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67 Cards in this Set
- Front
- Back
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What is the relationship between homelessness and mental illness?
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20-40% of homeless people in the US have a major mental illness. It is not homelessness that causes mental illness but rather mental illness that makes it difficult for people to function well in a community
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What is the prevalence of schizophrenia in the general population?
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The incidence is 1%
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Describe the 3 phase for the development of schizophrenia?
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Premorbid phase - characterized by negative symptoms (deterioration in personal, social and intellectual functioning)
Active phase - Usually precipitated by a stressful event, development of positive symptoms: active delusions, hallucinations and bizarre behaviour Residual phase: patients are left with impaired cognitive ability, marked by bizarre ideation, delusions, peculiar behaviour, poor personal hygiene and social isolation |
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What is the difference between delusions and hallucinations?
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A delusion is an erroneous belief that usually involves a misinterpretation of perceptions or experiences whereas a hallucination is a sensory experience that exists only in the mind of the person experiencing it.
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List 5 medical conditions that can cause acute psychosis?
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Metabolic
Inflammatory (Sarcoidosis and SLE) Organ failure (hepatic encephalopathy, uraemia) Neurologic Disorders (Alzheimer's, CVA, encephalitis) Endocrine (Addison's, Cushing's, Parathyroid) |
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What is MAD FOCS?
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Are the factors differentiating organic(medical) and functional (psychiatric)
M- Memory Deficit A - Activity D - Distortions F - Feelings O - Orientation C - Cognition S - Some other findings |
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What are important steps when evaluating a patient with a suspected thought disorder?
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-Must ensure staff safety
-Complete history and physical examination, including a detailed mental status evaluation to rule out an organic brain syndrome -Assessment of the patient's thought processes through the initial interview |
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When are antipsychotics such as haloperidol or droperidol contraindicated?
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-If there is concern for prolonged QT interval
-pregnant or lactating female -PCP overdose -anticholinergic drug-induced psychosis |
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Discuss the sentence: disadvantages of BZD are the need to repeat
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I don't believe that this is a disadvantage because it requires patient re-evaluation
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Dystonia: what is it? Pathophysiology? Incidence? Treatment
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-Sudden onset of muscle contractions of the face, neck or back
-disruption of the dopaminergic-cholinergic balance in the nigrostriatal pathway of the basal ganglia -1-5% of patients -1-2mg IV/IM benztropine or 25-50mg IV/IM diphenhydramine |
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List the 4 types of disturbances associated with depression and give on example of each.
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Depressive disorders (unipolar) Major Depressive Disorder
Bipolar disorders - Bipolar Type I (associated with at least one manic episode) Mood disorder secondary to general medical condition - Parkinson's Substance induced mood disorder - intoxication or chronic heavy use of alcohol |
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How do you differentiate between substance use induced mood disorder and a true mood disorder?
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When the mood disorder predates the period of substance abuse or lasts longer than 1 month after the period of abuse, the diagnosis of an underlying mood disorder with a comorbid substance abuse or dependence diagnosis
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Which type of patients with mood disorders warrant hospitalization?
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-Patient demonstrates risk of suicide or homicide or of significant harm to self or to others
-Patient lacks the capacity to cooperate with treatment -Patient has inadequate psychosocial support for safe outpatient treatment and compliance Patient has a comorbid condition or complication that makes outpatient treatment unsafe (acute psychosis, bizarre behaviour, need for detox) |
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What are four neurotransmitters/hormones associated with the pathophysiology of depression?
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-Serotonin
-Norepinephrine -Dopamine -Cortisol -TSH |
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List symptoms commonly attributed to anxiety?
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Respiratory - hyperventilation and dyspnea
Cardiovascular - palpitations, chest discomfort, awareness of missed beats Gastronintestinal - dry mouth, difficulty in swallowing, epigastric discomfort, flatus, loose stools Genitourinary Neuromuscular |
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What are factors that make you think of an organic anxiety syndrome?
