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80 Cards in this Set
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Personality Disorders
Diagnostic Criteria Age Considerations Categorization |
An PERVASIVE and ENDURING pattern of thought and behavior which DEVIATES markedly from norm and causes DISTRESS and IMPAIRMENT and is NOT 2° to another disorder, medical condition or substance
Must cause problems in 2/4 of: cognition, affect, interpersonal fnx, or impulse control PD's start in early and persist. Likely to exacerbate under stress or loss but new onset: more suggestive of substance/medical condition <18 yo features must be present for ≥ 1 year, as children often outgrow maladaptive patterns; Antisocial not dx'd <18 yo Cluster A: Odd/Eccentric: schizoid, schizotypal, paranoid Cluster B: Dramatic/Emotl: antisocial, borderline, histrionic, narcissistic Cluster C: Anxious/Fearful |
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Schizoid Personality Disorder
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Detached Loners with Indifference & Limited Range of Affect
Cluster A: Odd/Eccentric works well in social isolation ± brief periods of psychosis (<1d) ± premorbid to delusional disorder or schizophrenia Tx: Doc is not going to change the unsociability, but can reduce the isolation. -Supportive Listening -Correct disortions in worldview -Give Advice (generally avoided, but not here) -Role playing to help with job interviews & social skills Tx is slow, never group |
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Schizotypal PD
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Social and Interpersonal Deficits coupled with Perceptual Distrubances
Cluster A: Odd/Eccentric -Behavior/Apperance is odd/eccentric -ideas of reference: external events = particularly meant for them -paranormal, magical thincking -sense presences, that someone is near -odd speech phrasing, construction, word use -no friends outside of 1° relatives -constant social anxiety even w/ familiar people, from paranoid fears not negative judgement Tx: gently correct reality distortions -gently question irrational thoughts & suggest more rational ones -Antipsychotics & Antidepressants |
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Paraonoid Personality Disorder
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Distrust and Suspiciousness
Cluster A: Odd/Eccentric Mn: SUSPECT Spousal infidelity suspicions Unforgiving: bears grudges Suspicious Perceives attacks & reacts accordingly Enemies among Friends: suspects even friends Confiding in others not an option Threats perceived in benign events Reinforcing cycle: hostility towards others → hostility among others ± brief psychotic episodes FHx: Delusional Disorders & Schizophrenia M>F, Loner Childhood |
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Antisocial Personality Disorder
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Disregard for and violation of the rights of others
Cluster B: Dramatic/Emotl -Deceitful, Ignores laws & social norms, Reckless disregard for safety: their own and others', Impulsivity, Lack of Long Term Planning, Irresponsibility, Lack of remorse Cannot Dx <18 yo, Must have some elements of Conduct Disorder <15 Likely to burnout in 40's (repeat jail time) Genetics + Environment; FHx: antisocial among 1° relatives, substance abuse & somatization disorders Tx: inpt peer group (does not respond well to authority figures) determine if you as doc being used for 2° gain empathize with fear of exploitation & low self esteem Antidepressants Imuplse Control: Li+, β=blockers, anti-convulsants |
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Borderline Personality Disorder
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Instability in relationships, self-image, affects & behavior
Cluster B: Dramatic/Emotl Relationships: Idealization → extreme disillusionment Mood reactivity & angry outbursts Unstable self image; goals, values jobs Impulsivity in 2 areas Often comorbid with mood disorders, eating disorders, ADD/ADHD, other PD's, PTSD (often victims of abuse) → Tx the Borderline First F>M; genetic (5x in 1°'s) FHx: substance, mood problems, antisocial ~10% of pts commit suicide likely to improve by middle age, 50% resolve w/ tx Tx: antidepressents, mood stabalizers, anxiolytics plan emergency procedures in advance therapy: treatment of choic among dialectical behavior tx, cognitive behavioral tx, STEPPS SystemTraining for Emotl Predictability and Problem Solving |
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Dialectical Behavior Therapy
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Therapy of Choice for Borderline Personality Disorder
Core idea: BPD pts react abnormally to emotl stimulation: arousal goes up quicker, peaks higher and persists longer DBT tries to teach skills to cope with sudden, intense surges of emotn 2 part process: weekly psychotherapy in which a problematic behavior or event is explored in detail, beginning with the CHAIN of events that led up to it, going through alternative solution, and examining what kept the pt from using different solutions weekly 2.5h group sessions to teach mindfullness skills, interpersonal effectiveness, emotl regulation, distress tolerance, and reality acceptance skills in a social contxt |
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Cognitive Behavioral Therapy
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Active, Directive, Time Limited, Structured Therapy
Based on the idea that individuals affect and behavior determined by how they structure their world & that cognitions are based on past experience CBT identifies, reality tests & corrects cognitive distortions pt keeps logs, homeworks & activity scheules -monitor negative, automatic thoughts -recognize the connection btw cognition, affect & behavior -examine evidence for & against distortions -substitude more reality based thoughts in place of distorted ones |
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STEPPS
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System Training for Emotl Predictability & Problem Solving: 20 weekly classroom sessions led by male, female pair, each starting with a rating scale to assess progress; start with illness education, each session has homework
