Psych

Front 1

Mental status

Back 1

Object characterization of current psychiatric state

general description, speech, mood, thought process, thought content, cognition, insight, judgement

Front 2

General description during a mental status exam

Back 2

Appearance
Behavior (facial expression, pyschomotor, movements, attitude toward you)

Front 3

Pyschomotor agitation

Back 3

Motor restlessness

Can reflect inner restlessness ie anxiety

Front 4

Pyschomotor retardation

Back 4

Body is slowed down

eg depression

Front 5

Mannerisms and tics

Back 5

Repeated, purposeless movements

grimacing, orofacial dyskinesias

Front 6

Catatonia

Back 6

Hypoactive to immobile
Often with abnormal posturing

Front 7

Speech evaluation in a psychiatric exam

Back 7

Rate
Volume
Idiosyncrasies of speech

Front 8

Blunted affect

Back 8

severely reduced expression of feeling

Front 9

Flat affect

Back 9

absent expression of feeling

Front 10

Labile affect

Back 10

unstable, rapidly fluctating affect

Front 11

Inappropriate affect

Back 11

laughing at a funeral

Front 12

Mood congruent

Back 12

Affect matching mood

Depressed patient appears depressed

Front 13

Affect

Back 13

Objective evaluation of a patient's display of their feeling

Front 14

Goal directed thought process

Back 14

Logical, coherent, easy to follow
Normal

Front 15

Loosening of association

Back 15

disconnections between thoughts

Front 16

Flight of ideas

Back 16

Patient moves quickly from one thought to the next

Front 17

Circumstantiality/Circumfrentiality

Back 17

Patient strays from the point but eventually returns

Front 18

Tangentiality

Back 18

Patient gets derailed form the topic never comes back

Front 19

Thought blocking

Back 19

Interruption of a train of thought before the idea is complete

Front 20

Perservation

Back 20

Repeating words phrases or sentences in a relatively meaningless way

Front 21

Delusions

Back 21

Fixed false beliefs not held by society/culture

Front 22

Paranoid/persecutory delusion

Back 22

"The FBI is out to get me"

Front 23

Grandiose delusion

Back 23

"I am the president"

Front 24

Referential delusion

Back 24

"The television is sending me messages"

Front 25

Somatic delusion

Back 25

"My heart is gone"

Front 26

Thought broadcasting delusions

Back 26

"My thoughts are being played over the intercom"

Front 27

Thought insertion delusions

Back 27

"Someone is making me think about hurting my mother"

Front 28

Hallucinations

Back 28

Sensory perceptions in the absence of stimuli
Audio - almost always pyschiatric
Visual - sometimes pyschiatric
Smell, taste, touch -- usually neurologic

Front 29

Illusions

Back 29

Misperceptions of benign stimulus

Front 30

Depersonalization

Back 30

Feeling of having lost ones sense of personal identity

Feel strange or unreal

Front 31

Derealization

Back 31

Feeling that everything around oneself is unreal or strange

Front 32

Disorientation

Back 32

Time, place, person
Time is most easily disturbed, person least

Common in delirium, mod/sever dementia

Front 33

Attention

Back 33

Ability to focus and direct cognitive processes

Without this, rest of cognitive testing (fnc) cannot occur

Front 34

Concentration

Back 34

Ability to sustain attention over time

Can be impaired in depression, anxiety, AD, also with poor effort

Tests - world, serial 7s

Front 35

Registration

Back 35

Capacity for immediate recall of new learning, last a few seconds

Repeating back 3 words

Front 36

Short term memory

Back 36

Recall lasting seconds to minutes
"Working memory"

Recall of 3 words after 1 to 5 minutes

Front 37

Long term memory
2 types

Back 37

Semantic - general knowledge bank (name last 4 presidents)
Episodic - important personal events, usually best preserved

Front 38

Construction

Back 38

Ability to make 2 or 3 dimensional objects
Involves visuospatial/visuomotor skills

Front 39

Abstraction test

Back 39

Similarity
Proverbs

Front 40

Insight/judgement

Back 40

insight -- knowledge involved in decision making

judgement -- opinion or conclusion arrived at

Front 41

Mood

Back 41

Subjective state patient expresses about their feeling

Typically state in patients words

Front 42

Components of cognition

Back 42

Orientation
Attention and Concentration
Memory
Visuospatial
Abstraction
Insight and Judgement

Front 43

Digit span

Back 43

Test of attention

Slowly read set of numbers to patient and the have then repeat back

Front 44

Patient characteristics psychiatric emergencies

Back 44

Young adults
Lower SE class
Chronic issues w/ acute exacerbation

Front 45

Behaviors prompting emergent pyschiatric evaluation and treatmetn

Back 45

Suicidal, violent, agitate/extremes of affect, withdrawn

Front 46

Suicide

Back 46

Attempt to escape an unbearable anguish
Sometimes chronic/somtimes transient
Not always associated with psychiatric diagnoses
Mood disorders, schizophrenia, substance abuse

Front 47

Risk factors for completing a suicide attempt

Back 47

Male
Increasing age (to 50 for women, 75 for men), also adolescents
Previous attempts
Single marital status
Unemployed/recent job loss (esp professional)
Psychiatric disoder
Medical problems

Front 48

Suicidality evaluation

Back 48

Intentionality -- expressed level of desire to die
Lethality -- how lethal is the plan
Means -- does patient have means to carry out plan
Viability -- what is the patients ability to accept help

Front 49

Suicide "gesturer"

Back 49

Plan unlikely to succeed
Acute interpersonal conflict

Often 20-40 women, younger people with personality disoders

Front 50

Hospitalization of a suicidal patient

Back 50

Needs to occur when plan is lethal, desire to die is high, viability is low, or external support is unavailable

Not always possible to do voluntarily

Front 51

Violent or combative patients

Back 51

Typically have history of violence
Typically men 15-30 (also elderly w/ dementia)
Low self esteem, embittered
Disinhibition by drug/alcohol common
Often become violent after embarrassment or losing face

Front 52

Organic states resulting in violent behavior

Back 52

Drug (esp PCP)/alcohol
Delirium
Dementia
Partial complex seizures - rarely

Front 53

Psychiatric diagnoses associated with violent behavior

Back 53

Schizophrenia
Mania
Paranoia
Character disturbances

Front 54

Medication in the violent or combative patient

Back 54

Use of neuroleptic and benzodiazapines

Halperidol 5-10 mg w/ lorezapam 1-2mg
available IM
Newer - IM ziprasidone

Front 55

Tenets of pyschosocial model of development

Back 55

1. Most kids are normal
2. Development has consistency, but also variations
3. Most parents are trying and will be "good enough" parents
4. Changes in development always set off a cascade of change
5. Intervention should be based in strengths not weaknesses

Front 56

Erikson stage I

Age
Crisis
Outcome

Back 56

First year of life
Trust vs Mistrust
Trust and optimism

Need consistent nurturing

Front 57

Erikson stage II

Age
Crisis
Outcome

Back 57

Second year of life
Autonomy vs Shame/Doubt
Sense of self, control and mastery

Need to avoid overly critical or hovering parents

Front 58

Erikson stage III

Age
Crisis
Outcome

Back 58

3-5 yrs
Initiative vs guilt
Purpose and direction, ability to initiate

children start to form relationships with others

Front 59

Erikson stage IV

Age
Crisis
Outcome

Back 59

6- puberty
Industry vs inferiority
Competence in intellectual, physical, social skills

Competition also enters

Front 60

Erikson stage IV

Age
Crisis
Outcome

Back 60

Adolescence
Identity vs role confusion
Integrated sense of unique self

Front 61

Erikson stage V

Age
Crisis
Outcome

Back 61

Early adulthood
Intimacy vs Isolation
Close and lasting relationships, career development

Front 62

Erikson stage VI

Age
Crisis
Outcome

Back 62

Middle adulthood
Generation vs self absorption
Concern for family, future generations

Front 63

Erikson stage VII

Age
Crisis
Outcome

Back 63

Aging years
Integrity vs despair
Sense of fulfillment, leaving a legacy

Front 64

Risk factors for mental health problems in kids

Back 64

Chronic medical problems (self or family)
Brain damage
Temperament (aggressive, uninhibited)
Genetics
Family
Stress

Front 65

Mental age

Back 65

Intellectual age of a child

Can be assessed using Stanford Binet

Front 66

Neurologic development during childhood

Back 66

Nerve proliferation until 11 (girls) 12 (boys)
Pruning organizes things during adolescence
Prefrontal cortex develops last -- normal for adolescents to be somewhat impulsive

Front 67

6 week developmental milestone

Back 67

Social smile

Front 68

2 month developmental milestone

Back 68

Head upright and steady

Front 69

4 month developmental milestone

Back 69

Roll over

Front 70

6 month developmental milestone

Back 70

Sits alone

Front 71

8-10 month developmental milestone

Back 71

Stranger anxiety
Pulls to stand

Front 72

12 months developmental milestone

Back 72

Walks
Uses cup

Front 73

12-24 months developmental milestone

Back 73

Talking
Single words, 2 word phrases

Front 74

18 month developmental milestone

Back 74

Throws ball

Front 75

3-4 years developmental milestone

Back 75

Draws closed circle

Front 76

4 years developmental milestone

Back 76

Hops on one foot
Dresses self with help

Front 77

Temperament in infant

Back 77

Consistent style or pattern of behavior

Activity level
Rhythmicity
Approach/withdrawal
Adaptability
Intensity
Response threshold
Mood
Distractibility
Attention span
Persistance

Front 78

"easy, difficult, slow-to-warm-up" temperament clusters in infants

Back 78

Easy - positive mood, adaptable, regular, approachable, low/moderate expressiveness
Difficult - negative mood, not adaptable, irregular, highly expressive, highly active
Slow to warm up-- not adaptable, not approachable, low expressiveness, low activity level

Front 79

Emotional development

Back 79

From general states -- "excited"
to specific emotions -- "anger or delight"

Anger -- expressed by frustration often peaks around 2 when autonomy is threatened

Front 80

Attachment

Back 80

Affectionate tie between two people

Front 81

Bonding

Back 81

Selective attachment that is maintained event when there is no contact

Front 82

Attachment behavior

Back 82

Behavior in infant that promotes proximity or contact with attachment figure

Front 83

Phases of attachment

Back 83

Undiscriminating social responsiveness 0-3 months
Discriminating social responsiveness 3-7 months
Actively seeking proximity and contact: 7 months - 3 years
Goal directed partnership 3 years +

Front 84

Mahler infant/mother dynamics theory

Back 84

First symbiosis - infant sees mother as part of self (normally up to 5 months)
-- social smile
Separation-individuation -- infant develops distance from mother

Front 85

Mahler subphase: differentiation

Back 85

5-10 months
Infant begins to move away physically

Stranger anxiety

Front 86

Mahler subphase: practicing

Back 86

10-16 months
More physical distance -- walking
More exploration
Separation anxiety occurs

Front 87

Mahler's third subphase: Raprochment

Back 87

16 to 24 months
Self awareness ---> anxiety and conflict

Wants to stay close AND wants to explore

Front 88

Mahler's fourth subphase: Object constancy

Back 88

24 to 36 months
Child able to retain internal representation of mother

Tolerates separations with knowledge of reunion

Front 89

Basis of attachment behavior (bowbly)

Back 89

Survival of infant
Needs attention

Will persist even in the face of maltreatment

Front 90

Disturbing attachment process?

