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211 Cards in this Set

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What is the definition of delusion?
Belief that is:

1) Fixed (not susceptible to argument or evidence)

2) Not consistent with patient's sociocultural background

It doesn't matter if the belief is true or false, but rather the thought processes that lead to the belief and cause it to be fixed
What is a hypnogogic hallucination?
Hallucination as you're falling asleep
What is a hypnopompic hallucination?
Hallucination as you're waking up
What are two situations in which hallucinations might be considered normal?
As you're falling asleep (hypnogogic) or as you're waking up (hypnopompic)
What is psychosis?
Symptom, or syndrome of symptoms, rather than a specific disorder

Best characterized as impairment in reality testing

Psychotic symptoms:
1) Delusions
2) Hallucinations
3) Disordered thinking as evidenced by disorganized speech or behaviour
What is the difference between bizarre and non-bizarre delusions?
Non-bizarre delusions are plausible and potentially not immediately recognizable as false, bizarre delusions are not plausible and instantly recognized as delusional
Describe an approach to psychosis:
1) Rule out organic cause (medical condition, drugs)

2) Gather other associated/psychiatric symptoms, especially mood symptoms

3) Get the timeline
What are the 5 subtypes of delusional disorder?
Erotomanic type - delusion that someone's in love with individual

Grandiose type - delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person

Jealous type - delusions that sexual partner is unfaithful

Persecutory type: delusions that the individual is being malevolently treated in some way

Somatic type: delusion that individual has some physical defect or general medical condition

Mixed type

Unspecified type
What are the primary psychotic disorders?
Brief psychotic disorder
Schizophreniform disorder
Schizophrenia
Schizoaffective disorder
Delusional disorder
Psychotic disorder NOS
What symptoms and personal factors suggest organic aetiology of psychosis?
1) Non-auditory hallucinations
2) Clouded sensorium
3) Older age at first onset
What are the characteristic symptoms (criteria A) of schizophrenia?
2 or more of the following, each present for a significant portion of time during a 1 month period:

1) Delusions
2) Hallucinations
3) Disorganized speech/thought process (derailment, incoherence)
4) Disorganized or catatonic behaviour
5) Negative symptoms (flattened affect, alogia, avolition)
What does "downward drift" refer to?
Negative symptoms of schizophreniform disorder, schizoaffective disorder, and schizophrenia (avolition, alogia, affective flattening)
What kinds of delusions do people get with Delusional Disorder?
Non-bizarre delusions (grandiose, erotic, persecutory, somatic, jealous)
What is akathisia?
Inner restlessness, inability to sit still
What are the extrapyramidal symptoms (EPS)?
Side effects of typlical neuroleptics due to dopamine blockade in nigrostriatal pathway of the basal ganglia

Symptoms:

Parkinsonism (hypokinesia)
Akathisia
Dystonia (usually hypertonia)
What is tardive dyskinesia?
Choreiform movements involving the mouth, lips, and tongues

"Iatrogenic Huntington's" rather than the "Iatrogenic Parkinson's" that is part of the EPS

Possibly results from increased dopamine sensitivity because of prolonged dopamine blockage (up-regulation of receptors, increased sensitivity to receptors)
What is the advantage of atypical neuroleptics?

What is the disadvantage?
Advantage: Decreased EPS, decreased tardive dyskinesia, POSSIBLE (questionable) decrease in negative symptoms

Disadvantage: Metabolic syndrome, diabetes, cardiovascular disease
What essential qualities make a particular belief delusional?
Not arrived at through normal processes of logical thinking

Cannot be altered by evidence to the contrary

FIXED!
What is a primary delusion?
Delusion that arrives suddenly and fully formed without any mental events leading up to it
What is a folie a deux?
Delusion shared by two or more people, shared delusion
What is Wahnstimmung?
Delusional mood

The term is unsatisfactory because the mood is not delusional but rather a real mood or sense of foreboding that precedes the onset of a delusion
What is Capgras Syndrome?
Delusional syndrome of which the primary feature is the delusion that people have been replaced by identical imposters
What is the Fregoli delusion?
Belief that a number of people with different appearances are actually the same persecutor in disguise
What is a delusional memory?
Memory is not false, but the meaning retrospectively attributed to it is delusional

E.g. person who believes someone's trying to poison him cites a time when he ate something and threw up
What are delusions of control?
Belief that actions, impulses, or thoughts are controlled by an outside agency

Delusions of control strongly suggest schizophrenia
What are delusions of thought insertion?
Patient believes that some thoughts are not his/her own but have been implanted by an outside agency

