Psychiatry Flashcards
Classical Conditioning
Learning in which a natural response (salivation) is elicited by a conditioned, or learned, stimulus (bell) that previously was presented in conjunction with an unconditioned stimulus (food)
Usually deals with involuntary responses. Pavlov’s classical experiments with dogs - ringing the bell provoked salivation.
Operant conditioning
Learning in which a particular action is elicited bc it produces a punishment or reward. Usually deals with voluntary responses.
1) Positive reinforcement - desired reward produces action (mouse presses button to get food)
2) Negative reinforcement - Target behavior (response) is followed by removal of aversive stimulus (mouse presses button to turn of continuous loud noise)
3) Punishment - Repeated application of aversive stimulus extinguishes unwanted behavior
4) Extinction - Discontinuation of reinforcement (positive or negative) eventually eliminates behavior. Can occur in operant or classical conditioning
Transference
Patient projects feelings about formative or other important persons onto physician (like…Psychiatrist is seen a parent)
Countertransference
Doctor projects feelings about formative or other important persons onto patient (patient reminds physician of younger sibling)
Ego defenses
Unconscious mental processes used to resolve conflict and prevent undesirable feelings (anxiety, depression)
Immature:
1) Acting Out
2) Denial
3) Displacement
4) Dissociation
5) Fixation
6) Identification
7) Isolation (of affect)
8) Passive aggression
9) Projection
10) Rationalization
11) Reaction formation
12) Regression
13) Repression
14) Splitting
Mature:
1) Altruism
2) Humor
3) Sublimation
4) Suppression
Acting out
Expressing unacceptable feelings and thoughts through actions.
Ex/ Tantrums
Ego defense (immature)
Denial
Ego defense (immature)
Avoiding the awareness of some painful reality
Ex/ A common reaction in newly diagnosed AIDS and cancer patients
Displacement
Ego Defense (immature)
Transferring avoided ideas and feelings to a neutral person or object (vs projection)
Mother yells at her child, bc her husband yelled at her
Dissociation
Ego Defense (immature)
Temporary. drastic change in personality, memory, consciousness, or motor behavior to avoid emotional stress
Extreme forms can result in dissociative identity disorder (Multiple personality disorder)
Fixation
Ego Defense (immature)
Partially remaining at a more childish level of development (vs regression)
Adults fixating on video games
Identification
Ego Defense (immature)
Modeling behavior after another person who is more powerful (though not necessarily admired)
Abused child identifies with an abuser
Isolation (of affect)
Ego Defense (immature)
Separating feelings from ideas and events
Describing murder in graphic detail with no emotional response.
Passive aggression
Ego Defense (immature)
Expressing negativity and performing below what is expected as an indirect show of opposition
Disgruntled employee is repeatedly late to work
Projection
Ego Defense (immature)
Attributing an unacceptable internal impulse to an external source (vs displacement)
A man who wants another woman thinks his wife is cheating on him.
Rationalization
Ego Defense (immature)
Proclaiming logical reasons for actions actually performed for other reasons, usually to avoid self-blame
After getting fired, claiming that the job was not important anyway
Reaction formation
Ego defense (immature)
Replacing a warded-off idea of feeling by an (unconsciously derived) emphasis on its opposite (vs sublimation)
A patient with libidinous thoughts enters a monastery
Regression
Ego Defense (immature)
Turning back the maturational clock and going back to earlier modes of dealing with the world (vs fixation)
Seen in children under stress such as illness, punishment, or birth of a new sibling (bedwetting in a previously toilet-trained child when hospitalized)
Splitting
Ego Defense (immature)
Believing that people are either all good or all bad at different times due to intolerance of ambiguity. Commonly seen in borderline personality disorder.
A patient says that all the nurses are cold and insensitive but that the doctors are warm and friendly.
