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 because it produces a punishment or reward. Usually deals with voluntary responses.
Positive reinforcement
A type of operant conditioning. A desired reward produces action (mouse presses button to get food).
Negative reinforcement
A type of operant conditioning. A target behavior (response) is followed by removal of averse stimulus (mouse presses button to turn off continuous loud noise).
Punishment reinforcement
A type of operant conditioning. repeated application of aversive stimulus extinguishes unwanted behavior.
Extinction reinforcement
A type of operant conditioning. Discontinuation of reinforcement (positive or negative) eventually eliminates behavior. It can occur in operant or classical conditioning.
Transference
Patient projects feelings about formative or other important person onto physician (eg psychiatrist is seen as parent).
Countertransference
Doctor projects feeling about formative or other important persons onto patient (eg patient reminds physician of younger sibling).
Ego defenses
Unconscious mental processes used to resolve conflict and prevent undesirable feelings (eg. anxiety and depression).
Acting out
Expressing unacceptable feelings and thoughts through actions. For example, tantrums.
Denial
Avoiding the awareness of some painful reality. For example, a common reaction in newly diagnosed AIDS and cancer patients.
Displacement
Transferring avoided ideas and feelings to a neutral person or object (vs projection). For example, a mother yells at her child, because her husband yelled at her.
Dissociation
Temporary, drastic change in personality, memory, consciousness, or motor behavior to avoid emotional stress. For example, extreme forms can result in dissociative identity disorder (multiple personality disorder).
Fixation
Partially remaining at a more childish level of development (vs regression). For example, adults fixating on video games.
Identification
Modeling behavior after another person who is more powerful (though not necessarily admired). For example, abused child identifies with an abuser.
Isolation of affect
Separating feeling from ideas and events. For example, describing murder in graphic detail with no emotional response.
Passive aggression
Expressing negativity and performing below what is expected as an indirect show of opposition. For example, disgruntled employee is repeatedly late to work.
Projection
Attributing an unacceptable internal impulse to an external source (vs displacement). For example, a man who wants another woman thinks her wife is cheating on him.
Rationalization
Proclaiming logical reasons for actions actually performed for other reasons, usually to avoid self-blame. For example, after getting fired, claiming that the job was not important anyway.
Reaction formation
Replacing a warded off idea or feeling by an (unconsciously derived) emphasis on its opposite (sublimation). For example, a patient with libidinous thoughts enters a monastery.
Regression
Turning back the maturational clock and going back to earlier modes of dealing with the world (vs fixation)
Repression
Involuntarily withholding and idea or feeling from conscious awareness. For example, a 20 year old does not remember going to counseling during his parents’ divorce 10 years earlier.
Splitting
Believing that people are either all good or all bad at different times due to intolerance of ambiguity. It is commonly seen in borderline personality disorder. For example, a patient says that all the nurses are cold and insensitive but that the doctors are warm and friendly.
Altruism
A mature defense. Alleviating negative feelings via unsolicited generosity. For example, mafia boss makes large donation to charity.
Humor
A mature defense. Appreciating the amusing nature of an anxiety-provoking or adverse situation. For example, nervous medical student jokes about the boards.
Sublimation
A mature defense. 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). For example, teenager’s aggression toward his father is redirected to perform well in sports.
Suppression
Intentionally withholding an idea or feeling from conscious awareness (vs repression); temporary. For example, choosing to not worry about the big game until its time to play.
Mature defenses
Altruism, humor, sublimation, and suppression. Mature adults wear a SASH.
Infant deprivation effect
Long term deprivation of affection in infants results in crying or Wah, Wah, Wah, Wah: Weak: decreased muscle tone, weight loss, and physical illness. Wordless: poor language skills and anaclitic depression. Wanting: poor socialization skills. Wary: lack of basic trust. Anaclitic depression or hospitalism is depression in an infant attributable to continued separation from a caregiver resulting in withdrawn and unresponsive infants. Deprivation greater than 6 months can lead to irreversible changes or even death
Physical child abuse
Physical child abuse can present with: Healed fractures on x-ray, Cigarette burns, Subdural hematomas, Multiple bruises, Retinal hemorrhage or detachment, Spiral fractures, Skin lesions (most common sign of child abuse), Avoidance of eye contact during examination. Active physical abuse is usually inflicted by the mother (or primary care-giver if not the mother). Physical child abuse typically occurs in children less than 3 years old. Any signs of child abuse must be reported to authorities.
