Pre-Mid Mod Flashcards
The changes in synapses that affect the process of how information is transmitted through the nervous system
Neuroplasticity
What is the general progression of developmental neuroplasticity
Neuronal pathways that are used more are strengthened (potentiation) and pathways that are used less are weakened (depression)
What are some of the proposed drivers of neuroplasticity
The amount of neurotransmitters in the cleft; the amount of post-synaptic receptors (both control the amount of response by the post-synaptic cell, which affects the pre-synaptic cell); structurally could drive the amount of dendrites being produced
Describe the progression of visual development in the brain
During the fetal period, nerve fibers from both of the eyes make connections with overlapping territories of the visual cortex
What is the critical period for vision development
Ends at ~6-8 years old
Condition where one eye has a competitive advantage for space in the visual cortex, which results in lack of input to/from the other eye (causes loss of vision in the affected eye, strabismus)
Amblyopia
When is the maximal amount of dendritic spine formation (synaptic development)/peak of CNS myelination
~6 months old
What are some inhibitory/damaging agents of synaptic development
Perinatal hypoxia
Malnutrition
Environmental toxins
What genetic diseases can inhibit the myelination of CNS neurons
Leukodystrophies
Phenylketonuria
(also malnutrition)
What two locations in the brain are continuously creating new neurons via stem cells (neurogenesis)
Olfactory bulb
Hippocampus
What are the four types of amblyopia and what causes them
- Refractive- hyperopia/myopia/astigmatism
- Strabismic- deviation of eye position
- Visual deprivation- cataracts/infections/hemorrhages/etc.
- Occlusion- overcorrection by blocking the healthy eye
What is the treatment for amblyopia
Eyepatch the good eye for a time
What types of signals is the thalamus responsible to relay
-Sensory
-Consciousness
-Sleep
-Alertness
What are the functions of the hypothalamus
-Autonomic control
-Temperature regulation
-Water balance
-Pituitary control
Describe the neuropathology of a fever
Inflammatory mediators (IL-1, IL-6, and TNF) enter the brain and stimulate prostaglandin E2 synthesis in the anterior hypothalamus (severe damage to this area will develop hyperpyrexia)
What are the symptoms of hypothalamic syndrome
-Diabetes insipidus (loss of ADH)
-Fatigue (low cortisol)
-Obesity
-Temperature dysregulation
What are the signals transmitted by the limbic system
Emotion
Long-term memory
Smell
Behavior modification
ANS
What are the brain components of the limbic system
Cingulate gyrus
Hippocampus
Fornix
Amygdala
Mamillary bodies
Damage to the bilateral amygdalas; characterized by hyperphagia, hyperorality, inappropriate sexual behavior, and visual agnosia
Kluver-Bucy Syndrome
What is a possible cause of Kluver-Bucy Syndrome
HSV1 encephalitis
What is the symptom of lesions of the hippocampus
Anterograde amnesia
What is a common cause of damage to the hippocampus
Hypoxic injury
What is the progression of the fear response associated with the amygdala
Cortex/thalamus (sensory input) > lateral amygdala > central medial amygdala > paraventricular thalamus (cortisol release)/lateral hypothalamus (ANS)/periaqueductal gray matter (fear behavior)
What is the location of the amygdala
Anteromedial temporal lobe
Inherited disorder (auto rec) that is associated with bilateral calcifications of the amygdala, leading to reduced fear and heightened aggression
Urbach-Wiethe Disease
What are the symptoms of seizures in the amygdala
Powerful emotions of fear and panic
What area of the limbic system is associated with pleasure emotions
Septal area
What are the symptoms of lesions to the septal area
“Sham rage”- sudden outburst of aggressive behavior
I would just kinda know that emotions/sensory input/memories/endocrine/ANS control are connected within the limbic system, which makes sense (*)
*
Describe the progression of the hypothalamic-pituitary-adrenal axis (stress response)
Acute stress > hypothalamus secretes CRH > posterior pituitary secretes ACTH > binds to adrenal gland, produces cortisol
What are the functions of cortisol
-Increases gluconeogenesis
-Increases effect catecholamines on cardiovascular system (inc. HR and BP)
-Suppresses inflammation
What are some clinical consequences of amygdala hyperactivation
PTSD
Social anxiety disorder
Phobias
What is drug dependence
Chronic exposure that results in physical necessity to retain normal functioning
What is drug addiction
Compulsive, relapsing behavior that is a consequence of psychological necessity to retain normal functioning
What is the target in the brain of addictive drugs
Mesolimbic-dopamine system
What is the mechanism of class 1 addictive drugs (opioids, THC, GHB, GPCRs)
Indirect increase in dopamine by inhibiting GABA neurons (that are inhibitory interneurons) in the VTA
What is the mechanism of class 2 addictive drugs (benzodiazepines, nicotine, ethanol)
Direct stimulation of dopaminergic neurons in the VTA
What is the mechanism of class 3 addictive drugs
Interfere with dopamine reuptake/promote release in the nucleus accumbens
What are the two broad forms of memory
Explicit (declarative)
Implicit (nondeclarative)
What are some components of explicit memory
Semantic (factual) and episodic memory
Where is semantic memory processed
Lateral/Anterior temporal cortex, prefrontal cortex
Where is episodic memory processed
Hippocampus, medial temporal lobe, neocortex
What are the components of implicit memory
Procedural
Priming/perceptual
Associative learning (classical conditioning)
Nonassociative learning (habituation, sensitization)
Where is procedural memory processed
Striatum, cerebellum, motor cortex
Where is priming/perceptual memory processed
Neocortex
Where is associated learning processed
Amygdala, cerebellum
Where is nonassociative learning processed
Reflex pathways
What are the 3 stages of memory formation
- Working memory (very short periods)
- Short-term memory (second to hours)
- Long-term memory (years to life)
What is the functional difference between long and short-term memory
Resistance to disruption (strengthening/weakening conduction via use/unuse)
Postsynaptic stimulus in response to an acute stimulation; causes Ca2+ to accumulate in the presynaptic neuron
Posttetanic potentiation
Continual stimulus of a neutral stimulus w/ repetiton; over time, decreased Ca2+ in presynaptic neuron causes decreased neurotransmitter release w/ each activation- thus, the stimulus becomes less reactive
Habituation
A new, noxious stimulus is paired w/ habituated stimulus; results in increased cAMP production (short-term) and protein synthesis (long-term)
Sensitization
Describe the process of Long-Term Potentiation
1) NMDA receptor-mediated Ca2+ intake to the postsynaptic neuron
Inc. stimulus frequency expels inhibitory Mg2+ from the NMDA receptors
2) Ca2+/calmodulin kinase phosphorylates AMPA receptors > they travel to the synaptic surface and inc. conductance
3) Postsynaptic neuron releases NO > presynaptic neuron increases glutamate release
How does Long-Term Depression of stimuli occur
Less synaptic stimulation results in less intracellular Ca2+ > weakens the receptor availability at the synapse
What are the key structures of the medial temporal lobe memory system (2)
Hippocampal formation (dentate gyrus, hippocampus, and subiculum)
Parahippocampal gyrus
What are the cells of the dentate gyrus
Granule cells
What are the cells of the hippocampus/subiculum
