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163 Cards in this Set
- Front
- Back
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What is the fundamental purpose of diagnosis & classification?
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to isolate a group of discrete disease entities, each of which is characterized by a distinct pathophysiology &/or etiology
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What are main purposes of psychiatric diagnosis? (5)
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1. to introduce order & structure to our thinking & reduce the complexity of clinical phenomena in psychiatry
2. to facilitate communication b/w physicians 3. to help predict the outcome of a disorder 4. to decide on appropriate treatment 5. to assist in the search for pathophsiology & etiology |
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What are other purposes of psychiatric diagnosis? (4)
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1. to monitor treatment & make decisions about reimbursement
2. used by attorneys in malpractice suits & other litigation 3. epidemiology: to determine incidency & prefalence of various diseases 4. to make decisions about insurance coverage |
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To what extent have diagnosis & classification been achieved in psychiatry?
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DSM-IV-TR [Diagnostic & Statistical Manual of Mental Disorders]:
consistent & comprehensive formalized diagnostic procedures. Very reliable but may sacrifice validity. |
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Summarize the major components of the mental status examination. (14)
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1. Appearance & attitude
2. Motor activity 3. Thought & speech 4. Mood [patient's report if possible]& affect [inferred from emotional responses to stimulus] 5. Perception [e.g., hallucinations] 6. Orientation [date, time, etc] 7. Memory [very short term, short term, long term] 8. General Information [dementia] 9. Calculations [serial 7s] 10. Capacity to read & write 11. Visuospatial ability [copy figure, draw clock face] 12. Attention [11, spell backwards] 13. Abstraction [proverbs] 14. Judgment & insight |
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Positive symptoms of psychosis? (5)
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1. delusions - abnormality in content of thought
2. hallucinations - abnormality in perception 3. bizarre or disorganized behavior 4. disorganized speech (positive formal thought disorder) 5. inappropriate affect |
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Common negative symptoms of psychosis? (6)
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1. catatonic motor behavior
2. alogia 3. affective flattening or blunting 4. avolition-apathy 5. anhedonia-asociality 6. poor attention |
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Examples of delusions?(11)
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"fixed false beliefs"
1. persecutory 2. jealousy 3. sin/guilt 4. grandiose 5. religious 6. somatic 7. reference (remarks, statements, events refer to or have special meaning to person) 8. passivity/being controlled mind-reading 9. thought broadcasting/audible thoughts 10. thought insertion 11. thought withdrawal |
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Examples of hallucinations? (4)
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1. auditory (voices commenting or conversing)
2. somatic/tactile 3. olfactory 4. visual |
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Symptoms of depression? (12)
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1. dysphoric mood
2. change in appetite or weight 3. insomnia or hypersomnia 4. psychomotor agitation or retardation 5. loss of interest or pleasure 6. loss of energy 7. feelings of worthlessness 8. diminished ability to think or concentrate 9. recent thoughts of death/suicide 10. distinct quality to mood (not like when a family member died) 11. nonreactivity of mood 12. diurnal variation |
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Symptoms of mania? (7)
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1. euphoric mood
2. increased activity 3. racing thoughts/ flights of ideas 4. inflated self-esteem 5. decreased need for sleep 6. distractibility 7. poor judgment |
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Symptoms of anxiety? (6)
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1. panic attacks
2. agoraphobia 3. social phobia 4. specific phobia 5. obsessions - persistent thoughts 6. compulsions - repeated acts |
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Contrast dementia with delirium.
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Dementia - Delirium
1. chronic/insidious - acute/rapid 2. sensorium unimpaired early - sensorium clouded 3. normal level of arousal - agitation or stupor 4. usually progressive & deteriorating - often reversible 5. common in nursing homes & psych hospitals - common on medical, surgical, & neuro wards |
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Compare dementia with delerium.
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cognitive disorders (as is amnestic disorder):
*impaired memory, thinking, or judgment that produces a clinically significant decline from a previous level of functioning *may be caused by a general medical condition *both benefit from low-stimulus environment *consistency & routine are important to help keep the patient calm *avoid anticholinergics *only use essential medications |
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Describe Alzhemier's Disease.
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Irreversible cause of dementia
50-60% of degenerative dementias. Insidious onset. Death 8-10 yrs after symptoms recognized. Physical findings generally absent or present only in later stages (hyperreflexia, Babinski, frontal lobe release signs). May experience illusions, hallucinations, or delusions. Cortical atrophy, enlarged cerebral ventricles. |
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Early-onset Alzheimer's Disease: differences from later-onset?
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early:
familial usually onset in 50s mutations on chr 1, 14, 21 relatively rare |
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Describe histopathological findings in Alzheimer's. (4)
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1. senile plaques (degenerating neurons tangled around an amyloid core)
2. neurofibrillary tangles (hyperphosphorylated tau protein filaments tangled w/in the cellular cytoplasm 3. neuronal granulovacuolar degeneration of nerve cell bodies 4. Hirano bodies (elongated red structures) in hippocampus |
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What are the two clinical syndromes seen in frontotemporal dementia?
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aka Pick's Disease; irreversible
1. disinhibition & shallow affect 2. early & progressive loss of expressive language w/severe naming difficulties |
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What triad of symptoms cluster in normal-pressure hydrocephalus?
