Psychiatry Clerkship_2 Flashcards
what % of patients treated with lithium show partial reduction of mania?
70%
long term use of lithium reduces what?
suicide risk
what is the mortality rate in acute overdose of lithium?
25%
what is the action of carbamazepine and valproate in BpID?
anticonvulsant and mood stabilizer
what are the indications and risks for use of anticonvulsants in BpID?
they are especially useful for rapid cycling BpD and mixed episodes, although associated with ↑ risk for suicide
what are the atypical antipsychotics used in BpID?
olanzapine • quetiapine • ziprasidone
how are atypical antipsychotics useful for treatment of BpID?
they are effective as both monotherapy and adjunct therapy for acute mania, with careful monitoring of adverse effects
what is the role of antidepressants in the treatment of BpID?
they are discouraged as monotherapy due to concerns of activating mania or hypomania. the addition of antidepressants as adjunctive therapy to mood stabilizers has not shown to be effective
what is the role of psychotherapy in the treatment of BpID?
supportive psychotherapy, family therapy, group therapy (prolongs remission once the acute manic episode has been controlled)
what is the role of ECT in BpID?
-works well in treatment of manic episodes • - especially effective for refractory or life threatening acute mania or depression
what is the difference between ECT for bipolar vs depression?
bipolar usually requires more treatment than depression
bipolar II disorder is alternately called what?
recurrent major depressive episodes with hypomania
DSM IV criteria for diagnosis of BpIID?
hx of >=1 MDE and >=1 hypomanic episode, without EVER having a manic episode in the past
which is more prevalent bp1d or bp2d?
bp2d
what is the gender predilection of bp2d?
slightly more common in women
when is the onset of bp2d?
onset usually before age 30
what is the ethnic predilection of bp2d?
no ethnic differences
how is bp2d misdiagnosed?
frequently misdiagnosed as unipolar depression and thereby mistreated
what are the course and prognosis of bp2d?
tends to be chronic, requiring long term tx
what is the treatment for bp2d?
same as bp1d
what are the sytmptoms of dysthymic disorder?
CHASES • Concentration/decision difficulty • Hopelessness • Appetite ↑↓ • Sleep disturbance • Energy ↓ • Self esteem ↓
what is the difference between MDD and dysthymic disorder?
MDD tends to be episodic, while dysthymic disorder is generally persistent
what do patients with dysthymic disorder look like?
they have chronic, mild depression most of the time with no dicrete episodes. they rarely need hospitalization
what are the DSM IV criteria for diagnosis of dysthymic disorder?
- depressed mood for the majority of time most days for at least 2 years (or 1 in kids) • 2. >2: • - poor concentration • - feelings of hopelessness • - poor appetite • - insomnia/hypersomnia • - low energy • - low self esteem • 3. during 2 years: • - the person has not been without the above symptoms for > 2 months at a time • - no MDE • - no hx mania or hypomania
what is double depression?
patients with major depressive disorder with dysthymic disorder during residual periods
what is the lifetime prevalence of dysthymic disorder?
6%
what is the gender predilection in dysthymic disorder?
2-3x more common in women
when is the typical onset of dysthymic disorder?
before 25yo in 50%
what is the course and prognosis of dysthymic disorder?
20% of patients will develop major depression, 20% will develop bpd, >25% will have lifelong symptoms
what is the treatment for dysthymic disorder?
- cognitive therapy and insight oriented psychotherapy are most effective • 2. antidepressant medications are useful when used concurrently with psychotherapy
what is cyclothymic disorder?
alternating periods of hypomania and periods with mild to moderate depressive symptoms
what are the DSM IV criteria for diagnosis of cyclothymic disorder?
- numerous periods with hypomanic symptoms and periods with depressive symptoms for at least 2 years • 2. person must never have been symptom free for > 2 mo during those 2 years • 3. no hx of MDE or manic episode
what is the lifetime prevalence of cyclothymic disorder?
<1%
cyclothymic disorder may coexist with which Axis II?
borderline personality disorder
when is the onset of cyclothymic disorder?
usually age 15-25
what is the gender predilection in cyclothymic disorder?
M=F
what is the course and prognosis of cyclothymic disorder?
chronic course • 1/3 of patients are eventually diagnosed with bpd
what is the tx for cyclothymic disorder?
antimanic agents as used to treat bpd
what is minor depressive disorder?
episodes of 2-4 depressive symptoms that do not meet the full five or more for MDD, euthymic periods are also seen • - still associated with functional impairments • - 18% may fit the criteria for MDD in 1 year
what is the triad for seasonal affective disorder?
- irritability • 2. carb craving • 3. hypersomnia
criteria for diagnosis of seasonal affective disorder?
> 2 consecutive years of 2 MDE during the same season • - often respond to light therapy
criteria for diagnosis of postpartum major depression?
onset within 4 weeks of delivery
adjustment disorders happen when?
when maladaptive behavioral or emotional symptoms develop after a stressful life event
when does adjustment disorder happen?
symptoms begin within 3 months after the event, end within 6 months, and cause significant impairment in daily functioning or interpersonal relationships
DSM-IV criteria for adjustment disorder?
- development of emotional or behavioral symptoms within 3 months after a stressful life event. these symptoms produce either: • - severe distress in excess of what would be expected after such an event • - significant impairment in daily functioning • 2. the symptoms are not those of bereavement • 3. symptoms resolve within 6 months after stressor has terminated
what are the subtypes of adjustment disorders?
based on predominance of: • - depressed mood • - anxiety • - disturbance of conduct (aggression) • - combinations of the above
how common are adjustment disorders?
very common
what is the gender predilection in adjustment disorders?
2x more common in females
what is the typical age of onset of adjustment disorder?
most frequently diagnosed in adolescents but may occur at any age
what is the difference between PTSD and adjustment disorder?
adjustment disorder= not life threatening stressor event • PTSD= life threatening traumatic event
what is the etiology of adjustment disorders?
triggered by psychosocial factors
what is the prognosis of adjustment disorders?
may be chronic if the stressor is recurrent; symptoms resolve within 6 months of cessation of stressor
what is the tx of adjustment disorder?