Altruism
Ego defense (mature)
Alleviating negative feelings via unsolicited generosity
Mafia boss makes large donations to charity
Humor
Ego defense (mature)
Appreciating the amusing nature of an anxiety-provoking or adverse situation
Nervous medical student jokes about the boards
Sublimation
Ego defense (mature)
Replacing an unacceptable wish with a course of action that is similar to the wish but does not conflict with one’s value system (vs reaction formation)
Teenager’s aggression toward his father is redirected to perform well in sports
Suppression
Ego defense (mature)
Intentionally withholding an idea or feeling from conscious awareness (vs repression); temporary
Choosing to not worry about the big game until it is time to play
Infant deprivation effects
Long-term deprivation of affection results in:
1) Failure to thrive
2) Poor language/socialization skills
3) Lack of basic trust
4) Anaclitic depression (infant withdrawn/unresponsive)
4 W’s = Weak, Wordless, Wanting (socially), Wary
Deprivation for more than 6 months can lead to irreversible changes
Severe deprivation can result in infant death
Child Abuse
1) Physical Abuse
Evidence = Spiral fractures (or multiple fractures at different stages of healing), burns (cigarette, butt/thighs), subdural hematomas, posterior rib fractures, retinal detachment.
During exam, children often avoid eye contact.
Abuser = Usually biological mother
Epi = 40% of deaths in children less than 1 year old
2) Sexual Abuse
Evidence = Genital, Anal, or oral Trauma; STDs; UTIs
Abuser = Known to victim, usually male
Epi = Peak incidence 9-12 years old
Child Neglect
Failure to provide a child with adequate food, shelter, supervision, education, and/or affection.
Most common form of child maltreatment.
Evidence = poor hygiene, malnutrition, withdrawal, impaired social/emotional development, failure to thrive
As with child abuse, child neglect must be reported to local child protective services
ADHD
Onset before 12. Limited attention span and poor impulse control. Characterized by hyperactivity, impulsivity, and/or inattention in multiple settings (school, home, places of worship, etc).
Normal intelligence, but commonly coexists with difficulties in school.
Continues into adulthood in as many as 50% of individuals. Associated with lower frontal love volume/metabolism.
Tx = stimulants (methylphenidate) +/- cognitive behavioral therapy (CBT); atomoxetine may be an alternative to stimulants in selected patients.
Conduct Disorder
Repetitive and pervasive behavior violating the basic rights of others (physical aggression, destruction of property, theft)
After age 18, many of these patients will meet criteria for diagnosis of antisocial personality disorder.
Tx for both = CBT
Oppositional Defiant Disorder
A childhood/early onset disorder
Enduring pattern of hostile, defiant behavior toward authority figures in the absence of serious violations of social norms. Tx = CBT
Separation Anxiety Disorder
Common onset at 7-9 years. Overwhelming fear of separation from home or loss of attachment figure. May lead to factitious (fake) physical complaints to avoid going to or staying at school. Tx = CBT, play therapy, family therapy
Tourette Syndrome
Onset before 18. Characterized by sudden, rapid, recurrent, nonrhythmic, stereotyped motor and vocal tics that persist for more than 1 year.
Coprolalia (involuntary obscene speech) found only in 10-20% of patients. Associated with OCD and ADHD.
Tx = Psychoeducation, behavioral therapy.
For intractable tics, low-dose high-potency antipsychotics (fluphenazine, pimozide), tetrabenazine, and clonidine may be used.
Autism Spectrum Disorder
A pervasive developmental disorder
Characterized by poor social interactions, communication deficits, repetitive/ritualized behaviors, restricted interests. Must present in early childhood. May or may not be accompanied by intellectual disability; rarely accompanied by unusual abilities (savants).
More common in boys
Rett Syndrome
A pervasive developmental disorder
X-linked disorder seen almost exclusively in girls (affected males die in utero or shortly after birth)
Symptoms usually become apparent around ages 1-4, including regression characterized by loss of development, loss of verbal abilities, intellectual disability, ataxia, stereotyped hand-wringing.
Neurotransmitter changes with diseases
1) Alzheimer Disease
Low ACh, High Glutamate
2) Anxiety
High NE, Low GABA, Low 5-HT
3) Depression
Low NE, Low 5-HT, Low Dopamine
4) Huntington Disease
Low GABA, Low ACh, High Dopamine
5) Parkinson Disease
Low Dopamine, High ACh
6) Schizophrenia
High Dopamine
Orientation
Patient’s ability to who who he or she is, where he or she is, and the date and time.
Common causes of loss of orientation: alcohol, drugs, fluid/electrolyte imbalance, head trauma, hypoglycemia, infection, nutritional deficiencies
Order of loss: 1st - time. 2nd - place. Last - Person
Amnesias
1) Retrograde - inability to remember things that occurred before a CNS insult
2) Anterograde - Inability to remember things that occurred after a CNS insult (lower acquisition of new memory)
3) Korsakoff Syndrome - Amnesia (anterograde > retrograde) caused by B1 deficiency and associated destruction of mammillary bodies. Seen in alcoholics. Confabulations are characteristic.