This is a delusion about the ORIGIN of thoughts. The patient will not accept that they originated in his/her own mind, which differentiates thought insertion from obsession or delusion of control.
What are delusions of thought withdrawal?
Belief that thoughts are removed from mind by outside agency

Usually accompanies thought blocking
What is thought broadcasting?
Beileif that unspoken thoughts are unknown to other people through radio, telepathy, or some other way
Describe three delusions concerning the possession of thoughts. What disorder do these delusions strongly suggest?
Thought insertion

Thought withdrawal

Thought broadcasting

Delusions about the possession of thoughts strongly suggest schizophrenia.
What are persecutory delusions?
Belief that some person, group, or other force is acting malevolently towards you (trying to harm you in some way)
What is De Clerambault's Syndrome?
Erotomania
What are religious delusions?
Delusions with religious content (outside of what others of religious group might believe)
Give 5 "categories" of delusions that you use to help you remember them all:


Name 11 common delusions:
1) The "me" delusions
2) The "r"s
3) Delusions about the body
4) Emotional delusions
5) Delusions related to thought

1) Delusions of persecution
2) Delusions of grandeur
3) Erotomania (De Clerambault's syndrome)
4) Religious delusions
5) Delusions of reference
6) Delusions of guilt
7) Jealous delusions
8) Somatic delusions
9) Nihilistic delusions
10) Delusions of control/passivity
11) Delusions of thought (thought insertion/withdrawal/broadcasting)
What is an obsession?
Persistant thoughts, impulses, or images that enter the mind despite the person's attempts to exclude them
What is the characteristic feature of an obsession?
Subjective sense of struggle/resistance: patient resists thought which nevertheless enter into his or her awareness
How is personality disorder defined by the DSM?
Enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture.

The enduring pattern is inflexible across a broad range of personal and social situations

The enduring pattern is stable and of long duration, with onset traceable back to adolescence

The impairment leads to significant clinical distress or social or occupational impairment

Not better accounted for by a different psychiatric diagnosis, not accounted for by general medical condition/substance use
What are the cluster A personality disorders?
Paranoid Personality Disorder, Schizoid Personality Disorder, Schizotypal Personality Disorder
What are the cluster B personality disorders?
Borderline Personality Disorder, Narcissistic Personality Disorder, Histrionic Personality Disorder, Antisocial Personality Disorder
What are the cluster C personality disorders?
Avoidant Personality Disorder, Dependent Personality Disorder, Obsessive Compulsive Personality Disorder
What percentage of patients with borderline personality disorder have another psychiatric diagnosis?
90%
What percentage of the general population have borderline personality disorder?
2%
What does "splitting" refer to and which two psychiatric disorders is it a feature of?
Dividing things into things that are all bad and things that are all good (theoretically results from part object relationships)

Feature of BPD and NPD
What are the criteria necessary for diagnosing borderline personality disorder?
5 or more of the following:

The heart of the matter:

1) Markedly and consistently unstable self image or sense of self

Emotional abnormalities:

1) Marked REACTIVE lability of mood
2) Chronic feelings of emptiness
3) Inappropriate, intense anger or inability to control anger

Thinking abnormalities:
1) Extremes of idealization and devaluation of people (evidenced by unstable and INTENSE interpersonal relationships)

Behavioural abnormalities

1) Frantic efforts to avoid real or imagined abandonment
2) Impulsivity in areas that are self damaging (sex, substance abuse, reckless driving)
3) Recurrent suicidal behaviour, gestures, threats, or self-mutilation

Other:

Transient, stress related paranoid ideation or severe dissociative symptoms
What are the hallmarks of cluster B disorders?
Market mood reactivity and lability, poor impulse control
What are the proposed psychodynamic aetiologies of borderline personality disorder?
Incomplete self-other differentiation (poor sense of self, poor sense of separation from others)

Part object relationship rather than whole object relationship (one part stands in for the whole person: something's either great or terrible because one part of that thing is good or bad)

Things are therefore all good or all bad
What is the hallmark of cluster A personality disorders?
These are the "mad" personality disorders marked by eccentricity and odd beliefs
What are the 3 cluster A personality disorders?
Paranoid
Schizoid
Schizotypal
What is the central characteristic of Paranoid Personality Disorder?
Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent
What are the criteria for Paranoid Personality Disorder?
4 of the following:

1) Baseless suspicion that others are exploiting, harming, or deceiving him or her

