PMHNP Certificate Study Disorders Flashcards
A constellation of symptoms marked by an acute onset (hours to days) causing short-term decline in cognition with a disturbance in consciousness and inattention.
Delirium
Delirium that is characterized by psychomotor retardation, apathy
hypoactive delirium
Delirium that is characterized by psychomotor agitation, restlessness, hypervigilance
Hyperactive delirium
Delirium that is characterized by cycling through psychomotor agitation and retardation, from apathy to hypervigilance
mixed delirium
A constellation of signs and symptoms characterized by the gradual onset of multiple cognitive impairments in executive function, intellect, impaired problem-solving, and alteration in memory with preservation of level of consciousness.
Dementia
Usually occurs in the sixth decade of life, indicated for use in acute extrapyramidal symptoms such as dystonia, oculogyric crisis, and diaphragm spasm and is the most prevalent type. It is characterized by a gradual onset and progressive decline, without focal neurological deficits.
Alzheimers
Characterized by abnormal clumps of protein causing neuronal malfunction, and characterized by visual hallucinations of small creatures, exacerbated by antipsychotic medications.
Lewy Body Dementia
Onset in the fifth–sixth decade of life, more common in men, marked by personality change; cognitive decline occurs later in this disease process.
Pick’s disease (frontotemporal lobe dementia)
Dementia that is characterized by Uninhibited cheery, hypersexual, hyperorality (carbohydrates especially)
Kluver-Bucy syndrome
Precipitous onset prion disease, sometimes referred to as mad cow disease. Remarkable for a rapid decline that progresses to death within 6 months. It is more common in middle-aged adults and initially presents as fatigue, flu-like symptoms, and cognitive impairment. Later, it progresses with aphasia, apraxia, emotional lability, and psychosis.
Creutzfeldt–Jakob disease
Subcortical dementia characterized by motor abnormalities including psychomotor slowing, choreoathetoid movements, and executive dysfunction complicated by impaired language, memory, and insight later in the disease process.
Huntington Disease
Rare under age 65, more sudden onset, caused by cardiovascular and cerebrovascular disease, manifests with progressive cognitive decline in a stepwise fashion, evidenced by rapid episodic deterioration with interspersed plateau phases marking new baselines. Previously lost function is not regained.
Vascular Dementia
In the treatment of dementia what are the three main medications of choice?
memantine, donepezil, Rivastigmine
Antipsychotics and dementia
While antipsychotics are not recommended and have a black box warning they can be used at the lowest effective dose with attempts at weaning periodically.
Co-occurring depression and dementia
Treat depressive symptoms targeting insomnia first, followed by loss of appetite, irritability, and depressed mood.
Least amount of most effective doses for 6 to 12 months and attempt to taper, although usually chronic and may require lifelong treatment.
Depressive symptoms may be less severe as dementia progress and as awareness of circumstances diminishes.
characterized by duration of associated loss of consciousness at the time of injury, effect on verbal and motor skills, and posttraumatic amnesia.
Traumatic brain injury
used to assess visuospatial impairment, which reflects the function of the right parietal lobe, basal ganglia, and prefrontal cortex.
intersecting pentagon
a precipitous onset cognitive decline that rapidly progress to death; symptoms include fatigue and cognitive impairment and eventually aphasia, apraxia, emotional lability, and psychosis
Creutzfeldt–Jakob disease
Disorganized behavior with accompanying (one of three of the following) delusions, hallucinations, and/or disorganized speech (marked by frequent derailment or incoherence) lasting 1 day to <1 month
Brief psychotic disorder
Disorganized behavior with accompanying (one of three of the following) delusions, hallucinations, and/or disorganized speech (marked by frequent derailment or incoherence) lasting >1 month but <6 months
Schizophreniform Disorder
Disorganized behavior with accompanying (one of three of the following) delusions, hallucinations, and/or disorganized speech (marked by frequent derailment or incoherence) lasting more than 6 months
Schizophrenia
What are the diagnostic criteria/symptoms of schizophrenia?
Either delusions, hallucinations, or disorganized speech WITH either grossly disorganized or catatonic behavior OR negative symptoms such as affect blunting, avolition, anhedonia, apathy, alexithymia)
A deeply held belief despite evidence to the contrary lasting at least 1 month without prominent hallucinations.
