Psychiatry

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Psychiatry
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Psychiatry
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  1. Classical conditioning
    • Pavlov's dog: ringing bell provokes salivation
    • Learning in which a natural response (salivation) is elicited by a conditioned, or learned stimulus (bell) that previously was presented in conjunction with an unconditional stimulus (food)
  2. Operant conditioning
    define, types
    • Learning in which a particular action is elicited because it produces a reward
    • Positive reinforcement: Desired reward produces action (mouse presses button to get food)
    • Negative reinforcement: Target behavior (response) is followed by removal of aversive stimulus (mouse presses button to turn off continuous loud noise)
    • Punishment: Repeated application of aversive stimulus extinguishes unwanted behavior
    • Extinction: Discontinuation of reinforcement (positive or negative) eventually eliminates behavior
  3. Transference and countertransference
    Transference: Patient projects feelings about formative or other important person onto physician (e.g., psychiatrist is seen as parent)

    Contertransference: Doctor projects feelings about formative or other important persons onto patient
  4. Ego defenses
    Unconscious mental processes used to resolve conflict and prevent undesirable feelings (e.g., anxiety, depression)
  5. Immature defenses
    • Acting out
    • Dissociation
    • Denial
    • Displacement
    • Fixation
    • Identification
    • Isolation (of affect)
    • Projection
    • Rationalization
    • Reaction formation
    • Regression
    • Repression
    • Splitting
  6. Acting out
    • Unacceptable feelings and thoughts are expressed through action
    • Tantrums
  7. Dissociation
    • Temporary, drastic change in personality, memory, consciousness, or motor behavior to avoid emotional stress
    • Extreme form: dissociative identity disorder
  8. Denial
    • Avoidance of awareness of some painful reality
    • Common reaction in newly diagnosed AIDS and cancer patients
  9. Displacement
    • Process whereby avoided ideas and feelings are transferred to some neutral person or object (vs. projection)
    • Example: mother yells at her child, bc her husband yells at her
  10. Fixation
    Partially remaining at a more childish level of development (vs. regression)
  11. Identification
    • Modeling behavior after another person who is more powerful (though not necessarily admired)
    • Abused child identifies himself/herself with an abuser
  12. Isolation (of affect)
    • Separation of feelings from ideas and events
    • Describing murder in graphic detail with no emotional response
  13. Projection
    • An unacceptable internal impulse is attributed to an external source (vs. displacement)
    • A man who wants another woman thinks his wife is cheating on him
  14. Rationalization
    • Prolcaiming logical reasons for actions actually performed for other reasons, usually to avoid self-blame
    • After getting fired, claiming that the job was not important anyway
  15. Reaction formation
    • Process whereby a warded-off idea or feeling is replaced by an (unconsciously derived) emphasis on its opposite (vs. sublimation)
    • A patient with libidinous thoughts enters a monastery
  16. Regression
    • Turning back the maturational clock and going back to earlier modes of dealing with the world (vs. fixation)
    • Seen in children under stress as illness, punishment, or birth of a new sibling
  17. Repression
    • Involuntary withholding of an idea or feeling from conscious awareness (vs. suppression)
    • Not remembering a conflictual or traumatic experience; pressing bad thoughts into the unconscious
  18. Splitting
    • Belief that people are either all good or all bad at different times due to intolerance of ambiguity
    • Seen in borderline personality disorder
    • A patient says that all the nurses are cold and insensitive but that the doctors are warm and friendly
  19. Mature defenses
    • Sublimation
    • Altruism
    • Suppression
    • Humor
    • *Mature adults wear a SASH
  20. Altruism
    • Guilty feelings alleviated by unsolicited generosity toward others
    • Mafia boss makes large donation to charity
  21. Humor
    • Appreciating the amusing nature of an anxiety-provoking or adverse situation
    • Nervous medical students jokes about boards
  22. Sublimation
    • Process whereby one replaces an unacceptable wish with a course of action that is similar to the wish but does not conflict with one's value system (vs. reaction formation)
    • Teenager's aggression toward his father is redirected to perform well in sports
  23. Suppression
    • Voluntary withholding of an idea or feeling from conscious awareness (vs. repression)
    • Choosing not to think about USMLE until the week of the exam
  24. Psych - pathology
  25. Infant deprivation effects
    • Long-term deprivation of affection results in:
    • -↓ muscle tone
    • -Poor language skills
    • -Poor socialization skills
    • -Lack of basic trust
    • -Anaclitic depression (infant withdrawn/unresponsiveness)
    • -Weight loss
    • -Physical illness

