Psych Flashcards
Domains of disorder in Mental life
- Behavior:
- Substance abuse, eating disorders, pathological gambling, non-adherence, negative symptoms - Emotion:
- Major depression, bipolar, anxiety disorders - Thinking:
- Process (loose associations, tangentiality): ex: speaking fluently about real things but listener unable to follow train of thought
- Content (delusions, overvalued ideas, distortions) - Perception:
- Hallucinations (hearing/seeing something that’s not there), illusions, depersonalization
Mental status exam
- Appearance and behavior
- hygiene, dress, alertness, level of cooperation, eye contact, psychomotor activity level, mannerisms, posture, gait - Speech:
- Rate, volume, clarity, stream, progression, prosidy, response latencies, pressured speech, language abnormalities - Mood: subjectively reported (direct quote/paraphrase)
- Affect: observed/objectively described
- Thought process
- Thought content
- Abnormal perceptions: hallucinations, visual, tactile, etc
- Abnormal ideas: delusions, suicidal/homicidal ideation - Cognitive capacities:
- Level of alertness
- Orientation
- Attention/concentration (tap to letters)
- General information/fund of knowledge (modify for educational level)
- Abstraction (proverb interpretation, similarities/contrasts)
- Judgement
- Insight
Affect
Bizarre= phenomenon culture views as implausaible
Jealous= one’s partner unfaithful
Erotomanic= delusion that another person (usually famous) is in love with individual
Grandiose= delusions of inflated worth, power, knowledge, special relationship to deity/famous person
Passivity= delusion that feelings/thoughts/impulses/actions are under control of external force
Referential= delusion that events/objects, other people have personal significance
Persecutory= Central theme of being attacked, harassed, cheated, conspired against
Somatic= delusion focused on bodily health/function
Systematized= “delusional world”
Hallucinations
Can present in any sensory modality:
- Auditory
- Gustatory
- Olfactory
- Tactile
- Visual
Pentaxial system of DSM-IV
Axis 1= majory psychiatric diagnosis
- Schizo, bipolar
Axis II= personality disoders, mental retardation
Axis III= general medical conditions
Axis IV= Psychosocial/environmental factors (stress)
- Social support, medical illness
- Grade stress as mild, mod, severe
Axis V= Global assessment of functioning (GAF); current, past 12 months
- Rated on scale 0-100
- 100= superior functioning, sought out by others due to positive qualities
- 80= transient/expectable reactions to stressors with no more than slight impairment
- 60= moderate symptoms, moderate difficulty in social functioning
- 50= serious symptoms/impairment
- 10= persistent danger to self/others, inability to maintain personal health, serious suicidal act with expectation of death
Prevalence of ADHD
3-7% in school-aged children
US/Worldwide prevalence is similar (5-12%)
Child psychiatric outpatient= 30-50%
Child inpatient= 40-70%
M:F in elementary children: 3-9:1 (Clinical)
2-3:1 in community
Girl:
- More likely to have inattentive type, comorbid anxiety, depression
- Less likely to have comorbid disruptive behaviors- less likely to receive treatment
Adults: 30-60% of cases persist
- 2-7% of all adults have residual ADHD
- M:F 1-2:1
- Males more likely to develop substance abuse, antisocial behavior
- Higher rates of MDD
- More frequent job, partner changes, money problems
- Girls/women- higher rates of unwed pregnancy
Diagnostic criteria of ADHD: inattention criteria
6+ of following symptoms for 6+ months, maladaptive/inconsistent with developmental level:
- Makes careless mistakes in school/work/other activities
- Difficulty sustaining attention
- Does not seem to listen when directly spoken to
- Does not follow through on instructions, fails to finish schoolwork/chores, work
- Difficulty organizing tasks/activities