Delusion
What are the types of delusions?
JPEGS (Jealous, Persecutory, Erotomaniac, Grandiose, Somatic)
The patient has characteristic features of schizophrenia (hallucinations, delusions, disorganization) >2 weeks without prominent mood symptoms, AND manic or depressive features are present most of the time when not in psychosis.
Schizoaffective Disorder
Which phase of schizophrenia is characterized by odd beliefs, ideas of reference, unusual perceptual experiences, negative symptoms, and deterioration of function prior to the onset of active psychosis.
Prodrome
Which phase of schizophrenia is characterized by delusions, hallucinations, disorganized speech, grossly disorganized behavior, and negative symptoms.
Active psychosis
Which phase of schizophrenia is characterized by persistent functional impairment, abnormalities in affect, impaired cognition, and impaired communication.
Residual phase
biochemistry of the sleep-wake cycle is regulated by the
hypothalamus
Lightest stage of sleep, can last up to 15 minutes, drowsiness easily disrupted, muscle tone begins to relax, hypnic jerks (head nods, sensation of falling).
NREM Stage 1
Accounts for 40% to 60% of total sleep time, more difficult to arouse, eye movement slows, activity busts (sleep spindles) and K complexes occur on EEG. Body temp and heart rate decrease.
NREM Stage 2
Accounts for 5% to 15% of total sleep time (higher in duration during periods of rapid growth and development), deep restorative sleep, delta waves occur on the EEG, most difficult to arouse, parasomnias (sleepwalking, night terrors, somniloquy [sleep talking]) occur in this stage.
NREM stage 3
Usually occurs 90 minutes after sleep onset and can last from 10 to 15 minutes.
REM Stage 4
Two or more episodes of sleep latency less than 8 minutes and or two or more episodes of sleep with rapid eye movement periods
Narcolepsy
What test can be used to diagnosis narcolepsy?
Cerebrospinal fluid testing with hypocretin (orexin) level <109
Characterized by difficulty falling asleep, staying asleep, or waking up too early (given opportunity for sleep) with EDS.
Insomnia
Sleep disorder characterized by multiple episodes of apnea and waking during the night.
Obstructive sleep apnea
A diagnosis of exclusion characterized by persistent sleepiness despite getting at least 7 hours of sleep overnight. Symptoms include a strong sleep drive, difficulty waking up from sleep accompanied by feelings of confusion, combativeness, or irritability
Hypersomnolence Disorder
A movement disorder of the lower limbs triggered at the moment of falling asleep, creating an irresistible urge to move the legs that disrupts the initiation of sleep. Symptoms may arise also in the upper extremities
Restless leg syndrome
Pharmacological agents to assist in sleep may include:
Benzodiazpeines (last resort), sedative hypnotics (ambien and lunesta), melatonin receptor (Ramelteon), Orexin receptor antagonist (Suvorexant), antidepressants TCAs, mirtazapine, trazadone, and stimulants (armodafinil and modafinil)
What hormone is often found elevated in patients with depression and early morning awakening?
cortisol
What stage of sleep are night terrors and parasomnias likely to occur?
Stage 3-4. They do not occur during REM or stage 1 or 2.
characterized by the tetrad of hypersomnia (excessive daytime sleepiness), cataplexy (transient loss of motor tone in the presence of strong emotions, e.g., embarrassment, laughter, fear), and sleep paralysis (partial or total loss of muscle function during sleep-wake transition).
Narcolepsy
What is a good diagnostic difference between narcolepsy and hypersomnia?
Narcolepsy has sleep paralysis or cataplexy and hypersomnia does not.
What infection has been associated with severe obsessive compulsive disorder?
Streptococcus
What sleep problem might arise when a patient starts an SSRI?
Increased sleep latency (difficulty falling asleep)
Which medication is a serotonergic agent commonly used to help with sleep latency and maintenance, which can reduce wandering at night?
Trazadone
Which antidepressants category have been used to treat chronic neuropathic pain in addition to major depressive disorder, specifically targeting symptoms of poor appetite, disturbed sleep, and depressed mood.
TCA
What are four risk factors for developing postpartum depression?
poor marital relationships, stressful life events, negative attitude towards pregnancy, and lack of social support.
What are some atypical presentations of depression?
