פסיכיאטריה Flashcards
(106 cards)
1
Q
Schizophrenia - epidemiology
- Frequency in general population is … [1]
- Peak incidence age in men… [2], while in women is…[3]
- Only…[4] present after the age of…[5]
- People born in… [6]
- …[7] socioeconomic levels and …[8] areas have higher tendency
- This is explained by two hypotheses…[9][10]
- More frequent in patients with… [11] personality disorder
A
- 1%
- 15-25
- 25-35
- Late onset is considered after the age of 45
- 3-10%
- 40
- Rarely presents before the age 10 and after the age 60
- Winter or early spring
- Lower
- Urbanic
- Downward drift hypothesis
- Social causation hypothesis
- Schizotypal
2
Q
Schizophrenia - biological factors
- Dopamine theory
- Serotonin theory
- Loss of…[3] in the hippocampus
- Related to increase in…[4]
- Decreased concentration of…[5] and…[6] receptors in the caudate, hippocampus and the pre-frontal cortex
A
- The main one is the dopamine theory
- Decreased activity in the mesocortical pathway, leads to positive symptoms
- Increased activity in the mesolimbic pathway, leads to negative symptoms
- The tuberoinfundibular pathway and the nigrostraital pathway are related only in the way of drugs side effects
- Increased serotonin - leads to both negative and positive symptoms
- GABAgeric
- Glutamate
- Nicotinic
- Muscarinic
3
Q
Schizophrenia - genetic factors
- Risk of…[1] in sick brother
- Risk of… [2] in child of one sick parent
- Risk of… [3] in child of two sick parents
- Risk of…[4] in DZ twin, while there is risk of…[5] in MZ twin
- According to some studies, …[6] over the age…[7], while making the child is also risk factor for the child to develop schizophrenia
A
- 8%
- 12%
- 40%
- 12%
- 47%
- Father
- 60
4
Q
Schizophrenia - Bleuler’s areas of life
A
- Described as the 4A’s
- Affect
- Ambivalence
- Association
- Autism
- Later, alogia, avolition and anhedonia were added
5
Q
Schizophrenia - Schnider’s symptoms
A
- Schnider’s described the characteristics of the hallucinations and the delusions of schizophrenic patients
- Delusions of control - stealing, implanting, control of thoughts
- Auditory hallucinations:
- Own thoughts
- Speaking to the patients
- Criticizing the patient’s behavior
- Somatic hallucinations
6
Q
Schizophrenia - negative symptoms
A
- Flat affect
- Decreased emotional range
- Cognitive decrease - blocking, low content
- Decrease in function
- Anhedonia
- Apathy
- Decreased energy
- Abulia
- Alogia
It has been shown that males have higher frequency of negative symptoms
7
Q
Schizophrenia - cognitive symptoms
A
- Defect in memory, listening and in the ability to preform tasks
- Defective insight
- Defective abstract thinking
- Disorders in concentration, executive function, working memory and episodic memory
- Considered as the most importnat prognostic factor for later immersion in society
- Tends to have lower IQ scores than the general population
8
Q
Schizophrenia - diagnosis (DSM-5)
A
- 2 or more of the following, where the one of the first 3 must be present for a significant time of one month:
- Delusions
- Hallucinations
- Disorganized speech
- Disorganized behavior (catatonic)
- Negative symptoms
- Decrease in function for significant time, since the disease onset
- For at least 6 months
- No affective disorder
- If autism is present - hallucinations or delusion must be present
9
Q
Schizophrenia - paranoid type