- supportive psychotherapy (most effective) • 2. group therapy • 3. pharmacotherapy for associated symptoms (insomnia, anxiety, depression)
what are the symptoms of anxiety?
- cardiac: • - palpitations, tachycardia, hypertension • 2. pulmonary: • - SOB, choking sensation • 3. neurologic • - dizziness, light-headedness, hyperreflexia, mydriasis (dilation), tremors, tingling in the peripheral extremities • 4. psychological: • - restlessness (pacing), “butterflies in the stomach” • 5. other: • - sweating, gastrointestinal, urinary urgency and frequency
what is anxiety?
the subjective experience of fear and its physical manifestations
what is the difference between physiologic and pathologic anxiety?
pathologic anxiety= symptoms interfere with daily functioning and response is inappropriate
which neurotransmitters have been implicated in anxiety?
↑NE • ↓GABA, 5-HT
what are the medical causes of anxiety?
- hyperthyroidism • 2. B12 deficiency • 3. hypoxia • 4. neurological disorders (epilepsy, brain tumor, MS, cerebrovascular disease) • 5. cardiovascular disease • 6. anemia • 7. pheochromocytoma • 8. hypoglycemia
what are the medication or substance induced anxiety disorders?
- caffeine intake and withdrawal • 2. theophylline • 3. amphetamines • 4. etOH and sedative withdrawal • 5. other illicit drug withdrawal • 6. mercury or arsenic toxicity • 7. organophosphate or benzene toxicity • 8. penicillin • 9. sulfonamides • 10. sympathomimetics • 11. antidepressants
what is the lifetime prevalence of anxiety in women?
30%
what is the lifetime prevalence of anxiety in men?
19%
in which socioeconomic group is anxiety disorder more common?
higher income
types of anxiety disorders include what?
- panic disorder • 2. agoraphobia • 3. specific and social phobias • 4. OCD • 5. PTSD • 6. acute stress disorder • 7. generalized anxiety disorder • 8. anxiety disorder secondary to general medical condition • 9. substance induced anxiety disorder
what are the panic attack criteria?
PANICS • 1. palpitations • 2. abnormal stress • 3. numbness, nausea • 4. intense fear of death • 5. choking, chills, chest pain • 6. sweating, shaking, SOB
panic attacks are associated with conditions such as what?
- mitral valve prolapse • 2. asthma • 3. pulmonary embolus • 4. angina • 5. anaphylaxis
what are panic attacks?
discrete periods of heightened anxiety and fear that classically occur in patients with panic disorder, but can also be seen with other anxiety disorders (phobic disorders, PTSD)
what is the onset and timing of panic attacks?
peak within 10 minutes and last <25 minutes
what causes panic attacks?
they may be provoked by triggers or come spontaneously
to diagnose a panic attacks the patient must have what?
> 4: • 1. palpitations • 2. sweating • 3. shaking • 4. SOB • 5. choking sensation • 6. chest pain • 7. nausea • 8. light headedness • 9. depersonalization • 10. derealization • 11. fear of losing control • 12. fear of dying • 13. numbness or tingling • 14. chills or hot flashes
panic disorder is characterized by what?
spontaneous recurrent panic attacks with no obvious precipitant
how often do patients with panic disorder get panic attacks?
average: • - 2x/wk • range: • - several/day - few/year
what happens between panic attacks in a patient with panic disorder?
anticipatory anxiety is common
what are the DSM IV criteria for diagnosis of panic attack?
> 1 attack must be followed by >1 of the following: • 1. persistent concern about having additional attacks • 2. worry about the implications of the attacks • 3. a significant change in behavior related to the attacks • – rule out other causes in dDx of panic attack • – always specify whether panic disorder is w/ or w/o agoraphobia
more than 40% of patients presenting with chest pain and normal angiograms may have what?
panic disorder
what are the conditions in the medical dDx for panic disorder?
chf • angina • MI • thyrotoxicosis • temporal lobe epilepsy • MS • pheochromocytoma • carcinoid syndrome • COPD
what are the medications/drugs in the dDx for panic disorder?
intoxication: • amphetamine • caffeine • nicotine • cocaine • hallucinogens • • etOH or opiate withdrawal
what are the other psychiatric disorders commonly associated with panic disorder?
depressive disorders • phobic disorders • OCD • PTSD
panic disorder is associated with dysregulation of which physiological systems?
SNS • CNS • cerebral blood flow
panic disorder is related to changes in which neurotransmitter activity?
↑NE • ↓ 5HT and GABA
panic attacks may be induced by what?
caffeine, nicotine, hyperventilation
what is the lifetime prevalence panic disorder?
2-5%
what is the gender predilection in panic disorder?
3x more common in females than males
what how strong is the genetic predisposition for panic disorder
4-8x greater risk of panic disorder if 1st degree relative is affected
when is the typical onset for panic disorder?
late teens to early thirties, but may occur at any age
how should SSRI therapy be managed in panic disorder patients?
always start SSRI at a low dose and ↑ slowly b/c some SSRI’s can have side effects that may initially worsen anxiety
what are the course and prognosis of panic disorder?
variable course but is often chronic • relapses are common with d/c of medical therapy • -10-20 % of patients continue to have significant symptoms that interfere with daily functioning • - 50% continue to have mild infrequent symptoms • - 30-40% remain free of symptoms after treatment
what are the characteristic situations avoided in agoraphobia?
bridges • crowds • buses • trains • any open areas outside the home
what are the common specific phobias?
animals • heights • blood or needles • illness or injury • death • flying
what is the best long term treatment for panic disorder?
SSRI’s, especially paroxetine and sertraline, and at higher doses than for depression
what are the other antidepressants that can be used for panic disorder?
clomipramine • imipramine
what is the role of benzodiazepines in panic disorder treatment?
they are effective immediately but are best used temporarily b/c of their risk for abuse and dependency
how long should treatment for panic disorder continue?
> =8-12 months, as relapse is common after discontinuation of therapy
what are the nonpharmacological treatments for panic disorders?
relaxation training, biofeedback, cognitive therapy, insight-oriented psychotherapy
what are the common social phobias?
speaking in public • eating in public • using public restrooms
what is agoraphobia?
the fear of being alone in public places
what does the anxiety in agoraphobia lead to?
the avoidance of being in places or situations from which escape or help might be difficult
agoraphobia often develops secondary to what?
panic attacks- due to apprehension about having subsequent attacks in public places where escape may be difficult
what % of agoraphobia coexists with panic disorder?
