Psychiatry Exam 2

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1. What is psychoanalysis?

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The theory based on the premise that unconscious events play a role in shaping of personality, behavioral responses, and symptoms of the analysand (client).

During the course of psychoanalysis repressed memories will be disclosed by the analysand which will reveal psycho-social conflicts that occurred earlier in life, referred to as “recollections; and through transference will replay their conflicts using the analyst as the target of their conflict; the analyst helps bring the client to conscious light which was hitherto repressed with unresolved feelings so that the client can recover and live happier.
The object is to help the analysand realize hidden meanings, verbalize repressed material, ward off underlying conflicts, and understand ego defense mechanisms used.

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2. What is transference?

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Transference are feelings from one’s past interactions with others that become transferred into current relationships.

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3. What is counter-transference, and how does it have a deleterious effect to treatment?

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Counter-transference is the therapist's transferring feelings in the therapy and/or towards the client.

Usually has a deleterious effect to treatment since the clinician expects the patient to live up to the unwarranted, unwanted and unknown expectations of the clinician. The therapeutic relationship is typically tainted by the counter-transference and often the clinician will welcome or reject a patient based on the counter-transference.

Counter-transference has nothing to do with the patient but everything to do with the clinician’s experiences.

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4. What are ego defense mechanisms?

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Ego Defense mechanisms - are unconscious mechanizations used to deflect or lessen the effects of unwanted feelings such as fear and anxiety. The concept of the defense mechanism originated with Sigmund Freud.

Defense mechanisms allow negative feelings to be lessened by distorting the reality of that situation in some way. They can help in coping with stress, or they can become a person's primary mode of responding to problems.

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5. What are the 16 defense mechanisms?

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1. Denial
2. Repression
3. Suppression
4. Projection
5. Displacement
6. Reaction formation
7. Regression
8. Fixation
9. Identification
10. Rationalization
11. Isolation
12. Sublimation
13. Intellectualization
14. Acting out
15. Passive aggression
16. Fantasy

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6. What is denial?

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Denial - distorts reality by keeping things hidden from conscious awareness. Reality that is unpleasant is often ignored.

Example: Upon hearing that her father was just diagnosed with Alzheimer’s a woman states “This can’t be happening; it must be a nightmare.”

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7. What is repression?

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Repression - Freud’s most common defense mechanism, also distorts reality by simply forgetting painful conscious feelings. However, they are stored in the unconscious, from which, under certain circumstances, they can be retrieved. Some instances of repression fall under the category of forgetfulness, and inaccurate recollection, misplace things, or slips of the tongue.

Example: Possibly the most extreme example of repression is child abuse, the memory of which may remain repressed long into adulthood, sometimes being deliberately retrieved in therapy through hypnosis and other techniques.

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8. What is suppression?

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Suppression - not thinking about unpleasant feelings. *Suppression differs from repression and denial in that with suppression undesirable feelings are available but deliberately ignored.* Cognitive behavior therapy in particular makes use of this technique to help people combat negative thought patterns that produce maladaptive emotions and behavior. Suppression is considered one of the more mature and healthy defense mechanisms.

Example, people with phobias may be instructed to block feelings of fear by thinking about a pleasant experience, such as a party, an academic achievement, or a victory in a sporting event.

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9. What is projection?

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Projection – transfers anxiety-producing feelings felt by oneself onto another source or onto another object. In projection, the undesirable feelings one owns are attributed to another person or persons.

Example: A man who has feelings of being unfaithful to his wife, frequently teases her that people with whom his wife works have “crushes” on her.

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10. What is displacement?

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Displacement - a reaction to a situation perceived as dangerous is not targeted at the cause of the anxiety but aimed at another target considered to be more benign and less threatening than is the original target believed to be.

Example: being angry at an employer, but releasing anger onto a family member instead.

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11. What is reaction formation?

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Reaction formation - involves behavior that is completely opposed to the impulses or feelings that one is trying to repress.

Example, a parent who represses feelings of frustration or even rejection toward a child may overcompensate by appearing to be spoiling the child.

Example: A man has homosexual tendencies that he can’t acknowledge to himself or others. He becomes very “macho” in his behavior and lashes out at any behavior in other men that seems “gay.”

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12. What is regression?

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Regression – reversal of behaving, and/or in thinking to a more children-like frame of reference when confronted with a situation that produces conflict, anxiety, or frustration. The childish behavior was comforting, enjoyable, or protective.

Example: adult temper tantrums to get others to take care of us

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13. What is fixation?

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Fixation – refusal to advance to successive stages of process or development because developmental progress has come to be associated with anxiety in some way.

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14. What is identification?

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Identification, - the adopting of characteristics of someone else, as a motive to cope with a fear of losing the person with whom one identifies.

Example:, identification with a perpetrator (kidnapping, hostage or war), where someone who is victimized in some way takes on the traits of the victimizer to combat feelings of powerlessness.

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15. What is rationalization?

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Rationalization - is an attempt to deny one's true motives (to oneself or others) by using a reason (or rationale, i.e., self-serving explanations to justify a behavior and avoid feelings of guilt) that is more logical or socially acceptable than one's own impulses. The goal is to convince yourself that an action was justified, even though deep down you know it wasn’t. In other words, the individual tries to find a reason or excuse for one's behavior which is more acceptable to the ego and superego. This particular defense mechanism works extremely well as it totally rids the individual of any sense of guilt, remorse, or responsibility.

Example : "I couldn't get my homework done because I had too many other things to do."

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16. What is isolation?

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Isolation – involves the separation of experience from accompanying feelings. The purpose is to allow the event to be consciously available without the threat of painful feelings.

Example : in a crisis action may be more efficient without experiencing the feeling, in the moment

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17. What is sublimation?

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Sublimation - one of the healthiest defense mechanisms, involves re-channeling the energy connected with an unacceptable impulse into one that is more socially acceptable. In this way, inappropriate sexual or aggressive impulses can be released in sports, creative pursuits, or other activities.

Example : those with an urge to kill, may join groups who support the death penalty.

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18. What is intellectualization?

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Intellectualization - using an abundance of cognitive rationale to distance the person from an unacceptable feeling, impulse, etc.

Example : quoting real or imaginary statistics to defend a personal position.

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19. What is acting out?

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Acting Out - involves dealing with stress by using action rather than reflection or feeling. *Sublimation is the opposite of acting out, we don't act out.*

Example : Hockey players who sublimate their desires for physical violence into a game. Expressing the desire, but doing it in a socially acceptable way like being a hockey player or a boxer.

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20. What is passive aggression?

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Passive Aggression - involves dealing with stress by indirectly and unassertively expressing aggression toward others. The person displays an outward superficial cooperativeness that masks the underlying resistance, resentment, and hostility.

This defense may be adaptive in situations where direct and assertive communication is punished (e.g., abusive relationships).

Example. An adolescent is told by his parent to take out the garbage, but does not want to take out the garbage and procrastinates enough with the result that someone else takes out the garbage.

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21. What is fantasy?

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Fantasy - gratifying frustrated desires by imaginary achievement. Fantasy is a normal and acceptable behavior, and can be positive in many ways, such as providing a motivation to achieve. However, it must be realized that fantasy and reality are two separate entities, and that fantasizing will neither resolve conflicts nor bring about self-improvement.

Example : Day dreaming watch an action movie and envision yourself as a daring hero or heroine.

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22. Which types of pts should psychoanalysis be recommended for?

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Psychoanalysis is indicated for those who;

1. desire self awareness
2. are able tolerate strong emotions that emerge from the analysis
3. are not self destructive
4. be reasonably mature and honest
5. are intellectually capable for cause – effect thinking
6. can be abstract and symbolically oriented about unconscious revelations

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23. Contraindications for psychoanalysis?

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Psychoanalysis is contraindicated for those who;

1. seek symptomatic relief
2. have a serious thought disorders such as psychosis, or with suicidal ideation.
3. have poor impulse control
4. are unable to tolerate strong emotional feelings
5. have an antisocial personality disorder
6. cannot financially afford costly long term therapy

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24. What is brief dynamic psychotherapy?

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Based on psychoanalytic principles of Peter Sifneos who suspected that psycho-social complaints had more to do with interrelational conflicts than repressed unconscious material.

Old patterns of coping may become dysfunctional and manifest as anxiety, anger, frustration and a host of other maladaptive patterns. Consequently, the presenting problem may only be the tip of the iceberg. Therapeutic sessions are observed between clients and the therapist identifies and interprets dysfunctional patterns of behavior and encourages optional adjustments to interactions which may be more effective.

This therapy focuses on:
A. Here and the Now – stay in the moment and only learn from the past and avoid distant futuristic thinking.
B. Break through patterns of defensiveness and resistances to change
C. Short term involvement

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25. What is crisis intervention?

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According to Eastern philosophy crisis is a combination of danger and opportunity.

Crisis work is six weeks in duration. By that time it is suspected that any crisis will have worked itself out with or without intervention. The purpose of intervention is to make the outcome less dangerous and more opportunistic.

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26. What are the 3 important elements of crisis intervention?

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1. perception of the event – events happen to everyone, and each person needs to interpret the personal weight of the event(s).

2. situational supports – when others are available to help

3. available coping mechanisms – identifies the individual’s typical ways they deal with events: i.e., mature and constructive or immature and destructive.

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27. Who was Eric Lindemann?

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Eric Lindemann – was a prime mover for the impetus for crisis intervention counseling occurred on November 28, 1942, at 10:11 PM which was a Saturday night at a nightclub in Boston. On that night and at that time, a fire started in the basement lounge of the Coconut Grove nightclub in the Bay Village neighborhood of Boston. Approximately 1,000 occupants were crowded into the nightclub that night. The 1,000 was 400 over the club’s legal occupancy limit of 600. A tragic fire engulfed the entire nightclub. Approximately half of the individuals on the premises that evening 492 patrons were killed in the fire. Exits were either blocked or locked closed. Autopsies indicated that, in addition to the fire itself, the leak of a refrigerant, methyl chloride, may have contributed to the high death toll. Casualties arrived every eleven seconds at Boston City Hospital for a solid hour of which 300 of these were dead on arrival (DOA), and 129 were admitted for care.

From this fire it was learned how to more effectively fight fires, to adhere to ordinances for numbers of occupants, to have safer fire exits, and deal with the psychological impact of crises. In addition a lot was learned about bereavement.

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28. What is dialectic behavioral therapy (DBT)?

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Developed by Marsha Linehan, Ph D

Dialectic means to weigh and integrate contradictory facts or ideas as a means to arrive at a consensus. What makes the dialectics work are the base assumptions that everything is connected in some way to everything else, change is a part of life, change is constant and inevitable, and opposite thoughts and feelings can be integrated and need not be excluded which creates a stronger truthful fabric.

DBT is a therapy especially designed for individuals who demonstrate or report self harming behaviors, e.g., suicidal ideation, cutting and burning themselves. Most common diagnostic category who demonstrate these behaviors are those who meet the criteria for Borderline Personality Disorder, but more recently DBT has been used with women who over-eat, adolescents who are depressed with/without suicidal ideations.

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29. What are 3 features of DBT?

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1) individual psychotherapy - on a weekly basis, 60-90 minutes

2) group psycho-education therapy – weekly for one year, 120 minutes. These groups have curriculum of skills to be learned that include interpersonal effectiveness, regulation of emotions to prevent the real highs and the real lows, how to tolerate distress

3) phone coaching – on an as needed basis especially at times when they feel self harmful. The Coach will walk them through intervention strategies that hopefully deter the harmful behavior.

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30. What are the 3 goals of DBT?

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1) Change from being Out of Control to being In Control
a. reduce and then eliminate life threatening urges, fantasies, thoughts and feelings
b. reduce and eliminate treatment resistant behaviors, e.g.,"", how to use helpers correctly rather than over-use and burning them out, ensure homework assignments are completed, attendance compliance, disclosing
c. decrease behaviors that impair the quality of life, e.g., anxieties, depression, substance abuse, eating disorders, environmental conditions housing, and employment

2) Change from being Emotionally Closed to being Emotionally Open
a. teaching how not to suffer in silence
b. being able to disclose deep emotions brought on by such experiences as PTSD

3) Being Ordinary – to work with day to day issues

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31. What is eye movement desensitization and reprocessing therapy (EMDR)?

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Paul Federn, EMDR a developer of this therapeutic intervention suspects individuals “introject” aspects of others. Introject is a gestalt term meaning taking on characteristics, values, traits of another and making them our own. We may introject a critical parent and therefore criticize ourselves, we may introject beliefs such as it is better to do unto others before they do it unto you, etc.

EMDR assumes that this process has a biological component similar to Rapid Eye Movement (REM). REM is a method by which we retrieve information. The process of EMDR has been targeted to work with experiences that have some traumatic underpinning, such as natural disasters, war, crime, PTSD, anxiety disorders, substance abuse, and stress management.

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32. What is involved in EMDR?

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EMDR utilizes a direct holistic approach, attending to ongoing effective and physiological changes. The therapy involves;

1. teaching self-control techniques

2. rate distress causing images using the Validity of Cognition Scale (VOC), to gauge “false" and "true" responses to automatic thoughts, and Subjective Unit of Disturbance (SUD) scale rating between "calm" and "the worst possible distress" and identifies and locates the body sensations accompanying the emotions.

3. progressive desensitization, along with the therapist moving their finger so the patient can visually follow a path from side to side for 15 or more seconds as the patient mentally focuses on;
a. the visual image
b. the identified negative belief
c. emotions, and physiological sensations

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33. So, how does EMDR work?

