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166 Cards in this Set
- Front
- Back
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Goals of initial medical interviews
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make a diagnosis
develop therapeutic relationship b/w patient and physician |
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the differential dx completed at the end of the initial interview will determine
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prognosis
tx options |
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how do you introduce yourself
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use your full name, call them by last name
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MSE exam is based on the patient's status over what period of time?
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THAT DAY only (judgment is maybe the only exception)
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Criteria for Major Depressive Episode
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5 of the following (with 1 of starred):
*Depressed mood *Anhedonia -Sleep disturbances (if decrease, wake in middle of night or early AM) -Guilt or feelings of worthlessness -Energy loss (fatigue, feel in a fog or like weight is on shoulders) -Concentration is poor; indecisive -Appetite/weight change (up or down) -Psychomotor agitation/retardation (usually observed in interview) -Suicidal ideation --2 weeks --change from previous functioning --most of the day, nearly every day --cause significant distress/impairment --NOT due to medical condition (e.g. hypothyroidism) --NOT due to substance --NOT due to bereavement (same sx except suicidality) |
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under 45, leading global cause of years lost to disease
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depression
significant morbidity and mortality extremely treatable; at the same time, many people don't realize they have it and/or don't seek help |
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Depression's associated non-specific sx
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anxiety, diminished libido, low self-esteem
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Epidemiology of Major Depression
(door to door studies) General pop: --Current --Lifetime *Women *Men Primary care pop: |
General:
Current - 5% Lifetime - 17% --Women - 20-25% --Men - 7-12% Primary Care - 10% (not necessarily diagnosed in 10%, but when trained people looks for it in this pop) **substance abuse has opposite ratio |
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Depression usually:
lasts for... can last up to ... if untreated typical age of onset recurrence? |
6-9 months
2 years (1/3 of patients) 20's one episode puts at higher risk for another (50-50 chance) *increased risk of mortality from cardiovascular disease in people with a history of depression |
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should you ask people if they know "why" depression happened?
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NO! ask what was going on around the time
(also, being empathetic prob won't cheer them up because nothing can) |
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when to use ECT
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suicide risk or when antidepressants haven't worked
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how does REM relate to depression?
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decreased REM latency (deep sleep earlier)
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genetics of depression?
other risk factors? and treatment? |
runs in families to SOME extent
early loss, early trauma, general stress --the trauma folks respond better to psychotherapy than medication |
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History of schizophrenia
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may be relatively new -- first described in 1809 as "neither melancholic nor manic yet completely insane" -- not described by physicians
called "precocious dementia" in mid-1800s by Morel (depression has been described for a very long time) |
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Kraeplin's theory
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turn of 20th century -- "dementia praecox" (schizophrenia) is
1. dementia with sometimes intact reasoning 2. delusions and hallucinations 3. chronic, unremitting, and deteriorating course (as opposed to bipolar's psychotic episodes) 4. caused by specific brains lesions **DSM based more on his than Bleuler's |
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Bleuler's theory
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early 1900s -- coined term "schizophrenia" -- split-mind -- dissociation between thoughts/emotions/behavior
Pathognomonic features: Primary features: 1. association defect 2. autistic behavior/thinking (retreat to internal problems) 3. abnormal affects 4. ambivalence Accessory symptoms: delusions and hallucinations |
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Freud's notion of schizophrenia
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defensive alteration of reality -- thought they should be seen by a neurologist
sx represent resolution of intrapsychic conflicts or withdrawal of libidinal energy from external world notion of schizophrenic mother was debunked in the 1970s |
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Four categories of criteria for schizophrenia
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1. characteristic sx (positive, negative, disorganized)
2. functional deterioration (doesn't mean you have to have chronic, unremitting course) 3.time course 4. exclusion criteria |
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types of positive sx of schizo
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Hallucinations: auditory more common...visual, tactile possible
Delusions: persecutory (very common) erotomanic (starlette in love with me) "made thoughts" (made me push her onto the platform...i didn't want to) grandiose thought insertion religious thought withdrawal thought broadcasting somatic |
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types of negative sx of schizophrenia
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affective flattening (verbal and non-verbal)
anhedonia attentional disturbance (distractable) asociality poverty of content of speech alogia (poverty of speech) can also be secondary negative sx (e.g. secondary to primary symptom of delusions you stay quiet; secondary to depression) |
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types of disorganized symptoms
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derailment (loose associations)
illogicality thought blocking incoherence catatonic disturbances (mutism, negativisim, stereotyped movements, excitement/agitation) |