- Avoids, dislikes, reluctant to engage in tasks requiring sustained mental effort
- Often loses things necessary for tasks
- Easily distracted by surroundings
- Often forgetful in daily activities
Diagnostic criteria of ADHD: hyperactivity/impulsivity
6+ of following symptoms for 6+ months, maladaptive/inconsistent with developmental level:
- Fidgets hands/feet
- Leaves seat when remaining seated is expected
- Runs/climbs excessively
- Difficulty in playing/engaging in leisure activity quietly
- Acts “on the go”, driven by motor
- Talks excessively
Impulsivity: - Blurts out answers before questions completed
- Difficulty awaiting turn
- Interrupts/intrudes on others
Additional criteria for ADHD diagnosis
Hyperactive-impulsive or inattentive symptoms causing impairment before age 7
Some impairment present in 2+ settings
Clinically significant impairment in social, academic, occupational functioning
Do not occur during course of pervasive developmental disorder (autistic spectrum), schizophrenia, other psychotic disorder (not better accounted for by another disorder)
Subtypes of ADHD
Three types:
- Combined= most common:
- Overactivity
- Impulsivity
- Distractibility - Predominently Hyperactive-impulsive type (v. young children)
- Predominantly inattentive type:
- Daydreamer/spacey
- comorbid anxiety, depression
- More likely to be overlooked (not overactive/impulsive)
Situational factors and symptoms of ADHD
Worsened in:
- situations needing sustained attention/mental effort
- Unstructured, boring, minimally supervised
Improved/absent:
- Highly structured/novel setting
- Engaged in stimulating activity (computer game)
- Alone with interested adult (doctor’s office)
ADHD symptoms in adults
- Difficulty organizing/prioritizing tasks
- Poor time management, procrastination
- Difficulty switching tasks
- Feeling overwhelmed by intense stimuli
- Starting too many projects at once
- Leaving projects unfinished
- Trouble listening to partners, friends, colleagues
- Irritability, rigidity, low frustration tolerance
- Appearing driven at work, keeping long work hours
- Road rage, multiple traffic violations
- Symptoms tend to decrease with age, may not be present in adolescents/adults
Comorbidities of ADHD
54-84% meet criteria for Oppositional Defiant Disorder
1/3 of patients with ADHD have mood/anxiety disorder
¼-1/3 have learning/language problems
Tourettes/mental retardation
Adults:
- MDD
- Dysthymia
- Bipolar disorder
- Anxiety disorder
- Substance abuse
Etiology of ADHD
Relative dysfunction of frontal cortex (heterogenous)
- Frontal cortex= planning, organization, focus, impulse control
- Genetic predominance
- Biological environmental insults
- School/home can influence severity, not presence
- Sugar/diet have not proved causes
Biological etiologies of ADHD
Multiple neurotrans systems involved: NE, DA activity in frontal cortex decreased
Anatomic imaging: differences in brain areas associated with executive functioning
- Decreased frontal cortex activation
- Smaller frontal lobe volume
- Different symmetry of caudate, smaller cerebellar vermis
Imaging only used to rule in/out suspected focal brain finding
Medical risk factors for ADHD
Prenatal: - Young mother, poor maternal health, cigarettes/alcohol, drugs Birth complications: - bleeding, hypoxia, toxemia, prolonged labor Perinatal: - Low birth weight, prematurity Infancy: - malnutrition, early deprivation Lead poisoning Brain injury Genetic disorders: - Fragile X, G6PD deficiency, TH resistance, phenylketonuria
Clinical diagnosis for ADHD
Clinical evaluation
- Interviews
- Standardized parent/teacher behavior ranking scales
No imaging/lab studies
Treatment response for ADHD
60-80% response rates
MTA study= psychostimulant medication
- 50% response in preschoolers
Treatment improvements:
- Motor control, social function with peers, attention, patience, task persistence, irritability, aggression, academic work quality, rule compliance, athletic performance
