Psychiatry Flashcards
What is negative reinforcement?
You remove a stimulus to increase a behavior
What is dissociation? Give an example.
A drastic, temporary modification of identity / character to avoid emotional distress
-> feel numb and detached when thinking about abusive event
What is Fixation? How does it differ from Regression? Give an example
Part of your personality remains at a more childish level of development
i.e. A surgeon handles conflicts via throwing tantrums in the operating room
vs Regression where you previously developed the ability to maturely handle problems, but INVOLUNTARILY turn back the maturational clock to earlier modes of dealing with the world (i.e. a child starts bed-wetting after new stressor).
What is identification? Give an example?
Unconscious assumption of the characteristics, qualities or traits of another person or group. This happens when you internalize the qualities of someone as part of their identity, and you want to be like them.
I.e. a child who stays up late to be like his parents
What is Isolation of Affect? Example?
Separating feelings from ideas and events
-> i.e. describing murder in graphic detail with no emotional response, as if he was describing the weather
What is reaction formation vs sublimation?
Reaction formation -> doing the opposite of an unacceptable wish or impulse. I.e. going to a monastery when you feel like having sex, overcompensating but not being genuine. (unconscious)
Sublimation -> channeling those feelings into something positive / something that does not conflict with your value system -> i.e. former cocaine addict works for a substance abuse hotline to help others after he feels like smoking da crack (conscious)
How does suppression differ from repression and denial?
Suppression is conscious
Repression and denial are not conscious
Repression involves involuntarily holding a feeling from consciousness / awarenss
Suppression is saving that feeling until you are ready to deal with it -> Voluntary
What are the longterm effects of infant stimulus depression? How long do they have to be deprived for irreversible changes?
Effects of deprivation longterm:
- Anaclitic depression - Children become susceptible to physical illness and are depressed when separated from primary caregiver
- Social / emotional deficits - poor socialization / language / trust in others
- Physical effects - failure to thrive, even death
> 6 months = irreversible changes
What is reactive attachment disorder?
Infant withdrawn / unresponsive to comfort following attachment difficulties.
Who is the normal abuser in the case of physical abuse? Where will hemorrhages / hematomas typically occur?
Usually the biological MOTHER
Subdural hematomas
Retinal hemorrhages
What is the peak incidence of sexual abuse of a child?
Age 9-12 years old
What is vulnerable child syndrome? What will result
When parents perceive the child as especially susceptible to illness / injury, usually following a serious illness or life-threatening event of child
-> can result in missed school or overuse of medical services
What are the two subtypes of ADHD and when must they be present before to make a diagnosis?
Inattentive subtype
Hyperactive / impulsive subtype
Must be present before age 12
What are first line and second line pharmacotherapies for ADHD?
First line: Stimulants - Methylphenidate and dextroamphetamine
Second line: Alpha-2 agonists - Guanfacine, Clonidine
NRI - Atomoxetine
Is oppositional behavior normal in development?
Yes, it normally peaks around age 2 (the terrible two’s)
What are the two kinds of disruptive behavior disorders (DBD)?
- Oppositional defiant disorder (ODD)
2. Conduct disorder (CD)
When does ODD start, and what do many children go on to develop?
Usually before age 8, many children will develop conduct disorder later in life
When is conduct disorder (CD) diagnosed and what is it generally?
Repetitive & persistent pattern of behavior in which basic rights of others or major age-appropriate societal norms / rules are violated
Diagnosed until 18, or after age 18 if criteria for antisocial personality disorder are not met
Do most CD adolescents develop into antisocial personality disorder? How are they related?
No, but a diagnosis of conduct disorder between age 15 is required for ASPD diagnosis
What are the three evidence-based psychosocial treatments for CD and which one shows a long-term reduction in arrest / incarceration?
- Parent Management Training
- Probleming-Solving Skills Training
(First two are same as ODD) - Multisystemic Therapy (MST) -> leads to a reduction in re-arrest. Includes involvement of school, home, justice system, etc.
There is NO indication for pharmacotherapy!!!!
When is autism typically diagnosed, and is it more common in boys or girls?
Typically diagnosed around age 4, more common in boys
-> symptoms typically noticed by 2nd year of life
Symptoms may not precipitate until the social demands exceed their capacities, or may be masked by coping techniques
What are the diagnostic features of ASD?
