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161 Cards in this Set
- Front
- Back
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what are the risk factors for schizophrenia?
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male
young post-psychotic depression realistic assessment of deterioration due to illness |
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schizophrenia
ages of onset for females and males |
males 18-25 yo
females 25-35 yo |
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schizophrenia
F:M ratio |
equal
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schizophrenia
higher rates during |
winter and spring
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schizophrenia
higher in _____countries |
urban and industrialized
and mothers w/ OB complications |
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schizophrenia
have higher risk of |
concurrent illness up to 80%
10-15% commit suicide 50% attempted suicide |
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schizophrenia
substances abuse associated w/ poor prognosis |
cigarette smoking 75-90%
alcohol cannabis/cocaine |
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hypotheses for low socioeceonomic groups of schizophrenics
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downward drift hypothesis
social causation hypothesis |
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Stress-Diathesis Model
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specific vulerability (diathesis) that when acted on by a stress --> schizophrenia
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4 areas (of brain) implicated in schizophrenia
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limbic system
frontal cortex cerebellum basal ganglia |
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dopamine hypothesis of schizophrenia
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1. dopamine receptor antagonists are effective anti-psychotics
2. drugs that increase dopamine are psychomimetics 3. do not know if due to excess dopamine, dopamine receptors, hypersensitivity of receptors or combination 4. insufficient explanation |
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changes in brain of schizophrenic
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decreased size (amygdala, hippocampus, parahippocampal gyrus)
disorganization of neurons within hippocampus BG: awkward gait, facial grimacing, stereotypes mvmt disorders involving BG associated w/ psychosis lateral and 3rd ventrical enlargement reduced cortical volume |
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eye mvmts dysfunction of schizophrenia
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inability to accurately follow a moving visual target
controlled by frontal lobe |
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____T cell interleukin 2 production in schizophrenia
also reduced number of responsiveness of ____________ |
decreased
peripheral lymphocytes |
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abnormal ECGs
inability to_____ extremely sensitive to ______ |
filter irrelevant sounds
background noise |
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Diagnosis requires 2 or more of what symptoms for a significant portion of 1 month
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delusions
hallucinations disorganized speech grossly disorganized or catatonic behavior negative symptoms |
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Dx ONE symptoms of
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bizarre hallucinations
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duration of disturbance
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at least 1 months of symptoms
disturbance of 6 months |
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good prognosis of schizophrenia
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late onset
obvious precipitating factors acute onset good premorbid history good disorder symptoms married family history of mood disorders good support system positive symptoms |
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poor prognosis of schizophrenia
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young onset
no precipitating factors insidious onset poor premorbid social, sexual, work histories withdrawn, autistic behavior single, divorced, widowed poor support systems negative symptoms neurological signs and symptoms history of perinatal trauma no remission in 3 yrs many relapses history of assaultiveness family history of schizophrenia |
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schizophrenia is a brain disease that disrupts normal functioning of cognitive abilities
what 3 things are affected, consistent w/ frontotemporal defects |
vigilance
memory concept formation |
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in psychological testing, you can also test
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imparired attention
retention time problem solving motor ability impaired IQ is lower bizarre ideation |
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mental status exam
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hygiene poor
dress odd poor eye contact psychomotor agitation and retardation posturing, grimacing, echopraxia |
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affect of schizophrenia
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sad
tearful blunted flat agitated reactive appropriate inappropriate congruent w/ mood |
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type of hallucinations
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auditory: most common
visual: consider substance abuse tactile uncommon: consider cocain or delirium gustatory and olfactory uncommon-consider neurological disorder |
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form of thought
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looseness of association
interrupt train of thought word salad neologisms circumstantially, tangentially, echolalia, poverty of though mutism |
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what drug is the most effective?
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clozapine but has lots of side effects (agranulocytosis)
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what are the 1st generation antipychotics?
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dopamine receptor antagonists
haldol prolixin navane |
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what are the 2nd generation antipsychotics?
