Psych- Exam 1 Flashcards

Question

Social Anxiety Disorder * What is anticipatory anxiety?

Answer 1

Anticipatory anxiety can appear days or weeks before feared event. This then becomes a "self-fulfilling prophecy, contributing to an actual or perceived poor performance in the feared situation. A never ending cycle of further anticipatory anxiety develops with subsequent perceived or true poor performance

Answer 2

* Fear of trembling hands- avoid drinking, eating, writing, or pointing in public * Some individuals avoid urinating in public restrooms

Answer 3

* Lifetime risk of depression about 2 to 4 times higher in persons with Social Anxiety (especially older adults) * Alcohol use disorders are commonly co-morbid * Is frequently co-morbid with bipolar disorder or body dysmorphic disorder

Answer 4

If Social Phobia is circumscribed- limited to certain settings- public speaking/ artistic performance * Use meds on as-needed basis and to est. feelings of reassurance: B- blockers SSRI, SNRIs, MAOi, others off label: gabapentin, pregabalin, inosital Exposure, CBT, social skills training (ex. skills with eye contact, starting/cont conversation), Sx management (calming)

Answer 5

Recurrent unexpected panic attacks PANIC ATTACK: abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: * Palpitations, pounding heart, or accelerated heart rate * Sweating * Trembling or shaking * Sensations of shortness of breath or smothering * Feelings of choking * Chest pain or discomfort * Nausea or abdominal distress * Feeling dizzy, unsteady, light-headed or faint * Chills of heat sensations * Paresthesias (numbing or tingling sensations * Derealization (feelings of unreality) or depersonalization(being detached from oneself) * Fear of losing control or “going crazy.” * Fear of dying

Answer 6

At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: * Persistent concern about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”. * A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations * The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition(e.g., hyperthyroidism, cardiopulmonary disorders * The disturbance is not better explained by another mental disorder

Answer 7

* Panic Attacks peak around 10 minutes * Are thought to last maximum of 20 minutes because individual’s nerve endings depleted of norepinephrine by that time. ## Footnote BE CAREFUL BECAUSE PANIC ATTACK IS NOT THE SAME AS PANIC DISORDER

Answer 8

Drugs of abuse * Intoxication (cannabis; stimulant * Withdrawal (sedative-hypnotic; alcohol; benzos) * Prescription/over-the-counter drugs: Decongestants; stimulants, dopaminergic agents, asthma meds * Caffeine/energy drinks/bars Panic attacks can occur in context of any anxiety disorder When panic attack identified, should be noted as a specifier (e.g., posttraumatic stress disorder with panic attacks

Answer 9

An abrupt surge of intense fear or discomfort that reaches a peak within minutes and during which time four (or more) of following symptoms occur: * Palpitations, pounding heart, or accelerated heart rate * Sweating * Trembling or shaking * Sensations of shortness of breath or smothering * Feelings of choking * Chest pain or discomfort * Nausea or abdominal distress * Feeling dizzy, unsteady, light-headed, or faint * Chills or heat sensations * Paresthesias (numbness or tingling sensations) * Derealization (feeling of unreality) or depersonalization (being detached from oneself) * Fear of lsing control or “going crazy” * Fear of dying ## Footnote THe same as above

Answer 10

Nocturnal panic attack * Waking from sleep in a state of panic

Answer 11

* Many patients with panic disorder report constant or intermittent feelings of anxiety more broadly related to health and mental health concerns. * Often restrict food intake or avoid specific foods or medications – concerned about physical symptoms that provoke panic attacks. * Anticipate catastrophic outcomes from mild physical problems or medical issues ## Footnote Only minority of individuals have full remission without subsequent relapse within a few years

Answer 12

* Sodium lactate * yohimbine * Caffeine * CO2 * Isoproterenol * cholecystokinin

Answer 13

* CBT with and without SSRIs; SNRIs * Inositol * Symptom management skills: relaxation training, calming techniques - specifically for fear of panic attack * Behavioral Desensitization with/without * Flooding * Psychodynamic Psychotherapy * EMDR: Eye Movement Desensitization and Reprocessing * Supportive Psychotherapy * Group Therapy and Support Groups * Complementary/alternative treatments:Yoga, massage

Answer 14

Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms

Answer 15

The situations are avoided or else endured with marked distress or anxiety about having a panic attack or panic-like symptoms. Those affected may require the presence of a companion for reassurance. * The patient makes an association between the attack and where it first occurred and will avoid that place. The attacks might spread to other places, limiting the patient even more

Answer 16

Marked fear or anxiety about two (or more) of the following five situations 1. Using public transportation (e.g. cars, buses, trains, ships, planes) 2. Being in open spaces (e.g., parking lots, marketplaces, bridges) 3. Being in enclosed places (e.g., shops, theater or cinemas) 4. Standing in line or being in a crowd 5. Being outside of the home alone

Answer 17

* The individual fears or avoids these situations because of thought that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of incontinence) * The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more

Answer 18

The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more

Answer 19

* Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events or activities * The person finds it difficult to control the worry

Answer 20

1. Restlessness or feeling keyed up or on edge 2. Difficulty concentrating or mind going blank 3. Irritability 4. Muscle tension 5. Sleep disturbance 6. Being easily fatigued

Answer 21

* Associated with muscle tension, trembling, twitching, feeling shaky, and muscle aches, or soreness * May experience somatic symptoms (e.g., sweating, nausea, diarrhea, exaggerated startle response * Symptoms of autonomic hyperarousal less prominent in GAD than other anxiety disorders * Frequently accompanied by other conditions that may be associated with stress e.g., irritable bowel syndrome, headaches

Answer 22

Rule out Endocrine Issues * Ex: **Thyroid**, parathyroid, adrenal dysfunction Rule out Deficiency States * Ex: Vitamin B12 Rule out Neurologic issues * Ex: Epilepsy; migraine; neoplasms Rule out Hypoglycemia, Carcinoid Use of substances or a prescription medication, including antibiotics

Answer 23

* MEDICATION: SSRIs, SNRIs, * CBT * Symptom Management * Inositol; L-theanine * Psychodynamic Psychotherapy * Supportive Psychotherapy * Group Therapy and Support Groups * Self-hypnosis; mindfulness; meditation; exercise

Answer 24

Specific Phobia if avoidance limited to one or only a few specific situations

Answer 25

* Pheochromocytoma * Diabetes mellitus * Temporal lobe epilepsy * Hyperthyroidism * Carcinoid * Alcohol withdrawal * Arrhythmias

Answer 26

Panic attacks (PA)or anxiety predominant * Is evidence from history, P.E. or lab findings of both 1) and 2) PA or anxiety developed during or soon after substance intoxication or withdrawal or after exposure to a medication This dx should be made instead of diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and are sufficiently severe to warrant clinical attention

Answer 27

SUICIDE RISK! ## Footnote Identify specific psychiatric symptoms associated with suicide attempts or suicide- * Aggression * Violence toward others, * Impulsiveness * Hopelessness * Agitation * Psychosis * Mood and substance use disorders

Answer 28

* Assessment of past suicidal behavior- include intent and lethality of self-injurious acts * Family history of suicide and mental illness * Current stressors * Potential protective factors: positive reasons for living

Answer 29

Endogenous depression May be influenced by external events, but primarily determined by biological factors. Examples: * Bipolar depression * Depression as a medication side effect * PMS * Depression secondary to hypothyroidism ## Footnote medication, with supportive psychotherapy as an adjunct

Answer 30

Reactive depression * Exogenous (from outside the body) * Neurotic depression, internalized rage, introjection Treatment of choice: * psychotherapy (to expel the introject) * Antidepressant medication will interfere with the process of expelling the introject (externalizing the rage).

Answer 31

* Chronic depression originating in childhood * Loss (including chronic abuse or neglect) and rage happen early enough that depression becomes chronic. * Treatment of choice: Combination of antidepressant medication and supportive psychotherapy * The goal is to manage the patient’s condition, not to seek a cure

Answer 32

* Postponed bereavement or reactivated trauma * Treatment of choice: Psychotherapy to discover the anniversary * It is difficult (if not impossible) to discover the anniversary and resolve the depression if the patient is taking antidepressant medication

Answer 33

* Simple bereavement is not depression. Antidepressant medication inhibits and prolongs the bereavement process. * In cases where bereavement is complicated by reactive depression, the patient is not able to go through the bereavement process and do the work of mourning. * Treat reactive depression first using psychotherapy. Then encourage the bereavement process.

Answer 34

Vast majority of individuals whose has sxs that meet criteria for all the symptoms of a manic episode also experience major depressive episodes during their lifetime

Answer 35

* Essential feature: Distinct period during which there is an abnormally, persistently elevate, expansive, or irritable mood AND persistently increased activity or energy present for most of the the day, nearly every date for at **least 1 week** * Requires at least 3 additional symptoms from Criterion B UNLESS mood is irritable (rather than elevated or expansive) and then must have 4 Criterion B sxs

Answer 36

* Manic= euphoric, excessively cheerful, high, or “feeling on top of the world.” * May be characterized by unlimited and haphazard enthusiasm for interpersonal, sexual, or occupational interactions. * Often predominant mood is irritable rather than elevated * Lability= rapid shifts in mood over brief periods of time: alternating among euphoria, dysphoria, and irritability * In children: happiness, silliness and “goofiness” Must be accompanied by persistently increased activity or energy levels

Answer 37

* When manic, individual may engage in multiple overlapping new projects. * Projects often started with little knowledge of the topic * Nothing seems undoable. * May see increased activity levels at unusual hours of the day

Answer 38

Inflated self-esteem typical: uncritical self-confidence to marked grandiosity. May rise to degree of delusional proportion (what type of delusions) * Grandiose delusions common. Ex:having a special relationship with a famous person Despite not having an experience or talent, individual may embark on complex tasks such as writing a novel or seeking financial backing for an impractical project

Answer 39

Children: Grandiosity seen as overestimation of abilities and belief in oneself as the best or smartest must be confirmed as contrasting with evidence to the contrary. Other behavior- attempting dangerous feats. These must demonstrate a distinct change from normal behavior

Answer 40

Decrease need for sleep * Common symptom * Often heralds the onset of a manic episode

Answer 41

* Rapid, pressured, loud, difficult to interpret * May talk continuously and intrusively, without giving others a chance to speak * Speech sometimes characterized by jokes, puns, amusing irrelevancies, and theatricality * May exhibit dramatic mannerisms, singing, and excessive gesturing * If mood irritable (rather than expansive) speech may be marked by complaints, hostile comments or angry tirades

Answer 42

Race at a rate faster than they can be expressed through speech Flight of ideas= a nearly continuous flow of accelerated speech, abrupt shifts from one topic to another * If severe, speech may become disorganized and incoherent

Answer 43

Distractibility * Inability to censor unimportant external stimuli * Often prevents individuals from holding rational conversation or pay attention to instructions

Answer 44

* Increase in goal-directed activity Excessive planning and participation in multiple activities: sexual, occupational, political, or religious * When manic usually show increased sociability without regard to the intrusive, domineering, and demanding nature of the interactions * By pacing or by holding multiple conversations simultaneously, excessive letters, e-mails, text messages, etc to friends, public figures, or media

Answer 45

Increased activity criterion in children often difficult to ascertain * Ex= child takes on many tasks simultaneously, starts devising elaborate and unrealistic plans for projects, develops previously absent and developmentally inappropriate sexual preoccupations

Answer 46

Expansive mood, excessive optimism, grandiosity, and poor judgment often lead to reckless behavior that is unusual for the person * Spending sprees * Giving away possessions, reckless driving, foolish business investments, and sexual promiscuity

Answer 47

Someone demonstrating an expansive mood adopts a grand or lavish style of behavior, assuming a superior or grandiose attitude, perhaps dressing and behaving flamboyantly.

Answer 48

* physiological effects of a drug of abuse (e.g., cocaine or amphetamine intox) * Side effects of medications/treatments (e.g., steroids, antidepressants, stimulants, L-dopa) * Another medical condition

Answer 49

HOWEVER, a fully syndromal manic episode arising during treatment (meds, light therapy, etc) or drug use that persists beyond the physiological effects of the “inducing” agent (after a medication is fully out of a person’s system or effects of therapy-ECT- would be expected to have dissipated completely) is evidence for a manic episode diagnosis

Answer 50

* May become hostile and physically threatening to others * When delusional- may be assaultive or suicidal * Poor judgment, loss of insight, and hyperactivity usually have catastrophic consequences * Depressive sxs may occur during manic episode and might last moments, hours, or, more rarely days (with mixed features specifier)

Answer 51

* Person does not perceive is ill or in need of treatment * Resists treatment * May change dress, makeup, personal appearance to a more sexually suggestive or flamboyant style * Some perceive sharper sense of smell, hearing, vision * May gamble; demonstrate antisocial behavior

Answer 52

Environmental- more common in high-income than low-income countries Genetic and physiological * Family history of bipolar disorder one of strongest and most consistent risk factor * Is 10 fold increased risk among adult relatives of individuals with Bipolar I and II disorders

Answer 53

Highly co-morbid with all anxiety disorders * See in ¾ of individuals * ADHD, any disruptive, impulse-control, or conduct disorder and any substance use disorder occur in over 50% individuals with Bipolar I Disorder * Metabolic syndrome and migraine more common * More than half have alcohol use disorder (both present greater risk for suicide attempt)

Answer 54

Mean age at onset of the first manic, hypomanic, or major depressive episode is approx 18 years for Bipolar I disorder Onset occurs throughout the life cycle * Could first appear in individual in 60’s or 70’s * Onset of manic symptoms (e.g., sexual or social disinhibition) in late mid-life or late-life , evaluation medical condition (e.g., frontotemporal neurocognitive disorder) and substance ingestion or withdrawal

Answer 55

* Must have at least one episode of major depression and at least one hypomanic episode * The major depressive episodes must last 2 weeks * Hypomanic episode must last 4 days

Answer 56

* Individuals usually present for RX of depression. Unlikely to complain initially of hypomania * Hypomanic episodes do not cause impairment.

Answer 57

* Major depressive episodes * Persistent pattern of unpredictable mood changes and fluctuating * Unreliable interpersonal or occupational functioning (friends bothered by erratic behavior)

Answer 58

Compared to Bipolar I, individuals with II * Have greater chronicity of illness * On average spend more time in depressive phase (which can be severe and/or disabling) Depressive sxs can co-occur during hypomanic episode and the reverse is also true

Answer 59

Common associated feature is impulsivity * Can contribute to suicide attempts and substance use disorders Might have heightened levels of creativity * Sometimes reluctant to take med for this reason

Answer 60

Average age at onset mid 20’s * Slightly later than for Bipolar I disorder * Earlier than MDD Most often begins with depressive episode * True dx not known until hypomania occurs (True of 12% of individuals) * Anxiety, substance use, or eating disorders may precede dx

Answer 61

* Number of lifetime episodes (both hypomanic and major depressive episodes) tends to be higher than for MDD or Bipolar I Disorder * Individ with Bipolar I actually are more likely to experience hypomanic symptoms than are individuals with Bipolar II * Interval between mood episodes in course of bipolar II tends to decrease as individual ages * Although hypomanic episode is feature that defines BP II, depressive episodes are more enduring and disabling over time

Answer 62

Can have rapid cycling * Multiple (four or more) mood episodes (hypomanic or major depressive) within previous 12 months

Answer 63

no psychotic sx in hypomanic episodes

Answer 64

* Nonepisodic (lacks well-demarcated periods of altered mood) associated with elevated risk for anxiety disorders and major depressive disorder but NOT bipolar disorder as adults * Persistently irritable youths- lower familial rate of bipolar disorder than youths who have Bipolar

Answer 65

* more education * Fewer years of illness * Less severe depression Rapid cycling pattern associated with poorer prognosis

Answer 66

Childbirth may be a specific trigger for hypomanic episode * Can occur in 10-20% of females and usually in early postpartum period. * Postpartum hypomania may foreshadow onset of a depression that occurs in about half of females who experience postpartum “highs”

Answer 67

* Individual has mild swings between two poles of depression and hypomania * When hypomanic, person not so high that is socially or professionally incapacitated * Depression not severe enough to meet criteria for a full major depressive episode * Individuals swing high to low and may have chronic mild mood instability

Answer 68

* During the two year period, hypomanic and depressive symptoms “have to be present for at least half the time.” * Cannot be without symptoms for more than 2 months at a time

Answer 69

* Levadopa * Corticosteriods * Antidepressents: MAOIs andTricyclic * Stimulant medication * Adderall

Answer 70

Refers to children with persistent irritability and extreme behavioral dyscontrol Core feature is chronic, severe persistent irritability * Temper outbursts- verbal/behavioral * Chronic, persistently irritable or angry mood

Answer 71

* Applies up to the age of 12 years * These children usually go on to develop unipolar depressive disorders or anxiety disorders

Answer 72

* Higher in males of school age (non-adolescent) * Must develop before age 10 * Cannot apply to child with developmental age less than 6 yrs * Rule out Intermittent Explosive Disorder-> No disruption in mood between outbursts

Answer 73

* Discrete episodes of at least 2 weeks duration-> Most last longer * Clear-cut changes in affect, cognition, and neurovegetative functions * Inter-episode remissions * Often winds up being a recurrent illness

Answer 74

Bereavement does not typically induce episode of MDD If bereavement and MDD occur together * Depressive symptoms tend to be more severe * Functional impairment more severe * Prognosis worse * Is treated with antidepressants

Answer 75

* Grief: Emptiness and loss * MDE: Persistent depressed mood and inability to anticipate happiness or pleasure

Answer 76

* Grief: decreases in intensity over days to weeks; Occurs in waves (pangs of grief) * More persistent. Not tied to specific thoughts or reminders

