X - Psych Part 3

Front 1

SEXUAL DISORDERS

- GROUPS

Back 1

1. Sexual dysfunctions
- very common: 43%
a. Desire
b. Arousal
c. Orgasmic
d. Pain

2. Paraphilias
- most irritating to others/society
a. non-human objects
b. impose humiliation/suffering
c. nonconsenting partners

3. Gender Identitiy DIsorders
- rare

Front 2

SEXUAL DYSFUNCTION

- Categories
- disorders
- men vs. women (rates)

Back 2

1. SEXUAL DESIRE DISORDERS
- Hypoactive sexual desire
- Sexual aversion

2. SEXUAL AROUSAL DISORDER
- Male erectile
- Female sexual arousal

3. ORGASMIC DISORDERS
- Female
- Male
- Premature ejaculation

4. Sexual Pain
- Dyspareunia
- Vaginismus

41% of women; 31% of men

Front 3

NORMAL SEXUAL RESPONSE CYCLE

- stages

Back 3

1. Desire/Appetitive Stage
- sexual fantasies; desire

2. Excitement/Arousal

3. Orgasmic:
- muscles in feet spasm
- outer 1/3 of vaginal mm contract
- uterus contracts rhythmically
- same for men @ base of penis
- Highest rate of BP / HR/ Breathing

4. Resolution
- detumescence

Front 4

HYPOACTIVE SEXUAL DESIRE DISORDER


aka low libido

Back 4

1. Persistent/Recurrent deficiency in or absence of sexual fantasies or desier for sex

>1/3 women will meet this at one pt of their lives
(75% of women treated for sexual dysfxn have this)
vs.
5% of men

reasons: stressors, opportunity, etc.

Front 5

SEXUAL AVERSION DISORDER

Back 5

Persistent AVOIDANCE of genital contact

- extreme fear, panic, or disgust

- Can be part of OCD or Depression
- High prevalence of sexual abuse/victimization in hx's of these pts.

Front 6

Treatment of Sexual desire disorders

Back 6

1. Testosterone tx
- inconsistent results (hirsutism)
- "Dual" sex therapy

Front 7

MALE ERECTILE DISORDER
(IMPOTENCE)

- primary vs secondary
- rates

Back 7

PRIMARY:
- NEVER had a sufficient erection
- rare

SECONDARY:
- successful in past, but develops difficulty getting/maintaining an erection

1/4 of men (--> 1 in 9 men)
(50% of men seeking tx for sexual disorders)
- 2 fold increase each decade
(70% of men aged 70-79)

Front 8

male erectile disorder

- rates of physical causes
- psychological causes

Back 8

MCC: Atherosclerosis (40% in men >50 yo)

2. 18% - HTN
3. 16% - Diabetes
4. 5% ischemic <3 dz

PSYCH: Anxiety

DIFFERENTIATE:
- Erections occur upon awakening, with masturbation, or periodically throughout the day
--> psychological factors

SCREEN FOR THESE DISEASES IN EVERY MAN WHO PRESENTS W/ ED

Front 9

male erectile disorder

- tx

Back 9

1. MEDS: increase NO
- relaxes penile smooth mm
- encourages engorgement of spongy tissue
- SE: headache, GI upset, muscle cramps
- Sildenafil, vardenafil, tadalafil

2. VACUUM PUMP DEVICES
- increase blood flow to penis
- need a metal ring to maintain erection

3. Surgery
- penile prosthesis

4. Dual sex Therapy

Front 10

FEMALE SEXUAL AROUSAL DISORDER

Back 10

Failure to attain/maintin lubrication-swelling response
- OR complete lack of excitement or pleasure
- can still retain DESIRE for sexual activity

Can develop "performance anxiety"

Rule out Hormonal problems (low Estrogen = less lubrication)

Assc'd with anorgasmia
Affects 1/3 married women

tx: dual sex tx
- exposure to porn
- meds
- lube
- vacuum pumps
- meds: HRT, natural estrogens (flaxseeds, herbs)

Front 11

MALE AND FEMALE ORGASMIC DISORDER

Back 11

Delay in/Absence of orgasm following a normal excitement stage
- adequate desire & arousal stages

Take into account pt's:
- age
- sexual experience
- amt of sexual stimulation received
(age-related changes)

#1 Complaint of females seeking tx
- 25% of women have trouble orgasming

tx: dual sex tx & masturbation

Front 12

PREMATURE EJACULATION

Back 12

Persistent / recurrent ejaculation with minimal stimulation
- BEFORE the man WANTS to ejaculate

Common; 21% married men
- more common in younger, less experienced men
- decline with age

**NO corresponding disorder in women**

TX:
- Squeeze method: abort ejac.
- SSRIs: delay ejac (via a SE); can decrease libido tho
- Topical anesthetic creams
- Condoms: decrease penile stimulation enough

Front 13

PREMATURE EJACULATION

Back 13

Persistent / recurrent ejaculation with minimal stimulation
- BEFORE the man WANTS to ejaculate

Common; 21% married men
- more common in younger, less experienced men
- decline with age

**NO corresponding disorder in women**

TX:
- Squeeze method: abort ejac.
- SSRIs: delay ejac (via a SE); can decrease libido tho
- Topical anesthetic creams
- Condoms: decrease penile stimulation enough

Front 14

SEXUAL PAIN DISORDERS

- Dyspareunia
- Vaginismus
- TX

Back 14

DYSPAREUNIA:
- Painful sex in maels or females
- NOT solely due to lack of lubrication or vaginismus
- common among women w/ hx pelvic sx

VAGINISMUS:
- involuntary muscle contractions making penile insertion painful

TX:
- DUAL SEX TX
- PSYCHOTHERAPY
- HEGAR DILATORS (gradually enlarge vaginal opening)

Front 15

SEXUAL PAIN DISORDERS

- Dyspareunia
- Vaginismus
- TX

Back 15

DYSPAREUNIA:
- Painful sex in maels or females
- NOT solely due to lack of lubrication or vaginismus
- common among women w/ hx pelvic sx

VAGINISMUS:
- involuntary muscle contractions making penile insertion painful

TX:
- DUAL SEX TX
- PSYCHOTHERAPY
- HEGAR DILATORS (gradually enlarge vaginal opening)

Front 16

DUAL SEX THERAPY

Back 16

INVOLVES BOTH PARTNERS
- addresses psych & physiologic aspects of sex functioning
- focuses on dysfunctional behavior (rather than underlying psychodynamic issues)

HW assignments
- sensate focus assignments: encourage sensory awareness of erogenous zones. Nonsexual, nondemanding touching/massage
Sex is prohibitied during this stage

GOAL: take pressure off intercourse; decrease anxiety
- when pressure is removed, pt is comfortable enough to have sex

Front 17

paraphilias

Back 17

Disturbance in the object or expression of sexual satisfaction

- limits the capacity for RECIPROCAL affectionate sexual activity
- also term used to imply NON-mainstream sex practices
(varies by culture)

HIGH COMORBIDITY PSYCH:
- ANXIETY
- MOOD
- SUBSTANCE ABUSE

DON'T usually seek tx, unless their desires cause them distress or get into LEGAL trouble

Front 18

DUAL SEX THERAPY

Back 18

INVOLVES BOTH PARTNERS
- addresses psych & physiologic aspects of sex functioning
- focuses on dysfunctional behavior (rather than underlying psychodynamic issues)

HW assignments
- sensate focus assignments: encourage sensory awareness of erogenous zones. Nonsexual, nondemanding touching/massage
Sex is prohibitied during this stage

GOAL: take pressure off intercourse; decrease anxiety
- when pressure is removed, pt is comfortable enough to have sex

Front 19

paraphilias

Back 19

Disturbance in the object or expression of sexual satisfaction

- limits the capacity for RECIPROCAL affectionate sexual activity
- also term used to imply NON-mainstream sex practices
(varies by culture)

HIGH COMORBIDITY PSYCH:
- ANXIETY
- MOOD
- SUBSTANCE ABUSE

DON'T usually seek tx, unless their desires cause them distress or get into LEGAL trouble

Front 20

MALE ERECTILE DISORDER
(IMPOTENCE)

- primary vs secondary
- rates

Back 20

PRIMARY:
- NEVER had a sufficient erection
- rare

SECONDARY:
- successful in past, but develops difficulty getting/maintaining an erection

1/4 of men (--> 1 in 9 men)
(50% of men seeking tx for sexual disorders)
- 2 fold increase each decade
(70% of men aged 70-79)

Front 21

male erectile disorder

- rates of physical causes
- psychological causes

Back 21

MCC: Atherosclerosis (40% in men >50 yo)

2. 18% - HTN
3. 16% - Diabetes
4. 5% ischemic <3 dz

PSYCH: Anxiety

DIFFERENTIATE:
- Erections occur upon awakening, with masturbation, or periodically throughout the day
--> psychological factors

SCREEN FOR THESE DISEASES IN EVERY MAN WHO PRESENTS W/ ED

Front 22

male erectile disorder

- tx

Back 22

1. MEDS: increase NO
- relaxes penile smooth mm
- encourages engorgement of spongy tissue
- SE: headache, GI upset, muscle cramps
- Sildenafil, vardenafil, tadalafil

2. VACUUM PUMP DEVICES
- increase blood flow to penis
- need a metal ring to maintain erection

3. Surgery
- penile prosthesis

4. Dual sex Therapy

Front 23

FEMALE SEXUAL AROUSAL DISORDER

Back 23

Failure to attain/maintin lubrication-swelling response
- OR complete lack of excitement or pleasure
- can still retain DESIRE for sexual activity

Can develop "performance anxiety"

Rule out Hormonal problems (low Estrogen = less lubrication)

Assc'd with anorgasmia
Affects 1/3 married women

tx: dual sex tx
- exposure to porn
- meds
- lube
- vacuum pumps
- meds: HRT, natural estrogens (flaxseeds, herbs)

Front 24

MALE AND FEMALE ORGASMIC DISORDER

Back 24

Delay in/Absence of orgasm following a normal excitement stage
- adequate desire & arousal stages

Take into account pt's:
- age
- sexual experience
- amt of sexual stimulation received
(age-related changes)

#1 Complaint of females seeking tx
- 25% of women have trouble orgasming

tx: dual sex tx & masturbation

Front 25

PREMATURE EJACULATION

Back 25

Persistent / recurrent ejaculation with minimal stimulation
- BEFORE the man WANTS to ejaculate

Common; 21% married men
- more common in younger, less experienced men
- decline with age

**NO corresponding disorder in women**

TX:
- Squeeze method: abort ejac.
- SSRIs: delay ejac (via a SE); can decrease libido tho
- Topical anesthetic creams
- Condoms: decrease penile stimulation enough

Front 26

SEXUAL PAIN DISORDERS

- Dyspareunia
- Vaginismus
- TX

Back 26

DYSPAREUNIA:
- Painful sex in maels or females
- NOT solely due to lack of lubrication or vaginismus
- common among women w/ hx pelvic sx

VAGINISMUS:
- involuntary muscle contractions making penile insertion painful

TX:
- DUAL SEX TX
- PSYCHOTHERAPY
- HEGAR DILATORS (gradually enlarge vaginal opening)

Front 27

DUAL SEX THERAPY

Back 27

INVOLVES BOTH PARTNERS
- addresses psych & physiologic aspects of sex functioning
- focuses on dysfunctional behavior (rather than underlying psychodynamic issues)

HW assignments
- sensate focus assignments: encourage sensory awareness of erogenous zones. Nonsexual, nondemanding touching/massage
Sex is prohibitied during this stage

GOAL: take pressure off intercourse; decrease anxiety
- when pressure is removed, pt is comfortable enough to have sex

Front 28

paraphilias

Back 28

Disturbance in the object or expression of sexual satisfaction

- limits the capacity for RECIPROCAL affectionate sexual activity
- also term used to imply NON-mainstream sex practices
(varies by culture)

HIGH COMORBIDITY PSYCH:
- ANXIETY
- MOOD
- SUBSTANCE ABUSE

DON'T usually seek tx, unless their desires cause them distress or get into LEGAL trouble

Front 29

HOW DO PARAPHILIAS GET STARTED?