4) Dissociative - Inability to recall important personal information, usually subsequent to severe trauma or stress. May be accompanied by dissociative fugue (abrupt travel or wandering during a period of dissociative amnesia, associated with traumatic circumstances)
Delirium
“Waxing and waning” level of consciousness with acute onset; rapid decrease in attention span and level of arousal. Characterized by disorganized thinking, hallucinations (often visual), illusions, misperceptions, disturbances in sleep-wake cycle, cognitive dysfunction
Usually secondary to other illness (CNS disease, infection, trauma, substance abuse/withdrawal, metabolic/electrolyte disturbances, hemorrhage, urinary/fecal retention)
Most common presentation of altered mental status in inpatient setting. Abnormal EEG.
Treatment is aimed at identifying and addressing underlying condition. Haloperidol may be used as needed. Use benzos for alcohol withdrawal.
DeliRIUM = changes in sensoRIUM
May be caused by medications (anticholinergics), esp in the elderly. Reversible
T-A-DA approach (Tolerate, Anticipate, Don’t Agitate) helpful for management
Dementia
Decline in intellectual function without affecting level of consciousness. Characterized by memory deficits, apraxia, aphasia, agnosia, loss of abstract thought, behavioral/personality changes, impaired judgment.
A patient with dementia can develop delirium (patient with Alzheimer disease who develops pneumonia is at higher risk for delirium)
Irreversible causes: Alzheimer Disease, Lewy Body dementia, Huntington Disease, Pick Disease, cerebral infarct, Creutzfeldt-Jakob disease, chronic substance abuse (due to neurotoxicity of drugs)
Reversible causes: Hypothyroidism, depression, vitamin B12 deficiency, normal pressure hydrocephalus
Increased incidence with age. EEG usually normal
Dementia characterized by memory loss. Usually irreversible. In elderly, depression and hypothyroidism may present like dementia (pseudodementia). Screen for depression and measure TSH, B12 levels.
Psychosis
A distorted perception of reality characterized by delusions, hallucinations, and/or disorganized thinking.
Psychosis can occur in patients with medical illness, psychiatric illness, or both
1) Hallucinations - perceptions in the absence of external stimuli (seeing a light that is not actually present)
2) Delusions - Unique, false beliefs about oneself or others that persist despite the facts (thinking aliens are communicating with you)
3) Disorganized speech - words and ideas are strung together based on sounds, puns, or “loose associations”
Hallucination types
1) Visual - more commonly a feature of medical illness (drug intox) than psychiatric illness
2) Auditory - More commonly a feature of psychiatric illness (schizo) than medical illness
3) Olfactory - Often occur as an aura of psychomotor epilepsy and in brain tumors
4) Gustatory - Rare, but seen in epilepsy
5) Tactile - Common in alcohol withdrawal (formication - sensation of bugs crawling on one’s skin). Also seen in cocaine abusers (“Cocaine crawlies”)
6) Hypnagogic - Occurs while going to sleep. Sometimes seen in narcolepsy
7) Hypnopompic - Occurs while waking from sleep. Sometimes seen in narcolepsy
Schizophrenia
Chronic mental disorder with periods of psychosis, disturbed behavior and thought, and decline in functioning lasting more than 6 months. Associated with higher dopaminergic activity. Lower dendritic branching.
Diagnosis requires 2 or more of the following (first 4 are POSITIVE symptoms)
1) Delusions
2) Hallucinations - often auditory
3) Disorganized speech (loose associations)
4) Disorganized or catatonic behavior
5) Negative Symptoms - flat affect, social withdrawal, lack of motivation, lack of speech or thought
Genetics and environment contribute to the etiology of schizophrenia
Frequent cannibis use is associated with psychosis/schizophrenia in teens
Lifetime prevalence - 1.5% (males = females, blacks = whites). Presents earlier in men (late teens - early 20s vs late 20s - early 30s in women). Patients are at higher risk for suicide.
Tx = atypical antipsychotics (risperidone) are first line
Brief Psychotic Disorder - lasting less than 1 month. Usually stress related.
Schizophreniform Disorder - 1-6 months.
Schizoaffective Disorder - lasting > 2 weeks. Psychotic symptoms with episodic superimposed major depression or mania (or both). Psychosis is present with and without mood disorder, but mood disorder is present only with psychosis.
