Psychopathology notecards.txt

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Psychopathology notecards.txt
2011-04-08 12:03:32

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  1. Axis 1
    Mental disorders except MR and personality disorders
  2. Axis 2
    Personality disorders, MR, disorders that go way back in person's development
  3. Axis 3
    GMC that may affect, cause, or influence Axis I condition
  4. Axis 4
    Psychosocial and environmental probs (not mental illness b/might contribute)
  5. Axis 5
    • Global Assessment of Fcng
    • Usual 80-90 (absent/minimal sx)
    • 41-50 means severe sx (suicidal ideation, severe obsessional rituals, freq shoplifting), or severe impairment in social or occupational fcning
  6. MDE criteria
    >=5 of the SIGECAPS criteria in same 2 wk period: Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor agitation, Suicidality
  7. Sx do not meet criteria for mixed episode
    • *Sx cause distress or impairment of fcng
    • Not explained by GMC or bereavement
  8. SIGECAPS (MDD criteria) stands for...
    • Sleep (increased or decreased)
    • Interest (anhedonia)
    • Guilt, worthlnessness
    • Energy levels
    • Concentration probs, indecisiveness
    • Appetite (increased or decreased)
    • Psychomotor agitation (increased or decreased)
    • Suicidal thoughts
  9. MDD (single episode vs. recurrent) and rule outs...
    • Single episode - MDE + r/o
    • Recurrent - 2+ MDE's + r/o's, must have >2 consec mo.s where pt does not meet MDE criteria
    • R/O - psychotic disorder, manic or hypomanic episodes, drugs and GMCs
  10. MDD epidemiology
    • F:M ratio= 2:1
    • 6-13% overall lifetime prevalence
    • Avg age onset 25-35 y/o
    • 5-10% devel bipolar
    • 15% commit suicide
    • Comorbidities: anxiety, subs abuse
    • 50% relapse after 1 episode
    • 80% relapse after 3 episodes
  11. MDD etiology
    • Monoamine hypothesis (defy in DA, NE, 5HT or receptor probs)
    • Drugs (presribed or illicit)
    • GMC (VINDICATED acronym)
  12. VINDICATED acronym for causes of MDD
    • Vascular: Stroke, MI
    • Infectious: syphilis, brain abscess, Viral
    • Neoplasm: primary or mets
    • Def/y, degeneration: Dementia, B12, folate, Wilson's Huntington's
    • Intoxication: meds, alcohol, Pb
    • Trauma
    • Endocrine
    • Drugs
  13. Depression vs. bereavement
    • MDD - >2 mo.s, suicidal ideation often, worthlessness, blaming self, prolonged fcnal impairment
    • Grief - < 2 mos., absent suicidal ideation, feelings of loss, crying, survivor guilt if any, return to baseline over time
  14. Dysthymia (overview)
    • Depressed mood for most of the day for more days than not for at least 2 years
    • While depressed, do at least 2 of the following: poor appetite or overeating, insomnia/hypersomnia, low energy levels, low self-esteem, poor concentration or difficulty making decisions, feelings of hopelessness
  15. Dysthymia (tx)
    • SSRIs - 1st line
    • TCAs (2nd line b/c safety profile)
    • MAOIs
    • Medications can prevent relapse
    • Psychotx
    • ECT (esp during pregnancy)
  16. Manic episode
    • persistently elevated, expansive, or irritable mood for at least 1 wk (less if hospitalized), and during mood disturbance need 3-4 of DIGFAST
    • Doesn't meet criteria for mixed epsiode, causes impairment to the point of hospitalization or psychotic features
    • DIGFAST= Distractability, Indiscretion/impulsivity, Grandiosity, Flight of Ideas, Increased activity, Decreased sleep, talkative
