Psych Flashcards
1
Q
What medication can you NEVER give a pt with an eating disorder?
A
wellbutrin (buproprion)
this is because it can lower the seizure threshold which is already a problem in pts with nutritional disorders
*wellbutrin can also make urine tox show up positive for ecstasy
2
Q
Maudsley Method
A
an in home therapy program for eating disorder pts
step 1 is that pts don’t have control over their meal plan, basically have to sit at the table until all their food has been consumed
3
Q
What are the goals of inpt treatment for a pt with anorexia?
A
1) restore nutrition and weight
2) modify distorted eating behavior
3) change distorted body image issues (both inpt and outpt)
4
Q
What are the stages of grief?
A
Denial Anger Bargaining Depression Acceptance
5
Q
Zyprexa
A
Olanzapine
atypical antipsychotics
high risk of weight gain and metabolic syndrome
block postsynaptic DA-R, block serotonin-R, variable effect on histaminic and cholinergic-R
6
Q
Abilify
A
Aripiprazole
atypical antipsychotic
block postsynaptic DA-R, block serotonin-R, variable effect on histaminic and cholinergic-R
7
Q
Seroquel
A
quetiapine
atypical antipsychotic
block postsynaptic DA-R, block serotonin-R, variable effect on histaminic and cholinergic-R
need q6 month eye exam due to risk of cataracts
8
Q
Risperidone
A
Risperdal or consta
atypical antipsychotic
block postsynaptic DA-R, block serotonin-R, variable effect on histaminic and cholinergic-R
least amount of SE
highest risk of hyperprolactinemia
9
Q
Pathologic anxiety
A
occurs when the sxs are excessive, irrational, out of proportion to the trigger or are without an identifiable trigger
10
Q
What is the function of benzodiazepines?
A
enhance activity of GABA at GABA-A receptors
11
Q
What defines a panic attack?
A
fear response that occurs spontaneously or is triggered
peaks within minutes
resolves within 30 minutes
12
Q
What are risk factors for panic attacks?
A
smoking
first degree relative with panic attacks
W > M
20-40yo onset
13
Q
What are the sxs of a panic attack?
A
Da PANICS Dizziness, disconnectedness, derealization, depersonalization Palpitations, paresthesias Abdominal distress Numbness, nausea Intense fear of dying, "going crazy" Chills, CP Sweating, shaking, SOB
14
Q
What is the DSM -5 Criteria for panic attacks?
A
recurrent, unexpected panic attacks w/o identifiable trigger
1+ attacks followed by >/= 1 months of continuous worry about having another attack and/or maladaptive change in behavior
not caused by the direct effects of a substance, another mental disorder, or medical condition
15
Q
What is the treatment for panic attacks?
A
CBT
SSRT first line med
16
Q
What is the definition of agoraphobia?
A
intense fear of being in public places where escape or obtaining help may be difficult –often develops with panic disorder
17
Q
What is the DSM 5 criteria for agoraphobia?
A
intense fear/anxiety about >2 situations due to concern of difficulty escaping or obtaining help in case of panic or other humiliating sxs:
outside of home alone, open spaces, enclosed spaces, public transportation, crowds/lines
the triggering situation cause fear/anxiety out of proportion to the potential danger posed, leading to endurance of intense anxiety, avoidance
sxs last >/= 6 months
sxs cause sig social or occupation dysfunction
18
Q
What is the treatment for agoraphobia?
A
CBT
SSRI
19
Q
What is the etiology of GAD?
A
W > M
33% genetic
worry sxs begin in childhood
median age onset: 30yo
20
Q
What is the DSM 5 criteria for GAD?
A
excessive, anxiety/worry about various daily events/activities >/=6 months
difficulty controlling the worry
associated >/=3 sxs: restlessness, fatigue, impaired concentration, irritability, muscle tension, insomnia
sxs are not caused by the direct effects of a substance, or another mental or medical condition
21
Q
What is the treatment for GAD?
A
CBT + SSRI or SNRI
22
Q
Obsessions
A
recurrent intrusive, undesired thoughts that increase anxiety
23
Q
Compulsions
A
repetitive behaviors or mental rituals
24
Q
What is the DSM 5 criteria for OCD?
A
obsessions and/or compulsions that are time consuming (>/= 1hr/day)
25
What is the epidemiology of OCD?
mean age of onset: 20yo
no gender preference
sig genetic component
26
Somatic symptom disorder definition
some physical sxs, often pain, in which pts seek help from multiple doctors
27
What is the DSM 5 criteria for somatic symptom disorder?
one or more somatic sxs (pain MC) that are distressing or resulting in significant disruption
excessive thoughts, feelings, or behaviors related to the somatic sxs or associated health concerns
lasts at least 6 months
28
What is the epidemiology of somatic symptom d/o?
F > M
general adult population prevalence 5-7%
RF:
older age, fewer year of education, lower socioeconomic status, unemployment, hx of childhood sexual abuse
29
What is the other name for conversion disorder?
functional neurological symptom disorder
pts "convert" psychological distress or conflicts to neurological sxs
30
What is the DSM 5 criteria for conversion disorder?
at least 1 sxs of altered voluntary motor or sensory function
evidence of incompatibility between the sxs and recognized neurological or medical conditions
common sxs: paralysis, weakness, blindness, mutism, sensory complaints (paresthesias)
*(not on the DSM criteria - but often these pts are surprisingly calm and unconcerned when describing their sxs)
31
What is the epidemiology of conversion disorder?
