Psychiatry - Pathology (1)

Question 1

Infant deprivation effects

• Long-term deprivation of affection results in:
• Deprivation for > 6 months
• Severe deprivation

Answer 1

• Long-term deprivation of affection results in:
  
  • Decreased muscle tone
  • Poor language skills
  • Poor socialization skills
  • Lack of basic trust
  • Anaclitic depression (infant withdrawn / unresponsive)
  • ƒƒWeight loss
  • Physical illness
• The 4 W’s:
  
  • Weak
  • Wordless
  • Wanting (socially)
  • Wary
• Deprivation for > 6 months
  
  • Can lead to irreversible changes.
• Severe deprivation
  
  • Can result in infant death.

Question 2

Child abuse

• For each
  
  • Evidence
  • Abuser
  • Epidemiology
• Physical abuse
• Sexual abuse

Answer 2

• Physical abuse
  
  • Evidence: Healed fractures on x-ray (e.g., spiral fractures are highly suggestive of abuse), burns (e.g., cigarette, scalding), subdural hematomas, pattern marks/bruising (e.g., belts, electrical cords), rib fractures, retinal hemorrhage or detachment
  • Abuser: Usually biological mother
  • Epidemiology: ~3000 deaths/yr in U.S., 80% < 3 yr old
• Sexual abuse
  
  • Evidence: Genital, anal, or oral trauma; STDs; UTIs
  • Abuser: Known to victim, usually male
  • Epidemiology: Peak incidence 9–12 years old

Question 3

Child neglect

• Definition
• Evidence

Answer 3

• Definition
  
  • Failure to provide a child with adequate food, shelter, supervision, education, and/or affection.
  • Most common form of child maltreatment.
  • As with child abuse, child neglect must be reported to local child protective services.
• Evidence
  
  • Poor hygiene, malnutrition, withdrawal, impaired social/emotional development, failure to thrive.

Question 4

Attention-deficit hyperactivity disorder

• Definition
• Findings
• Treatment

Answer 4

• Definition
  
  • Childhood and early-onset disorder
  • Onset before age 12.
  • Limited attention span and poor impulse control.
  • Normal intelligence, but commonly coexists with difficulties in school.
  • Continues into adulthood in as many as 50% of individuals.
• Findings
  
  • Characterized by hyperactivity, impulsivity, and/or inattention in multiple settings (school, home, places of worship, etc.)
  • Associated with decreased frontal lobe volume/metabolism.
• Treatment
  
  • Methylphenidate, amphetamines, atomoxetine, behavioral interventions (reinforcement, reward).

Question 5

Conduct disorder

Answer 5

• Childhood and early-onset disorder
• Repetitive and pervasive behavior violating the basic rights of others (e.g., physical aggression, destruction of property, theft).
• After age 18, many of these patients will meet criteria for diagnosis of antisocial personality disorder.

Question 6

Oppositional defiant disorder

Answer 6

• Childhood and early-onset disorder
• Enduring pattern of hostile, defiant behavior toward authority figures in the absence of serious violations of social norms.

Question 7

Tourette syndrome

• Definition
• Findings
• Treatment

Answer 7

• Definition
  
  • Childhood and early-onset disorder
  • Onset before age 18.
  • Lifetime prevalence of 0.1–1.0% in the general population
  • Associated with OCD and ADHD
• Findings
  
  • Characterized by sudden, rapid, recurrent, nonrhythmic, stereotyped motor and vocal tics that persist for > 1 year.
  • Coprolalia (involuntary obscene speech) found in only 10–20% of patients.
• Treatment
  
  • Antipsychotics and behavioral therapy.

Question 8

Separation anxiety disorder

• Definition
• Treatment

Answer 8

• Definition
  
  • Childhood and early-onset disorder
  • Common onset at 7–9 years.
  • Overwhelming fear of separation from home or loss of attachment figure.
  • May lead to factitious physical complaints to avoid going to or staying at school.
• Treatment
  
  • SSRIs and relaxation techniques/behavioral interventions.