A
- Abrupts in 20-30 - better prognosis
- Mainly delusions (grandiosity and presecution) and hallucinations
- There is lack of the other symptoms
- No negative symptoms
10
Q
Schizophrenia - disorganized type
A
- Before the age of 25 - bad prognosis
- Characterized by disinhibition and predominant negative symptoms
- All the 3 need to found: disorganized speech, disorganized behavior, flat affect
11
Q
Schizophrenia - catatonic type
A
- At least 3 of the following:
- Catalepsy, including waxy flexibility
- Motor action without goal
- Extreme negativism
- Wired motor activity
- Echopraxia or echolalia
12
Q
Schizophrenia - residual type
A
- Patients after schizophrenic abruption that are left only with the negative symptoms
- In this stage there are no characteristics of psychosis
13
Q
Schizophrenia - undifferentiated type
A
- Schizophrenic patients that does not fit to any other subtype
14
Q
Schizophrenia - post-psychotic depression
- Occurs in…[1] of patients
- …[2] will try to suicide, and …[3] will commit suicide
- Criteria …[4]
A
- 25%
- 50%
- 10-13%
- 3 conditions:
- Criteria for MDD
- Abrupt in the residual phase of schizophrenia
- Isnt on the background of medications or other organic disease
15
Q
Schizophrenia - violence risk
- Risk factors
- Emergency treatment
- Treatment
A
- Higher risk, more common in patients that does not undergoing treatment
- The most important risk factor is past violent episode
- Other risk factors: delusion of persecution, neurological deficits
- Acute treatment: restrication and isolation, sedation with lorazepam 1-2 mg/h
- Anti-psychotics
16
Q
Schizophrenia - substance addiction
- more then…[1] have substance addiction
- …[2] of the patients are smokers
- …[3] are addicted to alcohol
- …[4] consume cannabis
- …[5] consume cocaine
A
- 50%
- >90%
- Decrease AE’s of anti-psychotics
- Decrease positive symptoms
- Improves functioning
- 30-50%
- 15-25%
- 5-10%
17
Q
Schizophrenia - physical co-morbidity
- Life-expectancy is…[1] then the general population
- Co-morbidities include…[2-6]
- Other psychiatric co-morbidities include…[7-9]
- Schizophrenia is found to protective against…[10], with the rate of about…[11] less then the general population
A
- Shorter
- Obesity
- T2DM
- CVD
- COPD
- HIV
- x1.5-2.0 higher than the general population
- Prevasive developmental disorder (PDD)
- Schizoaffective
- MDD
- Rheumatoid arthritis
- 33%
18
Q
Schizophrenia - prognosis
- …[1] will be re-admitted within 2 years of the first admission
- Within 5-10 years from the first admission only…[2] get prolonged remission
- …[3] get remission
- …[4] have normal lifestyle
- …[5] have intermidate strength symptoms
- …[6] have significant functional damage for the rest of their life
- …[7] of the patients have bad prognosis
A
- 40-60%
- 10-20%
- 10-60%
- 20-30%
- 20-30%
- 40-60%
- >50%
19
Q
A
20
Q
Schizophrenia - suicide risk
- The…[1] cause of death in schizophrenic patients
- …[2] try to commit suicide, while…[3] succeed
- Patients with…[4] prognosis have higher risk
- The most significant risk factor is…[5], which is experienced by…[6] of the patients in any point during their life
- Additional risk factors include…[7-9]
A
- Leading
- 50%
- 10-13%
- Good
- Depressive episode
- 80%
- Young age (although it is found in the bad prognosis criteria)
- Substance abuse
- Delusions
21
Q
Schizophrenia - pharmacologic treatment
