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
factitious disorder tx
meds and CBT not helpful
confrontation generally not helpful
keep linked to care but do no harm, try to push toward psych, treat comorbidities
big 5 personality traits
consistent
reliable
OCEAN
Openness to new experiences
Conscientiousness - following societal expectations, rules, rigidity
Extroversion
Agreeableness - likelihood to agree with group, more suggestible
Neuroticism - more likely to experience negative emotions over positive
personality disorders
TIDE Traits become Inflexible Disabling Extreme
Cluster A
“weird”:
paranoid
schizoid
schizotypal
few shared underlying etiologies/pathologies - only superficial similarities
highest chance of misdx of paranoid disorders
Cluster B
"wild": borderline antisocial narcissistic histrionic
most similar in underlying etiologies/pathologies relative to other 2 clusters
- sense of unbalanced emotions
- extreme emotional states
- does not specifically fit one single mood disorder, but often comorbid
- poor self-image
Cluster C
“worried”
dependent
obsessive-compulsive
avoidant
few shared underlying etiologies/pathologies - only superficial similarities
personality disorders demo
10% worldwide
~30% psych
reluctant to dx b/f age 18, but early intervention and treatment is associated with best outcomes
personality disorders px
often levels off in severity over lifetime
major risk factor for failure of tx of comorbid conditions
personality disorders tx
CBT/DBT > meds
tx cormorbidities
paranoid personality disorder
mistrust of most people
unlikely to confide
social isolation but often don’t mind
extreme low agreeableness
paranoid disorders:
- generally one or a few fixed belief systems
paranoid personality disorders:
- jump between many paranoid beliefs, objects of paranoia (people)
schizoid personality disorder
asociality lack of interest in social relationships indifference to praise coldness/aloofness preference for alone time extreme low extroversion
schizotypal personality disorder
many weird ideas e.g. mystical, magical, or outright delusional
unusual perceptions such as hearing name called in empty room, but not outright hallucinations
loneliness and isolation d/t fear of (or actual) judgement, not disinterest
no direct link to OCEAN traits
many genetic links to schizophrenia
often pre-schizophrenia
Cluster B disorders by demo and level of impairment
Borderline - Antisocial
most impairing
Histrionic - Narcissistic
least impairing
Borderline - Histrionic
F>M
Antisocial - Narcissistic
M>F
BPD
chronic instability in most areas
I DESPAIR (5+/9)
Identity instability - follow the crowd, or narrowly defined by single interest
Dysphoria
Emotional instability - affective lability - mood swings w/in minutes - esp exacerbated around relationship troubles
Self-harm/chronic suicidality - cutting common in bpd, rare in other disorders
Psychotic/dissociative - transient, related to severe personal stress - generally related to others judging them etc rather than complex belief systems
Anger/hostility
Impulsivity
Relationships - unstable and short-lived (1) - rejection sensitivity (2)
BPD tx
DBT 1-2 yr b/f meaningful outcomes long waiting lists not often covered by insurance specific training required
DELAPSE Diagnose Educate Life outside tx; "work before love" Avoid meds - they don't help; do treat sx if needed, e.g. antipsychotics and antidepressants Prioritize - tx of bpd comes before other psych conditions except when immediate threat exists - improvements in others will follow Safety plan Expect change
antisocial pd
purposeful infringement on rights and safety as others
ACID LIAR (adult and 3+/7) Adult >18 Criminality Impulsivity Disregard for own and others' safety Lying/cheating/deceiving w/ or w/o purposeful gain Irresponsibility Aggression - purposeful and targeted Remorselessness - but remorse is sometimes present
consistent and repeated independent of circumstances
cluster B vs psychopathy
- cluster B - externalizing negative emotion, taking them out on others
- psychopathy - inability to empathize
ASPD tx
difficult
hard to get pts to engage
narcissistic pd
inflated sense of self
demand for admiration
fantasies of success or power
disregard for others emotions - but not safety per se
manipulation
prone to irritability esp d/t feedback, not being center of attention