- Development / reinforcement

**disorder of sexual satisfaction**

Back 29

1. Different backgrounds
A. Inadequate development of consensual adult pattersn
2. Early inappropriate sexual asscs/experience
3. Inadequate developement of adult social skills

--> 2. Inappropriate sexual fantasies repeatedly associated with masturbatory activities
= STRONG REINFORCEMENT

--> 3. Repeated attempts to inhibit undesired arousal & behavior ---> INCREASE in paraphilic thoughts / fantasies / behavior

--> 4. PARAPHILIAS!

Front 30

PARAPHILIAS

- EXHIBITIONISM
- FETISHISM
- FROTTEURISM

Back 30

EXHIBITIONISM:
- Exposure of genitals to unsuspecting strangers
- thrill/risk necessary for arousal

FETISHISM:
- Inanimate objects are PREFERRED or oNLY means of sexual gratification
- usually multiple objects of fetishistic arousal
- related to PARTIALISM
(sexual gratification linked to one particular body part)

Front 31

PARAPHILIAS

- PEDOPHILIA

Back 31

Prepubertal children

Most pedos are MALE
- usually NOT attracted to adult women
- can be female
- most common pedophilia (MC reported anyway)
- Pedos are uncomfortable w/ adult interaction
- engage in morally compensatory behavior (church/volunteer, etc)

**NOT ALL CHILD MOLESTERS ARE PEDOS**
- primary sexual orientation is not nec. to children
- ex// inecestuous offendors
--> lower rates of recidivism & lower numbers of victims
- these people have appropriate (but dysfunctional) relationships w/ peers & can be married
- more likely to respond to behavior interventions (82% recovery rate)

"TRUE" pedophiles
- often require meds
--> decrease sex drive (reduce risk to others)
- also focus on strengthening adult social skills

Front 32

PARAPHILIAS

- sexual masochism vs. sadism

Back 32

MASOCHISM
- SUFFERS pain/humiliation to attain sexual gratification
- pain/humiliation may or may not be sexual

SADISM:
- INFLICTING pain/humiliation to attain sexual gratification

Front 33

PARAPHILIAS

- Transvestic fetishism
- voyeurism

Back 33

Transvestic:
- Arousal w/ act of dressing clothing of opp. sex
- Cross dressing FOR THE PURPOSE OF SEXUAL GRATIFICATION
(vs. those w/ gender identity)

VOYEURISM:
- Observing an unsuspecting individual undressing or naked
- risk of being caught necessary for arousal

Front 34

TREATMENT OF PARAPHILIAS

- behavioral interventions
- child molestoers
- meds

Back 34

very few even seek tx
- usu. due to impact on other parts of their life or cuz they got caught

BEHAVIORAL INTERVENTIONS: target deviant/wrong sexual associations
1. Covert Sensitization: replace fantasies w/ unpleasant images
2. Orgasmic Reconditioning
- encourage appropriate fantasy through repeated masturbation
3. Family/Marital therapy
4. Coping & relapse prevention

CHILD MOLESTORS: 82% RECOVERY RATE
- using behavioral interventions

MEDS:
1. Testosterone-lowering meds
- decrease LH & FSH (work centrally)
- "chemical castration"
- voluntary & involuntary use
2. SSRIs: decrease fantasies & urges (SE: decreased libidO)
- also reduce compulsive tendencies in pts.

Front 35

GENDER IDENTITY DISORDER
(TRANSGENDER; TRANSSEXUAL)

*relatively rare

- onset & course

Back 35

Person is assigned one gender/sex, but IDENTIFIES as belonging to another gender

Gender Dysphoria = key feature
- discomfort in assigned gender

*NOT dx'd in gender non-conforming teens or sexual orientation

ONSET: usually childhood
- gender established ~2-3 yo
- does not HAVE TO correlate w/ gender identity disorder in adulthood
**High correlation with gender identity disorder in childhood & homosexuality**

Front 36

GENDER IDENTITY DISORDER

- Comorbidity
- diff dx

Back 36

COMORBID:
- DEPRESSION (35%)
- SUBSTANCE ABUSE (12%)
- PERSONALITY DISORDERS
- self-mulitation
- separation anxiety in kids
- 46% of absentee fathering

*Suicide rate: 20%

*Also high risk for being victims of hate crimes / violence
(murder rate is 16x national average)

DIFF DX:
- SCHIZO: can be part of systematized delusion
- Transvestic fetishism: these people DON'T have a gender dysphoria

Front 37

GENDER IDENTITY DISORDER

- TX/MANAGEMENT

Back 37

1. Early Intervention is useful
- kids can be isolated & be depressed/anxious
- focus on self-esteem & being happier
- vs. gender reassignment/sexual pref.

2. Acceptance of oneself NOT as male/femal
- pt. is a unique, transgender identity

3. Gender reassignment
- 3 stages: real life experience, hormonal tx, & surgery
- recommened that they're followed by a psychotherapist (not req'd)

Front 38

GENDER REASSIGNMENT SX

- 3 requirements

Back 38

1. Real-life experience
- CHANGE SEX ON DRIVER'S LICENSE
- fucntion at work/school as desired gender
- follow w/ a therapist
- Minimum THREE mos before moving on to hormone tx

2. Hormonal tx:
- androgens to women
- estrogen, prog., testosterone-blockers to men
*must be 18!!*
- must know knowledge of health risk of Hormone tx
- Any co-morbid psych disorder must be stable

3. SURGICAL INTERVENTION
- 12 MO of REAL-LIFE exp.
- 12 MO of hormone tx
- must understand risks/benefits + cost
(risk 2 sexual fxn)

Most pts improve post-sx
- 87% satisfaction for male --> female
- 97% satfisfaction for F --> M
- Suicide rate drops to 0.5%

Front 39

STEROIDS
- CENTRAL EFFECTS ON SEXUAL FXN

- estrogen
- testosterone
- progesterone
- DA / 5HT / NE
- Prolactin
- Oxytocin

Back 39

DESIRE:
- Testosterone, Estrogen, Progesterone, & DA
- Testosterone = initiator & increases estrogen (permissive)
- Progesterone ( receptivity)

3. DA:
- helps out in Desire & Subjective Excitement

4. Subjective Excitement:
- DA, NE = positive
- Prolactin = Neg.

5. Orgasm:
- Oxytocin

Front 40

Erikson's Stages of Development

1. infancy: 0-18 mo.
2. Toddler: 18 mo - 3 yo
3. Early school: 4-7 yo
4. Middle school: 8-11 yo
5. Early Adolescence: 12-14 yo
6. Mid Adolescence: 14-17
7. Late Adolescence: 18-25 yo

Back 40

1. Infancy: Trust vs. distrust
- Age of dependency
- sensory/motor & self/other

2. Toddler: Autonomy vs. shame & doubt
- Age of control
- Pre-operational; "no"; parallel play

3. Early School: Initiative vs. Guilt
- Age of Triad/Oedipal
- Competitive w/ parents & imitative

4. Middle School: Industry v. Inferiority
- Peers & learning
- Sports, concrete opeartions, morality, friendship/fantasy

5. Early Adolescence: parents --> peer group
- Puberty, deductive logic, less dept.

6. Mid-adolescence: Identity vs Role confusion
- anticipate adult roles
- formal logic, sex, intimacy, planning

6. Late Adolescence: Intimacy vs Isolation
- Marriage, career, training
- specialization & selection

Front 41

Problems Usu Evident in EARLY development

Back 41

1. Mental Retardation
- Down's syn
- Fragile X syn
- PKU
- Rubella
- FAS
- Acquired: infxn, trauma, anoxia, etc.

2. Pervasive Developmental Disorders
- Autism
- Rett's Disorder
- Childhood disintegrative disorder
- Asperger's disorder

3. Feeding/Eating disorders
- Pica
- Rumination

4. Reactive Attch Disorder

Front 42

Problems Starting in Middle Childhood

Back 42

1. ADHD

2. Disruptive Behavior Disorders

3. Conduct Disorder

4. Separation Anxiety Disorder

5. Elimination Disorders
- encopresis
- enuresis

6. Tic Disorders
- Tourettes
- Chronic motor / vocal
- Transient

Front 43

PSYCHOLOGICAL DISORDERS IN KIDS

Back 43

1. Mood Disorders
- Depression
- Suicide

2. Schizophrenic & Psychotic Disorders

*Also consequences of sexual & physical abuse & substance abuse*

Front 44

Mental Retardation

- general definitions
- characteristics of mild/moderate/severe/profound

Back 44

SUB-AVERAGE intellectual function
<70 IQ
+
Deficits in 2+
(Communication, self-care, home living, social skills, self-direction, academic skills, health & safety)
DSM IV:
- mILD: 50-70 IQ; 6th grade; self-support w/ social/vocational skills
- Moderate: 35-55; work training; self-maintenance
- Severe: 20-40; partial self-care
- Profound: <25; constant supervision; ltd self-care

Front 45

MENTAL RETARDATION

- EPIDEMIOLOGY
- ETIOLOGY

Back 45

EPIDEMIOLOGY:
- 85% = mild
- 1% general prev
- 1.5: 1 (male: female)

ETIOLOGY:
- Severe MR: 75% cause known
- Mild MR: 50% cause known

1. Down's Syn: MCC; 3 types
- Genetics test & mom's age
2. Fragile X syn: 2nd MCC
- phenotype
3. PKU:
- Early dx important
4. Rubella: MCC maternal infxn --> MR
- earlier in pregnancy = ^ risk
5. FAS
6. Acquired:
- infxn
- head trauma
- anoxia (near drowning)
- long term lead exposure

Front 46

DOWN'S SYNDROME & Mental retardation

Back 46

CAUSES: 3 Chromosome Problems
1. Trisomy 21
2. Nondisjunction postfertilization
- mosaicism of trisomic & normal
3. Translocation/fusion of 21 &15
"extra chromosome 21 material"

STATS:
- one in 700 births
- 1% in moms > 32yo

COURSE:
- normal for 6-12 mo
- Gradual IQ decline from 1 yo
- MAJOR deterioration by 30-40s
- 100% get Alzheimer's & die ~30-40s
- only minority has iQ > 50

Front 47

FRAGILE X SYN & MR

Back 47

MTT on X chromsome @ "fragile site"

TYPICAL PHENOTYPE (VARIES)
- Large, long head & ears
- Short statures
- Hyperextensible joints
- postpubertal macro-orchidism
- Mild-severe retardation

0.1% males
0.05% females (not as bad)

Front 48

PHENYLKETONURIA

Back 48

METABOLIC DEFECT
- can't convert Phe --> Paratyrosine
- Auto Recessive
- 1/10,000 births
- Early dx can eliminate Phe from diet <3 mo & PREVENT MR

Front 49

FETAL ALCOHOL SYNDROME

- clinical
- prev
- at risk for what else?

