Psych Pathophys Flashcards

Question

# Bipolar Diosrder clinical tx tips

Answer 1

* Acute mania → think lithium and/or depakote +/- SGA * Depression → think lamotrigine (off label) + approved antipsychotic * Rapid cycling → Seroquel is a good option * Augment with antipsychotics, they work faster! * Bipolar II can sometimes be treated with SSRIs + mood stabilizer * You may need to tx other conditions such as ADHD, anxiety, SUD.

Answer 2

* Almost all SGAs will treat mania. Choose based on side effects, comorbidities and past med trials. * Seroquel will treat mania, maintenance and depression * Vraylar will treat mania, mixed and depression. * Only bipolar depression tx include: Seroquel, Latuda, Vraylar and Symbyax (olanzapine/fluoxetine). Why not SSRIs/SNRIs?? * Not typically effective and can trigger mania in some patients * Will sometimes with in bipolar II with concurrent mood stabilizer

Answer 3

* more common in women than men * age of onset late teens/20's and in elderly * important to know how patient is coping (EtOH, drugs, rx, ED, cutting, exercise, therapy) * high co-morbidity in presence of phobia, substance abuse, panic disorders

Answer 4

* Background: "what has been going on" * Affect: "how do you feel about that" * Trouble: "what troubles you the most" * Handle: "how are you handling this" * Empathy: "this must be difficult for you"

Answer 5

* compressed therapy/limited * focuses on the present NOT the past * make connections between thoughts and actions/choices to change your thinking/behaviors (ultimately chaning emotions) * highly structured w/ clear goals/practical techniques * pt may have homework * empowers patient to make choices | similar effectiveness compared to meds but better long term outcomes

Answer 6

* unlimited time (pt decides when to stop) * rooted in Freud * less structure, no homework * Pt leads sessions * Transference (discuss the past & how it affects the present) * explores unconscious thoughts & past experiences to gain insight into present thoguhts/emotions * goal is to better understand self/health emotional wounds

Answer 7

* used a lot in PTSD & phobias * based on habituation (desensitization) * exposure to a fear for a set amount of time & they learn that they are safe

Answer 8

* PTSD therapy * processing the trauma while stimulating different areas of brain w/ light, vibration, or sound (thought to disrupt stored trauma by dual stimulation) * helps people dissociate form feelings of the event and introduce more logic to the event

Answer 9

* TLC: stress management techniques, yoga, exercise, relaxation therapy, mindfullness time

Answer 10

* **Transcranial Magnetic Stimulation (TMS)**: noninvasive procedure that delivers magnetic pulses to the brain to alter nerve cell activity in specific areas of the brain ( usually cerebral cortex) that regulate mood; indicated for anxiety, ocd, ptsd- non painful. Treatment is 4-5 times a week for 4-6 weeks x 40 minutes * **Acupuncture**: Stimulating specific points seeks to balance energy flow through meridians; positive data in PTSD and GAD

Answer 11

* yoga * counting method * power therapies (focus on trauma while getting acupuncture)

Answer 12

1. SSRIs (sub: SNRI): first line for GAD/Panic Disorder, few SE 2. TCAs 3. MAOIs (not typical to see in modern day) 4. Benzos (see largely in older ladies; caution due to addiction) 5. Anxiolytic (Buspirone- takes 2-3 mo to have noticable effect, should be used w/ SSRI) Misc Meds * Beta Blockers (controls physical sx) * Benzos (last resort) * Anti-Histamines (sedating)

Answer 13

* Ketamine: dissociative psychedelic; affects glutamate which regualtes pain perception, emotion, learning * D-Cycloserine: acts on NMDA and glutamate receptors * MDMA: affects dopamine, serotonin, norepi, oxytocin, cortisol, prolactin, vasporessin * Sirolimus

Answer 14

* contamination: hand washing/cleaning * pathologic doubt/safety: worry about things = repetitive checking * intrusive thoughts: obsessive thoughts w/out compulsions * symmetry: rearranging items in extremely slow/precise methods * misc: nail biting, picking, religious obsession, hair pulling

Answer 15

* **With** **excessive** **acquisition**: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space. (Approximately 80 to 90 percent of individuals with hoarding disorder display this trait.) * **With good or fair insight**: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic. * **With poor insight**: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. * **With absent insight/delusional beliefs**: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