relationship difficulties
underlying poor sense of insecurity, fear of being unloved
M>F
histrionic pd
excessive/exaggerated center of attention approval seductive/provocative dramatic/over the top emotions flashy dress/make up theatrical speech unstable affect suggestibility/peer pressure belief that relationships are more intimate than they actually are
desire to be loved unstable sense of identity poor self-image least impairing of cluster B no clear connection to childhood abuse
dependent pd
over reliance on others for most lings
extremely defferential in relationships
rarely remain on own
excessively high agreeableness
tx:
- maladaptive thought processes
- maladaptive relationship behaviors
OCPD
overly conscientious neat, controlled, orderly excessively rigid unable to delegate excessive perfectionism overreliance on checklists - to point of questioning essentialness of overall project inability to spend money on oneself unable to throw things out excessive religiosity in some cases ego-syntonic - reluctant to seek tx
tx:
- CBT
- IPD
avoidant pd
desire connection but shun companionship avoidance of social activities unwillingness to meet new people fear/avoidance of interpersonal relationships inhibited behavior in social situations poor self-image view selves as inept or unworthy of love reluctant to take risks or do anything potentially embarrassing
highly comorbid w/ social anxiety disorders
better conceptualized as severe social anxiety disorder than a personality disorder
tx:
SSRIs
CBT
bpd demo
5-10%
30% in psych
50% heritability
few symptoms from early in life e.g. impulsivity, emotional instability
most first meet full criteria by adolescence or young adulthood
can be dx before 18 y/o
must be stable for >1 year and above normal personality fluctuation
overdx in women
dx: 3xW>M
actual: W=M
bpd prognosis
50% remission at 2 years, 85% at 10 years even w/o tx (<5/9 criteria)
more extreme sx e.g. cutting, impulsivity, emotional instability tend to diminish with age
dysphoria, interpersonal trouble, occupational dysfunction tend to persist throughout life
cluster B ASPD
externalizing negative emotions
reactive violence
high neuroticism
when planned violence: “I need to look after myself b/c no one else will”
poor social skills
lack of executive functioning
lack of understanding of social rules
few acquaintances, no close friends
cluster B ASPD demo
~5% general population
~25% group homes
~50% jails/prisons
significant heritability
begin in adolescents
- generally first evident as conduct disorders: ODD, CD, IED, DMDD
M>F 5x
cluster B ASPD px
improve generally by 30s-40s
peak in adolescence and early adulthood
negative mood, addiction, occupational dysfunction, interpersonal dysfunction tend to persist
cluster B ASPD tx
no good tx - but does improve on its own with time
pts often difficult to engage
DBT and anticonvulsants may help w/ impulsivity
short incarcerations (<1 year) may reduce recidivism but longer will not
psychopathy/sociopathy
lack of emotional range
lack of empathy
subtype of ASPD
BDSM Boldness Disinhibition Shallowness Meanness
Boldness
- high self confidence
- tolerance for danger
- calmness in danger or when caught
Disinhibition
- instrumental violence
- impatience and need for immediate gratification
- more overtly violent behavior/more severe crimes
- criminal versatility
- substance use, but controlled
Shallowness
- lack of emotional range
- if any emotion is expressed, generally affective mimicry (not genuine underlying emotion)
- may be superficially charming, manipulative
- perpetual boredom and apathy
- lack of long-term goals –> more likely to engage in criminal behavior vs corporate progression/more conventional schemes
Meanness
- inability to feel emotions of others
- aggressive resource seeking
- empowerment through cruelty
psychopathy demo
0.5% general population
10% ASPD
15% prisons
30% violent prisoners
> 90% heritable
but environment still matters
M>F 20x
psychopathy progression thru life
often starts very early
babies:
- difficult temperament
- lack of social smile
- excessive crying
- hyperactivity
early childhood:
- mild physical aggression e.g.
- biting
- hitting
school age:
- setting fires
- stealing small items
- torturing animals
adolescence:
- bullying
- stealing larger objects e.g. cars
adult:
- major crimes e.g.
