Psychiatry Exam 1

Front 1

1. Explain the differences between psychiatrists and non psychiatric physicians.

Back 1

By tradition or by default many patients have viewed physicians as authoritarians who identify a diagnosis, direct the treatment, and provide cures much like an ego surrogate, while the patient patiently is passive and awaits being told what to do and /or what not to do.

However, the role of the psychiatrist typically has been different than the role of non psychiatric physicians. Psychiatrists have been considered to be those who create interpretations of behavior to the patient, but not directing the treatment, not curing the patient, as many psychiatric diagnoses are described as non curable, e.g., schizophrenia, dementia, personality disorders, and others. Psychiatry is the medical specialty that focuses on brain disorders such as depression, anxiety disorders, schizophrenia, substance abuse disorders, and developmental disorders to name a few.

Front 2

2. Explain the similarities between psychiatrists and non psychiatric physicians.

Back 2

Today’s psychiatric treatment rests on a greater scientific knowledge base than it did years ago. Psychiatry uses evidenced based models to find treatments, prevent relapses, and extends the quality of life for individuals inflicted with brain disorders.

Traditionally, disorders falling into the province of psychiatry have been those of unknown etiology. However, with the advent of more sophisticated laboratory results and neuroimaging diagnoses have become more of a scientific process.

Front 3

3. What is the Multi-Axial diagnostic technique?

Back 3

The American Psychiatric Association (APA) began to organize and classify mental disorders according to symptomatic features so that clinicians around the world could function with a standardized nomenclature based on symptomatic features.

Eventually during the 1970’s the APA’s system became known as a multiaxial system which replaced the more observational methods of diagnosing, which suffered from inter-clinician reliability. Studies conducted before the multiaxial system of diagnosing found an inter-clinician rater reliability of “using kappa coefficients (which controlled for chance agreements between clinicians) of 0.33 to 0.77, with a median kappa coefficient of 0.53. Studies of structured interviews using kappa coefficients had produced 0.36 to 0.93 ranges of reliability with median kappa coefficient between 0.73 and 0.79,”

The psycho-medical-social integration is the theory in support of the Multi-Axial system of psychiatric diagnosing using the DSM-IV.

Front 4

4. What are 9 strengths of psychiatry?

Back 4

1. Newer assessment tools - that are based on structured diagnostic techniques
2. Preventions of relapses & recurrences - with maintenance pharmacotherapy
3. Multiple dimensions to assess and to diagnose,- e.g., all five Axes
4. Systematic evidence base - disorder-specific psychosocial treatments, e.g.,
a. cognitive behavior and /or problem solving therapy for depression
b. addictions model approach to treatment substance related disorders
5. Scientifically committed - to optimize treatment outcomes and personalize treatments
6. Evidence-based practice - to reach both specialty mental health and general medicine settings.
7. Advances in psychopharmacology - to decrease dangerous or adverse side effects, develop medications centered on patho-physiology based illness models rather than on serendipitous discoveries.
8. Developing a clinical neuroscience - to expand knowledge of the neural substrates for the cognitive and affective functions in psychiatric disorders
9. Creating database - for testable hypotheses about the biological underpinnings of psychiatric illness

Front 5

5. What are 3 major weakness of psychiatry?

Back 5

1. Limitations of the limited perspectives of clinical neuroscience that effect,
A. an understanding of genetics
B. efficient depth of brain imaging
C. cognitive and affective explanations for behaviors
D. psychometric theory used to;
1. define etiology
2. explain pathophysiology
3. create treatment-relevant phenotypes
4. personalizing treatment by identifying which treatment should be used for which patient at what point in the illness trajectory

2. Inequalities in the delivery of mental health services to vulnerable populations.

3. The integration of mental health services into other areas of medicine, from pediatrics to geriatrics.

Front 6

6. What is meant by “criminalization of psychiatric illness”?

Back 6

“Criminalization of the mentally ill,” which relates to the mentally ill being incarcerated, (Abramson, 1972),

Front 7

7. What is meant by “psychiatrization” of criminal behavior”?

Back 7

“Psychiatrization of criminal behavior,” by John Monahan, Ph D in 1973 which relates to some criminals finding their way into the treatment system by malingering in order to avoid prosecution and sentencing into prisons.

Front 8

8. According to the World Health Organization, neuropsychiatric disorders account for at least ____% of the global burden of illness-related disability

Back 8

According to the World Health Organization, neuropsychiatric disorders account for at least 20% of the global burden of illness-related disability, and all represent complex disorders of brain function,

Front 9

9. What is the sliding scale of informed consent?

Back 9

During assessments for refusal of treatment, clinicians must bear in mind that standards for informed refusal of a life-saving measure are greater than standards for consent to such a treatment.

Simply put, when the risk of the pts decision is great and the benefit is low, the pt must demonstrate a fuller and more complete understanding and appreciation of the situation. This has come to be known as the sliding scale of informed consent.

Front 10

10. What is meant by paternalistic care?

Back 10

Historically, physicians tended to act assertively and paternalistically toward those in their care, as a parent makes decisions for a child.

By assuming sole responsibility for medical decision making, the paternalistic physician emphasized the ethical principles of beneficence and nonmaleficence over respect for autonomy.

Front 11

11. Differentiate between transference and countertransference

Back 11

A transference is a reaction in which the patient's feelings for important figures in their lives are being enacted in the relationship with the phsyician.

A countertransference reaction is a physician's recognizing and managing his own feelings towards patients.

Front 12

12. How does this process apply to dealing with a difficult patient? What is the 3-step model here?

Back 12

1. Identify precisely what it is about the patient that is perceived as "difficult" (countertransference)
2. The physician should strive to view the troublesome behavior as a clinical sign that can provide useful clues to the pt's situation or illness (transference)
3. Look for a way to respond therapeutically to the patient

Front 13

13. What is Freud's Structural Theory of the Mind?

Back 13

He described the mind as having three levels; the id, ego, super-ego.

id – contains sexual (aka, libido) and aggressive instincts that are not accessible to
conscious awareness, and operates on the “Pleasure Principle.”

super ego – represents society’s moral standards that becomes integrated with the
personality. Like the id, the super ego is not bounded by reality, but operates from an “Ego Ideal”

ego – the arbitrator between the sexual and aggressive urges and what is morally right
and wrong. Provides for judgment, decision making, and is governed by the “Reality Principle.” Protected from anxieties by “Defense Mechanisms.”

Front 14

14. Describe normal development in terms of the health model

Back 14

(Normality is seen as the absence of pathology). If the deviant behavior ceases,
the patient is considered Cured.


Heredity & physiological malfunctions may predispose individuals to schizophrenia

Neural transmission play a major contributory role in mood disorders

Defect in the autonomic nervous system is suspect in the etiology of anxiety disorders

Dementia – has physiological causes, (primary -Alzheimer's and secondary - HIV)

Front 15

15. Describe normal development in terms of the statistical model

Back 15

In the psychological realm tests and measurements would be included in the statistical model where normality is determined by numbers.

The bell shaped concept that suggests normality is found under the curve, while abnormality is found at either end (or tail) of the curve.

The statistical method is used largely in psychometric testing, research, or in the definition of having achieved landmarks in behavioral development from birth to early childhood.

Front 16

16. What does 1, 2, or 3 standard deviations mean?

Back 16

+ / - 1 standard deviation means the data include 68% of the population.

+ / - 2 standard deviation mean the data includes 96% of the
cases will lie within

+ / - 3 standard deviations means that the data includes 99.8%

Front 17

17. What is the percentile rank?

Back 17

Percentile rank – the proportion of scores in a distribution that a specific score is greater than or equal to, usually used to determine the relative standing of a score in a series of scores

(# of scores below X) + (0.5)(# of scores = X)
/divided by/
(total # of scores)

Front 18

18. When are Z-scores used?

Back 18

Z scores - are used when it is necessary to compare different entities (also known as, population means).

The Z score normalizes the numbers by eliminating the original scores and then providing each entity (population) score with a mean of “0” and a standard deviation of “1” from the mean. Therefore, allowing comparison of different entities (populations) that will have equal distributions with a mean of “0” and a standard deviation of “1.”into a statistical significant language.

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19. When are T-scores used?

Back 19

T score – utilized in setting up norms for standardized tests. Used in studies where the population parameters are known, rather than estimated.

As it is very unusual to know the entire population, the t-test is much more widely used to obtain;
A. the average of the values in a sample
B. the standard deviation of a sample's values
C. the number of values in a sample.

Front 20

20. What are Wechsler IQ’s?

Back 20

Wechsler IQ’s – a measurement of intelligence involving the ability to perform a variety of cognitive powers that would include the processes of thinking, analyzing, synthesizing, aptitude, and making decisions.

Testing for intelligence involves assessing cognitive levels of ability through language (VIQ, verbal intelligence quotient) known on the test as verbal comprehension, and perceptual organization; and non verbal language (PIQ, performance intelligence quotient) on the test referred to as working memory, processing speed.

The statistical standardized score of VIQ and PIQ is referred to as the Full Scale Intelligence Quotient, (FSIQ). As a standard score the FSIQ has a mean of 100 and a standard deviation of approximately 15.

Front 21

21. How does one calculate an IQ?

Back 21

Mental age
---------------- x100
Chronological age

Front 22

22. What are 5 purposes of IQ?

Back 22

1. first used to identify learning-impairment
2. today also used to identify children with mental retardation
3. identifies learning disabilities
4. assesses for skills and abilities
5. assesses for aptitude and achievement, e.g., SAT

Front 23

23. What is a stanine scale?

Back 23

Stanine –is a type of scaled score used in many norm-referenced standardized tests. There are nine stanine units (the term is short for "standard nine-point scale"), ranging from 9 to 1.

Typically, stanine scores are interpreted as above average (9, 8, 7), average (6, 5, 4), and below average (3, 2, 1). Using only nine numbers, stanine scoring is usually easier to understand than other scoring models.

Front 24

24. Describe normal development in terms of the self model

Back 24

Self Model Perspective of normality is Evolution or Developmental

Includes:
Kornei Chukovsky
Harry Harlow
Carl Rogers
Abraham Maslow
Jean Piaget
Lev Vygotsky
Frederick Perls
Erik Erikson

Front 25

25. Kornei Chukovsky believed that...?

Back 25

Kornei Chukovsky, (1882-1969) Children as linguistic geniuses

In the normal developing child early life milestones achieved within the first year of life include; language and interpretation. Chukovsky contended that children are linguistic geniuses and tired explorers as in their early years they not only learn to talk but also inspect the usage of words.

Front 26

26. What was Harry Harlow's experiment?

Back 26

Studied social learning and the effects of social isolation in monkeys.

The monkeys preferred the terry-cloth surrogates, which provided contact and comfort, to the feeding surrogate. The result of the experiment was that over time the isolated monkeys were maladjusted demonstrated by being emotionally withdrawn, unable to mate, incapable to care for their own offspring,

The results of Harlow's experiments were widely interpreted as indicating that infant attachment is not simply the result of feeding.

Front 27

27. What causes disorganized attachment behavior (or Reactive Attachment disorder)?

Back 27

In families where the parent/caregiver deprives the child of timely and effective nurturing, and consistently unavailable due to being socially, emotionally, or otherwise unprepared for parenthood the child develops insecurity and what is referred to as “disorganized attachment behavior,” or Reactive Attachment disorder.

A clinical picture of this child may be described as the non-organic failure to thrive such as with a retarded developmental physical appearance and may be malnourished, and the expected social interaction and liveliness are not present. The infant may appear sad, joyless, listless, and frightened.

Front 28

28. Carl Rogers believed that psychological disorder is the degree of incongruity between ....?

Back 28

Psychological disorder is the degree of incongruity between the Ideal and the Real Self. Self Actualization is the closest fit possible between the two selves.

Self actualization to Rogers is the closeness of fit (“congruence”) between Ideal Self and Real Self.

Front 29

29. Rogers believed that the seat of abnormal behavior is what?

Back 29

Rogers believed that the seat of abnormal behavior is is the anxiety of conditional acceptance.

For example, parents often convey the notion that being good is rewarded by attention, affection, and permission. Love in that situation is a condition of “if’s” if the child is good they can receive attention, affection and permission, but “if” the child is not good they do not receive attention, affection and permission. The child develops anxiety and insecurity about not being good and therefore will be un-loved.