    • *The 4 W'sWeak, Wordless, Wanting (socially), Wary
    • *Deprivation > 6 months → irreversible changes
    • *Severe deprivation can result in infant death
  26. Child abuse
    Physical abuse
    • Evidence:
    • -Healed fractures on x-ray
    • -burns,
    • -subdural hematomas,
    • -multiple bruises,
    • -retinal hemorrhage or detachment

    Abuser: usually male caregiver

    • Epidemiology: ~3000 deaths/yr in US
    • -80% < 3 yr of age
  27. Child abuse
    Sexual abuse
    • Evidence:
    • -Genital, anal, or oral trauma
    • -STI
    • -UTI

    Abuser: Known to victim, usually male

    Epidemiology: Peak incidence 9-12 years of age
  28. Child neglect
    • Failure to provide a child with adequate food, shelter, supervision, education, and/or affection
    • Most common form of child maltreatment
    • Evidence: poor hygiene, malnutrition, withdrawal, impaired social/emotional development, failure to thrive
  29. Childhood, early onset disorders
    • Attention-deficit hyperactivity disorder (ADHD)
    • Conduct disorder
    • Oppositional defiant disorder
    • Tourette's syndrome
    • Separation anxiety disorder
  30. Attention-deficit hyperactivity disorder (ADHD)
    • Onset < age 7
    • Limited attention span or poor impulse control
    • Characteristics: hyperactivity, impulsivity, inattention in multiple settings (school, home, place of worship)
    • Normal intelligence, but commonly coexist with difficulties in school
    • Can continue into adulthood: as many as 50% of individuals
    • Associated with: decrease frontal lobe volumes
    • Tx: methylphenidate, amphetamines, atomoxetine, behavioral interventions (reinforcement, reward)
  31. Conduct disorder
    • Repetitive and pervasive behavior violating the basic rights of others
    • (physical aggression, destruction of property, theft)
    • After age 18 → antisocial personality disorder (many, not all)
  32. Oppositional defiant disorder
    Enduring pattern of hostile, defiant behavior toward authority figures in the absence of serious violations of social norms
  33. Tourette's syndrome
    • Onset before age 18
    • Characterized by sudden, rapid, recurrent, nonrhythmic, stereotyped motor and vocal tics that persist for >1 year
    • Lifetime prevalence: 0.1-1.0% in general population
    • Coprolalia: found in only 10-20% of patients
    • Association with OCD
    • Tx: antipsychotics and behavioral therapy
  34. Separation anxiety disorder
    • Age of onset: 7-9 years
    • Overwhelming fear of separation from home or loss of attachment figure
    • May lead to factitious physical complaints to avoid going to or staying at school
    • Tx: SSRIs, relaxation techniques/behavioral interventions
  35. Pervasive development disorders
    • Characterized by difficulties with language and failure to acquire (or early loss of) social skills
    • -Austistic disorder
    • -Asperger's disorder
    • -Rett's disorder
    • -Childhood disintegrative disorder
  36. Austistic disorder
    • Severe language impairment and poor social interactions
    • Greater focus on objects than on people
    • Features: repetitive behavior, below-normal intelligence (usual), unusual abilities (savants; rare)
    • Boys > males
    • Tx: behavioral and supportive therapy to improve communication and social skills
  37. Asperger's disorder
    • Milder form of autism
    • Features: all-absorbing interests, repetitive behavior, problems with social relationships
    • Language is normal; normal intelligence
  38. Rett's disorder
    • X-linked disorder seen almost exclusively in girls (affected males die in utero or shortly after birth)
    • Sx: begin by age 1-4, regression, loss of verbal skills, mental retardation, ataxia, stereotyped hand-wringing
  39. Childhood disintegrative disorder
    • Age of onset: 3-4 years
    • Marked regression in multiple areas of function after >2 years of normal development
    • Loss of: expressive or receptive language skills, social skills or adaptive behavior, bowel or bladder control, play or motor skills
    • Boys more common
  40. Neurotransmitters changes in disease...
  41. Anxiety
    • ↑ NE
    • ↓ GABA
    • ↓ serotonin (5-HT)
  42. Depression
    • ↓ NE
    • ↓ serotonin (5-HT)
    • ↓ dopamine
  43. Alzheimer's dementia
    ↓ ACh
  44. Huntington's disease
    • ↓ GABA
    • ↓ ACh
    • ↑ dopamine
  45. Schizophrenia
    ↑ dopamine
  46. Parkinson's disease
    • ↓ dopamine
    • ↑ serotonin (5-HT)
    • ↑ ACh
  47. Orientation
    AOx3
    • Patient's ability to know who he or she is, where she or he is, and the date and time
    • Loss of orientation: alcohol, drugs, fluid/electrolyte imbalance, head trauma, hypoglycemia, nutritional deficiencies
  48. Amnesias
    • Retrograde amnesia: inability to remember things that occurred before a CNS insult
    • Anterograde amnesia: inability to remember things that occurred after a CNS insult (no new memory)
    • Korsakoff's amnesia: Classic anterograde amnesia caused by thiamine deficiency and the associated destruction of mammillary bodies
    • - may also include some retrograde amnesia
    • - alcoholics; associated with confabulations
    • Dissociative amnesia: inability to recall important personal information, usually subsequent to severe trauma or stress
  49. Cognitive disorder
    • Significant change in cognition (memory, attention, language, judgment)
    • Associated with abnormalities in CNS, general medical condition, medications, or substance use
    • Includes delirium and dementia
  50. Delirium
    • "Waxing and waning" level of consciousness with acute onset
    • -Rapid ↓ in attention span and level of arousal