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neurocognitive defects in schizophrenia
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typically perform poorly on all cognitive tests; most marked deficits in areas of:
attention short-term memory working memory executive function usually see 8-10 pt. drop in IQ no one pathognomonic finding, though |
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mood syndromes in shizophrenia
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depression (high co-morbidity)
suicidality agitation |
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__% of schizos have insight deficits
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75%
maybe these are a result of neuro. problem, or it's a defensive avoidance of reality |
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Schizophrenia criteria
what is like it but shorter |
2 or more of these:
-delusions -hallucinations -negative symptoms -disorganized speech -grossly disorganized behavior -criterion met if bizarre delusions or hallucinations of voices commenting or conversing *1 month duration, occuring most of the time *functional deterioration *at least 6 months including prodromal and/or residual sx *exlude known medical conditions schizophreniform has same sx but shorter than 6 mo |
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Differential Dx of schizophrenia
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1. drug induced psychosis (most common reason for psychosis)
2. other organic psychosis (renal, liver toxicity, lupus) 3. brief psychotic disorder (20-30 days duration with full resolution), typically due to stressor 4. schizophreniform (1-6 months) 5. delusional disorder 6. bipolar or depression with psychotic features 7. schizoaffective disorder: major depressive, manic, or mixed episode concurrent with active phase symptoms |
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criteria for schizophreniform
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same as schizophrenia, but 1-6 mo. in duration
brief psychotic disorder is less than a month |
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delusional disorder
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circumscribed delusionin absence of other typical schizophrenic symptoms
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schizophrenia subtypes
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1. paranoid (organized, systematic delusions)
2. disorganized (thought disorder or bizarre behavior) 3. catatonic (significant abnormal motoric behavior) 4. undifferentiated (no predominant sx of any type) 5. residual (few active psychotic symptoms) paranoid has better prognosis than disorganized we have good treatment for positive sx, not really for negative |
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epidemiology of schizophrenia
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1% lifetime prevalence
2 million american affected *slightly higher in MALES who have an earlier onset and worse prognosis -usually live almost as long as healthy -outcomes may be better in less developed countries -definitely don't see end-stage deterioration in all cases |
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Mania criteria
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-grandiosity, decreased sleep, pressured speech, racing thoughts, distractibility, increased activity, poor judgment
*duration of 1 week *marked impairment, hospitalization, psychotic features |
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subtypes of mania
related disorders |
psychotic
rapid-cycling mixed, schizoaffective |
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hypomania criteria
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*4 days duration*
*without marked impairment, hospitalization, psychosis* *change in functioning, observable by others |
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dysthymia criteria
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*2 years duration
*at least 2 of following: -(S) sleep changes -(G) low-self esteem -(E) fatigue -(C) concentration poor, indecisive -(A) change in appetite -hopeless |
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bipolar disorder type I criteria
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mania
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bipolar disorder type II criteria
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hypomania + MDE
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cyclothymia criteria
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hypomania + dysthymia
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subtypes of major depression
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melancholic
atypical psychotic - 15% (major suicide risk, esp. if mood-incongruent symptoms) post-partum seasonal |
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epidemiology of mania
-age of onset -prevalence -gender -genetics? -progression |
-typically in 20s
-0.5-2.0% of population -about equal in men and women -stronger genetic component -tends to get worse with age (more symptomatic, more frequent) -90% mania have depression or dysthymia |
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which is more serious, atypical or melancholic
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melancholic
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features of atypical depression
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over sleeping
over eating leaden paralysis |
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for *brain* problems, order of memory loss
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time lost 1st -->
place lost 2nd --> person lost 3rd order can be different for psychological problems |
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components of cognitive MSE
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1. attention and orientation (who/where/when)
2. memory (simon, short term, long term) 3. fund of knowledge (current and past presidents) 4. complex functions 5. abstract thought |
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types of cognitive disorders
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delirium (many causes; waxing/waning attn)
dementia (many causes) amnesic (specific etiology...only abnormality is memory, and specific memory deficits) |
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confabulation
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when you don't know the answer to something so you make up an answer...not considered to be a delusion
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mental disorders due to general medical condition (formerly known as organic mental syndrome)
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psychotic disorder due to...