Front 30

30. What is Maslow's hierarchy of 5 needs?

Back 30

Self Actualization - fulfill one’s unique potential, obtained only after all lower stages have been fulfilled

Esteem needs – self esteem related to the seeking the respect of others, and to create an internal locus of control and self respect

Love and Affiliation – warm relationships, with friends and family

Security and Safety – stable and predictable environment

Physiological - satisfy hunger, drink, s ex drives

Front 31

31. What did Maslow believe about self actualization?

Back 31

Self Actualization or normality to Maslow is attained by mastering a Hierarchy of Needs. Movement into a higher level can only be achieved if antecedent levels are satisfied.

As the levels are sequentially satisfied the person develops a normal personality but frustration at any stage stops normal growth and
development and the person remains at the last stage successfully completed. (Stagnation)

Front 32

32. What is Genetic Epistemology

Back 32

Genetic Epistemology is a theory based on stages of evolutionary cognitive process.

Piaget thought that “understanding” correct from incorrect responses as measured by standardized IQ tests was equally important as to know HOW the children get it wrong, i.e., how does knowledge grow?

Front 33

33. Piaget noted that even infants have....?

Back 33

He noticed that even infants have sensori-motor schemas - which are skills of how infants learn about objects in their environment, and these skills direct the way in which the infant explores their world.

For example, an infant is gratified by the oral cavity regardless if this behavior is learned or instinctual.

Front 34

34. What is assimilation?

Back 34

When infants and children associate new objects in the environment by using understandings already in existence Piaget referred to this as assimilation.

For example, when a child learns that a spoon can be used to eat with, becomes associated with the notion that all spoons can be used for eating.

Front 35

35. What is accommodation?

Back 35

When the child expands the schema into more abstract awareness Piaget referred to this as accommodation.

For example., from the spoon seen as an eating utensil, the child may see spoons and similar objects as a way to move things such as shovels, and steam shovels.

Front 36

36. Assimilation and accommodation are the two sides of...?

Back 36

Adaptation, which is Piaget’s term for what most of us would call learning, or also explained as using mental processes to organize the environment.

Front 37

37. What is equilibrium?

Back 37

According to Piaget, assimilation and accommodation are directed at a balance between the structure of the mind and the environment as the ideal state he called equilibrium.

Front 38

38. Piaget's 4 stages of cognitive development

Back 38

1. Sensorimotor (birth - 2 years)
2. Preoperational (2- 7 years)
3. Concrete operational (7-11 years)
4. Formal operational (11+ yrs)

Front 39

39. Sensorimotor stage - what is the critical achievement of this stage?

Back 39

Sensorimotor (birth to 2 years) - mental processes that encompass use of motor and sensory reflexes to interact with the environment, trying to effect change in the environment, *object permanence* (in which out of sight does not equate with out of existence), is the critical achievement of this stage,* and shows signs of reasoning to master their world.*

For example, repeating behaviors such as repeatedly squeezing a toy that makes a noise just to make the noise last longer.

Front 40

40. Preoperational stage - what are two critical achievements of this stage?

Back 40

Preoperational (2 years to 7 years) – is when the mastery of symbols takes place.

A symbol is a thing that represents something else i.e., **creative play***, wherein toys become pretend, such as pretend food, a box becomes a bed, etc.

The child is quite ***egocentric***, everything that happens in the world is because of them, and for them.

Front 41

41. Concrete operational stage - what is the critical achievement at this stage?

Back 41

Concrete operational (7 years to 11 years) - children learn *mastery* of categories, relations, and numbers and how to ***reason***

Front 42

42. Formal operational stage - what is the critical achievement at this stage?

Back 42

Formal operational (abstract thinking) (11 years and up) - The last stage deals with the mastery of adult style of thought.

This stage involves using logical operations, and using them in the abstract, rather than the concrete. We often call this hypothetical thinking and ***deductive reasoning***

Front 43

43. Lev Vygotsky identified what zone?

Back 43

He identified the Zone of Proximal Development, which meant the distance between what a child can do alone from what the child can do with the help of someone else.

In other words, lessons learned from the socio-cultural tools of interaction such as speech, and writing are what connects people and these tools become internalized which leads to higher thinking skills.

Vygotsky's social development theory stands in opposition to traditional teaching methods, known as lecture and cognitive regurgitation.

His theory suggests that social development learning, facilitates cognitive development over other instructional strategies.

Front 44

44. How does Frederick Perls feel about fragmentation?

Back 44

Normality to Perls was the Unification of Self while Abnormality was the Fragmentation of the Self.

Gestalt Theory conceptualizes the Self as a Wholeness ( i.e., body to mind, organism to environment) but having polarities. E.g., it is not likely that we can have a phenomenon of youngness without having its polarity of oldness, or hot to cold. Gestalt theory is to re-unite the whole, which is a way to create a new “gestalt,” from polarized splits.

Organisms are believed to have unity, i.e., proprioception (sensory system) works in tangent with movement and manipulation from the musculo-skeletal system. When there is unity it can then be said the person - is - normal.

Normality exists when there is organismic self regulation.

Front 45

45. Give me more info on this Gestalt theory...

Back 45

New gestalts happen frequently and so long as the individual responds adequately to wants and needs, and to what happens in the environment the individual is in harmony.

Equilibrium occurs when we can realistically evaluate situations and responsibly initiate actions in accordance to who one is and what the situation requires.

Abnormality exists when there is dissonance among the organismic systems of the person. For example, old ways of doing things (gestalts) do not give way to new ways of doing things when the new ways are more efficient. Some old behaviors linger because they remain known to the individual, while newness becomes threatening due to its lack of familiarity.

The system may have made cognitive commitments to change but the affective system may not be in harmony with change.

Front 46

46. What theory did Erik Erikson create? (hint - it also starts with an E)

Back 46

The “Epigenetic theory,” of Erikson believed normal or abnormal behavior occurs throughout a Life Cycle.

At each stage he perceived certain challenges. If the challenges were successfully accomplished the individual will develop normally, but if the challenges were not successfully accomplished the individual will perpetuate abnormal reactions at each successive stage.

Front 47

47. What are Erikson's 8 stages of development?

Back 47

1. Hope: Trust vs. Mistrust (Infants, 0 to 1 year)
2. Will: Autonomy vs. Shame & Doubt (Toddlers, 1 to 3 years)
3. Purpose: Initiative vs. Guilt (Preschool, 3 to 6 years)
4. Competence: Industry vs. Inferiority (Childhood, 6 to 11 years)
5. Fidelity: Identity vs. Role Confusion (Adolescents, 11 to 20 years)
6. Love: Intimacy vs. Isolation (Young Adults, 20 to 30 years)
7. Care: Generativity vs. Stagnation (Middle Adulthood, 30 to 65 years)
8. Wisdom: Ego Integrity vs. Despair (Seniors, 65 years to death)

Front 48

48. Explain abnormality in terms of the biological model

Back 48

Biological approaches usually involve (but are not limited to) the use of medications to deal with mental illness.

However, it has been found to be a best practice method to combine medication therapy with insight-oriented and/or cognitive – behavioral psychotherapy.

Front 49

49. Left & right hemispheres

Back 49

Left hemisphere involved with language and general cognitive functions, such as sequential analysis, logical interpretation of information, interpretation and production of symbolic information, abstraction and reasoning. Memory stored as language .

Right hemisphere, manages nonverbal processes, such as attention, pattern recognition, line orientation and the detection of complex auditory tones, such as processing multi-sensory input simultaneously, coordinates visual spatial skills.

Front 50

50. Basal ganglia

Back 50

The head of caudate nucleus and the pathway that connects the caudate with the prefrontal cortex and cingulate gyrus – a disturbance of this site is believed to be involved with Obsessive-Compulsive disorders

Front 51

51. Cerebellum

Back 51

Involved with balance and motor control, impairment to this site may relate to speech impairment, tremors, ataxia and nystagmus

Front 52

52. Hypothalamus

Back 52

Regulates homeostasis. It has regulatory areas for thirst, hunger, body temperature, water balance, and blood pressure, and expressions of emotion

Front 53

53. Frontal lobes

Back 53

Involved with future planning, judgment, concentration, emotions, inhibitory functions, personality, and movement. Some patients with schizophrenia have CT scans and MRI scans and blood flow studies that suggest a disturbance in the system that connects the basal ganglia to the frontal lobes, and some others seem to have disturbances in the frontal lobes.

Impairment may manifest as flat affect, reduced social and sexual inhibitions, and difficulty with learning new skills.

Front 54

54. Temporal lobes

Back 54

Involved with expressive and receptive speech, language memory, aggressiveness, learning and emotions. Some patients with schizophrenia have CT scans and MRI scans and blood flow studies that suggest a thinner cortex of the medial temporal lobe than people who do not have a diagnosis of schizophrenia.

Impairment may manifest as agitation, irritability, and receptive and sensory aphasia.

Front 55

55. Parietal lobes

Back 55

Involved with perception as with visual-spatial information, and body sensations such as touch, one’s image with extrapersonal space.

Impairment may manifest as an inability to orient self to person, place or time.

Front 56

56. Hippocampus

Back 56

Is essential for the formation of long-term memories. Some patients with schizophrenia have CT scans and MRI scans and blood flow studies that suggest that the anterior portion of the hippocampus is smaller than people who do not have a diagnosis of schizophrenia.

Front 57

57. Amygdala

Back 57

Involved with emotions and sends signals to the hypothalamus and medulla which can activate the flight or fight response of the autonomic nervous system. The amygdala receives a rich supply of signals from the
olfactory system, and this may account for the powerful effect that odor has on emotions (and evoking memories).

Front 58

58. Hypothalamus

Back 58

Involved with mediating irrational from rational thought and behaviors

Front 59

59. Cholinergic system

Back 59

Cholinergic system “acetylcholine” – is the primary transmitter of the PNS, and involved with dementia such as with Alzheimer’s disease

Front 60

60. Dopamine

Back 60

Involved with motor functions as well as neurological activity.

1. Too little dopamine may interact with environmental conditions may trigger tremors and paralysis such as with Parkinson’s disease.
2 Too much dopamine may cause hallucinations and bizarre thoughts of schizophrenia.
3. D2 receptor subtype seems to be the major site of action for traditional antipsychotic medications that bind to and block dopamine receptors.
4 D1 and D4 subtypes are implicated with the newer Atypical antipsychotic medications

Front 61

61. Norepinephrine

Back 61

Drives the excitatory sympathetic nervous system; increases heart rate and blood pressure. A deficit of norepinephrine is believed to be implicated in depression

Front 62

62. Serotonin

Back 62

Performs inhibitory roles in regulating behavior and involved with mood, sleep, pain, sensitivity, appetite, sexuality and impulse control.
Deficits may cause poor impulse control, violent behavior, sleep disorders, OCD or aggressive behavior depending upon what part of the brain is affected. For example, serotonin deficits in the amygdala that processes fear and emotions may result in anxiety.

Front 63

63. Explain abnormality in terms of the behavioral theory (what are the 5 theories on behavior?)

Back 63

1. Classical conditioning (Pavlov)
2. Classical conditioning (Watson)
3. Operant condition (Skinner)
4. CBT (Beck)
5. Rational-Emotive theory (Ellis)

Front 64

64. Classical conditioning (Pavlov)

Back 64

Pavlov had studied the digestive system of dogs when he accidentally found a cause – effect reaction with dogs.

In Pavlov’s experiment the food was the stimulus and the salivation was the response. However, Pavlov found dogs to salivate when they were not supposed to salivate, for instance some dogs began to salivate at the sight of a lab assistant who brought their food, other dogs began to salivate when they heard the sound of the food bowl, and some other dogs even salivated at the time of the day they usually were fed.

Front 65

65. What is the unconditioned stimulus?

Back 65

By the term unconditioned was meant unlearned, involved no previous learning, or naturally occurring.

(food)

Front 66

66. What is the unconditioned response?

Back 66

It is the unlearned reaction that occurs because of genetic pre-plannings of the nervous system.

In Pavlov’s study the salivation is the UCR.

Front 67

67. What is the controlled stimulus?

Back 67

Almost any stimulus could be associated with the UCS if paired often enough and close enough in time to the UCS. I

The dish itself began to produce salivation response, which then became known as the Conditioned Stimulus because the dogs learned to salivate at the sight and sound of the dish. A ringing of a bell was also used for the CS.

Front 68

68. What is the conditioned response? What happens if the CR is not reinforced?

Back 68

Conditioned Response (CR) – a reflex response to the CS. In other words, the dogs salivated in response to the dish (CS).