Back 90

Leaves the infant insecure as an adult

Front 91

Strange situation

Back 91

A test of attachment
Mother leaves infant and stranger approaches
Mother reappears

Infant goes toward mother and is readily soothed = strong attachement

Front 92

Better attachment leads to what in kids

Back 92

Reliance on parents for help -- 18 months
Better liked by peers
More independent in preschool
Less problem behaviors in school

Front 93

Insecure-avoidant attachment

Back 93

In Strange Situation, infant ignores mother on return and focuses on toys

Front 94

Insecure-resistant attachment

Back 94

In Strange Situation, infant seeks mother on return but cannot be comforted. Show signs of anger

Front 95

Insecure-disorganized attachment

Back 95

In Strange Situation, easily startled, approach parent with head down, disoriented and freezing behavior

Front 96

Failure to thrive in infancy

Back 96

Disorder related to attachment

Abscence/lack of attachment
Growth failure and poor health

"hospitalism"

Front 97

Separation Anxiety Disorder

Back 97

Attachment related disorder
Normal in infants/toddlers

Not normal in school aged children
Symptoms of depression, difficulty concentrating

Front 98

Reactive Attachment Disorder

Back 98

Inhibited -- withdrawn, unresponsive

Disinhibited -- inappropriate approach to stranger

Treat with facilitated 1:1 with primary care giver

Front 99

Chronic exposure to stress in a child

Back 99

Disrupts attachement
Changes brain -- HPA axis, morphology, memory disruption

Constant, moderate -- resiliance
Unpredicatable, chronic --vulnerability

Front 100

Effects of severe abuse and neglect on childhood behavior

Back 100

Aggressive
Distrustful
Impulsive
Isolating

Front 101

Schema's of Piaget

and effect of new knowledge

Back 101

Way to organize knowledge

New knowledge is assimilated in or
causes accommodation of existing or creation of new schema

Front 102

Sensorimotor stage
Piaget

Back 102

0-2
Perceive and manipulate
No reasoning
Language begins
Object permanence obtained

Front 103

Preoperational stage
Piaget

Back 103

2-7
Symbolic thought
Egocentrism
Lack of concept of conservation

Front 104

Where does thought fail with concept of conservation?

Back 104

Centration - focus on one dimension

Irreversibility of thought -- cannot imagine things going in other direction

Front 105

Concrete operational

Back 105

7-12
Increasingly logical
Understanding of mental operations
Categorization and classification
Less egocentric
Able to think abstractly/hypothetically

Front 106

Formal operational

Back 106

12-adulthood

Hypothetico-deductive reasoning

Adolescent egocentrism show by personal fable and imaginary audience

Front 107

Critique of Piaget

Back 107

Underestimates kids abilities
Overestimates differences in thought
Vague about process of change
Underestimates environment
Lack of evidence

Front 108

Language development

Back 108

Newborns can differentiate sounds

Babble up to 6 weeks
Filler syllables to 5 months
Consonants from 5 mo - year
Words 8-18 months
200 words by age 2
Pronouns by 2
Rules of grammar by 4

Front 109

Gender identity

Back 109

Parents tend to gender infants
By 1 infants can tell difference in faces
By 2 gender id
By 3 gender categories
3-6 gender stereotyped play
6-7 gender segregated groups

Front 110

Repression

Ego Defense Mechanism

Back 110

Preventing painful or dangerous thoughts from entering consciousness

Front 111

Sublimation

Ego Defense Mechanism

Back 111

Working off unmet desires or inappropriate thoughts through activities

Changing an unacceptable instinct into a socially acceptable one

Front 112

Denial

Ego Defense Mechanism

Back 112

Protection from unpleasant reality by refusing to perceive it

Front 113

Rationalization

Ego Defense Mechanism

Back 113

Substituting socially acceptable reasons

Front 114

Intellectualization

Ego Defense Mechanism

Back 114

Ignoring emotional aspects of an painful experience by focusing on abstract thoughts, words, ideas

Front 115

What are ego defense mechanism for?

Back 115

Distorting reality to avoid failing to satisfy both the id (pleasure) and superego (society)

Front 116

Projection

Ego Defense Mechanism

Back 116

Transferring unacceptable motives or impulses to others

Front 117

Reaction formation

Ego Defense Mechanism

Back 117

Refusing to acknowledge unacceptable feelings, urges, thoughts by exaggerating the opposite of them

Front 118

Regression

Ego Defense Mechanism

Back 118

Reacting to a threatening situation in a way appropriate for an earlier age or level of development

Front 119

Displacement

Ego Defense Mechanism

Back 119

Substituting a less threatening object for the original object or impulse

Front 120

Social development sequence

Back 120

Born - regards face
1 month - spontaneous smile
2 months - responsive smile
5 months - work for toy
8 months - wave bye
10 months - communicate want with pointing
12 months - pat-a-cake: joint attention

Front 121

Language development sequence

Back 121

1 month- respond to bell
2 months- ooh/ahh
4 months - laugh
6 months - turn to voice
9 months - mama/dada -- babble
12 months - mom/dad specific

Front 122

DDx for being non verbal

Back 122

Hearing problems/Auditory processing disorders
Oromotor dyspraxia
Cerebral palsy
Selective mutism
Autism spectrum
Downs, fragile x, klinefelters

Front 123

Austism
3 features

Back 123

Impaired communication
Impaired social functions
Repetitive behavior

Front 124

Autism cognition

Back 124

40-60% have impairment

Front 125

Autism gender ratio

Back 125

4:1
Boys: girls

Front 126

Genetics of Autism

Back 126

Twins/siblings associated with increased risk

A number of genes identified

Associated with tuberous sclerosis, fragile X, pku, congenital rubella, thalidomide

Fathers>40 6x more likely that Fathers<30

Front 127

DSM of Autism

Back 127

Abnormal function/delay prior to 3 of
A. Social fnc
B. Language as communication
C. Repetitive behaviors

Not Rhett's or childhood disintegrative

Front 128

Autism loss of social fnc criteria

Back 128

Need 2
Impaired use of non verbal communication - eye contact, facial expression, posturing

Failure to develop peer relationships

Lack of spontaneous seeking to share interests (no bringing, pointing)

Lack of social/emotional reciprocity, not wanted to play social games, ec

Front 129

Autism communication impairment critera

Back 129

Need 1
Failure to develop verbal language without compensation with gesture

With language, but difficulty conversing

Stereotyped or repetitive language

Lack of imagined play, social mimicry

Front 130

Autism repetitive behaviors criteria

Back 130

Need 1
Encompassing preoccupation with activity that is inappropriate in intensity or focus

Inflexible adherence to rituals

Sterotyped, repetitive motor mannerisms

Persistent preoccupation with parts of objects

Front 131

Treatments in autism

Back 131

Applied Behavior Analysis
Teaches appropriate behavior
Antecedent, behavior, consequence

30 hours a week may change behavior

Occ therapy
- sensory
Physical therapy
Speech therapy (augmented comm)

Front 132

General patterns in early gross motor development

Back 132

Cephalad to caudal
Flexion to extension

Front 133

DDx for delay in walking

Back 133

Problems in
Brain
Spinal cord
Peripheral nerve
Muscle
Bone

Front 134

Fine motor task progression

Back 134

0-6 months going from flexed hands to extended hands

7-12 bringing hands together, mastering thumb finger

Front 135

Cerebral palsy

Back 135

Non progressive motor function deficit
See echodensities in periventricular white matter
Not related to birth trauma

1-5/1000

50% have global developmental delay

Front 136

Treatment of cerebral palsy

Back 136

Braces, assist devices
PT/OT
Surgery to release a limb
Meds to decrease tone/ improve fnc

Front 137

What defines adolescence?

Back 137

Appearance of secondary sexual characteristics

Front 138

Who experiences peer group issues related to puberty the most?

Back 138

Early maturing girls
Late maturing boys

Front 139

Growth spurt first or sexual maturation?

Boys or girls first?

Back 139

Growth spurt by a year

Girls by 2 years
within a family

Front 140

Peer group development in adolescence

Back 140

Early - same sex
Middle - mixed groups
Late - pairing

Front 141

Appearance development in adolescence

Back 141

Part of self exploration

early - neglect
middle -- take on appearance of a group
late - individualization

Front 142

Affiliations development in adolescence

Back 142

Family
Groups, clubs, teams
Close peers, self-define friendships

Front 143

Sexuality development in adolescence

Back 143

Abhorrent but fascinating
Experimentation
Continued relationship development

Front 144

Early adolescence

Back 144

11-13
Physical changes begin
Same sex peer groups
Neglect appearance
Crushes
Conflicts between parents and friends

Front 145

Middle adolescence

Back 145

14-16
Abstract thinking begins
Mixed peer groups
Sexual exploration
Rejection of parental values
--often initially adopt extreme values (idealism)

Appearance important

Front 146

Late adolescence

Back 146

16+
Good abstract thinking
Argue
Still challenge parental values
Idealism blends with pragmatism
Relationships become more serious
Decreased importance of appearance

Front 147

Unsuccessful outcome of identity vs identity diffusion (adolescence)

Back 147

Identity confusion
Psychological dependence
Social isolation
Impulsivity and aggression

Front 148

Successful outcome of identity vs identity diffusion (adolescence)

Back 148

Cohesive sense of self
Goals for future
Identity separate from family
Self-confidence within peer group

Front 149

Risk and teenage mind

Back 149

Trial and error is going to happen

Risk assessment is difficult

Front 150

Increased likelihood of living to be 100

Back 150

Lean
Non smoker
Old relatives
Handle stress above average

Most have avoided chronic medical conditions

Front 151

Predictors of health at 70-80 in Valliant Harvard Study

Back 151

No or moderate smoking
No alcohol abuse
No depression
Humor and ability to anticipate
Warm marriage
Good physical health

Front 152

Nun's study--protective factors for aging well vs developing Alzheimer's

Back 152

High idea density as teens - 85% predictive
Staying mentally active
Avoiding strokes, head injuries
Diet high in folic acid

Positive outlook expressed in teen had longer overall survival

Front 153

Modifiable factors in aging

Back 153

Exercise
Diet
Coping skills
Social support

With the exception of extreme longevity, genetics have <50% effect on aging

Front 154

Exercise while aging?

Back 154

Those who started during midlife had almost as much protection from disability as life long exercisers

Front 155

Participating in cultural activities does what for the elderly?

Back 155

Great physical health assessment
Fewer doctors visits
Less meds
Fewer falls
Less loneliness
Greater total involvement in activity

--controlled trial

Front 156

What does social engagement do in nursing homes?

Back 156

increases survival

Front 157

Selective Optimization with compensation

Back 157

Successful aging strategy based on experience

Risk activities to a few domains
Optimize reserves, choices
Compensation with technology

Front 158

Neurobiological explanations of wisdom

Back 158

Myelin continuous production (peak at 50)
Reduction in hemispheric asymmetry
Reduction in amygdala activation (more able to cope with stress)

Front 159

Mature coping skills

Back 159

Humor
Altruism
Sublimation
Anticipation
Suppression

Front 160

Prevalence of pyschiatric diagnosis in US children and adolescents

Back 160

14-20%
1 in 4 receive treatment
Comorbitiy is the rule

Front 161

Cardinal features of ADHD

Back 161

Inattention
Hyperactivity
Impulsivity

Girls more likely to have inattentive subtype

Front 162

Major depressive disorder in kids epi

Back 162

More common in adolescents than kids
7.7% of 14-18s
Boys=Girls in childhood
Girls 2x more likely as adolescents

Front 163

Major depressive disorder presentation in kids

Back 163

May not acknowledge depressed mood

Oppositional
Irritable
Physical complaints
Aggression

Front 164

Major depressive disorder diagnosis in childhood increases chance of being diagnoses with

Back 164

Bipolar disorder
>25% chance

Front 165

Treatment of child/adolescent major depression

Back 165

Multimodal
Pyschotherapy, social interventions, meds

Pharma is controversial

Suicidality assessment is very importat

Front 166

OCD features

Back 166

Obsessions -- recurrent thoughts, urges, impulses

Compulsions -- repetitive behaviors or mental acts

Causing distress and inferring with fnc

Front 167

OCD prevalence in children

Back 167

1-2%

Initially more boys than girls, then evens

Front 168

Comorbid psychiatric disease with OCD

Back 168

Tourette's
other anxiety disorders
major depression
vocal/motor tics

Front 169

Treatment of OCD

Back 169

SSRI + CBT with exposure/response

80% improve but 40-70% still meet criteria

Front 170

Projective testing

Back 170

Testing drive, conflict, intrapsychic defense structure

Uses highly unstructured stimuli

Front 171

Risk factors for kids developing psychiatric illness

Back 171

Chronic health problems
Brain damage
Temperament (aggressive, behaviorally inhibited)
Genetics
Family factors
Psychosocial factors/Stress

Front 172

Suicide attempt prevalence in adolescents

Back 172

9% overall
12% of females
5% of males

Front 173

SSRIs and suicide in teens

Back 173

Conflicting evidence
Suicide attempts on trials
Suicide attempts in untreated depression

Thought that serotonin might be activating a previously depressed individual to at out behaviors

Front 174

FDA approved SSRIs for OCD in kids

Back 174

Sertraline >6
Fluoxamine >8
Fluoxetine >7
Anafril > 12

Front 175

FDA approved SSRI for depression in pedi patients

Back 175

Fluoxetine >8

Front 176

Behavioral inhibition

Back 176

A temperament, about 20% of Caucasians

Shy, Fearful
Novelty avoidance
Consistent over time
Long latency to verbal response
Sympathetic activation

Front 177

Anxiety begets anxiety

Back 177

Kids with anxiety (GAD, SAD) are more likely to have parents with panic disorder (21%) or other (81%)

Parents with depression/anxiety are more likely to have kids with SAD, inhibition, school phobia

Front 178

Anxiety prevalence in pedi patients

Back 178

10-20% meet criteria
Often goes undiagnosed

Front 179

What makes worry pathologic

Back 179

Intensity, pervasiveness, time consuming, debilitating

Front 180

Prognosis in anxiety spectrum disorders in children?