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-onset of anxiety symptoms after the age of 35years
-lack of personal or family history of an anxiety disorder -lack of a childhood history of significant anxiety, phobias or separation anxiety -lack of avoidance behaviour -absence of significant life events generating or exacerbating the anxiety symptoms -poor response to anti panic agents |
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When do you use intravenous anxiolytics
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-When an anxiety state renders a patient so helpless and out of control that there is a significant threat to the safety of self or others
-Anxious patient experiencing a significant medical illness or undergoing a medical procedure |
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Which patients would not be candidates to receive short term treatment for anxiety with BZD?
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-Patients with excessive alcoholism or drug abuse
-Excessively and emotionally dependent patients -Patients that become anxious in response to normal stress |
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What symptoms have the best predictive value for somatisation disorder?
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-dysmenorrhea
-the sensation of a "lump" in the throat -vomiting -shortness of breath -burning in the sex organs -painful extremities -amnesia lasting hours to days |
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Contrast somatisation, hypochondria and pain disorder?
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Somatisation - numerous symptoms and complaints involving a variety of organ systems with few or no physical findings to explain those symptoms
Conversion disorder - the sudden onset of a single symptom typically simulating some non painful neurologic disorder for which there is no pathophysiologic or anatomic explanation Hypochondria - physical symptoms disproportionate to demonstrate organic disease -fear of disease and conviction that one is sick -preoccupation with one's own body -persistant and unsatisfying pursuit of medical care |
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What medical conditions must be excluded in the ED when a patient is suspected of somatisation?
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-acute psychosis
-organic brain syndrome -grief reaction -depression -anxiety |
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What are the two principle causes of death in children affected by Munchausen by proxy?
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Suffocation
Poisoning |
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List potential gains for those presenting to the ED with malingering?
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-obtaining drugs
-insurance payments -industrial injury settlements |
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How can one physician protect his liability when treating a patient with suspected Munchausen?
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Involve hospital administrators and risk management
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How is a diagnosis of Factitious disorder usually made?
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-patient is accidentally discovered in the act
-incriminating items are found -lab values suggest non organic aetiology -the diagnosis is made by exclusion |
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List risk factors for suicide.
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Firearm in home
Living alone separated/widowed/divorced unemployed homeless recent personal loss veterans recent incarceration lack of religious affiliation |
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Explain the "mobilization of energy theory"
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Patients who are profoundly depressed may develop the energy to attempt suicide as their condition improves.
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What are DSH and DSP?
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Deliberate self-harm
Deliberate self- poisoning |
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What are legal obligations to protect confidentiality when contacting relatives of a patient who may have attempted suicide in order to obtain collateral information?
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A suicide attempt can be an exception to confidentiality, allowing the physician to disclose protected health information without an individuals authorization
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Discuss the difference between the SAD PERSONS and the RSQ questionnaire.
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Sex
Age (<19, >45) Depression (2) Previous attempts Excessive alcohol or drug use Rational thinking loss (2) Separated, divorced, widowed Organized or serious attempt (2) No social supports Stated future intent (2) (<5 questionable outpatient tx, >6emergency psych tx/eval, >9psych hospitalization) RSQ- Risk of Suicide Questionnaire Are you here because you tried to hurt yourself? in the past week have you had thoughts of killing yourself? Have you ever tried to hurt yourself in the past? Has something very stressful happened in the past few weeks? Any positive answer correlated with risk of Self Harm |
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Comment on the use of restraints for non agitated suicidal patients.
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Physical restraints may compromise rapport
Chemical may make evaluation difficult However restraint may be useful/necessary in situations where self-harm, violence or elopement are a concern |
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What are the DSM-IV criteria for schizophrenia
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A.Two or more of the following present for a significant portion of time during a 1 month period
-delusions -hallucinations -disorganized speech -grossly disorganized catatonic behaviour -negative symptoms B. Social/occupational dysfunction - for a significant portion of the time since the onset of the disturbance. C. Duration- continuous signs of the disturbance persist for at least 6 months. D. Schizoaffective and mood disorder exclusion E. Substance/general medical condition exclusion F. Relationship to a pervasive developmental disorder |
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What is the difference in memory deficit between organic and functional psychosis?