  17. DIGFAST criteria (for manic episode)...
    • Distractability
    • Indiscretion/impulsivity
    • Grandiosity
    • Flight of ideas
    • increased Activity
    • decreased Sleep
    • Talkative
  18. Changes during mania
    • Mood/affect: labile; euphoric --> irritability
    • Cognition: tangential thought processes, distractability, racing thoughts, sexual/religious preoccupation, gradiosity, subtle delusions
    • Behavior: bizarre and frenzied psychomotor actiity, no/little sleep, pressured speech, impuslivity, spending, sex, projects, occas assaultive behavior
  19. Hypomania - "not quite mania"
    • Elevated/ expansive/ irritable mood lasting through at least 4 days that is clearly dif from usu nondepressed mood
    • Also 3-4 DIGFAST
    • Assoc w/ change in functiong of person and observable by others
    • **DOESN'T causes social/occupational dysfcn, does NOT need hosp/n, NO psychosis
    • No suicidal ideation
  20. Mixed Episode
    • Very angry and irritable
    • Meets criteria for both manic and MDE for 1 wk
    • causes impairment in fcng OR social activities OR relationships, OR necessitates hospital/n OR has psychotic features
  21. Cyclothymia
    • For at least 2 years (1 in kids) the presences of numerous periods with hypomanic sx and depressive sx b/ don't meet MDE criteria
    • During first 2 yrs no MDE, manic, or mixed episodes, other r/o's
    • Causes distress or imapired functioning
  22. Bipolar epidemiology
    • Lifetime prevalence = 1%
    • Age of onset ~25
    • 15% commit suicide
    • 50% have psychotic sx at some point, substance abuse common
    • Very common to have comorbidities (borderline, histrionic, obesity, overweight, personality disorder)
  23. Bipolar tx
    • Mood stabilizers w/ or w/o antipsychotics
    • Lithium (can be effective)
    • Anticonvulsants (depakote, carbamazepine, lamotrigine)
    • Antipsychotics
    • ECT
    • Psychothx
    • Be careful w/ antidepressants so you don't induce manic switch
  24. Suicide (epidemiology)
    • 2nd leading cause of death 25-34 y/o
    • 3rd leading cause of death in 15-24 y/o
    • However, elderly still attempt at a higher rate
    • Men complete more, women attempt more
    • 2/3 tell someone
    • 40% have had prior attempt
  25. Suicide - risk factors
    Previous attempts, mood disorders, alcohol, subs abuse, FHx, impulsiveness, hopelessness, anxiety, psychic pain, lack of social support, domestic violence, lack of executive function, HIV/AIDS, ESRD, pain syndromes
  26. Suicide - protective factors
    Children in home, sense of responsibility to family, pregnancy (not with mood disorder or if psychotic), religiosity, life satisfaction, reality testing ability, positive coping and problem solving skills, positive social support
  27. Anorexia nervosa (overview)
    • Restrictive subtype (only restrict
    • Bing-purge subtype (restrict mostly, ocasionally binge purge)
  28. Anorexia nervosa (physical findings)
    • Clin pres: cold intol, dizziness, constipation, abd discomfort
    • PE: emaciation, skin (hypocarotenemia, lanugo hair), CV (orthostatic changes, peripheral edema)
    • Labs: Low phosphate, low Mg, low T3, low T4, low albumin
    • EKG: Bradycardia, T wave inversion
    • Heme: Anemia, leukopenia
    • Renal: Decreased BUN and urine osmolality
  29. Bulimia nervosa (overview)
    • Purging substpe (vomiting, laxatives, etc)
    • Nonpurging subtype (exercise, restrict)
  30. Bulimia nervosa (physical findings)
    • May be any weight
    • salivary gland atrophy (if vomiting at high frequency)
    • Dental pathology
    • Orthostatic hypotension
    • Dehydration, abrasions on dorsum of fingers (from forcing vomtiting)
    • Labs: electrolytes abnormal (decreased K, Na, Cl, arrhythmias)
    • Vomtiting -> metabolic alkalosis
    • Laxative abuse/diarrhea -> metabolic acidosis
    • increase or decrease inserum amylase (good indicator of self-induced vomiting)
    • Anemia, esophageal erosions (labs often normal but can change quickly)
  31. Eating disorder NOS
    • Purging anorexia nervosa
    • Binge eating disorder
    • Night eating syndrome
  32. Pica
    • Dx: persistent eating of nonnutritive substance for >1 mo, innappropriate to developmental level and not a culturally sanctioned practice
    • Often related to anemia
  33. Night eating syndrome
    • Anorexia and ulimia often pass through this on road to recovery
    • Morning anorexia, evening hyperphagia, insomnia
  34. Comorbidities with Eating disorders
    • Anxiety and depression
    • OCD (assoc w/ anorexia> bulimia)
    • Drugs and alcohol (bulimia> anorexia)