    • Features:
    • disorganized thinking, hallucination (often visual), illusions, misperceptions, disturbance in sleep-wake cycles, cognitive dysfunction
    • *Usually secondary to other illness (CNS disease, infection, trauma, substance abuse/withdrawal

    *Most common presentation of altered mental status in the hospital

    • Abnormal EEG
    • Tx:
    • -Identify and address underlying cause
    • -Optimize brain condition (O2, hydration, pain)
    • -Antipsychotics (mainly haloperidol)
    • *T-A-DA approach (Tolerate, Anticipate, Don't Agitate
  51. Dementia
    • Gradual ↓ in intellectual ability or "cognition" without affecting level of consciousness
    • *"Dementia" is characterized by memory loss

    • Characteristics: usually irreversible
    • -memory deficits
    • -aphasia
    • -apraxia
    • -agnosia
    • -loss of abstract thought
    • -behavioral/personality changes
    • -impaired judgement
    • -pt with dementia can develop delirium

    • Cause:
    • -Alzheimer's disease
    • -cerebral vascular infarcts
    • -HIV
    • -Pick's disease
    • -Chronic substance abuse
    • -Creutzfeldt-Jakob disease
    • -NPH
    • -others

    • Presentation:
    • -↑ incidence with age. EEG usually normal
    • -elderly patients with depression may be present like dementia
  52. Psychotic disorder
    Distorted perception of reality (psychosis) or reality testing

    • Characterized by:
    • -delusions
    • -hallucinations
    • -disorganized thinking

    Can occur in pts with medical illness, psychiatric illness, or both
  53. Signs of psychosis
    • Hallucination: Perceptions in the absence of external stimuli
    • Delusions: False beliefs about oneself or others that persist despite the facts
    • Disorganized speech: words or ideas are strung together based on sounds, puns, or 'loose association'
  54. Hallucination types
    • Visual: more common in medical illness (drug intoxication) than psychiatric illness
    • Auditory: more commonly a feature of psychiatric illness that medical
    • Olfactory: aura of psychomotor epilepsy and in brain tumors
    • Gustatory: rare
    • Tactile: Common in alcohol withdrawal; cocaine abusers
    • HypnaGOgic: occurs while GOing to sleep
    • HypnoPOMPic: Occurs while waking from sleep ("POMPous upon awakening")
  55. Schizophrenia
    • Chronic mental disorder with periods of psychosis
    • disturbed behavior and thought
    • decline in functioning that lasts > 6 months
    • Associated with ↑ dopaminergic activity, ↓ dendritic branching
    • ↑ risk for suicide
  56. Schizophrenia
    Subtypes
    • Paranoid (delusions)
    • Disorganized (with regard to speech, behavior, and effect)
    • Catatonic (automatisms)
    • Undifferentiated (elements of all types)
    • Residual
  57. Schizophrenia
    Diagnosis
    • Diagnosis requires 2 or more of the following (fist 4 are "positive symptoms")
    • -Delusions
    • -Hallucinations: often auditory
    • -Disorganized speech (loose associations)
    • -Disorganized or catatonic behavior
    • -"negative symptoms" - flat affect, social withdrawal, lack of motivation, lack of speech or thought
  58. Schizophrenia
    Epidemiology, etiology
    • Etiology: genetics and environment
    • Associated with frequent cannabis use in teens