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treatable; cause usually unknown
1. dementia 2. gait disturbance 3. urinary incontinence |
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What are different causes of irreversible dementia? (12)
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1. Alzheimer's (Early-onset <=65yrs OR Late-onset >65yrs)
2. Parkinson's 4. dementia w/Lewy bodies 5. HIV 6. Head trauma 7. Huntington's 8. Frontotemporal dementia 9. Creutzfeldt-Jakob disease 10. substance-induced persisting dementia (Wernicke-Korsakoff syndrome) 11. cerebellar degeneration 12. motor neuron degeneration (ALS) |
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What are different causes of (hopefully) treatable dementia? (9)
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1. vascular (multi-infarct d/t HTN, SBE, MI, heart failure)
2. metabolic/endocrine (hypothyroid, hyperparathyroid, pituitary insufficiency, uremia, hepatic encephalopathy) 3. Nutrition (pernicious anemia, alcoholism & thaimine deficiency, pellagra (niacin), folate deficiencies) 4. toxicity (bromides, mercury, lead) 5. infections (crypto meningitis, encephalitis, sarcoidosis, postinfectious encephalomyelitis) 6. mass effect (intracranial tumor, subdural hematoma) 7. subclinical seizures 8. demyelinating disease 9. normal pressure hydrocephalus |
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What is pseudodementia? Signs & symptoms?
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a depressed patient appears to have dementia.
*also seen in schizophrenia, main, other disorders Unable to remember correctly, cannot calculate well, complains of lost cognitive abilities & skills. Treatable; NOT dementia. |
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What medications could be used to slow the rate of cognitive decline?
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1. cholinesterase inhibitors [mild to moderate]:
*donezpezil *galantamine *rivastigmine *tacrine [hepatic toxicity] 2. cognitive enhancer[moderate to severe]: *memantine |
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What is the mechanism of memantine?
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blocks N-methyl-D-aspartate (NMDA) receptor, which normally binds glutamate. The NMDA receptor is thought to mediate certain aspects of learning & memory.
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Which antidepressants should be avoided in those with dementia?
Which should be used? |
1. Avoid tricyclic antidepressants;
2. Use SSRIs |
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Why should low-potency antipsychotics be avoided in patients with dementia?
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anticholinergic side effects.
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What medications can usually be used in patients with dementia to help reduce aggressive, combative, etc beviors?
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1. 2nd-generation (atypical antispychotics:
olanzapine quetiapine risperidone trazodone 2. anticonvulsants: carbamazepine, valproate 3. anxiolytic: buspirone 4. use benzodiazepines only occasionally |
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Discuss Wernicke's Encephalopathy.
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1. alcohol-related amnesia
2. probably due to chronic thiamine (B1) deficiency 3. ophthalmoplegia, ataxic gait, nystagmus, mental confusion 4. requires emergency thiamine treatment |
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Discuss Wernicke-Korsakoff Syndrome.
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1. Cognitive and memory impairment endure after thiamine treatment for alcohol-related amnesia.
2. Autopsy shows hemorrhage & sclerosis of hypothalamic mamillary bodies & nuclei of thalamus; more diffuse lesions in brainstem, cerebellum, & limbic system. |
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What are the major categories of sleep disorders?
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1. dyssomnias
2. parasomnias 3. sleep disorders related to another mental disorder 4. other sleep disorders (d/t general medical condition or substance-induced) |
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What are the different dyssomnias? x6
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1. Primary insomnia
2. Primary hypersomnia 3. Narcolepsy 4. Breathing-related sleep disorder 5. Circadian rhythm sleep disorder 6. Dyssomnia not otherwise specified |
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Describe primary insomnia.
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-difficulty initiating or maintaining sleep, or nonrestorative or nonrestful sleep
-l month + duration -not d/t another mental disorder, general medical condition, or substance -more frequent among eldery, in women, limited education & lower socioeconomic status, chrnoic or multiple medical problems |
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Describe primary hypersomnia.
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-excessive daytime somnolence
-1 month+ -5% population; men = women -prolonged sleep episodes or daytime sleep episodes almost daily, causing significant distress -no other causes |
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Describe narcolepsy.
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-excessive sleepiness associated w/irresistible sleep attacks
-may be alone -may include cataplexy, sleep paralysis, hypnagogic hallucinations -1/2000 people affected -men = women -may have hereditary basis -attacks last 30s-30min+ -60-90% have cataplexy (loss of muscle tone) -sleep paralysis & hypnagogic hallucinations less frequent |
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Discuss breathing-related sleep disorder.
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Sleep Apnea:
-central, obstructive (more common), or mixed origin -episodes of breathing cessation for 10sec+ during sleep -10-15 events/hour -significant oxygen desaturation -sx: snoring, gasping, snorting, reflux, nocturia, excessive body movts, night sweats, morning headaches -excessive sleepiness during day or sleep attacks |
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Discuss circadian rhythm sleep disorder
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-jet lagged or shift workers
-sleepy when need to be awake -awake when should be sleeping |
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What are sleep hygiene measures?