Answer 77

Pain * Of grief: may also see positive emotions and humor * MDE: Positive emotions and humor not characteristic. Usually pervasively unhappy and feel misery Thought content * Grief: Focused on thoughts and memories of deceased * MDE: Self critical and self ruminations

Answer 78

Self esteem: * In grief usually preserved. If any self-derogatory ideation present, focuses on not having done enough * MDE: Feelings of worthlessness and self-loathing common Thoughts of death and dying * Grief: To join loved one * MDE: End one’s life because feels worthless, undeserving of life or unable to cope with pain of depression

Answer 79

* Diagnosed only if at least 12 months elapsed since death of loved one (6 months in children)-> Time frame distinguishes normal grief from persistent grief * The nature and severity of grief must be beyond expected norms * Could be associated with hallucinations of deceased. Also somatic complaints, including sxs the deceased experienced

Answer 80

* Can occur at any age- as early as 1 yr of age * Sxs can appear immediately after the death, but could be delay of months or years * Individuals frequently report suicidal ideation

Answer 81

* Insomnia or fatigue may be (only) presenting complaint-> Clinician needs to probe deeper * May just present with somatic complaints * Fatigue and sleep disturbance seen in large # of cases * Psychomotor disturbances seen less often but indicate greater severity * May see delusional or near delusional guilt

Answer 82

Essential feature is either depressed mood or loss of interest or pleasure in nearly all activities * Mood often described as sad, hopeless, discouraged, or “down in the dumps” Children often irritable rather than sad Adults sometimes present mainly with irritability If insomnia usually middle insomnia- waking up in middle of night and unable to go back to sleep. Could have initial insomnia

Answer 83

When treated successfully, memory problems often full abate * Pseudodementia- appears as though there is a dementia but cognitive problems totally due to depression and remit with treatment In some, especially elderly, MDE may sometimes be the initial presentation of an irreverible dementia

Answer 84

Some patients with mania or psychotic depression: enlarged cerebral ventricles on CT Some depressed patients: Decreased blood flow in basal ganglia MRI: Depressed patients have smaller caudate nuclei and smaller frontal lobes than normals * Theory: abnormal regulation of membrane phospholipid metabolism

Answer 85

* ANHEDONIA : Inability to experience feelings of pleasure at all * Neuro-vegetative symptoms = vegetative symptoms = common somatic manifestations of depression

Answer 86

Physiologic disturbances associated with mood disturbances. Some include the following: * Anorexia/hyperphagia * Insomnia/hypersomnia; early am awakening * Diurnal variation of sxs (worse in a.m.) * Diminished libido * Constipation * Pica: craving and eating of nonfood substances like clay or paint

Answer 87

* Abnormal menses * Insatiable hunger and voracious eating: seen in atypical depression

Answer 88

Episodes more common in fall and winter * Develops with shortened daylight in winter and fall * Disappears during spring and summer Hypersomnia, hyperphagia, and psychomotor slowing Must occur over 2 year period Treat with exposure to bright artificial light May see in patients also diagnoised with Bipolar I and II disorders

Answer 89

Mood disturbance continues for * At least 2 years- adults * At least 1 year- children May be preceded by a major depressive disorder May occur simultaneously with a major depressive disorder (sometimes referred to as double depression)

Answer 90

Has early and insidious onset (i.e., childhood, adolescence, or early adult life) Early onset- if before age 21 years * Assoc with higher likelihood of comorbid personality and substance use disorders * Childhood risk factors- parental loss or separation Late onset- at age 21 years or older

Answer 91

* Prefrontal cortex * Anterior Cingulate * Amygdala * Hippocampus

Answer 92

* Essential features: Mood lability, irritability, dysphoria, anxiety that occur repeatedly during premenstrual phase and peak and then remit around onset of menses * Are behavioral and physical symptoms * Must have sx-free period in follicular phase after menstrual period starts

Answer 93

Delusions and hallucinations * Described in late luteal phase of cycle * Rare Affected individuals worsen as approach menopause Symptoms cease after menopause

Answer 94

* Does not require 5 sxs * No stipulation for affective sxs * Thought to be less severe than PDD

Answer 95

* Diagnostic features include sxs of a depressive disorder but are associated with ingestion, injection, or inhalation of an substance * Developed during or within 1 mo after use of substance * Depressive sxs persist beyond expected length of effects of the substance

Answer 96

* Stimulants * Steroids * L-dopa * Antibiotics * CNS system drugs * Dermatological agents * Chemotherapeutic agents * Immunologic agents

Answer 97

* Interferon and Neuropsychiatric Sx associated with treatment of Hepatits C * Huntington’s Disease * Parkinson’s Disease * TBI * Stoke

Answer 98

Depression is a risk factor for cardiovascular disease * 3-4 fold increase in risk of recurrent cardiac events and death in patients with coronary artery disease * After controlling for multiple variables, psychosocial factor index was a stronger risk factor for acute MI than hypertension, diabetes, or obesity * Depression predicts mortality and morbidity in patients who have had coronary artery bypass procedures. Depression in patients with preexisting cardiac disease * Predictive of future cardiac mortality and morbidity in patients with coronary artery disease * Patient with MI have SEVEN times greater risk of recurrent MI

Answer 99

* Increased Platelet reactivity causing increased platelet aggregation and thrombus formation * Inflammatory markers increased in depression linked to CHF, atherosclerosis, MI, stroke

Answer 100

* Stress is a risk factor for depression * Depression risk factor of increased cortisol secretion * Increased cortisol secretion can have potentially adverse cardiovascular effects

Answer 101

Women with Bipolar disorder * 23% had illness episodes during pregnancy * 52% ill during postpartum period Women with Unipolar depression * 4.6% had illness episodes during pregnancy * 30% during postpartum period Depression was the symptom seen most often during pregnancy but sometimes a woman manifested a dysphoria that was due to bipolar disorder

Answer 102

* 50% of “postpartum major depressive episodes actually begin PRIOR to delivery. These are referred to as peripartum episodes * Risk of occurrence was higher with bipolar disorder I, next with bipolar II, and then unipolar depression

Answer 103

* Having an illness onset after 1992 (no one knows why) * Never married * Unemployed and not a homemaker, student, or retiree * Educated beyond high school * Having an onset age below median of 33 years * Having a (prior) diagnosis of bipolar (I or II) * Relatively few pregnancies- less than four vs more than four

Answer 104

* Neonates exposed to SSRIs or SNRIs late in the third trimester have developed complications requiring prolong hospitalization, respiratory, support, and tube feeding. Can arise immediately upon delivery * Clinical findings reported: respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyper-reflexia, tremor, jitteriness, irritability and constant crying * Sxs consistant with either direct toxic effect of SSRIs/SNRIs or possibly drug discontinuation sx

Answer 105

* Mild “BABY BLUES”- different from postpartum depression * Symptoms: crying, “mild” irritability, “mild” mood swings * Onset 0-3-10 days after delivery * Usually resolves on its own in ONE WEEK or TWO

Answer 106

If does not resolve after one or two weeks, then one must consider patient has a **postpartum depression**

Answer 107

* Meets the full criteria for Major Depressive Disorder (MDD)->Etiologically related to MDD * Must be watchful for several months after delivery as symptoms may manifest later

Answer 108

* An even bigger concern is a depression with psychotic features that could prompt mother to harm child while influenced by psychosis * Evidence indicates that a depressed mother affects child’s temperament and cognitive development

Answer 109

* Some researchers believe that depression that begins for the first time in the postpartum period is more likely to have a bipolar outcome * Postpartum psychosis is frequently a manifestation of bipolar disorder

Answer 110

* May present (in new mother) with rapid onset of hallucinations, delusions, mood swings, confusion, and insomnia. * Counsel women with a history of bipolar disorder and their significant others to report these sxs immediately if they occur. * Consider risk/benefits of antipsychotics or mood stabilizers during pregnancy and postpartum

Answer 111

* Many individuals with this diagnosis require hospitalization * Need to determine if have delusions about or thoughts about harming infants

Answer 112

* Sleep deprivation in susceptible women * Hormonal shifts after birth (Primarily rapid drop in estrogen) * Bipolar Disorder history * Schizoaffective Disorder history * Past hx or family hx of Postpartum Psychosis * Previous psychiatric hospitalization (esp during prenatal period) for Bipolar or psychotic condition

Answer 113

A woman with PPD or PPP may report depressed mood, but in PPP depressed mood is often related to rapid mood changes Other clinical features that may suggest PPP: * Unusual hallucinations such as olfactory or tactile * Hypomanic or mixed mood symptoms * Confusion Suicidal or harming the infant can be in both

Answer 114

* These disorders are marked by a similar presence of impaired self-regulation that results in difficult, disruptive, aggressive, or antisocial behavior. * They vary: May be defensive, premeditated, or impulsive * There is a clinical and biological connection along a developmental spectrum for Oppositional Defiant Disorder, Conduct Disorder, and Antisocial Personality Disorder

Answer 115

* Have a pattern of negative, hostile and defiant behavior * Do not exhibit the serious violation of societal norms or rules (as seen in Conduct Disorder) * Demonstrate a pattern of defiant, angry, and negative behavior that lasts for at least 6 months

Answer 116

* Child who frequently loses his temper, is resentful, easily annoyed, and overtly defies requests and rules right in front of adults (he knows) and with peers * May observe as early as 3 years of age * Usually picked up by time 8 years old

Answer 117

* Such children spiteful or vindictive (seen at least twice within 6 month period) * May be result of unresolved conflicts * May be a reinforced, learned behavior * Behavior not limited to relationship with a sibling

Answer 118

Persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from one that is symptomatic: * For children younger than 5 years, behavior should occur on most days for a period of at least 6 months * For children 5 years and older, behavior should occur at least once per week for at least 6 months

Answer 119

Developmental-stage oppositional behavior * Durations shorter * Symptoms not as frequent or intense Adjustment Disorder * Behavior observed in reaction to stress Conduct Disorder * Basic rights of other individuals violated * Is possible to have Conduct Disorder and ODD simultaneously

Answer 120

Psychotherapy- including family therapy * Parenting skills * Prognosis determined by health of parents and family over all as well as development of any co-morbid psychopathology in child * Consider in- home consult with behaviorist Medication * Treat co-morbid disorders (e.g. anxiety) * Of label- guanfacine (Tenex) or its long- acting version: Intuniv

Answer 121

* Aggressive outbursts that are rapid in onset and have short duration * Usually little or no prodrome * Verbal assaults * Destructive and nondestructive assault on property * Injurious or non-injurious physical assault * Outbursts most commonly in response to minor provocation

Answer 122

This diagnosis can be made in addition to diagnosis of * ADHD * Conduct disorder * ODD * Autism Spectrum Disorder when recurrent impulsive aggressive outbursts are in excess of those usually seen in the above disorders and require independent clinical attention

Answer 123

* Essence of the disorder us that the outburst is grossly out of proportion to what might occur in most individuals faced with a stressful situation * Applies to individuals at least 6 years or older to adulthood * Behavior not premeditated. It is impulsive * Dx not used in children ages 6-18 who manifest aggressive behavior but have dx of Adjustment Disorder

Answer 124

* Either high frequency and low intensity (two outbursts per week for 3 months) * Or low frequency and high intensity (three or more severe outbursts a year)

Answer 125

Essential feature = repetitive and persistent pattern of behavior in which basic rights of others or major age-appropriate social norms or rules are violated Examples * Aggressive conduct that causes or threatens harm to others or animals * Non-aggressive behavior that causes property damage * Stealing; Deceitfulness * Serious violation of rules

Answer 126

* Childhood-onset: One sx appears prior to 10 years * Adolescent-onset: No sxs seen prior to age 10 yrs * With limited prosocial emotions: Included to describe childhood equivalent of the adult with psychopathy

Answer 127

* A distinct syndrome within the antisocial spectrum * Characterized by lack of empathy and concern for the feelings, wishes, and well being of others * Such traits found in minority of youth with Conduct Disorder

Answer 128

Antisocial Personality Disorder

Answer 129

* Attention deficit * Low frustration tolerance * Impulsivity, recklessness * Learning disorders, especially reading * Negative mood * Sullenness * Irritability * Volatile anger outbursts * Low self-esteem

Answer 130

Impaired cognition: * Distortion of size and time awareness. * Lack of and distorted connection between prior events and consequences * Limited ability to generate, evaluate, and implement alternative problem-solving strategies Use of less adaptive intra-psychic mechanisms * Minimization * Avoidance * Externalization * Denial * Identification with the aggressor

Answer 131

Emotional deficits * Minimization of fear and sadness * Inability to control and modulate anger * Lack of empathy * Lack of guilt Impaired interpersonal relations * Suspiciousness or paranoia, with cognitive distortions * Attributional bias: misperceives others' actions as hostile * Preference for nonverbal, action-oriented, aggressive solutions to problems

Answer 132

Pyromania is defined as a pattern of deliberate setting of fires for pleasure or satisfaction derived from the relief of tension experienced before the fire-setting. The name of the disorder comes from two Greek words that mean "fire" and "loss of reason" or "madness." Classified as a disorder of impulse control, meaning that a person diagnosed with pyromania fails to resist the impulsive desire to set fires—as opposed to the organized planning of an arsonist or terrorist.

Answer 133

* Kleptomania is a complex disorder characterized by repeated, failed attempts to stop stealing. It is often seen in patients who are chemically dependent or who have a coexisting mood, anxiety, or eating disorder. Other coexisting mental disorders may include major depression, panic attacks, social phobia , anorexia nervosa , bulimia nervosa , substance abuse, and obsessive-compulsive disorder . People with this disorder have an overwhelming urge to steal and get a thrill from doing so. The recurrent act of stealing may be restricted to specific objects and settings, but the affected person may or may not describe these special preferences. People with this disorder usually exhibit guilt after the theft. * Detection of kleptomania, even by significant others, is difficult and the disorder often proceeds undetected. There may be preferred objects and environments where theft occurs. One theory proposes that the thrill of stealing helps to alleviate symptoms in persons who are clinically depressed.

Answer 134

* Unwanted intrusions into awareness and behavior * Inability to access information or control mental functions that usually an individual can control

Answer 135

* Criterion A acknowledges a marked discontinuity in the sense of self and agency * Switch to (at least) a second personality has to represent a break with an individual’s usual thinking and behavior * In some cultures the change to a second (or more) personality states is described as an experience of possession

Answer 136

The "sense of agency" (SA) refers to the subjective awareness that one is initiating, executing, and controlling one's own volitional actions in the world. It is the pre-reflective awareness or implicit sense that it is I who is executing bodily movement(s) or thinking thoughts.

Answer 137

* These symptoms are experienced consciously (reflecting an alter’s intrusion into a person’s conscious functioning) * Individual’s sense of self is disrupted * Individual’s may lose his sense of directing his or her speech and actions

Answer 138

* Voices might intrude into the conscious mind * Individual might experience sudden emergence of strong emotions and/or impulses * A person may become a depersonalized observer of his actions- powerless to stop it * Individual’s body may feel different (like that of opposite gender or of a small child)-> Accompanied by the recognition that the feelings do not belong to the individual

Answer 139

Diagnosis does not apply in situation where the disturbance is a normal part of a broadly accepted cultural or religious practice Diagnosis excludes * Physiologic effect of a substance (e.g. blackouts or chaotic behavior during alcohol intoxication, hallucinogens, PCP) * Another medical condition- e.., complex partial seizures, brain tumors

Answer 140

* Most individuals with non-possession form do not display their discontinuity of identity for long periods of time * Only a small minority of individuals present to clinical attention with observable alteration of identities

Answer 141

1. Gaps in remote memory of personal life events (periods of childhood or adolescence) such as death of a grandparent, giving birth, getting married 2. Lapses in dependable memory (what happened today, well-learned skills such as how to do job, use computer, read, drive 3. Discovery of evidence of everyday actions and tasks the person does not remember doing

Answer 142

* May experience dissociative fugues (Find themselves in Vermont and no recollection of how got there) or somewhere at home with no recollection of how got there * Amnesia in DID NOT limited to stressful traumatic events. May have amnesia for everyday events

Answer 143

* Have loss of contact with or disorientation to the current reality * Subsequent amnesia for content of flashback

Answer 144

Can manifest at any age Children usually do not present with identity changes * Instead, present with Criteria A sxs of problems with memory, concentration, attachment, and traumatic play

Answer 145

* Recovery is generally incomplete * Individual personalities may have their own separate mental disorders, mood disorders, and personality disorders, with other dissociative disorders being the most common

Answer 146

Psychotherapy * Insight-oriented, often with hypnotherapy or drug-assisted interviewing * Goal- reconciliation of disparate, split-off affects by helping patient understand original reasons for the dissociation no longer exists and one whole personality can express all the feeling without the self being destroyed. Pharmacotherapy * Drug-assisted interviewing to obtain hx and identify unrecognized identities * Antidepressant and anti-anxiety medications useful adjuvants * Anticonvulsant meds (eg: Tegretol) helpful in some patients

Answer 147

* Primarily affects the ability to recall personal information about oneself-> It may be selective for specific events or more global * Criterion specifies two types of amnesia- localized (selective) and generalized * Person may feel he/she is “going crazy” or may have concerns about self-identity * Dissociative amnesia must be distinguished from other mental disorders

Answer 148

* Dissociative fugue is a specifier * Used when a person unexpectedly travels away from home or the workplace, or wanders bewilderedly, during an episode of dissociative amnesia

Answer 149

Onset of dissociative amnesia often abrupt History usually shows a precipitating emotional trauma charged with painful emotions and psychological conflict Patient aware has lost memory * Some upset by this * Others unconcerned or indifferent

Answer 150

* The forgotten memories usually relate to day-to-day information that is routine part of conscious awareness (who a person is) * Patient does have capacity to learn and remember new information * General cognitive functioning and language capacity usually intact