    • Lifetimes prevalence: 1.5%
    • -males = females (earlier in men)
    • -blacks = whites
  59. Brief psychotic disorder
    • <1 month
    • usually stress related
  60. Schizophreniform disorder
    1-6 months
  61. Schizoaffective disorder
    • > 2 weeks of stable mood with psychotic symptoms
    • major depressive
    • manic
    • or mixed
    • Subtypes: bipolar, depressive
  62. Delusional disorder
    • Fixed, persistent, nonbizarre belief system lasting > 1 month
    • Functioning otherwise not impaired
    • Examples: woman who believes she's married to a celebrity
    • Shared psychotic disorder: development of delusions in a person in a close relationship. Often resolves upon separation
  63. Dissociative disorders
    • Dissociative identity disorder
    • Depersonalization disorder
    • Dissociative fugue
  64. Dissociative identity disorder
    • Formerly known as multiple personality disorder
    • Presence of 2 or more distinct identities or personality states
    • More common in women
    • Associated with history of sexual abuse
  65. Depersonalization disorder
    Persistent feelings of detachment or estrangement from one's own body, social situation, or environment
  66. Dissociative fugue
    • Abrupt change in geographic location with inability to recall the past, confusion about personal identity, assumption of a new identity
    • Associated with traumatic circumstances
    • Leads to significant distress or impairment
    • Not the result of substance abuse or general medical condition
  67. Mood disorder
    • Characterized by an abnormal range of moods or internal emotional states and loss of control over them
    • Impairs social and/or occupational functioning
    • -Major depressive disorder
    • -Bipolar disorder
    • -Dysthymic disorder
    • -Cyclothymic disorder
    • *Psychotic features may be present
  68. Manic episode
    • Distinct period of abnormally and persistently elevated, expansive, or irritable mood
    • Abnormal and persistent increased activity or energy lasting at least 1 week
    • Diagnosis: 3 or more of the following (DIG FAST)
    • -Distractibility
    • -Irresponsiblility - seeks pleasure without regard to consequences
    • -Grandiosity
    • -Flight of ideas
    • -Agitation/ ↑ goal-directed Activity
    • -↓ need for Sleep
    • -Talkativeness or pressured speech
  69. Hypomanic episode
    • Like manic episode except mood disturbance is not severe enough to cause marked impairment in social/occupational functioning or need hospitalization
    • No psychotic features
  70. Bipolar disorder
    • ≥1 manic (bipolar I) or hypomanic (bipolar II) episode
    • Depressive symptoms always occur eventually
    • Functioning, mood return to normal between episodes
    • Caution: antidepressants can lead to ↑ mania
    • High suicide risk
    • Tx: mood stabilizers (lithium, valproic acid, carbamazepine), atypical antipsychotics
  71. Cyclothymic disorder
    • Dysthymia and hypomania
    • milder form of bipolar disorder lasting at least 2 years
  72. Major depressive disorder
    • Self-limited disorder, with major depressive episodes usually lasting 6-12 months
    • Dx: >5 of the following for 2 or more weeks:
    • -Sleep disturbance
    • -Loss of Interest (anhedonia)
    • -Guilt or feelings of worthlessness
    • -Loss of Energy
    • -Loss of Concentration
    • -Appetitie/weight changes
    • -Psychomotor retardation or agitation
    • -Suicidal ideations
    • -Depressed mood
    • *SIG E CAPS