50-75%
what happens to agoraphobia when coexisting panic disorder is treated?
it usually resolves
what happens when agoraphobia is not associated panic disorder?
it is usually chronic and debilitating
what is required for a person with shyness to be diagnosed with social phobia?
the provoked anxiety has to interfere with their daily functioning
what conditions are commonly comorbid with phobias?
substance disorders, esp etoh • 1/3 of phobic patients also have associated major depression
performance anxiety is often successfully treated with what?
beta blockers
what is a specific phobia ?
a strong, exaggerated fear of a specific object or situation
what is a social phobia?
social anxiety disorder- • a fear of social situations in which embarrassment can occur
what are the DSM IV criteria for the diagnosis of specific phobias?
- persistent excessive fear brought on by a specific situation or object • 2. exposure to the situation brings about an immediate anxiety response • 3. patient recognizes that fear is excessive • 4. the situation is avoided when possible or tolerated with intense anxiety • 5. if person is under age 18, duration must be at least 6 months
what are the DSM IV diagnostic criteria for social phobia?
same as for specific phobia except that the feared situation is related to social settings in which the patient might be embarrassed or humiliated in front of other people
what are the most common mental disorders in the united states?
phobias
what percent of the population is affected with a phobic disorder?
5-10%
which is more common, specific or social phobia?
specific
what is the range of onset for phobias?
5 yo for seeing blood • 35 yo for situational (like heights)
when is the average age of onset for social phobias?
mid teens
what is the gender predilection of specific phobias?
2x F:M
what is the gender predilection in social phobia?
M=F
what is the cause of phobias?
most likely multifactorial, with genetic and neurochemical factors playing a role
what is systemic desensitization?
the gradual exposure of a patient to a feared object or situation while teaching relaxation and breathing techniques
what is flooding?
directly confronting the patient with their full fear
what is the difference between shyness and social phobia?
in social phobia is there is complete avoidance of scrutiny and exaggerated fears in day to day life that cause significant distress and/or disability
what is the treatment for specific phobia?
- pharmacologic treatment has not been found effective • 2. behavior therapy is most effective and systemic desensitization (graded exposure/flooding) is a common technique • 3. if necessary, a short course of benzos or beta blockers may be used during desensitization to help control autonomic symptoms
what is the treatment for social phobia?
- paroxetine is FDA approved for the treatment of social anxiety disorder • 2. beta blockers are frequently used for performance anxiety • 3. cognitive and behavioral therapies are useful adjuncts
what is an obsession?
a recurrent and intrusive thought, feeling, or idea that is ego dystonic
what is a compulsion?
a conscious repetitive behavior linked to an obsession that, when performed, functions to relieve anxiety caused by the obsession
what is OCD?
an axis I disorder in which patients have obsessions that ↑ their anxiety level. they usually relieve this with compulsions
do patients with OCD typically have insight?
yes they are generally aware of their problems and realize that their thoughts and behaviors are irrational
what are the DSM IV criteria for diagnosis of OCD?
Either or of: • 1. Obsessions: • - repetitive and intrusive • - cause anxiety, but not simple worries about real worries • - attempts to suppress thoughts • - realizes thoughts are product of own mind • 2. Compulsions: • - repetitive behaviors in response to obsessions • - behaviors aimed at reducing distress, but not realistically linked to it • - aware that obsessions and compulsions are unreasonable and excessive • - obsessions cause distress and interfere with life
compulsions can often take the form of what?
repeated checking • very specific rituals
patients with OCD often present in what setting?
in other specialty like dermatology to treat “skin condition” related to frequent hand washing
what % of OCD patients have both obsessions and compulsions?
75%
which disorders are frequently comorbid with OCD?
Tourette’s and OCD
what is the lifetime prevalence of OCD?
2-3%
when is typical onset of OCD?
early adulthood
what is the gender predilection in OCD?
m=f
OCD is associated with which conditions?
MDD • eating disorders • other anxiety disorders • OCPD
the rate of OCD is higher in patients with first degree relatives who have what?
Tourette syndrome
what is the neurochemical etiology of OCD?
associated with abnormal regulation of serotonin
what is the genetic etiology of OCD?
higher in first degree relatives and monozygotic twins than general population
what medical conditions can cause OCD?
head injury • epilepsy • basal ganglia disorders • postpartum conditions
what are the psychosocial etiologies of OCD?
the onset of OCD is triggered by a stressful life event in approximately 60% of patients
what is the course and prognosis for OCD?
usually chronic with ~30% significantly improving with treatment, 40-50% moderate improvement, 20-40% remain significantly impaired
what are the pharmacologic treatments for OCD?
SSRI’s are the first line at higher than normal doses • TCA’s
what are the behavioral treatments for OCD?
exposure and response prevention, with relaxation to help the patient manage the anxiety after compulsion deprived
what are the last resort therapies for OCD?
ECT • cingulotomy
what are the 5 most common patterns of OCD?
- contamination → wash • 2. doubt → check • 3. symmetry → lining up • 4. intrusive sexual or violent thoughts with no compulsion • 5. somatic obsessions
what is PTSD?
a response to a catastrophic life threatening experience in which the patient re-experiences the trauma, avoids reminders of the event, and experiences emotional numbing or hyperarousal
how long must symptoms be present for PTSD to be diagnosed?
1 month
who should be screened for PTSD?
a patient who is experiencing recurrent thoughts and nightmares about a past trauma
what are the comorbidities with PTSD?
high incidence of associated substance abuse and depression
what is the prognosis for patients with PTSD?
one half of patients remain symptom free after 3 months of treatment
what are the pharmacological treatments for PTSD?
- SSRI, TCA, MAOI • 2. anticonvulsants (for flashbacks and nightmares
what are the other treatments for PTSD?