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atypical antypsychotics
clozapine risperdal xypresa etc |
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what is the major cause of nonresponse is
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NONCOMPLIANCE
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perhaps most effective psychosocial therapy
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cognitive behavioral therapy
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paranoid type
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preoccupation with one ore mode delusions of frequent auditory hallucinations
not prominent: disorganized speech, disorganixed and catatonic behavior, flat and inappropriate affect |
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disorganized type
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prominent:
disorganized speech disorganized behavior flat or inappropriate affect |
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catatonic type
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motor immobility
excessive motor activity extreme neativism peculiarities of voluntary mvmt echolalia or echopraxia |
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undifferentiated type
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not paranoid
disorganized catatonic |
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residual type
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no prominent delusions, hallucination, diorganized speech, grossly disorganized catatonic behavior
have negative symptoms or 2 or more schizo sx in attenuated form |
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schizophreniform last between
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1 and 6 months
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schizophreniform has rapid onset WITHOUT
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significant prodrome
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if schizophreniform has not good prognostic features -->
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early schizophrenia
60-80% progress to schizophrenia |
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tx of schizophreniform
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hospitalized to evaluate and stabilize
3-6 month course of antipsychotic meds |
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schizoaffective disorder has features of both
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schizophrenia AND affective mood disorder
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higher rates of schizoaffective disorder in m or f?
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females
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diagnosis for schizoaffective disorder
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uninterrupted illness with either:
MDD manic mixed episode delusions hallucination for at least 2 weeks |
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tx for schizoaffective disorder
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antisychotic medications
mood stabilizer for bipolar antidepressant psychososcial therapies |
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delusional disorder is rare
mean onset is |
40 yo
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delusional disorder
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unremarkable appearance
slightly more females than males females likely erotomanic delusions males likely paranoid delusions |
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what are the types of delusional disorder?
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erotomanic
grandiose jealous persecutory somatic mixed unspecific |
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what is the prognosis of delusional disorder?
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psychosical stress
IQ lower than average more and more involved until delusional inquality |
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tx for delusional disorder
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difficult to treat
antipsychotics psychotherapy - establish trusting relationship |
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erotomanic type
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delusions that another person is in love with them
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grandiose type
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delusions of inflated worth, power, knowledge, identity, special relationship to deity
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jealous type
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individual's sexual partner is unfaithful
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persecutory type
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person is malevolently treated in some way
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somatic type
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delusion that person has physical defects and general medical condition
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mixed type
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delusions characteristic of more than one of the above types
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prognosis
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psychosocial stress
IQ lower than average more and more involved until delusional in quality |
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shared psychotic disorder
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chronically ill
less intelligent rare |
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diagnosis for shared psychotic disorder
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delusion in context of close relationship w/ another person who has an already established delusion
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brief psychotic disorder
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acute transiet uncommon
higher incidence in women in developing countries seen with personality disorders emphasize presence of inadequate coping mechanisms labile mood confusion strange or bizarre behavior screaming/muteness impaired memory up to 50% later diagnosed w/ chronic disorder |
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tx for brief pyschotic disorder
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antipsychotics/adjunctive BDZ
psychotherapy about stress |
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post partum psychosis
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underlying mood disorder or bipolar
psychiatric emergency onset 2-3 weeks after delivery tx: hospitalization, medication, psychotherapy, high rates of recovery |
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secondary psychotic disorders
dx |
prominent hallucinations or delusions
direct physiological consequence of medical condition not better accounted for by another mental disorder |
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tx secondary pyschotic disorder by
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treating underlying medical or substance condition
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culture bound syndrome
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recurrent locally specific patterns of aberrant behavior, troubling experiences
culture signs and symptoms of mental distress |
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ghost sickness
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preoccupation with death
bad dreams weakness feeling of danger hallucinations LOC confusion |
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mal de ojo
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evil eye
children esp a risk fitful sleep crying without apparent cause diarrhea vomiting fever |
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mood is
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SUSTAINED emotional state
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mood disorder
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a syndrome of cluster of signs and symptoms lasting weeks or months
marked departure from habitual functioning tend to recur in periodic and cyclic fashion |
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elevated mood
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expansive