- Poor social interactions, social communication deficits
2. Repetitive / ritualized behaviors, and restricted interests.
How is head size associated with autism?
Macrocephaly is associated with autism (enlarged head)
What causes Rett syndrome and who gets it?
X-linked dominant MECP2 gene mutation -> homozygous lethal in males
MeCP2 gene = Methyl Cytosine-binding Protein 2 -> needed for brain development
-> cases are usually de novo, but some are rarely asymptomatic (not penetrant)
Seen in females only
What are the diagnostic features of Rett syndrome?
Encephalopathy beginning between 6 months and 2 years (normal development early)
Loss of purposeful hand movements, with stereotypic hand-wringing, ataxia, head circumference growth deceleration, loss of language skills
What are the DSM criteria of separation anxiety disorder (SAD)?
Inappropriate, excessive anxiety concerning separation from attachment figures (i.e. Meghan), lasting for >4 weeks.
Distress from separation, worry about attachment figure, refusal or fear to leave home or be alone, refusal to sleep away from home or without attachment figure. Nightmares w/separation themes common.
When does SAD usually start / originally develop?
Starts after a life stress, usually ages 7-9 years.
What are the criteria for Tourette’s Disorder (TS)? How long must the tics be present????
- 2+ motor AND 1+ vocal tics present during illness, but not necessarily at same time
- Tics must persist for greater than 1 year since onset (though the tics can change during this time)
- Must occur before age 18 (usually around age 11)
What conditions are most commonly comorbid with Tourette’s disorder?
OCD & ADHD are most commonly comorbid
What is the typical progression of tic disorders?
Simple, transient motor tics arise around age 4-6
Rostrocaudal progression of tics
Phonic tics appear ages 8-15 (does not happen in all, but if you have a phonic tic you most likely have a motor tic)
Tics severity peaks age 10-12
Waxing / waning is normal
How are tics differentiated from stereotypies?
Stereotypies - will have onset earlier than tics (before 3 years), and tend to increase when excited. Usually a feature of autism.
What is the best psychotherapy for tic disorders?
Habit Reversal Training (HRT)
-> Teaches awareness of tic, and “competing response practice” -> channel the urge into a less functionally impairing tic which cannot be seen
When is pharmacotherapy used for tic disorders and what drugs should be avoided?
Used when there is a significant impairment due to the tic, i.e. they are being bullied, or they dislocated their shoulder from the movement
Avoid stimulants like methylphenidate when treating co-morbid ADHD, which can exacerbate the tic disorder by increasing dopamine levels
What are three classes of drugs used in treatment of tic disorders?
- Alpha-2 receptor agonists - first line (clonidine, guanfacine)
- D2 receptor antagonists - neuroleptic drugs like haloperidol pimozide (typical antipsychotics mostly, since you want to inhibit the basal ganglia)
- Tetrabenazine - a VMAT2 inhibitor used for Tardive dyskinesia, Huntington’s disease, etc -> prevents basal ganglia excitation (do NOT confuse with trihexyphenidyl + benztropine)
What are the pharmacotherapies available for enuresis if there is a major functional impairment? Major risks?
Imipramine - tricyclic with anticholinergic properties, cardiac arrhythmia is a concern
DDAVP - desmopressin - reduces urine production, may lead to hyponatremia and seizure due to water intoxication
What disorder is characterized by severe and recurrent temper outbursts out of proportion to situation, being angry and irritable between outbursts? Typical treatment?
Dysruptive Mood Dysregulation Disorder (DMDD) - think Sam Yurgil
Psychostimulants - remove impulsivity
Antipsychotics - i.e. risperidone
What is PANDAS?
Abrupt onset of OCD in children following Streptococcus infection (Group A Strep)
-> analogous to Syndenham’s chorea, due to autoimmune condition
What is the order of loss of the three components of orientation?
Time, place, then person
How do you tell dissociative amnesia apart from other amnesias?
Dissociative amnesia is related to inability to recall important personal information in DISTANT memory (violates Ribot’s low) usually subsequent to severe trauma.
Patient can form new memories but doesn’t remember their past at all, very atypical. In retrograde amnesia you typically still remember things which happened a long time ago, just not more recent things which have not yet converted into longterm memory.
