Psychiatry Clerkship

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flucas
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217705
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Psychiatry Clerkship
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2013-05-09 11:36:57
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psychiatry behavior
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psych review
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  1. What is the prevalence of alcohol abuse?
    • males: 20%
    • female: 10%
  2. What is the prevalence of alcohol dependence?
    • males: 10%
    • females: 5%
  3. What is the lifetime prevalence of illicit substance abuse?
    20% of people
  4. What is the lifetime prevalence of illicit substance use of one or more times?
    40% of people
  5. What is the prevalence of people who haves used an illicit substance in the past year?
    15%
  6. What is the # of Americans who require treatment for alcohol abuse?
    13 million
  7. What is the # of Americans >12yo who require treatment for drug abuse?
    5.5 million (27%)
  8. What percent of hospital admissions have drug/ETOH as a factor?
    40%
  9. What percent of deaths have drug/ETOH as a factor?
    • 25%
    • 100,000 deaths/year
  10. What percent of MVA's, murders, and DV cases have ETOH as a factor?
    • MVA: 50%
    • Murders: 50%
    • DV: 50%
  11. What is the definition of intoxication?
    a specific syndrome ofmaladaptive behavioral or psychologicalchanges due to the recent ingestion of orexposure to a substance that acts of the CNS
  12. Substances inducing intoxication identified in the DMS IV?
    • alcohol
    • amphetamines
    • caffeine
    • cannabis
    • cocaine
    • hallucinogens
    • inhalants
    • opiates
    • phencyclidine
    • sedatives/hypnotics/anxiolytics
    • residual category: steroids, nitrous oxide
  13. What factors play a role in the clinical picture of intoxication?
    • substance
    • dose
    • duration/chronicity
    • individual degree of tolerance
    • time since last dose
    • person's expectations as to the effect
    • contextual variables
  14. What is the definition of neroadaptation?
    underlying CNS changes that occur following repeated use of a drug such that a person develops tolerance and/or withdrawal
  15. What is the definition of tolerance?
    • need to use greatly increased amount in order to achieve desired effect
    • OR
    • markedly diminished effect being associated with continued use of the same amount
  16. What is withdrawal?
    maladaptive behavioral change with physiological and cognitive effect that occurs when concentration of a substance declines in the body
  17. What is the definition of substance abuse?
    • = maladaptive pattern of use leading to clinically significant impairment or distress
    • manifests as at least 1 of the following:
    • failure to fulfill role obligations/poor work performance
    • use in hazardous situations
    • substance related legal problems
    • persistent or recurrent social/interpersonal problems
    • (also have never met criteria for dependence)
  18. What is substance dependence?
    • = maladaptive pattern of use leading to clinically significant impairment or distress manifests as at least 3 of the following within 12mo:
    • need for more to achieve same effect
    • decreased effect with same amount
    • characteristic withdrawal syndrome
    • using substance to avoid withdrawal symptoms
    • substance taken in larger amt or for longer time than intended
    • persistent unsuccessful attempts to cut down or control use
    • great deal of time spent obtaining using, or recovering from use
    • important social, occupational, recreational activities given up or reduced
    • use is continued despite persistent/recurrent physical or psychological problems
  19. Define early, sustained, partial, and full remission.
    • Early: no criteria met for >1mo and <12mo
    • Sustained: >12mo
    • Partial: occasional criteria met
    • Full: no criteria met 
    • (i.e. early full, early partial, etc)
  20. What factors contribute to the learning and phsyiologic basis for dependence?
    • reinforcing behaviors
    • pleasure circuit
    • reward circuit
    • hippocampal and limbic memory circuit
    • acute increases of levels of neurotransmitters in the brain:
    • increased dopamine in limbic area
    • ventral tegmental dopamine neurons synapsing on the nucleus accumbens
    • some drugs increase serotonin and/or NE
    • brain cells downregulate receptors and/or decrease production of neurotransmitters that are in excess of normal levels