Answer 16

* The most primal function of the brain is to keep us alive. Trauma affects the brain * Limbic brain: “reptilian brain”, develops in utero, located in the brain stem, tells us to cry, void, eat; shape in response to experience- emotions, safety, pleasure, threat * Traumatized people perceive the world differently * After trauma, the brain and nervous system have altered sense of risk and safety * Cortisol levels remain elevated in a person who has been exposed to stress or trigger * MRI of people with trauma look different ( activated right hemisphere (intuitive, emotional, visual, spatial, and tactual brain- carries feelings related to an experience) and deactivated left hemisphere ( linguistic, sequential, and analytical- does the talking) * Leads to people being “stuck” in fight or flight. You cannot process an event if you are overwhelmed by it- stuck in R brain thus cannot be logical (L brain); remains “raw and undigested”

Answer 17

* social engagement (call for help/support or comfort) * fight/flight * freeze/collapse

Answer 18

* In a “normal brain” dopamine is released from the ACC to the NC when we do things that promote survival (drinking water, eating food, having sex, and sleeping) as a positive reinforcement mechanism. * Various substances, including all of the most commonly abused substances, hijack this system by releasing significantly higher levels of dopamine from the ACC into the NC, and for a greater duration of time. After this occurs, victims are now much more likely to repeat the behavior as nothing else is able to produce that type of euphoria - their reward center has been introduced to a new threshold of pleasure

Answer 19

Frontal lobe is responsible for: * Storing negative consequences to avoid poor actions in the future * Inhibiting impulsivity and appropriately delay gratification Patients with addiction have a severely underdeveloped frontal lobe. Meaning high impulsivity and difficulty recognizing consequences of poor choices.

Answer 20

Addiction also affects neurotransmission and interactions between…. * The cortical and hippocampal circuits and the nucleus accumbens, such that the memory of previous exposures to rewards (such as heroin) leads to a biological and behavioral response to external cues → triggering craving and/or engagement in addictive behaviors.

Answer 21

* inactive frontal lobe (reduced impulse control, reduced ability to utilize learned social behavior/logic) * Hyperactive reward center (has new/high stanards for gratification) those together = pt w/ very little control over their drug use

Answer 22

* Resiliencies which the individual acquires (through parenting or later life experiences) can affect the extent to which genetic predispositions lead to the behavior and other manifestations of addiction * Patients can be born with underlying biological deficits in the function of reward circuits resulting in a exaggerated reward response within the NA

Answer 23

a problematic pattern of "substance" use leading to clinically significant impairment or distress characterized by 2+ within 12 mo period: * Substance is taken in larger amounts or over a longer period than was intended * There is a persistent desire or unsuccessful efforts to cut down or control substance use. * A great deal of time is spent in activities necessary to obtain, use, or recover from it’s effects * Craving, or a strong desire or urge to use the substance * Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home * Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance * Important social/work/ rec activities are given up or reduced because of use * Recurrent use in situations in which it is physically hazardous * Use is continued despite knowledge of having a persistent or recurrent physical or psych problem that is likely to have been caused or worsened by substance * Tolerance * Withdrawal

Answer 24

* mild: 2-3 criteria met * moderate: 4-5 criteria met * severe: 6+ criteria met

Answer 25

* in early remission: no criteria met for 3+ mo but less than 12 mo (except cravings) * in sustained remission: no criteria for 12+ mo (except cravings)

Answer 26

* Family history of alcohol use disorder and other substance use disorders * Availability of alcohol * Heavy alcohol use * Binge drinking * Permissive societal attitudes towards alcohol use * History of childhood abuse * History of conduct or mood disorder in childhood * Having mental health conditions such as depression or post-traumatic stress disorder * Impulsivity

Answer 27

At Risk Drinking * men: > 4 drinks/day or > 14 drinks/wk * women: > 3 drinks/day or > 7 drinks/wk * any gender > 65 yrs: > 3 drinks/day or > 7 drinks/wk Binge Drinking * men: 5+ drinks in 2-3 hr period * women: 4+ drinks in 2-3 hr period

Answer 28

* Gastritis * Stomach/duodenal ulcers * Liver cirrhosis * Pancreatitis * Esophageal and stomach cancer * Hypertension * Cardiomyopathies, hypertriglyceridemia, elevated LDL * Myopathies * Severe memory impairment * Degenerative changes in the cerebellum * Thiamine deficiency → Wernicke-Korsakoff Syndrome