Pyramidal cells
What is the physiological connection between the association cortex and the hippocampal formation (the input)
Entorhinal cortex (ant. to parahippocampal gyrus)
Where are memories believed to be stored
In the association/primary cortices
What is the important output pathway of the hippocampal formation
Projection from the subiculum to the entorhinal cortex, and back to the associated cortex
Deficit in forming new memories
Anterograde amnesia
Loss of memories from a previous period of time
Retrograde amnesia
What kind of symptoms are associated with lesions of the medial temporal lobe/medial diencephalic systems
Combination of retrograde and anterograde amnesia
What are some notable possible causes of memory loss, and note whether they are permanent or reversible
-Cerebral contusions (permanent)
-Concussions (reversible)
-Infarcts/ischemia (permanent)
-Global cerebral anoxia
-Acomm aneurysm rupture
-Wernicke-Korsakoff syndrome (permanent)
-Psychogenic amnesia
-Seizures (complex partial and tonic-clonic)
-Benign senescent forgetfulness
*Really any cause of bilateral medial temporal lesions/medial diencephalic lesions
What is a possible psychological consequence of cardiac arrest
Memory loss secondary to hippocampal anoxic injury
What is classical and operant conditioning
Classical conditioning- Pavlov’s dog (pairing neutral stimuli with an active stimulus)
Operant conditioning- reward/consequence learning
Describe how the systematic desensitization of fear strategy works
Patient is asked to relax, imagine ascendingly intimidating tasks/objects, and deliberately relax as they progress through each fear
“baby steps of imagination to actual practice”
Acute confusional state in which agitation and hallucinations are prominent; reversible and oscillating symptoms
Delirium
Occurs after alcohol withdrawal, associated with shaking, shivering, sweating, elevated HR, and hallucinations
Delirium tremens
What is the treatment for delirium tremens
Benzodiazepines
What are common causes of delirium
Toxic/metabolic disorders that are followed by infection, trauma, or seizures
Chronic decline in memory and cognitive abilities to a point of impaired functional status; progressive and consistent symptoms
Dementia
What are the EEG findings for delirium and dementia
Delirium = slowed EEG
Dementia = normal EEG
What is the cause of Alzheimer’s Disease
Acetylcholine loss in the brain from the buildup of B-amyloid plaques and tau tangles in the basal nucleus of meynert
Symptoms of normal attention span w/ decreased recent memory; some loss of motor and language skills, disorientation in a very gradual progression
Alzheimers Disease
What are the causes of vascular dementia
Multiple infarcts and ischemia (and intracranial neoplasia)
Symptoms of stable cognition with step-wise cognitive decline
Vascular dementia
What are the causes of frontotemporal dementia/Pick Disease
Ubiquinated TDP43 (or tau protein) buildup in neurons
Symptoms of disinhibition, personality changes, impaired understanding, loss of speech; parkinsonism in a slow and then quick progression; positive primitive reflexes (grasp)
Frontotemporal dementia/Pick Disease
What are the causes of Lewy Body Dementia
Buildup of a-synuclein in the cortex/substantia nigra (Lewy Bodies)
Early symptoms of difficulty focusing, poor memory, hallucinations, depression, disorganized speech
Late symptoms of resting tremors with stiff, slow movements and reduced facial expressions
Lewy Body Dementia
Dementia from recurrent trauma injuries resulting in anoxic brain injury
Dementia puglistica
What is the role of acetylcholine loss in Alzheimer’s Disease
Loss of hippocampal theta rhythm
What genes are associated with increased risk of Alzheimers Disease
PSEN1/PSEN2 on chromosome 14
APP on chromosome 21
ApoE4 on chromosome 19
All are associated with increased amyloid deposition
What genes are associated with decreased risk of Alzheimers Disease
ApoeE2 on chromosome 19
Describe the pathology of amyloid deposition in Alzheimer’s Disease
Amyloid precursor protein (APP gene) is not cleaved (PSEN genes) and then is not cleared (ApoE4)
What is the MOA and use of donepezil
Reversible cholinesterase antagonist (for Alzheimers)
What are the contraindications of donepezil
Patients with bradycardia/syncope
What are the major side effects of donepezil
GI distress
Muscle cramping
Abnormal dreams
What is the MOA and use of Rivastigmine
Reversible cholinesterase antagonist (for Alzheimers)
What is the contraindications for use of rivastigmine
Patients with bradycardia and syncope
What are the major side effects of rivastigmine
GI distress
Muscle cramping
Abnormal dreams
What is the MOA and use of galantamine
Acetylcholinesterase inhibitor (for Alzheimers)
What are the contraindications for using galantamine
Patients with bradycardia and abnormal dreams
What is the MOA and use of memantine
Non-competitive NMDA glutamate receptor (for Alzheimers)
What is the contraindications for using memantine
Patients with severe renal damage
What are the major side effects of memantine
Headache
Dizziness
What are the pathologic features of chronic traumatic encephalopathy
Cortical loss with ex vacuo ventricular dilation; microscopic neurofibrillary tangles and amyloid plaques
Rapid-onset dementia with psychiatric/behavioral disturbances; myoclonus; multiple round vacuoles in the neuropil of cortical gray matter
Creutzfield-Jakob Disease
What is the cause of Creutzfield-Jakob Disease
Prion protein (PrP)- encoded by the PRNP gene on chromosome 20; is conformational changed to an abnormal form (PrPc > PrPSc), which is protease resistant and results in cerebral cortex degeneration/vacuolization
What is the EEG finding of CJD
Biphasic/Triphasic synchronous sharp-wave complexes that are superimposed upon a slow background rhythm
What are the causes of changes in drug distribution and clearance with age
-Reduced distribution volume (less body mass/water)
-Reduced hepatic metabolism (P450 function)
-Reduced renal clearance
-Reduced cardiac output of blood to organs
What are some “accelerators” of Alzheimers progression
-Postmenopausal loss of estrogen
-Inflammation
-Oxidative free radicals
-Vascular brain disease
-High cholesterol
-Glutamate excitotoxicity
What is the checklist of issues to be addressed for patients with Alzheimers Disease
- Safety (driving, living, medication, hazards, falls, wandering)
- Day-to-day living with remaining abilities
- General health monitoring
- Advanced care planning and advance directive
Briefly describe what is the general idea of the biopsychosocial model
Observe biochemical/morphological changes IN RELATION to how they affect the patient’s emotional patterns, life goals, attitude, and social environment
Basically puts the physician’s role as managing physical/psychological/social treatments- as they all have a role in patient presentation
I like to think of this as TOTAL FLOURISHING
What is one of the implications of the biopsychosocial model on the patient
Illness can be largely due to lifestyle factors- which can be modified with personal initiative (there are multiple factors, and some are dependent on behavior)- this puts great emphasis on correcting emotion and behaviors
Circumstances/events that require a person to adapt to new feelings of tension
Stress
Cumulative cost to the body for maintaining homeostasis in response to stress
Allostatic load
The process of maintaining constancy or equilibrium in the physiological activities of the organism; what are the two components of this?