  21. What factors predict treatment outcome?
    frequency, intensity, and duration of treatment
  22. What percent of people are eventually able to abstain/not meet criteria after treatment for drug dependence?
    70%
  23. What percent of people with substance related disorders have a mental disorder?
    50%
  24. What type of patient would be best suited for substance dependence treatment with hospitalization?
    • drug overdose
    • risk of severe withdrawal
    • severe/multiple medical comorbidities
    • requires restricted access to drugs
    • with psychiatric illness and suicidal ideation
  25. What type of patient would be best suited for substance dependence treatment with residential treatment facility?
    • do not require intensive medical/psychiatric monitoring
    • require a restricted environment
    • partial hospitalization
    • step down unit
  26. What type of patient would be best suited for substance dependence treatment in an outpatient program?
    • no risk of med/psycho comorbidity
    • highly motivated patient
  27. What methods are useful for substance dependence treatment in ambulatory setting and relapse prevention?
    • CBT
    • modify persistent/habitual behaviors
    • intense therapy
    • relapse prevention model
    • motivation enhancement therapy
    • "client centered": focus on benefits of stopping vs benefits of ongoing use
  28. What is a common clinical presentation of alcohol intoxication?
    • legal definition = BAL 0.08-0.10 g/dL
    • mood lability
    • impaired judgment
    • ataxia
    • nystagmus
    • slurred speech
    • decreased concentration
    • anterograde memory loss (blackouts)
  29. What is clinical picture of delirium tremens?
    • DT: within 72hrs of last drink
    • confusion
    • alternating level of consciousness
    • hallucinations
    • HTN
    • tachycardia
    • diaphoresis
    • vascular collapse
    • seizures (@48-72hrs)
  30. What is the treatment for alcohol withdrawal based on CIWA score?
  31. What factors are on the CIWA scale?  Scores?
    • (vital signs checked but not part of score)
    • nausea/vomiting
    • tremors
    • anxiety
    • agitation
    • paroxysmal sweats
    • orientation/clouding sensorium
    • tactile disturbances
    • auditory disturbances
    • visual disturbances
    • headache

    • score 0-9 = absent/minimal WD
    • score 10-19 = mild/moderate WD
    • score >20 = severe WD
  32. At what CIWA scores do you start medication?
    • score >6-8: start PRN benzos
    • score >15: start PRN + scheduled benzos
    • score >35: consider ICU transfer
    • (per slides: score >10 start meds, recheck 1hr)
  33. What medications are used to treat ETOH dependence? Mechanism of action?
    • Antabuse (disulfiram) = inhibits aldehyde dehydrogenase and dopamine beta hydroxylase
    • naltrexone = opioid antagonist of Mu receptors
    • Campral (acamprosate) = unknown MOA, thought to stabilize neuron excitation/inhibition, interact with GABA and Glu receptor?
  34. What monitoring is required when using antabuse (disulfiram)?
    • LFT's
    • Hep C serology (initial)
    • polyneuropathy signs
    • psych effects (psychosis, depression confusion, anxiety)
    • skin (rash)
  35. What monitoring is required when using naltrexone?
    LFT's
  36. Alcohol vs benzo intoxication?
    similar but less cognitive/motor impairment with benzos
  37. What drug properties make it more likely to promote addiction?
    • more lipophilic --> faster onset
    • shorter duration
  38. What side effects are common with TCA's?
    • antihistaminic (sedation and weight gain),
    • anticholinergic (dry mouth, dry eyes, constipation, memory deficits and potentially delirium),
    • antiadrenergic (orthostatic hypotension, sedation, sexual dysfunction)
  39. Describe serotonin syndrome
    • abdominal pain, diarrhea, sweats,
    • tachycardia, HTN, myoclonus, irritability,
    • delirium. Can lead to hyperpyrexia,
    • cardiovascular shock and death.
  40. What are the most common side effects of SSRI's?
    • GI upset,
    • sexual dysfunction (30%+!), anxiety,
    • restlessness, nervousness, insomnia, fatigue or
    • sedation, dizziness
    • 􀂾 Very little risk of cardiotoxicity in overdose
    • 􀂾 Can develop a discontinuation syndrome with
    • agitation, nausea, disequilibrium and dysphoria
  41. You warn a patient about discontinuation syndrome with SSRI's, what do you tell them?
    • Can develop a discontinuation syndrome with
    • agitation, nausea, disequilibrium and dysphoria
  42. What are the IM antipsychotics?
    • ziprasidone (Geodon)
    • olanzapine (Zyprexa)
    • Haloperidol (Haldol)
    • Droperidol (Inapsine)
    • Aripiprazole (Abilify)
  43. What are the tertiary TCA's?
    • = tertiary amine group
    • block primarily serotonin receptors
    • e.g. imipramine
    • amitriptyline
    • doxepin
    • clomipramine
  44. What are the secondary TCA's?
    • = metabolites of tertiary amines
    • block NE
    • e.g. desipramine
    • nortriptyline
  45. Which SSRI's are non-sedating? Other non-sedating antidepressants?
    • Citalopram
    • Fluoxetine
    • Sertraline

    Buproprion
  46. Which antidepressants are sedating?
    • Paxil
    • Mirtazapine (esp. low dose)

    (also associated with wt gain)
  47. Which psych meds are useful in treating neuropathic pain?
    • TCA's 
    • Duloxetine (Cymbalta)
    • lamotrigine (Lamictal)