In classical conditioning the premise is that behaviorists can elicit desired responses from controlled actions. The response will continue if it is reinforced. However, when the CR is not reinforced, i.e., extinction occurs and the CR goes away.

Front 69

69. Why was Pavlov's experiment important?

Back 69

Pavlov’s discovery was seminal in the concept that human responses and not instinct may be the result of learned behavior where our values are carved out of a conditioning process as association with our environment. E.g., we associate nurturance and caring with food and warmth; we associate enemy with pain.

Front 70

70. Classical conditioning (Watson)

Back 70

WATSON has been credited for founding the psychology school known as “Behavioralism.”

Watson’s popular 1920 experiment of “Little Albert” was written in his article “Conditioned Emotional Reactions,” in which he indicated that he was able to predict and control behavior.

The bottom line for Watson was that the fears of humans may be the result of conditioning.

Front 71

71. What was little Albert's experiment?

Back 71

Albert was said to have no fears at 11 months of age. He wanted to play with a white laboratory rat. However, whenever Albert reached for the white rat, someone would strike a metal bar with a hammer behind Albert and out of Albert’s sight. Albert had no immediate significant reaction to the sound except to be startled. However, when the experiment continued the more times Albert heard the noise in relation to having reached for the white rat, Albert became frightened, crawled away from the rat and cried. After several exposures with Albert, the rat and the noise, the noise was removed and Albert showed the same fearful reaction to the rat without the noise.

Front 72

72. Implications of little Albert

Back 72

Watson indicated that he used a classic pavlovian stimulus-response model to account for Little Albert’s phobic response. Little Albert’s anxiety was instigated by a naturally arousing stimulus, i.e,"", a white rat, but Watson presented the white rat at the same time he introduced a neutral stimulus i.e., loud noise, the hammer striking the metal bar. He paired these two stimuli on several occasions, and then discovered by way of elimination that the neutral stimulus could elicit the anxiety response. Therefore, the neutral stimulus becomes the conditioned stimulus for anxiety. If the conditioned stimulus is not reinforced by the unconditioned stimulus it loses its effectiveness.

The experiment created a conditioned fear reaction.

Front 73

73. What is operant conditioning (Skinner)?

Back 73

Operant Conditioning - behavior is based on internal conditioning rather than on environmental forces.

Operant conditioning follows the Law of Effect – if a response is followed by a pleasurable consequence it will tend to be repeated, and if followed by an unpleasant consequence, it will tend not to be repeated

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74. What did Skinner believe about behavior?

Back 74

SKINNER, held that the concept of “consequences of behavior,” may be the determinant to human behavior i.e., behavior that is followed by pleasurable consequences will be repeated, and behavior that results in pain or discomfort will be discontinued.

Front 75

75. What is positive reinforcement?

Back 75

Behavior increases

Something added increases likelihood that desired behavior will be repeated.

E.g., to keep employees working they are provided with a pay check.

Front 76

76. What is negative reinforcement?

Back 76

Behavior increases

To increase the likelihood of a behavior to re-occur something is taken away from a situation in order to increase the chances of the desired behavior happening.

E.g. to quiet the sound of a seat bell alarm one must buckle their seat belt which is then compliant with safety standards and the law.

Front 77

77. What is positive punishment?

Back 77

Behavior decreases

A noxious or unpleasant stimulus is added to decrease unwanted behavior, E.g., a grounding for disobeying.

Front 78

78. What is negative punishment?

Back 78

Behavior decreases

To decrease the likelihood of a behavior by invoking some punishment to be used as a deterrent when the behavior is exhibited by removing something good.

E.g., losing money through being fined, or losing the right to live by being executed. Knowing these punishments exist is intended to encourage avoidance of unwanted behaviors.

Front 79

79. Difference between classical and operant conditioning?

Back 79

Classical: Learning a reflex depends on an antecedent

Operant: Learning a reflex depends on what happens after the consequence

Front 80

80. What is CBT (Beck)?

Back 80

CBT has as its premise that people act in abnormal ways due to having inappropriate thinking processes.

BECK – believes that mood disturbances could be the result of faulty thinking. People will cognitively distort thoughts, beliefs, attitudes etc., for example by magnifying minor events, to which Beck referred to as over-generalizing, and/or catastrophizing, or choosing selective reactions over a myriad of potential reactions, or ignoring the evidence which would reveal the distorted thinking

Front 81

81. What is the Beck's negative cognitive triad?

Back 81

Individuals develop automatic thoughts from which schema’s (rules by which to lead one’s life) are reinforced.

Included a negative:
1. View of self- e.g., “I’m no good”
2. View of world- e.g., “The world
is out to get you”
3. View of future- e.g., “There will never be someone for me”

Front 82

82. What is Rational emotive-behavioral theory (RET)?

Back 82

(RET) - is the process to repair
dysfunctional personality, which has roots in irrational beliefs, and that which results in erroneous self appraisals

Front 83

83. What are Ellis' A, B, C's of RET?

Back 83

A: Activating event
B: Belief system
C: Consequence

In other words, undesirable emotional Consequences (e.g., severe anxiety, clinical depression, hostility, feelings of inadequacy) can be traced to the individual’s irrational Beliefs that emanate from Activating events.

Front 84

84. What are the 3 main forms of irrational beliefs in RET?

Back 84

1. I MUST be competent, adequate, and win the approval of everyone else. When these are not attainable the individual “awfulizes” (a term coined by Ellis) and the person’s belief system registers him/her as a failure and as a rotten person.
2. Others MUST treat the self with kindness, and fairness. When this does not happen the individual condemns everyone as worthless. The self then takes on hostile feelings, sometimes violent, vindictive and at extreme circumstances homicidal.
3. I need and MUST have everything I really want. The world in which the self lives must gratify desires easily, and immediately. Discomfort and deferred gratifications are intolerable.

Front 85

85. What is the psychoanalytic theory?

Back 85

Psychoanalysis is concerned with the process of how the individual internalizes the outside world, through sensory systems, motor systems, and associative functions. Understanding the nature of the mind has led to development of models of psychoanalysis.

Front 86

86. What was Freud's contribution to psychoanalytic theory?

Back 86

Freud – is credited as having developed psychoanalytic psychology, and for being referred to as the the father of psychoanalysis.

Some of his most impacting contributions to psychology / psychiatry has to do with unconscious processes that characterize our personality. Such processes include: topographical theory of the mind, stages of sexual development, structural theory of the mind, ego defense mechanisms, dream interpretations, and doctor – patient transference and countertransference issues

Front 87

87. What is the conscious mind?

Back 87

Conscious – the mental process in which external perceptions and internal perceptions come into awareness. It is bound by time, (i.e., things that are not significant become lost to recall).

Front 88

88. What is the unconscious mind?

Back 88

Unconscious - the mental process that is motivated by primary wish fulfillment related to sexual drives and self-preservation drives but are censored from conscious awareness. It is not bound by the temporal limitation of time. Feelings about events that happened to us a long time ago are just as relevant in the moment as when they occurred. Verbal symbols are meaningless to the unconscious, consequently during free association of psychoanalysis words are again re-united with memory and the recall can then move into the consciousness again.

Front 89

89. What is the preconscious mind?

Back 89

Preconscious - the mental process that serves as the transitional conduit to bring unconscious material to the conscious level.

Front 90

90. What are the 5 stages of psycho-sexual development?

Back 90

1. Oral stage (birth to 18 mos)
2. Anal stage (18-36 mos)
3. Phallic stage (3 to 6 years)
4. Latency stage (6 years to puberty)
5. Genital stage (puberty to adulthood)

Front 91

91. Which of Freud's stages is analogous to Erikson's stage of Autonomy vs Shame and Doubt?

Back 91

Stage 2 - Anal stage – 18 to 36 months

Establishes independence from self doubt.

The period of neuromuscular control over anal sphincters. When the toddler can toilette train, s/he becomes more active and not a passive recipient of being taken care of. These voluntary control lessons enable the toddler to become ready to manage future struggles with body functions, relationships, impulses and fantasies.

Front 92

92. Which of Freud's stages is analogous to Erikson's stage of Industry vs. Inferiority?

Back 92

Stage 4 - Latency stage - 6 years to puberty

Establishes sex-role identity and ability to delay gratification.

Emphasis on learning the environment, play, and making friends. The sexual arousal is placed in a state of quiescence. Relationships apart from family take on meaning, (e.g.,. teachers, school peers)

Front 93

93. Which of Freud's stages is analogous to Erikson's stage of Identity vs. Role confusion?

Back 93

Stage 5 - Genital stage (puberty onwards)

Establishes separation from parent.

Time when physiology and interpersonal developments
with significant others establishes a sense of personal identity with
adult roles. The ability to form intimate relationships allows the
separation from dependence on parents.

Front 94

94. Which of Freud's stages is analogous to Erikson's stage of Trust vs. Mistrust?

Back 94

Stage 1 - Oral stage (birth to 18 mos)

Establishes trusting dependence if possible.

The oral cavity is the infant’s primary source of gratification, and
becomes the infants primary tool to explore their world. Food
deprivation or excessive feeding may develop pathological
personalities. If child is frustrated may evolve into expression of
rage by biting things or others.

Front 95

95. Which of Freud's stages is analogous to Erikson's stage of Initiative vs. Guilt?

Back 95

Stage 3 - Phallic (oedipal) stage (3 to 6 years).

Establishes gender identity.

The child becomes aware of sexual differences and functions related to sex such as loving and being loved. Genital excitement becomes the focus of sexual interest and stimulation. The oedipal complex for boys (electra complex for girls) occurs during this stage where children come to channel their sexual interests apart from possessing their opposite parents into fantasy, play and creativity on their way to self esteem, and the ability to tolerate frustration.

Front 96

96. What was Carl Jung's contribution?

Back 96

JUNG, a contemporary of Freud, had established his own theory of personality development, which later became known as “Analytical Psychology.” Jung’s premise is that personality was not an accumulation of fragmented stages of development, but the personality at birth is a whole organism to which he referred to as psyche.

Psyche is a Latin derivative meaning soul or spirit. Jung believed that every human has an expectation to develop their wholeness to the greatest degree possible with regards to differentiation, coherence and harmony.

Front 97

97. To Jung, the psyche is composed of what 3 levels?

Back 97

1. Consciousness- known directly by and to the individual. Consciousness relates to how people process information. This concept is the basis for the Myers-Briggs Personality Indicator. (MBPI).

2. Personal unconscious – the memory container where all psychic activity goes that are incongruous with the conscious
mind. These are readily accessible. A group of personal unconscious material forms a complex (are like mini personalities within the larger personality). Complexes can be helpful and instructive or can be tyrannical and inhibitory.

3. Collective unconscious – ***perhaps the single most psychological concept that set Jung apart from Freud and other psychoanalysts is that of a collective unconscious. Jung referred to the collective unconscious as DNA of the psyche.

Front 98

98. What are archetypes according to Jung?

Back 98

To Jung, evolution and heredity were partially responsible for personality makeup. Inherited genetic material has influence over the ways a person will behave, (I.e., predisposition).

Just as humans possess similar physical traits such as same looking torso, extremities, and internal organs, they also possess similar psychological predispositions such as themes involving relationships, and behavioral patterns that exist in every culture.

Thus each person is linked to the experiences of the past. The content of the collective unconscious are called archetypes.

Front 99

99. What is the persona?

What is the shadow?

Back 99

Persona – a public (outward) façade, the need to be seen in a good light.

The Shadow - our unconsciousness, therefore it is underdeveloped and can be dark or positive aspects of self. everything in us that is unconscious, repressed. The more people confront their shadows the greater degree of self awareness.

Front 100

100. What is the anima in males?

Back 100

Anima (in males) – balances the male ego with a contrasexual aspect that makes projections onto females of whom he knows very little if at all and feels an infatuated compulsion toward.

The feminine personality side of the male includes emotions, a need for relatedness, and at times he will act childish and immature.

Front 101

101. What is the animus in females?

Back 101

Animus (in females) – balances the female ego with a contrasexual aspect that makes projections onto males of whom she knows very little if at all and feels an infatuated compulsion toward.

The animus can be described with possessiveness, leadership, need for independence. At times she may appear opinionated, argumentative and domineering.

Front 102

102. What is the parent?

What is the champion?

Back 102

The Parent – a father archetype supplies structure and
order, protector and provider, while also can be harsh, dogmatic. The mother archetype supplies protection and nourishment, homemaking, and child rearing, and possessive.

The Champion – seeks external achievements, and social recognition, while it can also be insensitive.