2) Unjustified doubts about the loyalty or trustworthiness of friends or associates

3) Reluctance to confide in others for fear that information will be used to hurt them

4) Reads hidden demeaning or threatening meanings into benign remarks or events

5) Persistently bears grudges (unforgiving)

6) Perceives that attacks on his/her character or reputation are not apparent to others and is quick to react angrily or to counterattack

7) Recurrent suspicions of partner's fidelity
What is the central characteristic of Schizoid Personality Disorder?
Detachment from social relationships, restricted range of expression of emotion

Neither desires nor enjoys social relationships, a hermit
What are the criteria for Schizoid Personality Disorder?
4 of the following:

1) Neither desires nor enjoys close relationships

2) Almost always chooses solitary activities

3) Has little interest in sexual experiences with OTHER people

4) Takes pleasure in few, if any activities

5) Lacks close friends

6) Indifferent to praise and criticism of others

7) Shows emotional coldness, detachment, or flattened affect
What is the central characteristic of Schizotypal Personality Disorder?
Pervasive pattern of social deficits marked by acute discomfort with, and reduced capacity for, close relationships

Cognitive/perceptual distortions and eccentricities of behaviour
What are the criteria for Schizotypal personality disorder?
1) Ideas of reference (not delusions of reference)

2) Odd beliefs or magical thinking that is inconsistent with subcultural norms

3) Unusual perceptual experiences, including bodily illusions

4) Odd thinking and speech

5) Suspiciousness or paranoid ideation

6) Inappropriate or constricted affect

7) Behaviour or appear that is odde, eccentric, or peculiar

8) Lack of close friends or confidants
What is the hallmark of cluster B personality disorders?
REACTIVE mood lability
Name the 4 Cluster B personality disorders:
Antisocial
Borderline
Narcissistic
Histrionic
What is the central characteristic of Antisocial Personality Disorder?
Disregard for and violation of the rights of others
What is the central characteristic of Borderline Personality Disorder?
Instability:
-in self-identity
-in interpersonal relationships
-in mood (reactive lability)
What is the central characteristic of Histrionic Personality Disorder?
Excessive emotionality and attention seeking
What are the central characteristics of Narcissistic Personality Disorder?
Grandiosity, need for admiration, and lack of empathy
Name the 3 cluster C personality disorders:
Avoidant Personality Disorder, Dependant Personality Disorder, Obsessive-Compulsive Personality Disorder
What are the central characteristics of Avoidant Personality Disorder?
Social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation
What is the central characteristic of Dependant Personality Disorder?
Pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation
What is the central characteristic of Obsessive Compulsive Personality Disorder?
Preoccupation with orderliness, perfectionism, and mental and interpersonal control at the expense of flexibility, openness, and efficiency
What is the hallmark of cluster C personality disorders?
Low self esteem

Tapes, "I am unacceptable"
How do you distinguish APD from social phobia?
Avoidant can be the life of the party, give presentations in public, but can't get close to anyone
Describe the type of hallucinations typically seen in Lewy Body Dementia?
Well formed visual hallucinations
What percentage of children diagnosed with ADHD continue to manifest symptoms into adult life?
1/3 to 2/3
What three eating disorders are outlined in the DSM?
1) Anorexia Nervosa

2) Bulimia Nervosa

3) Eating Disorder Not Otherwise Specified
What are the DSM criteria for Anorexia Nervosa?
ALL of the following:

BEHAVIOURAL DISTURBANCES:

1) Refusal to maintain body weight at or above a minimally normal weight for age and height (less than 85% of expected body weight for age and height)

EMOTIONAL DISTURBANCES:

2) Intense fear of gaining weight or becoming fat, even though underweight

THOUGHT DISTURBANCES:

3) Disturbance in the way in which one's body weight or shape is experienced
OR
Undue influence of body shape/weight on self-evaluation
OR
Denial of the seriousness of the current low body weight

OTHER:

4) In postmenarchial females, amenorrhea (absence of three consecutive menstrual cycles)
What are the two types of Anorexia Nervosa?
Restricting Type
-just means there has been no binging or purging

Binge-Eating/Purging Type
-binge eating with self-induced vomiting or misuse of laxatives/diuretics/enemas
What are the DSM criteria for Bulimia Nervosa?
ALL of the following:

BEHAVIOURAL DISTURBANCES:
1) Binging
2) Purging
THOUGHT DISTURBANCES:
3) Undue influence of body shape and weight on self evaluation
TIMELINE:
4) At least 2x per week for 3 months
CRITERIA OF EXCLUSION:
5) Disturbance does not occur exclusively during periods of anorexia nervosa
What are the two types of Bulimia Nervosa?
Purging type
-self-induced vomiting, abuse of laxatives, diuretics, enemas, or other medications