Back 180

>80% remit
1/3 develop a new adult disorder

Front 181

Positive reinforcement

Back 181

Turning on a positive stimulus in response to a behavior

Front 182

Negative reinforcement

Back 182

Turning off a positive stimulus in response to a behavior

Front 183

Punishment

Back 183

Turning on a negative stimulus in response to behavior

Front 184

Extinction

Back 184

Turning off a positive stimulus in response to behavior

Front 185

Success, failure, pseudo in the 20-30

Back 185

Committed love
Self-absorption
Absorption into other

Front 186

Success in Career vs self absorption

Back 186

Career w/ competence, compensation, commitment, and contentment

Childrearing

Front 187

Success in generativity vs stagnation

Back 187

Accept death, wisdom (vs power), guide/mentor role

Reconcile personal successes and failures
Focus is on community

Front 188

Failure in generativity vs stagnation

Back 188

Chronic depression
Midlife crisis

Front 189

Factors that might alter progression through stags

Back 189

Delay from physcial illness

Culture

Front 190

General pattern of development

Back 190

From self -- primary love object-- community -- world

Front 191

Domains of symptoms of mood disorder

Back 191

Mood state
Pyschomotor
Psychiatric
Physical

Front 192

Unipolar disorder
Define and diseases within

Back 192

Pts who moods only deviate towards depression

Adjustment disorder with depressed mood
Dysthymic disorder
Major depressive disorder +/-pyschosis

Front 193

Bipolar disorder and subtypes

Back 193

Experience of depression and mania

Type I - Mania +/- depression
Mixed state - very rapid cycling
Type II - Depression with hypomania
Type III - NOS

Front 194

Mood symptoms of a depressive disorder

Back 194

Sadness, apathy, irritability

Anhedonia
Loss of self-esteem
Feeling worthless/useless
Guilty

Front 195

Physical symptoms of a depressive disorders

Back 195

Weight loss
Weight gain (in atypical, SAD)
Sleep disturbance
with early morning or midcycle awakening
Decreased libido
Fatigue

Front 196

Physical symptom associated with severity of depression

Back 196

Amount of weight loss

Front 197

Movement symptoms associated with depressive disorders

Back 197

Psychmotor retardation
-everything gets slower

Psychomotor agitation
- increased risk of suicide with severe agitation

Front 198

Cognitive symptoms associated with depressive disorders

Back 198

Lack of concentration

Suicidal ideation

Front 199

Adjustment disorder with depressed mood

Back 199

Development of distressing emotional or behavior symptoms linked to an identifiable stressor within three months of onset

Significant functional impairment

Not bereavement

Front 200

Adjustment disorder with depressed mood prevalence and treatment

Back 200

Most common unipolar depression
Often untreated
Can be treated with brief psychotherapy, meds if situation in ongoing and not likely to resolve, short-term use of hypnotics for anxiety/insomnia

Front 201

Dysthymia diagnosis

Back 201

Depressed mood for most of the day on most days for two years

2/6:
Poor appetite or overeating
Insomnia or hypersomnia
Low energy
Low self-esteem
Poor concentration/difficult with decisions
Feelings of hopelessness

Not MDD, never been manic, not organic

Front 202

Double depression

Back 202

Dysthymia diagonsis
Followed by an MDD diagnosis

Poor prognosis

Front 203

Dysthymia treatment

Back 203

Pyschotherapy

Meds if not return to euthymia

Response to antidepressants less robust than MDD

Front 204

Dysthymia specifications

Back 204

Primary -- no other chronic Axis I or III diagnoses

Secondary -- chronic diagnoses

Early (<21) or late (>21) onset

Front 205

Major depression epi

Back 205

20% of US adults at one point in their life
Fall and winter prevalence increase
Genetic component

Front 206

Psychotic symptoms that can be seen with severe major depression

Back 206

Severe delusional thought content
Perceptual distortion
Auditory hallucinations of persecutory nature

Front 207

Major depression criteria

Back 207

5 everyday for two weeks
Depressed mood
Anhedonia
Worthless feelings, guilt
Diminished concentration/thought
Weight loss/gain, poor appetite
Pyschomotor agitation/retardation
Insomnia/hypersomnia
Suicidial thoughts

Front 208

SIGECAPSS

Back 208

Criteria symptoms of depression

Sad, interested, guilty, concentration, appetite, psychomotor, sleep, suicide

Front 209

MSE in Depression

Back 209

General -- Unkempt, agitation/retardation, poor eye contact
Affect-- constricted, teary
Mood --depressed/irritable
Speech -- slow, limited, quiet
Thought - hopeless, guilty, preoccupied with somatic complaints, delusional
Cognitive- distracted, difficulty concentrating
Insight -- impaired because of feelings of worthlessness

Front 210

Somatic preoccupations often seen in depression

Back 210

Cardiac
GU
Chronic pain

Front 211

Mood disorders and suicide

Back 211

50% of people who commit suicide are clinically depressed


15% of people with mood disorders commit suicide

Front 212

Tricyclic antidepressents

Back 212

Imipramine, desipramine, amitryptyline, nortryptylline, doxepin
Very effective
Lethal in overdose
May cause arrythmias even at low blood levels

Front 213

MAOIs

Back 213

Phenelzine, trancyclopromine
Effective
Need to avoid certain foods (wine, cheese, avocados)
Many SEs

Front 214

Second gen antidepressants

Back 214

Amoxapine, Maprotiline, Trazadone

Have many side effects
Trazadone used for sleep

Front 215

Venlafaxine is used for ...

Back 215

FDA approved for anxiety/depression

Front 216

Mertazipine is used for...

Back 216

Anxiety, increasing appetite

Front 217

Duloxetine is used for...

Back 217

Pain

Front 218

What's better about the SSRIs and other new meds vs older meds

Back 218

Safety profile
Few SEs
Better adherence

Front 219

ECT

Back 219

electroconvulsive therapy

Inducing a seizure under anesthesia
Mechanism for depression treatment unknown

Front 220

ECT indications

Back 220

Major depression
Bipolar depression
Psychotic depression
Mania/depression during pregnancy
Depression in elderly
Mania
Refractory schizophrenia
Neuroleptic malignant syndrome
Status epilepticus

Front 221

ECT side effects

Back 221

HA, nausea

Amnesia
retrograde - 6 months
anterograde during treatment

0.3% chance of permanent memory loss

Front 222

Repetitive transcranial magnetic stimulation

Back 222

Approved for refractory depression

Weak magnetic fields induced in brain by rapidly changing electric fields

Some risk of seizure in pts with epilepsy

Front 223

CBT in depression

Back 223

Cognitive behavior therapy
Interactive with therapist, homework assignments
Short term
Works on hopelesses about self/past/future

Good evidence base

Front 224

Interpersonal therapy

Back 224

Specific short term therapy for non-bipolar, nonpyschotic outpatient depression

Works on current interpersonal relationships

Changing interactions will get different results from world

Front 225

Criteria for Mania

Back 225

Dramatically elevated, expansive or irritable mood lasting for at least one week (or until hospitalization)

3+
Grandiosity
Decreased need for sleep
Talkative/pressured speech
Flight of ideas
Distractability
Increase in goal driven behavior
Excessive pleasure seeking with high risk

Front 226

DIGFAST

Back 226

Mania symptoms
Distractibility
Indiscretion (about consequences)
Grandiosity
Flight of ideas
Activity increase
Sleep, lack of need
Talkative

Front 227

General appearance of someone with mania in interview

Back 227

Psychomotor agitation
Seductive/colorful dress
Intrusive grooming
Entertaining
Bizarre
Threatening

Front 228

Criteria for hypomania

Back 228

4+ days of elevated mood and mania symptoms without significant impairment or need for hospitalization

Front 229

What's important in characterizing a bipolar disorder

Back 229

Mania ever -- biopolar I

Hypomania AND depression -- bipolar II

Front 230

Biopolar rapid cycling

Back 230

Mania/depression cycle in 2-3 days

May be difficult to treate

Front 231

Cyclothymic disorder

Back 231

Hypomania/depression alternating two years

Substance use common

Treatment of choice--lithium

Front 232

Lithium in bipolar

Back 232

Best choice for preventing the depression

80% response rate in type I

Acute mania can be managed with antipsychotics/ECT

Front 233

Long term SE of lithium

Back 233

Kidney failure

Front 234

AED's in biopolar

Back 234

If lithium is ineffective in controlling manias, adding an AED

topirimate, valproate, carmazepine, lamotrigine

Front 235

Antidepressants in bipolar

Back 235

Caution: may precipitate mania

Buproprion and paroxetine less so

May lower suicide risk

Front 236

Lifetime suicide risk with bipolar disorder

Back 236

19%

Front 237

Pyschotherapy in biopolar

Back 237

Lithium + pyschotherapy is better than either
Group, family, CBT

Not indicated during mania

Front 238

Symptom cluster in Schizophrenia

Back 238

Positive
Negative
Disorganization
Cognitive deficit
Mood symptoms

Front 239

General appearance of schizophrenic

Back 239

Neglect of hygiene
Social withdrawn
Impaired cue response
Apathy
Amotivation
Impaired functioning
Behavioral disturbance
Catatonia

Front 240

Speech characteristics in schizophrenic

Back 240

Inappropriately loud
Slowed
Pressured
Mechanical

Front 241

Mood in schizophrenic

Back 241

Depressed
Manic
Anhedonic
Flat, without mood

Front 242

Affect in schizophrenia

Back 242

Inappropriate
Flat
Pyschmotor agitation/retardation

Front 243

Thought process of schiozphrenic

Back 243

Latency
Thought blocking
Loose associations, tangential, word salad, Incoherence
Delusions
Ideas of reference
Magical thinking

Front 244

Erotomanic delusion

Back 244

A celebrity is my lover

Front 245

Somatic delusion

Back 245

Implanted device is listening in to my brain

Front 246

Perceptions of schizophrenic

Back 246

Hallucinations
Auditory or auditory +
Most often persecutory voices

Ilusions
Disortions

Front 247

Cognition in schizophrenic

Back 247

Impaired memory
Impaired executive fnc
Impaired motor planning
Impaired insight
Disorientation

Front 248

Criteria for Schizophrenia

Back 248

2+ for most of a month total >6 months
Hallucinations
Delusions
Disorganized speech
Negative symptoms
Disorganized behavior
AND
Social/occupational dysfunction
AND
No mood or medical condition explaining

Front 249

How to buy a diagnosis of schizophrenia with only one symptom

Back 249

Bizarre delusions
or
Hallucinations that are of running commentary
or
Hallucinations that are of 2 voices conversing

Front 250

With pervasive developmental disorders what symptoms must be present for diagnosis of schizophrenia?

Back 250

Hallucinations and delusions

Front 251

Schizoaffective disorder

Back 251

Major depressive, manic, or mixed symptoms
+
Schizophrenia symptoms

Delusions/hallucinations must persist for 2 weeks outside of mood episode

Mood should be present for substantial portion of duration

Substance abuse, medical exclusion

Front 252

Delusional disorder

Back 252

Non bizarre delusions >1 month
Never meet schizo criteria
Functioning, behavior not markedly impaired
Mood symptoms absent or brief
Exclude substance use, medical

Front 253

Schizophreniform disorder

Back 253

Meets criteria for schizophrenia except duration (impairment also not necessary)

Duration includes prodrome, active, residual

Front 254

Brief psychotic disorder

Back 254

Delusions, hallucinations, disorganized behavior or speech
Completely resolved by 1 month

At higher risk for developing schizophrenia

Front 255

Brief psychotic disorder subtypes

Back 255

By onset

Marked Stressor
Without marked stressor
Post partum

Front 256

Shared psychotic disorder

Back 256

Developing the same delusion as a close relationship partner holds

Front 257

Mood disorders with psychotic features, why not schizoaffective?