- Also linked to reduced adolescent substance abuse
Psychopharmacology of ADHD
Medication= primary treatment
Specific predictor of response not IDed, though predictive based on relatives’ response to meds
Many require continued medication into adulthood
Medications for ADHD
Psychostimulant meds= greatest effect size, first line = Methylphenidate (Ritalin, concerta) = Dexmethylphenidate (focalin) = Dextroamphetamine = Mixed amphetamine salts (Adderall)
Atomoxetine= NE reuptake inhibitor
- Second line, some evidence of efficacy
- Inhibits presynaptic NE importers
Alpha-2-adrenergic agonist meds (clonidine, Guanfacine): 3rd line
- Can also be used in comorbid tic disorder
- Good for overaroused children
Antidepressants= almost never used due to safety concerns in children/adolescents
- Bupropion= DA reuptake inhibitor
- Venlafazine= NE/Serotonin reuptake inhibitor
- Tricyclics= NE/Serotonin reuptake inhibitors (ONLY used in adults)
** All meds increase CNS dopaminergic, norepinephrine synapse levels
Fear
A cognitive process that leads to the conclusion that there is a threatening stimulus; a clear and present danger in the outside environment
Involves a pathway for activation of the adrenal cortex BEFORE threat is even identified
- It is the appraisal of danger
Anxiety
Feeling of arousal we experience when we perceive either concrete or abstract danger
This danger often exists in the form of a possible threat in the future
**remember: ALL fear activates anxiety, but not all anxiety comes from identifiable fear
Pathologic anxiety
“The fear of fear itself”
- recurrent and unexpected
- Panic - Specific, but viewed as excessive/unreasonable
- Phobias - Chronic worry in all spheres
* * interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities relationships
- all anxiety disorders
Theoretical/clinical orientations for Anxiety development
- Biological
- Born this way
- Baby who cries a lot, child who can’t have sleepovers
- “Anxious disposition” - Behavioral
- Developing fears after event (ex. having car accident makes one a nervous driver) - Cognitive
- Psychodynamic
- Relationship with parents, interactions with parents
Biologic theory of anxiety
Central noradrenergic system:
- Locus coeruleus is the major source of the brain’s adrenergic innervations
- Stimulation of the LC generates panic
Limbic system:
- GABA neurons mediate general anxiety, worry, and vigilance
Serotonin systems (esp. raphe nuclei): - important modulators of the two systems outlined above
Cognitive behavioral model of anxiety
Behavioral: Anxiety is mistakenly paired
- Classical Conditioning: Neutral stimuli paired with noxious responses
- Stimulus Generalization
Cognitive: Anxiety is “disordered thought”
- catastrophic interpretations of events/symptoms
- hypersensitive alarm system
- impaired objectivity and “mislabeling”
- loss of voluntary control
- dichotomous thinking
- fortune telling without evidence
Anxiety disorders in DSM IV
9: PASS GO, PA
- Panic D/O with or without Agoraphobia
- Agoraphobia without Panic D/O
- Specific Phobia
- Social Phobia
- Generalized Anxiety Disorder
- Obsessive Compulsive Disorder
- Post Traumatic Stress Disorder
- Acute Stress Disorder
3 “other” diagnoses:
- Anxiety due to general medical condition
- Substance-induced anxiety disorder
- Anxiety disorder not otherwise specified
Panic disorder
“A discrete period in which there is the sudden onset of intense apprehension, fearfulness, or terror, often associated with feelings of impending doom. During these attacks, symptoms such as SOB, palpitations, CP, choking or smothering sensations, and fear of ‘going crazy’ or losing control are present.”
- Recurrent, UNEXPECTED attacks are required for diagnosis
- Agoraphobia may or may not be present
Onset: Most frequently in the third decade of life within 6 months of a major stressful life event.
