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163 Cards in this Set
- Front
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1. What are somatoform disorders?
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Somatoform disorders are conditions in which patients present with prominent physical complaints or concerns in the absence of any obvious illness. These concerns often lead to frequent medical consultation and numerous tests and interventions. Because of the apparent medical nature of their complaints, patients usually present to primary care physicians or emergency departments.
Somatoform disorders are characterized by physical symptoms for which there are no demonstrable organic findings or known physiological mechanisms for which positive evidence or a strong presumption that the symptoms are linked to psychological factors. The four types are: I. Somatization disorder II. Conversion disorder III. Hypochondriasis IV. Body Dysmorphic disorder |
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2. What is alexithymia?
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When people are under psychosocial stress, they may express their symptoms physically rather than verbally or emotionally. Certain patients may be more prone to this than others. The concept of alexithymia, which comes from the Greek for “lack of words for feelings,” has been introduced to identify these patients.
They have been described as people who have limited abilities to experience fantasies or dreams or to think in an imaginative ways. |
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3. How are factitious and malingering disorders different from somatization disorders?
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One factor somatization disorders share is that the symptoms are not intentionally produced (as in factitious disorder or malingering) but develop out of unconscious processes.
In somatization disorders: 1. Symptom production is unconscious 2. Motivation is unconscious 3. Control of symptoms is involuntary |
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4. So, what is a factitious disorder?
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Symptoms production is intentional
Motivation is unconscious Control of symptoms is voluntary |
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5. What is a malingering disorder?
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Symptom production is intentional
Motivation is conscious, or intentional Control of symptoms is voluntary |
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6. What are secondary gains?
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The role of being a patient or of being sick, may likely have secondary gains which can be described as: the role of being a patient or of being sick releases the individual from obligations while providing a socially acceptable excuse.
For example, they may unconsciously use the somatization disorder to obtain nuturance or attention from others, have manipulative power over others, etc... |
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7. What is the etiology of somatization disorders?
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Psycho-Social factors
-family histories often have been characterized by; 1. a lack of emotional supports 2. alcohol problem in the family 3. delinquency from school An outward expression of underlying conflicts such as; 1. physical abuse 2. sexual abuse Histrionic features – learned behavior of turning psychosocial conflict into physical complaints Biological factors - Suspect faulty perception with somatosensory input as manifested by; a few brain imaging studies suggested a decreased metabolism in the frontal lobes and dysfunction in the non dominant hemispheres with impairment greater in the anterior as oppose to the posterior regions |
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8. Criteria for somatization disorder? The presence of what 4 symptoms must be met for Dx?
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A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.
Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance: 1. Four pain symptoms 2. Two GI symptoms 3. One sexual symptom 4. One pseudoneurologic symptom These above symptoms cannot be fully explained by a general medical condition. |
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9. What is the 4-tiered approach for somatization disorder Tx?
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1. Psychiatric consultation
2. Therapeutic relationship 3. Patient education 4. Reassure |
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10. Should medications be used on pts w/somatization disorder?
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Pharmacotherapy – consistent with best practice methods for depression and anxiety.
Somatized patients have a characteristic trait of complying erratically and unreliably with medications, so as to develop a drug dependence or use the medications as tools in a suicide attempt. Consequently, it is helpful to understand the patient’s social network to help manage the personal conflicts. |
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11. What is a conversion disorder?
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The disorder was identified by Joseph Breuer (1842-1925) and Sigmund Freud (1856-1939) and gets its name from the notion that the patient is converting unconscious psychological problems into a pseudo-neurological dysfunction in which there is inability to move specific parts of the body or to use their senses in a normal function which therefore appears to be a neurologic or general medical condition.
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12. What are some symptoms of conversion disorder?
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Symptoms may relate to the underlying psychological stress.
Common conversion symptoms often have a sudden onset in the setting of psychological stress and include psychogenic, nonepileptiform seizures (pseudoseizures), blindness, deafness, paralysis, mutism, falling, and psychogenic vomiting. Gait problems are common. |
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13. What is the etiology of conversion disorder?
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When patients present with conversion disorder, they may be trying to resolve or express an unconscious conflict.
Psychological factors: 1. Anxiety 2. General medical disorder 3. Histrionic personality disorder 4. Sexual abuse 5. Secondary gain Biologic factors: 1. brain imaging studies – found hypometabolism of the dominant hemisphere and hypermetabolism of the non dominant hemisphere 2. There may be excessive cortical arousual that sets off negative feedback loops between the cerebral cortex and the brainstem reticular formation. 3. There may be elevated levels of corticofugal output that inhibits the patient’s awareness of bodily sensation |
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14. What is the epidemiology of conversion disorder?
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Conversion disorder has a prevalence rate of approximately 0.1% but is far more common in psychiatric and neurologic populations and more common in women with a male-to-female ratio of at least 2:1.
Unlike other somatoform disorders, it is common in children and adolescents, where the gender ratio is equal. Like somatization disorder, conversion disorder is seen more commonly in patients with lower levels of education. Those from rural areas develop conversion disorder more commonly; even more striking is the increased prevalence among people from the developing world. |
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15. What is the criteria for conversion disorder?
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A. One or more symptoms or deficits affecting voluntary motor or sensory functions that suggest a neurological or other general medical condition.
B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors. C. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering) D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance. |
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16. What are 8 clinical features of conversion disorder?
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1. Most common in the extremities, maybe hemianesthesia.
2. Some who complain of complete lack of feeling in their legs are able to walk and have negative Romberg test paralysis, Babinski is absent, Hoover sign will elicit a pressure response. 3. Tremor – disappears when patient is distracted 4 Bilateral blindness – pupillary reflex is present 5. Globus hystericus – can swallow without difficulty 6. Parkinsonian – in a test for retropulsion, the conversion patient will try to gain balance 7. Syncope – draw attention and then fall 8. Nonepileptic seizures sometimes referred to as “pseudoseizures.,” depression is the most common co-occurring diagnosis, anxiety disorders , dissociative disorders, and personality disorders. Denial of external stressors is a cognitive factor more prevalent in patients with nonepileptic seizures than in patients with epilepsy |
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17. What are the treatment options for conversion disorder?
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1. Conservative (reassurance)
2. Aggressive (medications) 3. Insight-oriented therapy (talking about her experiences seemed to offer some relief from her symptoms, aka psychoanalysis) |
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18. What is hypochondriasis?
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A fear and/or preoccupation of having an illness, in spite reassurance to the contrary. The symptoms usually do not follow a recognizable pattern of organic dysfunction and are generally not associated with abnormal physical findings. Symptoms adversely affect social and occupational functioning and cause significant distress.
May begin during adolescence, with peak age in the 20’s and 30’s. There are no identifiable premorbid or prodromal signs. Etiology: 1. An exaggeration of normal somatic sensations 2. Social learning role of learning to be sick 3. May have an underlying mood disorder 4. Pain and suffering may be atonement for guilt feelings |
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19. Criteria for hypochondriasis?
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A. A preoccupation with fears of having or the idea that one has a serious disease based on the person’s misinterpretation of bodily symptoms.
B. The preoccupation persists despite appropriate medical evaluation and reassurance. C. The belief in Criterion A is not delusional and is not restricted to body appearance. D. The duration of the disturbance is at least 6 months. |
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20. Tx for hypochondriasis?
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Psychotherapy and pharmacotherapy
1. Collaboration among professionals involved with the patient 2. Reframe the patient from using the “sick role.” 3. Regular appointments 4. Prognosticators; i.e., severity of symptoms and duration of illness |
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21. What is a pain disorder?
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Pain disorder is likely the most common of all the somatoform disorders. Lifetime prevalence has been estimated as high as 12%.
