Psychiatry

Question 1

cognitive behavioral therapies: visualization, systemic exposure therapy, flooding

benzodiazepines
SSRIs/SNRIs/TCAs (sometimes augmented with anticonvulsants/antipsychotics)

Answer 1

treatment for anxiety disorders

Question 2

Presence of excessive anxiety and worry about a variety of topics, events, or activities

Worry when there is nothing wrong or in a manner that is disproportionate to actual risk
Worry may be accompanied by reassurance-seeking from others
Worry may be about job responsibilities or performance, one’s own health/health of family, financial matters, typical life circumstances
Worry is challenging to control

Worry occurs more often than not for at least 6 months

Worry is associated with at least 3 of the following:
Edginess or restlessness
Tiring easily, more fatigued than usual
Impaired concentration or feeling as though the mind goes blank
Irritability (which may or may not be observable to others)
Increased muscle aches or soreness
Difficulty sleeping (due to trouble falling asleep or staying asleep, restlessness at night, or unsatisfying sleep)

Other symptoms: sweating, nausea, diarrhea

Difficulty carrying out daily responsibilities, problems in relationships/at work

Symptoms unrelated to other medical condition, cannot be explained by substance use, not better explained by another mental disorder

F more than M
Any age but especially over 30 years

Cognitive/anticipations: money, health, safety, failure

Physiological/arousal: tonic, persistent tension, insomnia

Behavioral/avoidance: general constriction of life

Answer 2

Generalized Anxiety Disorder (GAD)

Question 3

Experience of persistent and typically unanticipated panic attacks that are marked by continual fear of having future attacks, shifts in one’s behaviors to avoid these attacks, or both for at least one month

Panic attacks must be associated with subsequent worry about having another attack/consequences of attack maladaptive behavioral changes for a duration of more than one month

Panic attacks cannot be due to medical disorder, substance use, or another mental disorder

Other symptoms: headache, cold hands, diarrhea, insomnia, fatigue, intrusive thoughts, ruminations

F more than M
Age of onset less than 30 years

Cognitive/anticipations
anticipatory anxiety (fear of fear)
misinterpretation of bodily sensations, belief that avoidance is protective
fear of bodily symptom sensation

physiologic/arousal: panic

behavioral/avoidance: agoraphobia

Answer 3

Panic Disorder

Question 4

fear of open spaces

experience of intense fear or anxiety in at least two of the following situations:
being outside the home alone
public transportation
open spaces
public places 
crowds/standing in line with others

patient must exhibit avoidance behaviors
fear of experiencing a panic attack or anxiety related symptoms
avoidance impairs the sufferer’s quality of life and overall functioning

persistent phobia and avoidance usually lasting six months or longer

Answer 4

agoraphobia

Question 5

fear of specific stimulus

marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (flying, heights, animals, receiving an injection, seeing blood)

fear persists for at least 6 months

exposure to stimulus almost invariably provokes an immediate anxiety response

fear or anxiety is out of proportion to the actual danger posed by the specific object and is not a typical response in the person’s social/cultural context

most adults will recognize the fear is excessive but this is not necessary for diagnosis

phobic situations are avoided or else are endured with intense anxiety or distress

distress interferes significantly with the person’s normal routine

F more than M
Age of onset less than 12 years

Cognitive/anticipations: natural environment, blood, idiosyncrasies

Physiological/arousal: panic

Behavioral/avoidance: avoidance of specific stimulus

Answer 5

simple phobia

Question 6

fear of scrutiny or judgement

fear or anxiety specific to social settings in which a person feels noticed, observed, or scrutinized

first date, job interview, oral presentation – in children must be experienced with peers not with adults

fear of displaying their anxiety and experiencing social rejection

social interaction consistently provokes distress

social interactions are avoided or painfully/reluctantly endured

fear/anxiety is grossly disproportionate to the actual situation and persists for at least 6 months

causes personal distress and impairment of functioning in one or more domains

cannot be attributed to medical disorder, substance use, or another mental disorder