What is depersonalization vs derealization?
Depersonalization - sense of being outside observer of self
Derealization - subjective sense of detachment or unreality of surroundings / outside world
What is depersonalization/derealization disorder vs dissociative identity disorder?
Depersonalization/derealization - Just an alteration in subjective feeling, subject knows they are not truly detached. Does not require trauma.
-> can be a feature of PTSD / Borderline personality disorder, and thus cannot be diagnosed if better explained by these disorders.
Dissociative identity disorder - Multiple personality disorder, more common in women following a major trauma.
Is a visual or an auditory hallucination more likely to be present as part of a medical illness?
Visual hallucinations, especially human-like figures, but can be lights / shapes
Auditory hallucinations are more likely part of a psychiatric illness (i.e. Schizophrenia)
What does an EEG generally show for delirium?
Moderate to severe background slowing
What is the treatment of delirium typically based around? What is the only time benzodiazepines should be used in the treatment of delirium?
Removal of precipitating stimulus, i.e. infection / drug (i.e. anticholinergics)
May use antipsychotics like haloperidol if severe.
Benzos should only be used in delirium secondary to benzodiazepine / alcohol withdrawal
What vitamin deficiencies and endocrine deficiencies can present as dementia?
Vitamins -
B1 - (Wernicke-Korsakoff)
B3 - Pellagra (Diarrhea, dermatitis, dementia)
B12 - Subacute combined degeneration
Endocrine -
Hypothyroidism
Note: Depression may also present as pseudodementia
What is dementia now called in the DSM 5, and what are its diagnostic criteria?
Major Neurocognitive Disorder
Significant decline in 1+ cognitive domains, as assessed by clinical assessment. They interfere with daily life and do not occur exclusively in delirium or as a part of another psych disorder.
What are the major cognitive domains?
- Complex attention
- Executive function
- Learning and memory
- Language
- Perceptual-motor
- Social cognition
What are the features of “psychotic” behavior?
Delusions
Hallucinations
Disorganized speech
Disorganized and catatonic behavior
What is meant by disorganized speech?
Any change in thought process from tangential thinking, to loose associations, to total incoherence
What is flight of ideas vs loose associations?
Flight of ideas - Rapid speech about one idea to the next, but generally the listener is able to follow the thought process because the thoughts are loosely connected
Loose associations - NO associations - flow of thoughts in a completely unrelated manner, listener cannot follow. Speech may even be incoherent.
A speaker has no goal-directed associations and never gets to the desired end point when asked a question. How do you describe their speech?
Tangential
Define hallucination. How does this differ from illusion?
False sensory perception not associated with real external stimuli.
Illusion -> real external stimuli prompt a false sensory perception (thought you saw something you didn’t).
What are the names for normal sensory hallucinations which happen when falling asleep or waking up?
Falling asleep - Hypnagogic
Waking up - Hypnopompic (hopping out of bed)
What is meant by disorganized behavior?
Age inappropriate silliness, agitation, bizarre appearance, catatonia, inappropriate social behavior & outbursts of emotion
What is meant by catatonic behavior?
Decrease in reactivity Includes (possibly): 1. Negativism - resistance to instruction or doing the exact opposite 2. Rigid / bizarre posture (catalepsy) 3. Mutism 4. Lack of motor response - stupor 5. Stereotypes like grimacing, staring 6. Echolalia/Echopraxia 7. Purposeless or excessive motor activity - catatonic excitement
What symptoms are thought to be most debilitating in schizophrenia? Describe them
Negative symptoms - more difficult to treat
Includes negative clarity and tone of speech (affect flattening), emotional expression (alogia, failure to elaborate), and motivation (avolition)
Problems with social interactions (asociality), slowed movements
What are the A criteria for Schizophrenia?
Presence of 2+:
Hallucinations Delusions Disorganized speech Disorganized or catatonic behavior Negative Symptoms
At least 1 of the 2 has to come from first three (the first four are positive symptoms).
What is the remaining criteria for Schizophrenia?
Must have a decreased functioning in some aspect of life, and symptoms persist for at least 6 months which are at least prodromal, residual, attenuated, or negative symptoms of Criterion A.