- therapy: CBT, supportive, psychodynamic • 2. relaxation training • 3. support groups, family therapy • 4. EMDR (eye movement desensitization and reprocessing)
what is cognitive processing therapy?
a modified form of CBT in which thoughts, feelings and meanings of the event are revisited and questioned
what is the difference between PTSD and Acute Stress Disorder?
- in PTSD an event occurred at any time in the past and the symptoms have been going on > 1 month • 2. in ASD, the event occurred < 1mo ago and symptoms last >1mo
which meds should be avoided in PTSD?
addictive meds like benzos, because of the high rate of substance abuse in these patients
the diagnosis of ASD is reserved for who?
patients who experience a major traumatic event, but have anxiety symptoms for only a short duration. symptoms must occur within 1 month of the trauma and last for a max of one month
patients with GAD have what?
persistent, excessive hyperarousal and anxiety about general daily events
patients with GAD usually seek out what type of help?
nonpsychiatric specialist because of somatic complaints such as muscle tension or fatigue
what are the DSM IV criteria for diagnosis of GAD?
- excessive anxiety and worry about daily events and activities (that is difficult to control) • 2. >3: restlessness, fatigue, difficulty concentrating, muscle tension, sleep disturbance
what is the lifetime prevalence of GAD?
45%
what is the gender predilection in GAD?
2x W:F
what is the typical onset of GAD?
<20yo
50-90% of patients with GAD have what?
coexisting mental disorder especially major depression, social or specific phobia, panic disorder
if a patient complains of constant worry in his life what must be the case for it to be GAD?
cause significant distress • occur most days of the week • last >6mo
what is the etiology of GAD?
not completely understood, but biological and psychosocial factors contribute
what is the prognosis in GAD?
chronic, with lifelong fluctuating symptoms in 50%. other 50% fully recover within several years of therapy
what is the most effective therapy for GAD?
combination of pharm and CBT: • 1. SSRI/Buspar/Venlafaxine • 2. Benzos should be tapered off when possible because of risk of tolerance and dependence
what is the nature of anxiety in GAD?
it is free floating as opposed to being fixed on a specific person, event, or activity
what is personality?
one’s set of stable, predictable, emotional and behavioral traits
personality disorders involve what?
deeply ingrained, flexible patterns of relating to others that are maladaptive and cause significant impairment in social or occupational functioning
the personality disorders include what problems?
marked limitations in problem solving • low stress tolerance
how much insight does someone with a personality disorder have?
lack insight • symptoms are egosyntonic
patients with personality disorders are at risk of developing what when under stress?
symptoms of axis 1 disorders
personality disorders are what axis diagnoses?
axis II
what is the international prevalence of personality disorders?
6%
what are the DSM IV criteria for the diagnosis of personality disorders?
- pattern/experience that deviates from culture manifesting as: • CAPRI • Cognition • Affect • Personal Relations • Impulse control • 2. pattern: • pervasive and inflexible • stable- onset no later than late teens • not accounted for by substance or illness
which personality disorders fall into cluster A?
schizoid, schizotypal, paranoid
what are characteristics of cluster A disorders?
- patients seem eccentric, peculiar, or withdrawn • - familial association with psychotic disorders
what are the cluster B personality disorders?
antisocial, borderline, histrionic, narcissistic
what are the characteristics of cluster B disorders?
- patients seem emotional, dramatic, or inconsistent • - familial association with mood disorders
what are the cluster C personality disorders?
avoidant, dependent, OCPD
what are the characteristics of cluster C disorders?
familial association with anxiety disorders
Personality Disorder NOS includes what?
personality disorders that don’t fit into cluster A, B ,or C • -passive-aggressive personality disorder • - depressive personality disorder
what is the etiology of personality disorders?
- biological, genetic, and psychosocial factors during early childhood and adolescence contribute to the development of personality disorders • 2. the prevalence of personality disorders in MZT is several times higher than in DZT
how hard is it to treat a personality disorder?
NAME?
what is the course and prognosis of personality disorders?
tend to be chronic and lifelong
how useful is pharmacologic treatment for personality disorders?
limited usefulness
what is the most helpful treatment for personality disorders?
psychotherapy and group therapy
what is the clinical picture of paranoid personality disorder?
- pervasive distrust, suspiciousness of others, interpretation of acts as malevolent • - blame problems on others and seem angry and hostile • - pathologically jealous and accusing partner of infidelity
what are the DSM IV criteria for the diagnosis of paranoid personality disorder?
general distrust beginning early adulthood present in a variety of contexts: • >4: • 1. suspicion that others are exploiting or deceiving • 2. preoccupation with doubts of loyalty or trustworthiness • 3. reluctance to confide in others • 4. interpretation of benign remarks as threatening or demeaning • 5. persistence of grudges • 6. perception of attacks on his or her character that are not apparent to others; quick to counterattack • 7. recurrence of suspicions regarding fidelity of spouse
what is the prevalence of paranoid personality disorder?
0.5-2.5%
what is the differential diagnosis for paranoid personality disorder?
- paranoid schizophrenia • 2. social disenfranchisement and social isolation
what is the course and prognosis for patients with PPD?
some patients with PPD may eventually be diagnosed with schizophrenia • the disorder has a chronic course, causing lifelong marital and job related problems
what is the treatment for paranoid personality disorder?
- paychotherapy is the treatment of choice • 2. patients may also benefit from anxiolytics or short course of antipsychotics for transient psychosis
what is the difference between schizoid and avoidant personality disorder?
unlike with avoidant personality disorder, patients with schizoid prefer to be alone
patients with schizoid personality disorder have a lifelong pattern of what?
social withdrawal
patients with schizoid personality are often perceived as what?
eccentric and reclusive • quiet • unscociable • constricted affect
how do patients with schizoid personality disorder perceive others?
no desire for close relationships and prefer to be alone
what are the DSM IV criteria for the diagnosis of schizoid personality disorder?
pattern of voluntary social withdrawal and restricted range of emotional expression, beginning by early adulthood and present in a variety of contexts • >4: • 1. neither enjoying no desiring close relationships (including family) • 2. generally choosing solitary activities • 3. little interest in sexual activity with another person • 4. taking pleasure in few activities • 5. few close friends or confidants • 6. indifference to praise or criticism • 7. emotional coldness, detachment, or flattened affect
what is the prevalence of schizoid personality?