mood disorder due to... anxiety disorder due to... personality change due to... e.g. depression due to hypothyroid disorder |
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substance induced disorders
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intoxication
withdrawal (from Rx or recreational drugs) |
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exception to onset in 20s
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cognitive disorders, esp. mental disorder due to a general medical condition
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suggestive signs and symptoms of mental disorders due to a medical condition
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-onset >40 years
-sx inconsistent with usual psychiatric presentation -presence of drugs (Rx or prescription) -abnormal neurological exam |
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DSM eating disorders
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1. anorexia nervosa
2. bulimia nervosa 3. EDNOS |
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descriptions of anorexia go back to
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1689
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key diagnostic features of anorexia
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1. relentless pursuit of thinness
2. fear of becoming fat 3. significantly underweight (by definition) |
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criteria for anorexia
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1. refusal to maintain body weight at 85% (adjusted for age and height)
2. intense fear of gaining weight/getting fat, even though underweight 3. disturbance in the way their body shape is experienced or denial of seriously low weight 4. amenorrhea |
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subtypes of anorexia
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1. restricting
2. binge/purge |
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behavioral sx of anorexia
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1. obsession with food
2. peculiar eating (concoctions, timing) 3. binge eating 4. depression 5. compulsive behavior (weighing, checking body, exercising) 6. laxatives, diuretics 7. social isolation 8. increased physical activity |
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physiological sx of anorexia
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1. hypothermia, bradycardia, hypotension
2. lanugo 3. anemia, leukopenia 4. increased LFTs 5. edema 6. low estrogen, LH, FSH (hypothalamic amenorrhea); low testosteroe in men 7. low-normal T4 8. high cholesterol 9. decreased brain mass 10. osteoporosis |
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WWII starvation experiment showed same behavioral signs except that
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activity decreased in them
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epidemiology of anorexia
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-90% women
-12-40 y.o. -middle/upper class -caucasian -premorbid perfectionism? driven? -0.5% of women |
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prevalence of anorexia
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0.5% of women
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anorexia prognosis:
full recovery - death - alive but not well - obesity - |
1/3-1/2 make full recovery
5% die per decade followup the rest rare **5% mortality is way too high for this population...this is one of the most lethal psychiatric illnesses |
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key features of bulimia nervosa
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recurrent episodes of binge eating
recurrent inappropriate compensatory behavior note: bulimia is the name of the behavior...bulimia nervosa is the d/o |
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criteria for bulimia
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1. recurrent episodes of binge eating
2. recurrent inappropriate compensatory behavior 3. these occur at least *twice a week for 3 months* 4. self evaluation is usually unduly influenced by body shape/weight 5. doesn't occur during anorexia (trump criteria) |
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subtypes of bulimia nervosa
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1. purging (vomiting, laxatives)
2. non-purging (not eating for a day or exercising extremely) |
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what is a binge?