    • PTSD
  35. Anxiety disorders
    • Pathological vs. normal anxiety - pathological when significant change in behavior and impaired response
    • Generaliized anxiety disorder
    • Panic disorder with agoraphobia
    • Agoraphobia
    • PTSD
    • OCD
    • Social Phobia
    • Specific Phobia
    • GMC -> anxiety
  36. Generalized anxiety disorder
    • chronic excessive worry about numberof events/activities with difficulty controlling worry
    • at least 3 of the following: restlessness, fatigue, concentration problems, irritability, mm tension, sleep disturbance
    • Sx>6 mos
    • increased rates in women and African Americans
    • Tx: SSRIs and psychotx
  37. Panic disorder with agoraphobia
    • 2-3% of women, onset mid 20s
    • 50% comorbid MDD
    • Recurrent, unexpected panic attacks
    • Anxiety assoc with >=4 phys or cognitive sx
    • At least one month of worry about having an add'l attack or conseq of attack
  38. Agoraphobia
    • anxiety in situations where escape might be difficult (or embarrassing) or help might not be avail in event of panic attack
    • situations are avoided or endured with marked distress
  39. PTSD
    • has to be induced by some traumatic event (often men - combat, women - rape)
    • reexperiencing event (flashbacks, hallucinations)
    • Avoidance of stimuli/psychologic numbing (anhedonia)
    • Increased arousal
    • Sx>1 mo
    • BDZs should only be used short term
  40. OCD (overview)
    • Obsessions, repetitive, intrusive thoughts, images, or impulses that cause anxiety and are difficult toresists
    • Compulsions are repetitive actions or thoguhts aimed to neutralize anxiety or discomfort, rituals may be overtly or mentally performed
    • Obsessions and compulsions can cause marked distress, are time consuming, or interfere with person's daily routine activities
    • M>F often h/o harsh discipline as child
    • Work to exclusion of lesiure activities and friendships
    • Hoarder, miserly, rigidity and stubbornness
  41. Social phobia
    • Marked persistent fear of social or performance situations where person is exposed to unfamiliar people or possible scrutiny by others
    • Fear of embarrassment or humiliation and patient recognizes it as excessive w/ sx of anxiety, panic, and avoidance
    • ~12% of population, usu begins b4 adol
    • Beta blockers can be used, along with CBT
  42. Specific phobia
    • Marked, persistent, excessive, unreasonable fear cued by anticipated presence of specific object or situation
    • Exposure causes anxiety sx or panic
    • Pt recognizes it is unreasonable
    • Situations avoided or endured with anxiety
  43. GMCs causing anxiety
    • Endocrine: hyperthyroid, pheo, hypoglycemia
    • CV: tachycardia
    • Resp: COPD, pneumonia, asthma
    • Metabolic: Vit B12 defy
    • Neuro conditions
  44. Substances causing anxiety via INTOXICATION
    • Alcohol
    • Amphetamines
    • Caffeine
    • Cannabis
    • Cocaine
    • Hallucinogens
    • Inhalants
    • OCP
  45. Substances causing anxiety via WITHDRAWAL
    • Alcohol
    • Cocaine
    • Sedatives
    • Hypnotics
    • Anxiolytics
  46. Tic disorders
    • MOtor or verbal tics (Transient < 1 yr, Chronic > 1 yr)
    • Tourette's - multiple motor and 1+ vocal tics for > 1 yr
    • Tics occur many x/day, usu in bouts, not tic-free for more than 3 mos, onset before 18 y/o
  47. OCD comorbidities
    • Tic disorders - including Tourette's
    • ADHD
    • Learning disorders - big split b/w verbal and nonverbal IQ
    • Depression (rate of comorbidity increases with age)
    • Other anxiety issues (social phobia, sep/n anxiety, panic attacks)
    • Autism and PDDs
    • Alcohol, drug abuse, dependence
    • Oppositional defiant disorder
    • Family stress
  48. Tic disorder comorbidities
    • OCD (~1/3 have OCD sx)
    • ADHD (up to 50%)
    • Learning disorders, depression
    • Anxiety problems
    • PDDs
    • Family stress and related problems
    • Add'l probs with tourettes: social rej/n or anxiety about having tics in social situations
  49. OCD tx
    • CBT (exposure and response prevention)
    • Meds (mainly SSRIs)
  50. Tic disorder tx
    • CBT
    • Alpha adrenergics - clonidine and guanfacine
    • Neuroleptics - risperidone, ziprasidone (or older meds like haldol, pimozide)
  51. Psychotic disorders
    • Psychotic disorders: brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, delusional disorder
    • In contrast to
    • Med/neuro conditions: GMC, Dementia, Delirium, Subs-induced
    • Mood disorders: Bipolar, MDE
  52. Schizophrenia (overview)