Back 33

Visual movement therapy continues until the patient reports shifts in cognitive ratings (VOC) and the SUD rating generally indicates a calmness. The patient then cognitively re-frames previously identified distressing images and automatic thoughts with positive self-statement.

Rhythmic, saccadic eye movements that were introduced with the traumatic image and the corresponding thoughts become reframed and thus restored. The reframing causes a neural balance through the "neural bursts evoked by the repeated saccades" causing a pathological change in the neural elements, and maintaining the incidents in their original anxiety-producing form corrections in the excitatory/inhibitory balance in the brain.

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34. What is CBT?

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Emphasizes the role of how thinking influences our judgments, feelings and behaviors.

Aaron Beck, one of the main movers of Cognitive therapy, has demonstrated this therapy to be most efficient with depressive disorders. Also, due to the nature of re-shaping, re-framing and repairing irrational thinking, this modality seems to be the treatment of choice for non psychotic thought processing dysfunctions such as Obsessive compulsive disorder, Generalized disorders.


He believes thoughts are linked to feelings and to behaviors which means people are capable to change the way they think, and they may feel / act better even if the situation does not change.

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35. What are 3 goals of CBT?

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1. Examine the evidence – make sure all assumptions are based on logical facts and not on emotional impressions

2. De-castrophize – prepare for the worst case scenario in the hope that it will not materialize but be ready if it does happen

3. Limit overgeneralizations – determine emotional and cognitive responses to select issues and not as an indictment to the whole of anything

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36. What is systematic desensitization?

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Systematic Desensitization – a form of counter-conditioning that creates a gradient hierarchy of anxiety-provoking situations, followed by relaxation processes with each level in the hierarchy until the individual remains relaxed even when thinking about or actually confronting the anxiety-provoking situation.

This process of referred to as reciprocal inhibition.

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37. What is assertiveness training?

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Assertiveness training – being social phobic, having low self esteem, anxious of making bad impressions, and have a general attitude of being helpless can be ameliorated by teaching techniques to increase an individuals ability to negotiate, say no to unreasonable demands from others, communicate more productively. Learning to live with embarrassment.

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38. What is the definition of intelligence?

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Intelligence – the ability to perform a variety of cognitive powers that would include the processes of thinking, analyzing, synthesizing, aptitude, and making decisions.

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39. What is the VIQ, PIQ, and FSIQ?

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Language (VIQ, verbal intelligence quotient) known on the test as verbal comprehension

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.

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40. Who were Simon and Binet?

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In 1905 Simon and Binet constructed the first intelligence measure, based on standardized scoring that identified average mental levels for various age groups in order to target students who exhibited low level of intellectual functioning, with the assumption that lower IQ indicated the need for more teaching, not an inability to learn.

The test focused on the intellectual development of children from three years old to twelve years old. The instrument was composed of problems designed to measure general intelligence, and items were graded according to age level. The child's score, based on the number of correct answers, yielded the child's mental age.

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41. Who was William Stern?

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Stern followed up on the work of Alfred Binet with regards to child studies.

Stern designed the notion of individual test scores being related to "mental ages" which he then compared to actual "chronological ages" to determine a degree of advancement. He took the mental age and divided it by the chronological age, and named this ratio the intelligence quotient.

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42. Who was David Wechsler?

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Wechsler generated current popularly used tests of child and adult intellectual quotients. Wechsler began creating tests around 1939 the first having been the Wechsler-Bellevue Intelligence Scale. The more modern of the Wechsler tests are the Wechsler Adult Intelligence Scale (WAIS-III) and the Wechsler Intelligence Scale for Children, (WISC).
The Wechsler tests are based on verbal and performance subtests. Wechsler believed the subtests were collectively capable of yielding important clinical insights that could be used for differential diagnosis as well as measuring a broad range of psychological functioning.

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43. 5 purposes of IQ tests, and one criticism

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a first used in a standardized format by Alfred Binet to identify learning-impairment
b. today also used to identifying children with mental retardation
c. identifies learning disabilities
d. assesses for skills and abilities
e. assesses for aptitude and achievement, e.g., SAT

One criticism of intelligence testing is that it is difficult to insure that test items are equally meaningful or difficult for members of different socio-cultural groups.

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44. What is the Wechsler Adult Intelligence Scale for Adults –III (WAIS-III)?

Back 44

Are among the most widely used scales for IQ tests.
Will provide subscales for:
1. Verbal Intelligence Quotient (VIQ)
2. Performance Intelligence Quotient (PIQ)
3. Full Scale Intelligence Quotient (FSIQ)

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45. VIQ subscales

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Verbal IQ (VIQ) subscales provide information related to verbal ability, knowledge, comprehension, perceptual organization and working memory:

1. Information
2. Digit span
3. Vocab
4. Arithmetic
5. Comprehension
6. Similarities

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46. PIQ subscales

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Performance IQ (PIQ) sub scales provide information regarding problem solving, learning new tasks, and process speed

Subscales:
1. Picture completion
2. Picture arrangement
3. Block design
4. Digit/symbol/coding/animal house
5. Object assembly
6. Matrix Reasoning – (a WAIS-III addition) a group of designs that the test taker makes a forced choice to select a design that will complete a pattern or sequence, measures abstract nonverbal reasoning ability

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47. What are the 4 factors of the Stanford-Binet test?

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1. Fluid reasoning- measures verbal knowledge and ability to apply verbal skills to new situations

2. Quantitative reasoning, including numerical reasoning and concentration

3. Visual-spatial processing; including visualizing patterns, and problem-solving skills

4. Short term / working memory

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48. What are neuropsychological tests?

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Neuropsychological tests are tests that assess cognitive functioning such as memory, attention, and executive functioning (planning, and decision making).

The purpose of these tests is clarify how changes in the brain structure and function affects behavior.

Can be assessed on a continuum of: simple motor performance to complex reasoning and problem solving.

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49. Why are neuropsychological tests important in differentials?

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Neuropsychological tests are the most effective differential diagnostic methods to differentiate pathophysiological dementia from age-related cognitive decline, cognitive difficulties that are depression-related, and other related disorders.

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50. What is the Bender-Gestalt test?

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Lauretta Bender believed to assess perceptual perceptual maturation and neurological impairment. The test is a series of 9 cards each having designs. The test taker is directed to copy the design, and once all 9 cards are completed, the test taker is directed to reproduce the designs from visual memory to assess for organic dysfunction and spatial relationships.

Administration is for children to adults.

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51. What is the Benton-Visual Retention test?

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The Benton-Visual Retention is created and designed to assess visual perception, visual memory, and visual-constructive abilities.

Administration is for children to adults. Scoring is determined by errors, and correct scores, omissions, rotations, perseverations, additions, and substitutions.

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52. What is the Halstead-Reitan test?

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Halstead-Reitan- (c. 1947) created by Ward Halstead and Ralph Reitan in the 1940’s. The subtests are used to determine the location and the effects of specific brain lesions.

The subtests include;
1 abstracting ability.
2. memory and localization.
3. discriminate between like and unlike pairs
4. discriminate spoken syllables.
5. manual dexterity.
6. reproducing movement from sight as well as ability to estimate time span.

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53. What is the Luria-Nebraska neuropsychological battery (LNNB)?

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Luria-Nebraska Neuropsychological Battery- (LNNB) is based on the theory of higher cortical functioning by Aleksandr R. Luria, who utilized unstructured qualitative techniques in assessing neurologically impaired patients.

When compared to the Halstead Neuropsychological Battery, there was found equivalency among clinical neuropsychologists with each battery having achieved an overall hit rate of approximately 80%.

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54. What are state dynamics? What are trait dynamics?

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State dynamics refers to changeable variables such as, occupations, living arrangements, and activities.

Trait dynamics are those variables that are unchangeable such as, skin color, height.

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55. What are projective measurements?

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Projective measurements - composed of ambiguous and vague tasks to which a test taker is asked to provide meaning. The meaning given by the test taker is suspected to be the individual’s repressed issues that become projected onto the test material, and used to try and unlock unconscious beliefs, attitudes and thoughts intended to by pass ego defense mechanisms.

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56. What is the Rorschach test?

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Rorschach, - (aka, “the inkblot test”). Named after its originator, Hermann Rorschach, a Swiss psychiatrist, who created the test in the early 1900’s. Provides an insight into personality construct, and the process by which an individual processes their environment. Some people process the environment thoroughly by taking in all minute details, while others may process the environment haphazardly by discounting some of the obvious details.

The Rorschach can provide indications of psychopathology. The responses to 10 stimulus cards are compared to other popular standard responses, and to other not so popular responses. The less similar to the popular standard response the greater the likelihood of psychopathology.

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57. What is the thematic apperception test (TAT)?

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Thematic Apperception Test, (TAT) created by Christina Morgan and Henry Murray from the Harvard’s Psychology Clinic in the 1930’s.

The intention of the TAT is to reveal personality features, drives, emotions and motivations that may be unconscious when the test taker creates stories to 10 stimulus cards.

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58. What is the children's apperception test?

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Children’s Apperception Test, is very much like the TAT,but instead of using images of people, the CAT uses more friendly figures of animals performing anthropomorphic behaviors.

The purpose is to seek out conflicts and concerns in the child.

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59. What is the incomplete sentence blank test?

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Incomplete Sentence Blank, test form has several items that each have a noun and/or a noun and a verb. The test taker is directed to complete the sentence.

The responses are suspected to be repressed material from the test taker that are projected onto the test form. The clinician searches for themes or topics of distress.

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60. What is the Draw a Person, House-Tree-Person test?

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Draw a Person, House-Tree-Person, quality, size, proportion, angulations, perspective, and theme are used to assess a test taker’s projected feelings and thoughts. Interpretations are guarded for age and development.

Various qualities in the drawing would be used as inquiry to better understand a test taker’s meanings. For example, a house drawn with a proportionately small door and few windows, might project some secrets that the individual is withholding information about themselves or about activities that occur or have occurred inside their home.

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61. What are 2 objective measures of personality?

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1. MMPI-2
2. Mellon clinical multiaxial inventory

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62. What is the MMPI-2?

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Minnesota Multiphasic Personality Inventory-2. Perhaps the most widely used measure of personality. There are 566 True and False statements and/or questions to which a test taker must endorse. The reading level is for 6th grade and administration time, depending upon reading comprehension is about 90 - 180 minutes. Scoring compares self endorsed statements of psychopathology, to those already endorsed by groups of people diagnosed with various psychopathologies.

The test by itself is not diagnostic, but provides a pattern of personality that may be similar those individuals who have already provided responses to the MMPI-2 and who have diagnoses of depression, mania, schizophrenia, hypochondriasis, personality disorder, and paranoia. The MMPI-2 has been normed on a non clinical population, unlike the original MMPI which was normed on a psychiatric population. The instrument has built in measures to detect deception.

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63. What are the 3 scales on the MMPI-2 that attempt to detect perception?

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The (L)ie scale is sensitive to whether a test taker tries to deliberately present themselves unlikely favorable light. This scale asks questions that most anyone would acknowledge to have experienced such as minor flaws and weaknesses that the person who wants to lie will answer in the negative.

The (F) Infrequency scale detects deviant or atypical responses that may include paranoid thinking, antisocial attitudes, and unlikely poor physical health.

The (K) Suppressor scale is sensitive to individuals who either try and deny psychopathology and present themselves in an unlikely favorable light or exaggerate psychopathology and try to appear in an unfavorable light as may the case in personal injury law suits.

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64. What is the Mellon clinical multiaxial inventory?

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Mellon Clinical Multiaxial Inventory. Focuses primarily on personality disorders as identified in the DSM-IV. The reading level is eighth grade, and administration time is about 20 to 30 minutes.

Profiles may be interpreted to illuminate the interplay between long-standing characterological patterns and the distinctive clinical symptoms currently manifested.

Uses of actuarial base rate data, rather than normalized standard score transformations The test is a 175 true and false item instrument which provides measures of 24 clinical scales, that include;

personality styles
expressed concerns
behavioral correlates

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65. What are the 9 components of the mental status exam?

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1. General description (appearance, behavior, attitude)
2. Sensorium (alertness, orientation via MMSE)
3. Speech
4. Mood and affect
5. Perception (hallucinations/delusions)
6. Thoughts (form/process/content)
7. Impulsivity
8. Judgment/insight
9. Reliability

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66. What are the components of the MMSE?

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1. Orientation to time and place
2. Concentration/registration
3. Attention and calculation
4. Recall/memory
5. Language
6. Repeat the following
7. Follow a 3-stage command
8. Read and obey

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67. How is the MMSE scored?

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Scoring; has a maximum of 30, a score of 24 or less is suspicious for dementia.

There is an inverse relationship between MMSE scores and age, ranging from a median of 29 for those 18 to 24 years of age, to 25 for individuals 80 years of age and older. The median MMSE score is 29 for individuals with at least 9 years of schooling, 26 for those with 5 to 8 years of schooling, and 22 for those with 0 to 4 years of schooling.

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68. What is the difference between the MMSE and the MSE?

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The difference between a MSE and a MMSE is that:

MSE – provides information about mood, thought content and thought processes, some personality

MMSE – provides information related to cognitive functions such as orientation, mental organization

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69. So, does the MSE examine an individual's dynamic or static forces?

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A Mental Status Examination (MSE) is an examination of an individual’s dynamic (changeable) forces.

Static (unchangeable) forces would be the individual’s history.

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70. What is the Glasgow Coma scale?

