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A pt goes from hospital to hospital reporting sx of colon cancer. In each hx she is discharged without significant findings. She has ________.
Munchausen syndrome -can also do stuff to induce sickness or provide false proof of sx
Define dissociative disorder
=distrubance of normally integrated fxns of identity, memory, and consciousness -includes: 1. amnestic states -dissociative amnesia -dissociative fugue 2. Dissociative identity disorder 3. depersonalization disorder 4. dissociative NOS
Define pain disorder
=somatiform disorder -pain in one or more anatomical sites w/ psychological factors contributing to cause -if just pain w/out psychological factors but has medical factors -> NOT pain d/o -can be acute (less than 6 months) or chronic (longer than 6 months)
How do we treat somatiform disorders?
1. regular scheduled visits 2. strong dr-pt relations 3. CBT 4. SSRI 5. amytal or hypnosis interview 6. avoid habit forming drugs 7. should legitimize the pts sx (so they don't feel rejected)
Define body dysmorphic disorder
=somatiform disorder -preoccupied w/ imagined defect in appearance rather than having more diffuse complaints -pt not delusional and may acknowledge his/her concerns may be exaggerated -may show ritualized grooming, seek lots of plastic surgery
True or false: beta blockers are most likely to be the most effective tx for social anxiety
Name some general medical conditions that can present as a psychopathological condition
1. CNS infections 2. Head trauma 3. Prescribed medications 4. Toxins 5. Nutritional deficiencies 6. Acute intermittent porphyria 7. Acquired metabolic disturbances 8. Endocrine disorders 9. Stroke 10. Brain tumors 11. MS 12. CNS vasculitides -secondary to SLE 13. Cancer or chronic infection 14. Any chronic condition can cause delirium via hypoxia and cerebral hypoperfusion
Define hallucination
=perceptions w/out external stimuli occurring in any sensory modality -sustained, vivid, or frequent indicate serious illness -usu more fantastic hallucinations w/drug disorders
Define illusion
=distortions or misinterpretations of a real stimulus -can occur w/fatigue, strong emotional state or mental illness
Define delusions
=fixed, false beliefs -not in keeping w/one's education or background, not shared by a large number of others -ie the FBI is spying on me
Define ideas of reference
=delusional interpretations of the actions of others -the delusion is always referred to the self -ex "everyone always staresat me when I walk down the street as if they know what I'm thinking"
Define psychosis
=presence of hallucinations, delusions, and unusual behavior that adversely affects one's daily fxn
Contrast reality testing vs reality testing
reality perception= ability to accurately perceive the real world reality testing= ability to determine if one's perceptions are accurate
Define agitation
=increased motor activity usu reflecting an intense mood -ex restlessness, figeting, pacing -nonspecific sign -seen in delium, mood disorders, anxiety states, intoxications
Give examples of disorders that show 1) hyperactivity 2) hypoactivity
Hyperactivity 1. Mania 2. stimulant drugs Hypoactivity 1. depression 2. frontal lobe syndromes 3. schizophrenia 4. CNS depressant substance abuse
Define flight of ideas
-speech pattern =person jumps from topic to topic, without completing a single thought -occurs in context of rapid, hyperverbal speech -typical w/mania
Define circumstantial
=speech filled with unnecessary detail or parenthetical remarks -seen with: 1. mania 2. hypomania 3. alcoholics 4. chronic stimulant drug users 5. some elderly
Define formal thought disorder
=fluent, aphasic-like speech (paraphasias and occasional strings of meaningless speech) w/ adequate repetition -seen w/: 1. Schizophrenia 2. Chronic psychosis w/ hallucinogenic drug use
Define emotional blunting/flat affect
=loss of emotional expression and loss of volition for any action -typical of: 1. schizophrenia 2. some frontal lobe lesions
Describe the 5 axes of DSM-IV
1. A state of illness from which the patient "recovers" at least until the next acute episode 2. A long-lasting unchanging pattern of maladaptive behavior that may not be due to underlying pathology 3. A psychiatric disorder due to underlying general medical condition 4. A scale of severity of psychosocial stressors 5. A scale assessing the patient's overall level of fxning
Name the 3 most common DSM described conditions
1. alcohol and drug abuse disorders 2. anxiety disorders 3. mood disorders
True or false: in general, the more severe the mental illness, the lower the SES of a person
-true -EXCEPT bipolar (incidence increases with SES)
Name some disorders that show a genetic component
1. Schizophrenia 2. Mood disorders 3. substance abuse 4. mental retardation -Down syndrome -fragile X 5. personality disorders -antisocial 6. selected dementias -Huntington's -early onset alzheimers
Define personality disorders
=lifelong pattern of inner experience, interpersonal relations and consequent behaviors -pervasive, inflexible, stable over time -culturally nonconforming outliers -functionally dysfxnal -> distress and impairment
Name the 3 DSM-IV clusters of personality disorders
"Weird, wild, and worried" 1. Cluster A=eccentric -cognition, self-expression, interpersonal relations 2. Cluster B=dramatic -social normals, impulse, emotions, grandiose, behavior, relational 3. Cluster C=anxious -abnormal fears, social relationships, separation, control
Name the 3 Cluster A/eccentric personality disorders
1. Paranoid 2. Schizoid 3. Schizotypal
Name the 3 Cluster B/dramatic personality disorders
1. Antisocial 2. Borderline 3. Histrionic 4. Narcissistic
Name the 3 Cluster C/anxious personality disorders
1. Avoidant 2. Dependent 3. Obsessive Compulsive PD -different from OCD on axis I
What are personality disorders NOT?