- Drugs…[1]
- Injections are given when…[2]
- …[3] will get full remission
- After psychosis, antipsychotic medications decrease the relapse rate from…[4] to…[5]
- Maximal effect within… [6]
- If there is no effect after…[7], …[8]
A
- Atypicals are the first option - risperidone or olanzapine
- If typicals are given, perphenazine is given
- There is lack of compliance or in acute stage
- 60-70%
- 50-70%
- 15-25%
- 6-8 weeks
- 4 weeks
- Increase the dose or change of clozapine
22
Q
Schizophrenia - psychosocial treatment
!!!!!!להוסיף מנקודות
A
- Social skills - improve relations, eye contact, spontanic interactions, understanding of social interactions
- Family treatment
- CBT - found beneficial for supressing delusions and hallucinations
- Psychotherapy
- Rehabilitation
23
Q
Schizophrenia - adjuvant therapy
A
- Lithium - decrease psychotic signs
- Anti-epileptics - decrease violent episodes
- Benzodiazepines
24
Q
Schizophreniform disorder - diagnosis (DSM-5)
A
- Criteria A (signs), D (rule-out affective disorder) and E of schizophrenia
- Less then 6 monthes, but more then 1 month
- Specificy with or without good prognosis (good prognosis if 2 or more are present)
- Acute onest (psychoitc feats. within 4 weeks of change of behavior or function)
- Confusion in the time of psychosis
- High function before onset
- No flat affect
25
Schizophreniform disorder - prognosis
* ...[1] will turn to schizophrenia patients
* Higher frequency of...[2]
1. 60-80%
2. Post-psychotic depression
26
Schizophreniform disorder - treatment
1. Drugs
2. Recurrent episodes
3. Catatonic symptoms or prominent depression
4. Psychothrapy
1. Antipsychotics for 3-6 months
2. Mood stabilizers - lithium, carbamazepine, valproic acid
3. Consider ECT
27
Schizoaffective disorder - epidemiology
* Lifetime prevalance of...[1]
* More common in...[2] gender
* Age of onset in females is...[3]
* Males tend to show more...[4] signs and...[5]
* In the bipolar type gender division is...[6] males, and...[7] females
* In the depressive type gender division is...[8] males, and...[9] females
* Can have delusion or hallucinations that are... or...[10]
* Important to diagnose periods of...[11] of more then...[12]
* ...[13] gene is associated with both schizoaffective disorder and...[14] disorder
1. 0.5-0.8%
2. Female
3. Later
4. Anti-social
5. Flat affect
6. 50%
7. 50%
8. 33%
9. 66%
10. Mood congurent or mood incongruent
11. Delusions or hallucinations
12. 2 weeks
13. DISC1
14. Bipolar
28
Schizoaffective disorder - diagnosis (DSM-5)
* During the disease period - depressive episode/manic episode/mixed episode together with criteria A of schizophrenia
* At least two weeks of only delusions/hallucinations
* Affective symptoms are present in most of the time of the disease period
* Rule out drugs or general medical condition
29
Schizoaffective disorder - treatment
* Drugs
* In manic episode
* Refractory mania
* Depressive episode
* Mood stabilizer, sometimes with combination of antipsychotics
* Increase the dose of mood stablizers
* Consider ECT
* SSRI's
Carbamazepine is more efficient than lithium in the bipolar subtype
30
Schizoaffetive disorder - prognosis
* Better prognosis than...[1] patients
* Worse prognosis than...[2] patients
* Multiple...[3] signs are bad prognostic indicators
1. Schizophrenia
2. Mood disorder
3. Schizophrenic
31