Homeostasis: biological mechanisms and regulatory behavior
In what kind of situations would behavioral interventions be more important for a patient than biological ones
Adherence/Lifestyle issues
What are two benefits of the family system approach to care
Wider understanding of illness
Broader range of solutions
What are the components of families to consider in the family systems approach
Family Stability
Family Transition
Family World View
Relational context of the symptom(s)
What kind of family encouragement is associated with improved medical outcomes
Autonomy
Self-reliance
Personal achievement
Family cohesion
What kind of family encouragement is associated with worse medical outcomes
Control
Criticism
Overprotection
What is the general pathway of the ascending arousal system
Monoaminergic/cholinergic/histaminergic neurons from the brainstem > Intralaminar/reticular nuclei of the thalamus > wide distribution within the cortical lobes
Also has collaterals from the trigeminal, auditory, visual, and olfactory systems
What neurotransmitters are associated with the awake state
Norepinephrine and serotonin (from raphe and locus ceruleus) > reduced acetylcholine-containing pontine neurons
What neurotransmitters are associated with the sleep state
GABA (from hypothalamus) > reduced histamine > reduced thalamus and cortex activity
What is the biochemical basis of the circadian rhythm
Hypothalamic release of GABA induces sleep, and decrease in GABA release induces wakefulness
What does an EEG measure
The summation of dendritic postsynaptic potentials (NOT action potentials)- helps determine the polarity of the neuron body (will be opposite the dendrites)
What does a negative EEG entail about the neuron
The neuron is depolarized/hyperexcitable
What is the frequency and amplitude of normal alpha EEG rhythm
8-13 Hz
50-100 uV
What conditions can decrease the frequency of normal alpha EEG rhythm
Hypoglycemia
Low body temperature
Low adrenal glucocorticoid hormones
High PaCO2
Hyponatremia
Vitamin B12 deficiency
Acute intoxication (alcohol, amphetamines, barbiturates, phenytoin, and antipsychotics)
What drug can be given to induce a normal alpha EEG rhythm
Propofol (sedative)
What is the difference between the causes of alpha and beta EEG rhythms
Alpha is a lack of attention (eyes closed), beta is focused attention (aka arousal)
What type of EEG rhythm is associated with stage 1 non-REM sleep
Theta- low voltage/mixed frequency (4-7 Hz)
What is the frequency and amplitude of normal beta EEG rhythm
13-30 Hz
Low voltage
What type of EEG rhythm is associated with Stage 2 non-REM sleep
Sinusoidal waves of 7-15 Hz (sleep spindles) with occasional high voltage biphasic waves (K complexes)
What type of EEG rhythm is associated with Stage 3 non-REM sleep
Slow frequency, high amplitude
What type of EEG rhythm is associated with REM sleep
Rapid frequency, low amplitude
How long is a typical sleep cycle
90 minutes (about 4-6 REM periods per night)
What is the trend of time spent in REM sleep as you age
REM is about 50% in infants, and gradually drops to 20% in the elderly
Sudden loss of voluntary muscle tone, irresistible urge to sleep during the day, and possibly brief episodes of total paralysis; caused by a brain’s inability to regulate sleep-wake cycles (fewer orexin-producing neurons in hypothalamus)
Narcolepsy
What is the genetic predisposition to narcolepsy
Strongly tied to HLA-DR2 or HLA-DQW1 on chromosome 6
Fragmented sleep at night caused by breathing cessation for more than 10 seconds, via obstruction of upper airway caused by reduced muscle tone
Obstructive sleep apnea
Stereotypical rhythmic extension of the big toe and dorsiflexion of the ankle during sleep lasting for about 0.5-10 seconds at 20-90 second intervals
Periodic limb movement disorder
What is the general mechanism of amphetamine
Enters the CNS to act as a simulant- releases norepinephrine and dopamine
Amphetamine variant drug used to treat narcolepsy/childhood ADHD
Methylphenidate
What is the mechanism and use of modafinil
Inhibits both norepinephrine and dopamine transporters to increase their synaptic concentrations, as well as decreasing GABA; used to treat narcolepsy
What is the function of the suprachiasmatic nuclei of the hypothalamus
Secrete norepinephrine to stimulate the pineal gland to secrete melatonin
What stimulates the suprachiasmatic nuclei
The retinohypothalamic fibers send information about the light-dark cycle
Difficulty initiating/maintaining sleep several times a week; comorbid with depression
Insomnia
What mechanism is associated with insomnia and depression
Abnormal regulation of corticotropin-releasing factor
Sedative-hypnotic drug that slows brain activity to promote sleep onset
Zolpidem/Ambien
What is used to treat jet lag and insomnia in older individuals
Melatonin
Disordered, rhythmic, synchronous firing of populations of brain neurons
Seizure
Symptoms of periodic and unpredictable seizures
Epilepsy
What is the manifestation of a motor cortical seizure
Clonic jerking of the body part associated with that area of the cortex
Where do most focal seizures originate from
Temporal lobe
What is a classic symptom of a temporal lobe seizure
Loss of awareness
Symptoms of impaired consciousness, often associated with purposeless movements for 30sec-2min