flight of ideas decreased need for slee heightened self esteem grandiosity irritability |
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depressed mood
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loss of energy
loss of interest guilty feelings poor concentration loss of appetite change in neuroveg functions: sleep, appetite, sexual function |
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MDD
lifetime prevalence of ____ in men ___ in women |
5-12%
10-25% |
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MDD: throughout life cycle
50% 20-40 yo increased incidence in _____ and those that live in |
single/divorced
rural areas |
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bipolar I disorder
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equally represented in men and women
onset 30 lifetime prevalence 0.4-1.6% |
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men usually present with____ in bipolar I disorder
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MANIA
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women with bipolar I present with
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depression or mixed state with rapid cycling
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bipolar II criteria
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hypomania in combo with MDD
related to earlier age of onset than bipolar I and marital disruption greater risk of suicide attempts and completion than those with bipolar I and MDD |
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mood disorders - etiology
the THEORIES (list form) |
1. dysregulation of biogenic amines (NE, 5HT, D)
2. dysregulation of amino acid NT like GABA 3. dysregulation of neuroactive peptides, endogenous opiates 4.dysregulation of neuroendocrine systems: adrenal 50%, GH-blunted sleep induced increased inGH 5. disordered sleep circadian rhythm dysregulation: transient improvement in mood with sleep deprivation 6. relationship with limbic system, hypothalamus, basal ganglia |
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psychosocial factors of mood disorders
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stressful life events precede onset of 1st episode of bipolar disorder and MDD
CNS is changed biologically in a longstanding fashion most compelling is loss of parent unemployment is associated with 3x more likely to report depressive symptoms stressor most associated with MDD is loss of spouse |
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cognitive theory of depression
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chronic habituated thoughts
depressive schemata |
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Beck's triad of depression
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view of self as NEGATIVE
view of environment and world as HOSTILE/DEMANDING view of future as SUFFERING/FAILURE |
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catatonia of MDD
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stuporous/motoric immobility
excessive motor activity extreme negativism psychomotor retardation w/ posturing and waxy flexibility echolalia echopraxia |
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MDD single episode and recurrent
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psychotic features may have congruent and incongruent hallucinations
poorer prognosis if long duration episode temporal association of mood and psychotic symptoms poor premorbid social functioning |
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melancholic
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loss of pleasure of pleasurable activity
lack of reactivity to usually pleasurable stimuli 3 or more of following: distinct quality of depressed mood early morning awakening marked pyschomotor retardation, agitation significant weight loss of anorexia excessive and inappropriate gait |
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atypical features of MDD
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mood reactivity
2 or more significant weight gain or increase appetite hypersomnia leaden paralysis long history of interpersonal rejection sensitivity more common in women |
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pseudodementia of MDD
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present at cognitive fysgunction resembling dementia
occurs in elderly with prior history depressive symptoms are prominent respond to antidepressants or ECT |
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rapid cycling
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4 episodes in 12 months
increased incidence in females with MDD and hypomanic episodes |
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postpartum onset
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severe depression within 4 weeks of giving birth
preexisting mood or psych conditions marked insomnia, fatigue with suicidal thoughts, can be mergency |
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catatonia of MDD
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stuporous/motoric immobility
excessive motor activity extreme negativism psychomotor retardation w/ posturing and waxy flexibility echolalia echopraxia |
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chronic
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present at least 2 yrs
more common in elderly men more common in substance/alcohol disorders responds poorly to meds occurs in bipolar I and II |
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MDD single episode and recurrent
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psychotic features may have congruent and incongruent hallucinations
poorer prognosis if long duration episode temporal association of mood and psychotic symptoms poor premorbid social functioning |
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seasonal pattern
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depression develops with shortened daylight
seasonal affective disorder hypersomnia, hyperphagia, psychomotor slowing abnormal melatonin metabolism |
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melancholic
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loss of pleasure of pleasurable activity
lack of reactivity to usually pleasurable stimuli 3 or more of following: distinct quality of depressed mood early morning awakening marked pyschomotor retardation, agitation significant weight loss of anorexia excessive and inappropriate gait |
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tx seasonal pattern depression with
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bright artificial light
may occur in bipolar I and II Disorders |
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atypical features of MDD
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mood reactivity
2 or more significant weight gain or increase appetite hypersomnia leaden paralysis long history of interpersonal rejection sensitivity more common in women |
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pseudodementia of MDD
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present at cognitive fysgunction resembling dementia
occurs in elderly with prior history depressive symptoms are prominent respond to antidepressants or ECT |
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rapid cycling
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4 episodes in 12 months
increased incidence in females with MDD and hypomanic episodes |
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postpartum onset
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severe depression within 4 weeks of giving birth
preexisting mood or psych conditions marked insomnia, fatigue with suicidal thoughts, can be mergency |
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chronic
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present at least 2 yrs
more common in elderly men more common in substance/alcohol disorders responds poorly to meds occurs in bipolar I and II |
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seasonal pattern
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depression develops with shortened daylight
seasonal affective disorder hypersomnia, hyperphagia, psychomotor slowing abnormal melatonin metabolism |
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tx seasonal pattern depression with