Back 49

CLINICAL
1. Mental retardation
2. Facial dysmorphism
3. High incidence of learning disorders & ADHD
4. Frequent Heart defects

15% of babies born to alcoholic moms

Also ^ risk:
- ADHD
- Learning disorder
- MR

*can occur w/o any facial dysmoprhism characteristic of FAS

Front 50

OTHER CAUSES OF MENTAL RETARDATION

- GENETIC

Back 50

1. Turner's XO
2. Prader-Willi : Chrom 15 del
3. Rett's Disorder: X-linked dom
4. Lesch-Nyhan syn: X-linked
- deficient purine metabolism
5. Cri-du-chat Syn: Chrom 5 del

Front 51

PSYCH COMORBITIDY IN KIDS W/ MR

- prev
- psych symptoms not a separate disorder

Back 51

PREV:
1/3 - 2/3 of kids w/ MR have comorbid psych issue

NOT a separate disorder (maybe):
- Hyperactive
- Short attention span
- Self-injurious
- Repetitive stereotypical behaviors

Front 52

MENTAL RETARDATION

TX

Back 52

TX: Increase functional capacity

1. Special education
2. Bevhior therapy - shape appropriate behaviors
3. Family education
4. Psychotherapy: help w/ attitudes/conflicts in pt & family
5. Meds
- Mood stabilizer: self-injurious
- Beta-blockers/Buspirone: Explosive rage
- Methylphenidate: ADHD

Front 53

AUTISTIC DISORDER

- CLINICAL FEATURES

Back 53

Impaired SOCIAL interaction
- Impaired use & interpretation of NONverbal social cues
- Impaired imitation
- Can't make friends w/ peers
- Don't seek comfort when distressed

IMPAIRED COMMUNICATION & IMAGINATION
- Weird nonverbal comm
- Fails to initiation or modulate social interaction
- No imagination
- Weird speech, content, & modulation
- Irrelevant remarks
- Can't start/sustain conversation w/ others

RESTRICTED REPERTOIR OF ACTIVITIES
- Stereotypes body moves
- Preoccupation w/ parts of objects
- Unreasonable routines
- Distress over trivial environment changes
- Insistence on precise routines
- Restricted range/preoccupation of interest

Front 54

AUTISM

- EPIDEMIOLOGY

Back 54

MILDER FORMS ON THE RISE
273% increase in autistic pts wanting services 1987-1998
- Other subtypes rose 41%

Milder = better rehab potential

Male: Female = 3-5:1

Front 55

AUTISM:

- ETIOLOGY
- TX

Back 55

BIOLOGIC ABNORMALITY DURING BRAIN DEVELOPMENT OT AT BIRTH

1. Genetics
- 50x greater in 1st degree relative
- Identical twins have 3x higher prev than dizygotic twins

2. Neurologic Abnormalities
- Congenital rubella
- PKU
- Tuberous sclerosis
- Rett's disorder

3. PHYSICAL (abnl dev)
- ^ rate of minor congenital physical anomalies
- High rate of grand mal seizures
- Ventricular enlargement

4. > normal Perinatal Complications

TX:
1. Structured classroom training
2. Behavior modification
3. Parent training: structured home programs
4. MEDS:
- SSRIs & atypical neuroleptics (specific symptom tx)

Front 56

RETT'S DISORDER

- definition

**mostly females**

Back 56

1. Apparently normal prenatal & perinatal dev
2. Apparently normal psychomotor dev 1-5mo
3. Normal head circumference @ birth

ONSET AFTER NL DEV:
1. Deceleration of head growth bw 5-58 mo
2. Loss of previously acquired purposeful hand movement
- hand-wrigning or washing
3. Loss of social engagement early in the course
4. Poorly coordinated gait or trunk movements
5. Severely impaired expressive & receptive language dev
6. SEVERE psychomotor retardation

Front 57

CHILDHOOD DISINTEGRATIVE DISORDER

**normal for at least ____ yrs***

Back 57

Apparently normal dev for at least first 2 years
- age appropriate verbal/nonverbal comm
- social relatipnships
- play & adaptive behavior

Clinical significant loss of previously acquired skills BEFORE 10 YO
- Expressive/receptive lang
- Social skills / adaptive behavior
- Bowel or bladder control
- Play
- Motor

Abnormal functioning in 2+:
- Social interaction/nonverbal behaviors, peer relationships, social reciprocitiy
- Communication (delay, initiate/sustain, sterotype, repetitive, no imagination)
- Restricted, reptitive stereotyped behaviors

Front 58

ASPERGER'S DISORDER

- DEFINITION
- DIFF FROM AUTISM

Back 58

IMPAIRED SOCIAL INTERACTION
- Nonverbal behaviors suck
- Peer friendship fail
- No spontaneity
- No social/emotional reciprocity
- Restricted repetitive behaviors/interests
- Preoccupation w/ restricted patterns & adherence to them
- Sterotyped motor mannerism
- Preoccupied w/ parts of objects

DIFF FROM AUTISM:
NO DELAY IN EARLY LANG DEV
- NO DELAY IN COG DEV
- NO DELAY in age-level slef help skill
- curious abt environment

Front 59

PICA

- CLINICAL
- ETIOLOGY
- COMPLICATIONS

Back 59

Eating NON-NUTRITIVE crap for at LEAST ONE MONTH

Complications
- lead poison, intestinal parasites, zinc def (clay), iron def (starch), intestinal obstruction

ETIOLOGY: UNKNOWN!
- Genetics
- Nutritional deficiencies
- Parental neglect/deprivation
- Cultural practices (occasional eating): r/o

Front 60

PICA
- EPIDEMIOLOGY
- COURSE

Back 60

EPIDEM:
- 10-30% of kids 1-3 yo
- 25% of MR'd institutionalized kids
- equal men:female

course:
- onset: 12-24 mo usually
- Incidence declines w/ age; usually remits w/ adolescence

Front 61

RUMINATION DISORDER

- CLINICAL
- EPIDEM

Back 61

1. FUNCTION NORMALLY for a while
2. REGURGITATE & RECHEW food
- no nausea, retching, or associated GI diosrder
- gives SATISFACTION
- kid reswallows it or spits it out

EPIDEM:
MOSTLY: 3mo-1yo
MORE: MR'd kids
CO-EXIST w/ other eating disorders (bulimia)

Front 62

REACTIVE ATTACHEMENT DISORDER

- CLINICAL
- CAUSE
- ASSC'D FINDINGS

COURSE: Variable; longer in bad environment = worse prognosis

Back 62

Major distrubed & inappropriate social-relatednes in most contexts
- RELATED TO PATHOLOGICAL NEGLECT

BEFORE 5 YO - 2 POSS PATTERNS
1. Persistent failure to initiate/repsond to most social interactions
- not interested
2. OVERLY friendly
- strangers

CAUSE:
- Grossly pathogenic care
- disregard for kid's basic emotional & physical needs
- Repeated changes of primary caregiver prevented stable attchs

ASSC'D FINDINGS:
- FTT (non-organic)
- Malnutrition & dehydration (neglect)

*Social weirdness is Not solely due to MR & kid doesn't meet criteria for pervasive dev. disorder

Front 63

ATTENTION DEFICIT HYPERACTIVITY DISORDER

- definition

Back 63

Poor attention span, hyperactivity & impulsivity, or BOTH
- at least 6 months
- severe enough to impair academic/social functioning
- PRIOR to age 7

Symptoms:
1. INATTENTION
2. HYPERACTIVE
3. IMPULSIVE

Front 64

ADHD

- TESTING/DX
- EPIDEMIOLOGY

Back 64

1. Behavior rating scales
- child behavior checklist vs. rating scale

2. PSYCH testing
- continuous performance task
- general psych tests of intellience, personality, and education can assess kid's full range of abilities & difficulties

EPIDEM:
3-5% of prepubertal elem. kids
boys:girls = 3-5:1
- girls are less hyperactive & have more learning problems

Front 65

ADHD

- ETIOLOGY
- COURSE/PROGNOSIS

Back 65

1. GENETICS
- higher in monozygotes
- siblings have 2x higher risk
- Parents have higher rates
(also higher rates of Antisocial, Alcohol use, Conversion Disorder)**

2. Brain/Neuro Problems
- Mild neurologic abnl
- Brain morphology is actually NOT abnl (CT studies)
- PET: decreased Cerebral BF & decreased metabolic rates in FRONTAL LOBES
= disinhibition of subcortical brain areas

3. PSYCHOSOCIAL: unclear
- in emotionally deprived kids, symptoms go away when placed in good home

Front 66

ADHD

- TX

Back 66

BOTH MEDS & THERAPY

4 TYPES OF MEDS:
1. CNS STIMULANTS
- Dextroamphetamine
- Methylphenidate (ritalin)
- pemoline (cylert)

2. NE Reuptake Inhibitors (Strattera)

3. Tricyclic antidepressants

4. Clonidine (alpha-agonist)

PSYCHOTHERAPY:
- Individual
- Behavior modifcation
- parent counseling
- tx of coexisting learning disorder

Front 67

ADHD

- COURSE/PROGNOSIS

Back 67

COURSE: very variable
1st to remit: Overactivity
Last 2 remit: Distractibility
Remission: 12-20 yo
- most = partial remission

PERSISTENT ADHD SYMPTOMS
INCREASED RISK:
1. conduct disorder
2. antisocial personality disorder
3. substance use
4. mood disorder

*outcome of ADHD in kids is super related to amt of persistent conduct disorder additionally present in kid
& degree of chaos in family functioning

Front 68

CNS STIMULANTS

DEXTROAMPHETAMINE (DEXEDRINE)
METHYLPHENIDATE (RITALIN)
PEMOLINE (CYLERT)

- GOOD
- SE'S
- MECHANISM

Back 68

MECHANISM IS UNKNOWN

USE: ADHD
- Decrease distractibility, impulsiveness, explosiveness, irritability
- Increased ability to focus & academic performance

SIDE EFFECTS:
- Headahces, stomach, nausea
- insomnia
- can worsen a tic disorder

Front 69

strattera / atomoxetine

NOREPINEPHRINE REUPTAKE INHIBITOR

Back 69

GOOD:
- NONSTIMULANT TX TO ADHD

SIDE EFFECTS:
- INCREASED BP, HR,
- Anorexia, wt loss
- nausea, somnolence
- skin rash
- weird ECG
- BP/HR changes are similar to those of ritalin/methylphenidate

METABOLISM
- Cytochrome P450
- at least 1 metabolite is active

Front 70

TRICYCLIC ANTIDEPRESSANTS & ADHD

Back 70

- CNS stimulants are better for hyperactivity

Use in kids w/ comorbid anxiety or depressive disorder

*SUDDEN DEATH reported in ADHD pts tx'd with DESIPRAMINE
- watch CARDIAC fxn closely

Front 71

OPPOSITIONAL DEFIANT DISORDER

general & symptoms

Back 71

General:
>6 mo
Pattern of negative, hostile, defiant behavior
- NO serious violations of social norms or rights of others

Symptoms:
- short temper, argues w/ adults, defiant, deliberately annoying, blames, angry/resentful, spiteful, vindictive

Front 72

OPPOSITIONAL DEFIANT DISORDER

- epidem & COURSE

Back 72

EPIDEM:
Onset: ~8yo
Pre-puberty: more males; equal after puberty

Other disorders ^ Risk:
- Antisocial personality
- Substance abuse

COURSE/PROG:
- 25% spontaneously remit w/in years
- Remaining --> conduct disorder

POORER PORG
- Presence of other behavioral or psych disorders in the kid
- Degree of psychopathology in other family members

Front 73

CONDUCT DISORDER

- CLINICAL FEATURES
- types

Back 73

> 6 mo
Violates basic rights of others and/or major societal norms/rules

Specific symptoms:
1. AGGRESSION to people or animals
- uses weapons; starts fights
- physical curelty
- rape; stealing

2. DESTRUCTION OF PROPERTY
- Breaking & entering
- cons others; steals

3. SERIOUS VIOLATIONS OF RULES
- breaks curfew
- runs away overnite >2x
- often truant

TYPES:
- CHILDHOOD ONSET: <10 yo; at least 1 symptom
- Adolescent onset: NO symptoms <10 yo

Front 74

CONDUCT DISORDER

- EPIDEM
- ETIOLOGY
- COURSE
- HIGHE RRISK OF ?

Back 74

EPIDEM
Boys: 6-16%; Girls: 2-9%
Boy:Girl = 4-12:1
- more common w/ parents w/ ASPD & alcohol dep

ETIOLOGY:
1. pARENTAL FACTORS:
- home strife, abuse, neglect
- psych disorders in parents
2. Neurobio: not well studied

POOR PROG:
- Earlier age of onset
- greater # of behaviors
- greater freq of engaging in behaviors
- present of other behavioral problems in kid

AT HIGHER RISK:
- ASPD
- MOOD
- SUBSTANCE ABUSE

Front 75

CONDUCT DISORDER TX

Back 75

1. Placement in stable environment w/ firm rules
2. Behavioral tx techaniques
3. Individual psychotherapy
- improve problem-solving skills
4. MEDS
- antipsychotics
- lithium
- carbamazepine
- clonidine

Front 76

SEPARATION ANXIETY DISORDER

MC ANXIETY DISORDER OF CHILDHOOD
- also see social phobia & GAD

- CLINICAL
- EPIDEM

Back 76

Inappropriate & excessive anxiety abt separation from home/people

3+ symptoms (obvious)

epidem:
3-4% schoolkids
equal gender ratio
- external life stresses coincide w/ dev of disorder

Front 77

SEPARATION ANXIETY DISORDER

- COURSE/PROGNOSIS
- TX

Back 77

BETTER PROG:
Younger age of onset
shorter duration of symptoms
NO comorbid anxiety/depression

**Depression & SAD overlap a lot
- kids are more likely to get anxiety disorder in adulthood

TX:
- FAMILY TX
- COGNITIVE TX & relaxation exercises
- Gradual return to school
- Tricyclic antidepressants

Front 78

CONDUCT DISORDER

- CLINICAL FEATURES
- types

Back 78

> 6 mo
Violates basic rights of others and/or major societal norms/rules

Specific symptoms:
1. AGGRESSION to people or animals
- uses weapons; starts fights
- physical curelty
- rape; stealing

2. DESTRUCTION OF PROPERTY
- Breaking & entering
- cons others; steals

3. SERIOUS VIOLATIONS OF RULES
- breaks curfew
- runs away overnite >2x
- often truant

TYPES:
- CHILDHOOD ONSET: <10 yo; at least 1 symptom
- Adolescent onset: NO symptoms <10 yo

Front 79

CONDUCT DISORDER

- EPIDEM
- ETIOLOGY
- COURSE
- HIGHE RRISK OF ?