- robbery
- fraud
- assault
- rape
- murder
psychopathy px
poor
extreme violent acts such as rape and murder tend to decrease after young adulthood
core traits persist
psychopathy tx
very difficult to treat poor tx compliance no meds anticonvulsants not helpful as this only helps with reactive violence little engagement in therapy punishment doesn't seem to help
appearance of therapy success often associated with more recidivism likely b/c deceit
ODD
oppositional defiant disorder
argumentative
vindictive
outbursts/temper tantrums
rule-breaking
persistent anger and irritability (no waning b/w episodes)
consistent
intentional
less severe than conduct disorder: stops short of overt violence, aggression, theft
ODD demo
3% of children
6-8 yr
persist into adolescence
70% no sx as adult
M>F 2x
ODD tx
individual and family therapy
meds not helpful unless ADHD comorbid
CD
conduct disorder
overt violation of rights of others
persistent anger, irritability (no waning b/w episodes) consistent intentional more extreme/severe acts e.g.: - threats - violence - fire setting - property damage - robbery - sexual coercion
CD demo
1-2% of children
<10 yr
ODD –> CD fairly common
40% –> ASPD
M>F 3-4x
CD tx
individual and family tx
less beneficial than in ODD
meds not helpful except comorbidities
IED
intermittent explosive disorder
screaming
hitting
kicking
tantrums
discrete episodes <1h
reactionary but out of proportion to events
anger/irritability, wanes b/w episodes (not persistent)
episodic
reactive, not intentional
lower severity than CD or other premeditation
IED demo
5% children and adolescents
~13 yr average
M>F 2x
often lifelong but severity decreases w/ age
IED tx
individual and family tx
2nd line: SSRIs
DMDD
disruptive mood dysregulation disorder
similar to IED
- tantrums
- episodic
- reactive
- lower severity than CD
BUT
- persistent negative emotions
- anger, irritability, disruptive behaviors during outbursts
- irritability, sadness, anger between episodes
DMDD tx
individual and family tx
2nd line: SSRIs
externalizing disorders
behavioral disorders in children
externalization of negative emotion
CD - most severe - premeditated overt acts, persistent anger; ~40% –> ASPD
ODD - intentional, non-overtly violent acts, persistent anger
DMDD - episodic outbursts, reactive, persistent anger
IED - episodic outbursts, reactive, negative emotion wanes between episodes
considerations when dx externalizing disorders
use caution as relying on parental narrative rather than child’s in most cases
often a response to stressor, complex situations
hx of trauma, early life neglect
ADHD
most common: inattentive type (– hyperactivity)
persistent and inflexible sx, esp in inappropriate locations
- must be in at least 2 settings
dx of exclusion
- trauma
- hunger
- young compared to peers (e.g. youngest child in class)
FIDGETY Functionally impairing Impulsivity ± Distractibility Greater than normal Exclude other causes Two or more settings Young at onset (≤12)
inattentive sx ADHD
DETAILS OFF Details sloppy Easily distracted Task Avoidance Ignor instructions Lose things Sustained attention difficulty Organization lacking Forgetful Fail to finish tasks
hyperactivity sx ADHD
HE RILED UP Hyperactive Energetic Running around Interrupts Loud Effusive Delay intolerant Unseated Prematurely answers
ADHD demo
10% children 5% adults 2/3 inattentive 10% hyperactive 20% combined
75% heritable other risk fx e.g.: - in utero drug or alcohol exposure - poverty - cultural factors
3-8 y/o initial sx usually
M > F 2x
inattentive more common in F
2/3 persistent sx to adulthood
Hyperactivity usually improves
long-term outcomes related to education attainment, career performance, relationships, self-worth, etc.
ADHD tx
therapy - behavior and family training
rx: stimulants - methylphenidate - amphetamines non-stimulant - atomoxetine - guanfacine - clonidine - smaller effect size - generally reserved for when stimulants are c/i or add-on is needed
autism spectrum disorder
social communication difficulties restricted interests early development impairing exclude other causes
ASD
Aloneness
Sameness
Development
±:
- communication difficulties - verbal and nonverbal
- sensory hyper/hyposensitivity
- motor signs
- savantism
- intellectual disability
communication disorders in ASD
not required for dx but often present
delayed speech - often one of initial presenting signs
mutism
nonverbal communication
- body language
- facial expressions
- overly literal
- intonation
- context
implicit rules of social interaction
- greetings
- reciprocity
- turn-taking
- sharing
restricted interests ASD
“insistence upon sameness”
e. g.
- routines and distress when disrupted
- repetitive meals
- special interest - single subject, hobby, activity
- same movies, same games, etc.