Answer 151

* Patients usually alert before and after period of amnesia * Some report slight clouding of consciousness during period immediately surrounding onset of amnesia * Amnesia may provide primary or secondary gain (Example: woman amnestic about birth of dead infant

Answer 152

Localized - memory loss for events over short period of time * May be broader than for one single traumatic event (e.g., child abuse over months or years/intense combat) * Selective or systematized amnesia -inability to recall some but not all events over a short time

Answer 153

Generalized amnesia - Loss of memory for a whole lifetime of experiences * May forget personal identity (rare) * Onset acute * Seen in individuals experiencing extreme emotional distress or conflict * Disorientation, perplexity, and purposeless wandering usually brings them to the attention of the authorities | Cannot be due to general medical condition or ingestion of substance

Answer 154

R/o Dementia or delirium * In this circumstance, amnesia associated with many cognitive sxs R/O Epilepsy * Ck for abnormal EEG

Answer 155

* Symptoms of dissociative amnesia terminate abruptly * Recovery complete with few recurrences * May last long time in some patients (esp if there is secondary gain) * Lost memories should be restored asap or the repressed memory may form a nucleus in the unconscious mind where future amnestic episodes may develop * Generally, recover spontaneously->Accelerated with treatment

Answer 156

Psychotherapy * to help incorporate the memories into patient’s conscious state * Hypnosis can be used primarily as means to relax the patient sufficiently to recall forgotten information Pharmacotherapy * Drug-assisted interviews with short-acting barbiturates, such as Pentothal (thiopental) and Amytal (sodium amobarbital) iv; and benzos may be used to help patients recover their forgotten memories

Answer 157

* Presence of persistent or recurrent experiences of depersonalization, derealization, or BOTH * Intact reality testing

Answer 158

DEPERSONALIZATION: Experiences of unreality, detachment, being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing

Answer 159

* Anomalous body experiences (i.e., unreality of the self and perceptual alterations * Emotional or physical numbing * Temporal distortions with anomalous subjective recall

Answer 160

Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted)

Answer 161

* Feel in fog or bubble * There is veil or glass wall between individual and world * Surroundings seem artificial, colorless, or lifeless * Commonly see subjective visual distortions: blurriness, heightened acuity, widened or narrowed visual field, two-dimensionality or flatness, exaggerated three-dimensionality, altered distance or size of objects (macropsia or micropsia) * Auditory distortions: voices or sounds muted or intensified

Answer 162

* Persistent, recurrent episodes of feeling detached from one’s self or body * Pt reports seems like watching herself in a movie, feeling mechanical, or as if in a dream (dreaming)”I am no one; I have no self” * Episodes are ego-dystonic (unwelcomed and uncomfortable) * Patients recognize the unreality of the symptoms

Answer 163

May feel subjectively detached from aspects of the self, including feelings (e.g., hypoemotionality: “I know I have feelings but I don’t feel them.” “My thoughts don’t feel like my own,” “my head is filled with cotton.” May feel robotic A split self- one part observing and one part participating * In extreme form known as out-of-body experience

Answer 164

* Affected individuals think they are crazy or going crazy * Fear irreversible brain damage * Altered sense of time (too fast or slow) * Subjective difficulty in vividly recalling past memories and owning them as personal and emotional * Vague somatic sxs: head fullness, tingling, lightheadedness * Ruminate/obsess about whether they really exist

Answer 165

* Transient depersonalization/derealization sxs lasting hrs to days common in general population * One-half of all adults have experienced at least one lifetime episode of depersonalization/derealization. ## Footnote Meeting full criteria for disorder less common than transient sysmptoms

Answer 166

* Mean age onset- 16 yrs. Can start in early or middle childhood * Onset can be sudden or gradual * Duration varies from hours or days to weeks, months, years * Course is often persistent-> 1/3 cases discrete episodes/continuous episodes/initially episodic course becomes continuous

Answer 167

Clear association between disorder and childhood interpersonal traumas (but still not as extreme as in DID) * Sexual abuse much less common that other stressors: physical abuse, growing up with seriously mentally ill parent, unexpected death or suicide of family member or close friend

Answer 168

* Most common proximal precipitants are severe stress, depression, anxiety, and illicit drug use * Sxs specifically induced by marijuana, hallucinogens, ketamine, MDMA (such as ecstasy), and salvia * Marijuana may precipitate new-onset panic attacks and depersonalization/derealization symptoms simultaneously

Answer 169

* Major morbidity- Impairment in both interpersonal and occupational spheres * Comorbidity- Unipolar depressive disorder and any kind of anxiety disorder and, for many, both

Answer 170

* Benzos/SSRI’s may do something. Some recent evidence- Lamictal * Cognitive behavioral- re-learn feelings and attitudes

Answer 171

* Cluster A: Odd/eccentric * Cluster B: Dramatic/erratic * Cluster C: Anxious/fearful

Answer 172

* The odd and eccentric cluster * Tend to be detached and distrustful * Includes the following: Paranoid Personality, Schizoid Personality, Schizotypal Personality * Involve use of fantasy and projection * Associated with tendency toward psychotic thinking and Cognitive disorganization when stressed

Answer 173

* Odd or unusual thought processes and experiences, including depersonalization, derealization, and dissociative experiences * Mixed sleep-wake state experiences; * Thought control experiences

Answer 174

* The dramatic, emotional, and erratic cluster * Individuals tend to be emotionally unstable, impulsive and intense. * Includes: Borderline Personality, Antisocial Personality, Narcissistic Personality, Histrionic Personality

Answer 175

* Use defense mechanisms- dissociation, denial, splitting, and acting out. * Disorders in this group are common

Answer 176

* Individuals tend to be nervous, fearful, passive or rigid and preoccupied * Includes: Dependent Personality, Avoidant Personality, Obsessive-compulsive personality * Commonly used defense mechanisms- isolation, passive aggression, and see illness anxiety issues

Answer 177

If one places the word deficient before any of the traits just listed, one can perceive the problems associated with the various personality disorders

Answer 178

* The definition should include emotional, motivational, and adaptive traits. * Includes harm avoidance, novelty seeking, reward dependence, and persistence * Dysfunction in these dimensions leads to problems that Cloninger sees as occurring along a continuum

Answer 179

If there is impairment in this constellation of patterns so that the pattern of an individual's inner experience and outward behavior deviates significantly and persistently from the person's culture and leads to significant distress and relationship problems, then the person

Answer 180

* Usually are not particularly upset by their flawed patterns of thinking and behavior * They can become distressed by the consequences of the maladaptive behaviors (unlike other mental illnesses)

Answer 181

The result of a complex matrix of biological (genetic), psychological, social, and spiritual factors * Example: Individuals with Borderline and Antisocial Personality Disorders commonly have histories of sexual abuse during childhood

Answer 182

An enduring pattern of feeling, thinking, and behaving that deviates markedly from the expectations of the person's culture. This pattern is manifested in at least two of the following areas: 1. Cognition (ways of perceiving and interpreting self, other people and events) 2. Affect (the range, intensity, volatility, and appropriateness of their emotional responses) 3. Interpersonal relationships 4. Impulse control

Answer 183

* People with disorders of personality and character are excessively self-involved * They have difficulty understanding and accepting other people's points of view * Often do not bother to consider how what they say or do might affect the people who are closest to them-> People with Antisocial Personality Disorder may inflict severe psychological and physical damage on others to meet their own needs and achieve their own ends

Answer 184

Are so self-absorbed that they distort reality * They are often conflicted about their own angry and sexual feelings, that they unconsciously project onto others * Result is they feel threatened and persecuted for no substantiated reason

Answer 185

* Take the credit for the accomplishments of others * Exaggerate their own achievements * Ignore people whom they believe cannot advance their status * Exploit others to enhance their self-image and self-esteem

Answer 186

* Disturbances in interpersonal relationships among mother, father, and child key factors leading a child to develop histrionic personality disorder as an adult * As a rule they are highly suggestible and have characteristic styles of thinking that are impressionistic and deficient in logic- mental states that are likely brain based and genetically determined * A pattern of excessive emotionality and attention seeking

Answer 187

Many people with personality disorders will not accept that they have problems, will refuse treatment, and therefore will not change May blame all their relationship problems on someone else

Answer 188

Often they become involved with the most kind, accommodating, and selfless individuals, perhaps sought out because they are vulnerable to exploitation * Such vulnerable people will respond to the relentless criticism and devaluation by trying to change and improve themselves to satisfy the individual with personality issues–but to no avail

Answer 189

* Insight-oriented and cognitive-behavioral psychotherapies are the first-line treatments for most people with personality disorders * Anxiety and mood disorders commonly coexist with personality disorders so medication may be a component of treatment

Answer 190

* Usually the first evidence is in late adolescence or early adulthood * Impulsive traits associated with increased levels of testosterone, 17- estradiol, and estrone. Low levels of platelet monoamine oxidase may be associated with sociability or with schizotypal personality disorder

Answer 191

Overall are the result of a complex matrix of biological (genetic), psychological, social, and spiritual factors * People with Borderline and Antisocial Personality Disorders commonly have histories of sexual abuse in childhood

Answer 192

Neuropsychological testing Projective testing * Minnesota Multiphasic Personality Inventory: MMPI-2 * Draw a Person Test * Rorschach * Thematic Apperception Test: TAT

Answer 193

* Ego function impairment * Superego impairment * Self-image, self-esteem problems * Enactments of inner psychological conflicts based on past experiences, with impairments in judgment

Answer 194

A pattern of distrust and suspiciousness such that others’ motives interpreted as malevolent

Answer 195

1. Suspects without sufficient basis, that others are exploiting, harming, or deceiving him/her 2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates 3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him/her 4. Suspicious about partner's fidelity 5. Responds by counterattacking 6. Perceives attacks on his or her character and is quick to react angrily 7. Persistently bears grudges 8. Reads hidden demeaning or threatening meanings into benign remarks or events

Answer 196

* Classic defenses – projection, denial, and rationalization * Shame a prominent feature * Superego projected onto authority

Answer 197

* The main feature of Paranoid Personality Disorder is a pervasive mistrust so that the motives of others are interpreted as being deliberately hurtful. * These patients have difficulty maintaining friendships because of their continual accusations or thoughts of malevolence, exploitation, deception, and humiliation toward them

Answer 198

* Psychotherapy is the treatment of choice * Group therapy is NOT choice treatment but can help with social skills and to decrease suspiciousness * Anti-anxiety meds for agitation and anxiety * Sometimes low dose antipsychotic medication * Cognitive-Behavioral therapy

Answer 199

Delusional disorder, persecutory type- the patient has systematized, encapsulated non-bizarre delusions: * Systematized: a scheme of actions and concerns that appear logical “only IF” the initial premise of persecution is taken as correct * Encapsulation indicates the activities of the person outside the delusion are not obviously unusual. A patient with Delusional Disorder, Persecutory type evidences circumscribed area of paranoia

Answer 200

A pattern of detachment from social relationships and restricted range of emotional expression

Answer 201

1. Neither desires nor enjoys close relationships 2. Almost always chooses solitary activities 3. Has little, if any, desire for a sexual experience with another person 4. Takes pleasure in few, if any, activities 5. Lacks close friends or confidants other than first-degree relatives 6. Appears indifferent to the praise or criticism of others 7. Shows emotional coldness, detachment, or flattened affect

Answer 202

* Pervasive social inhibition * Social needs are repressed to ward off aggression

Answer 203

* May appear as constricted, aloof, or inappropriately serious * May avoid spontaneous speech, use occasional odd metaphors but can abstract/interpret proverbs

Answer 204

* Psychotherapy (These individuals may be introspective) * Low dose anti-psychotics (still, not considered psychotic), low dose antidepressants (With serotonergic meds may become less sensitive to rejection), low dose psychostimulants * Group Therapy

Answer 205

* Paranoid Personality Disorder- the patient is involved with others * Schizotypal Personality Disorder- the patient exhibits oddities and eccentricities of manners * Avoidant Personality Disorder- the patient is isolated but WANTS to be involved with others

Answer 206

* Prefer to do things alone * Why bother? Who cares? * Withdrawn and reclusive * May work below potential and/or may show considerable creativity * Lacks interests or hobbies * Little apparent desire to pursue relationships * Goes through the motions but is aloof, distant, and cold * Emotionally constricted

Answer 207

A pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior

Answer 208

1. Ideas of reference 2. Odd beliefs or magical thinking 3. Unusual perceptual experiences 4. Odd thinking and speech 5. Suspiciousness or paranoid ideation 6. Inappropriate or constricted affect 7. Behavior or appearance is odd, eccentric or peculiar 8. Lack of close friends or confidantes other than first degree relatives 9. Excessive social anxiety that does not diminish with familiarity

Answer 209

* These people are overtly odd and eccentric * When test with Rorschach they answer like a person with a thought disorder * Abnormal saccadic eye movements with poor eye tracking * Diminished brain mass, especially in the temporal lobe

Answer 210

* Rarely seek treatment for their personality eccentricities alone * Usually an acute stressor or the encouragement of a family member brings them in “for help” * In response to stress, these individuals may experience periods of psychosis that last from minutes to hours. These episodes are referred to as micropsychotic episodes. * Last less than 24 hours and therefore do not meet criteria for a Brief Psychotic Disorder

Answer 211

* Psychotherapy * Low dose anti-psychotics (to deal with ideas of reference/illusions) * Antidepressants if depression occurs

Answer 212

Paranoid Personality Disorder- the patient is suspicious and guarded Schizoid Personality Disorder- the patient has no particular eccentricities Borderline Personality Disorder- the patient shows emotional instability, int ensity and impulsiveness Schizophrenia- the patient is out of touch with reality; has true thought disorder

Answer 213

A pervasive pattern of disregard for and the violation of others, occurring since age 15 years, as indicated by three or more of the following: 1. Failure to conform to social norms with respect to lawful behaviors 2. Deceitfulness 3. Impulsivity or failure to plan ahead 4. Irritable or aggressive 5. Reckless disregard for safety of self and others 6. Consistently irresponsible 7. Has no remorse for behavior or its consequences

Answer 214

* Must be 18 years of age (If not, use Conduct Disorder * There is evidence of a conduct disorder with onset before the age of 15 years * The disorder involves maladaptive behavior in which the patient does not recognize the rights of others-> It is not synonymous with criminality (even though criminals may have this disorder)

Answer 215

Mask of Sanity * May appear trustworthy but commonly manipulative, cunning, and calculating Criminal or dishonest activities are common * Lying, truancy * History of violence or have potential for violence

Answer 216

* Lack remorse for actions * Impulse dyscontrol and failure to plan * Characteristically show a lack of sensitivity to others * Irritability and aggression are common * Deceit and irresponsibility are a way of life * Disregard for the safety of others and themselves

Answer 217

History of brain damage somewhat common (may see abnormal EEG and/or soft neurologic signs * Perinatal brain injury * Head trauma * Encephalitis (Affecting the frontal lobe) History of parental abandonment or abuse very common

Answer 218

1. Frantic efforts to avoid real or imagined abandonment 2. Unstable and intense interpersonal relationships (alternating between idealization and devaluation). 3. Identity disturbance 4. Impulsivity in at least 2 areas that are potentially self-damaging 5. Recurrent suicidal behavior, gestures, threats or self-mutilating behavior 6. Affect instability (Unstable mood) 7. Chronic feelings of emptiness 8. Inappropriate intense anger or difficulty controlling anger 9. Transient, stress related paranoia or dissociation

Answer 219

* Patients are impulse-ridden with associated ego deficits in planning and judgment-> Superego deficits or lacunae * Conscience is primitive or poorly developed * Object relational difficulties are significant-> Failure with love, empathy(lack it), basic trust * Aggressive features often prominent * May see sadomasochism, narcissism, and depression

Answer 220

* Separation-individuation problems * Affective control problems * Intense, personal attachments * Self-image problems

Answer 221

* Many episodes of having a crisis * Mini-psychotic episodes are possible, often with paranoia or transient dissociative symptoms * Self-destructive, self-mutilating acts * Suicidal threats ,gestures, or acts * Relationships are tumultuous * Intolerant of being alone and driven by object hunger * Engage in efforts to avoid real or imagined abandonment

Answer 222

* May be easily enraged * Often manipulative, sometimes transparently so * Self-image and identity are unstable * Impulsive with regard to money and sex * Engage in substance abuse, reckless driving, or binge eating * Mood reactivity. Affect storms * Pan-anxiety * Chaotic sexually

Answer 223

Splitting: Patient manifests rage without a consciousness of ambivalent or positive emotions toward someone. It is usually transient. An associated feature is the ability to divide persons into those who like and those who hate the patient, and into those who are all "good" or all "bad". Primitive idealization

Answer 224

* Patient attributes idealized positive or negative features to another person, then seeks to engage the other in various interactions that confirm the patient's belief * Patient tries, unconsciously, to induce the therapist to play the projected role

Answer 225

Marked fear of abandonment Object constancy is impaired * Results in a failure of internal structuring and control * Self-hate and loathing * Generalized ego dysfunction resulting in identity disturbances

Answer 226

Psychotherapy DIALECTICAL BEHAVIORAL THERAPY (DBT) * A cognitive behavioral model * Core mindfulness * Interpersonal Effectiveness * Emotion Regulation * Distress Tolerance * Develop strategies to self-soothe

Answer 227

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts

Answer 228

1. Patient is uncomfortable when he or she is not the center of attention 2. Sexually seductive or provocative 3. Rapidly shifting and shallow expression of emotions. 4. Self dramatization, theatricality, exaggerated expression of emotion 5. Speech is excessively impressionistic and lacking in detail 6. Consistently uses physical appearance to draw attention to oneself 7. Suggestible 8. Considers relationships to be more intimate than they actually are