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1. eating, in a discrete period of time, an amount that is definitely larger than most people would eat under similar circumstances
2. sense of lack of control over eating |
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bulimia clinical characteristics:
1. prevalence 2. gender 3. onset 4. presentation age 5. binge 6. purging methods |
1. 1-2%
2. 90% female 3. 18 years 4. 23 years 5. 2000 kcal NOT primarily carbs (sweet/fat combos) 6. 90% vomiting, 33% laxatives *average patient comes in after purging 5-10 years, 5-10 times per week |
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physical signs, sx of bulimia
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swollen parotids (not painful)
dental erosion ipecac toxicity irregular menses gastric rupture laxative dependence |
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possible lab abnormalities from bulimic vomiting
(usually are physically fine |
hypokalemia
hypochloremia hyponatremia alkalosis **acidosis from laxatives hyperamylasemia |
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prevalence of non-DSM yet clinically significant eating d/o
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5%
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Eating d/o
1. predisposing factors 2. precipitating factors 3. perpetuating factors |
1. genes, environment, female, emphasis on thinness
2. stress of adolescence 3. dieting --> binge eating --> dieting |
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Tx of anorexia:
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**WEIGHT GAIN**
need 4000 kcal above maintenance per pound gained (e.g. gain 2 lbs per week by adding 8000 kcal) parenteral methods rarely needed **PSYCHOTHERAPY** family therapy a must for younger pts **MEDS DON'T HELP** |
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Tx of bulimia:
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1. CBT (psychotherapy)
2. antidepressant meds (meds alone and CBT alone are equally effective, but not as good as combo) |
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top 3 causes of disability
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Depression
Alcoholism Schizophrenia |
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T/F: Schizophrenia is a brain disorder
T/F: it is recurrent and lifelong |
true
true |
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pathological dimensions of schizophrenia
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1. positive symptoms
2. negative symptoms 3. cognitive symptoms (memory, attn, executive function) 4. mood symptoms (depression, anxiety, hopelessness, stigmatization, suicidality) 5. substance/suicidality/violence all leads to... problems with work, interpersonal relationship, self-care |
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__% of homeless have mental illnes, majority of which is schizophrenia
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40%
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relative risks of schizophrenia
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general: 1%
2nd degree relative: 2%-6% 1st degree relative: 6-17% MZ twin: 48% two parents: 46% |
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percent of schizophrenia cases that are "sporadic" aka "non-familial"
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60-80% (so, the majority are sporadic)
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types of genetic variation that could be possible for schizophrenia
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SNP
-mismatch -deletion copy number variant -gene duplication/repetition -gene deletion |
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hypotheses on schizo genetics
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common disease/common allele - more than 10% allele that is not highly penetrant, need more than one susceptibility gene that combine to increase risk
common disease/rare allele - rare but highly penetrant gene mutation in single genes (can be point mutation that affects protein structure, or could be DNA deletion/duplication that affects one or more genes) **either way, it's probably a little ~52% due to genes and ~48% due to environment |
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genetic neurodevelopmental disorders
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Down's syndrome
Fragile X Turner's Velocardiofacial syndrome Autism **schizophrenia is different than the rest in that the phenotype is not immediately apparent |
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Phases of natural history of schizo
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Premorbid (Neurodevelopmental)
Prodromal (Period of risk) Onset/Progression (Deterioration -- 80-90% of cases) Chronic/Residual (early 30s...negative symptoms, functional impairment, cognitive deficits) |
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psychotic break defined by
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severity that affects function -- this is when they present
after this, medication will help for a while, but then there will be relapses...will improve again, but not as much as last time...etc (clinical deterioration) luckily, unlike parkinson's, huntington's, alzheimer's, it doesn't keep going down until death...reaches end-phase, chronic-residual plateau |
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biologically, what's going on at time of schizo onset
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gonadal hormone density
synaptic pruning patients seem to have accelerated deterioration of gray matter |
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neuro changes in autism
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increased head circumference (failure of regulation of synaptic development?)