Focal seizure with impaired awareness
What drugs are used to treat focal aware/impaired aware seizures
Cabamazepine
Phenytoin
Valproate
Symptoms of a focal seizure that evolves to loss of awareness and sustain contractions of muscles throughout the body; followed by periods of muscle contraction with alternating periods of relaxation
Focal to bilateral tonic-clonic seizure
Symptoms of abrupt onset of impaired consciousness associated with staring and cessation of ongoing activities; typically less than 30 seconds
Generalized absence seizure
Symptoms of a brief, shock-like contraction of muscles that may be restricted to part of one extremity or generalized
Generalized myoclonic seizure
Symptoms of periods of muscle contraction alternating with periods of relaxation
Generalized tonic-clonic seizure
What is the difference between a simple partial and complex partial seizure
Simple partial seizures do not have a loss of consciousness
What kind of agonists/antagonists can trigger seizures
GABA antagonists
Glutamate agonists (NMDA, AMPA)
What is the general mechanism of anti-seizure medications
Enhancing GABA-mediated synaptic inhibition
Antagonizing glutamate receptors
What is noted on the EEG during seizures
Interictal spike- sharp waveform
What does the depolarization shift (DS) on an EEG tell you
Localizes the brain region from which the seizure originates
Continuous seizures that last for hours
Status epilepticus
What is the physiological state of neurons during a seizure
They are depolarizing at very high frequencies
What is the EEG hallmark of an absence seizure
Generalized spikes and wave discharges at a frequency of 3 Hz
What is the mechanism of thalamic involvement in seizures
Activation of T-type currents (low threshold) amplifies thalamic membrane potential oscillations to the neocortex
These are targeted by anti-seizure meds
What is the difference in mechanism between anti-focal seizure and anti-absence seizure drugs
Anti-focal seizure drugs inhibit voltage Na+ channels
Anti-absence seizure drugs inhibit voltage Ca2+ channels
What is the genetic cause of epilepsy- Dravet Syndrom (catastrophic severe myoclonic epilepsy)
Spontaneous SCN1A (encodes part of voltage Na+ channel) mutation result in loss of Na+ channel function
Juvenile-onset condition characterized by myoclonic, tonic-clonic, and often absence seizures (most common generalized epilepsy)
Juvenile Myoclonic Epilepsy
What kind of seizures is considered a medical emergency
Status epilepticus- generalized or focal to bilateral seizures lasting continuously or in rapid succession
What is the progression of treatment for a status epilepticus emergency
Benzodiazepines/Antiepileptics > intubation
What is an immediate test for any case of unexplained loss of consciousness
EEG
What are common causes of seizures by age
Children- genetic, infection (febrile), trauma, congenital, metabolic
Adults- tumors, trauma, stroke, infection
Elderly- tumors, trauma, stroke, infection, metabolic
What drugs are used to treat focal to bilateral tonic-clonic seizures
Carbamazepine
Phenytoin
Primidone
Valproate
Phenobarbital
What is the treatment for generalized absence seizures
Ethosuximide!
Valproate
Clonazepam
What drugs are used for generalized myoclonic seizures
Valproate
Clonazepam
What drugs are used for generalized tonic-clonic seizures
Carbamazepine
Phenytoin
Primidone
Valproate
Phenobarbital
What is the mechanism of benzodiazepines
GABAa agonist on the post-synaptic neuron
What is the mechanism of valproate
GABA transaminase blocker (reuptake) in the inhibitory neuron; Ca2+ channel blocker on the excitatory neuron; Na+ channel blocker
What drugs are Na+ channel blockers on the excitatory neuron
Phenytoin
Carbamazepine
Valproate
Lamotrigine
Topiramate
What is the mechanism of levetiracetam
SV2A receptor blocker on the excitatory neuron
What is the mechanism of barbiturates
Decrease neuron firing by increasing duration of Cl- channel opening > facilitates GABAa action
What are the possible side effects of barbiturates
Respiratory and cardiovascular depression; CNS depression
What is the mechanism of benzodiazepines
Decrease neuron firing by increasing frequency of Cl- channel opening > facilitate GABAa action
What drugs are used for early status epilepticus
IV Lorazepam/Diazepam (OR IM midazolam)
What drugs are used for persistent status epilepticus
IV fosphenytoin
IV valproic acid
IV levetiracetam
What is a common side effect in older males after taking anticholinergics
Prostate enlargement > urinary retention
What does “aura” of a seizure refer to
A subjective experience/sensation before the seizure (ex: in the amygdala will produce a fear aura)
What drug is used to treat the symptoms of cataplexy associated with narcolepsy
Sodium oxybate
What is the MOA and use of oxcarbamazipine
GABAa agonist; antiepileptic
What are the toxicities of oxcarbamazepine
-Inhibits oral contraceptives (cyt P450 inducer)
-Hyponatremia
What is Erikson’s State of psychosocial development for ages 0-18 months
Trust vs mistrust (environment)
What is Erikson’s State of psychosocial development for ages 18 months-3 years
Autonomy vs shame (self-control)
What is Erikson’s State of psychosocial development for ages 3-6 years old?
Initiative vs guilt (tasks)
What is Erikson’s State of psychosocial development for ages 6-12 years old?