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The Glasgow Coma Scale is the most widely used scoring system used in quantifying level of consciousness following traumatic brain injury. *Can be used as a tool to test for Disturbance of Consciousness on the sensorium scale for the MSE*.

Eye openings +
Verbal responses +
Motor responses +

1. Mild is 13 through 15 points
2. Moderate is 9 to 12 points
3. Severe 3 through 8 points
4. Patients with score less than 8 are in Coma

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71. What does SED mean?

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An estimated 20% of the child and adolescent population in the U.S. may have a psychiatric disorder as found in the DSM-IV. Of the 20%, there are perhaps 4 - 8% who have a disorder severe enough to qualify as Seriously Emotionally Disturbed (SED).

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72. What does mental retardation mean?

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A significantly sub average general intellectual functioning (below 70) that manifests before the age of 18 AND IS accompanied by significant limitations in adaptive functioning in at least 2 of the following:

1. communication
2. self care
3. home living
4. social / interpersonal skills
5. use of community resources
6. self direction
7. work
8. leisure
9. health
10. safety
11. functional academic skills
Mental retardation is an intellectual range deficit of skills. Mental Retardation can be a developmental disorder, as well as an acquired disorder secondary to head injury or other physical trauma, or deterioration of the CNS. If acquired, mental retardation is typically diagnosed as dementia.

Front 73

73. Explain the relevance of Public Law 94-142

Back 73

Public Law 94-142 enacted by the U.S. Congress in 1970 also known as the “Education for all Handicapped Children Act,” established that public education must provide for appropriate educational resources within the least restrictive environment for all children regardless of disability.

Front 74

74. Explain the relevance of Public Law 106-402

Back 74

Public Law 106-402 enacted by the U.S. Congress October 30, 2000 also known as the “Developmental Disabilities Assistance and Bill of Rights.”

Congress finds that disability is a natural part of the human experience that does not
diminish the right of individuals with developmental disabilities to live independently, to exert control and choice over their own lives, and to fully participate in and contribute to their communities through full integration and inclusion in the economic, political, social, cultural, and educational mainstream of United States society.

Front 75

75. DSM criteria for mental retardation

Back 75

Significantly subaverage intellectual functioning; an IQ of approximately
70 or below on an individually administered IQ test, (for infants a clinical judgment is needed).

Concurrent deficits or impairments in present adaptive functioning (e.g, effectiveness to meet standards expected for age, in at least (2) of the following areas;
1. communication
2. self care
3. home living
4. social / interpersonal skills
5. use of community resources
6. self direction
7. functional academic skills
8. work
9. leisure
10. health
11. safety

Front 76

76. 3 classifications of mental retardation

Back 76

>50-70 up through 75 IQ = Educable MR (EMR)

> 30-50 IQ = Trainable MR (TMR)

> 30 and below IQ = Severely MR (SMR)

Front 77

77. Define mild mental retardation

Back 77

IQ 50-55

85% of mentally retarded population.

6th grade reading level

Can develop social and communications kills. Minimum self support as an adult.

Front 78

78. Define moderate mental retardation

Back 78

IQ 35-40 to 50-55

10% of mentally retarded population

May not advance beyond a 2nd grade. experience defects that interfere with find motor skills, e.g., coloring between the lines; as well as with gross motor skills, e.g., running.

Unskilled, or at best semi-skilled work. Function best under supervision. may be able to travel independently to familiar places using routine means of transportation

Front 79

79. Define severe mental retardation

Back 79

IQ 20-25 to 35-40

3-4% of population

May be able to be taught basic survival language skills. Function best in group homes. Exhibit little or no communication skills. An elementary level of self care skills.

Front 80

80. Define profound mental retardation

Back 80

IQ < 20-25

1-2% of population

Have neurological conditions that accounts for the mental retardation. Have impaired sensorimotor functioning. Need sheltered living and have high mortality rates.

Front 81

81. What is Down syndrome?

Back 81

Down’s Syndrome – Estimated to be 1/700 births, and increases incidence with age of mother’s over 35 years old. Down’s is equally common among the sexes. Features include;
1. flattened occiput
2. epicanthal folds
3. broad bridge of nose
4. small mouth with protruding tongue
5. tend to be short stature

*Mental retardation is the overriding feature of Down syndrome. Most persons with the syndrome are moderately or severely retarded, with only a minority having an IQ above 50.

Front 82

82. What is Fragile X syndrome?

Back 82

Fragile X is the most common inheritable form of mental retardation, but is a mild case.

Occurrence is about 1/1,000 male births and 1/2,000 female births.

Features include;
1. facial dysmorphism, i.e.,
a. projection of jaw beyond projection of the forehead)
b. a high broad forehead
2. autistic traits
3. high rates of ADD, and ADHD, learning disorder,
pervasive developmental disability

Front 83

83. Other features of Fragile X syndrome

Back 83

Persons with fragile X syndrome seem to have relatively strong skills in communication and socialization; their intellectual functions seem to decline in the pubertal period.

Female carriers are often less impaired than males with fragile X syndrome, but females can also manifest the typical physical characteristics and can be mildly retarded.

Front 84

84. Prader-Willi syndrome

Back 84

Prader-Willi syndrome is postulated to result from a small deletion involving chromosome 15 of paternal origin, usually occurring sporadically.

During the first 6-24 months infants tend to be somnolent and hypotonic and eat very little.

Prevalence is about 1/10,000.

Features beside obesity include;
1. compulsive eating/obesity
2. hypogonadism, micropenis, and cryptorchidism, lack of breast development, and lack of pubic hair, varying degrees of amenorrhea
3. oppositional and defiant behavior,

Front 85

85. What is Phenylketonuria (PKU)?

Back 85

Phenylketonuria (PKU) is a metabolic disorder results with impaired brain development, and typically severe mental retardation is identified around the 6th month of life. Fewer than 4% of untreated children achieve IQ’s greater than 50 or 60.

About one third are unable to walk, and about two thirds are unable to talk. Verbal communication is severely limited. This condition can be avoided by dietary restriction of phenylalanine intake early in life. Prevalence is about 1::10,000 births

Front 86

86. Cat's Cry (Cri-du-Chat) syndrome

Back 86

Children with cat's cry syndrome lack part of chromosome 5. They are severely retarded and show many signs often associated with chromosomal aberrations, such as microcephaly, low-set ears, oblique palpebral fissures, hypertelorism, and micrognathia.

The characteristic cat-like cry caused by laryngeal abnormalities that gave the syndrome its name gradually changes and disappears with increasing age.

Front 87

87. PKU

Back 87

A metabolic disorder results with impaired brain development, and typically severe mental retardation is identified around the 6th month of life.

Fewer than 4% of untreated children achieve IQ’s greater than 50 or 60.

About one third are unable to walk, and about two thirds are unable to talk. Verbal communication is severely limited.

This condition can be avoided by dietary restriction of phenylalanine intake early in life. Prevalence is about 1/10,000 births,

Front 88

88. Causes of PKU

Back 88

The basic metabolic defect in PKU is an inability to convert phenylalanine, an essential amino acid, to paratyrosine because of the absence or inactivity of the liver enzyme phenylalanine hydroxylase, which catalyzes the conversion.

Two other types of hyperphenylalaninemia have recently been described.

One is caused by a deficiency of the enzyme dihydropteridine reductase, and the other to a deficiency of a cofactor, biopterin.

Front 89

89. What is Rett's disorder?

Back 89

X-linked dominant mental retardation syndrome that is degenerative and affects only females

Characterized by mental retardation, microcephaly, autistic features, and stereotypical hand movements. Has a prevalence rate of 1/10,000. Infants are apparently normal until the end of their first year. Their normal development exhibits a general slowing, failure to make expected weight gain, failure to progress to crawling, withdraw from social contacts.

Most patients are severally retarded.

Front 90

90. 6 infections acquired in the prenatal period that are associated with mental retardation

Back 90

1. Rubella (German measles)
2. Toxoplasmosis
3. Cytomegalic inclusion disease
4. Syphilis
5. Herpes simplex
6. AIDS

Front 91

91. Complications of pregnancy that can result in mental retardation

Back 91

Toxemia of pregnancy and uncontrolled maternal diabetes present hazards to the fetus and sometimes result in mental retardation.

Maternal malnutrition during pregnancy often results in prematurity and other obstetrical complications.

Vaginal hemorrhage, placenta previa, premature separation of the placenta, and prolapse of the cord can damage the fetal brain by causing anoxia.

Front 92

92. Perinatal issues that can cause mental retardation

Back 92

Premature babies with low birth weight (less than 1,000 grams) are at high risk for neurological and intellectual impairments that occur at the time of school age. These impairments may include cerebral palsy, mental retardation, autism, low intelligence, and learning problems.

Abnormal labor (i.e., abnormal fetal positions) can create critical pressure on the skull and other complications, e.g., anoxia which can cause damage to brain tissue.

Front 93

93. Postnatal (acquired) issues that can cause mental retardation

Back 93

1. Infection, (e.g, among the most serious are encephalitis, and meningitis)

2. Head trauma, (e.g., caused by vehicular accidents, household accidents, or seizures)

Front 94

94. What is FAS?

Back 94

Fetal Alcohol Syndrome - Up to 15% of babies born to women who regularly ingest large quantities of alcohol have a high incidence rate of ADHD, learning disorders, and mental retardation with or without facial dysmorphism, (e.g., hypertelorism, microcephaly, short palperbral fissures, inner epicanthal folds, and short turned up nose).

Front 95

95. What is the primary prevention of mental retardation?

Back 95

A. Socialize the community to the strengths and abilities of the mentally retarded, and not focusing on the disabilities.

B. legislative and social supports are to be encouraged to create necessary protections so the mentally retarded can function independently as possible in society to the best of their respective capabilities

Front 96

96. Secondary and tertiary prevention in mental retardation

Back 96

Includes medical treatments to with intervening and rectify metabolic and endocrine disorders. E.g., PKU and hypothyroidism, can be maintained by diet control and /or hormonal replacement therapy.

Front 97

97. Goals of education in mentally retarded

Back 97

a. adaptive skills training
b. vocational training
c. communication skills

Front 98

98. Two forms of therapy for the mentally retarded

Back 98

Cognitive psychotherapy – for those individuals having communication skills can benefit from insight oriented counseling.

Behavioral therapy - remains the most common form of psychotherapy because rather than understand THE SOURCE of asocial behaviors, this form of therapy intervenes to reduce asocial behaviors by schedules of reinforcement or adverse stimulation to increase pro-social behaviors.

Front 99

99. Family education in those families with mentally retarded

Back 99

Family Education will assist the individuals, perhaps largest and most immediate support system, to maintain realistic expectations of the mentally retarded, and to maintain a balance between independence and where needed supervision

Front 100

100. Explain the concept of normalization

Back 100

“Normalization” a concept that grew out of the 1970’s focuses on
ways to make the mentally retarded functional members of the community by:

a. making available to the mentally retarded conditions of every day life that are as close as possible to the norms and patterns of the mainstreamed society
b. having no institutionalized mentally retarded children
c. have special educational classes within a regular school setting so that there can be some inclusive interaction

Front 101

101. Who was John Bowlby?

Back 101

John Bowlby studied the attachment of infants to mothers and concluded that early separation of infants from their mothers had severe negative effects on children's emotional and intellectual development

Front 102

102. What are attachment disorders?

Back 102

Children with this diagnosis are typically neglected, abused, or moved multiple times from one caregiver to another. Since the child’s basic needs for comfort, affection and nurturing fail to be met the child does not establish emotional attachments with others. These unmet needs may be life long and interfere with future relationships,

Attachment disorders can be manifested in such other diagnoses as:
Failure to Thrive syndrome
Depressive disorders
Separation Anxiety
Delinquency
Avoidant Personality disorder
Academic problem

Front 103

103. What is Reactive Attachment Disorder, (RAD)? What are the 2 types?

Back 103

This disorder typically begins before age 5 years old. There are two types of RAD:

A. Inhibited type – persistent failure to initiate or respond in a developmentally normal way to most social interactions, such as to shun relationships and attachments to virtually everyone. E.g, children may inconsistently respond to caregivers with approach, or avoidance and resistance to being comforted

B. Disinhibited type – to seek attention from virtually everyone, including strangers, with lack of discrimination with whom the child becomes familiar

Front 104

104. What are the signs and symptoms in infants and children for RAD?

Back 104

Signs / symptoms:

Infants:
1. listless appearance
2. failure to smile
3. failure to reach out when picked up
4. no interest in playing peekaboo or other interactive games

Toddlers, older children and adolescents may include:
1. withdrawing from others
2. avoiding or dismissing comforting comments or gestures
3. watching others closely but not engaging in social
interaction
4. failing to ask for support or assistance
5. alcohol or drug abuse in adolescents

Front 105

106. 5 factors that may increase the chance of developing RAD

Back 105

1. institutional care / prolonged hospitalization
2. frequent changes in foster care or caregivers
3. inexperienced parents
4. physical, sexual or emotional abuse
5. parents who have a mental illness, anger management problems, or drug or alcohol abuse

Front 106

107. DSM criteria for RAD

Back 106

A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, by either (1) or (2):

(1) persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, manifested by;
a. excessively inhibited
b. hypervigilant
c. highly ambivalent
d. contradictory responses (e.g., child may respond to being
comforted by approachable, avoidant, resistant)

(2) diffuse attachments with indiscriminate sociability (e.g., may become familiar with strangers, and lack selectivity in choice of figures to whom one wishes to be attached,
B. Not accounted for by Mental Retardation
C. Pathogenic care as evidenced by at least one of the following;
a. persistent disregard for the child’s basic emotional needs
b. persistent disregard for the child’s basic physicals needs
c. repeated changes of primary caregiver that prevents the formation of stable attachments, (DSMIV, 1994)

Front 107

108. What are the 3 groups of pervasive developmental disorders?

Back 107

1. Autism spectrum disorders
- Autism, severe form
- Asperger's disorder, milder form

2. Rett's disorder

3. Childhood disintegrative disorder

Front 108

109. Mental retardation and pervasive developmental disorders

Back 108

Mental retardation and pervasive developmental disorders often coexist; 70 to 75 percent of those with pervasive developmental disorders have an IQ below 70.