Question 9

Pervasive developmental disorders

• Definition
• Examples

Answer 9

• Definition
  
  • Characterized by difficulties with language and failure to acquire or early loss of social skills.
• Examples
  
  • Autism spectrum disorder
  • Rett disorder

Question 10

Autism spectrum disorder

• Definition
• Findings

Answer 10

• Definition
  
  • Pervasive developmental disorder
  • Must present in early childhood
  • More common in boys
• Findings
  
  • Characterized by poor social interactions, communication deficits, repetitive/ritualized behaviors, and restricted interests.
  • May or may not be accompanied by intellectual disability
  • Rarely accompanied by unusual abilities (savants).

Question 11

Rett disorder

• Definition
• Findings

Answer 11

• Definition
  
  • Pervasive developmental disorder
  • X-linked disorder seen almost exclusively in girls (affected males die in utero or shortly after birth).
• Findings
  
  • Symptoms usually become apparent around ages 1–4, including regression characterized by loss of development, loss of verbal abilities, intellectual disability, ataxia, and stereotyped hand-wringing.

Question 12

Neurotransmitter changes with these diseases

• Alzheimer disease 
• Anxiety
• Depression
• Huntington disease
• Parkinson disease
• Schizophrenia

Answer 12

• Alzheimer disease 
  
  • Decreased ACh
• Anxiety 
  
  • Increased norepinephrine
  • Decreased GABA
  • Decreased 5-HT
• Depression 
  
  • Decreased norepinephrine
  • Decreased 5-HT
  • Decreased dopamine
• Huntington disease 
  
  • Decreased GABA
  • Decreased ACh
  • Increased dopamine
• Parkinson disease 
  
  • Decreased dopamine
  • Increased 5-HT
  • Increased ACh
• Schizophrenia 
  
  • Increased dopamine

Question 13

Orientation

• Definition
• Common causes of loss of orientation
• Order of loss

Answer 13

• Definition
  
  • Patient’s ability to know who he or she is, where he or she is, and the date and time.
  • Often abbreviated in the medical chart as “alert and oriented × 3” (AO×3)
• Common causes of loss of orientation
  
  • Alcohol, drugs, fluid/electrolyte imbalance, head trauma, hypoglycemia, infection, nutritional deficiencies.
• Order of loss
  
  • 1st—time
  • 2nd—place
  • Last— person

Question 14

Amnesias

• Retrograde amnesia
• Anterograde amnesia
• Korsakoff amnesia
• Dissociative amnesia

Answer 14

• Retrograde amnesia
  
  • Inability to remember things that occurred before a CNS insult.
• Anterograde amnesia
  
  • Inability to remember things that occurred after a CNS insult (no new memory).
• Korsakoff amnesia
  
  • Classic anterograde amnesia caused by thiamine deficiency and the associated destruction of mammillary bodies.
  • May also include some retrograde amnesia.
  • Seen in alcoholics, and associated with confabulations.
• Dissociative amnesia
  
  • Inability to recall important personal information, usually subsequent to severe trauma or stress.
  • May be accompanied by dissociative fugue (abrupt travel or wandering during a period of dissociative amnesia, associated with traumatic circumstances).

Question 15

Cognitive disorder

Answer 15

• Significant change in cognition (memory, attention, language, judgment) from previous level of functioning.
• Associated with abnormalities in CNS, a general medical condition, medications, or substance use.
• Includes delirium and dementia.

Question 16

Delirium

• Definition
• Findings
• Treatment

Answer 16

• Definition
  
  • “Waxing and waning” level of consciousness with acute onset
    
    • Delirium** = changes in sensorium.**
  • Usually 2° to other illness (e.g., CNS disease, infection, trauma, substance abuse/withdrawal, metabolic/electrolyte disturbances, hemorrhage, urinary/fecal retention)
  • Most common presentation of altered mental status in inpatient setting
  • Check for drugs with anticholinergic effects.
  • Often reversible.
• Findings
  
  • Rapid decrease in attention span and level of arousal
  • Characterized by disorganized thinking, hallucinations (often visual), illusions, misperceptions, disturbance in sleepwake cycle, cognitive dysfunction.
  • Abnormal EEG.
• Treatment
  
  • Identify and address underlying cause.
  • ƒƒOptimize brain condition (O2, hydration, pain, etc.).
  • Antipsychotics (mainly haloperidol).
  • T-A-DA approach (Tolerate, Anticipate, Don’t Agitate) helpful for management.