Course: Within 2 months of first attack, symptoms intensify and become more frequent. Usually symptoms are chronic and unremitting
Prevalence: Studies vary, but lifetime prevalence likely 2% or more
- Often patients develop secondary depression (can’t predict, disabling)
Agoraphobia
Essentially a fear of situations in which one might feel trapped
Most commonly develops in patients who are already experiencing panic attacks
Like panic disorder, usually chronic and unremitting
** Doesn’t have to occur simultaneously with panic d/o
Social phobia
Marked and persistent fear of social or performance situations in which embarrassment may occur
Exposure to the situation almost invariably provokes an immediate anxiety response
Patient recognized fear is excessive or unreasonable
Most often, the situation is avoided, although it is sometimes endured with dread
- “Unlike agoraphobics, social phobics fear scrutiny rather than the crowd itself.”
Onset: Late childhood thru early adulthood
Course: Chronic; often with pervasively impaired functioning
Prevalence: unclear, perhaps as high a 5% lifetime prevalence, with female preponderance
Specific (simple) phobia
Persistent fear of specified stimulus other than panic, entrapment, or social criticism
Most common anxiety disorder
- 10% lifetime prevalence
Generalized anxiety disorder
Characterized by excessive anxiety and worry, occurring frequently and chronically, about numerous events or activities
The worry is difficult to control, and accompanied with some emotional or physical symptoms
The individual DOES NOT ALWAYS identify the worry as excessive, but DOES recognize subjective distress
Obsessive Compulsive Disorder
Obsessions are persistent ideas, thoughts, impulses, or images.
Obsessions are experienced as intrusive and inappropriate and cause marked anxiety or distress. Attempts to resist them fail.
Compulsions are repetitive behaviors or mental acts, with a goal of preventing or reducing anxiety or distress (no pleasure).
Compulsions are either clearly excessive or not connected in a realistic way to what they are designed to neutralize or prevent
Post-traumatic stress disorder
Characteristic symptoms develop following exposure to an extreme traumatic stressor
Response to stressor involves intense fear, helplessness or horror (passivity)
Symptoms include flashbacks, avoidance of associated stimuli, emotional numbing, and exaggerated startle response
Lifetime prevalence likely 10%
Anxiety disorder due to medical condition
A variety of medical conditions may cause anxiety symptoms
Usually endocrine, cardiovascular, respiratory, metabolic, or neurological
- ex: hyperthyroidism, pheochromocytoma
Some medical work up is indicated in the assessment of every patient with new-onset anxiety
Substance-induced anxiety disorder
Anxiety symptoms are judged to be due to the direct physiological effects of a substance (intoxication OR withdraw)
Not just alcohol and “street drugs” (think about medications, toxin exposures, caffeine, etc.)
Considering substance-induced anxiety is necessary in the assessment of every patient with new-onset anxiety
Pharmacotherapy for anxiety disorders
SSRI= First line for:
- Generalized Anxiety D/O,
- Panic D/O with and without Agoraphobia,
- Social Anxiety D/O.
SSRI’s also used in PTSD and OCD (rarely effective as monotherapy)
- Citalopram
- Escitalopram
- Fluoxetine
- Sertraline
- Fluvoxamine
- Paroxetine
- Mirtazapine
- Buspirone
- SNRIs (Duloxetine, Venlafaxine)
- Benzodiazepines
- Used to treat symptoms in variety of anxiety disorders
- Bridge therapeutic efficacy in GAD, panic d/o, social phobia (SSRIs take weeks to build up effectiveness)
- Can be used as needed in phobia (ex: infrequent flier)
- Should be avoided in PTSD
OCD:
- SSRIs + behavioral therapy
PTSD:
- SSRIs + EMDR (eye movement control), CBT, psychotherapy, behavioral therapy
** May need to use other pscyhopharmacology for PTSD, OCD
Psychotherapy for anxiety disorder
Numerous psychotherapeutic approaches used to treat anxiety disorders.
Includes psychodynamic, interpersonal, supportive, cognitive-behavioral
** Psychotherapy alone can be used to treat most anxiety disorders (CBT has most data)
Psychotherapy + Pharmacotherapy
- Best for PTSD
- Best for most anxiety d/o
Cognitive behavioral therapy
Best studied, manualized (not as idiosyncratic as pscyhotherapy)
Behavior therapy
NOT CBT
- Involves exposure to feared stimulus, desensitization
- Various forms useful in OCD, phobias, PTSD (exposed to detailed recall of traumatic events)
Psychosis
A state of mind in which a person loses the ability to distinguish what is real from what is not. There is a breakdown in processing what comes from within the brain, and what is derived from the senses. External events become invested with meaning derived from one’s inner life.