Increased appetite, increased sleep, physical sensation of heaviness, binge eating, pornography, risk taking behavior, substance use disorder
How long does a depressive episode need to last in order to be categorized as MDD?
two weeks
What are some ways children may manifest depression that is different than adults?
irritability, somatic complaints, and social withdrawal
What are some ways the elderly may present with depression that is different then adults?
somatic complaints, hypochondriacal symptoms, psychotic delusions, or ambivalence about the severity of symptoms
SSRIs carry a black box warning for all
children
Which nonpharmacological treatments can be used for depression first?
Exercise, CBT, family therapy group therapy, interpersonal psychotherapy, phototherapy
Which antidepressants can raise blood pressure?
SNRI
What should you check before starting SSRI?
Baseline labs and an EKG
What is the most common electrolyte abnormality associated with antidepressants?
hyponatremia
What are TCAs at high risk for and when should they be avoided?
high risk for overdose and avoided in patients with cardiac disease or conduction defects
MAOIs are third line in depression AFTER?
ECT
How long is the washout from all SSRI/SNRI if starting an MAOI?
14 days
What are the symptoms of a hypertensive crisis related to antidepressant use?
worst headache ever, facial flushing, palpitations, pupillary dilation, fever, diaphoresis
How do you treat hypertensive crisis?
Phentolamine 5-15 mg IV or IM and ED evaluation
What are the indications for ECT?
Patient preference, nihilistic delusions with severe neurovegetative symptoms, treatment resistance, benefits outweighs the risk of treatment/anesthesia
What are the contraindications for ECT?
Cardiovascular disease, aortic stenosis, pulmonary insufficiency, inability to tolerate anesthesia
Possible adverse effects of ECT?
Cardiovascular ischemia, headache, muscle aches, cognitive impairment
skin surface electrode/coil on the scalp to create a magnetic region throughout the head. Performed in an office setting, does not require anesthesia, requires five sessions per week for 6 weeks.
Transcranial magnetic stimulation
Indicated for treatment resistant depression, requires a pulse generator implanted in the subclavian area (anesthesia required). Adverse effects can include voice changes, muscle spasms, dyspnea, throat or neck pain, skin tingling, and dysphagia.
Vagal Nerve Stimulation
Characterized by a depressed mood most of the day for a majority of the days for at least 2 years.
Dysthymia
Characterized by an acute onset affective lability, irritability, anger, and/or increased interpersonal conflicts; may be accompanied by feelings of depressed mood, feelings of low self-worth, hopelessness, self-deprecating thoughts, and increased anxiety, occurring in the week preceding menstruation. Symptoms improve in the second or third day of menstruation and resolve by the week after menstruation.
Premenstrual Dysphoric Disorder
characterized by severe and recurrent temper outbursts manifested verbally and/or behaviorally that are grossly out of proportion to the provocation with irritable or angry mood most of the days between the outbursts.
Disruptive Mood Dysregulation
DIGFAST for mania
Distractibility, Indiscretions/impulsivity, grandiosity, flight of ideas, decreased need for sleep, talkativeness
Characterized by at least one manic episode that may have been preceded by or followed by a hypomanic or major depressive episode. Impairment required hospitalization for stabilization.
Bipolar 1
Characterized by at least one hypomanic episode and one major depressive episode
Bipolar 2
Distinct period of elevated mood or irritability lasting 4 days and 3 DIGFAST symptoms.
Hypomania
A distinct period of irritable mood or elevated energy lasting 7 days comprising at least three of DIGFAST symptoms
Mania
Characterized by periods of hypomanic symptoms that do not exceed full criteria and depressive episodes that do not meet full criteria for major depressive disorder
Cyclothymic Disorder
When treating Bipolar or cyclothymia what is the most important thing to regulate FIRST?
sleep
What is hospitalization criteria for psychiatric patients?
Suicidality with lethality, lacking social supports, unable to care for self.
Melancholic depression with a history of poor response to medications and the need for a quick antidepressant response are the universally accepted criteria that encourage
ECT over medication in MDD
a nihilistic delusion (things, including the self, do not exist) associated with psychotic depression in this case (missing pieces or organs etc…)
Cotard’s Syndrome
a shared delusion of one person influenced by another in which the treatment is to separate the two parties.