7%
what is the gender predilection in schizoid personality?
men is twice that of women
is there and increased incidence of schizoid personality disorder in families with history of schizophrenia?
no
what is the differential diagnosis for schizoid personality disorder?
paranoid schizophrenia • schizotypal personality disorder
what is the course of schizoid personality disorder?
usually chronic course, but not always lifelong
patients with schizotypal personality disorder have a pervasive pattern of what?
eccentric behavior and peculiar thought patterns
patients with schizotypal personality disorder are often perceived as what?
strange and eccentric
schizotypal personality disorder was developed out of what observation?
certain family traits predominate in first degree relatives with schizophrenia
what are the DSM IV criteria for the diagnosis of schizotypal personality disorder?
eccentric behavior, cognitive or perceptual distortions, and discomfort with close relationships, beginning by early adulthood and present in a variety of contexts • - >5: • 1. ideas of reference • 2. odd beliefs or magical thinking • 3. unusual perceptual experiences • 4. suspiciousness • 5. inappropriate or restricted affect • 6. odd or eccentric appearance or behavior • 7. few close friends or confidants • 8. odd thinking or speech • 9. excessive social anxiety
magical thinking may include what?
belief in clairvoyance or telepathy • bizarre fantasies or preoccupations • belief in superstitions
in schizotypal personality disorder, odd behaviors may include what?
involvement in cults or strange religious practices
what is the prevalence of schizotypal personality disorder?
3%
what is the differential diagnosis in schizotypal personality disorder?
paranoid schizophrenia • schizoid personality disorder
what is the difference between patients with paranoid schizophrenia and patients with paranoid personality disorder?
unlike patients with schizophrenia, patients with paranoid personality disorder do not have any fixed delusions and are not frankly psychotic, although they may have transient psychosis under stressful situations
what is the difference between social disenfranchisement and social isolation and paranoid personality disorder?
without a social support system, persons can react with suspicion to others. the differential in favor of the diagnosis can be made by the assessment of others in close contact with the person, who identify what they consider as excess suspicion
what is the difference between patients with paranoid schizophrenia and patients with schizoid personality disorder?
unlike patients with schizophrenia, patients with schizoid personality disorder do not have any fixed delusions, although these may exist transiently in some patients
what is the difference between schizotypal personality disorder and schizoid personality disorder?
patients with schizoid personality disorder do not have the same eccentric behavior or magical thinking seen in patients with schizotypal personality disorder. schizotypal patients are more similar to schizophrenic patients in terms of odd perception, thought, and behavior
what is the difference between patients with paranoid schizophrenia and patients with schizotypal personality disorder?
unlike patients with schizophrenia, patients with schizotypal personality disorder are not frankly psychotic (though they can become transiently so under stress), nor do they have fixed delusions
what is the difference between patients with schizoid personality disorder and patients with schizotypal personality?
patients with schizoid personality disorder do not have the same eccentric behavior seen in patients with schizotypal personality disorder
what is the course of schizotypal personality disorder?
- course is chronic or patients may develop schizophrenia • - premorbid personality type for schizophrenia
what is the treatment for schizotypal personality disorder?
- psychotherapy is the treatment of choice to help develop social skills training • - short course of low dose antipsychotics if necessary (for transient psychosis). antipsychotics may help decrease social anxiety and suspicion in interpersonal relationships
cluster B includes what?
antisocial, borderline, histrionic and narcissistic personality disorder
how do patients with cluster B disorders behave?
they are often emotional, impulsive and dramatic
how do patients with antisocial personality disorder behave?
- show superficial conformity to social norms but are exploitative of others and break rules to meet their own needs • - lack empathy and compassion; lack remorse for their actions • - impulsive, deceitful, violate the law • - skilled at social cues and appear charming and normal to others who meet them for the first time and do not know their history
what are the DSM IV criteria for the diagnosis of antisocial personality disorder?
- pattern of disregard for others and violation of the rights of others since age 15 • - patients must be at least 18 years old for this diagnosis; history of behavior as a child/adolescent must be consistent with conduct disorder • - three or more of the following should be present: • 1. failure to confirm to social norms by committing unlawful acts • 2. deceitfulness/repeated lying/manipulating others for personal gain • 3. impulsivity/failure to plan ahead • 4. irritability and aggressiveness/repeated fights or assaults • 5. recklessness and disregard for safety of self and others • 6. irresponsibility/failure to sustain work or honor financial obligations • 7. lack of remorse for actions
what is the mnemonic for the symptoms of antisocial personality disorder?
CONDUCT • Capriciousness • Oppressive • Non-confrontational • Deceitful • Unlawful • Carefree • Temper
what is the prevalence of antisocial personality disorder?
3% men • 1% women
what is the socioeconomic distribution of antisocial personality disorder?
there is a higher incidence in poor urban areas and in prisoners but no racial difference
how strong is the genetic component in antisocial personality disorder?
5x ↑ risk in first degree relatives
what is the differential diagnosis for antisocial personality disorder?
drug abuse
how do you differentiate between antisocial personality disorder and drug abuse?
it is necessary to ascertain which came first. patients who began abusing drugs before their antisocial behavior started may have behavior attributable to the effects of their addiction
what is the course of antisocial personality disorder?
usually has a chronic course, but some improvement of symptoms may occur as the patient ages
what other problems are associated with antisocial personality disorder?
- many patients have multiple somatic complaints, and coexistence of substance abuse and/or major depression is common • - there is ↑ morbidity from substance abuse, trauma, suicide, homicide
antisocial personality disorder begins in childhood as what?
conduct disorder
patients with antisocial personality disorder may have a history of what?
being abused (physically or sexually) as a child or have a history of hurting animals or starting fires
what is the treatment for antisocial personality disorder?
- psychotherapy is generally ineffective; DBT and CBT are the best choice • - pharmacotherapy may be used to treat symptoms of anxiety or depression, but use caution due to high addictive potential of this patient
what is the mnemonic for the symptoms of boderline personality disorder?