They are NOT: 1. your personality characteristics 2. your temperament (affective tone) 3. your morals
When do personality disorders start?
-usu in the teens -early onset in life and pervasive -anti-social PD may have even earlier onset
As a group, personality disorders affect______% of the population.
Which personality disorders are more common in men? in women?
Men 1. Antisocial 2. Schizoid Women 1. Borderline 2. Avoidant 3. Dependent
How do we treat personality disorders
-mainly by cognitive and behavioral approaches -very little medication used
A 38 yo male presents with suspiciousness, preoccupation with distrust, won't confide, mistinterprets motives, and feels attacked. He has been this way since his teens and significantly impairs his relationships with family/friends and at work. He has _
paranoid personality disorder
A 43 yo male is reluctantly brought in by his mother. He solitary, eschews closeness, has no interest in sex, is indifferent, and doesn't have any close friends. He has been this way since he was a teenager. He has ______.
Schizoid PD
Contrast schizoid PD with schizotypal PD
Schizoid PD -detached w/few emotions -don't have a lot of magical beliefs Schizotypal PD -have discomfort w/relationships, cognitive distortions, eccentric -ideas of references, perceptual disorders, paranoia, odd magical beliefs
A 22 yo is brought in by his mother. He has been in and out of juvenile hall. He has a hx of impulsive, aggressive, unlawful behavior for which he shows no remorse. He has a hx of harming his little brother. He has ________.
-antisocial personality disorder -more prevalent in males vs females -disregard for rights of others -may have conduct disorder as a child -High rate of death by: suicide, homicide, accidents -may mellow out in 30s-40s
What is some of the biological evidence for anti-social PD?
1. Lack of rise of cortisol in times of stress 2. Neuroimaging differences in frontal lobes and limbic differences
A 53 yo female has a constantly changing personality characterized by unstable relationships. She often engages in impulsive spending and impulsive spending. She often has fears of abandonment and temporary paranoia. She has been like this since her te
Borderline PD -can tx with CBT
True or false: schizoid and schizotypal personality disorder are prodromes to schizophrenia
A women with dramatic behavior, constant demand for attention, and exaggerated affect presents. She is vain, shallow, and dependent. She has no problem getting boyfriends but can't maintain a longterm relationship. She has been like this since her teen
=Historionic PD
A female who has grandiose but unstable sense of self-importance. She constantly seeks attention/admiration but expects others to perform special favors for her. She has been like this since she was a teenage. She has________.
=narcissistic PD -often show lack of empathy for others -benefit from psychodynamic therapy
True or false: persons with PD frequently seek treatment
-false! -they perceive themselves as normal and so don't seek treatment even though their behavior is bothersome to others
Which disorder do these characteristics correspond to? -fear of rejection in interpersonal relationships -low self-esteem -want relationships -hypersensitive -have been this way since teens
-avoidant PD -may benefit from group therapy, CBT, benzos, antidepressants
A female with low self esteem that frequently allows others to assume responsibility for her schooling, choice of a mate, etc. She has been this way since her teens. She has _______.
-dependent personality disorder -tx: CBT, psychodynamic therapy
This person is right, conformist, and perfectionistic. He is a workaholic and unable to delegate. He has been this way since his teens. He has________.
=obsessive-compulsive PD
Define delirium
=disturbance in consciousness with impaired attention/concentration, change in cognition, reduced awareness of environment -waxing and waning -psychosis often develops -10-15% incidence in inpatient hospital -high mortality if not txed immediately -ACUTE onset -pt may deteriorate rapidly -Need aggressive eval (labs, etc) to rule everything that could cause delerium out
How do we tx delirium when it's recognized?
1. Discontinue all non-essential meds 2. Avoid sedatives and benzos 3. Give low dose high potentcy antipsychotics 4. Make sure environment is dimmed and calm
Define dementia
=impaired congitive fxn w/decline in social and occupational fxn -chronic -INSIDIOUS onset -neurodegenerative -usu occur after age 6 -freq changes in behavior and personality -psychosis can occur -some types may be more treatable
Name the 4 A's of dementia
1. Aphasia 2. Amnesia 3. Apraxia 4. Agnosia
How do we treat dementia?
