Psych disorders Flashcards
SIGECAPS
symptoms of depression
Sleep Interest - anhedonia Guilt Energy Concentration Appetite Psychomotor slowing Suicide
5+ sx 2+ weeks
Must include depressed mood and anhedonia
risk of recurrent depressive episodes
20% ever
50% after 1st episode
80% after 2nd episode
suicide rate in depression
5%
melancholic depression
- severe
- not a reaction to outside events
- neurovegetative symptoms
- insomnia
- decreased appetite
- weight loss
tx:
- consider aggressive tx e.g. ECT sooner
atypical depression
- reactive mood - worse during sad events, better during happy events
- sensitivity to interpersonal rejection, even when not depressed
- increased appetite
- increased sleep
- sense of heavy legs - leading paralysis
tx:
- MAOIs
postpartum depression
d/t:
- hormone changes
- sleep deprivation
- stress of child rearing
tx:
- consider safety in breastfeeding
seasonal affective disorder
- worse in winter
- most likely linked to less sunlight
tx:
- bright light therapy
- meds, psychotherapy
dysthymia
aka persistant depressive disorder
- not episodic
- generally not as severe as depressive episode
- less likely to include psychomotor retardation, suicidality
HE'S 2 SAD - hopelessness - energy low - self-esteem low - sleep disruption - appetite changes - decision making impaired 2+ years
double depression
dysthymia punctuated by depressive episodes
DIG FAST
signs of mania
Distractibility Impulsivity Grandiosity Flight of ideas *Activity, goal-directed (energy, business) - necessary for diagnosis Sleep Talkativeness, pressured speech
elevated mood \+3 sx OR irritable mood \+4 sx
likelihood of mood episode following mania
> 90%
cyclothymia
hypomania
dysthymia
2+ years
mixed states
low mood, depressive symptoms
increased goal-directed activity
higher risk of suicide and risky behavior
diagnostic of and common in bipolar I
frequency of psychotic features in bipolar
> 50% lifetime
sx of addiction
Time 2 CUT DOWN PAL
2+ must be present:
Time spent
Cravings
Unable to stop
Tolerance
Dangerous use
Others affected
Withdrawal
Neglecting roles
Physical/psych problems
Activities
Larger amounts or for Longer
3 Reapers
All 3 features must be present for a dx of addiction:
- REPeated use
- Positive REinforcement
- negative REPercussions
passive SI
thoughts about being dead or wishing to be dead
active SI
thoughts about killing oneself
stages of suicidal ideation
- passive SI
- active SI
- contemplation of methods
- intent
- plan
- preparatory behaviors
- suicidal behaviors/attempt
positive sx schizo
HD BS Hallucinations - mostly auditory Delusions Behavior (disorganized) Speech (disorganized)
negative sx schizo
5 A’s
Affect flat Ambivalence (difficulty making decisions) Alogia (struggling with speech) Anhedonia Asociality
dx schizophrenia
2+ positive and/or negative sx
6+ months
brief psychotic disorder
schizo symptoms x1 mo
1/3 chance of progression to schizophrenia
schizophreniform disorder
schizo sx x2-6 mo
2/3 chance of schizophrenia
delusional disorder
- persistent, fixed beliefs
- similar delusions to schizo
- without other positive or negative symptoms
- often lead mostly normal lives and may be perceived as normal except when talking about delusions
tx:
- rx not generally helpful
- CBT often does not change the delusions but can help to control negative effects by teaching when it is socially appropriate to talk about them
schizoaffective disorder
- mood disorder + schizophrenia
- psychotic sx must be present during both mood episode and euthymic episode (at least 1 of each)
- may be bipolar type or depressive type
- must not be attributable to substance use
HATS
Half or more of time ill must be spent with mood sx
Alone (psychotic –mood)
Together (psychotic +mood)
Substances absent
mood sx in excess of those typically seen in schizo, e.g. anhedonia, flat affect - must have explicitly depressed or manic mood
ddx:
- mood disorder w/ psychotic fx
- substance-induced psychotic disorder
- regular schizophrenia
- BPD
- bipolar w/o psychotic fx
- – grandiosity (bipolar) –> delusion (schizophrenia)
- – flight of ideas –> thought disorganization
- – similar tx for these symptoms + wait and see which becomes more prominent (mood or delusions)
mood disorder w/ psychotic features
- psychotic symptoms only during mood episode
- may be bipolar type or depressive type
substance-induced psychotic disorder
- psychotic ± mood sx due to substance use
common culprits:
- meth
- cannabis
- hallucinogens
borderline personality disorder
- extreme mood swings (100%)
- paranoia or psychosis (25-50%)
- fear of abandonment, unstable relationships
- unstable sense of identity
- impulsivity
