood:** presents with feelings of depression, tearfulness, and hopelessness
* **Adjustment disorder with anxiety:** presents with symptoms of feeling restless, nervousness, lack of concentration.
* Adjustment disorder with mixed anxiety and depression: a patient has a mix of symptoms from both of the above subtypes (depressed mood and anxiety).
* Adjustment disorder with disturbance of conduct: a child may violate other people’s rights or violate social norms and rules. Examples include: not going to school, destroying property, driving recklessly, or fighting.
* Adjustment disorder with mixed disturbance of emotions and conduct: a child has a mix of symptoms from all of the above subtypes.
87
Pharmacological and nonpharmacological management of PTSD
Pharmacological Mgmgt
* SSRIs, TCAs
*** Prazosin for nightmares
* Sertraline and paroxetine are FDA apporved for treatment of PTSD**
Nonpharmacological
* EMDR
* CBT
* Exposure therapy with response prevention
* Supportive group therapy
* Relaxation therapy
88
What disorder is associated with the presence of anxiety provoking obsessions and/or compulsions that function to reduce the person’s subjective anxiety level
OBSESSIVE COMPULSIVE DISORDER (OCD)
89
What are obsessions
* Defined as recurrent and persistent thoughts, impulses, or images that are experienced and cause anxiety and distress
* Experienced as intrusive and inappropriate
90
What are compulsions
* Defined as repetitive behaviors or mental actions that a person feels driven to perform in response to an obsession
91
What are risk factors for OCD?
* First degree relatives
*** PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) should be considered in children with sudden onset OCD symptoms.**
92
Pharmacological and Nonpharmacological management for OCD
Pharmacological Mgmt
o SSRIs (sertraline and fluoxetine). Clients often need higher range for adequate symptom control.
o Fluoxetine (Prozac) for adults and children 7 years and older
o Fluvoaxamine (Luvox) for adults and children 8 years older
o Paraoxtine (Paxil) for adults only.
o Sertraline (Zolofy) for adults and children 6 years and older.
o TCA (clomipramine)
o Clomipramine (Anaframil) for adults and children 10 years and older.
Nonpharmacological Mgmt (p.221)
* CBT
* Exposure therapy
93
What criteria must one meet to be dx with Tourettes?
**At least 2 motor tics and at least 1 vocal (phonic) tic have been present, not necessarily at the same time.**
Tics may wax and wane in frequency but have occurred for more than 1 year.
Tics started to appear before the age of 18.
Tics are not cause by the use of a substance or other medical condition.
94
What neurotransmitters are involved in Tourette's Disorder
**Dopamine**
Norepinephrine (noradrenaline)
serotonin
95
Pharmacological and Nonpharmacological management for Tourette's Disorder
Pharmacological management
* Atypical antipsychotic
* FDA: haloperidol, pimozide, aripiprazole
* Medications such as clonidine (catapres, kapvay) and guanfacine (Intuniv) can help control behavrioral symtoms such as impulse control problems and rage attacks
* Antidepressants such as Fluoxetine (Prozac) might help control symptoms of sadness, anxiety, and OCD
Nonpharmacological mgmt.
* Behavioral therapy
* CBT
96
Age onset for males and females for schizophrenia
18-25 in males
25-35 females
97
What are causes of schizophrenia?
Genetics
Intrauterine insults such as: prenatal exposure to toxins includging viral agents, oxygen deprivation, maternal malnutrition, substance use, or otherillness
98
Positive symptoms in schizophrenia
o Hallucinations
o Delusions
o Referential thinking
o Disorganized behavior
o Hostility
o Grandiosity
o Mania
o Suspiciousness
99
Negative symptoms of schizophrenia
o Affective flattening
o Alogia or poverty of speech
o Avolition (lack of motivation or ability to do task)
o Apathy (lack of interest)
o Abstract thinking problems
o Anhedonia (inability to feel pleasure)
o Attention deficits.
100
Neurobiological defect associated with schizophrenia (
**o Enlarged ventricles**
o Smaller frontal and temporal lobes
o Reduced symmetry in temporal, frontal, and occipital lobes
o Cortical atrophy
o Decreased cerebral blood flow
o Hippocampal and amygdala reduction
MRI/PET SCAN
101
Suspected altercation in chemical neuronal signal transmission
o Excess dopamine in mesolimbic pathway
o Excess glutamate
o Decreased GABA
o Decreased serotonin
102
103
Wha should you monitor when you have a schizophrenic patient on an antipsychotic medication.
o Monitor routine labs to screen for complications of treatment
**o Fasting serum glucose and fasting lipid panels**
**o Weight, BMI, and waist to hip ratio (measure abdominal obesity)**
o Liver and kidney function (based on medication)
o CBC
o Perform annual eye exam if on antitypical agents or Seroquel
104
Nonpharmacological managament of schizophrenia
o Individual therapy
o Group therapy
o Assertive Community Treatment (ACT)
105
Which antipsychotic has evidence that it can decrease SI in schizophreia
Clozaril
106
106
Which antipsychotics is the least likely to cause weight gain?
Ziprasidone (Geodon)
Aripiprazole
Lurasidone
107
Which SGAs are associated with weight gain
Clozapine
Olanzapine
Quetiapine
Risperidone
108