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NT in schizo
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*GABA disinhibited (shut down), leading to more DA in limbic region (ventral striatal, mesiotemporal), leading to positive symptoms
*glutamatergic feedback stimulation shut down, leading to less DA in frontal lobe, leading to negative symptoms and cognitive dysfunction *D2 receptor is holy grail (origin of both ventral striatal and frontal projections is VTA dopamine cell boies |
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PCP causes psychotic symptoms because it
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blocks the NMDA receptor (so presynaptic release increases, leading to glutamate neurotoxicity in AMPA, KA neurons using glutamate)
(NMDA antagonists cause positive, negative, and cognitive symptoms...this is even more evident in scz patients) interestingly, ketamine is used in children but not adults because they would have psychotic sx = development dependent sensitivity...change after puberty |
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PCP binding site
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plugs up middle of channel
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role of GABA in schizo
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post-mortem shows reduction in GABA interneurons, which are studded with NMDA receptors, that synapse onto cortical pyramidal cells...perhaps they die due to lack of activation, the pyramidal cells release more glutamate
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cell sickness stage
neuropil structural change |
functional imaging (synapses less effective)
volumetric imaging |
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is schizo diffuse, uniform atrophy?
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no; preference for left-side atrophy (though it does not appreciably alter brain weight)
also, high proportion of cases with internal hydrocephalus |
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morphology in schizo
cortex? white matter? ventricles? |
1. reduction of frontal and temporomedial cortex (progressive widening of sulci) - decreased dendrites and spines
2. white matter abnormalities are not gross structural abnormalities 3. hydrocephalus |
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study of patient vs. control gray matter vs drugs
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patient gray matter starts lower (don't know if it's b/c of degeneration or it didn't form as well in development)
haloperidol showed more deterioration over time (cause or compliance?) olanzapine showed gray matter maintenance compared to non-treated |
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during prodromal and onset/progression/deterioration phase of schizo, you see
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neurochemical dysregulation
-sensitization by dopamine -excitatory neurotoxicity of glutamate |
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during chronic/residual phase of schizo, you see
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neurodegeneration?
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the difference between the premorbid level and chronic/residual level is
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margin of prevention
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in schizo, natural history follows...
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pathophysiology
*early intervention and prevention is necessary key* best hope is to prevent progression rather than regenerate after progression |
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rates of ___ and ___ are about two times higher in women
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major depression, dysthymia
(SAD is also much higher in women) |
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prevalence for ___ is about 2-3x higher in women, except ___
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anxiety disorders (panic, agoraphobia, specific phobia, GAD, PTSD)
except OCD and social phobia, where rates are equal |
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gender of:
bipolar type I bipolar type II |
type I - about equal
type II - more women (and more mixed episodes, more rapid cycling = more severe course) |
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gender of schizophrenia
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about equal, though onset is later for women (25-35) with biomdal distribution...may be because of puberty/hormones?
women have higher premorbid functioning and social functioning ...plus a *more benign course* |
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gender of substance abuse
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men 2-4x more
women with affective d/o are more at increased risk |
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gender of personality d/o
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women higher for borderline, histrionic
men higher for anti-social, narcissistic, obsessive-compulsive (is it just dx difference though?) |
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women and depression...why?
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-biological vulnerability
-reproductive events (menstrual cycle, pregnancy, post-partum, menopause, hormone therapies) -psychosocial factors (gender-based violence, socioeconomic status, multiple roles) |
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higher incidence of major depression in women at ___; less marked ___
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puberty
post-menopausal |
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prevalence of PMDD
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5%
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suicidal behavior more common in ___ estrogen states
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low (thus, higher suicidality outside ovulation)
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huge rate of _____ immediately after pregnancy
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psych admissions (hormones or stress of baby?)
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hormones and mood (list)
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estrogen
progesterone LH FSH testosterone HCG prolactin oxytocin |
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why does estrogen have anti-depressive effect?
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estrogen decreases activity of MAO/COMT, thus increasing serotonin in cleft
progesterone does the opposite |
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physical symptoms of PMS, PMDD
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hypersomnia, hyperphagia, fatigue, bloating, breast tenderness, muscles aches, joint pain, swelling of extremities
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psychological symptoms of PMS, PMDD
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depression, anxiety, irritability, anger, affective lability, sensitivity to rejection, poor concentration, sense of feeling overwhelmed, social withdrawal
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symptoms of PMS, PMDD begin...