- repetitive movements e.g. stimming, flapping
- fidget objects
- self-injurious behavior (banging head against wall)
sensory disturbance ASD
common but not required for dx
hyper and hyposensitivity
e.g. overstimulated by sounds and lights, sensitive to certain textures, smells, tastes
less sensitive to heat, pain
motor signs ASD
common but not required for dx
poor coordination weak muscle tone odd gait e.g. walking on tip-toes stimming flapping rocking
savantism ASD
somewhat common but not required for dx
>50% of savants have autism
some autistics have savantism - intellectual disability is more common
extremely high intelligence especially in one specific domain
- memory
- calculation
intellectual disability ASD
common but not required for dx
ASD demo
0.1 - 2% general population depending on dx criteria
spectrum of severity
highly heritable
2-3 first sx
sx often improve over lifespan - likely d/t compensatory tools
M>F 4x dx
likely underdx in women due to more subtle sx
risk fx:
- children of older fathers (?)
ASD tx
behavioral tx
- specific adaptive skills e.g. speaking, responding appropriately to others, recognizing emotions
family tx
- improve skills
- educate caregivers
tx:
- none for core features
- tx comorbidities
newborn psych milestones
primitive reflexes - rooting - gripping - toe curling (babinsky) - moro or startle (loud sounds) - galant (stroking lower back) hearing smelling seeing 20:600 - faces and objects w/ sharp contrast
infancy motor milestones
gross and fine motor dev
6 wk
- head control
- reaches for objects
4 mo
- rolling front to back
- grasping objects
6 mo
- sitting unattended
- rolling back to front
- transferring objects across midline
9 mo
- pull to stand
- refined pincer grasp (feeding)
12 mo
- starting to walk unattended
- pointing to objects
infancy language milestones
2-4 mo
- cooing
- orienting to voice
6 mo
- babbling
9 mo
- responds to name
9-10 mo
- mama and dada
12 mo
- following simple commands
- ≥1 word
infancy social-emotional milestones
2-3 mo
- responsive smile
6 mo
- sense of self
- attachment w/ caregiver
<9 mo
- stranger anxiety
9-10 mo
- separation anxiety
12 mo
- early empathy
infancy cognitive milestones
0-4 mo
- modify/regulate reflexes
4-8 mo
- meaningfully manipulate objects
~7mo
- attention span ~5 min
9 mo
* object permanence
9-12 mo
- goal-directed behaviors
toddlers motor milestones
15 mo
- crawl upstairs
- walk bckwards
18 mo
- walk stair w/ help
- run
- scribbling
24 mo
- kick ball
- tip toes
- clothing
30 mo
- jump
- tower of ~8 blocks - proper estimate is age in yr x3 (2.5 *3 = 8)
36
- alternate feet on stairs
- bridge of blocks
toddlers language milestones
18 mo
- 50-75 spontaneous words
24
- 50-200 words
- 2+ word phrases
36
- 300+ words
- 3+ word phrases
toddlers social milestones
18 mo
- peak of separation anxiety, persists to ~3-4 yr
24 mo
- rapprochement - moves away from and returns to parent
toddlers cognitive milestones
12-18 mo
- cause and effect
18-24 mo
- symbolic representation
- conceptualize body parts
24 mo
- start of simple concepts e.g. size, color, number
24+ mo
- focus 5-10 min on activity, w/ parental encouragement
24-36 mo
* parallel play (w/ other children)
preschool motor milestones
3
- broad jump
- gallop
- utensils
- hand preference - if hand preference is sooner explore pathology e.g. one-sided weakness
4
- hop on foot
- skip
5
- balance 10 sec on one foot
- print letters
preschool language milestones
3 yr
- 3 word phrases
- follow multi-step commands
- 75% intelligible
- use 300+ words
- understand 1000+ words
4 yr
- 4 word sentences
- follow multi-step commands
- ~100% intelligibility
<5 yr
- conversation
- recalling events
- using language to learn
- express feelings
- talk about past
- understand and use grammar
- improved intelligibility
preschool social milestones
3 yr
- know own age
- know gender
- imaginative play
- imaginary friends
- turn taking
- sharing
- toilet training
4 yr
- interactive small-group play
- pretend social scenarios
- role playing
4-5 yr
- simple board games
- rule following
preschool cog milestones
4 yr
- colors
4-5 yr
- complex body parts
5-6 yr
- abstract symbols e.g. letters and numbers
- -> reading (variable)
school age motor milestones
- refinement of coordination
- coordination for structured athletics
- coordination for fine arts
- cursive writing
