Psychiatry III Flashcards
Diagnostic criteria for obesity?
More than 20% ideal weight/BMI>30
Block which 3 receptors would cause weigh gain?
H1/M receptor/5HT2c/also block D2 increase prolactin cause weight gain in women
What are some drugs for obesity?
Amphetamine/Orlistat (lipase inhibitor)/topiramate and zonisamide (anti-convulsants)
DSM 5 criteria for anorexia?
Refuse to maintain normal weight/don’t eat/fear of gaining/body image dysmorphism (self restricted)/restricting (don’t purge) and binge type
Highest mortality rate of psych disorder?
Anorexia
What characteristics does anorexia pt usually have?
Rigid/type A personality/high endogenous opiate/Lanugo hair
Treatment for anorexia?
If severe enough—>force feeding tube/have to be firm with them
DSM 5 criteria for bulimia
eating an atypically large amount of food (compulsion)—>1 time a week for 3 month/purging (compensatory behavior) and non purging type/no anorexia symptoms/
Which is more prevalent, anorexia or bulimia?
Bulimia
Which has better prognosis, anorexia or bulimia?
Bulimia
What are some medical signs of bulimia?
Poor dentition/low phosphate and magnesium/salivary enlargement/normal to obese weight/Russel’s sign
Treatment for bulimia?
Psychotherapy/SSRI/TCA
What is the mild anorexia disorder called
Avoidant/restrictive food intake disorder
What is the mild bulimia disorder called
Binge eating disorder
Diagnostic criteria for delusional disorder?
Single focused delusion/no hallucination/normal lives
What is Capgras delusion?
Delusion where pt feels someone has been replaced by an imposter
What is Fregoli delusion?
Delusional disorder that the pt thinks different people are actually the same person that change appearance or in disguise/paranoid—>you are following me….
What is vampirism?
Delusion that one is a vampire
What is lycanthropy?
Delusion that one is a werewolf
What other disorder do pyschopathic cannibalism pts have?
Antisocial/psychopathy/and delusion about eating people
What is folie a deux or shared delusion disorder?
Symptoms of a delusional belief are transmitted from one person to another (voodoo zombie)
What is cotard’s delusion?
Delusion that the pt believe that he/she is dead
What is the heroin like drug that rot flesh?
Krokodil
What is Morgellons/delusional parasitosis?
Delusion that you are infested with parasite and they are underneath your skin/might actually find some bacteria or parasite (self induced)
What is erotomanic delusion?
Pt think another person (stranger/famous people) is in love with him/her
What part of the brain is hyperactive in delusional disorder?
Mesolimbic system with high DA like schizo
Treatment for delusional disorders?
Psychotherapy help to cope/antipsychotic doesn’t work that well—>hard to treat
Progression of Alzheimer’s disease?
Normal—>mild cognitive impairment (mild memory lost) —>dementia
DSM 5 criteria for Azheimer’s?
Mild or major (can’t live alone) neurocognitive disorder. Focus on decline of function/cognition/behaviors
What are early and late onset AD?
Early onset—>30-60/rare/single gene mutation (presenilin 1/2)
Late onset—->over 60 but usually around 80
Some risk factors for AD?
Age/female/fewer year of education/psych illness/alcohol abuse
Distinguish depression from dementia?
On test dementia pt would try to impress but depression pt would not want to participate
Is brain imaging helpful for AD pts?
Not really—>nonspecific findings
What would you see on a PET scan for AD pt?
More blue tone/enlarged ventricles—>less blood flow
The most common frontotemporal dementia is?
Pick’s disease—>decline in social interpersonal conduct (behavioral)—>memory problems come later
What to give frontotemporal dementia pt?
Divalproex for behavioral/SSRI for irritability. depression and impulsive behaviors/don’t use SGA
What’s the brain of an AD pt like?
Cerebral atrophy/hippocampus atrophy
What kind of stain do you use to stain neuritic and neurofibrillary tangles?
Silver stain
What stain is used to confirm the presence of amyloid plaques?
Congo red
Familiar onset AD has higher Abeta40 or 42?