  48. What are the indications for starting mood stabilizers?
    • Bipolar disorders
    • cyclothymia
    • schizoaffective 
    • impulse control
    • intermittent explosive disorders
  49. What is the only medication shown to reduce suicide rate?
    lithium
  50. What is the rate of completed suicide in BAD?
    ~15%
  51. What is lithium effective for?
    • long-term prophylaxis of mania and depressive episodes (>70% of BAD I pts)
    • reducing suicide rate
  52. What factors predict a positive response to lithium?
    • 􀁺 Prior long-term response or family member with good
    • response
    • 􀁺 Classic pure mania
    • 􀁺 Mania is followed by depression
  53. What tests do you want before starting lithium?
    • pregnancy test (1st trimester only)
    • creatinine/chem-7
    • TSH
    • CBC
  54. What birth defect is associated with lithium?
    • Ebstein's anomaly
    • only with use during 1st trimester
  55. What should be monitored when taking lithium?
    • start/change med: steady state >5d, check levels 12hrs after last dose
    • once stable: check levels q3mo, check TSH and creatinine q6mo
    • (birth control)

    (goal blood level = 0.6-1.2)
  56. What is the goal blood level of lithium?
    0.6-1.2
  57. What are common lithium side effects?
    • 􀂾 Most common are GI distress including reduced
    • appetite, nausea/vomiting, diarrhea
    • 􀂾 Thyroid abnormalities
    • 􀂾 Nonsignificant leukocytosis
    • 􀂾 Polyuria/polydypsia secondary to ADH
    • antagonism. In a small number of patients can
    • cause interstitial renal fibrosis.
    • 􀂾 Hair loss, acne
    • 􀂾 Reduces seizure threshold, cognitive slowing,
    • intention tremor
  58. What does lithium toxicity look like at different levels?
    • 􀂾 Mild- levels 1.5-2.0 see vomiting, diarrhea,
    • ataxia, dizziness, slurred speech,
    • nystagmus.
    • 􀂾 Moderate-2.0-2.5 nausea, vomiting,
    • anorexia, blurred vision, clonic limb
    • movements, convulsions, delirium,
    • syncope
    • 􀂾 Severe- >2.5 generalized convulsions,
    • oliguria and renal failure
  59. What factors predict a positive response with valproic acid?
    • 􀁺 rapid cycling patients (females>males)
    • 􀁺 comorbid substance issues
    • 􀁺 mixed patients
    • 􀁺 Patients with comorbid anxiety disorders
  60. What tests do you want to get before starting valproic acid?
    • pregnancy test
    • LFT's
    • CBC
  61. How do you monitor valproic acid?
    • start/change med: steady state 4-5d, check 12hrs after last dose, repeat CBC and LFT's
    • (birth control)

    (goal blood level = 50-125)
  62. What is the goal blood level of valproic acid?
    50-125
  63. What are valproic acid side effects?
    • 􀂾 Thrombocytopenia and platelet
    • dysfunction
    • 􀂾 Nausea, vomiting, weight gain
    • 􀂾 Transaminitis
    • 􀂾 Sedation, tremor
    • 􀂾 Increased risk of neural tube defect 1-2%
    • vs 0.14-0.2% in general population
    • secondary to reduction in folic acid
    • 􀂾 Hair loss
  64. What mood stabilizers are indicated for rapid cyclers and mixed pts?
    • valproic acid (Depakote)
    • carbamazepine (Tegretol)
  65. What are 1st line mania meds?
    • lithium
    • carbamazepine
  66. What tests do you want to get before starting carbamazepine?
    • LFT's
    • CBC
    • EKG
  67. How do you monitor carbamazepine?
    start/change med: steady state >5d, check 12hrs after last dose, repeat CBC and LFT's

    (goal blood level = 4-12 mcg/mL)
  68. What is the goal blood level of carbamazepine?
    4-12 mcg/mL
  69. What drug induces its own metabolism?
    carbamazepine (tegretol)
  70. What are the side effects of carbamazepine?
    • 􀂾 Rash- most common SE seen
    • 􀂾 Nausea, vomiting, diarrhea, transaminitis
    • 􀂾 Sedation, dizziness, ataxia, confusion
    • 􀂾 AV conduction delays
    • 􀂾 Aplastic anemia and agranulocytosis (<0.002%)
    • 􀂾 Water retention due to vasopressin-like effect
    • which can result in hyponatremia
    • 􀂾 Drug-drug interactions!
  71. What drugs increase carbamazepine levels?
    (antihistamine, antiarrhythmic, antifungals, anti-TB meds, etc.)

    • acetazolamide, cimetidine (both can cause rapid toxic reactions),
    • clozapine (may act synergistically to suppress BM), diltiazem, INH,
    • fluvoxamine, occasionally fluoxetine, erythromycin, clarithromycin,
    • fluconazole, itraconazole, ketoconazole, metronidazole,
    • propoxyphene, verapamil, diltiazem.