Answer 229

Psychotherapy * Assistance in clarifying individual’s feelings important because these patients are frequently unaware of their true feelings Pharmacotherapy * Antidepressants for depression and somatic complaints. Antianxiety meds for anxiety. * Antipsychotics for derealization and illusions

Answer 230

Pattern of grandiosity, heightened sense of self importance, preoccupation with fantasies of ultimate success and self image, and disturbance in interpersonal relationships

Answer 231

1. Grandiose sense of self importance 2. Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love 3. Believes that he or she is special and can only be understood by other high ranking or special people 4. Requires excessive admiration 5. Sense of entitlement 6. Interpersonally exploitative 7. Lacks empathy 8. Often envious of others or believes that others are envious of him/her 9. Shows arrogant, haughty behavior or attitudes

Answer 232

* Common cited factor is failure in maternal empathy with early rejection or loss * Psychodynamics: Grandiosity and empathic failure defend against primitive aggression. Grandiosity compensates for sense of inferiority

Answer 233

* Patients have grandiose sense of self-importance (in fantasy or in behavior) * Great need for admiration * Lack empathy * Chronic, intense envy * Handle criticism or defeat poorly- become enraged or depressed * Fragile self-esteem and interpersonal relationships

Answer 234

Characterized by perfectionism, orderliness, inflexibility, stubbornness, emotional constriction, and indecisiveness

Answer 235

1. Preoccupied with details, rules, lists, order, organization, etc 2. Perfectionism that interferes with task completion 3. Excessively devoted to work with the exclusion of leisure activities and friendships 4. Over-conscientious, scrupulous and inflexible about matters of morality, ethics, or values 5. Unable to discard worn-out or worthless objects even when they have no sentimental value 6. Reluctant to delegate tasks to others unless they submit to doing things exactly his or her way 7. Hoards money (miserly spending) 8. Rigid and stubborn

Answer 236

Backgrounds of harsh discipline Psychodynamics * Isolation, reaction formation, undoing, intellectualization, and rationalization * Distrust of emotions * Issues of defiance and submission psychologically important * Fixation in anal period

Answer 237

* Have stiff, formal and rigid demeanor * Lack spontaneity and have serious mood * Preoccupied with rules, regulations, orderliness, neatness, and details * Lack interpersonal skills * Lack sense of humor, alienate people and difficulty compromising * Eager to please powerful figures and carry out their wishes in authoritarian way

Answer 238

* Patient who has obsessive-compulsive disorder has true obsessions or compulsions. * Patient with personality disorder does not actually have true obsessions or compulsions

Answer 239

* Timid (shy) personality * Intense sensitivity to rejection * NOT asocial and show great desire for companionship * But strong need for reassurance and guarantee will be accepted and not criticized * Often described as having inferiority complex

Answer 240

1. Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval or rejection 2. Unwilling to become involved with others unless certain of being liked 3. Shows restraint with intimate relationships because of fear of shame or ridicule 4. Preoccupied with being criticized or rejected in social situations 5. Inhibited in new interpersonal situation because of feelings of inadequacy 6. Views self as socially inept, personally unappealing, inferior to others 7. Reluctant to take personal risks or to engage in any new activity for fear of embarrassment

Answer 241

* Patients are dependent and submissive. * Lack self confidence * Get others to assume responsibility for major areas of life

Answer 242

1. Difficulty making everyday decisions without an excessive amount of advice or reassurance from others 2. Needs others to assume responsibility for major areas of his or her life 3. Difficulty expressing disagreement because of fear of loss of support or approval 4. Difficulty initiating new projects 5. Goes to excessive lengths to obtain nurturance or support (volunteers to do things that are unpleasant) 6. Feels uncomfortable when alone 7. Urgently seeks another relationship when one relationship ends 8. Unrealistically preoccupied with fears of being left alone

Answer 243

Psychodynamics * Unresolved separation anxiety * Dependent stance is defense against regression Intense need to be taken care of Clinging behavior Fear of separation Interpersonal dependency

Answer 244

Psychogenic Nonepileptic Seizure (PNES, Pseudoseizure) Seizure-Like Symptoms without abnormal electrical activity

Answer 245

Risk factors: * Traumatic Brain Injury * Sexual Trauma Causes: * Anxiety Disorder: Panic Attacks and Post-Traumatic Stress Disorder * Conversion Disorder * Acute stress response

Answer 246

Pseudoseizures (or Psychogenic Seizures, PNES) are not Malingering Patients having Psychogenic Seizures typically do not know this is happening PNES diagnosis does not exclude neurologic Seizures * PNES can coexist with Epilepsy and neurologic Seizures

Answer 247

* Gradual onset and last 2-3 minutes (contrast with 1 minute for typical Seizure) * Waxing and waing course (contrast with rhythmic periodicity of Seizure) * Recur frequently * Typically lacks the postictal period of Seizure Disorder

Answer 248

* Resistance to multiple antiepileptic agents * Emotional or situational triggers * Postictal crying * May remember episode (contrast with Seizure where there is no memory of the episode)

Answer 249

Prolonged Seizure * Oxygen Saturation falls * End-Tidal CO2 rises Prolonged Psychogenic Seizure * Oxygen Saturation remains normal * End-Tidal CO2 remains normal

Answer 250

* Typical Seizure as confirmed by witnesses of Seizure * No corresponding EEG abnormalities * Interrater reliability of EEG monitoring is poor

Answer 251

* Postictal Serum Prolactin * Tongue-biting, self-injury or Incontinence * Psychological Testing * Outpatient Electroencephalogram

Answer 252

Acute Seizure management * Start with Benzodiazepines (as with Status Epilepticus) Interdisciplinary approach * Psychogenic Seizure cannot be fully differentiated from epileptic Seizure without EEG Mental Health * Cognitive Behavioral Therapy may reduce PNES events in the short term

Answer 253

* Characterized by the presence of obsessions and/or compulsions * Obsessions: Recurrent and persistent thoughts, urges, or images that are intrusive and unwanted * Compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be rigidly applied.

Answer 254

These disorders differ from developmentally normative preoccupations and rituals * Are excessive * Persist beyond developmentally appropriate periods

Answer 255

Symptom dimensions (or themes) in OCD common to many individuals with disorder * Cleaning (contamination obsessions and cleaning compulsions) * Symmetry (Symmetry obsessions and repeating, ordering, and counting compulsions) * Forbidden or taboo thoughts (e.g., aggressive, sexual, and religious obsessions and related compulsions)

Answer 256

Some individuals with OCD have tics. * Up to 30% have lifetime tic disorder * Most common in males with onset of OCD in childhood The tic related specifier is used when an individual has a current or past history of a tic disorder. Is a difference with those with OCD and tics and those with OCD and no tics

Answer 257

Presence of obsessions, compulsions, or both

Answer 258

* Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress * The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e. by performing a compulsion)

Answer 259

* Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly * The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation. However, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive

Answer 260

The obsessions or compulsions are time-consuming (take more than 1 hr/day) or cause clinically significant distress or impairment in social, occupational, or other imp areas of functioning

Answer 261

* With good or fair insight: Individual recognizes that OCD beliefs are definitely or probably not true or that they may or may not be true. * With poor insight: The individual thinks OCD beliefs are probably true. * With absent insight/delusional beliefs: The individual is completely convinced that OCD beliefs are true

Answer 262

* An inflated sense of responsibility * Tendency to overestimate threat * Perfectionism * Intolerance for uncertainty * Over-importance of thoughts (e.g., believing that having a forbidden thought is as bad as acting on it) * The need to control thoughts

Answer 263

Individuals with OCD experience wide range of affective responses when confronted with situations that trigger obsessions and compulsions: * Marked anxiety and even panic attacks * Strong feelings of disgust * Distressed sense of “incompleteness” or uneasiness until things look, feel, or sound “just right”

Answer 264

May avoid people, places, or things that trigger obsessions or compulsions: * Ex: individuals with contamination concerns might avoid public situations (e.g., public restrooms, restaurants)

Answer 265

* Ob-comp personality involves enduring and pervasive maladaptive pattern of excessive perfectionism and rigid control * The ob-comp personality does not have intrusive thoughts, images, or urges or repetitive behavior performed in response to an intrusive thought

Answer 266

* Cognitive Behavioral Therapy-Mainstay * Exposure and Desensitization over 13-20 week period * Increasingly expose patient to avoided stimulus * Response prevention * Prevented from performing associated rituals * Thought stopping

Answer 267

* Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others * At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g. mirror checking, excessive grooming, skin picking, reassurance seeking ) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns

Answer 268

The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder

Answer 269

Individuals preoccupied with one or more perceived flaws in physical appearance- * Think are ugly, abnormal, or deformed * Can be extreme: Think look hideous or like a monster Focus on one or many body areas * Skin most common * Hair- thinning/excessive body or facial hair * Nose

Answer 270

* Preoccupations intrusive, unwanted, time consuming (on average 3-8 hours/day) * Feel driven to repetitive behavior that are not pleasurable and may increase anxiety and dysphoria * May camouflage with makeup, clothing * Compulsive skin picking to improve perceived skin defects

Answer 271

* Muscle dysmorphia * Occurs almost exclusively in males * Preoccupied with idea one’s body to small or insufficiently lean or muscular * Actually have normal-looking body/may be muscular * May be preoccupied with other body areas- skin or hair * Will diet, exercise, and/or lift weights excessively (sometimes cause damage) * May use dangerous anabolic steroids/other substances to make body bigger and more muscular * Generally poor insight

Answer 272

Many individuals have ideas or delusions of reference: * Other people take special notice of them or mock them because of how they look Many have high levels of anxiety, social anxiety, social avoidance, depressed mood, low self esteem Often seek dermatologic Rx and surgery

Answer 273

Associated with executive dysfunction and visual processing abnormalities * Have bias for analyzing and encoding details rather than holistic aspect of visual stimuli

Answer 274

Major Depression is most common comorbid disorder- onset usually AFTER that of body dysmorphic Disorder

Answer 275

Treating the physical "defect" does not resolve Body Dysmorphic Disorder Pharmacotherapy is similar to Obsessive Compulsive Disorder * Selective Serotonin Reuptake Inhibitors (SSRIs)-> requires high end of dosing range * Clomipramine (Anafranil)

Answer 276

* Persistent difficulty discarding or parting with possessions, regardless of their actual value * This difficulty is due to a perceived need to save the items and to distress associated with discarding them * The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use

Answer 277

Specify if with excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed for which there is no available space * Individuals acquire through excessive collecting, buying, or stealing

Answer 278

* Indecisiveness, perfectionism, avoidance, procrastination, difficulty planning and organizing tasks, and distractibility * Animal hoarding- accumulation of large number of animals and a failure to provide minimal standards of nutrition, sanitation, and veterinary care and to act on deteriorating condition of animals

Answer 279

* Recurrent pulling out of one’s hair, resulting in hair loss * Repeated attempts to decrease or stop hair pulling

Answer 280

Essential feature is the recurrent pulling out of one’s own hair * From any region of body * Most common sites-scalp, eyebrows, eyelids * Less common sites-axillary, facial, pubic. And peri-rectal regions

Answer 281

* Hair pulling may be accompanied by a range of behaviors or rituals involving hair * May search for a particular kind of hair to pull (certain texture or color) * May tried to pull out hair in specific way: e.g., root intact * May visually or tactiley examine or orally manipulate the hair-including biting it or swallowing

Answer 282

* May be preceded or accompanied by various emotional states * Maybe triggered by feelings of anxiety or boredom * May be preceded by an increasing sense of tension * May lead to gratification, pleasure, or a sense of relief when the hair is pulled out

Answer 283

* Some focus their attention on the hair pulling (with preceding tension and subsequent relief) * Some display more autonomic behavior(occurs without full awareness) * Some report a mix of both behavioral styles * Some experience an itch-like or tingling sensation in the scalp alleviated by act of pulling

Answer 284

* Tonsure trichotillomania-pattern of nearly complete baldness except for a narrow perimeter on the outer margins of the scalp, particularly at the nape of the neck * Eyebrows and eyelashes may be completely absent

Answer 285

* Some individuals have urge to pull hair from others * Some may pull hair from pets, dolls, and other fibrous material(e.g., carpets, sweaters) * Majority of individuals also have one or more other body-focused repetitive behaviors- skin picking, nail biting, and lip chewing

Answer 286

* Hair pulling may be seen in infants->Typically resolves during early development * Onset most commonly coincides her follows the onset of puberty * Course is chronic.-> Minority remitted without subsequent relapse within a few years of onset

Answer 287

Skin biopsy and dermoscopy (noninvasive method that allows the in vivo evaluation of the epidermis can differentiate disorder from other causes of alopecia

Answer 288

* Damage to hair growth and hair quality may be irreversible * Infrequent medical consequences include-digit purpura, musculoskeletal injury (e.g.carpal tunnel syndrome; back, shoulder, and neck pain). * Hair swallowing (trichophagia) may lead to trichobezoars,with subsequent anemia, abdominal pain, hematemesis, nausea and vomiting, bowel obstruction, and even perforation

Answer 289

* recurrent skin picking resulting in skin lesions * Repeated attempts to decrease or stop skin picking * Essential feature is recurrent picking at one’s own skin * Most commonly picked sites of the face, arms, and hands. Many pick from multiple body sites * Most use fingernails; mainly used tweezers pins or other objects ## Footnote Make pick at healthy skin, at minor skin irregularities, at lesions such as pimples or calluses, or at scabs from previous picking

Answer 290

* May also be skin rubbing, squeezing, lancing, and biting * Significant amounts of time spent on picking behavior, sometimes several hours per day. May go on for months and years * Often attempt to conceal or camouflage lesions * May cause a feeling a loss of control, embarrassment, and shame

Answer 291

* May be accompanied by a range of behaviors or rituals involving skin or scabs * Make examine, play with, or mouth or swallow the skin after it has been pulled * May be preceded or accompanied by various emotional states: Triggered by feelings of anxiety or boredom, may be preceded by increasing sense of tension, and lead to gratification, pressure or a sense of relief when skin or scab picked

Answer 292

* Onset most often during adolescence, coinciding with the onset of puberty. Usually begins with a dermatological condition such as acne. Sites of skin picking may vary over time * Course is chronic with waxing and waning if untreated * May, and go for weeks, months, or years of the time

Answer 293

* Majority of individuals spend at least one hour per day picking, thinking about picking, and resisting urges to pick * Medical complications include tissue damage, scarring, and infection and can be life threatening * Rarely, synovitis of the wrists can occur * Frequently requires antibiotic treatment for infection On occasion may require surgery

Answer 294

Obsessions, compulsions, skin picking, hair pulling, other body-focused repetitive behaviors, or other symptoms characteristic of the obsessive-compulsive and related disorders predominate in the clinical picture

Answer 295

There is evidence from history, physical examination, or laboratory findings of both (1) and (2) 1. The symptoms in criterion A developed during or soon after substance intoxication or withdrawal or after exposure to medication 2. The involved substance/medication is capable of producing the symptoms in criteria A

Answer 296

* The disturbance is not better explained by an obsessive-compulsive and related disorder that is not substance/medication induced * The disturbance does not occur exclusively during the course of a delirium

Answer 297

With onset during intoxication With onset during withdrawal With onset after medication use * Must have its onset while the individual is receiving the medication * Once treatment is discontinued, symptoms usually improve or remit within days to several weeks to one month * If symptoms persist longer than one month from the time of severe intoxication or withdrawal

Answer 298

Use with: * Stimulants(including cocaine) * Heavy metals and toxins Urine toxicology useful to measure substance intoxication as part of assessment

Answer 299

* Obsessions, compulsions, preoccupations with appearance, hoarding, skin picking, hair pulling, or other body-focused repetitive behaviors, or other symptoms characteristic of obsessive-compulsive and related disorder predominate in the clinical picture * There is evidence from history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical * Not better explained by another mental disorder

Answer 300

* With obsessive-compulsive disorder-like symptoms * With the parent’s preoccupations * With hoarding symptoms * With hair-pulling symptoms * With skin- picking symptoms

Answer 301

* Neurological manifestation of rheumatic fever * Due to group A streptococcus infection * Motor and non-motor features * May present with obsessive-compulsive disorder-like symptoms

Answer 302

Postinfectious autoimmune disorder characterized by the sudden onset of obsessions compulsions and/or tics accompanied by a variety of acute neuropsychiatric symptoms Because of controversial diagnosis, renamed “pediatric acute-onset neuropsychiatric syndrome” (PANS)

Answer 303

* Tic disorder and/or OCD behaviors-> Often begins with acute anxiety and increases over time * Pediatric onset from 3 years to puberty * Onset temporally related to strep infection or presence of undetected strep infection * May observe neurological abnormalities and/or choreaform/random body or facial movements * Treatment: antibiotics, sometimes long term

Answer 304

Mild presentation * abrupt onset with hyperactivity, agitation, tics, anxiety issues that are OCD-like. * Symptoms rapidly diminish with antibiotics Acute presentation * Appears suddenly * Looks like acute encephalitic-like illness: psychotic thoughts, terror, intense anxiety, suicidal comments

Answer 305

* Can present as a classic triad of inattention, hyperactivity and impulsivity * Some individuals only inattentive; some primarily hyperactive

Answer 306

Actually ADHD is a disorder of INCONSISTENT attention * Sometimes there is hyper attention * Other times there is inability to sustain attention Affected individuals have poor impulse control, speak before they think, and are easily distracted. Many are disorganized and find it difficult to focus, especially in areas that are not of particular interest or in environments where there is a lot of noise or things going on

Answer 307

Symptoms of inattention must be present for 6 months To satisfy criteria for dx: * Children require 6 of 9 possible sxs under inattention * Adults require 5 of 9 possible sxs under inattention