Non-purging type
-restriction, excessive exercise
What are the two characteristics of binge eating:
Binge eating is characterized by A) the AMOUNT that is eaten in a short period of time and B) a sense of LACK OF CONTROL over eating

In essence, this inability to control eating is the primary defect in Bulimia Nervosa. It leads to eating a lot in a short period of time, which is followed by purging/restricting only in response to the amount that was eaten before.
If someone with Bulimia Nervosa simply maintains a normal body weight, what is the point of his or her binging and purging? Why not just eat a normal amount?
Because losing weight is not the point. Part of the definition of binging is a sense of lack of control over eating. They binge because they can't help it; that's their problem. The purging is simply to make up for their binging.

Anorexia nervosa = hypercontrol over eating

Bulimia nervosa = lack of control over eating
What is the etymology of bulimia?
Greek, ravenous hunger
What are the potential complications of the weight loss and malnutrition seen in anorexia nervosa?
1) Constitutional
-hypothermia, hypersensitivity to cold

2) Cardiovascular
-cardiomyopathy, valvulopathy (mitral valve prolapse)
-bradycardia
-hypotension

3) Gastrointestinal
-gastroparesis
-constipation

4) Reproductive
-secondary amenorrhea (crazy endocrinological abnormalities)


5) Musculoskeletal
-osteoporosis
Name 2 gastrointestinal complications of extreme weight loss and malnutrition commonly seen in Anorexia Nervosa:
Gastroparesis
Constipation
Can a patient with Anorexia Nervosa still become pregnant?
Yes!
What laboratory tests should someone with Anorexia Nervosa be sent for?
CBC

Electrolytes

Kidney: BUN/creatinine

Liver:

TSH

Nutrition: B12,
What is the prevalence of Anorexia Nervosa amongst high school and college-aged girls? What about for Bulimia Nervosa?
AN: 1%

BN: 4%
Describe an outward expression that betrays the anorexic's internal fear of gaining weight?
Obsession, worrying, and excessive interest in food
What is the death rate for Anorexia Nervosa?
11%
What percentage of patients with an eating disorder have a good outcome?

Good outcome means return to eating normally, no binging or purging, and emotional adjustment.
25-40%
What are the goals of management for anorexia nervosa:
1) Restore nutritional status and body weight

2) Modify eating behaviours

3) Modify erroneous beliefs about the benefits of weight loss
What is the only psychotropic medication used to treat binging/purging?
Fluoxetine (Prozac)
What is the DSM definition of dementia?
The cognitive deficitis:

-Impairment in learning and memory plus at least one of the following:
-Impairment in handling complex tasks
-Impairment in reasoning
-Impairment in spatial ability or orientation
-Impairment in language

The onset and progression:

-The impairment must represent a significant decline from a previous level of functioning
-The disturbances are of insidious onset and are progressive

The typical disorder definer:

The impairment must significantly interfere with the individual's work performance, usual social activities, or relationships with other people

Criteria of exclusion:
-Impairment does not occur exclusively during delirium
-Not better accounted for by a major psychiatric diagnosis
-Not better accounted for by a systemic disease or another brain disease
Which 5 cognitive impairments does DSM include in its definition of dementia?
1) Impairment in learning and memory

Plus at least one of the following:

2) Impairment in handling complex tasks
3) Impairment in reasoning
4) Impairment in spatial ability
5) Impairment in language
Self-reported memory loss suggests which diagnosis?
Depression
Informant-reported memory loss suggests which diagnosis?
Dementia
How can delirium be differentiated from dementia in term of onset of symptoms?
Delirium: sudden, acute onset

Dementia: insidious onset
Give a differential diagnosis for memory loss:
1) Delirium
2) Depression
3) Dementia
What is the pretest probability of dementia in an older person with reported memory loss?
At least 60%
What percentage of people over age 65 meet criteria for dementia?