Answer 29

* BAC, or blood alcohol concentration: (>200mg/dL in any non-tolerant pt should demonstrate severe intox) * **GGT** (gamma-glutamyltransferase): normal to high value; about 70% of patients with elevated GGT are persistently heavy drinkers (8+ per day) * **CDT** (carbohydrate-deficient transferrin): levels of **> 20 units** can be useful in identifying individuals who drink/abuse alcohol regularly * MCV: normal to high; not a good predictor of abstinence due to long lifespan of RBC’s * **LFT**: **AST:ALT ratio > 2:1** is indicative of heavy alcohol use

Answer 30

* Morphine * Heroin * Meperidine * Methadone * Propoxyphene * Oxycodone * Hydrocodone * Hydromorphone * Diphenoxylate * Fentanyl

Answer 31

* Access to and availability of opioids * Previous exposure to substance use (e.g., having friends or family who use substances) * Current or past substance use disorder * Family history of substance use disorder * Having mental health conditions such as depression or post-traumatic stress disorder * History of abuse during childhood * History of conduct disorder as a child or adolescent

Answer 32

* cocaine * methamphetamine * amphetamine * ADHD meds

Answer 33

* Xanax * Valium * Ativan * Lunesta * Ambien * Belsomra * Rozerem * Halcion

Answer 34

* PCP * Angel Dust * Ketamine

Answer 35

* LSD * Peyote * Psilocybin

Answer 36

* nitrous * spray paint * butane * markers * glue * cleaning solutions * air conditioning refrigerant

Answer 37

* advanced maternal age * low birth wt * exposure to depakote * family hx

Answer 38

* Patterns of behaviours and inner experiences that deviates significantly from the expectations of an individual's culture * Pervasive and inflexible * Typically present in adolescents to early adulthood and is life-long * Causes impairment but not necessarily destress

Answer 39

* neglect * childhood abuse * genetic factors (twin studies)

Answer 40

* **EGOSYNTONIC**: behaviors, values, and ideas that are aligned with the ideal self & current self image (most here) * **EGODYSTONIC**: behaviors, values, ideas that aren't aligned w/ the ideal self

Answer 41

* million clinical multiaxial inventory (MCMI): self administered, true/false inventory of 344 items * minnesota multiphasic personality inventory (MMPI): used to assess pt more globally (500+ items)

Answer 42

* A: odd/eccentric; schizoid, schizotypical, paranoid * B: dramatic/emotional/impulsive; histrionic, narcisssistic, borderline, antisocial * C: anxious/fearful; avoidant, dependent, obsessive-compulsive

Answer 43

A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings

Answer 44

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior

Answer 45

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts

Answer 46

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

Answer 47

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts

Answer 48

A pervasive pattern of grandiosity, need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts

Answer 49

* asa psychopathy (born) vs sociopathy (made) * A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years

Answer 50

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning in early adulthood and present in a variety of contexts

Answer 51

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation

Answer 52

* Involuntary loss of urine in children * Can occur in the daytime, at night, or both

Answer 53

* younger age * male sex * family hx enuresis (1 parent = 44%; 2 parents = 77%) * psychiological stress (divorce, birth of sibling)

Answer 54

Multi-Factorial * Decreased arousal from sleep in response to a full bladder * Delayed bladder maturation * Decreased ADH (vasopressin) production or alteration in circadian release * Decreased functional capacity of the bladder

Answer 55

Involuntary or unintentional passage of feces in inappropriate situations in children older than 4 years of age in the absence of neuromuscular disease

Answer 56

Classified as: * **Retentive**: associated w/ constipation, secondary overflow and leakage of stool around the obstruction (80% of cases) * **Non-Retentive**: w/out constipation Subclasses * **Primary**: fecal continence has never been achived * **Secondary**: fecal incontinence returns after successful toilet training; marked by higher level of stressors/psychological disorders

Answer 57

Retentive - large stool volume with BM - painful defecation - abd pain - careful diet hx (excessive diary, insufficient fiber) Non-Retentive - no evidence of retention Both - hx concurrent behavior problems or recent change in school performance - potentially traumatic changes at home

Answer 58

SEVERE FECAL IMPACTION IN RECTUM

Answer 59

* **Ideation**: thoughts of hurting oneself (can range from plan to fleeting consideration); does not necessarily include the final act of suicide * **Attempt**: non-fatal, self directed, injurious behavior w/ the intent to die; may not result in injury/death * **Successful Attempt**: death caused by self directed, injurious behavior w/ intent to die