Delusional Disorder
Fixed, persistent, false belief system lasting more than 1 month. Functioning otherwise not impaired. Example: a woman who genuinely believes she is married to a celebrity when in fact she is not.
Dissociative Identity Disorder
Formerly known as Multiple Personality disorder. Presence of 2 or more distinct identities or personality states. More common in women. Associated with history of sexual abuse, PTSD, depression, substance abuse, borderline personality disorder, somatoform conditions
Depersonalization/disrealization Disorder
Persistent feelings of detachment or estrangement from one’s own body, thoughts, perceptions, and actions (depersonalization) or one’s environment (Disrealization)
Mood disorder
Characterized by an abnormal range of moods or internal emotional states and loss of control over them. Severity of moods causes distress and impairment in social and occupational functioning.
Includes Major Depressive Disorder, Bipolar Disorder, Dysthymic Disorder, and Cyclothymic Disorder.
Episodic superimposed psychotic features (delusions or hallucinations) may be present.
Manic Episode
Distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy lasting at least 1 week. Often disturbing to patient.
Diagnosis requires hospitalization or at least 3 of the following (manics DIG FAST)
D = Distractibility I = Irresponsibility - seeks pleasure without regard to consequences (hedonistic) G = Grandiosity - inflated self-esteem F = Flight of ideas - racist thoughts A = Increase in goal-directed Activity/psychomotor Agitation S = Sleep (lower need for it) T = Talkativeness or pressured speech
Hypomanic episode
Like manic episode except mood disturbance is not severe enough to cause marked impairment in social and/or occupational functioning or to necessitate hospitalization. No psychotic features.
Lasts at least 4 consecutive days.
Bipolar Disorder (Manic Depression)
Bipolar I defined by presence of at least 1 manic episode with or without a hypomanic or depressive episode
Bipolar II defined by presence of a hypomanic and a depressive episode
Patient’s mood and functioning usually return to normal between episodes. Use of antidepressants can precipitate mania. High suicide risk.
Tx = mood stabilizers (Lithium, Valproic Acid, Carbamazepine), atypical antipsychotics
Cyclothymic Disorder - dysthymia and hypomania; milder form of bipolar disorder lasting at least 2 years.
Major Depressive Disorder
May be self-limited disorder, with major depressive episodes usually lasting 6-12 months. Episodes characterized by at least 5 of the following 9 symptoms for 2 or more weeks (symptoms must include patient-reported depressed mood or anhedonia)
Tx = CBT and SSRIs are first line. SNRIs, mirtazapine, bupropion can also be considered. ECT in select patients.
SIG E CAPS S = Sleep disturbance I = Interest (loss of interest - anhedonia) G = Guilt or feelings of worthlessness E = Energy loss and fatigue C = Concentration problems A = Appetite/weight changes P = Psychomotor retardation or agitation S = Suicidal ideations \+ Depressed Mood
We need 5/9 of the above.
Patients with depression typically have the following changes in their sleep stages
- Less slow-wave sleep
- Less REM latency
- High REM early in sleep cycle
- High total REM sleep
- Repeated nighttime awakenings
- Early morning wakening (terminal insomnia)
Persistent Depressive Disorder (Dysthymia) - Depression, often milder, lasting at least 2 years
Atypical Depression
Differs from classical forms of depression. Characterized by mood reactivity (being able to experience improved mood in response to positive events, albeit briefly), “reversed” vegetative symptoms (hypersomnia, hyperphagia), leaden paralysis (heavy feeling in arms and legs), long-standing interpersonal rejection sensitivity.
Most common subtype of depression.
Tx = CBT and SSRIs are first line. MAOIs are effective but not first line bc of their risk profile
Postpartum mood disturbances
Onset within 4 weeks of delivery
1) Maternal (postpartum) “blues” - 50-85% incidence rate. Characterized by depressed affect, tearfulness, and fatigue starting 2-3 days after delivery. Usually resolves within 10 days
Tx = supportive. Follow up to assess for possible postpartum depression.
2) Postpartum depression - 10-15% incidence rate. Characterized by depressed affect, anxiety, and poor concentration starting within 4 weeks after delivery.
Tx = CBT and SSRIs first line
3) Postpartum psychosis - 0.1-0.2% incidence rate. Characterized by mood-congruent delusions, hallucinations, and thoughts of harming the baby or self. Risk factors include Hx of Bipolar or psychotic disorder, frst pregnancy, family Hx, recent discontinuation of psychotropic medication.