What about people over 85?
5%

35-50%
Define mild cognitive impairment (MCI):
Presence of memory difficulty and objective memory impairment but preserved ability to function in daily life
What laboratory and imaging work up does the American Academy of Neurology recommend for all patients presenting with dementia?
B12 deficiency

Hypothyroid

Noncontrast CT/MRI
What are the major cholinergic pathways in the brain?
...
Alzheimer's Disease accounts for what percentage of cases of dementia in the elderly?
60-80%
After Alzheimer's Disease, what is the next most common cause of dementia in the elderly?
Vascular disease
In patients under 65, which dementia syndrome rivals AD for the most common?
Frontotemporal Dementia (FTD)
What is "pseudodementia"?
Dementia-like picture in a depressed patient
Provide a differential diagnosis for dementia:
NEURODEGENERATIVE:
-Alzheimer's disease (AD)
-Parkinson's disease related dementia (PDD)
-Dementia with Lewy bodies (DLB)
-Frontotemporal dementia

VASCULAR:
Vascular (multi-infarct) dementia

ENDOCRINOLOGICAL:
-Hypothyroidism
-Adrenal insufficiency or Cushing's

NEOPLASIA:
Primary Brain Tumour
Metastatic Brain Tumour

INFECTION:
HIV
Neurosyphilis

NUTRIENT DEFICIENCY
Thiamine deficiency (Korsakoff's Syndrome)
B12 deficiency

TRAUMA

SUBSTANCE
Drug or medication poisoning



ORGAN FAILURE:
-Renal failure
-Liver failure
-Pulmonary failure
What is normally the first symptom in Alzheimer's Disease?
Memory loss
What's the most important investigative step in a patient presenting with dementia?
RULE OUT REVERSIBLE CAUSES!

-endocrine
-nutrient deficiency
-depression
What drugs are used to treat dementia?
Cholinesterase inhibitors:

Donepezil (5-10mg)
-Aricept

Rivastigmine (1.5 - 6 mg BID)
-Exelon

Galantamine (8-24 mg)
-Reminyl ER
What are the pathological hallmarks of Alzheimer's disease (AD)?
Intracellular neurofibrillary tangles (NFTs) and extracellular senile plaques
What are the neurofibrillary tangles (NFTS) seen in Alzheimer's disease?
Mis-phosphorylated forms of the tau protein, a protein usually associated with cytoskeletal elements
What are the senile plaques seen in Alzheimer's disease?
Core of amyloid-beta proteins surrounded by altered/diseased nerve fibers and areas of reactive gliosis
What neurotransmitter is depleted in Alzheimer's disease (AD)?
Acetylcholine
What are Lewy bodies? What diseases are Lewy bodies seen in?
Lewy bodies are round, eosinophilic, intracytoplasmic inclusions in the nuclei of neurons

An aggregated and insoluble form of alpha-synuclein is a major component of Lewy bodies

Seen in Parkinson's disease (PD), Dementia with Lewy bodies (DLB)
What is the main structural protein in Lewy bodies?
Alpha-synuclein
What are the first symptoms of FTD?
Behavioural disturbances rather than memory disturbances

-Apathy
-Poor judgement/insight
-Disinhibition
-Speech/language abnormalities
-Hyperorality
Which protein is mutated in Frontotemporal dementia?
Progranulin
What are the typical presenting symptoms of Dementia with Lewy bodies?
Psychotic symptoms:
-Well-formed visual hallucinations
-Capgras syndrome

REM sleep disturbances

Parkinsonism
What are the symptoms of hypomania?

How is hypomania different than mania?
Distinct period of abnormally and persistently elevated, expansive, or irritable mood

During the period of the mood disturbance, 3 or more of the following symptoms:

1) Inflated self-esteem or grandiosity
2) Decreased need for sleep
3) More talkative than usual or pressure to keep talking
4) Flight of ideas or subjective feeling that thoughts are racing
5) Distractibility
6) Increase in goal-directed activity
7) Excessive involvement in pleasurable activities that have a high potential for painful consequences

Lasts at least 4 days, or any period of time if hospitalization is required

Disturbance NOT sufficient to cause social or occupational impairment
What are the symptoms of mania?
Distinct period of abnormally and persistently elevated, expansive, or irritable mood

During the period of the mood disturbance, 3 or more of the following symptoms:

1) Inflated self-esteem or grandiosity (T)
2) Decreased need for sleep
3) More talkative than usual or pressure to keep talking
4) Flight of ideas or subjective feeling that thoughts are racing
5) Distractibility
6) Increase in goal-directed activity
7) Excessive involvement in pleasurable activities that have a high potential for painful consequences

Lasts at least one week, or any period of time if hospitalization is required

Disturbance sufficient to cause social or occupational impairment
What are the four possible phases a patient with bipolar disorder could be in?
Manic, hypomanic, depressed, mixed
What are the characteristics of a mixed episode?
Criteria met for both a manic episode and a major depressive episode nearly every day during the same 1 week period
What is cyclothymic disorder?
As dysthymic disorder is to MDD, cyclothymic disorder is to BPD