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Developed for people with chronic insomnia:
1. waking up & going to bed at same time every day, even on weekends 2. avoiding long periods of wakefulness in bed 3. not using bed to read, watch TV, or work 4. leaving the bed & not returning until drowsy if sleep does not begin w/in a set period (20-30 min) 5. avoiding napping 6. exercising at least 3-4x/week (not in evenings) 7. discontinuing or reducing the consumption of alcoholic beverages, beverages containing caffeine, cigarettes, & sedative-hypnotic drugs |
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What are the normal sleep stages of an adult?
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Stage 0, 1, 2, 3, 4, & REM
REM & NREM alternate in 70-120 min cycle; REM gets longer as sleep progresses. |
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What is REM sleep?
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Reduced level of muscle tone w/rapid conjugate eye movements.
Occur in phasic bursts w/fluctuations in respiratory & cardiac rate; engorgement of penis or clitoris. 20-25% of total sleep period. aka desynchronized sleep. |
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What is the 1st stage of NREM?
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stage 0: wakefulness w/eyes closed, just before sleep onset.
increased muscle tone. sinusoidal alpha waves over occput w/low amplitude |
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What is the 2nd stage of NREM?
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Stage 1:
Sleep-onset stage/drowsiness Brief transition from wakefulness to sleep. alpha activity diminishes, beta & theta more prominent. 5% of total sleep period. |
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What is the 3rd stage of NREM?
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Stage 2:
Dominated by theta activity. Sleep spindles (rhythmic) & K complexes (sharp, negative spikes) - response to CNS stimuli. Increased muscle tone. 45-55% of total sleep period. |
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What is the 4th stage of NREM?
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Stage 3:
20-50% high-voltage delta waves. Increased muscle tone (like in stage 2), but eye movements are absent. |
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What is the 5th stage of NREM?
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Stage 4:
delta waves >50% Often indistinguishable from stage 3. |
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What is slow-wave sleep?
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aka delta sleep or deep sleep
stages 3 & 4 15-20% of total sleep period |
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When should hypnotic agents be used?
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To treat transient & short-term insomnia IN COMBINATION with sleep hygiene.
*can be habit-forming *can develop tolerance |
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What are preferred hypnotic agents?
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Benzodiazepines
Nonbenzodiazepines Chloral hydrate Diphenhydramine & doxylamine (antihistamines) Trazodone (antidepressant) |
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What are some common benzodiazepines?
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Estazolam (ProSom)*
Flurazepam (Dalmane) Quazepam (Doral) Temazepam (Restoril)* Triazolam (Halcion)] * preferred |
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What are some common Nonbenzodiazepines?
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Eszopiclone (Lunesta)
Ramelteon (Rozerem) Zaleplon (Sonata) Zolpidem (Ambien) |
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What is the difference between nightmare disorder & sleep terrors?
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NIGHTMARE DISORDER consists of repeated awakenings w/detailed recall of extended & frightening dreams
rapidly alert & oriented upon awakening usually during REM sleep SLEEP TERROR DISORDER sudden partial arousal from delta sleep screaming & frantic motor activity during first third of sleep episode scream, tachycardia, rachypnea may not fully awaken or have any detailed recall |
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How is hypersomnia managed?
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Combination of
1. sleep hygiene measures 2. stimulant drugs [dextroamphetamine, methylphenidate*, modafinil, nonsedating TCAs] 3. naps *DOC |
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What are the three major types of sexual disorders?
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1. sexual dysfunctions
2. paraphilias 3. gender identity disorders (4. sexual disorder not otherwise specified) |
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What are the stages of the sexual response cycle?
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1. appetitive stage
2. excitement stage 3. orgasmic stage 4. resolution stage |
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Describe the appetitive stage.
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lasts minutes to hours
sexual fantasies & desire for sexual intimacy |
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Describe the excitement stage.
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foreplay
-early: lasts minutes to hours penile erection; vaginal lubrication, nipple erection, vasocongestion of external genitalia -late: seconds to minutes drops of fluid at head of penis; tightening of outer 1/3 vagina & breast engorgement |
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Describe the orgasmic stage.
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lasts 5-15 sec
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Describe the resolution stage.
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detumescence
feelings of relaxation & well-being |
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What are disorders of the appetitive stage?
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1. hypoactive sexual desire disorder
2. sexual aversion disorder |
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What are the causes of male erectile disorder/impotence?
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1. physical: CV disease, renal disorders, liver disease, malnutrition, DM, MS, traumatic SC injury, etOH abuse, psychoactive drugs, psychotropic meds, prostate surgery, pelvic irradiation
2. psychological (more likely if spontaneous erections) |
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What is dual sex therapy?
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Involve both members of couple.
Review psychological & physiological aspects of sexual functioning, couple's attitudes & ability to communicate. After Dx, graded assignments Focus on correcting dysfunctional behavior. |
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What medications are used to treat male impotence?
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1. Sildenafil (Viagra): quick DoA
2. Vardenafil (Levitra): lasts up to a day 3. Tadalafil (Cialis): lasts up to 3 days 4. Alprostadil: placed in urethra |
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How common are paraphilias (sexual deviations)?
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Less common than sexual dysfunctions.
Not commonly reported. Mostly males. pedophilia > exhibitionism |
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How are paraphilias treated?
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1. Behavioral interventions/CBT
2. Testosterone-lowering medications |
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Describe cognitive-behavioral therpy for a person w/paraphilia.