Industry vs inferiority (success)
What is Erikson’s State of psychosocial development for ages 12-18 years old
Identity vs role confusion (personality)
What is Erikson’s State of psychosocial development for ages 19-40 years
Intimacy vs isolation (community)
What is Erikson’s State of psychosocial development for ages 40-65 years old
Generativity vs stagnation (contribution)
What is Erikson’s State of psychosocial development for ages 65+ years old
Integrity vs despair (fulfillment)
What is the focus of Erikson’s model of development
Psychosocial development
What is the focus of Piaget’s model of development
Cognitive development
What is Piaget’s stage of cognitive development at birth-2 years old
Sensorimotor (senses + repetition)
What is Piaget’s stage of cognitive development at 2-7 years old
Preoperational (intuition + perspective)
What is Piaget’s stage of cognitive development at 7-11 years old
Concrete operational (categorical + logical)
What is Piaget’s stage of cognitive development at 12+ years old
Formal operational (abstract + hypothetical)
How does an infant develop trust in its environment
By observing the caretaker’s cues and identifying emotions to associated with experiences (“nurturing”)
The development of an infant sharing inner emotional experiences with others
Intersubjectivity
The behavior of babies to read emotional signals of caregivers to modify their behavior
Social referencing
What is one of the first signs of autism (in the first two months)
Delayed attachment bonding; absence “social smile”/eye contact
What is the major skill developed in the sensorimotor stage
Object permanence
At what age does stranger anxiety usually develop (the ability to recognize unfamiliar faces)
7-9 months old
What is the primary developmental task of the caretaker during the first year of life
Attachment between baby and caretaker
What enables the toddler to develop increased autonomy
Mobilization/walking
What is the primary developmental task of the child in the toddler age
Detachment and development of autonomy- comes with “practice” of different activities > repetitive nature of children
Normal issue with toddler development that involves inner conflict of child’s autonomy and dependence that results in the child pushing away the caregiver’s help
Rapprochement crisis (sort of like tantrums?)
What kind of psychosocial care do toddlers need from their parents
Reassurance that they won’t lose the love/support of the caregiver by becoming their own person
What is a major development in play in the toddler age
Symbolic/”Pretend” play
Development of what has an inverse relationship with the occurrence of tantrums
Verbal expressiveness (thus why kids with verbal issues may have more behavioral issues)
At what age does separation anxiety (due to inability to hold stable images of parents in mind) disappear
About 24-36 months
At what age does self-stimulation of genitals begin
2-3 years old
What age is most susceptible to separation anxiety from a caretaker
Toddler age (2-3 years old)
What kind of coping strategies does a toddler employ
External means of comfort (ex: stuffed animals and special blankets)
What is the psychosocial danger associated with preschool-age
Too much guilt results in overwhelmed and aggressive feelings
At what age does morality and guilt typically begin to form
Preschool age (3-6 years old)
What is a major development in play of the preschool age
Cooperative and imaginative play
At what age do communication disorders typically present
3-6 years old
What is the primary developmental goal of the school-age child (6-11 years old)
Establish competency/mastery > self-esteem
At what age does idealization of parents/other external characters occur
School-age (6-11 years old)
At what age do kids typically start understanding and accepting rules
Age 7-8
What is the distinguishing skill between preoperational and concrete operational stages
Object conservation
What is the development of gender/sexuality during the school-age
Tends to turn toward the same-sex parents and friendships; also develops sexual modesty
What is the psychosocial danger associated with the school-age
Too much focus on accomplishments/failures can result in significant self-esteem issues
What psychological disorders are typically identified during ages 7-11
ADHD
Communication disorders
OCD
Anxiety/Mood/Depressive/Adjustment disorders
Tic disorders
What marks the beginning of adolescence
Puberty
What is the first-line treatment for women with eclampsia/pre-eclampsia (hypertension + seizures)
Magnesium Sulfate
What is the primary psychosocial developmental goal of adolescence
Acceptance of body image, comparison with peers, and sexual attractiveness > progresses to achieving autonomy
What is a major social development in adolescence
Identifying with groups as a means to reduce anxiety (due to a lack of individual identity)
What is likely the source of adolescent feelings of anxiety and depression
Being relatively unfocused/confused about their role/expectations in new, less-structured settings (failure results in a lack of trust in themselves)
What is a major task of the parents of adolescent children
Tolerate increasing disengagement, and support search of child’s autonomy
At what age does self-image become more coherent
16-17 years old (middle adolescence)
What is a major driving force behind acquiring responsibility/more realistic concepts of the future in a teenager (decentering process)
Consolidation of individual identity
What emotions/fears are usually associated with the first sexual experiences in adolescents
Anxiety (about performance), fears of intimacy, guilt (because in previous stages, such behavior was unconsciously repressed)
At what stage of development do children typically start engaging in risky behavior; why
Adolescence/Teenage years; increased activity in the limbic region as compared to prefrontal cortex
What is the primary psychosocial developmental vulernability associated with teenage boys and girls, respectively
Boys- Cultural emphasis on “manliness” leads to rebellious and self-destructive behavior
Girls- Priority of maintaining connections leads to denial or suppression of autonomous needs
What notable behaviors actions/behaviors are expected by the 1st birthday
Sitting up
Babbling
Social smile
Pulling up
Says “mama and dada” and uses appropriately
Understands “No”
What notable behaviors/actions are expected by the 3rd birthday
Feeding self
Running, pivoting, walking backwards
Walking up and down stairs
Able to say first and last name
Can name common objects and identify body parts
Imitates speech
Shares toys/takes turns
Can identify some differences
What notable behaviors/actions are expected by the 6th birthday
Draw circle and square
Skipping
Balancing
Catches a ball
Some reading skills
Activity independence
Understands size and time
What notable behaviors/actions are expected by 12th birthday
Team sports skills
Begins to lose baby teeth
Some body hair/menarche
Peer recognition
Routines
Sequences of directions
What notable behaviors/actions are expected by 18th birthday
Fully adult height, weight, and sexual maturity
Completion of puberty
Values peer acceptance and recognition
Understands abstract concepts
What are the two major psychosocial development keys in adults
Successful work life
Mature, committed, intimate love relationships