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bright artificial light
may occur in bipolar I and II Disorders |
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catatonia of MDD
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stuporous/motoric immobility
excessive motor activity extreme negativism psychomotor retardation w/ posturing and waxy flexibility echolalia echopraxia |
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MDD single episode and recurrent
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psychotic features may have congruent and incongruent hallucinations
poorer prognosis if long duration episode temporal association of mood and psychotic symptoms poor premorbid social functioning |
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melancholic
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loss of pleasure of pleasurable activity
lack of reactivity to usually pleasurable stimuli 3 or more of following: distinct quality of depressed mood early morning awakening marked pyschomotor retardation, agitation significant weight loss of anorexia excessive and inappropriate gait |
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atypical features of MDD
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mood reactivity
2 or more significant weight gain or increase appetite hypersomnia leaden paralysis long history of interpersonal rejection sensitivity more common in women |
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pseudodementia of MDD
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present at cognitive fysgunction resembling dementia
occurs in elderly with prior history depressive symptoms are prominent respond to antidepressants or ECT |
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rapid cycling
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4 episodes in 12 months
increased incidence in females with MDD and hypomanic episodes |
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postpartum onset
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severe depression within 4 weeks of giving birth
preexisting mood or psych conditions marked insomnia, fatigue with suicidal thoughts, can be mergency |
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chronic
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present at least 2 yrs
more common in elderly men more common in substance/alcohol disorders responds poorly to meds occurs in bipolar I and II |
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seasonal pattern
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depression develops with shortened daylight
seasonal affective disorder hypersomnia, hyperphagia, psychomotor slowing abnormal melatonin metabolism |
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tx seasonal pattern depression with
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bright artificial light
may occur in bipolar I and II Disorders |
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what is an important stressor for depression in elderly
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loss of spouse
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clinical features of bipolar II disorder
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increased marital discord
great suicide risk than major depressive disorder or bipolar I |
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clinical features of dysthymic disorder
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less severe than MDD
more common and chronic long term stress and sudden losses coexist w/ substance abuse, personality disorders, OCD more common in 1st degree relative with MDD |
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clinical features of cyclothymic disorder
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less severe disorder with alternating periods of hypomania and moderate depression
chronic and nonpsychotic condition equally rep in men and women onset typically late adolescence and early adulthood substance abuse is common mood swings lead to social and work probs may respond to lithium |
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myxedema madness
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hypothyroidism with fatique, depression, suicidality
more common in women may mimic psychosis |
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Mad hatter's syndrome
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due to mercury intoxication
produces manic symptoms occasionally depression |
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substance induced mood disorder
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caused by drug or toxin
must always be ruled out when patients present with mood disorders often coexist with substance abuse and dependence disorders |
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vanlafaxine
duloxetine |
serotonin
norepinephrine reuptake inhibitors may be good for refractory cases |
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nefazadone
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serotonergic activity with postsynaptic 5HT2 blockade
improves sleep and less sexual dysfunction avoid liver toxicity |
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panic disorder - incidence
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2.4 million adults
1.7% of adult pop women 2x> men high comorbidity with MDD visit ER multiple times |
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diagnostic criteria for panic disorder
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discrete period of intense fear or discomfort with 2 or more symptoms that peak within 10 min
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tx for panic disorder
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acute: BDZ
ongoing tx: SSRIs in doses HIGHER than depression psychotherapy: factors that trigger or reinforce symptoms |
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social phobia-incidence
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5.3 million adults
3.7% of the adult population equally common in men and women |
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social phobia dx
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marked and persistent fear of one ore more social or performance situations
individual fears that he or she will act in a way that is humiliating or embarrassing feared social situation --> anxiety (predisposed panic attack) recognize fear is excessive and unreasonable (axis I) feared social or performance situations either avoided or endured with intense anxiety |
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tx for social phobia
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persistent anxiety in social and performance settings
excessive shyness SSRI cognitive behavioral therapy approaches that address self esteem help |
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incidence of specific phobia
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6.3 million
4.4% of adult population |
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diagnosis of specific phobia
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persistent fear, unreasonable
cued by presence or anticipation of an object or situation promotes anxiety response recognizes fear is excessive avoid phobic situation or endure with intense anxiety or distress phobia interferes with life |
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tx of specific phobia
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exposure-based procedures
reduce or eliminate most or all components of disorder no pharmacological intervention has been shown to be effective HUG A TOILET |
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OCD very difficult disease to treat
incidence |
3.3 million adults
2.3% of adult population equally common among men and women |
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obsession
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thoughts
recurrent and persistent thoughts/impulses/images intrusive and inappropriate disturbances that cause marked anxiety or distress attempts to ignore or suppress |
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compulsions
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behaviors
repetitive behaviors or mental acts aimed at preventing or reducing distress |
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what treatment for OCD?