  72. what drugs decrease carbamazepine levels?
    • neuroleptics
    • barbiturates
    • phenytoin
    • TCA's
  73. What specific indication does lamotrigine have?
    bipolar depression
  74. What tests do you want to get before starting lamotrigine?  How do you monitor?
    • baseline: LFT's
    • start/change: start with 25mg daily, increase q2wks
    • must retitrate if med stopped >4d
  75. What are the side effects of lamotrigine?
    • 􀂾 Nausea/vomiting
    • 􀂾 Sedation, dizziness, ataxia and confusion
    • 􀂾 The most severe are toxic epidermal necrolysis and
    • Stevens Johnson's Syndrome. The character/severity of
    • the rash is not a good predictor of severity of reaction.
    • Therefore, if ANY rash develops, discontinue use
    • immediately.
    • 􀂾 Blood dyscrasias have been seen in rare cases.
  76. What drugs increase lamotrigine levels?
    • valproic acid (2x amt!)
    • sertraline
  77. What is a "rapid cycler"?
    4 or more depressive or manic episodes/year
  78. What are the indications for antipsychotics?
    • schizophrenia
    • schizoaffective disorder
    • bipolar disorder (mood stabilization and/or when psychotic features are present)
    • delirium
    • psychotic depression
    • dementia
    • trichotillomania
    • augmenting agent in treatment-resistant anxiety disorders
  79. What are the key pathways affected by dopamine in the brain?
    • mesocortical (ventral tegmentum/cortex)
    • mesolimbic (ventral tegmentum/limbic)
    • negrostriatal (substantia nigra/basal ganglia)
    • tuberoinfundibular (hypothal/ant pit)
  80. What does dopamine suppress?
    • acetylcholine activity
    • prolactin activity
  81. What are Parkinsonian movements and what causes them?
    • caused by dopamine hypoactivity:
    • rigidity
    • bradykinesia
    • tremors
    • akathisia
    • dystonia
  82. What are the low potency/low affinity typical antipsychotics?
    • thioridazine
    • chlorpromazine
  83. Which antipsychotics are considered wt neutral?
    • ziprasidone
    • aririprazole
  84. Which antipsychotics can lead to transaminitis?
    • olanzapine
    • quetiapine
  85. What antipsychotic carries risk of QT prolongation?
    ziprasidone (Geodone)
  86. What are some wt neutral psych meds?
    • aripiprazole
    • ziprasidone
    • buproprion
  87. What is the risk of agranulocytosis with clozapine?
    0.5-2% annually
  88. What monitoring is used for clozapine use?
    • weekly blood draws for 6mo
    • then blood draws q2wks for 6mo
  89. What is the annual risk of tardive dyskinesia with antipsychotic use?
    5% per yr
  90. What agents are useful to treat EPS?
    • anticholinergics (benzotropine, trihexyphenidyl, diphendydramine)
    • dopamine facilitators (amantadine)
    • beta-blockers (propranolol)
  91. What clinical risk is akathisia associated with?
    • EPS
    • suicide
  92. What are the indications for anxiolytic prescription?
    • panic disorder
    • generalized Anxiety disorder
    • substance-related disorders and
    • their withdrawal
    • insomnias and parasomnias.
    • (often use anxiolytics in combination with SSRIS or SNRIs for treatment)