W > M
onset at any age but more common in adolescence or early adulthood
high incidence of comorbid neurological, depressive, or anxiety disorders
32
What is the treatment for conversion disorder?
primary treatment: education about the illness
CBT +/- PT
while spontaneous recover occurs often, prognosis overall is poor, as sxs may persist, recur, or worsen in 40-66% of pts
33
What is illness anxiety disorder?
preoccupation with having or acquiring a serious illness
somatic sxs are not present or, if present, are mild in intensity
high level of anxiety about health
performs excessive health-related behaviors or exhibits maladaptive behaviors
lasts >/= 6 months
34
What is the epidemiology of illness anxiety disorder?
this is the only somatic sxs related d/o that is more common in men than in women
average age of onset: 20-30
67% have coexisting mental d/o
35
What is the treatment of illness anxiety disorder?
regularly scheduled visits to the one primary care MD
CBT most useful of all psychotherpaies
Comorbid anxiety and depression should be treated with SSRI
36
Psychological factors affecting other medical conditions
DSM 5:
a medical sxs or condition (other than mental disorder) is present
psychological or behavioral factors adversely affect the medical condition in at least one way, such as influence the course or treatment, constituting an additional health risk factor
ex: anxiety worsening asthma, denial of need for treatment for acute CP, manipulating insulin doses in order to lose weight
37
NMS
neuroleptic malignant syndrome
associated with typical and atypical antipsychotics as well as anit-emetics
rare: 0.02-3%
38
What are the signs and sxs of NMS?
1) AMS - "agitated delirium"
2) Rigidity (more like any EPS)
3) Hyperthermia (>38)
4) Autonomic instability (HR, BP, sweating, tachypnea)
if a pt who has been exposed to an antipsychotic med also has any 2 of these sxs you should have high suspicion of NMS
39
What are the risk factors for NMS?
dehydration, exhaustion, giving antipsych IV (vs IM), change in medications, rapid titration, familial NMS cluster
also: familial hx of malignant hyperthermia seen with anasethsia (succinylcholine) adverse reaction
40
What is the DDX for NMS?
encephalitis, meningitis, 5HT syndrome, malignant catatonia, drug withdrawal, tetanus, pheo, thyrotoxicosis
41
What labs would you expect to see for someone with NMS?
elevated CK is the most specific (>1000, >3000 more specific)
elevated AST, ALT, Alk Phs, LDH
AKI - myoglobinuria
42
What is the treatment for NMS?
treat the fever, HTN, etc
Dantrolene x 10d with 15d taper (muscle relaxant) - be sure to monitor liver enzymes during treatment d/t risk of hepatotoxicity
Bromocriptine - dopamine agonist (can worsen psychosis tho)
Amantadine - dopimingeric/anticholinergic
43
What is the prognosis of NMS?
recovery within 7-11 days most common
5% mortalitity if dantrolene or bromocrpitine started right away
IF myoglobinuria and renal failure present --> 50% mortality
44
What are the two presentations of delirium?
agitation or solomnece
45
Biopsychosocial model
Bio:
gender, physical illness, disability, genetic vulnerability, immune function, neurochemistry, stress reactivity, medication effects
Psycho:
learning/memory, attitudes/beliefs, personality, behaviors, emotions, coping skills, past trauma
Social:
social supports, family background, cultural transitions, social/economic status, education
46
Content vs process?
Content: "what's" being said
Process: the "way/how" and sometimes the "why"
47
The 4 Ps model
Predisposing factors: Why me?
Precipitating factors: "why now? Triggers?
Perpetuating factors: "why is it still happening?"
Protective factors: What is my "ace" in the hole, my strengths, what or who can I count on?
48
What are the components of the MSE?
```
General appearance and attitude
Motor activity/behavior
Orientation/level of consciousness
mood and affect
Speech
Though form and content
Perception
Memory and cognition
Judgement and insight
```
49
Echopraxia
involuntary repetition or imitation of another person's actions typically seen in pts with Tourette's Syndrome or autism
50
Akathisia
movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion; common side effects of neuroleptic antipsychotic or other medications; can cause restlessness, pacing, repeated sitting and standing
51
Catelepsy
(waxy flexibility)
condition of a person who can be molded into a position that is then maintained for a prolonged period of time; seen in catatonic schizophrenia
52
Catatonia
a severe disturbance of motor function, usually manifested by markedly decreased activity, but may involve hyperactivity, with alternation between these states; in the hypoactive state, the person is immobile and maintains peculiar postures for lengthy periods
53
Dystonia
involuntary muscle contractions that cause slow repetitive movements or abnormal postures; can be painful; can be drug induced
54
Dyskinesia
difficulty or distortion in performing voluntary movements
55
Stuporous vs obtunded
stuporous: only awakening in response to pain
obtunded: slowed response to stimulation
56
Mood vs affect
mood: inquired - reported by the pt about their sustained emotion
affect: observed- - expression of emotion
57
Circumstantiality
thought disorder
overinclusion of trivial or irrelevant details that impede the sense of getting to the point
58
Clanging
thought disorder
thoughts that are associated by the sound of words rather than by their meaning (ex. through rhyming or assonance)
59
Derailment
thought disorder
loos associations - a breakdown in both the logical connection between ideas and the overall sense of goal-directedness. Words make sentences, but the sentences do not make sense
(how is this difference than word salad/incoherence?)