Abeta 42
Where are presenilins located?
Gamma-secretase
What caused the earlier onset of AD?
Down syndrome
What are the 2 types of plaques do you see in AD pt?
Diffuse and neuritic plaques (dark center)
What’s in neurofibrillary tangles?
Hyperphosphorylated Tau proteins
What is granulovacuolar degeneration (GVD) and hirano bodies and where do you see them?
GVD—>granulocyte in a vacuole in a neuron/AD pts or old ppl
Two subtypes of frontotemploral degeneration?
FTLD-tau (Pick’s) and FTLD-TDP
Is senile and memory lost as one ages a normal phenomena?
No
What are the 2 kinds of drugs used for AD?
AChE inhibitor and NMDA receptor antagonists
HTN causes ___ infarct of the ____ and causes ____ dementia?
Lacunar infarcts/lenticulostriate/vascular dementia
Clinically, vascular dementia presents as a ___ progression
Step wise—>decline, level off, decline, level off and repeat/emotionally lability
What other risk factors do vascular dementia pt has?
Cardiovascular
Treatment for vascular dementia
Control cardiovascular risk factors/AD drugs
End stage Parkinson’s show ___ loss
severe neuronal loss
What are other symptoms do you see with lewy body dementia that you don’t see with AD?
Vivid hallucination and delusions/memory less affected/nigral pallor/atrophy of the limbic system/REM sleep disorder (act out dreams)/high neuroleptic sensitivity
What is the appearance difference between the lewy body in substantial nigra and cortical?
SN—->round and dark in the middle
Cortical—>acentral nucleus
Treatment for lewy body dementia?
AChE inhibitor/levodopa for movement disorder/NO antipsychotic drugs
What is mini metal status examination (MMSE)?
Screening tool for dementia (non specific for types)—>out of 30 (higher the better)
What are the 5 areas of MMSE?
Orientation/registration/attention and calculation/recall/language
What is montreal cognitive assessment (MoCA)?
Screening tool for dementia (out of 30)—>more comprehensive than MMSE
What is DEATH for ADL and SHAFT for IADL?
DEATH—>dressing/eating/ambulating/toileting/hygiene
SHAFT—>shopping/housekeeping/accounting/food preparation/transportation
What is the difference between adult home/assisted living facilities and nursing facilities?
Adult home—>rent a room/provides meal/not much medical problem/elderly is independent
Assisted living—>assist with IADLs/no medical nor nursing care
Nursing facilities—>pt is dependent of all ADLs (like incontinence)
The lower the score on Geriatric Depression Scale the ___?
Better
What is the score range for normal/mild/moderate/severe of MoCA and MMSE?
Normal >26
Moderate 20-26
Mild 10-20
Severe
Fundamental hypothesis of psychoanalytic theory: every event and symptom has ___?
Meaning
___ is the reservoir of the reasons of why you do certain thing that can not be explained by consciousness
Unconsciousness
What is unconscious?
Repressed thoughts and feelings
What is libido in psychosexual stages of development?
Anything that makes you want to do things
When and what is the oral phase of psychosexual stages?
birth - 1 year and half—>baby sucking and putting things in their mouth/dependency
What is adult oral traits?
Ppl who enjoy food/drink/smoke to the excess—>become passive and dependent
When and what is the anal phase?
1 and half to 3 years—>emphasis on control (parents tell the kids “no”/potty training/crawling and exploring
What is adult anal traits?
Being too controlled/neat/correct/careful with money/organized
What is fixation and regression regarding psychosexual stages?
Fixation—>extra investment of libido in one phase
Regression—>reverse back to earlier phase (under stress like being sick)
When and what is the phallic phase?
3-5/6—>curious about sex differences/close to parent of opposite sex
When and what is latency phase?
6 to teens—>boys and girls learn how to be boys and girls/they don’t like each other
When and what is genital phase?
Teen to adult—>true intimacy
What are the 3 structural model of the mind?