A pervasive developmental disorder results in distortion of the timing, rate, and sequence of many basic psychological functions necessary for social development. Because of their general level of functioning, children with pervasive developmental disorders have more problems with social relatedness and more deviant language than those with mental retardation.

In mental retardation, generalized delays in development are present, and mentally retarded children behave in some ways as though they were passing through an earlier normal developmental stage, rather than one with completely aberrant behavior.

Front 109

110. What is autism spectrum disorder?

Back 109

Autism spectrum disorders (ASD) are a group of biologically based neurodevelopmental disorders characterized by impairments in three major domains: socialization, communication, and behavior

Front 110

111. Etiology of autism spectrum disorder

Back 110

Psychodynamic & sociological contributions
– No valid research indicating specific parenting styles of parents w/ autistic child
– child may be excruciatingly sensitive to small changes in families and immediate envt – ie family discord, moving, new sibling)

Perinatal factors
– clinical dysmaturity
– bleedings after 1st trimester
– meconium in amniotic fluid
– severe infection in pregnancy
– reduced Apgar scores
– high incidence of RDS and neonatal anemia

Front 111

111. 3 co-occurring medical problems in pts with autism

Back 111

1. Epileptiform abnormalities on EEG are common – are defined as spike waves, sharp waves, spike and wave activity, or other rhythmic waveforms that imply epilepsy or may be associated with epilepsy. However, epileptiform activity alone does not confirm a diagnosis of epilepsy. Clinicians need to consider EEG when clinical spells are suspected to represent seizures.

2. Gastrointestinal problems – such as chronic diarrhea, constipation, vomiting, and frequent abdominal pain have been noted as common GI complaints, however there is unclear relationship between these complaints at Autism.

3. Sleep disturbances – such obstructive sleep apnea, gastroesophageal reflux, and abnormal melatonin regulation have been observed.

Front 112

112. Clinical features of autism

Back 112

Onset, early infantile autism may demonstrate delayed milestones (delayed speech development, or lack of responsiveness to sounds)
– prefer solitary activities
– May develop a fascination w/clothing, jewelry, things that spin.
– repetitious behavior (ie arm flapping)
– fixed gaze, as if to stare past someone
– may bite themselves
– if hurt, will not accept comfort
– speech is monologue (vs dialogue)
– sameness, meaning while doing some form of activity it is
– Important for them for anyone involved in the activity to be at same place doing same behavior (ie sitting around a meal table, everyone must always sit in same chair. Any variance may cause catastrophic effects the child)

Front 113

113. DSM criteria for autism

Back 113

At least 6 from (1), (2), and (3), with at least (2) from (1) and one each from (2) and (3).

(1) impairment in social interaction (at least 2):
– impairment in use of multiple nonverbal behaviors (eye-to-eye gaze, facial expression, body postures, gestures to regulate social interaction)
– Failure to develop peer relationships appropriate to development level
– Lack of spontaneous seeking to share enjoyment, interests or achievements (lack of showing, bringing, pointing out objects of interest)

(2) impairment in communication (at least 1)
– Delay in, or total lack of, the development spoken language (w/o gesturing/miming)
– If have adequate speech, can’t initiate or sustain conversations.
– Stereotyped & repetitive use of language or idiosyncratic language
– Lack of varied, spontaneous make-believe play

(3) restricted repetitive and stereotyped patterns of behavior, interests, and activities (at least 1)
– preoccupation w/ 1 or more stereotyped and restricted pattern of interest that is abnormal either
– inflexible adherence to specific, nonfunctional routines or rituals
– stereotyped & repetitive motor mannerisms

And Delays or abnormal functioning in at least 1 of the following (prior to age 3): social interaction, language as used in social communication, or symbolic or imaginative play.

Not better accounted for by Rett’s disorder or childhood disintegrative disorder

Front 114

114. What is Asperger's disorder?

Back 114

Known as a “high functioning form of autism, Asperger Syndrome is a neurobiological disorder named for a Viennese physician, Hans Asperger, who in 1944 published work on a disorder in which he described behaviors of children who had normal intelligence and language development, but who also exhibited autistic-like behaviors and marked deficiencies in social and communication skills. Asperger’s disorder was identified in the DSM-IV in 1994.

Front 115

115. Epidemiology and etiology of Aspergers

Back 115

Epidemiology -
a. no clinically significant delays in language, cognitive development, or of self help skill,
b. prevalence – more common in males
c. course – appears to have a later onset than does autism.

Etiology:
Cause unknown.

Front 116

116. Clinical features of autism

Back 116

1. abnormal nonverbal communication (gazes, facial expressions, gestures)
2. repetitious motor mannerisms (hand or finger flapping, complex whole body movements), delayed motor milestones
3. preoccupation with parts of objects
4. overstimulated by loud noises, lights, or strong tastes or textures,
5. showing an intense obsession with one or two specific, narrow subjects, such as baseball statistics, train schedules, weather
6. having a hard time "reading" interpersonal reciprocity
7. a voice that is monotonous, rigid or unusually fast
8. Good prognosis are associated with: normal IQ & high level social skills

Front 117

117. Major differences between Asperger disorder and Autism?

Back 117

The major differences between Asperger disorder and Autism is that with Asperger disorder the child;

1. has normal language
2. normal intellectual development
3. makes more of an effort than those with autism to make friends and engage in activities with others.

Front 118

118. What is Rett's disorder?

Back 118

Described as a neurodevelopmental disorder that occurs almost exclusively in females. Named after Andreas Rett, an Austrian neuron-pediatrician in 1966.

Features;
The child goes through initial normal development, then gradually loses speech and purposeful hand use, followed by deceleration of head growth as an early sign.

Front 119

119. What are the 4 stages of Rett's disorder?

Back 119

Stage I — onset is between 6 to 18 months, there developmental arrest. During this time there is less eye contact, reduced play, gross motor delays, nonspecific hand wringing, and decelerating head growth Infants seem placid and not cuddly.

Stage II — onset is typically between one to four years, when there is loss of purposeful hand use and spoken language, and periodic breathing irregularities. During this stage, many affected girls exhibit autistic-like behavior. Many experience variable periods of unprovoked inconsolable crying or irritability and a disturbed sleep pattern.

Stage III — begins at 2 to 10 years of age, and behavioral improvement and some improvement in hand use and communication skills, Motor dysfunction and seizures are more prominent during this stage.

Stage IV — usually begins after 10 years of age, with increased rigidity and reduced mobility, dystonia, and bradykinesia. May live more than a decade after diagnosis, patients may be wheelchair bound with muscle wasting, and no language ability.

Front 120

120. Criteria for Rett's disorder

Back 120

All of the following;
1. apparently normal prenatal and Perinatal development
2. apparently normal psychomotor development through the first 5 months after birth
3. normal head circumference at birth

Onset of all of the following after the period of normal development;
1. deceleration of head growth between ages of 5 and 48 months
2. loss of previously acquired purposeful hand skills between ages 5 and 30 months, and development of stereotyped hand movements (e.g, hand wringing or hand washing).
3. loss of social engagement early, but may develop later
4. poor gait or trunk movements
5. impaired receptive and expressive language and psychomotor retardation

Front 121

121. What are 9 associated conditions with Rett's disorder?

Back 121

1. Bone mineral deficit and fractures
2. Epileptic seizures
3. Cardiac abnormalities
4. Scoliosis
5. Growth failure
6. Low dietary intake/malnutrition
7. Motor dysfunction
8. Breathing dyfunction
9. Sleep disturbance

Front 122

122. Compare Rett's disorder to autism

Back 122

Retts:
a. there is progressive deterioration after achieved milestones
b. hand motions are present
c. lost verbal abilities
d. seizures
e. respiratory problems

Autism:
a. developmental problems are present early on.
b. hand motions may or may not be present
c. may have language capabilities
d. no typical seizures
e. no typical respiratory problems

Front 123

123. What is childhood disintegrative disorder?

Back 123

This disorder is extremely rare and is characterized with normal development of age-appropriate verbal and nonverbal communication, social relationships, play, and adaptive behavior during the first two years of life. For children with this disorder, *after two years of life is reached and before age 10 years, the child looses previously acquired skills in at least two of the following areas*:

1. expressive – the ability to say words or sentences
2. receptive language – the ability to understand verbal and nonverbal communication
3. social skills or adaptive behavior – failure to develop peer relationships, lack of emotional reciprocity, inability to understand social cues
4. bowel or bladder control
5. play, or motor skills – the ability to move the body in a purposeful way

Front 124

124. Differentiate childhood disintegrative disorder from autism

Back 124

Childhood Disintegrative Disorder (CDD) is differentiated from Autism in that;

1. the onset with CDD is later that with Autism
2. CDD has a more significant loss of skills
3. CDD has a greater likelihood of mental retardation

Front 125

125. What is the classic triad of ADHD in children?

Back 125

1. Hyperactivity
2. Distractibility
3. Impulsiveness

Front 126

126. Features of ADHD in adolescents?

Back 126

In adolescence – predominately restlessness, impatience, inattentiveness and impulsivity.

Remission may occur in about 50% of the cases during adolescence. The inattentiveness affects primarily academics, and impulsiveness may get them into the criminal justice system, due to underage drinking, use of substances, shop lifting, destruction of property, etc.

Front 127

127. What are the features of adult ADHD?

Back 127

In adulthood – according to rating scales such as the Wender Utah Rating Scale (WUR S) for adults is a 61 item questionnaire that correctly identified 86% of patients with ADHD in a 1993 study. According to (Ward, 1993; Ossman, 2003), the WURS identified the following criteria for ADHD in adults:

a. hyperactivity
b. poor concentration
c. affective lability
d. hot temper / impulsive
e. inability to complete tasks
f. disorganization
g. stress intolerance
h. restlessness

Front 128

128. Criteria for ADHD

Back 128

Either (1) or (2):
(1) 6 or more of the following of Inattention have persisted for at least 6 months:
Inattention, often:
a. fails to give close attention to details or makes careless mistakes
b. has difficulty sustaining attention
c. does not seem to listen when spoken to directly
d. does not follow through on instructions, and fails to finish assignments, (not due to being oppositional)
e. has difficulty organizing
f. avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort
g. loses things necessary for tasks
h. is easily distracted by extraneous stimuli
i. is forgetful in daily activities

(2) 6 or more of the following of Hyperactivity, Impulsivity have persisted for at least 6 months;
Hyperactivity, often;
a. fidgets with hands or feet or squirms in seat
b. leaves seat wherever remaining seated is expected
c. runs about or climbs wherever it is inappropriate
d. has difficulty playing or engaging in leisure activities quietly
e. is “on the go” or acts as if “driven by a motor”
f. talks excessively

Impulsivity, often:
g. blurts out answers before question have been completed
h. difficulty waiting awaiting turn
i. interrupts or intrudes on others

Some hyperactivity – impulsive or inattentive symptoms were present before the age of 7 years.

Some symptoms are present in more than in one setting

Subtypes;
1. ADHD, Combined
2. ADHD, Predominantly Inattentive
3. ADHD, Predominantly Hyperactive – Impulsive

Front 129

129. Brown ADD Rating Scales for Children, Adolescents and Adults

Back 129

Brown ADD Rating Scales for Children, Adolescents and Adults 16 page booklets for use in a comprehensive clinical assessment for ADHD and related learning or psychiatric problems.

These booklets include: formats and record forms for: review of DSM-IV symptoms, integration of relevant psychological testing results screening for comorbid learning and psychiatric disorders.

Front 130

130. WHO Adult ADHD screening tool

Back 130

Grading: Add the number of checkmarks that appear in the darkly shaded areas.

Four or more checkmarks indicate that your symptoms may be consistent with Adult ADHD. It may be beneficial for you to talk with your family physician about an evaluation. Published by the World Health Organization, 2003.

Front 131

131. Genetic etiology of ADHD

Back 131

genetic factors include;
a. a greater concordance in monozygotic twins : : dizygotic twins
b. biological parents of children with ADHD have a greater risk for ADHD than to children of adoptive parents

Front 132

132. Neural etiology of ADHD

Back 132

Neurobiology – “theory of frontal lobe disinhibition,” involvement with frontal lobes, basal ganglia, cerebral sensory and somatosensory areas
a. PET scans show hypoperfusion in the frontal lobe and basal ganglia during object naming task
b. PET has also shown hypoperfusion of striatal brain regions along with hyperperfusion of cerebral sensory and somatosensory areas

Neurochemistry – “Catecholamine hypothesis” - involves hypothetical dysfunction in the adrenergic, domaminergic, and norepinephrinergic systems which interferes with concentration;
a. since medications such as stimulants, impact on the symptoms of ADHD there are hypotheses that suggest neurochemistry is related to the etiology of ADHD, by impacting on the dopaminergic systems and norepinephrine systems
b. the noradrenergic system affects performance, attention, arousal, all deficient with ADHD, and noradrenergic medications seem to be effective treatment agents

Front 133

133. Structural brain imaging in children with and without ADHD

Back 133

Structural brain imaging in children with and without ADHD demonstrates significant differences:

a. CT head scans of ADHD children show no consistent findings

b. one hypothesis involves a genetic imbalance in catecholamine metabolism in the cerebral cortex.

c. indications of ADHD have also demonstrated at times;
1. a reversed or absent asymmetry of the caudate nucleus
2. smaller cerebral and cerebellar volume
3. smaller posterior corpus callosum regions
4. increased gray matter in the posterior temporal and inferior parietal cortices

Front 134

134. Classic type of ADHD

Back 134

Classic –
1. Characteristics - the typical symptoms of hyperactive, restless, impulsive, disorganized, distractible, and trouble concentrating
2. SPECT findings – normal brain activity at rest, decreased activity especially in the pre-frontal cortex during concentration .
3. Long term consequences – these people are in trouble with someone
4. Etiology – deficiency of dopamine, low basal ganglia (involved with feelings, thoughts, and movement; and pre-frontal cortex activity (involved with guiding behavior related to executive functions, impulse control and time management among others); which results in low amounts of dopamine being produced to drive the prefrontal cortex.