Pain without physical cause, or pain that is felt beyond the histopathologic findings may be referred to as pain with psychological underpinnings. Patients with pain disorder present with predominant complaints about pain, which can be in any anatomic location but commonly include headaches and neck, back, abdominal, and pelvic pain. The psyche can be contributory of pain to; a. precipitate the pain b. maintain the thresholds of the pain c. exacerbate the pain |
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22. Criteria for pain disorder?
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A. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.
B. The pain causes clinically significant distress or impairment in social, occupational or other important areas of functioning. C. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain. D. The symptom or deficit is not intentionally produced or feigned as in factitious disorder or malingering. Acute = duration less than 6 months Chronic = duration more than6 months or longer |
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23. Treatment for pain disorder?
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Patients are best served in multidisciplinary pain clinics that have specialty programs designed to treat patients suffering with chronic pain. Analgesics are of limited benefit, and narcotic medications carry the risk of abuse and dependence. Dual action (serotonin and norepinephrine) antidepressants such as venlafaxine and duloxetine can benefit patients with pain disorder. Tricyclic antidepressants also have established effectiveness, but patients must be monitored closely for side effects.
Tramadol (Ultram)– mild to moderate acute or chronic pain, has dual pharmacological effects; 1. weak opiate agonist 2. reuptake inhibition of norepinephrine and serotonin. Adjunctive supportive psychotherapy aimed at improving functioning is also of benefit, as is relaxation training and physical therapy aimed at regaining function. |
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24. What is the McGill pain questionnaire?
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Can be used to evaluate significant pain experience, and monitor the pain over time, and can determine the effectiveness of any intervention
• minimum pain score: 0 (would not be seen in a person with true pain) • maximum pain score: 78 • The higher the pain score the greater the pain. |
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25. So, what is factitious disorder?
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A major distinction between factitious disorders and somatoform disorder, is that factitious disorders have no medical basis for the symptoms, and the patient produces reasons to be a sick person.
Factitious disorder is described as a disorder in which individuals present physical or psychological signs and symptoms BUT in the *absence of significant external incentives*. Certain patients will seek out medical providers and even hospitalizations by feigning symptoms. *This condition colloquially has been referred to as Munchausen syndrome.* |
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26. What are some symptoms of patients with factitious disorder?
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Characterized by:
1. Simulating a disease 2. Fabricating a histopathologic interview, onset, and causes 3. Evidence of self induced physical signs 4. Have some knowledge of medical field Also, A. exhibit numerous surgical scars B. display an evasive manner C. provide a medical history that has questionable trustworthiness D. clandestinely conceal information from medical providers that would uncover the patient’s feigned behavior E. learn symptoms and procedures on the internet |
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27. Criteria for factitious disorders?
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A. Intentional production or feigning of physical or psychological signs or symptoms.
B. The motivation for the behavior is to assume the sick role. C. External incentives for the behavior such as economic gain, avoid legal responsibility, or improving physical well being as in malingering are absent. |
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28. Factitious patients are typically...?
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1. young women
2. have family supports and involvement 3. passive and immature 4. have health related job training 5. single system complaints 6. not many hospitalizations |
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29. What are the guidelines for the diagnosis of factitious disorder with psychological signs and symptom?
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1. the symptoms are not constant, and change markedly from day to day
2. the symptoms are unconventional and fantastic 3. changes in symptoms are unrelated to the treatment provided, and may be more influenced by suggestibility, and exacerbation when patient senses they are being observed 4. an atypical lists of symptoms are simultaneous when the patient tries to convince others of the connectedness among the symptoms 5. the patient’s actual medical history are difficult to obtain due to; a. patient’s may refusal to authorize others to obtain records b. typically the patient has few or no visitors and prevents medical personnel from contacting family members or other persons able to provide information |
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30. What is the subtype of factitious disorder called Munchausen's syndrome?
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Munchausen syndrome is perhaps the most invasive of factitious disorders and is characterized by behaviors such as;
1. dermatologic ("dermatitis artifacta") 2. cardiac ("cardiopathia fantastica") 3. neurologic ("neurologica diabolica") 4. self induced symptoms 5. pathological lying (aka pseudologia fantastica) 6. abdominal ("laparotomophilia migrans") 7. hemorrhagic ("hemorrhagica histrionica") 8. febrile ("hyperpyrexia figmentatica") 9. doctor shopping May be a subset of plastic surgery patients that meet the SHAFT syndrome: Sad, Hostile, Angry, Frustrated, Tenacious |
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31. What is factitious disorder by proxy?
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Factitious disorder by proxy is a form of abuse. The identified patient is a child of a person with a factitious disorder who submits their children to tests and will feign symptoms in the child.
Usually (but not always) the perpetrator is the mother and the victim is her child in the pre or early verbal stage of development. Producing the signs and symptoms parallel those of factitious disorder. Factitious disorder by proxy carries great risks for the victim both in the short and long term (including death and physical or psychological illnesses). |
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32. Etiology of factitious disorder by proxy?
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1. Histories suggest childhood abuse, in which
2. having been hospitalized or sheltered from abuse, which nurturance was provided by medical staff idealized as authoritarian figures. 3. masochistic use of pain as punishment for past sins 4. frustrated desires to be a physician or other health professional may lead to playing out disappointment in the medical setting. |
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33. 9 warning signs of factitious disorder by proxy
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1. the symptoms occur recently after parent was with the child
2. child has been evaluated by numerous caregives without a diagnosis 3. only one parent involved despite the ostensive illness 4. the parent has a track record of fabrications 5. parent continues to request invasive and painful procedures for the child 6. the child consistently fails to respond to usual medical therapies 7. the signs / symptoms are lesser or absent when not around the parent 8. another child in the family has unexplained illness or childhood death 9. parent has a factitious disorder |
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34. What is the treatment for a factitious disorder?
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Patients with factitious disorder do not respond to any known psychological treatments.
The nature of the disorder has a paradoxical manifestation to treatment, ie, people simulate medical disorders. At best the medical community may attempt to mitigate against invasive and/or treatment methods that can have negative consequences to an otherwise healthy organism. In Proxy cases, legal intervention may be necessary to prevent procedures that are not medically recommended. It is necessary to not routinely discount a person’s legitimate medical problem who may also have a factitious disorder. In addition, counter-transference needs to be monitored. Patient education may be the most efficient intervention. |
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35. What is a malingering disorder?
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Malingering is the intentional production of symptoms in order to obtain both the sick role and some further secondary gain. Patients are typically interested in the material goods associated with illness, including disability benefits and housing.
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36. Symptoms of malingering disorder?
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Patients may present with malingering in order to avoid responsibility, gain material goods, obtain favorable judgments in criminal and civil proceedings, and access drugs of abuse.
Patients may present with specific complaints and requests and become quickly frustrated with delays in care or proposed alternatives. They may have rapid escalation in their behavior if their demands are not met and must be monitored for impulsive destructive behavior and suicide attempts. |
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37. Factors to consider if malingering is suspected:
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1. Presence of an antisocial disorder since this diagnostic category has associated symptoms of a sense of entitlement to get what they want and a lack of conscientiousness
2. Patient is non compliant with recommended action plan or treatment plan. 3. Errors in testing that are obviously exaggerated. 4. Inconsistent medical –social – psychological histories. 5. Treatment of an injury is significantly past the time of the accident. 6. The individual is cleared to return to work, but fails to do so. |
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38. Which is the only somatoform disorder that is as common in men as in women?
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Hypochondriasis
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39. Again, how is factitious disorder distinguished from conversion and malingering?
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Factitious disorder must be distinguished from conversion disorder and malingering. In conversion disorder, the production of symptoms is unconscious and usually related to a psychological factor.