Question 17

Dementia

• Definition
• Findings
• Irreversible causes
• Reversible causes

Answer 17

• Definition
  
  • Gradual decrease in intellectual ability or “cognition” without affecting level of consciousness.
  • A patient with dementia can develop delirium (e.g., patient with Alzheimer disease who develops pneumonia is at increased risk for delirium)
  • Increased incidence with age.
  • Usually irreversible.
  • In elderly patients, depression may present like dementia (pseudodementia).
• Findings
  
  • Characterized by memory deficits, aphasia, apraxia, agnosia, loss of abstract thought, behavioral/personality changes, impaired judgment.
    
    • “Dememtia” is characterized by memory loss.
  • EEG usually normal.
• Irreversible causes
  
  • Alzheimer disease, Lewy body dementia, Huntington disease, Pick disease, cerebral infarcts, Creutzfeldt-Jakob disease, chronic substance abuse (due to neurotoxicity of drugs).
• Reversible causes
  
  • NPH, vitamin B12 deficiency, hypothyroidism, neurosyphilis, HIV (partially).

Question 18

Psychosis

• Definition
• Hallucinations
• Delusions
• Disorganized speech

Answer 18

• Definition
  
  • A distorted perception of reality (psychosis) characterized by delusions, hallucinations, and/or disorganized thinking.
  • Psychosis can occur in patients with medical illness, psychiatric illness, or both.
• Hallucinations
  
  • Perceptions in the absence of external stimuli
  • e.g., seeing a light that is not actually present
• Delusions
  
  • Unique, false beliefs about oneself or others that persist despite the facts
  • e.g., thinking aliens are communicating with you
• Disorganized speech
  
  • Words and ideas are strung together based on sounds, puns, or “loose associations.”

Question 19

Hallucination types

• Visual
• Auditory
• Olfactory
• Gustatory
• Tactile
• Hypnagogic
• Hypnopompic

Answer 19

• Visual
  
  • More commonly a feature of medical illness (e.g., drug intoxication) than psychiatric illness.
• Auditory
  
  • More commonly a feature of psychiatric illness (e.g., schizophrenia) than medical illness.
• Olfactory
  
  • Often occur as an aura of psychomotor epilepsy and in brain tumors.
• Gustatory
  
  • Rare.
• Tactile
  
  • Common in alcohol withdrawal (e.g., formication—the sensation of bugs crawling on one’s skin).
  • Also seen in cocaine abusers (“cocaine crawlies”).
• HypnaGOgic
  
  • Occurs while GOing to sleep.
• HypnoPOMPic
  
  • Occurs while waking from sleep
  • “POMPous upon awakening”

Question 20

Schizophrenia

• Definition
• Etiologies / associations
• Prevalence
• Diagnosis
• Brief psychotic disorder
• Schizophreniform disorder
• Schizoaffective disorder

Answer 20

• Definition
  
  • Chronic mental disorder with periods of psychosis, disturbed behavior and thought, and decline in functioning that lasts > 6 months.
  • Associated with increased dopaminergic activity, decreased dendritic branching.
  • Patients are at increased risk for suicide
• Etiologies / associations
  
  • Genetics and environment contribute to the etiology of schizophrenia.
  • Frequent cannabis use is associated with psychosis/schizophrenia in teens.
• Prevalence
  
  • Lifetime prevalence—1.5% (males = females, blacks = whites).
  • Presents earlier in men (late teens to early 20s vs. late 20s to early 30s in women).
• Diagnosis requires 2 or more of the following (first 4 in this list are “positive symptoms”):
  
  • ƒƒDelusions
  • ƒƒHallucinations—often auditory
  • ƒƒDisorganized speech (loose associations)
  • ƒƒDisorganized or catatonic behavior
  • “Negative symptoms”—flat affect, social withdrawal, lack of motivation, lack of speech or thought
• Brief psychotic disorder
  
  • < 1 month, usually stress related.
• Schizophreniform disorder
  
  • 1–6 months.
• Schizoaffective disorder
  
  • At least 2 weeks of stable mood with psychotic symptoms, plus a major depressive, manic, or mixed (both) episode.
  • 2 subtypes: bipolar or depressive.

Question 21

Delusional disorder

Answer 21

• Fixed, persistent, untrue belief system lasting > 1 month.
• Functioning otherwise not impaired.
• Example: a woman who genuinely believes she is married to a celebrity when, in fact, she is not.