Answer 308

Hyperactivity and impulsivity * 6 (or more) sxs for at least 6 months * 5 (or more) sxs for anyone 17 years and older Several inattentive or hyperactive-impulsive sxs must have been present prior to age 12 years

Answer 309

* Must distinguish it from worry, rumination, internal stimuli due to anxiety and /or depression * Disruptive mood dysregulation disorder- do not see impulsivity and disorganized behavior as in ADHD * ADHD not characterized by fears of abandonment , self injury, extreme ambivalence as might see in personality disorder

Answer 310

Genetic disorders * Fragile X syndrome * Glucose-6-phosphate dehydrogenase deficiency * Phenylketonuria Brain Injury * Trauma * Infection

Answer 311

ADHD is a life concern not (just) a school problem There are issues about safe driving (they are reckless), likelihood of abusing drugs, self medicating, being accident prone, and having difficult interpersonal relationships. (Some individuals with ADHD manifest irritability)

Answer 312

Behavioral and Family Therapy is first line treatment for ADHD Psychostimulants * Methylphenidate (Ritalin) * Long-acting methylphenidate preparations (Concerta, Metadate CD, Ritalin LA) * Dextroamphetamine (Dexedrine): Adderall- a long acting dextroamphetamine compound, Adderall XR- a longer acting dextroamphetamine and Vyvanse- only active when it is in gut * Cylert (magnesium pemoline)- not used very much because of liver toxicity

Answer 313

Essential feature is persistent impairment in reciprocal social communication and social interaction across multiple contexts * This impairment is pervasive and constant Many demonstrate absent speech or delay in onset of speech Communication may be impaired even when formal skills, (vocabulary and grammar) intact

Answer 314

Obvious deficits in social-emotional reciprocity * Young children my show little or no initiation of social interaction and no sharing of emotions Early finding- poor or absent eye contact

Answer 315

* Child demonstrates restricted, repetitive patterns of behavior, interests, or activities (e.g., prefers rigid routines and fixed ways of doing things) * May exhibit stereotyped or repetitive behaviors (e.g., hand flapping; finger flicking)

Answer 316

Excessive adherence to routines and restricted patterns of behavior = * Resistance to change * Ritualized patterns of verbal or nonverbal behavior (e.g., repetitive questions) Abnormal, restricted, intensive and fixated interests (preoccupation with lawn mower)

Answer 317

Unusual high or low levels of reactivity : extreme responses to specific sounds or textures, excessive smelling or touching objects, fascination with lights or spinning objects, (sometimes) indifferent to heat, cold, pain

Answer 318

* Symptoms manifest early in life. * Core diagnostic features evident in developmental period * Must be differentiated from intellectual disability and global developmental delay because they can be associated with communication difficulties

Answer 319

* Insistence on routines and aversion to change and sensory sensitivities affect eating, sleeping, dental appointments, haircuts, etc. a challenge * Rigidity and difficulty with new situations may limit independence in even very intelligent individuals with this disorder

Answer 320

* Rett’s Disorder * Childhood Disintegrative Disorder * Asperger’s Disorder * Pervasive Developmental Disorder

Answer 321

* Now incorporated under Autism Spectrum Disorder * Normal pregnancy and delivery * Grow and behave normally for the first six months * First sign is smaller than normal head. Later delayed growth in other parts of body.

Answer 322

Brain growth slows after birth Significant loss of movement (motor) skills between 12 and 18 months * 1st sign include decrease in hand control and ability to crawl or walk normally

Answer 323

* Develop abnormal hand movements- hand wringing, squeezing, clapping, tapping * Unusual eye movements: blinking, staring intensely * Breathing issues (while awake): breath-holding, hyperventilation, forceful exhalation of air or saliva * Increasing agitation and irritability. Long periods of crying and screaming

Answer 324

* Sudden, odd facial expressions * Long bouts of laughter * Thought to occur primarily in girls. Boys who have the same genetic mutations usually do not survive beyond infancy * Commonly develop seizures: spasms- epilepsy * Scoliosis (begins between age 8- 10 years * Irregular heart rhythm ## Footnote Life long help

Answer 325

* Named the sleep phase associated with slow rolling rhythmic eye movements non-rapid eye movements (NREM) sleep * Sleep phase associated with the fast erratic eye movements (REM) * Dement and Kleitman (1955) discovered that REM sleep was associated with dreaming

Answer 326

Electroencephalogram (EEG) – a recording of the electrical activity of cortical neurons via scalp electrodes that are placed at standardized positions

Answer 327

* Polysomnograpy is the method used to objectively evaluate sleep. * Involves simultaneous recording of multiple physiological variables in a standardized fashion known as a polysomnogram

Answer 328

* Electroencephalogram (EEG) – a recording of the electrical activity of cortical neurons via scalp electrodes that are placed at standardized positions * Electrooculogram (EOG) – a recording of eye movements * Electrocardiogram (ECT) – a recording of heart rhythm * Electromyelogram (EMG) – a recording of the activity of the left and right tibialis anterior muscles and the submental chin muscles * Respiratory effort – a recording of nasal and oral airflow * Pulse oximetry – a recording of oxygen saturation * Snore monitor – a recording of snoring

Answer 329

* In normal health individuals, this cycle begins with NREM 1 and progresses to NREM 2, 3, 4, 3, 2 and then REM * The pattern repeats itself at 90 and 120 minute intervals

Answer 330

* NREM 3 and 4 are most prominent in the first half of the night * REM sleep is less prominent in the first half of the night and increases as the night progresses * Sleep latency is the time from lights out to the first NREM 2. Normal sleep latency is 10-20 minutes

Answer 331

* REM latency is the time from sleep onset until the first REM. Normal REM latency is 90-100 minutes * Sleep architectures is the pattern and distribution of sleep stages across an average night

Answer 332

* The “biological clock” is an endogenous rhythm of bodily functions that is influenced by environmental cues. * This cycle is unique to each person, averages 25 hours but can be as long as 50 hours for some

Answer 333

* Infants spend more than 2/3 of the day sleeping whereas adults spend less than 1/3 * The elderly experience a reduction in the intensity, depth, and continuity of sleep

Answer 334

* Increased sleep latency * Reduced NREM 3 and 4 * Reduced REM latency * Reduced total REM amount * Frequent awakenings * Decreased sleep awakenings.

Answer 335

primary sleep disorders that results in complaints of either sleeping too little (insomnia) or too much (hypersomnia)

Answer 336

Primary insomnia – insomnia is the subjective complaint of deficient, inadequate, or unrefreshing sleep. To qualify as a primary insomnia, there must be objective daytime sleepiness and/or subjective feelings of not being rested.

Answer 337

* Sleep-state misperception – also known as subjective insomnia or non-restorative sleep. Sufferers complain of inadequate and/or poor sleep, but objective findings on the polysomnogram are lacking * Idiopathic insomnia – chronic insomnia present from childhood

Answer 338

Primary Hypersomnias – The hallmark of all primary hypersomnias is the complaint of somnolence and excessive daytime sleep * Recurrent hypersomnia – also known as Kleine-Levin syndrome is a rare, often self-limiting condition that primarily affects adolescent males. Symptoms include hypersomnia, hyperphagia, and hypersexuality

Answer 339

defined by the following: Sleep paralysis that occurs upon falling asleep or waking up, sleep attacks with sleep-onset REM periods (SOREMPs) which are usually brief, cataplexy (a condition of sudden and transient bilateral weakness or paralysis) triggered by strong emotions, hypnagogic hallucinations

Answer 340

Circadian Rhythm Disorders – emerge which societal expectations conflict with an individual’s preferred circadian rhythm. I.e. jet lag syndrome, shift-work sleep phase disorder (“night owls”), advanced sleep phase disorder (“larks”), and non-24 hour day

Answer 341

Periodic limb movement disorder – common dyssomnia affecting 40% of people over the age of 65 years, and 11% of people complaining of insomnia * Brief (0.5-5sec) stereotypic contractions of the lower limbs at intervals of 20-60 sec * Dopamine agonists (L-dopa, pergolide, bromocriptine) and benzodiazepines (clonazepam) provide some relief

Answer 342

* Restless leg syndrome (RLS) – is a movement disorder characterized by deep sensations of creeping or aching inside the calves when lying or sitting that produce an overwhelming urge to move them * Post-traumatic hypersomnia – hypersomnia that occurs within one year of a head trauma * Idiopathic hypersomnia – hypersomnia of unknown origin

Answer 343

Parasomnias are sleep disorders in which undesired activities are performed during sleep; they arise during specific sleep stages or at the transition between wakefulness and sleep

Answer 344

Wake-sleep transition disorders * Sleep Starts - Hypnogogic jerks involve involuntary contractions of the legs and/or arms at the moment in which the individual enters sleep * Rhythmic Movement Disorder (jactatio capitus nocturna) – involves head-banging at sleep onset

Answer 345

Light sleep stage disorders – arises during NREM 1 and 2 and includes Sleep talking and bruxism * Sleep-talking (somniloquism) – vocalization ranging from simple words and phrases to complete conversations. * Bruxism – repeated tooth-grinding during sleep

Answer 346

NREM sleep disorders – occurs mainly during NREM 3 and 4 (slow wave) sleep. The most commonly encountered NREM sleep disorders include sleepwalking and night terrors.

Answer 347

Sleep walking (somnambulism) – occurs predominantly during the first third of the night and upon partial emergence from delta sleep * Individuals may walk for some distance and carry out semi-purposeful activities such as running and eating * While most patients are quite adept at avoiding obstacles, serious accidents, such as tripping or falling out of open windows, have been reported * Sufferers are frequently unresponsive to efforts to wake them, and once awakened, are amnestic to the event * Sleep walking begins in childhood and often resolves by adolescence

Answer 348

Night terrors (pavor nocturnus) – like sleep walking occur during partial arousal from delta sleep but can begin in NREM 2 * Patients generally scream, flail about, sit up in bed, and experience autonomic activity, including tachypnea, tachycardia, and mydriasis * Episodes last 1-10 minutes, tape place early in the night, when NREM duration is at the longest * Patients are often amnestic to the episode * In children is not associated with psychiatric illness; in adults it can be associated with PTSD, Generalized anxiety disorder, and borderline personality disorder

Answer 349

arises exclusively during REM sleep and includes nightmare disorder and REM behavior disorder

Answer 350

Nightmare disorder – terrifying dreams whose content is often remembered by the patient. * Unlike sleep terror, nightmare disorder lacks autonomic arousal, frequently occurs late in the night as REM intervals increase, and demonstrates muscle atonia

Answer 351

REM behavior disorder – patients appear to be acting-out dream content through simple to quite complex movements that result from the loss of muscle atonia during REM sleep * In contrast to sleep walking which occurs during the night during delta sleep, REM behavior disorder occurs during the second half of the night during REM sleep * Patients often recall their dreams in vivid detail * 60% of cases idiopathic; up to 1/3 are due to brainstem pathology and alcoholism * More commonly in the elderly, and affects males nine times more frequenlty than females

Answer 352

Diffuse Sleep Disorders – May occur in any or all sleep stages * Nocturnal enuresis – A condition of involuntary micturition occurs without conscious arousal.-> Affects children more than adults and usually self-limited * Sleep-related seizures – rare entity involving seizures that mainly occur during light NREM sleep and usually the first 2 hours of sleep.

Answer 353

Psychotic disorders – difficulty with sleep initiation and maintenance, which are most common with sleep initiation and maintenance * Total sleep time and sleep efficiency are often decreased * REM is disrupted early in the episode

Answer 354

Mood disorders * Classic findings attributed to depression include early morning awakening, decreased delta sleep, decreased REM latency, a long first REM period, increased REM density, and nocturnal restlessness. With atypical depression, there is often hypersomnia as well as an increase in appetite. Anxiety Disorders – most common psychiatric cause of insomnia. * Increased pre-sleep worry with difficulty initiating sleep, decreased sleep efficiency, and poor sleep maintenance.

Answer 355

Substance-induced sleep disorders – substances whether prescription medications or recreational drugs, can cause a wide range of sleep abnormalities * Generally, if the substance is a CNS depressant, intoxication causes sedation and withdrawal causes insomnia. Likewise, if the substance is a CNS stimulant, intoxication results in insomnia and withdrawal results in sedation * Alcohol is widely used and abused – in acute intoxication, alcohol decreases REM sleep and withdrawal produces insomnia, increases REM sleep, and decreases stages 3 and 4 sleep. Paradoxically, chronic use frequently results in insomnia

Answer 356

Sleep hygiene refers to the practices and habits that are conducive to sleeping well on a regular basis. Physician assistants can play a crucial role in educating patients about effective sleep hygiene to improve their sleep quality and overall health. * Prescribe Hypnotics ONLY as last resort. * Benzo are not sleep aids, they inhibit REM

Answer 357

* Screen: One hour before * Excerise: 3 hours before * Nap: 20-30 mins

Answer 358

* An acute, potentially fatal, idiosyncratic reaction to a neuroleptic medication (which for most part are the antipsychotic medications) * The principal manifestations are due to problems with thermoregulation and skeletal muscle metabolism mediated via central mechanisms

Answer 359

* Exposure to a dopamine antagonists, or withdrawal from dopamine-agonist, within past 72 hours of onset of symptoms * Hyperthermia- Fever ›100.4° F or 38.0º C on at least two occasions * (Extreme) generalized rigidity * Altered mental status * Elevation of creatinine kinase (at least 4 times upper limit of normal)

Answer 360

* Tachycardia (25% above baseline) plus tachypnea (≥50% above baseline) * Blood Pressure Elevation: ≥25% above baseline * Blood Pressure Fluctuation: ≥20 mmHg (diastolic) or ≥ 25 mm Hg (systolic) change within 24 hours

Answer 361

Mental status is ALWAYS altered, typically in form of delirium. Pt may become agitated/combative. May progress to stupor, obtundation, and coma Extreme muscular rigidity described as "lead pipe rigidity" May also observe: * Diaphoresis * Sialorrhea * Dysphagia

Answer 362

Common lab abnormalities * Elevation of CPK (muscle fraction usually massively elevated) * Leukocytosis * Electrolyte disturbances may occur secondarily as well as hypocalcemia, hypomagnesemia,and hypophosphatemia Urinalysis often shows proteinuria and myoglobinuria from rhabdomyolysis CSF normal EEG might show diffuse slowing without focal abnormalities (encephalopathy pattern)

Answer 363

* Anti-dopaminergic activity of antipsychotic medications, particularly D2 receptor antagonism * Involves an interplay between multiple central and systemic pathways and neurotransmitters * All of the antipsychotic medications reported to cause NMS in individuals. No way to know which med/what patient/when * Also some antiemetic medications that are also neuroleptics: prochlorperazine maleate (Compazine) and metoclopramide (Reglan)

Answer 364

* Dehydration; agitation; exhaustion; low serum iron levels * Primary diagnosis of affective disorder (especially Bipolar Disorder and Psychotic Depression) * Concurrent presence of organic brain syndromes- dementia * Higher doses and parenteral administration of neuroleptics, * Rapid titration of dose * Prior history of NMS * Any medical or neurologic illness: Catatonia * Recent history of substance abuse or dependence * Dopamine receptor dysfunction * Basal ganglia dysfunction

Answer 365

* Dehydration from poor oral intake * Acute renal failure from rhadomyolysis * Deep vein thrombosis and pulmonary embolism from rigidity and immobilization * If have to take patient off antipsychotic medication, return of symptoms: psychosis, etc. * Cardiac Arrest * Infection * Aspiration * Respiratory failure * Seizure * Pulmonary embolism * Hepatic failure * Death ## Footnote 10-20% mortality rate-> Higher in individuals who develop severe muscle necrosis and then have rhabdomyolysis

Answer 366

* Clustering of risk factors, dysphagia, and severe diaphoresis early in treatment with neuroleptic medication- consider NMS * Supportive measures to lower temp and ensure good fluid intake are essential * Correct electrolyte abnormality * Monitor for signs of impending respiratory failure secondary to severe muscle rigidity and inability to handle oral secretions

Answer 367

* Dopamine agonists (bromocriptine and amantadine) and/or direct muscle relaxants (dantrolene) * Dopamine agonists in high doses can cause psychosis and/or vomiting * Benzo’s to relax if agitated or catatonic

Answer 368

* 87% individuals who had NMS will be able to tolerate another antipsychotic medication in the future. Recommendation is to switch to different class of antipsychotic when restarting. * Often SGA is preferred choice because it is thought that incidence with newer antipsychotics lower

Answer 369

* intraoperatively and reflects a pharmacogenetic disorder of calcium regulation in skeletal muscle. * Rigidity in malignant hyperthermia does not respond to peripheral-acting muscle relaxants

Answer 370

* Serotonin Syndrome is caused by drug toxicity where there is too much serotonin. * In comparison, Neuroleptic Malignant Syndrome is an idiosyncratic drug reaction involving dopamine

Answer 371

It is a pharmacologic situation characterized by abrupt increases of serotonin in the body and in the central nervous system * Characterized by mental status changes, neuromuscular dysfunction, and autonomic instability

Answer 372

May occur when add a new medication or increase the dose of a medication (causing increase in serotonin) * Most usually occurs within several hours * Mild forms may go away within 24- 36 hours of stopping medication that caused symptoms or stopping a pre-existing medication

Answer 373

* Headache * Diarrhea * Rapid heart rate * Elevated blood pressure * Confusion * **Dilated pupils** * Lose of muscle coordination or muscle twitching * Sweating * Shivering * Goose bumps * Severe: Hyperthermia, seizures, arrhythmias and unconsciousness

Answer 374

Serotonin synthesized from amino acid L-tryptophan. (Serotonin cannot cross blood-brain barrier so need L-tryptophan to take into the CNS) Once synthesized * Serotonin stored in neuronal vesicles or * Metabolized by monoamine oxidase (MAO A or B) to 5-hydroxyindoleacetic acid * (MAO-B has preferential affinity to dopamine)

Answer 375

* MAO-A has preferential affinity to metabolize serotonin * Drugs that inhibit MAO-A have greater risk of causing serotonin syndrome * Serotonin binds 1 of 7 postsynaptic 5- hydroxytryptophan (5-HT) receptors. * Hyper-stimulation of the 5-HT receptors in the brain and/or spinal cord is thought to cause serotonin syndrome.