Answer 60

* 10th most common cause of death * 2nd leading cause of death among individuals aged 10 -24 (after unintentional injuries) * One death every 11 minutes * Women attempt suicide 3–4x more often than men * Men are 4x more likely to complete suicide (Men aged 85 and older have the highest rate of suicide)

Answer 61

* Prior attempt (greatest risk factor) * Access to a firearm * Men > 65 years old * Positive family history * RURAL areas of US (highest rates in WY, MT, AK) * Modifiable risk factors: Mental illness, Chronic medical illness, Substance use disorder, Life stressors (unemployment, financial stressors, homelessness, divorce) * Ethnic groups: American Indian/Alaska Native population and Non-Hispanic whites * Special groups: Military personnel, Healthcare workers, First responders, Mining/construction workers, Lesbian, gay, or bisexual young people

Answer 62

* Reflective and deep-thinking skills * Participation in programs to help with mental illness and substance use disorder * Access to psychiatric help * Support from friends and family * Cultural programs discouraging suicide * Religious beliefs (faith in God and religious activities) * Constructive activities (sports or artistic pursuits)

Answer 63

Firearms * 50% * Most common method of completed suicide * More commonly used by men Other Methods * Hanging/suffocation – 28% * Poisoning – 11%- (Prescription medications are used more than illicit substances; More commonly used by women) * Self-inflicted trauma

Answer 64

* Process of making close observations, evaluations, and estimations of an individual’s probability to commit suicide * Includes evaluating a patient's suicidal ideation, plan, and intent Screenings * Columbia-Suicide Severity Rating Scale (C-SSRS) * Beck Scale for Suicide Ideation (BSI) * Suicidal Ideation Attributes Scale (SIDAS) * Patient Health Questionnaire-9 (PHQ-9) Alert signs * Patient created a clear plan * Patient started writing a will, funeral plan, or suicide note * Unexpected visiting friends and family members * Recent visit to the primary care physician * Patient is in severe, acute, immediate stress * Recent suicide attempt was a highly lethal method (deep, cutting wounds)

Answer 65

Active * Experiencing current, specific, suicidal thoughts * Conscious desire to inflict self-harming behaviors * Level of desire, above zero, for death to occur * Example of an Active SI assessment: “Over the past day or two, when you have thought about suicide, did you want to kill yourself? How often? Do you want to kill yourself now?” Passive * General wish to die * No plan of inflicting lethal self-harm to kill oneself * Often received less attention from clinicians * Example of a Passive SI assessment: “In the past month, have you ever wished you were dead?” **Studies have shown that prediction of suicide attempt based on reported passive SI verses active SI shows no significant difference**

Answer 66

Cognitive behavioral therapy: * Problem-oriented strategy that focuses on current problems and finding solutions * Strongly recommended for patients with a recent history of self-directed violence to reduce future incidents * Patient satisfaction with CBT focused on suicide prevention is generally high Dialectical behavior therapy: * Incorporates CBT elements, skills training, and mindfulness techniques * Aims to develop skills in emotion regulation, interpersonal effectiveness, and distress tolerance * Suggested for individuals with borderline personality disorder (BPD) who have recently engaged in self-directed violence

Answer 67

Cyclic changes in hormones * Signs and symptoms of premenstrual syndrome change with hormonal fluctuations (progesterone) and disappear with pregnancy and menopause Chemical changes in the brain * Fluctuations of serotonin, a neurotransmitter that is thought to play a crucial role in mood states, could trigger premenstrual mood symptoms * Insufficient amounts of serotonin may contribute to premenstrual depression, fatigue, food cravings and sleep problems Postulated that PMS/PMDD symptoms develop because of a decline of progesterone in the late luteal phase

Answer 68

* Recurrent luteal-phase disorder characterized by a variable cluster of psychological and physical symptoms * Symptoms are occurring with the hormonal fluctuations of the menstrual cycle (~7-10 days before onset of menstruation)

Answer 69

Alcohol consumption is associated with a moderate increase in the risk of development

Answer 70

A severe form of premenstrual syndrome (PMS) characterized by mood, behavioral, and physical symptoms causing significant distress and/or functional impairment

Answer 71

* History of traumatic events * Comorbid anxiety disorders * Smoking * Obesity - linear relationship of BMI and risk of incident PMS

Answer 72

* The time after giving birth when a woman's body returns to its pre-pregnant state * Usually lasts six to eight weeks, but can last longer * Common time for the emergence or exacerbation of psychiatric disorders Three most common disorders: * Postpartum blues * Postpartum depression * Postpartum psychosis Postpartum psychiatric disorders are not distinct entities in the DSM-V * Use a “with peripartum onset” modifier if the onset of symptoms occur during pregnancy or within 4 weeks postpartum