    Prevalence: 5-12% in males; 10-25% in females
  73. Dysthymia
    Milder form of depression lasting > 2 years
  74. Seasonal affective disorder
    • Symptoms associated with winter season
    • improves in response to full-spectrum bright-light exposure
  75. Atypical depression
    • Mood reactivity: being able to experience improved mood in response to positive events
    • "Reversed" vegetative symptoms (hypersomnia and weight gain)
    • Leaden paralysis (heavy feeling in arms and legs)
    • Long-standing interpersonal rejection sensitivity
    • *Most common subtype of depression
    • Treatment: MAO inhibitors; SSRIs
  76. Postpartum mood disturbances
    • Maternal (postpartum) "blues"
    • Postpartum depression
    • Postpartum psychosis
  77. Maternal "blues"
    • Incidence rage: 50-85%
    • Features: depressed affect, tearfulness, fatigue starting 2-3 days after delivery
    • Usually resolves within 10-14 days
    • Tx: supportive
  78. Postpartum depression
    • Incidence rate: 10-15%
    • Features: depressed affect, anxiety, poor concentration starting within 4 weeks after delivery
    • Lasts 2 weeks to a year or more
    • Treatment: antidepressants, psychotherapy
  79. Postpartum psychosis
    • Incidence rate: 0.1-0.2%
    • Features: delusions, hallucinations, confusion, unusual behavior, possible homicidal/suicidal ideations or attempts
    • Usually lasts 4-6 weeks
    • Treatment: antipsychotics, antidepressants, possible inpatient hospitalization
  80. Electroconvulsive therapy
    • Treatment option for major depressive disorder refractory to other treatment
    • Also for pregnant women with depressive disorder
    • Painless seizure in an anesthetized patient
    • AEs: disorientation, temporary anterograde/retrograde amnesia (usually recovers in 6 months)
  81. Risk factors for suicide completion
    • Sex
    • Age
    • Depression
    • Previous attempt
    • Ethanol or drug use
    • Loss of Rational thinking
    • Sickness
    • Organized plan
    • No spouse
    • Social support lacking
    • Women try more; men are more often successful
    • *SAD PERSONS are more likely to complete suicide
  82. Anxiety disorder
    • Inappropriate experience of fear/worry and its physical manifestation when the source of fear/worry is either not real or insufficient to account for severity of sx
    • Sx interfere with daily function
    • Lifetime prevalence: 30% in women; 19% in men
    • Includes: panic disorder, phobias, OCD, PTSD, generalized anxiety disorder
  83. Panic disorder
    Recurrent periods of intense fear and discomfort

    • Peaking in 10 minutes; at least 4 of the following: PANICS
    • -Palpitations
    • -Paresthesias
    • -Abdominal distress
    • -Nausea
    • -Intense fer of dying or losing control
    • -LIght-headedness
    • -Chest pain
    • -Chills
    • -Choking
    • -DisConnectedness
    • -Sweating
    • -Shaking
    • -Shortness of breath