IMPULSIVE • Impulsive • Moody • Paranoid under stress • Unstable self image • Labile, intense relationships • Suicidal • Inappropriate anger • Vulnerable to abandonment • Emptiness
what are the DSM IV criteria for the diagnosis of borderline personality disorder?
- Pervasive pattern of impulsivity and unstable relationships, affects, self image, and behaviors, present by early adulthood and in a variety of contexts • - >5: • 1. desperate efforts to avoid real or imagined abandonment • 2. unstable, intense interpersonal relationships • 3. unstable self image • 4. impulsivity in at least to potentially harmful ways • 5. recurrent suicidal threats or attempts or self mutilation • 6. unstable mood/affect • 7. difficuly controlling anger • 8. difficult controlling anger • 9. transient, stress related paranoid ideation or dissociative symptoms
borderline patients commonly use which defense mechanism?
splitting
what is the prevalence of borderline personality disorder?
1-2%
what is the gender predilection in borderline personality disorder?
2xF:M
what is the suicide rate in borderline personality disorder?
10%
what is the differential diagnosis for borderline personality disorder?
Schizophrenia • Bipolar II
what is the difference between schizophrenia and borderline personality disorder?
unlike patients with schizophrenia, patients with BPD do not have frank psychosis (may have transient psychosis if decompensated under stress)
what is the difference between bipolar II and borderline personality disorder?
mood swings experienced in Borderline Personality Disorder are moment-to-moment reactions to perceived environmental triggers. they are also no characterized by spending excess amounts of money or heightened sexual activity
pharmacotherapy has been shown to be useful in which personality disorder more than any other?
borderline
the name borderline comes from what?
from the patient’s being on the borderline of neurosis and psychosis
what is the course of borderline personality disorder?
usually has a stable chronic course
borderline personality disorder has a high incidence of what coexisting conditions?
major depression and or substance abuse
what is the treatment for borderline personality disorder?
- psychotherapy (DBT) is the treatment f choice • - pharmacotherapy to treat psychotic or depressive symptoms as necessary
patients with histrionic personality disorder exhibit what behavior?
attention seeking behavior and excessive emotionality • -they are dramatic, flamboyant, and extroverted but are unable to form long lasting meaningful relationships • -sexually inappropriate and provocative
what are the DSM IV criteria for the diagnosis of histrionic personality disorder?
- pattern of excessive emotionality and attention seeking, present by early adulthood and in a variety of contexts • - >5: • 1. uncomfortable when not the center of attention • 2. inappropriately seductive or provocative behavior • 3. uses physical appearance to draw attention to self • 4. has speech that is impressionistic and lacking in detail • 5. theatrical and exaggerated expression of emotion • 6. easily influenced by others or situation • 7. perceives relationships as more intimate than they really are
what is the prevalence of histrionic personality disorder?
2-3%
what is the gender predilection in histrionic personality disorder?
F>M
what is the differential diagnosis for histrionic personality disorder?
borderline personality disorder
what is the difference between histrionic personality disorder and borderline personality disorder?
patients with BPD are more likely to suffer from depression, brief psychotic episodes, and to attempt suicide. HPD patients are generally more functional
what is the course of histrionic personality disorder?
usually has a chronic course, with some improvement of symptoms of age
what is the treatment for HPD?
-psychotherapy is the treatment of choice • - pharmacotherapy to treat associated depressive or anxious symptoms as necessary
what are the DSM IV criteria for the diagnosis of HPD?
-pattern of grandiosity, need for admiration, and lack of empathy beginning by early adulthood and present in a variety of contexts • - >5: • 1. exaggerated sense of self importance • 2. preoccupation with fantasies unlimited money, success, brilliance, etx • 3. believes that he or she is special or unique and can only associate only with other high-status individuals • 4. needs excessive admiration • 5. has sense of entitlement • 6. takes advantage of others for self gain • 7. lacks empathy • 8. envious of others or believes others are envious of him or her • 9. arrogant or haughty
what is the prevalence of narcissistic personality disorder?
<1%
what is the differential diagnosis for narcissistic personality disorder?
antisocial personality disorder
what is the difference between antisocial personality disorder and narcissistic personality disorder?
both types of patients exploit others, but NPD patients want status and recognition, while antisocial patients want material gain or simply the subjugation of others. narcissistic patients become depressed when they don’t get the recognition they think they deserve
what is the course of narcissistic personality disorder?
usually has a chronic course; higher incidence of depression and midlife crises since these patients put such a high value
what is the treatment for narcissistic personality disorder?
- psychotherapy is the treatment of choice. group therapy may help these patients learn empathy • - antidepressants or lithium may be used as needed (for mood swings if a comorbid mood disorder is diagnosed)
Cluster C includes which disorders?
avoidant, dependent, and obsessive compulsive personality disorder
how do patients with cluster C disorders appear?
anxious and fearful
what are the characteristics of patients with avoidant personality disorder?
- pervasive pattern of social inhibition and an intense fear of rejection • - avoid situations in which they may be rejected • - fear of rejection is so overwhelming that it affects all aspects of their lives • - avoid social interactions and seek jobs in which there is little interpersonal contact • patients DESIRE contact but are extremely shy and easily injured
what are the DSM IV criteria for the diagnosis of avoidant personality disorder?
- a pattern of social inhibition, hypersensitivity, and feelings of inadequacy since early adulthood • - >4: • 1. avoids occupation that involves interpersonal contact due to a fear of criticism and rejection • 2. unwilling to interact unless certain of being liked • 3. cautious of interpersonal relationships • 4. preoccupied with being criticized or rejected in social situations • 5. inhibited in new social situations because he or she feels inadequate • 6. believes he or she is socially inept and inferior • 7. reluctant to engage in new activities for fear of embarassment
what is the prevalence of avoidant personality disorder?