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luteal phase, resolve completely by onset of menses (this is when progesterone is at its peak)
PMDD has >5 symptoms in most cycles PMDD can really impair function; distinct in that you don't see symptoms in follicular phase (which would suggest underlying mood disorder) |
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PMDD tx
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1. exercise
2. SSRIs (fluoxetine, paroxetine, sertraline) 3. CBT 4. calcium, vitamin B6, Mg, vitamin E 5. hormone therapy 6. chasteberry is questionable |
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increased risk for first depressive episode during
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menopausal transition (perimenopause = time of irregular periods)
decreased risk of first episode during post-menopausal period |
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estrogen replacement?
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effective for mild sx, but not major depression
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sx that overlap between menopause and depression
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fatigue,
sleep disturbances, low concentration, weight gain, libido change *depressed mood, anhedonia, worthless mood are NOT a normal symptoms of menopause |
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HCG when?
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curve is pretty much entirely in first trimester
(estrogen and progesterone peak right before birth and then just plummet) |
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rate of MDE during pregnancy
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10-15%
(high rate of relapse if anti-depressants are stopped during pregnancy--50-70%) **pregnancy itself is probably not either protective or destructive...it's the post-partum period |
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risk of bipolar relapse in pregnancy off meds
postpartum? |
same as non-pregnant women - 50%
postpartum risk is 4x higher |
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risk factors for depression in pregnancy
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prior episode
poor overall health greater alcohol use smoking unmarried unemployed lower education level |
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what might happen if depression is untreated in pregnant women
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-level of suffering bad- for mom and partner
-decreased prenatal care -suicide risk -low birth weight, preterm delivery, preeclampsia -postpartum depression and effects on family -smoking/drinking/drugs |
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tx of depression in pregnancy
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psychotherapy
light treatment omega-3 FA psychosocial supports no psychotropic meds are FDA-approved for pregnant women (too risky to ever test) *all meds cross the placenta *maximize non-med options, reduce meds and reduce depression |
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SSRIs in pregnancy
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no evidence of incr. overall birth defects (maybe more rare ones)
mixed evidence on birth weight and preterm neonatal toxicity no evidence of long term developmental effects |
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baby blues prevelance
sx peak of symptoms length tx |
50-85% (it is not an illness, but a normal emotional change -- probably a hormonal shift)
mood lability (hallmark commercial), anxiety, tearfulness, irritability day 4,5 may last a few hours to several days (does not interfere with functioning) reassurance rather than treatment **however, if sx last for more than 2 weeks, they should be evaluated for more serious mood disorder |
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postpartum psychosis prevelance
onset features differential: |
0.1%
24 hr - 3 weeks postpartum insomnia, obsessions, rapid mood swings, hallucinations, delusions (often involving infant care), impaired reality testing disorientation, disorganized behavior higher risk of suicide/infanticide (though still low overall)...thus psychiatric emergency, evaluate immediately differential: medically caused delirium, PPD, schizophrenia about 70% appear to be bipolar presentation (bipolar women at very high risk of PPP) |
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postpartum depression prevalence
risk factors differential criteria |
10-15%
prior episode, marital discord, unplanned pregnancy, infant medical problem, lack of social support, low socioeconomic status anemia, diabetes, thyroid same as for depression, though it's complicated b/c some symptoms align with motherhood (i.e. sleep disturbances)...but hopelessness, worthlessness, suicidality are not normal parts of postpartum period -comorbid anxiety with obsessional thoughts about the baby is common (worried they'll throw baby out the window)...need to distinguish from psychosis Edinburgh post-natal depression scale |
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tx for postpartum depression
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-psychotherapy (IPT, CBT, supportive, psychodynamic, couples, group)
**improved social supports** -help with infant care -light therapy -meds: SSRIs, tricyclics, benzos if comorbid with anxiety NB: all psychotropic medications end up in breast milk (concentrations vary widely; peak concentrations attained at 6-8 hours, but it's hard to work around that)...so you don't want to remove protective effects of breastfeeding, but you don't want a mentally unhealthy mom infant toxicity depends on exposure and hepatic metabolism...relationship is unclear; THM: monitor these infants well |
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T/F: many women are reluctant to seek treatment