    • Char sx w/ 2 or more of folowing for sig time in 1 mo period
    • Pos sx: Delusions, Hallucinations, Disorganized speech, Grossly disorganized or catatonic behavior
    • Neg sx: affective flattening, alogia, or avolition
    • Only 1 criteria A sx needed if delusions are bizarre or the hallucinations have continually talking voice or 2 voices conversing
  53. Schizophrenia (symptoms)
    • Formal thought disorder: loose associations, tangentially related, circumstantiality, thought blocking
    • Delusions: fixed false belief even in face of contradictory evidence
    • Hallucinations: perceptual disturbances: auditory, visual
    • Olfactory h.s seen more often in temporal lobe epilepsy
    • Behaviors: biarre, inappropriate, disorganized, cataonia, violence
    • Affect - blunted, restricted, often incongruent with mood
  54. Schizophrenia (etiology)
    • Proposed - overactive DA system (may also have serotonin, GABA influence)
    • Mesolimbic pathway - pos sx
    • Mesocortical - neg sx
    • Nigrostriatal - cause EPS
  55. Schizophrenia (treatment)
    • Start with chlorpromazine (1st gen/n)
    • DA receptor antagonists
    • 1st gen/n antipsychotics (specific for DA: D2>>5HT or NE) - treats pos sx and has more EPS s/e
    • 2nd gen/n - D2~5HT, tx for pos and neg sx w/ less s/e
  56. Schizophrenia (diagnostic criteria)
    • 2 or more psychotic sx for one month (shorter if treated)
    • impairent in social, occupational functioning
    • Some signs for at least 5 mos
    • Not due to mood or schizoaffectivedisorder
    • Not due to med, neuro, subs induced disorder
    • Subtypes - catonic, disorganized, paranoid, undifferentiated, residual
  57. Brief psychotic disorder
    • only pos sx of schizop. (delusions, hallucinations, disorganization)
    • 1 day to 1 mo duration
    • don't go on to devel schizop
    • have underlying psych disorder
    • often acute stressor
  58. Schizophreniform disorder
    • duration: >1 mo but <6 mos w/ complete remission of sx
    • Not due to med/neuro/subs induced disorder
  59. Schizoaffective
    • Meets criteria for MDE or manic episodes and psychotic sx of schizop
    • 2 wks of psychotic sx in absences of mood sx
    • Mood sx spend time in active and residualphases
    • Ongoing psychotic sx in b/w depressive and manic episodes
  60. Delusional disorder
    • Nonbizarre delusions for at least 1 month - being folllowed, poisoned, infected, loved, etc (but not aliens= bizzare)
    • Never met psychotic criteria for schizophrenia
    • functioning is not markedly impaired
    • Subtypes - erotomanic, grandiose jealous, persecutory, somatic, mixed
  61. Shared psychotic disoder
    Delusion develops in person in close relationship with someone who already has delusional disorder
  62. Substance induced psychotic disorder
    • prominent hallucinations or delusions
    • Can't include hallucinations if they realize it is due to the subs
    • E.g. LSD, mushrooms, amphetamines, alcohol, PCP, cocaine
  63. Premenstrual dysphoric disorder (PMDD)
    • must have 1 of 4 sx below:
    • Feeling sad, hopeeless, self-deprecating
    • Feeling tense, anxious, on edge
    • marked lability of mood interspersed with freq tearfulness
    • Persistent irritability, anger, and increased interpersonal conflicts
    • A number of other things may also be present
    • Increased risk of past and future depression
    • PMS looks more at physical sx
    • Tx for PMDD - SSRIs, luteal phase use of antidepressants
  64. Postpartum blues
    • mild transitory state with sx like rapid mood shifts, irritability, tearfulness, fatigue, insomnia, anxiety, poor appetite
    • sx last 1 wk postpartum -> several hours to 2 wks and resolves
    • minimal effect on functiong
    • incidence 26-85% and could be normal variant
    • 25% of these will devel postpartum depression in 1st postpartum year
  65. Postpartum depression
    • Occurs in 10-15% women -> MDD with postpartum onset
    • Sx range from mild dysphoria to psychotic depr/n
    • Most commonly tearful, mood lability, poor concentration, attention, fatigue
    • TX: most often SSRI started (Sertraline (Zoloft) is tx of choice)
    • Risk factors: depression and anxiety during pregnancy stressful recent life events, lack of social support, prior h/o depression, OB or pregnancy complications, SES
  66. Postpartum psychosis
    • rare emergency, usu 2-4 wks postpartum b/ can be 48-72 hrs
    • Labile mood, delusions, hallucinations, often delusions focused on infant and may include command auditory hallucinations to harm self or baby