  93. What is the appropriate benzo taper schedule?
    decrease no more than 5mg Diazepam dose equivalents q1-2wks
  94. What % of people smoke cigarettes?
    • 25% current smokers
    • 25% former smokers
  95. What % of deaths are related to tobacco smoking?
    • 20%
    • most important preventable cause of disease/death in USA
    • 45% of smokers die of tobacco induced disorders
  96. What % of schizophrenic pts smoke cigarettes?
    75-90%
  97. How should you approach a psychotic pt?
    •  Acknowledge you believe they are experiencing what
    • they are reporting
    •  Try not to collude with the pt
    •  Try to establish rapport before confronting psychotic
    • beliefs
    •  Don’t be overly friendly or it can feed into the paranoia
  98. What is required to "rule in" the diagnosis of depressed mood disorder with psychotic features?
    • Pt needs to currently meet criteria for a major
    • depressive episode and not have other reasons for
    • psychosis for example
  99. What general medical conditions lead to psychotic disorders?
    •  Brain tumors
    •  Seizure disorders
    •  Delirium
    •  Thyroid disorders
    •  Uremia
    •  SLE
    •  Huntington’s disease
    •  Multiple Sclerosis
    •  Cushing’s syndrome
    •  Vitamin deficiencies
    •  Electrolyte abnormalities
    •  HIV
    •  Wellbutrin
    •  Anabolic steroids
    •  Corticosteroids
    •  Antimalarial drugs
  100. What is the lifetime prevalence of delusional disorder?
    0.03%
  101. What are the subtypes of delusional disorder?
    •  Erotomanic
    •  Grandiose
    •  Persecutory
    •  Jealous
    •  Somatic
    •  Mixed 

    •  See erotomanic delusions more often in
    • women
    •  See persecutory delusions more often in
    • men
  102. How long must a person stop using a substance to determine if mood symptoms were SIMD?
    >1mo
  103. What is the lifetime prevalence of schizoaffective disorder?
    0.7%
  104. What is the annual risk of TD?
    • 3-5% per year for typical antipsychotics
    • highest in older women with affective disorders
    • risk of dystonic reaction highest in young males
  105. Who is at greatest risk for dystonic reaction while using antipsychotics?
    young males
  106. What are other psychiatric disorders that can mimic psychotic illness?
    •  Delirium‐ pts often have paranoia, visual
    • hallucinations
    •  Paranoid personality disorder and schizotypal
    • personality disorder can dance very near the edge of
    • psychosis
    •  Obsessive compulsive disorder‐ at times obsessions
    • can be difficult to discern from psychosis
  107. What are examples of mood congruent symptoms of psychosis?
    • delusions or hallucinations consistent
    • with themes of a depressed mood such as:
    • personal inadequacy
    • guilt
    • disease
    • death
    • deserved punishment

    • For manic mood themes: 
    • worth
    • power
    • knowledge
    • special relationship to a deity
  108. What are examples of mood incongruent symptoms of psychosis?
    • delusions of control
    • persecution
    • thought broadcasting
    • thought insertion
  109. What are the mood disorders with psychotic features?
    • MDD with psychotic features
    • Bipolar disorder, manic or mixed
    • schizoaffective disorder
  110. How often do psychotic features occur in MDD pts?
    18.5% of MDD pts have psychotic features
  111. What are the remission rates for psychotic and nonpsychotic depressed pts?
    • psychotic depression: 95% remission
    • nonpsychotic depression: 83% remission
  112. In what % of bipolar pts who are manic or having a mixed episode experience psychotic features?
    ~25% of bipolar I pts
  113. What is the definition of schizophrenia?
    •  Two or more of the following present for a
    • significant portion of the time during a 1 month
    • period:
    •  Delusions*
    •  Hallucinations* (See link on website for examples)
    •  disorganized speech*
    •  grossly disorganized or catatonic behavior*
    •  negative symptoms (affect flattening, alogia, avolition,
    • apathy)
    •  Only one criteria needed if delusions bizarre or
    • hallucinations consist of a voice keeping a running
    • commentary or two voices talking to each other
    •  Must cause significant social/occupational dysfunction
    •  Continuous signs of disturbance for 6 months
  114. What are the schizophrenia subtypes?
    •  Paranoid: preoccupation with one or more delusions or frequent auditory hallucinations
    •  Disorganized: disorganized speech, behavior and flat or inappropriate affect are all present
    •  Catatonic: motoric immobility or excessive activity, extreme negativism, peculiar movements, echolalia or echopraxia
  115. What is the lifetime prevalence of schizophrenia?
    1-2%
  116. What is the typical age of onset of schizophrenia?
    • males: 17-27yo
    • females: 17-37yo
    • (only 10% of cases have onset >45yo)
  117. What do twin studies show about schizophrenia?
    • about 50% heritability
    • (40-50% twin concordance)
  118. What is the pathophysiologic theory behind schizophrenia?
    •  Possibly due to aberrant neuro‐developmental processes such as increase in normal age‐associated pruning frontoparietal synapses that occur in adolescence and young adulthood