M = F
Age of onset less than 25 years

Cognitive/anticipations: negative social expectations
distorted interpretations of other’ responses
belief that avoidance is protective

physiologic/arousal: panic, blushing, tremor

behavioral/avoidance: social isolation

Answer 6

social phobia

Question 7

anxiety is the most frequently displayed symptom in some form even though there is another medical condition present that underlies and leads to anxiety

muscle tension, heart palpitations, sweating, dizziness, difficulty catching breath

restlessness, possibly fear of something impending that will be catastrophic or fear of being embarrassed or humiliated

careful and thorough medical evaluation must be conducted to determine the presence of the medical condition that leads to the anxiety

medical conditions that may be involved: hyperthyroidism, hypothyroidism, hypoglycemia, hyperadrenocorticism, heart related problems, breathing problems (COPD, pneumonia), encephalitis, neoplasms

anxiety symptoms must occur close in time to the onset, worsening, or lessening of the medical condition

Answer 7

Anxiety secondary to a general medical condition

Question 8

more severe manifestation of abnormal mood compared to depression

hospitalization due to symptoms fulfills criteria

Distinct period of abnormally and persistently elevated or irritable mood and persistently increased goal-directed activity or energy lasting at least a week or requiring hospitalization

During this period 3 or more (4 or more if irritable) of the following:
Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressured speech
Flight of ideas or racing thoughts
Distractibility (attention is drawn to unimportant stimuli)
Increased goal directed activity
Excessive involvement in risky behavior

Answer 8

mania

Question 9

Similar but fewer and less severe symptoms than mania

Duration is 4 days

Not severe enough to cause marked impairment in social or occupational functioning

Difficult to diagnose in retrospect

Answer 9

hypomania

Question 10

one manic episode

Answer 10

bipolar I

Question 11

one hypomanic episode plus one major depressive disorder

Answer 11

bipolar II

Question 12

M = F
prevalence: 1.5-3%
often misdiagnosed especially in the primary care setting

poor memory, poor insight
social complications
comorbid psychiatric disorders and substance use disorders are common

manic episodes start more abruptly and are shorter in duration than depressive episodes

manic episodes are treated aggressively
chronic, relapsing illness that requires long-term maintenance
recurrence results from medical non-adherence, environmental stress, sleep disruption, may be spontaneous

mood stabilizers are an essential element of treatment, psychotherapy may be used to enhance medication adherence
cognitive and family therapy may also be used

Answer 12

bipolar disorder

Question 13

Chronic, bipolar-like condition characterized by numerous periods of symptoms of hypomania and periods of symptoms of depression that do not meet the threshold for a major depressive episode

Lasts at least 2 years, symptoms are present most of the time, no more than two months symptom free

Answer 13

cyclothymia

Question 14

5+ of the following during the same 2 week period and represent a change from previous functioning (at least one symptom is either depressed mood or loss of interest/pleasure):
depressed mood for most of the day nearly every day
markedly diminished interest or pleasure in all or almost all activities most of the day nearly every day
significant weight loss when not dieting or weight gain or decrease in appetite nearly every day
insomnia or hypersomnia nearly every day
psychomotor agitation or retardation nearly every day (observable by others)
fatigue or loss of energy nearly every day
feelings of worthlessness or excessive or inappropriate guilt nearly every day
diminished ability to think or concentrate, or indecisiveness, nearly every day
recurrent thoughts of death, recurrent suicidal ideation without a specific plan, suicide attempt or specific plan for committing suicide

symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning

episode is not attributable to the physiological effects of a substance or to another medical condition
consider presence of disorder in addition to normal response to loss

occurrence is not better explained by other mental disorders
there has never been a manic or hypomanic episode