5. Treatment – psycho-stimulants – because is taken up slowly in the basal ganglia and manages the release of dopamine in a timely manner. Examples of medications are,
a. amphetamine; dextroamphetamine
b. methylphenidate
c. dextroamphetamine

Front 135

135. Inattentive type of ADHD

Back 135

Inattentive –
1. Characteristics – labeled as distracted (daydreamers), slow, lazy, spacey and unmotivated to find interests, complains of being bored.
2. SPECT findings – normal brain activity at rest, decreased activity especially in the pre-frontal cortex, decreased activity in the temporal lobes
3. Etiology – deficiency of dopamine, decreased activity in the prefrontal cortex

4. Treatment – psycho-stimulants –
a. high protein, low carbohydrate diet
b. regular exercise
c, L-tyrosine 500 mgs BID
d. amphetamine; dextroamphetamine

Front 136

136. Overfocused type of ADHD

Back 136

Over focused – perhaps the 3rd most common type
1. Characteristics – over-focused, difficulty shifting attention, tendency to get stuck or locked into negative thought patterns or behaviors.

2. Etiology:
a. frequently found in families in which substance abuse is generational
b. excessive activity in the anterior cingulate gyrus (which helps the brain shift gears) as in OCD.

3. SPECT findings – overactive lateral prefrontal cortex and anterior cingulate gyrus (which is heavily innervated by serotonergic neurons).

4. Etiology – deficiency of dopamine, decreased activity in the prefrontal cortex, overactive frontal lobes

5. Treatment – *psychostimulants do not work with this type, perhaps even exacerbates the symptoms.
Serotonergic medications, e.g,"",
1. Risperdal
2. Effexor

Front 137

137. Temporal lobe ADHD

Back 137

Temporal lobe –
1. Characteristics –severe behavior problems, temper flare ups, mood instability, learning disabilities, memory problems.
2. Etiology – temporal lobe impairment, reduced blood flow to the prefrontal cortex during concentration.
2. SPECT findings – decreased activity in temporal lobes (which is believed to be involved with memory, emotional stability, learning, temper control and socialization). Problems in the temporal lobe usually equates with aggressive behavior toward self as in suicide, and toward others as in assaults, mild paranoia, reading difficulties, emotional instability
3. Etiology – deficiency of dopamine, decreased activity in the prefrontal cortex, overactive frontal lobes

4. Treatment –
Anticonvulsant medications, e.g.,
1. divalproex sodium (Depakote)
2. gabapentin (Neurontin)
3. carbamazepine (Tegretol), (Carbatrol)

Front 138

138. Limbic ADD

Back 138

Limbic – ADD and depression are co-occurring.
1. Characteristics – moodiness, negativity, low energy, sadness, decreased interests.
2. Etiology – excessive activity in the deep limbic system (hypothalamus included) results with negativity and depression, it is through this system in which emotional reactions are defined. Results of being victimized by a PTSD type trauma, or were honored with a great feat these memories are stored in the deep limbic system. Hyperactivity in the deep limbic system also has the result of lowered motivation and decreased drive.
3.SPECT findings – decreased prefrontal cortex activity and increased activity in the limbic system.

4. Treatment
1. DL-phenylalanine
2. L-tyrosine
3. Exercise
4. anti-depressant, (NDRI)
5. Amphetamine; dextroamphetamine

Front 139

139. Ring of fire ADHD

Back 139

Ring of Fire –
1. Characteristics – angry, aggressive, sensitive to noise, light and touch, cyclic mood changes, inflexible, insists on having
2. Etiology – excessive brain activity across the entire cerebral cortex especially in the cingulate gyrus, parietal lobes, temporal lobes, and prefrontal cortex.
3. SPECT findings – decreased prefrontal cortex activity and increased activity in the limbic system.

4. Treatment - ***psychostimulants, antidepressants DO NOT work with this type, perhaps even exacerbates the symptoms.*
a. often an anticonvulsant or antipsychotic medication are effective , e.g, risperidone, olanzapine
b. high protein, low carbohydrate diet

Front 140

140. 5 first line meds for ADHD

Back 140

1. Methylphenidate (Ritalin, stimulant), (Concerta, stimulant), (Focalin, stimulant), (Daytrana, stimulant)
2. Dextroamphetamine, (Dexedrine, stimulant)
3. Amphetamine (Adderall, stimulant), (Vyvanse – stimulant but has no street value)
4. Atomoxetine (Strattera, SNRI)
5. Modafinil (Provigal, Wake promoting)

Front 141

141. 3 second line meds for ADHD

Back 141

1. Bupropion (Wellbutrin, NDRI)
2. Venlafaxine (Effexor, SNRI)
3. Venlafaxine desvenlafaxine, (Pristiq, SNRI)

Front 142

142. Counseling and specific psychotherapies for ADHD

Back 142

Behavior modification, helpful for;
1. use time outs, & token economy to make effective behavior control
2. need an integrated plan with school officials and family
3. use positive reinforcement to encourage productive behaviors, & aversive reinforcement to extinguish non productive behaviors

Front 143

143. What are the two disruptive behavioral disorders?

Back 143

1. Oppositional defiant
2. Conduct disorder

Front 144

144. What is oppositional defiant disorder?

Back 144

A milder form of Conduct disorder, and at risk for developing a conduct disorder.

Etiology:
1. begins as developmentally normal, mild defiance, the “terrible two’s.” May be a result of abnormal development in the separation – individuation phase when children seek out differences between themselves and their parents. ODD may also be related to authority figures who overreact.
2. largely an interpersonal parent-child conflict, but more extreme than typical rebellion
3. little evidence is available for significant neurobiological contributions
4. the vast majority of families where children have been diagnosed ODD, typically have issues related to power and control, especially in families where strong willed children challenge the authority of the parent

Front 145

145. Clinical features of ODD?

Back 145

1. irritability (loss of temper)
2. resentment
3. quick to take the offense
4. resist compliance with rules
5. blaming others

Front 146

146. Criteria for ODD

Back 146

(criterion met only if the behavior occurs more frequently than is typically observed in people of a comparable age or developmental level)

A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months during which time 4 or more of the following are present;
1. often loses temper
2. often argues with adults
3. often actively defies or refuses to comply with adult’s requests or rules
4. often deliberately annoys people
5. often blames other for his/her mistakes or misbehavior
6. is often touchy or easily annoyed by others
7. is often angry or resentful
8. is often spiteful or vindictive

Front 147

147. What is parent-child interaction therapy?

Back 147

Therapists teach parents to work w/ their child positively to set appropriate limits, to act consistently, to be fair in their discipline decisions, and to establish more appropriate expectations regarding the child. Also teach the child better social skills

-video tape modeling works towards the same goals

Front 148

148. What is conduct disorder? What are the 2 subtypes?

Back 148

Presents as disobedient, violating the basic rights of others. Individuals may commonly become involved with illegal acts. Along with ADHD, Conduct disorder is one of the most frequently diagnosed childhood / adolescent maladaptive disorders.

Subtypes:
Childhood onset – one symptom before the age of 10. Males are likely to have an increased chance of physical aggression and more likely to progress into Antisocial Personality disorder, since the traits become more entrenched

Adolescent onset – no symptoms before the age of 10. Likely to be less aggressive and less likely to become Antisocial Personality disorder. Have more effective premorbid functioning,.

Front 149

149. Criteria for conduct disorder

Back 149

A repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate society norms or rules are violated, with the presence of 3 or more of the following in the past 12 months, with at least 1 criterion present in the past 6:

Aggression to people and animals – e.g.,
1. bullies, intimidates
2. used weapon to cause physical harm
3. stolen during a confrontation (robbery, mugging, purse snatching)
4. forced someone into sexual activity
5. stolen something when confronting a victim, such as mugging, purse snatching, armed robbery
6. physically cruel to people or animals

Destruction of property – e.g.,
7. deliberately set fires to cause damage
8. deliberately destroyed the property of others

Deceitfulness or theft – e.g.,
9. broken into a home or car, or building
10. lies to obtain what they want, or to avoid responsibilities
11 stolen things without confronting a victim, such as shoplifting, breaking and entering, forgery.

Serious violations of rules, e.g.,
12. habitually violates curfews
13. run away from home overnight
14. often truant from school

Front 150

-terol

Back 150

Beta 2 agonist

eg. Albuterol

Front 151

151. What are the 4 different motor and vocal tics?

Back 151

A. Simple motor tics – repetitive eye blinking, jerking, shoulder shrugging, and facial grimacing.

B. Simple vocal tics – coughing, throat clearing, grunting, sniffling, snorting, barking

C. Complex motor tics – have a more ritualistic appearance with smelling objects, touching behaviors, echopracaxia (imitation of the behaviors of others), copropraxia (obscene gestures)

D. Complex vocal tics – repeating echolalia (repeating the last heard words of others)

Front 152

152. Epidemiology of Tourette's disorder

Back 152

Epidemiology –
1. 5 to 30 per 10,000 children; 1 to 2 of 10,000 adults
2. Occurs 3 times more often with boys than girls
3. Most tic disorders disappear within weeks or months

4.Frequently associated co-occurring disorders such as;
a. OCD
b. ADHD
c. CD
d. Stuttering

5. Self Injurious Behavior may be common due to the repetitive behaviors, such as;
a. Nail biting
b. Nose picking
c. Trichotillomania
d. More attention paid to areas of pain

Front 153

153. Criteria for Tourette's disorder

Back 153

A. Both multiple motor and 1 more vocal tics have been present at some time during the illness, although not necessarily concurrently. A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.

B. The tics occur many times a day, nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.

C. The onset is before age of 18 years old.

Front 154

154. Treatment for Tourette's

Back 154

1. Consideration the need for watch and wait versus instituting a medication regimen. If the tic is a reaction to some psychosocial stressor, the tic may extinguish without intervention once the stressor is resolved.

2. Behavioral therapies such as habit reversal may be efficatious –countering interventions to the Tics

3. Use of Premonitory Urge for Tics Scale (PUTS) helps the patient to recognize, respond and replace urges prior to Tic behavior

Pharm:
a. Haloperidol
b. Pimozide
c. Risperadal
d. Olanzapine

Front 155

155. Stuttering disorders

Back 155

A disturbance of normal fluency by interruptions of typical flow of speech. There
are repetitions of sounds and prolonged words and for diagnosis needs one or more of the following:

1. Sound and syllable repetitions
2. Sound prolongation
3. Interjections
4. Broken words (pauses within a word)
5. Audible or silent blocking (filled or unfilled pauses in speech)
6. Circumlocutions (word substitutions to avoid problematic words)
7. Words produced with an excess of physical tension
8. Monosyllabic whole – word repetitions (I – I – I – I see him)

Front 156

156. Epidemiology and etiology of stuttering disorders

Back 156

Epidemiology:

1. Onset about 2 years to 7 years old
2. Affects 3 to 4 males : : 1 female
3. Approximately 80% of children to stutter remit by adolescence
4. Pre-schoolers and school age children who stutter have an increased incidence rate of anxiety symptoms, i.e., social anxiety, and school refusal.

Etiology:

Believed to be multi-factorial;
a. genetic – there is a high rate of affected first degree relatives who stutter
b. neurophysiologic – EEG findings indicate that males had right hemispheric alpha suppression across stimulus words and tasks, and non stuttering had left hemispheric suppression
c. psychological – the learning theory suggests that stuttering to be a learned response to early childhood dysfluencies, such a breakdown in the feedback loop,

Front 157

157. Treatment for stuttering disorders

Back 157

1. Speech therapy – modifies the stuttering response to fluent sounding speech by systematic steps, speech mechanics.

2. Reducing tension and anxiety during speech – by breathing exercises, and relaxation therapy which slows the rate of speech

3. Psychopharmacological steps aim at promoting relaxation with benzodiazepines such as clonazepam (Klonopin).

Front 158

158. What is gender identity disorder?

Back 158

A persistent preference to be a member of the opposite anatomical sex. The H – Y antigen which is responsible for the genetic sex in utero, is in competition with the post natal psychosocial and environmental pressures of sex role identification.

GID typically is established by three years old. It is perhaps more of an issue with the ways the child is reared in opposition to biological factors as evidenced with children born with ambiguous genitalia.

Sigmund Freud asserted that GID problems is likely an oedipal problem between child and both parents, i.e,"", masculine – devaluing mother, and/or an ineffective emotionally absent father. Those things that interfere with a loving relationship between identifying with the same sex parent and the opposite sex parent interferes with normal identity.