1-10%
what is the gender predilection in avoidant personality disorder?
unknown
what is the differential diagnosis for avoidant personality disorder?
schizoid personality disorder • social phobia • dependent personality disorder
what is the difference between avoidant personality disorder and schizoid personality disorder?
patients with avoidant personality disorder desire companionship but are extremely shy, whereas patients with schizoid personality disorder have no desire for companionship
what is the difference between social phobia and avoidant personality disorder?
both disorders involve fear and avoidance of social situations. if the symptoms are an integral part of the patient’s personality and have been evident since before adulthood, personality disorder is the most likely diagnosis. social phobia is a fear of EMBARRASSMENT, where as avoidant personality is a fear of REJECTION. A patient can have both diagnoses.
what is the difference between dependent personality disorder and avoidant personality disorder?
avoidant personality patients cling to relationships, similar to dependent personality patients; however, avoidant patients are slow to get involved, whereas dependent patients actively and aggressively seek relationships
what is the mnemonic for the symptoms of avoidant personality disorder?
AFRAID • Avoids occupation with others • Fear of embarrassment and criticism • Reserved unless they are certain that they are liked • Always thinking rejection • Isolates from relationships • Distances self unless certain they are liked
what is the course of avoidant personality disorder?
usually chronic
when is avoidant personality particularly difficult?
during adolescence, when attractiveness and socialization are important
patients with avoidant personality disorder have an increased incidence of what?
associated anxiety and depressive disorders
what happens to an avoidant personality disorder patient if their support system fails?
patient is left very susceptible to depression, anxiety, and anger
what is the treatment for avoidant personality disorder?
- psychotherapy, including assertiveness training, is most effective • - β blockers may be used to control autonomic symptoms of anxiety, and SSRI’s may be prescribed for major depression
what are the characteristics of patients with dependent personality disorder?
- poor self confidence and fear separation • - excessive need to be taken care of and allow others to make decisions for them • - feel helpless when left alone
what are the DSM IV criteria for the diagnosis of dependent personality disorder?
- pattern of submissive and clinging behavior due to excessive need to be taken care of • - >5: • 1. difficulty making everyday decisions without reassurance from others • 2. needs others to assume responsibilities for most areas of his or her life • 3. cannot express disagreement because of fear of loss of approval • 4. difficulty initiating projects because of lack of self confidence • 5. goes to excessive lengths to obtain support from others • 6. feels helpless when alone • 7. urgently seeks another relationship when one ends • 8. preoccupied with fears of being left to take care of self
what is the prevalence of dependent personality disorder?
~1%
what is the gender predilection in dependent personality disorder?
F>M
regression is often seen in patients with which personality disorder?
DPD
what is the mnemonic for symptoms of dependent personality disorder?
OBEDIENT • Obsessive about approval • Bound by others’ decisions • Enterprises are rarely initiated due to their lack of self confidence • Difficult to make own decisions • Invalid feelings when alone • Engrossed with fears of self-reliance • Needs to be in a relationship • Tentative about decisions
what is the differential diagnosis for dependent personality disorder?
avoidant personality disorder • borderline personality disorder • histrionic personality disorder
what is the difference between patients with dependent personality disorder and those with BPD or HPD?
patients with DPD usually have a long lasting relationship with one person on whom they are dependent. patients with borderline and histrionic personalities are often dependent on other people, but they are unable to maintain a long lasting relationship
what is the course of dependent personality disorder?
usually has a chronic course • often symptoms ↓ with age and/or therapy
patients with dependent personality disorder are prone to what?
-depression, particularly after loss of a person on whom they are dependent • - difficulties with employment since they cannot act independently or without close supervision
people with debilitating illnesses tend to develop traits of which personality disorder?
dependent traits; however, to be diagnosed with DPD, the features must manifest early in adulthood
what is the treatment for dependent personality disorder?
- psychotherapy, particularly groups and social skills training, is the treatment of choice • - pharmacotherapy may be used to treat associated symptoms of anxiety or depression
what are the characteristics of patients with OCPD?
- pervasive pattern of perfectionism, inflexibility, orderliness • - so preoccupied with unimportant details that they are often unable to complete simple tasks in a timely fashion • - they appear stiff, serious, formal, with constricted affect • - successful professionally but with poor social skills
what are the DSM IV criteria for the diagnosis of OCPD?
- pattern of preoccupation with orderliness, control, and perfectionism at the expense of efficiency, present by early adulthood and in a variety of contexts • - >4: • 1. preoccupation with details, rules, lists, and organization such that the major point of the activity is lost • 2. perfectionism is detrimental to the completion of the task • 3. excessive devotion to work • 4. excessive conscientiousness and scrupulousness about morals and ethics • 5. will not delegate tasks • 6. unable to discard worthless objects • 7. miserly • 8. rigid and stubborn
what is the prevalence of OCPD?
unknown
what is the gender predilection in OCPD?
M>F
what is the birth order predilection in OCPD?
occurs most often in the oldest child
how strong is the genetic component in OCPD?
↑incidence in 1st degree relatives
what is the differential diagnosis for OCPD?
OCD • narcissistic personality disorder
what is the difference between OCD and OCPD?
patients with OCPD do not have the recurrent obsessions or compulsions that are present in OCD • -Symptoms of OCPD are egosyntonic vs egodystonic in OCD
what is the difference between OCPD and narcissistic personality disorder?
both personality involve assertiveness and achievement, but NPD patients are motivated by status, whereas OCPD patients are motivated by the work itself
what is the course of OCPD?
unpredictable course • - some patients later develop OCD • - some develop schizophrenia or MDD • - others improve or remain stable
what is the treatment for OCPD?
- psychotherapy is the treatment of choice. group therapy and behavior therapy may be useful • - pharmacotherapy may be used to treat associated symptoms as necessary
the diagnosis Personality Disorder NOS is reserved for what?
personality disorders that do not fit into Cluster A, B, or C
Personality disorder includes what?
passive agressive personality disorder • depressive personality disorder • sadomasochistic personality disorder • sadistic personality disorder
what are the characteristics of patients with passive aggressive personality disorder?
- stubborn • - inefficient procrastinators • - alternate between compliance and defiance and passively resist fulfillment of tasks • - make excuses for themselves and lack assertiveness • - attempt to manipulate others to do their chores, errands, frequently complain about their misfortunes
what is the treatment of choice for passive aggressive personality disorder?
psychotherapy
what are the characteristics of patients with depressive personality disorder?
lifelong traits of depressed-like state • pessimistic, self doubting, chronically unhappy, distressed
what is the mnemonic for substance abuse?