Tx = hospitalization and initiation of atypical antipsychotic
If insufficient - ECT may be used.
Pathologic Grief
Normal bereavement characterized by shock, denial, guilt, and somatic symptoms. Duration varies widely.
Pathologic grief lasts more than 6 months, satisfies major depressive criteria (weight loss, anhedonia. passive death wish), and/or includes psychotic symptoms (delusions). Hallucinations (hearing the voice of a deceased loved one) in the absence of other psychotic symptoms are NOT considered pathologic.
ECT
Electroconvulsive Therapy
Used mainly for treatment-refractory depression, depression with psychotic symptoms, and acutely suicidal patients. Produces grand mal seizure in an anesthetized patient. Adverse effects include disorientation, temporary HA, partial anterograde/retrograde amnesia usually resolving in 6 months.
Risk factors for suicide completion
SAD PERSONS
S = Sex (male) A = Age (teens or elderly) D = Depression P = Previous attempt E = Ethanol or drug use R = Rational Thinking (loss of it) S = Sickness (medical illness, 3 or more prescription meds) O = Organized plan N = No spouse (divorced, widowed, or single, especially if childless) S = Social support lacking
Women try more often; men succeed more often.
Anxiety disorder
Inappropriate experience of fear/worry and its physical manifestations (anxiety) incongruent with the magnitude of the perceived stressor. Symptoms interfere with daily functioning. Includes panic disorder, phobias, generalized anxiety disorder, PTSD
Tx = CBT, SSRIs, SNRIs
Panic Disorder
Defined by recurrent panic attacks (periods of intense fear and discomfort peaking in 10 minutes with at least 4 of the following): PANICS
P = Palpitations, Paresthesias A = Abdominal distress N = Nausea I = Intense fear of dying/losing control, Light headedness C = Chest pain, Chills, Choking, disConnectedness S = Sweating, Shaking, SOB
Strong genetic component
Tx = CBT, SSRIs, and venlafaxine are first line. Benzos sometimes used in acute setting.
Diagnosis requires attack followed by 1 month (or more) of 1 (or more) of the following:
1) Persistent concern of additional attacks
2) Worrying about consequences of attack
3) Behavior change related to attacks
Symptoms are the systemic manifestations of fear.
Specific phobia
Fear that is excessive or unreasonable and interferes with normal function. Cued by presence or anticipation of a specific object or situation. Person recognizes fear is excessive. Can treat with systematic desensitization
Social Anxiety Disorder - exaggerated fear of embarrassment in social situations (public speaking, using public restrooms) Tx = CBT, SSRIs
Agoraphobia - exaggerated fear of open or enclosed places, using public transportation, being in line or in crowds, or leaving home alone. Tx = CBT, SSRIs, MAOIs
Generalized Anxiety Disorder
Anxiety lasting more than 6 months unrelated to a specific person, situation, or even. Associated with sleep disturbance, fatigues, GI disturbances, difficulty concentrating
Tx = CBT, SSRIs, SNRIs are first line. Buspirone, TCAs, Benzos are 2nd line.
Adjustment Disorder - emotional symptoms (anxiety, depression) causing impairment following an identifiable psychosocial stressor (divorce, illness) and lasting less than 6 months (more than 6 months in presence of chronic stressor). Tx = CBT, SSRIs
OCD
Recurring intrusive thoughts, feelings, or sensations (obsessions) that cause severe distress; relieved in part by the performance of repetitive actions (compulsions).
Ego-dystonic: behavior inconsistent with one’s own beliefs and attitudes (vs Obsessive compulsive personality disorder)
Associated with Tourette Syndrome.
Tx = CBT, SSRIs, and clomipramine are first line
Body Dysmorphic Disorder - preoccupation with minor or imagined defect in appearance leading to significant emotional distress or impaired functioning; patients often repeatedly seek cosmetic surgery. Tx = CBT
PTSD
Persistent reexperiencing of a previous traumatic event (war, rape, robbery, serious accident, fire)
May involve nightmares or flashbacks, intense fear, helplessness, horror. Leads to avoidance of stimuli associated with the trauma and persistently increased arousal
Disturbance lasts more than 1 month and impairs social-occupational functioning. Tx = CBT, SSRIs, and venlafaxine are first line
Acute Stress Disorder - lasts between 3 days and 1 month. Tx = CBT - pharm is usually not indicated.