    • Strong genetic component
    • Persistent fear of having another attack

    • Treatment:
    • -Cognitive behavioral therapy (CBT)
    • -SSRIs
    • -Venlafaxine
    • -Benzodiazepines (risk of tolerance, physical dependence
  84. Specific phobia
    • Fear that is excessive or unreasonable and interferes with normal function
    • Cued by presence or anticipation of specific object or situation
    • Person recognizes that fear is excessive
    • Tx: systematic desensitization; SSRIs
    • Social phobia: exaggerated fear of embarrassment in social situation
  85. Obsessive-compulsive disorder
    • Recurring intrusive thoughts, feelings, or sensations that cause severe distress
    • Relieved (partly) by performing repetitive action
    • Ego dystonic: behavior inconsistent with one's own beliefs and attitudes (vs. Obsessive-compulsive personality disorder)
    • Associated with Tourette's disorder
    • Tx: SSRIs, clomipramine
  86. Post-traumatic stress disorder
    • Persistent reexperiencing of a previous traumatic event
    • Nighmares, flashbacks, intense fear, helplessness, or horror
    • Leads to avoidance
    • Disturbance lasts > 1 month
    • Cause significant distress or impairment of function
    • Tx: psychotherapy, SSRIs
    • Acute stress disorder: lasts between 2 days and 1 month
  87. Generalized anxiety disorder
    • Pattern of uncontrollable anxiety for at least 6 months that is unrelated to a specific person, situation, or event
    • Associated with sleep disturbance, fatigue, GI disturbance, and difficulty concentrating
    • Tx: SSRI, SNRI
  88. Adjustment disorder
    Emotional symptoms (anxiety, depression) causing impairment following an identifiable psychosocial stressor (divorce, illness) and lasting < 6 months (>6 months in presence of chronic stressor)
  89. Malingering
    • Patient consciously fakes or claims to have a disorder in order to attain a specific 2° gain (avoiding work, obtaining drugs)
    • Poor compliance with treatment or follow-up of diagnostic tests
    • Complaints cease after gain (vs. factitious disorder)
  90. Factitious disorder
    Patient consciously creates physical and/or psychological symptoms in order to assume "sick role" and to get medical attention (1° gain)
  91. Munchausen's syndrome
    • Chronic factitious disorder with predominantly physical signs and symptoms
    • Characterized by a history of multiple hospital admissions and willingness to receive invasive procedures
  92. Munchausen's syndrome by proxy
    • When illness in a child or elderly patient is caused by the caregiver
    • Motivation is to assume a sick role by proxy
    • Form of child/elder abuse
  93. Somatoform disorders
    Category of disorders characterized by physical symptoms (at least 4 pain, 2 GI, 1 sexual, 1 pseudoneurologic) over a period of years, developing before age 30
  94. Conversion
    • Sudden loss of sensory or motor function (paralysis, blindness, mutism), often following acut stressor
    • patient is aware of sx, but sometimes indifferent toward symptoms
    • Females, adolescents, young adults
  95. Hypochondriasis
    Preoccupation with and fear of having a serious illness despite medical evaluation and reassurance
  96. Body dysmorphic disorder
    • Preoccupation with minor or imagined defect in appearance, leading to significant emotional distress or impaired functioning
    • Patients often repeatedly seek cosmetic surgery
  97. Pain disorder
    • Prolonged pain with no physical findings
    • Pain is the predominant focus of clinical presentation and psychological factors play an important role in severity, exacerbation, or maintenance of the pain
  98. Peronality trait
    An enduring, repetitive pattern of perceiving, relating to, and thinking about the environment and oneself
  99. Personality disorder
    • Inflexible, maladaptive, and rigidly pervasive pattern of behavior causing subjective distress and/or impaired functioning
    • Person is usually not aware of problem
    • Usually presents by early adulthood
  100. Cluster A personality disorder
    • Weird (Accusatory, Aloof, Awkward)
    • Odd or eccentric
    • inability to develop meaningful social relationship
    • No psychosis
    • genetic association with schizophrenia
    • -Paranoid
    • -Schizoid
    • -Schizotypal
  101. Paranoid
    • Pervasive distrust and suspiciousness
    • projection is the major defense mechanism
  102. Schizoid
    • Voluntary social withdrawal, limited emotional expression, content with social isolation (vs. avoidant)
    • Schizoid = distant
  103. Schizotypal
    • Eccentric appearance, odd beliefs or magical thinking, interpersonal awkwardness
    • Schizotypal = magical thinking
  104. Cluster B personality disorders
    • Dramatic, emotional, or erratic
    • Genetic association with mood disorders and substance abuse
    • Wild (Bad to the Bone)
    • -Antisocial
    • -Borderline
    • -Histrionic
    • -Narcissistic
  105. Antisocial
    • Disregard for and violation of rights of others, criminality
    • Males > females
    • Conduct disorder if <18 years
    • Antisocial = sociopath
  106. Borderline
    • Unstable mood and interpersonal relationships, impulsiveness, self-mutilation, boredom, sense of emptiness
    • Females > males
    • splitting is a major defense mechanism
  107. Histrionic
    • Excessive emotionality and excitability
    • Attention seeking
    • sexual provocative
    • overly concerned with appearance
  108. Narcissistic
    • Grandiosity, sense of entitlement
    • Lacks empathy and requires excessive admiration
    • often demands the "best" and reacts to criticism with rage
  109. Cluster C personality disorders
    • Anxious or fearful
    • Genetic association with anxiety disorders
    • Worried (Cowardly, Compulsive, Clingy)
    • -Avoidant
    • -OBsessive-compulsive
    • -Dependent
  110. Avoidant
    • Hypersensitive to rejection,
    • socially inhibited,
    • timid,
    • feelings of inadequacy,
    • desires relationships with others
    • (vs. schizoid)
  111. Obsessive-compulsive
    • Preoccupation with order, perfectionism, and control
    • Ego-syntonic: behavior consistent with one's own beliefs and attitudes
    • (vs. OCD)
  112. Dependent
    • Submissive and clinging
    • excessive need to be taken care of
    • low self-confidence
  113. Schizoid < schizotypal < schizophrenic < schizoaffective
    • Schizotypal: (schizoid + odd thinking)
    • Schizophrenic: (greater odd thinking than schizotypal)
    • Schizoaffective: (schizophrenic psychotic symptoms + bipolar or depressive mood disorder)
  114. Schizophrenia time course
    • <1 mo: breif psychotic disorder, usually stress related
    • 1-6 mo: schizophreniform disorder
    • >6 mo: schizophrenia
  115. Eating disorders
    • Anorexia nervosa
    • Bulimia nervosa
  116. Anorexia nervosa
    • Excessive dieting +/- purging
    • intense fear of gaining weight, body image distortion, ↑ exercise
    • body weight 85% of ideal body weight
    • Associated with ↓ bone density
    • Clinical features: severe weight loss, metartasal stress fractures, amenorrhea, anemia, electrolyte distrubances
    • Can coexist with depression
  117. Gender identity disorder
    • Strong, persistent cross-gender identification
    • Characteriezed by persistent discomfort with one's sex → significant distress, impairs function
    • Transsexualism: desire to live as the opposite sex, often through surgery or hormone treatment
    • Transvestism: paraphilia; wearing clothes (e.g., vest) of the opposite sex
  118. Substance dependence
    • Maladaptive pattern of substance use defined as 3 or more of the following signs in 1 year:
    • -Tolerance: need more to achieve same effect
    • -Withdrawal
    • -Substance taken in larger amounts, over longer time, than desired
    • -Persistent desire or unsuccessful attempts to cut down
    • -Significant energy spent obtaining, using, or recovering from substance
    • -Important social, occupational, or recreational activities reduced because of substance use
    • -Continued use in spite of knowing the problems that it causes
  119. Substance abuse
    • Maladaptive pattern leading to clinically significant impairment or distress
    • -Recurrent use results in failure to fulfill obligations
    • -recurrent use in physically hazardous situations
    • -recurrent substance-related legal problems
    • -Continued use in spite of persistent problems caused by use
  120. Stages of change in overcoming substance addiction
    • 1. Precontemplation: not yet acknowledging that there is a problem
    • 2. Contemplation: knows there's a problem, not ready to make change
    • 3. Preparation/determination: getting ready to make change
    • 4. Action/willpower: changing behaviors
    • 5. Maintenance: maintaining the behavior change
    • 6. Relapse: returning to old behaviors and abandoning new changes
  121. Depressants
    Intoxication, Withdrawal
    • Intoxication:
    • -nonspecific
    • -mood elevation, 
    • -↓ anxiety
    • -sedation
    • -behavioral disinhibition
    • -respiratory depression