60
Flight of ideas
thought disorder
a succession of multiple associations so that thoughts seem to move abruptly from idea to idea; often expressed through rapid pressured speech
61
Neologism
thought disorder
the invention of new words or phrases or the use of conventional words in idiosyncratic ways
62
Perseveration
thought disorder
persistent repetition of specific words or concepts despite the absence of cessation of a stimulus; seen in cognitive d/o and schizophrenia
63
Tangentiality
thought disorder
in response to a questions, the pt gives a reply that is appropriate to the general topic without actually answering the question
64
Thought blocking
thought disorder
a sudden disruption of thought or a break in the flow of ideas
65
Word salad/incoherence
thought disorder
speech makes no sense at all. words joined, but do not convey a message
(how is this different that derailment?)
66
Pressured speech
thought disorder
fast and difficult to interrupt/understand; seen in bipolar-mania
67
Distractible speech
thought disorder
during the course of a discussion, pt changes subject in response to something unrelated in the environment
68
Thought form/process vs thought content
thought form/process: HOW their talking
thought content: WHAT they are thinking about
69
Thought content
WHAT they are thinking about
preoccupations (obsessions, phobias)
delusions
alogia (poverty of speech, poverty of thought)
70
Delusions
False, fixed personal beliefs that are not shared by others (seen in psychotic d/o)
```
Types:
Grandiose
Religious (special status with God)
Persecution (someone wants to cause them harm)
Erotomanic
Jealousy
Nihilistic (belief that self or part of self, others, or the world does not exist)
Thought broadcasting
Thought insertion
Thought withdrawal
Ideas of reference
Ideas of influence (someone is controlling an aspect of their behavior)
```
71
Illusions vs hallucinations
illusions: misperception or misinterpretation of REAL external sensory stimuli (seen in delirium and psychosis)
hallucinations: abnormal perceptions in which pt hears, sees, tastes, smells, or feels something that others can not. (seen in psychosis)
72
Insight vs judgment
Insight: ability of pt to understand and acknowledge factors that influence a situation; such as his/her illness
Greater the degree of insight, greater the potential for sound judgement
Judgement: assessment of real-life problem-solving skills
73
Factitious disorder
pt intentionally falsify medical or psychological signs or sxs in order to assume the role of a sick pt
the way they do this is often dangerous (central line infections, insulin injections)
the absence of external rewards is a prominent feature of this disorder
```
1% of hospitalized pts
W > M
higher incidence in health care workers
associated with personality disorders
many pts have a hx of illness and hospitalization, as well as childhood physical or sexual abuse
```
74
What is the DSM 5 criteria for factitious disorder?
falsification of physical or psychological signs or sxs or induction of injury or disease, associated with identified deception
the deceptive behavior is evident even in the absence of obvious external rewards (such as malingering)
behavior is not better explained by another mental disorder, such as delusional disorder
commonly feigned sxs:
psychiatric - hallucinations, depression
medical - fever, infection, hypoglycemia, abdominal pain, seizure, and hematuria
75
What is malingering?
intentional reporting of physical or psychological sxs in order to achieve personal gain
common external motivations include avoiding the police, receiving room and board, obtaining narcotics, and receiving monetary compensation
this is NOT considered a mental illness
M > W
76
What is the DSM criteria for intermittent explosive disorder?
recurrent behavioral outbursts resulting in verbal and/or physical aggression against people or property
either: frequent verbal/physical outbursts (that do not result in physical damage to people, animals, or property) twice weekly for 3 months
OR
rare (>/= 3x/year) outbursts resulting in psychical damage to others, animals, or property
outbursts and aggression are grossly out of proportion to the triggering event or stressor
77
What is the epidemiology of intermittent explosive disorder?
M > W
late childhood or early adolescence
may be episodic or progress in severity until middle age
genetic, perinatal, environmental
head trauma, seizures, hx of child abuse
low levels of 5HT in the CSF have been shown to be associated with impulsiveness and aggression
78
What is the treatment for intermittent explosive disorder?
SSRIs, anticonvulsants, or lithium
| CBT is effect in combo with meds
79
Kleptomania DSM criteria
failure to resist uncontrollable urges to steal objects that are not needed for personal use or monetary value
increasing tension immediately prior to theft
pleasure or relief is experienced while stealing; however, intense guilt and depression are often reported
80
What is the epidemiology and treatment of kleptomania?
W > M
4-24% of shoplifters
increase incidence of comorbid mood disorders, eating disorders (BN), anxiety, substance use, personality
illness usually begins in adolescence and is episodic
tx: CBT and SSRIs
(some evidence of naltrexone use)
81
Pyromania DSM
at least 2 episodes of deliberate fire setting
tension or arousal experienced before the act, and pleasure, gratification, or relief experienced when setting fires or witnessing/participating in their aftermath
fascination with, interest in, curiosity about, or attraction to fire and contexts
82
What is the epi and tx of pyromania?
M > W
most begin in adolescence or early adulthood
most don't get treatment and there is no real treatment
try CBT and SSRIs
83
What are some medical complications associated with anorexia?