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Organic: recent impairment
Functional: remote impairment |
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What is the difference in activity deficit between organic and functional psychosis?
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organic: psychomotor retardation, tremor, ataxia
Functional: repetitive activity, posturing, rocking |
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What is the difference in distortions between organic and functional psychosis?
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organic: visual hallucinations
functional: auditory hallucinations |
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What is the difference in feelings between organic and functional psychosis?
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organic: emotional lability
functional: flat affect |
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What is the difference in orientation between organic and functional psychosis?
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organic: disoriented
functional: oriented |
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What are the differences in cognition between organic and functional psychosis?
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organic: islands of lucidity, perceives occasionally, attends occasionally
functional: continuous scattered thoughts, unfiltered perceptions, unable to attend, unable to focus |
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What are the other differences between organic and functional psychosis?
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organic:
age>40 sudden onset physical examination often abnormal vital signs may be abnormal social immodesty aphasia functional: age <40 gradual onset physical examination normal vital signs usually normal social modesty intelligible speech awake and alert |
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What are the DSM-IV criteria for a major depressive episode
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>/5 of the following almost daily for the same 2 weeks period and representing a change from previous. On eor more symptoms must be depressed mood or loss of interest or pleasure
Depressed mood Loss of interest or pleasure in activities Significant weight loss or weight gain insomnia or hypersomnia psychomotor aggitation or retardation Fatigue or loss of energy Feelings of worthlessness, or excessive inappropriate guilt Diminished ability to thick or concentrate or indecisiveness Recurrent thoughts of death -Symptoms do not meet criteria for a mixed episode -Symptoms cause clinically significant distress or impairment ins social, occupational or other functioning -Symptoms are not caused by the direct physiologic effects of a substance or GMC -Symptoms are not better accounted for by bereavement |
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What factors should be evaluated in depression
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M SIGE CAPS
Mood Sleep Interest Guilt Energy Concentration Appetite Psychomotor activity Suicide |
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What are vegetative symptoms of depression?
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Disturbances in
Sleep Appetite Sexual dysfunction |
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What medical conditions are associated with depression?
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Neurologic
Parkinsons Stroke MS head trauma Sleep apnea Neoplastic Pancreatic carcinoma Brain tumor Disseminated carcinomatosis Endocrine Hypo/Hyperthyroidism Cushing's disease Addison's disease Diabetes mellitus infectious HIV Cardiac Coronary artery disease MI Renal ESRD Renal dialysis CTD Lupus Rheumatoid |
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What is the differential for depression
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Major depressive episode
Depression due to a general medical condition Depression due to a substance Adjustment disorder Dysthymic disorder Grief or bereavement Borderline personality Bipolar disease Cyclothymic disorder Dementia |
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Differentiate Bipolar I and bipolar II
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Bipolar I - at least one manic episode and patients ahve typically had one or more major depressive episodes
Bipolar II - hypomanic episode and at least one major depressive episode. Hypomanic episode: features of a manic episode without psychosis, marked impairment of function or the need for hospitalization |
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What are the criteria for a manic episode?
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GST PAID
Grandiosity Sleep Talkative Psychomotor aggitation Attention Ideas (flight of ideas) Devastating consequences |
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What is the differential for a manic episode
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Acute intoxication with a sympathomimetic drug
Hallucinogen abuse Alcohol or sedative withdrawal Delirium Hyperthyroidism Brief reactive psychosis Schizoaffective disorder Schizophrenia Subarachnoid Meningitis/encephalitis Pheochromocytoma Addisonian crisis |
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What are criteria for hospitalization of ED patient with acute psychiatric episode
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Patient demonstrates risk of suicide or homicide or of significant harm to self or others
Patient lacks the capacity to cooperate with treatment Patient has inadequate psychosocial support for safe outpatient treatment and compliance Patient has a comorbid condition or complication that makes outpatient treatment unsafe (acute psychosis, bizzare behaviour, need for detoxification) |
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What are the 6 predictors of organic anxiety syndrome?