- explosive anger
- self destructive behavior, self harm
- feelings of emptiness
vs schizoaffective:
- rapid minute-to-minute or hour-to-hour mood swings (BPD) vs months to yrs cycles (schizoaffective)
- transient, vague paranoia and psychosis (BPD) vs fixed, persisting beliefs
- auditory hallucinations (if present) coming from inside head, vague or unclear what they’re saying vs coming from outside head, distinct words, multiple voices, taunting
acute anxiety
STUDENTS Fear C’s
anxiety attack
Sweating Trembling Unsteadiness or dizziness Dissociation Elevated hr Nausea Tingling SOB Fear of dying, losing control, or going crazy Chest pain Chills Choking
chronic anxiety
MISERABLE
± somatic complaints
+ ruminative thoughts
Muscle tension Irritability Sleep difficulty Energy decreased Restlessness Attention decreased Believing the worst Lability Eating changes
demographic anxiety
30% overall lifetime risk
F>M 2x
begin <25 y/o
persistent, non-episodic but has periods of waxing and waning
tends to become more stable/less clinically significant after age 55
tx anxiety
CBT is first line
meds more sparingly - less effective (SSRIs, buspirone)
benzos for panic attacks, but chronic use worsens long-term outcomes
GAD
EGADS! I’m MISERA-ble
Excessive Generalized - affects/concerns many domains of life Anxiety Days (most) Six or more months
and 3+ of: Muscle tension Irritability Sleep difficulty Energy decreased Restlessness Attention decreased
panic attacks
STUDENTS Fear C’s
a lot of people will have one or a few in their lifetime, doesn’t always rise to the level of panic disorder
panic disorder
SURP-rise
Sudden
Unexpectid
Recurrent
Panic attacks
rising to the level of
excessive and dysfunctional anxiety
agoraphobia
fear of leaving house
25% of those w/ panic attack d/t fear of having panic attack in public
specific phobia
significant extra effort to avoid stimulus
tx:
exposure therapy (uncomfortable but not overwhelmed)
rarely rx
social anxiety disorder
anxiety specific to fear of rejection or humiliation in social situation
10% of people
≠ shyness
CBT (± SSRIs)
OCD
- obsessions: specific thought process/ruminations
- compulsions: specific actions taken to reduce anxiety associated with obsessions
- disorder: rises to level of significant impairment/interference with life
cyclical reinforcement
obsessions
I MURDER?
Intrusive - sudden, no warning
Mind-based - recognized as internal - not hallucination
Unwanted
Resistant - hard to make them go away
Distressing
Ego-dystonic - not reflective of true desires
*Recurrent
compulsions
neutralizing behaviors that calm obsessions
don’t work for long - vicious cycle
- minimal satisfaction once error is fixed, action repeated even when unnecessary
often reinforce obsession
demographic OCD
1% prevalence 3% lifetime F = M typical onset childhood or adolescence, almost all by age 30 range in disability
tx OCD
first line: CBD/ERP
(exposure response therapy)
rx:
- 2nd line: SSRIs (high dose)
- clomipramine - gold standard but 3rd line d/t strength, sfx
BDD
body dysmorphic disorder
Fix ME DOC
Fixation on perceived deformity
Medical care - e.g. excessive plastic surgery, weight loss
Ego-syntonic - don’t recognize thought as a problem (vs dystonic where they know intrusive thought is not what they actually want/actually true)
Disabling - time spent correcting or hiding
Obsessions - I MURDR (intrusive, mind-based, resistant, distressing, recurrent)
Compulsions - body checking, mirror checking, excessive grooming, seeking validation/reassurance, hiding, plastic surgery
BDD demographics
1-2% prevalence
~10% in derm clinics
~30% in plastic surgery
F (too large) = M (too small)
typically starts around puberty
tx BDD
CBT > SSRIs
difficult to engage pts in tx since it is ego-syntonic
anorexia nervosa
UNDER-rexia
Underweight* <17.5 Nervous about weight Distorted perceptions Excessive exercise Restricting calories
medical sx:
- fatigue/cognitive changes
- amenorrhea
- cardiac abnormalities
- electrolyte abnormalities
- anemia
- nutrient deficiencies
- –> damage to essential organ systems
often associated with OCD, except ego-syntonic
more accurately associated with OCPD (personality disorder), which is ego-syntonic, has higher comorbidity, high conscientiousness, and rigid behaviors
anorexia nervosa demographics
<0.5%
F > M 10x
usually by 18 years
associated with environmental factors such as:
- participation in thin-centric activities (ballet, modeling, wrestling)
- parental or peer pressure
anorexia nervosa prognosis
deadliest mental illness: 20%
moderate suicide rates
medical comorbidities
but highly variable prognosis based on severity
anorexia nervosa tx