Back 79

EPIDEM
Boys: 6-16%; Girls: 2-9%
Boy:Girl = 4-12:1
- more common w/ parents w/ ASPD & alcohol dep

ETIOLOGY:
1. pARENTAL FACTORS:
- home strife, abuse, neglect
- psych disorders in parents
2. Neurobio: not well studied

POOR PROG:
- Earlier age of onset
- greater # of behaviors
- greater freq of engaging in behaviors
- present of other behavioral problems in kid

AT HIGHER RISK:
- ASPD
- MOOD
- SUBSTANCE ABUSE

Front 80

CONDUCT DISORDER TX

Back 80

1. Placement in stable environment w/ firm rules
2. Behavioral tx techaniques
3. Individual psychotherapy
- improve problem-solving skills
4. MEDS
- antipsychotics
- lithium
- carbamazepine
- clonidine

Front 81

SEPARATION ANXIETY DISORDER

MC ANXIETY DISORDER OF CHILDHOOD
- also see social phobia & GAD

- CLINICAL
- EPIDEM

Back 81

Inappropriate & excessive anxiety abt separation from home/people

3+ symptoms (obvious)

epidem:
3-4% schoolkids
equal gender ratio
- external life stresses coincide w/ dev of disorder

Front 82

SEPARATION ANXIETY DISORDER

- COURSE/PROGNOSIS
- TX

Back 82

BETTER PROG:
Younger age of onset
shorter duration of symptoms
NO comorbid anxiety/depression

**Depression & SAD overlap a lot
- kids are more likely to get anxiety disorder in adulthood

TX:
- FAMILY TX
- COGNITIVE TX & relaxation exercises
- Gradual return to school
- Tricyclic antidepressants

Front 83

ENCOPRESIS

Back 83

> 4 YO
Feces is passed into inappropriate places on a regular bases

TYPES:
1. Constipation + overflow incontinence
- chronic rectal distention & overflow encopresis
- high rates of abnl anal sphincter contractions

2. Without constipation & overflow incontinence
- intentionally engage in eccoprotic activity
- have OTHER psych issues

Front 84

ENURESIS

- what?
- types
- epidem
- ddx
- tx

Back 84

>5 YO
Repeated voiding of urine into the bed/clothes

THREE TYPES:
1. Nocturnal only
2. diurnal only
3. BOTH

EPIDEM:
- declines from approx 7% of 5 yo --> 1% adolescents/adults

DDX:
- GU problem
- Diabetes
- Seizures
- SEs from meds

High rate of spontaneous remission
TX:
- Toilet training (if pt never achieved urinary continence)
- Behavior therapy
- Meds: tricyclic antidepressants (severe cases)

Front 85

TIC DISORDERS

- characteristics
- classification
- epidem
- course

Back 85

CHARACTERISTICS
- Frequent
- ONSET: ~7yo; <15 yo (99%)
- Changes over time
(frequent, intensity, severity, site, nature of tics)

CLASSIFICATION:
- Tourett's: multiple motor & 1+
vocal tics
(4-5/10,000)
- Chronic motor or vocal tic
- Trnasient motor or vocal tic (<1 yr duration)

aNY TIC DISORDER: 4-20% prevalence

course: varies a lot
Complete Remission: 24-61%
(8% of tourette's disorders)
- Usually, severity decreases w/ age (unless they persist into adulthood)

Front 86

DEFINE TIC

- simple/complex motor tics
- simple/complex vocal tics

*corpropraxia & corprolalia

Back 86

MOTOR movement or Vocalization

- involuntary
- sudden, rapid, brief, ejaculatory
- recurrent, repetitive
- non-rhythmic (irregular intervals)
- PURPOSELESS
- Irresistible, but acutally can be suppressed for varying periods

Front 87

TICS & OCD

- COMORBID
- GENETIC
- CHEMICAL

Back 87

Unwanted behaviors; urgency to complete; relief when done

COMORBID
Severe OCD: 20% MOTOR TICS
Tics: 40% also have some OCD stympoms
50% Tourett's also have ADHD

GENETIC
- First degree relatives of Tourette's = ^ OCD risk
(even if pt has NO OCD symptoms)

NEUROANATOMIC SUBSTRATES:
- BASAL GANGLIA lesions = TICS
- drugs affect here
- hYPERMETABOLISM in BG, frontal & temporal regions

Front 88

MEDICAL DISORDERS & EMOTIONAL DISTRUBANCE IN KIDS

- PSYCH PROBLEMS

Back 88

1. DIABETES
2. ASTHMA
3. JUVENILE RA
4. SICKLE-CELL ANEMIA
5. SEIZURE DISORDER

- family issues
- siblings more likely to get psych tx than pt is
- divorce
- pt is overprotected or neglected

Front 89

SCHIZOPHRENIA & PSYCHOTIC DISORDERS IN KIDS

- dx
- epidem
- tx

Back 89

Same symptoms as adults
- Hallucinations most frequently reported (80%): not always diagnostic
- delusions are less frequent (if so - persecutory & somatic)

Men:female = 2.7:1
MC in Lower SES & low IQ

TX:
SAME AS ADULTS
- harder to tx tho
- varied reponse to tx

Front 90

MOOD DISORDERS IN KIDS

DEPRESSION

*under-dx'd in kids*
2' theories on personality structure

Back 90

DEPRESSION
- similar to adults

Behavioral symptoms
- miss school
- less energy
- low grades

MOOD SYMPTOMS:
- sad/unhappy
- angry, defiant, irritable
- stomach ache, headache
- hopeless, helpless, irritable

*kids don't use language to communicate until ~ 7 yo

Family hx usually + mood disorder

MANIA LOOKS LIKE ADHD

Front 91

ADOLESCENT SUICIDE

- STATS
- REASONS
- METHODS

Back 91

STATS:
#3 MCC death amont teens
^ 4x since 1958
- only 12 % of attempts get medical attn
- many who attempt sought help in previous month

REASONS:
- Increased depression rates
- alcohol abuse
- availability of firearms
- increased divorce/broken families
- increased moving
- decreased religious faith

METHODS: FIREARMS ^^^

Front 92

ADOLESCENT SUICIDE RISK FACTORS

suicidality:
- increased talk of death
- withdrawal from pleasurable activities
- social isolation
- giving away treasured possessions

Back 92

1. Social/personality
- academic difficulty
- antisocial
- perfectionist/explosive

2. Psychiatric
- Depression: 70%
- Substance Abuse: 30%
- Prior Attempts: 50%

3. Precipitatns
- Disciplinary/legal crisis
- Interpersonal loss/conflict
- exposure to suicide
- accum of stressors
- acute intoxication

4. PSYCH
- hostile
- hopeless
- poor social skills
- poor school performance
- impulsive

Front 93

PSYCHOLOGICAL RESPONSES & CONSEQUENCES TO SEXUAL & PHYSICAL ABUSE

Back 93

1. Denial
2. Alter the affective response
3. Change the meaning of abuse
- it didn't matter
4. Reframe the abuse
- "my fault"

**most likely assume the blame for it
- Gross inequality of power bw/ adult & child
- Children want to experience parents' actions as loving

*Victims are at increased risk for subsequently becoming abusers/ marrying abusers

Front 94

SUBSTANCE BAUSE & KIDS

- gateway drugs
- comorbidity
- assessment
- tx

Back 94

CIGS & CAFFEINE = GATEWAY
--> marijuana

Kids who develop substance abuse problems started partaking ~ 1 yr before non-abusing peers
10-13 vs. 11-14yo

COMORBID: 2+ others
- ADHD
- DEPRESSION (esp girls)
- ODD
- CONDUCT

ASSESSMENT
- ask specific questions to det abuse & minor experimenting
- Family hx of abuse or mood disorder
- assess for comorbid issues

TX:
- EDUCATION of consequences/effects
- group therapy
- focus on fxn/effect/use
- dev alternate coping skills
- dev independcne & peer groups
- TWELVE STEPS

Front 95

What are the critical variables affected response to trauma?

Back 95

1. How old was the pt when it occurred?
2. Was it a single incident, or REPEATED incident?
3. COPING SKILLS of pt (can be age-dependent).
4. Social SUPPORT
5. Adequate time to adjust post-trauma.

Front 96

What are the components in a pt response to a single traumatic event? Multiple events?

Back 96

Single: avoidance symptoms, relive the experience, increased arousal, tries to repeat or re-enact the event, changes attitudes, development of specific fears, and grief.

Multiple: same as above but also with SEVERE AVOIDANCE, AMNESIA (large blocks of time), INABILITY TO FEEL, DISSOCIATION, and RAGE.
(more extreme in general)

Both: Chemical dependency & depressive disorders.

Front 97

Stress/Trauma disorders

Back 97

1. Acute Stress
2. Adjustment disorders
3. Breif psychotic disorder
4. PTSD
5. Trauma-specific phobias
6. Pathologic grief
7. Dissociative disorders

*Repeat trauma can make pts developt Cluster B personality disorders (The wild) or somatoform disorders

Front 98

What is the difference b/w acute stress disorder and a normal stress reaction?

Back 98

Both experience a variety of upsetting emotions as well as preoccupation with thinking about the trauma (may actually try and re-enact the trauma).

HOWEVER, Acute Stress Disorder symptoms IMPAIR THE LIFE OF THE PATIENT MORE and LAST FOR MORE THAN 2 DAYS (up to 4 weeks --> longer becomes PTSD)

Front 99

What is the difference b/w acute stress disorder and PTSD?

Back 99

Symptoms are similar, BUT ACUTE STRESS DISORDER RESOLVES W/IN 4 WEEKS while PTSD lasts longer.

Front 100

What is dissociation?

- why do kids use it more than adults?

Back 100

A capacity to suspend the normal sense of connectedness with one's IDENTITY, BODY ("out of body experience"), past MEMORIES, the CURRENT SITUATION, or the usual FLOW OF TIME.

KIDS:
- They have LESS WELL-DEVELOPED "normal" defenses.
- Seen most often in 6-12 year olds, when the capacity to dissociate is greatest.

Front 101

What is the purpose served by dissociation in the face of trauma?


**people vary in their capacity to dissociate**
(only 12% people are highly hypnotizable)

Back 101

TO ESCAPE from an overwhelming situation. This is a somewhat immature defense mechanism to allow us to MANAGE AND CONTROL the emotions that situations can elicit.


*mental control is SO important when physical control is lost*

Front 102

What are some examples of dissociative symptoms?

Back 102

- Amnesia (typically the traumatic event is lost)
- Depersonalization (feeling detached from a situation or one's own body)
- Derealization (feeling that there is something "off" about the world)
- Anesthesia (numb to physical/emotional pain)
- Distorted Sense of Time (usually slowed)
- Reduced Awareness ("dazed")

Front 103

What are the avoidance symptoms associated with PTSD?

Back 103

- avoid the MEMORIES (can be amnesia or an actual attempt on the pts part to avoid situations or thoughts that remind them of the trauma)

- avoid CONTACT with others / Deep feelings (diminished interest in activities, cannot feel deep emotions, seeks interpersonal distance or estrangement).

- avoid "DANGER" (crowds, anger-provoking situations).

- avoid COPING (instead experience escapism through drugs/alcohol, thrill-seeking, and excessive work).

Front 104

PTSD

- MAIN 3 CATEGORIES OF SYMPTOMS

Back 104

1. RE-EXPERIENCE THE TRAUMA

2. Hyper arousal: living as if in constant danger

3. Avoid danger & distress

Front 105

What seems to underlie the re-enactments and repetitions associated with PTSD?