identify & challenge distorted perceptions, help w/ specific behavioral changes, including psychoeducation & skills training Emphasizes: Behavior management skills, setting goals, balanced diet, sleep hygiene, regular exercise, leisure activities, health maintenance, abuse avoidance, and helathy relationship management Shorter & Less Labor Intensive than DBT Uses CBT techniques to suppplement ongoing tx recognizes the importance of family & friends seems to keep pts in treatment longer integrates w/ current doc to avoid abandonment issues Doc's reframe BPD as an "emotl intensity disorder" |
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Emotional management skills
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theraputic option for Borderline Personality Disorder
goal setting to manage problem behaviors improve communication skills to better describe & define feelings identify distorted thinking & dvlp new patterns engage in emot'l intensity loiwering behaviors identify & define probems, then plan and carry out actions |
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Avoidant Personality Disorder
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Social Inhibition from self perception of inadequacy + hypersensitivity to criticism
M=F Tx: individual & group therapy: assertiveness training & systematic desensitization Rx: β-blockers, SSRI's, Antidepressents, Anxiolytics Systemic Desensitization: First learn relaxation skills (eg progressive relaxation which focuses on the contrast between relaxing and clenching); Create hierarchy of anxiety provoking situations from least to greatest; learn to produce a relaxed state for each item on the list until feared stimulus is paired with relaxation not anxiety. |
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Dependent Personality Disorder
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Pervasive, Excessive need to be taken care of, inability to fnx as independent adult
dormat lack of assertiveness, inability to start projects urgent need for replacement relationship if 1° fails (dead mother) Tx: several options of therapy: individual, group, family, behavioral (social skills & asssertiveness training) antidepressants for mood prolbems Assertiveness training: finding middle ground between aggressiveness and passiveness, using Ghandi & MLKJ as exemplars. Identify the difficult situations, then role play, feedback &roll play again; therapist may act to demonstrate the differences; practice new behaviors. find out what the person actually likes themselves (runaway bride) |
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Coding Personality Disorders
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Axis II
Code Traits |
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Somatization Disorder
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Multiple Physical Complaints that are 1. Not intentially produced 2. Not fully explained by a medical condition 3. Not the result of substance abuse and 4. Result in seeking medical attention or cause impaired functioning; Sx present for years before age 30
--DDx: MS, SLE, Schizophrenia, Anxiety/Mood Disorders --Dx: Comprehensive exam w/ family member interview; no organic cause or manifestations beyond expected for organic cause; 4/2/1/1: 4 pain complaints, 2 non-pain GI complaints, 1 non-pain sexual complaint, 1 pseudoneurological complaint--Tx: approach as real and treatable illness: ↓ healthcare burden by >1/2; minimize # of clinicians, invasive/diagnostic procedures; schedule regular visits, treat medical psychiatric conditions; avoid habit forming Rx's &, prn tx's. Empower Pt by explaining Sx; Legitimize suffering, remove blame; link sx to stressful life events and explain that psychological chagnes can occur w/ depression & anxiety --SSRI's --CBT, promote healthy behaviors, treatment contracts, set realistic short term & long term goals, practical ways of coping, daily log of thoughts, feelings & coping behaviors, daily relaxation & exercise, promote pt control & automony |
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Conversion Disorder
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Sx which causes distress/impairment not explained organically/culturally and not intentionally produced; Sx is not bettter explained by another mental disorder (including somatization), and is not limited to sexual fnx
DSM: motor, sensory, seizure/convusion or mixed accts for 10% of neurlogy pts 30 yo women w/ other psychiatric problem likely to remit quickly & relapse commonly Dx: investigate complaint Tx: reassurance that complaint will resolve; physiotherapy, anxiolytics & relax'n techniques; psychotherapy is controversial |
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ADHD Critera
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Critera: Hyperactive, Impulsive, Short Attention Span
Onset before age 7; Impairment in ≥2 settings (school & home) Subtypes: predominantly inattentive, predominantly impulsive/hyperactive, Combined Inattentive Sx: Inattention to details, Easily Distracted, Does not listen, does not finish tasks, cannot organize tasks, forgetful, poor frustration tolerance, loses the things necessary for work Hyperactive Sx: fidgetty, cannot remain seated, cannot play quietly, blurts out/interrupts conversations, cannot wait turn Workup: ADHD rating from teachers, Hx, FHx, RO medical conditions:LD, MR, dvlptl delays |
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ADHD Tx
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Rx: DA & NE from Locus Ceruleus → Prefrontal Cortex for Exectuvie Fnx: Arousal, Attn, Planning;
central α2 agonists: clonidine, guanfacine atypical antidepressants NE reuptake inhibitors TCA's; stimulants like methylphenidate (ritalin) and methamphetamine (adderall) Simulants: Concerta, Metadate CD, Ritalin LA, Focalin XR, Datrana patch, Adderall XR, Vyvanase Thearpy: Behavioral Modification, Anger Management, Family Tx, Individaul Tx, Social Skills training |
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Methylphenidate
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Short acting: <5h: ritalin, methylin (chewable & liquid)
Intermediate: <8h: Ritalin SR, Metadate ER, Methylin ER Long acting 8-12: metadate CD, Ritalin LA, Concerta, Focalin XR |
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Mixed Amphetamine Salkts
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Short Acting:
Detroamphetamine suflate Dextrostat Adderall Intermediate Dexstrostat SR: 5-15 mg Adderall XR: 5-30 mg Long Acting |
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Lisdexamfetamine Dimesylate