    • Tx: haldol, if 2/2 bipolar-> lithium; prophylactic estrogen and lithium in high risk, ECT also option
  67. Postpartum anxiety disorder
    • more vulnerable to recurrent panic sx due to to sign personal, social changes
    • in women w/ OCD, 30% will have increase in sx after pregnancy
  68. Sexual disorders in women
    Women presenting with impaired desire 2x more liekly to have h/o MDD
  69. Women's sexual interest/desire disorder
    • Genital sexual arousal disorder
    • Vaginismus
    • Dyspareunia
    • Sexual aversion disorder
    • Persistent sexual arousal disorder
  70. Menopause
    • 12 consec mos amenorrhea
    • avg onset ~51 y/o
    • Smokers and depressed women -> earlier onset
    • Depression, anxiety, irritability may accompany menopause
  71. Alcohol addiction
    • Dx: tolerance
    • Withdrawal sx: Sweating, tachycardia, increased BP, insomnia, vivide dreams, hand tremor, loss of appetite, HA, N/V, hallucinations, seizures
    • Delirium tremens is med emergency - 10-15% die w/o tx
  72. Alcohol-induced persisting amnestic disorder
    • (formerly Wernicke-Korsakoff)
    • due to thiamine defy
    • Wernickes (acute phase) - memory disturbances, ophthalmoplegia, atxia
    • Thiamine is tx (must be given IV b4 giving IV glucose)
    • Korsakoff's psychosis - chronic phase and devels if thiamine not addressed - may see confabulation
  73. Dissociative disorders (overview)
    • spearation of mental structures or content that were previously connected
    • can vary in onset, duration, and severity
    • Alteration defines disorder
    • -------
    • Depersonalization - sensation and perception
    • Amnesia - consciousness
    • Fugue - identity and motor behavior (most transient of all)
    • DID - memory, behavior, and sense of who they are (multiple personality disorder)
  74. Depersonalization
    • alteration of exper: feeling deatched from body, dream-like state
    • Reality testing is NOT impaired and significant distress
    • Occurs as part of PTSD, other anxiety disorders, LSD, THC, fatigue, partial complex seizures, sleep deprivation
    • May be accomp by derealization (altered perception of external objects, nothing is real)
    • D/Dx: psychoses, subs related disorders, organic brain syndromes, personality disorders, anxiety disorders
    • Tx: comorbid conditions - sometimes spontaneous resolution
  75. Dissociative amnesia
    • inabil to recall imp personal info, more than usu forgetfulness
    • Can be localized (to specific time), selective, systematized, continuous
    • Epidem: 5-20% of combat vets and disaster victims
    • D/Dx: Organic brain syndromes: TBI, stroke; Malingering
  76. Dissociative fugue
    • inability to recall identity or past
    • Partial (confusion) vs. complete (new identity)
    • Thought to be related to stressful events (disasters, assaults, etc)
    • Tx: hypnosis, amobarbital, help one accept what happened and integrate into normal life
    • Upon return of memory, help pt understand reason for memory loss
  77. Dissociative identity disorder
    • (formerly multiple personality disorder)
    • 2+ personalities or behavior patterns in indiv
    • Personalities (alters) may not be aware of other alters
    • Alters repeatedly assume contorl of pt's behavior
    • Common forgetfulness can't explain it
    • Epidem/Etiol: >90% report h/o abuse, begins in childhood b/ often dx as adol, young adult
    • Comorbid: BPD in 70% DID pts
    • D/Dx: Schizphrenia and other psychoses, subs-rel disorders, severe personality disorder, malingering
  78. Somatoform disorders (overview)
    • Somatization disorder
    • Conversion disroder
    • Hypochondriasis
    • Pain disorder
    • Body dysmorphic disorder
    • Undiff'd somatoform disorder
    • Somatoform disorder NOS
  79. Somatization disorder
    • Have many phys sx (ROS)
    • Onset b4 age 30, more common in women, really feel aches and pains
    • DSD IV criteria: 4 pain sx, 2 GU sx, 1 sexual sx, 1 psychoneuro sx
    • Sx exaggerated and unfounded
    • Production of sx not intentional
    • Tx: geared to breaking cycle of anxiety and depression
    • D/dx: panic disorder, MDD, psychosis
  80. Conversion disorder
    • Phys sx usu suggesting neuro condition
    • Seizures, paralysis, blindness- often following acute stressor
    • repressed psychological conflict - anatomic connection varies
    • Rapid onset with sudden termination and reappearance
    • More common in women and combat veterans'
  81. Hypochondriasis
    • Preoccupied w/ possibilit of disues due to misinterpreted normal sensations
    • 6 mos duration
