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512 Cards in this Set
- Front
- Back
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No logical connections from on ethought to another
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Loosening of associations
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A fast stream of very tangential thoughts
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Flight of Ideas
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Made-up words
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Neologisms
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Incoherent collection of words
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Word salad
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"my car is red. I've bene in bed. It hurts my head"
Word connections due to phonetics rather than actual meaning |
Clang associations
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Abrupt cessation of communication before the idea is finished
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Thought blocking
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Point of conversation never reached due to lack of goal'directed associations between ideas
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Tangentiality
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Point of conversation is reached after circuitous path
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Circumstantiality
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Too few versus too many ideas expressed
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Poverty of thought vs. Overabundance
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fixed, false beliefs that are not shared by the person's culture and cannot be changed by reasoning
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DELUSIONS
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Persistent irrational fears
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Phobias
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Repetitive, intrusive thoughts
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Obsessions
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Repetitive behaviors that the person feel compelled to perform in response to an obsession
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Compulsions
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What kind of delusion:
Belief that one has special powers beyond those of a normal person "I am the all-powerful son of God and I shall bring down my wrath on you if I cannot have a smoke." |
Delusions of Grandeur
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What kind of delusion:
Belief that one is being persecuted "The CIA is after me and taps my phone." |
Paranoid Delusion
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What kind of delusion:
Belief that some event is uniquely related to patient (e.g., a TV show character is sending patient messages) "Jesus is speaking to ME through teh TV characters." |
Ideas of Reference
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What kind of delusion:
Belief that one's thoughts can be heard by others |
Thought broadcasting Delusion
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What kind of delusion:
Conventional beliefs exaggerated (e.g., Jesus talks to me) |
Religious Delusion
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Axis I =
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All diagnoses of mental illness (including substance abuse and developmental disorders), NOT including personality disorders and mental retardation
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Axis II =
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Personality disorders and Mental retardation
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Axis III =
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General Medical conditions
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Axis IV =
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Psychosocial and environmental problems
(homelessness, divorce, e.g.) Legal issues, DUI = severe |
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Axis V =
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Global Assessment of Function (GAF)
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What is the Tarasoff Rule?
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Doctor should notify potential victoms and/or protection agencies if pt. admits to wanting to hurt themselves or others.
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MMPI-2 tests what?
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Objective Personality Assessment Test:
Tests personality of different pathologies and behavioural patterns Most commonly used |
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What are the Projective Personality Assessment Tests?
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Thematic Apperception Test
& Rorschach Test |
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Thematic Apperception Test:
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Test taker creates stories based on pictures of people in various situaitons
Used to eval. MOTIVATIONS behing BEHAVIORS |
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Rorschach Test:
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INK BLOTS interpretation
Used to identify TOHUGHT DISORDERS adn DEFENSE MECH's |
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A break from reality involving delusions, perceptual disturbances and/or disorder of thinking
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Psychosis
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What disorder should you ALWAYS consider in a pt with psychosis
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Bipolar Disorder
Also Delirium/Dementia |
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Which delusion?
False Belief that one is quilty or responsible for something "I caused the flood in Mozambique" |
Delusions of Guilt
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Difference between:
Schizophrenic Schizopreniform Schizoaffective Brief psychotic episode |
Schizophrenia: sx > 6 mo
Schizophreniform: sx 1-6 mo Brief psychotic episode: 1 day - 1 mo Schizoaffective: Schisophrenia + Mood/Mania disorder |
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5 A's of Schizophrenia's
Negative symptoms |
Anhedonia
Affect [flat] Alogia [poverty of speech] Avolition/Apathy Attention [poor] |
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Highest functioning type of Schizophrenia, older age of onset.
Preoccup. with delusions/ freq. auditory hallucinations. Not a lot of disorganized speech, catatonic behaviour or inappropriate affect |
Paranoid Schizophrenia
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Poor-functioning type of schizo. early onset.
Disorganized speech, behaviour and flat or inappropriate affect. Mirror gazing, giggling, facial grimacing, poor grooming |
DIsorganized Schizophrenia
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Rare type of schizo with motor immobility, XS purposeless motor activity, extreme negativism/mutism, Echolalia or echopraxia, blank facial expression
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Catatonic Schizophrenia
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Type of Schizo with prominent NEGATIVE sx, flattenend affect, and only minimal positive sx. Atleast 1 prev psychotic episode
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Residual Schizophrenia
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Neurotransmitter effects in Schizophrenia
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INCREASED: Dopamine...
Serotonin Norepi DECREASED: GABA |
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Which area of the brain causes the Negative sx in schizo?
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Prefrontal cortex
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Which area of the brian causes Positive sx in schizo?
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Mesolimbic
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Neuroleptics block the Tuberoinfundibular tract, causing what side effect?
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Hyperprolactinemia
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Neuroleptics block the Nigrostriatal tract, causing what side effects?
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Extrapyramidal Side effects
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Schizo causes enlargement of which ventricles?
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3rd and Lateral ventricles
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Assoc. w/ Better prognosis in schizo:
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Later onset
Good social support Positive Symptoms Mood Symptoms Acute onset FEMALE sex Few relapses Good Premorbid fxn |
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Assoc. w/ Worse prognosis in schizo:
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Early onset
Poor social support Negative sx + Family history Gradual onset MALE sex Many relapses Poor premorbid fxn |
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Typical neuroleptics treat which sx in schizo?
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positive symptoms
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ATypical neuroleptics treat which sx in schizo?
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negative symptoms
Risperidone clozapine olanzapine quietapine aripiprazole ziprosidone |
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HIGH Potency typical neuroleptics:
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Haloperidol
Perphenazine Fluphenazine Trifluoperazine |
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LOW potency typical neuroleptics
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Chlorpromazine
Thioridazine |
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Dystonia, facial spasms, Parkinsonism, resting tremor, rigidity, bradykinesia, akathesia, restlessness =
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Extrapyramidal Side Effects
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How do you treat EPS?
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Bromocriptine
Benztropine Amantadine (Antiparkinson rx/dopamine agonists) can also use benzo's |
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Anticholinergic sx occur more from....
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low potency typical neuroleptics
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Darting writhing movements of face, tongue, and head =
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Tardive Dyskinesia
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Which kind of neuroleptic causes EPS and tardive dyskinesia and NMS?
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HIGH potencies like haloperidol, trifluoroperazine
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TX of Tardive Dyskinesia
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Discontinue the offending agent
Benzo's Beta blockers cholinomimetics |
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Confusion, high fever, elevated BP, tachycardia, "lead pipe" rigidity, sweating elevated CPK
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Neuroleptic Malignant Syndrome
Life threatening |
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TX of NMS:
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Dantrolene (dantrium)
then Bromocriptine - or - Amantadine |
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Which neuroleptic causes agranulocytosis
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Clozapine
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Which neuroleptic causes irreversible retinal pigmentation
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Thioridazine
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Which neuroleptic causes deposits in lens and cornea
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chlorpromazine
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TX of Schizophreniform disorder
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Hospitalization
3-6 months of antipsychotics Supportive psycho therapy |
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TX of Schizoaffective d/o
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Hospitalization
Supportive therapy Antipsychotics prn |
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TX of Brief Psychotic Episode
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Brief Hospitalization
Supportive psychotherapy Antipsychotics of psychosis Benzo for agitation |
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What are Nonbizarre delusions?
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Beliefs that might occur in real life but are not currently true, like having a disease, or your wife cheating on you
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What are Bizarre delusions?
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Beliefs that have no basis in reality, like aliens living in the attic
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What is Delusional Disorder?
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Nonbizarre, fixed delusions for atleast 1 month
Doesn't meet the criteria for schizophrenia Life Fxning is not impaired too much |
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TX for delusional disorder
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Psychotherapy
Antipsychotics: high potency typical OR Newer atypical Antipsychotics usu don't owrk but should be tried |
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Pt develops the same delusional sx as someon he/she is in a close relationship with
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Shared Psychotic Disorder
or Folie a deux |
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TX for Shared Psychotic disorder
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Remove the source
Psychotherapy Antipsychotics if don't improve |
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Pt believes his penis is shrinking and will disappear, causing death
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Koro
Asia |
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Sx of Major Depressive Episode
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SIG E CAPS
Sleep Interest Guilt Energy Concentration Appetite Psychomotor activity Suicidal ideation Must have 5 of these for 2 weeks |
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Endocrinopathies that cause MDD
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Cushing's
Addison's HYPOglycemia hypo/hyperthyroid hyper/hypocalcemia hyperparathyroid |
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Viral causes of MDD
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Mononucleosis
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Cancerous causes of MDD
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LYMPHOMA
PANCREATIC CARCINOMA |
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Criteria for MDD
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Atleast 1 major depressive episodem (sig e caps)
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Triad for Seasonal Affective Disorder:
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Irritability
Carbohydrate drawing Hypersomnia |
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Avg onset of MDD and more common in...