Front 103

103. What is the companion?

What is the confidant?

Back 103

The Companion – provides concern for others, individual expression, and extroverted, while it can also be a Peter Pan syndrome of one who never grows up.

The Confidant – helps us to express love and interaction, while can also keep us from growing.

Front 104

104. Describe normal development in terms of the object relations theory (Mahler)

Back 104

Mahler – noted for the theory of Object Relations which can be described as a movement within psychoanalysis that combines the psychoanalytical psychotherapy with stages of infant development.

Mahler concluded from her 10 year observational study of normal children that the infant goes through 6 growth stages to become an individual.

Front 105

105. What are Mahler's 6 stages of growth?

Back 105

Stage 1: Normal autism (birth to 2 months). Baby sleeps more than s/he is awake akin to intrauterine life.

Stage 2: Symbiosis (2 months to 5 months). Mother and child form a single entity, they are one.

Stage 3: Differentiation (5 months to 10 months). Child becomes aware of the separation of self from mother, referred to as Separation-Individuation.

Stage 4: Practicing (10 months to 18 months). Child becomes aware of the world and their relative autonomous place in the world. Darts away from mother as if not needed.

Stage 5. Rapprochement (18 months to 24 months). Child realizes they are not autonomous and remains helpless and dependent, but wanting to be independent alternates with the need of being cared for. Child returns to mother to emotionally refuel

Stage 6: Object Constancy (24 months to 60 months). Re-assurances to the child that out of sight does not mean out of existence. There is loving presence despite occasional absences.

Front 106

106. What was John Bowlby's contribution to object relations theory?

Back 106

John Bowlby 1907-1990, “Attachment Theory” - contributed to the concept of Object-Relations by demonstrating early mother-infant relationship process.

According to Bowlby: *Attachment is when the child desires to be with the caregiver and then clings to the caregiver. *Bonding is when mothers develop concern for the infant such as to make skin to skin contact and voice and eye contact.

Front 107

107. What is stranger and separation anxiety?

Back 107

Mothers (caregivers) who typically provide re-assurance to an infant after a sudden startle create a secure environment, which Bowlby separated as opposite from anxiety.

Bowlby suggested that toddlers around 8 months develop a stranger anxiety which is a reaction to people they do not know and could last until about 3 years old.

Children may develop Separation Anxiety, which is the absence of a parent (caregiver).

Front 108

108. To Bowlby, Attachment disorders are the result of...?

Back 108

To Bowlby, Attachment disorders are the result of biopsychosocial maternal deprivation, due to mother’s mental illness and thus her inability to provide nurturing.

Consequently, attachment disorders can be manifested in;
a. Failure to Thrive syndrome
b. Separation Anxiety
c. Avoidant Personality disorder
d. Depressive disorders
e. Delinquency
f. Academic problems

Front 109

109. What was Otto Kernberg's contribution to object relations theory?

Back 109

Otto Kernberg 1928 - “Object-Relations, Borderline Personality disorder”

KERNBERG - is the principal architect of object relations theory and is widely regarded as the world's leading expert on Borderline Personality Disorders and pathological narcissism.

Object relations theory is a psychoanalytical concept in which the development of the ego, super ego and id are influenced by life’s earliest relations with significant others.

Front 110

110. What causes borderline personality disorder according to Kernberg?

Back 110

From birth on, our relations with significant others are full of emotions and become internalized as affective memory the
degree to which our basic needs were gratified or not. These early
affective memories contain the representation of the self, and the representation of the other person—called "object".

People having Borderline Personality Disorder may split the ego and define others and/or situations as all good or all bad, they do not see the gradations or categorical dynamics of others. They may manipulate some people to love them while other people may despise them. They may have exaggerated self-love while concurrently devaluing others. Individuals with an exaggerated self love are excessively dependent on being admired and accepted by others.

On the one hand, these people may be very grandiose, yet on the other hand, they may be easily hurt, feel easily rejected and easily can get very envious and resentful of other people.

There is also a sense of emptiness due to the void they have to experience the richness of life that comes from gratifying intimate relationships.

Front 111

111. What is malignant narcissism?

Back 111

People with an abnormal grandiose self-sense cannot invest normally in values, and their life is impoverished. There is a particular malignant development that consists of a return to primitive aggression and an idealization of the self as an aggressive self with power over others. This pathological idealization of the self as an aggressive self is clinically called "malignant narcissism."

Narcissists have the capacity to identify with and admire powerful people, but are characteristically self-absorbed and insensitive that often result in a trail of victims--emotional wreckage left in the narcissist’s wake.

Front 112

112. What are the traits of a malignant narcissist?

Back 112

The malignant narcissist can demonstrate overt active or passive antisocial behavior, paranoid traits and ego syntonic (that behavior which agrees with the person)
aggression and sadism that can be directed toward others as well as the self.

The aggression can be expressed in unjustifiable violence, sadistic cruelty or self destructiveness where aggression and sadism is combined with elation and increased self esteem.

Front 113

113. Axis I on DSM-IV

Back 113

Axis I includes all the patient's major psychiatric diagnoses except for personality disorders or mental retardation and developmental disabilities.

Front 114

114. Axis II on DSM-IV

Back 114

Axis II includes all the patient's personality disorders or mental retardation and developmental disabilities.

Axis II may also include the presence of maladaptive personality traits not meeting the threshold for a personality disorder Dx.

Front 115

115. Axis III on DSM-IV

Back 115

Axis III is for reporting general medical conditions that may impact a pt's presentation, treatment, or outcome.

Front 116

116. Axis IV on DSM-IV

Back 116

Axis IV documents the presence and severity of psychosocial and environmental factors that may affect the Dx, treatment, or prognosis of axis I and axis II disorders. These may include social support, homelessness, education or occupational problems, legal problems, or financial strain.

Front 117

117. Axis V on DSM-IV

Back 117

Global Assessment of Functioning – on a scale that ranges from;

10 – 20 = persistent danger
of harming self or others

50 - 60 = Serious to
moderate symptoms that
may impair social,
occupational functioning.

90-100 = Absent to minimal
symptoms, to superior
functioning in all areas

Front 118

118. Differentiate normal anxiety from pathological anxiety

Back 118

Normal anxiety is described as; an apprehension that is unpleasant and/or vague, and often accompanied by autonomic symptoms. Stimulation of the Autonomic Nervous System leads to tachycardia, headache,
diarrhea, and tachypnea
For ex, we may feel anxiety when we make a speech to an audience

***Anxiety becomes pathological when the apprehension causes the individual significant distress and perhaps dysfunction. The pathologic anxiety results from emotional reactions (e.g., phobias, or obsessions / compulsions) that may have no external basis to warrant:
1. one to feel threatened, or
2. one’s response to an external threat to be over the top.

Front 119

119. Where is panic speculated to originate in the brain?

Back 119

Panic is speculated to originate in an abnormally sensitive fear network centered in the amygdala, which receives input from the thalamus and the prefrontal cortical projections, the locus coeruleus (arousal), the brain stem (respiratory activations), hypothalamus (activation of the HPA stress axis)

Front 120

120. Explain the difference between fear and anxiety

Back 120

Anxiety is a normal component of the human condition. Anxiety does not typically prevent daily functioning, nor does it destroy a grasp on reality.

However, persistent anxiety with dysregulation of the regulatory systems in the body may contribute to several types of psychiatric morbidity.

For example, a persistent fear of subsequent panic attacks may actually trigger a panic attack.

Front 121

121. What is the role of norepinephrine in anxiety?

Back 121

Norepinephrine – NE is increased by stressful or novel environmental stimuli.

It is theoretically assumed that people with anxiety disorders have a poorly regulated noradrenergic system which results in symptoms such as; panic attacks, insomnia, and autonomic hyperarousal.

Front 122

122. What is the role of GABA in anxiety?

Back 122

GABA – benzodiazepine system – SPECT and PET studies have revealed decreased of benzodiazepine receptor binding was found in the prefrontal cortex and hippocampus among subjects who experienced panic attacks.

An MRI study revealed those subjects having panic attacks had deficient GABA neuronal responses after oral benzodiazepine administration

Front 123

123. What is the role of serotonin in anxiety?

Back 123

Serotonin – not yet widely researched but it is suspected that serotonergic medications may act by desensitizing the brain’s fear network

Front 124

124. What are panic attacks according to DSM-IV?

Back 124

A. IS NOT A CODABLE DISORDER, the specific diagnosis in which the panic attack occurs is necessary.

B. A period of time of intense fear or discomfort when 4 of the following are abrupt and reached a peak within 10 minutes:
• palpitations, pounding heart, accelerated heart rate
• sweating
• trembling or shaking
• sensations of shortness of breath or smothering
• feeling of choking
• nausea or abdominal distress
• feeling dizzy, unsteady, lightheaded or faint
• derealization (unreality) depersonalization (detached from self
• fear of dying
• parethesis (numbness or tingling sensations)
• chills or hot flashes

D. Not accounted for by any other psychiatric, general medical or substance related disorder.

Front 125

125. What is the criteria for panic disorders according to DSM-IV?

Back 125

Need to have both 1 and 2:

1. Recurrent unexpected panic attacks.

2. At least one of the attacks has been followed by One or More of;
a. persistent concern about having additional attacks
b. worry about implications of the attack or its consequences e..g, losing control, having a heart attack, going crazy
c. significant change in behavior related to the attack

3. Significant impairment in social, occupational, or other important areas of
functioning

4. *Absence of agoraphobia OR Presence of agoraphobia*

5. Not accounted for by any other psychiatric, general medical or substance related disorder

Front 126

126. What does agorophobia mean?

Back 126

Panic attacks are described as either with or without agoraphobia. Agoraphobia is
described as being in places or in situations either of which escape is in doubt, or of having a panic attack in public from which help may not be available. Common agoraphobic situations include: outdoors, in tunnels, on bridges, traveling.

Individuals who have agoraphobia seem to gravitate around “safe” places or people, at home or with friends and family, respectively.

Front 127

127. What are the two psychotherapy treatments for panic disorders?

Back 127

Psychotherapy
A. Cognitive behavioral therapy (CBT) — *first line treatment* - correcting maladaptive thoughts to not be frightening or uncontrollable
B. Short-term psychodynamic therapy - focuses on the psychological significance to the individual of panic and avoidance.

Front 128

128. What are the 4 pharmacologic treatments for panic disorders?

Back 128

1. Selective Serotonin Reuptake Inhibitors (SSRIs); serotonin- are the *first-line treatment of choice for panic disorder in the primary care setting* Studies have supported the efficacy of fluvoxamine, paroxetine, sertraline, citalopram, and fluoxetine.

2. Norepinephrine Reuptake Inhibitors (SNRIs) - Venlafaxine has been found to reduce global severity of panic, and fear and avoidance of panic-triggers, but did not lead to significantly greater freedom from panic, in a randomized placebo-controlled trial.

3. Tricyclic antidepressants (TCAs) - are not generally considered first line therapy because of associated adverse effects.

4. Benzodiazepines - offer an alternative treatment for patients who are unable to tolerate or who do not benefit from an adequate trial of SSRI agents or TCAs. Alprazolam, lorazepam, and clonazepam have all been found to be more effective than placebo for the treatment of panic disorder. Patients with polydrug or alcohol abuse, chronic pain disorders, and severe personality disorders should not be prescribed benzodiazepines in light of potential problems with abuse.

Front 129

129. What about combination therapy for panic disorders?

Back 129

Combination therapy — A meta-analysis of 11 trials that compared cognitive behavioral therapy with antidepressants for panic disorder demonstrated similar outcomes (decrease in symptoms by 50 percent and decreased global anxiety and depression)

Front 130

130. What is the treatment duration like for panic disorders?

Back 130

Panic disorder symptoms can typically be stabilized within four months.

Pharmacotherapy should be continued for at least one year.

Success usually occurs when symptoms are relieved and the
psychosocial stressors have been significantly reduced.

Antidepressants can be tapered over 4 to 8 weeks, while
benzodiazepines may need to be tapered over 10 to 16 weeks to minimize withdrawal.

Front 131

131. What is social phobia?

Back 131

Phobia can be defined as an irrational, marked, and persistent fear of a specific object, activity, or situation, which is actively avoided or endured with intense anxiety or distress.

Social phobia is characterized by a fear that if something is done in public the person may appear in ways that they do not want to be seen, e.g. inept, or foolish. People with social phobia are cognizant of the irrationality of their thoughts and behaviors.