```
bradycardia
orthostatic hypotension
arrhythmias
ATc prolongation
anemia
leukopenia
cognitive impairment
lanugo
muscle wasting
amenorrhea
loss of libido
```
purging: parotid enlargement, increase amylase, hypokalemia
84
Anorexia nervosa is commonly associated with what other psych disorder?
OCPD
85
What is the DSM criteria for AN?
restriction of energy intake relative to requirements, leading to significant low body weight - defined as less than minimally normal
intense fear of gaining weight or becoming fat, or persistent behaviors that prevent weight gain
disturbed body image, undue influence of weight or shape on self evaluation, or denial of the seriousness of the current low body weight
86
What is the epidemiology of AN?
10:1 F >M
13-14 yo (hormonal influence); 17-18 yo (environmental influences)
Exaggeration of social values (achievement, control, and perfectionism)
87
What is the DDx for AN?
Medical: endocrine disorders (hypothalamic disease, DM, hyperthyroidism), GI illness (IBD, malabsorption), genetic (Turner), cancer, AIDs
MDD, BN, somatic symptom disorder, schizophrenia
88
What is refeeding syndrome?
electrolyte and fluid shifts that occur when severely malnourished pts are refed too quickly
look for fluid retention (edema) and decrease levels of phosphorus, magnesium, calcium
complications: arrhythmia, respiratory failure, delirium, seizure
89
What 3 electrolytes are commonly low in refeeding syndrome?
phosphorus, magnesium, calcium
90
What is the course and prognosis for AN?
chronic and relapsing
most remit within 5 years
Mortality rate is cumulative and approximately 5% per decade d/t starvation, SUICIDE, or cardiac failure
91
What is the treatment for AN?
FOOD
pts may be treated as outpt as long as their body weight isn't too dangerously low or if there are serious medical or psych complications
CBT, family therapy (Maudsley), observed weight gain\
SSRIs can NOT be used in anorexia d/t the need for protein building blocks for SSRIs to be effective, that doesn't exist when someone is under weight
92
Who is more likely to seek help, AN or BN?
BN d/t their sxs being more ego-dystonic (distressing)
93
What is the DSM criteria for BN?
recurrent episodes of binge eating
recurrent, inappropriate attempts to compensate for overeating and prevent weight gain (such as laxatives, vomiting, diuretics, fasting, excessive exercise)
binge eating and compensatory behaviors occur at least 1 time per week for 3 months
perception of self-worth is excessively influenced by body weight and shape
94
What are some possible signs and sxs of BN?
Sialadenosis (salivary gland enlargement), dental erosions, callouses/abrasions on dorsum of hand (Russell's sign) petechiae, peripheral edema
```
hypochloremic, hypokalemic alkalosis
metabolic acidosis (laxative use)
elevated bicarb (compensation)
increased BUN and amylase
hypernatremia
```
95
How do cortisol levels differ between pts with AN vs BN?
cortisol is typically elevated in AN pt and normal in Bn pts
96
Which has a better prognosis, AN or BN?
BN
97
What is the prognosis of BN?
50% recover fully
| 50% have chronic course with fluctuating sxs
98
What is the treatment for BN?
antidepressants + therapy (more effective combo in BN and AN)
SSRI- first line
Fluoxetine is the only FDA approved medication for bulimia
AVOID bupropion d/t potential for lower seizure threshold
99
What is Binge eating disorder?
pts who suffer emotional distress over their binge eating, but they do not try to control their weight by purging or restricting
not fixated on their body shape and weight
100
What is the DSM criteria for binge eating disorder?
recurrent episodes or binge eating (eating an excessive amount of food in a 2hour period associated with lack of control), with at least three of the following:
eating very rapidly
eating until uncomfortably full
eating large amounts when not hungry
eating alone d/ embarrassment
feeling disgusted/depressed/guilty after eating
severe distress over binge eating
binge eating occurs at least once a week for 3 months
101
What are the most common medical complications of pts with binge eating disorder?
typically they're obese
metabolic syndrome
type 2 DM
CV disease
102
What is the treatment for binge eating disorder?
CBT with strict diet and exercise program
not commonly used but there are certain meds that suppress appetite:
stimulants (phentermine and amphetamine)
antiepileptics (topiramate and zonisimide)
103
Anhedonia
inability to feel pleasure
104
Catatonia
waxy
move the pt and they stay that way
MC in depressive mood disorders
105
Mood Disorders
Can be classified with:
Psychotic features
Cataonic features
Postpartum onset - within 4 weeks of onset of childbirth
106
What is the peak age of onset for MDD?
30-40 yo
another smaller peak at 50-60 yo
107
When does seasonal affective disorder typically resolve?
spring
108
What does it mean to have major depression with psychotic features?
delusions or hallucinations are present
109
Melancholic depression
loss of pleasure in most activities, nonreaction to pleasurable stimuli, worsening of sx in early morning hours, psychomotor retardation, excessive weight loss or guilt
responds best to TCAs or MAOIs
110
Atypical depression
when appetite and sleep are increased
111
What percentage of pts with MDD attempt suicide?
15%
112
What is the DSM 5 criteria for Major Depressive Episode?