1. Make sure it's not a "reversible/treatable" type 2. Cholinesterase inhibitors 3. NMDA anatagonist
Name some "irreversible" types of dementia
1. Alzheimer's type 2. Lewy body type 3. Frontotemporal type 4. Huntington's disease 5. Creutzfeldt-Jakob disease 6. Parkinson's disease
Describe frontotemporal dementia
-disinhibition -shallow affect -early progressive loss of expressive language w/naming difficulties -tau inclusions
Describe Creuzfeldt-Jakob disease
-"irreversible" type of dementia -prions -spongiform encephalopathy -long incubation period -startle response is impaired
Name some "treatable" types of dementia
-note: if progressed too far there may be some residual damae 1. Vascular type -prevent recurrence, stepwise decline 2. Subdural hematoma -can dx w/CT 3. Normal pressure hydrocephalus -triad: dementia, gait disturbance, urinary incontinence 4. Infections -syphillis, HIV 5. Metabolic disorders -endocrine, renal, hepatic 6. Nutritional -Werniecke's, folate def, pellagra 7. Depression (pseudodementia)
Define anorexia nervosa
=refusal to maintain body wt at minimally normal wt for age and height -intense fear of gaining wait or becoming fat -disturbed self body image -amenorrhea
Name the 2 subtypes of anorexia nervosa
1. restricting type -no evidence of purging or binge eating 2. binge eating/purging subtype -regularly engages in these behaviors during AN episode
Define Bullemia nervosa
=recurrent episodes of binge eating -recurrent inappropriate compensatory behaviors to prevent wt gain (self-induced vomiting, laxatives) -must happen at least 2x's/week for 3 months -disturbance not during episodes of anorexia nervosa
Describe some of the biological findings related to Anorexia
1. Twin studies demonstrate heritability 2. genes encode for susceptibility factors but NOT diagnostic entity (ex perfectionism as child, etc) 3. increased rate of AN, BN with first degree relatives with the disorder
Describe the clinical course of anorexia nervosa
-onset during puberty -mainly female -body image distortions, fear of being fat -dieting but preoccupation w/food -profound wt loss -denial, resistance to tx
Name some sx of anorexia nervosa
1. body image distortion 2. neg affect/perfect/obsessive 3. exericse 4. anhedonic
Name some sx of bulemia nervosa
1. body image distortion 2. neg affect/perfect/obsessive 3. drugs, EtOH, poor impulse control
True or false: anorexics feel better when they don't eat
-true -they get anxious when they eat/ anhedonia -vs bulemics overeat to get over dysphoria/anxiety
True or false: recover from anorexia is tyically rapid
-false -often chronic disease -max of 50% will recover, 10% will die from anorexia (high mortality for a mental illness)
Name some co-morbid disorders for people with anorexia
1. OCD -many had OCD as children 2. anxiety -anxiety usu develops before eating disorder 3. depression
True or false: people with anorexia can recognize someone else as being too thin but not themselves
-true -they don't think they have a problem
How do we treat anorexia nervosa
-if just focus on weight gain to reverse medical consequences w/out txing personality/cognitive distrubances -> high rate of relapse -now goal is to prevent relapses and keep out of hospital -specialized psychotherapies (family, CBT, DBT) helpful
True or false; people with anorexia have little difficulty regaining weight
-false -they are in a hypermetabolic state so need really high caloric amounts of food
True or false; SSRIs to tx anorexia have no effect on sx or preventing hospitalization
Define binge eating disorders
=binge eating w/out use of laxative/purging to get rid of excessive wt -often associated w/obesity -more common in African Americans and Latinos -often seek various forms of tx (overeaters anonymous, gastric bypass) -not simply obesity w/comorbid psych disorder
The prevalence of schizophrenia in the US is ________.
=1% -men develop disease earlier than women -onset usu before age 30
Describe the cause and biological changes w/schizophrenia
=multifactorial -neurodevelopmental NOT neurodegenerative -increased prev w/ family hx 1. affected sibling (10%) 2. 1 affected parent (5%) 3. both parents affected (50%)
Describe some of the structural changes in the brain w/ schizophrenia
1. ventricular enlargement 2. thalamus 3. amygdala/hippocampus 4. temporal lobes 5. basal ganglia 6. some evidence of decreased density of neuronal cells and dendritic interconnections
What factors are associated w/ a better prognosis for schizophrenia?