Sexual child abuse
Sexual child abuse may present as: Oral trauma, Genital trauma, Anal trauma, Sexually transmitted diseases, Urinary tract infections. The abuser is usually male and is known to the victim. Peak incidence is between 9-12 years of age.
Child neglect
Failure to provide a child with adequate food, shelter, supervision, education, and/or affection. It is the most common form of child maltreatment. Evidence includes 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.
Attention Deficit Hyperactivity Disorder (ADHD)
Attention Deficit Hyperactivity Disorder (ADHD) is characterized by: Inattention: problems with listening, concentrating, paying attention to details, organizing tasks, easily distracted, or often forgetful. Hyperactivity and Impulsivity: blurting out answers, interrupting, fidgeting, and talking excessively. The onset of ADHD is before age 12. The patient’s behavior is inconsistent with their age or development. Children with ADHD often have normal intelligence. ADHD is associated with decreased frontal lobe volume. Two thirds of children with ADHD also have conduct disorder or oppositional defiant disorder. The treatment of ADHD includes: CNS stimulants (methylphenidate, dextroamphetamine) +/- cognitive behavioral therapy. Non-stimulants such as norepinephrine reuptake inhibitors (atomoxetine)
Tourette’s Disorder
Tourette’s Disorder is characterized by both motor and vocal tics lasting for more than 1 year. Tourette’s disorder must be diagnosed prior to age 18, and usually presents around 7-8 years of age. The incidence is three times greater in boys. Vocal tics may appear years after motor tics and can include: Coprolalia is the repetition of curse words (not necessarily made by another person) and tends to be uncommon. Echolalia is the repetition of words made by another person. There is a genetic relationship of Tourette’s Disorder to attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). First line treatments for Tourette’s disorder includes psychoeducation and behavioral therapy. Treatment for the intractable tics of Tourette’s disorder includes: Low-dose, high-potency antipsychotics (e.g. fluphenazine, pimozide, haloperidol); Tetrabenazine (VMAT inhibitor); Clonidine (α2 agonist)
Conduct Disorder
Conduct Disorder is characterized by a pattern of behavior that involves violation of basic rights of others. Behaviors may include: Aggression towards people or animals; Destruction of property; Deceitfulness. There is an increased incidence of ADHD, learning disorders, substance abuse, and criminal behavior in children with conduct disorder. After age 18, conduct disorder is considered antisocial personality disorder.
Oppositional defiant disorder
Oppositional defiant disorder is characterized by at least 6 months of disobedient and defiant behavior toward authority figures. Children with oppositional defiant disorder do not violate social norms with violence or crime, which differentiates this disorder from conduct disorder. At least 4 of the following are present in oppositional defiant disorder: Frequent loss of temper, Arguments with adults, Defying rules set by adults, Deliberately annoying people, Being easily annoyed, Anger and resentment, Spitefulness, Blaming others for mistakes.
Separation anxiety disorder
Separation anxiety disorder is characterized by excessive anxiety concerning separation from home or from those to whom the individual is attached. When forced to separate, children with separation anxiety disorder worry about losing their parents forever and try to avoid separation by feigning physical complaints. It commonly occurs at 7-8 years of age after a stressful life event such as the birth of a new sibling, moving out of a house, or starting a new school. Treatment of separation anxiety disorder includes: SSRIs, Behavioral therapy, Play therapy, Family therapy
Pervasive developmental disorders
Characterized by difficulties with language and failure to acquire or early loss of social skills. Includes autism spectrum disorder and Rett syndrome
Autism spectrum disorder (ASD)
Autism spectrum disorder (ASD) is characterized by: Impaired social interaction (reduced empathy, reduced interest in socialization), Impaired communication (inability to understand social cues and nonverbal messages), Repetitive/stereotyped patterns of behavior (fixated interests, inflexibility to change), According to DMS-V, ASD symptoms must be present by “early development” (previous DSM-IV timeframe was age 3). Individuals with autism spectrum disorder may have increased serotonin levels. Neuroanatomical findings in autism spectrum disorder include increased cortical thickness and increased total brain volume.