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Avg age 40
more common in women |
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Sleep symptoms in MDD
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- Multiple awakenings
- Hard to fall asleep, and early am awakenings - Hypersomnia - REM shifted to earlier in night - Stages 3 & 4 Decreased - More REM's per night |
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Other sx in MDD
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- Increased core body temp
- Decreased anterior brain metabolism on PET scan |
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NT's in MDD
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Decreased Serotonin and NE
Increased cortisol: failure to suppress dexamethasone test Abnormal Thyroid axis |
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What events and genetics predisposes someone to MDD later?
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- Loss of a parent before age 11
- Have a first-degree relative with MDD, makes you 2-3x |
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When do you hospitalize pts with MDD?
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If the pt is at risk of suicide, homicide, or unable to care for themselves
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TX of MDD
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**SSRI's usu first line, b/c of low SE's
TCA's MAOI's Psychotherapy ECT |
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TX for refractory MDD
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MAOI's
or methylphenidate |
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Which antidepressant is most lethal in overdose?
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TCA's
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When do you use ECT for MDD?
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if the pt is unresponsive to pharmacotherapy, cant tolerate pharmacotherapy, or if you need to reduce their sx really quickly, like in suicide.
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Which meds do you use to premedicate pts for ECT
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Atropine
then general anesthesia and a muscle relaxant 8 treatments over a 2-3 week poeriod |
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Side effects of ECT
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Retrograde Amnesia
Headache |
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TX for atypical amnesia
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MAOI's
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****What typical pts CAN you usu do ECT on?
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Pregnant
Elderly b/c they usu can't handle the side effects of the antidepressants |
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SE's of SSRI's
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effects mild:
SEXUAL DYSFXN Headache GI sx Rebound anxiety Serotonin syndrome |
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SE's of TCA's
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Sedation
Weight GAIN Orthostatic hypotension Anticholinergic Aggravates QTC syndrome |
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SE's of MAOI's
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Refractory depression
HYPERTENSIVE CRISIS with tyramine-rich foods or sympathomimmetics Serotonin syndrome with SSRI |
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TX of Catatonic type of Depression
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Antidepressants
+ Antipsychotics |
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Criteria for DX of Bipolar I Disorder
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1 manic or mixed episode
Manic episode = EMERGENCY don't need any episodes of major depression |
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How long do untreated manic episodes usu last?
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3 months
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Which has a worse prognosis, Bipolar d/o or MDD?
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Biopolar
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TX of Bipolar I D/o
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Lithium - mood stabilizer
(BUN<18, Cr<1.2) Anticonvulsants - Carbamazepine or valproic acid Olanzapine - atypical Psychotherapy once the acute episode is treated ECT helps with manic episodes too |
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Criteria for Bipolar II D/o
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Hx of 1 or more major depressive Episodes
& Atleast 1 hypomaniac episode No full manic episodes ever/at all |
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Side effects of LITHIUM
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Diabetes insipidus
wt. GAIN Tremor GI probs Fatigue Arrhythmias Seizures Goiter/hypothyroid Leukocytosis (benign) Coma Pulyuria Polydipsia Alopecia Metallic taste |
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If your first degree relative has bipolar disorder, what are the chances of you having it?
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8-18% higher chance than normal
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TX of Bipolar II D/o
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same as I
Lithium Carbamazepine/valproic acid Olanzepine Psychotherapy ECT |
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Criteria for Dysthymic D/o
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Depressed mood for the majority of time of most days for atleast 2 YEARS
In KIDS, for atleast 1 YEAR |
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Sx of Dysthymic D/o
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CHASES:
- poor Concentration/diff. making decisions - Hopelessness - Appetite poor/XS - Sleep (none, or too much) - Energy low, fatigue - Self-esteem low |
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2D's of Dysthymic Disorder (DD)
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2 yrs of Depression
2 from the lister criteria Never asymptomatic > 2 months |
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Difference between MDD and DD
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MDD is usu episodic
DD is usu persistent |
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DD never has....
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Manic episodes
Hypomanic episodes Psychosis Remember that! |
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TX of DD
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Cognitive Therapy
and Insight-oriented psychotherapy *are the most effect* only used SSRI's,TCA's if WITH the above |
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Criteria for Cyclothymic Disorder
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Numerous periods of hypomania
+ periods of depressive sx for 2 years Never have been sx-free more than 2 mo |
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In Cyclothymic D/o the pt must NOT have.....
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hx of Major Depressive episode or Manic episode
Its basically ongoing hypomania with periods of mild depressive sx |
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TX for Cyclothymic D/o
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Same as Bipolar d/o
Lithium Carbamazepine/valproic acid Olanzepine |
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NT imbalances with Anxiety disorders:
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Increased NE
Decreased GABA Decreased Serotonin |
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What are the difference types of Anxiety disorders?
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Panic Disorder
Agoraphobia Specific and Social phobias OCD PTSD GAD Anxiety d/o secondary to General medical condition Substance-induced anxiety |
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Medical causes of Anxiety disorders
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Hyperthyroidism
Vit. B12 def. Hypoxia Neurological disorders (epilepsy, brain tumor, multiple sclerosis) Cardiovascular dz Anemia Pheo Hypoglycemia |
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Substance-induced Anxiety disorder or from meds
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Caffeine intake adn withdrawal
Amphetamines EtOH & Sedative withdrawal Mercury or Arsenic toxicity Organophosphate or Benzene tox PCN Sulonamides Sympathomimetics Antidepressants |
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Criteria for Panic Attack
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Period of intense fear and discomfort plus 4+ of the following:
Palpitations, sweating, shaking, SOB, choking, chest pain, nausea, light-headedness, depersonaization, fear of losing control or "going crazy", fear of dying, numbness/tingling, chills or hot flashes |
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Criteria for Panic Disorder:
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Spontaneous recurrent panic attacks w/ no obvious precipitant
1 mo of constant concern about having additional attacks, worry about the implications of the attack, or a significant change in behavior related to the attacks |
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What things can trigger Panic attacks?
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Hyperventilation
Caffeine Nicotine |
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TX of Panic Disorder
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ACUTE: Benzodiazepines (short course) tapered down as SSRI is gradually instituted
CHRONIC: SSRIs esp PAROXETINE & SERTRALINE Cont. for 8-12 months can also use Clomipramine or imipramine |
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When starting a panic disorder on an SSRI how should you dose them?
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Start at a low dose, and SLOWLY increase cuz they're prone to develop "activation" side effects
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What percentage of pts with agoraphobia have panic disorder too?
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50 - 80% agoraphobia commonly occus after a panic attack cuz they're scared they'll be left alone in public with no help
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TX of Agoraphobia
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SSRI = first-line treatment
+ Behavioral therapy |
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Fear of speaking in public =
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SOCIAL PHOBIA
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Fear of heights
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Specific phobia
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What is the most common mental disorder in the US?
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Phobias
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TX of Specific Phobias:
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NO DRUGS
Systemic Desensitization +/- hypnosis: gradual exposure to the object with relaxation techniques |
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TX of Social Phobias:
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PAROXETINE!!!
(an SSRI) |
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TX for Performance Anxiety
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Beta-Blocker
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Difference between OCD and Obsessive Compulsive Personality Disorder
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OCD the pt is aware of their problem = ego-dystonic
OCPD the pt is UNaware that they're like that = ego-syntonic |
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NT's with OCD
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decreased SEROTONIN
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TX of OCD
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SSRI's = first-line tx
higher than normal dose TCA's clomipramine may also be effective |
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Best, most effective tx for OCD
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SSRI + Behavioural therapy: Exposure and response prevention therapy
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TX of SEVERE OCD
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ECT or Cingulotomy
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Requirements for PTSD
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Having experienced or witnessed a traumatic event (war, rape, natural disaster
Persistent re-experiencing of the event Avoiding things that remind them of the event [like the parking lot where she was raped :( ] Sx must be present for 1+ months |
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TX for PTSD
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TCA's - Imipramine and Doxepine
SSRIs, MAOIs Anticonvulsants Psychotherapy, relazation, support groups, family therapy |
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Criteria for Acute Stress Disorder
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Happens after a traumatic event.
MUST have the sx WITHIN 1 month of the event AND LAST for only 1 month MAX |
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Differential diagnosis for Acute Stress Disorder
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PTSD
ADJUSTMENT Disorder |
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Diff. between PTSD and Acute Stress disorder:
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PTSD:
Event occurred at ANY time in the past Sx last > 1 mo Acute Stress D/o: Event occured < 1mo ago Sx last < 1 month |
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TX for Acute Stress Disorder
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Same as PTSD
TCA's - Imipramine and Doxepine SSRIs, MAOIs Anticonvulsants Psychotherapy, relazation, support groups, family therapy |
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Criteria for GAD
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persistent anxiety and hyperarousal for atleast 6 months
Difficult to control the worry Must have 3+ of the following: Restlessness Fatigue Trouble concentrating Irritability Muscle tension Sleep disturbance |
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50 - 90% of pts w/ GAD have what other problems?