1. Later onset of disease 2. Paranoid subtype
Name the 5 subtypes of schizophrenia
1. paranoid -best prognosis 2. disorganized -worst prognosis 3. catatonic 4. undifferentiated -schizophrenia NOS 5. residual -pts w/chronic schizophrenia
Name the 3 categories of sx in schizophrenia
1. Positive sx 2. Negative sx 3. Cognitive sx
Name some positive sx of schizophrenia
1. hallucinations 2. delusions -being controlled, thought insertion, thought w/drawl 3. bizzare behavior 4. thought disorder -disorganized thinking -positive sx usu determine ED visits, hospitalizations, medication use -positive sx may remit or attenuate over time
Name the negative sx of schizophrenia
=6A's 1. Affective flattening 2. alogia -decreased spontaneous speech b/c of thought disorder 3.avolition 4. apathy 5. anhedonia 6. asociality -difficult to tx -affect negative longterm prognosis
Name some cognitive sx of schizophrenia
1. executive fxn slowing 2. some memory deficits 3. concreteness of thinking 4. prodcedural fxning decline -cognitive sx can be earliest signs -often why pts can't perform at work -difficult to tx
What is the minimum criteria for a diagnosis of schizophrenia?
=duration longer than 6 months with at least one month w/delusions, hallucinations, disorganization, negative sx -may often see nonlocalizing neurological soft signs, EtOH and drug dependence
Describe the course of disease for schizophrenia
1.prodromal sx apparent at least 2 yrs prior to acute psychotic break phase =when pt starts tx 3. residual phase -can come and go depending on pt's cycling between active phases
How do we tx schizophrenia?
1. Drugs -typical and atypical antipsychotcs -best for positive sx 2. involves family 3. social skills 4. work rehab 5. psychotherapy 6. cognitive rehab
Name 3 typical antipsychotics
1. Chlorpromazine -sedation 2. Fluphenazine 3. haloperidol -tx positive sx and prevent episodes -Tardive dyskinesias most feared side effect from longterm use -has high rate of EPS
Name 6 atypical antipsychotics
1. Clozapine -best for all sx, agranulocytosis 2. Ziprasidone -likes lots of Rs 3. Resperidone 4. Quetiapine -dose dependent R profile; good for neg sx 5. olanzapine -high rate of metabolic syndrome 6. aripiprazole -partial agonist and antagonist -tx positive and negative sx -lower rate of EPS side effects but can have cardiac, hematologic, and metabolic SE
Define delusional disorder
Characterized by: 1. nonbizzare delusions 2. generally fxnal in society and personal life outside of delusion 3. delusions systematized and encapsulated -diff subyptes: 1. persecutory 2. erotomanic 3. grandiose 4. jealous 5. somatic -tx with antipsychotics
Define schizoaffective disorder
=schizophrenia + stand alone mood disorder -schizophrenia sx predominate and persist outside mood disorder -types: 1. bipolar 2. depressive -both elements must be treated
Define schizophreniform disorder
=schizophrenia sx that persist for 1 month but less than 6 months -not distinct disorder -tx aggressively at 1st psychotic outbreak
Define brief psychotic disorder
=less than one month of psychotic sx -types 1. W/marked stressor 2. W/out marked stressor 3. Postpartum
Define somatization disorders
=type of somatiform disorder w/complaints of sx w/no organic disease -usu present early in life -more common in females than males -Criteria: 1. 4 pain 2. 2 GI 3. 1 sexual complaint 4. 1 pseudoneurological
Name some subtypes of somatoform disorders
1. Somatization disorders 2. Conversion disorder 3. Hypochondriasis 4. Pain 5. Body dysmorphic
Define somatiform disorders
=conditions characterized by unexplained physical sx -pts behave as those ill yet w/out organic disease -common; 30% of primary care visits w/no explained sx -often resist their problem is psychiatric -several diff. forms
Define Conversion disorder
-type of somatiform disorder -common -must be dx of exlucsion -sx of neurological or medical condition but no pain (otherwise diagnose as pain disorder) -must demonstrate sx not under pts control (ie faking it) and no underlying disease -more freq in women than men -Ex: paralysis, inability to speak, blindness, deafness -must show psychological factors initiated sx -pts usu very interested in sx and seek tx
Define hypochondriasis
=somatiform disorder -preoccupation w/fears of having, or belief that one has a serious disease based on misinterpretation of bodily sx -usu last for a long time and not relieved by reassurance of doctors and dx tests -often related w/depression and anxiety -may begin at any age and equally affects males and females (vs somatization d/o)
Define dissociative amnesia
=psychologically induced memory loss -can't recall impt personal info -usu related to traumatic or stressful event -pts usu distressed or perplexed by amnesia -tx: 1. Amytal or hypnosis interview 2. therapy
Define dissociate fugue
=psychological induced memory loss w/inability to recall the past and assumes new identity -associated w/sudden, unexpected move away from home and work -tx: 1. therapy 2. amytal or hypnosis interviews -also associated w/ stress
Define dissociative identity disorder
=multiple personality disorder -2 or more distinct personality states -usu in women and often related to childhood physical or sexual trauma -often starts in childhood -often associated w/pseudohallucinations -very difficult to tx -tx: 1. therapy 2. amytal or hypnosis interviews
Define depersonalization disorder
=characterized by feeling detached from oneself or one's surroundings as though one was an outside observer -may be associated w/ derealization (a sense of detachment, unreality, and altered relation to the outside world) -reality testing is intact during episodes -often unpredictable -starts in early adulthood -thought to be associated w/unacceptable feelings and painful experiences -tx: 1. therapy 2. SSRIs 3. benzos
Define factitious disorder
=intentional production (or feigning) of physical or psychological sx -no obvious external incentive for being sick -motivated by unconscious desire to occupy sick role -includes Munchausen syndrome -tx is exposure and support -can be difficult to recover from
Define malingering
=intentionally cause sx with secondary gain present -pt is aware of why they are producing the sx -tend to occur in males -NOT related to facitious disorder
The unique therapeutic actions of clozapine are due to its actions at ________ Rs
=5HT2 R
Which antipsychotic drug simultaneously blocks 5HT2 and D2 R
=risperidone -atypical antipsychotics? -NOT typical antipsychotics
Which of the following is least likely to be a risk factor for schizophrenia? a. fam hx of schizophrenia b. abuse of hallucinogenic drugs c. maternal obstetrical complications d. maternal exposure to viral infections e. prematurity
=exposure to hallucinogenic drugs
Which of the following is better than other neuroleptics at improving the positive sx of schizophrenia? a. fluphenaizine b. risperidone c. haloperidol d. chlorpromazine e. none of the above
e. none of the above
True or false: chlorpromazine shows prominent muscarinic R (mACH R) blockade.