Rett syndrome
Rett syndrome is an X-linked disorder marked by regression in physical and psychomotor development after around 6 months of normal development. This is an important distinguishing factor when compared to autism spectrum disorder. Rett syndrome is predominantly seen in girls, since affected males die in utero. The classic description of Rett syndrome is stereotyped hand-wringing movements. Associated with the de novo mutations of the MECP2 gene on the X chromosome.
Changes of neurotransmitters with Alzheimer disease
ACh decreases, glutamate increases
Changes of neurotransmitters with anxiety
Norepinephrine increases, GABA decreases, 5-HT decreases.
Changes of neurotransmitters with depression
Norepinephrine decreases, 5-HT decreases.
Changes of neurotransmitters with Huntington disease
GABA decreases, ACh decreases, dopamine increases
Changes of neurotransmitters with Parkinson disease
Dopamine decreases, ACh increases
Changes of neurotransmitters with Schizophrenia
dopamine increases
Orientation
Orientation refers to the ability of a patient to know who she or he is, what date and time it is, and what his or her present location and circumstance are (Oriented x 3 = person, place, time). Order of loss of orientation is as follows: 1st time → 2nd place → 3rd person. Several common causes of loss of orientation include (among others): Alcohol intoxication, Drug overdose, Electrolyte imbalance, Trauma, Hypoglycemia, Infection
Retrograde Amnesia
Retrograde Amnesia is defined as the inability to remember things that occurred before a CNS insult resulting in an inability to recall previously formed memories.
Anterograde Amnesia
Anterograde Amnesia is defined as the inability to remember things that occurred after a CNS insult resulting in difficulty forming new memories
Dissociative Amnesia
Dissociative Amnesia is defined as the inability to remember significant personal information, usually a result of severe trauma or stress. Dissociative fugue is characterized by reversible amnesia for personal identity, including memories, and personality; it is associated with unplanned travel or wandering. After recovery from fugue, previous memories usually return intact; however, during the fugue episode, there is complete amnesia.
Korsakoff’s Amnesia
Korsakoff’s Amnesia is a form of anterograde amnesia (and if severe, retrograde amnesia as well) that is caused by thiamine deficiency. In Korsakoff’s amnesia, chronic insult leads to bilateral destruction of the mammillary bodies. Korsakoff’s amnesia is classically seen in alcoholics and associated with confabulations.
Delirium
Delirium is a disorder of impaired cognitive functioning with a hallmark of waxing and waning level of consciousness (DeliRIUM = changes in sensoRIUM). Delirium often is characterized by visual hallucinations, which are rare in dementia. Delirium usually has an abnormal EEG, which distinguishes it from dementia. Delirium is the most common psychiatric condition in patients treated in medical hospital units. Causes of delirium (AEIOU TIPS): Alcohol; Electrolytes; Iatrogenic (anticholinergics, anticonvulsants, antihypertensives, anti-Parkinson drugs, antibiotics, benzodiazepines, disulfiram, H2 receptor blockers, hypoglycemics, insulin, narcotics, NSAIDs, steroids); Oxygen hypoxia (bleeding, pulmonary disease, carbon monoxide poisoning); Uremia and hepatic encephalopathy; Trauma; Infection (especially urinary tract infection); Poisons; Seizures (post-ictal). The 1st line treatment of delirium is antipsychotics. The underlying cause must be treated as well after acute stabilization. (The only type of delirium treated by benzodiazepines is delirium tremens)
Dementia
Dementia is a disorder of impaired memory and gradual decrease in cognitive functions. The hallmark characteristic is cognitive deficit with normal consciousness. (DeMEntia = MEmory loss). Dementia usually has an insidious onset, while delirium has an acute onset. Delirium is typically reversible, while dementia is most often not. The most common type of dementia is Alzheimer disease. It is a clinical diagnosis that can only be truly confirmed after death by autopsy. Vascular dementia is characterized by focal neurological deficits. Pick disease is characterized by pronounced personality changes and inappropriate behavior. Lewy body dementia is characterized by Lewy bodies in the cortex (as opposed to being confined to the substantia nigra in Parkinson’s). Consider Lewy body dementia when the patient experiences visual hallucinations and Parkinsonism (resting tremor, bradykinesia, etc.). Normal pressure hydrocephalus is a potentially reversible cause of dementia. Suspect it when a patient also has ataxia and incontinence. Treatment of dementia involves ruling out reversible causes like normal pressure hydrocephalus and pseudodementia. Cholinergic agonists such as donepezil, galantamine, and rivastigmine may be used to slow cognitive decline, but ultimately cannot reverse or stop the disease.