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Coexisting mental disorders:
major depression, social or specific phobia, or panic disorder |
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TX for GAD
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Drugs: Buspirone
Benzos (usu clonazepam or diazepam) should be tapered ASAP SSRIs Venlafaxine XR Other: Behavioral therapy, psychotherapy |
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Criteria for Adjustment Disorder
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Emotional/behavioural sx within 3months of a stressful life event. the sx produce:
- XS Distress of what could be expected after a stressful event - Signif. impairment in daily functioning The sx are NOT those of bereavement Sx resolve within 6 months after the stress has ended |
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Diff. between Adjustment disorder and PTSD/ASD
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In adjustment disorder the stressful event is NOT life threatening.
In PTSD/ASD it IS life threatening |
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Adjustment disorders most frequently occur in who?
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Adolescents
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TX of Adjustment disorder
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Supportive psycho therapy is most effective
can then try gorup therapy or drugs for the symptoms like insomnia, anxiety, depression |
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Personality Disorders are ego-........
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SYNTONIC
they are unaware of them. |
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Onset of Personality disorders
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no later than adolescence or early adulthood
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Onset of Schizophrenia
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20's in men
30's in women |
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Cluster A Personality d/o's
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MAD
Schizoid Schizotypal Paranoid Pts Eccentric, peculiar, w/drawn Familial assoc. w/ Psychotic d/o |
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Cluster B Personality d/o's
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BAD
Antisocial Borderline Histrionic Narcissistic Emotional, Dramatic, inconsistent Familial assoc. w/ Mood d/o |
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Cluster C Personality d/o's
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SAD
Avoidant Dependent Obsessive-Compulsive Anxious, fearful Familial assoc. w/ Anxiety d/o |
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30 y.o. M says his wife has been cheating on him b/c he does not havea good enough job to provide for her needs. He also claims that on his previous job, his boss laid him off b/c he did a better job than his boss
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Paranoid Personality Disorder
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Paranoid Personality Disorder
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Have a pervasive distrust and suspiciousness of others and often interpret motives as malevolent. They tend to blame their own problems on others and seem angry and hostile
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Paranoid PD, men or women more likey?
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Men more likely than women
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Paranoid PD vs. Paranoid Schizophrenia
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in Paranoid PD, no fixed delusions, and are not frankly psychotic, although they may have transient psychosis under stressful situations
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TX of Paranoid PD
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Psychotherapy = TOC
Can use antianxiety and antipsychotics for transient sx |
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A 45 y.o. scientist works in the lab most of the day and has no friends, according to his coworkers. He expresses no desire to make friends and is content with his single life. He has no evidence of a thought disorder.
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Schizoid PD
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Schizoid PD
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Pts PREFER to be alone and have a lifelong pattern of social withdrawal
Often viewed as eccentric |
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Criteria for Schizoid PD
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4+:
- Doesn't enjoy or desire close relationships (even fam) - Genreally choosing solitary activities - Little to no interest in sexual activity - Taking pleasure in few/no activities - Few/no close confidants - Indifference to praise or criticism - Emotional coldness, detachment, or flattened affect |
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Prevalence of Schizoid PD
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7%
MEN 2x more likely than women |
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TX for Schizoid PD
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Psychotherapy = TOC
Low-dose antipsychotics (short course) or antidepressants for respective sx |
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A 35 y.o. man dresses in a space suit every Tuesday and Thur. He has computers set up in his basement to "detect the precise time of alien invasion." He has no evidence of auditory or visual hallucinations.
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Schizotypal PD
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Schizotypal PD
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Have a pervasive pattern of eccentric behavior and peculiar thought patterns. Often viewed as strange and eccentric.
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Criteria for Schizotypal PD
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5+ of:
Ideas of reference (NOT Delusions of reference) Odd beliefs or magical thinking Unusual perceptual experiences Suspiciousness Inappropriate/restricted affect Odd/eccentric appearance/behaviour Few close friends/confidants Odd thinking or speech XS social anxiety |
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Clairvoyance, telepathy, bizarre fantasies, belief in superstitions...think
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Schizotypal PD
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TX for Schizotypal PD
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Psychotherapy = TOC
short course of antipsychotics for transient psychosis |
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A 30 y.o. unemployed male has been accuse of killing 3 senior citizens after robbing them. He is surprisingly charming in the interview. In his adolescence, he was arrested several times for stealing cars and assaulting other kids.
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Antisocial PD
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Criteria for Antisocial PD
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Pattern of disregard for others since age 15
Must be 18 or older Had conduct disorder as a child 3+ of... - Commits unlawful acts&doesnt conform to social norms - Deceitful/repetetive lying/manipulating others for personal gain - Impulsivity aggressiveness/ repeated fights - Recklessness and disregard for safety of self/others - Irresponsibilty/failure to sustain work/honor financial obligations - Lack of remorse for actions |
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TX for Antisocial PD
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Psychotherapy = TOC
Watch out using drug therapy to help b/c they have a high addictive potential |
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A 23 y.o. medical student attempted to slit her wrist b/c things did not work out w/ a guy she was going out with over the past 3 weeks. She states that guys are jerks and "not worth her time." She often feelsthat she is "alone in this world."
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Borderline PD
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Borderline PD
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High # of suicide attempts
Unstable moods, behaviours, and interpersonal skills. They feel alone in the world and have problems with self-image |
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Borderline PD mnemonic:
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IMPULSIVE:
Impulsive Moody Paranoid under stress Unstable self image Labile, intense relationships Suicidal Inappropriate anger Vulnerable to abandonment Emptiness |
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Which gender is more likely to have Borderline PD?
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Women are 2x more likely than men
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Whats the suicide rate amongst ppl with Borderline PD?
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Suicide rate = 10%
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What co-existing problems are high amongst pts w/Borderline PD?
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Depression and risk of suicide
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TX for Borderline PD
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Psychotherapy = TOC:
Beh. therapy, cognitive therapy, social skills training etc. Drugs to help with depression/psychosis if needed |
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A 33 y.o. scantily clad woman comes to your office complaining that her fever feels like "she is burning in hell." She vividly describes how the fever has affected her work as a teacher.
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Histrionic PD
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Histrionic PD
|
Attention-seeking, excessive emotionality, dramatic, flambouyant, sexually inappropriate, have to be center of attention
Usu the lady who comes in with a low cut dress and making passes as the doctor |
|
|
Which defense mechanism do ppl with Histrionic PD use?
|
REGRESSION
|
|
|
Histrionic PD is sometimes confused with..
|
Borderline PD
|
|
|
TX of Histrionic PD
|
Psychotherapy = TOC
Can use drugs for assoc. depression or anxiety |
|
|
A 48 y.o. company CEO is rushed to the ED after an automobile accident. He doesnot let teh residents operate on him and requests the Chief of Trauma Surgery b/c he is "vital to the company." He makes several business phone calls in teh ED to stay on "top of his game."
|
Narcissistic PD
|
|
|
Narcissistic PD
|
Sense of superiority, a need for admiration, and a lack of empathy.
Consider themselves as "special" and will exploit others for their own gain. Often have fragile self-esteems Preoccupied with money and success. Only associate with high status ppl |
|
|
TX of Narcissistic PD
|
Psychotherapy = TOC
Antidepressants ot Lithium for moodswings |
|
|
A 30 yo portal worker rarely goes out with her cowrokers and often makes excuses when they ask her to join them b/c she is afraid they will not like her. She wishes to go out and meet new ppl but according to her, she is too "shy."
|
Avoidant PD
|
|
|
Avoidant PD
|
Disorder of social inhibition and intense fear of rejection. DESIRE companionship, but think they're not good enough, or have some kind of insecurity
|
|
|
Avoidant PD is confused with....
|
Schizoid PD
|
|
|
Avoidant PD vs. Schizoid PD
|
Avoidant PD pts WANT companionship, but are VERY insecure, and scared of rejection.