5+ of the following sxs present nearly every day for at least 2 weeks (must have at least one of the first two listed below):
- depressed mood
- loss of interest or pleasure in most or all activities
- insomnia or hypersomnia
- change in appetite or weight gain
- psychomotor retardation or agitation
- low energy
- poor concentration
- thoughts of worthlessness or guilt
- recurrent thoughts about death or suicide
```
SIGECAPS
sleep
interest
guide
energy
concentration
appetite
psychmotor
suicide
```
113
What is the DSM 5 criteria for MDD?
at least one major depressive episode
| no h/o mania or hypomania
114
Dysthymia
a chronic, milder mood disturbance that has been present for at least 2 years
115
Adjustment disorder with depressed mood
occurs when identifiable psychosocial stressor(s) that has occurred within last 3 months - can be attributed to depressed mood
depressed mood resolves within 6 months after the stressor has ended
116
Personality
one's set of stable, predictable, emotional, and behavioral traits
117
Personality disorders
enduring patterns of inner experience and behavior that deviate markedly from expectations of an individuals culture
118
What is the DSM criteria for personality disorders?
Enduring pattern of behavior/inner experience that deviates from the person's culture and is manifested in two or more of the following ways:
-cognition
-affect
-interpersonal functioning
-impulse control
The pattern:
-is pervasive and inflexible in broad range of situations
-is stable and has an onset no later than adolescence or early adulthood
-leads to significant distress in functioning
-is not accounted for by another mental/medical illness or by use of a substance
Clusters A- C
119
Cluster A
Personality disorders
schizoid, schizotypal, and paranoid
-pts seem eccentric, peculiar, or withdrawn
-familial association with psychotic disorders
120
Cluster B
antisocial, borderline, histrionic, and narcissistic
- pts seem emotional, dramatic, or inconsistent
- familial association with mood disorders
121
Cluster C
avoidant, dependent, and obsessive-compulsive
- pts seem anxious or fearful
- familial association with anxiety disorders
122
Treatment for personality disorders
typically very difficult to treat -- because pts don't know they need help
psychotherapy is usually the most helpful
123
Cluster A is referred to as what?
eccentric
124
Paranoid Personality Disorder (PPD)
pervasive distrust and suspiciousness of others and often interpret motives and malevolent
tend to blame their own problems on others and seem angry and hostile
pathologically jealous
125
What is the DSM criteria for PDD?
diagnosis requires a general distrust of others, beginning by early adulthood and present in a variety of contexts
At least 4 of the following must be present:
-suspicion (without evidence) that others are exploiting or deceiving him or her
-preoccupation with doubts of loyalty or turstworthiness of friends
-reluctance to confidence in others
-interpretation of benign remarks as threatening or demeaning
-persistence of grudges
-perception of attacks on his or her character that is not apparent to others; quick to counterattack
-suspicions regarding fidelity of spouse or partner
126
Epidemiology of PDD?
M > W
| higher incidence in family members of schizophrenics
127
What is the treatment for PDD?
psychotherapy
group therapy should be AVOIDED
128
Schizoid personality disorder
prefer to be alone
social withdrawal
perceived as eccentric and reclusive
no desire for close relationships
129
What is the DSM criteria for schizoid personality disorder?
a pattern of voluntary social withdrawal and restricted range of emotional expression, beginning by early adulthood and present in a variety of contexts
4 or more of the following:
-neither enjoying nor desiring close relationships (including family)
-generally choosing solitary activities
-little (if any) interest in sexual activity with another person
-taking pleasure in few activities (if any)
-few close friends
-indifference to praise or criticism
-emotional coldness, detachment, or flattened affect
130
What is the treatment for schizoid personality disorder?
lack insight for individual psychotherapy, and may find group therapy threatening; may benefit from day programs or drop -in centers
antidepressants only if MDD comorbid
131
Schizotypal personality disorder
have a pervasive pattern of eccentric behavior and peculiar thought patterns
they are often perceived as strange or odd
the disorder was developed out of the observation that certain family traits predominate in first-degree relatives of those with schizophrenia
132
What is the DSM criteria for Schizotypal personality disorders?
a pattern of social deficits marked by eccentric behavior, cognitive or perceptual distortions, and discomfort with close relationships, beginning by early adulthood and present in a variety of contexts
5 or more of the following:
-ideas of reference (excluding delusions of reference)
-odd beliefs or magical thinking, inconsistent with cultural norms
-unusual perceptual experiences (such as bodily illusions)
-suspiciousness
-inappropriate or restricted affect
-odd thinking or speech (vague, stereotyped)
-excessive social anxiety
magical thinking may include:
-belief in clarivoyance or telepathy
-bizarre fantasies or preoccupations
-belief in superstitions
odd behaviors may include involvement in cults or strange religious practices
133
What is the treatment for schizotypal personality disorder?
psychotherapy - to help develop social skills training
134
A 30yo unemployed man has been accused of killing 3 senior citizens after robbing them. He is surprisingly charming in the interview. In his adolescence, he was arrested several times for stealing cars and assaulting other kids.
antisocial personality disorder
135
A 23 yo medical student attempted to cut her wrist because things did not work out with a man she had been dating over the past 3 weeks. She states that guys are jerks and "not worth her time." She often feels that she is "alone in this world"
borderline personality disorder
136
A 33yo scantily clad woman comes to your office complaining that her fever feels like "she is burning in hell." She vividly describes how the fever has affected her work as a teacher.
Histrionic personality disorder
137
What is the DSM criteria for antisocial personality disorder?
Pattern of disregard for and violation of the rights of others since 15.