    • Withdrawal:
    • -Nonspecific
    • -Anxiety
    • -tremor
    • -seizures
    • -insomnia

    • Drugs:
    • -Alcohol
    • -Opiods (morphine, heroin, methadone)
    • -Barbiturates
    • -Benzodiazepines
  122. Alcohol
    Intoxication, withdrawal
    • Intoxication:
    • -Emotional lability
    • -slurred speech
    • -ataxia
    • -coma
    • -blackouts
    • -Serum γ-glutamyltransferase (GGT): sensitive indicator of alcohol use
    • -Labs: AST > ALT (~2:1)

    • Withdrawal:
    • -Mild withdrawal: similar to other depressants
    • -Severe withdrawal: autonomic hyperactivity, delirium tremors
    • -Tx: benzodiazepines (for DTs)
  123. Opioids
    (morphine, heroin, methadone)
    Intoxication, withdrawal
    • Intoxication:
    • -Euphoria
    • -Respiratory and CNS depression
    • -↓ gag reflex
    • -pupillary constriction (pinpoint pupils)
    • -Seizures (OD)
    • Tx: naloxone, naltrexone

    • Withdrawal:
    • -Sweating
    • -dilated pupils
    • -piloerection ("cold turkey")
    • -fever
    • -rhinorrhea
    • -yawning
    • -nausea, stomach cramps, diarrhea ("flu-like" symptoms)
    • Tx: long-term support, methadone, buprenorphine
  124. Barbiturates
    Intoxication, withdrawal
    • Intoxification:
    • -Low safety margin
    • -Marked respiratory depression
    • Tx: symptom management (assist respiration, ↑BP)

    • Withdrawal:
    • -Delerium
    • -Life-threatening cardiovascular collapse
  125. Benzodiazepines
    Intoxication, withdrawal
    • Intoxication:
    • -Greater safety margin
    • -Ataxia
    • -minor respiratory depression
    • Tx: flumazenil (competitive benzodiazepine antagonist)

    • Withdrawal:
    • -Sleep disturbance,
    • -depression,
    • -rebound anxiety,
    • -seizures (severe)
  126. Stimulants
    intoxication, withdrawal
    • Intoxication:
    • Nonspecific: mood elevation
    • -psychomotor agitation
    • -insomnia
    • -cardiac arrhythmias
    • -tachycardia
    • -anxiety

    • Withdrawal:
    • Nonspecific: post use "crash"
    • -depression
    • -lethargy
    • -weight gain
    • -headache

    • Drugs:
    • -Amphetamines
    • -Cocaine
    • -Caffeine
    • -Nicotine
  127. Amphetamines
    Intoxication, withdrawal
    • Intoxication:
    • -Euphoria
    • -grandiosity
    • -pupillary dilation
    • -prolonged wakefulness and attention
    • -hypertension
    • -tachycardia
    • -anorexia
    • -paranoia
    • -fever
    • -Severe: cardiac arrest, seizure