Repeated hypomanic episodes

Repeated sub-syndromal depressive episodes
What is bipolar rapid cycling?
4 or more episodes of mood disturbance (manic, hypomanic, depressed, mixed) per year
What mood disturbances are required to diagnose bipolar II?
Hypomanic phase AND depression phase (at least one of each)

If patient has psychotic symptoms they are manic, not hypomanic, and meet criteria for bipolar I
What is the lifetime prevalence of bipolar disorder?
1%
What do you want to rule out when someone presents in an apparently manic state?
Hyperthyroidism
Antidepressants "flipping you high"
Substances
Name common trigger that can send a bipolar into mania/hypomania:
Sleep deprivation
Antidepressants
What is the natural history of bipolar disorder?
10 or more episodes, intervals between episodes narrow as they get older
What's the lifetime prevalence of a psychiatric disorder in patients with a developmental disability?
40%
What percent of the general population has a developmental disability?
3%
On which access is mental retardation coded?
Axis II
What is the politically correct term for the DSM category of mental retardation?
Developmental disability
OR
Intellectual disability (probably new term in DSM V)
What is the DSM term for developmental disability/intellectual disability?
Mental retardation
What is the definition of mental retardation in the DSM?
1) Significantly subaverage intellectual functioning (IQ of 70 or below, 2 standard deviations below the norm)

2) Impairments in present adaptive functioning

3) Onset before the age of 18 years
What is the most common measure of adaptive behaviour?
Vineland adaptive behaviour scales (VABS)
What percentage of people with mental retardation have only mild mental retardation (IQ 55-70)?
The vast majority, 85%
What is the developmental age of someone with mild mental retardation?
9-12 years
Name 3 Pervasive Developmental Disorders ("Autistic Spectrum Disorders"):
1) Autistic Disorder
2) Asperger's Disorder
3) PDD NOS
What's the most important aspect of working up a patient with a developmental disability for behavioural problems/changes:
RULE OUT AN ORGANIC CAUSE!
When medically treating someone with mental retardation, what should you never forget to do?
Assess capacity

Medication mantra: start low, go slow
What is the typical presentation of frontotemporal dementia?
1) "Behavioural variant"
-progressive change in personality and social behavior (e.g. apathy, social withdrawal, lack of social insight)

2) "Progressive nonfluent aphasia" or "Semantic dementia"
-progressive form of aphasia
What is the natural history of FTD?
Initial behavioural or language disturbance progressing to global dementia, death within 4-8 years
What neuroimaging finding strenghtens a diagnosis of FTD?
Focal atrophy of the frontal and/or temporal lobes that worsen over time
What are the clinical manifestations of Dementia with Lewy bodies?
1) Dementia

Plus 2/3 of the so called "core" features:

a) Fluctuating level of cognition
b) Well-formed visual hallucinations
c) Parkinsonism
What neurotransmitter systems are affected in DLB?
Acetylcholinergic pathways

Dopaminergic pathways

Serotonergic pathways
What's the difference between DLB and Parkinson's disease with dementia?
In PDD, dementia occurs in the setting of well established parkinsonism, while in DLB, dementia usually occurs concomitantly with or before the development of parkinsonian signs
How is DLB treated medically?
Cholinesterase inhibitors
Why must you be cautious in treating psychotic symptoms of Parkinson's disease with neuroleptics?

What strategies should be tried first?
30-50% will have extreme sensitivity, exacerbating parkinsonian and autonomic symptoms

First, try a trial with a cholinesterase inhbitor. Also consider lowering the patient's PD medication
What's another name for frontotemporal dementia (FTD)?
Pick disease
What is the most frequent neurological complication of HIV infection?
HIV dementia
Describe the features of HIV dementia:
Cognitive deficits (dementia)
Motor deficits
Behavioural changes

Often presents as a sloowing down:

Impaired attention and concentration, psychomotor slowing, forgetfullness, slow reaction time, mood changes
Which nutrient deficiency results in Wernicke's Encephalopathy and Korsikoff Syndrome?
Thiamine
What is the classic syndrome of normal pressure hydrocephalus?
Wet, wobbly, and wild