In factitious disorder, patients are aware that they are producing symptoms even if they are unaware of the factors motivating them to do so. In contrast, patients who are malingering are aware of their motivation, typically secondary gain from being ill (benefits, housing, etc.). |
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40. Differentiate normal behavior from dissociative behavior
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Normal behavior:
1. spacing out during a lecture 2. daydreaming 3. becoming immersed in a book 4. doing something on automatic, (e.g., driving hypnosis - is driving without realizing how long one has been driving) Dissociative behavior 1. disruptions of consciousness, memory, identity, or perception of the environment 2. dissociative amnesia 3. dissociative fugue 4. dissociative identity disorder 5. depersonalization |
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41. Dissociative disorders are disturbances with integrated organization of...
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A. Memory
B. Identity C. Perception D. Consciousness |
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42. Describe the concept, etiology, and epidemiology of dissociative amnesia?
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1. Inability to recall important personal information (such as a personal memory), usually due to a traumatic or stressful nature that is too extensive to be explained by normal forgetfulness.
2. A loss of memory without neurological cause. 3. It is a rare disorder. 4. Recent behavioral health concerns about this disorder have created new interest especially with individuals who had a history of physical and sexual abuse Etiology 1. blow to the head 2. brain disorders 3. No apparent organic cause – pretending to have amnesia can have a secondary gain to avoid culpability of an event Epidemiology 1. typically adolescence or early adulthood 2. during a time of crisis / disaster |
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43. What are the 3 types of dissociative amnesia?
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1. Localized disturbance of recall – most common form, forget all events that occurred during a specific time, (e.g, a morning, or several days)
2. Selective amnesia – certain events not remembered, others events are remembered 3. Generalized amnesia – lack of recollection of the life prior to the event or the insult |
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44. Is the amnesia retro or anterograde in dissociative amnesia?
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Amnesia is retrograde (loss of memory for events preceding the onset of amnesia and NOT anterograde (loss of events after the onset of the amnesia as in trauma)
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45. DSM criteria for dissociative disorder
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The predominant disturbance is one or more episodes of inability to recall important personal information usually of traumatic or stressful nature not explained by ordinary forgetfulness.
The disturbance does not occur exclusively during any other medical or psychiatric disorder Significant impairment in social, occupational, or other important areas of functioning |
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46. Tx for dissociative amnesia?
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i. Remove the patient from the threatening circumstance
ii. Explore distress through psychotherapy – has been known to be effective for having amnesia clear without other interventions iii. The use of hypnosis, or evaluation under Pentothal may help recover lost memories iv. legal implications can place victims with amnesia at a disadvantage, and place perpetrators with a defense. |
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47. Describe the concept, etiology, and epidemiology of dissociative fugue
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with inability to recall some or all of the details of one’s past. Confusion about personal identity or assumption of a new identity
Etiology 1. Traumatic circumstances leading to an altered state of consciousness dominated by a wish to flee 2. Struggle with extreme emotions or impulses 3. Symptoms can last from hours to days, recovery is common but there may be refractory episodes of dissociative fugue. Epidemiology 1. More common during natural disasters, wartime, or major social dislocation and violence 2. Primarily in the military |
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48. What are the clinical features of dissociative fugue?
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During a fugue state they do not have intellectual impairment and maintain all cognitive skills. Dissociative Fugue states are typically short lived.
After recovery from a fugue, individuals may pursue psychotherapy to try and make sense out of what happened, and the memory from the fugue becomes amnestic. Dissociative fugue individuals may have a purpose to their behavior. |
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49. Criteria for dissociative fugue disorder?
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i. Sudden, unexpected travel away from home, work, with inability to recall one’s past
ii. Confusion about personal identity or assumption of a new identity iii. Not exclusively during the course of another DID or due to substance abuse iv. Cause distress or functional impairment |
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50. Describe the concept, etiology, and epidemiology of dissociative identity disorder (DID)
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The presence of two or more distinct identities or personality states that alternately take control of behavior. The individual has an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. They may change their names, handwriting, personality. They have lapses of time.
Etiology 1. severe experiences of childhood trauma or maltreatment 2. physical and sexual abuse Epidemiology: Limited case studies with EEG findings indicate variations of mood and in muscular reactions in cerebral blood flow and with smaller hippocampal and smaller amygdala volumes among alters. |
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51. What are the clinical features of DID?
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1. mood swings – may be misdiagnosed as mood disorder
2. sleep disturbances – may be misdiagnosed as anxiety or mood disorder 3. suicidal behavior 4. hallucinations – may be misdiagnosed as schizophrenia or mood disorder with psychotic symptoms 5. anxiety - that may be consistent with panic attack 6. quasi-neurological symptoms such as; -headaches -syncope -pseudoseizures -numbness -parathesias |
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52. DID patients have a “host” personality which is the personality that is present in the here and now, and an alter personality(s) that have their own distinct...?
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1. set of memories
2. thought patterns 3. personality, behavior, and attitudes 4. psychological test profiles 5. physiological characteristics, different alters have been known to even have different -GSR -heart rate and muscle tone -visual acuity, visual fields, color vision, & measures of ocular physiology and eye muscle balance *The transition between alters may be triggered by psychosocial stressors* |
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53. What are 10 patient complaints of DID?
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1. a fear they of being followed by some shadowy figure
2. discontinuity with thoughts and occasional thought slippages may be the result of alter identity switching 3. socially, many people with DID may job hop, and move around a lot, they may even doctor shop under the guise of a different identity 4. time distortions, without being able to account for the lapse 5. told of activities, not remembered by the individual 6. strangers know the individual, maybe by different name 7. uses the word “we” or “us” in discussion 8. being in possession of objects for which cannot be accounted 9. history of emotional/physical trauma 10. different handwriting styles |
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54. Criteria for DID
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i. The presence of two or more distinct identities or personality states that alternately take control of behavior.
ii. At least 2 of these identities recurrently take control of the person’s behavior iii. Inability to recall important personal info that is too extensive to be from ordinary forgetfulness iv. Not due to other substances |
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55. Explain the forensic issues associated with Dissociative Identity Disorder.
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Avoid culpability for a crime
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56. Differentiate normal behavior from Depersonalization Disorder
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Normal
1. waking up from a bad dream 2. entering a familiar room that was just re-decorated 3. déjà vu (sensation of feeling as if one has already experienced a situation when in a strange environment) or jamais vu, (sensation of being in a strange environment when in familiar surroundings), 4. food or sleep deprivation for a significant period of time may give one the sensation of being an observer of their own body Abnormal 1. Idiopathic – i.e., without an identified cause with a chronic course. 2. Secondary to other disorders, e.g., a. depression b. psychotic disorders, i.e., schizophrenia, borderline personality disorder, psychotic disorder not otherwise specified, even epilepsy c. anxiety disorders such as Panic disorder d. substance abuse such as with hallucinogens, sedatives, and narcotics |
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57. Features of depersonalization disorder
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Depersonalization is unlike other Dissociative disorders in that there is no Amnesia or disturbance of memory.
When such perceptual disturbances are persistent and severe enough to cause disruptions to their lives, these conditions are then diagnosed Depersonalization Disorder |
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58. Describe the concept, etiology, and epidemiology of Depersonalization Disorder.
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Concept
1. Persistent or recurrent episodes of feeling detached from and as if one is an outside observer of one’s mental process or body. 2. Feeling as if to be in a dream 3. Reality testing is intact, but environmental experiences seem *unrelated to the individual. Etiology 1. Overwhelming or painful experiences or conflictual impulses as triggering events 2. Traumatic stress 3. Serotonin regulation, NMDA receptor Epidemiology 1. After depression and anxiety 2. Seizure pts and migraine sufferers 3. Marijuana or LSD use, anticholinergic meds 4. Mild to moderate head injury or life threatening experiences 5. Late adolescence or early adulthood, middle age or older is rare, and typically sudden |
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59. Criteria for depersonalization disorder
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A. Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one's mental processes or body (e.g., feeling like one is in a dream).
