Psych Flashcards
Echolalia
Repeating questions
Neologisms
New words
Dissociation
Split off mental contents from conscious awareness
Projection
Unconsciously reject and attribute unacceptable aspects of the self to others
Reaction formation
Adopting ideas and behaviors that are the opposite of impulses harbored un-/consciously
Sublimation
Unacceptable conscious drives are redirected to personally/socially acceptable channels
Anxiety disorders: Features
Familial pattern of 30-50% concordance in identical twins
Disrupted limbic circuits with less cortical modulation
Treatment of anxiety disorders
Strengthen prefrontal cortex (therapy)
Increase serotonin levels (SSRIs for anxiety/SNRIs for lethargy)
Increase GABA inhibition in amygdala/hippocampus (benzodiazepines)
MAOIs do what?
What other things do this?
Increase Nor, Dopa, and Sero levels
Cocaine, Ecstasy, Exercise
Wellbutrin does what?
Increases Nor & Dopa
Panic disorders
Recurrent, unexpected panic attacks not due to organic causes
Usual onset as teen/young adult
Treat with therapy & SSRIs, TriCycs, Benzos, MAOIs
Responds to lower doses than depression
Social anxiety disorders
Marked and persistent fear of social situations for >6mths that significantly interferes with life.
Onset usually 11-15yo
More common in females
Generalized anxiety disorder
General anxiety symptoms lasting >6mths interfering with functioning.
Early onset more common in women, associated with childhood fears
Can treat with therapy & benzos, SSRIs, buspirone
OCD
Less activity and control in extrapyramidal and basal ganglia pathways
SSRIs are most effective in higher doses
PTSD
Severe trauma re-experienced
Therapy, SSRIs help ~50%, anticonvulsants may be helpful
Most common in abused patients, military
Schizophrenia
~1% of population
Onset 15-25
Chronic
Affected thought process and content on mental status exam = disorder of impaired thought
Psychotic: Hallucinations, delusions, disorganization
Restricted/inappropriate affect, avolition, alogia
Cognitive impairment in attention, processing information
Patient has lost touch with reality and lacks insight into condition due to frontal, parietal lobe abnormality
Psychosocial dysfunction, lack of relationships
Attitude: Suspicious, guarded
Appearance: Disheveled, inappropriate for weather
Behavior: Awkward, Parkinsonian gait/tremors
Mood and Affect: Flat, irritable, hostile
Thought processes: Tangential, word salad
Thought content: Distorted reality, paranoid, delusions of thought broadcasting, auditory hallucinations
Accelerated brain gray matter loss
Increased morbidity and mortality
ASD (Autism)
Persistent difficulties in social interaction, non-/verbal communication, and repetitive behaviors
Symptoms present early in development (6mths-2yrs), but may not manifest until social demands exceed limitations
Language delay
Restricted, repetitive behaviors - insistence on sameness
More common in boys
Unknown etiology, BUT NOT BAD PARENTING
M-CHAT survey of child’s habits, behaviors for screening
Vaccines not related to occurrence
ADHD
Symptoms start Block Nor, Dop reuptake) and behavioral interventions together are best
1st gen antipsychotics
E.g. Haldol, Prolixin
Effective at sedating psychotic patients
Long-term Parkinsonian side effects are irreversible
2nd gen antipsychotics
E.g. Abilify, Seroquel
Fewer psychological side effects, however insulin resistance and T2DM may develop
Purpose of defense mechanisms
To unconsciously provide relief from emotional conflict and anxiety
Somatoform disorders
Patient has physical symptoms that cause significant distress and impairment that are far in excess of what would be expected based on patient history, physical, and labs
More common in females
Somatization vs. Somatoform illness
Somatization = tendency to experience and communicate psychological/emotional distress as physical symptoms
Somatoform illness = somatization causing significant dysfunction in patient’s life
Facititious disorder
Symptoms are produced/feigned in order to appear ill without a perceivable benefit
Can be imposed on self or others (usually mothers to children)
Patient may be evasive/argumentative, dramatic with history, have multiple malpractice claims, predict their own decline before discharge, or be unwilling to undergo testing
Most patients sign out rather than accept diagnosis
Malingering
Symptoms are produced/feigned in response to external incentive (discrepancy between claimed disability and physical exam)
Uncooperative, associated with antisocial personality disorder
Somatic symptom disorder
How to manage?