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.
Hallucinations
Hallucination is defined as a perception in the absence of an external stimulus.
Delusions
Unique, false beliefs about oneself or others that persist despite the facts (eg thinking aliens are communicating with you)
Disorganized speech
Words and ideas are strung together based on sounds, puns, or loose associations.
Visual hallucinations
Visual hallucinations are common in delirium (medical illnesses).
Auditory hallucinations
Auditory hallucinations may be present in psychiatric illnesses: Schizophrenia, Cocaine intoxication, Alcohol withdrawal, Sleep deprivation
Olfactory hallucinations
Olfactory hallucinations often occur as an aura of psychomotor epilepsy or as a result of a brain tumor.
Tactile hallucinations
Tactile hallucinations (e.g. formication - the sensation of ants crawling on one’s skin) can occur in patients experiencing severe alcohol withdrawal (delirium tremens) as well as in cocaine and amphetamine users.
Hypnagogic hallucinations
HypnaGOgic hallucinations occur just as an individual GOes to sleep.
Hypnopompic hallucinations
HypnoPOMPic hallucinations occur just as an individual wakes up (POMPous upon wakening).
Schizophrenia
Schizophrenia is a mental disorder characterized by psychotic episodes and decline in functioning that can be diagnosed after 6 months of schizophrenic symptoms. Schizophrenia is characterized by both “positive” and “negative” symptoms. Schizophrenia is associated with decreased dendritic branching. Lifetime prevalence of schizophrenia is 1.5% with equal rates in males and females and whites and blacks. Schizophrenia presents earlier in men (late teens to early 20s) as compared to women. Those born during the winter have a higher incidence of schizophrenia. Frequent cannabis use is associated with schizophrenia in teens. Patients with schizophrenia have a high risk of suicide.
Negative symptoms of schizophrenia
Negative symptoms of schizophrenia are “subtracted” from a normal person’s behavior. They include: Flattening of affect, Thought blocking (sudden halt in train of thought), Deficiencies in speech content, Cognitive disturbances, Poor grooming, Lack of motivation, Social withdrawal. Negative symptoms of schizophrenia are associated with decreased dopaminergic activity in the mesocortical pathway.
Positive symptoms of schizophrenia
Positive symptoms of schizophrenia include Delusions, Hallucinations, Disorganized speech (e.g., loose associations), Disorganized or catatonic behavior (immobility and unresponsive to environment. They are associated with increased dopaminergic activity in the mesolimbic pathway.
Diagnosis of schizophrenia
Diagnosis of schizophrenia requires at least two of the following: Delusions, Hallucinations, Disorganized speech (e.g., loose associations), Disorganized or catatonic behavior (immobility and unresponsive to environment), Presence of negative symptoms.
Treatment of schizophrenia
The mainstay treatment of schizophrenia centers around typical and atypical antipsychotics . Atypical antipsychotics are better suited to treat the negative symptoms of schizophrenia.