> 1: • WILD • Work, school, or home role obligation failure • Interpersonal or social consequences • Legal problems • Dangerous use
what are the DSM IV criteria for the diagnosis of substance abuse?
- pattern of substance use→impairment or distress for at least 12 months plus • - >1: • 1. failure to fulfill obligations at work, school, or home • 2. interpersonal or social consequences • 3. recurrent substance related legal problems • 4. continued use despite social or interpersonal problems due to the substance use
what are the DSM IV criteria for the diagnosis of substance dependence?
substance use → impairment or distress manifested by at least 3 of the following within a 12 month period: • 1. tolerance • 2. withdrawal • 3. using substance more than originally intended • 4. persistent desire or unsuccessful efforts to cut down on use • 5. significant time spent in getting, using, or recovering from substance • 6. ↓ social, occupational, or recreational activities because of substance use • 7. continued use despite subsequent physical or psychological problem
is it possible to have substance dependence without having physiological dependence?
yes
what is the lifetime prevalence of substance abuse or dependence in the united states?
~17%
what is the gender predilection in substance abuse/dependence?
M>F
what are the most commonly used substances?
alcohol • nicotine
what is the difference between substance induced and primary mood disorder?
substance induced mood symptoms go away with abstinence and primary mood symptoms do not
what is withdrawal?
the development of a substance-specific syndrome due to the cessation of substance use that has been heavy and prolonged
what is tolerance?
the need for increased amounts of the substance to achieve the desired effect or diminished effect if using the same amount of the substance
withdrawal symptoms of a drug are usually what?
opposite of its intoxication effects
what is the treatment for substance abuse/dependence?
- behavioral counseling should be part of every substance abuse/dependence treatment • - psychosocial treatments are effective and include motivational intervention (MI), CBT, contingency management, individual and group therapy • - 12 step programs should be encouraged • - pharmacotherapy is available for some drugs of abuse
what are the direct testing considerations for alcohol?
- stays in system for only a few hours • - breathalyzer test, commonly used by law enforcement • - blood/urine test more accurate
what are the direct testing considerations for cocaine?
urine drug screen positive for 2-4 days
what are the direct testing considerations for amphetamines?
urine drug screen positive for 1-3 days • most assays are not of adequate sensitivity
what are the direct testing considerations for PCP?
urine drug screen positive for 3-8 days • CPK and AST are often elevated
what are the direct testing considerations for sedative-hypnotics?
in urine and blood for variable amounts of time: • 1. barbiturates: • - short acting (pentobarbital): 24 hours • - long acting (phenobarbital): 3 weeks • 2. Benzodiazepines: • - short acting (lorazepam): 3 days • - long acting (diazepam): 30 days
what are the direct testing considerations for opioids?
- urine drug test remains positive for 2-3 days, depending on opioid used • - methadone and oxycodone will come up negative on a general screen (order a separate panel)
what are the direct testing considerations for marijuana?
urine detection: • - in heavy users, up to 4 weeks (THC is released from adipose stores) • - after a single use, about 3 days
what is the MOA of etOH?
activates GABA and serotonin receptors in CNS, inhibits glutamate receptors and voltage gated Ca channels → potent CNS depressant
what is the life time prevalence of etoh dependence in the USA?
3-5% women • 10% men • twice as many meet the criteria at some point in their life
how is etoh metabolized?
- alcohol → acetaldehyde (alcohol dehydrogenase) • 2. acetaldehyde → acetic acid (aldehyde dehydrogenase)
what is the effect of heavy drinking on alcohol metabolism in heavy drinkers?
there is upregulation of alcohol dehydrogenase and aldehyde dehydrogenase
what genetic difference in alcohol metabolism is common in asians?
they often have less aldehyde dehydrogenase resulting in flushing and nausea and protecting against alcohol dependence
pregnant women should not drink alcohol as it can lead to what?
fetal alcohol syndrome in the newborn, which is the leading cause of mental retardation in the USA
what is the most common coingestant in drug overdoses?
alcohol
at what BAL will most adults show signs of intoxication?
some signs >100mg/dl • obvious signs >150mg/dl
alcohol, methanol, and methylene glycol can all cause what metabolic disturbance?
metabolic acidosis with ↑ anion gap
the absorption and elimination rates of alcohol depend on what?
age • sex • body weight • chronic nature of use • duration of consumption • food in the stomach • state of nutrition • liver health
spousal abuse is more common in which homes?
those in which the male is involved in some kind of substance abuse, especially alcohol
what is the treatment for etoh intoxication?
- monitor: ABC’s, glucose, lytes, acid base status • - naloxone may necessary to reverse effects of co-ingested opioids • - CT of the head maybe necessary to rule out subdural hematoma or other brain injury
what are the effects seen at BAL 20-50mg/dl?
↓ fine motor control
what are the effects seen at BAL 50-100 mg/dL?
impaired judgement and motor control
what are the effects seen at BAL 100-150 mg/dL?
ataxic gait and poor balance
what are the effects seen at BAL 150-250mg/dL?
lethargy, difficulty sitting upright, difficulty with memory
what are the effects seen at BAL 300mg/dL?
coma in the novice drinker
what are the effects seen at BAL 400 mg/dL?
respiratory depression, death possible
what is the most commonly abused substance in the united states?
alcohol
what happens to excess alcohol in the body?
liver will eventually metabolize alcohol without intervention
patients severely intoxicated with alcohol may require what?
mechanical ventilatory support with attention to acid base balance, temp, lytes
is gastrointestinal intervention indicated in alcohol intoxication?
evacuation (gastric lavage, emesis, charcoal) is not indicated unless a significant amount of etOH was ingested in the preceding 30-60 minutes
attempted suicide is associated with what?
mental illness • young females • alcoholism
what is the drug of choice for benzo taper in a post op patient in etoh withdrawal?
chlordiazepoxide (Librium)
how serious is alcohol withdrawal?
potentially lethal
signs and symptoms of alcohol withdrawal syndrome include what?
insomnia • anxiety • hand tremor • irritability • anorexia • nausea • vomiting • autonomic hyperactivity (diaphoresis, tachycardia, hypertension) • psychomotor agitation • fever • seizures • hallucinations • delirium