    •  Excessive activity in mesocortical and mesolimbic dopamine pathways
  119. What percent of schizophrenics have met criteria for some form of drug/ETOH abuse/addiction?
    47%
  120. What are the odds that a schizophrenic pt has an alcohol or drug use disorder?
    • 4-6x greater odds vs rest of pop
    • >3x greater odds ETOH abuse vs pop
    • >6x greater odds drug abuse vs pop
  121. What % of schizophrenic patients return to pre-illness level of social and vocational functioning?
    <10%
  122. What percent of schizophrenic pts die by suicide?
    10%
  123. What is the general clinical picture of the schizophrenic population?
    •  1/3 have severe symptoms & social/vocational impairment
    • and repeated hospitalizations
    •  1/3 have moderate symptoms & social/vocational
    • impairment and occasional hospitalizations
    •  1/3 have no further hospitalizations but typically have
    • residual symptoms, chronic interpersonal difficulties and
    • most cannot maintain employment
  124. What are the symptoms of a manic episode?
    • D = Distractibility and easy frustration
    • I = Irresponsibility and erratic uninhibited behavior
    • G = Grandiosity
    • F = Flight of ideas
    • A = Activity increased with weight loss and increased libido
    • S = Sleep is decreased
    • T = Talkativeness
  125. What is the prevalence of OCPD?
    2%
  126. What is the prevalence of avoidant PD?
    1-2%
  127. What is the prevalence of paranoid PD?
    2%
  128. What is the prevalence of histrionic PD?
    2%
  129. What is the prevalence of antisocial PD?
    1-4%
  130. What is the prevalence of borderline PD?
    2-3%
  131. What is the prevalence of schizoid PD?
    1%
  132. What is the prevalence of dependent PD?
    0.5%
  133. What is the prevalence of schizoid PD?
    1%
  134. What is the prevalence of schizotypical PD?
    1%
  135. What is the prevalence of narcissistic PD?
    0.5-1%
  136. What are the mature defense mechanisms?
    •  Altrusim: deal with stress or conflict through dedication to meeting other’s needs
    •  Anticipation: anticipate possible adverse events and prepare for them
    •  Humor: deal with stress by seeing irony
    •  Sublimation: channel potentially maladaptive impulses into socially acceptable behavior
    •  Suppression: avoid thinking about stressor
    •  Affiliation: turn to others for support
  137. What are neurotic defense mechanisms?
    •  Displacement: transfer negative feelings about one object to another
    •  Externalization: blame problems on another
    •  Intellectualization: rely excessively on details to maintain distance from painful emotions
    •  Repression: expel disturbing thoughts from consciousness
    •  Reaction formation: do opposite of what you feel
  138. What are primitive defense mechanisms?
    •  Denial: refuse to acknowledge aspect of reality
    •  Autistic fantasy: excessive day-dreaming
    •  Passive-aggressive: indirectly express aggressive feelings towards others
    •  Acting out: engage in inappropriate behavior without consideration of consequences
    •  Splitting: compartmentalize opposite affective states
    •  Projection: falsely attribute unacceptable feelings to another
    •  Projective identification: falsely attribute to a second individual who in turn projects back to patient
  139. What is the prevalence of personality disorders in the adult US pop?
    6-13%
  140. What is the heritability of personality disorders?
    overall ~50% (same as "normal" personality traits)

    • Personality disorder Mean
    • Paranoid 0.34
    • Schizoid 0.43
    • Schizotypal 0.54
    • Antisocial 0.41
    • Borderline 0.61
    • Histrionic 0.59
    • Narcissistic 0.56
    • Avoidant 0.42
    • Dependent 0.56
    • Obsessive-compulsive 0.60
  141. What PD has the highest heritability?
    • borderline personality disorder
    • (then histrionic)
  142. What is the criteria of schizoid PD?
    • • Pervasive pattern of detachment from
    • social relationships and restricted
    • expression of emotion with 4 or more the
    • following:
    • • Neither desires nor enjoys close
    • relationships
    • • Almost always chooses solitary
    • activities
    • • Little if any interest in sexual
    • experiences with another person
    • • Takes pleasure in few in any activities
  143. What is the criteria of schizotypal personality disorder?
    • • A pervasive pattern of social and
    • interpersonal deficits with reduced
    • capacity for close relationships as well as
    • cognitive or perceptual distortions and
    • eccentricities of behavior with 5 or more of
    • the following:
    • • Ideas of reference
    • • Odd beliefs or magical thinking
    • • Unusual perceptual experiences
    • including bodily illusions
    • • Odd thinking and speech
    • • Suspiciousness or paranoid
    • ideation
    • • Inappropriate or constricted affect
    • • Behavior or appearance that is odd
    • or eccentric
    • • Lack of close friends other than
    • first-degree relatives
    • • Excessive social anxiety that does
    • not diminish with familiarity
  144. What is the criteria of antisocial personality disorder?
    •  • A pervasive pattern of disregard
    • for and violation of the rights of
    • others occurring since the age
    • of 15 years as indicated by 3 or
    • more of the following:
    • • Failure to conform to social norms
    • with respect to lawful behaviors
    • • Deceitfulness and conning others
    • for personal profit or pleasure
    • • Impulsivity or failure to plan ahead
    • • Irritability or aggressiveness as
    • indicated by repeated fights or
    • assaults
    • • Reckless disregard for safety of
    • self or others
    • • Consistent irresponsibility
    • • Lack of remorse
    • • There is evidence of Conduct
    • Disorder with onset before age 15
  145. What neuroimaging supports a theory of defective emotional learning being the basis of antisocial personality disorder?