Back 257

Psychosis resolves when mood does

Front 258

What runs in families that have schizophrenia

Back 258

Schizotypal personality disorder

Front 259

Substance induced psychotic disorder

Back 259

Prominent hallucination/delusions
-more than typical of withdrawl or
intoxicaiton
Onset w/in month of use or cessation
Not better explained by other pysch diagnosis
Symptoms do not exist purely in delirium

Front 260

Psychotic disorder due to general medical condition

Back 260

Prominent delusions or hallucinations
Direct consequence of medical condition
Not better accounted for by other psychotic disorder
Not just during delirium

Ex pyschosis from herpes encephalitis

Front 261

Delirium

Back 261

Disturbance of consciousness
and perception

Frequently have non auditory hallucinations

Front 262

Dementia and psychosis

Back 262

Often happens

Front 263

Paranoid subtype of schizophrenia

Back 263

Preoccupation with delusions or auditory hallucinations

Not disorganized or catatonic

Front 264

Disorganized subtype of schizophrenia

Back 264

Disorganized speech, behavior
Inappropriate or flat affect

Front 265

Catatonic schizophrenia

Back 265

Extreme physical immobility, stupor
or excessive activation
Extreme negativism
Posturing
Sterotyped movement
Echolalia

--decreasing in frequency

Front 266

Residual schizophrenia

Back 266

Attenuated delusions, hallucinations, disorganization or catatonia

Front 267

Schizophrenia epi

Back 267

1% of population
0.5% population -- schizoaffective

Increased risk with lower SES, childhood trauma, exposure to stress in first trimester

Not just a genetic disease

Front 268

Onset of schizophrenia
When to treat?

Back 268

Onset typically teens-20s
Rare after 45

Initial episode response best to treatment

Longer untreated psychosis leads to overall poor treatment response, psychosis is toxic

Front 269

Brain changes in progression of schizophrenia

Back 269

Ventricular enlargement
Anterior hippocampal loss

Front 270

Gender difference in schizophrenia

Back 270

Women have later onset

Better response to traditional antipsychotics

Estrogen has neuroprotective effects and inhibits D2

Front 271

Course of schizophrenia

Back 271

Prodrome -- social, cognitive deficits for years
First episode-- treatment responsive
Active phase -- full syndrome, 3-4 decades
Residual phase -- 1/3 remission, 1/3 reduced symptoms in old age

Dopamine decreases at around 50

Front 272

Effectiveness of treatment?

Back 272

Get into a remission and stay on antipsychotics:

3% relapse rate

Front 273

Suicidality in schizophrenia

Back 273

20-40% attempt
10% complete

Usually in first decade of illness, in between psychotic episodes

Front 274

Violence risk in schizoprenia?

Back 274

When psychotic

Front 275

Clozapine in schizophrenics

Back 275

Can reduce sucidality and violence

Front 276

Schizophrenia and lifespan

Back 276

10-20 shorter
Worst if untreated
Suicide
Lung cancer - smoking rate
Poor self care
Chronic disease rates high
Med effects (weight gain, sudden cardiac death, neuroleptic malignant syndrome)

Front 277

Reward deficiency syndrome

Back 277

Schizophrenics are not getting enough reward from normal behaviors

Easier to get addicted to substances

50% lifetime, 25% at any time point
3-5x rate of substance abuse disorder

Can easily destabilize the schizophrenia

Front 278

Effect of drug use on schizophrenia

Back 278

Poorly med compliance
Higher relapse rate
Earlier onset
Poorer med response
Greater brain loss
Increase risk of violence, disease

Front 279

Nicotine and caffeine use in schizophrenia

Back 279

90% smoke

Shown to help with cognitive deficits
A form of self medicating

Front 280

Histology of schizophrenia

Back 280

Some atrophy, enlarged ventricles
Reduction in caudate, hippocampus

Disordered neuronal migration and connection

Front 281

fMRI of schizophrenic

Back 281

Deficits in hippocampus, prefrontal cortex

Front 282

Pathophysiology of schizophrenia

Back 282

Dopamine

Hyperactivity in mesolimbic system
Hypoactivity in mesocortical (cognitive and mood symptoms

Front 283

Drugs that inhibit NMDA receptors in normals can produce?

Back 283

Schizophrenia symptoms

A dopiminergic pathway is not be stimulated?

Front 284

Schizophrenia genetics

Back 284

50% coincidence in monozygotic twins
5% in parents of
10% in children, sibs of

Genes involved with GABA/glutamte/dopamine balance, learning, memory, neuronal plasticity

Front 285

COMT variant in schizophrenia

Back 285

COMT metabolized dopamine in prefrontal
Hyperactive COMT associated with schizo
Cannabis increases risk in this genotype

Front 286

Neurodevelopment model of schizophrenia cause

Back 286

Early brain abnormality (probably mesial temporal)
Hypofrontality develops
Mesolimbic system later becomes hyperactive

Front 287

Neurodegenerative model

Back 287

Glutamate dysregulation leads to neuronal apoptosis

Antipsychotics can protect rats during PCP (NMDA-antagonist) trials

Psychosis toxicity could be glutamate excitotoxicity as well

Front 288

First generation antipsychotics

Back 288

D2 antagonists

Clorpromazine, halperitold

Parkinsonian side effects

Front 289

Second generation antipsychotics

Back 289

D2,5HT antagonists

clozapine, atypical antipsychotics

Front 290

Third gen antipsychotics

Back 290

D2 partial agonists

aripiprazole

Front 291

Effects of antipsychotics

Back 291

Reduce acute symptoms
Prevent relapse into those symptoms

Some reduce neg symptoms and cognitive impairments

10-20% remission rate

Front 292

What helps reduce relapse in schizophrenia other than meds?

Back 292

Personal therapy
Supported work
Family intervention treatment -- esp

Front 293

Treatment of dual diagnoses

Back 293

Substance abuse + schizophrenia response rates better with integrated care of both problems by same team

Front 294

Suppression

Ego defense

Back 294

Conscious decision to postpone or avoid an emotionally troubling issue

Front 295

Altruism

Ego defense

Back 295

Addresses an emotional conflict through constructive attention to the needs of others, rather than self

Front 296

Passive aggression

Ego defense

Back 296

Anger expressed indirectly through passivity or inaction

Front 297

Turing against self

Back 297

Passive aggression that involves hostile feelings towards another directed toward self

Front 298

Dissociation

Back 298

Splitting off a portion of an experience
(consciousness, memory, identity, perception, or a combo) that would normally be integrated with other parts of the conscious self

Front 299

Hypochondriasis (somatization)

Ego defense

Back 299

Transfer of emotional conflict or painful feelings to somatic symptoms or complaints

Not malingering

Front 300

Fantasy

Ego defense

Back 300

Creation of self contained fantasies as means of restoring emotional equilibrium

Front 301

Splitting

Ego defense

Back 301

Inability to tolerate ambivalence

Involves concrete, typically intense black and white thinking and emtions that can shift back and forth depending on emotional state

Idealization and devaluation

Front 302

Having less mature ego defenses is associated with

Back 302

Axis I and II diagnoses

Front 303

Mature ego defenses

Back 303

Sublimation
Suppression
Altruism
Humor

Front 304

Neurotic defenses

Back 304

Associated with symptom formation, maladaptive character traits

Repression, displacement, isolation of affect, reaction formation

Front 305

Immature defenses

Back 305

Dissociation, acting out, fantasy, projection, hypochondriasis, splitting

Front 306

Narcissistic (psycotic) defenses

Back 306

Denial

Front 307

What delays development in Fruedian model?

Back 307

Conflict between a conscious desire and an unconscious desire/fear
Individual is perplexed by associated discomfort

Anxiety forms, defense activates and if its a bad one -- symptoms

Front 308

Psychic determinism

Back 308

All behavior is motivated

Front 309

Epigentic development of personality

Back 309

Experience is cumulative over time

Front 310

Elements of personality

Back 310

Character traits -- enduring patterns of expression
Coping style
Stress tolerance/management
Vulnerabilities

Front 311

In most of the country what is the percentage of patients with serious psychiatric illness receiving no treatment?

Back 311

50%

Front 312

Goals of community based care

Back 312

Help complete their life goals

Stable housing
Competitive employment
Symptom management
Freedom from addiction
Avoidance of hospitalization

Front 313

Big problem with chronic mental illness and emotion/mentation?

Back 313

Sense of hopelessness

Illness defined self

Front 314

Supported housing

Back 314

Regular community housing with optional mental health services

Studies show works as well as more structured for most people with chronic mental illness

Front 315

What responds better to treatment positive or negative symptoms?

Back 315

Positive

Front 316

Med compliance among the chronically mentally ill

Back 316

About 50%

Pts as likley to use alcohol/street drugs as psychiatric meds

Front 317

Work desire and employment rate in chronically mentally ill

Back 317

75% want to work
Unsupported- 15% are working

Front 318

Presentation of anxiety

Back 318

Subjective feeling of unease, apprehension, fear

Signs of sympathetic arousal : dry mouth, trembling, SOB, palpitations, urinary hesitancy, GI distress, unsteadiness, paresthesias

Front 319

Common presentation of major depressive disorder in the elderly?

Back 319

Anxiety

Front 320

General medical conditions causing anxiety disorders

Back 320

Hypoxia
COPD
delirium
hyperthyroidism
acidosis
hypoglycemia

Front 321

Substance induced anxiety disorder culprits

Back 321

Caused by exposure or withdrawl

Caffeine
Alcohol
Benzos
Amphetamines
Cocaine
Other adrenergics

Front 322

Areas of brain that have been implicated in anxiety

Back 322

Locus coruelus -- panic disorder
Amygdala - normal fear
Orbitofrontal-basal ganglia network
OCD

Front 323

Neurotransmitters involved with anxiety

Back 323

NE, serotonin, gaba

Front 324

Behavior of anxiety

Back 324

Conditioned response from pairing of unconditioned stimulus with conditioned stimulus

Fear where there is not danger

Front 325

Cognition of anxiety

Back 325

Catastrophizing

Front 326

Lifetime prevalence of an anxiety disorder

Gender

Back 326

25%

Women 2x men

This data excluded PTSD and OCD

Front 327

Treatment success in anxiety disorders

Back 327

Not as good as MDD

May mitigate but not get rid of symptoms

Front 328

Panic attack

Back 328

Discrete period of intense fear
Physical symptoms develop abruptly and resolve in less than an hour

palpitations, sweating, trembling, feel SOB, feel choking, chest pain, dizziness, separation from reality, fear of dying, paresthesias, chils/hot flashes

Front 329

Panic disorder

Back 329

Recurrent unexpected panic attacks

At least one is followed by a month+ of
fearing more attacks, fearing implications of attacks, changing behaviors to avoid

Not explained by medical other pyschological diagnosis

Front 330

Agoraphobia

Back 330

Fear of situations which are difficult to escape/ get help for a panic attack
and
Restriction of activities/distress doing activities
and
Not better explained by social phobia, etc

Front 331

What is feared in panic disorder?

Back 331

Physical symptoms

Front 332

Anxiety sensitivity

Back 332

Level to which someone fears the panic attack, can make a difference in developing panic disorder

Front 333

Behavioral action tendencies in anxiety

Back 333

Escape and avoidance
Procrastination
Jittery behaviors
Safety checks

Front 334

CBT in anxiety

Back 334

Psychoeducation
Modification of unhelpful stimuli
Exposure to phobic stimuli

Less focus on self-regulation because people are already spending too much time thinking about inner workings

Front 335

Treating panic disorder with agoraphobia

Back 335

Consider starting with some drugs
--if you can't think you can't do CBT
CBT with progressive exposure
interoceptive, naturalistic, in vivo

Front 336

Fear is maintained by

Back 336

Avoidance behaviors
- feel relief by avoiding
- also prevents any new learning

Faulty cognitions persist

Front 337

Exposure therapy

Back 337

Extinction of fear stimulus

Negative consquence (physical arousal) decreases over time with behavior

Front 338

Panic disorder exposure

Back 338

Fear is of the bodily sensations

Make run in place, feel racing heart
Challenging misinterpretations
racing heart does not equal MI
De-catastrophizing

Front 339

Social phobia, what is the fear?