Schizoid PD pts just want to be ALONE, DON'T want companionship at all. |
|
|
Prevalence of Avoidant PD
|
1-10%
gender prev. unknown |
|
|
TX of Avoidant PD
|
Psychotherapy = TOC: Assertiveness training
Beta-Blockers help for autonomous sx of anxiety, SSRI's for depression |
|
|
A 40 yo man who lives with his parents has trouble deciding on how to go about having his car fixed. He calls his father at work several times to ask very trivial things. He has been unemployed over the past 3 years.
|
Dependent PD
|
|
|
Dependent PD
|
Poor self-confidence and they fear separation. Have XS need to be take care of, allow others to make decisions for them. Cannot express feelings of disagreement b/c of fear of loss of approval
|
|
|
Prevalence in Dependent PD
|
~ 1%
WOMEN > men |
|
|
TX of Dependent PD
|
Psychotherapy = TOC
Drugs to help with added depression or anxiety |
|
|
A 40 yo. secretary has been recently fired b/c of her inability to prepare some work projects in time. According to her. they were not in the right format and she had to revise them six times, which led to the delay. This has happened before but she feels that she is not given enough time.
|
Obsessive-Compulsive PD
|
|
|
Obsessive-Compulsive PD
|
Pervasive pattern of perfectionism, inflexibility, and orderliness. They get so preoccupied in unimportant details that they are often unable to complete simple tasks in a timely fashion. Appear stiff, serious, and formal with constricted affect.
|
|
|
Gender prev. in Obsessive-Compulsive PD
|
MEN > women
|
|
|
Obsessive-Compulsive PD occurs more often in which child?
|
the oldest child.
|
|
|
OCPD vs. OCD
|
in OCPD, its a personality d/o so they don't know that they have it, they don't see their problem
In OCD, they are aware that they hare having a problem. |
|
|
Narcissistic PD vs. OCPD
|
Narcissistic PD: they're motivated by STATUS
OCPD: they're motivated by the WORK itself |
|
|
TX for Obsessive-Compulsive PD
|
Psychotherapy = TOC: Group therapy, and beh. therapy
drugs to treat assoc. sx |
|
|
An overweight woman starts a diet, loses 5 pounds and then says she's taking a "break" from the diet b/c she "hasn't been feeling well."
|
Passive-Aggressive PD
|
|
|
Pattern of substance use leading to impairment or distress for atleast 1 year w/ 1 or more of:
- Can't fulfill obligations at work, school, home - Use in dangerous situations - Recurrent substance-related legal problems - Cont. use despite interpersonal problems |
Substance ABUSE
|
|
|
Substance use leading to impairment or distress with 3+ of these in 12month period:
- Tolerance - Withdrawal - Using substance > intended - Persistent desire or unsuccessful efforts to decr. use - Spend lots of time getting, using, recovering from substance - Decr. social/occupational activities b/c of use - Use despite health problems |
Substance DEPENDENCE
|
|
|
Is substance dependence more common in men or women?
|
Men
|
|
|
What are the most commonly used substances?
|
Caffeine
Alcohol Nicotine |
|
|
NT's involved in EtOH use
|
+ GABA
+ Serotonin - Glutamine N.B. EtOH Sedates |
|
|
Prevalence of alcoholism
|
7-10%
|
|
|
Asians lack which enzyme that make sthem flush when drinking alcohol
|
Aldehyde dehydrogenase
|
|
|
CAGE =
|
Do you ever...
wanna CUT down? get ANNOYED? feel GUILTY? need an EYE-OPENER? |
|
|
At what BAL do most non-tolerant adults show obvious signs of intoxication?
|
BAL > 150 mg/dL
(= 0.15mg%) |
|
|
At what BAL do you see
Decreased fine motor montrol |
20-50 mg/dL
|
|
|
At what BAL do you see
Impaired judgement and coordination |
50-100 mg/dL
|
|
|
At what BAL do you see
Ataxic gait and poor balance |
100-150 mg/dL
|
|
|
At what BAL do you see
Lethargy; difficulty sitting upright |
150-250 mg/dL
|
|
|
At what BAL do you see
Coma in the novice drinker |
300 mg/dL
|
|
|
At what BAL do you see
Respiratory depression |
400 mg/dL
|
|
|
D/Dx for EtOH INTOX
|
HYPOglycemia
Hypoxia mixed EtOH-drug od Ethylene glycol/methanol poison'g hepatic encephalopathy psychosis psychomotor seizures brain injury |
|
|
What physiological effect do methanol, ethylene glycol and ethanol cause?
|
Metabolic Acidosis
+ Increased anion gap Think MUDPILES |
|
|
TX for Acute EtOH Intoxication
|
- Ensure ABCs
- Monitor Electrolytes and acid-base status - Accu check to rule out hypoglycemia - THIAMINE (to x Wernicke's) - NALOXONE (to reverse any opioid ingestion) - FOLATE |
|
|
Do you use GI evacuation (gastric lavage + charcoal) in EtOH over intox?
|
no, but you can use it for mixed EtOH-drug overdose
|
|
|
TX for Chronic EtOH use/Dependence
|
- AA
- Disulfiram - Psychotherapy + SSRI - Naltrexone: helps reduce etoh craviings |
|
|
When do the earliest sx of EtOH Withdrawal begin?
|
6 - 24 hrs after last drink
|
|
|
How long do they last?
|
2 - 7 days
|
|
|
When do DTs usually start?
|
within 72 hours of last drink
|
|
|
D/Dx of EtOH Withdrawal
|
- Alcohol-induced hypoglycemia
- Acute schizophrenia - drug-induced psychosis - encephalitis - thyrotoxicosis - anticholinergic poisoning - withdrawal form sedatives/hypnotics |
|
|
TX of EtOH Withdrawal
|
1. Benzo Taper: Librium or lorazepam
2. Thiamine, folic acid, and multivit. 3. Mag Sulfate for postwithdrawal seizures |
|
|
Wernicke-Korsakoff syndrome is caused by a deficiency in
|
Thiamine
(B1) |
|
|
Wernicke's Encephalopathy
|
Acute, reversible with thiamine
- Ataxia - Confusion - Nystagmus, gaze palsies |
|
|
Korsakoff's Syndrome
|
Chronic, permanent
- Impaired recent memory - Anterograde amnesia - +/- Confabulation |
|
|
MOA of Cocaine
|
Blocks dopamine reuptake from the synaptic cleft causing
STIMULANT effect |
|
|
Clinical Presentation w/ Cocaine intox.
|
Euphoria
+/- BP Tachy or Bradycardia Nausea DILATED pupils weight loss Psychomotor agitation/depression Chills sweats Resp. depression Seizures Arrhythmias Tactile Hallucinations |
|
|
SE's/Complications of Cocaine use
|
MI
CVA Indirect sympathomimetic |
|
|
D/Dx of Cocaine Intox.
|
Amphetamine
PCP intox Sedative withdrawal |
|
|
How long is Cocaine positive in your blood stream?
|
3 days
|
|
|
TX of Acute Cocaine Intox. for
Mild to Moderate Agitation |
Benzodiazepine
|
|
|
TX of Acute Cocaine Intox. for
Severe agitation/psychosis |
Haloperidol
|
|
|
TX for Cocaine Dependence
|
1. Psychotherapy
2. TCA's 3. Amantadine, Bromocriptine (Dopamine agonists) |
|
|
Is Cocaine withdrawal life threatening?
|
no
But causes "crash": malaise, fatigue, depression, hunger, constricted pupils, vivid dreams, psychomotor agitation/retardation |
|
|
Types of Classic Amphetamines
|
Dextromethamphetamine
Methylphenidate (ritalin) Methamphetamine (Desoxyn, ice, speed, "crystal meth," "crack") |
|
|
Substituted amphetamines
|
MDMA
MDEA |
|
|
What is MDMA?
|
Ecstasy
|
|
|
MOA of classic amphetamines
|
Release dopamine from nerve endings
STIMULANT |
|
|
MOA of Designer amphetamines
|
Releases Dopamine and Serotonin
both STIMULANT and HALLUCINOGENIC effect |
|
|
Amphetamine intox. sx
|
Same as cocaine
|
|
|
Amphetamines are positive in a UDS for how long?
|
1-2 days
|
|
|
Amphetamine withdrawal sx
|
Same as cocaine
|
|
|
MOA of PCP
|
Antagonizes NMDA glutamate receptors
Activates Dopaminergic neurons |
|
|
Person has a positive UDS and has rotatory nystagmus =
|
PCP
|
|
|
SX of PCP intox.
|
Recklessness, impulsiveness
impaired judgement Assaultiveness Rotatory nystagmus Ataxia HTN, tachy Muscle rigidity high tolerance to pain |
|
|
PCP overdose can cause
|
seizures or coma
|
|
|
TX of PCP Intox.
|
- Monitor BP, Temp, Electrolytes
- Ammonium Cl, and Ascorbic Acid to acidify urine - Benzo or Dopamine antagonist to control agitation and anxiety - Diazepam for muscle spasm/seizure - Haloperidol for agitation/psychosis |
|
|
D/Dx of PCP intox.
|
- Acute psychotic states
- Schizophrenia |
|
|
How long is PCP positive in UDS?
|
> 1 week
|
|
|
What lab values are seen with PCP use?
|
Elevated CPK and AST
|
|
|
SX of PCP Withdrawal
|
no withdrawal syndrome
but "flashbacks" |
|
|
Benzo's are used for..
|
Anxiety
|
|
|
MOA of Benzo's
|
Increase the FREQUENCY of Cl channel opening on the GABA receptor
Potentiate the effects of GABA |
|
|
Barbiturates are used for...
|
tx of epilepsy and as anesthetics
|
|
|
MOA of Barbiturates
|
Increase the DURATION of Cl channel opening on the GABA receptor
Potentiate the effects of GABA |
|
|
High doses of Barbs does what
|
At high doses of Barbiturates they act like direct GABA agonists, so have a lower margin of safety relative to BDZ's
|
|
|
SX with Sedative-hypnotic intox.
|
Drowsiness, slurred speech, ataxia, impaired judgement, nystagmus, respiratory depression, coma/death on overdose.