Answer 376

* If take more than one medication that increases serotonin levels * You take herbal supplements that increase serotonin levels * Use illicit drugs that increase serotonin levels * Individuals whose cytochrome P450 enzyme system does not metabolize or slowly metabolizes a medication that is involved with that enzyme system

Answer 377

Prescription medications Dietary supplements Over-the counter/herbal/complementary/alternative substances. Illicit drugs

Answer 378

* **SSRI**’s- Prevent the reuptake of serotonin released into the synapse. Same for St John’s Wort * SNRI’s :Effexor (venlafaxine); Cymbalta (duloxetine) * Bupropion (Wellbutrin/Zyban) * **Tricyclic antidepressants** * Buspar (buspirone)- Direct stimulation of serotonin receptors * MAOI’s (monoamine oxidase inhibitors)- Prevent metabolism of stored serotonin. Examples included antidepressants such as phenelzine (Nardil), tranylcypromine (Parnate), selegiline transdermal (Ensam). * Anti-migraine medications: Triptans * Pain Medications (by increasing release of stored serotonin): Flexeril (cyclobenzaprine), Duragesic (fentanyl), Demerol (merperidine), and Ultram (tramadol) **Lithium**

Answer 379

* LSD by direct stimulation of serotonin receptors * Ecstasy, cocaine, amphetamines- by increasing the release of stored serotonin * Herbal supplements: St John’s Wort; ginseng. L-tryptophan containing substances: increase production of serotonin by providing increased amount of precursors * Cough and cold medications that contain dextromethorphan- Mucinex DM; Robitussin DM

Answer 380

Anti-nausea medications: Zofran (ondansetron); Reglan (metoclopramide) Antibiotic linezolid (Zyvox) Anti-retroviral medication used to treat HIV/AIDS – Ritonavir (Novir)

Answer 381

* Discontinue offending medications * Cyproheptadine (a serotonin antagonist- blocks serotonin production). Most patients respond to one or two doses * Muscle relaxants for agitation, muscle stiffness, seizures * O2 and IV fluids as needed * Medication for cardiac issues and blood pressure

Answer 382

A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: * The child rarely or minimally seeks comfort when distressed * The child rarely or minimally responds to comfort when distressed

Answer 383

* Minimal social and emotional responsiveness to others * Limited positive affect * Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers

Answer 384

* Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults * Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g. frequent changes in foster care) * Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g. institutions with high child-to-caregiver rations

Answer 385

* Disturbance is evident before age 5 years * Child has a developmental age of at least 9 months

Answer 386

* These children rarely or minimally turn preferentially to an attachment figure for comfort, support, protection, or nurturance * Essential feature: absent or grossly underdeveloped attachment between child and (putative) caregiving adults * These children have potential to form selective attachments * They do not expect and respond only minimally to comfort from caregivers * Exhibit compromised emotional regulation-> Display episodes of negative emotions of fear, sadness, or irritability that are not readily explained

Answer 387

Neglect, malnutrition, cognitive delays, language delays, stereotypies

Answer 388

A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following: * Reduced or absent reticence in approaching and interacting with unfamiliar adults * Behavior (that is not consistent with culturally sanctioned and age-appropriate social boundaries) * Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings * Willingness to go off with an unfamiliar adult with minimal or no hesitation

Answer 389

The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following * Social neglect or deprivation in form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults * Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g. frequent changes in foster care) * Rearing in unusual settings that severely limit opportunities to form selective attachments ## Footnote The child has a developmental age of at least 9 months

Answer 390

* Essential feature is pattern of behavior that involves culturally inappropriate, overly familiar behavior with relative strangers. * The overly familiar behavior violates the social boundaries of the culture * Not uncommon to present with no current signs of neglect (shared etiological association with social neglect) because signs of the disorder often persist even after signs of neglect no longer present

Answer 391

* Social neglect often present in first months of life (before dx made) * No evidence that neglect beginning after age 2 years is associated with manifestations of the disorder * Indiscriminate social behavior and lack of reticence with unfamiliar adults in toddlerhood accompanied by attention-seeking behaviors in preschoolers.

Answer 392

When disorder persists into middle childhood, clinical features = verbal and physical overfamiliarity as well as inauthentic expression of emotions (especially apparent when child interacts with adults) Peer relationships most affected in adolescence * Indiscriminate behavior * Conflicts

Answer 393

* Recurrent, involuntary and intrusive distressing memories of the traumatic event. * Children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed * Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic events *Children may have frightening dreams without recognizable content * Dissociative reactions (e.g. flashbacks) in which individual feels or acts as if traumatic event(s) were recurring (Could occur on continuum with most extreme expression being complete loss of awareness of present surroundings) * Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) * Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)

Answer 394

* Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) * Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

Answer 395

* Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs) * Persistent and exaggerated negative beliefs or expectations about oneself, other or the world (e.g., “I am bad, “No one can be trusted,” “ The world is completely dangerous,”,” My whole nervous system is permanently ruined”.) * Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others * Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame) * Markedly diminished interest or participation in significant activities * Feelings of detachment or estrangement from others * Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings)

Answer 396

* Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects * Reckless or self-destructive behavior * Hypervigilance * Exaggerated startle response * Problems with concentration * Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep

Answer 397

Duration of disturbance (Criteria B,C,D,and E) is more than 1 month

Answer 398

* Directly experiencing the traumatic event(s) * Witnessing in person, the event(s) as it occurred to others, especially primary caregivers (Does not include events witnessed only in electronic media, tv, movies, or pictures * Learning that the traumatic event(s) occurred to a parent or caregiving figure

Answer 399

* Recurrent, involuntary and intrusive distressing memories of the traumatic event (May not appear distressing and may be expressed as play reenactment) * Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic events * Dissociative reactions (e.g.flashbacks) in which child feels or acts as if traumatic event(s) were recurring (Could occur on continuum with most extreme expression being a complete loss of awareness of present surroundings) Such trauma-specific reenactment may occur in play * Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) * Marked physiological reactions to reminders of the traumatic event(s) *

Answer 400

One(or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s) must be present, beginning or worsening after the event(s)

Answer 401

* Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of traumatic event(s) * Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event

Answer 402

* Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion). * Marked diminished interest or participation in significant activities, including constriction of play * Socially withdrawn behavior * Persistent reduction in expression of positive emotions

Answer 403

* Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects(exclude extreme temper tantrums * Hypervigilance * Exaggerated startle response * Problems with concentration * Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep

Answer 404

* The duration of the disturbance is more than 1 month * May have depersonalization * May have derealization * May regress and lose ability to use language

Answer 405

Can occur at any age after the first year of life Symptoms usually begin within first 3 months after trauma * Could be delay of months, even years before criteria for dx met * “Delayed expression”: new label for “delayed onset”

Answer 406

* Some 3 months (50% of adults) * Some symptomatic longer than 12 months and sometimes for more than 50 years * Symptom recurrence and intensification may occur with reminders of original trauma, ongoing life stressors, or newly experienced traumatic events

Answer 407

The following may exacerbate PTSD sxs in older individual: * Declining health * Worsening cognitive functioning * Social isolation Children may exhibit primarily mood changes because of limitations expressing thoughts, labeling emotions

Answer 408

* SSRIs; SNRIs; (Recently, considering atypical antipsychotic meds) * CBT * EMDR * Group Therapy * Individual and supportive psychotherapy * “Exposure” Therapy

Answer 409

* Exposure * Symptoms of intrusion * Negative Mood * Dissociative Symptoms * Avoidance Symptoms * Arousal Symptoms * Duration of 3 days to 1 month after trauma exposure

Answer 410

* Directly experiencing the traumatic event(s) * Witnessing, in person, the event(s) as it occurred to others * Learning that the event(s) occurred to a close family member of close friend (Event has to have been violent or accidental

Answer 411

Experiencing repeated or extreme exposure to aversive details of the traumatic even (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse).

Answer 412

* intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred

Answer 413

* Recurrent, involuntary, and intrusive distressing memories of the traumatic even In children repetitive play may occur in which themes or aspects of traumatic event(s) are expressed * Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s) In children, may be frightening dreams without recognizable content

Answer 414

* Dissociative reactions (e.g. flashbacks) in which individual feels or acts as if traumatic event(s) were occurring (Such reactions may occur on a continuum with the most extreme expression being a complete loss of awareness of present surroundings In children reenactment may occur in play * Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)

Answer 415

Negative * Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings DISS0CIATIVE SYMPTOMS * An altered sense of the reality of one’s surroundings or oneself (e.g. seeing oneself from another’s perspective, being in a daze, time slowing.) * Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs

Answer 416

* An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing). * Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs) * Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) * Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event

Answer 417

* Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep). * Irritable behavior and angry outbursts (with little or no provocation, typically expressed as verbal or physical aggression toward people or objects * Hypervigilance * Problems with concentration * Exaggerated startle response

Answer 418

* In some, a dissociative or detached presentation but typically also display strong emotional or physiological reactivity in response to trauma reminders * Others, strong anger response: might be irritable or aggressive

Answer 419

* Triggering cue could be physical sensation (e.g., a sense of heat for a burn victim, dizziness for survivors of head trauma * Might see depersonalization or derealization * Concentration difficulties (remembering daily events. Phone #s) * May engage in catastrophic thinking about their role in traumatic event * May experience panic attacks

Answer 420

The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 (THREE) months of the onset of the stressor

Answer 421

* Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptoms severity and presentation * Significant impairment in social, occupational, or other important areas of functions * The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder * Symptoms ≠normal bereavement

Answer 422

than an additional 6 (SIX) months

Answer 423

* Essential feature is presence of emotional or behavioral symptoms in response to an identifiable stressor * Stressor could be single event (ending romantic relationship). Stressors could be multiple and/or stressors may be recurrent * Adjustment Disorders may be diagnosed following death of a loved one when the intensity, quality, or persistence of grief reactions exceeds what normally might be expected

Answer 424

* All of disorders share common feature: prominence of somatic symptoms associated with significant distress and impairment * Patients with somatic sxs commonly encountered in primary care and other medical settings rather than psychiatric settings

Answer 425

* Positive signs and symptoms (distressful somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these sxs) * Not based on absence of a better medical explanation for somatic sxs

Answer 426

Distinctive characteristics * Not the somatic symptoms per se * Is the way patients present and INTERPRET them Somatic Symptom Disorders can also accompany diagnosed medical disorders

Answer 427

Remember- certain mental disorders my manifest primarily with somatic sxs (e.g., major depressive disorder, panic disorder) * These dxs may account for the somatic sxs OR may occur alongside one of the Somatic Symptom and Related Disorders

Answer 428

* Genetic (e.g., increased sensitivity to pain) * Early traumatic experiences (e.g., violence, abuse, deprivation) * Learning (e.g., attention obtained from illness, lack of reinforcement of non-somatic expressions of distress) * Cultural/social norms that devalue and stigmatize psychological suffering

Answer 429

Variations in sx presentation due to interaction of multiple factors within cultures. Affect how individuals * Identify and classify bodily sensations * Perceive illness * Seek medical attention for themselves

Answer 430

There is no category “hypochondriasis” * Individuals are best characterized by dx-Somatic Symptom Disorder * There are 25% of individuals who have “high health anxiety” that do not fit into Somatic Symptom Disorder. For them, use Illness Anxiety Disorder

Answer 431

* Individuals typically have multiple, current, somatic sxs * Sometimes presents with only one severe sx- commonly its pain * Sxs can be specific (e.g., localized pain) OR relatively nonspecific (e.g.,fatigue)

Answer 432

* Have to have some evidence of a medical explanation of sxs to have this dx. But sxs may or may not be associated with another medical condition * Sxs sometimes represent normal bodily sensations or discomfort that does not signify serious disease.

Answer 433

worry about illness * Bodily sxs unduly threatening, harmful, or troublesome * Think the worst about their health * Health-related quality of life often impaired: physically and mentally * In severe cases, disorder could lead to person becoming an invalid

Answer 434

High level of utilization of medical care * Alleviates concerns * May seek care from multiple doctor’s for same sxs to be reassured over and over Unresponsive to medical interventions New interventions may only exacerbate presenting sxs Some individuals unusually sensitive to side effects of medications

Answer 435

* Some will take view that their medical assessment and Rx inadequate * May fear physical activity might damage the body * Repeatedly check body for abnormalities * Cannot get off subject of their medical concerns * Reassurance helps temporarily or is experienced as though the treater is not taking sxs seriously

Answer 436

Most common sxs = recurrent abdominal pain, headache, fatigue nausea A single prominent sx more common Young children may have somatic complaints but rarely worry about “illness” per see prior to adolescence * Parents’ response affects level of associated distress

Answer 437

* A preoccupation with having or acquiring a serious UNDIAGNOSED MEDICAL ILLNESS * Somatic sx are NOT present, or if present, are VERY mild * Individuals distress does not emanate from a physical complaint. Instead is anxiety about the meaning, significance, or cause of the complaint (suspected medical diagnosis)

Answer 438

* A normal physiological sensation (e.g., orthostatic dizziness) * Benign self-limited dysfunction (e.g., transient tinnitus) * Bodily discomfort not generally considered indicative of disease e.g., belching)

Answer 439

* Believe they are medically ill * Have extensive yet unsatisfactory medical care * Some are too anxious to seek medical care * Medical attention can lead to paradoxical exacerbation of anxiety

Answer 440

Essential feature is presence of symptoms or subjective deficits affecting motor or sensory functioning, or apparent impairment in level of consciousness * Some examples of motor symptoms: weakness, paralysis of body part; abnormal body movements-tremor, jerky movements-, and other hyper-or hypokinetic movement abnormalities; gait abnormalities; and abnormal limb posturing

Answer 441

Symptoms are not intentionally produced or feigned

Answer 442

* Sensory symptoms such as altered, reduced, or absent skin sensation, vision, or hearing. Episodes of abnormal generalized limb shaking with apparent impaired/loss of consciousness resembling epileptic seizures (pseudoseizures) * Person may collapse and be motionless and unresponsive in an episode resembling syncope or coma. * Optokinetic nystagmus occurs in blind person * Paralyzed arm does not fall on patient's face during evaluation

Answer 443

* Motor deficits do not follow neuronal pathways. Reflexes intact and EMG normal. * “Blindness” is not associated with lack of pupillary response and patient uncannily does not run into objects or walls * Seizures: pupillary and gag reflexes are retained and there is no increase in prolactin concentration * Astasia-abasia * Deafness: loud noise awakens patient * Sensory deficits do not follow dermatome distribution

Answer 444

* Astasia = motor incoordination with inability to stand * Abasia = inability to stand or to walk although the legs are otherwise under control * Astasia abasia- an unsteady gait that does not cause patient with conversion disorder to fall or sustain injury *

Answer 445

lack of concern about illness or obvious impairment * Has been associated with Conversion Disorder but is not specific for Conversion Disorder and should not be used to make the diagnosis

Answer 446

* Other symptoms: reduced or absent speech volume, sensation of lump in throat, and diplopia * Must be evidence of functional neurological symptoms * True neurological disease must be ruled out * Research shows that some individuals diagnosed with Conv Dis. later found to have medical or neurological illnesses- so keep an open mind

Answer 447

* Transient conversion symptoms are common * Dissociative sxs common. Could see both Conversion Disorder and Dissociative Disorder * Associated with maladaptive personality traits * May be hx of childhood abuse and neglect. Often see stressful life events * Risk factor- presence of neurological disease that causes similar sxs

Answer 448

Essential feature is presence of one or more clinically significant psychological or behavioral factors that adversely affects a medical condition by increasing the risk for suffering, death, or disability

Answer 449

* Psychological distress * Patterns of interpersonal interaction * Coping styles * Maladaptive health behaviors (e.g., denial of sxs or poor adherence to medical recommendations)

Answer 450

* Anxiety-exacerbating asthma * Denial of need for rx of acute chest pain * Manipulation of insulin by person with diabetes wishing to lose weight * Takotsubo cardiomyopathy * Chronic occupational stress increasing hypertension * Functional syndromes- migraine, IBS, fibromyalgia

Answer 451

Thought that adrenaline and/or cortisol “stun” the heart and cause either heart muscle cell changes or coronary blood vessel changes or both. Results - left ventricle does not contract effectively. It is thought that the reduced estrogen level in postmenopausal women makes them more vulnerable

Answer 452

* Symptoms cannot be distinguished from those of MI. EKG may be abnormal, consistent with findings of MI (elevated ST-segments) * Must do catheterization to determine no evidence of blockages (especially to rule out microvessel disease as it is more common cause of MI sxs in older women) * A rapid but small rise in cardiac biomarkers (In MI they rise more slowly)

Answer 453

* INTENTIONAL production or feigning of physical or psychological symptoms * Motivation is to assume the sick role and be a patient * Other external secondary stimuli are absent

Answer 454

1. Intentional production of physical or psychological signs or symptoms that are under voluntary control, originate voluntarily and are not explained by any other underlying physical or mental disorder

Answer 455

A strong desire to assume the sick role * Examples: Feigned depression, hallucinations, dissociation, bizarre behavior, pseudologia fantastica (extensive and colorful fantasies associated with the presentation of the patient's story). The listener's interest in the story pleases patient and reinforces behavior. * May claim death of child or parent * Impostership may involve assuming the identity of a prestigious person

Answer 456

3. A lack of incentives that reinforce behaviors such as economic gain and avoidance of legal responsibility

Answer 457

* Those with the disorder are at risk for experiencing significant psychological distress or functional impairment by causing harm to themselves (by proxy- to others) * Characterized by the persistence of the behavior and how intentionally the person tries to conceal the disordered behavior through deception

Answer 458

* Brief Somatic Symptom Disorder: duration of sxs less than 6 months * Brief Illness Anxiety Disorder: Duration of sxs less than 6 months

Answer 459

False belief of being pregnant that IS associated with objective signs and reported symptoms of pregnancy

Answer 460

The INTENTIONAL PRODUCTION of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.