Back 339

Embarassment

Front 340

Social phobia

Back 340

Marked and persistent fear that social performance with strangers will lead to embarassment
AND
Feared situation provokes anxiety
AND
Fear is self-recognized as excessive
AND
Avoidance/pained endurance
AND
Interferes with functioning

Front 341

Specific phobia

Back 341

Marked and excessive fear cued by presence or anticipation of specific stimulus
AND
Exposure evokes anxiety
AND
Recognition of excess
AND
Avoidance/pained endurance of phobia
AND
Interferes with fnc/distress about phobia

Front 342

What is feared in Generalized Anxiety Disorder?

Back 342

Bad things happening

Front 343

GAD criteria

Back 343

Excessive worry for most days for >6 months
AND
Worry in more than one domain
AND
Difficult to control worry
AND 3+
fatigue/restlessness, impaired concentration, muscle tension, sleep disturbance
AND
Impairment
NOT
other pysch/med diagnosis

Front 344

GAD predisposers

Back 344

Parental modeling
Uncontrollable negative events as child

Front 345

What do people worry about in GAD

Back 345

normal stuff

but too intensely, too often, out of control, focused on small matters too much

Front 346

Process of worry

Back 346

Mostly thought, verbal

Not imagined

Sympathetic arousal (which reduces emotions)

Front 347

CBT theory of GAD

Back 347

Worry is like avoidance

Worry inhibits emotional processing by focusing on verbal rather than imagined

Front 348

Treatment of GAD

Back 348

Education
Somatic relaxation
Reduction of avoidance
Worry exposure

Front 349

What is feared in OCD?

Back 349

The intrusive thought

Front 350

OCD criteria

Back 350

Obsessions or compulsions
AND
Recognition of excess
AND
Distress, time consuming >1hr/day
NOT
related to another Axis I, or medical

Front 351

Obsessions

Back 351

Recurrent and persistent thoughts, images, impulses that are intrusive and cause anxiety

Not simply excess of real life issues

Pt attempts to ignore, suppress or neutralize these thoughts

Thoughts are recognized as internal not inserted

Front 352

Compulsions

Back 352

Repetitive behaviors or mental acts that person feels compelled to perform in response to an obsession or as part of a strict rule

Behaviors are aimed at neutralizing a thought or avoiding a feared event, but are not causally linked to that event

Front 353

OCD treatmetn

Back 353

Meds
Exposure and response prevention
CBT

Front 354

Personality

Back 354

Pattern of cognition, behavior, emotion with which an individual interacts with the world and thinks of self

Individual has many character traits, usually flexible to fit situation

Front 355

Personality disorder

Back 355

Inflexible personality traits resulting in social/occupational/interpersonal problems

Lifelong

Front 356

Personality disorders affect on ego

Back 356

Usually ego syntonic

Problem is with others, not self

Front 357

When are personality disorders easiest to notice?

Back 357

High stress and interpersonal relationships

Front 358

Personality disorders prone to pyschotic episodes with stress

Back 358

Boderline
Schizotypal

Front 359

Base pathology in personality disorders

Back 359

Distorted internal representation of self and others

Front 360

Where do aberrant behaviors originate from in personality disorders

Back 360

Ego defenses
Usually immature ones
Trying to prevent harm in a hostile internal environment

Front 361

Etiology of personality disorder

Back 361

Many dysfunctional/abusive families
-although not necessary or sufficient
Genetic factors

Develop view of world: unstrustworthy, unpredictable, overly demanding or dangerous

Front 362

Acquired personality disorders?

Back 362

From

Frontal lobe trauma
MS
Seizures
Dementing processes

Front 363

Cluster A

Back 363

Odd, Eccentric
Difficulty interpreting of environment, social cues, connecting with others

Paranoid, schizoid, schizotypal

Front 364

Paranoid personality disorder

Back 364

Suspects without evidence that others are exploiting, harming, tricking

Is preoccupied with doubting others

Avoids confiding in others

Reads hidden meaning into benign statements

Is unforgiving/grudge holding

Reacts angrily to perceived attacks on character/self

Is not pyschotic during symptoms

Front 365

Paranoid personality disorder epi

Back 365

Men>women
0.5% - 2.5%

On schizophrenia spectrum

Front 366

Paranoid personality disorder ego dense

Back 366

Frequent use of projection

Front 367

Schizoid personality

Back 367

Nether desires nor enjoys close relationships

Chooses solitary activities

Has little to no sexual interest

Get pleasure from few activities

Lack friends/confidants

Indifferent to praise/disdain of others

Flat affect, emotional coldness

Not psychotic or explained by pervasive developmental disorde

Front 368

Schizoid personality disorder epi

Back 368

<1%
Male 3: Female 1
? relationship to schizophrenic disorders

Front 369

Schizotypal personality disorder

Back 369

Odd beliefs and magical thinking outside of subcultural norms

Ideas of reference

Paranoid ideation

Odd behavior

Lack of close friends outside family

Inappropriate or constricted affect

Social anxiety not remitting with familiarity 2/2 paranoia

Unusual perceptions like bodily illusions

Not during course of psychosis

Front 370

Schizotypal personality disorder epi

Back 370

3%

Associated with schizophrenia, relatives with schizophrenia

Front 371

Cluster B

Back 371

Dramatic, emotional cluster

Affective dysregulation, impulsivity, distorted sense of self

Borderline, antisocial, narcissistic, histrionic

Front 372

Borderline personality disorder

Back 372

Frantic effort to avoid real/imagined abandonment

Intense, unstable relationships characterized by idealization and devaluation

Identity disturbance

Impulsivity with danger potential

Chronic feelings of emptiness

Recurrent suicidalilty, parasuicidal behavior

Affective instability

Inappropriate and difficult to control anger

Stress related paranoia, dissociation

Front 373

Borderline personality disorder epi

Back 373

1-2% of population
10+% of psychiatric admissions

2 females: 1 male

Increased prevelance of MDD, alcohol dependence/abuse, substance abuse (also in 1st degree relatives)

Front 374

Etiology of borderline

Back 374

80% reported significant childhood trauma

Genetic component -- mothers with borderline, increase in affective disorders in first degree relatives

Front 375

Histrionic personality disorder

Back 375

Uncomfortable out of center of attention

Interactions often sexual/provocative

Rapid, shallow emotions

Uses body to draw attention to self

Speech is impressionistic

Behavior is dramatic

Considers relationships more intimate than they are

Front 376

Histrionic personality disorder epi

Back 376

2-3%
F > M

Front 377

Histrionic personality disorder DDx

Back 377

Somatiform
Convergence

Front 378

Narcissitic personality disorder

Back 378

Grandiose sense of self-importance

Preoccupied with schemes of ultimate success

Belief in own uniqueness, need to be around other high fncing

Require excessive admiration

Entitled

Exploitive

Lacking empathy

Envious/perceives envy of self

Arrogant, haughty behaviors

Front 379

Suicide and narcissism

Back 379

High rates of suicide

Usually after a narcissistic injury
- wife leaving

Front 380

Narcissistic PD epi

Back 380

1%

Can be high functioning

Front 381

Antisocial PD

Back 381

Failure to adhere to social norms like laws

Deceitful

Impulsive

Irritable and aggressive (fights)

Reckless with self-others

Consistent irresponsibility

Lack of remorse

Front 382

Antisocial PD epi

Back 382

3% men, 1% women

Genetic and correlated link with EtOH dependence

High population in prisons

Front 383

Antisocial PD brain

Back 383

Differences seen

Inability to process negative reinforcement?

Front 384

Cluster C

Back 384

Fearful, anxious

Avoidant, Obsessive compulsive, Dependent

Front 385

Avoidant personality disorder

Back 385

Avoids significant interpersonal contact for fear of rejection, humiliation

Unwilling to get involved until assured of liking

Restraint in intimate relationships, inhibited socially

Preoccupied with rejection in social situations

Views self as inept, inferior, unattractive

Reluctant to take risks

Front 386

Difference between avoidant and schizoid PD

Back 386

Avoidants very much desire the personal relationships

Front 387

Avoidant personality

Epi
Treatment

Back 387

1% of population

Treat with exposure/group

Front 388

Dependent personality disorder

Back 388

Has difficult with decision making

Needs others to assume most responsibility for his/her life

Difficulty disagreeing

Difficult initiating projects b/c lack of self confidence

Goes to great lengths to obtain nurture (volunteer for unpleasant)

Feels helpless/uncomfortable when alone

Urgently seeks another relationship when one ends

Preoccupied with being left alone to take care of self

Front 389

Dependent personality disorder epi

Back 389

1.5%

F>M

High medical comorbidity/obesity

Front 390

Obsessive compulsive personality disorder

Back 390

Preoccupied with details, lists, rules to the point that activity purpose is lost

Perfectionism interferes with completion

Devotion to work in exclusion of leisure/friendships

Inflexible morals, values

Unable to discard objects, even without meaning

Reluctant to delegate

Miserly (hoard for doomsday)

Rigid and stuborn

Front 391

Obsessive compulsive PD epi

Back 391

1%

NOT OCD

Front 392

Treating personality disorders

Back 392

Many do not seek treatment (exception: borderline)

CBT, DBT (+eastern philos)
Gives skills need to fnc

Treat Axis I

Sometimes pharma is helpful

Front 393

Characteristics of a successful physician in counseling

Back 393

Non judgmental
Supportive
Knowledgable
Encourages/educates about coping
Socially sanctioned for healing

Front 394

Supportive therapies

Back 394

Help pts cope

Supportive therapy, crisis intervention, mutual self help groups

Front 395

Expressive therapies

Back 395

Focus on gaining insight
Need to have higher fnc

Psychoanalysis/psychodynamic therapy
Insight oriented
-generally focused on present

Front 396

Behavioral therapies

Back 396

Focused on changing behaviors rather than understanding the problem

Relaxation, social skills training, exposure/response, contingency management

Mood, anxiety, substance abuse, psychotic

Front 397

Cognitive therapy

Back 397

Focused on changing the thoughts associated with disorder

Often combined with behavioral

Front 398

What is CBT used in?

Back 398

Mood
Panic
GAD
bulemia
PTSD
anger problems
others

Front 399

Behavior therapy particularly useful when?

Back 399

There is a behavior to change

OCD
Eating disorders
Substance abuse

Front 400

Behavioral therapy sequence

Back 400

Explanation of rational
Identification of pt issues
Model new behavior
Practice new behavior
Give pt homework

Front 401

Relaxation train useful in

Back 401

Mood, anxiety, anger, substances , pain

Slow breathing with conscious muscle relaxation

Front 402

Social skills training

Back 402

Allows for better relationships, more intrinsically rewarding interactions

Better abilities to refuse

Front 403

Contingency management

Back 403

Use rewards for behavior that is inconsistent with disorder

Helps with operant behavior disorders--drug use
Also childhood disorders

Can be very effective

Front 404

Schemata

Back 404

Deeply ingrained belief that can engender automatic thoughts and behaviors

"I am only lovable if I am think"
I must lose weight
Vomitting

Front 405

Cognitive restructuring

Back 405

Replace maladaptive thought with a more realistic one

Front 406

Common maladaptive thought processes

Back 406

All or none
Generalization
Catastrophe
Must, should, never
Emotional reasoning
Fortune telling
Labeling

Front 407

Challenging automatic thoughts

Back 407

ID distortion
Examine evidence
Shades of gray
Double standard -- what would you tell friend?
Experimentation -- let's ask someone
Cost benefit analysis

Front 408

Patient improves on a medical treatment, why?

Back 408

Disease just got better

Placebo

Specific effects

Front 409

Enhancing power of a medication

Back 409

MD - make right diagnosis, use right dose, educate, be optimistic

Med - SEs

Pt-- adhere

Front 410

Somatic disorders

Back 410

Physical symptoms or concern about physical symptoms
No medical diagnosis to explain
Symptoms are not intentionally produced--Unconscious
Symptoms cause distress/impairment

Front 411

Malingering

Back 411

Not a diagnosis

Process of intentionally faking symptoms get desired response (ie narcotics)

Front 412

Factitious disorder

Back 412

Conscious to attempt to simulate or stimulate illness

Front 413

Thought processes of somatiform disorders

Back 413

Masochism
Guilt
Dependency
Hostility
Anger
Illness as punishment

Front 414

Somatization disorder

Back 414

Multiple physical complaints w/o medical cause
Must be from 4 different systems
Pain, GI, sexual, quasi-neurologic

Onset before 30
Lasts years

AKA Briquet's, Hysteria

Front 415

Somatization disorder epi

Back 415

F>M
0.2-2% population, more in hospital
Varies by culture?