Sx augmented when combined with EtOH. Long-term use causes dependence |
|
|
D/Dx of Benzo and Barb use
|
Alcohol intox.
Delirium/generalized cerebral dysfunction |
|
|
Benzo's and Barb's are positive on UDS for how long?
|
1 week
|
|
|
TX of Benzo Intox.
|
- Maintain ABC
- Activated Charcoal to prevent further GI absorption - **Alkalinize the urine w/ Sodium Bicarb to +renal excre. - Supportive care |
|
|
TX of Barb Intox.
|
- Maintain ABC's
- Activated charcoal - ** FLUMAZENIL in OD. - Supportive care |
|
|
Whats the big thing about Benzo or Barb withdrawal
|
Can be life threatening
|
|
|
Physiological dependence is more likely with what kind of Benzo's
|
Short-acting
|
|
|
What is Flumazenil?
|
A very short-acting BDZ antagonist.
Be careful with it cuz it can precipitate seizures |
|
|
SX of Benzo/Barb withdrawal
|
- Autonomic hyperactivity
- Tachy, sweating - Insomnia - Anxiety - Tremor - n/v - Delirium - Hallucinations - SEIZURES |
|
|
TX of Benzo/Barb withdrawal
|
- a Long-acting benzo: Librium or dizepam + taper
- Tegretol or valproic acid for seizure control |
|
|
MOA of Opiates
|
Stimulate kappa, mu and delta opioid receptors to cause analgesia, sedation and dependence
|
|
|
SX of Opiate Intox.
|
Drowsiness
N/V Constipation Slurred Speech Constricted pupils seizures respiratory depression |
|
|
Which opioid should you avoid with MAOI's and why?
|
Meperidine
causes Serotonin Syndrome: Hyperthermia, confusion, hyper/hypotension, muscular rigidity |
|
|
D/Dx of Opioid intox.
|
- Benzo/Barb intox.
- Severe EtOH intox. |
|
|
Opioids positive in UDS for how long?
|
12 - 36 hours
|
|
|
Classic triad of opioid overdose:
|
Resporatory depression
Altered mental status Miosis, Pinpoint pupils |
|
|
TX of Opioid intox.
|
Ensure good ABC's
|
|
|
TX of Opioid overdose
|
- Admin. of Naloxone/Naltrexone
- Watch out for withdrawal - Ventilatory support if necessary |
|
|
TX of Opioid Dependence
|
- PO Methadone once daily, tapered over months to years
- Psychotherapy, support groups, NA |
|
|
SX of Opioid withdrawal
|
NOT life threatening
- Dysphoria - Insomnia - Lacrimation - Rhinorrhea - Yawning - Weakness, sweating - Piloerection - N/V/F - DILATED pupils |
|
|
TX of Opioid Withdrawal:
Moderate sx |
Clonidine &/or buprenorphine
|
|
|
TX of Opioid Withdrawal:
Severe sx |
Detox w/ Methadone/suboxone taper over 7 days
|
|
|
Examples of Hallucinogens
|
Psilocybin (Mushrooms)
Mescaline LSD |
|
|
LSD acts on which system?
|
Serotonin
|
|
|
SX of Hallucinogen intox.
|
- Perceptual changes
- Papillary dilation - Tachycardia - Tremors - Incoordination - Sweating - Palpitations |
|
|
TX of hallucinogen intox.
|
Guidance + reassurance, Talking down the pt is usu enough
May need antipsychotics or benzo's |
|
|
SX of Hallucinogen withdrawals
|
None
may experience "flashbacks" where the sx come back later in life from there fat stores. |
|
|
What is the main active component in Marijuana?
|
THC: Tetrahydrocannabinol
|
|
|
MOA of cannabinoid receptors
|
in the brain they inhibit adenylate cyclase
|
|
|
What is Marijuana used for legally/medically?
|
To treat nausea in cancer patients
& Increase appetite in AIDS pts. |
|
|
How long is marijuana positive on UDS?
|
up to 4 weeks in heavy users
(release from adipose stores) |
|
|
TX for marijuana intox.
|
Supportive and symptomatic therapy
nothing else really |
|
|
Inhalants generally act as...
|
CNS depressants
|
|
|
Who usually uses inhalants
|
Adolescent males
|
|
|
SX of inhalant intox.
|
Belligerence
Impulsivity Perceptual disturbances Lethargy Dizziness Nystagmus Tremor Hyporeflexia Ataxia Slurred speech |
|
|
Effects of Long-term use of Inhalants
|
Permanent damage to CNS, PNS, Liver, Kidney and muscle
|
|
|
TX for inhalant intox.
|
- Monitor ABC's
- Symptomatic tx prn - Psychotherapy and counseling for dependent pts |
|
|
How long do inhalants show up positive on UDS
|
4-10 hours
|
|
|
SX of Inhalant withdrawal
|
none
|
|
|
Substances of abuse that cause nystagmus:
|
- PCP (rotatory)
- Benzo's - Barb's - Inhalants |
|
|
Most commonly used psychoactive substance in the US
|
Caffeine
|
|
|
MOA of caffeine
|
Adenosine antagonist, increasing cAMP and a STIMULANT effect via Dopaminergic system
|
|
|
Caffeine intox. occurs at/over consumption of what level of caffeine
|
> 250 mg
|
|
|
SX of Caffeine intox.
|
- Anxiety, Insomnia
- Twitching - Rambling speech - Flushed face - Diuresis - GI disturbance - Restlessness |
|
|
Consumption of over 1g of caffeine may cause what?
|
Tinnitus
Severe agitation Cardiac arrhythmias |
|
|
Consumption of how muhc caffeine leads to death secondary to what?
|
over 10 g
secondary to seizures and respiratory failure |
|
|
TX for Caffeine intox.
|
Supportive and symptomatic
|
|
|
SX of Caffeine withdrawal
|
Resolve in 1 week
Headache N/V Drowsiness Anxiety Depression |
|
|
TX for Caffeine withdrawal
|
- Taper coffe consumption
- Use analgesics ot treat HA's - Rarely, a short course of benzo's might be needed for anxiety |
|
|
Why are cigarettes addictive?
|
Act on the dopaminergic system
|
|
|
Is nicotine a stimulant? or a depressant
|
Stimulant
|
|
|
Effects of smoking during pregnancy
|
- Low birth weight
- Persistent Pulmonary HTN of the newborn |
|
|
TX of Nicotine withdrawal
|
- Behavioural counseling
- Nicotine replacement therapy(gum, patch) - Zyban: antidepressant to reduce cravings - Clonidine |
|
|
Impairment of memory and other cognitive functions w/out alteration in the level of consciousness.
|
Dementia
|
|
|
SX associated with Dementia
|
- Delusions and Hallucinations in 30%
- Affective sx: depression and anxiety in 40-50% - Personality changes |
|
|
MCC of Dementia
|
1. Alzheimers: 50-60%
2. Vascular Dementia: 10-20% 3. Major Depression (Pseudo-dementia |
|
|
Psychiatric D/Dx for Dementia
|
Depression
Delirium Schizophrenia Malingering |
|
|
Work up to rule out reversible causes of Dementia
|
CBC
Electrolyte (BMP) TFTs VDRL/RPR B12 and folate levels Brain CT or MRI |
|
|
Dementia w/ stepwise increase in severity + focal neurol. signs...think...
|
Multi-infart dementia
Confirm with CT/MRI |
|
|
Dementia + cogwheel rigidity + resting tremor...think...
|
Lewy Body dementia
Parkinson's Disease Confirm clinically |
|
|
Dementia + ataxia + urinary incontinence + dilated cerebral ventricles...think...
|
Normal pressure hydrocephalus
Confirm w/ CT/MRI |
|
|
Dementia + obesity + coarse hair+ constipation + cold intolerance...think...
|
Hypothyroidism
Confirm w/ free T4, TSH |
|
|
Dementia + diminished position an dvibration sensation + megaloblasts on CBC...think...
|
Vit. B12 deficiency
|
|
|
Dementia + tremor + abnormal LFTs + Kayser-Fleisher rings...think...
|
Wilson's Disease
Confirm w/ ceruloplasmin levels |
|
|
Dementia + diminished position and vibration sensation + Argyll-Robertson Pupils...think...