Folie a deux
a delusional belief that people have been replaced by impostors, and is associated with psychosis
Capgras syndrome
If a patient is within 4 weeks of delivery of a baby and has depression, mood lability, delusions, and hallucinations they will be diagnosed as
Depression with psychosis
is used to screen for acute intermittent porphyria, which often manifests through manic or psychotic symptoms and is typically associated with abdominal pain, nausea, vomiting, muscle pain, numbness, tingling, hallucinations, paranoia (commonly occurring after excessive heme demand-triggered alcohol consumption), recreational drug use, stress, and fasting
Urinary Porphobilinogen
Which TCA is known for its anticholinergic properties?
Doxepin (Sinequan)
What is the most common adverse effect associated with ECT?
Amnesia
How many sessions of ECT would be needed for someone with resistant depression?
6-12
How many sessions of ECT would be needed for catatonia?
2-4
How many sessions of ECT would a patient with psychosis or mania need?
20-40
Which psychiatric comorbid disorder is associated with microvascular ischemia (CVA and MIs)
Depression
Characterized by a fear of avoidance of multiple situations due to thoughts that it may be difficult to escape the situation if panic symptoms occur.
Agoraphobia
Characterized by an avoidance of social situations in which the person perceives they will be critiqued by others.
Social Anxiety Disorder
Characterized by avoidance of situations specifically related to the likelihood of encountering the object related to the fear
Specific phobia
Characterized by avoidance of situations that arouse upsetting memories, thoughts, or feelings about a specific traumatic event.
PTSD
Characterized by the avoidance resulting from a delusional concern (e.g., will not go outside because they believe they are being followed).
Delusional disorder or psychotic features
Characterized by an avoidance behavior that is intended to prevent triggering an obsession or compulsion (avoids going outside because of becoming contaminated and unable to wash hands).
OCD
Characterized by avoidance of situations that require being away from the major attachment figure, which can lead to avoidance of going out of one’s house
Separation anxiety disorder
A discrete episode of heightened arousal characterized by intense apprehension, fearfulness, terror; often associated with an impending sense of doom.
Panic Disorder
Characterized by apprehension and worry about a specific illness rather than separation from the attachment figure.
Illness anxiety disorder
Characterized by reexperiencing an extremely traumatic event after the direct exposure to, witnessing of, or hearing about an actual or threatened death, serious injury, or sexual violence. Symptoms may also arise in first responders collecting human remains, or those exposed to or dealing with victims of abuse or assault
PTSD
What are the three diagnostic category symptoms for PTSD?
Reexperiencing symptoms, avoidance symptoms, and persistent hyperarousal symptoms
How long must symptoms last for a diagnosis of PTSD?
Longer than one month
Characterized by an inability to recall important autobiographical information, usually in response to a traumatic exposure in which the person experiences depersonalization, derealization, and or disassociation
Dissociative Disorder
An alteration in the perception of the external world so that it seems unreal.
Derealization
A perception of detachment from the self.
Depresonalization
A mental process in which an individual feels they are detached from their thoughts, feelings, memories, or identity.
Dissociation
Recurrent and persistent thoughts, impulses, or images that cause distress
Obsessions
Repetitive behaviors or mental actions that the person is driven to perform in response to the obsession in order to relieve the distress.
Compulsions
If acute signs and symptoms arise of OCD in children acutely. What should be considered?
PANDAS (Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections).
Characterized by recurrent pulling out of one’s hair accompanied by repeated attempts to stop pulling out the hair, causing significant distress and impairment in functioning. The hair pulling is not an attempt at correcting an imperfection or improving one’s appearance as in grooming.
Trichotillomania
Characterized by recurrent skin picking, resulting in skin lesions accompanied by repeated attempts to stop causing significant distress or impairment
Excoriation Disorder
Characterized by a preoccupation with perceived defects or flaws in physical appearance in which the individual engages in repetitive behavior such as mirror checking and reassurance seeking.
Body Dysmorphic Disorder
a speech pattern that is overly inclusive and includes a lot of unnecessary details and digressions but eventually reaches the point
Circumstantial
a thought pattern that uses a lot of unnecessary details and digressions but never returns to the main point
Tangential
a thought pattern with erratic direction changes with an identifiable connection between thoughts
Flight of ideas
characterized by an illogical connection between thoughts digressing in multiple directions, but sentence structure remains intact.