Front 416

Somatization disorder etiology

Back 416

Somatization of unconscious processes

Expression of social needs

Frontal lobe dysfunction

Relationship with hyponotizability
80% were highly hypnosable
40% had DID

Front 417

Somatization disorder associations

Back 417

Axis II, MDD, Panic, Substances

Childhood abuse

Families with somatiform, substances, antisocial personality

Front 418

Somatization disorder management

Back 418

Work up any possible organic illness

Consistent brief visits w/ PCP
-psych consult may help minimize cost

Pyschologic -- move away from physical to emotional pains
CBT improved physical symptoms
5-10% recovery

Pharma
antidepressent trials

Front 419

Undifferentiated somatiform disorder

Back 419

Physical symptoms without medical cause

>1, lasting > 6 months

AKA Subsyndromal somatization disorder, abridged somatization

Front 420

Undifferentiated somatoform disorder epi

Back 420

5-10%
20% in general med populations

Front 421

Conversion disorder

Back 421

1+ deficits is voluntary motor or sensory fnc with no medical cause

Excludes pain, sexual dysfunction

L>R

Sometimes preceeded by stressor

AKA Hysterical neurosis, conversion type

Front 422

Conversion disorder epi

Back 422

1-3% mental health outpatients
25% of medical and pysch inpatient
5-40% epilepsy pts

F>M

Increases with lower SES, rural populations

Front 423

Conversion disorder associated diagnoses

Back 423

MDD, dissociative disorders, histrionic, antisocial, dependent

Some familial association with conversion, antisocial PD

Front 424

Pathogenesis of conversion disorder

Back 424

Resolution of some unconscious conflict
primary and secondary gain
may not be distress by symptom because of resolution of pysch symptoms

Decreased blood flow to contralateral thalamus/basal ganglia
during episode

Self hypnosis?

Predisposition from having an organic illness

Front 425

Conversion disorder treatment

Back 425

Workup for organic cause
recently shown 0-3%
Confrontation
Suggestion of rapid recovery
Hypnosis - not very supported
Amytal interview -- access unconscious issues

Recovery is about 90%

Front 426

Pain disorder

Back 426

Pain without medical cause
Evidence of psychologicl factors

Can be associated with general medical condition or not

Front 427

Pain disorder epi

Back 427

Prevalence unclear up to 50% of pain has no known cause

Front 428

Pain disorder associations

Back 428

Mood disorders, anxiety disorders

Familial with pain disorder, mood disorder, ETOH dependence

Front 429

Pain disorder etiology

Back 429

? decreased tolerance
? conditioned behavior
? social/culture factors

Social exclusion -- neurally similar to physical pain : activation of anterior cingulate)

Front 430

Pain disorder treatment

Back 430

Maintain activity - PT/OT
CBT
Hypnosis
CAM
NSAIDs - not opiates
Antidepressants, antiepileptics
TENS

Front 431

Hypochondriasis

Back 431

Preoccupation with having a serious illness despite reassurance

Preoccupation is not delusional, not about appearance

>6 months

Front 432

Hypochondriasis epi

Back 432

5-10%
M=F (F get help more)
Onset in early adulthood
Chronic

Many more with intermittent worry

Front 433

Hypochondriasis association

Back 433

Axis I
Anxiety and Depressive disorders

? increased somatization, anxiety in families

Front 434

Hyochondriasis pathognesis

Back 434

Somatization/alexathymia

Misinterpretation of bodily sensations

Defense manifestations related to perceived internal threat

Learned

Serotingergic deficit -- esp with overvalued thoughts

Front 435

Hypochondriasis treatment

Back 435

? frequent visits
SSRI if anxious
CBT does not work especially well

Front 436

Body dysmorphic disorder

Back 436

Excessive preoccupation with perceived deficit in physical appearance

AKA dysmorophophobia

Front 437

BDD prevalence

Back 437

2% of pop
12% psych outpatients
7-15% of those seeking cosmetic surgery

Front 438

BDD onset and associations

Back 438

Onset usually in adolescence, usually chronic

80% have MDD, 40% have OCD, associated with other anxiety, axis II

If insight ranges to delusion --> delusion disorder, somatiform type

Front 439

BDD etiology

Back 439

Serotinergic deficit
Social ideal influence

?OCD varient
?eating disorder viarent

Front 440

BDD treatment

Back 440

CBT, group
SSRI, clomipramine
Levetiracetam
Severe - neuroleptic, buspirone, gabepentin
?ECT, cosmetic surgery

Front 441

Pseudomalingering

Back 441

Pretending to have a disease and then getting it

Front 442

Factitious disorder, who are the pts

Back 442

F, 20-40, health care worker
M, middle aged, socially isolated

Front 443

Factitious disorder treatment

Back 443

Nothing good really

Confront pt in face saving way....if this is a physical diagnosis, this treatment will work

Give space for psychological expression

Front 444

Factitious disorder by proxy

Back 444

Proxy is usually child <4, mother is usually perpetrator (76%)

22 months from onset -- diagnosis
6% dead, 7% long term injury at diagnosis
25% have dead siblings, 61% of siblings had suspicious symptoms

Front 445

Self mutilation and the opioid system

Back 445

Theory
Endogenous opioid system occurs as a result of adequate attachment

Serves to self sooth during distress

With poor attachment this system may be underactive and require hyperstimulation

Front 446

Relative prevalence of various types of child abuse

Back 446

Physical
Sexual
Emotional
Medical Neglect

Front 447

Most common cause of PSTD in women in US?

Back 447

Sexual abuse

Front 448

Attachment and trauma

Back 448

Security of attachment bond is greatest mitigating factor against trauma induced disorganization

80% of traumatized kids have disorganized attachment

Front 449

What best predicts severe symptoms from trauma?

Back 449

Victim feeling that he/she had no one to turn to with whom he/she woul dbe safe

Front 450

Age and child abuse

Back 450

Younger the child the worse the consequence, generally

Front 451

Trauma experience

Back 451

Threat of life or wellbeing to self or others that cannot be escaped

Experienced or observed

Front 452

Disorganization of defense system

Back 452

Autonomic arousal with no ability to escape or fight
Gets overwhelmed and disorganized
Fear state persists

Front 453

Dissociation

Back 453

Separation of normally integrated functions

Ex. Memory but no emotion

Front 454

Coping with abuse parents

Back 454

Children must find a way not to blame parents

Repression and dissociation are most common

Front 455

Psychiatric patients with a history of sexual abuse?

Back 455

2/3

Front 456

What has highest correlation with early childhood sexual abuse?

Back 456

Somatizaton disorder -- 90+% correlation

Front 457

Biology of dissociation

Back 457

Glutamate mediated?
Ketamine is an NMDA receptor antagonist
-deactivation of large, association fibers

Front 458

PET during flashback

Back 458

Shows deactivation of language and communication areas

Front 459

Dissociation as a child

Back 459

Seems to be adaptive for survival of trauma

Predisposes to development of PTSD

Front 460

Dissociative identity disorder

Back 460

Presence of two or distinct, enduring personalities
AND
At least two of the states recurrently take control
AND
Inability to recall information too extensive for forgetfulness
AND
Not 2/2 substance/medical condition

Front 461

Not all abused kids develop diagnoses, what's different?

Back 461

Neurobiologic change

Genetics FKBP5 variant with altered glucocorticoid pathway activation

Front 462

Neurobiologic changes seen in abuse sufferers--->PTSD

Back 462

Long term changs in HPA axis
Changes in hippocampal morphology
Changes in hippocampal based memory

Increased ventricular volume and decreased brain volume

Front 463

Abuse in childhood, adolescence and self harm

Back 463

Abuse in childhood correlates with increase in all self harm behaviors

Abuse in adolescence, increases risk of suicide, anorexia only

Front 464

Lifetime effect of childhood abuse

Back 464

Increased lifetime psychopathology
Physical = sexual

Eating disorders correlation is not a strong

Front 465

Most powerful predictor of self destructive behavior?

Back 465

Neglect

Front 466

PTSD is a disorder of

Back 466

Reactivity, rather than basal state

Front 467

Psychological outcomes of trauma

Back 467

PTSD
New onset substance abuse
Anxiety disorder

Front 468

Lifetime incidence of PTSD in US

Back 468

7%
F 2: M 1
40% in combat veterans
-combat is worst male trauma

Front 469

Components of the generalized stress response

Back 469

HPA
Locus coruleus
Immune system

Front 470

Structural changes in PTSD

Back 470

Decrease hippocampal volume
Decrease in medial prefrontal cortex
-fear extinction
Increase in orbital prefrontal cortex
- fear extinction

Front 471

Psychiatric responses to domestic violence

Back 471

Women - anxiety disorders
Men - substance abuse

Front 472

Sexual vs nonsexual crime

Back 472

Sexual violence victims 2x as likely to get PTSD

Front 473

How does PTSD effect life?

Back 473

More suicide attempts
More medical illnesses
Worse physical health
Less employment
Negative impact on personal relationships

Front 474

Pregnancy with PTSD

Back 474

Higher rates of
ectopics, miscarriages, hyperemesis, preterm labor, excessive fetal growth

Front 475

Highest levels of post traumatic stress with

Back 475

Female gender
Marital separations
Pre-event depression or anxiety disorder
Physical illness
Intensity of exposure
Early diengagement from coping

Front 476

Criteria for PTSD

Back 476

Exposure to trauma: experienced or witnessed
AND
Respond with intense fear, helplessness, horror
AND
Rexperiencing, Avoidance/numbing, and Hyperarousal
AND
Impairment/Distress

Lasting > 1 month

Front 477

Re-experiencing criteria of PTSD

Back 477

Persistent experience of 1+:
Distressing recollections
Distressing dreams
Acting/feeling event recurring
Distress at cues resembling event
Reactivity at cues resembling event

Front 478

Avoidance/numbing criteria of PTSD

Back 478

3+ of
Avoid thoughts, feelings, convos related
Avoid people, places, activities related
Unable to recall parts of trauma
Decreased interest in activities
Estrangement from others
Restricted range of affect
Foreshortened vision of future

Front 479

Arousal criteria of PTSD

Back 479

2+
Sleep difficulties
Outbursts of anger or irritability
Difficulty concentrating
Hypervigilance
Exaggerated startle response

Front 480

Comorbities with PTSD

Back 480

Alcohol abuse
Depression
Social phobia

Front 481

PTSD first line treatment

Back 481

CBT
--cognitive processing
--prolonged exposure
Eye movement desensitization and reprocessing
SSRIs

Front 482

PTSD first line meds

Back 482

SSRIs
sertraline, paroxetine, fluoxetine
SNRIs
venlafaxine

Front 483

Prazosin

Back 483

Minipress
Promising PTSD

Used to stop nightmares, now also during day

Front 484

Anxiolytics in PTSD

Back 484

Don't really work

Front 485

Cognitive processing therapy in PTSD

Back 485

Psychoeducatoin
Written exposure
write about impact of trauma on thoughts of self/othrs
interpretations of event
Challenge interpretations

Restructure beliefs disrupted by trauma

Front 486

What therapy has long lasting improvements with PTSD

Back 486

Cognitive processing therapy

Prolonged exposure therapy

Have about 80% reduction in criteria meeting at 5 years

Front 487

Eating disorders epi

Back 487

4% prevalence
9 females: 1 male
Onset is usually adolescence

Front 488

Eating disorders risk factors

Back 488

Genetics
AN - families with eating disorder or affective disorder
Bulemia -- families with eating disorder, affective disorder, or substance abuse

Twin study concordance

Front 489

Eating disorders comorbidity

Back 489

Depression 50-75%
OCD 25% AN
Substance abuse 12-18% BN
Personality disorder 40-70% AN

Front 490

Anorexia Nervosa criteria

Back 490

Refusal to maintain body weight above minimum for height and age (85%, BMI18.5)
and
Intense fear of getting fat
and
Disturbance in perception of body, undue influence of body weight on self-image, or denial of seriousness of underweight
and
Ammenorrhea when applicable

Front 491

Anorexia Nervosa subtypes

Back 491

Restricting
Binge/purge

Front 492

Bulemia Nervosa criteria

Back 492

Recurrent episodes of binge eating
Excess consumption
Feeling unable to stop
Recurrent inappropriate compensatory behavior

At least twice and week for three months

Self evaluation is unduly influenced by shape/weight

Front 493

Bulemia subtypes

Back 493

Purging - vomitting, laxatives
Nonpurging - excercise, fasting

Front 494

Eating disorder NOS

Back 494

Most are subsyndromal anorexia or bulemia

Also binge eating disorder

Front 495

Binge Eating Disorder

Back 495

Binge eating in absence of compensatory behaviors

Commonly overweight, but not always

Body dissatisfaction, depression, low self esteem

Front 496

Anorexia tardiva

Back 496

Anorexia diagnosed after 25

Front 497

Anorexia onset

Back 497

As young as 7-12 (often with OCD)
Typically in adolescence

Front 498

Bulemia associated with what childhood disorder

Back 498

Pica

Rare is bulemia seen in <12

Front 499

Binge Eating Disorder onset

Back 499

Adulthood

Front 500

Binge eating disorder gender ratio

Back 500

More common in men

Front 501

BDD genders

Back 501

M=F

Men often have muscle dysmorphism -- Adonis complex

Front 502

Female athlete triad

Back 502

Disordered eating
Ammenorhea
Osteopenia

Front 503

Sports and eating disorders

Back 503

Female high school athletics is protective
Female college athletics is a risk factor

Body building/wrestling risk for bulemia

Front 504

Personality disorder and eating disorder

Back 504

AN -- cluster C

BN -- clusters B and C

Association of borderline and long term bulemia

Front 505

Childhood disorders associated?