(re-experiencing symptoms)

Back 105

RE-WORK THE TRAUMA: Typically occurring after a SINGLE TRAUMA, re-enactments are a way for pts to see how the situation could have been avoided or how they could have acted in a better way.

- symptoms come when relaxing or encountering a "trigger"
- symptoms are unwanted & unbidden; INTRUSIVE, and distressing

Front 106

What is the difference b/w flashback sensory phenomena and hallucinations common to psychotic disorders?

Back 106

Flashbacks for PTSD pts will only have TRAUMA-SPECIFIC MATERIAL.

Front 107

What are the arousal symptoms associated with PTSD?

Back 107

HYPER-VIGILANCE (increased ANS activity), increased STARTLE response, marked ANS RESPONSE when experiencing trauma-like situation, irritability and angry outbursts, difficulty with SLEEP and CONCENTRATION.

Front 108

What are the risk factors for developing PSTD?

Back 108

- Reduced HIPPOCAMPAL VOLUME
- Severity of the Trauma (increased severity = increased risk of PTSD)
- Pre-Existing Personality Problems
- Past Trauma
- Younger
- Going Through the Trauma Alone
- No Time to Process or Adjust After the Trauma
- Less Social Support

Front 109

COURSE OF PTSD

- onset
- exacerbating factors

Back 109

Onset: can be delayed for years

COURSE: OFTEN CHRONIC; symptoms wax & wane

Exacerbate:

- Other Stresses
- DEPRESSION
- ANNIVERSARY of TRAUMATIC EVENT
- TRIGGERING STIMULI

Front 110

What are the ANS findings of PTSD pts?

Back 110

OVERACTIVITY IS THE HALLMARK OF PTSD.
- The response is specific, only a trigger that is reminiscent of their trauma will result in a response.

- also persistent: remains for years; likely permanent in severe cases

**Elevated levels of NE at baseline AND with exposure 2 stimuli*

Front 111

What are the gluccocorticoid findings of PTSD pts?

Back 111

Glucocorticoid-R HYPERsensitivity
= LOW cortisol levels
(opposite findings in MDD)

Hyper-Positive Dexamethosone test indicates that PTSD pts are super sensitive to gluccocorticoid levels. Scientists think that this phenomenon is due to the fact that PTSD pts have significantly HIGHER NUMBERS of glucocorticoid receptors, and this may lead to down-regulation of cortisol layers overall (body can respond to lower levels of cortisol, so will not produce more than it needs).

*Test shows an EXAGGERATED response to exogenous steroids*

Front 112

What are the MRI findings of PTSD pts?

**abnormal circuit

Back 112

REDUCED HIPPOCAMPAL VOLUME appears to be a predisposing factor for the development of PTSD.

**Hippocampus & medial PFC normally regulate amygdala's response to stimlui
- amygdala is HYPER responsive w/o inhib from hippo

Front 113

Why does group therapy help PTSD pts?


- other tx's?

Back 113

MOST POWERFUL THERAPY FOR PTSD PTS

- Learn you are not crazy, alone, or different.
- Receive and give support.
- Begins resocialization process.
- Confronts maladaptive thought, attitude, and behavioral responses.

CAN EVEN PREVENT THE DEVELOPMENT OF PTSD PTS IF INSTITUTED CLOSE ENOUGH TO THE TRAUMA.


-tx for PTSD = psychotherapy & meds (antidepressants & mood stabilizers)

Front 114

What is the difference b/w normal and pathologic grief?

Back 114

They both look similar (self-blame, worthlessness, apathy, hyponchondriasis, numbness, irritability, sadness, dysphoria).

However, PATHOLOGIC GRIEF PERSISTS LONGER THAN 6-8 MONTH
- Pts DEFINITELY DEVELOP MAJOR DEPRESSIVE DISORDER (occasionally will develop bizarre behaviors too).

Front 115

What are the risk factors for developing pathologic grief?

Back 115

- Pt had ambivalent (positive and negative) feelings towards the deceased.
- Death was unexpected and "UNFAIR."
- The person has POOR SOCIAL SUPPORT after the death.
- There are MULTIPLE NEGATIVE CONSEQUENCES (social, financial, etc.) due to the death.

Front 116

WHAT ARE THE DISSOCIATIVE DISORDERS?

Back 116

1. Dissociative amnesia
2. Dissociative fugue
3. Depersonalization disorder
4. Dissociative identity disorder

**time period & severity**

Front 117

How does adaptive use of dissociation progress to chronic maladaptive use?

Back 117

The more one uses dissociation as a defense mechanism, the more one may become adept at using dissociation, thus, they may use it to cope with even less stressful events.

Persistant of dissociation is extremely maladaptive and dissociative identity disorder is its most extreme manifestation (super rare).

Front 118

What are the essential features of dissociative identity disorder (used to be called multiple personality disorder)?

Back 118

- Existence of 2 or more DISTINCT PERSONALITIES or PERSONALITY STATES w/in a pt.

- At least 2 of the personalities TAKE CONTROL OF THE PTS BEHAVIOR AT ONE POINT.

Front 119

What is the definition of "alters?"


*alters can be fully or partially developed and change over time*

Back 119

Alter = Alternate Personality
or
"discrete state of consciousness with its own memories, behaviors, mental contents, roles, sense of identity, thoughts, and actions."

**psychologicla structures; not separate people*

Front 120

What is the origin of the symptom of "time loss" seen in pts with dissociative identity disorder?

Back 120

"Time loss" occurs when another alter takes over (many alters experience these amnestic periods so it is not just confined to the original personality).

*66% hear voices (hallucinations) of other alters orr PTSD flashbacks
- 80% know it's from their own head

Front 121

What is the core problem occurring in people with dissociative identity disorder?

Back 121

The core of the problem is the EXCESSIVE MALADAPTIVE USE OF DISSOCIATION to create or maintain new personalities as a means to cope with stress.

Front 122

What is the most frequent cause of dissociative identity disorder?

Back 122

Usually originates in CHILDHOOD TRAUMA, when the child does not have mature defense mechanisms and may use dissociation too frequently to escape the trauma.

Front 123

What is the gender that is at risk for dissociative identity disorder?

Back 123

Probably female because they have an approximate 10:1 rate of being sexually abused and child abuse is the trigger for this disorder.

Plus, Cybil was a girl :0).

Front 124

What are the essential features of dissociative amnesia?

Back 124

- An INABILITY TO RECALL IMPORTANT INFORMATION about onself.

- "Lost" material is usually TRAUMATIC or STRESSFUL.

- RETROGRADE memories are usually lost, anterograde memories are usually intact.

Front 125

What is the usual precipitant of dissociative amnesia?
- course?

Back 125

Usually begins ABRUPTLY FOLLOWING SEVERE PSYCHOLOGICAL DISTRESS.


GOOD PROGNOSIS: Termination is also usually abrupt with full recovery of memories and rare recurrence.

Front 126

How does one distinguish dissociative amnesia from other disorders?

- diff dx

Back 126

Dementia - loss of memory is gradual.
Blackouts from Intoxication - memories not recovered.
Amnestic Disorder - deficit is in learning new memories primarily.
Post Concussion Amnesia - Hx of trauma.
Transient Global Ischemia - Loss of recent memories + 6-24 hours of anterograde memories.
Malingering - does not display consistent findings of any memory impairment, hard to Dx.

Front 127

What are the essential features of dissociative fugue?

Back 127

- SUDDEN unexpected TRAVEL from home or work.

- IDENTITY CONFUSION

- INABILITY to RECALL ONE'S PAST.

Front 128

What is the usual precipitant of dissociative fugue?

and course?

Back 128

SEVERE PSYCHOSOCIAL STRESS OR CONFLICTS.

Good Prognosis: rapid recovery, rare recurrences, though pt will not remember the period of fugue.

**Usually unaware of amnesia during fugue AND unaware of fugue state when terminated

Front 129

What is the essential feature of depersonalization disorder?


inception? =)

Back 129

Distressing & PERSISTENT feelings that ONE's OWN REALITY HAS BEEN LOST OR CHANGED. Pts feel like they are simply observing one's own body or mental processes (as if they are a robot or in a dream).

*NOT a delusion; pts knows sensation is not real

Front 130

What is the difference b/w normal depersonalization experiences and the disorder?

Back 130

Disorder is diagnosed only if the depersonalization episodes are PERSISTENT, RECURRING, and DISTRESSING.

Front 131

What is the usual course of depersonalization disorder?

Back 131

Course is generally CHRONIC WITH REMISSIONS interspersed. Exacerbations occur in the context of anxiety or depression.

Front 132

What are the types of problems seen in survivors of repetitive abuse?


* see common behavioral patterns*

Back 132

Note: not all abused exhibit these features and not all pts that exhibit these features have been abused.

- Depressive disorders (high prevalence)
- Chemical dependency (pseudo "self-medication")
- PTSD (quite common)
- Self-Abusive Behavior (40% - 70% of repetitively abused attempted suicide)
- Self-Mutilation

Front 133

What are the motivations for self-mutilation?

Back 133

- Punishes oneself for perceived wrongs.
- To feel something (pts often feel empty or numb)
- To relieve tension and anxiety.

Front 134

What are some reasons why victims may become re-victimized?

Back 134

Victims often enter into relationships that RECREATE THE CHILD ABUSE (ex. 55% - 90% of prostitutes are victims of childhood sexual abuse).



- May be an unconscious attempt at trying to relive the trauma so that the pt can make it "come out right" or so that the pt can "gain mastery over the situation this time."

Front 135

What are some reasons why victims may utilize erotization or somatization?

Back 135

Erotization (abused kids can show precocious sexual behavior)
- May know few other ways of approaching relationships.
- TURNS THE SITUATION AROUND (now the victim is in control and is the person who can deliver the hurt).

Somatization
- Easier to focus on physical problems and complaints than emotional ones.
- Some symptoms actually re-enact the abuse ("somatic memories" like pelvic pain w/ no evidence of damage in previously abused women).

Front 136

What are the factors contributing to impaired relationships and poor parenting in survivors of repeated child abuse?

Back 136

- Difficulty TRUSTING
- DETACHED
- Rage, HOSTILITY
- SEXUAL difficulties
- No models of healthy parenting or relationships.
- Poor ability to deal with stresses (parental included).

Front 137

Why can victims of child abuse become perpetrators themselves?

Back 137

Note: the VAST MAJORITY OF PERPETRATORS WERE THEMSELVES ABUSED.

- Poorly controlled anger and rage.
- Feelings of inadequacy and inferiority in the presence of adults.
- Feelings of power and control in the presence of children.

Front 138

What is somatization?

Back 138

A process by which an individual consciously or unconsciously uses the body or bodily symptoms for psychological purposes of personal gain.

Front 139

How can one distinguish b/w signs and symptoms?

Back 139

Symptoms - a problem that the pt REPORTS.

Signs - something the PHYSICIAN DIRECTLY OBSERVES.

Pts with somatoform disorders will have more SYMPTOMS than SIGNS.

Front 140

How can one tell somatoform disorders from factitious disorders or malingering?

Back 140

- In SOMATOFORM disorders, the pt TRULY THINKS he has a naturally induced medical problem (but doesn't; or at least it is not as severe as he believes).

- In FACTITIOUS disorders, the pt KNOWS he has FAKED or self-induced medical problems but honestly COULD NOT TELL YOU WHY he did it.
(pt's role is an end in itself)

- In MALINGERING, the patient has FAKED or self-induced a medical problem and (if honest) COULD TELL YOU WHY he did it (has a secondary gain; means to an end).

Front 141

What are the reasons people may employ somatization?

1' vs 2' gain

Back 141

Primary Gain
- Benefits are PSYCHOLOGICAL (reduction of INNER TENSION or ANXIETY, resolution of a psychological CONFLICT, or keeping psychological disturbances away from pts awareness)

Secondary Gain
- Benefits are TANGIBLE (external) ADVANTAGES that people accrue for being sick (manipulation of relationships, FINANCIAL GAINS, get others to care for you "SANCTIONED DEPENDENCY," or EXCUSED from RESPONSIBILITIES).

Primary = Beneficial response from OWN "PSYCHE"
Secondary = Beneficial response from THOSE AROUND YOU.

Front 142

What are the family factors predisposing to the use of somatization?

Back 142

- Parents modeled somatization (and it worked).
- Parents were caring and loving when pt was ill but demanding when pt was well.
- Parents suffer illness.
- Pt didn't acquire healthy defense mechanisms.