Front 159

159. Criteria for gender identity disorder

Back 159

A. A strong and persistent cross-gender identification more than merely a desire to be the opposite sex for secondary gains, and in children a need for four or more of the following:

1. Repeatedly stated desire to be, or an inconsistency that he or she is the opposite sex.
2. In boys, preference for cross dressing, in girls, insistence on wearing only stereotypical masculine clothing.
3. Strong and persistence preferences for cross sex roles in make believe play or persistent fantasies of being the other sex.
4. Intense desire to participate in the stereotypical games and pastimes of the other sex.
5. Strong preference for playmates of the other sex.

B. Persistent discomfort with his/her sex or sense of inappropriateness in the gender role of that sex.
1. In male children,
a. disgust with penis and testes
b. aversion toward rough and tumble play
c. rejection of stereotypical male toys, games, activities
2. In female children,
a. rejection of urinating in a sitting position
b. belief that she will grow a penis
c. assertion that she does not want to grow breasts or menstruate
d. aversion toward feminine clothing
3. In adolescents and adults;
a.a preoccupation with getting rid of primary and secondary sex characteristics

Front 160

160. Tx for GID in children

Back 160

In Children - there have been no hormonal or psychopharmacological treatments identified. It is difficult to ascertain whether a child’s play and/or desires are truly transsexual or are more gender role behavior, i.e,"", many male children will play with dolls, while many female children will participate in traditional male activities without necessarily being transsexual.

When transsexualism is suspected is when the child repeatedly complains about being the member of the opposite sex that they desire to be. E.g., transsexual males will cross dress, wear jewelry, makeup; transsexual females will cross dress, wear boys clothes, and short hair.

The current trend in children is to develop the social skills assigned to their birth anatomy. Later, they integrate transsexual skills. Hormonal or surgical therapies should not be considered for this age group. Behavior therapy can lessen the emotional effects of peer criticism in children and adolescents. Individual psychotherapy can help children and adolescents with such family dynamics that are often present in such cases as a powerful masculine-devaluing mother, or an ineffective and emotionally absent father.

Front 161

161. Tx of GID in adolescents

Back 161

In Adolescents – those who have suspected since childhood that they have a transsexual dilemma there are several indices to consider;

1. understand the process by which they have been managing their unwanted secondary sexual characteristics
2. treatments have been implemented that “slows down or even stops pubertal changes expected by anatomical birth sex, they implements cross sex body changes with cross sex hormones”
3. homosexual urges may present a novel set of anxiety producing feelings that needs to be addressed by individual and even family intervention for support.

Front 162

162. Tx of GID in adults

Back 162

In Adults – no pharmacological agent has yet been identified that effectively reduces cross gender desires.

A comprehensive assessment is required for transsexual issues from childhood through adulthood. The process of Sex Reassignment Surgery can be implemented if necessary

Front 163

163. Gateway drug theory

Back 163

Gateway drug theory – concept that drug abuse is a four step sequential progression from least impacting to most impacting and evolves from childhood into adulthood.

Step one: legal drugs such as alcohol or cigarettes
Step two: marijuana
Step three: illicit drugs, hallucinogens, inhalants, opioids
Step four: prescription drugs

Front 164

164. Explain the cycle of addiction

Back 164

Cycle of Addiction - addiction is believed to begin with a desire to ease physical or emotional pain. Drugs are taken to avoid pain and discomfort. Once taken and the pain / discomfort is avoided, there becomes a perceptive sense that the drug had resolved the problem. Almost all psychoactive drugs activate the mesolimbic dopamine system which is involved with mediation of rewards and appetite behaviors.

Consequently, the need to maintain drug use is reinforced. At some point during usage, the drugs change from being pain reduction instruments, to having obsessive need for drug effects. The more drugs are used, the greater the chance to be involved with legal problems, health concerns, and employment issues.

The abuser tries desperately to hide from these problems. As deception becomes the modus operandi of the abuser, family and friends become replaced with using, relaxing and finding more drugs. For those users who are aware of the effects of drugs, the need to avoid withdrawal becomes a paramount importance. Consequently, the abuser is obsessed to have drugs in their system to just function and avoid withdrawal.

Front 165

165. What is enabling? How is it different from helping?

Back 165

Enabling - attempts to "help" addicts actually make it easier for the addict to continue in the progression of the disease. The addict can avoid the consequences of his / her actions because the enabler becomes the rescuer from the mistakes made by the addicted person.

The difference between helping and enabling is that helping is doing something for someone that they are not capable of doing themselves; while enabling is doing for someone things that they could, and should be doing themselves.*

To break enabling behavior one needs to interrupt the cycle of never-ending problems and pain of addiction, Stop making excuses, refuse to lie, and not bail them out of their problems.

Front 166

166. What is the criteria for dependency?

Back 166

Dependency – when the use of substances leads to THREE OR MORE of the following occurring at any time in the SAME 12 MONTH PERIOD:

1. tolerance –
a. need for increasing quantity / frequency to achieve intoxication or the desired effects
b. diminished effects with continued use of the same amount of the substance

2. withdrawal – is manifested by either;
a. drug relative withdrawal symptoms
b. substances are taken to relieve or avoid withdrawal

3. substances used over longer period of time than intended
4. a persistent desire or unsuccessful effort to cut down / control use
5. time is spent trying to obtain, use, or recover from the effects
6. substance use interferes with participating in functions
7. using despite recurrent physical or psychological problems

Front 167

167. What is the criteria for abuse?

Back 167

Abuse – when the use of substances leads to a significant impairment or distress, with at least ONE of the following WITHIN A 12 MONTH period when a recurring use of substances;

1. results in failure to fulfill obligations i.e., work, school. or home
2. is physically hazardous to do so, e.g., driving, job related activities
3. is related to legal involvement (arrests)
4. interferes with interpersonal or social life

Front 168

168. What is intoxication?

Back 168

Intoxication - ubiquitous to all substances.

1. a reversible substance specific syndrome by ingesting a substance
2. CNS effected maladaptive behavior caused by a substance, e.g, belligerence, mood lability, impaired cognition, judgment, functioning

Front 169

169. What is withdrawal?

Back 169

Withdrawal – development of;

1. a substance specific syndrome due to cessation or reduction of heavy or prolonged use
2. causes distress in functioning
3. mostly related to alcohol, amphetamines, cocaine, nicotine, opioids, sedatives, hypnotics, or anxiolytics.

Front 170

170. 11 signs and symptoms of substance abuse

Back 170

1. Depressed or anxious patients - may self medicate, suicide potential due to drug induced feelings of helplessness and hopelessness.
2. Employment issues – e.g., job hopping, job terminations, financial difficulties, relationship problems
3. Burns and fractures
4. DUI’s
5. Elderly patients - are at risk of developing dependence on sedative-hypnotics
6. Pregnant women - may not disclose information regarding drug usage for fear of legal consequences to child
7. High stress occupations - e.g. physicians, health care workers, law enforcement
8. Family history
9. Physical appearance - infections, poor hygiene, contaminated drug paraphernalia, abdominal discomfort such as an enlarged or shrunken liver due to alcoholic hepatitis or infectious hepatitis, possible HIV infection.
10. Respiratory problems, - from nicotine or cocaine
11. IV drug users, or "tracks" needle marks

Front 171

171. Definition and epidemiology of alcoholism

Back 171

One definition is: repetitive intake of alcoholic beverages to a degree that harms the drinker in health or social/economic factors, with indication of inability to control the occasion or amount of drinking.

Epidemiology
1. Alcohol is the most abused drug for all ages
a. 10% of all U.S. adults may be classified as problem drinkers *
b. male :: female ration is 4::3 *
c. alcohol use has been implicated in 15% of all vehicular accidents *
d. the cost of treating alcohol dependence is at $7 billion dollars, and treating the adverse medical consequences of alcohol consumption is at $19 billion dollars. **

Front 172

172. BAC levels of 0 - 0.10

Back 172

@0.00 = safe to drive

@0.01 – 0.05 = Subclinical – behavior is nearly normal. Feel mildly relaxed, maybe slightly lightheaded. Body feels warm. Some detriment in judgment.

@0.08 – 0.10 = most states defines as legally intoxicated. People believe they function better than they really function. Slurred speech, poor muscle coordination, short term memory loss, reaction time delayed, motor skills beginning to become impaired, sense of balance is abnormal.

Front 173

173. BAC levels 0.11 - 0.20

Back 173

@0.11 – 0.15 = major loss of balance difficulty walking or even standing, feelings vacillate from euphoria to aggressive, cannot remember the number of drinks actually drank, severely impaired judgment and perception, may experience blackout.

@0.18 – 0.20 = confusion, disoriented, exaggerated emotional stages (with fear, rage, grief), nausea and vomiting are likely, visual impairment to color, motion, dimensions, increased pain threshold.

Front 174

174. BAC levels 0.25 - 0.45

Back 174

@0.25 – 0.40 = Stupor, approaching loss of motor functions, decreased response to stimuli, inability to stand or walk, increased risk of asphyxiation from choking on vomit or being injured by accidents, little comprehension of orientation, reported cases of individuals dying with BAL’s at this level.

@0.40- 0.45 = Coma, nerve centers controlling respirations and heart rate slow, subnormal temperatures, possible death.***

Front 175

175. Complications of long term alcoholism

Back 175

A. Liver – increased drinking can result in an accumulation of fats and proteins potential for alcohol hepatitis and hepatic cirrhosis

B. Gastrointestinal – long term heavy drinking is associated with esophagitis, gastritis, and gastric ulcers; disorders of the small intestine, pancreatitis, and pancreatic cancer; can also inhibit the intestines capacity to absorb nutrients, i.e, vitamins and amino acids.

C. Blood pressure – associated with significant intake of alcohol

D. Dysregulation of lipoprotein, and triglyceride metabolism

E. Hypoglycemia

F. Cancer of the neck, head, esophageal, stomach, colon and lung

Front 176

176. Anatomic findings in the brain of alcoholics

Back 176

Structural imaging from (CT and MRI) demonstrated that; the brain of someone who drank continuously over a five year period demonstrates a progressive shrinkage to the cortex of the frontal lobe, (as compared to non alcoholics) believed to be involved with intellectual functions. However, shrinkage of the frontal cortex has not found a correlation with impairment of short term memory and problem solving.

Functional imaging from SPECT and PET scans have identified blood flow and decreased metabolic rates in certain brain regions of heavy drinkers especially in the;

a. cortex, (outer layer) of the frontal lobe, involved with higher mental abilities
b. cerebellum, responsible for gait and balance, also involved with learning. When imaging the cerebellum, research has detected associated impairment of balance and gait, which may cause falls among older alcoholics, leading to head injury.*

Front 177

177. Lab findings of alcoholics

Back 177

An elevation of 30> units of gamma-glutamyltransferase (GGT) is an indicator of heavy drinking. About 70% of people with a high GGT are persistent heavy drinkers. Liver function tests (e.g, serum glutamic oxaloacetic transaminase (SGOT) and alkaline phosphatase can reveal liver injury that is a consequence to heavy drinking. Elevations of lipid levels can result from decreases in gluconeogenesis associated with heavy drinking. High normal levels of uric acid can occur with heavy drinking.

The most direct test to measure alcohol consumption cross-sectionally is blood alcohol concentration which can be used to judge tolerance to alcohol. Concentrations of 100 mgs/dl of ethanol in the of blood of a person who does not show signs of intoxication can be presumed to have acquired at least some degree of tolerance to alcohol.

At 200 mg/dl, most nontolerant individuals demonstrate severe intoxication; 300-400 mg/dl in a nontolerant individual can cause inhibition of respiration and pulse, and even death,

Front 178

178. Genetic factors in alcoholism

Back 178

Genetic factors: research suggests that genes affecting activity of the NTs serotonin and GABA may be candidates for involvement in alcoholism risk. However, relationships b/w NT genes and alcoholism are complex, and not all studies have shown a connection b/w alcoholism risk and these genes.

Front 179

179. Type 1 alcoholism

Back 179

Type 1- 75% of male alcoholics characterized by: onset of alcohol related problems usually before age of 25, low degree of spontaneous alcohol seeking behavior, low percentage of alcohol related fighting, psychological dependence, couple w/guilt, and fear about alcohol dependence, low degree of novelty seeking and high degree of harm and avoidance

Front 180

180. Type 2 alcoholism

Back 180

Type 2 - characterized by: infrequent feelings of guilt and fear about alcohol dependence, low degree of fear or harm from and desire to avoid alcohol

Front 181

181. What is FAS?

Back 181

FAS- relates to birth defects found in kids whose moms consumed alcohol during pregnancy. FAS is perhaps still the leading known preventable cause of mental retardation. Alcohol causes cell damage esp. in fetus where embryonic cells can be destroyed.

Alcohol may interfere w/brain development by altering production of natural regulatory processes that promote normal growth and differentiation of neurons. The quantity of alcohol that can be safely imbibed by pregnant moms isn’t known.

FAS kids have reduced brain size. Prenatal alcohol consumption may result in: damage to basal ganglia (spatial memory), reduced cerebellum (involved w/balance, gait, and coordination), impaired development or complete absence of the corpus callosum.

FAS is characterized by: facial abnormalities, growth retardation, brain damage

Front 182

182. What is Wernicke's encephalopathy? What is Korsokoff's syndrome?

Back 182

Wernicke’s encephalopathy is a reversible condition with treatment. It is characterized by
ataxia primarily with gait, vestibular dysfunction, confusion, ocular motility abnormalities such as horizontal nystagmus, and gaze palsy. It may clear or progress into Korsokoff’s syndrome.