Back 505

AN and OCD
BN and social phobia

Front 506

Effects of vomiting/overexercise

Back 506

Relief of tension
Emotional anesthetic
High similar to cutting

Front 507

Effects of low weight

Back 507

Starvation

Food obsession, ritualization

Depression, anxiety, irritability, mood swings
Social withdrawal

Decreased concentration, poor judgement
Apathy

Front 508

Hunger level of anorexics

Back 508

Extremely high

Eating takes them down to where most people peak

Front 509

Early physical signs of AN

Back 509

Hair thinning
Feeling cold
Complaints of bloating or nausea
Amenorrhea

Front 510

Anorexia nervosa -- other ways to present

Back 510

Low sex drive
Depression/anxiety
Weakness, fatigue
Chest pain, palpitations
Sports injury, stress fracture

Front 511

Physical findings in anorexia

Back 511

thin, pale
dependent edema
reduced muscle mass
bradycardia <50
arrythymias
hypotension
abdominal pain on exam

Front 512

Lab finding in anorexia

Back 512

Usually come on late in weight loss

Hypokalemia, metabolic acidosis -- laxative
Metabolic alkalosis -- vomiting

Rare hypoglycemia
Ca, Mg down, amylase up

Front 513

DDx with anorexia

Back 513

Malabsorption syndrome
Endocrine
Malignancy

Anxiety
Depression
Psychotic

Front 514

AN treatment goals

Back 514

Restore healthy weight
Educate
Prevent relapse

Front 515

AN Nutritional rehab

Back 515

2-3 lb/week inpt, 0.5-1/week out
Goal is 90%, better success at 95%

Normalize eating patterns
Reunderstand hunger and satiety
Correct malnutrition

Front 516

AN therapy after weight has been restored

Back 516

Understanding
Identify antecedents
Secondary gain issues
Avoid relapse
How to deal with stress better

Front 517

Where to treat a pt with AN

Back 517

>85% IBW - outpatient
>90% intensive outpt
85-75% - partial hospitalization, residential treatment
<75% Inpatient

Also check: medical status, suicidal, motivation, stressors, amt of support needed

Front 518

What kind of therapy in AN

Back 518

Family - Maudlsey - young children

CBT and DBT individually

Group, esp CBT based

12-step programs

Meds

Front 519

Medicaitons in AN

Back 519

Not in used much in acute phase
SSRIs may prevent relapse after weight recovery

Front 520

AN medical issues in recovery

Back 520

Dermatologic
Cardiac
GI
Endocrine - ammenorhea, hypothermia
Muscoloskeletal - osteopenia/porosis, fractures
Cognitive
Reproductive - arrest sexual development, infertility, neonatal complicaitons
Heme - anemia, neutropenia

Front 521

Refeeding syndrome

Back 521

Too rapid feeding of the severely malnourished <70%

Down P, Ca, Mg, Thiamine

Fluid retention, cardiac arrythmias, cardiac failure, respiratory insufficiency, red cell dysfunction, seizures, delerium, death

Front 522

Non eating related sign of bulemia

Back 522

Difficulty managing money and time

Front 523

BN physical signs

Back 523

Fluctuating weight
Menstrual irregularities
Swollen salivary/parotids
Dental problems

Abdominal discomfort, anxiety, depression, palpitations

Front 524

BN physical exam

Back 524

Range of weights
Poor skin turgor
Dental decay
Inflamed oral mucosa, oropharynx
Arrythmias
Cardiomyopathy

Front 525

Abnl labs in bulemia

Back 525

Metabolic alkalosis and decrease K with vomiting
Metabolic acidosis with laxative use

Increased amylase from vomiting
Increased LFTs late 2/2 fatty degeneration

UA with increased specific gravity

Front 526

BN DDx

Back 526

Malignancy
GI illness
Hyperthyroidism

Anxiety disorder (somatoform)
OCD
Personality disorders (additional self-harm behaviors)

Front 527

Bulemia stabilization

Back 527

Restore electrolyte balance
Rehydrate

Typically followed by outpt treatment

Front 528

Meds for bulemia

Back 528

Fluoxetine shown 50-75% reduction in binge eating/vomiting rates

Front 529

Bulemia medical risks

Back 529

GI - tears, ruptures, reflux, stomatitis
CV - arrythmias
Renal failures
Tooth loss

Frequent relapse

Front 530

Eating disorder prognosis

Back 530

10% overall mortality

33% of AN have full recov, more partial
75% of BN have full recov

Front 531

Dementia criteria

Back 531

Multiple cognitive deficits

Memory impairment (amnesia)
with
Aphasia, agnonsia, apraxia, or loss of executive fncing

Impairment from previous level

Front 532

Most common dementias

Back 532

AD
Mixed (AD with vascular)
Lewy body
Vascular (multiinfarct)
Frontotemporal
Parkinson's associated

Front 533

Factors that may encourage earlier onset of AD

Back 533

Hypertension
Obesity
Hypercholesteremia
Diabetes

Front 534

Meds that can worsen symptoms of AD

Back 534

Anticholingergics

Lots of others -- including opiods, steroids, sleeping pills

Front 535

Lab tests to work up AD

Back 535

CBC, lytes, B12, folate, LFTs

Front 536

CSF in AD

Back 536

Low beta mayloid, high tau

Front 537

Progression of AD

Back 537

Mild - trouble with money, navigating, word finding, starting things

Moderate - trouble with recognition, safety, appearance declines, needs help with ADLs

Severe
Gibberish, no recognition of self/family, groans and moans when touched, total assistance with ADLs

Front 538

Antidementia meds

Back 538

Cholinesterase inhibitors : donepezil, rivastigmine, galantamine

NMDA receptor antagonist
Memantine

Modest, symptomatic relief -- slow cognitive decline, preserve fnc, decrease mood/behavior problems

Front 539

Affects of psychological intervention with caregiver of Alzheimer's pt

Back 539

Benefits caregiver

Slows nursing home placement

Front 540

Behavioral symptoms in dementia

Back 540

90% of pts get significant behavior symptoms at some point

No meds approved -- atypical antipsychotics have black box on dementia

Front 541

Racial difference in AD preference

Back 541

Hispanics 1.5 x whites
Blacks 2 x whites

Probably mediated by HTN, hypercholesterolemia, diabetes, etc

Front 542

Genetic risks of AD %s

Back 542

With 1 parent -- 2.5x

With both parents -- 20-25% risk

Front 543

Peak behavioral problems based on stage of AD

Back 543

Mild -- apathy
Moderate - delusions
Severe - agitation

Depression, anxiety, restlessness fairly high throughout

Front 544

Eating disorder prognosis

Back 544

10% overall mortality

33% of AN have full recov, more partial
75% of BN have full recov

Front 545

Dementia criteria

Back 545

Multiple cognitive deficits

Memory impairment (amnesia)
with
Aphasia, agnonsia, apraxia, or loss of executive fncing

Impairment from previous level

Front 546

Most common dementias

Back 546

AD
Mixed (AD with vascular)
Lewy body
Vascular (multiinfarct)
Frontotemporal
Parkinson's associated

Front 547

Factors that may encourage earlier onset of AD

Back 547

Hypertension
Obesity
Hypercholesteremia
Diabetes

Front 548

Meds that can worsen symptoms of AD

Back 548

Anticholingergics

Lots of others -- including opiods, steroids, sleeping pills

Front 549

Making diagnosis of AD

Back 549

Dementia

Other causes ruled out

Gradual and progressive decline

Front 550

Delirium

Back 550

Disturbance of consciousness with reduced ability to sustain attention
and
Change in cognition/perception
and
Develops quickly and fluctuates
not
Better explained by dementia

Front 551

Delirium AKA

Back 551

Altered mental status
Acute confusional state
Toxic/metabolic encephalopathy
Acute brain failure

Front 552

Signs of delirium

Back 552

Change in consciousness: stupor -- hyperarousal

Hallucinations, illusions

Parnoid delusions

Altered sleep-wake

Change in activity level

Emotional/cognitive changes

Front 553

Most common diagnosis of pts referred to psych consult for crying

Back 553

Delirium

Front 554

Cognitive disturbances with delirium

Back 554

Disorientation
Short term memory impairment
Incoherent speech
Trouble naming
Impaired construction

Front 555

Hyperactive vs hypoactive delirium

Back 555

Agitation vs lethargy
Hallucination vs confusion

Hypoactive is probably more common but underdiagnosed

Hypo- mistaken for depression
Hyper - pyschotic disorders

Front 556

Prevalence of delirium

Back 556

50% of elderly admitted acutely
40-90% in ICU

Post op
10% of elderly for any surgery
25-35% CT surgery
40-50% hip fracture repair

Front 557

Delirium in kids/young adults

Back 557

Increased rate w/ MR. seizure disorder, previous brain surgery

Often med induced (diphenhydramine)

Front 558

Risk factors for delirium

Back 558

Increasing age
Dementia
Medical illness
H/o brain injury
H/o alcohol abuse
Male
Sensory impairment
Malnourished, dehydrated

Front 559

What's so bad about delirium in hospital

Back 559

Increases length of stay/infections

Increases chance of death w/in 2 years of hospitalization

Increased institutionalization at discharge

Stay delirious on discharge - worse

Front 560

Etiology of delirium

Back 560

Medical not psychologic

Front 561

EEG in delirium

Back 561

Diffuse slowing

Front 562

Exam in delirium

Back 562

non focal

general dysfunction in cortical/subcortical structures, more on non-dominant side

Front 563

Neurotransmitter theory

Back 563

Too much dopamine
dopamingergics can mimic d

Not enough AcH
anticholinergics can mimic

Reports of altered glutamate, GABAs, serotonin, histamine

Front 564

I WATCH DEATH

Back 564

Causes of Delirium
Infection
Withdrawal
Acute metabolic (acidosis, renal fail)
Trauma
CNS pathology
Hypoxia
Deficiencies
Endocrinopathies
Acute vascular
Toxins/drugs
Heavy metals

Front 565

Drugs associated with delirium

Back 565

Opiods
Anticholinergics
Corticosteroids
Benzodiazapines

Others

Front 566

DDx for delirium

Back 566

Mania
Schizophrenia
Dementia
Depression

Way to differentiate -- fluctuating impairment of the sensorium

Front 567

Best test for delirium

Back 567

Confusions assessment method
1. Acute onset and fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness

1 + 2 +3/4 = delirium

Front 568

Treatment of delirium

Back 568

Treat underlying medical cause

Remove potentially delirious meds
Support safety

Front 569

Behavioral treatments for delirious pts

Back 569

Orient -- clock, calendar
Glasses and hearing aids
Regular sleep-wake
Mobilize as soon as possible
Avoid restraints when possible

Front 570

Pharmacological treatment of delirium

Back 570

Typical antipsychotics
(like halperidol --IV/IM/PO)
Atypical antipyschotics
not as well establish
resperidone, olanzapine
Non-benzodiazapine anxiolytics
trazadone -- nice and safe
gabepentin

Front 571

What not to give to delirious pt?