|
Neurosyphilis
Confirm w/ CSF FTA-ABS or CSF VDRL |
|
|
Waxing and waking of consciousness which can be assoc. w/ almost any medical disorder, and can last from days to weeks
|
Delirium
|
|
|
What are the 2 types of delirium?
|
Quiet and Agitated
|
|
|
Quiet Delirium can be confused with...
|
Depression, so an MMSE to distinguish
|
|
|
TX of Delirium
|
1.) Rule out life-threatening causes
2.) Treat reversible causes: Hyperthyroid, electrolyte imbalance, UTI 3.) First line: Antipsychotics: Quietapine(Seroquel). Also can use Haloperidol po/im 4.) 1:1 5.) Reorient pt often 6.) Avoid napping 7.) Keep area well lit 8.) Orders: "Hold for sedation" |
|
|
When using Haloperidol, what do oyu need to watch out for/monitor
|
Torsades, so keep pt on cardiac monitor when using IV Haloperidol
|
|
|
Differential for Delirium:
|
AEIOU TIPS:
Alcohol Electrolytes Iatrogenic O2 hypoxia Uremia/hepatic encephalopathy Trauma Infection Poisons Seizures (post-ictal) |
|
|
Are visual hallucinations common with Delirium or Dementia?
|
Delirium
|
|
|
In which (delirium/dementia) is awareness affected reduced?
|
Delirium
|
|
|
In which (delirium/dementia) do you see EEG changes?
|
Delirium
|
|
|
Alzheimer's is more common in who? and has an avg life expectancy of
|
Women
8 yrs after diagnosis |
|
|
Clinical Manifestations of Alzheimer's
|
- Memory Impairment + 1 of: Aphasia, Apraxia, Agnosia or Diminished executive functioning
- Personality/mood changes |
|
|
NT's involved in Alzheimer's
|
Decreased ACh: locus ceruleus
Decreased Norepi: basal nucleus of Meynert of teh midbrain |
|
|
Pathology of Alzheimer's
|
- Diffuse atrophy w/ enlarged ventricles and flattened sulci
- Senile plaques of amyloid - Neurofibrillary tangles of tau - Neuronal and synaptic loss |
|
|
TX of Alzheimer's
|
1. Memantine (NMDA rec blocker
2. Cholinesterase inhibitors: Tacrine, Donepezil, Rivastigmine 3. Tx of symptoms: low-dose, short-acting benzo for anxiety, quetiapine for agitation/psychosis, antidepressants for depression 4. Physical and emotional support |
|
|
Dementia that presents very similar to Alzheimer's, but with a more step wise loss of function
|
Vascular Dementia
|
|
|
Vascular Dementia vs. Alzheimer's
|
- Focal neuro deficits w/ vasc. dem. like hyperreflexia, paresthesias
- Vasc. dem usu more abrupt - > perseveration of personality - Can reduce risk of vasc. dem. but modifying risk factors |
|
|
TX of vascular dementia
|
Just supportive therapy, no cure, physical and emotional support
|
|
|
Diiference between Pick's disease and Alzheimer's
|
Picks has personality and behavioral changes that are more prominent early in the disease.
Has the aphasia, apraxia, and agnosis etc just like Alzheimer's |
|
|
Pathological findings of Picks
|
- Atrophy of Frontotemporal lobes
- Pick bodies: introneuronal inclusion bodies |
|
|
TX of Picks Disease
|
None really, just supportive
|
|
|
Onset of Huntington's
|
35 - 50
|
|
|
What genetic abonorm do ppl with huntington's have?
|
Chromosome 4
Trinucleotide repeat Basal ganglia |
|
|
Diagnostic findings with Huntingdon's (which part of the brain)
|
- Caudate atrophy on MRI
- sometimes cortical atrophy - Genetic testing |
|
|
TX for huntingdon's
|
none, just supportive
|
|
|
Cortical Dementias =
|
Alzheimer's
Pick's CJD Decline in intellectual functioning |
|
|
Subcortical Dementias
|
Huntingdon's
Parkinson's NPH Multi-infarct dementia More prominent affective and movement sx. |
|
|
Progressive dz w/ neuronal loss in the substantia nigra, presents as: Bradykinesia, Cogwheel rigidity, resting tremor, pill-rolling, masklike fascies, shuffling gait, dysarthria
|
Parkinson's Disease
|
|
|
Prevalence of depression amongst parkinson's pts
|
50% of park. pts have depression
|
|
|
Etiology of Parkinson's
|
- Idiopathic: MC
- Traumatic: Muhammed Ali - Drug or toxin induced - Encephalitic - Familial: Rare |
|
|
TX of Parkinson's
|
1. Levodopa
2. Carbidopa 3. Amantadine 4. Anticholinergics 5. Dopamine agonists: Bromocriptine 6. Selegiline: selective for MAO-B |
|
|
Surgical TX of Parkinson's
|
Thalotomy or pallidotomy
if no longer responsive to meds |
|
|
A rapidly progressing, degenerative disease of the CNS caused by Prions; inherited, sporadic, or acquired.
|
Creutzfeldt-Jakob Disease
|
|
|
Clinical manifestations of CJD
|
- Rapidly progressive dementia within 6-12 months.
- MYOCLONUS - EPS - Ataxia - LMN sx |
|
|
What are the types of prion disease
|
- Kuru
- Gerstmann-Straussler syndrome - Fatal familial insomnia - Bovine spongiform encephalopathy(Mad cow) |
|
|
Pathological findings with CJD
|
Spongiform changes of cerebral cortex
Neuronal loss Hypertrophy of glial cells |
|
|
How to diagnose CJD
|
Definitive: proof of spongiform changes in brain
Probable: rapidly progressing dementia & periodic gen. sharp waves on EEG + 2 of: myoclonus, cortical blindness, ataxia, eps, mm atrophy, mutism. |
|
|
One reversible cause of Dementia
|
Normal pressure hydrocephalus
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Clinical Triad of NPH
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1. Gait disturbance (usu appears first)
2. Urinary Incontinence 3. Dementia (mild, insidious onset) |
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TX of NPH
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Relieve the pressure with SHUNT
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D/Dx of Delirium
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- Dementia
- Fluent aphasia (Wernicke's) - Acute amnesic syndrome - Psychosis - Depression - Malingering |
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TX of delirium
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Tx the underlying cause first!
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Delirium + hemiparesis or other focal neuro signs/sx...think...
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CVA
or Mass Lesion Confirm with Brain CT/MRI |
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Delirium + HTN + Papilledema
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Hypertensive encephalopathy
Confirm w/ Brain CT/MRI |
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Delirium + dilated pupils + tachycardia...think...
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Drug intoxication
Confirm w/ UDS |
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Delirium + Fever +nuchal rigidity + photophobia...think...
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Meningitis
Confirm w/ Lumbar puncture |
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Delirium + tachycardia + tremor + thyromegaly...think...
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Thyrotoxicosis
Confirm w/ free T4 adn TSH |
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Causes of Amnestic disorders
|
- Hypoglycemia
- Thiamine deficiency - Hypoxia - Head trauma - Brain tumor - CVA - Seizures - Multiple sclerosis - Herpes simplex Encephalitis - Substance abuse (Alcohol, benzo's, meds) |
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Stages of Normal Aging:
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- Decreased muscle mass/increased fat
- Decr. brain wt./Incr. ventricles & sulci - Impaired vision & hearing - Minor forgetfulness |
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Stages of Dying:
Normal emotional responses to death/loss of a loved one |
- Denial
- Anger (blaming others for ur illness) - Bargaining - Depression - Acceptance |
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Dementia vs. Pseudodementia:
Onset acute |
Pseudodementia
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Dementia vs. Pseudodementia:
Pt. delights in accomplishments |
Dementia
In pseudo, pt focuses on failures |
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Dementia vs. Pseudodementia:
Sundowning common |
Dementia
Increased confusion at night |
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Dementia vs. Pseudodementia:
Pt will confabulate/guess at answers even if they are wrong |
Dementia
Pseudo: pts will say "i don't know" |
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Dementia vs. Pseudodementia:
Pts aware of the problem |
Pseudodementia/Depression
Dementia: Pt is unaware |
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Dementia vs. Pseudodementia:
Pt c/o vague sx, stomach pain, memory loss |
Pseudodementia/Depression
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TX of Pseudodementia
|
- Supportive therapy, psychodynamic psycho therapy
- LOW DOSE SSRI's - ECT - Mirtazapine: appetite stim. and good for insomnia - Methylphenidate as adjunct to antidepressants |
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Normal grief reactions:
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- Feeling guily/sad
- MILD sleep disturbance - Illusions: seeing/hearing the dead person - Attempts to resume daily life - SX resolve in 1 YEAR (worst in 2 months) |
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SX of ABNORMAL grief:
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- Feelings of severe guilt and worthlessness
- SIGNIFICANT sleep disturbance & wt. loss - Hallucinations/delusions - NO attempt to resume daily activities - SUICIDAL ideation - SX last MORE than 1 year (worst sx more than 2 months) |
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Whta sleep changes occur in elderly?