True or false: fluphenazine is an example of a high potency phenothiazine
-true -haloperidol is a high potency butyrophenones
The lifetime rates for depression are ______ women and _______ men
women: 1/4 men: 1/10
True or false: depression rates are lower among med students and doctors
-false -they're prob higher
Define Major depression
-sx present for at least 2 weeks -Sx include: A. dysphoria B. anhedonia 1. weight changes (usu wt loss) 2. sleep changes (usu insomnia) 3. Motor activity changes (slow) 4. low engergy 5. high guilt 6. low concentration 7. suicidal ideation 8. feeling helpless 9. feeling hopeless Need at least A or B + 5 of the numbered sx
True or false: pts with depression often present to their PCP with somatic complaints or memory changes
-true -esp seen w/elderly, other cultures
How do we distinguish depression from just having the blues
depression is: 1. pervasive (it's always there) 2. persistent 3. disabling
True or false: most people only have a single major depressive episode
-false -depression is usu recurrent and chronic
Define melancholia
=severe form of depression -loss of interest and anhedonia predominate -pts can become catatonic -vegetative sx can be pervasie -can respond well to ECT
Define postpartum depression
-often associated with depression but can have mania component -must be present w/in 4 weeks of delivery -can have psychosis -need to tx aggressively
Define dysthmyic disorder
=chronic low grade depression -persistent dysphoria -must be present for at least 2 years 0can have episodes of major depression while having dysthmia
Name some common medical disorders which may cause depression
1. Hepatitis 2. HIV 3. anything affecting the brain 4. thyroid disorders 5. certain cancers (pancreatic) 6. MIs 7. stroke
Name some substances that can induce depression
1. EtOH 2. amphetamines 3. cocaine 4. opioids 5. interferon 6. corticosteroids 7. anabolic steroids
Name some of the major risk factors for depression
1. previous episode of depression 2. female 3. fam hx of depression 4. separated, divorced, or unhappy marriage 5. postpartum 6. ethnicity (Native Am > white > black > asians) 7. Lack of social support 8. substance abuse
The recurrence rate of a depressive episode w/in three years is over _____.
50% -risk factors 1. severe depression 2. hx of 2 or more episodes 3. residual sx for current episode 4. female
True or false: depression has a bio-psycho-social etiology
-true 1. Bio -genetics/heritability -def in NT: NE, 5HT -upregulate beta and 5HT Rs 2. Psychological -loss of a parent as a child -childhood abuse -negative thoughts about self, surroundings -> negative feelings 3. Social -stress
True or false: depression is associated w/decreased activity of the hypothalamic pituitary axis
-false -increased activity, higher levels of cortisol
People with depression show the following sleep changes: a. short latency from sleep onset to first REM sleep b. more REM sleep c. less stage 3 and 4 sleep d. all of the above
=all of the above
What are some brain-related changes that result from stress that can lead to depression?
-increased glucocorticoids -decreased BDNF -shrinkage of dendritic branches -atrophy of neurons tx with antidepressants help reverse these changes
Who is at greatest risk of suicide from depression?
-elderly white males
Name 4 major risk factors for suicide
1. mental illness 2. past attempts 3. plan 4. means, esp fire arms Additional factors 1. isolation 2. anxiety, agitation 3. drug/EtOH abuse 4. hx of physical or emotional abuse 5. feeling hopeless or desparate
How do we treat depression
1. therapy -psychodynamic, CBT, interpersonal 2. drugs -MAOIs, TCAs, SSRIs, Buproprion, -want to do both therapy and drugs
Which antidepressant do you NOT give to pregnant women b/c it's a teratogen?