Pts must be at least 18 yo for the dx; hx of behavior as a child/adolescent must be consistent with conduct disorder
3 of the follow must be present:
-failure to conform to social norms by committing unlawful acts
-deceitfulness/repeated by lying/manipulating others for personal gain
-impulsivity/failure to plan ahead
-irritability and aggressiveness/repeated fights or assaults
-recklessness and disregard for safety of self or others
-irresponsibility/failure to sustain work or honor financial obligations
-lack of remorse for actions
138
What is the treatment for antisocial personality disorder?
nothing really
jail maybe
psychotherapy is ineffective
pharmacotherapy only for anxiety and depression, caution d/t risk of abuse and addiction
139
Borderline personality disorder
cluster B
unstable moods, behaviors, and interpersonal relationships
they fear abandonment and have poorly formed identity
aggression is common
impulsive and hx of repeated suicide attempts
140
What is the DSM criteria for borderline personality disorder?
Pervasive pattern of impulsivity and unstable relationship, affects, self-image, and behaviors, present by early adulthood and in a variety of contexts.
At least 5 of the following:
-frantic efforts to avoid real or imagined abandonment
-unstable, intense interpersonal relationships
-unstable self image
-impulsivity in at least two potentially harmful ways (spending, sexual activity, substance use, binge eating)
-recurrent suicidal threats or attempts or self-mutilation
-unstable mood/affect
-chronic feelings of emptiness
-difficulty controlling anger
-transient, stress-related paranoid ideation or dissociative sxs
141
What is the treatment for borderline personality disorder?
psychotherapy (DBT - dialectical behavior therapy)
142
Histrionic personality disorder
attention seeking behavior and excessive emotionality
they are dramatic, flamboyant, and extroverted, but are unable to form long-lasting meaningful relationships
often sexually inappropriate and provocative
143
What is the DSM criteria for histrionic personality disorder?
Pattern of excessive emotionality and attention seeking, present by early adulthood and in a variety of contexts
at least 5 of the following
-uncomfortable when not the center of attention
-inappropriately seductive or provocative behavior
-rapidly shifting but shallow expression of emotion
-uses physical appearance to draw attention to self
-speech that is impressionistic and lacking in detail
-theatrical and exaggerated expression of emotion
-easily influenced by others or situations
-perceives relationships as more intimate than they actually are
144
What is the treatment for histrionic personality disorder?
psychotherapy (supportive, problem solving, interpersonal, group)
145
What defense mechanism is most commonly seen with histrionic personality disorder?
regression
146
Who is more functional, borderline or histrionic?
histrionic
borderline more likely to suffer from depression, brief psychotic episodes, and attempt suicide
147
Narcissistic personality disorder
cluster B
sense of superiority, a need for admiration, lack of empathy
they consider themselves "special" and will exploit others for their own gain. Despite their grandiosity, however, these pt often have fragile self-esteem
148
What is the DSM criteria for Narcissistic personality disorder?
Pattern of grandiosity, need for admiration, and lack of empathy beginning by early adulthood and present in a variety of contexts
5 or more of the following:
-exaggerated sense of self importance
-preoccupation with fantasies of unlimited money, success, brilliance,
-believes that he or she is "special" or unique and can associate only with other high-status individuals
-requires excessive admiration
-has a sense of entitlement
-takes advantage of others self gain
-lacks empathy
-envious of others or believes others are envious of him or her
-arrogant or haughty
149
What is the treatment for narcissistic personality disorder?
psychotherapy
150
A 30yo postal worker rarely goes out with her coworkers and often makes excuses when they ask her to join them because she is afraid they will not like her. She wishes to go out and meet new people but, according to her, she is too "shy"
Avoidant personality disorder (cluster C)
151
A 40yo man who lives with his parents has trouble deciding how to get his car fixed. He calls his father at work several times to ask very trivial things. He has been unemployed over the past 3 years.
Dependent personality disorder (Cluster C)
152
A 40yo secretary has been recently fired because of her inability to prepare some work projects in time. According to her, they were not in the right format and she had to revise them 6 times, which led to the delay. This has happened before but she feels that she is not given enough time.
OCPD (cluster C)
153
What is the DSM criteria for substance use disorders?
problematic pattern of substance use --> impairment or distress manifested by at least 2 of the following within a 12 month period (the criteria is the same regardless of the substance)
- using substance more than originally intended
- persistent desire or unsuccessful efforts to cut down on use
- significant time spent in obtaining, using, or recovering from substance
- craving to use substance
- failure to fulfill obligations at work, school, or home
- continued use despite social or interpersonal problems due to the substance use
- decrease social, occupational, or recreational activities because of substance use
- use in dangerous situations
- continued use despite subsequent physical or psychological problem
- tolerance
- withdrawal
154
Withdrawal
the development of a substance specific syndrome due to the cessation (or reduction) of substance use that has been heavy and prolonged
155
Tolerance
the need for increased amounts of the substance to achieve the desired effect or diminished effect if using the same amount of the substance
156
How long is cocaine positive in the system for?
urine drug screen 2-4d
157
How long is amphetamines positive in the system for?
urine for 1-3 days
158
PCP is positive in the system for how long?
urine for 4-7 days
| CPK and AST are also elevated
159
How long is marijuana positive in the system for?
after a single use, about 3 days
| heavy users, up to 4 weeks
160
How long are opioids positive in the system for?