Answer 461

To avoid “pain” (difficult situations or punishment) To seek pleasure (obtain medication or financial compensation) * Example: Institutional setting- malinger mental illness to do “easier time” or obtain drugs

Answer 462

* If subject gives clear and articulate explanation of being confused * Subject gives conflicting versions of his history * Alleges having hallucinations yet shows no evidence of being distracted * Reports seeing visual hallucinations in black and white. Genuine visual hallucinations seen in color

Answer 463

People with genuine hallucinations * Do not always obey the voices, especially if creates danger * Usually present with NON-command hallucinations (85%) and delusions (75%) as well If a person alleges an isolated command hallucination without other psychiatric symptoms, BE SUSPICIOUS ## Footnote Command hallucinations easily fabricated

Answer 464

Genuine schizophrenic hallucinations tend to diminish when patients are involved in activities. To deal with their hallucinations, persons with schizophrenia * Engage in activities * Change posture (Lie down, walk) * Seek interpersonal contact * Take medications

Answer 465

If suspect person of malingered auditory hallucinations, ask what he does to make voice/s go away or diminish Malingerers may report auditory hallucinations of stilted or implausible language * Ex: Person charged with attempted rape alleges voices said, “Go commit a sex offense.”

Answer 466

* In a true hallucination people are of normal size and in color * Genuine hallucinations of small people (Lilliputian hallucination) may be associated with alcohol use, organic disease, or toxic psychosis (such as anti-cholinergic toxicity) * Psychotic people see the same if eyes open or closed * Drug-induced- more readily seen with eyes closed or in the dark

Answer 467

Unformed hallucinations such as flashes of light, shadows, or moving objects-

Answer 468

Absence of active or subtle signs of psychosis Marked inconsistencies and contradictions Patient endorses improbable symptoms * Depression concomitant with euphoria * Overly dramatic * Extremely unusual comments

Answer 469

Patient evasive or uncooperative * Excessively guarded or hesitant * Frequently repeats questions * Frequently replies, “I don’t know” to simple questions * Hostile, intimidating * Seeks to control interview or refuses to participate

Answer 470

Malingerers are quick to “thrust forward” their illness. Patients with genuine schizophrenia are often reluctant to discuss symptoms Malingerers often believe that faking intellectual deficits, in addition to psychotic symptoms, will make them more believable * Ex: College educated man said he did not know the colors of the American flag

Answer 471

Minnesota Multiphasic Personality Inventory Revised (MMPI-2) * F-scale and F-K Index Structured Interview of Reported Symptoms (SIRS) Miller Forensic Assessment of Symptoms Test (M-FAST) * A Brief reliable screen. Takes 10-15 min

Answer 472

Symptoms may stay for years, come and go, become less frequent, etc PRIMARY- cause unknown * Thought due to abnormalities of taste and sensory nerves either peripherally or centrally

Answer 473

* Meds * Oral yeast infection; geographic tongue * Anxiety, depression, excessive health concerns * Dentures * Damage to nerves that control taste and pain receptors in tongue * Allergies, food flavorings/additives, fragrance

Answer 474

* NOT a Somatoform Disorder * Pain/burning/irritation in areas around the vaginal orifice * Other possible sxs are soreness, itching, stinging, rawness, painful intercourse, throbbing

Answer 475

* Thought to be due abnormality of nerves in muscles of pelvic floor * Possible injury or irritation of nerves in vulvar region * Previous vaginal infections * Allergies or localized skin hypersensitivity * Can make sitting painful as well as sexual intercourse

Answer 476

* Tricyclic antidepressants; Anticonvulsants such as Tegretol or Neurontin. * Antihistamines to address itching * Biofeedback to control specific body responses to help eliminate pain

Answer 477

Psychosis is a gross impairment of reality testing which can result from a variety of psychiatric AND/OR MEDICAL problems Symptoms fall into FOUR categories * Disorders of perception * Disorders of Thought Content * Disorders of Thought Processes * Disorder of Form of thought

Answer 478

Hallucinations * Sensory Perceptions in the absence of external stimuli(An example: Hearing voiceswhen alone in the room) Hypnogogic (while Going to sleep) are normal and do not count Hypnopompic (while awakening) considered to be in range of normal experience

Answer 479

* False belief of being referred to by others * Example: The thought that one is being discussed by someone on the TV or radio

Answer 480

Delusions: Firmly held false beliefs * Of persecution (Feeling of being followed by the FBI) * Of Somatic nature * Of Grandeur * Of jealousy * Feeling that someone has been replaced by an impostor (CAPGRAS' SYNDROME) Idea of reference

Answer 481

Impaired ability to abstract-> Therefore the patient is concrete * Example: When asked what brought her to the emergency room, the patient answers, "An ambulance.“ * Another situation where see concrete thinking: Person cannot explain proverbs

Answer 482

Inventing new words * Example: The patient refers to his doctor as the medocrat

Answer 483

Loosening of Associations- * Characteristic schizophrenic thinking or speech disturbance involving a disorder in the logical progression of thoughts, manifested as a failure to communicate (verbally) adequately * Shift of ideas from one subject to another in an unrelated way * The patient begins to answer a question about her health and then shifts to a statement about baseball

Answer 484

* Getting further away from the point as speaking continues (On the “outskirts of the topic”) * Oblique, digressive or even irrelevant manner of speech in which the central idea is not/not well communicated * Example: A patient is asked where he is from. He answers “from Connecticut” but then continues on that he is not sure if his ancestors came from Ireland or England

Answer 485

* Incoherence * Over-inclusiveness * Thought blocking * Echolalia * Poverty of Speech

Answer 486

* THOUGHT INSERTION: A person thinks THOUGHTS PUT IN ONE’S HEAD BY EXTERNAL FORCES * THOUGHT WITHDRAWAL: A person thinks THOUGHTS TAKEN FROM ONE’S HEAD BY EXTERNAL FORCES * THOUGHT BROADCASTING: A PERSON THINKS HIS INNER THOUGHTS ARE BEING BROADCAST TO OTHERS OUTSIDE OF HIM

Answer 487

Inability to abstract by itself without other symptoms is not necessarily an indication of psychosis. * For example, it may be an indication of a person’s educational level.

Answer 488

* The preceding list begins with the diagnosis of least severity of illness and continues in increasing order of severity (of illness) because that is how DSM 5 is configured * Schizotypal Personality Disorder is included because of its presence within the schizophrenia spectrum. It will be covered in the section: Personality Disorders

Answer 489

* Have persistent delusions but relatively normal psychosocial functioning apart from the ramifications of the delusions * Exhibit behavior that may not be obviously odd or bizarre * One or more delusions have to have duration of at least one month

Answer 490

Delusions are fixed beliefs that are not amenable to change even if there is conflicting evidence Content of delusions may include a variety of themes (i.e., that one will be harmed, harassed by a person or group) Delusions usually about situations that could be possible in real life * Being followed * Being infected * Loved at a distance

Answer 491

* Erotomanic type- Patient believes that someone- usually of higher (e.g.,socioeconomic) status- is in love with him or her. More common in women. See stalking behavior * Grandiose type- Inflated sense of worth, power, or knowledge. Conviction of having some great talent or insight. Person may think he has special relationship to someone who is prominent

Answer 492

Jealous type- delusions of infidelity. Belief not based on any observed behavior or information but is based on incorrect inferences supported by “evidence” that is unfounded such as disarrayed clothing * Delusional person confronts spouse or lover and attempts to intervene in the imagined infidelity

Answer 493

Persecutory type-Belief that is being conspired against, cheated, spied on, followed, poisoned, maliciously maligned, harassed, or obstructed in pursuit of long-term goals. Small slights exaggerated. Delusional individual may engage in repeated attempts to obtain satisfaction by legal or legislative action. Often are resentful and angry. May resort to violence against those thought to be hurting the delusional person * Most common type

Answer 494

Central theme involves body functions or sensations. Can occur in several forms. * Most common belief is that individual emits a foul odor * There is an infestation of insects on or in skin * Parasites internally * Parts of the body are not functioning

Answer 495

* A proportion of individuals with Delusional Disorder go on to develop schizophrenia * Common characteristic is their seemingly normal behavior and appearance when delusional ideas are not being discussed or acted on. * Usually do not require hospitalization and may be treated as outpatient * Treatment: Oral antipsychotic medications (increase dose slowly)

Answer 496

May require hospitalization if * Unable to control suicidal or homicidal impulses * Impairment extreme. Ex: Will not eat because thinks food is poisoned SSRI’s may be helpful with somatic delusions Psychotherapy: Individual more effective than group Success of treatment measured more by satisfactory social adjustment than decrease in delusions

Answer 497

Delusions of parasitosis: A delusion of infestation by parasitic organisms * Sensations of crawling, burrowing, and biting from parasites * May describe elaborate, detailed descriptions of the parasites ## Footnote Previously known as monosymptomatic hypochondriasis

Answer 498

May engage in obsessive/ritualistic behaviors * Picking at skin * Apply disinfectants and pesticides Present their collection of lint, dried blood, hairs, and other skin fragments (believed to be the parasites) in a small box or container (matchbox sign)

Answer 499

Different from formication- patients experience crawling, biting or stinging sensations but pt not convinced it is due to parasites Illicit drugs such as amphetamines can cause formication and can result in delusional state * Indistinguishable from delusions of parasitosis Cocaine abuse can be associated with visual hallucinations and feeling of bugs crawling beneath skin (cocaine bugs)

Answer 500

* Patient has unshakeable belief that fibers or some other material is imbedded or emerging from his skin * Pick and dig at skin to extract offending material. If pick and dig using instruments such as nail clippers or tweezers, this portends a more malignant psychological profile (So ask what they are doing) * May also exhibit matchbox sign- bring in fibers etc as evidence

Answer 501

Also known as delusion of bromhidrosis: * Bromhidrosis is excessive body odor that emanates from skin (order usually unpleasant) * Pt has delusion that an unpleasant odor is emanating from his/her skin. Also known as Olfactory Reference Syndrome (ORS). * Primarily an olfactory delusion * Pts wash excessively, change clothes more often, restrict social and domestic activities

Answer 502

* Must consider the possibility of temporal lobe epilepsy. * Because of close relationship with social anxiety spectrum disorders, treatment based on SSRI’s or TCA’s and CBT

Answer 503

Diagnosis used for relatively brief episodes of psychosis lasting at least ONE day but less than ONE month Occurs in individuals who either * Otherwise have not experienced a decline in their day-to-day functioning * Or display signs that later on suggest prodrome of schizophrenia

Answer 504

Symptoms like those for schizophrenia EXCEPT for the negative symptoms (not included) If occurs within 4 weeks postpartum, use specifier “with postpartum onset” * Typically women with postpartum onset generally develop symptoms within 1-2 weeks of delivery. * Often referred to as postpartum psychosis

Answer 505

* Occurs after childbirth and characterized by severe depression and delusions. * Thoughts of wanting to harm baby or self * Patients are confused, irrational, delusional, and are obsessively concerned about the baby

Answer 506

* Diagnosis is used for symptoms of schizophrenia that last AT LEAST 1 month but LESS THAN 6 months. * When symptoms last 6 months or longer, diagnosis changes to schizophrenia, even if only residual symptoms remain (e.g., blunted affect) * Some individuals with this diagnosis develop schizophrenia but others develop a mood disorder or schizoaffective disorder

Answer 507

1. Delusions 2. Hallucinations 3. Disorganized speech (e.g., frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior 5. Negative symptoms (diminished emotional expression or avolition)

Answer 508

* In DSM V schizophrenia is defined by a group of symptoms such as Delusions, hallucinations, and negative symptoms (i.e., diminished emotional expression or avolition = a lack of motivation or initiative) * Deterioration in social, occupational, or interpersonal functioning * Continuous signs of the disturbance for at least 6 months

Answer 509

* Positive: At least one of the two required symptoms must be delusions, hallucinations, or disorganized speech * Negative symptom has been described as “diminished emotional expression or avolition. This is meant to emphasize the restricted affect one might observe in an affected individual. You may still see/hear descriptions of someone demonstrating a flat affect, another way to describe the diminished emotional expression

Answer 510

* Prodromal symptoms may precede the active phase of the illness. * Residual symptoms may follow * Negative symptoms are common in the prodromal and residual phases and can be severe

Answer 511

Some prodromal and residual symptoms are mild and may be seen as just starting such as hallucinations or delusions May express unusual or odd beliefs that do not reach the level of an actual delusion: * Ideas of reference * Magical thinking (remember, this by itself is not psychotic thinking) * Person may describe unusual perceptual experiences (sensing a presence of someone but not actually seeing him)

Answer 512

* Speech may be comprehendible but vague and somewhat off topic * Individual may mutter to himself in public

Answer 513

* Mood problems are common and may occur during the active phase of the illness with the typical psychotic symptoms that characterize this disorder * BUT to have a diagnosis of Schizophrenia, the individual must have delusions or hallucinations in the absence of mood episodes, OR the total duration of the mood episodes must be present for only a small part of the total duration of the active (period)and residual periods of the disease. (Otherwise, the diagnosis would be Schizoaffective Disorder)

Answer 514

* Positive sxs (delusions; hallucinations) * Disorganization (pf speech or grossly abnormal behavior * Negative sxs (decreased emotional expression and/or motivation)

Answer 515

Can be seen in many forms * Hallucinations * Hyperactivity and hypervigilance * Grandiosity * Suspiciousness * Hostility Positive symptoms give rise to * Problems in cognitive processing * Altered perceptions * Misattribution of environmental cues * Bias toward threatening information

Answer 516

* Blunted affect * Emotional withdrawal * Poor rapport with others * Difficulty with abstract thinking; loss of spontaneous conversation * Rigid, repetitious or barren thought content * Severe negative sxs associated with worse premorbid function (fewer vocational skills, fewer avocational interests, lower mean IQ,

Answer 517

Most individuals with schizophrenia are not violent but the illness, especially if psychosis not treated is a risk factor for violence Predictors of violence * Childhood conduct problems * Substance misuse * History of victimization * Economic deprivation * Living with others (not living alone)

Answer 518

* Increased positive sxs associated with increased rates of violent behaviors * Negative symptoms were protective against violence * Prison systems have many mentally ill individuals who have been violent due to their illness

Answer 519

Average lifespan is up to 25 years shorter * Large share of early death is cardiovascular disease associated with smoking, obesity, diabetes, dyslipidemia, lack of exercise, and cardiac side effects of antipsychotic drugs

Answer 520

Clozapine is thought to reduce suicide risk

Answer 521

Nicotine most commonly used substance Higher rate of smoking than general population * Some thought that the nicotinic system involved in pathophysiology of the illness * Smoking increases metabolism of many antipsychotic drugs

Answer 522

* Decreased cocaine craving * Decreased smoking rates * Decreased substance use * Increased abstinence

Answer 523

ales manifest illness earlier than females * Early –to-mid 20’s in males * Late 20’s in females Overall peak ages of onset between 15 and 35 years of age (50% before 25 years) Onset is earlier in males but equally prevalent in men and women

Answer 524

* Onset before age 10 or after age 45 (called late-onset) is uncommon but not impossible * Is a second smaller peak in women near menopause at ages 40-45 years * Symptoms in diagnosed females may worsen after menopause

Answer 525

* Symptoms thought to result from increased limbic dopamine activity (positive symptoms) and decreased frontal dopamine activity (negative symptoms) * Pathology may be result of abnormal receptor number or issues with receptor sensitivity. * Dopamine receptors that have been identified (for all individuals) D1-D5 * Theory is based on psychotogenic effects of drugs that increase dopamine levels (like cocaine, amphetamines etc) and the antipsychotic effects of dopamine receptor antagonists such as haloperidol (Haldol)

Answer 526

Limitation of the theory: all types of psychosis may be responsive to dopamine-blocking agents * Would suggest that are multiple causes of dopaminergic abnormalities. Other complex factors probably play a role such as serotonin-dopamine interaction, effects of amino acid neurotransmitters

Answer 527

* Increased norepinephrine levels lead to increased sensitization to sensory input * Another hypothesis: Decreased GABA activity results in increased dopamine activity

Answer 528

Serotonin metabolism is abnormal in some individuals with chronic schizophrenia * Both hyperserotoninemia and hyposerotoninemia reported * Antagonism at serotonin 5-HT2 receptor emphasized as important in reducing psychotic symptoms (also development of movement disorders related to D2 antagonism

Answer 529

* Hypofunction of the glutamate N-methyl-D-aspartate (NMDA)-type receptor might cause positive and negative symptoms based on what is seen with phencyclidine and ketamine (Ketalar). * Other support comes from the therapeutic effects of glycine and D-cycloserine (NMDA antagonists) in research situations

Answer 530

Abnormal neuronal migration during second trimester of fetal development may cause abnormal neuronal function and could lead to symptoms- particularly in adolescence.