True or false: depression is a highly fatal disorder
-true -if depressed, higher rate of mortality due to suicide, cardiovascular, infections -if have MI and depressed, more likely to die
Define bipolar disorder
=manic depressive disorder -characterized by episodes of mania and depression -depression + at least 1 manic episode
Define mania
=elevated, expansive, irritable mood of at least 1 week -also have the following: 1. grandiosity 2. insomnia 3. pressured speech 4. flight of ideas 5. distractability 6. PMA 7. increased goal directed activity 8. increased pleasure seeking regardless of consquences -full mania can last few days-months -usu acute onset -full manic episode -> BP type I -usu very impairing, may need to be hospitalized
What are some associated sx with bipolar disorder?
1. increased libidio 2. spending sprees 3. psychosis 1/2 of all BP pts, can have delusions 4. antisocial behavior 5. suicidality 6. alcohol and substance abuse 7. poor impulse control
Define mixed episode disorder
=mania and depression simultaneously -can have different presentations -ultra rapid cycling -have to meet full DSM criteria for depression AND mania simultaneously -very high risk of suicide -should be treated as if manic -do NOT give antidepressants -> will make it worse
True or false: antidepressants are effective to tx bipolar disorder
-false -even when depressed, a mood stabilizer (lithium, etc) will often help bring them out of the depression -antidepressants often make worse (ex can trigger a mixed state)
Contrast Bipolar I vs Bipolar II
Bipolar I=full mania and depression Bipolar II= depression most of the time with short periods of hypomania
Define hypomania
=attenuated mania (milder and briefer) -usu don't require hospitalization -often presents at baseline mood presentation of pt
Define cyclothymia
=mood disorder pts who cycle rapidly between mania and depression but low amplitude mood swings -very disabling b/c never feel normal
Describe the clinical features of bipolar disorder
-age of onset in early 20s -1-2% prevalence -unipolar depression 5x more common -equal male and female prevalence -most cases begin w/mania -dx requires longitudinal observation so often misdiagnosed when only seen at 1 time point
True or false: bipolar disorder has a stronger genetic component than major depression
How do we treat bipolar disorder?
Mood stabilizers 1. lithium 2. Valproic acid (depakote) Anticonvulsants -if in mixed state 1. Carbamazepine 2. Lamotrigene Atypical antipsychotics Benzos ECT PRN NOT antidepressants (may make worse) med compliance is very impt
How long do people with several major depressive episodes need to be txed with antidepressants?
-at least several years -may be evaluated periodically after that time
All of the following are associated with completed suicide EXCEPT? a. person under 30 w/substance abuse b. fam hx of suicide c. personal hx of antisocial acts or poor impulse control d. often occurs during episodes of mania or hypomania e. painful me
-often occurs during episodes of mania or hypomania
True or false: the volume of the pituitary gland can increased during depression
-true -associated w/increased activity of HPA axis w/depression and high levels of cortisol
True or false: all classes of antidepressants are equally effective
Which is not true about lithium? a. protection against manic episodes in BP b. subclinical hypothyroidism c. polyuria and polydipsia common d. narrow TI e. leukopenia common
-leukopenia common
True or false: the age of onset in bipolar tends to be later than in unipolar (major depressive)?
Which type of therapy has shown the least amount of efficacy to tx depression? a. CBT b. interpersonal c. psychodynamic
True or false: antidepressants should be given 6-9 months for the first major episode of depressive
Define anxiety disorders
-excessive or irrational fear and worry 1/4 Americans -persistent and impairs w/fxning -includes: 1. panic 2. phobic (specific or social) 3. generalized anxiety disorder 4. PTSD 5. OCD -if have 1 anxiety disorder, more likely to have other anxiety disorders -can have co-morbid depression
Define panic disorder
=recurrent, unexpected panic attacks -concern about having an attack, over at least 1 month -also need 4/13 sx of panic attack -need to distinguish w/ or w/out agoraphobia -seen more in females -attacks usu last a few minutes -can lead to medical illness, suicide, depression -often have co-morbid social phobia or GAD -tx with antidepressants (SSRI best) and CBT
Define agoraphobia
-type of anxiety disorder =fear of being unable to escape a place or situation -pts start to avoid certain things in life -tx: antidepressants, CBT, exposure therapy
Define Obsessive Compulsive disorder
-type of anxiety disorder -NOT OC PD -obsession=recurrent, persistent thoughts /impulses/ruminations and disrupt one's life and cause great distress -compulsion=repetitive and intentional behavior or mental acts that are rigid and designed to alleviate anxiety -pts recognize these are not normal and distressing, interfere w/fxning -men have earlier onset and sx develop in -tx: SSRI, CBT, behavior and family therapy
True or false: at first presentation of an anxiety disorder w/palpitations, you need to rule out heart disease
Define GAD
=generalized anxiety disorder -excessive anxiety and worry occuring more days than not for at least 6 months, about a number of events or activities -person finds difficult to control the worry -need 3/6 sx 1. restlessness/feeling keyed up 2. difficulty concentrating 3. easily fatigued 4. irritable 5. muscle tension 6. sleep disturbance -must rule out other causes of anxiety (other psychiatric illness, substances, med conditions) -very common -do NOT give Benzos! -few seek tx -tx: antidepressants, individual therapy
Define phobic disorders
-anxiety disorders that may be intense fears that are either social or specific -equal prev in males and females -few pts seek tx -can develop substance dependence in attempt to self-medicate -DA pathways in brain thought to be involved -tx: MAOIs, behavior therapy, exposure, flooding, CBT
When do most social phobias develop?