Frequent doctor visits
May refuse to acknowledge psychological contribution to symptoms
Excessive use of analgesics for pain
Common co-morbid depressive symptoms
Manage with single physician, regular followup, discussing stressors, full physical exam, and realistic goals to reduce pain and increase function
Illness anxiety disorder
How to manage?
Excess worry regarding mild/absent symptoms
Prev. hypochondriasis
4 D’s: Disease fear, preoccupation, conviction; and Disability
Manage by identifying stressors, refer for supportive and cognitive therapy, SSRIs
Conversion disorder
Best management?
Requires clear evidence of incompatibility with neurological disease
At least 1 symptom (e.g. pseudoseizures) of altered voluntary motor/sensory function that is incompatible with neurological syndromes
Symptoms are distractible and don’t cause atrophy
Sensory symptoms may split at midline
Indifference about major disability
Outcomes improve with identifiable trauma/stressor at onset, anxiety/depression treatment, and framing the issue as “stress related” to the patient
Common examples of psychological factors affecting other medical conditions?
Anxiety and asthma
Occupational stress and hypertension
Alcohol abuse and liver disease
Cluster A personality disorders
Odd, eccentric behavior
Paranoid
Schizoid
Schizotypal
Cluster B personality disorders
Dramatic, erratic emotional behavior Antisocial Borderline Histrionic Narcissistic
Cluster C personality disorders
Anxious and fearful behavior
Avoidant
Dependent
Obsessive-compulsive
Personality
Enduring pattern of thinking, feeling, and behaving uniquely recognizable in each individual
Personality disorders in general are due to … causing impairment in … ?
Other important features?
Use of limited coping strategies regardless of adaptability
Cognition, social functioning, and impulse control
Generally lifelong and diagnosed in adults who are egosytonic (think everything is fine)
Paranoid Personality Disorder
Scan environment for signs of slight
See/make hidden meanings
Bear grudges
Use projection
Schizoid Personality Disorder
Loner indifferent to others’ responses
Non-goal directed fantasies
Schizotypal Personality Disorder
Unusual loner with social anxiety and odd beliefs, speech, and perceptions Has ideas (not delusions) of reference Uses magical (superstitious) thinking
Antisocial Personality Disorder
Deficits in conscience:
Defies social norms, irresponsible, without empathy or remorse
Act out, rationalize
Borderline Personality Disorder
Fractured identity manifested in anger, mood swings, self-injurious acts, and intense relationships
Use splitting things as good/bad and projection
Histrionic Personality Disorder
Lives to convince others
Dramatic, seductive, must be center of attention, preoccupied with appearance, “shallow”
Use repression and physical conversion
Narcissistic Personality Disorder
Self-absorbed, entitled, exploitative
Lacks empathy
Uses denial and projection
Avoidant Personality Disorder
Sensitive to rejection, but interested in interaction
Views self as socially inept, needs lots of reassurance
Dependent Personality Disorder
Needs someone else to nurture/care for Fearful of independence Stays in relationships or quickly finds new ones No anger Uses denial, repression
Obsessive/Compulsive Personality Disorder
Lives for structure/control, perfectionist
Emotionally constricted
Uses isolation, reaction formation, undoing
Isolation of affect (defense mechanism)
Attempt to avoid painful thought/feeling by objectifying and emotionally detaching oneself from it
“Reward center” of mesolimbic dopamine system affected in all addicts either in-/directly
Nucleus accumbens
Alcohol - mechanism of action
Indirectly stimulates dopamine release in NuAcc
Directly stimulates GABA-a receptor (disinhibits)
Inhibits NMDA receptor (excitatory transmitter)
Cocaine - mechanism of action
Blocks reuptake of dopamine
Stimulates release of noradrenaline
Blocks Na+ channels (cardiac signs)
Amphetamines - mechanism of action
Directly stimulate dopamine release
Opiates - mechanism of action
Bind to mu, sigma, and kappa receptors centrally and peripherally
Indirectly stimulate release of dopamine in VTA
Substance use disorder
Maladaptive pattern of substance use leading to clinically significant impairment/distress over at least 3 months
Criteria:
- Increasing amounts or increasing time period of use
- Unsuccessful at cutting down
- Lots of time spent to obtain
- Craving
- Failure to fulfill obligations (work, school, home)
- Continued use despite problems
- Giving up/reducing important social/recreational/occupational activites
- Recurrent use in hazardous situations
- Continued use despite insight into problem
- Tolerance
- Withdrawal
Patient may intentionally hide this from you
How to diagnose substance abuse?