    • Persists despite medical reassurance
    • Comorbidities: depressive, anxiety d/o
    • Tx: psych and PCP reg sched F/U visits
  82. Pain disorder
    • Pain in 1 or more sites, no clear phys cause or clearly out of proportion
    • Acute vs. chronic (>6 mos)
    • Pain is not better accounted for by mood or anxiety disorders and is NOT consciously produced
    • People have h/o childhood abuse or neglect and poor coping skills, sx reinforced by response of othedrs
    • Tx: analgesics not helpful b/c not physicaly pain, TCAs and SSRIs may help
  83. Body dysmorphic disorder
    • Excessive concern with imagined or slight defects in appearance
    • Freq visits to plastic surgeons
    • D/dx: OCD, delusional disorder, anorexia nervosa
    • Tx: Focus on psychol stress, tx comorbid conditions (60% depression)
  84. Factitious disorder not SOMATOFORM DISORDERS
    • Voluntary production of sxcan be personal or by proxy
    • Vol prod/n sx b/ unconscious motivation to assume sick role
    • *Lack of exteranl incentives
    • Medical bkgd
    • Tx: rapport, confrontation
  85. Malingering not SOMATOFORM DISORDERS
    • Rare, dx of exclusion
    • Motivated by external incentives
    • Tx: comorbiditeis, confrontation
  86. Chart of WHAT and WHY of "somaticized" sx
    • Somatoform disorder - not conscious of motivation nor substitution of psych needs for somatic sx
    • Factitious disorder - not conscious of motivation but is conscious of substitution
    • Malingering - Conscious of everything
  87. Personality disorders (overview) (include the cluster letters)
    • Deeply ingrained, inflexible, maladaptive patterns of relating to and perceiving both environment and selves
    • Sx are egosyntonic (part of them, who they are)
    • Axis II
    • Cluster A (odd, eccentric)- Paranoid, schizoid, schizotypal
    • Cluster B (dramatic, emotional, erratic) - Antisocial, borderline, Histrionic, narcissistic
    • Cluster C (anxious, fearful) - Avoidant, Dependent, OCD
  88. Paranoid personality disorder
    • M>F, increased risk in relatives of schizophrenics, minorities, deaf
    • Suspects w/o sufficient basis that others are exploiting, harming, deceiving him or her
    • reluctant to confide in others b/c unwarranted fear that info wil lbe used maliciously a/g him or her
    • Reads into message or remarks
    • perecieves atacks on char not apparent to others and reacts angrily
    • Does not occur exclusively w/in course of psychotic disorder and no GMC either
  89. Schizoid personality disorder
    • Up to 7.5% population; 2:1 M:F ratio
    • Criteria: Neither enjoys or desires close relationships, usu chooses solitary activities
    • decreased sexual interest, pleasure in other activities,
    • lacks close friends or confidants
    • Indifferent to praise and criticism of others
    • Shows emotional coldness - detachment or flat affect
    • Not exclusively during PDD or 2/2 GMC
  90. Schizotypal personality disorder
    • 3% pop/n; increased risk in relatives of schizophrenics
    • Criteria: Ideas of reference (excluding delusions)
    • Odd beliefs or magical thinking that influences behavior and is consistent with subcultural norms
    • Unusual perceptual experiences, including bodily illusions
    • Suspiciousness or paranooid
    • Lack of close friends
    • Excessive social anxiety that doen'st diminish with familiarity and tends to be assoc w/ paranoid fears rather than neg judgements about self
    • Doesn't occur exclusively during psychotic disorder or PDD
  91. Antisocial personality disorder
    • 3% in men, 1% in women, most common in poor urban pop/ns
    • 75% in prison populations
    • Failure to conform tosocial norms WRT lawful behaviors
    • Deceitfulness, impulsivity, aggressiveness
    • Reckless disregard for sfety of others
    • Lack of remorse as indicated by beign indifferent to or rationalizing having hurt, mistreated, or stolen from another
    • indiv >18 y/o and evidence of conduct disordr w/ onset before 15 y/o
    • Behavior not just during schizophrenia or manic episode
  92. Borderline personality disorder
    • 1-3% popn, 2x women than men
    • Most prevalent PD In all clinical settings
    • Frantic efforts to avoid real or imagined abandonment
    • Unstable and intesnse relationshisp alternating b/w idealization, devaluation
    • Identity disturbance - unstable
    • Impulsivity in >2 areas pot'ly self-damaging behaviors
    • Chronic feelings of emptiness
    • Recurrent suicidality
    • Anger probs
    • IN primary relatives, found an increased prevalence in MDD and alcohol/subs abuse