Front 143

Why do somatizers make doctors mad?

Back 143

- They want to be sick (don't follow Tx regimens, etc.) and resist efforts to make them better.
- Normal tests is not good news to them .
- They challenge your sense of adequacy (they claim you missed something).

Front 144

What are the general principles of management of somatization?

Back 144

1. Thorough INITIAL evaluation (don't want to miss a real threat).
2. Give tests and Tx ONLY FOR NEW SIGNS (not as much for new symptoms).
3. Discourage multiple doctor use.

4. Shift focus from removing symptoms to coping with symptoms.
5. Schedule regular return visits (don't want to reinforce the idea that the pt needs a new symptom to see you).
6. Obtain a good social and family hx.
7. Inquire about pts support system.
8. Monitor for addiction or suicidality.
9. Severe impairment cases should be referred to a psychiatrist.

Front 145

What are the pathways and brain structures involved in pain sensation?

Back 145

Asc AND Desc pathways:
A-delta & C fibers = Nociceptors -> gluatamte (ketamine) Dorsal Root Ganglion -> STT -> Thalamus -> Primary Somatosensory Cortex -> Heteromodal Association Cortex -> Limbic Structures (emotion can affect pain) -> Periaqueductal Gray Matter -> Response (endorphin release).

*Inhibitors:
1. PAG --> SC (dampens)
- PAG has major input from thoughts and emotions (affect pain sensation)
2. Gating: Simultaneous stimulation of mechanoreceptors
- reduces transmission of nociceptive input

Front 146

What are the interventions that can reduce acute pain sensation?

Back 146

1. ^ Serotonin from raphe nuclei
@ DRG

2. ^ Opioid release @ PAG & DRG

3. Ketamine: Block glutamate release from nociceptors

4. localized mechanoreceptors can also reduced nociceptive input ("rubbing the hurt area").

Front 147

What are the differences in the way that acute and chronic pain present?

*don't base pt's subjective pain by how they look*

Back 147

Acute
Obvious DISTRESS (expressions and body movement).
ANS AROUSAL (sweating, increased BP & pulse).

Chronic
NO ANS arousal.
Fewer expressions of pain.

Take-Home Point: just the severity of chronic pain by the pts subjective report, not by whether they look to be in pain.

Front 148

What are the essential features of pain disorder?

- Common features: Long hxs w/ multiple doctor visits; pain = Primary preoccupation & source of all woe

Back 148

A preoccupation with pain in the absensce of adequate medical or neuorlogical explanation to account for the pain.
- Physical findings may be present, BUT ARE NOT ENOGUH TO ACCOUNT FOR THE DEGREE OF PAIN.
- Pain may not fit classical anatomical patterns.

*Psych factors play important role in ONSET, severity, and Maintenance of pain

Front 149

What are the common psychological patterns seen in pain disorders?

Back 149

- In 50% of cases, the pain is from real physical trauma that PERSISTS for longer than the pain should.

- Commonly seen in driven Type-A people who are consistently taking care of others so much that an injury can be seen as a welcome experience b/c it gets them out of their usual responsibilities and causes others to care for them. This an unconscious action taken by the "sick" pt.


*1' and 2' gains also operating

Front 150

How can pain disorder relate to depression?

Back 150

Depression is so common in this disorder that some believe that pain disorder is depression presenting with a more "acceptable" symptom (pain).

Front 151

How can one manage a pt with pain disorder?

Back 151

Pain is SUBJECTIVE, but REAL TO THE PT.

1. Thus, it is useful to shift the goal of Tx from ELIMINATION OF PAIN TO FUNCTIONING IN SPITE OF THE PAIN.

2. Establishing RAPPORT helps.

Tx Types:
A. Psychotherapy (very helpful)
B. Biofeedback (use to learn to control pain response)
C. PT (reduce complications like restricted movement),
D. Anesthesia (nerve blocks), E. pain management education
F. nerve stimulators (reduces # of pain signals) = transcutaneous; "gating" effect
G. AVOID NARCOTIC USAGE
(SSRIs and TCAs may be used instead).

Front 152

What are the essential and associated features of hypochondriasis
?



Note: the name is hypochondriasis or "under the ribs." Expect to see abdominal complaints.


PREOCCUPATION WITH FEAR OR ILLNESS that doesn't resolve w/ medical reassurance

Back 152

Essential Features: preoccupation with the FEAR or IDEA that one has a serious dz bases on INACCURATE or UNREALISTIC interpretation of MINOR PHYSICAL SENSATIONS.

This is NOT a PANIC ATTACK or a DELUSIONAL DISORDER (pt can acknowledge that the fear is unfounded).

Associated Features: Hx of frustrating doctor relationships, repeated diagnostic procedures, and anxiety or depressive disorders (up to 80% of pts).

Front 153

What are the research findings regarding the sensitivity of sensory modalities in hypochondriasis?

Back 153

Pts with hypochondriasis have a LOWER THRESHOLD for noticing bodily sensations and experience GREATER DISCOMFORT (e.g. pain) from minor sensations.

Front 154

How can one manage a pt with hypocondriasis?

Back 154

Use the general management principles used for all somatization disorders (highlighted in green above).

- DO NOT discount or dispute the fear. Although note that we do not have any evidence to support the suspected illness.

- Agree to follow the pt regularly to monitor any developments.

Front 155

What are the essential features of conversion disorders?

Back 155

Alteration or loss of VOLUNTARY MOTOR or SENSORY functioning that CANNOT BE EXPLAINED BY A KNOWN MEDICAL OR NEUROLOGIC DISORDER (i.e. "pseudoneurologic symptoms")

- This is not an INTENTIONAL act and it is usually due to a serious STRESSOR. See commonly in younger uneducated women (think rural areas).

**Stressor/conflict --> initation or worsening of symptoms
- usually just ONE symptom (or related cluster)

Front 156

What is the usual course of conversion disorder?

Back 156

A psychosocial stressor occurs -> onset of Symptoms -> onset is short-lived (good prognosis).

Front 157

What are the common symptoms associated with conversion disorder?

Back 157

There is USUALLY just ONE SYMPTOM/cluster of symptoms

- Paralysis
- Blindness
- Mutism
- Impaired Coordination
- Anesthesia
- Seizures ("pseudo seizures")

Hallmark: pt seems surprisingly UNCONCERNED given the degree of impairment ("La belle indifference"). Helpful, but not incredibly specific.

Front 158

What are the common psychological factors involved in conversion disorders?

Back 158

The symptom has...

- a SYMBOLIC RELATIONSHIP to underlying conflict.
- keeps the FOCUS OFF of internal conflicts (a distractor).
- results in RELIEF from difficult life situations.
- is UNCONSCIOUSLY MODELED after someone important to the pt (ex. recently deceased relative).

Front 159

What is the general treatment approach to pts with conversion disorder?

*best make sure it's not a real illness first!
- MS & SLE look really weird
- 25-50% conversion pts end up having a real dz

Back 159

- Brief psychotherapy that focuses on current STRESSES and COPING SKILLS.
- SUGGESTIVE THERAPIES (hypnosis, amobarbital or "truth serum" interviews, placebo with strong encouragement on effectiveness).
- Take the symptoms seriously, the pt needs it.

Front 160

What are the essential features of somatization disorders?

(shit tons of symptoms for no reason)


aka hysteria or Briquette's syn

Back 160

The CHRONIC (years) presence of RECURRENT and **MULTIPLE** somatic complaints BEGINNING BEFORE THE AGE OF 30.

- The symptoms have NO ADEQUATE physical explanation.
- The affected pt TAKES ACTION (see doctors, takes medicine, alters lifestyle, etc.).

Symptoms (need to exhibit all of these symptoms @ some point during their affliction)

FOUR PAIN symptoms (@ 4 different sites)
TWO GI symptoms (OTHER THAN PAIN)
ONE SEXUAL symptom (OTHER THAN PAIN)
ONE PSEUDONEUROLOGIC symptom

(OTHER THAN PAIN, PRESENTS LIKE CONVERSION DISORDER)

Front 161

What is the prevalence in primary care populations of somatization disorder?

Back 161

5-10% will meet full criteria (4th MC Dx in primary care setting).

Front 162

Which gender is most affected by somatization disorder?

Back 162

WOMEN
Prevalence of 1-2%
Female to Male Ratio = 20:1


Note: not sure how her statistics match up b/w this and the last question, I am just going from the notes.

Front 163

What are the disorders found in the somatizer pt's family?

Back 163

In the men of the family: Antisocial PD and Addiction

In the women of the family: Somatization

The family factors are felt to be the critical factors in development of this disorder.*
(like family member also being somatizer or giving sick members preferential tx)

Front 164

In a somatization pt, what are the typical features found in the pts' life and medical histories?

Back 164

Social Hx: poor interpersonal relationships, lead chaotic lives (mimics their dz).

Medical Hx: Anxiety, Depression, Doctor Hopping, Multiple unnecessary procedures and Tests, Multiple Rx, Frequently DEPENDENT on Rx Medications.

Front 165

What are the principles of management for somatization behavior?

Back 165

Somatization is the MOST SEVERE manifestation of somatization disorders. Thus, it requires the most rigorous following of the general management principles used for all somatization disorders (highlighted in green above). Unfortunately, most of these pts RESIST PSYCHIATRIC REFERRAL.

Front 166

What are the essential features of body dysmorphic disorder?

Back 166

A preoccupation or excessive concern with a IMAGINED DEFECT in appearance of a NORMAL APPEARING person (usually involves the FACE).

Front 167

What are the complications and consequences of body dysmorphic disorder?

Back 167

- Repeated visits to PLASTIC SURGEONS or DERMATOLOGISTS.
- Significant AVOIDANCE of social situations due to anxiety about defect.

Front 168

Is there any merit to the claim that body dysmorphic disorder and OCD are related?

Back 168

About 50% of pts have reduced symptoms when treated with medications helpful in OCD.

Front 169

How does one manage a pt with body dysmorphic disorder?

Back 169

- Need to determine if genuine anxiety or depression (i.e. not associated with perceived defect) is present.
- Suggest getting help to cope with the negative thoughts (i.e. get them a psychiatric referral).

Front 170

What are the essential features of factitious disorders?

- what is compulsive about this dz?

Back 170

CONSCIOUS, INTENTIONAL, mimicking or production of physical illness with the GOAL OF ADOPTING THE SICK ROLE (there is a compulsive quality to the actions of the pt). The illness may be...

- Self-Inflicted.
- Completely Fabricated.
- Purposeful exacerbation of an actual condition.


Pts have a COMPULSIVE quality to their NEED TO BE IN THE SICK ROLE.

Front 171

What is the most commonly seen demographic with factitious disorder?

Back 171

Young, educated, socially conforming women that are in the medical field.

Front 172

What are the 3 psychological factors that may contribute to factitious disorder?

Back 172

- Mastery and Control Issues (specifically over medical personal)

- Masochism (enjoy invasive procedures)

- Dependency (enjoy the attention and personal care they receive)

Front 173

What is the definition of "Munchausen's Syndrome?"

Back 173

The most chronic and severe form of factitious disorder. Characterized by...

- Dramatic presentation of symptoms.
- Pathologic lying.
- WANDERING from hospital to hospital, city to city (rare minority of pts).

Front 174

How does one manage a pt with factitious disorder?

Back 174

- Obtain a thorough life Hx (trying to determine the ROLE, PLACE, and FUNCTION of the sick role).
- Determine if PD or psychiatric syndromes are present.
- Use NON-PUNITIVE and SUPPORTIVE MANNER to confront the pt.
- Frame behavior as a "cry for help."
- Use the general management principles used for all somatization disorders (highlighted in green above).

Front 175

What are the essential features of malingering?

Back 175

INTENTIONAL FEIGNING of illness MOTIVATED by EXTERNAL INCENTIVES

Front 176

What are the common reasons for malingering?

Back 176

1. Avoid military duty or work.
2. Financial compensation (litigation, disability, worker's comp., etc.)
3. Evading criminal prosecution.
4. Obtaining drugs.
5. Securing a warm place to stay with regular meals.

Front 177

What are the warning signs for the possible presence of malingering in a pt?

Back 177

1. Impending disability evaluation or legal situation.
2. MARKED DISCREPANCY b/w pts symptoms and physical exam findings.
3. LACK OF COOPERATION with diagnostic procedures or poor compliance.
4. Hx suggest Anti-Social PD.