What type of therapy has been found most helpful for sexual dysfunction problems
Behavior therapy
What is the major psychosocial vulnerability in aging populations
Changing relationships/loss of long-standing relationships
At what age do most mood/anxiety disorders appear
Age 40-50
What is the range of mild intellectual disability
IQ 50-70
What is the range of profound intellectual disability
IQ below 20-25
What two things are needed for a diagnosis of intellectual disability
Low IQ
Impaired adaptive functioning
What is the formula for calculating degree of developmental delay
Developmental age/chronological age (will be less than 1 if impared)
What domains of function are assessed for developmental progression (5)
Gross motor skills
Fine motor skills
Communication
Problem-solving
Personal-social
What is the most common cause of severe cases of intellectual disability
Chromosomal/genetic factors (40%)
What are the levels of educational potential for moderate and severe intellectual disability (measured by reading skills)
Moderate- 2nd grade level
Severe- preschool level
Symptoms of congenital cognitive impairment with long face, large mandible, large everted ears, macroorchidism (usually has some level of genetic anticipation)
Fragile X Syndrome
Caused by CGG trinucleotide repeats of the FMR1 gene on the X chromosome (leads to excessive methylation)
Fragile X Syndrome
Symptoms of persistent lack of social-emotional reciprocity, joint attention, facial expression, vocalization; along with a restricted repertoire of behaviors that is repetitious; extreme sensitivity/insensitivity to temperature
Autism Spectrum Disorder
What is the difference between autism level 1 vs 2 and 3
Significant delays in verbal/nonverbal communication
What is the best predictor of autism outcome
Language development
Symptoms of demonstrable impairment of standardized measure of communication, compared with norms for intellectual capacity
Communication disorders
Impairment of the acquisition and usage of spoken language (accompanied by frustration/shame/awareness of issues)
Language Disorder
Failure to recognize and utilize specific speech sounds (ex: lisping) not caused by a physiological defect
Speech sound disorder
Dysfluency that creates increased physical tension when speaking and having multiple monosyllabic/whole-word repeats
Childhood onset fluency disorder (stuttering)
Persistent difficulty in the social use of verbal/nonverbal communication, without any of the social signs of autism
Social (pragmatic) communication disorder)
What is the first step in treating a child with a speech delay
Audiogram to rule out hearing impairment
What is the treatment strategy for children with autism
Treating specific psychiatric symptoms (Ex: resperidone to treat self-destructive, aggressive behavior)
Also includes several different therapy modalities targeted at developing social skills and speech
Symptoms of abrupt, purposeless, recurrent, non-rhythmic motor movements/vocalizations; BEFORE 18 years old
Tics
Symptoms of multiple motor AND one or more vocal tics that persist for more than 1 year
Tourette’s Disorder
Symptoms of single/multiple motor OR vocal tics (not both) for more than 1 year
Persistent (chronic) motor or vocal tic disorder
Symptoms of single/multiple motor and/or vocal tics that have been present for less than 1 year
Provisional tic disorder
What is a common side effect of antipsychotics
Acute/tardive akathisia/dyskinesias
What is a common side effect of stimulants
Tics
What is an important differentiator between tic disorders and OCD
The obsessive component of OCD
What conditions typically worsen tic symptoms
Illness
Fatigue
Anxiety
Excitement
What is the treatment for tic disorders
Psychoeducation and reassurance; habit reversal training (CBT)
Symptoms of manic behavior, mood instability, irritability, severe tantrums; depressive symptoms
Bipolar Disorder
What is the first-line pharmacological treatment for bipolar disorder
Lithium/valproate
(may additionally require antidepressants)
Symptoms of chronic, consistent, severe irritability and frequent temper outbursts in children; 3+ times a week for 1 year in multiple settings
Disruptive mood dysregulation disorder
Symptoms of irritability, low frustration tolerance, and temper tantrums in children/adolescents; often a lack of focus in school/loss of enjoyment in activities; weight loss, sleep disturbances, isolation
Pediatric Major Depressive Disorder
Symptoms of headaches and gastric distress that become more apparent with the anticipation of being separated from a caregiver
Separation Anxiety Disorder
Symptoms of obsessive behavior with repetitive behavior; often triggered by hand washing, cleaning, repeating, and counting
Pediatric obsessive-compulsive disorder
Symptoms of experiencing fear of speaking in front of a group, eating in front of peers, attending social events, reading aloud
Social Phobia/Social Anxiety Disorder
Symptoms of repetitive play/expression of aspects of traumatic events, frightening dreams, and defiant behavior
Pediatric posttraumatic stress disorder
What is the primary way that children express depression
Excessive worrying
What is the treatment for persistent, severe anxiety symptoms in children
CBT/Selective serotonin reuptake inhibitors
What drugs are used to treat pediatric OCD
Clomipramine
Fluoxetine
Fluvoxamine
Sertraline
Repeated voiding of urine into bedding or clothing by a child over the age of 5 (2x week for 3+ months)
Enuresis
What is the primary treatment for enuresis (diurnal and nocturnal)
Diurnal: Behavior therapy with positive reinforcement
Nocturnal: Inhibiting fluid intake after 7pm
Symptoms of fecal voiding in inappropriate places in a child older than 4 years old; usually associated with constipation; 1x month for 3 months
Encopresis
Symptoms of hyperactivity, impulsivity, and inattention in multiple settings for at least 6 months
ADHD
What neurotransmitters are involved in the symptoms of ADHD
Norepinephrine and Dopamine (presynaptic deficiency)
What is the first-line treatment for ADHD
Low-dose sychostimulants (methylphenidate) (or Atomoxetine)
What is the MOA and use of methylphenidate
Blocks reuptake of DA and NE in the presynaptic neuron; ADHD
What is the MOA and use of amphetamine (Adderall)
Increases DA and NE release from presynaptic neuron via reversing the transporters; ADHD
What is the MOA and use of Atomoxetine
Inhibits NE reuptake; ADHD
Symptoms of recurrent pattern of disobedient, defiant, negative, and argumentative behavior toward authority figures (hyperintense and hyperfrequent)
Oppositional Defiant Disorder
What is a common progression from Oppositional Defiant Disorder
Conduct Disorder
Symptoms of a persistent pattern of behavior that violates the rights of others/social norms (premeditated) before age 10
Conduct Disorder
What categories/observations are included in a mental status examination
Appearance/Behavior/Speech/Attitude
Mood
Affect
Thought process
Thought content
Perception
Cognitive
Insight (self)
Judgment
What adjunctive tests are important to acquire when taking a detailed history of psychiatric symptoms
Blood and urine panels (and toxicology if suspected); CT/MRI/EEG
What is the purpose of broadband rating scales
Used to identify symptoms in an individual that would merit further evaluation
What is the purpose of narrow-band rating scales