Loosening of association
PTSD symptoms that have been occurring for less than four weeks
Acute Stress Disorder
This therapy is an evidence-based psychotherapeutic approach indicated for anxiety disorders and mood disorders
CBT
This therapy is specifically developed for the treatment of posttraumatic stress disorder (PTSD)
EMDR
This therapy looks at the relationships contributing to depression
Interpersonal therapy
This type of therapy aims to strengthen the patient’s defense mechanisms to restore function and is typically reserved for patients with more primitive coping mechanisms.
Supportive psychotherapy
This disorder is characterized by feigning a sick role to produce symptoms of an illness for personal gratification. May include inducing their own illness.
Factitious Disorder
This disorder is characterized by pretending to be ill for financial or material gain
Malingering
This disorder is characterized by the patient experiencing numerous physical symptoms that are unrelated to any specific disease state or organ system; usually, symptoms are unrelated, multiple, and difficult to measure.
Somatoform
Primary treatment for sexual dysfunction that does not have an underlying medical condition
CBT
This disorder is characterized as the sudden onset of a singular neurological defect, often in the setting of acute stress
conversion
This therapy is a modality of cognitive behavioral therapy in which the patient controls the stressful impetus until a more muted response is produced
Systematic Desensitization
the delusion that the penis is shrinking into the abdomen, found in South and East Asian cultures
Koro
a culture-bound syndrome delusion of being spirit possessed, found in North and East African cultures and Middle Eastern cultures.
Zar
a Japanese culture bound syndrome in which one perceives their body to be offensive to others
Taijin Kyofusho
neurodegenerative prion disease that leads to death, found in New Guinea and transmitted through the cannibalistic funeral ritual of eating the brains of the dead.
Kuru
Impaired attainment of intellectual abilities (reasoning, problem-solving, planning, abstract thinking, judgment, academic learning, and vicarious learning) and impaired attainment adaptive functions resulting in a failure to meet sociocultural standards for personal responsibility and social responsibility
Intellectual Disability
Gross developmental delay, loss of eye contact, placidity and poor motor tone, breath holding spells. Stereotypic hand movements while awake, irregular breathing pattern, absence seizures, sleep disorders, and increased irritability. Increased rigidity, bruxism, abnormal involuntary movements extrapyramidal symptoms of the head and neck, poor feeding, weight loss, increased seizure activity. Unable to walk, worsening trunk control, deterioration plateau, and reduced seizure activity.
Rett Syndrome
congenital neurodevelopmental disorder primarily occurring in females, characterized by specific deficits following a period of normal function, growth, and development
Rett Syndrome
Primarily characterized by persistent social interaction deficits across multiple contexts with associated restricted range of interests, repetitive patterns of behavior
Autism Spectrum Disorder
Manifests as a restriction of caloric intake relative to requirements, leading to a significantly lower than expected body mass index (BMI); associated with an intense fear of gaining weight, and a delusion in the way in which one’s body weight or shape is experienced.
Anorexia nervosa
What is the FADE acronym for Anorexia?
Fear of gaining weight or becoming fat, Amenorrhea, Delusion related to body weight, Expected body weight (failure to maintain at least 85%
Characterized by recurrent episodes of binge eating accompanied by inappropriate compensatory behaviors of elimination (emesis and enemas) to prevent weight gain.
Bulimia Nervosa
Characterized by recurrent episodes of binge eating associated with significant distress without compensatory measures to prevent weight gain or enhance weight loss despite over-valuation of body weight and shape
Binge eating disorder
Which medication is FDA approved for bulimia nervosa?
Fluoxetine
Which therapy is utilized for those with an eating disorder?
CBT
Characterized by consistent symptoms of inattention in at least two domains (academic, social, occupational), and may or may not have hyperactivity and impulsivity that is inconsistent with the developmental age, and negatively impacts function, causing distress
ADHD
Characterized by a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness without aggression. May be seen by resistance to work and school tasks because of resistance to authority, accompanied by hostility and defiance.
ODD
Characterized by persistently pervasive irritability and low frustration tolerance. Characterized by temper outbursts three or more times per week for at least 12 months without a period of 3 months or more without symptoms.
Disruptive mood dysregulation
Characterized by high levels of impulsive behavior with episodes of serious aggression toward others (verbal or physical aggression towards others). Outbursts are grossly disproportionate in intensity to the provocation with persistent irritable, angry mood nearly every day between outbursts.