  93. Histrionic personality disorder
    • 2-3% W>M, assoc w/ somatizaiton disorder and alcohol abuse
    • Must be center of attention
    • Often inappropriate behavior, esp sexual advances
    • Rapidly shifting and shallow expression of emotions, uses physical appearance to draw att/n to self
    • Shows self-dramatization
    • Easily influenced by others or circumstances
  94. Narcissistic personality disorder
    • 2-15% in general population - e.g Charlie Sheen
    • Has grandiose sense of self-importance
    • Preoccupied by fantasies of unlimited success, power, brilliance, beauty
    • Behaves he/she is special/unique
    • Requires extensive admiration
    • Sense of entitlement
    • Exploitative
    • lacks empathy
  95. Avoidant personality disorder
    • 1-10% may be same as related to genearlized social phobia
    • Avoids activites with increased interpersonal contact b/c fears of criticsm, disapproval, rejection
    • Fear of shame and diricule so trouble forming new or significant relationships
    • Views self as socially inept, perosnally unappealing, or inferior to others
    • Usu reluctant to take risks b/c might be embarrassed
  96. Dependent personality disorder
    • 2-4% population, F>M
    • Diff/y in decisions w/o excessive advice, reassurance from others
    • needs others to assure responsibility in life
    • Diff/y expressing disagreement b/c fear loss of support or approval
    • lack of initiative in actions (b/c lack of slef-confidence in judgment or abilities)
    • Feels uncomfortable or helpless when alone
    • Urgently seeks another relationship as source of care and support when clsoe relationship ends
  97. Personality disorder NOS
    • Passive aggressive personality disorder
    • Depressive personality disorder
    • Specific traits or behaviors (sadism or masochism)
  98. Disruptive disorders (overview)
    • Examples include:
    • ADHD, Conduct disorder, oppositional defiant disorder
  99. ADHD
    • Sx present b4 age 7 and in at least 2 settings
    • Hyperactivity, inattention, impulsivity, carelessness, propensity for accidents, h/o excessive crying, high sensitivity to stimuli and irregular sleep patterns in infancy
    • Hyperactivity is 1st sx to disappear as child reaches adol, most have remission by adulthood
  100. Conduct disorder
    • behavior that grossly violates social norms (torture animals, stealing, fire setting, etc)
    • Can begin in childhood (6-10) or adol (no sx b4 10 y/o)
    • Prognosis: risk for criminal behaivior, antisocial personality disorder, subs abuse, and mood disorders in adulthood
    • Most children show remissio nby adulthood
  101. Oppositional defiant disorder
    • Behavior that while defiant, negativive, noncompliant does not grossly violate social norms (anger, argumentativeness, resentment toward authority figures)
    • Gradual onset, usu b4 age 8
    • A significant number progress to conduct disorders
    • most remission by adulthood
  102. Sexual response phases
    • Desire
    • Excitement/arousal
    • Orgasm
    • Resolution
  103. NTs and sex
    • Increasing DA increases desire (few antidepressants, buproprion, etc)
    • Increasing serotonin decreases desire (SSRIs)
  104. Psychosexual disorders (overview)
    • Sexual arousal disorders
    • Orgasmic disorders
    • Sexual pain disorders
  105. Sexual arousal disorders
    • Hypoactive sexual desire disorder
    • Sexual aversion disorder
    • Female sexual arousal disorder
    • Male erectile dysfcn disorder
  106. Orgasmic disorders
    • Female orgasmic disorder
    • Male orgasmic disorder
    • Premature ejaculation
  107. Sexual pain disorders
    • Dyspareunia
    • Vaginismus
  108. Paraphilias
    • Exhibitionism
    • Voyeurism
    • Fetishism
    • Transvestic fetishism
    • Frotteurism
    • Pedophilia
    • Sexual masochism
    • Sexual sadism
  109. Substance addiction - opiates
    • Effects: analgesia, euphoria, decreased anxiety, pupillary constriction, drowsiness, n/v/constipation
    • Overdose: Triad of pupillary constrction (miosis), coma, resp arrest (if pupils dilated = near death)
    • OD Tx: Naloxone
    • Opioid withdrawal sx: dysphoric mood, n/v/, myalgia, lacrimation, pupillary dilation, piloerection, sweating, abd cramps,fever, insominia
    • NeuroA of withdrawal: increased NE release from locus ceruleus
    • Tx: Naltrexone (blocker), Methadone (in special clinics), Buprenorphine (Rx use)
  110. Substance addiction - cocaine
    • Effects: Produces vasoconstriction, blocks reuptake of NTs -> increased levesl in synapse