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1. masturbatory satiation
2. covert sensitization 3. masturbatory conditioning 4. social skills training 5. restructure faulty cognitions used to justify behavior 6. relaxation training |
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What medications can be used to dampen unwanted sexual behaviors?
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1. medroxyprogesterone & leuprolide lower serum testosterone levels & reduce sex drive
2. triptorelin (GRH analogue) reduces serum testosterone levels 3. SSRIs reduce paraphilic fantasies & behavioral impulsivity 4. naltrexone may curb paraphilic fantasies & behavior *use testosterone-lowering medications if SSRIs & naltrexone don't work |
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What are the treatments for gender identity disorder?
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1. individual & group sessions aimed at helping pts accept their anatomical sex, develop an ability to experience pleasure from genitals, & sucessfully adjust in other important areas of their lives
2. hormonal therapy 3. gender reassignment surgery |
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What factors predict a good outcome to gender reassignment surgery?
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1. lifelong cross-gender identification
2. were able to pass convincingly as member of opposite sex before surgery 3. have good social support 4. have college education 5. have a steady job |
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When is anxiety normal? Abnormal?
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Abnormal anxiety affects one's life? Normal anxiety (& fear) is protective. Abnormal anxiety is detrimental.(Couldn't find an explicit answer.)
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What is the relationship between panic disorder & agoraphobia?
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Agoraphobia is a complication of panic disorder.
Fear being unable to escape a place or situation & avoids it. Often afraid of having a panic attck & embarassing themselves or being unable to get help. |
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What are the findings in genetic studies of panic disorder?
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Probably hereditary.
Morbidity is 20% of first degree relatives w/disorder. Identical twins have 45% concordance rate; fraternal have 15%. |
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What is the differential diagnosis of panic disorder?
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MANY.
MEDICAL: angina, cardiac arrythmias, CHF, hypoglycemia, hypoxia, pulmonary embolism, severe pain, thyrotoxicosis, carcinoid, pheochromocytoma, Meniere's disease. PSYCHIATRIC: schizophrenia, mood disorders, personality disorders, adjustment disorder w/anxious mood DRUGS: caffeine, aminophylline, sympathomimetics, MSG, psychostimulants & hallucinogens, EtOH withdrawal, benzodiazepines/other sedative-hypnotics withdrawal, thyroid hormones, antipsychotic medication |
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What is the pharmacological treatment of panic disorder?
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SSRIs are DOC
SNRI venlafaxine past: TCAs, MAOIs benzodiazepines (high dose) B-blockers (propanolol) less effective |
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What is the pharmacological treatment of GAD?
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SSRIs: paroxetine, escitalopram
SNRI: venlafaxine Busipirone (nonbenzodiazepine anxiolytic) |
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What is the pharmacological treatment of social phobia?
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SSRIs: FLUOXETINE, PAROXETINE, SERTRALINE
SNRI: extended release venlafaxine MAIOs benzodiazepines TCAs less effective B-blockers for short term |
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What is social phobia? specific phobia? What is the difference?
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SOCIAL: fear of humiliation or embarrassment in public places
SPECIFIC: fear of a specific thing (e.g., snakes) BOTH have prevalence ~12% BOTH use avoidance. SPECIFIC tends to get better w/age. |
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What is the natural history of different anxiety disorders?
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PANIC DISORDER(w/w/o Agoraphobia): sudden, recurrent panic attacks w/persistent worry about more attacks, implications or consequences of attack, or significant change in behavior d/t attack
>1 month GAD: excessive anxiety & worry for at least 6 mos common sx: restlessness/keyed up/on edge easily fatigued difficulty concentration/ mind going blank irritability muscle tension sleep disturbance sx cause significant distress or impairment |
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How are obsessions distinguished from delusions?
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OBSESSIONS are recognized as a product of pts mind
DELUSIONS are NOT recognized as of self |
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When is anxiety normal? Abnormal?
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NORMAL:
short term appropriate to situation doesn't affect normal functioning ABNORMAL: chronic or recurrent excessive affects daily living |
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What is the relationship between panic disorder and agoraphobia?
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Agoraphobia is a disabling complication of panic disorder.
Fear of being unable to esape a place or situation so much that one avoids it. |
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What are the findings in genetic studies of panic disorder?
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hereditary.
20% for 1st degree relatives w/disorder [2% control]. 45% for identical twins 15% for fraternal twins |
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What is the MEDICAL differential diagnosis of panic disorder?
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angina, cardiac arrhythmias, CHF, hypoglycemia, hypoxia, PE, severe pain, thyrotoxicosis, carcinoid, pheochromocytoma, Meniere's disease
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What is the PSYCHIATRIC differential diagnosis of panic disorder?
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schizophrenia
mood disorders personality disorders adjustment disorder w/anxious mood |
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What is the DRUG differential diagnosis of panic disorder?
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caffeine, aminophylline, sypathomimetic agents, MSG, psychostimulants & hallucinogens, EtOH withdrawal, BZ & other sedative-hypnotic withdrawal, thyroid hormones, antipsychotics
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What is the pharmacological treatment of panic disorder?