B. During the depersonalization experience, reality testing remains intact. C. The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The depersonalization experience does not occur exclusively during the course of another mental disorder, such as Schizophrenia, Panic Disorder, Acute Stress Disorder, or another Dissociative Disorder, and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy). |
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60. What is delirium? What is its course?
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Delirium is a syndrome characterized by the rapid onset of variable and fluctuating
changes in consciousness, (mental status) caused by physiologic consequences of a medical disturbance. Typically, delirium develops over hours to days, and changes in mental status wax and wane over a short period of time. In most cases delirium improves fairly quickly when the causative factor is identified and corrected. Unlike dementia, *delirium is an acute or subacute condition with a reversible cause.* Altered level of arousal (either, over-active or under-active) and fluctuation in cognition and behavioral problems throughout the day and night are common. |
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61. Delirium may be a result of what three underlying disorders?
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1. General medical condition
-cardiac conditions -endocrine and metabolic disturbances -CNS insults -nutritional deficiencies -UTI's -fever -hypothermia 2. Substance intoxication -associated with psychoactive substances such as alcohol, amphetamines, caffeine, cannabis, opioids, hallucinogens, inhalants, phencylclidine, and sedative – hypnotics may cause delirium 3. Substance withdrawal -are possible with alcohol, sedative – hypnotics, and anxiolytics, narcotic drugs e.g., histamine (H-2) blocking agents, digitalis, and anticholinergics may cause delirium |
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62. What is pseudodelirium?
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Individuals having delirious symptomatology, but laboratory tests do not indicate a medical illness, it is possible the individual has pseudodelirium, which is when the symptoms may be related to a psychiatric illness such as dissociative fugue or a traumatic state
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63. What are the basic lab tests for delirium?
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a. Blood chemistries and tests, complete blood count
b. Electrocardiogram (ECG) c. Measures of arterial blood gases / oxygen saturation d. Serum and Urine drug screen e. Measurement of serum drug levels (e.g., digoxin, lithium, theophylline, phenobarbital, cyclosporine) f. CT or MRI of the brain g. Electroencephalogram (EEG) |
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64. What is the criteria for delirium?
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Evidence from lab work, physical exam, MMSE, and history that they etiology is due to:
A. Disturbance of consciousness, with reduced ability to focus, sustain or shift attention B. A change in cognition C. Disturbance develops over short period of time and tends to fluctuate during the course of the day |
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65. What are the 5 major clinical features of delirium?
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1. Sleep-Wake Cycle- disturbances of this cycle are common, often 1st symptom
2. Illusions – hallucinations: Visual hallucinations are the most common type of perceptual disturbance in the delirious patient 3. Behavior: psychomotor disturbances ranging from somnolence and lethargy to restlessness, agitation, and belligerence. 4. Cognition: attention and concentration are impaired in the delirious patient. Evidenced by distractibility during bedside interview. Specific tests include: serial sevens, digit-span testing, spelling “world” backwards, and repeating the months of the year in reverse order. 5. Memory: memory impairment is usually limited to the period of the delirium for which many patients are amnestic. Long term memory is generally preserved during an episode. |
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66. What is dementia?
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Dementia refers to a loss of cognitive function (cognition) due to changes in the brain caused by disease or trauma.
Usually the change involves some memory impairment that could be either anterograde or retrograde while in a state of full awareness. Dementia may also affect personality changes |
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67. Etiology, course, and epidemiology of dementia
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Course: the changes may occur gradually or quickly, and how they occur may determine whether dementia is reversible or irreversible
Etiology: Dementia is usually caused by degeneration in the cerebral cortex, they part of the brain responsible for thoughts, memories, actions and personality -Age – most common risk factor -Alzheimer’s (genetic inheritance) -Untreated infectious and metabolic disease and substance abuse • Epidemiology: and estimated 2 million people in the US suffer from sever dementia and another 1 to 5 million people experience mild to moderate dementia. *Risk doubles ever 5 years past 65* |
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68. What are the clinical features of dementia?
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1. Forgetfulness – frequent or inexplicable forgetting names or appointments
2. Difficulties with familiar activities – being absent minded (forgetting the oven is on) 3. Language problems – difficulties remembering simple words or the use of inappropriate filters 4. Problems with spatial and temporal orientation – not being aware of the street they live on 5. Impaired judgment – wearing inappropriate clothing for season or activity 6. Problems with abstract thinking – difficulty with numbers and calculations and cause and effect situations (ie putting the iron in the fridge) 7. Mood swings and behavioral changes 8. Personality change 9. Loss of initiative 10. Wandering – may roam inside a home or outside a home and become lost or endanger themselves in traffic |
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69. A requirement to diagnose a dementia is...?
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Memory Impairment, which is a prominent early symptom. Individuals with dementia also experience difficulty learning new material or forgetfulness of already learned material.
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70. What are the 3 types of dementia?
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1. Cortical – characterized by prominent memory impairment, specifically recall and recognition. In a addition to language deficits, apraxia, agnosia, and visuospatial deficits. Generally lack prominent motor signs.
2. Subcortical – has a greater impairment in recall memory, decreased verbal fluency without anomia (ability to name objects), bradyphrenia (slowed thinking) a depressed mood, apathy, and decreased attention and concentration. Typically feature prominent motor signs 3. Combination - some dementia types may present with a combination of features. |
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71. What are some examples of cortical dementias?
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CORTICAL:
1. Alzheimer's 2. Frontotemporal dementia 3. Pick's disease 4. Creutzfeldt Jakob |
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72. What are some examples of subcortical dementias?
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1. HIV
2. Parkinson's 3. Huntington's 4. MS |
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73. What are some examples of combination dementias?
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1. Vascular, multi-infarct
2. Vascular, post-stroke 3. Lewy body 4. Fragile X |
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74. Features of delirium
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FEATURE: DELIRIUM
Onset: Acute, often at night Course: Fluctuating, worse at night Duration: Hours to weeks Awareness: Reduced Alertness: Abnormally low or high Attention: Lacks direction, Distractible Orientation: Impaired for time Memory: Immediate and recent impaired Thinking: Disorganized Perception: Illusions and hallucinations Speech: Incoherent Sleep-Wake cycle: Always disrupted |
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75. Features of dementia
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FEATURE: DEMENTIA
Onset: Insidious Course: Stable over course of day Duration: Months or Years Awareness: Clear Alertness: Usually normal Attention: Unaffected Orientation: Often impaired Memory: Recent and remote impaired Thinking: Impoverished Perception: Often absent Speech: Difficulty finding words Sleep-Wake cycle: Fragmented sleep |
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76. Describe the biological, social, and psychodynamic etiologies of anorexia nervosa
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Biological – endogenous opioids may contribute to denial of hunger (think about increased appetite and weight gains in patients given opiate antagonists)
-Starvation leads to biochemical changes – high cortisol, thyroid suppression; amenorrhea, lower hormonal levels - bradycardia and hypotension that accompanies starvation is expected to be related to a decrease in norepinephrine -loss of appetite may be due to lower serotonin Social – Societal emphasis on thinness and exercise, especially on women -Sometimes have poor relationships with family – hostility, chaos, isolation, low levels of nurturance and empathy. Psychological and Psychodynamic -Adolescent desire for independence and desire to increase sexual functioning -Self-discipline helps them feel sense of autonomy and self-hood -Difficulty separating self from mother – by not feeding the body they aim to arrest development and destroy the intrusive object |
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77. What is anorexia nervosa?