Define PTSD
-anxiety disorder -must have experience w/life or limb threatening situation to self or to loved ones -components: 1. reexperiencing trauma (dreams, flashbacks, etc) 2. emotional detachment 3. sx of autonomic hyperarousal 4. avoidance -can be acute (less than 3 months) or chronic (more than 3 months) -can have delayed onset -many pts develop substance abuse -tx: antidepressants, extensive therapy (CBT, prolonged exposure therapy)
What are some of the brain structural findings in PTSD?
1. dysregulation of HPA axis 2. reduced hippocampal volume 3. increased activity in limbic regions
Define acute stress disorder
-can be precursor to PTSD -must have some dissociative sx, intrusion, avoidance, hyperarousal sx -must last 2 days-4 weeks -tx is similar to PTSD
What is in the differential diagnosis for patients presenting with anxiety disorder?
Medical disorders 1. Thyroid problems 2. cardiac problems 3. seizure disorders Substance use 1. Stimulants (ex caffeine) 2. sedative withdrawl
___________ is a medication indicated for tx of GAD
Define panic attack
-acute paroxysms of anxiety -typically last 5-30 min -get autonomic hyperarousal -start to feel terrified but no explanation for why they feel that way -will start to avoid things they associate with their panic attacks -linked to agoraphobia (b/c start to avoid places they associate w/panic attacks) -people who are anxious and depressed tend to have increased risk of suicide
Name some sx of a panic attack
1. palpitations 2. sweating 3. trembling,shaking 4. sensations of SOB 5. feeling of choking 6. chest pain/discomfort 7. nausea/abdominal distress 8. feeling dizzy, lightheaded 9. Derealization or depersonalization 10. Fear of losing control or going crazy 11. fear of dying 12. Paresthesias (tingling or numbness) 13. chills or hot flashes
Which of the following are more common in persons with OCD than general population? a. motor tics b. hx of head injury c. Tourette's syndrome d. none of the above e. all of the above
=all of the above
True or false: MAOIs are useful to treat OCD.
-false: SSRIs are most useful -MAOIs may be useful in tx of panic d/o
Huntington's disease is characterized by_____.
1. psychomotor slowing 2. prominent attentional problems 3. difficulty learning new things
True or false: almost all persons with AIDs develop HIV dementia
True or false: depression is a common cause of dementia in the elderly
The biologic core or substrate of personality refers to______.
True or false: anticonvulsants can help stabilize borderline patients
True or false: antisocial PD is the PD most likely to be associated w/psychotic sx.
-false -borderline PD is most likely
________ PD is most likely to be tied to increased risk for drug dependence
=antisocial -NOT narcissistic
True or false: etiology of alcohol dependence is 60% genetics and 40% environment
-true -over 10 genes involved
_____% with substance abuse go on to develop dependance
-10% -40% remain in abuse -50% downgrade from abuse
True or false: alcoholics tend to have a shorter life expectancy
-true -mostly death due to heart disease, cancer, then accidents
Describe the natural hx of alcoholism in a pt
-1st drink: 13-15 years -1st drunk: 15 years -1st problem: 18 -1st dependence: 25-40 -death: 60
What biologic effects due heavy doses of EtOH have on the body?
1. Myocardial degeneration -> increased risk idiopathic cardiomyopathy 2. Impairs immune fxn -> increased risk for about every type of cancer
Describe psychological features seen with heavy drinking.
-at any time in course of heavy drinking, 40% show signs of severe depression (will look like -with 2-4 weeks of abstinence, symptoms will go away -higher risk of suicide during major depression symptoms -during periods of withdrawal panic attacks, etc (look like anxiety disorder) -3-5% will have hallucinations (psychotic episodes)
True or false: At least 50% of stimulant users will develop psychosis that will go away with abstinence
Having a diagnosis of which of the following disorders predisposes you to increased risk of substance/EtOH abuse? a. anti-social b. bipolar c. schizophrenia d. all of the above
-all of the above
Name the 3 major stages of tx of alcoholism
1. identification 2. detoxification 3. rehabilitation
What are the tx goals of alcohol detoxification?