Take a good history - smell, hepatomegaly, mental status, track marks, weight loss, withdrawal symptoms, pupil size
CAGE:
Have you ever tried to Cut down?
Have you been Annoyed by criticism?
Have you felt Guilty of things done while intoxicated?
Have you had an Eye-opening experience?
Mildly elevated AST, ALT (100s)
How to present substance abuse diagnosis?
Don’t present diagnosis while patient is intoxicated
Don’t argue with/threaten/shame patient
Don’t hedge (only partially explain) diagnosis
Don’t expect rapid change
State the diagnosis
Express concern
Explain this is a disease, not a moral weakness
Explain treatment is possible, but there is individual responsibility
Develop a plan
Drugs requiring detox?
Alcohol, opiates, sedative hypnotics
Disulfiram
Inhibits aldehyde dehydrogenase –> aldehyde accumulation on alcohol consumption
Causes flushing, nausea, hypotension, hepatotoxicity
Naltrexone
Blocks mu-opioid receptor
May decrease risk and length of relapse
Hepatotoxicity
Methadone and Buprenorphine
Replaces opiates
Administered in controlled setting combined with counseling and other interventions –> Most successful treatment for heroin addiction
Major depressive episode - criteria
Depressed mood, or anger/irritability Anhedonia (^^^at least one of these two^^^) Weight/appetite change In-/hypersomnia, not restful Psychomotor agitation/retardation Fatigue Feelings of guilt/worthlessness/hopelessness, nihilistic delusions Diminished ability to think/concentrate Recurrent thoughts of suicide ^^^At least 5 every day for 2 weeks^^^ Impairment/distress No organic cause No schizophrenia (May present with non-specific somatic complaints)
Major depressive episode - pathogenesis
Genetic contribution, variable sensitivity to life stressors
Increased cortisol/CRH secreation (Dexomethosone suppression test)
~15% of population in lifetime
Suicidality risks?
Family history, previous attempts, male
Manic episode - diagnosis
Elevated or irritable mood characterized by at least 3 of the following with "marked impairment" in functioning: Grandiosity Little need for sleep More talkative Racing thoughts Distractability Increased activities/agitation and risk-taking Impulsiveness
Patient compliance is low since they may feel pleasure in manic state
Mixed episode
Patient satisfies criteria of both manic and major depressive episodes over 1 week
Hypomanic episode
4 days plus 3-4 symptoms of manic episode
Moderate or mild impairment in function, but may also ENHANCE function
Major Depressive Disorder
Episodes of depressed mood daily for >2wks
Ser, Nor, and Dop implicated
Treat with Cognitive Behavioral Therapy and SSRI/SNRI/TCA/MAOI
ECT or TMS for memory loss
Address suicidality with direct questioning
Educate patient to adhere to meds and that this is a disorder, not a character weakness
Dysthymic Disorder
Chronic ongoing (>1yr) mild depressive symptoms
Bipolar I
Mixed episodes of mania and depression within the same week
Bipolar II
History of depression with hypomanic episodes
Cyclothymia
Cyclic hypomanic and depressive episodes
Bipolar disorders - Pathogenesis
“Kindling effect” - over time patient is more susceptible to episodes
Bipolar disorders - Treatment
Mania: Mood stabilizers (lithium, valproic acid)
Depression: Atypical antipsychotics (Seroquel, Symbyax)
Diseases that may cause depression
Endocrine: Hypothyroidism, Cushing’s disease
Neuro: CVA (esp. frontal), Parkinson’s, Huntington’s, AZD
Infectious: HIV, hepatitis, mono, flu
Neoplastic: lung, pancreas, CNS
Metabolic: Folate/B12 deficiency, high Ca++, low Mg++
Other: Alcoholism, drugs/other causes of CNS depression
Drugs causing mania
Stimulants, decongestants, weight loss preps
Dopamine agonists (L-DOPA)
Antidepressants
Steroids
Diseases causing mania
Endocrine: Hyperthyroidism Neuro: Temporal lobe seizures or CVA, MS, Huntington's Infectious: HIV, encephalitis Neoplastic: CNS Metabolic: Low Ca++
Important general history questions related to depression?