Used to measure symptoms that are specific to diagnosis (used to confirm a diagnosis)
What is the most commonly used test for intelligence
Wechsler Adult Intelligence Scale
What are some factors that can contribute to decreased treatment adherence
Acute illness
Asymptomatic
High costs
High-risk/addictive behaviors involved
Simply not knowing why a treatment is prescribed or how to take it (or possible side effects)
Pill burden
What are some factors that can contribute to increased treatment adherence
Give complete and honest directions
Allow space for questions
Praise favorable results
Provide a simple-as-possible plan
Positive physician-patient relationship/Collaboration
What are the five parts of informed consent
- Describe the diagnosis in clear/layperson language
- Present medically reasonable alternatives for treatment w/the risks and benefits of each
- Make sure that patient understands their options/can explain them back
- Support the patient’s decision
- Obtain authorization/refusal
What is the difference between capacity and competence in decision-making
Competence is a legal term (to enter into contracts)
Capacity is a medical term (to understand and decide based on informed consent)
What are the four components of capacity
Communicating a choice
Understanding (recall and critical thinking)
Appreciation (non-denial)
Rationalization (weigh risks and benefits)
What mini-mental status exam score is usually indicative of capacity
Above 24 (17-23 is kinda iffy)
What test is the gold standard for determining capacity
MacArthur Competence Assessment Tools for Treatment test
What aspects of a family meeting is included in the chart post-meeting
Attendance
Problem list
Global assessment of family functioning
Family strengths and resources
Treatment plan
Enduring and habitual patterns of behavior, cognition, emotion, and motivation that are characteristic of an individual
Personality
What are some important characteristics of personality disorders
- Rigid/extreme personality traits
- Traits interfere with daily functioning
- Traits cause significant distress to the individual/those around them
- Negatively impact psychological and social functioning in many different domains
- Disturbances in sense of self
Pervasive pattern of mistrust and suspiciousness that begins in early adulthood and presents in a variety of contexts
Paranoid Disorder
Detachment from social relationships along with restricted range of emotional expressions; detachment from interest to establish meaningful relationships
Schizoid Disorder
Social and interpersonal deficits (social anxiety) along with cognitive/perceptual distortions and eccentricities
Schizotypal Disorder
What are the Cluster A personality disorders
Paranoid
Schizoid
Schizotypal
(Odd/eccentric)
What are the Cluster B personality disorders
Antisocial
Borderline
Histrionic
Narcissistic
(dramatic/emotional/erratic)
What are the Cluster C personality disorders
Avoidant
Dependent
Obsessive-Compulsive
(anxious/fearful)
Blatant disregard/violation of the rights of others without remorse/empathy for wrongdoing; repeated illegal actions
Antisocial Disorder
Marked impulsivity along with instability of interpersonal relationships, self-image, and affects; usually set off by disruption of a relationship
Borderline Disorder
Excessive/Superficial emotionality and attention-seeking behavior; usually seductive
Histrionic Disorder
Extreme grandiosity and need for admiration; fantasies of unlimited success and power; internally plagued by feelings of inferiority and envy
Narcissistic Disorder
Social inhibition along with feelings of inadequacy, and hypersensitivity to criticism; often suffer anxiety, depression, and self-esteem issues
Avoidant Disorder
Excessive need to be taken care of; submissive behavior and fear of separation
Dependent Disorder
Preoccupation with orderliness and perfectionism; infatuated with mental and interpersonal control
Obsessive-Compulsive Disorder
What are the key clinical features of Cluster A personality disorders
Profound interpersonal relationship problems centered around severe mistrust/lack of interest in others
Paranoid thinking
Rarely seek treatment independently
What are the key clinical features of Cluster B personality disorders
Hightened emotional reactivity
Poor impulse control
Unclear sense of identity
High levels of aggression
Highly extroverted
Which personality disorders have the most favorable prognosis
Cluster C and histrionic disorder
What emotion is typically associated with psychotic disorders
Suspicion
What kind of behavior is typically associated with anxiety disorders
Avoidant behavior
What emotion is typically associated with mania/hypomania
Grandiosity
What emotion is typically associated with bipolar disorder
Affective instability
What emotion is typically associated with depressive disorders
Self-criticism
A deficiency of what neurotransmitter has been associated with antisocial and borderline personality disorders
Serotonin
What usually brings someone with a personality disorder to seek medical attention
When something traumatic to their disorder occurs (ex: important relationship is lost for a patient with dependent disorder)
What defense mechanism do patients with Borderline Personality Disorder often exhibit
Projection
What defense mechanism do patients with Schizoid Personality Disorder often exhibit
Fantasy
Defense mechanism: the refusal to perceive/register significant external events
Denial
Defense mechanism: splitting of the thoughts and their associated feelings from conscious awareness; ex: amnesia
Dissociation
Defense mechanism: seeing others in black and white terms
Splitting
Defense mechanism: seeing another person/thing as perfect and ignoring their faults
Idealization
Defense mechanism: Maintaining an entirely negative view of another person by ignoring the person’s values
Devaluation
Defense mechanism: attributive one’s own thoughts/feelings/behaviors to another individual
Projection
Defense mechanism: expressing thoughts and feelings in actions rather than words
Acting out
Defense mechanism: Individual wishes to put something unpleasant out of their own awareness and does so
Suppression
Defense mechanism: blocking a thought/feeling/memory from conscious awareness
Repression
Defense mechanism: acting opposite to one’s own desires
Reaction formation
Defense mechanism: thinking or talking about an emotion-laden subject in an unemotional way
Intellectualization
Defense mechanism: attributing one’s behavior to a cause that one finds more acceptable than the actual cause
Rationalization
What are the 4 mature ego defenses
Suppression
Altruism
Humor
Sublimation
XY individuals born with female genitalia/physical features (wide range of presentations)
Androgen Insensitivity Syndrome
XY individuals with underdeveloped male genitalia that may be misjudged as a clitoris at birth
5-Alpha-Reductase Deficiency
XX individuals with a masculinized body and retarded breast/pubic hair development
Congenital Adrenal Hyperplasia
XX individuals with enlarged clitoris, or masculinized female genitalia
Progestin-Induced Virilization
Discomfort/Distress associated with a discrepancy between a person’s gender identity and inherited sex
Gender Dysphoria
What are the steps of the arousal cycle (aka sex)
Excitement
Plateau
Orgasm
Resolution
Latency