Syndrome:
- Delusions
- Hallucinations
- Disorganized speech/behavior
- Impaired reality testing
- NOT a specific disorder itself
Hallucinations
Perceptions in the absence of real stimulus.
- In schizophrenia they are generally auditory (most common) or visual (25%).
Delusions
Fixed, false ideas or beliefs that society does not accept
- Often are paranoid or persecutory in nature.
- Can also be bizarre, somatic, grandiose or referential.
In schizophrenia a patient may have the delusion that their thoughts are being broadcasted or thoughts are inserted or withdrawn from their mind.
- In schizophrenia these can be paranoid and persecutory;
- generally bizarre and implausible (e.g. patient’s belief that aliens have implanted computer chips inside of their abdomen and can read their thoughts).
- Grandiose
- Erotomanic
** vs Delusional disorder where delusions are theoretically possible (e.g. patient’s belief that the government is tapping all of their phone calls).
Formal thought disorder
Disturbances in thinking that make ideas difficult to follow.
- This is a disturbance of process (vs. content) of thinking.
- Connections between the patients ideas may not be readily apparent.
- Examples include loosening of associations, clanging, neologisms, tangential, circumstantial and thought blocking
- NOT due to lesion (responds to antipsychotics, vs Wernicke’s)
Positive symptoms
Symptoms seen in schizophrenia. They include hallucinations, delusions, agitation, anxiety and peculiar behaviors and rituals.
These are called positive symptoms as they are symptoms which have been “added” on to normal mental life
Negative symptoms
Symptoms seen in schizophrenia. These include social isolations, blunted affect (decreased emotional states), paucity of speech/thought, poor self-care and disorganization.
These are called negative symptoms as the patient has a decrease/removal of normal behavior; i.e., these are “lost” from mental life vs. positive symptoms that are “added” to mental life.
- Most detrimental aspect of Schizophrenia
Examples:
- Avolition (no desire to do anything)
- Anhedonia (derives no pleasure)
- Affective flattening
- Alogia (paucity of speech)
- Asociality
Epidemiology of Schizophrenia
1% of population (2.2 millionAmericans)
- 1/3-1/2 of all homeless
- 10% of inmates have Schizophrenia, bipolar, or depression (4x greater than in hospitals)
- 10-15% employed full-time
- 50% on disability ($1100 a month)
Men and women equally affected
- Onset earlier in men (15-25)
- Women “catch up” by age 35, tend to have better outcomes
Patients die young (25 years earlier)
- 10% die from suicide
- 18-55% attempt suicide
- Patients do not access care
Diagnosis of Schizophrenia
Onset= adolescence or early adulthood
- First break in Freshman/Sophomore year of college
Course of Illness:
- Prodromal phase in 50%
- Outgoing person–> shy, reclusive, preoccupied with vague/odd concepts
- Poor peer relationships, academic problems
- Weeks to months of gradual deterioration, social withdrawal - Psychotic phase:
- Lose touch with reality
- 20% without further symptoms
- 30% have further episodes with baseline functioning
- 30% have decreased functioning but managed with meds
- 30% have multiple repeat psychosis, may live in group home, homeless - Residual phase:
- Phase between psychotic episodes
- In touch with reality, significantly impaired
- Predominantly negative symptoms
- Deterioration
Prognostic factors
- Later onset= better prognosis
- Less exposure to changes in brain function in development - Acute better than Insidious
- High premorbid function= better
- Mood symptoms= better to see moods
- Respond better when they express moods (vs flat affect) - Predominantly positive symptoms better
- Strong social supports
- Women do better than men
- Adherence to meds