Malingering
Patient consciously fakes, profoundly exaggerates, or claims to have a disorder in order to attain a specific secondary (external) gain (avoiding work, obtaining compensation). Poor compliance with treatment or follow-up of diagnostic tests. Complaints cease after gain (vs Factitious disorder)
Factitious Disorders
Patient consciously creates physical and/or psychological symptoms in order to assume “sick role” and to get medical attention (primary [internal] gain)
1) Munchausen Syndrome - Chronic factitious disorder with predominantly physical signs and symptoms. Characterized by a history of multiple hospital admissions and willingness to undergo invasive procedures
2) Muchausen Syndrome by Proxy - Illness in a child or elderly patient is caused or fabricated by the caregiver. Motivation is to assume a sick role by proxy. Form of child/elder abuse
Somatic symptoms and related disorders
Category of disorders characterized by physical symptoms with no identifiable physical cause. Both illness production and motivation are unconscious drives. Symptoms not intentionally produced or feigned. More common in women.
1) Conversion Disorder - Loss of sensory or motor function (paralysis, blindness, mutism), often following an acute stressor; patient is aware of but sometimes indifferent toward symptoms (“la belle indifference”), more common in females, adolescents, and young adults.
2) Illness Anxiety Disorder (Hypochondriasis) - Preoccupation with and fear of having a serious illness despite medical evaluation and reassurance
3) Somatic symptom Disorder - Variety of complaints in one or more organ systems lasting for months to years. Associated with excessive, persistent thoughts and anxiety about symptoms. May co-occur with medical illness.
Personality trait
An enduring, repetitive pattern of perceiving, relating to, and thinking about the environment and onself
Personality disorder
Inflexible, maladaptive, and rigidly pervasive pattern of behavior causing subjective distress and/or impaired functioning’ person is usually not aware of problem. Usually presents by early adulthood.
Three Clusters - ABC remember Weird, Wild, and Worried based on symptoms
Cluster A Personality Disorders
“Weird” (Accusatory, Aloof, Awkward)
Odd or eccentric; inability to develop meaningful social relationships. No psychosis; genetic association with schizophrenia.
1) Paranoid - Pervasive distrust and suspiciousness; projection is the major defense mechanism
2) Schizoid - Voluntary social withdrawl, limited emotional expression, content with social isolation (vs avoidant) SchizoiD = Distant
3) Schizotypal - Eccentric appearance, odd beliefs or magical thinking, interpersonal awkwardness.
SchizoTypal = magical Thinking
Cluster B Personality Disorders
“Wild” (Bad to the Bone)
Dramatic, emotional, or erratic; genetic association with mood disorders and substance abuse
1) Antisocial - Disregard for and violation of rights of others, criminality, impulsivity; males more than females; must be more than 18 years old and have history of conduct disorder before age 15. Conduct disorder if younger than 18.
Antisocial = sociopath
2) Borderline - Unstable mood and interpersonal relationships, impulsivity, self-mutilation, boredom, sense of emptiness; females more than males; splitting is a major defense mechanism
Tx = dialectical behavior therapy
3) Histrionic - Excessive emotionality and excitability, attention seeking, sexually provocative, overly concerned with appearance
4) Narcissistic - Grandiosity, sense of entitlement; lacks empathy and requires excessive admiration; often demands the “best” and reacts to criticism with rage
Cluster C Personality Disorders
“Worried” - Cowardly, Compulsive, Clingy
Anxious or fearful; genetic association with anxiety disorders
1) Avoidant - Hypersensitive to rejection, socially inhibited, timid, feelings of inadequacy, desires relationships with others (vs Schizoid)
2) Obsessive-Compuslive - Preoccupation with order, perfectionism, and control; ego-syntonic: behavior consistent with one’s own beliefs and attitudes (vs OCD)
3) Dependent - Submissive and clingy, excessive need to be taken care of, low self-confidence
Patients often get stuck in abusive relationships
Keeping schizo straight
Schizoid 6 months - schizophrenia
Anorexia nervosa
Excessive dieting +/- purging; intense fear of gaining weight and body image distortion
BMI
Bulimia nervosa
Binge eating with recurrent inappropriate compensatory behaviors (self-induced vomiting, using laxatives or diuretics, fasting, excessive exercise) occurring weekly for at least 3 months. Body weight often maintained within normal range. Associated with parotitis, enamel erosion, electrolyte disturbances, alkalosis, dorsal hand calluses from induced vomiting (Russell Sign).