-tx sx -Vitamins (good nutrition) -Reassurance -+/- benzodiazepines (don’t use short-acting) -withdrawl: autonomic dysfxn, insomnia, anxiety -depressants have greatest rate of death during withdrawl -give them the amount of drug they need on first day of withdrawl to reduce anxiety, make comfortable, then reduce by 20% to 0 over 5 days -no increased risk of suicide during withdrawl
What are the tx goals during alcohol rehabilitation?
-motivational interviewing -increase motivation (to keep motivation going once crisis phase is gone) -help rebuild life -relapse prevention -+/- medications
How does naltrexone work?
-tx alcoholism -rationale: opioid R blocker -mechanism: once block opioid R, impact on reward feeling if go back to drinking, and probably helps decrease craving -decrease drinks/day -lower relapse
How does acamprosate work?
-tx alcoholism -impact on GABA, glutamate (looks like BDZ but doesn’t have much brain depression of BDZ side effects) -NMDA glutamate R antagonists -helps decrease protracted symptoms of withdrawl to help maintain abstinence
What medications should NOT be given when txing an alcoholic in rehab?
1. lithium 2. antidepressants
What are the DSM criteria for substance dependence?
1. tolerance 2. withdrawl 3. larger amounts/longer period than intended 4. inability to, or persistent desire to cut down or control 5. a great deal of time spent obtaining, using, or recovering 6. important activities given up or reduced 7. use despite problems caused or exacerbated by use
What are the DSM criteria for substance abuse?
1. failure to fulfill major role obligations 2. use in hazardous situations 3. legal problems 4. use despite problems
What 2 medications do you give for opiate rehabilitation
1.methadone -long acting opiate 2. naltrexone -long-acting opioid antagonist; blocks rewarding effects of opioids by blocking the Rs
Name 3 depressants and their actions
1. EtOH 2. Benzos 3. Barbiturates -act by boosting GABA 1. relax muscles 2. increase seizure threshold (anti-convulsant) 3. diminish autonomic activity 4. good to tx tremor 5. euphoria 6. help you fall asleep
True or false: cannabinoids can kill you on overdose
Describe the withdrawl state from depressants
-anxiety -depression -insomnia -BP goes up -temp goes up -tremor -can have convulsions only depressants associated with death during withdrawl vs other drugs of abuse
Contrast delirium and psychosis
delirium= can get psychotic sx but with CONFUSION psychosis=not confused
True or false: substance-induced psychoses typically disappears within 2-3 weeks of abstinence
Name 3 stimulant drugs and their actions
1. Cocaine 2. Amphetamphine 3. Wt loss drugs Actions -immediate euphoria -feel energized -feel like don’t need to sleep -increase autonomic nervous system fxning -feel like don’t need to eat -highs of these drugs are similar -high last 20 minutes -if mix with etoh, get new substance with longer half life
True or false: stimulants are very dangerous on overdose
-true -tx of overdose: -tx of overdose of drug: support vital signs, and let body clear drugs -low BP, tx arrhythmias, pack in ice
Describe stimulant withdrawl
-eat too much -sleep too much -depressed -can’t focus attention -tx: no medications used to tx withdrawl
Contrast physiological dependence vs psychological dependence
psychological dependence= something in your life that you are comfortable without physiological dependence= tolerance +/- withdrawal symptoms
Describe the sx of opioid intoxication
1. miosis 2. bradycardia, risk of resp depression and pulm edema 3. slurred speech 4. psychomotor activity may be increased or decreased 5. impaired attention and memory, drowsiness to coma 6. no autonomic signs 7. constipation, poor nutrition 8. make have needle tracks and marks, dental neglect
Name some opioid drugs and name their actions
1. heroin 2. morphine 3. hydromorphone 4. codeine Uses/actions 1. pain control 2. euphoria 3. sense of well-being 4. drowsiness 5. inactivity 6. impaired concentration
Describe the sx of opioid withdrawl
Minor sx 1. Lacrimation, rhinorrhea, sweating 2. piloerection, HTN, tachycardia More severe 1. hot and cold flashes 2. muscle and joint pain 3. nausea, vomiting, abd cramps 4. anxiety, restlessness, irritability, insomnia
True or false: the risk for alcohol dependence in patients coming to a health care provider is higher than in the general population
True or false: once acute withdrawl ends, all withdrawl sx are likely to cease
True or false: approx 40% of drinkers have some life adverse effect associated with EtOH
True or false: the age of first drink in alcoholics is about the same as in the general population
Name a lab marker for heavy drinking.
=carbohydrate deficient transferrin CDT values greater than 20%
True or false: benzos may be helpful in treating EtOH withdrawl
Which of the following groups of medications is most strongly associated w/ teratogeneity? a.TCA b. SSRI c. mood stabilizers d. benzos e. neuroleptics
-mood stabilizers

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