Front 132

132. What is the cycle of social phobia?

Back 132

Social encounters are anticipated with apprehension and self doubt
↗
Feared encounters are avoided
or suffers in silence
↗
Social encounter may result in panic embarrassment and humiliation.

Front 133

133. DSM criteria for social phobia

Back 133

A. Marked and persistent fear of one or more social or performance situations when there is exposure to unfamiliar people or to possibly scrutiny by others which may lead to humiliation or embarrassment.
B. Exposure to the feared social situation almost always provokes anxiety / panic attack.
C. Recognizes the fear is excessive or unreasonable
D. The avoidance, anticipation, or distress interferes with normal routines and functions.
E. Not accounted for by any other psychiatric, general medical or substance related disorder

Front 134

134. First line Tx's for social phobia

Back 134

Cognitive behavioral therapy is considered an appropriate first-line option for treating social anxiety disorder by using techniques, that reduce fears and avoidances

SSRIs - collectively are considered appropriate first-line therapy for social phobia disorder. The therapeutic effects may take as long as 12 weeks to show clear improvements, treatment continued for 6 to 12 months or longer.

Also, SNRI - venlafaxine appears to be effective for the treatment of social anxiety disorder

Front 135

135. What is the Social Phobia Inventory (SPIN) ?

Back 135

Social Phobia Inventory (SPIN) - involves fear, avoidance, and physiological discomfort

A cut off value of 19 distinguishes between subjects with and without social phobia disorder

Front 136

136. What is a specific phobia disorder?

Back 136

Occurs in the presence of a specific object (e.g, insects, reptiles, blood ) or situation (e.g., heights, tunnels, closed in places). The affected individual expresses excessive or irrational fears to the objects / situations.

Subtypes of specific phobias include;
1. animal – usually begins in childhood and can involve snakes, spiders, dogs etc.
2. natural environmental -usually begins in childhood, and can involve fear of storms, heights, darkness, etc
3. blood injection injury – anxiety in response to seeing blood or injury or getting an injection is often familial and associated with fainting.
4. situational – cued by specific situations, e.g, elevators, bridges tunnels, enclosed places, but without panic disorder or agoraphobia
5. other – other irrational fears such as illness, fear of falling

Front 137

137. DSM criteria for specific phobia disorder

Back 137

A. Marked and persistent fear that is excessive or unreasonable *cued by
the presence or by the anticipation of a specific object or situation** (e.g, flying, animals, heights)
B. Exposure to the stimulus almost always provokes the immediate anxiety response
C. Recognizes the fear is excessive or unreasonable
D. The avoidance, anticipation, or distress interferes with normal routines and functions.
E. Not accounted for by any other psychiatric, general medical or substance related disorder

Front 138

138. Treatment for specific phobia disorder?

Back 138

Often improves spontaneously or responds effectively to cognitive-behavioral therapy in which the phobic object or situation is confronted and the fear is desensitized and overcome

Can use medications, but do not use barbiturates for anxiety or insomnia!

Front 139

139. What is Post Traumatic Stress Disorder, (PTSD) disorder?

Back 139

PTSD occurs when people experience extraordinary events that are above and beyond what most others would ever experience such as life-threatening circumstances of war, natural disasters,
torture, death camp, physical and/or sexual abuse, or having been witness to similar events.

The person suffering from PTSD will re-experience or even re-live the event which may be prompted by witnessing a similar event, discussing the event or an event with similar circumstances, an anniversary of the event, a smell that was present during the event, etc.

Front 140

140. Dx criteria for PTSD according to DSM

Back 140

Symptoms can appear immediately following a traumatic event, or be in latency for months or even years. As the trauma is recalled individuals may;
1. Re-experience the event such as;
a. intrusive memories – cued from pictures, anniversaries, similar events
b. nightmares
c. difficulty with concentration
d major depression is common
e. substance abuse is common
f. children who play out their abuse with their toys
2. Symptoms of autonomic arousal may be;
a. exaggerated startle response
b. sleep impairment (delayed, interrupted sleep)
c. hypervigilence
d. irritability

Front 141

141. Tx for PTSD

Back 141

SSRIs - effective as first-line drug therapy

Tricyclic antidepressants decrease intrusive nightmares and flashbacks

Psychodynamic psychotherapy – reinterpretation of the event

Cognitive – behavioral psychotherapy –re-definition of the personal impact, threats, meanings,

Front 142

142. What is the PTSD Checklist Civilian Version (PCL-C)?

Back 142

PTSD Checklist Civilian Version (PCL-C)

A total score of 50 or greater is suggestive of PTSD

Front 143

143. What is OCD?

Back 143

Thoughts and/or impulses that are intrusive and are realized as inappropriate are referred to as (obsessions), and repetitive behaviors that are realized as unreasonable are referred to as (compulsions). The function of compulsions is to reduce the distress associated with the obsessions. Compulsions are performed in a stereotyped manner (e.g, touching, counting, arranging) in an attempt to alleviate the anxiety which most frequently results from the obsessions. Often these behaviors are believed to help defend the patient and others from potential harm.

Front 144

144. What neurotransmitter, and what part of the brain is implicated in OCD?

Back 144

There appears to be a dysregulation of serotonin in the formation of obsessions and compulsions.

During OCD episode demonstrated increased blood flow in the orbitofrontal cortex bilaterally, the right caudate nucleus, and the anterior cingulated cortex

Front 145

145. Tx for OCD?

Back 145

SSRIs - are as first-line treatment for OCD. Treatment with SSRIs should continue for at least 10 to 12 weeks before they are considered ineffective.

Venlafaxine may also be of benefit in OCD

Front 146

146. What is the scoring for the Yale Brown Obsessive-Compulsive scale?

Back 146

Add up the numbers you have circled:
0 - 7: not worth treating
8 - 15: mild
16 - 23: moderate
24 - 31: severe
32 - 40: extreme

Front 147

147. What is Generalized Anxiety disorder (GAD)?

Back 147

Patients who complain of “free floating anxiety,” means that they have excessive and unrealistic worries about events that may not yet have happened.

Unlike the other anxiety disorders where the anxiety is focused on a panic situation, a traumatic situation, a particular phobic situation, etc. GAD is global and without an identified trigger and with exaggerated worry and tension.

Individuals with GAD worry about multiple concerns, i.e., physical components such as, fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, hot flashes, and sleep disturbances.

Front 148

148. Tx for GAD?

Back 148

1. Cognitive behavioral therapy (CBT) is frequently recommended as first line
psychological treatment for GAD.
2. SSRIs and SNRI’s (eg venlafaxine), and buspirone because of their lower side
effect profiles and lower risk for tolerance have become first-line treatment
3. Benzodiazepines and tricyclic antidepressants (TCAs) traditionally were commonly used drug treatments for GAD.

Front 149

149. What is the GAD-7?

Back 149

GAD-7
How often during the past 2 weeks have you felt bothered by, etc...

Total Score:

A score of 10 or higher means significant anxiety is present. Scores over 15 are severe. In the study, they find that people diagnosed with GAD have an average score of 14.4 while people without GAD average only 4.9.

Front 150

150. What is Adjustment Disorder with Anxiety?

Back 150

Adjustment disorder is a short-term condition that occurs when a person is unable to cope with, or adjust to, a particular source of stress, such as a major life change, loss or event. Because people with adjustment disorders often have symptoms of anxiety or depression such as tearfulness, feelings of hopelessness and loss of interest in work or activities, an

Adjustment disorder is sometimes called "situational depression."

*The symptoms develop within three months of the beginning of the stressful problem. An adjustment disorder usually lasts no longer than three to six months.

Front 151

151. What is the difference between adjustment disorder and anxiety disorder?

Back 151

The difference between Adjustment Disorder and Anxiety disorders is that with an Adjustment Disorder the related anxiety is associated with an event and usually the emotional response repairs itself once the person adapts to the event / stressor.

Front 152

152. DSM criteria for adjustment disorder

Back 152

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) OCCURRING WITHIN THREE (3) MONTHS OF THE ONSET OF THE STRESSOR(S).
B. The symptoms and behaviors are clinically significant as evidenced by either;
1. marked distress that is in excess of what would be expected from exposure to the stressor or
2. significant impairment in social or occupational (academic) functioning.
C. Once the stressor is terminated, the symptoms do not persist for more than an additional six (6) months.
D. Not accounted for by any other psychiatric, general medical or substance related disorder.

Front 153

153. What is separation anxiety?

Back 153

Refusal to go to school often begins following a period at home in which the child has become closer to the parent, such as a summer vacation, a holiday break, or
a brief illness. It also may follow a stressful occurrence, such as the death of a pet or relative, a change in schools, or a move to a new neighborhood.

The child may complain of a headache, sore throat, or stomach-ache shortly before it is time to leave for school. The "illness" subsides after the child is allowed to stay home, only to reappear the next morning before school. In some cases the child may simply refuse to leave the house.

Front 154

154. What are some symptoms of separation anxiety disorder?

Back 154

Children with an unreasonable fear of school may:
a. feel unsafe staying in a room by themselves
b. display clinging behavior
c. display excessive worry and fear about parents or about harm to themselves
d. shadow the mother or father around the house
e. have difficulty going to sleep
f. nightmares
g. exaggerated, unrealistic fears of animals, monster, burglars
h. fear of being alone in the dark,
i. have severe tantrums when forced to go to school

Front 155

155. What does euthymia mean?

Back 155

Euthymic (normal) – Greek derivative, Eu = a sense of well being, while Thymia = refers to the core of existence and emotional center.

Current interpretation is that euthymia describes a normal non-depressed, reasonably positive mood.

Front 156

156. List the meaning and the terms of the mnemonic - SIGECAPS

Back 156

There are no pathognomonic markers of depression. Diagnosis is based on a set of specific signs and symptoms, that can be organized around the acronym, SIGECAPS:

S = Sleep
I = Interest
G = Guilt
E = Energy
C = Concentration
A = Appetite
P = Psychomotor
S = Suicide

Front 157

157. List the meaning and the terms of the mnemonic - DIG FAST

Back 157

As with major depressive episodes, if a manic episode is suspected, a thorough evaluation should be conducted. The comprehensive interview should include a thorough history of present illness that is reviewed for the symptoms of a manic episode.

The DIG FAST mnemonic is commonly used to help remember the diagnostic criteria:

Distractibility
Injudiciousness
Grandiosity

Flight of ideas
Activities [increase]
Sleep [decreased need for]
Talkativeness

Front 158

158. What is the DSM criteria for adjustment disorder w/depressed mood?

Back 158

Adjustment disorder is a short-term condition that occurs when a person is unable to cope with, or adjust to, a particular source of stress, such as a major life change, loss or event.

Depressive symptoms occurring within *3 months of a stressor, and symptoms do not persist for more than 6 more months*

Front 159

159. How is adjustment disorder w/depressed mood different from major depression?

Back 159

The difference between Adjustment Disorder and Major Depression is that with an Adjustment Disorder the depression is associated with an event and usually the emotional response repairs itself once the person adapts to the event / stressor.

Front 160

160. What is the criteria for a major depressive episode?

Back 160

5+ symptoms have been present nearly every day *during a same 2 week period* and are a change from typical functioning. At least one of the symptoms is either (1) or (2) below:

1. depressed mood most of the day, nearly every day (e.g. feeling sad, or empty, or observed by others (e.g, appears tearful)
2. markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day
3. significant weight loss when not dieting, or weight gain, (a change of more than 5% of body weight in a month, or decrease or increase in appetite
4. insomnia or hypersomnia
5. psychomotor agitation or retardation
6. fatigue or loss of energy
7. feelings of worthlessness or excessive and inappropriate guilt
8. diminished ability to think or concentrate, indecisive
9. recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicidal attempt or a specific suicidal plan

Front 161

161. What is the DSM criteria for a manic episode?

Back 161

A. *A period of abnormally and persistently elevated, expansive or irritable mood, lasting ONE WEEK.*

B. During that time three (3) or more below have persisted:
1. inflated self esteem or grandiosity
2. decreased need for sleep (feels rested after only 3 hours of sleep
3. more talkative than usual, pressure to keep talking
4. flight of ideas, subjective experience that thoughts are racing
5. distractible, attention easily drawn away
6. increase in goal directed activity, or psychomotor agitation
7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., unrestrained buying sprees)
8. sexual indiscretions, foolish business investments)

C. Symptoms cause marked impairment in occupational functioning, social
activities and relationships, may be need to hospitalize to prevent harm, may have psychotic features.