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An obsession with weight and body shape. Use of food to deal with emotional problems and a desire for control. These individuals are always on guard to not gain weight and perceive themselves to be fat when in fact they are dangerously thin. They typically strive for perfection.
Intense fear of gaining weight Obsessions/Rituals with food Purging Secretiveness Rigidity of behaviors – inflexible, perfection driven |
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78. What will the physical exam show for a pt with anorexia nervosa?
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1. cachexia
2. low temperature, pulse and blood pressure 3. skin is dry 4. lanugo 5. poor oral hygiene 6. enlarged salivary glands 7. lab findings -depressed count of red blood cells, platelet and white blood cells -hypokalemia -elevated SGOT, LDH and alkaline phosphate -elevated amylase, in those who are emetic -EEG may show bradycardia, prolonged QT interval, nonspecific ST changes, and occasionally U waves, arrhythmias, ventricular fibrillation & asystole; syncopal episodes may occur |
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79. Criteria for anorexia nervosa
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A. Refusal to maintain body weight at or above a minimally normal weight for age and height, e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected.
B. Intense fear of gaining weight ore becoming fat even though underweight C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self evaluation or denial of the seriousness of the current low body weight. D. significant impairment in social, occupational, or other important areas of functioning Restricting type– has not regularly engaged in binge eating or purging (vomiting, diuretics or enemas.) Binge Eating / Purging type – regularly engages in binge eating or purging behaviors |
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80. What is bulimia nervosa?
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Ravenous overeating followed by guilt, depression and self anger. This kind of overeating is exclusive of holiday binge most people do. For the eating to be a bulimia nervosa, once eating begins there develops a sense of loss of control.
Isolation and secrecy – ashamed of their behavior – hide binging/purging Lack of eating schedule Specific foods – high in caloric value, and foods easy to digest (ice cream, pastry) Cognitive distortion – see themselves as fat Co-occurring disorders -Major depression -Anorexia nervosa -Panic Disorder -Borderline Personality Disorder -Substance Abuse |
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81. Describe the biological, social, and psychodynamic etiologies of bulimia nervosa
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Predisposing Factors
1. adolescent / young adult females 2. personal / family history of mood disorders, and/or obesity Biological factors 1. serotonin and norepinephrine have been implicated 2. vomiting may raise plasma endorphin levels Psychosocial factors 1. there are cultural nuances regarding thinness & physical fitness 2. typically occurs in certain occupations, arts (acting, dancing), athletics Exigent factors -Restricting food intake for fear of gaining weight may actually exacerbate binge eating -Decreased self esteem -Automatic thoughts and schemas -Physiological disturbances |
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82. Physical exam and lab findings for bulimia nervosa
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Lab tests may indicate;
1. elevated amylase levels 2. serum potassium may be decreased 3. magnesium may be decreased Physical examination for the patient with bulimia nervosa should include the above elements. In addition, patients may have parotid gland hypertrophy from vomiting, and erosion of the enamel of the anterior teeth due to chronic acid exposure from vomiting. Skin lesions on the fingers used to induce vomiting (Russell's sign) may also be found. Chronic conditions may result in; 1. acute gastric dilatation, (severe abdominal pain) 2. caries (decay of tooth tissue) 3. gastroesophageal reflux esophagitis 5. hypokalemia, (due to vomiting or over use of diuretics) 6. arrhythmias 7. cardiomyopathy (from extensive use of ipecac) 8. laxactive dependency |
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83. Criteria for bulimia nervosa
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A. Recurrent episodes of binge eating, characterized as:
1. eating in a discrete period of time, within any 2, an amount of food that is larger than what most people would eat during a similar period of time and/or similar circumstances 2. a sense of lack of control over eating during the episode, a feeling that one cannot stop eating or control what or how much one is eating B. Behaviors to prevent weight gain, i.e., self induced vomiting, misuse of laxatives, diuretics, or other medications, fasting or excessive exercise. C. Binge eating and compensatory behaviors both occur, on average, at least twice a week for 3 months. D. Self evaluation is unduly influenced by body shape and weight E. The disturbance does not occur exclusively during episodes of anorexia nervosa Purging type – regularly engages in self induced vomiting or the misuse of laxatives, diuretic, or enemas Non Purging type – fasted, excessive exercise, but not purging behaviors |
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84. Identify the parameters when hospitalization would be necessary for a person having an eating disorder
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Medical instability:
1. Weight less than 85 % of average body weight than expected 2. Dehydration 3. Hypotension (<80/50 mmHg) 4. Hypothermia (less than 96 F) 5. Electrolyte disturbances: a. hypokalemia b. hyponatremia c. hypophosphatemia 6. Cardiac dysrhythmia a. bradycardia [HR < 50 bpm day or < 45 bpm night b. orthostatic changes in pulse (> 20 bpm) or BP > 10 mmHg) 7. Evidence of organ compromise Acute psychiatric complications: 1. suicidal ideation 2. acute psychosis 3. obsessive compulsive disorder 4. severe family dysfunction Also: Failure of outpatient treatment Acute food refusal Uncontrollable binging and purging Poorly motivated patient needs a highly structured environment to eat |
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85. Explain re-feeding syndrome.
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Can occur during the first two to three weeks of refeeding among some patients having severe anorexia nervosa defined as one of two indices: having less than 75 percent of ideal body weight; and / or having lost a large amount of weight rapidly
Patients with severe weight loss who are rapidly refed are at greatest risk. Patients with recent rapid weight loss, as well as patients who have had prolonged weight loss, may also be at increased risk. Some of the complications of refeeding syndrome include; hypophosphatemia, cardiovascular collapse, rhabdomyolysis, seizures, and delirium |
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86. What are the two physiologic states of sleep?
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Normal sleep is divided into two physiological states. (NREM and REM) which alternate about every 90-100 minutes of normal sleep
In NREM, the metabolic demand of brain is decreased (dreamless sleep) In REM, there's paradoxical sleep (dreaming) |
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87. What are the 4 stages of NREM sleep?
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Stage 1 – beta level, body begins to transition between wake and sleep, brain is awake and relatively alert. Accounts for 5-10%
Stage II – alpha level, relaxed state, eyes closed, heart rate and breathing decreased. 40-50% sleep time Stage III – theta level, brain continues its slow waves Stage IV – delta level, “the deep sleep”, sleep walking and sleep talking. 20% sleep time |
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88. What are the features of REM sleep?
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-High level of brain activity
-Heart rate and breathing increase and become erratic -DREAMS occur – result of increase in blood flow to the primary cortical regions, and an associated decrease in blood flow to prefrontal cortex which may explain bizarre dreams -Plays role in MEMORY storage and creativity During REM sleep dreams may be the result of an increase in blood flow to the primary cortical regions, and an associated decrease in blood flow to the prefrontal cortex which may explain bizarre dream content. |
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89. What are 3 interesting things that can occur in REM sleep?
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1. Hypnopompic hallucinations
2. Hypnagogic hallucinations 3. Cataplexy |
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90. What are hypnopompic hallucinations?
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Hypnopompic hallucinations
–ordinary state of dreams or seeing visual images persisting after sleep and before complete awakening |
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91. What are hypnagogic hallucinations?
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2. Hypnagogic hallucinations – ordinary state of dreams that occur just before falling to sleep.
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92. What is cataplexy?
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Cataplexy – short term loss of muscle control (can last seconds and up to 30 minutes) experiences. May be induced by emotional intensity of anger, being surprised, or laughter. There is loss of muscle energy such as;
a. sagging jaw b. drooping eyelids, head or arms c. drop objects being carried d. buckle at the knees |
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93. What is the normal adult sleep cycle?