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Vyvanase
prodrug: L-lysine must be cleaved: low abuse potential ages 6-12 and adults 20-70 mg |
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Stimulant Side Effects
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Tics
Δ Behavior Δ Mood Δ Sleep Δ Appetite Anxiety Psychosis |
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α2 agonists
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Clonidine: po & patches: sedating
Clonidine Hydrochloride ER: Kapvay: 24 hr long acting; guanfacine: tenex, non sedating guanfacine ER: Intuniv; 34 hour long acting Side effects: hypotension, dizziness, bradycardia, av block, syncope, somnolence, fatigue |
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NEReuptake Inhibitor
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Atomoxetine
increases DA and NE in prefrontal cortex w/ little DA involvement in Nucleus accumbens or straitum make take 6 weeks for full theraputic effect |
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Antidepressents for ADHD
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Burpropion
Despiramine Imipramine Black Box Warning: Suicidal thinking GI effects Aggitations |
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Tics 2° to ADHD medication
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DA inpacting striatum
should clear after discontinuation could be early tourettes brought out early |
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Tics
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Rapid involuntary mvmts or sounds
Tourette's starts motor → vocal w/ rostrocaudal progression Tics start ~9 and freq burn out in adoloescence Tics are able to be suppressed |
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Tx of Tourettes
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Tpyical Antipsychotics:
Haloperidol Pimozide Atypical Antipsychotics Risperidone Olanzapine Quetiapine Pripripazole α2 agonists |
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OCD Criteria
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Obessessions: intrusive, recurrent thoughts or images that exceed real life worries
&/ Compulsions: repettive behaviors that a person is driven to perform |
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Tx of OCD
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SSRI's
TCA Atpyical Antipsychotics Behavioral Interventions: CBT, Thought Stopping,Desnsitization or Flooding Challange: ADHD tx → OCD OCD Tx → ADHD |
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SSRI's
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Fluoxetine (Prozac)
Sertaline (Zoloft) Paroxetine (Paxil) Fluoxamine (Luvox) Citalopram (Celexa) Escitalopram (Lexapro) |
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TCA's
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Clomipramine
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PDD's
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Pervasive Development Disorders
Autism Asperger's Rett's Sro: Females Childhood Disintegrative Disorder: Males >3 PDD NOS |
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Autism
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Impairment in reciprocal social interactions
limited repertoire of interests & activites |
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Asbergers
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normal IQ, normal language
limited range of interests w/ social impairment |
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Tx for PDD's
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Goal: Sx Control
-Impulse OC SIB: self injerous behavior: risperidone & atypical antipsychotics attn span Early intervention -Applied Behavioral Analysis High Structure Specailized Education adn Behavioral Modification Programs Communciation Therapy: language fnx by age 5 is strong predictor of outcome social skill dvlpt sensory impairment tx pharmacotherapy: atpyical antipsychotics |
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atypical antipsychotics
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risperidone
olanzapine ziprasidone quetiapine ariprazole invega saphris |
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Applied Behavioral Analysis
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Therapy for autism: language skill at age 5 is strong preidctive factor for the course over lifetime
Majority of pre-school children benefit from 2 years of 1:1 bheavioral instrx for 40hr/week focus on the building blocks oflanguage dvlpt, imitation &matching through reinforced practice no benefit after age 4 goal is to learn language, social & play skills through behavior interactions. as much about maintaining skills as learning them. literally coaching children on how they should answer questions, starting their answers for them and getting them to complete their own answers. |
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Sensory Integration
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Therapy for Sterotypes & OCD Sx as well as aggression/temper
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Theraputic Trial
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Dosing
Duration Compliance Drug/Drug Interactions Choice of Medication Special Considerations for Children, Elderly, Pregnant/Nursing, Hepatic/Renal Insuffficiency |
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CNS NE transmission
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Produced by Neurons in Locus Ceruleus and Tegmental Region
modulates attn, mood, energy, mvmt, HR, BP Depletion → Depression Descending pathways for pain modulation |
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Serotonin
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Projects from raphe nucleus to limbic system & cortex
depression, anxiety, OCD & sleep disorders |
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DA
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produced in ventral tegmentum
distributed in substantia nigra, hypothalamus, nucleus accumbens, and basal ganglia Low DA in nucleus accumbens: pleasure seeking Low DA in ventral basal ganglia: Parkinsons |
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ACh
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From nucleus basalis of meynert & septum to cerebral cortex & hippocampus