Question 22

Dissociative disorders

• Dissociative identity disorder
• Depersonalization / derealization disorder

Answer 22

• Dissociative identity disorder
  
  • Formerly known as multiple personality disorder.
  • Presence of 2 or more distinct identities or personality states.
  • More common in women.
  • Associated with history of sexual abuse, PTSD, depression, substance abuse, borderline personality, and somatoform conditions.
• Depersonalization / derealization disorder
  
  • Persistent feelings of detachment or estrangement from one’s own body, thoughts, perceptions, and actions (depersonalization) or one’s environment (derealization).

Question 23

Mood disorder

Answer 23

• Characterized by an abnormal range of moods or internal emotional states and loss of control over them.
• Severity of moods causes distress and impairment in social and occupational functioning.
• Includes major depressive disorder, bipolar disorder, dysthymic disorder, and cyclothymic disorder.
• Psychotic features (delusions or hallucinations) may be present.

Question 24

Manic episode

• Definition
• Diagnosis

Answer 24

• Definition
  
  • Distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy lasting at least 1 week.
  • Often disturbing to patient.
• Diagnosis requires hospitalization or at least 3 of the following (manics DIG FAST):
  
  • ƒƒDistractibility
  • Irresponsibility—seeks pleasure without regard to consequences (hedonistic)
  • ƒƒGrandiosity—inflated self-esteem
  • Flight of ideas—racing thoughts
  • Increase in goal-directed Activity/psychomotor Agitation
  • Decreased need for Sleep
  • Talkativeness or pressured speech

Question 25

Hypomanic episode

Answer 25

• Like manic episode except mood disturbance is not severe enough to cause marked impairment in social and/or occupational functioning or to necessitate hospitalization.
• No psychotic features.
• Lasts at least 4 consecutive days.

Question 26

Bipolar disorder

• Definition
• Bipolar I vs. II
• Treatment
• Cyclothymic disorder

Answer 26

• Definition
  
  • Patient’s mood and functioning usually return to normal between episodes.
  • Use of antidepressants can lead to increased mania.
  • High suicide risk.
• Bipolar I vs. II
  
  • Bipolar I defined by the presence of at least 1 manic episode with or without a hypomanic or depressive episode.
  • Bipolar II defined by the presence of a hypomanic and a depressive episode.
• Treatment
  
  • Mood stabilizers (e.g., lithium, valproic acid, carbamazepine), atypical antipsychotics.
• Cyclothymic disorder
  
  • Dysthymia and hypomania
  • Mlder form of bipolar disorder lasting at least 2 years.

Question 27

Major depressive disorder

• Definition
• Symptoms
• Patients with depression typically have the following changes in their sleep stages:
• Persistent depressive disorder (dysthymia)
• Seasonal affective disorder

Answer 27

• Definition
  
  • May be self-limited disorder, with major depressive episodes usually lasting 6–12 months.
  • Episodes characterized by at least 5 of the following 9 symptoms for 2 or more weeks
    
    • Symptoms must include patient-reported depressed mood or anhedonia and occur more frequently as the disorder progresses
• Symptoms (SIG E CAPS)
  
  • Sleep disturbance
  • Loss of Interest (anhedonia)
  • ƒƒGuilt or feelings of worthlessness
  • Energy loss and fatigue
  • ƒƒConcentration problems
  • Appetite/weight changes
  • Psychomotor retardation or agitation
  • Suicidal ideations
  • ƒƒDepressed mood
• Patients with depression typically have the following changes in their sleep stages:
  
  • Decreased slow-wave sleep
  • Decreased REM latency
  • Increased REM early in sleep cycle
  • Increased total REM sleep
  • Repeated nighttime awakenings
  • Early-morning awakening (important screening question)
• Persistent depressive disorder (dysthymia)
  
  • Depression, often milder, lasting at least 2 years.
• Seasonal affective disorder
  
  • Symptoms usually associated with winter season
  • Improves in response to full-spectrum brightlight exposure.

Question 28

Atypical depression

• Definition
• Findings
• Treatment

Answer 28

• Definition
  
  • Differs from classical forms of depression.
  • Most common subtype of depression
• Findings
  
  • Mood reactivity (being able to experience improved mood in response to positive events, albeit briefly)
  • “Reversed” vegetative symptoms (hypersomnia and weight gain)
  • Leaden paralysis (heavy feeling in arms and legs)
  • Long-standing interpersonal rejection sensitivity.
• Treatment
  
  • MAO inhibitors, SSRIs.