Front 162

162. What is the DSM criteria for a hypomanic episode?

Back 162

Hypomanic Episode - is a milder form of manic episodes, sharing the same list of symptoms ***but hypomanic episodes occur for 4 days.***

Front 163

163. What is the DSM criteria for a mixed episode?

Back 163

A. The criteria are met for both a manic episode and for a major depressive episode (except for duration) nearly every day during at least a 1 week period.

B. The mood disturbance is sufficiently severe enough to cause marked impairment in functioning and usual activities.

Front 164

164. What is the definition of major depression?

Back 164

Major depression - one or more major depressive episodes lasting most of the day, most every day within a two week period and no history of manic episodes.

Front 165

165. What is the definition of dysthymia?

Back 165

Dysthymia - not severe enough to fulfill the criteria for a major depressive disorder, no history of manic episodes, *and lasts for at least two years*

Front 166

166. What is bipolar I disorder?

Back 166

Bipolar I disorder - at least one manic or mixed episode, with or without episodes of major depression.

May experience additional psychotic symptoms such as delusions and hallucinations.

Front 167

167. What is bipolar II disorder?

Back 167

Bipolar II disorder- at least one episode of major depression and one episode of hypomania, but NEVER HAD A MANIC OR MIXED EPISODE.

Hypomania generally does not impair a person's daily functioning or cause the need for hospitalization.

Bipolar II by definition cannot have psychotic features. This disorder may develop into bipolar I disorder if a manic episode occurs.

Suicidality is a greater risk among Bipolar II disorder patient than with Bipolar I patients and Major Depression disorder.

Front 168

168. What is cyclothymia?

Back 168

Cyclothymia - repeated mood swings with hypomania and lows in mood that do not meet the criteria for major depressive episodes. This disorder is chronic and lasts for at least two years. Can evolve into a Bipolar I.

Cyclothymia can be conceptualized as dysthymic disorder with intermittent hypomanic episodes (up and down followed by up and down episodes for more than 2 years, but does not meet the 1 week duration for a manic episode.

Front 169

169. What is SAD?

Back 169

Seasonal Pattern disorder (SAD) - becoming depressed during a particular season (most often the winter). Formerly referred to as Seasonal Affective Disorder [SAD]. During the low-light months of fall and winter it is normal that many people have a reduced desire to be active and may even have an increased desire to sleep more related to the colder temperatures and longer periods of darkness.

Unknown, but certain reactions have been identified and include;
a. circadian rhythm – affected by temperatures and reduced sunlight
b. melatonin – linked to depression and effects body temperature and sleep. Believed to increase during darker winter months.
c. serotonin - it is suspected that reduced sunlight may encourage a decreased level of serotonin,

Front 170

170. What is the DSM criteria for seasonal pattern specifier mood disorder?

Back 170

A. There has been regular temporal relationship between the onset of major depressive episodes in bipolar I, or bipolar II disorder or major depressive disorder, recurrent and a particular time of the year (e.g., regular appearance of the major depressive episode in the fall or winter).

Not to include psychosocial seasonal stressors as seasonal unemployment.

B. In the last two (2) years, two major depressive episodes have occurred

Front 171

171. What is postpartum depression (PPD)?

Back 171

Postpartum depression (PPD) – about 6 months following childbirth, has increased risk for emotional instability and include; postpartum blues (a waxing and waning that begins in the first 2-4 days after delivery and can last one to two weeks, tearfulness, irritability and anxiety, typically resolves spontaneously), postpartum depression, postpartum psychosis, postpartum panic attack with or without agoraphobia, and the latest is postpartum obsessive compulsive disorder.

Symptoms include: impairments with sleep, energy level, appetite, weight, gastrointestinal functioning, decreased libido, and inhibition of caring for the baby.

Front 172

172. What is rapid cycling?

Back 172

Rapid cycling – can be applied to bipolar I or bipolar II disorder and is a time frame element in that the intervals between mania and depression may change quickly, i.e, changing several switches of mood in a 24-hour period, and in continuous cycling an individual swings back and forth between mania or hypomania continuously with little or no period of identifiable normal mood between the swings, to occurrence of four or more episodes in a given year.

Eventually episodes can occurring spontaneously, which is referred to as “kindling.”

Front 173

173. What is the DSM criteria for major depression disorder?

Back 173

A. Presence of two or more major depressive episodes.
B. There has never been a manic episode, a mixed episode or a hypomanic episode.

Not accounted for by any other psychiatric, general medical or substance related disorder.

Front 174

174. When do you hospitalize a pt for mood disorders?

Back 174

When to hospitalize – perhaps one of the most invasive decisions a physician will
have to make. Treatment is always made with the least restrictive form intervention possible.

At times, in-patient becomes the least restrictive form of treatment either voluntarily or involuntarily and may be decided when;
A. the patient is overtly suicidal
B. the patient is overtly homicidal due to a mental disorder (as opposed to
contemplating a criminal act and being fully culpable for their behavior).
C. there is insufficient social and/or community resources to prevent harm from happening to a patient due to a mental disorder.

Front 175

175. What are 3 helpful determinants in making a decision to hospitalize?

Back 175

1. Signs of impaired decision making (not using sound judgment)
2. Clinically significant weight loss
3. Manic state sleep - deprivation

Front 176

176. What are the psychotherapy treatments for mood disorders?

Back 176

1. CBT- Premise is that individuals have defeatist thoughts about the “negative
triad” which constitutes;
1. the world
2. the self
3. the future

2. Interpersonal therapy - – brief 12-20 sessions works from the meaning relationships have on depression. The focus is to help the patient work through expectations of relationships, such as roles of each partner, communication patterns, identifying areas of disagreement and create potential strategies to problem solve.

3. Psychodynamic psychotherapy – takes into account intrapsychic
conflicts, defense mechanism resistances, and personality impairments. Longer term than IPT.

Front 177

177. What is ECT?

Back 177

Electroconvulsive Therapy (ECT) - ECT is referred to as “Shock Treatment,” or “Electroshock.”

Useful when, first line treatment of antidepressant medications, and psychotherapy are not effective and/or are too slow.

Most common side effects of ECT, (confusion, memory loss of about 30 minutes, muscle aches, headaches). Informed Consent outlining benefits and potential risks (permanent severe memory loss),

Front 178

178. In which 4 populations is ECT approved for use?

Back 178

Recommended for use with:

Major Depressive Disorders
Bipolar Disorders
Manic Episodes
Schizophrenia

May be effective for:
Neuroleptic malignant syndrome
Obsessive-compulsive disorder
Neuroleptic-induced Parkinsonism
Neuroleptic-induced tardive dyskinesia

Front 179

179. In which 4 populations is ECT not recommended?

Back 179

Not recommended for use:

Dysthymia
Substance Abuse disorders
Anxiety disorders
Personality disorders

Front 180

180. What is serotonin syndrome?

Back 180

Occurs when there are excessive amounts of serotonergic
stimulation.

Excessive amounts of serotonin can be caused from an overdose of serotonergic agents or combining medications (usually 2 or more) and other substances that include
serotonin, i.e,
1. SSRIs
2. SNRIs
3. Bupropion, (Wellbutrin, Zyban)
4. MAOIs
5. St. John’s Wort
6. Illicit drugs, including MDMA, LSD, Ecstasy, cocaine and amphetamines

Front 181

181. What are some signs and symptoms of serotonin syndrome?

Back 181

Signs and symptoms include;
1. diagnosis requires 3 of the following;
a. confusion
b. agitation
c. fever or hyperthermia
d. diaphoresis
e. diarrhea
f. myoclonus
g. hypertonia or hyperreflexia

2. Associated symptoms include;
a. insomnia
b. restlessness
c. tachycardia
d. tachypnea
e. dyspnea
f. hypotension or hypertension

Serotonin syndrome generally goes away within a day once serotonin levels are back to normal. Symptoms can range from mild to life threatening

Front 182

182. What is serotonin discontinuation syndrome?

Back 182

Serotonin discontinuation syndrome occurs after being using serotonergic agents for a period of time, patients sometimes experience symptoms when the medication is removed.

Removing these kinds of medications should be done with tapering especially medications with short half lives.

Symptoms include;
1. dizziness
2. headaches
3. parathesia
4. nauseau
5. insomnia
6. irritability,
7. flu-like symptoms

Front 183

183. What is deep brain stimulation?

Back 183

Deep brain stimulation, (DBS) — is high frequency electrical deep brain stimulation that involves stereotaxic placement of electrodes connected to a permanently implanted neurostimulator. Preliminary evidence reveals that some patients with treatment-resistant depression may benefit from DBS

Front 184

184. What is repetitive transcranial magnetic stimulation?

Back 184

(rTMS) uses an electric coil to generate magnetic fields that stimulate the cerebral cortex.

In contrast to ECT, does not require the use of anesthesia and does not appear to cause cognitive impairment.

However, a systematic review of studies that used rTMS concluded that there is no strong evidence of benefit with rTMS in depressed patients, more than which could be collected by using paper and pencil Beck Depression Scale and / or Hamilton Depression Rating Scale.

Front 185

185. What is vagus nerve stimulation?

Back 185

Vagus nerve stimulation (VNS) has also been studied for the treatment of refractory depression. Although the United States Food and Drug Administration (FDA) approved VNS in 2005 for adjunctive use in patients with depression who failed at least four adequate antidepressant trials, it remains unclear from the literature how effective this treatment modality is.

Front 186

186. What are the symptoms of depression across childhood age spectrum?

Back 186

Infants: Listless, withdrawn, weepy, refusing to eat/sleep problems

Pre School:
lack of playfulness, angry, apathetic, uncooperative, phobias

Elementary School:
depressed appearance,
poor school performance,
agitation, separation anxiety, running away, somatic complaints, could have auditory hallucinations

Adolescents:
grouchiness, social withdrawal, truancy, substance abuse, sensitive to rejection, antisocial, behaviors, sexual, promiscuity, suicidal

Front 187

187. What about mania in adolescence?

Back 187

In children and adolescents, manic episodes are more likely to be characterized by irritability and destructive outbursts than by elation or euphoria. Adolescents by nature typically have inordinate amounts of energy. Therefore, it is difficult to readily distinguish mania from typical adolescent energy.

The major distinction are:
1. Severity of symptoms
2. Persistence of symptoms

Front 188

188. Depression among the elderly is seen with a greater amounts of what 5 things?

Back 188

Depression among the elderly is seen with a greater amounts of;
1. melancholia
2. hypochondriasis
3. low self esteem
4. feelings of worthlessness
5. suicidal ideations

Front 189

189. How to treat depression in elderly?

Back 189

Recent research suggests that brief psychotherapy (talk therapies help a person in day-to-day relationships or in learning to counter the distorted negative thinking that commonly accompanies depression) is effective in reducing symptoms in short-term depression in older persons who are medically ill.

Psychotherapy is also useful in older patients who cannot or will not take medication. Efficacy studies show that late-life depression can be treated with psychotherapy.

Front 190

190. Hamilton Rating Scale for Depression

Back 190

Hamilton Rating Scale for Depression – Maximum score = 86;

Sample Items include:
-Depressed Mood (sadness, hopelessness, helpless, worthlessness)?
0 Absent
1 These feeling states indicated only on questioning
2 These feeling states spontaneously reported verbally
3 Communicates feeling states non-verbally, i.e., through facial expression,
posture, voice, and tendency to weep
4 Patient reports virtually only these feeling states in his/her spontaneous
verbal and non-verbal communication

Front 191

191. Geriatric Depression scale

Back 191

Geriatric Depression scale – best answer for how you have felt over the past week:

Scoring the GDS, maximum score = 15
0 - 4 normal, depending on age, education, complaints
5 - 8 mild depression
8 - 11 moderate depression
12 - 15 severe depression

Front 192

192. Beck Depression Inventory, (BDI)

Back 192

The BDI is a self-administered 21 item self-report scale measuring symptoms of depression. The BDI takes approximately 10 minutes to complete. Prepared on a fifth – sixth grade reading level. Internal consistency for the BDI ranges from .73 to .92 with a mean of .86. Correlations with clinician ratings of depression using the revised BDI range from .62 to .66.

Scoring the BDI:
00-04 Possible denial of depression, faking good.
05-10 These ups and downs are considered normal.
40+ Severe depression, suggesting possible exaggeration of depression.