    • Intox sx: Euphoria or affective blunting, increased energy, alertness, decreased need for sleep, insomnia, decreased appetite, decreased judgment, anxiety, irritability, anger, paranoia
    • Phys sx: Tachy- or bradycardia (latter is more likely withdrawal), pupillary dilation, perspiration or chills, N/V, wt loss, mm weakness, increased BP (decreased in withdrawal), HA, tremors, bruxism, coma, SUDDEN DEATH
    • Tx: BDZ, Phentolamine to tx HTN if hyperadenergic, NOT Beta blockers
    • NE: elevation of pulse and BP, also involved in regulating mood
    • DA: blocking of DA reuptake from axons of neurons in VTA to nucleus accumbens
    • 5HT: modulates reward potency of cocaine
  111. Development quotient
    Mental age / chronological age (max # =16) * 100
  112. Mild intellectual disability (ID)
    • IQ 50-55 to 70 (> 2 SD below mean of 100)
    • employment and supervised indep living atainable with community supprot and if no comorbid disorders
    • Most common
    • Some syndromes and dx have mild ID--> e.g. Prader Willi
    • Phys devel usu normal b/ emotional and cognitive changes, esp at puberty can be challenge for pt and family
  113. Moderate intellectual disability (ID)
    • IQ 35 to 50-55
    • Most are ambulatory and toilet-trained
    • More gross and fine motor movment, delayed devel
    • Expressive language often more imapired than nonverbal
    • Seizures more common than in mild ID
  114. Severe intellectual disability (ID)
    • IQ 20-35
    • Adult functions at 3-6 y/o level
    • Language us more impaired than general cognition
    • /\ seizures
    • less typically included in normal ed/nal exper.s
    • Profound intellectual disability (ID)
  115. Profound ID
    • IQ <20
    • Trouble makign it out of the hospital
    • high mortality
  116. Borderline IQ 71-84
    • Genetic syndromes assoc with ID:
    • Down's syndrome (most common genetic ID)
    • Fragile X (most common heritable form of ID)
    • Velocardiofacial syndrome
    • Prader-Willi
    • Williams syndrome
  117. Autistic disorder
    • Qualitative impairment in reciprocal social devel
    • Qualitative impairment in communication
    • Restricted and repetitive interests
    • Onset b4 3 y/o
    • Not Rett's disorder or Childhood disintegrative disorder
  118. Autism Social devel probs
    • Marked impairment in use of multiple non-verbal behaviors such as eye-eye gaze, facial expression, body postures, and gestures to regulate social interaction
    • Failrue to develop peer relationships appropr to developmental level
    • Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people
    • Lack of social or emotional reciprocity
  119. Autism Communication probs
    • Delay in or total lack of devl of spoken language - not accomp'd by attempt to compensate through gesture or mime
    • Freq nonverbal
    • Marked impairmentin ability to initative or sustain conversation
  120. Rett's disorder
    • Dx: excludes Autistic disorder or other PDD's
    • Sx: Decel/n of head growth, loss of purposeful motor skills, Handwringing
    • Only DSM IV single gene disorder: MECP2 on Xq28
  121. Childhood disintegrative disorder
    • Normal devel for at least 2 years -> loss of acquired skills b4 age 10 in at least 2 of following domains:
    • Expressive or receptive language
    • Social skills or adaptive behavior
    • Bowel or bladder control
    • Play
    • Motor skills
  122. Asperger's disorder
    • Autism criteria not met
    • *Only social interaction probs*
    • no clinical sign general dealy in language, cog devel, adaptive behavior
  123. Delirium (overview)
    • Acute brain failure, usu acute onset
    • 2 criteria: waxing and waning level of consciousness, attentional deficits
    • Delirium predicts death
  124. Delirium (risk factors)
    • dementia (already lowered mental reserve)
    • AGed
    • Multiple meds (>3 new meds)
    • Some types of meds (anticholinergics - atropine, benadryl, trazodone, antipsychotics, furosemide; opiates; GABA drugs - e.g BDZs)
    • UTIs - r/o w/ UA and culture
    • Pneumonia - r/o w/ CXR
    • Other probs - check PMHx and ROS
  125. Dementia (overview)
    • usu unaltered state of consciousness
    • insidious onset
  126. Alzheimer's disease
    • Cortical dementia
    • Memory problem
    • One of the following: Aphasia, Agnosia (probs recognizing things), Apraxia, Executive dysfcn
  127. Vascular dementia
    • Subcortical dementia
    • Brain doesn't get enough O2
    • major risk factor is HTN
    • Lenticulostriate aa can be affected easily - basal ganglia probs
    • many other causes of dementia also