Answer 73

Hormonal factors * Drastic changes in hormonal levels (↓ estrogen, progesterone, and cortisol) within 48 hours after delivery * Estrogen levels can have an effect on serotonin and dopamine levels → affective and psychotic symptoms * Estrogen promotes synthesis, prevents degradation, and inhibits reuptake of serotonin * Estrogen decreases the release of GABA, the main inhibitory neurotransmitter in the brain, promoting increased dopamine transmission Psychosocial factors * Women who report inadequate social supports, marital discord or dissatisfaction, or recent negative life events are more likely to experience postpartum depression Biologic vulnerability * Women with a prior history of depression or family depression of a mood disorder are at increased risk * Women with a prior history of postpartum depression or psychosis having 90% risk of recurrence

Answer 74

* Young age (< 25 years) * History of psychotic illnesses (anxiety and depression) * Previous episode of postpartum psychiatric disorder (up to a 90% recurrence rate) * Family history of psychiatric illnesses * Stressful life events (during pregnancy or near delivery) * Unintended pregnancy * Poor social support * Financial difficulties * History of intimate partner violence or sexual abuse * Cesarean sections, traumatic birth experience, or other perinatal complication (gestational diabetes) * Difficulties with breastfeeding * Women with infants having health problems and/or infants admitted to the NICU * Childcare stress (inconsolable crying infant)

Answer 75

Prevalence * Postpartum blues: very common, up to 80% of pregnancies * Postpartum depression: often underdiagnosed, approximately 10%–25% of pregnancies * Postpartum psychosis: rare, < 1–2 per 1000 births **Impact** Maternal suicide * One of the leading causes of maternal mortality * Rates of maternal mortality due to suicide are similar to mortality from infection Infanticide * Killing of a child within a year of its birth * ~300 in the US each year Negative effects on children * Untreated postpartum mood disorders in mothers are associated with long-term effects on cognitive, behavioral, and emotional development in childhood through adolescence

Answer 76

* physical sx with an unknown cause that lead to mental distress * AKA: hysteria or somatization * unintentional, unconscious sx

Answer 77

persistent disturbance of eating behavior that impairs health or psychosocial functioning

Answer 78

* multi-factorial (combination of biological, sociocultural, and psychological factors) * genetic (biologic) risk is strongest for anorexia

Answer 79

* 5% females; 2% males * highest among individuals w/ obesity

Answer 80

* close relative w/ an eating disorder (parent/sibling) * close relative w/ mental health condition * hx of dieting * T1 diabetes

Answer 81

* perfectionism * cognitive inflexibility * impulsivity * body image dissatisfaction * personal hx of mental health conditions * personal hx of substance use disorder

Answer 82

* wt stigma * teasing/bullying * limited social networks * personal experiences of trauma

Answer 83

* do you make yourself **S**ick because you feel uncomfortably full? * do you worry you have lost **C**ontrol over how much you eat? * have you recently lost more than **O**ne stone (14 lbs, 6.35 kg) in a 3-mo period? * do you believe yourself to be **F**at when others say you are too thin? * would you say that **F**ood dominates your life? "yes" to 2+ = pos screen

Answer 84

reduced LH & FSH

Answer 85

scars/calluses on the hand from contact with the teeth

Answer 86

* malnutrition * delayed puberty * amenorrhea * osteoporosis * electrolyte imbalances * CV manifestations (cardiomyopathies, prolonged QT syndrome, bradycardia)

Answer 87

* Constellation of critical acid-base and electrolyte disturbances that may occur due to refeeding of malnourished patients who are persistently starved * sudden reintroduction of caloric intake (carbs) leading to increased insulin (sudden shift of fluid/electrolytes into cells), electrolyte imbalances lead to arrhythmias, salt & H2O retention leads to edema) Prevention * slow introduction of calories * vitamin supplementation

Answer 88

Epi * women 18-35 most affected * prevalence: 1% Pathophys * hunger & satiety states not accurately recognized by anterior insula * alterations in hormones and neuropeptides 9ghrelin and leptin)

Answer 89

* ghrenlin: stimulates appetite & signals brain when time to eat * regulates energy balance by suppressing hunger & promoting feelings of fullness

Answer 90

* women more affected than men * median age = 21 yrs * more common in obese pts