Front 193

193. Zung Depression Scale

Back 193

The Zung Self-Rating Depression Scale is a short self-administered survey to quantify the depressed status of a patient. There are 20 items on the scale that rate the four common characteristics of depression: the pervasive effect, the physiological equivalents, other disturbances, and psychomotor activities.

Scores on the test range from 20 through 80.

The scores fall into four ranges:
20-49 Normal Range
50-59 Mildly Depressed
60-69 Moderately Depressed
70 and above Severely Depressed

Front 194

194. The Social Re-Adjustment Rating Scale

Back 194

The Social Re-Adjustment Rating Scale - was developed by two medical students in 1967, Richard Rahe, M.D., and Thomas Holmes, M.D.

The instrument is designed to identify the effects of an accumulation of life changes over time can contribute to medical illness, it is not diagnostic.

Total of Life Change Unit:
<150 = 30% Chance of suffering an Accident or Injury within the year
150 – 300 Accident/Injury quotient increases by 50%, within the year
>300 = Likelihood of having an Accident or becoming ill increases by 80%
within the year.

Front 195

195. Psychoanalytical (Freudian) explanation of mood disorders

Back 195

Depression suspected to be the result of a loss and is expressed symptomatically as anger turned inward.

The loss could have been a loss of interpersonal relationship, of freedom, of property, prestige, or self esteem, to name a few possibilities.

Front 196

196. Two other explanations for mood disorders

Back 196

The external environment (places where people live, work and play) or the internal environment (self confidence, self respect, etc) lacks positive reinforcement which would result in a self perpetuating cycle of dysphoria, reduction of reinforcing behaviors, lowered self esteem, hopelessness and isolation.

Self interpretation of life with distorted irrational negative self thoughts. This concept is referred to as the negative triad (the world is unsafe; the future is hopeless, and the individual is inadequate).

Front 197

197. What is normal behavior?

Back 197

Normal behavior - daily living has its own stressors and unwanted situations which may cause our customary thought processes to react uncharacteristically. For example, when asked to speak in front of groups, we may initially feel confused, be unable to pull together our thoughts, and we may forget what was intended to have been said.

People may humorously refer to these events as having a schizophrenic episode, but these are not examples of schizophrenia.

Front 198

198. What is abnormal behavior?

Back 198

Abnormal behavior - people with schizophrenia do not always act abnormally. The modern atypical antipsychotic agents satisfactorily address the positive (symptoms that are present such as hallucinations and delusions) as well as the negative (symptoms that have deficits such with affect, speech, grooming, and motivation, among others) of schizophrenia. Though not all individuals receive the same medication efficacy, some people with the illness can at times appear normal and can be responsible.

The behavior of someone diagnosed with schizophrenia may change over time, becoming bizarre if the psychotropic medication is stopped, and they return closer to normal when they receive appropriate treatment.

Front 199

199. What was Emil Kraepelin's contribution to schizophrenia?

Back 199

Emil Kraepelin classified the symptoms of schizophrenia based on physical etiology, to provide prognosis, treatment for schizophrenia.

He termed “dementia praecox” to relate to a long term deteriorating course of delusions, hallucinations, and bizarre motor problems. His work separated dementia praecox from manic depressive illness, which remains a fundamental differentiation.

*Symptoms he identified would now be considered negative symptoms.

Front 200

200. What was Eugene Bleuler's contribution to schizophrenia?

Back 200

Bleuler generated the term from the German “schizen” meaning split, and “phren” meaning of the mind. Bleuler indicated that emotions, perceptions, and cognitions all being functions of the mind each become split off from the others. To Bleuler the concept of schizophrenia was a split with internal and/or external reality (and not with personality).

Consequently he used the four A’s to describe schizophrenia;

Associations
Ambivalence
Affect
Autism

Front 201

201. What was Kurt Schneider's contribution to schizophrenia?

Back 201

Kurt Schneider categorized first and second rank symptoms of schizophrenia. Schneider contended that a diagnosis of schizophrenia can be made with only one first rank symptom, while second rank symptoms were more vague.

First rank symptoms:
1. Hearing voices
2. Thought processes influence from outside source
3. Delusional perceptions such as though broadcasting

Second rank symptoms:
1. Affective extremes
2. Apathy
3. Depressive and euphoric mood changes

Front 202

202. Explain the concept that schizophrenia is a medical condition and brain disorder

Back 202

Most recent theories suggest that schizophrenia is a “brain disorder” manifested with abnormalities in cognitions, behavior, and affect. Individuals having the diagnosis of schizophrenia are not a homogenous group with similar etiologies, or treatment responses. No cure for schizophrenia has been discovered, but with proper treatment, many people with this illness can lead productive and fulfilling lives.

Front 203

203. Diagnosing schizophrenia more reliable when what 5 specific criteria are met?

Back 203

Tip: Diagnosing schizophrenia is more reliable when specific criteria are met:

1. auditory hallucinations
2. 6 month’s duration time of symptoms
3. no prominent mood disorder
4. no medical illness causing the symptoms
5. no drug use precipitating the symptoms

Front 204

204. What is the prevalence and epidemiology of schizophrenia?

Back 204

Gender = seems to affect men and women with equal frequency

Incidence rate: -
Slightly higher rates for people born in urban areas in the U.S., and increased incidence rate for people born in winter months, which is speculated to be linked to active viral associations.

Onset – seems to appear early for men, usually in the late teens or early twenties, while women are generally affected in the 20’s to early 30’s. It is unusual for individuals to be diagnosed with schizophrenia at ages before 10 years

Prevalence rate;
Lifetime prevalence = 1%
Annual prevalence = .5% to 5.0% per 10,000

Front 205

205. What is the genetics theory of schizophrenia?

Back 205

The disorder tends to be familial with individuals having predispositions to schizophrenia. Neurons forming inappropriate connections during fetal development may be a factor in the development of schizophrenia.

Some genes may fail to be expressive in childhood which may be the reason that in some instances schizophrenic symptoms develop during adulthood.

Front 206

206. What gestiational problems may lead to schizophrenia?

Back 206

1. Viral infection, particularly influenza in the second trimester
2. Illicit drugs in adolescence and young adulthood
3. Starvation

Front 207

207. What about nature vs. nurture in the development of schizophrenia?

Back 207

Adoptive studies – a dated but classic study conducted in 1966 identified 47 adoptees born to hospitalized schizophrenic mothers, and 50 adoptees whose mothers were not schizophrenic.

***Schizophrenia was found only in the children of schizophrenic mothers

Front 208

208. What do consanguinity studies show regarding schizophrenia?

Back 208

The results have indicated, a correlation between the closer the consanguinity, with higher incidence of schizophrenia.

General Population 1%
Sibling w/schizo 8%
One Parent w/Schizo 12%
Dizygotic Twin Sibling 12%
Both Parents Schizo 40%
Monozygotic Twin schizo 47%

Front 209

209. What are the 4 dopamine pathways?

Back 209

1. Mesolimbic pathway
2. Mesocortical pathway
3. Nigrostriatal pathway
4. Tubuloinfundibular pathway

Front 210

210. Role of mesolimbic pathway

Back 210

Mesolimbic pathway – if dopamine is increased in this pathway the result will be hallucinations and delusions. Blocking dopamine in this pathway decreases the symptoms.

This pathway is also involved with reward and pleasure for such elements as food, sex and by addictive psychoactive drugs, such as cocaine, amphetamines.

The intense feelings aroused by the previously mentioned elements leads for desire of repetition.

Front 211

211. Role of mesocortical pathway

Back 211

Mesocortical pathway - malfunction in this pathway results with disordered thinking.

Slowed motivational and emotional responses and negative symptoms of schizophrenia which include avolition, alogia, and flat affect.

Front 212

212. Role of nigrostriatal pathway

Back 212

Nigrostriatal pathway - motor control which will produce muscular dyscontrol and trembling if there is a decrease in dopamine in this pathway, while an increase in dopamine in this pathway reduces the incidence of extrapyramidal side effects, such as tardive dykinesia

Front 213

213. Role of tubuloinfundibular pathway

Back 213

Tubuloinfundibular pathway - connects the hypothalamus to the pituitary gland, where it influences the secretion of hormones such as prolactin.

Some antipsychotic medications block dopamine in the this pathway, which can cause an increase in prolactin levels which can cause abnormal lactation in men or women. This condition is known as hyperprolactinemia and can lead to sexual dyfunction in either sex.

Front 214

214. What is the dopamine hypothesis of schizophrenia?

Back 214

In the early 1950’s it was discovered that a high dosage of chlorpromazine calmed highly agitated and aggressive patients who had schizophrenia or manic depressive symptoms.

Historically it appears that the efficacy of chlorpromazine was established before the mechanism of action was understood.

It was later discovered that typical antipsychotic drugs have a high affinity for D2 receptors, which are therefore thought to be one of the major sites of the therapeutic action of these typical antipsychotic drugs.

Front 215

215. Role of serotonin in schizophrenia?

Back 215

Serotonin hypothesis – Excess of serotonin may be causal for either positive or negative
symptoms, which is supported by the efficacy of serotonin-dopamine antagonists such as clozaril, risperidone, olanzapine, quetiapine, and ziprasidone to decrease the positive symptoms.

Front 216

216. Role of GABA in schizophrenia?

Back 216

Some schizophrenic patients have a loss of GABAergic neurons in the hippocampus.

GABA has a regulatory effect on dopamine activity and the loss of inhibitory GABAergic neurons could lead to the hyperactivity of dopaminergic neurons.

Front 217

217. Role of neuropeptides in schizophrenia?

Back 217

Substance P and neurotensin are localized with the catecholamine and indolamine neurotransmitters and influence the action of neurotransmitters.

Alteration of neuropeptide mechanisms could facilitate, inhibit, or otherwise alter the pattern of firing these neuronal systems.

Front 218

218. What are the neurologic abnormalities often shown in schizophrenics?

Back 218

60% to 70% of schizophrenic patients show soft signs of neurological abnormalities, e.g.,

A. stereognosis (perceptual disturbance - ability to recognize by touch)
B. coordination
C gait
D. balance

Front 219

219. What is the most frequently reported finding in CT scans of the brain among patients with schizophrenia?

Back 219

An increase in the size of the lateral ventricles, which is related to;
a. cognitive impairment
b. poor response to neurolepectic medication
c. more negative than positive symptoms

*However, there is a lack of scientific evidence to use the enlarged ventricles as diagnostic for schizophrenia at this time

Front 220

210. What are 4 other neuro-imaging findings in schizophrenics?

Back 220

1. Brains are smaller than normal
2. Thinning of neuritic processes
3. A decrease in gray matter volume may explain a cause for the smaller brains
4. The size of the CSF spaces of schizophrenics were significantly enlarged when compared to a control group

Front 221

211. What are the findings of the Rorschach test with schizophrenics?

Back 221

1. Little movement seen of the ink blot
2. Responses are crudely formed
3. Lack of imagination or creativity

Front 222

212. What about the Thematic Apperception Test and the WAIS test in schizophrenics?

Back 222

TAT stories tend to be disorganized and distorted

WAIS - it is common to have preserved verbal intelligence, but w/low performance intelligence w/schizophrenia

Front 223

213. What about the MMPI-2 test w/schizophrenics?

Back 223

Minnesota Multiphasic Personality Inventory-2 – (MMPI-2) - scales Psychasthenia (Pt) and Schizophrenia (Sc) have relationship to schizophrenic process.

(Pt) scale assesses thought patterns for excessive doubts, compulsions, obsessions and unreasonable fears.

(Sc) scale measures for characteristics in disturbed thinking (bizarre mentation, peculiarities of perception, delusions, and hallucinations), in mood, and in behavior.

Front 224

214. What are the 5 positive symptoms of schizophrenia?

Back 224

1. Delusions
2. Hallucinations
3. Disorganization
4. Agitated or bizarre behavior
5. Suspiciousness

Front 225

215. What are the 5 negative symptoms of schizophrenia?

Back 225

1. Blunted or flat affect
2. Avolition
3. Alogia
4. Attentional problems
5. Anhedonia

Front 226

216. What are the 6 different types of delusions?

Back 226

1. Persecution – fear of harm, being spied on, being lied on, poisoned
2. Grandiosity – exaggeration of one’s abilities, or importance
3. Referential thinking – random events related to the person
4. Thought broadcasting (others can hear the patient’s thoughts)
5. Thought insertion (others can insert thoughts inside one’s head)
6. Thought extraction, (others can remove thoughts from one’s head)

Front 227

217. What are some examples of loosened associations?

Back 227

1. Neologisms – invented words
2. Primitive logic
3. Concreteness, (does not deal with abstraction)
4. Echolalia – repeating words spoken by others
5. Word salad – use of words with no apparent relationship

Front 228

218. What are 4 qualitative changes – unusual abnormal movements in schizophrenics?

Back 228

1. Echopraxia - mimic the movements of another
2. Catatonic positioning - hold positions
3. Mannerisms and grimacing - hebephrenia
4. Perseveration - repeating tasks or statements

Front 229

219. What is the DSM criteria for schizophrenia?

Back 229

Criterion A states that two (or more) of the following characteristic symptoms must be present for at least 1 month: delusions, hallucinations, disorganization, and/or negative symptoms.