Back 571

Benzos
can have paradoxical effect

Do give if its DTs, in antipsychotics are contraindicated
-lorazepam

Front 572

Insomnia define

Back 572

Difficulty initiating or maintaining sleep or early awakening or insufficient sleep

Front 573

Excessive sleepiness

Back 573

Intrusive dozing/involuntary dozing

Front 574

Circadian rhythm disorder

Back 574

Changes is sleep wake

Front 575

Parasomnias

Back 575

Abnormal behaviors, events, or medical disorders related to sleep

Front 576

Insomnia epi

Back 576

10-15% report chronic insomnia
35% report occassional sleep disturbances

Higher rates in older individuals, women, those w/ medical or psychiatric concerns, substance abuse

Front 577

Insomnia perception vs reality

Back 577

Report extremely little sleep
Objective changes often mild

Something about the sleep is unrestful that they think they are awake

Front 578

Insomnia fatigue?

Back 578

Fatigue
May report feeling sleepy
Have = or greater sleep latency than normals

Front 579

Insomnia pathogenesis

Back 579

Hyperarousal

Show hyperarousal during day, increased HR, caffeine simulation

Front 580

Daytime consequences of insomnia

Back 580

Poor cognition, mood, motor fnc, overal fnc/performance
Physical symptoms

Front 581

Causes of insomnia

Back 581

Psychiatric -40%
Substance induced
Circadian
shift work,
Medical/neuro
breathing, restless leg
Primary sleep disorder
Primary insomnia

Front 582

Adjustment insomnia

Back 582

Related to acute stress
Usually time limited

May become chronic if complicated

Treat to prevent development of chronic

Front 583

MDD and sleep

Back 583

>90% complain of sleep disturbances
Impaired initiation and maintenance
Early morning awakening

Non restorative sleep, MDD worse in morning

Front 584

Sleep physiology in MDD

Back 584

Increased latency
Fragmented sleep
Diminished slow wave
REm onset earlier, more REM

Front 585

Substances that can induce insomnia

Back 585

Stimulants
Methylxanthines
Steroids
Alcohol
Nicotine
Withdrawal from sleep medication
Pthers

Front 586

Circadian disorders

Back 586

Jet lag
Shift work disorder
Delayed/advanced phase
Irregular sleep/wake rhythm

Front 587

AD and circadian rhythm

Back 587

Decreased amplitude of melatonin rhythm and total production

Temp cycle intact

Front 588

Restless leg syndrome

Back 588

Desire to move limbs associated with paresthesias/dysthesias

Motor restlessness

Increased at rest/partially relieved by activity

Symptoms worse in evening/night

Front 589

Periodic limb movement disorder

Back 589

Clinical features of light/interupted sleep, daytime sleepiness

Repetitive muscle contractions (last 5 s), may awake or arouse

Front 590

Periodic limb movement disorder causes

Back 590

Familial/sporadic
Neuropathy/radiculopathy/myelopathy
Fe deficiency
End stage renal disease
RA
Substances

Front 591

Periodic limb movement disorder treatments

Back 591

Dopamimetics
Benzos
Opiods
Carbmazepine
Gabapentin
Clonidine

Front 592

Psychophysiologic insomnia

Back 592

Conditioned insomnia

Tension/anxiety/arousal in response to efforts to sleep
Neg expectations surrounding ability to sleep
Ability to fall asleep better when not trying
Sleep better when not at home

Can be initiating/maintaining
More fixed over time
No other psych diagnosis

Front 593

Psychophysiologic insomnia treatment

Back 593

Sleep hygiene
CBT

Hypnotics
Benzos
Imidazopyridines
Cyclopyrrolones
Pyrazolopyrimidines
Sedating antidepressants

Front 594

CBT in pyschophysiologic insomnia

Back 594

Stimulus control
Bed only when sleepy/sex
Get up if not sleeping
Maintain cycle -- no naps

Sleep restriction
Keep in bed time to actual sleep time
With success increase time in bed, with trouble, decrease it

Front 595

Sleepiness

Back 595

Increased ability to fall asleep spontaneously

Front 596

Causes of excessive sleepiness

Back 596

Low sleep quantity
Bad sleep quality
Substances
anxiolytics, hypnotics, some AEDs, antipsychotics
Sleep/wake
Pysch
Medical
Narcolepsy/idopathic hypersomulence

Front 597

Narcolepsy

Back 597

Inappropriate manifestations of REM
1/5000

Intrusive drowsiness (sleep attacks)
Restorative naps
Disturbed noctural sleep

Front 598

Cataplexy

Back 598

Inappropriate intrusion of REM atonia into wakefulness

Fairly diagnostic of narcoplexy

Front 599

Narcolepsy tetrad

Back 599

Narcolepsy
Cataplexy
Sleep paralysis
Hypnogogic hallucinations

only 15% have tetrad

Front 600

Narcolepsy on multiple sleep latency test

Back 600

mean time to sleep <5 minutes

2+ sudden onset REM episodes

Front 601

Narcolepsy onset

Back 601

10-30

Front 602

Narcolepsy pathogenesis

Back 602

Autoimmune?

Associate with HLA type

Destruction of hypocretin (orexogenic) neurons in lateral hypothalamus

Front 603

Hyponcretin (orexogenic neurons)

Back 603

Lateral hypothalmus

Project to cortex, thalamus, basal forebrain, brainstem (dorsal raphe, locus ceruleous, pp tegmentum)

Keeps stable sleep wake cycle

Front 604

Treatment of narcolepsy

Back 604

Naps

Stimulants

Modafenil - histamine, alpha 1 agonist, ?hypocretin activation

Front 605

Narcolepsy treatment of cataplexy, sleep paralysis, hallucinations

Back 605

REM suppressant: SSRi, TCA, SNRI

GHB

Support

Front 606

Idiopathic hypersomulence

Back 606

Chronic drowsiness
Naps do not help
Deep/long noctural sleep
Sleep drunkeness
?autonomic disturbance
Chronic fatigue link

Poorly responsive to treatment

Front 607

Disorders of arousal

What kind of sleep, when, meory

Back 607

Stage 3/4
Partial arousal w/ amnesia or partial
Extreme autonomic activation
First 1/3 of night

Stuck between deep sleep and wakefullness

Front 608

Sleep arousal epi

Back 608

Predominantly kids
2-8, most 4-6

1-2% are problems

Front 609

Sleepwalking
Sonambulism

Back 609

Disorder of arousal
Complex behavior with deep sleep
Confusion, incoherence

Wide range of behaviors

Leading cause of sleep related injury

Front 610

Night terrors
Parvor nocturnus

Back 610

Sudden arousal from deep sleep
Scream/terror
Extreme autonomic arousal
Variable motor activity
- escape imagery

Front 611

Treating disorders of arousal

Back 611

Safety management

Benzos

Psychotherapy

Front 612

REM Behavior disorder

Back 612

Acting out dream behavior because of loss of REM atonia

Dream related actions

Wide range of behaviors
talking, walking, violence

Last seconds to minutes

Front 613

REM behavior disorder epi

Back 613

Mostly elderly men
50% with known neuropathology

Front 614

Can normal people lack atonia in REM

Back 614

Yes, but its much less frequent than in someone with REM behavior disorder

Front 615

Markers of REM behavior disorder

Back 615

Loss of smell, loss of color identification

Front 616

REM behavior disorder treatment

Back 616

Neurologic evaluation

Safety

Clonazapem
Melatonin (2nd line)

Front 617

What problems show up in a substance abusers life?

Back 617

Relationships
Work/school
Social
Medical

Front 618

Substance Abuse criteria

Back 618

In 12 month span:
Recurrent use resulting in failure to fulfill obligations
or
Recurrent use in situations where its physically hazardous
or
Recurrent substance use legal problems
or
Continued use despite social/interpersonal problems made worse by use

Front 619

Substance abuse or dependence, what's worse?

Back 619

Dependence

Front 620

Substance dependence criteria

Back 620

Maladaptive pattern of use causing distress characterized by 3+ at least once in a year

1. Tolerance
2. Withdrawal
3. Substance taken in larger amounts or over longer than intended
4. Persistent desire to cut back or failed attempts to do so
5. Great deal of time spent obtain, using, recovering
6. Important social/occupational/personal activities given up/reduced because of use
7. Continued use despite knowledge of physical/psychological issue worsened by use

Front 621

Is alcoholism dangerous

Back 621

Progressive and potential fatal

Front 622

Lifetime prevalence of alcohol disorders, dependence

Back 622

Overall 30% and 12%

Men 40%, 25%
Women 20%, 8%

Front 623

Lifetime dependence alcohol prevalence by race

Back 623

Native Americans -- 22%
White 14%
Hispanic 10%
Black 8%
Asian 6%

Front 624

Groups with higher rates of alcohol dependence

Back 624

18-29
Never married
No college (6x), some college (3x)
Low SES (20K-35K)
West and midwest

Front 625

African Americans and alcohol

Back 625

More abstain

Those who drink have worse medical consequences

Front 626

How much does alcohol and drugs cost the country a year in treatment/secondary effects?

Back 626

Half a trillion dollars

Front 627

Worst drug for you physically acutely? longterm?

Back 627

Acutely -- cocaine
arrythmias, strokes, seizures, death
Long term -- EtOH

Front 628

Liver damage sequence in alcoholism

Back 628

Fatty change -- reversible
Hepatitis - mostly reversible
Cirrhosis -- not reversible
Death by liver failure, esophageal varices

Front 629

Esophageal varices

Back 629

Enlarged blood vessels in esophagus
Portal HTN is cause
If rupture, can cause very major bleed

Liver disease also effects clotting factors production

Front 630

GI damage in alcoholism

Back 630

Pancreatitis
Reflux esophagitis
Gastritis
Diarrhea

GI cancers
esophageal, mouth, larynx
-esp with smoking

Front 631

Alcohol effect on CV system

Back 631

HTN -- 3 drinks a day +
Cardiac arrythmias
Dilated cardiomyopathy

Front 632

Alcohol effects on reproductive system

Back 632

Decreased sexual performance in men
Sperm abnormalities
Hypogonadism -- chronic use with liver damage results in higher estrogen levels

Front 633

Fetal alcohol syndrome facial features

Back 633

Small head
Epicanthal folds
Small palpebral fissues
Flattened nasal bridge
Smooth philtrum
Thin upperlip
Short nose
Underdeveloped jaw

Front 634

Alcohol effects on hematopoesis

Back 634

Macrocytic anemia
Decreased WBC
Decreased plts
Anemia 2/2 nutritional deficiency

Front 635

Alcohol effects on skin

Back 635

facial edema and redness

worsening of conditions like psoriasis

Front 636

Alcohol effects on musculoskeletal sysem

Back 636

Asceptic hip necrosis more preavlent
Osteopenia progresses faster
Limb compression syndrome
-ischemia from passing out in weird position
Injuries while intoxicated

Front 637

Alcohol effect on nervous system

Back 637

Peripheral neuropathy
--reflex, sensory, motor fibers
--bilateral, distal
--treated with B vitamins, PT
TBI
Wernicke-Korsakoff - in a few malnourished alcoholics

Front 638

Wernicke's encephalopathy

Back 638

Confusion, ataxia, eye symptoms
-- EOM paralysis and nystagmus

Usually impaired consciousness at this point

Can be reversible with thiamine

Front 639

Korsakoff's psychosis

Back 639

Amnesia and confabulation

Not usually reversible

Front 640

Red flags for alcoholism in occupational history

Back 640

Frequent job changes
Tardiness
Absenteeism - Monday mornings
Work related accidents

Front 641

Effectiveness of treating addiction

Back 641

40-60% of treated addicts are continuously abstinent 1 year post treatment
+
15-30% that have not returned to dependent use

Front 642

Relapse paradox in alcohol as a chronic disease

Back 642

In other chronic diseases, relapse is a demonstration of the necessity/effectiveness of treatment

In alcoholism, its considered evidence of treatment failure

Front 643

What is predictive of alcohol dependence

Back 643

Genetics
Ethnicity

No alcoholic personality

Front 644

Factors that predict successful recovery

Back 644

Development of vital interest to replace drinking

Consistent reminders of how bad drinking was

Presence of a new intimate relationship

Front 645

Family effect on alcoholism

Back 645

Risk of alcoholism is 3x higher with close relatives
More of them is worse

A - reward drinkers, mom or dad alcoholis
B -- dad is alcoholic, 9x more likely, quickly progressive

Front 646

Twin alcoholic risk

Back 646

Doubles risk compared to having fraternal or sibling

Front 647

How important is environment on alcoholism development

Back 647

Adoption studies show effect of biological parent alcoholism

Environment may have greater effect on women

Front 648

Groups with low rates of alcoholism

High?

Back 648

Jews, Asians

Native American, French, Irish