Wet - urinary incontinence
Wobbly - gait disturbance
Wild - dementia
What is the defining characteristic of a factitious disorder?
INTENTIONAL report or misrepresentation of symptoms, or INTENTIONAL self-infliction of physical signs for, and here's the kicker, PRIMARY GAIN (i.e. to meet a psychological need)
What's another name for a factitious disorder?
Munchausen syndrome
What is malingering?
Voluntary production of symptoms or physical signs in order to accomplish a tangible goal (e.g. receive insurance payments, avoid jail time or punishment)
What is the difference between a factitious disorder and malingering?
Both involve voluntary and intentional production of symptoms and/or physical signs

The difference lies in the objective of this behaviour:

In malingering, the patient produces symptoms so as to achieve a tangible goal (e.g. shelter, insurance money, avoidance of jail time)
What's the difference between primary and secondary gain?
Primary gain satisfies an internal motivation (e.g. alleviation of some internal distress)

Secondary gain satisfies an external motivation (missing work, gain sympathy, avoid jail time)
Garlicky odour on the breath is indicative of which kind of intoxication?
Arsenic
What is anterograde amnesia?
Loss of ability to create new memories

Remembers things from BEFORE the illness
What is retrograde amnesia?
Loss of memories formed before the onset of a disease

Remembers things from AFTER the illness but not before
Which type of amnesia is typical in Korsakoff's syndrome?
Both retrograde and anterograde amnesia
What characterizes hypochondriasis?
Preoccupation with having a medical condition based on the misinterpretation of his or her own bodily symptoms
Which hormone is elevated after a generalized tonic-clonic seizure?
Prolactin

Prolactin levels can be used to distinguish a real seizure from a pseudoseizure
What is the most effective treatment of postcardiotomy delirium?
Modification of the environment to include cues as to time and place (calendar, clock, etc...)
What is the prevalence of postcardiotomy delirium?
32%
What is the most common cause of new onset hallucinations in a recently hospitalized patient?
Delirium tremens
A patient is admitted to hospital for a broken bone suffered in an accident and 3-4 days later develops hallucinations. What is the most likely cause?
Delirium tremens from alcohol withdrawal (timeline is perfect, DTs the most common cause of new-onset hallucinations in recently hospitalized patients)
What condition, ocurring after a head trauma or aneurysm, can cause a reversible dementia?
Chronic subdural hematoma
What is a conversion disorder?
Disturbance in sensory or voluntary motor dysfunction that results from psychological conflict or need
Name a defense mechanism characteristic of borderline personality disorder:
Splitting
Which drug and route is indicated for psychotic symptoms of delirium?
Haloperidal
What progressive disease do all individuals with trisomy-21 syndrome (Down syndrome) develop if they survive past the age of 30?
Alzheimer's disease
What is Creutzfeldt-Jakob disease?

What causes it?

What's another name for Creutzfeldt-Jakob disease?
Neurodegenerative disease caused by a transmissable infectious agent, the prion

Also called Mad Cow Disease in cows
What is the most common mechanism of transmission of Creutzfeldt-Jakob disease?
Iatrogenic transmission:

Transplant of infected corneas
Contaminated neurosurgical instruments
What are the characteristics of a temporal lobe epilepsy (TLE) personality?
Hyposexuality
Perseverance
Emotional intensity
What are the symptoms of neuroleptic malignant syndrome?
Muscular rigidity
Hyperthermia

F ever (hyperthermia)
E ncephalopathy (delirium)
V itals unstable (autonomic instability, e.g. tachycardia)
E levated enzymes (CPK)
R igidity (muscular rigidity)
How is neuroleptic malignant syndrome managed medically?
Withdrawal of causative agent

Dantroline or bromocriptine (dopamine receptor agonists)

Supportive therapy
What should always be on the differential for a schizophrenic presenting with confusional states and seizures?
Water intoxication
About 20% of schizophrenics do what to excess?
Drink excessive amounts of water, at times causing chronic hyponatremia or water intoxication
Which psychiatric symptoms is seen in 90% of all terminally ill patients?
Delusions
Name the 5 somatoform disorders described in the DSM:
1) Somatization Disorder
2) Conversion Disorder
3) Hypochondriasis
4) Pain Disorder
5) Body Dysmorphic Disorder
What are the defining characteristics of somatization disorder?
Ongoing reporting and experiencing of symptoms that are not medically explainable but nevertheless cause impairment
Symptoms must begin before what age to meet criteria for Somatization Disorder?
30
What kinds and quantity of symptoms must be met for a diagnosis of somatization disorder?
4 pain symptoms
2 GI symptoms
1 sexual symptom
1 pseudoneurological symptom
What is Pain Disorder?
Somatoform disorder characterized by preoccupation with pain in the absence of physical disease to account for the pain or its intensity