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SSRIs are good treatment
Clomipramine is very good in sever cases BDZs for immediate action, adjunctive therapy; slow down thoughts enough to make sense of them psychotherapy: cognitive behavioral therapy or traditional behavioral |
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post-traumatic stress disorder--incidence
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5.2 million adults
8.6% of adult population women more likely than men genes predisposed to this |
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PTSD - diagnosis
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has been exposed to a traumatic even
1. experience actual or threatened death or serious injury 2. response involve intense fear, helplessness, horror |
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tx of PTSD
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SSRIs
psychotherapy old school antidepressants MAOI or TCA |
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generalized anxiety disorder- incidence
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4 million adults
2.8 of adult population women are TWICE more likely than men |
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generalized anxiety disorder - diagnosis
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similar to ADHD
very comorbid with other disorders excessive anxiety and worry focus of anxiety and owrry is not confused to feature of axis I disorder |
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tx for generalized anxiety disorder
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subjective anxiety and tension
excessive worry variety of physiologica complaints SSRIs buspirone BDZs for short term psychotherapy: cognitive behavior psychotherapy |
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agoraphobia
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anxiety about being in places or situations from which escape might be difficult
situations are avoided or endured with marked distress anxiety about having a panic attack or panic-like symptoms require presence of a companion anxiety or phobic avoidance is not better accounted for by another mental disorder |
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Axis I disorder
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clinical disorders
conditions that are a focus of clinical attention |
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Axis II disorder
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personality disorder
mental retardation habitually used defense mechanisms |
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Axis III disorder
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physical disorders
general medical conditions |
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Axis IV disorder
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psychosocial
environmental stressors |
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Axis V disorder
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Global Assessment of Function (GAF)
current and recent: social, occupational psychological spheres |
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rationale for formulating and writing up mental status exam
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present state exam
verbal picture of pt at time of interview structure description of patient analogy to physical exam source of data: pt statements, asnwers to questions, interviewer observations importance of terms and descriptions in psychiatry |
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AMSIT
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Appearance, behavior, speech
Mood and affect Sensorium Intellectual function Thought |
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appearance of wakefulness is called
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arousal
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sum of cognitive and affective function is called
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content
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consciousness
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content depends on arousal but normal arousal does not guarantee normal content
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encephaopathy
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person who appears to be awake, eyes are open, they look around but completely disoriented and incoherent
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consciousness =
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arousal + content
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coma
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total absence of awareness of self, environment even with external stimulation
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content of consciousness depends upon activities of cerebral cortex, _______, and their relationship
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thalamus
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arousal to coma
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decreased arousal --> alertness --> lethargy --> obtundation --> stupor --> coma
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decreased content -->
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delirium - irritable, out of contact but alert, encephalopathy
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vegetative state
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return of alertness but no evidence of cognitive function (lose all of brain, only brainstem intact)
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regaining arousal means what structure in brainstem is functioning?
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reticular formation
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apallic syndrome
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same as vegetative
when we lose corex, we lose content |
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locked in syndrome
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evidence of cognitive function but inability to communicate with outside world
brainstem lesion from pons down |
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cognitive function depends on
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cortical and thalamocortical integrity
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uncal herniation
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host of cranial nerve deficits -subtentorial
compression of hippocampal gyrus over free edge of tentorium compression of cranial nerve III often treatable can give pt mannitol to decrease ICP |