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Occur about every 90 minutes (may be a shorter period of time for depressed individuals or those diagnosed with narcolepsy – so they would get to REM faster than most people)
Waking usually transitions into NREM sleep REM occurs 4-5 times in a normal 8 – 9 hour sleep period First REM of night is usually about 10 minutes and then they increase in length to about 60 min |
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94. Characteristics of infants and elderly sleep cycles
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Infants sleep cycle: Infants have an overall greater total sleep time than any other age group (14-16 h)
Elderly: duration of III and IV sleep decreases. Increased time to fall asleep and more arousal periods at night |
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95. What are primary sleep disorders?
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Primary sleep disorders seem to be related to endogenous abnormalities in the sleep/wake timing and are subdivided into:
1. Dysomnias (quantitative changes) 2. Parasomnias (qualitative changes) |
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96. What are the 5 dysomnias?
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1. Primary insomnia
2. Primary hypersomnia 3. Narcolepsy 4. Breathing related sleep disorder 5. Circadian rhythm sleep disorder -delayed sleep phase type -jet lag type -shift work type -unspecified type |
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97. What is insomnia?
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Primary: the inability to fall asleep or maintain sleep and last for at least one month and have no physical or medical cause
Secondary: caused by a physical condition or clinical depression Etiology: diet, emotional difficulties, stress, underlying med disorder, RLS, apnea, etc Clinical features – difficulty falling asleep, frequent awakenings, poor quality, worry, etc |
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98. Criteria for primary insomnia?
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A. The predominant complaint is difficulty initiating or maintaining sleep for at least 1 mo
B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning C. The sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder or a parasomnia |
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99. What is primary hypersomnia?
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Definition: excessive somnolence, a compulsion for people to nap often during the day. Naps usually provide no relief of symptoms, which last for at least one month
A. The predominant complaint is excessive sleepiness for at least one month as evidenced by either prolonged sleep episodes or daytime sleep episodes that occur almost daily B. The excessive sleepiness causes clinically significant distress or impairment in social, occupational, or other important areas of functioning Etiology: narcolepsy, disrupted nighttime sleep, sleep apnea, ANS dysfunction, drug or alcohol abuse, medical conditions |
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100. What is narcolepsy?
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Definition – a chronic neurological disorder that impairs the ability of the central nervous system to regulate sleep, characterized by:
-Sudden shifts from wakefulness to sleep -Excessive daytime sleepiness -“nap attacks” that can occur almost anywhere -Cataplexy (loss of muscle tone) -Hallucinations (non-pathologic: hypnagogic and hypnopmpic) |
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101. What is the etiology of narcolepsy?
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a. there are no certain determinants
b. genetics is suspected c. environmental stressors that affect brain chemicals, such as a virus d. there seems to be an associative relationship between narcolepsy and intense emotions (sadness, frustration etc) |
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102. What is the Epworth sleepiness scale?
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Epworth Sleepiness Scale – patient rank orders the intensity to situations that induce sleepiness
1 – 6 points = Normal sleep 7 - 8 points = Average sleepiness 9 – 24 points = Possible pathological sleepiness |
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103. Criteria for narcolepsy
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A. Irresistible attacks of refreshing sleep that occur daily over at least 3 months
B. The presence of one or both of the following. Cataplexy and recurrent intrusions of elements of REM sleep into the transition between sleep and wakefulness. C. The disturbance is not due to the direct physiological effects of a substance |
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104. What are some other measures to evaluate narcolepsy?
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a. Epworth Sleepiness Scale – patient rank orders the intensity to situations that induce sleepiness
b. Nocturnal polysomnogram - electrical brain activity (EEG) and heart activity (EKG), and muscle activity (EMG) and eyes (electro-oculogram) and usually requires an overnight stay at a sleep clinic for observation purposes. c. Multiple Sleep Latency Test (MSLT) – measures the time it takes to fall asleep during the day, and identify sleep patterns. Can be used diagnostically when there are two or more sleep-onset REM periods during a MSL Test. d. blood test - measures antigens, often found in people with a family history of narcolepsy. Blood tests are not conclusive but may establish the possibility and probability of narcolepsy. |
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105. What is a breathing related sleep disorder, and what are the 3 types?
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Essential Feature: “sleep disruption leading to excessive sleepiness or insomnia due to abnormalities of ventilation during sleep. These abnormalities include apneas, hypopneas, and hypoventilation.
Three types are: 1. Obstructive sleep apnea 2. Central sleep apnea 3. Hypoventilation syndrome |
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106. What is obstructive sleep apnea?
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Most common, caused by obstruction of airway, often accompanied by snoring. Person wakes up often gasping for air.
The snoring is caused by partially obstructed airways (hypopnea); while the silent periods are caused by complete airway obstructions (apnea), for a period of 10-90 seconds. |
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107. What is central sleep apnea?
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Much less common and is due to a brain signal problem; the brain signal that instructs the body to breathe is delayed.
May be associated with irregular heartbeat, high blood pressure, MI, and stroke. |
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108. What is hypoventilation syndrome?
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Is a condition in which the lungs do not draw in sufficient air, can lead to fragmented rest due to decreased oxygen levels.
The condition can be caused by obesity, respiratory problems, or brain mechanism difficulties, and cardiovascular disease. |
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109. Criteria for breathing related sleep disorder
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A. Sleep disruption leading to excessive sleepiness or insomnia, that is judged to be
due to a sleep related condition, e.g, obstructive or central sleep apnea syndrome or central alveolar hypoventilation syndrome. B. Significant impairment in social, occupational, or other important areas of functioning |
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110. What is a circadian rhythm sleep disorder?
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The circadian rhythm is is the body's internal resting/wakefulness schedule over the course of a day. Each person has their own idiosyncratic rhythm which may be the reason for early risers, versus people who like late evening socializing.
A circadian rhythm sleep disorder is a mismatch between desired sleep and actual sleep, and can be characterized by: 1. Jet lag 2. Shift work 3. Delayed sleep phase syndrome |
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111. What is a delayed sleep phase syndrome?
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A delayed sleep phase syndrome occurs when people fall asleep more than two hours later than their desired bedtimes. This means the body wants to remain asleep until correspondingly later in the morning, making awakening at a desired time difficult.
Forcing the body to wake up too early leads to sleep deprivation. |
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112. Criteria for circadian rhythm sleep disorder
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A. A persistent or recurrent pattern of sleep disruption leading to excessive sleepiness or insomnia that is due to a mismatch between the sleep-wake schedule required by a person’s environment and his or her circadian sleep-wake pattern
B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning C. The disturbance does not occur exclusively during the course of another sleep disorder or other mental disorder Types: 1. delayed onset sleep phase type – inability to fall asleep 2. jet lag type – repeated across time zones 3. shift work type – frequent shift changes 4. unspecified type – irregular variable sleep and waking behavior that disrupts regular sleep – wake pattern. Associated with frequent daytime naps at irregular times. |
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113. What is Restless Leg Syndrome, (RLS)?
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RLS, a dyssomnia NOS, characterized by Itching, or sensations of something crawling in the legs, especially when lying down, The feeling is intrusive and alleviated slightly by moving the legs. Fragmented and poor quality rest due to constant leg motion leads to daytime fatigue and tiredness
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114. What is periodic limb movement syndrome (PLMS)?
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PLMS, a dyssomnia NOS, is most likely associated with renal disease, iron and vitamin B12 anemia, in which there are contractions of leg muscles that include toes to be extended, and flexion of the ankle and knee.
Typically middle to elderly age issue. |
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115. What are parasomnias? What are the 3 types?