Maybe review bacterial and parasitic and viral STI’s? (*)
*
What is the most common sexual dysfunction in men
Early ejaculation
What drugs can cause decreased sexual interest/arousal difficulties
Cocaine, opiates, amphetamines, sedatives, hypnotics
What drugs can cause erectile difficulties
Antihypertensives, histamine H2 receptor antagonists, antidepressants, anabolic steroids, stimulants, anxiolytics
What psychological pathologies can cause sexual dysfunction
Chronic stress/depression
Prolonged sexual abstinence
What is the mechanism of sildenafil (viagra)
Phosphodiesterase 5 inhibitor- vasodilator + smooth muscle relaxant to increase blood flow to penis
What is used to treat both men and women with low sexual desire
Testosterone
What is used to treat early ejaculation
SSRIs
Abnormally intense and persistent sexual interests accompanied by significant distress or functional impairment (prior to 18 years old)
Paraphilia sexual disorder
Peeping for sexual arousal
Voyeuristic disorder
Flashing for sexual arousal
Exhibitionistic disorder
Groping for sexual arousal (nonconsentual)
Frotteuristic disorder
What is the difference between sexual sadism and masochism
Sadism- likes to inflict pain
Masochism- likes to feel pain
Persistent and intense sexual arousal related to nonliving objects or nongenital parts of the body
Fetishistic disorder
Persistent and intense sexual arousal caused by cross-dressing and experiencing significant distress
Transvestic disorder
What is the treatment for the paraphilic disorders
CBT (and Jesus)
What is the difference between suicidal ideation and intent
Ideation is a thought about killing yourself; intent is an intensity of a wish to die (ideation does not always include intent)
What are some common emotions of suicidal patients
Frustration
Helplessness
Hopelessness
Pessimism
Self-critical
What are the risk factors for suicide
Sex (male)
Age (young or older adult)
Depression
Prior attempts
Ethanol/Drug use
Rational thinking loss (psychosis)
Support system loss
Organized plan
No significant other
Sickness (medical illness)
(there may also be some level of family history)
What neurotransmitter imbalance is associated with suicide risk
Serotonin deficiency
When should you treat a suicidal patient through outpatient
When you are certain that the patient wants help and has a support system in place (will help with treatment compliance)
When should you treat a suicidal patient through inpatient
Psychotic patients; they have a detailed plan; they refuse any help following an attempt
What medications are usually prescribed for suicidal patients
SSRIs (with VERY careful monitoring)
Lithium (with blood level monitoring)
What are the four phases of aggression
Calm- relaxed, alert, fully conscious; normal social interaction
Psychomotor agitation- constant chatting/questioning, increased physical activity with approach-avoidance behavior
Verbal aggressive- yelling or cursing; insistent/demanding
Physical aggressive- intimidation, assault, property destruction (may be followed by guilt)
What are the factors for assessing risk of patient violence
Current behavior
Current ideation (look for a specific plan/target)
Recent behavior (ie assaulted someone already, access to weapons)
Past history of aggression
Support Systems existing
Substance use
Ability to cooperate with treatment
Neurological/Medical conditions
When should you hospitalize a potentially violent patient
1) Patient has directed homicidal ideation
2) Patient is psychotic and hallucinates having homicidal/violent content
3) Patient had recent violent episode/displays severe impulsivity + agitation
4) Change in mental status toward aggressive ideation
5) Patient w/ psychiatric illness describes directed aggressive ideation
6) Patient has known means to commit directed ideations
7) Patient continues to be a violence risk despite outpatient treatment
Disturbance of eating habits including under-eating OR binge-eat/purge; psychological preoccupation/disturbance in perception of body image; does not maintain >18.5 BMI
Anorexia nervosa
Disturbance of eating habits including binge-earting/purge (often vomiting); psychological preoccupation/disturbance in perception of body language; loss of control when binging
Bulimia nervosa
Periods of uncontrolled eating but do not take compensatory measures after binging; psychological preoccupation/disturbance in perception of body image; “eating impairs their lives”
Binge-eating disorder
What are the steps of the Binge-Purge Cycle
1) Strict diet
2) Diet slips/difficult situation arises
3) Binge eating triggered
4) Purging to avoid weight gain
5) Feelings of shame/self-hatred
What is the BMI level for anorexia
19.5
What is a notable pattern of behavior of people with anorexia nervosa in terms of exercise
Hyper-focused on eating, body-checking, exercise to the point it may look like OCD
What is the basis of severity rating for bulimia nervosa
Frequency of compensatory behavior (NOT weight)
Symptoms of morning anorexia, evening hyperphagia, and insomnia
Night eating syndrome
Regular occurrence of purging in the absence of binge eating
Purging Disorder
What is the typical demographic for a patient with anorexia nervosa
14-18 year old female
What are the two causes of death in patients with anorexia nervosa
Suicide
Starvation complications (about half and half)
Which is more common anorexia or bulimia?
Bulimia (about 2x more common)
Which is more lethal anorexia or bulimia?
Anorexia
What are some common comorbidities with anorexia and bulimia?
Major Depressive Disorder
OCD
Social phobia
Cluster B/Cluster C Personality Disorders
What are the physical exam findings for anorexia
History:
-Constipation
-Abdominal discomfort
-Cold intolerance
Exam:
-Bradycardia
-Hypotension
-Hypothermia
-Lanugo
-Dry skin
Labs:
-Leukopenia
-Elevated BUN/AST/ALT
-Hyponatremia/hypokalemia
What are the physical exam findings for bulimia
History:
-Emesis w/ blood
-Menstrual irregularities
-Large bowl abnormalities
Exam:
-Teeth enamel erosion
-Salivary gland enlargement
-Calluses on dorsum of hand
Labs:
-Hypokalemia/Hyponatremia/Hypochloremia/Hypomangesemia
-Metabolic alkalosis
What percentage of anorexia patients achieve full recovery
25% (most develop bulimia)
What percentage of bulimia patients achieve full recovery
About half
Dysregulation of what neurotransmitters are implicated in eating disorders
NOR and Serotonin (deficiency in satiety)
Leptin and Peptide YY deficiency as well
What contributes to the neuroendocrine reinforcement of eating disorders
Elevated corticotropin-releasing hormone
Decreased luteinizing hormone (reflects low leptin)- causes amenorrhea
What contributes to the gastrointestinal effects of eating disorders
Decreased cholecystokinin secretion leads to decreased satiety after meals
What is the treatment for anorexia
Weight gain is critical
Behavior treatment- requires commitment and support
Not really much support for pharmacotherapy
What is the treatment for bulimia
Weight monitoring
Antidepressants (TCAs, SSRIs, MAOIs)
Psychotherapy (CBT- self-monitoring skills)
What is the treatment for binge-eating disorder
Antidepressants
CBT
What is a possible complication of treating anorexic patients and what does it look like
Refeeding syndrome- congestive heart failure, pulmonary edema, metabolic acidosis, Wernicke-Korsakoff Syndrome, Tetany, Dyspnea, Cardiac arrest, Coma, DEATH