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[medication & psychotherapy]
SSRIs effective 70-80% SNRI venlafaxine also effective TCAs & MAOIs used more previously |
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What is the pharmacological treatment of GAD?
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[medication & psychotherapy]
SSRI: paroxetine & escitalopram SNRI: venlafaxine non-BZ anxiolytic: Buspirone BZ: short periods only; tolerance & dependence TCAs infrequent |
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What is the pharmacological treatment of social phobia?
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SSRI: fluoxetine, paroxetine, sertraline
SNRI: extended release venlafaxine Probably effective: other SSRIs, MAOIs, BZs |
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What are social & specific phobias? How do they differ?
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Phobia: irrational fear of specific objects, places or situations, or activities; excessive & disproportionate
SOCIAL: fear of humiliation or embarrassment in public places SPECIFIC: fear of a specific thing that could conceivably cause harm |
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When is anxiety normal? Abnormal?
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NORMAL:
short term appropriate to situation doesn't affect normal functioning ABNORMAL: chronic or recurrent excessive affects daily living |
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What is the relationship between panic disorder and agoraphobia?
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Agoraphobia is a disabling complication of panic disorder.
Fear of being unable to esape a place or situation so much that one avoids it. |
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What are the findings in genetic studies of panic disorder?
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hereditary.
20% for 1st degree relatives w/disorder [2% control]. 45% for identical twins 15% for fraternal twins |
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What is the MEDICAL differential diagnosis of panic disorder?
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angina, cardiac arrhythmias, CHF, hypoglycemia, hypoxia, PE, severe pain, thyrotoxicosis, carcinoid, pheochromocytoma, Meniere's disease
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What is the PSYCHIATRIC differential diagnosis of panic disorder?
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schizophrenia
mood disorders personality disorders adjustment disorder w/anxious mood |
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What is the DRUG differential diagnosis of panic disorder?
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caffeine, aminophylline, sypathomimetic agents, MSG, psychostimulants & hallucinogens, EtOH withdrawal, BZ & other sedative-hypnotic withdrawal, thyroid hormones, antipsychotics
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What is the pharmacological treatment of panic disorder?
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[medication & psychotherapy]
SSRIs effective 70-80% SNRI venlafaxine also effective TCAs & MAOIs used more previously |
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What is the pharmacological treatment of GAD?
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[medication & psychotherapy]
SSRI: paroxetine & escitalopram SNRI: venlafaxine non-BZ anxiolytic: Buspirone BZ: short periods only; tolerance & dependence TCAs infrequent |
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What is the pharmacological treatment of social phobia?
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SSRI: fluoxetine, paroxetine, sertraline
SNRI: extended release venlafaxine Probably effective: other SSRIs, MAOIs, BZs |
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What are social & specific phobias? How do they differ?
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Phobia: irrational fear of specific objects, places or situations, or activities; excessive & disproportionate
SOCIAL: fear of humiliation or embarrassment in public places SPECIFIC: fear of a specific thing that could conceivably cause harm |
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What is the natural history of panic disorder?
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Chronic & lifelong.
Attacks fluctuate in frequency, intensity, severity. Total remission uncommon. 50-70% show some improvement over time. Increased risk for peptic ulcers, HTN, death, suicide. |
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What is the natural history of GAD?
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Usually chronic.
Symptom severity fluctuates. 1/4 develop panic disorder. Major depression & substance abuse most frequent complications. |
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What is the natural history of social phobia?
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Tends to develop slowly, are chronic, no obvious precipitating stressor.
1/8 develop substance misuse. 1/2 have comorbic psych disorder (MD or other anxiety disorder). Doesn't tend to improve with advancing age. May cause disability. |
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What is the natural history of specific phobia?
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often precipitating stressor.
Tends to improve with advancing age. If doesn't abate, rarely causes disability. |
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What is the natural history of OCD?
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Tends to lessen with time.
Good outcome: mild or typical symptoms, good premorbid adjustment Poor outcome: early onset, presence of severe personality disorder. Worsed by depressed mood & stressful events. Major depression recurrent episodes in 70-80% of OCD patients. |
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What is the natural history of PTSD?
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usually chronic.
Syptoms fuctuate, typically worse during stressful periods. Good outcome: rapid onset, good premorbid functioning, strong social support, & absence of psychiatric or medical comorbidity. Many develop MD, other anxiety disorders, or substance abuse. |
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What is the natural history of acute stress disorder?
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precursor to PTSD.
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How are obsessions distinguished from delusions?
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OBSESSIONS: unwanted resisted, & recognized by the patient as having internal origin.
DELUSIONS: typically not resisted, considered by patient to be of external origin |
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How do bulimia nervosa and anorexia nervosa differ?
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BN: recurrent episodes of binge eating w/feeling of lack of control over eating; recurrent use of inappropriate compensatory behaviors to prevent weight gain; ~2 binges/wk for 3 months
AN: *discrepancy between weight & perceived body image* |
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How do bulimia nervosa and anorexia nervosa overlap?
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persistent overconcern with body shape & weight
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What are the sociodemographic characteristics of eating disorder patients?
Is their prevalence increasing? |
M:F 1:10
onset during adolescence or young adulthood (AN earlier than BN). Found in in all social strata, but less common in AA in US & in nonindustrialized countries. Probably not increasing prevalence; probably due to increased recognition & better treatment. |
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What are some of the physiological & psychological theories about the cause of anorexia nervosa?