1-3 days
161
What is the treatment for substance use disorders?
```
behavioral counseling
motivational intervention
CBT
group therapy
12 step groups like AA or NA
```
162
EtOH activates which receptors in the brain?
activates: GABA, DA, 5HT
inhibits: glutamate and VTCaC
163
How is alcohol metabolized?
alcohol --> acetaldehyde --> acetic acid
this occurs in the liver at the same rate (about 0.03/hr) regardless of tolerance (??)
164
EtOH can cause which type of acid-base imbalances?
metabolic acidosis with increase anion gap
165
What is the treatment for EtOH withdrawal?
Benzo taper
| Clordiazepoxide (Lirbrium) or lorazepam (ativan)
166
What are the signs and sxs of EtOH withdrawal syndrome?
insomnia, anxiety, hand tremor, irritability, anorexia, N/V autonomic hyperactivity (diaphoresis, tachycardia, HTN), psychmotor agitation, fever, seizures, hallucinations, and delirium
167
When do you see EtOH withdrawal syndrome?
between 6 and 24 hours after the pts last drink
generalized tonic-clonic seizures usually occur between 12 and 48 hours after cessation of drinking, with a peak around 12-24 hours
168
Delirium Tremens
medical emergency - the most serious form of EtOH withdrawal
usually begins 48-96 hours after the last drink but may occur later
while only 5% of pt who experience EtOH withdrawal develop DTs, there is roughly a 5% mortaility rate (35% if left untreated)
age >30 and prior DTs increased the risk
tx: Benzos (chlordiazepoxide, diazepam, lorazepam)
169
Confabulations in association with EtOH is seen where?
Korsakoff's "psychosis"
inventing stories - pts are unaware that they are "make these up"
170
What is the first line treatment for EtOH use disorder?
naltrexone
- opioid receptor blocker
- works by decreasing the desire/craving and "high" associated with EtOH
- in pts with physical opioid dependence, it will precipitate withdrawal
acamprosate (campral)
- thought to modulate glutamate transmission
- should be started post detox for relapse prevention in pt who have stopped drinking
- can be used in pts with liver dz
second line:
disulfiram (antabuse)
topiramate (topamax)
171
Wernicke's encephalopathy
caused by thiamine (vitamin B1) deficiency resulting from poor nutrition
acute and can be reversed with thiamine therapy
features: ataxia, confusion, ocular abnormalities (nystagmus, gaze palsies)
172
Korsakoff syndrome
progression of wernicke's encepahlopathy
chronic amnestic syndrome
reversible in only about 20% of pts
features: impaired recent memory, anterograde amnesia, compensatory confabulation (unconsciously making up answers when memory has failed)
173
What is cocaines effect on the brain?
blocks the reuptake of dopamine, epinephrine, and norepinephrine from the synaptic cleft, causing a stimulant effect
DA plays a role in the behavioral reinforcement system
174
Cocaine OD can cause death secondary to what?
cardiac arrhythmia, MI, seizure, or respiratory depression (d/t vasoconstrictive effect)
175
What does cocaine intoxication look like?
euphoria, heightened self-esteem, labile BP and HR, N/ DILATED pupils, weight loss, psychomotor agitation or depression, chills, sweating
176
What is the treatment of cocaine intoxication?
for mild-to-moderate agitation and anxiety: reassurance and benzos
for severe agitation or psychosis: antipyschotics (haloperidol)
177
What is the treatment for cocaine use disorder?
there is no FDA approved drug for cocaine dependence
| disulfiram, modafinil, topiramate are used off-lable
178
Cocaine withdrawal
NOT life threatening
produces post-intoxication depression ("crash")
with mild to moderate cocaine use, withdrawal sxs resolve within 72hrs
for heavy use: 1-2 weeks
179
What are the sxs of amphetamine abuse?
euphoria, DILATED pupils, increased libido, tachycardia, perspiration, grinding teeth, CP
180
What is the mechanism behind amphetamines?
block reuptake and facilitate release of DA and NE - stimulant effect
ex: Dextroamphetamine (dexedrine), methylphenidate (ritaline), methamphetamine (desoxyn, speed, crank, crystal meth)
181
When are amphetamines used medically?
ADHD
narcolepsy
occasionally depressive disorders
182
Ecstasy
considered a substituted or club or designed amphetamine
MDMA
releases DA, NE, and 5HT from nerve endings - stimulants and hallucinogenic properties
also: MDEA ("eve")
183
What is the DSM5 criteria for delirium?
Disturbance in attention and awareness
Disturbance in an additional cognitive domain
Develops acutely over hours to days, represents a change from baseline, and tends to fluctuate
Not better accounted for by another neurocognitive disorder
Not occurring during a coma
Evidence from hx, PE, or labs that disturbance is a direct consequence of another medical condition, substance intoxication/withdrawal, exposure to toxin, or d/t multiple etiologies
184
Why are benzos contraindicated in delirium?
Worsen delirium by causing paradoxical disinhibition or oversedation
185
What is the most common underlying etiology of major NCDs (Dementias)?
Alzheimers
186
Note about BBW of antipsychotics
Increased risk of death in pts with dementia
187
What is the treatment for alzheimers?