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Involve waking someone from sleep they may have bizarre behaviors. It involves activation of the autonomic nervous system, motor system, or cognitive processes during sleep or sleep – wake transition and occur during sleep.
Types: 1. Nightmare disorder 2. Sleep terror disorder 3. Somnambulism |
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116. What is a nightmare disorder?
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Nightmare disorder are dreams that provoke anxiety which usually wakes up the individual. Always occur during REM sleep and usually after a long REM period late at night.
Most every one has an occasional nightmare. Usually occur during periods of stress. It is a myth that harm that waking someone up who is having a nightmare will do them harm. |
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117. Criteria for nightmare disorder
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A. Repeated awakenings from the major sleep period or naps with detailed recall of extended and extremely frightening dreams, usually involving threats to survival, security, or self esteem. The awakenings generally occur during the second half of the sleep period.
B. On awakening from the frightening dreams, the person rapidly becomes oriented and alert (in contrast to the confusion and disorientation seen in sleep terror disorder and some form of epilepsy). C. Significant impairment in social, occupational, or other important areas of functioning |
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118. What is a sleep terror disorder?
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Sleep Terror Disorder is a sudden awakening and/or screams, sitting up in bed. At times the individual, most commonly a child, will attempt to run and escape the terror thereby awakening an autonomic response with piercing scream and cry. Related symptoms may be tachycardia, rapid breathing, flushed skin, sweating, and dilation of the pupils, typically unresponsive to comfort.
***Typically occurs in the first one third of the night during NREM (stage III and IV sleep). The sleeper may awaken disoriented but return to sleep. May evolve into Sleepwalking disorder. |
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119. Criteria for sleep terror disorder
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A. Repeated episodes of abrupt awakening from sleep, usually occurring during the first third of the major sleep episode and beginning with a panicky scream.
B. Intense fear and signs of autonomic arousal, such as tachycardia, rapid breathing, and sweating, during each episode. C. Relative unresponsiveness to efforts of other to comfort the person during the episode. D. No detailed dream is recalled and there is amnesia for the episode. E. significant impairment in social, occupational, or other important areas of functioning |
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120. What is somnambulism?
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Sleep walking. These behaviors occur in the *first third of the night during deep NREM (stage III and IV) sleep*, may be as simple as sitting up in bed and then lying back down, or as complex as taking a walk or cooking.
Somnambulism is not often dangerous, but injuries may occur due to falls or leaving the house while asleep. The person frequently returns to sleep without recollection. Common triggers for sleepwalking include sleep deprivation, sedative agents (including alcohol), febrile illnesses, and certain medications. Onset usually around 4 to 8 years old and terminates in adolescence. |
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121. Criteria for somnambulism?
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A. Repeated episodes of rising from the bed during sleep and walking about usually occurring during the first third of the major sleep episode.
B. While sleepwalking the person has a blank, staring face, is relatively unresponsive to the efforts of others to communicate with him/her, and can be awakened only with great difficulty. C. On awakening (either from the sleepwalking episode, or the next morning) the person has amnesia for the episode. D. Within several minutes after awakening from the sleepwalking episode, there is no impairment of mental activity or behavior (although there may initially be a short period of confusion and disorientation). |
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122. What are some parasomnias NOS?
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1. REM sleep behavior disorder
-motor activity often of aviolent nature that arises during REM sleep. 2. Sleep paralysis 3. Situations in which the primary cause is due to a general medical condition or substance induced |
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123. What is sleep related bruxism?
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Tooth grinding - predominantly occurs during stage 2. It is estimated that 5-10% of the population brux to noticeable damage to their teeth. Symptoms include jaw aches.
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124. What is Kleine – Levin syndrome?
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Kleine-Levin Syndrome (“KLS”) characterized by the need for excessive amounts of sleep (hypersomnolence), (up to 20 hours a day); excessive food intake (compulsive hyperphagia); and behavioral changes i.e., hypersexuality, and irritability, lack of energy (lethargy), and/or lack of emotions (apathy), may appear confused (disoriented) and experience hallucinations.
May go for weeks or months without symptoms, then symptoms may persist for days to weeks and disappear with advancing age. Cause unknown suspected genetic predisposition, may be related to malfunction of the portion of the brain that helps to regulate functions such as sleep, appetite, and body temperature (hypothalamus). Occurs most commonly in adolescent males. |
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125. What is a normal personality?
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Normal personality-- an enduring, habitual pattern of thinking, behaving, and relating that determines a person’s adaptation and reaction to the two worlds in which they inhabit, that is both the inner psychological works and the outer environment
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126. What is the definition of a personality disorder?
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Personality disorder-- an inflexible & maladaptive response in which an individual would rather alter the external environment, rather than change oneself since the symptomatology of the disorder is typically ego syntonic, i.e., symptoms are not disturbing to the patients
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127. What are the three clusters that the DSM-IV separates the 10 personality disorders into?
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1. Odd or Eccentric (cluster A)
2. Dramatic,Emotional,Erratic (cluster B) 3. Anxious or Fearful (Cluster C) |
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128. What are the cluster A personality disorders?
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1. Paranoid
2. Schizoid 3. Schizotypal (Odd or Eccentric) |
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129. What is paranoid personality disorder?
Six symptoms... |
1. Pervasive distrust and suspiciousness of others
2. Shun close relationships 3. Trust own ideas and abilities excessively 4. View other's motives as malevolent 5. Critical of weakness/fault in others but unable to recognize own mistakes 6. Sensitive to criticism |
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130. Etiology and epidemiology of paranoid personality disorder?
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Suspected to have a history of being a victim of abuse, or humiliation.
The person can develop feelings of a lack of trust and of hostility toward others. Epidemiology: 1. rarely seek treatment, can mask their unusual behavior and suspiciousness. 2. relatives with schizophrenia show a higher incidence than controls 3. more common in men 4. common to have problems with jobs and relationships / marriages |
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131. Do people with paranoid personality disorder have delusional suspicions?
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NO, suspicions are only inaccurate and/or inappropriate
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132. What is schizoid personality disorder?
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A PD characterized by persistent avoidance of social relationships and little expression of emotion
Also have no social anxiety. |
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133. What are some characteristics of schizoid PD?
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-Loners
-Little interest in sex -Indifferent to family -Focus on self -Unaffected by criticism or praise -Emotional coldness, detachment or flattened affectivity Employment is usually grave yard shifts, such as night watch people |
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134. Epidemiology and etiology of schizoid PD?
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Epidemiology
1. One of the rarest of all personality disorders 2. 2::1 male to female ratio Etiology: Likely have experienced childhoods in which parenting and child care was detached, neglectful, cold and ways in which it could have been learned that relationships do not provide comfort and closeness. There are some inheritable qualities such as shyness, and introversion, and prenatal exposure to famine has been common seen among schizoid personality individuals. |
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135. What is schizotypal PD?
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Schizotypal PD is characterized by extreme discomfort in close relationships, odd forms of thinking and perceiving, and behavioral eccentricities.
Their speech is usually vague and metaphorical. They demonstrate inappropriate affect such as laughing when describing something quite serious. They have few friends, and lack a desire for relationships. |
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136. What are some characteristics of schizotypal PD?
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-Ideas of reference
-Bodily illusions -Belief in special extrasensory abilities -Belief in having magical control -Difficulty keeping attention focused -Conversation can be digressive and vague |
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137. What are ideas of reference?
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Belief that unrelated events pertain to them in some important way
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138. How is schizotypal PD different from schizophrenia?