feeding - often forced feeding tx of medical complications therapy - especially family therapy no rx shown to benefit pts often reluctant to participate
bulimia nervosa
BOWL-emia
Binge eating
Offsetting (purging) - vomiting, laxatives
Weekly - 1x/week for 3 mo
Linked to self-esteem
- not as much BDD or OCD behaviors
- still distressed if perceived to be overweight
- more sensitivity to interpersonal rejection, poor self-esteem, fear of being alone
- closer to BPD
medical complications:
- teeth erosion
- kidney damage (dehydrations)
- K+ low
- metabolic alkalosis
- hormone changes
- boerhaave syndrome - esophagus damage from vomiting
- often damage to knuckles from self-induced vomiting
bulimia nervosa demographics
~1% adolescence or early adulthood F>M 10x in BPD: >50% often normal weight or potentially overweight
bulimia nervosa prognosis
highly variable
some self-recover, others require extensive tx
lower mortality rate and medical complications than anorexia
@10 years from dx:
- 50% full recovery
- 30-40% partial recovery
- 10-20% insignificant change
bulimia nervosa tx
CBT/IPT > SSRIs
generally both used
do not use bupropion - electrolyte changes –> seizures
binge eating disorder
similar to bulimia but no purging
M=F
often significantly overweight
better prognosis
BPD associated
CBT/IPT and SSRIs
avoidant/restrictive food intake disorder (ARFID)
highly selective about food intake or calorie restriction
not generally linked to BDD/fear of weight gain
instead
- chronically low appetite
- strong food aversions - color, appearance, texture, smell
- fear of consequences (not weight) e.g. vomiting, constipation, choking - often d/t history
medically can be as significant as anorexia, including extreme weight loss
ARFID demographics
limited studies
~0.2%
5-6 years at onset
ARFID tx
CBT
exposure/reward therapy
PTSD
TRAUMA
Traumatic event - violent, life-threatening - ~50% in intentional trauma, <10% in accidental
Re-experience - flashbacks - visual, auditory, sensory
Nightmares - usually related directly to trauma
Arousal - most of time and most settings (MISER-able)
Unable to function
Month or more - not necessarily 1st month
Avoidance - including emotional avoidance such as numbing
Have you experienced trauma?
Does it interfere with your life?
–> if yes, ask further questions to determine specific dx
PTSD demographics
3% prevalence 10% lifetime F>M 2x rarely <10 or >55, but highly variable age nature of trauma characteristics of person social support
PTSD prognosis
intentional trauma
- often does not improve, may get worse
unintentional
- usually improves with time
PTSD tx
CBT
exposure therapy
rx:
- SSRIs (2nd line)
- prazosin for nightmares
- avoid benzos d/t worse long term outcomes
Prazosin
Therapy
SSRIs
acute stress disorder
<1 month
meets all other PTSD criteria
may or may not progress to PTSD
trauma-related disorders
Personality
Trauma-related, other
Somatoform
Dissociative
especially chronic trauma
complex PTSD
PTSD+
emotion dysregulation
negative self-concept
interpersonal difficulties
avoidance or withdrawal from relationships
stable sense of self, but negative
generally no suicidality or tendency to self-harm
more resistant to tx than regular PTSD
CBT/IPT > SSRIs
adjustment disorder
depressive/anxious sx
+ recent major life stressor
<5/9 sx of clinical depression
does not meet criteria for anxiety disorder
distressing event, not a life-threatening trauma
lesser severity
“diagnosis of normalcy”
allows pt to access care
dissociation
detachment from reality
- feeling of reality vs psychosis = inability to tell reality from experiences
DDREAMS
Depersonalization - “indescribable” feeling
Derealization- world seems fake or alien, unsteady or uneasy
Retrograde amnesia - previous memories lost
Errors of commission - false memories of things that haven’t happened - rarer than omission
Absorption in imagination/own thoughts
Motor automaticity
Suggestibility - easily believe what others tell them
especially common following trauma
normal if not intense & often
dissociation demographics
1-3%
young adulthood
pathological: F>M 10%
non-pathological: F=M
dissociation prognosis
highly disabling often comorbid - personality disorders - substance use - depression - anxiety - physical
dissociation tx
tx comorbid conditions
no real consensus on treating dissociation itself
- CBT
- DBT
- supportive
- hypnosis
- art
- experiential
- education
*long term
often dissociative sx resolve eventually on their own (years) but comorbid conditions persist
avoid meds, generally don’t help
dissociative amnesia
retrograde amnesia
gaps in chronological memory
disorder = weeks or months
fugue state
r/o other causes of memory loss