    • Withdrawal:
    • -Anhedonia
    • -increased appetite
    • -hypersomnolence
    • -existential crisis
  128. Cocaine
    intoxiccation, withdrawal
    • Intoxication:
    • -impaired judgement
    • -pupillary dilation
    • -hallucinations (including tactile)
    • -paranoid ideations
    • -angina
    • -sudden cardiac death
    • Tx: benzodiazepines

    • Withdrawal:
    • -Hypersomnolence
    • -malaise
    • -severe psychological craving
    • -depression/suicidality
  129. Caffeine
    Intoxication, withdrawal
    • Intoxication:
    • -Restlessness
    • -↑ diuresis
    • -Muscle twitching

    • Withdrawal:
    • -Lack of concentration
    • -Headache
  130. Nicotine
    Intoxication, withdrawal
    • Intoxication:
    • -Restlessness

    • Withdrawal:
    • -Irritability
    • -anxiety
    • -craving
    • Tx: nicotine patch, gum, lozenges; bupropion/varenicline
  131. Hallucinogens
    • PCP
    • LSD
    • Marijuana (cannabinoid)
  132. PCP
    • Intoxication:
    • -Belligerence
    • -impulsiveness
    • -fever
    • -psychomotor agitation
    • -analgesia
    • -vertical and horizontal nystagmus
    • -tachycardia
    • -homicidality
    • -psychoisis, delirium, seizures
    • Tx: benzodiazepines, rapid-acting antipsychotic

    • Withdrawal:
    • -Depression, anxiety
    • -Irritability, restlessness
    • -anergia
    • -disturbances of thought and sleep
  133. LSD
    • Intoxication:
    • -Perceptual distortion (visual, auditory)
    • -depersonalization
    • -Anxiety
    • -Paranoia
    • -Psychosis
    • -possible flashbacks
  134. Marijuana
    • Intoxication:
    • -Euphoria, anxiety, paranoid delusions
    • -Perception of slowed time
    • -impaired judgment
    • -social withdrawal
    • -↑ appetitie, dry mouth
    • -conjunctival injection
    • -hallucinations
    • Rx: dronabinol - used as antiemetic, appetite stimulant

    • Withdrawal:
    • -Irritability, depression, insomnia, nausea, anorexia
    • -Most sx peak in 48 hours, lasts 5-7 days
    • -Generally detectable in urine for 4-10 days
  135. Heroin addiction
    Risk, treatment
    • Risks:
    • -Hepatitis
    • -Abscesses
    • -Overdose
    • -Hemorrhoids
    • -AIDS
    • -right-sided endocarditis

    • Methadone: long-acting oral opiate; used for heroin detoxification or long-term maintenance
    • Naloxone + buprenorphine: partial agonist; long acting with fewer withdrawal sx than methadone
    • -Naloxone is not active orally; withdrawal sx only occur if injected
  136. Alcoholism
    • Physiologic tolerance and dependence with sx of withdrawal (tremor, tachycardia, HTN, malaise, nausea, DTs) when intake is interrupted
    • Complications:
    • -alcoholic cirrhosis, hepatitis
    • -pancreatitis
    • -peripheral neuropathy
    • -testicular atrophy

    • Treatment:
    • -Disulfiram (condition the pt to abstain from alcohol use)
    • -supportive care (AA)
  137. Wernicke-Korsakoff syndrome
    • Thiamine deficiency
    • Presentation:
    • -Triad: confusion, opthalmoplegia, ataxia (Wernicke's encephalopathy)
    • -May progress to irreversible memory loss, confabulation, personality change (Korsakoff's psychosis)
    • -Associated with periventricular hemorrhage/necrosis of mammillary bodies

    Tx: IV vitamin B1 (thiamine)
  138. Mallory-Weiss syndrome
    • Longitudinal laceration at the GE junction caused by excessive vomiting
    • Presentation: hematemesis
    • Associated with pain (vs. esophageal varices)
  139. Delirium tremens (DTs)
    • Life-threatening alcohol withdrawal syndrome that peaks 2-5 days after last drink
    • Presentationin order of appearance
    • -autonomic system hyperactivity (tachycardia, tremors, anxiety, seizures)
    • -psychotic symptoms (hallucinations, delusions)
    • -Confusion

    Treatment: benzodiazepines

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