Answer 531

* Reduced volume of the prefrontal cortex, thalamus, hippocampus and superior temporal gyri * Decreased blood flow and metabolism of frontal lobes seen on brain imaging * Altered activation in prefrontal cortex and other areas (hippocampus, amygdala, and thalamus) during cognitive tasks during brain imaging studies

Answer 532

* Changes include decreased number of neurons, increased gliosis, and disorganization of neuronal architecture. * Degeneration in limbic system * Abnormal functioning in basal ganglia and cerebellum may explain movement disorders sometimes seen

Answer 533

* Lateral and third ventricle enlargement * Most have normal EEG’s * Cortical atrophy seen on CT scans

Answer 534

* Some patients show decreased frontal and parietal lobe metabolism * Dysfunction of frontal lobe seen in examination of PET scans and CBF (cerebral blood flow) studies.

Answer 535

* Increased primitive reflexes (grasp) * Paroxysmal saccadic movements (inability to follow objects through space with smooth eye movements * Abnormal sterognosis and two-pt discrimination * Dysdiadochokinesia (Impairment in ability to perform rapidly alternating movements)

Answer 536

* Thematic Apperception Test and Rorschach -> Bizarre responses * Parents of schizophrenic patients show more deviation from normal values in such projective tests * 20 % of patients have impaired attention and intelligence, decreased retention time, and disturbed problem-solving ability on Halstead-Reitan battery

Answer 537

Schizophreniform Disorder * Sx identical * Lasts less than SIX months * Deterioration less * Prognosis better Brief Psychotic Disorder

Answer 538

* Antipsychotic medications effective in the treatment of acute psychosis and preventing relapse * COGNITIVE-BEHAVIORAL THERAPY: Focuses on rationally exploring subjective nature of the psychotic symptoms, challenging the evidence for them, and subjecting beliefs and experiences to reality testing * INDIVIDUAL PSYCHOTHERAPY: Assists with management of life stressors, enhances medication compliance, and improving self esteem * Group: Provides supportive social network and good setting for teaching coping and interpersonal skills * ASSERTIVE COMMUNITY TREATMENT (ACT): Comprehensive integrated community services-> Patients assigned to one multidisciplinary team (case manager, nurse, and M.D.) * Family therapy: Can be helpful to prevent psychotic relapse and re-hospitalization * SOCIAL SKILLS TRAINING: Uses learning theory principles to improve social functioning

Answer 539

Diagnosis based in an uninterrupted period of illness during which there is a major mood episode- major depression or manic episode CONCURRENT with symptoms listed in Criterion A of schizophrenia * The major depressive episode must include Criterion A1: Depressed mood * During this period of uninterrupted illness, the patient continues to display active or residual symptoms of psychosis. (Diagnosis usually made during the period of psychosis)

Answer 540

* Criteria A for schizophrenia must be met. * Schizoaffective illness is diagnosed when the core symptom criteria for schizophrenia co-occur with a manic or major depressive episode but are preceded or followed by at least 2 weeks of delusions or hallucinations without a major mood episode * The major mood episodes must be present for the majority of the duration of the illness

Answer 541

* Frequently see impaired occupational functioning but not a defining criterion as seen with schizophrenia * May observe restricted social contact and difficulties with self-care but negative symptoms may be less severe and less persistent (compared to with schizophrenia)

Answer 542

Criterion C is designed to separate schizoaffective disorder from schizophrenia (Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness)

Answer 543

* Criterion B is designed to distinguish schizoaffective disorder from major depression or bipolar disorder with psychotic features (Criterion B: Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode- depressive or manic-during the lifetime duration of the illness) * In depressive or bipolar disorder with psychotic features, the psychotic features generally occur when there is a problem with mood

Answer 544

* BIPOLAR TYPE- If disturbance includes manic or mixed episode * Depressive type: If Disturbance only includes major depressive episodes

Answer 545

* Delusions or hallucinations (Criteria A) are causally related to the effects of a substance or med because they developed during or soon after the substance intoxication or withdrawal or after exposure to a medication (Criterion B) * Diagnosis used when sxs in excess of what one would see with an intoxication or withdrawal syndrome. Example: Hallucinations seen during alcohol withdrawal delirium and an additional diagnosis of a substance-induced psychotic disorder would not be appropriate

Answer 546

* At high doses may see delusions and hallucinations * May cause effects that mimic full range of symptoms of schizophrenia- delusions, paranoia, disordered thinking, sensation of distance from one's environment, catatonia * Speech often sparse and garbled * Long-time users have memory loss, difficulties with speech and thinking, depression and weight loss * Symptoms can persist up t one year after cessation of PCP use

Answer 547

* A dissociative anesthetic * A non-competitive antagonist of the NMDA receptor * Psychosis, perceptual alterations, thought disorder, and mood changes

Answer 548

LSD * Effects depend on the amount taken, patient's personality and expectations, and the surroundings when taken * May hear colors and see sounds MDMA: * Psychological effects can occur either during or weeks after use Steriods

Answer 549

* Addison's disease * Cushing's syndrome-> Dexamethasone suppression test * Hypo/hyperthyroidism

Answer 550

* Digitalis * Steroids * Others, even antibiotics

Answer 551

* Marked psychomotor disturbance that may involve decreased motor activity, decreased engagement when being interviewed or examined physically. * Psychomotor disturbance could range from marked unresponsiveness to marked agitation * Motoric immobility may be severe (mutism) or moderate (catalepsy and waxy flexibility).

Answer 552

* Decreased engagement may be may be severe (mutism) or moderate (negativism) * Excessive and peculiar motor behaviors can be complex (stereotypy) or simple (agitation). May include echolalia and echopraxia * In extreme cases, same individual may wax and wane between decreased and excessive motor activity

Answer 553

* May also manifest unusual facial contortions * Echolalia (almost parrot-like repeating of what someone says) * Echopraxia (mimics a person’s movements)

Answer 554

* Occurs in up to 35% of individuals with schizophrenia * Majority of catatonia cases involve individuals with depressive or bipolar disorders

Answer 555

* Endogenous opioids might contribute to denial of hunger in patients with AN * Increased endorphin levels described inpatients with BN after purging and may induce feelings of well being * Decreased norepinephrine turnover and activity suggested by reduced levels of 3-methoxy-4-hydroxyphenylglycol in the urine and CSF of some patients with AN.

Answer 556

* Hypercortisolemia * Nonsuppression of dexamethasone * Thyroid function suppression * Amenorrhea * Several CT brain studies revealed enlarged sulci and ventricles in starvation-> Reversed with weight gain * Is excess of ghrelin in BN

Answer 557

Some research revealed overlap between uncontrolled compulsive eating and compulsive drug seeking in drug addiction. * See reduced ventral striatal dopamine in both groups * The lower the frequency of dopamine D2 receptors, the higher the body mass index

Answer 558

In families of children with eating disorders, see * High levels of hostility, chaos, and isolation * Low levels of nurturance and empathy One view: anorexia is a reaction of adolescents as they try to become more independent or a response to societal pressures to be slender

Answer 559

* AN patients usually high achievers. 2/3 live at home with parents. Many consider their bodies to be under parents’ control * AN: Self starvation may be an effort to gain validation as unique person * Difficulties with impulse regulation often seen in patients with BN

Answer 560

Essential feature-eating one or more non-nutrititive, nonfood substance on a persistent basis over a period of at least ONE month * Typical ingested substances: paper, sap, cloth, hair, string, wool, soil, **chalk**, talcum powder, paint, gum, metal, pebbles, charcoal/coal, clay, starch, or ice

Answer 561

* Minimum age if 2 years suggested for dx to exclude developmentally normal mouthing of objects by infants they may ingest * In children, neglect, lack of supervision and developmental delay can increase risk for dx

Answer 562

* Repeated regurgitation of food after feeding or eating over a period of at least one month * Previously swallowed food (partially digested) brought up into the mouth without apparent nausea, involuntary retching, or disgust * Infants display characteristic position of straining and arching their back, making sucking movements with their tongue.

Answer 563

* Weight loss and failure to meet expected weight gain common features in infants * May see malnutrition, especially if regurgitated food is expelled. Also occurs in older children and adults when regurgitation is accompanied by restriction of intake * behavior has self soothing quality/function similar to repetitive motor behaviors like head banging

Answer 564

* Persistent energy intake restriction * Intense fear of gaining weight * Distorted body self-perception * Distorted self-image * Cognitive distortions regarding food and eating * Often engage in repeated weighing, measuring, and assessing their body in the mirror

Answer 565

* Key clinical feature – refusal to maintain body weight at or above a minimally normal level for age, sex, developmental trajectory, and physical health * In children and adolescents- may be failure to make expected weight gain or to maintain a normal developmental trajectory instead of weight loss * Associated with cardiac arrhythmias, growth retardation, osteoporosis) and mortality

Answer 566

* Restriction of energy intake relative to requirements leading to a significantly low body weight * Intense fear of gaining weight or of becoming fat * Persistent behavior that interferes with weight gain even though an individuals weight significantly low * Disturbance in way a person experiences one’s body weight or shape * Undue influence of body weight or shape * Persistent lack of recognition of seriousness of current low body weight

Answer 567

* RESTRICTING TYPE: during last 3 months, individual has not engaged in recurrent episodes of binge eating or purging behavior (self induced vomiting or misuse of laxatives, diuretics or enemas) Weight loss accomplished primarily through dieting, fasting, and/ or excessive exercise * BINGE-EATING/PURGING TYPE: During last 3 months, individual has engaged in recurrent episodes of binge eating or purging behavior (self induced vomiting or the misuse of laxatives, diuretics, or enemas.

Answer 568

* Often see obsessive compulsive behavior- when dealing with food intake as well as general way person carries out affairs of daily life * Suicide rate is higher in the restricting type * Binge eating/purging subtype demonstrated higher than expected rates of substance use disorders * Individuals tend to appear waif-like, child like * Seem uninterested in usual adolescent preoccupations: sex; attraction to the opposite sex

Answer 569

* May have electrolyte disturbance if bulimic and purging : hypokalemic alkalosis. A metabolic alkalosis (elevated serum bicarbonate) caused by loss of stomach acid due to vomiting * If vomiting- may have elevated serum amylase * May see ST-segment and T-wave changes on EKG (usually associated with electrolyte changes)

Answer 570

Pharmacologic strategies may be useful as an adjunct to psychotherapy * Anti-anxiety agents taken before meals May help an anorectic carry out a behavioral plan that includes a certain caloric intake->This is a time-limited strategy

Answer 571

Antidepressants can be useful with depression, prominent neurovegetative signs, severe anxiety, or OCD- SSRIs * Desired effects are decreased anxiety and depression, decreased obsessional thoughts about weight gain, increased interest in eating * Anti-psychotics may be used. Zyprexa (Olanzapine) could be used for anxiety and depression. It causes weight gain in most cases

Answer 572

Cognitive- Behavioral Therapy (CBT) Dynamic Psychotherapy Family Therapy * Emphasis on this form of therapy as one of the major components of treatment has received more support recently (as it once was in the past) * For adolescents there is growing literature suggesting they are gest treated using family approach (Maudsley Approach)

Answer 573

* Highly structured, manual based * Requires a therapeutic staff highly skilled in managing such patients * Parents encouraged to take control of individual’s eating behavior and other behaviors * As patient gains weight and assumes responsibility, focus shifts to more traditional family and personal problems and typical adolescent issues

Answer 574

* Weight significantly less than estimated healthy weight * Rapid, persistent decline in oral intake or weight despite maximally intensive outpatient interventions * Previous episode of physical instability at a certain weight * Serious physical issues: Electrolyte or metabolic abnormalities * Hematemesis * H.R. less than 40 or greater than 110 bpm * Inability to sustain body core temperature * Comorbid psychiatric illness: suicidal, depressed, unable to care for self

Answer 575

Good prognostic factors * Admission of hunger * Lessening of denial * Improved self esteem Poor prognostic factors * Initial lower weight * Presence of vomiting or lax abuse * Failure to respond to previous treatment * Disturbed family relationships * Conflicts with parents

Answer 576

* Eating, in a discrete period of time (e.g., within any 2 hour period) an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances * A sense of lack of control over eating during the episode

Answer 577

* Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications, fasting; or excessive exercise * Binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 weeks

Answer 578

Excessive exercise used by a subgroup of patients Insulin-dependent patients with diabetes mellitus may restrict their insulin use as a way of inducing glucosuria and causing weight loss * Dangerous- can result in neuropathy and retinopathy Some patient regurgitate and re-swallow food (rumination) Rarely- use of saunas to sweat off weight

Answer 579

* Patients typically ashamed of eating problems * Binge eating in secrecy * Individuals are often within normal weight range and restrict total caloric consumption between binges * Russell’s sign seen in those who self-induce vomiting (also seen in Anorexia) * Hair loss * Osteopenia * fluid and electrolyte abnormalities from vomiting-> Dehydration, hypochloremia, hypokalemia, and metabolic alkalosis, as well as tachycardia and hypotension

Answer 580

* Some evidence that many patients develop hypercortisolemia * Irregular menses common * Serum salivary amylase may be elevated if patient vomiting * Enlargement of parotid gland * Dental enamel erosion (from vomiting) * Gastric dilatation and esophageal rupture uncommon but dangerous

Answer 581

* Antidepressants, especially SSRIs (higher doses) * The only medication approved by FDA for treatment of bulimia is fluoxetine * Less effective than psychotherapy but still effective * Recent trials with Topamax- Topiramate- for binge eating in bulimia and binge eating Disorder-> Not FDA approved and issues with cognition * CBT best established therapy * Interpersonal therapy has been effective * Dynamic psychotherapy * Is a growing literature indicating DBT (dielectical behavioral therapy) may be effective with some * There are some other CBT-like therapies that are receiving attention

Answer 582

* Self monitoring * Meal planning * Cues and consequences * Cognitive restructuring (particularly related to weight and shape issues and attitudes toward food

Answer 583

Individuals with binge eating disorder are generally older, more likely to be male, and have a later age at onset of the disorder

Answer 584

* Weight and shape are not required for the diagnosis * An individual eats an amount of food that is larger than what most people would eat in a discrete period of time * The person feels she cannot stop eating or control what she is eating

Answer 585

* Eating much more rapidly than normal (Common among men) * Eating until uncomfortably full * Eating large amounts of food when not physically hungry * Eating alone due to embarrassment about how much one is eating * Feeling disgusted with oneself, depressed, or very guilty afterward (Most common among women)

Answer 586

* Binge eating occurs, on average, at least once/week for 3 months * They tend to have family members who are obese and they themselves have a history of heavier body weight before developing the disorder

Answer 587

* Binge eating is distressful * No use of (inappropriate) compensatory behavior such as using cathartics, etc. * Individuals often try to restrict their caloric intake early in the day and then binge-eat later in the day

Answer 588

* Evidence suggests these individuals meet criteria for obesity and also display an increased rate of severe obesity * Evidence suggests the disorder confers risk for negative medical outcomes beyond effects of obesity * Substance use disorder- most commonly alcohol abuse: 20-25% * May be associated with impulse-control disorder and ADHD

Answer 589

* Metabolic, orthopedic, and sleep related disorders * A significant fraction of individuals with binge-eating disorder display marked overvaluation of shape and weight * Presence of this feature seams to predict a particularly severe form of the disorder that is resistant to typical treatment

Answer 590

* Binge after periods of significant negative emotion * They may have deficits in decision making resulting in a disinhibited behavioral style that might increase the risk of binge eating * Some individuals report episodes are no longer characterized by an acute feeling of loss of control but a more generalized pattern of uncontrolled eating.

Answer 591

Psychotherapy or behavior therapy (thought to be most efficacious) * CBT (focuses on enhancing normal meal consumption and reducing inaccurate or unproductive cognitions about food, shape, or weight-related themes * IPT (focuses almost exclusively on relationship problems and interpersonal patterns of behavior that precipitate binging episodes * Guided self help (Uses CBT principals in a self-help meeting with a professional facilitating treatment)

Answer 592

Pharmacological interventions * Imipramine, sertraline, citalopram/escitalopram, and topiramate Weight-loss interventions * Very low calorie diets promote weight loss and significantly reduce binge-eating frequency

Answer 593

Purging: Recurrent purging behavior to influence weight or shape (e.g., self-induced vomiting; misuse of laxatives, diuretics, or other meds) in absence of binge eating NIGHT EATING SYNDROME: Recurrent episodes of night eating * Awakening from sleep or by excessive food consumption after the evening meal * Individual is aware and can recall the eating

Answer 594

* Parotid gland enlargement * Submandibular adenopathy * Dental caries * Hand abrasions (Russell's sign) * Decreased or increased bowel sounds * Rectal prolapse

Answer 595

Initial and periodic assessment of serum electrolytes for anyone with purging behavior * Hypomagnesemia and hypokalemia common with those who purge In anorexia nervosa * Hypoglycemia common * Leukopenia, neutropenia, anemia, thrombocytopenia

Answer 596

* Medical * Weight restoration * Correct electrolyte imbalances * Vitamin supplementation * Dental care * Nutritional counseling * COGNITIVE-BEHAVIORAL THERAPY is the best treatment for bulimia nervosa and for Binge Eating Disorder-BED. (CBT more effective than medication for both). In anorexia nervosa, CBT more effective when it includes a nutritional component

Answer 597

* Equally effective as CBT for bulimia but takes longer. Effective for BED * Other therapies: Psychodynamic psychotherapy, dialectical behavioral therapy, motivational enhancement therapy, guided imagery, and guided self-change have shown to be effective in bulimia nervosa

Answer 598

* FAMILY THERAPY effective for early-onset, non-chronic anorexia nervosa and is useful adjunctive modality for other eating disorders. More recently thought to be a more valuable treatment modality. * Group psychotherapy is useful adjunctive therapy for anorexia and bulimia nervosa. * Group CBT or IPT effective for BED