In Pain Disorder, pain does not follow a neuroanatomic distribution
What is the central feature of dissociative disorders?
Disruption of the normally integrated functions of consciousness, environmental perception, memory, and identity
Name the 4 dissociative disorders outlined in the DSM:
Dissociative amnesia
Dissociative fugue
Dissociative identity disorder
Depersonalization disorder
What is unique about the amnesia of dissociative amnesia?
The amnesia is selective: patient forgets certain, usually stressful or traumatic, events but otherwise memory is intact
What is dissociative fugue?
Sudden, unexpected travel away from home with the inability to recall all or some of one's past

Confusion about one's identity or assumption of a new identity
What's the new name for Multiple Personality Disorder?
Dissociative Identity Disorder
What is the central characteristic of Dissociative Personality Disorder?
Presence of two or more distinct identities or personalities, each of which, when present, will dominate the person's identities and attitudes as if the other personalities didn't exist
What is the central characteristic of Depersonalization Disorder?
Persistent feeling of detachment from oneself, as if in a dream or watching oneself in a movie

Patients feel that they are not in control of their actions
How long can depressive symptoms last after a death and still be considered part of normal bereavement?
2 months, after that consider adjustment disorder or MDD
How common is postpartum blues?

Postpartum depression?
20-40%

10-15%
What's the most common side effect of ECT?
Headache
What is the time required to diagnose dysthymic disorder in an adult? In a child?
2 years and 1 year
What is childhood disintegrative disorder?
Clinically significant loss of previously acquired skills before the age of 10
What possibility should be at the back of your mind for a child with repeated hospital visits of a suspicious nature?
Munchausen by proxy (parents using child to get attention)
There are typically 4 criteria (A-D) that must be met in order to diagnose delirium. What are those 4 criteria?
A) Disturbance in consciousness with reduced ability to focus, sustain, or shift attention
*Note that this is really two different things, disturbance in consciousness and disturbance in attention

B) Cognitive impairment (memory impairment, language impairment, disorientation) or perceptual disturbance
*Note again that these are two different things

C) The course: rapid onset with fluctuating course

D) The cause: evidence that the disturbance is a direct consequence of a medical condition/substance/substance withdrawal

*Note that included in the definition of delirium are not only the symptoms that constitute the syndrome but specifiers of course and etiology
What is the etymology of delirium
Latin, "frenzy"
What is "sundowning"?
Worsening of delirium that occurs in the evening or night
Name the four principle "disturbances" that are part of the delirium syndrome:
1) Disturbance in consciousness
-i.e. decreased level of consciousness

2) Disturbance in attention
-inability to sustain, focus, or shift attention

3) Disturbance in cognition
-memory impairment, language impairment, disorientation

4) Disturbance in perception
-illusions or hallucinations

In the DSM these are strangely bundled into two criteria rather than four, with disturbances of consciousness and attention bundled together and disturbances of cognition and perception bundled together
What is cataplexy?
Cataplexy is the sudden loss of muscle tone due to strong emotions during full wakefulness.

It is considered a normal intrusion of REM sleep phenomenon during normal wakefulness.
What is catalepsy?
Catalepsy is an immobile position that is constantly maintained.
What is negativism?
Negativism refers to a patient's resistance to any attempts to be moved, as well as any attempts to allow himself or herself to be moved, even when there is no obvious motive for such resistance
What psychiatric disorder is consistent with decreased latency of REM sleep?
Major Depressive Disorder
In cases of hereditary alzheimer disease, which protein is likely mutated?
Presenelin 1, sometimes presenelin 2
What is reaction formation?
Reaction formation is a proposed Freudian defence mechanism in which anxiety-producing impulses are mastered by exaggeration of the directly opposing tendency
What is "acting out"?
Acting out is a defence mechanism in which anxiety-producing situations are avoided in a socially inappropriate and attention-seeking manner
What is a defence mechanism?
Defence mechanisms are strategies employed in response to a threat to the ego. They are used to resolve internal uncomfortable feelings.
What is projection?
Projection is a defence mechanism in which personal feelings are projected on to somebody else.
What is denial?
Denial is a defence mechanism in which you simply deny the threat even exists.
What is undoing?
Defence mechanism in which a person tries to undo a threatening thought or action by engaging in opposite behaviour.
What is introjection?
Defence mechanism in which the subject replicates in itself behaviors, attributes or other fragments of the surrounding world, especially of other subjects