Answer 14

Major Depressive Disorder

Question 15

depressed mood for most of the day for more days than not as indicated by either subjective account or observation by others for at least 2 years

presence, while depressed of two or more of the following

during the 2 year period (1 year for children or adolescents) of the disturbance the individual has never been without symptoms for more than 2 months at a time

criteria may be present continuously for 2 years

there has never been a manic or hypomanic episode and criteria have never been met for cyclothymia

disturbance is not better explained by a different mental disorder

symptoms are not attributable to a medical condition or substance use

symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Answer 15

Persistant Depressive Disorder (Dysthymia)

Question 16

severe recurrent temper outbursts manifested verbally and/or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation

temper outbursts are inconsistent with developmental level

temper outbursts occur on average three or more times per week

the mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others

lasts for 12+ months without a period lasting 3+ months without all symptoms

symptoms present in at least 2 of the following settings: home, school, with peers

diagnosis should not be made before age 6 or after age 18
by history or observation age of onset should be before age 10

there has never been a distinct period lasting more than 1 day during which the full symptoms (except duration) for a manic or hypomanic episode have been met

behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder, medical condition, or substance use

Answer 16

Disruptive Mood Dysregulation Disorder (DMDD)

Question 17

in most menstrual cycles in the last year 5/11 of the following are present in the final week before onset of menses and start to improve within a few days after onset of menses and become minimal/absent in the week post menses

marked lability
imarked irritability or anger
markedly depressed mood
marked anxiety and tension

decreased interest in usual activities 
difficulty in concentration
lethargy and marked lack of energy
marked change in appetite
hypersomnia or insomnia
feeling overwhelmed or out of control
physical symptoms (breast tenderness, joint/muscle pain, weight gain)

one or more must be present from each of the above lists

criteria must be met for most menstrual cycles in the preceding year

symptoms are associated with clinically significant distress or interference with work, school, social activities, relationships

disturbance is not merely an exacerbation of the symptoms of another disorder, a medical condition or substance use

criteria confirmed with prospective daily ratings for at least two symptomatic cycles

Answer 17

Premenstrual dysphoric disorder (PDD)

Question 18

emotional or behavioral symptoms that develop in response to an identifiable stressor(s) within 3 months of the onset of the stressor(s) plus either 1 or both of the following:
marked distress that is out of proportion to the severity or intensity of the stressor, even when external context and cultural factors that might influences symptoms are considered
significant impairment in social, occupational, or other areas of functioning

stress related disturbance does not meet criteria for another mental disorder and is not an exacerbation of a medical disorder

symptoms are not due to normal bereavement

after termination of the stressor the symptoms persist for no longer than an additional six months

Answer 18

Adjustment Disorder

Question 19

in response to a major loss

sadness, despair, mourning
fatigue or low energy
tears
loss of appetite
poor sleep
poor concentration
happy and sad memories
mild feelings of guilt

gradually and after and undetermined amount of time, these feelings remit as the individual regains their equilibrium and return to normal life

Answer 19

bereavement

Question 20

not a DSM diagnosis
state of perceived incompetence, inability to cope, hopelessness, existential despair, and meaninglessness frequently prompting individuals to seek mental health treatment

“giving up” because the individual feels hopeless and feels that the amount of energy utilized to accomplish a goal does not translate into tangible results

personal history of early medical illness, multiple losses, life stressors

Answer 20

demoralization

Question 21

the presence of obsessions, compulsions, or both

obsessions:
recurrent and persistent thoughts, urges, or images that are experienced at some time during the disturbance as intrusive and unwanted, and cause marked anxiety and distress
the person attempts to suppress or ignore such thoughts, impulses, or images or to neutralize them with some other thought or action

compulsions:
repetitive behaviors or mental acts 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 distress or preventing some dreaded event/situation however these behaviors or acts are not connected in a way that could realistically neutralize the perceived threat or are clearly excessive

obsessions/compulsions must be time consuming (more than 1 hour per day) and result in impaired functioning
cannot be attributed to another mental disorder, medical disorder or substance use

Answer 21

Obsessive Compulsive Disorder