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Onset of anxiety symptoms after the age of 35 years
Lack of personal or family history of an anxiety disorder Lack of childhood history of significant anxiety, phobias or separation anxiety Lack of avoidance behaviour Absence of significant life events generating or exacerbating the anxiety symptoms Poor response to anti-panic agents |
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What is a panic attack
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Discrete period in which there is a sudden onset of intense apprehension, fearfulness or terror oten associated with feelings of impending doom
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What is agoraphobia
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An anxiety about or avoidance of places or situations from which escape might be difficult
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What is panic disorder with agoraphobia
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Recurrent, unexpected panic attacks and agoraphobia
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What is a specific phobia
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Clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidance behavior
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What is social phobia
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Clinically significant anxiety provoked by exposure to certain types of social or performance situations often leading to avoidance behavior. Blushing is the cardinal characteristic symptom
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What is OCD
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Obsessions that cause marked anxiety or distress and by compulsions that serve to neutralize anxiety
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What is post-traumatic stress disorder
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Experiencing of an extremely traumatic evetn accompanied by symptoms of increased arousal andby avoidance of stimuli associated with trauma
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What is acute stress disorder
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Symptoms similar to those of PTSD that occur immediately in the aftermath of an extremely traumatic event
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What is Generalized Anxiety Disorder?
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at least 6 months of persistant and excessive anxiety and worry
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What are general measures for the treatment of anxiety disorders
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Rule out organic illness
evaluate for substance abuse and medications associated with anxiety Determine whether anxiety is endogenous or exogenous Clarity what is currently frightening the patient Evaluate the patient's capacity for self -awareness Assess techniques that have worked in the past Support coping skills Give the patient as much control over the care plan as feasible Select patients to start a short course of BZD and educate patients about treatment Apply adjunctive techniques as appropriate |
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What are the criteria for the diagnosis of somatization disorder
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-There must be a history of medically unexplained physical symptoms beginning before the age of 30
-A history of all of the following: Pain related to four different sites or functions At least two GI symptoms other than pain at least one sexual or reproductive symptom other than pain at least one symptom or deficit suggesting a neurologic condition -Either the above symptoms must not be explained by any known medical condition or when there is a related GMC the complaints must be out of proportion to what is reasonably expected -the symptoms must not be intentionally produced or feigned |
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What are the presentations of conversion disorder
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Motor disturbances
-tremor -seizures -paralysis or paresis -aphonia -coordination disturbances Sensory disturbances -anesthesia -blindness and tunnel vision An occasional patient may present with other nonneurologic symptoms such as vomiting or pseudocyesis |
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What organic diseases may be mistaken for somatoform disorders?
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Endocrine disorders: hyperparathyroidism, thyroid disorder. Addisons, insulinoma, panhypopituitarism
Poisonings: botulism, CO, heavy metals Porphyria MS SLE Wilson's Guillain Barre Uremia Myasthenia Gravis |
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What are the treatment goals of somatoform disorders
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-decreased frequency and urgency of medical use
-avoidance of expensive hazardous procedures -improved work or school performance -more social activities -better personal relationships |
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What is a factitious disorder
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Characterized by symptoms or signs that are intentionally produced or feigned by the patient in the absence of apparent external incentives
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What are criteria for the diagnosis of munchausen syndrome by proxy
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-Apparent illness or health-related abnormality that the parent or someone has concocted or produced
-presentation of the child for medical treatment usually persistently -failure by the perpetrator to acknowledge the true etiology or deception -cessation of the acute symptoms and signs of illness when the child is separated form the perpetrator |
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What is malingering
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The simulation of disease by the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military conscription, avoiding work, obtaining financial compensation, evading criminal prosecution, obtaining drugs, gaining hospital admission or securing better living conditions
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Which patients are at low risk for suicide
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Few significant RF (SAD PERSONS <5)
Stable supportive home environment Patient agrees to no harm contract Family members or friend staying with patient Phone contact with HCP available Specific appointment made within 24-48 hours No gun in home young female who took non lethal ingestion or made hesitation cuts to wrists Patient expresses strong desire to live |