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BIOLOGICAL: genetics (70% identical twins; 20% fraternal twins), serotonergic disturbance (hypothalamus; high levels of 5-HIAA)
PSYCHOLOGICAL & PHYSIOLOGICAL: refuge from upsetting life events or developmental issues w/relationships & sexuality. Prolong childhood? Comfort in success w/dieting. Corticotropin-releasing hormone secretion enhanced in AN - may help maintain abnormal eating behavior. high vasopressin & oxytocin in CSF. |
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Clinical symptoms in anorexia nervosa?
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behaviors to promote weight loss: extreme dieting, special diets, refusal to eat w/family or in restaurants.
Unusual interest in food. Profound weight loss, hypothermia, dependent edema, bradycardia, hypotensions, constipation, hormonal abnormalities. |
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Clinical symptoms in bulimia nervosa?
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calluses on back of hands, dental erosion, caries.
Hypocalcemia, hpokalemic alkalosis. |
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What potential medical complications may result from anorexia & bulimia?
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amenorrhea, sensitive to cold, constipation, hypotension, bradycardia, lanugo hair, hair loss, petechia, carotenemic skin, parotic gland enlargement.
Dehydration, hypokalemia, hypochloremia, alkalosis, leukopenia, elevated transaminases & cholesterol, carotenemia, elevated BUN or amylase. Increaed GH, cortisol; loss of diurnal variation; reduced gonadotropin levels; abnormal glc tolerance test & dexamethasone suppression test results. Electrolyte disturbances -> weakness, lethargy, ECG changes, high cholesterol, malnutrition. |
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What is the natural history of anorexia & bulimia nervosa?
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ranges from full recovery to malignant weight loss & rapid death.
AN: 11% during a 12-yr follow-up. 25-40% have good outcome. |
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What are the major goals in the treatment of eating disorders?
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1. restore patient's nutritional state
2. modify patient's distorted eating behaviors 3. help change the patient's distorted & erroneous beliefs about the benefits of weight loss |
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Which medications are used in treating eating disorder patients?
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*bulk laxatives or stool softeners, viamins
*BULIMIA: psychotropics, antidepressants [SSRI fluoxetine]. BUPROPRION CONTRAINDICATED. ANOREXIA: 2nd-gen antipsychotics (but not carefully studied), mood stabilizers, antidepressants, anxiolytics if comorbidity. Fluoxetine & clomipramine may help prevent relapses of anorexia nervosa. |
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How is schizophrenia diagnosed?
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1. 2+ of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, & negative symptoms.
Only need 1 if delusions are bizarre or hallucinations keep running commentary or 2+ voices converse. Also: 2. social/occupational dysfunction 3. duration 6+ months 4. exclude schizoaffective & mood disorders, substance & general medical conditions |
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Most common differential diagnosis of schizophrenia?
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mood disorder (bipolar, depression), schizoaffective disorder, delusional disorder, personality disorders
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Other differential diagnoses of schizophrenia?
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brief psychotic, panic, depersonalization, or obsessive-compulsive disorder
temporal lobe epilepsy, tumor, stroke, brain trauma, endocrine, metabolic, vitamin disorders, infectious or autoimmune toxicity, stimulants, hallucinogens, anticholinergics, EtOH or barbiturate withdrawal |
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What are typical disorganized signs and symptoms of schizophrenia?
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disorganized speech, disorganized or bizarre behavior, & incongruous affect;
disorganized motor & social behavior (catatonic stupor or excitement, stereotypy, mannerisms, echopraxia, automatic obedience, negativism); deterioration of social behavior |
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What are typical negative signs and symptoms of schizophrenia?
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alogia, affective flattening or blunting, avolition, anhedonia
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What are typical psychotic signs and symptoms of schizophrenia?
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hallucinations, delusions
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What are the subtypes of schizophrenia?
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1. paranoid
2. disorganized 3. catatonic 4. undifferentiated 5. residual |
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What evidence supports a neurobiological basis for schizophrenia?
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genetic concordance (siblings 10%, 1 parent 5-6% chance).
Vulnerability genes found (neuregulin 1, dysbindin, COMT, DISC, BDNF). COMT affects DA production, neuregulin affects GABAergic & glutamatergic neurotransmission. Enlarged cerebral ventricles present from onset of disease. |
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What is the natural history of schizophrenia?
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1. prodrome: insidious onset over months to years (subtle behavior changes).
2. active: psychotic symptoms develop. 3. residual phase: active-phase symptoms absent or less prominent. Often role impairment, negative symptoms, or attenuated positive symptoms. HETEROGENEOUS OUTCOME. Good prognosis: high IQ, late onset, mild/moderate psychotic or negative sx, females, no structural brain abnormalities. |
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How is schizophrenia managed?
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1. antipsychotic medication:(block postsynaptic DA D2 receptors in forebrain, also 5-HT, NE, ACh, & His receptors).
*ACUTE: 2nd gen antipsychotics 1st-line [risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, NOT clozapine b/c agranulocytosis] *Maint: same as acute. *Adjuct meds: anxiolytics; lithium, valproate, carbamazepine; antidepressants. 2. psychosocial interventions: hospital or day treatment programs. Fit to needs of patient. Outpatient clinic. Family therapy. Cognitive rehavilitation, social skills training, psychosocial rehabilitation. |
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How does delusional disorder differ from schizophrenia?