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More # of times you have REM
Each time is shorter span Same TOTAL REM time as youngsters Increased Stage 1&2 Decreased Stage 3&4(deep) |
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MCC of sleep disorders in elderly
|
Primary sleep disorder/insomnia
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What treatments should you avoid when treating elderly for sleep disorders
|
Sedative-hypnotics, benzos,
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Proper TX for sleep disorders in elderly
|
1st: EtOH cessation, structured daily routine, stop daytime naps, tx underlying d.o
2nd: If sedative-hypnotic must be given: Hydroxyzine (Vistraril) or zolpidem (Ambien) |
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Incidence of Elder abuse
|
10% of all ppl > 65 yo
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Intelligence test for children age 2.5 - 12
|
Kaufman Assessment Battery for Children
(K-ABC) |
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This test determines IQ for ages 6 - 16
|
Weschler Intelligence Scale for Children-Revised
(WISC-R) |
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This test tests academic achievement in children
|
Peabody Individual Achievement test
(PIAT) |
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DSM criteria for Mental Retardation
|
- Significantly subaverage intellectual functioning w/ an IQ of 70 or less
- Deficits in adaptive skills approp. for the age group - Onset must be before age 18 |
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MR affects what % of the population
|
2.5%
and more common in males |
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MCC of MR
|
Idiopathic
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Second MCC fo MR
|
Fragile X Syndrome:
- X chromosome - Males > females |
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Prenatal Causes of MR
|
TORCH: Infxn & Toxins
Toxoplasmosis Other (syphilis, AIDS, etoh, drugs Rubella (German measles) CMV Herpes Simplex |
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Postnatal causes of MR
|
Hypothyroidism
Malnutrition Toxin exposure Trauma |
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Achievement in reading, mathematics, or writtne expression that is significantly lower than expected for chronological age, level of education, and level of intelligence.
|
Learning disorder
As defined by DSM |
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Learning disorders are usually due to...
|
Deficits in cognitive processing like abnormal attention, memory, visual perception etc.
Not from sensory deficits, poor teaching or cultural factors |
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What should you always rule out before diagnosing learning disorder
|
Hearing or visual deficit
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What are the types of Learning Disorder
|
- Reading d/o
- Mathematics d/o - D/o of written expression - Learning d/o not otherwise specified (NOS) |
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Prevalence of Reading d/o
and gender predominance |
4% of school-age children
Boys affected 3-4x as more often as girls |
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Prevalence of Mathematics d/o
|
5% of school-age children
|
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Prevalence of d/o of written expression
|
3-10% of school-age children
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TX of learning d/o's
|
Remedial education tailored to the child's specific needs
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What are the disruptive behavioral disorders in children?
|
Conduct d/o & Oppositional Defiant Disorder
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MC diagnosis in outpatient child psych clinics
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Conduct d/o
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DSM for Conduct Disorder
|
Pattern of beh. that involves violation of basic rights of others/of social norms & rules.
w/ 3+ of the following: - Aggressoin toward ppl & animals - Destruction of property - Deceitfulness - Serious violations of rules |
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Prevalence of Conduct disorder
|
Boys: 6-16%
Girls: 2-9% |
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What are the chances of a pt with conduct disorder developing antisocial disorder?
|
40% risk of developing antisocial personality disorder in adulthood
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Having Conduct d/o puts you at an increased risk of what comorbid d/o's?
|
- ADHD/Learning d/o's
- Mood, substance abuse, and criminal behavior d/o's |
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TX for conduct d/o
|
- Multimodal is most effective
- Firm rules - Indiv. psychotherapy w/behavior modif. and problem solving skills - Adjunct pharmacotherapy: antipsychotics/Lithium for aggression & SSRI's for impulsivity,mood lability |
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Difference between Conduct d/o and ODD
|
ODD does not involve violation of the basic rights of others.
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DSM for ODD
|
6+ months of negativistic, hostile, and defiant behavior while having 4 of the following:
- Freq. loss of temper - Arguments w/adults - Defying adults' rules - Deliberately annoying people - Easily annoyed - Anger & resentment - Spiteful - Blaming others for mistakes or behaviors |
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Prevalence of ODD
|
- 16-22% in kids > 6
- Usu begins by age 8 - Increased co-morbid d/o like conduct d/o - Remits in 25% of children |
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TX for ODD
|
Individual psychotherapy that focuses on behavior modification and problem-solving skills as well as parenting skills taining.
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What are the types of ADHD?
|
- Predominantly inattentive type
- Predominanty hyperactive-impulsive type - Combined type |
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DSM for ADHD
|
- 6+ sx involving inattentiveness, hyperactivity, lasting for 6 months
- Onset before age 7 - Behavior not consistent with age and development. |
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Epidemiology of ADHD
|
- 3-5% prevalence in school-age children
- 3-5x more common in boys - 20% of pts have sx into adulthood |
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Some Causes of ADHD
|
- Fetal alcohol syndrome
- Lead poisoning - Dysreg. of PNS&CNS NEpi systems - Emotional Deprivation |
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TX of ADHD
|
- 1st line: Methylphenidate
- other cns stim.'s: Dextromethamphetamine, pemoline. - SSRI's/TCA's as adjunct - Individual psychotherapy - Parental counseling - Group therapy |
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First line TX for ADHD
|
Ritalin
|
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Examples of Pervasive Developmental Disorders
(PDD) |
- Autistic Disorder
- Asperger's d/o - Rett's d/o - Childhood Disintegrative disorder |
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DSM for Autistic Disorder
|
6 sx from the following:
1. Problems with social interaction(2): - Impairment in nonverbal beh.(facial expression, gestures) - Failure to develope peer relationships - Failure to seek sharing of interests/enjoyment with others - Lack of social/emotional reciprocity 2. Impairments in communicaiton(1): - Lack of or delayed speech - Repetitive use of language - Lack of varied, spontaneous play 3. Repetitive & stereotyped patterns of beh, and act.(1) - Inflexible rituals - Preoccupation w/parts of objects and so on |
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Incidence of Autism
|
.02 - .05% of kids under 12 yo
Boys have 3-5x higher incidence than girls |
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Incidence of mental retardation in Autistic kids
|
70% of autistic kids have MR
only 1-2% can live independently as adults |
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Autism almost always starts before what age?
|
3 yo
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Autistic d/o is assoc. with what other conditions?
|
Fragile X
Tuberous sclerosis MR Seizures |
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TX for Autism
|
There is no cure but can also...
- Remedial Education - Behavioral therapy - Neuroleptics(to control aggression, hyperactivity) - SSRI's(adjunct, to help control repetetive/stereotyped behavior) - Some benefit from stimulants |
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DSM for Asperger's
|
1.) Impaired social interaction (2):
- Failure to develop peer relationships - Impaired use of nonverbal beh.(facial expression etc.) - Lack of seeking to share enjoyment/interests w/others - Lack of social/emotional reciprocity 2.) Restricted/stereotyped behaviors, interests, activities |
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Diff. between Asperger's and Autism
|
Asperger's is a milder form, so they have normal language and cognitive development
|
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TX for Asperger's
|
Supportive tx
Similar to autistic d/o Social skills training and behaviour modif. may be helpful |
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- Normal pre- & perinatal development
- Nml psychomotor dev. in first 5 mo after birth - Nml head circumference at birth, but decreases soon after - Loss of previously learned purposeful hand skills - Stereotyped hand wringing |
Rett's disorder
|
|
|
When does head circumference start and prev learned purposeful movements start declining in Rett's d/o?
|
Head circumference: 5-48 mo
Loss of learned movements: 5-30 mo |
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|
Other characteristics of Rett's
|
Early loss of social interaction followed by subsequent improvement
Severely impaired language and psychomotor dev. Seizures Cyanotic spells |
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|
Cognitive development in Rett's pts never goes past what age
|
First year of life
|
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|
Onset of Retts
|
5-48 months of age
|
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|
Can boys have Rett's?
|
If a boy does have Retts, it usu dies in utero.
Girls ony disease |
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Cause of Rett's
|
MECP2 gene mutation on X chromosome
|
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TX of Rett's
|
Supportive only
|
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DSM for Childhood Disintegrative Disorder
|
1. Normal dev. in first 2 years of life
2. Loss of prev acquired skills atleast 2 of: - Language - Social skills - Bowel/bladder control - Play - Motor skills 3. Atleast 2 of the foll: - Impaired social interaction - Imp. use of language - Restricted, repetetive, and stereotyped behaviors&interests |
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Onset of Childhood Disintegrative D/O
|
Age 2 - 10 years
|
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|
Gender prevalence of CDD
|
BOYS 4-8x higher incidence than girls
|
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|
TX for CDD
|
Just like Autistic, supportive.