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Differential factors between Schizophrenia and Schizotypal Personality is basically Schizoptypal personality disorder have an *absence of psychosis, or at best the psychoses are brief and fragmentary*
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139. Diagnostic Criteria: Schizotypal Personality Disorder: DSM-IV features Social-interpersonal deficits + cognitive-perceptual distortions
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5 of 9 symptoms needed to diagnose:
• Ideas of reference • Odd beliefs or magical thinking • Unusual perceptual experiences • Odd thinking or speech • Suspiciousness or paranoid ideation • inappropriate or constricted affect • Odd, eccentric, or peculiar behavior or appearance • Lack of close friends or confidants • Excessive social anxiety (associated with paranoid fears) |
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140. Which PD's are in the "dramatic" cluster (B)?
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1. Anti-social
2. Borderline 3. Histrionic 4. Narcissistic |
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141. What is antisocial PD?
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A PD marked by a general pattern of disregard for and violation of other peoples' rights.
These individuals have an abiding sense of entitlement, in that what ever they want and whatever they do, they believe they have an inalienable right to want it and/or to do it. |
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142. What are people with anti-social PD sometimes called?
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Sociopaths or psychopaths
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143. What is the epidemiology and etiology of anti-social PD?
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Epidemiology:
1. 3% in men and 1% in women 2. symptoms appear in childhood (Conduct disorder) 3. in prisons, the prevalence is as high as 75% 4. familial pattern is present Etiology: 1. Genetic factors - A. heritable traits include; 1. callousness 2. stimulus seeking B. abnormal serotonin transporter functioning manifested by; 1. impulsivity 2. aggressiveness 2. Physiological findings include; A. reduction brain volumes B. reduction in temporal lobe brain volumes C. deficient brain activation in limbic – prefrontal circuit during fear conditioning among psychopathic criminal offenders D. neurocognitive impairments in spatial and memory functions have been found 3.Psychosocial findings include; A. parenting styles; 1. absent 2. inconsistent 3. abusive B. substance abuse history |
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144. What are some characteristics of anti-social PD?
Five symptoms.... |
1. Lie
2. Careless w/ money and fail to pay debt 3. Irritable, aggressive, quick to fight 4. Reckless 5. Lack moral conscience |
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145. Criteria for anti-social PD?
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A. A pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years and significant impairment in social, occupational, or other important areas of functioning, as indicated by three of the following;
1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing act that are grounds for arrest 2. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure 3. impulsivity or failure to plan ahead 4. irritability and aggressiveness, as indicated by repeated physical fights or assaults 5. reckless disregard for the safety of self or others 6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations 7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another B. The individual is at least 18 years of age C. There is evidence of Conduct Disorder with onset before age of 15 years |
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146. What is borderline PD?
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A PD characterized by repeated instability in interpersonal relationships, self image, and mood and by impulsive behavior
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147. What are some characteristics of borderline PD?
six symptoms.... |
1. Emotions seem to always be in conflict w/ the world (paranoid ideation)
2. Prone to bouts of anger 3. Impulsive, self-destructive 4. Self-injurious 5. Intense, conflict-ridden relationships 6. Dramatic shifts in identity |
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148. In which gender is borderline PD more common?
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Twice as prevalent in women than in men
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149. Criteria for borderline PD
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-Features personal interpersonal instability and impulsivity
-5 of 9 symptoms needed to diagnose: • Frantic efforts to avoid real or imagined abandonment • Unstable and intense relationships • Unstable self-image or sense of self • Self-damaging impulsivity in at least 2 areas • Recurrent suicidal or self-mutilating behavior • Affective instability and reactivity • Chronic feelings of emptiness • Inappropriate, intense anger or difficulty controlling anger • Transient, stress-related paranoid ideation or dissociation |
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150. What is histrionic personality disorder?
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A PD characterized by a pattern of excessive emotionality and attention seeking
Patients diagnosed with this disorder impress others as overly emotional, overly dramatic, and hungry for attention. They may be flirtatious or seductive as a way of drawing attention to themselves, yet they are emotionally shallow. Histrionic patients often live in a romantic fantasy world and are easily bored with routine. More prevalent in women, and may be associated w/somatization disorder and EtOH use |
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151. What are some characteristics of histrionic PD?
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1. "emotionally" charged
2. Lack sense of really are 3. Vain, self-centered, demanding 4. Unable to delay gratification 5. Overreact when something gets in their way for attentions 6. Seductive or provocative behavior |
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152. What is narcissistic PD?
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A PD marked by a broad pattern of grandiosity, need for admiration, and lack of empathy.
. Narcissistic patients are characterized by self-importance, a craving for admiration, and exploitative attitudes toward others. They have unrealistically inflated views of their talents and accomplishments, and may become extremely angry if they are criticized or are outshone by others. They demand special attention. |
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153. Epidemiology and etiology of narcissistic PD?
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Epidemiology:
1. One of the rarest of the personality disorders 2. appears to be more common among males 3. may be a learned behavior passed down from one narcissist parent to their children instilling into the children their specialty, their omnipotence, their grandiosity, their beauty. Etiology: Theoretical premises supposes that these individuals use a learned survival tactic of masking their lessons that others have not demonstrated to be sources of support and/or comfort. Consequently, they develop an implausible sense of invulnerability and unrealistic sense of self support. |
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154. What are some characteristics of narcissistic PD?
Six things... |
1. Expect constant admiration and attention
2. Exaggerate achievements and talents 3. Appear arrogant 4. Choosy about friends 5. Make good first impressions 6. 75% are men |
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155. What are the PD's in the anxious cluster (C)?
three... |
1. Avoidant PD
2. Dependent PD 3. Obsessive-compulsive PD |
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156. What is avoidant PD?
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A PD characterized by consistent discomfort and restraint in social situations, overwhelming feelings of inadequacy, and extreme sensitivity to negative evaluation
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157. What are some characteristics of avoidant PD?
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1. Dread criticism
2. Feel unappealing or inferior 3. Exaggerate difficulties of new situation 4. Few or no close friends but yearn for intimate relationships 5. Feel depressed and lonely |
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158. Epidemiology and etiology of avoidant PD?
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Epidemiology
1. more susceptible among females 2. children with timid temperaments may be more likely to evolve into this disorder than children with high approach behaviors Etiology 1. research points to children whose childhood has serious episodes of isolation and rejection, poorer athletic performances, less involvement in hobbies, and being less popular 2. there is suspected inheritance of increased physiological arousal and avoidant traits in social situations as a retreat from unfamiliar situations and avoiding strangers |
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159. What is dependent PD?
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A PD characterized by a pattern of clinging and obedience, fear of separation, and an ongoing need to be taken care of
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160. How do dependent and avoidant PD differ in regard to relationships?
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People w/ avoidant PD have problems initiating relationships
People w/ dependent PD have difficulty with separation from relationships |
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161. What is obsessive-compulsive PD?
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A PD marked by such an intense focus on orderliness, perfectionism, and control that the individual loses flexibility, openness, and efficiency
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162. What are characteristics of obsessive-compulsive PD?
Six things... |
1. Fail to grasp point of activity b/c too focused on details/organization
2. Work is behind schedule 3. Set unreasonably high standards, perhaps due to history of harsh discipline 4. Rigid and stubborn 5. Usually white, educated, married, and employed 6. Twice as likely in men |
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163. How is obsessive-compulsive PD different from obsessive-compulsive disorder?
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This disorder should not be confused with Obsessive-Compulsive Disorder, which is an Axis I disorder, wherein there are actual obsessive behaviors and compulsive behaviors that interfere an individuals functioning.
OCD as an anxiety disorder has; A. repetitive thoughts B. ritualistic behaviors C. is ego dystonic (does not fit well) OCPD has; A. sense of orderliness B. perfectionism C. is ego syntonic, fits well |