Front 178

How does one manage a pt that is malingering?

Back 178

1. Examine your own feelings (so you can master your emotions).
2. Recognize that the pt may be desperately crying for help (David and the King).
3. CONFRONT the pt FIRMLY, but WITH EMPATHY.
4. You goal is to shift the focus from the feigned symptoms to the psychosocial factors and stresses present that create the need for the feigned symptoms.

Front 179

EATING DISORDERS

- prevalence
- course
- mortality rates
- males vs females
- comorbidities

Back 179

4% of population

COURSE:
within first 10 yrs --> 5-10% of anorexics die
- within 20 yrs --> 18-20% die
**only 30-40% fully recover**

EDO have the HIGHEST mortality rates of ANY mental disorder

19% of college females have bulimia
10% of EDO pts = males

>50% of EDO pts = MDD

Front 180

ANOREXIA NERVOSA

diagnostic criteria

Back 180

1. Refusal to maintain body wt @ or above minimally normal wt. (85% of expected body wt)
- via restriction, exercise, laxatives, diuretics, vomit, diet pills

2. Intense FEAR of gaining wt or becoming fat

3. Disturbed body image, denail of seriousness of current wt.

4. Amenorrhea (if postmenarcheal)
- absence of at least 3 consecutive menstrual cycles
- amenorrhea = periods occur only following hormone admin

Front 181

ANOREXIA NERVOSA TYPES

- restricting vs binge-eating/purging

Back 181

1. Restricting type:
- no regular binging or purging behavior

2. Binge-eating/purging type
- regular binging or purging

Front 182

ANOREXIA NERVOSA

- FEATURES
(prevalence, comorbid, mortality rate, population, onset)

Back 182

90% females (MC in western cultures)

Common age: 10-30yo
0.5-3.7% prevalence
- 1% adolescent girls

comorbid:
65% MDD
34% social phobia
26% OCD

**HIGHEST MORTALITY RATE OF ALL PSYCH DISORDERS
- up to 20%
- 57x higher rates of suicide
- death 2' suicide, starving, cardiac failure

Front 183

ANOREXIA NERVOSA

ETIOLOGY

- BIO / PSYCH / CX

Back 183

BIO:
- Monozygotic > dizygotic
- Chr 1p (5HT2A gene); abnl NE/5HT transporter genes

PSYCH:
- Temparent aversiave to change
- perfectionist
- Often enmeshed, overprotective families w/ poor conflict resolution

CULTURE:
- Values thinnes
- Females > males
- higher risk in adolescents in wt-focused sports (ballet, wrestling, etc)

Front 184

ANOREXIA NERVOSA

- PHYSICAL PRESENTATION

Back 184

Adolescents look Younger
Adults look Older

BMI < 17.5 or wt percentil < 85% in adolescents

- Cachexia
- Hypothermia
- Bradycardia
- Peripheral edema
- Yellowed skin from carotenemia
(Renal & Liver dysfxn)
- Lanugo & alopecia**
- Dental erosions & hand lesions (from vomiting)

Front 185

MEDICAL COMPLICATIONS OF ANOREXIA

- CARDIAC
- METABOLIC

Back 185

CARDIAC:
- Bradycardia
- hypotension
- Elevated QTC
- Hypokalemia
- arrhythmia
- infarction, MI

METABOLIC:
- Low prealbumin (more specific than albumin; fluid shifts)
- Decreased electrolytes
- Hypoglycemia

Front 186

MEDICAL COMPLICATIONS OF ANOREXIA

- RENAL
- ENDOCRINE

Back 186

RENAL:
- Increased BUN/Creatinine (dehydration)
- Elevated nitrogen (protein catabolism)
- Low urine specific gravitiy (water loading)
(higher in dehydration)
- UDS+ meth or diet pills

ENDOCRINE:
- Hypothyroid (normal TSH, low T4)
- Low GH
- Elevated Cortisol

Front 187

MEDICAL COMPLICATIONS OF ANOREXIA

- HEMATOLOGIC
- CNS
- GI

Back 187

HEM:
- Leukopenia
- anemia
- decreased ferritin

CNS:
- Decreased grey matter volumne on MRI
= impaired congition

GI:
- Constipation & GI emptying
- Increased serum amylase (vomiting)
- increased serum lipase
- pancreatitis
- stool+ for bisacodyl or laxative byproducts

Front 188

MEDICAL COMPLICATIONS OF ANOREXIA

- reproductive
- bone
- early

Back 188

REPRODUCTIVE:
- Infertility
- Premature birth
- Low FSH/LH
- Amenorrhea

BONE:
- Decreased density
- Poor growth
- Osteopenia/porosis on DEXA

EARLY:
- low C3, C4
- Low transferrin
**early indicators of malnutrition in presence of normal labs**

Front 189

ANOREXIA NERVOSA
- PSYCHOLOGICAL PRESENTATION

Back 189

1. Body distortion
2. Preoccupation with food/wt
3. Obessional, Perfectionist, Responsible
4. Guilt; rigidity with fear of failure
5. Controlling, competitive

6. Anorexia usually presents w/ rigid OCPersonalityD-Type symptoms
- B/P type has more impulsive BPD symptoms (better prognosis)

**anorexia: OCPD
**bulimics: borderline personality

Front 190

ANOREXIA THOUGHT PATTERNS

- food/sex/looks/appetite

Back 190

1. Constantly think about food
- Frequently love to cook (don't eat own cooking)
- Lot of (hidden) food in the house

2. Appetite is Preserved
- anorexia is a misnomer

3. Decreased sex drive

4. Obsessions about weight, looks
- weigh selves on scale frequently

Front 191

ANOREXIA DIFFERENTIAL DIAGNOSIS


**intense fear of wt gain seems to be main differentiation**

Back 191

1. Medical: WT. LOSS
- tumors, CAs, Addison's, hyperthyroid, SLE, malabs, Diabetes

2. MDD: no intense fear of wt gain; admits to poor appetite

3. Somatization: may have wt loss & amenorrhea (reproductive category)
- NO morbid fear of wt. gain

4. Schizophrenia
- delusions abt food are unrelated to calories/wt gain

5. Bulimia: don't lose 15% of body weight
- AN can become BN over time

Front 192

ANOREXIA NERVOSA TREATMENT OVERVIEW

- COURSE
- TX settings

Back 192

COURSE:
<50% Recover LONG-TERM

30% have PARTIAL recovering w/ lingering symptoms

20% CHRONIC illness

Treatment in outpt, inpt, residential, or partial hospital setting
- home environment factors in tx type

FOCUS on nutritional, psychosocial, & medication management
- give atypical med (which may cause wt gain; olanzapine) for OCD

Front 193

ANOREXIA NERVOSA TREATMENT SETTING

(criteria for inpatient vs residential vs PHP)

Back 193

INPATIENT
- Weight < 85% with food refusal
- HR <40; BP < 90/60 or orthostatic
- Glucose < 60; K < 3
- Temp < 97
- edema, hypoproteinemia
- Anemia, dehydration

RESIDENTIAL:
- Pt requires 24 hr structure & monitoring
- Failed PHP setting
- Unmanageable home stressors
- Significant family work needed

PHP:
- needs daily structure for meal plan
- Monitored by physician
- Daily vitals; biweekly wts, close lab monitoring

Front 194

TREATMENT OF ANOREXIA

- nutrition
- psychosocial

Back 194

NUTRITION: 1000-1600 cal/day
- increases based on nutritional deficits
- liquid supp
- restricted exercise

**FOCUS ON GOOD HEALTH**

PSYCHOSOCIAL:
- Individual & group therapy
- intensive family tx ***
- Identify +/- aspects of EDO & apply motivational strategies
- CBT for cognitive distortions

**CBT = better outcome
- 44% recovery vs 7% nutrition counseling alone

BUY NEW CLOTHES (sweats=)

Front 195

ANOREXIA MEDICATION MANAGEMENT

*pills tx symptoms (and underlying MDD, OCD)

Back 195

1. Chlorpromazine
- Used to be 1st line; helps OCD/perseveration/anxiety

2. SSRI: tx's comorbid MDD
- Prozac = 47% less dropout
- NO wellbutrin ( ^ seizures)

3. Antipsychotics:
- For Delusional BDD component
- avoid typicals (^ seizure, EKG abnl)
- Risperdal & Zyprexa helpful (^ wt)

4. MOOD STABILIZER
- use w/ caution in comorbid BMD & avoid Li (toxicity)

5. Reglan
- improves gastric emptying & bloating
- they get lots of constipation once they eat again

6. HormoneReplacementT:
- not helpful in treating osteopenia due to multifactorial
(Dec IGF / ^ Cortisol / Dec Estrogen)

7. AVOID TCAs
- heart problems/ EKG abnl

Front 196

anorexics vs bulimics personality type

Back 196

anorexics: very rigid
- "binge" = 1 taco

bulimics: very impulsive
- "binge" = 20 tacos

Front 197

BULIMIA NERVOSA

- diagnostic features
- types

Back 197

1. Recurrent episodes of binge eating
- lack of control over eating a LOT of food

2. Recurrent Compensatory behaviors to prevent wt loss
- purge/fast/exercise
(NOT necessarily vomiting)

3. 2x/week for 3 months

4. Self-evaluation is unduly influenced by shape/weight

5. Does NOT occur exclusively during AN

purging vs. non-purging types (fast, exercise)
(AN = amenorrhea w/ BMI < 17.5 or < 85%)

Front 198

BULIMIA NERVOSA

- PREVALENCE
- MORTALITY
- BIO/PSYCH

Back 198

90% Females
- LATER onset: early 20s

1-4% general population
- 20% college women (transient bulimia)

5% mortality rate

BIO: higher in mono twins; 1st degree relatives
- elevated NPY & low CCK (satiety)

PSYCH: impulsive, self-destructive, avoid conflict, fear abandonment, often h/o sexual abuse
- lack superego control of AN

Front 199

BMI IN EATING DISORDERS

Back 199

BODY MASS INDEX:

WT (kg) / HT (m2)

BMI is an effective screening tool, but NOT a diagnostic tool

**use BMI for age in kids
- sucks bc large variation among kids & doesn't account for differences of build

Front 200

PHYSICAL PRESENTATION OF BULIMICS

Back 200

1. Normal wt/overwt

2. Peripheral edema & bloating

3. CONJUNCTIVAL HEMORRHAGES
- purging

4. DENTAL EROSIONS
- BACK of teeth

5. Dorsal hand lesions
- vomit
- aka russell's signs

6. Weakness/fatigue

7. Swollen salivary glands

Front 201

MEDICAL COMPLICATIONS OF BULIMIA

- cardiac
- metabolic
- GI

**more traumatic to GI, but similar to AN; mostly less severe**

Back 201

MUCH LESS; LESS SERIOUS; lower mortality than AN

CARDIAC: Torsade de pointes, arrythmia, hypoK+ assc'd ST depression, QT prolonged

METABOLIC:
- hypokalemi HYPOCHLOREMIC metabolic alkalosis
- low Mg & Phos


GI:
- Mallory-Weiss Tears
- esophageal rupture
- hiatal hernia
- elevated salivary/serum amylase
- laxative dependence / rebound constipation

Front 202

MEDICAL COMPLICATIONS OF BULIMIA

- ORAL
- Reproductive

Back 202

ORAL:
- gum recession
- enamel erosion
- swollen parotid/salivary

REPRODUCTIVE:
- INFERTILITY
- SPONTANEOUS ABORTION

Front 203

psych presentation of bulimia

Back 203

1. obsessed w/ eating/w
- SIGNIFICANT SHAME/guilt related to EDO behaviors

2. low self esteem, IMPULSIVE, BPD traits

3. 50% MDD or social phobia

Front 204

diff dx of bulimia

Back 204

1. MEDICAL:
- Klein Levin ( hypersomnia & hyperphagia)
- Kluver Bucy ( frontal lob)
- brain tumors: endocrine
- malabsoprtion; enteritis

ATYPICAL DEPRESSION
- binging during winter months
- NO compensatory behaviors

BORDERLINE PERSONALITY
- many are comorbid
- hypersexual, suicidal, mood reactivity
- poor impulse control; chaotic lives

Front 205

BULIMIA TX

- nutrition
- psych

Back 205

NUTRITION: regular structured meal plans

PSYCHOSOCIAL:
- CBT, group, individual, FAMILY tx
- DBT can be viable tx in pts w/ trauma