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T
diagnosis often missed even so, risks and benefits of treatment and non-treatment must be carefully considered |
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difference between personality d/o and personality traits
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disorder - enduring pattern of **maladaptive** or *inflexible* thinking, feeling, acting that cause distress and/or impairment of functioning -- maladaptive extreme (either too much or too little) of trait
traits - pattern of interacting with environment and other people |
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criteria for personality d/o
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A. an enduring pattern of inner experience and behavior that *deviates* markedly from the expectations of your culture in at least TWO of the following ways:
1. cognitive 2. affectivitiy 3. interpersonal functioning 4. impulse control (thus you need to consider inner experience AND overt behavior...important to consider culture too) B. the pattern of behavior is *inflexible* and pervades a broad range of social and personal situations (if behavior is restricted to one person or situation, it's a relational problem or Adjustment Disorder) C. leads to distress or impairment in social/occupational/other functioning D. stable, can be traced back to adolescence E. not better accounted for as manifestation of Axis I mental d/o (Axis II is personality d/o's)...keep in mind that Axis I can be chronic too F. not due to substance or general medical condition (e.g. head trauma) |
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personality = __ + __
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temperament + experience
Personality disorders often linked to bad childhoods (though not always) they are hard to treat b/c of how entrenched they are don't want to dx in kids, usually, b/c they are still adaptable |
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Cluster A:
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odd (often look odd):
schizoid schizotypal paranoid |
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Cluster B:
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dramatic:
antisocial borderline histrionic narcissistic |
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Cluster C:
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anxious:
avoidant dependent obsessive-compulsive |
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paranoid can be self-fulfilling because
paranoid presentation |
being mistrustful of others may cause them to act in cautious/deceptive ways
may not seek help b/c they don't trust psychiatrist; usually wife makes them come in, but many can't manage to have long-lasting relationships hostility, irritability, avoidance, anxiety often secondary to the paranoids beliefs |
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schizoid presentation
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unable to form personal relationships or respond to others in an emotionally meaningful way; indifferent, aloof, detached, unresponsive to praise, criticism, etc
loners, no desire for friends unlikely to present, less likely to benefit from treatment |
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schizotypal
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schizoid + odd beliefs, speech patterns, paranoid tendencies, perceptual illusion, inappropriate affect
prodromal schizophrenia? low dose of genetic load? |
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borderline
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intense, chaotic relationships whith fluctuating and extreme attitudes toward others
self-destructive behaivors, unstable affect, lack clear sense of identity **suicide attempts and self-mutilation may result from rejection or disappointment in relationships substance use may trigger transient psychotic breaks |
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histrionic personality d/o
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attention seeking, self dramatizing, excessively gregrarious, seductive, manipulative, exhibitionistic
shallow emotions, labile, vain, demanding |
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narcissistic
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egocentric grandiose, crave admiring attention and praise; place excessive emphasis on displaying the accoutrement of beauty, power, fame, wealth
use relationships to meet their own selfish needs with little consideration for others' needs feel "entitled" to special rights, attention, privileges, and consideration has to be fairly extreme to cause problems, otherwise they get away with it pretty well |
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avoidant
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inhibited, introverted, anxious behavior
low self-esteem, hypersensitivity to rejection, social awkwardness, timidity, social discomfort ,*self conscious fears or being embarrassed or acting foolish* |
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dependent
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e.g. 45 y.o living at home
reliance on others, allow them to make important decisions, feel helpless when alone, subject own needs to those of others, tolerate mistreatment not uncommon for them to be in relatinoship with controlling, domineering, or overprotective person |
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obsessive-compulsive P.D.