ID—>”child”/goal is to get the most pleasure (fun and bad)
Superego—>”parent”/from age 5/what’s right and wrong (follow the rule)/learned from mentors and models in life
Ego—>”adult”/it is who we are (personality)/evolving—>balancing between superego and ID
When ego is under stress (don’t know what to do know)—>stress—>we utilize ____?
Defense mechanism—>decrease stress
What is the level I defense mechanism?
Psychotic—>change reality/common for ppl before age 5 and adult dreams and fantasy (real bad)
What are the 3 level I defense mechanisms?
Delusional projection—>putting down somebody else to make you feel better (lead to paranoid)
Psychotic denial—>denying reality
Distortion—>reshape reality to suit your need
What is level II defense mechanism?
immature mechanisms/common for ppl from 3-15/trying to be close to people but its not working—>what can i do to make you care about me?
What are the 4 level II defense mechanisms?
Projection—>project one’s own bad feeling onto you (being paranoid (paranoid personality) that everybody is out to get you and in a way everyone is connected to you—>make you felt connected)
Somatization—>turn one’s own bad feeling into physical illness or pain then seek attentions from others
Acting out—>antisocial behaviors (I don’t like my feeling so i would do something (punch ppl) instead of feeling something)
Splitting—>See ppl or event as completely good or bad (black or white)—>borderline personality disorder
What is level III defense mechanism?
common in ppl from 3-90/seems odd or quirky/in acute distress from healthy people (high functioning)
What are the first 4 level III defense mechanism?
Denial—>just don’t wanna deal with it right now (cancer pt)
Displacement—>lash out to a safer target (can’t yell at dean, yell at med students)—>phobias (afraid of something—>transfer to something i can deal with like a spider)
Dissociation—>after a traumatic event—>dissociate and forget your identity (long term is Multiple personality disorder)
Identification—>unconsciously joining the more powerful person or aggressor (Stockholm Syndrome)—>helpless person in an abusive situation
What are intellectualization/isolation of affect/rationalization of level III defense mechanism?
Intellectualization—>in acute distress you do something or explain with words (like when your spouse just passed away)—>the feelings are not there—>OCD
Rationalization—>explain away negative feelings (it’s not my fault)
Isolation of affect—>when you understand the situation but not feeling it (numb)
What are reaction formation/regression/undoing of level III defense mechanism?
Reaction formation—>do the opposite of how you feel (hate somebody you really like)
Regression—>child like behaviors during stress
Undoing—>do something in hope that something in the past can be corrected (superstition)
What is level IV defense mechanism?
mature/good for you and the society (virtues)
What are the 5 level IV defense mechanism?
Altruism—>do things for others to make you feel good
Sublimation—>really want to do something but can’t so im gonna do something else instead (like beating ppl up, can’t do that, take boxing lessons)
Anticipation—>plan ahead for something that might be anxiety provoking
Suppression—>suppress the anxiety for a brief period of time—>come back to it later
Humor—>express yourself in a humorous fashion that other people might accept it
What is transference and counter transference?
Transference—>pt use past to judge or reply the current relationship with the physician (e.g. prejudice)—>see physician as a father figure—>use past relationship with father to interact or expect from the physician
Countertransference—>the opposite goes from the physician to the pt
Pain (nociception) is detected what kind of nerve?
Free nerve endings
Difference between A delta and C fiber for nociception
A delta (highly myelinated)--->reflex C fiber--->long lasting dull pain
What is mechanical hyperalgesia?
The area around the injury is tender and painful as well
When the pain and temp comes into the spinal cord, it ___?
Crosses over to the other side and go up through the spinothalamic tract
Descending ___ system modulate pain and can be manipulated by opioid?
Descending pain modulatory system (contain opioid receptors)
__ receptor is the most important opioid receptor for pain relieve?
Mu
Endogenous opioid can be released ____ and ____ with ACTH
centrally and peripherally with ACTH
Opioid can cause hyper__? and how to stop this from developing?
Hyperalgesia (causing pain response)/block the GLU system
Which has a more sustained activity, NSAIDs or opioids?
NSAIDS
Inflammatory pain use? horrible pain, use __ for short time?