Sleep, appetite, enjoyment of activities, depressive thoughts, family history
Organic brain syndromes - cause
Disorders of the cerebrum
Delirium
Confusion in which the individual experiences terrifying hallucinations, usually with increased psychomotor activity
Amnesia
Loss of ability to form memories despite alert state of mind
Dementia
Loss of ability to reason without disturbance of perception
Always supplement a history of someone with a probable brain/psychiatric disorder with what?
Information from a person other than the patient
Causes of acute confusion?
Medical illness - uremia, hypoxia, hypoglycemia, hyponatremia; high fever; heart failure; PTSD
Drug intoxication
Nervous system disease - CVA, tumor, abscess; subdural hematoma; meningitis; encephalitis
Causes of delirium?
Medical illness - typhoid, pneumonia, septicemia, rheumatic fever, alcoholism
Nervous system disease - vascular, neoplastic; cerebral contusion; meningitis; subarachnoid hemorrhage; encephalitis
Causes of dementias?
(Lots)
Associated w/labs/other diseases: Hypothyroidism, Cushing’s, nutritional deficiency (Trp, thiamine, B12), Wilson’s, chronic intoxication
Associated w/other neuro signs: CVA, tumor, trauma, hydrocephalus, Huntington’s, Tay-Sach’s, prion disease
Only evidence of neuro disease: AZD
Eating disorder risk factors
Genetics Environment - higher in cultures valuing thinness Social - teasing Psychological stress - means of coping Female gender Early puberty Perfectionist personality Low self-esteem Family troubles
Eating disorder protective factors
High self-esteem Participation in non-elite sports Successful in multiple areas Good family and social support Well-developed problem solving skills
Anorexia Nervosa diagnosis
Restriction of energy intake leading to body weight lower than minimally normal or expected
Intense fear of gaining weight, becoming fat
Disturbance in experience of body weight or shape
Undue influence of body weight/shape on self-evaluation
Subtypes of anorexia
Restricting type - for last 3 months, no binge eating or purging have occurred
Binge Eating/Purging type
Bulimia Nervosa
Recurrent episodes of binge eating together with a sense of a lack of control with inappropriate compensatory behaviors to prevent weight gain, >1/wk for 3mths
Self-evaluation unduly influenced by body shape/weight
Binge-eating disorder
Recurrent binge eating episodes without inappropriate compensatory behavior as in bulimia
Symptoms of eating disorders
Menstrual irregularities
Abdominal pain/bloating
Cold intolerance and constipation (more AN)
Fatigue
GERD (BN)
Palpitations, syncope (due to orthostatic hypotension)
Anorexia physical exam findings
Acrocyanosis Bradycardia Emaciation Orthostatic hypotension Lanugo, alopecia Hypothermia Flat affect Salivary gland enlargement
Bulimia physical exam findings
Salivary gland enlargement
Calluses on knuckles from inducing emission
Mouth sores, enamel erosion from acid
Orthostatic hypotension
Mallory-Weiss tear of esophageal mucosa –> Blood in vomit
Clinical components of refeeding syndrome
Hypophosphatemia, -kalemia, -magnesaemia
Deficiencies of vitamins, other trace minerals
Volume overload, edema
Labs for suspected eating disorder
CBC, ESR (normochromic, -cytic anemia; low glucose) CMP (hyponatremia, liver enzymes?) Urinalysis (water loading?) Mg Urine B-hGC (pregnant?) FSH, LH, etc. Serum amylase (high if purging) Stool for blood (inflammatory bowel?)