    decreased amygdala and orbitofrontal cortex responses to emotionally provocative stimuli
  146. What is the definition of borderline PD?
    • • Pervasive pattern on instability of
    • interpersonal relationships, self image and
    • affects and marked impulsivity as
    • indicated by 5 or more of the following:
    • • Frantic efforts to avoid abandonment
    • • Unstable and intense interpersonal
    • relationships characterized by
    • alternating between extremes of
    • idealization and devaluation
    • • Identity disturbance
    • • Impulsivity in at least two areas that are
    • potentially self-damaging
    • • Recurrent suicidal behaviors, gestures
    • or threats or self-mutilating behaviors
    • • Affective instability due to a marked
    • reactivity of mood
    • • Chronic feelings of emptiness
    • • Inappropriate anger
    • • Transient, stress-related paranoia
  147. What is the definition of histrionic PD?
    • • Pervasive pattern of excessive
    • emotionality and attention seeking
    • indicated by >5 of the following:
    • • Uncomfortable in situations in which he
    • is not the center of attention
    • • Interaction with others often
    • characterized by inappropriate sexually
    • seductive behavior
    • • Displays rapidly shifting and shallow
    • expression of emotion
    • • Consistently uses physical appearance
    • to draw attention to self
    • • Has a style of speech that is excessively
    • impressionistic and lacking in detail
    • • Shows self-dramatization and
    • exaggerated emotion
    • • Is suggestible
    • • Considers relationships to be more
    • intimate than they are
  148. What is the definition of narcissistic PD?
    • • A pervasive pattern of grandiosity (in
    • fantasy or behavior), need for
    • admiration, lack of empathy as
    • indicated by >5 of the following:
    • • Grandiose sense of self-importance
    • • preoccupied with fantasies of unlimited
    • success, power, brilliance or beauty
    • • Believes he is special and can only be
    • understood or should associate with
    • other special or high status people
    • • Requires excessive admiration
    • • Has a sense of entitlement
    • • Is interpersonally exploitive
    • • Lacks empathy
    • • Is often envious of others and
    • believes others are envious of him
    • • Shows arrogant, haughty
    • behaviors or attitudes
  149. What is the definition of avoidant personality disorder?
    • • A pervasive pattern of social
    • inhibition, feelings of inadequacy
    • and hypersensitivity to negative
    • evaluation as indicated by >4 of the
    • following:
    • • Avoids social occupations that involve
    • significant interpersonal contact
    • • Is unwilling to get involved with people
    • unless certain of being liked
    • • Is preoccupied with being criticized in
    • social situations
    • • Shows restraint in intimate relationships
    • because of fear of being shamed or
    • ridiculed
    • • Inhibited in new interpersonal situations
    • because of feeling inadequate
    • • Views self as socially inept and
    • unappealing
    • • Is unusually reluctant to take personal
    • risks or engage in any new activities
    • because they may prove embarrassing
  150. What is the definition of dependent PD?
    • • A pervasive and excessive need to be
    • taken care of that leads to submissive and
    • clinging behaviors and fears of separation
    • as indicated by >5 of the following:
    • • Has difficulty making everyday decisions
    • without an excessive amount of
    • reassurance
    • • Needs others to assume responsibility
    • for most major areas of his life
    • • Has difficulty expressing disagreement with
    • others because of fear of loss of approval
    • • Difficulty initiating projects on his own because
    • of lack of self confidence
    • • Goes to excessive lengths to obtain nurturance
    • and support from others
    • • Feels uncomfortable or helpless when alone
    • • Urgently seeks another relationship as a source
    • of care and support when a relationship ends
    • • Is unrealistically preoccupied with fears of being
    • left to take care of himself
  151. What is the definition of obsessive-compulsive PD?
    • • A pervasive pattern of preoccupation
    • with orderliness, perfectionism and
    • mental and interpersonal control at
    • the expense of flexibility, openness
    • as indicated by >4 of the following:
    • • Preoccupied with details, rules, lists,
    • order or schedules to the extent that the
    • major point of the activity is lost
    • • Shows rigidity and stubbornness
    • • Perfectionism that interferes with task
    • completion
    • • Excessively devoted to work and productivity to
    • the exclusion of leisure activity and friends
    • • Over conscientious and inflexible about matters
    • of morals or ethics
    • • Is unable to discard worn or worthless objects
    • even those without sentimental value
    • • Reluctant to delegate tasks
    • • Adopts miserly spending style toward self and
    • others
  152. What are considered "ego-syntonic" personality disorders?
    • e.g. antisocial PD
    • narcissistic PD