most often localized = trouble recalling traumatic event
can be generalized = any of past
systematized, continuous
depersonalization-derealization disorder
either/or
1/2 persistent, 1/2 episodic
some spontaneous, some specific triggers including cannibis, hallucinogens
unpleasant, impairing
often affects work, home-life
covert dissociative identity disorders
by far most common form of DID
alters
- sensation of different identities
- not literal presence (despite most popular depictions)
affective lability memory errors inconsistent sense of self - sudden and dramatic shifts in way they perceive, think and feel - self-aware - know it's weird - certain characteristics of a different person - disorientation - powerless to understand - minutes to hours - repeated episodes
ongoing distress and disability
comorbidities
no good tx
underdiagnosed by most, over by some
overt DID
very rare - covert DID much more common (and is still rare)
outright assume > 2 distinct identities
talk and act differently completely take over body and mind not always aware forget portions of day -- may escalate to fugue potentially endangering - self-mutilation - suicide 75%
somatic symptom disorder
genuinely experience medically unexplained sx
distressing
SOME ATTIC
Somatic sx - any body system, most often GI, in women gyn One or more Medically unexplained Excessive Anxiety Thinking about Time and energy spent Impairing Chronic
high risk for iatrogenic disorders
factitious disorder
aka Munchausen’s
knowingly fake somatic sx
generally for attention
possible intentional self-harm
also factitious disorder imposed by another
- child
FRACK-titious
- failure of generally effective tx
- recurrent presentations
- atypical s/sx
- clingy/contentious
- knowledge of illness
malingering
knowingly face somatic or psych sx for external reward e.g. - settlement - favorable sentencing - disability pay - work absence - excused from military service - drug-seeking - food and shelter in hospital
SHAM Secondary gain Holes/inconsistencies in pt's story Antisocial traits Missing tx not of direct benefit
open-ended questions
avoid suggestion of which sx are important
connect w/ resources better geared toward them if possible
illness anxiety disorder
hypochondriasis persistent belief that one has a medical disorder ± sx despite contradictory evidence OCD-spectrum
conversion disorder/functional neurologic disorder
genuinely experienced sx subset of somatic sx disorder involving neurological sx - weakness - numbness - blindness - seizures similar to dissociative disorders
CAN'T - genuinely can't do things they say they can't Clinically unexplained Abnormality Nervous system Trigger/trauma (~50%)
somatic symptom disorder demographics
most to all people will experience some somatized sx in their life
5% incidence
F>M 10x
<30 y/o
75% transient, stress-related
25% chronic
80% improve even w/o tx
20% worsening sx, increasing anxiety
somatic symptom disorder tx
I Do CARE
Interface - interact w/ all other providers Do no harm CBT Antidepressants < CBT Regular visits Empathy
illness anxiety disorder
aka hypochondriasis
OCD-spectrum
obsessed with idea that they have a disease, especially a specific one
- obsession not with symptoms, but any symptoms often support their obsession (e.g. all headaches must be a brain tumor)
some avoid medical care for fear of results, others seek excessive care
significant time researching disease
significant time with other self-dx such as checking for lumps etc.
never get feeling of knowing despite negative tests
iatrogenic harm
illness anxiety disorder demo
0.5%
M = F
illness anxiety disorder prognosis
generally persistent, not episodic
cyclically reinforcing, like OCD
illness anxiety disorder tx
CBT
SSRIs
low engagement rate d/t lack of self-awareness
functional neurologic disorder demo
~30% of all neuro patients
mostly adolescents and young adults
F>M 3-10x
functional neuro disorder prognosis
90% resolve w/in days to weeks
70% never have another episode
depression, anxiety, other problems even after disorder resolves
functional neuro disorder tx
education
wait to resolve
CBT and meds not helpful
dissociative disorders and functional neuro disorders
comorbid in 30-50% of cases
some evidence for linked pathology
overlapping demo, response to tx
disconnect b/w real and perceived experience
suggestibility/hypnotizability
frequently early life traumas
factitious disorder demo
0.1% generally, 1% hospital
30s
F>M 2x
often family member that has or had an illness
many work in medicine, most often nursing
factitious disorder px
poor prognosis d/t comorbidity w/ other psych disorders
high suicide rate