Question 29

Postpartum mood disturbances

• Definition
• Maternal (postpartum) “blues”
• Postpartum depression
• Postpartum psychosis

Answer 29

• Definition
  
  • Onset within 4 weeks of delivery.
• Maternal (postpartum) “blues”
  
  • 50–85% incidence rate.
  • Characterized by depressed affect, tearfulness, and fatigue starting 2–3 days after delivery.
  • Usually resolves within 10 days.
  • Treatment: supportive.
  • Follow-up to assess for possible postpartum depression.
• Postpartum depression
  
  • 10–15% incidence rate.
  • Characterized by depressed affect, anxiety, and poor concentration starting within 4 weeks after delivery.
  • Lasts 2 weeks to a year or more.
  • Treatment: antidepressants, psychotherapy.
• Postpartum psychosis
  
  • 0.1–0.2% incidence rate.
  • Characterized by delusions, hallucinations, confusion, unusual
    behavior, and possible homicidal/suicidal ideations or attempts.
  • Usually lasts days to 4–6 weeks.
  • Treatment: antipsychotics, antidepressants, possible inpatient hospitalization, assessment of child safety.

Question 30

Pathologic grief

• Definition
• Findings

Answer 30

• Definition
  
  • Normal bereavement characterized by shock, denial, guilt, and somatic symptoms.
  • Duration varies widely, up to 6–12 months.
• Findings
  
  • May experience simple hallucinations (e.g., hearing name called).
  • Pathologic grief includes excessively intense grief; prolonged grief lasting > 6–12 months; or grief that is delayed, inhibited, or denied.
  • May experience depressive symptoms, delusions, and hallucinations.

Question 31

Electroconvulsive therapy

• For…
• Definition
• Adverse effects

Answer 31

• For…
  
  • Treatment option for major depressive disorder refractory to other treatment and for pregnant women with major depressive disorder.
  • Also considered when immediate response is necessary (acute suicidality), in depression with psychotic features, and for catatonia.
• Definition
  
  • Produces a relatively painless seizure in an anesthetized patient.
• Adverse effects
  
  • Disorientation, temporary headache, and partial anterograde/retrograde amnesia usually fully resolving in 6 months.

Question 32

Risk factors for suicide completion

• Risk factors
• Gender

Answer 32

• SAD PERSONS are more likely to complete suicide.
  
  • _​S_ex (male)
  • Age (teenager or elderly)
  • Depression
  • Previous attempt
  • Ethanol or drug use
  • Loss of Rational thinking
  • Sickness (medical illness, 3 or more prescription medications)
  • Organized plan
  • No spouse (divorced, widowed, or single, especially if childless)
  • Social support lacking.
• Gender
  
  • Women try more often
  • Men succeed more often.

Question 33

Anxiety disorder

Answer 33

• Inappropriate experience of fear/worry and its physical manifestations (anxiety) when the source of the fear/worry is either not real or insufficient to account for the severity of the symptoms.
• Symptoms interfere with daily functioning.
• Lifetime prevalence of 30% in women and 19% in men.
• Includes panic disorder, phobias, and generalized anxiety disorder.

Question 34

Panic disorder

• Definition
• Treatment
• Diagnosis

Answer 34

• Definition
  
  • Defined by the presence of recurrent panic attacks
  • Periods of intense fear and discomfort peaking in 10 minutes with at least 4 of the following) (PANICS):
    
    • Palpitations, Paresthesias
    • Abdominal distress
    • Nausea
    • Intense fear of dying or losing control, lIght-headedness
    • Chest pain, Chills, Choking, disConnectedness
    • Sweating, Shaking, Shortness of breath.
  • Symptoms are the systemic manifestations of fear
  • Strong genetic component.
• Treatment
  
  • Cognitive behavioral therapy, SSRIs, venlafaxine, benzodiazepines (risk of tolerance, physical dependence).
• Diagnosis requires attack followed by 1 month (or more) of 1 (or more) of the following:
  
  • Persistent concern of additional attacks
  • Worrying about consequences of the attack
  • Behavioral change related to attacks.