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TREATMENT OF BULIMIA

- MEDS
- COMBO

Back 206

MEDS:
**1. SSRI: Prozac - dec B/P
- NO wellbutrin or TCAs

**2. TOPAMAX: good!
50% reduction in B/P
- brings down appetite
- contraindicated w/ kidney stones

3. Ondansetron: 5HT3 antag
- decreases vagal activity: dec B/P
- anti-nausea

4. Flutamide:
- androgen antag: dec B/P in PCO (poly-cystic ovarian syn)

COMBO: BN is best tx'd with combo of antidepressant AND CBT

**get them off laxatives & diet pills*

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ASSESSING FOR EDO

- physical & nutritional

Back 207

Physical:
- ht/wt post void
- BMI
- vitals
- PE

LABS: cbc + extra stuff
- Mg, Phos
- Prealbumin, ferritin
- TSH/Free T3/4
- amylase, lipase
- lh/fsh
- estradiol
- stool for bisacodyl

TESTS:
- DEXA
- EKG

Determine BMI, goal wt, needed caloric adjustment with aid of dietician

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PERCENT BODY WT vs ideal body wt

best wt measurements = DEXA scan for body comp & underwater wt

Back 208

PERCENT BODY WT:

actual wt / ideal wt

Ideal = base + 5 lbs/inch above 5 ft
(female: 5ft = 100 lbs)
(male: 5 ft = 106 lbs)

Front 209

eating disorder types

Back 209

1. binge eating disorder

2. anorexia nervosa
- restricting
- purging

3. Bulimia nervosa
- purging
- non-purging

4. eating disorder NOS

Front 210

BINGE EATING DISORDER

Back 210

- Rpt uncontrolled overeating

- normal/obsese wt

- Depression/shame/guilt aobut overeating

- out-of-control binges

- eat alone; extreme eating patterns

- wt gain/ high BP

Front 211

anorexia epidemiology

Back 211

90-95% female
- mid to upper SES
- mostly caucasian (but increasing in other races)


**20-30% of younger pts are MALE**

2 LIFETIME PEAK AGES:
- age 13-14
- age 17-18
**development stress; precipitating events common

Front 212

basic goals of psychotherapy

Back 212

help people
- understand their condition
- learn how to identify bad thoughts/behaviors
- explore relationships & experiences
- learn better coping methods & solutions to problems
- learn how to set realistic goals

Front 213

types of psychotherapy covered

& main types of interventions used / techniques employed

Back 213

1. Classical psychoanalysis
- interpretation
for: last-resort

2 Psychodynamic / Insight-oriented psychotx
- Interpretation
- confrontation
- clarification

3. Humanistic or Supportive psychotx
- Encouragement
- Empathic validation
- advice/praise & affirmation
for: severe personality disorders

4. Behavioral tx
- Relaxation training
- exposure: imaginal, in vivo
(SEVERE ANXIETY DISORDERS)
- flooding - PHOBIAS
- behavioral modification
(good in kids - esp w/ conduct disorder & impulsivity; eating disorders & other sever mental illnesses - schizo)

5. CBT
- change core beliefs
- therapist as teacher
- dialectical behavior therapy: for borderline personality disorder

6. Group tx
-social skills training
- immediate feedback from peers
- observe pt in realistic setting

7. Systemic tx
- tx of pt's system (family, couple)
- clarification
- problem solving/communication education
*contraindications*

Front 214

EGO PSYCHOLOGY
"Structural model" of the personality

- define id / ego/supergo

Back 214

ID:
unconscious, primal
drives basic needs
"infant"

EGO:
Consciousness + unconscious tasks
- finds balance bw primitive drives, morals, & reality
- DEFENSE MECHANISMS used when id behavior conflicts
"adult"

SUPEREGO
conscious & unconscious
- conscience; punishing (guilt)
- internalization of social norms
"father"

Front 215

DEFINE TRANSFERENCE & COUNTERTRANSFERENCE

Back 215

TRANSFERENCE:
- feelings a pt has towards the therapist
- based pt's experiences with people from their past
- mostly unconscious
"i like my therapist bc she's like my kind grandma"

COUNTERTRANSFERENCE:
- feelings a clinical has towards the pt
- may be in response to pt's transference OR clinician's own past experiences
"i like this pt bc she's like my grandma"

Front 216

PSYCHOTHERAPEUTIC INTERVENTIONS

1. INTERPRETATION
2. CONFRONTATION
3. CLARIFICATION
4. ENCOURAGEMENT TO ELABORATE
5. EMPATHIC VALIDATION
6. ADVICE & PRAISE
7. AFFIRMATION

(moves from expressive - insight oriented --> supportive as you move from #1 --> #7)

Back 216

1. INTERPRETATION
- making something conscious that was unconscious
"maybe you have a hard time trusting your bf bc you're afriad he'll hurt you like your dad"

2. CONFRONTATION
- Address pt's avoidance / reluctance
- rarely aggressive
"i wonder if you're late today bc you didn't want to revisit guilty feelings.."

3. CLARIFICATION:
- pulling together pt's verbalizations
"So what I hear you saying is..."

4. ENCOURAGEMENT
"tell me more about..."

5. EMPATHIC VALIDATION
- Dr. expresses attunement w/ pt's subjective experience
"I can see why you feel so lonely"

6. ADVICE AND PRAISE
- Prescribing/Reinforcing activities
"You seem to be showing much improvement"
"I'd like you to being following a daily schedule of activities."

7. AFFIRMATION
- simple supporitve comments abt pt's behavior
"yes, I see."

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PSYCHOANALYSIS

- theory of what causes symptoms
- theory of how to relieve symptoms

Back 217

CAUSE: unconscious conflicts & unfulfilled wishes
--> neuroses / symptoms of anxiety, depression, & even psychosis

RELIEVING SYMPTOMS:
Neuroses can be treated by bringing the unconscious wishes & repressed memories to consciousness w/ tx

Front 218

PSYCHOANALYSIS
- most utilized intervention
- ultimate goal
- type of pt

Back 218

EXPRESSIVE TX
- analysis of transference & free assocation
--> interpretation (interpret above information)

*Transference can be indicative of how pt treats other people in their lives
- may contribute to distortions of reality

*Free assc: eventually a signficant memory/thought will surface

Therapist must be neutral
Longterm tx: 3-6 yr; 4x/wk
EXPENSIVE

FOR: pts that failed psychotherapy & psychopharmacology
- last ditch effort

Front 219

INSIGHT ORIENTED TX / PSYCHODYNAMIC PSYCHOTHERAPY

- theory of cause / how to relieve symptoms

Back 219

CAUSE:
- similar to psychoanalysis
(unconscious conflicts/unfulfilled wishes --> psych symptoms)

HOW TO RELIEVE:
- focus on day to day situations that may illustrate unconscious conflict

Front 220

psychodynamic tx

- interventions
- ultimate goals
- main focus of sessions

Back 220

ULTIMATE GOAL:
- partially reorganize & improve pt's DEFENSE MECHANISMS to improve INSIGHT into interpersonal conflict.

**ultimate goal is NOT to completely resolve unconscious conflict**

INTERVENTIONS:
- Interpretation
- confrontation
- clarification

MAIN FOCUS:
- Here & now situations

*long or short term; 1-3x/wk

Front 221

supporitve tx

- interventions
- type of pt
- therapist's characteristics

Back 221

INTERVENTIONS: supportive end
- Encouragement to elaborate
- empathic valdiation
- advice/praise
- affirmation

PT TYPE: Can't handle more expressive, uncomfortable type of tx
- Crisis
- Severe personality disorder

THERAPIST:
- WARM, FRIENDLY, PROVIDE strong example of how to cope/react w/ extremes of emotion

Front 222

SUPPORTIVE TX

- theory of cause/how to relieve

Back 222

CAUSE:
Poor coping & low self-esteem (usu during crises) leads to symptoms

HOW TO RELIEVE:
Maintain, restore, & improve self-esteem + encourage healthy coping skills
- provide "safe place" for extremes of emotion; normalize feelings & improve mood stability

Front 223

BEHAVIORAL TX

- THOERY OF CAUSE/HOW TO RELIEVE
- pt type

Back 223

CHANGE BEHAVIOR
--> FEELINGS WILL FOLLOW

CAUSE:
symptoms are consequence of maladaptive behaviors / maladaptive responses to stimuli

*BF skinner & pavlov

PT TYPE: anxiety & impulsivity (conduct disorder)

HOW TO RELIEVE SYMPTOMS:
- identify & change maladaptive behaviors & responses --> decrease negative consequences/sensations

*help pt come up w/ more functional behaviors less likely to have negative consequences

Front 224

BEHAVIORAL TX

- techniques employed

Back 224

1. Relaxation training: control somatic complaints
- progressive muscle relaxation
- diaphragmatic breathing

2. Exposure
(since avoidance = increased symptoms)
- Imaginal exposure
- In vivo exposure
FOR: more severe forms of anxiety

3. Flooding:
- continuous exposure to stimuli
FOR: phobias

4. Behavioral modification
A. antecedents
B. behavior
C. consequences
- based on contingencies
- schedule of reinforcement set @ beg of tx
FOR: kids (conduct dz & impulsivity), eating dz, schizo / severe mntal illness

Front 225

CBT

- theory of cause/how to relieve



**Behavior modification & cognitive (thought) therapy**

Back 225

CAUSE:
Unrealistic & negative thoughts cause distress

RELIEF:
Identify the negative/unrealistic thoughts
- examine the evidence for them
- develop more balanced outlook

Aaron Beck:
individual's affect & behavior are mostly determined by the way he structures the world
- thoughts influence behavior/feelings

Front 226

CBT

- ultimate goals
- How CBT aims to improve symptoms
- - how core beliefs influence automatic thought

Back 226

AIM: reduce unrealistic/negative thoughts that cause distress

Core beliefs: learned in childhood
- contribue to automatic thoughts/cognitive distortions
--> cause distress, guilt, etc.

ex// "i am always fearful" = overgeneralization
also:
- dichotomous thinking
- excessive responsbility
- excessive self-reference

CBT would catch these automatic thoughts, examine them for validity, and replace them w/ a more BALANCED thought

"I am sometimes fearful and fear can often be healthy."

THERAPIST IS A TEACHER
- give hw assignements
- expierment w/ beliefs abt oneself & test validity of assumptions

Front 227

GOALS AND USES OF DIALECTICAL BEHAVIOR TX

- WHAT PTS?

Back 227

DBT = subset of CBT

BORDERLINE PERSONALITY DZ

Helps pt manage extremes of emotion
- self monitor feelings
- help pt find middle ground bw rational mind & emotional mind

Front 228

GROUP THERAPY

- GOALS & HOW THEY'RE ATTAINED

Back 228

goals:
1. IMMEDIATE Feedback to and from one's peers
- improve awarenss of the way one relates to others

2. OBSERVATION of pt in realistic setting
- how does pt relate to others

*also, social skills therapy
- improve coping, relating to others, daily tasks
- severely ill pts

**Pts confront their problems together**

Front 229

GROUP THERAPY

- EXCLUSION CRITERIA
- THERAPIST'S ROLE

Back 229

Exclusion criteria:
- assess motivation to change & ability to interact w/ a group of peers
- dont' want unstable or aggresive pts

THERAPIST's role:
- define group goals
- establish/maintain therapeutic environment
*work of tx is done by group*

Front 230

SYSTEMIC THERAPY

- DEFINITION
- GOALS

Back 230

Cause:
Dysfunctional system leads to symptoms in one or all members of the system
- family
- couple

goals:
1. improve function as a unit
2. improve fxn as individuals
3. identify common goals
4. employ realistic expectations for others

Front 231

SYSTEMIC THERAPY

- THERAPIST'S ROLE
- CONTRAINDICATIONS

Back 231

Intervention:
- clarification
- problem solving & communication education

CONTRAINDICATION
- one side clearly wants a divorce
- one pt is paranoid/psychotic/clear deviation from normal
- one pt is unwilling to cooperate 2' anxiety or fear
- domestic violence pattern

Front 232

CBT

- uses
- success

Back 232

works faster than psychodynamically oriented treatments

85% remission for severe chronic depression when treated w/ combo antidepressant & CBT

Also good for maintenance tx