The remaining criteria for diagnosing schizophrenia include determining the level of disturbance in social and/or work functioning.

***The symptom presentation and disturbance must be present for a minimum of 6 months and other possible mental illnesses, such as schizoaffective disorder or a mood disorder, must be ruled out.

Front 230

220. What is late onset schizophrenia?

Back 230

A subcategory of the illness, late-onset schizophrenia, is reserved for those who present with symptoms for the first time after age 45.

An important warning on diagnosing late-onset schizophrenia is that a thorough search for earlier signs and symptoms should be done to definitively diagnose this condition. In many cases, patients who present as late onset have evidence of schizophrenia before age 45, which was either not obvious or unavailable.

Front 231

221. What are the 4 possible phases of schizophrenia?

Back 231

1. Acute onset
-symptoms appearing abruptly may likely be related to a “Brief Reactive psychosis,” or to a “Schizophreniform,” disorder

2. Insidious prodromal -the earlier in life that symptoms appear the less optimistic is the prognosis. Later onset means the individual had an opportunity to establish their highest level of functioning

3. Active phase
- demonstration of symptoms

4. Residual phase
-some symptoms remain, but not a complete set

Front 232

222. What are the 5 subtypes of schizophrenia?

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1. Paranoid type (persecutory or grandiose ideas, flat affect, hallucinations
2. Catatonic type (bizarre postures)
3. Disorganized type (flat or inappropriate affect and emotions, severely disorganized speech)
4. Undifferentiated type
5. Residual type (absence of any of the above type but continued evidence of the disturbance

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223. What is the typical treatment for schizophrenia?

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Combination of pharmacotherapy, psychotherapy and social work.

Traditional antipsychotic medications are dopamine receptor antagonists that are effective in treating the positive symptoms. Can develop serious side effects e.g., akathisia, Parkinsonian-like symptoms, and tardive dyskinesia (Thorazine, Haldol).

Newer atypical antipsychotics – effective against both positive & negative symptoms, and without the EPSE, (Risperdal, Clozaril, Olanzapine)

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224. What is neuroleptic malignant syndrome?

Back 234

Neuroleptic Malignant Syndrome (NMS) – some patients may develop a serious condition due to abrupt withdrawal of a dopamine precursor with the use of dopamine receptor antagonists, (i.e. typical antipsychotics such as chlorpromazine [thorazine], trifluoperazine [stelazine], fluphenazine [prolixin], thioridazine [navane], haloperidol [haldol].

Older neuroleptics as well as newer atypical antipsychotic medications may develop a complex of symptoms that includes hyperthermia, muscular rigidity, and autonomic dysregulation (that may include fever, increased blood pressure, and increased heart rate). This condition may be life threatening.

Symptoms can occur over 1-3 days and if untreated the syndrome can last 10 – 14 days. The mortality rate can be 20-30% and higher with depot dopamine receptor antagonist medications.

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225. What are the autonomic dysfunctions in NMS?

Back 235

1. Dry mouth
2. Constipation
3. Urinary retention
4. Bowel obstruction
5. Dilated pupils
6. Blurred vision
7. Increased heart rate
8. Respiratory problems
9. Weight gain

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226. What are the CNS impairments in NMS?

Back 236

1. Impaired concentration
2. Confusion
3. Attention deficiencies
4. Memory impairment
5. Delirium was association w/higher serum anticholinergic activity

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227. What is tardive dyskinesia?

Back 237

Tardive Dyskinesia – involuntary choreoathetioid movements of the face, trunk or extremities.

Typically occurs subsequent to prolonged exposure to dopamine receptor blocking agents., i..e., antipsychotic medications, but some anti-depressant medications as well. This condition may not resolve after its appearance.

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228. What is metabolic syndrome?

Back 238

Metabolic syndrome – second generation atypical antipsychotic medications have been implicated as a cause.

Diagnosed when a patient has 3 or more of the following risk factors;
1. abdominal obersity
2. high triglyceride level
3. low HDL cholesterol level
4. hypertension
5. elevated fasting blood glucose level

*The two atypical antipsychotic agents most implicated have so far been Clozapine and Olanzapine.

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229. Association of schizophrenics and substance abuse?

Back 239

Clinicians need to take precaution with schizophrenics who have a co-occurring substance abuse. Signs of drug abuse are sometimes similar to those of schizophrenia, and people with schizophrenia may be mistaken for people "high on drugs.”

Substance abuse can reduce the effectiveness of treatment for schizophrenia. Stimulants (such as amphetamines, cocaine, PCP or even marijuana) may cause a worsening of their schizophrenic symptoms. Substance abuse also reduces the likelihood that patients will follow the treatment plans recommended by their doctors.

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230. What is schizophreniform disorder?

Back 240

Falls between a diagnosis of Schizophrenia and a Brief Psychotic Disorder

Schizophreniform disorder essentially resembles schizophrenia, except for having a shorter duration. This disorder reflects a period of diagnostic uncertainty as to whether the patient will go on to develop schizophrenia. The diagnostic criteria include the Criterion A symptoms of schizophrenia (delusions, hallucinations, disorganized speech or behavior, etc., as described earlier) lasting at least 1 month but <6 months.

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231. What is the etiology of schizophreniform disorder?

Back 241

Unknown. These patients develop a disorder that has the same features of schizophrenia and will either;

1) undergo a spontaneous, complete and permanent remission in less than half a year
2) proceed on to a full diagnosis of schizophrenia

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232. What is the treatment for schizophreniform disorder?

Back 242

Similar for treatment of schizophrenia.

During acute stages of the disorder when psychotic symptoms are present, hospitalization may be required.

Pharmacotherapy, first line agents are the antipsychotic medications. Benzodiazepines may be used for acute anxiety agitation.

Psychosocial treatments help to rehabilitate and return to community.

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233. What is a brief psychotic disorder?

Back 243

Brief psychotic disorder could be considered on a timeline continuum with schizophreniform disorder and schizophrenia in that it involves similar symptoms but with duration of <1 month.

Symptoms can include the presence of hallucinations, delusions, disorganized speech, and/or disorganized or catatonic behavior that lasts from 1 day up to 30 days, with subsequent full recovery. Patients experiencing this disorder can often be frightened, anxious, confused, temporarily quite disabled, and at risk for poor self-care or self-harm. The onset of symptoms is usually sudden and occurs shortly after a traumatic event.

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234. What is the differential Dx for brief psychotic disorder?

Back 244

The average age of onset is in the late 20s to early 30s.

The differential diagnosis can be broad and may include ruling out delirium, other medical conditions (such as thyroid illness, Cushing disease, or a brain tumor), substance-induced psychosis (including intoxication), mood disorders, schizophrenia spectrum disorders, and even personality disorders (such as borderline personality disorder). Although challenging to identify, factitious disorder and malingering are part of the differential diagnosis and also must be ruled out.

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235. What are some factors that are associated with a brief psychotic disorder?

Back 245

The onset of symptoms is usually sudden and occurs shortly after a traumatic event.

These include:
1. Some stressful event, e.g.,
a. death of a close person
b. culture shock (move to a different country)
c. natural disaster
d. involved with a military activity (war, combat)
2. Having limitations in coping, e.g,
a. trying to manage serious financial issues
b. dealing with academic problems
c. being a child or an adolescent, for example, having to make choices in face of peer pressure

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236. What is schizoaffective disorder?

Back 246

Schizoaffective disorder describes a somewhat controversial entity, which is defined as the occurrence of continuous psychotic symptoms (Criterion A for schizophrenia) with periods of depression or mania.

DSM-IV-TR requires that a patient experience at least 2 weeks of prominent delusions or hallucinations in the absence of prominent mood symptoms. Finally, the mood symptoms must be present for a substantial portion of the total duration of the illness, although the specific duration of the mood symptoms is not defined.

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237. What is necessary for a Dx of schizoaffective disorder?

Back 247

To be considered for a diagnosis of schizoaffective disorder, full criteria for a major depressive episode or manic/mixed episode must be met while the patient is in the mood phase of this illness, and the patient must be experiencing intervening periods of psychosis.

To make this diagnosis, psychotic symptoms often need to precede the onset of the mood symptoms. Otherwise, a diagnosis of major depressive disorder with psychotic features or bipolar disorder, type I, may be more appropriate, as long as both have incomplete remission that results in lingering psychosis.

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238. Explain the mechanisms of two disorders that converge into a schizoaffective disorder.

Back 248

This condition is marked with symptoms that satisfy the DSM-IV diagnostic criteria for two disorders: schizophrenia and major depression.

Schizoaffective typically begins with a two month episode of pronounced auditory hallucinations and delusions. About two months into the psychotic symptoms begin the depressive symptoms and both are present for three months.

The individual recovers initially from the depressive symptoms but the psychotic symptoms remain for another month before there is recovery from those symptoms. The total period of illness lasts for about 6 months and there can be significant periods of time between episodes.

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239. What are 5 factors that are associated with a worse prognosis in schizoaffective disorder?

Back 249

1. insidious onset, early onset
2. poor premorbid functioning
3. absence of a clear precipitating stressor
4. prominent negative schizophrenic symptoms
5. family history of schizophrenia

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240. What is a delusional disorder?

Back 250

The key to the diagnosis of delusional disorder is the presence of nonbizarre delusions for at least 1 month, without other psychotic symptoms and features of schizophrenia.

In these patients, auditory hallucinations are not present, nor is significant disability in psychosocial functioning except as directly impacted by the false delusional beliefs. To receive this diagnosis, the nonbizarre delusion(s) must not occur in the context of a mood disorder and cannot be induced by substance use or medical illness.

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241. What are the 7 subtypes of delusional disorder?

Back 251

DSM-IV-TR identifies several subtypes of the disorder based on the theme of the delusion: erotomanic, grandiose, jealous, persecutory, somatic, mixed, or unspecified.

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241. What are erotomania delusions?

Back 252

Ertomania – the delusional individual has the belief that someone of notoriety is
in love with the patient. These individuals usually enjoy solitary existence, limited social interactions, are sexually inhibited and have poor occupational functioning.

These individuals are likely the stalkers of their prey. They may become violent toward the companions of their prey as they see the companions as interlopers. Likely make national news with stalking TV stars or politicians.

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242. What are persecutory delusions?

Back 253

Persecutory – along with jealousy type is probably the most treated by mental
health clinicians. This individual believes that someone, or some entity is harming them in some way.

The patient may display episodes of agitation and violence, and/or they may pursue retribution by way of frivolous law suits.

A schizophrenia delusion is without logic, or an elaborate systematic theme as is seen in a Delusional disorder.

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243. What is a somatic delusion?

Back 254

Somatic - they typically are unrelenting in their beliefs which is different than people to are diagnosed with hypochondriasis.

In hypochondriasis there is the suspicion from the patietn have three kinds of delusions;
A. delusion of infestation
B. delusion of dysmorphophobia – i.e, misshapen body, grotesque looking, exaggerated body sizes
C. foul body odors – i.e,. halitosis

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244. What is a delusion of Capgras?

Back 255

Unspecified type of delusion.

Delusion of Capgras – a syndrome in which the delusional person believes that familiar persons or persecutors can assume the guise of strangers, thus the familiar person has become an imposter.

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245. What is a delusion of nihilism (cotard syndrome)

Back 256

Also another unspecified delusion:

Delusion of nihilism (cotard syndrome) in which the delusional person believes that they have lost everything, i.e,"", their possessions, status, strength, heart, blood, internal organs and left with a feeling of nothingness.

*This delusion often is a precursor to schizophrenia or depressive episode.*

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246. What is folie a deux?

Back 257

A shared delusion.

Characterized by the transfer of delusions from one person to another. Typically the two individuals live together in relative social isolation.

The first one to have the delusion is chronically ill, which the second person is usually dependent, less intelligent, more gullible. Upon separation the second person may abandon the delusion.