Delusional disorder - epidemiology
* Prevalance of...[1]
* Avarage abruption age of...[2], and more common in...[3]
* More common in...[4] socioeconomic state
* During the years, less then...[5] will diagnosed with schizophrenia, and less then...[6] will be diagnoised with mood disorder
1. 0.2-0.3%
2. 40
3. Females
4. Low
5. 25%
6. 10%
32
Delusional disorder - risk factors
* ...[1] age
* ...[2] that can be physical, sensory or social
* ...[3]
* ...[4] socioeconomic state
1. Old
2. Isolation
3. Family history
4. Low
33
Delusional disorder - diagnosis (DSM-5)
* Delusions for at least a month
* Doesnt fulfill criteria A for schizophrenia
* No functional decrease, except the consequences of the delusional thoughts
* If there were affective states with the delusions, their length was short in relation to the delusions
* No drugs or other GMC
Sepcify the delusion kind
34
Delusional disorder - prognosis
* ...[1] recover, ...[2] get better, ...[3] with no change
* Good prognosis when starts at...[4] age
* Good prognostic indicators include:
* ...[5] pre-morbid condition
* ...[6] gender
* ...[7] onset
* Onset before the age of...[8]
* ...[9] duration
* ...[10], ...[11] and...[12] delusions
1. 50%
2. 20%
3. 30%
4. Young
5. Good
6. Female
7. Acute
8. 30
9. Short
10. Erotomanic
11. Persecution
12. Somatic
35
Delusional disorder - treatment
* Treatment of choice
* If there is no change within...[2], ...[3]
* Failure of treatment, consider...[4] or...[5]
* Psychotherapy
1. Antipsychotics with gradually increased dose
2. 6 weeks
3. Change to other antipsychotic
4. Mood stabilizers
5. Anti-depressents
36
Brief psychotic disorder - definition and epidemiology
* Definition
* More common in...[2] age, ...[3]
* ...[4] countries
* ...[5] socioeconomic states
1. Psychotic episode that lasts less then month and more then a day, and after which, there is full recovery and return to the premorbid function
2. Young
3. Females
4. Developing
5. Low
37
Brief psychotic disorder - diagnosis (DSM-5)
* At least one of:
* Delusions
* Hallucinations
* Disorganized speech
* Disorganized behavior
* One day - one month, will full return to premorbid function
* Cannot be explained by other organic of psychiatric conditions
Specify if there is a stressor: brief reactive psychosis/no stressor/postpartum
38
Brief psychotic diorder - prognosis
* ...[1] without major psychiatric disorders thoughout life
* About...[2] will develop chronic psychiatric disease
1. 50-80%
2. 50%
לפי נקודות: לרוב לא יהיו מחלות פסיכיאטריות לאחר אירוע אחד
39
Brief psychotic disorder - treatment
* Drugs
* Psychotherapy
* High potency antipsychotics (haloperidol) in low doses and benzodiazepines
40
Post partum psychosis
* ...[1] for each 1000 deliveries
* In...[2] - the first child
* ...[3] had nonpsychiatric perinatal complications
* More then...[4] have family of mood disorder
* Symptoms have to appear...[5] after delivery
* Treatment of choice [6]
1. 1/2
2. 50%
3. 50%
4. 50%
5. 4 months
6. Anti-depressents and lithium, sometimes in combination with antipsychotics
41
Catatonia - epidemiology
* ...[1] related to mood disorders
* ...[2] associated with schizophrenia
* Specifiers
1. 25-50% (בסבב ולדימיר אמר יותר מחמישים אחוז)
2. 10%
3. 3 types:
* Associated with another mental disorder
* Due to another medical condition
* Unspecified
42
Catatonia - diagnosis (DSM-5)
* At least 3 of the above:
1. Catalepsy
2. Waxy flexibility
3. Stupor
4. Agitation
5. Mutism
6. Posturing
7. Mannerism
8. Negativism
9. Stereotypies
10. Grimcing
11. Echolalia
12. Echopraxia
13. Rigidity (not sure!)
43
Catatonia - treatment
* Treatment in...[1]
* Important to take care of...[2]
* Options for treatment include:
* ...[3] are used, ...[4] is the gold standard
* ...[5] can also be used
* ...[6] can also be used
1. Hospitalization
2. Feeding and hydration. IV or NG tube can be used
3. Benzodiazepines
4. Lorazepam
5. Diazepam
6. ECT
44
OCD - epidemiology
* ...[1] of the general population
* ...[2] gender
* The avarage age of onset is...[3]
* In males the age is...[4], while in females...[5]
* More commmon in...[6], and in...[7] skinned
* The...[8] most common frequent disorder
1. 2-3%
2. F=M
* In adolescents M\>F
3. 20
4. 19
5. 22
6. Singles
7. White
8. 4th
45
OCD - genetic factors
* Is about...[1] of the etiology
* Relative of sick person have...[2] of having the disease, which is...[3] times more of the general population
* 40%
* 35%
* 3-5
46
OCD - clinical features
* In more than...[1] of the patients the onset will be...[2]
* ...[3] will present after...[4]
* The most common obessions [5]
* The most common compulsions [6]
* Decrease levels of...[7]
* Increased levels of...[8]
* There is...[9] of the...[10], but with increased metabolism
* Also increased metabolism in the...[11] lobes,...[12] and...[13]
1. 50%
2. Sudden
3. 50-70%
4. Stressful life event
5. זיהום, ספק פתולוגי, סומאטי, סימטריה, אגרסיה, מיניות
6. בדיקה, שטיפה, ספירה, צורך לשאול, סימטריה, אגרנות
7. Serotonin (low levels in the CSF)
8. Norepinephrine
9. Atrophy
10. Caudate nucleus
11. Frontal
12. Cyngulum
13. Thalamus
47
OCD - diagnosis (DSM-5)
1. Presence of obsession, compulsions or both:
* Obsession defined by both conditions:
1. Recurrent and persistent behaviors that are intrusive and unwated and cause anxiety or distress
2. The patient tries to ignore or supress the behaviors or to neutralize them
* Compulsions defined by both conditions:
1. Repetitive acts that the patient feel drive to preform in response to obsession
2. The acts are aimed at preventing/reducing anxiety or distress; however, this behviors are not connected in a realistic way with what designed to prevent
2. These are time consuming or cause distress or decrease function
3. Not due to substance abuse or GMC
4. Is not better explained by another mental disorder
* Specifiers:
* with good/fair/poor/absent insight/delusional beliefs.
* Tic-related
48
OCD - comorbidity
* The prevalence of MDD is...[1]
* ...[2] show social phobia
* ...[3] have tic disorder
* Tourette's syndrome...[4]
* In schizophrenic patients the prevalence of OCD is...[5]
1. 67%
2. 25%
3. 20-30%
4. 5-7%
5. 12%
49
OCD - prognosis
* In more then...[1] appears abruptly, in...[2] it appears after stressor
* ...[3] will show significant improvement in symptoms
* ...[4] will show some kind of improvment
* ...[5] will have chronic condition
* Favourable prognostic factors...[6-8]
* Poor prognostic factors...[9-16]
* ...[17] does not influence the prognosis
1. 50%
2. 50-70%
3. 20-30%
4. 40-50%
5. 20-40%
* Favorable factors:
1. Good pre-morbid condition
2. Onset after stressor
3. Episodic symptoms
* Poor factors:
1. Obligation to compulsions
2. Childhood onset
3. Bizzare compulsions
4. Hospitalization
5. Concurrent MDD
6. Delusional beliefs
7. Concurrent personality disorder (schizotypal)
8. Overvalued ideas
1. Obessions
50
OCD - adult treatment
1. CBT
2. Pharmacologic
* Augmentation
3. ECT
1. Have at least the same effect as pharmacologic treatment, thus, accounts for treatment of choice
* Exposure and reaction prevention
* Thought stopping
2. Few options:
* SSRI's are the first line - given in doses of 3-4 times more then in depression, ant strat to influence with 6-8 weeks
* Clomipramine (can also be used as first line)
* Augmentation with stabilizers or atypical anti-psychotics in low dose, MAOi's, buspirone, SNRI's
* At least 50-70% will respond to medications
3. To fully resistent disease
51
OCD - kid treatment