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DD: nonbizarre delusions for at least 1 month. If present, hallucinations are brief & not prominent
SCHZ: hallucinations, delusions, etc for 6+ months |
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What are the subtypes of delusional disorder?
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1. persecutory
2. erotomanic (belief that another person, usually of higher status is in love w/pt) 3. grandiose 4. jealous 5. somatic (belief that one has a physical defect, disorder, or disease) |
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How does schizoaffective disorder differ diagnostically from schizophrenia?
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In schizophrenia, the duration of all episodes of a mood syndrome is brief relative to the total duration of the psychotic disturbance.
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How does schizoaffective disorder differ diagnostically from psychotic mood disorders?
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In psychotic mood disorders, psychotic symptoms are generally not present in the absence of depression or main.
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What is the differential diagnosis of a brief psychotic disorder?
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psychotic mood disorders
schizophrenia drugs medication postpartum blues |
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What are the nine symptoms used to define a major depressive episode in DSM-IV-TR?
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1. depressed or irritable mood
2. markedly diminished interest or pleasure in (almost) all activities 3. significant weight loss (5%) OR decrease or increase in appetite 4. insomnia or hypersomnia 5. psychomotor agitation or retardation (observable by others) 6. fatigue or loss of energy 7. feelings of worthlessness or excessive or inappropriate guilt 8. diminished ability to think or concentrate; indecisiveness 9. recurrent thoughts of death, suicidal ideation w or w/o plan |
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What is the difference between delusions that are mood congruent and those that are mood incongruent?
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congruent: fit with depressed mood (e.g., going to Hell)
incongruent: don't fit with depressed mood (e.g., persecutory delusion) |
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Lifetime prevalence for bipolar disorder?
For major depressive disorder? |
bipolar I & II: nearly 4%
MDD: nearly 17% |
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Review the evidence that suggests that mood disorders are familial and may be genetic.
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increased rates of mood disorder (especially biopolar) of 1st degree relatives. Twin & adoption studies support. Unipolar tend to have unipolar relatives w/lower incidence of bipolar.
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Which neurotransmitter systems have been proposed to be dysfunctional in mood disorders?
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NE (MAOIs)
serotonin (SSRIs) |
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What is the evidence indicating that neuroendocrine abnormalities occur in patients with mood disorders?
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depression: more cortisol metabolites in urine & blood; abnormal diurnal variation in cortisol production
*blunting of growth hormone output & production of thyroid-stimulating hormone [hypothalamus abnormality is likely cause] |
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What is the difference between bereavement & a depressive episode?
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Bereavement:
usually self-limiting clear spontaneously over time different course & prognosis usually do not respond to antidepressants lack of guilt lack of suicidality |
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Describe 1st-line treatments & indications for depression.
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1st-line: SSRIs because well-tolerated & safe in OD; low dosages generally efective; frequent dosage adjustments unnecessary.
If pt has cardiac conduction defects, are impulsive, or suicidal should take SSRI. *but may increase risk for impulsive behavior & suicidality. |
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Describe adjunct medical treatments & their indications for depression.
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augment antidepressants w/lithium (or triiodothyronine, psychostimulants, beta-blockers, BZs, antipsychotics).
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Describe alternative medical treatments & their indications for depression.
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MAOIs - if patient doesn't respond to SSRI or cannot tolerate side effects - use caution d/t potentially dangerous side effects & interactions.
ECT - severe depression, high potential for suicide, CV disease, pregnancy. Still need maintenance after ECT. Vagal Nerve Stimulation - alter levels of NTs. 1/4 achieve remission. Side effects: haorseness, cough, dysphagia, expense. |
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Describe 1st-line treatments & indications for a manic episode.
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ACUTE:
Lithium Valproate Carbamazepine MAINTENANCE of BIPOLAR: Lamotrigine |
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Discuss alternative treatments for a manic episode.
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BIPOLAR DISORDER:
1. anticonvulsants: gabapentin & topiramate have mixed results 2. 2nd-gen antipsychotics: risperidone, olanzapine, aripiprazole, quetiapine, ziprasidone. (Quetiapine not approved). ECT highly effective when medication unsuccessful. |
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What are the risk factors for violent behavior?
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1.history of violent acts, especially childhood aggression
2.inability to control anger 3.history of impulsive behavior 4.paranoid ideation or frank psychosis 5.lack of insight in psychotic patients 6.command hallucinations in psychotic patients 7.stated desire to hurt or kill another person 8.presence of an acting-out personality disorder 9presence of dementia, delirium, or alcohol or drug intoxication 10.low socioeconomic status *history of violence & alcohol are most predictive* |
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What is the pathophysiology underlying violent behavior?
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low 5-HIAA levels in CSF (metabolite of serotonin)
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How is the violent or potentially violent patient assessed and managed?
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Ask patient:
1.ever thought of harming someone else? 2.ever seriously injured another person? 3.most violent thing ever done? Clinician should remain calm & speak softly. Seclusion or restraint as emergency safety measure. Agitated patients: high-potency antipsychotic + BA (haloperidol + lorazepam) |
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Why is suicide a major health problem?