NSAID/opioid
Progression of neuropathic pain?
Ca influx (sub-threshold pain response)—>Ca and Na influx (full pain response)—>wires got crossed (excess GLU)—>more rapid firing (central sensitization—>chronic pain)
What are the 3 “bus stops” of pain perception?
Spinal reflex (reflex pain—>curse/throw stuff)—>thalamus—>cortex and limbic (conscious pain)
Clinical management: if a pt in pain doesn’t response too much to Ca channel drugs, what other kind of drugs can you give?
Na channel blockers
Weak ascending NE to cortex/descending NE to spinal cord causes?
Depression, anxiety and many other psychiatry disorder/pain (that’s why depressed/anxious people has more pain—>they travel together)
How do antidepressant treat problems related to ascending and descending NE?
Antidepressant with NE reuptake inhibitors strengthen ascending and descending NE—>remit psychiatric disorders and decrease pain (NE stimulates GABA—>downregulate pain fiber—>pain relieve)
How you perceive pain is highly depends on your ___ and ___?
How you were raised and your personality/level of education (higher educated people don’t use opioid for pain)
When a pt who’s on opioid for years for pain management broke his leg–>he experience more or less pain than a pt that has not been on opioid?
More pain (opioid hyperalgesia)
What is anterior cingulate and orbital/ventralmedial prefrontal cortex’s roles in pain perception?
Anterior cingulate—>hypervigilance on where the next pain is gonna be from
Orbital and ventralmedial prefrontal cortex—>think of all the things that might cause pain (i hurt my ankle, i shouldn’t go out tonight)
How do you tell if a pt has opioid hyperalgesia?
Opioid level is going up and up and more pain/short cold pressure time (stick your arm into a huge pot of ice)—>low pain tolerance
What is analogue visual scale (AVS)?
Used to assess pain with pictures of faces
What are the 3 common factors for all the psychotherapy?
Alliance (importance varies among different therapies)/expectation/Hawthorne effect (you do better when you are watched)
What is the base and aim of psychoanalysis and psychodynamic?
Unconscious conflicts are repressed and causes difficulty/making unconscious conscious—>understanding conflict
What are the 4 techniques of psychoanalysis and psychodynamic?
Free association/analysis of transference and resistance/dream interpretation
How long is psychoanalysis and psychodynamic/interpersonal?
Long term therapy—>sometimes years/short term
What is the base and aim of interpersonal psychotherapy?
Problematic attachment early in life cause later interpersonal problem/correct the problems
What are the 4 techniques of interpersonal psychotherapy?
Loss and grief/role disputes/role transition (from med school to residency)/interpersonal deficits (social skills)
What do interpersonal treat?
Depression and eating disorder
What is family system psychotherapy/what are the 2 techniques/what does it treat?
The whole family is the patient/normalizing boundaries and redefining blame/child behaviors
What is group therapy?
Treat people with common experiences
What is the aim of behavioral psychotherapy and what does it treat?
Relieve symptoms by unlearning maladaptive behaviors/phobias, depression, autism, psychotic disorder and ODD and ADHD
Which psychotherapy is based on classical and operant conditioning?
Behavioral
What is classical conditioning?
unconditioned stimulant (natural, e.g. meat—>salivation) combine with neutral stimulant (tone)—->neutral stimulant become conditioned stimulant—>tone causes salivation
what is the change over time of the strength of the conditioned response (classical conditioning)?
Acquisition (pairing stimulants)—>extinction (neutral stimulant stop working)—>time delay—>hear tone, drool again but then decline without UCS
What is stimulus generalization and discrimination?
Stimulus is being generalized (when phobia pt develop agoraphobia)/pt learn to differentiate among similar stimuli (goal of the therapy)
What is systemic desensitization?
Derived from classical conditioning/aim to unlearn the association of a fear or addiction with certain object/e.g. phobia of clown—>start with a pic of a normal clown—>learn to relax when looking at it—>and then move up to real and more scary clowns
What is positive and negative reinforcer of operant conditioning?