Intermittent explosive disorder
Characterized in childhood by a repetitive and persistent pattern of disregard for social norms, rules, and the basic rights of others
Conduct Disorder
What is the MOST COMMON adverse effect associated with SSRIs in children?
Nausea
a feeding disorder of infancy and early childhood characterized by regurgitation shortly after eating without swallowing the spit up food, lasting at least 1 month following a period of normal function.
Rumination disorder
What is the MOST COMMONLY observed sign of MDD in children (not adolescents)?
Psychomotor agitation
What is the standard agent used in the treatment of nocturnal enuresis?
Imipiramine
At what age can a child identify age, gender, and ride a tricycle?
3
At what age can a child copy a circle?
24 months
At what age can a child copy a square?
5
What are the cluster A personalities?
Paranoid personality, Schizoid Personality, Schizotypal Personality
Characterized by a pervasive, persistent, and consistent distrust and suspiciousness of others such that motives are interpreted as malevolent.
Paranoid Personality Disorder
Characterized by a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings
Schizoid Personality Disorder
Characterized by a consistent and persistent pattern of social deficits associated with acute discomfort and reduced capacity for close relationships, complicated by cognitive and perceptual distortions and eccentric behaviors.
Schizotypal Personality Disorder
What are the cluster B personality disorders?
Antisocial Personality Disorder, Borderline Personality Disorder, Histrionic Personality Disorder, Narcissistic Personality Disorder
Characterized by a consistent and persistent pervasive disregard for the rights of others since the age of 15 and often has a previous diagnosis of a conduct disorder. This cannot be diagnosed until the individual is 18 years of age,
Antisocial personality Disorder
Characterized by an unstable sense of self and unstable interpersonal relationships, the individual is distressed by an unstable internal psychic state and chronic feelings of emptiness, exacerbated by intense separation anxiety, and an inability to be alone without persistent concern for the availability of other people to help reduce the internal distress.
Borderline Personality Disorder
Characterized by a consistent and persistent pervasive pattern of excessive emotionality and other attention-seeking (negative, positive, pity, sympathy) behaviors.
Histrionic Personality Disorder
Characterized by a persistent inferiority complex overcompensated by the overinflated sense of importance and being perceived as special. The grandiosity serves as a defense against not feeling valued while defensively putting off their need for others, despite craving constant admiration and reassurance from others. They feel entitled yet dependent on others with whom they often demonstrate a lack of empathy and concern, culminating in their disappointment, leading to rage.
Narcissistic Personality Disorder
What are the Cluster C personality Disorders?
Avoidant, Dependent, OCPD
Characterized by a consistent and persistent pervasive pattern of social inhibition, feelings of inadequacy, and a hypersensitivity to real or perceived critiques. This person may want socialization, but cannot have it.
Avoidant Personality Disorder
Characterized by a consistent and persistent pervasive pattern of maladaptive behaviors arising from an excessive need to be cared for and leading to submissive, clinging behavior with the goal of reducing the chance of separation.
Dependent Personality Disorder
Characterized by a consistent and persistent pervasive pattern of obsession with perfectionism, order, and inter-/intrapersonal control at the expense of openness, flexibility, and efficiency coupled with an excessive devotion to work
Obsessive compulsive personality Disorder
What is the treatment for a personality disorder?
Medications can be used to treat symptoms in order to enhance daily function. CBT and DBT are used to help with immature defense mechanisms.
What is the goal of therapy for personality disorders?
Reduce cognitive distortions, enhance a sense of control and accountability for individual actions, help develop realistic expectations of themselves and others
Terrorized by instability, “walking on eggshells” around the abuser. Lasting from hours to months. The victim engages in appeasement and avoidance behaviors in an effort to prevent the abusive incident or to garner sympathy and positive regard.
Tension building phase
characterized by overt aggressive behavior (hitting, raping, deprivation of basic needs, humiliation, depriving children) toward the victim.
Abusive INcident
Stage marked by the abuser subconsciously implementing defense mechanisms and cognitive distortions to alleviate the ego dystonic implication of the abuse (undoing, denial, reaction formation, suppression, regression).
Honeymoon phase
When is the most dangerous time for an abuse victim?
When fleeing