    --> harder to treat b/c ego-syntonic
  153. What symptoms improve specifically when serotonin levels increase?
    • depression
    • impulsiveness
    • rumination
    • sense of well being
  154. What therapies are effective for treating borderline PD's?
    • DBT
    • schema-focused therapy
    • transference-focused therapy
    • mentalization-based treatment
  155. What are common comorbid disorders of people with antisocial PD?
    • alcohol dependence
    • depressive disorders
  156. What are common comorbid disorders of people with borderline PD?
    • alcohol and drug dependence
    • mood disorders
    • anxiety disorders, PTSD
  157. What affect does comorbid personality disorder have?
    negative prognostic significance for Axis I disorders (e.g. mood and anxiety disorders)
  158. What are common reasons different ages of pts seek therapy?
    •  Children: behavioral, school, family issues
    •  Adolescents: as above and issues of separation and peer relationships
    •  Young adults: all of above plus career issues
    •  Mature adults: all of above plus issues of changing relationships, family alignments, health, work and social status
    •  Older adults: all of above plus end of life issues
  159. True/False: 
    quality of therapist/client relationship effects
    outcome more than specific therapy
    True
  160. What brain-imaging changes are seen with mindfulness based stress reduction programs for 8wks?
    changes in grey matter concentration in brain regions involved in learning and memory processes, emotional regulation
  161. What brain changes are associated with PTSD and MDD?
    decreased density or volume of hippocampus
  162. What is resistance?
    ideas unacceptable to conscious; prevents therapy from proceeding
  163. What is free association?
    • patient says what comes to mind uncensored.
    • Clues to unconscious
  164. What brain changes were seen with 6wks of interpersonal therapy?
    increased blood flow to R basal ganglia and posterior cingulate activity
  165. CBT is as effective as medication therapy for which conditions?
    • less severe depression
    • OCD
    • panic disorder
    • anxiety disorder
  166. What mental status exam questions test attention?
    • serial 7's
    • WORLD backwards
    • months of year backward
    • countdown from 20
  167. What are the most sensitive tests for delirium?
    • orientation
    • serial 7's (attention)
    • recall memory
  168. What level of risk does substance dependence/abuse plan in violent crime?
    30x increase risk of violence

    •  Antisocial personality disorder with co morbid
    • substance abuse or dependence carries greater than
    • 100X the risk compared to the general population.
  169. What level of risk does schizophrenia play in violent crime?
    •  Mental illness carries a 9X greater risk than the general
    • population particularly paranoid schizophrenia and
    • confused states related to medical problems.
  170. % of children with clinically significant psych disorders
    15%
  171. What drugs are FDA approved for pediatric OCD?
    • fluoxetine
    • fluvoxamine
    • sertraline
  172. Lifetime risk of depression?
    • women: 10-25%
    • men: 5-12%
  173. Point prevalence of depression?
    • women: 5-9%
    • men: 2-3%
  174. Comorbidity with depression?
    • 25% of pts with major medical comorbidity will develop MDD (highest with stroke and MI)
    • often comorbid with anxiety disorder
  175. Depression age of onset?
    mid-20's
  176. What % of MDD become BPAD?
    5-10%
  177. % of MDD who commit suicide?
    • 15%
    • (higher rate with dysthymic disorder)
  178. What is rapid cycling?  % of BPAD?
    • rapid cycling = >4 mood episodes (any type) <12mo
    • 10-20% of BPAD
    • 70-90% = women
  179. Lifetime risk of BPAD?
    • BPAD I: 1% (men = women)
    • BPAD II: 0.5% (women > men)
  180. Age of onset of BPAD?
    early 20's
  181. What antidepressants have highest switch rate to mani?
    TCA's
  182. % of BPAD who commit suicide?
    15%
  183. Lifetime risk of dysthymic disorder?
    6%
  184. Point prevalence of dysthymic disorder?
    • 3%
    • male = female
    • often comorbid personality disorders
  185. Prevalence of cyclothymic disorder?
    0.4-1%
  186. Criteria for atypical depression:
    • mood reactivity
    • >2 of:
    • wt gain, increased appetite
    • hypersomnia
    • leaden paralysis
    • long-standing interpersonal rejection sensitivity
  187. What meds does atypical depression respond to?
    • SSRI's
    • MAOI's
    • (not TCA's)
  188. What mood disorders have highest rates of comorbid susbtance use?
    BPAD I > BPAD II > MDD
  189. Age of onset of anxiety disorders? M v F?
    • teens, early 20's
    • female > male (2:1)
  190. Neuroanatomy involved in anxiety?
    • amygdala: emotionally salient stimuli
    • medial prefrontal cortex: modulation of affect
    • hippocampus: memory
  191. Tx for PTSD?
    • CBT
    • exposure tx
    • antidepressants
    • mood stabilizers
    • beta-blockers
    • clonidine
    • prazosin
    • gabapentin
  192. Neuroanatomy of PTSD?
    • hypoactivation of medial prefrontal cortex including orbitofrontal cortex and anterior cingulate cortex (affect regulation)
    • (tx with paroxetine increases anterior cingulate cortex function)

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