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8th most frequent cause of death for adults in US.
2nd leading cause of death in 15-24 |
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How do completed suicides differ from attempted suicides?
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COMPLETED:
male older depression, alcoholism, schizophrenia careful planning lethal/more violent means low availability of help ATTEMPTED: female younger depression, alcoholism, personality disorder impulsive attempt less lethal means (poison) high availability of help |
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Discuss different risk factors for suicide among youth & those who are older.
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YOUTH
academic problems troubled relationships with parents peer pressure OLDER poor finances poor health relationship loss |
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How should the suicidal patient be managed in the hospital?
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1.ask the patient about suicidal thoughts & plans
2.remove any potentially lethal items from patient 3.watch carefully 4.fully document patient's signs & symptoms 5.medication/treatment |
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How should the suicidal patient be managed in an outpatient setting?
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1.ask the patient about suicidal thoughts & plans
2.monitor suicidality frequently - in person or on phone 3.remove all firearms from house 4.medication |
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Describe some techniques useful in assessing children & establishing rapport with them.
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taking turns telling stories
playing games imaginative play |
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List IQ levels used to define borderline intelligence & levels of mental retardation.
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borderline: 71-84
mild MR: 50/55-70 moderate MR: 35/40-50/55 severe MR: 20/25-35/40 profound MR: below 20/25 |
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Distinction between autism, mental retardation, & learning disorders?
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AUTISM: uneven profile of functional intellectual abilities
MR: subnormal intelligence + deficits in adaptive functioning LEARNING DISORDERS:individual is performing markedly below a level expected in one area on the basis of a person's IQ |
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List well-recognized causes of mental retardation.
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Fetal Alcohol Syndrome
Down Syndrome Frqgile X Syndrome Polygenic Prenatal Factors Malnutrition Toxins Maternal infection |
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Define Learning Disorder.
Which three skils are commonly affected? |
individual is performing markedly below a level expected on the bases of the person's IQ.
reading disorder mathematics disorder disorder of written expression |
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Describe the three major domains that are abnormal in autism & examples of signs and symptoms within these domains.
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1.SOCIAL INTERACTION
*marked impairment in use of multiple nonverbal behaviors (eye-to-eye gaze, facial expression, body postures, other gestures) *failure to develop peer relationships apprpriate to developmental level *lack of spontaneous seeking to share enjoyment, interests, or achievements w/others *lack of social or emotional reciprocity. 2.IMPAIRMENTS IN COMMUNICATION *delay or lack of development of spoken language *if adequate speech, marked impairment in ability to initiate or sustain conversation *stereotyped & repetitive use of language or idiosyncratic language *lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level 3.RESTRIC REPETITIVE & STEREOTYPED PATTERNS OF BEHAVIOR, INTERESTS, & ACTIVITIES *encompassing preoccupation w/1+ stereotyped & restricted pattern of interest, abnormal in intensity or focus *apparently inflexible adherence to specific, nonfunctional routines or rituals *stereotyped & repetitive motor mannerisms *persistent preoccupation w/parts of objects |
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How common is autism?
Long term course & outcome? |
10-15/10,000 individuals
M:F 3or4:1 chronic, lifelong. some improve, some worsen. 2-3% progress normally through school or live independently. Defining features persist into adulthood. Good prognosis: higher IQ, better language & social skills. |
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How is autism treated?
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special education
specialized day care programs Conventional & 2nd-gen antipsychotics decrease aggressive & stereotypical patterns of behavior. Also clomipramine, naltrexone, fluoxetiine, carbamazepine. |
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What are the categories of symptoms used to define ADHD?
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1.INATTENTION
*fails to give close attn to details or makes careless mistakes *difficulty sustaining attention in tasks, play *doesn't seem to listen when spoken to directly *doesn't follow through on instructions, fails to finish duties *difficulty organizing tasks & activities *avoids, dislikes, or reluctant to engage in tasks that require sustained mental effort *loses things needed for tasks & activities *easily distracted by extraneous stimuli *forgetful in dailty activities 2.HYPERACTIVITY/IMPULSIVITY *fidgets or squirms in seat *leaves seat when shouldn't *runs or climbs excessively when inappropriate *difficulty playing or engaging in leisure activities quietly *on the go/motor-driven *talks excessively *blurts answers before questions completed *difficulty awaiting turn *interrupts or intrudes on others |
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Long term course & outcome of ADHD?
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50% have good outcome: complete school on schedule w/acceptable grades.
25% develop antisocial personality disorder. More substance abuse, arrests, suicide attempts, car accidents. Less school. Problems w/confidence & self esteem. Persists into young adulthood in 60-70% of cases |
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Medicines used to treat ADHD?
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Psychostimulants:
*1st line: methylphenidate 10-60 mg/day *next try: dextroamphetamine 5-40 mg/day *atomoxetine [alpha-2 agonist] *TCAs *Bupropion |
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Describe the symptoms of conduct disorder.
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aggression to people & animals
destruction of property deceitfulness or theft serious violations of rules |
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What are the prevalence & gender ratio for conduct disorder?
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up to 8% of boys & 3% of girls younger than 18.
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