Brief psychotic disorder
Brief psychotic disorder is an unprecedented episode of psychosis lasting more than a day but
Schizophreniform disorder
Schizophreniform disorder is an episode of psychosis lasting less than 6 months but greater than 1 month.
Schizoaffective disorder
Schizoaffective disorder is a disorder characterized by psychosis associated with a mood disorder, such as mania or depression. Schizoaffective disorder is distinguished from major depressive disorder (MDD) with psychosis in the following way: Schizoaffective is psychosis with intermittent mood disorders. Psychosis in the absence of a mood disorder rules out MDD. MDD with psychosis is a constant mood disorder with intermittent psychosis.
Delusional disorder
Delusional disorder can appear similar to schizophrenic delusions. It is characterized by a fixed, non-bizarre delusional system and few if any other thought disorders. An important difference for diagnosis is that individuals with delusional disorder have relatively normal social and occupational functioning.
Dissociative identity disorder
Dissociative identity disorder (multiple personality disorder) is defined by 2 or more distinct personalities within a single patient. The classic description is a patient who receives photos of his/herself doing things the patient doesn’t remember, with people the patient doesn’t know. Most patients have experienced prior trauma, especially child abuse.
Depersonalization disorder
Depersonalization disorder is characterized by feelings of detachment from oneself or one’s environment. Transient depersonalization may occur during periods of severe stress, but this disorder is defined by persistent depersonalization that causes social/occupational distress.
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. Types includes major depressive disorder, bipolar disorder, dysthymic disorder, and cyclothymic disorder. Episodic superimposed psychotic features (delusions or hallucinations) may be present.
A manic episode
A manic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least one week (or any duration requiring hospitalization). During the mood disturbance, three or more of the following are present. Use the DIG FAST mnemonic: Distractibility, Irresponsible and erratic behavior, Grandiosity (inflated self-esteem), Flight of ideas (racing thoughts), Activity is increased and goal directed, Sleep (decreased need), Talkativeness or pressured speech.
A hypomanic episode
A hypomanic episode is similar to manic episode except the mood disturbance must last at least four days and is not severe enough to cause marked impairment in social and/or occupational functioning or to necessitate hospitalization; there are no psychotic features.
Bipolar Disorder
Bipolar Disorder involves a spectrum of manic and depressive symptoms. In bipolar disorder, cycles between depressive episodes and manic episodes last between 6-9 months and become shorter as the illness progresses. If untreated, a manic episode lasts approximately 3 months. Patients with bipolar disorder have a high risk of suicide.
Bipolar Disorder I
Bipolar Disorder I requires at least one episode of mania with or without a hypomanic or depressive episode. Many patients with Bipolar I have also experienced a major depressive episode, but this is not required for diagnosis.
Bipolar Disorder II
Bipolar Disorder II requires episodes of both hypomania and a major depressive episode.
Cyclothymic disorder
Cyclothymic disorder is a mild form of bipolar disorder with dysthymia and hypomania lasting at least 2 years.
Treatment of bipolar disorder
First line medications for maintenance therapy of bipolar disorder include: Lithium, Valproic acid, Carbamazepine, Atypical antipsychotics (e.g., risperidone). Acute mania is treated with atypical antipsychotics (olanzapine, quetiapine, ziprasidone). In a misdiagnosed individual with bipolar disorder, antidepressants may trigger a manic episode.
Major Depressive Disorder (MDD)
Major Depressive Disorder (MDD) is marked by episodes of depressed mood associated with loss of interest in daily activities. MDD is characterized by at least 5 of the following for 2 weeks with either depressed mood or anhedonia (SIG E CAPS): Sleep disturbance, Interest loss (anhedonia), Guilt or feelings of worthlessness, Energy loss, Concentration or Cognitive deficits, Appetite loss, Psychomotor retardation or agitation, Suicidal ideations. Lifetime prevalence of major depressive episode is 5-12% for males and 10-25% for females. Recurrent major depressive disorder requires 2 or more depressive episodes with a symptom-free interval of 2 months. If major depressive disorder is untreated, it can last 6-12 months; with treatment, an episode resolves in approximately 3 months. First line treatment for depression is selective serotonin reuptake inhibitors (SSRIs) because they have limited side effects.