Korsokoff syndrome is irreversible in about 80% of those affected

Front 183

183. Wernicke-Korsakoff syndrome

Back 183

Neuropsychiatric disorder typically found in nutritionally depleted alcoholic pts. Thiamine deficiency is the pathophysiological connection between these two syndromes

S/S include: mental confusion, staggering gait, polyneuropathy, anterograde and retrograde amnesia

Front 184

184. 10 question drinking history

Back 184

10 question drinking history: produces valid responses bc questions are direct, specific to the alcohol type, and asked moral judgment

a. beer, wine, liquor: how many times/week, how many cans each time, ever drink more
b. has your drinking changed during the past year?

Front 185

185. What is the CAGE test?

Back 185

CAGE test: 4 question screening instrument that has a 60% to 95% sensitivity to identify a problem w/alcohol. CAGE assesses chronic habits but doesn’t focus on current alcohol or drug use. 2 or more affirmative answers are considered indicative of probable alcoholism, while even 1 affirmative response would give cause for further exploration.

C: have you felt the need to Cut down on your drinking
A: have people Annoyed you by criticizing your substance use
G: have you ever felt bad or Guilty about your drinking (or drug use)
E: have you ever needed an Eye opener the first thing in the morning to steady your nerves or get rid of a hangover

4 of 4 = 100% chance of alcoholism
3 of 4 = 75-90%
2 of 4 = 50-66%
1 of 4 = 25-33%

Front 186

186. Explain amphetamine related disorders in terms of medical uses, adverse effects, mechanisms of action, and clinical features

Back 186

Medical uses: tx obesity, ADHD (Dexedrine), narcolepsy, dilate airways which relieve asthmatics

Adverse effects: 4-6 hrs of additional awake time, reduces appetite, makes user feel energetic, irritable, anxious, restless, interferes w/natural capacity to energize by sleep and rest, problematic concerns for physicians are the risk guarding against allegations that amphetamine meds have been misplaced, destroyed, or stolen

MOA: cause release of catecholamines in the reward pathway, which is suspected to be the area of ventral tegmental area to the cerebral cortex and the limbic area into which the dopaminergic neurons project and it is this pathway that has been termed the reward pathway and is suspected to be heavily implicated as an addicting mechanism for amphetamines.

Clinical features: can produce- euphoria, heightened alertness, incoherence, delusional, anxiety, talkative, enhanced self confidence, impaired judgment, poor discretion, hypervigilance, sympathomimetic features (rise in BP, increase in pulse, ectopic atrial and ventricular beats may occur, papillary dilation, anorexia, decrease of smooth muscle contraction in the bronchial tubes), peripheral vasoconstriction cools the temp. of the skin, urinary retention and constipation result from inhibitory effect of sympathetic nerve supply to the bladder and bowel.

Front 187

187. Describe the 6 stages of methamphetamine

Back 187

1. rush – lasts 5 to 30 minutes, sympathomimetic symptoms.

2. high – 4 to 16 hours, feels aggressive / argumentative

3. binge – 3 to 15 days, hyperactive mentally and physically

4. tweaking – the most dangerous stage of the cycle, sleep deprivation 3 – 15 days, can lead to irritability, paranoia, violence, and criminal behavior.

5. crash – 1 to 3 days, lethargic and hypersomniac

6. normal – 2 to 14 days, return to deteriorated baseline condition

Front 188

188. DSM-IV Diagnostic Criteria for Cocaine or Amphetamine Intoxication

Back 188

A. Recent use of cocaine, amphetamine or related substance, e.g., methylphenidate
B. Clinically significant maladaptive behavioral or psychological changes, e.g.,
1. euphoria or affective blunting
2. changes in sociability
3. hypervigilance
4. interpersonal sensitivity
5. anxiety
6. tension or anger
7. impaired judgment
8. impaired social or occupational functioning
C. Two or more of the following developing during or shortly after use:
1. tachycardia or bradycardia
2. papillary dilation
3. elevated or lowered blood pressure
4. perspiration or chills
5. nausea or vomiting
6. evidence of weight loss
7. psychomotor agitation or retardation
8. muscular weakness, respiratory depression, chest pain, cardiac arrhythmias
9. confusion, seizures, dyskinesias, dystonias, or coma
D. significant impairment in social, occupational, or other important areas of functioning

Front 189

189. DSM-IV Diagnostic Criteria for Cocaine or Amphetamine Withdrawal

Back 189

A. Cessation or reduction in amphetamine or related substance use after a heavy or prolonged use.

B. Dysphoric mood and 2 or more of the following developing a few hours to several days after “A” above;
1. fatigue
2. vivid unpleasant dreams
3. insomnia or hypersomnia
4. increased appetite
5. psychomotor retardation or agitation

C. significant impairment in social, occupational, or other important areas of functioning

Front 190

190. Explain mechanisms of action, intoxication and withdrawal effects of caffeine

Back 190

MOA: DA activity is enhanced by caffeine. Caffeine is rapidly completely absorbed with peak plasma levels at 30 to 60 minutes, with a half life of 3 to 10 hours. It is only 15% to 30% protein bound.

Intoxication effects: single cup of brewed coffee contains 100-150 mgs of caffeine

@ 240 mgs; 4-5 cups - insomnia, headaches, palpitations

@1,000 mgs; 7-10 cups -muscle twitching, cardiac arrhythmias, & psychomotor excitement

@ 10 gr - grand mal seizures & death from respiratory failure

Front 191

191. Criteria for caffeine intoxication

Back 191

A. Recent consumption of caffeine usually in excess of 250 mg (e.g., 2-3 cups of brewed coffee.)
B. 5 or more of the following;
1. restlessness
2. nervousness
3. excitement
4. insomnia
5. flushed face
6. diuresis
7. gastro-intestinal disturbance
8. muscle twitching
9. rambling flow of thought and speech
10. tachycardia or cardiac arrhythmia
11. periods of inexhaustibility
12. psychomotor agitation
C. Significant impairment in social, occupational, or other important areas of functioning

Front 192

192. Criteria for caffeine withdrawal

Back 192

A. Prolonged daily use of caffeine
B. Abrupt cessation of caffeine use, or reduction in the amount of caffeine used, closely followed by headache and (1) or more of the following;
1. marked fatigue and drowsiness
2. marked anxiety or depression
3. nausea or vomiting
C. significant impairment in social, occupational, or other important areas of functioning

Front 193

193. Management of caffeine dependence

Back 193

1. Eliminate or seriously reduce the intake of caffeinated food, beverages and products.
2. Titration process occurs over a course of about a week, and substituting decaffeinated products in place of eliminate caffeinated products.

Symptomatic control may be needed for headaches (analgesics), or anxiety, muscle twitching (benzodiazepines, short term) Increase water intake and/or sugarless mints to help alleviate the craving for caffeine

Detoxification to complete abstinence, rather than simple reduction is more effective in preventing relapse.

Front 194

194. Describe the neuropharmacological signs of intoxication of cannabis related disorders

Back 194

Neuropharm signs of intoxication: marijuana has paradoxical effects of being:
a. a depressant usually at low doses
b. a stimulant at higher doses.

Effects of marijuana are systemic among the immune system, reproductive system and CV system. After inhalation or ingestion THC enters the CNS having a short term half life of 1- 2 hrs and redistributed second half life of days to weeks. Tolerance to THC develops quickly and continues a long time after stopping treatment.

Front 195

195. Medical effects of marijuana

Back 195

A. Can cause respiratory ailments. Mariquana smoke parallels nicotine effects in the lungs, ie, lung cancer potential, emphysema, COPD, and chronic bronchitis

B. Lower testosterone levels and sperm count, but without evidence of effects on fertility,

C. Cardiovascular effects may include;
1. increased heart rate
2. increased blood pressure may aggravate hypertension. Large doses may decrease systolic and diastolic blood pressure.

D. Lab testing – since mariquana metabolites are stored in adipose it can be excreted in the urine for several days. Therefore, a positive urine test does not necessarily prove current impairment. Nonetheless, a positive test does indicate recent marijuana ingestion.

E. Prescription mariquana (dronabinol) used for chemotherapy-induced nausea or HIV wasting syndrome can be differentiated from illicitly using mariquana by certain laboratory test.

F. For 8 – 12 hours after using cannabis users’ impaired motor skills interfere with the operation of motor vehicles and other heavy machinery

Front 196

196. Criteria for cannabis intoxication

Back 196

A. Recent use of cannabis

B. Clinically significant maladaptive behavioral or psychological changes, e.g.,
impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal.

C. (2) or more developing within 2 hours of use;
1. conjunctival injection
2. increased appetite
3. dry mouth
4. tachycardia

D. significant impairment in social, occupational, or other important areas of functioning

Front 197

197. Define amotivation syndrome

Back 197

Chronic heavy users of mariquana have developed what has become known as amotivational syndrome or as chronic cannabis syndrome.

The syndrome is characterized with cognitive dysfunction manifested with reduced ability to establish or attain goals in life, resulting in jobs that require less cognitive challenge or technological acuity

Front 198

198. Does cannabis have a withdrawal syndrome?

Back 198

It has been proposed that cannabis may have a withdrawal syndrome. Converging evidence from basic laboratory and clinical studies indicates that a withdrawal syndrome reliably follows discontinuation of chronic heavy use of cannabis or tetrahydrocannabinol.

Common symptoms are primarily emotional and behavioral, although appetite change, weight loss, and physical discomfort are also frequently reported.

However, one study investigated the likelihood of cannabis abuse becoming a drug dependency. Their findings indicated that “regular cannabis use . . . is associated with the development of a dependence syndrome"

Front 199

199. Define flashbacks

Back 199

Flashbacks- persisting perceptual abnormalities after cannabis use aren’t formally classified in DSM-IV-TR, although there are case reports of persons who have experienced sensations related to cannabis intoxication after the short-term effects of the substance have disappeared. Continued debate concerns whether flashbacks are related to cannabis use alone or to the concomitant use of hallucinogens or of cannabis tainted w/PCP.

Front 200

200. Explain the mechanism of action and neuropharmacology of cocaine related disorders

Back 200

MOA: acts on pleasure circuit to prevent re-absorption of DA, by binding the DA transporter molecule to cocaine. This causes a build up of DA in the synapse, which results in strong feeling of pleasure to euphoria.

Neuropharm: produces pleasure effects by stimulating the ventral tegmental area (VTA) which has relationship by way of nerve cells to the nucleus accumbens. The nucleus accumbens is 1 of brain’s centers for pleasure, eg. Food, water, sex. When a pleasurable event occurs, there is an increase in the amt of DA that’s released in the nucleus accumbens. The DA binds w/proteins referred to as DA receptors. Cocaine blocks DA from being released to other receptors, which results in an accumulation of DA. The accumulation of DA causes continual stimulation of receiving neurons, probably resulting in the euphoria produced by cocaine.

Front 201

201. How long do the effects of cocaine last?

Back 201

Tolerance can develop, therefore, the more used, the more frequently, or the greater quantities will be needed to produce the euphoric effects. The high from snorting is slow in onset and may last 15-30 mins. The high from smoking may last 5-10 mins.

In small amts, short term effects of cocaine produce: constricted blood vessels, dilated pupils, increase in body temp, HR, BP, feeling of euphoria, decreased need for food intake and sleep. Larger amts intensify the user’s high but also runs the risk of greater behavior such as: being erratic, being violent, having tremors, vertigo, mm twitching, paranoia.

Front 202

202. Medical complications from cocaine

Back 202

Medical complications: CV effects: disturbances in heart rhythm, heart attacks, has been related to ventricular fibrillation, accelerated heart beat, increased BP.

Respiratory effects: chest pain, respiratory failure, accelerated respirations.
Neuro effects: strokes, seizures, HA
GI effects: abdominal pain, nausea
Nourishment effects: since cocaine has a tendency to decrease appetite, the food intake for chronic cocaine users results in malnourishment and significant weight loss

w/alcohol: can be lethal combo producing cocathylene

Pregnancy: prenatal drug exposure complications aren’t definitely known. There seems to be high correlation of babies born to mom who use or abuse cocaine, to be prematurely delivered, w/low birth weights, w/smaller head circumferences, and are often shorter than average.

Front 203

203. Criteria for cocaine intoxication

Back 203

A. Recent use of cocaine

B. Clinically significant maladaptive behavior or psychological changes that developed during or shortly after use of cocaine, i.e,
1. euphoria
2. affective blunting
3. hypervigilance
4. anger
5. impaired judgment
6. impaired social or occupational functionin

C. Two or more of the following developing during or shortly after use of cocaine,
1.tachycardia or bradycardia
2. pupillary dilation
3. elevated for lowered blood pressure
4. perspiration or chills
5. nausea or vomiting
6. evidence of weight loss
7. psychomotor agitation or retardation
8. muscular weakness, respiratory depression, chest pain or cardiac arrhythmias
9. confusion, seizures, dyskinesias, dystonia, or coma

Front 204

204. Difference btwn flashback and hallucination

Back 204

The difference between a flashback and a hallucination is that flashback follows a period of normalcy secondary to drug use, whereas hallucinations are produced without drug involvement.