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perfectionist, excessively disciplined
behavior is rigid, formal, emotionally cool, distant, intellectualizing, and detalied driven, aggressive, competitive, impatient, chronic sense of time pressure and inability to relax excessive tendency to be in control of themselves/others/life situations |
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MSE components
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appearance
behavior/attitude/speech mood affect thought process thought content cognitive perception insight judgment |
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what should be noted in appearance/behavior/speech/attitude
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grooming, clothing, motor behavior **psychomotor agitation** (increase in body movements, e.g. hand wringing, pacing)
**psychomotor retardation** (slow speech and body movements, lack of usual fidgetiness) rate, volume, modulation of speech interaction with interviewer |
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mood normal descriptor
abnormal descriptors |
euthymic
dysthymic (depressed), sad, irritable, **expansive** (enthusiastic), **euphoric** (feeling great) these are subjective feeling states of the individual |
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affect normal descriptor
abnormal descriptors |
full range
blunted, flat, constricted, labile (unpredictable shifts in emotional state), inappropriate (not congruent with patient's thoughts objective, observed by clinician |
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thought process normal descriptor
abnormal descriptors |
coherent and goal directed
1. tangential 2. circumstantial 3. loosening of associations (disorganized; lapses in connections between thoughts) 4. word salad - incomprehensible speech, lapses of connection within sentence even 5. flight of ideas (flow is rapid, connections intact) 6. blocking (pt must confirm) 7. neologisms organization of thoughts reflected in verbal productions |
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thought content normal descriptors
abnormal descriptors |
no evidence of delusions; denies suicidal/homicidal ideation; denies obsessions
1. delusions - firmly held false belief not shared by others - NO reality testing 2. overvalued ideas, including ideas of reference and paranoid ideation - like a delusion, but not firmly held...reality testing maintained 3. obsessions - intrusive ideas, egodystonic, thus reality testing is maintained 4. ruminations - egosyntonic 5. paranoid ideation - can be delusion or overvalued idea 6. paucity of thought 7. idea of reference (overvalued idea) 8. phobia - avoidance in spite of realizing its irrationality 9. suicidal/homicidal ideation theme of pt's thoughts during interview, as well as overt signs of psychopathology |
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perceptions normal descriptors
abnormal descriptors |
denies auditory and visual hallucinations
specific type of hallucination (auditory, visual, olfactory, tactile) and describe also, depersonalization, derealization |
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cognitive normal descriptor
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alert, attentive, and oriented x3
describe findings of: attention and orientation memory fund of knowledge complex functions abstract thought |
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insight normal descriptor
abnormal descriptor |
intact, excellent
fair, impaired understanding of self in the context of wanting or needing help; "observing ego" assessment of abilities regarding above |
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judgment normal descriptor
abnormal descriptor |
intact, excellent
fair, impaired refers to actions they will take based on insight...usually reflects impulse control |
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___ psychosis is waxing and waning in character
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postpartum
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concrete thinking would be ____ of a patient with mania
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uncharacteristic
(auditory hallucinations are characteristic) |
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rapid cycling
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4 episodes per year (can be at both poles or not)...usually remittance in between...continuous cycling is bad sign
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__ is common in mixed states
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psychosis
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mixed states, treat with ___
def. of mixed state |
bipolar meds, NOT anti-depressants
may respond more slowly to treatment **high risk of suicide b/c depress + energy** aka "ultrafast rapid cycling" - mood changes over course of hours or a day |
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pseudodementia from depression ___s after meds
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resolves
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rapid cycling more common with
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bipolar II
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__% of schizos commit suicide
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10-15%
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__% of recurrently depressed will commit suicide
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15%
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delirium
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inability to focus or shift attention, perceptual disturbances, *waxing and waning mental status*
visual hallucinations common |
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dementia
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must have both memory impairment and one of the following (aphasia, apraxia, agnosia, executive function impairment)...slow decline
confabulation |
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postpartum depression tied to
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bipolar (bipolar has 90% recurrence after delivery)
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estrogen treatment is better for
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perimenopausal than post menopausal
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