Persistent depressive disorder
Persistent depressive disorder is depression lasting at least 2 years.
Sleep changes that occur in MDD
There are several sleep changes that occur in MDD, including: Decreased REM sleep latency, Increased total REM sleep, Decreased slow wave sleep, Early morning awakenings
Atypical Depression
Atypical Depression is a separate form of depression, which is characterized by: Mood reactivity, Hypersomnia, Weight gain, Leaden paralysis (arms and legs feel heavy), Rejection sensitivity. Atypical depression is treated with SSRIs, Cognitive Behavioral Therapy (CBT) and MAO Inhibitors.
Electroconvulsive Therapy (ECT)
Electroconvulsive Therapy (ECT) is an electrically induced painless seizure under anesthesia. It is used to treat Mania, Catatonia (motor immobility), Major depressive disorder refractory to pharmacotherapy, Acute suicidality. ECT is usually administered in 8 treatments over a 2-3 week period, but major improvements are seen after the 1st treatment. ECT is safe to use in patients who may not tolerate the side effects of antidepressant medications, including the elderly and pregnant women. Major adverse effects of ECT include: Disorientation, Anterograde amnesia, Retrograde amnesia
Postpartum mood disturbances
Postpartum mood disturbances are depressive-like symptoms that occur within 4 weeks of delivery of an infant. The three types of postpartum mood disturbances include: Postpartum “blues”, Postpartum depression, Postpartum psychosis
Postpartum “blues”
Postpartum “blues” are characterized by: Depressed affect, Tearfulness, Fatigue, Mild anxiety. The incidence rate of postpartum “blues” is 50-85%. The symptoms of postpartum blues usually appear 2-3 days after delivery and resolve within 10 days. The treatment of postpartum blues is supportive and follow-up is necessary.
Postpartum depression
Postpartum depression is characterized by: Depressed affect, Moderate-to-severe anxiety, Poor concentration, Hopelessness, Fatigue, Anhedonia. The incidence rate of postpartum depression is 10-15%. Postpartum depression starts within 4 weeks after delivery and lasts 2 weeks to a year or more. Treatment of postpartum depression includes antidepressants (SSRIs or TCAs) and psychotherapy.
Postpartum psychosis
Postpartum psychosis is characterized by: Delusions, Hallucinations, Confusion, Homicidal or suicidal ideations/attempts. The incidence rate of postpartum psychosis is 0.1-0.2%. Postpartum psychosis may last from days to 4-6 weeks. Treatment of postpartum psychosis includes: Antipsychotics, Antidepressants, Inpatient hospitalization
pathologic grief
To be considered pathologic grief must meet one or more of the following criteria: Lasts >6 months, Includes psychotic symptoms (e.g. delusions), Meets major depressive criteria (such as weight loss, passive death wish, etc.). Other signs of pathologic grief include: Feelings of worthlessness, Suicidal ideation, Severe symptoms over 2 months
Risk factors for suicide
Risk factors for suicide completion can be remembered with the mnemonic: “SAD PERSONS”: Sex (male), Age (elderly over 65 and teenagers 15-24), Depression, Previous attempt, Ethanol or drug use, Rational thinking lost, Sickness (medical illness or 3 or more prescription medications), Organized plan/Ownership of firearm, No spouse (divorced, widowed, or single, especially if childless), Social support lacking. Men successfully commit suicide three times more often than women, although women attempt suicide four times more often than men.
Anxiety disorder
An anxiety disorder is defined as excessive fear or worry, with physical manifestations of anxiety, which occur secondary to a source which is insufficient to account for the severity of the symptoms. In an anxiety disorder, the symptoms interrupt daily functioning. Anxiety disorders are more common in women. There are several types of anxiety disorders which include: Generalized Anxiety Disorder (GAD), Adjustment Disorder, Phobias, Panic Disorder, PTSD. Treatment inlcudes CBT, SSRIs, SNRIs.