- typing
school age language milestones
- inferences
- jokes
- sarcasm
- story telling
- complex narratives
- conversation
- reading
school age social milestones
- identity and self-esteem
- accomplishment - want to be “good”
- understand social rules, sportsmanship, morality
- increased importance of peer relationships
- best friend
- play segregated by gender
school age cognitive milestones
- “frontal lobe growth spurt”
- conservation of volume - perceive and understand multiple concepts at once
- reasoning
- classification
- mental rules
- time
- organization and sequential skills, e.g. homework
- active working memory
- attention span 0.5-1 hour
- emotional regulation
peripartum
pregnancy thru 4 week post-birth
matrescence
solidifying identity as a mother
normal state
involves a certain amount of discomfort and questioning identity
important to understand this baseline level of discomfort to distinguish from pathology e.g. postpartum depression
postpartum blues
not pathology (yet) - no fx impairments
~80% of women
peaks 4-5 days post delivery
spontaneous remission w/in 2 weeks d/t hormonal shift
sx:
- mood lability
- tearfulness
- anxiety
- irritability
- not necessarily sadness
MDD w/ peripartum onset
postpartum depression
15-20% frequency
during pro or w/in 4 wk after
SIGECAPS * anhedonia * low mood anxiety related to infant egodystonic intrusive thoughts e.g. hurting infant obsessions
peripartum MDD etiology and risk fx
d/t:
- high sensitivity to hormonal changes
risk fx:
- depressive sx in preg
- lack of partner support
- recent stressful life events
- personal hx of mood disorders
- personal hx of postpartum depression
- family hx of mood disorders
- COVID? maybe “just” isolation, health anxiety, shorter hospitalization around delivery
peripartum MDD tx
- r/o medical:
- postpartum thyroiditis
- anemia
- education, reassurance, and support
- CBT/IPT
- SSRIs
- crisis: hospitalization
postpartum pscyhosis
0.1%
emergency
4% rate of infanticide
most often 48-72 h post-delivery to 2 wk postpartum
r/o hx bipolar
sx: - dramatic presentation - restlessness - irritability - insomnia ± delusions ± auditory hallucination
postpartum psychosis tx
hospitalize
educate and reassure family
mood stabilizer - lithium - valproate - carbamazepine - lamotrigine antipsychotic
ECT in refractory cases
attachment relationship
quality of interaction b/w infant and caregiver
implications for relationships and dev thru lifespan
caregiver role:
- secure base: child supported to explore
- safe haven: child feel safe to return home after exploring
secure attachment
foundation of self esteem
separation distress, but consolable on return
caregiver sensitive and consistent response
child comfortable expressing range of emotions
child consolable
child learns to self-soothe
delirium
psych manifestation of another (usually somatic) illness
slower illness recovery
higher death rate
*impairment of memory and attention
Where THE F AM I? Where (disorientation) Thought disorganization Hallucinations - visual Energy changes - high or low Fluctuating - waxing and waning - vs dementia which is more stable Acute / transient Medical causes Intoxicants
delirium causes
PINCH ME Pain, poorly controlled Infections Nutrition Constipation Hydration Medications/rec drugs - benzos - opioids - diphenhydramine - steroids - alcohol intoxication AND withdrawal Endocrine
delirium demo
10-30% hospital
50-75% ICU
risk:
- older age
- M>F 2x
delirium px
delirium itself usually resolves w/in 1 week
but poor px indicator overall
- longer hospital stay
- higher M&M rate
delirium tx
U R SAFE Underlying cause Reorientation - remind them where they are Sleep Antipsychotics Family and friends Environment - calm, quiet, consistent
capacity
cognitive ability to provide own consent
for each tx not overall
CURBSIDE
need ALL criteria
Communicate in any way Understand: Risks, Benefits, Situation & Impact of tx Decide - clearly and consistently relay same choice Explain why they made that choice
catatonia
LIMP MEN Lethargic Immobility Mutism Positioning e.g. - catalepsy - loss of sensation or consciousness + rigidity - odd posturing, potentially for hours - waxy flexibility - hold position someone else puts them in