ineracts w/ & balances DA in the striatum |
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Glutamate:
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3 Types of Glutamate
NMDA: receptors present on all neurons in CNS. important in learning, memory & seizures Kianic acid AMPA |
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5HT1A Receptor
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Presynaptically: ↓ 5HT release
once down regulated: ↑ 5HT release, improves depression, anxiety Post synaptic: simulation improves Depression, Anxiety, OCD, Panic/Social Phobia, &Bulemia but DISRUPTS TEMPERATURE REGULATION |
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5HT1D Receptor
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stimulation has anti-migraine effects
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5HT2 Receptor
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Stimulation improves OCD & Bulemia
Causes: aggitation, anxiety, psychosis, sexual dysfnx, sleep disorders, hot flashes |
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Serotonin in the Depressed State
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↑ in dendritic region: acts on 5HT1A receptors
5HT1A receptors downregualte → increased 5HT release from axons → euthymic state |
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Why do SSRI's take so long to improve mood?
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First they increase the 5HT in the dendritic region, which then must down regulate 5HT1A receptors before causing an increase in 5HT relase from the axon. then the 5HT1A receptors in that axon need time to downregulate to promote euthymic state.
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The 4 pathways of Serononin and the Disorders from them
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From Raphe Nucleus
To frontal cortex: depression To Basal ganglia: OCD To Limbic/Hippocampus: Panic Disorder To Hypothalamus: bulemia |
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5HT2A
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Improve Depression
Improve OCD Improve Bulemia Increase Anxiety Increase Hallucination Increase Temperature Insomnia Sexual Dysnfx |
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5HT3
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Nausea, Diarrhea, HA, Decreased Appetite
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Side Effects of SSRI's
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Aggitation: ↑ sensitivity between raphe to limbic cortex & hippocampus
Nausea: Chemoreceptor trigger zone in brainstem triggered by 5HT3 agonsits Pheripehral 5HT3 and 5HT4 receptors in gut regualte appetite & GI motility Sleep Disturbances: 5HT2 disrupts slow wave sleep Decreased libido, ↓ ability to climax: 5HT2 neurons descending down spinal cord affecting spinal reflexes |
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great chart for neurotransmitter regulation of bood, congnition and behavior
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DA pathways
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Mesolimbic: high → positive psychosis
Mesocortical: low → negative psychosis Nigrostriatal: blockage will produce EPS: dystonia, akathesia, parkinsonian sx, tardive dyskinesia Tuberoinfundibular: blockade will produce hyperprolactinemia, galactorrhea, sexual disfnx, thirst, hunger & temrapture dysregualtion |
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Antipsychotics
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Haloperidol
Pimozide Fluphenazine Loxapine Thioridazine Mesoridazine Mechanism of action: D2HAM Blocks: D2, M1, α1, & H1 |
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Typical Antipsychotics
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Block D2 in mesolimbine & mesocortical pathway
most helpful for positive sx more risk for EPS not first line for adolescents & children |
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low potency antipsychotics
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sedating, and higher doses required
lower EPS risk risk for cardiac problems:hyptoension more anticholinergic effects |
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high potency antipsychotics
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more selective for DA receptor
less anticholinergic activity more EPS risk |
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5HT2A/D2 antagonist
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little EPS
minimal endocrine effects helps both positve and negative sx of schizophrenia serotonin antagonism stimualtes DA release in the nigro striatal, tuberoinfundibular and mesocortical pathways: reduces EPS meanwhile D2 blockade in emsolimbin pathway reduces positive sx |
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GABA
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GABAa in reticular formation, thalamus,c erebral cortex leads to sleep & decrreases anxiety. opens Cl channels and hyperpolarizes teh membrane
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Mood Stabalizers
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Lithium
Anticonvulsants Atypical Antipsychotics |
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Guide to Rx Tx of Psychiatric Disorders
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Medication should only be used to treat mental illness, not to control inappropriate behavior. minimize use of multiple medicatiosn
target sepcific sx and pathways understand potential meaning of medication to pt, family, school, & workplace consider & discuss risks &benefits. educate t on disorder & tx balance risks &benefits observed indications & dosing approved by FDA |
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Delerium Tx, Px
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Find and Fix the underlying medical cause
Provide medical, physical, sensory & environmental support Prevent accidents Don't sensory deprive, don't overstimulate Familiar Decorations & Objects Family, friends or regular sitter Clock & Calendar in the Room challenge is to treat & support sx w/o contributing to clinical picture Px: not good; rapid full recovery if underlying cause is fixed, but as mostly present in medically ill, very likely to die |
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Delerium
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.