Front 205

205. What are hallucinogens?

Back 205

Are drugs that cause altered states of perception and of feeling which can produce flashbacks. Drugs that are included as hallucinogens are;

1. Methylene-dioxyamphetamine, mescaline (from cactus)
2. psilocybin (from mushrooms

3. Lysergic Acid Diethylamide (LSD), presented as gelatin sheets, sugar cubes, or tablets/capsules, aka “microdot.” Binds to a serotonin receptor causing an abnormal exaggerated activation. An LSD “trip” begins about 30 to 60 minutes and peaks at about 2 to 6 hours later, and fades in about 12 hours. LSD is not known to cause physical dependence, but some users develop a psychological dependence. As a result, LSD produces brain effects that may include:
a. rapid mood swings
b. delusions and/or hallucinations
c. poor judgment, danger to self and to others, confusion
d. disorientation to time, person and/or place, disorganized behavior

4.Methylene-dioxymethamphetamine, MDMA (ecstasy) - leads to destruction of neurons containing dopamine, which produces Parkinsonian like symptoms, (i.e., lack of coordination, tremors and paralysis). MDMA has been linked to brain damage that manifests as thought and memory impairment. MDMA is a neurotoxic in that high doses can lead to increase in body temperature (malignant hyperthermia), leading to kidney and cardiovascular system failure. MDMA can damage and destroy serotonin neurons. As a result, MDMA can produce;
a. hallucinations, paranoia
b. confusion
c. depression / anxiety
d. sleep disorders
e. drug craving
f. increased blood pressure, and heart rate

Front 206

206. Criteria for Hallucinogen Intoxication

Back 206

A. Recent use of a Hallucinogen

B. Clinically significant maladaptive behavioral or psychological changes, e.g., marked
anxiety or depression, ideas of reference, paranoid ideation, impaired judgment, impaired social or occupational functioning.

C. Perceptual changes while fully awake and alert, e.g., intensified perceptions, depersonalization, derealization, illusions, hallucinations, synesthesias

D. (2) or more the following:
1. papillary dilation
2. tachycardia
3. sweating
4. blurring vision
5. palpitations
6. tremors
7. incoordination

E.significant impairment in social, occupational, or other important areas of functioning

Front 207

207. Consequence of long term use of hallucinogens

Back 207

One of the hallmarks of hallucinogen use Persisting Perceptual disorder (also known as Flashbacks). A flashback is an experience that can last several seconds to several minutes and is a transient spontaneous occurrences of some aspect of a hallucinogenic drug effect occurring after a period of normalcy that follows the original intoxication.

Flashbacks are unlikely to occur more than one year after the original hallucinogen experience, providing the person is clean of the drugs.

Front 208

208. Diagnostic Criteria for Hallucinogen Persisting Perceptual Disorder (Flashback);

Back 208

The re-experiencing following cessation of use of a hallucinogen of one or more of the perceptual symptoms experienced while intoxicated, e.g., geometric hallucinations, false perceptions, flashes of color, intensified colors, trails of images of moving objects, halos around objects, macropsia, or micropsia

Front 209

209. Identify the MOA of inhalant use

Back 209

For inhalants the mechanism is not clearly understood. Inhalants quickly enter the blood stream thereby affecting the CNS (brain and spinal cord) as well as the PNS (nerves throughout the body). Effects typically peak about 5 minutes after administration and can last 30 minutes to several hours.

Front 210

320. Criteria for inhalant intoxication

Back 210

A. Recent intentional use or short term high dose exposure to volatile inhalants

B. Clinically significant maladaptive behavioral or psychological changes, e.g., belligerence, assaultive, apathy, impaired judgment.

C. (2) or more;
1. dizziness
2. nystagmus
3. incoordination
4. slurred speech
5. unsteady gait
6. lethargy
7. depressed reflexes
8. psychomotor retardation
9. tremor
10. generalized muscle weakness
11. blurred vision or diplopia
12. stupor or coma
13. euphoria

D. significant impairment in social, occupational, or other important areas of functioning

Front 211

211. Medical dangers of inhalant use include (part 1)

Back 211

1. The most serious possible consequence is death from;
a. respiratory depression
b. cardiac arrhythmias
c. asphyxiation, (placing a head in a plastic bag with a inhalant soaked rag)
d. aspiration of vomitus
e. accident (driving while intoxicated)

2. neurological complications;
a. CT and MRI revealed diffuse atrophy of the;
1. cerebral
2. cerebellar
3. brainstem
4. leukoencephalopathy (white matter disease)
b. occupational hazards with house painters and factory workers show evidence of brain atrophy and decreased cerebral blood flow.

3. hepatotoxicity, in the central and peripheral nervous systems, (Hales, 2008, p. 395)

4. sudden death, aka, “Sudden Sniffing Death, (SSD)”, occurs when inhaled fumes replace oxygen in the lungs and CNS, (Shepherd, 1989)

5. cardiac arrhythmias, heart failure, myocardial ischemia, myocardial fibrosis,ventricular fibrillation

Front 212

212. Medical dangers of inhalant use include (part 2)

Back 212

6. irreversible effects include;
a. hearing loss, from
1. toluene (paint sprays, glue, dewaxers)
2. tricholoethylene (cleaning fluids, correction fluid)
b. peripheral neuropathies, from
1. hexane, (gasoline, glues)
2. nitrous oxide, (whipping cream, gas cylinders)

7. serious effects but reversible include;
a. liver and kidney damage from;
1. toluene, and substances containing chlorinated hydrocarbons (correction fluids, dry cleaning fluids)
2. blood oxygen depletion, from organic nitrates and methylene chloride (varnish removers, paint thinners)
8. IQ reduction

Front 213

213. Quit rates of common therapies for nicotine

Back 213

Typical Quit Rates of Common Therapies

1. Self quit 5%
2. Physician advice 10%
3. OTC gum /patch 15%
4. Medication plus advice 20%
5. Behavior therapy alone 20%
6. Medication plus group therapy 30%

Front 214

214. Identification of opiates

Back 214

Opiates originate from the poppy plant and contain morphine and codeine, both
of which are used as pain-killers, as well as in cough medicines, and anti-diarrhea treatments. All opioids produce similar subjective effects

The most widely used opiate is Diacetylmorphine, aka “heroin.” Heroin is particularly addictive because it enters the brain rapidly. Heroin is NOT approved for any therapeutic purpose

Front 215

215. MOA of opiates

Back 215

1. Opiate receptors are widely distributed throughout the CNS and PNS, but are concentrated in the CNS to gain the analgesic and euphoric effects.

2. most opioids such as morphine, heroin, and hydromorphone are pure agonists and act primarily on the mu receptor, and produce analgesia, euphoria, and respiratory depression

3. pentazocine has mixed agonist-antagonist effects and acts largely on the kappa receptor

Front 216

216. Clinical features of heroin or hydromorphone intoxication

Back 216

1. with heroin, morphine or hydromorphine intoxication;
a. rush - within (7- 8 seconds) after intravenous injection the body feels warmth, after a minute the rush is replaced by drowsiness
b. peristalsis is slowed, but nausea and vomiting can be present
c. person may have severe itching
d. addiction and need to maintain the addiction for fear of withdraw which can occur within hours after the last dose is taken.

2. with meperidine intoxication (pain relief, analgesia, Demerol)
a. may cause agitation
b. tremor
c. increased deep tendon reflexes

3. with pentazocine intoxication (Narcotic analgesic, Talwin, Naloxone)
a. dysphoria
b. hallucinations
c. diaphoresis
d. dizziness

Front 217

217. In an opioid overdose the individual may...

Back 217

a. may be stuporous, or a coma
b. pupils may be pinpoint
c. respirations decrease
d. body temperature falls, (skin cool and clammy)
e. intracranial pressure may rise
f. death caused by respiratory arrest

Front 218

218. Medical consequences of chronic opioid use include

Back 218

a. scarred and / or collapse veins
b. bacterial infections of the blood vessels and heart valves
c. abscesses and other soft tissue infections
c. kidney disease
d. respiratory ailments (pneumonia and tuberculosis) due to poor health conditions
e. potential HIV, hepatitis B and C from sharing needles
f. passed on blood born viruses to sexual partners and children
g. children of addicted mothers are at greater risk for Sudden Infant Death syndrome, (SIDS)
h. pregnant women run a risk of spontaneous abortion or premature
i. delivery, if detoxified from opiates
j. infants born to addicted mothers may show physical dependence.

Front 219

219. Theory of Addicition

Back 219

Regular and frequent use over time will cause the endogenous opioids to inhibit production.

Craving then may be linked to the deficiency of enkephalins and endorphins in addition to other neurochemical deficits

Front 220

220. What is PCP?

Back 220

Initially was used as an intravenous anesthetic but was discontinued for medical use due to the adverse effects of agitation, delusions, and irrational behavior.

PCP is metabolized in the liver and only a small portion of the drug is excreted unchanged in the urine. PCP is secreted into the acid gastric fluids, and considerable gastroenteric recirculation occurs; in addition, PCP is also stored in adipose tissue thus not metabolized quickly. The parent compound may be detectable in the blood for weeks or longer.

PCP is addictive and leads to psychological dependence, craving and compulsive drug seeking maintenance.

Front 221

221. MOA of PCP

Back 221

Not clearly understood, but believed to bind the sigma opioid receptor in the brain. It is believed that PCP blocks the re-uptake of norepinephrine, acetylcholine, and dopamine, while appear to facilitate the release of dopamine from presynaptic neurons.

There is belief that PCP also binds to the sigma receptor as does haloperidol and some endogenous opioids. PCP may block synaptic neuronal firings.

Front 222

222. Criteria for PCP intoxication

Back 222

A. Recent use of PCP or related substance

B. Clinically significant maladaptive behavioral or psychological changes, e.g.,
belligerence, assaultiveness, impulsiveness, unpredictability, psychomotor agitation, impaired judgment

C. Within an hour, (2) or more:
1. vertical or horizontal nystagmus
2. numbness or diminished responsiveness to pain
3. hypertension or tachycardia
4. ataxia
5. dysarthria
6. muscle rigidity
7. seizures or coma
8. hyperacusis

D. significant impairment in social, occupational, or other important areas of functioning

Front 223

223. MOA of benzos

Back 223

PET has demonstrated that benzodiazepine receptor binding sites are linked with the receptor for gamma-amino-butyric acid (GABA). GABA is the major inhibitory neurotransmitter in the brain and spinal cord. GABA decreases neuronal activity.

Activation of the benzodiazepine receptor potentiates the action of GABA. Benzodiazepines that enhance the effect of GABA are called agonists. Attachment of an agonist at the benzodiazepine receptor facilitates the effect of GABA, which in turn results in anxiety reduction, sedation, and increased seizure threshold.

Substances that attach to the benzodiazepine receptor and close the chloride ion channels (ionophones) produce an opposite effect, which is anxiogenic and lower the seizure threshold. Chronic exposure to benzodiazepines may decrease the functional coupling of the benzodiazepine receptor with the GABA receptor

Front 224

224. DSM-IV Criteria for Sedative, Hypnotic or Anxiolytic Intoxication

Back 224

A. Recent use of a Sedative, Hypnotic or Anxiolytic

B. Clinically significant maladaptive behavioral or psychological changes, e.,g, in
appropriate sexual or aggressive behavior, mood lability, impaired judgment, impaired functioning
1. short acting agents - in less than 1 day, peak at 1-3 days, and persist for 1 – 2 weeks

C. (1) or more;
1. slurred speech
2. incoordination
3. unsteady gait
4. nystagmus
5. impairment in attention or memory
6. stupor or coma
D. significant impairment in social, occupational, or other important areas of functioning

Withdrawal may be expected;
1. long acting agents, may peak may not occur for 5-7 days and persist 2-3 weeks, e.g, diazepam or phenobarbital;
2. clinical signs of withdrawal

Front 225

225. DSM-IV Criteria for Sedative, Hypnotic or Anxiolytic Withdrawal

Back 225

A. Cessation or reduction of Sedative, Hypnotic or Anxiolytic use

B. (2) or more developing within several hours to a days after criterion A;
1. autonomic hyperactivity, e.g., sweating or pulse rate greater than 100
2. increased hand tremor
3. insomnia
4. nausea or vomiting
5. transient visual, tactile or auditory hallucinations or illusions
6. psychomotor agitation
7. anxiety
8. grand mal seizures

Front 226

226. Anabolic steroids

Back 226

Type of drug with limited medical benefit. Anabolic –androgenic steroids are prescribed for hypogonadal men (i.e, testosterone deficiency), as well as the wasting syndrome associated with HIV infection, in women they can be used for metastatic breast cancer, osteoporosis, endometriosis, and adjunctive treatment of menopausal symptoms.

However, the analogs of testosterone have been illegitimately used for masculinizing effects for muscle building. The mode of transmission can be oral, injected for transdermal. The use is by cycles in that to obtain maximum benefits the drugs are used for several weeks and then stopped for awhile, and then stack steroids by combining several different types.

Front 227

227. Signs of steroid intoxication

Back 227

1. Impaired judgment
2. Hypomania or mania
3. Extreme mood swings, irritability
4. Aggression
5. Violent behavior
6. Paranoid jealousy
7. Delusional thinking
8. Euphoria

Front 228

228. Signs of steroid withdrawal

Back 228

1. Low mood
2. Fatigue
3. Restlessness
4. Craving for steroids
5. Insomnia
6. Decreased libido
7. Anorexia

Front 229

229. Medical complications of steroids

Back 229

1. Myocardial infarction
2. Stoke
3. Hepatic disease
4. Homicidal impulses
5. Hypertension
6. Acne
7. Decreases in high density lipoproteins
8. Increases in low density lipoproteins
9. Increased risk for prostate cancer
10. Gynecomastia
11. Reduced sperm count
12. Menstrual irregularity