Motor abnormalities e.g. - grimacing - mannerisms e.g. wagging finger - stereotypy - repeated actions e.g. walking into a wall repeatedly) - agitation Echolalia & echopraxia - repeating specific words and phrases - repeating actions - specific but not sensitive observation Negativism - e.g. stay still even when ball is being thrown at face
catatonia demo, causes
usually psych
>50% bipolar
30% depression
15% psychosis
2% of all severely ill psych patients
M = F
any age
catatonia px
<50% recover w/o tx
impairment to fx of life
most end up hospitalized
medical complications e.g. DVT
catatonia tx
BED Benzos - usually high dose - 80% effective w/in minutes - sometimes used to confirm suspected cases ECT 85-100% D/c antipsychotics
malignant catatonia
catatonia + autonomic instability
>50% die w/o tx
10% overall mortality
dementia
collection of major neurocognitive disorders (DSM term)
DIRE Decline in cognition - language - cognition - executive fx
Impairment
- IADLS
- ADLs in severe cases
R/o delirium
- temporary
- wax and wane
- medical cause
Exclude mental disorders
IADLs
instrumental activities of daily living
SHAFT Shopping Housekeeping Accounting Food preparation Transportation
ADLs
activities of daily living
DEATH Dressing Eating Ambulating Toileting Hygiene
types of dementia
Alzheimer's vascular dementia dementia w/ Lewy bodies frontotemporal dementia mixed dementia (2+)
Alzheimer’s
GRANDPA U OK?
Gradual, insidious - months to years
Relentless - unremitting and steady progression
Amnesia - anterograde > retrograde > implicit memory
Neurocognitive
Deficits
Psych sx - mood, insomnia > psychosis, delusional misidentification
Activity - less purposeful behavior, more purposeful
- sundowning 30% - wandering, agitation
Unable to fx
Objective biomarkers
Knowledge of illness - lack n
neurocog deficits in Alzheimers
- Aphasia expressive > receptive
- Apraxia complex > simple
- Agnosia - understanding symbols/meaning of objects, eventually basic signals
- visual-spatial - e.g. clock from memory
- executive fx
objective biomarkers in Alzheimers
cortical atrophy loss of cholinergic neurons esp in hippocampus senile plaques / amyloid beta NFTs / tau - tau and amyloid proteins seen in CSF - plaques and tangles seen on biopsy - not routine tests currently APOE4 mutations common
Alzheimers demo
<1% total
3% 65 - doubles every 5 years
20% at 80
50% at 90
F>M, may be b/c longer lifespan
avg life expectancy 5 yr
almost always die w/in 10
usually d/t medical complications
Alzheimers tx
sx reduction
no restoration of fx or slowing progression
cholinesterase inhibitors - increase ACh
memantine - increase NMDA
antidepressants & antipsychotics have risks and tend to be less effective
behavioral interventions
psychotherapy not helpful
vascular dementia
2nd most common dementia
series of repeated strokes
stepwise decreases in cognition
multiple areas of ischemic damage
no specific pattern of cognition loss as it’s based on where strokes occur
vascular dementia tx
reduce stroke risk e.g. blood thinners
dementia w/ lewy bodies
3rd most common
alpha syn aggregates
+ visual hallucinations
C’N STUFF
Cognitive deficits
- memory not necessarily first or more prominent domain
- distractibility, confusion, incoherence
Neuroleptic sensitivity
- sensitivity to antipsychotics
- EPS
- catatonia
- neuroleptic malignant syx
Sleep behavior
- acting out dreams
- flailing, thrashing, yelling while sleeping
- specific sign
Timing
- earlier onset >50
- more rapid cog decline - months rather than years
Unstable
- fluctuations in cognition w/in hours
- easier to mistake for delirium
Parkinsonism 80%
- tremor
- rigidity
- slow movement
- postural instability
Hallucinations
- even at early stages
- people or animals
- generally not bothersome
- have insight
dementia w/ Lewy bodies demo
0.5% >65
M=F
dementia w/ Lewy bodies px
worse than other dementias
life expectancy ~4 years
dementia w/ Lewy bodies tx
palliative
no specific tx - less effective than for other conditions, more side fx
- cholinesterase inhibitors
- antiparkinsonian drugs
FTD
frontotemporal dementia
OH DEAR
Obliviousness to emotions of others
Hyperorality - put anything into mouth, but preference for sweet foods
Disinhibition - hypersexual common
Executive dysfunction - memory and visual-spatial generally well preserved
Apathy
Repetitive behavior - simple or complex
FTD demo
<10% all dementias
45-65 y/o onset
M=F
FTD px
2-10 yr mortality
FTD tx
SSRIs
antipsychotics?