Positive—>add something to strengthen the response (give gold start to children)
Negative—>remove a bad stimulant to strengthen the response (anxious pt avoid something that makes them anxious)
How is the size and timing of the reinforcer affect the behaviors?
The bigger/and sooner you give the reinforcer after the response—>the better
What is the 4 kinds of partial reinforcement schedules (unlike continuous—>give every time after a response)?
Fixed ratio (like every 3 responses)/variable ratio (like 3 times a month)/fixed interval (like get paid every month)/variable interval (like get paid sometime per week some time per month)
What kind of schedule of reinforcement is most consistent across the longest time?
Interval
Difference between reinforcement and punishment regarding response of operant conditioning?
Response goes up for reinforcement and down for punishment (need to know the response afterwards to determine)
What is positive and negative punishment?
Positive—>add something bad (get hit by parents for stealing)
Negative—>lose something good (run with ice cream–>ice cream fall—>stop running with ice cream)
What are some drawbacks of punishment?
Does not erase a bad habit/need to do it every time after the response/the people who’s giving punishment can be angry and abusive/doesn’t tell you what is right
What is conversion disorder?
Triggered by trauma or stress—>sudden loss of 1 or more motor or sensory function (protecting you from experiencing the trauma again?)—>neurologic symptoms does not follow how the nervous system works
Unconscious and no 2nd gain
What are the 6 techniques of behavioral psychotherapy?
Systemic desensitization/flooding/aversive conditioning (punish when bad)/token economy (positive reinforcement)/self monitoring/stimulus control (change behavior to avoid punishment)
What is the aim of cognitive therapy?
to be mindful of their thoughts/challenge the thought/get rid of bad thoughts and replace it with good thoughts/correct errors in thinking
What are the 2 techniques for cognitive therapy?
Psychoeducation (recognize thoughts) and cognitive restructuring (challenge them)
How long and what does cognitive therapy treat?
short term/depression, anxiety and eating disorder
What are the 3 fundamental proposition of CBT?
Cognition affect behaviors (mediational model)/cognition can be monitored and altered/change cognition, change behaviors
What are the 3 classes of CBT?
Coping skill therapy—>manage stress
Cognitive restructuring method—>change how to think
Problem solving—>combination of the other two
Common things like homework that CBT does?
Homework/focus on future/give pt lots of info
What is the structure of a CBT session?
10-30-10/first 10 mins for yesterday’s hw/30 mins for actual work/last 10 assigning hw
What are the conscious and unconscious disorders of somatoform disorder?
Conscious—>on purpose (Factitious/malingering)
Unconscious—>not aware (conversion/somatization)
What are primary and secondary gain regarding somatofrom disorders?
Primary—>unconscious (my parents are like this so i’m like this)
Secondary—>external motivations (drugs/need housing)
Increasing number of somatoform symptoms increase the chance of ?
depression and anxiety
What is somatic symptom disorder?
Collection of medical problems that has no causes (2 GI/1 GU/1 neurological)—>accumulating symptoms
Unconscious/no 2nd gain
What is illness anxiety disorder?
Hypochondriasis—>unconscious and no 2nd gain
What is body dysmorphic disorder?
preoccupy by your appearance—>unconscious and no 2nd gain
What is pain disorder (DSM IV)?
Just one symptom that is painful (don’t meet somatization disorder—>milder version)
What is factitious disorder?
Known as Munchausen syndrome—>consciously faking medical problems for yourself (by proxy is what parents do to kids)
It is on purpose but the purpose might not be conscious
What is malingering?
Consciously faking it to gain something (criminal)
What are 2 drugs for anorexia?
Mirtazapine and olanzapine
Pain management for injury
Give opiate for acute injury/give NISAD and send him home/come back with neutropathic pain—>give AED or SSRI or SNRI
Aim of motivational interview?
work through ambivalence and help the pt to reach a decision
What are the 5 principles of MI?
DARES—>discrepancy/avoid confrontation/roll with resistance/empathy/support self efficacy
5 steps of MI (SBIRT)?
rapport—>pro and con—>personalized feedback—?assess readiness (readiness ruler)—>create action plan