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Mini-Mental Status Exam
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Orientation to Time: 5 year, season, month, day of week, date
Orientation to Place: 5 points: country, state, city, building, room Registration: 3 Repeating named prompts Attn & Calculation: 5 Serial Sevens 1/correct or Spelling World Backward; 1 point/ letter in the right place Immediate Recall: 3 total, 1/item Language 2 name a pencil & watch Repetition 1: Speaking back a phrase Complex Commands 6 Interprestation: ≥25 effectively normal 21-24 mild cognitive impairment 10-20 moderate cognitive impairment ≤9 severe cognitive impairment |
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Dementia
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4A's: Amensia, Aphasia, Apraxia, Agnosia, Impaired exeutive functioning
No impaired alertness, may sundown, but does not wax and wane; usually no SNS arousal, insidious onset: neither acute nor reversible Alzheimer's accts for majority of dementias; Vascular Dementia 2nd most common, 1/3 |
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Alzheimers Dementia
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majority of dementias
Risks: head injury, 1° relative, female, trisomy 21, depression may be confounding |
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Vascular Dementia
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2nd most common, 1/3 of dementias
aka multi-infarct dementia typically abrupt onset, step-wise progression same risk factors as MI's may superimpose on alzheimers |
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Lewy Body Dementia
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Much like Alzheimers
± visual halluciations & parkinsonism |
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Pick's Dementia
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Frotnotemporal
Disinhibition and language impaorment |
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Huntington's Dementia
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AD &Chrom 4
striatal atrophy choreoathetosis |
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Dementia Tx
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Step 1: verify dx, treat underlying cause if possible (strokes)
↓ polypharmacy as possible, esp anti-cholinergic meds Cholinesterase Inhibitors: Tacrine (Cognex), Donepezil (Aricept), Rivastigmine (Exelon), Galatamine (Reminyl, Razadyne) NMDA antagonist: Memantine antidepressents for depression and irritability benzos for anxiety restless may use antipsychotics for hallucations, delusiosn, aggression, agitation, hostility at best, medicine delays sx by 12 mo's psychosocial interventiosn are key dementa is a terminal illness: plan for decline & death Education & supportfor pt, family & caregivers: planning for future remove guns, make home safe, optimize vision, hearing, nutrition, manage sleep bowel & bladder problems, agitation & wandering. avoid confusion: calm, safe familiar environment |
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Tacrine (Cognex)
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Anti-cholinergic tx for dementia
hepatotoxicity- not used |
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Donepezil (Aricept)
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anti-cholinergic tx for dementia
well tolerated, widely used GI side effects |
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Rivastigmine (Exelon)
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anti-cholinergic tx for Alzheimers
Gi side effects acts on both AChesterase and butylcholinesterase |
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Galantamine (Reminyl, Razadyne)
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Inhibits AChesterase and stimulates nicotinic receptors to release ACh
GI side effects |
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Memantine (Namenda)
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Non competitive NMDA receptor antagonist (hypothesis is that excessive glutamate leads to cell death)
well tolerated. mild SE's:HA, constipation, confusion, dizziness |
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Gamma Secretase modulators
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Reduce amyloid protein and plaque load
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Wernicke-Korsakoff
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Thamine Deficieny of chronic alcoholism
Wernicke: Confusion, Ataxia,Ophthalmoplegia Tx: thiamine Korsakoff is chronic loss of short term memory; confabulation; Poor px |