cholinesterase inhibitors generally not effective
stages of sleep EEG signs
Beta waves Alpha waves Theta waves Sleep spindles & K complexes Delta sleep - deep sleep - most restorative REM - resembles awake on EEG - remember your dreams - remain still
circadian rhythm anatomy
suprachiasmatic nucleus
part of hypothalamus
controls circadian rhythm
pineal gland
releases melatonin
controls SCN
insomnia demo
30%
5% when r/o lifestyle fx
older age
F > M
risk:
- depression
- anxiety
insomnia px
tends to be persistent
may be episodic
impacts all domains of life
<4 h/night associated w/ 15% increase in mortality d/t related fx like accidents, poor physical health, use of stimulants
insomnia tx
CBTi - specific CBT for insomnia hypnotics - antihistamines - benzos - Z drugs - tolerance common after only a few days
OSA
obstructive sleep apnea
hypoxic episodes
transient awakenings
headache
chronic fatigue
STOP BANG Snoring Tired all the time Observed apnea Pressure (BP high) BMI high Age high Neck circumference high Gender M>F
risk of heart attack and stroke
RLS
restless leg syndrome
URGE Urge to move Rest worsens Gets better w/ activity Evening is worse
mostly idiopathic
iron deficiency
genetics
RLS tx
Lifestyle
Anticonvolsants
Iron supplementation
Dopamin antagonists
circadian rhythm disorders, tx
e.g. jet lag
lifestyle changes daytime: - bright light exposure - modafinil nighttime: - melatonin
somnambulism
sleepwalking
mostly idiopathic
iatrogenic - Z drugs
nightmare disorder
usually hx of trauma
stress reduction
tx prazosin
sleep terrors
non-rem nightmares
usually don’t remember
distress on awakening
physical signs similar to panic attack
mostly do not persist to adulthood
sleep paralysis
gains consciousness
remains unable to move
may hallucinate, esp figures in room/being watched
relaxation techniques
CBT
SSRIs
REM sleep behavior disorder
lack of paralysis during REM
>90% progress to neuro disorder e.g. Parkinson’s, Lewy body
narcolepsy
CHAP
Cataplexy, often triggered by strong emotional states
Hypnagogic and hypnopompic hallucinations - when going to sleep and waking up
(sleep) Attacks - seconds to minutes - not always present
(sleep) Paralysis
narcolepsy demo
onset early adulthood/adolescence
<0.1% population
M=F
tends to be persistent and cause disabiilty
narcolepsy tx
GHB - sodium oxybate
- direct impact on narcolepsy
modafinil
- helps promote wakefulness/sx tx
delirium tremens
potentially fatal
alcohol withdrawal
usually 48-72 h
DTS are HELL Delirium Tremor Seizures Hallucinations ESR increase Leukocytosis LFTs
tx:
- benzos (for any severe alcohol w/d)
wernike-korsakoff syx
chronic alcohol use
–> vitamin B1 deficiency
COAT RACK Confusion Opthalmoplegia - eye muscle weakness Ataxia Thiamine deficiency Retrograde amnesia Confabulation - (mainly unintentionally) filling in gaps in spotty memory w/ untrue details Knowledge of illness impaired
alcohol use disorder tx
detox - often inpatient
rehab
some meds:
- disulfiram - nausea when +alcohol
- naltrexone
- acamprosate - GABA AGonist
benzo use disorder
like a “cleaner” form of EtOH
*weaning as slow taper
each year on benzo –> month to quit
benzo use disorder and OD tx
flumazenil
GABA antagonist
little good evidence for use in OD but used anyways
opioid withdrawal
opposite of intoxication fx
hyperalgesia (pain) tachycardia, htn mydriasis (dilated pupil) dysphoria restlessness, anxiety, irritability diarrhea, abd cramping