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Onset of Tourette's
|
Before age 18
Usu. 7-8 yo |
|
|
Coprolalia
|
repetetive speaking of obscene words (uncommon in children)
|
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|
Echolalia
|
exact repetition of words
|
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DSM for Tourette's
|
- BOTH motor and vocal tics must be present
- Tics must occur multiple times/day ~everyday for > 1yr No tic-free period >3mo - Onset before 18yo - Distress/impairment in social/occ fxng |
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Prev. of Tourette's
|
.05% of children
|
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Gender prev of Tourette's
|
BOYS 3x MC than girls
|
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|
Tourette's has a high co-morbidity with what d/o
|
OCD
& ADHD |
|
|
NT's involved in Tourette's
|
Impaired regulation of DOPAMINE in the CAUDATE NUCLEUS
poss. imp. regulation of endogenous opiates n the noradrenergic system |
|
|
TX of Tourette's
|
Haloperidol / Pimozide
(Dopamine receptor antagonists) Supp. therapy |
|
|
Urinary continence is usu. establish by what age?
|
age 4
|
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|
WHen faced with a pt with enuresis, make sure to rule out what
|
Urethritis
Diabetes Seizures |
|
|
What is Primary Enuresis?
|
Child never established urinary continence
|
|
|
Secondary Enuresis?
|
Manifestation occurs after a period of urinary continence, MCly betw. 5-8yo
|
|
|
Diurnal Enuresis?
|
Includes daytime episodes
|
|
|
Nocturnal Enuresis?
|
includes nighttime episodes
|
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|
DSM for enuresis
|
- Involuntary voiding after age 5
- Occurs atleast 2x per week for 3 months or with marked impairment |
|
|
Prev. of Enuresis
|
7% of 5 yo
Prevalence decreases with age |
|
|
Enuresis is caused by low levels of what hormone
|
ADH
|
|
|
TX of Enuresis
|
Beh. Mod: Buzzer that makes child up when sensor detects wetness
Antidiuretics: DDVAP TCA's: Imipramine! |
|
|
What is Encopresis
|
Bowel incontinence
|
|
|
Bowel control is usu achieved by what age?
|
Age 4
|
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|
When dealing with encopresis, must rule out what?
|
- Metabolic like Hypothyroidism
- Lower GI: anal fissure, IBD - Dietary factors |
|
|
DSM for Encopresis
|
- Involuntary/intentional passage of feces in inappropriate places
- Must be atleast 4 yo - Occurred at least Once a month for 3 months |
|
|
Prev of encopresis
|
1% of 5 yo children
|
|
|
Encopresis is assoc. w/ wha tother conditions?
|
Conduct d/o
& ADHD |
|
|
TX of Encopresis
|
Psychotherapy, family and therapy
Stool softeners if cuased by constipation |
|
|
Evidence of sexual abise in a child:
|
- STD's
- Anal/genital trauma - Knowledge about specific sexual acts (inappr. for age) - Initiation of sexual activity with others - Sexual play with dolls (inappr. for age) |
|
|
The 4 types of Dissociative Disorders:
|
1. Dissoc. Amnesia
2. Dissoc. Fugue 3. Dissoc. Identity disorder (Multiple personality d/o 4. Depersonalization d/o |
|
|
Which Dissoc. d/o's are ego syntonic and dystonic?
|
- Dissoc. Amnesia: AWARE: ego dys.
- Dissoc. Fugue: UNaware: ego syn - Dissoc. ID d/o: UNaware: ego syn - Depersonalization: AWARE: ego dys. |
|
|
What is usu. the underlying cause of a dissociative d/o?
|
a stressful life event or personal problem
Usu have a hx of trauma or abuse in childhood |
|
|
DSM for Dissoc. Amnesia
|
- At least 1 episode of inability to recall important personal info, usu involving traumatic event
- The amnesia cannot be explained by ordinary forgetfulness - Sx cause significant distress/impairment in daily functioning. Pts usu cannot recall their Name, but can recall obscure details! Unlike Dementia! |
|
|
Epidemiology of Dissoc. Amnesia
|
MC Dissoc. d/o
MC in WOMEN MC in YOUNGER adults than older. |
|
|
Dissoc. Amnesia has an increased incidence w/ what other d/o's
|
Depression
& Anxiety d/o's |
|
|
TX for Dissoc. Amnesia
|
- Hypnosis/Sodium amobarbital/lorazepam during the interview to help pt talk more freely.
- Want help pt retrieve lost memories to prevent reoccurrence. - Then, psychotherapy - Lorazepam<Na amobarbital |
|
|
DSM for Dissoc. Fugue
|
- Sudden, unexpected travel away rom home/work + cant recall their past
- Confusion about personal identity - Not due to Diss. ID d/o |
|
|
Predisposing factors for Dissoc. Fugue
|
Heavy alcohol use, major depression, hx of head trauma, epilepsy
Usu occurs w/stressful life event |
|
|
TX of Dissoc. Fugue
|
Same as Dissoc. amnesia
|
|
|
Which Dissoc. d/o has the worst prognosis?
|
Dissoc. Identity d/o
(Multpile personality d/o) |
|
|
DSM of Dissoc. Identity disorder
|
- Presence of 2+ distrinct identities
- Atleast 2 of the id's recurrently take control of pt's behavior - Inability to recall personal info when the other personality is dominant - Most pts have had childhood trauma/ phys/sexual abuse |
|
|
Gender prev. of Dissoc. ID d/o
|
WOMEN = 90% of pts
|
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|
Avg age of dx of Dissoc. ID d/o
|
Age 30
|
|
|
Prognosis
|
Usu chronic and doens't resolve, unlike the other dissoc. d/o's
|
|
|
TX of Dissoc. Identity Disorder
|
- Hypnosis, drug-assisted interviewing, and insight oriented psychotherapy.
- Pharmacotherapy as needed if they have comorbids |
|
|
TX for depersonalization d/o
|
Antianxiety drugs
or SSRI's to treat assoc. sx. |
|
|
What are the 5 types of Somatoform Disorders?
|
1. Somatization d/o
2. Conversion d/o 3. Hypochondriasis 4. Pain d/o 5. Body dismorphic d/o |
|
|
DSM for Somatization d/o
|
- At least 2 GI sx
- At least 1 sexual/reproductive sx - Atleast 1 neurological sx - At least 4 pain sx - Onset BEFORE 30 |
|
|
Gender prev.
|
FEMALES 5-20X that of males
|
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|
TX for Somatization d/o
|
NO CURE
- Regularly scheduled visits to a Primary care doc. - Avoid/caution w/ meds - Relaxation therapy, hypnosis, indiv. and group therapy |
|
|
Common sx with conversion d/o
|
- Shifting paralysis
- Blindness - Mutism - Paresthesias - Seizures - Globus hystericus (feeling of lump in throat) |
|
|
TX of conversion d/o
|
- Insight-oriented psychotherapy
- Hypnosis - Most pts spontaneously recover |
|
|
Difference between Hypochondriasis and Somatization d/o
|
In hypochondriasis, pts are worried about the DISEASE
In somatization d/o the pts are worried about the SYMPTOMS |
|
|
TX for Hypochondriasis
|
NO CURE
- Frequent visits with Primary care doc, very tx to somatization d/o |
|
|
Gender prev. for Body dismorphic d/o
|
WOMEN more than men
MC in UNmarried than married |
|
|
Avg age of onset for Body dismorphic disorder
|
15-20 yo
|
|
|
Prev. of co-morbid d/o with body dismorphic d/o
|
90% have major depression
70% have anxiety d/o 30% have psychotic d/o |
|
|
TX for Body dismorphic d/o
|
- SSRI's reduce symptoms in 50% of pts
- Surgical/derm procedures are not successful |
|
|
TX for Pain d/o
|
SSRI's
Transient nerve stim., biofeedback, hypnosis and psychotherapy may help too. Alanalgesics don't help. |
|
|
Which somatization d/o is commonly seen in hospital and healthcare workers?
|
Factitious Disorder
|
|
|
DSM for Factitious d/o
|
- Pts INTENTIONALLY produce signs of physical/mental d/o's
- Produce sx to assuce the role of the pt. - No external incentives - Either predom. physical c/o or psych c/o |
|
|
Another name for factitious d/o with predominantly physical c/o about self.
|
Munchhausen syndrome
|
|
|
What percent of hospitalized pts have factitious d/o?
|
> 5%
|
|
|
Gender prev for factitious d/o
|
MEN have increased incidence!
|
|
|
TX of Factitious d/o
|
No effect tx.
- Avoid uneccessary prodecures - Keep close relationship with pts Primary care doc. |
|
|
Conscious, intentional, secondary gain:
|
Malingering
|
|
|
Conscious, intentional primary gain
|
Factitious
|
|
|
UNconscious, UNintentional
|
Somatization
& Conversion |