Cholinesterase inhibitors
Ex. Donepezil, rivastigmine, galantamine
NMDA antagonist
Ex. Memantine
188
Huntington’s Disease
Genetic disorder resulting from trinucleotide (CAG) repeats in the gene encoding the huntingtin (HTT) protein on chromosome 4
Autosomal dominant
Average age of dx is 40yo
Cognitive decline and behavioral changes can precede onset of motor signs for up to 15 years
Chorea: jerky, dance-like movements
Bradykinesia
189
What is the treatment for Huntington’s Disease?
Tetrabenazine
| Atypical antiphsycotics
190
Parkinson’s disease
Idiopathic, progressive neurodegenerative disease characterized by depletion of dopamine in the basal ganglia
Rigidity, resting tremor, bradykinesia, postural instability
Bradykinesia and tremor or rigidity MUST be present for dx
191
What is the treatment for parkinson’s disease?
Carbidopa-levodopa
| Dopamine agonists
192
Intellectual disability
Intellectual development disorder (instead of mental retardation)
Severely impaired cognitive and adaptive/social functioning
193
What is the DSM criteria for intellectual disability?
Deficits in intellectual functioning, such as reasoning, problem solving, planning, abstract thinking, judgment, and learning
Deficits in adaptive functioning, such as communication, social participation, and independent living
Onset during the developmental period
Intellectual deficits confirmed by clinical assessment and standardized intelligence testing
Adaptive functioning deficits require ongoing support for activities of daily life
194
What are causes of intellectual disability?
Down syndrome
Fragile X syndrome
TORCH infection (Toxoplasmosis, Other, Rubella, Cytomegalovirus, HSV)
Hypothyroidism, malnutrition, trauma
Anoxia at birth, premature birth, meningitis, hyperbilirubinemia
195
ADHD
Characterized by persistent inattention, hyperactivity, and impulsivity inconsistent with the pts developmental stage
There are 3 subcategories of ADHD:
Inattentive type, predominantly hyperactive, combined type
196
What is the DSM criteria for ADHD?
2 sxs domains: inattentiveness and hyperactivity/impulsivity
At least 6 inattentive sxs
-fails to give close attention to details or makes careless mistakes
-has difficulty sustaining attention
-does not appear to listen
-struggles to follow through on instructions
-has difficulty with organization
-avoids or dislikes tasks requiring a lot of thinking
-loses things
-easily distracted
-forgetful in daly activity
And/or
At least 6 hyperactivity/impulsivity sxs:
- fidgets with hands or feet or squirms in chair
- has difficulty remaining seated
- runs about to climbs excessively in childhood, extreme restlessness in adults
- difficulty engaging in activities quietly
- acts as if driven by a motor; may be an internal sensation in adults
- talks excessively
- blurts out answers before questions have been completed
- difficulty waiting or taking turns
- interrupts or intrudes upon others
Sxs >6months and present in 2 or more settings
Onset prior to the age of 12
197
What is the epidemiology of ADHD?
5% of children
2.5% of adults
M > F
Female more likely to have inattentive sxs
198
Autism is a umbrella term for what?
Asperger's
Childhood disintegrative disorder
pervasive developmental disorder
199
What is a red flag that should make you think Autism?
rapid decline of social and/or language in first 2 years of life
200
Who gets ASD and when?
autism spectrum disorder is seen more often in Males
typically 12-24 months
201
What are the genetic causes of ASD?
Rette's Syndrome
Down's Syndrome
Tubrerous sclerosis
Fragile X (MC cause)
associated with epilepsy
202
What is the DSM 5 criteria for ASD?
Problems with social interaction and communication
- impaired social/emotional reciprocity (inability to hold conversations)
- deficits in nonverbal communication skills (decrease eye contact)
- interpersonal/relational challenges (lack of interest in peers)
Restricted/repetitive patterns of behavior, interests, and activities
- intense, peculiar interest
- inflexible adherence to rituals
- stereotyped, repetitive motor
- hyper/hypoactivity to sensory input
abnormalities began in early development
203
What are the 6 cognitive domains?
```
Complex attention
executive function
learning and memory
language
perceptual-motor skills
social cognition (interaction)
```
204
What is the treatment for EPS?
benzotropine (Cogentin)
BB (akathisia)
amandtadine
diphenhydromine (acute dystonia)
205
What is EPS and what causes it?
extrapyramidal system
SE of typical antipsychotics
d/t blocking and depleting the DA in the basal ganglia
Dystonia (spastic retrocollis or torticollis)
Akathisia (motor restlessness)
Tardivedyskinesia
Parkinsonian
206
SAD PERSONS
risk factor for suicide
Sex: male
Age: >60yo
Depression
```
Previous attempts
EtOH/substance use
Rational thinking loss
Suicide in family (first degree relative)
Organized plan/access
No support
Sickness
```
207
Antidopaminergic effects
```
EPS
-parkinsonism
-askathisia
-dystonia
Hyperprlactinemia
```
208
Akathisia
subjective anxiety and restlessness
objective anxiety and restlessness, objective fidgetiness
pts may report a sensation of inability to sit still
best treated with BB and Benzos
209
Dystonia
sustained painful contraction of muscles of neck (torticollis)
tongue, eyes
it can be life threatening if it involves the airway or diaphragm
210
Tardive dyskinesia
choreoathetoid (writhering) movements of mouth and tongue that may occur in pts who have used neuroleptics for >6months
50% of cases are permanent