Seen mostly in adolescent girls.
Gender Dysphoria
Strong, persistent cross-gender identification. Characterized by persistent discomfort with one’s sex assigned at birth, causing significant distress and/or impaired functioning. Affected individuals are often referred to as transgender
Transexualism - desire to live as the opposite sex, often through surgery or hormone treatment
Transvestism - paraphilia, not gender dysphoria. Wearing clothes (e.g. vest) of the opposite sex (cross-dressing)
Sexual dysfunction
Includes sexual desire disorders (Hypoactive sexual desire or sexual aversion), sexual arousal disorders (ED), orgasmic disorders (anorgasmia, premature ejac), sexual pain disorders (dyspareunia, vaginismus)
DDx includes:
Drugs (antihypertensives, neuroleptics, SSRIs, ethanol)
Diseases (Depression, diabetes, STIs)
Psychological (performance anxiety)
Sleep terror disorder
Periods of terror with screaming in the middle of the night; occurs during slow-wave sleep. Most common in children.
Occurs during non-REM sleep (no memory of arousal) as opposed to nightmares that occur during REM (memory of a scary dream).
cause unknown, but triggers include emotional stress, fever, or lack of sleep. Usually self-limited
Narcolepsy
Disordered regulation of sleep-wake cycles; primary characteristic is excessive daytime sleepiness
Caused by lower hypocretin (orexin) production in lateral hypothalamus
Also associated with:
- Hypnagogic (just before sleep) or hypnopompic (just before awakening) hallucinations
- Nocturnal and narcoleptic sleep episodes that start with REM sleep
- Cataplexy (loss of all muscle tone following strong emotional stimulus, such as laughter) in some patients
Strong genetic component. Tx = daytime stimulants (amphetamines, modafinil) and nighttime sodium oxybate (GHB)
Substance use disorder
Maladaptive pattern of substance use defined as 2 or more of the following signs in 1 year
1) Tolerance - need more to achieve same effect
2) Substance taken in larger amounts, or over longer time than desired
3) Persistent desire or unsuccessful attempts to cut down
4) Significant energy spent obtaining using or recovering from substance
5) Important social, occupational, or recreational activities reduced bc of substance use
6) Continued use despite knowing substance causes physical and/or psychological problems
7) Craving
8) Recurrent use in physically dangerous situations
9) Failure to fulfill major obligations at work, school, or home due to use
10) Social or interpersonal conflicts related to substance use
Stages of change in overcoming substance addiction
1) Precontemplation - not yet acknowledging that there is a problem
2) Contemplation - acknowledging that there is a problem, but not yet ready or willing to make a change
3) Preparation/determination - getting ready to change behaviors
4) Action/willpower - changing behaviors
5) Maintenance - Maintaining behavior changes
6) Relapse - returning to old behaviors and abandoning new changes
Depressants (intox/withdrawal)
Intox = Nonspecific - mood elevation, lowers anxiety, sedation, behavioral disinhibition, respiratory depression
Withd = Nonspecific - anxiety, tremor, seizures, insomnia
Alcohol (intox/withdrawal)
Depressant
Intox - Emotional lability, slurred speech, ataxia, coma, blackouts. Serum y-glutamyltransferase (GGT) - sensitive indicator of alcohol use. AST value is twice ALT value
WithD- Mild alcohol withdrawal - symptoms similar to other depressants. Severe - autonomic hyperactivity and DTs (5-15% mortality rate). Tx for DTs = Benzos
Opiods - morphine, heroin, methadone (intox/withdrawal)
Depressants
Intox - Euphoria, respiratory and CNS depression. Depressed gag reflex, pupillary constriction (pinpoint pupils), seixures (OD). Tx = naloxone, naltrexone
W - Sweating, dilated pupils, piloerection (cold turkey), fever, rhinorrhea, yawning, nausea, stomach cramps, diarrhea (flu like symptoms) Tx = long-term support, methadone, buprenorphine
Barbituates (intox/withdrawal)
Depressants
I - Low safety margin, marked respiratory depression. Tx = symptom management (assist respiration, high BP)
W - Delirium, life-threatening cardiovascular collapse
Benzodiazepines (intox/withdrawal)
Depressants
I - Greater safety margin than Barbs. Ataxia, minor respiratory depression. Tx = flumazenil (benxo receptor antagonist, but rarely used as it an precipitate seizures)
W - Sleep disturbance, depression, rebound anxiety, seizure
Stimulants (intox/withdrawal)
I - Nonspecific - mood elevation, psychomotor agitation, insomnia, cardiac arrhythmias, tachycardia, anxiety
W - Nonspecific - Post-use “crash,” including depression, lethargy, weight gain, HA
Amphetamines (intox/withdrawal)
I - Euphoria, grandiosity, pupillary dilation, prolonged wakefulness and attention, HTN, tachycardia, anorexia, paranoia, fever. Severe = cardiac arrest, seizure
W - Anhedonia, higher appetite, hypersomnolence, existential crisis
Cocaine (intox/withdrawal)
I - Impaired judgment, pupillary dilation, hallucinations (including tactile), paranoid ideations, angina, sudden cardiac death. Tx = alpha blockers, benzo. B-blockers not recommended
W - Hypersomnolence, malaise, severe psychological craving, depression/suicidality
Caffeine (intox/withdrawal)
I - Restlessness, more diuresis, muscle twitching
W - Lack of concentration, HA
Nicotine (intox/withdrawal)
I - Restlessness
W - Irritability, anxiety, craving Tx = nicotine patch, gum or lozenges; bupropion/varenicline
PCP (intox/withdrawal)
I - Belligerence, impulsivity, fever, psychomotor agitation, analgesia, vertical and horizontal Nystagmus, tachycardia, homicidality, psychosis, delirium, seizures. Tx = benzo, rapid-acting antipsychotic
W - Depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep
LSD (intox/withdrawal)
I - Perceptual distortion (visual/auditory), depersonalization, anxiety, paranoia, psychosis, Possible flashbacks
W - N/A
Marijuana (intox/withdrawal)
I - Euphoria, anxiety, paranoid delusions, perception of slowed time, impaired judgement, social withdrawal, increased appetite, dry mouth, conjunctival injection, hallucinations.
Pharm form is dronabinol (tetrahydrocannabinol isomer): used as antiemetic (chemotherapy) and appetite stimulant (AIDS)
W - Irritability, depression, insomnia, nausea, anorexia. Most symptoms peak in 48 hrs and last for 5-7 days. Generally detectable in urine for up to 1 month
Heroin addiction
users are at higher risk for hepatitis, HIV, abscesses, bacteremia, right-heard endocarditis
Tx =
1) Methadone - Long-acting oral opiate used for heroin detox or long-term maintenance
2) Naloxone + Buprenorphine - Antagonist + partial agonist. Naloxone is not orally bioavailable, so withdrawal symptoms occur only if injected (lower abuse potential)
3) Naltrexone - Long-acting opioid antagonist used for relapse prevention once detoxified.
Alcoholism
Physiologic tolerance and dependence with symptoms of withdrawal (tremor, tachycardia, HTN, malaise, nausea, DTs) when intake is interrupted
Complications: Alcoholic cirrhosis, hepatitis, pancreatitis, peripheral neuropathy, testicular atrophy
Tx = disulfiram (to condition the patient to abstain from alcohol use)
Acamprosate, naltrexone, supportive care. Support groups such as AA are helpful in sustaining abstinence and supporting patient and family
Wernicke-Korsakoff Syndrome
caused by vitamin B1 deficiency. Triad of confusion, ophthalmoplegia, ataxia (Wernicke encephalopathy). May progress to irreversible memory loss, confabulation, personality change (Korsakoff Psychosis). Associated with periventricular hemorrhage/necrosis of mammillary bodies. Tx = IV vitamin B1
Mallory-Weiss Syndrome
Partial thickness tear at gastroesophageal junction caused by excessive/forceful vomiting. Often presents with hematemesis and misdiagnosed as ruptured esophageal varices
Delirium tremens (DTs)
Life-threatening alcohol withdrawal syndrome that peaks 2-4 days after last drink.
Characterized by autonomic hyperactivity (tachycardia, tremors, anxiety, seizures). Classically occurs in hospital setting (2-4 days postsurgery) in alcoholics not able to drink as inpatients Tx = benzos
Alcoholic hallucinosis is a distinct condition characterized by visual hallucinations 12-48 hrs after last drink. Tx = long acting benzos (Chlordiazepoxide, larazepam, diazepam)