* Pharmacotherapy
* First response
* Side effects
* Mainly SSRI's
* Sertraline - from the age 6
* Fluoxetine - form the age of 7
* Fluvoxamine - from the age of 8
* Citalopram can also be used
* The onset of the effect starts from 8-12 weeks
* Nausea, agitation, tremor, insomnia, fatiuge
52
BDD - epidemiology
* Prevalence of...[1]
* More in...[2] gender
* Disorder shows at the age...[3]
* More common in...[4]
1. 2.4%
2. Female
3. 15-30
4. Singles
53
BDD - clinical features
* Etiology appears to be realted to...[1]
* The main complaint is...[2] with rate of...[3]
* Followed by...[4] and...[5] with...[6] each
* Followed by...[7]
* ...[8] of the patients will isolte themselves at home
* Up to...[9] will try to commit suicide
1. Lack of serotonin
2. Hair
3. 63%
4. Skin
5. Nose
6. 50%
7. Eyes
8. 33%
9. 20%
54
BDD - diagnosis (DSM-5)
1. Preoccupation with precived physical defect, that others cannot notice
2. Repetitive behaviors or mental acts as response to this precived defect
3. Significant distress or decrease in function
4. Not due to eating disorder
* Specify:
* Good/fair/poor/absent/delusional beliefs
* With muscle dysphoria
55
BDD - comorbidity
* More then...[1] expreinced episodes of...[2]
* ...[3] had anxiety disorder
* ...[4] had psychotic disorder
1. 90%
2. MDD
3. 70%
4. 30%
56
BDD - treatment
1. CBT
2. Drugs
* Augmentation
1. The most effective therapy
2. Serotonergic products such as SSRI's, or clomipramine (TCA) are helpful in 50% of the time
* Augmentation of SSRI with clomipramine, buspirone, lithium, methylphenidate or anti-psychotics
57
Hoarding disorder - epidemiology and characteristics
* Prevalence of...[1]
* ...[2] gender
* More common in...[3]
* ...[4] usually causes onset or exacerbation
* ...[5] of OCD patients
* ...[6] have ADHD
* Familial predisposition of...[7]
* Ego-...[8]
* Treatment is...[9]
* Symptoms can be...[10] at onset
* Complete remission is...[11]
* Characterized by...[12] referral to treatment
1. 2-5%
2. F=M
3. Singles
4. Traumatic life event
5. 30%
6. 20%
7. 80%
8. Syntonic
9. Resistent
10. Fluctuant
11. Rare
12. Late
58
Hoarding disorder - diagnosis (DSM-5)
1. Presistent difficulty in parting of possessions
2. Due to the need to preserve, and distress while discarding
3. Items fill and block the living areas
4. Hoarding cause distress or decrease in function
5. Not due to other medical disease
6. Is not better explained by other mental disorder
* Specify:
* Good/fair/poor/absent insight/delusional beliefs
* With excessive acquisition
59
Trichotillomania - epidemiology
* Prevalence of...[1]
* More common in...[2] gender
* More common in...[3] age
* ...[4] chew or swallow their hair
* Can be...[5] or...[6]
* Good prognosis is associated with...[7] age at onset
1. 1-2%
2. Female
3. Adolescence
4. 35-40%
5. Automatic
6. Focused
7. Young!!
60
Trichotillomania - diagnosis (DSM-5)
1. Recurrent hair pulling or hair loss
2. Recurrent attempts to stop hair pulling
3. Causes distress or imapirment of function
4. No due to other medical condition
5. Is not better explained by other psychiatric disorder
61
Trichotillomania - treatment
1. Psychotherapy
2. Drugs
3. Hypnosis
1. Behavioral therapy
2. Topical steroids, SSRI's which can be augmented with pimozide
62
Excoriation - epidemiology and characteristics
* Prevalence of...[1]
* Onset is usually at...[2]
* More common in...[3] gender
* ...[4] have suicidal ideations, while...[5] attempt suicide
* Treatment is...[6]
1. 1-5%
2. Adolescence
3. Female
4. 15%
5. 12%
6. Resistent
63
Excoriation - diagnosis (DSM-5)
1. Skin picking resulting in lesions
2. Recurrent attepmts to stop skin picking
3. Symptoms cause distress and impairment in function
4. Not due to substance abuse
5. Not due to other mental disorder
64
Anxiety - etiology
* Biologic etiology:
* Increase in...[1]
* Decrease in...[2] and...[3] of sleep
* Decreased...[4] levels
* Increased activity of...[5] and...[6] neurotransmitters
* Increased activity in...[7-9]
* Psychoanalytic:
* In childhood, fear of...[10,11]
* Learning:
* Stress or chronic frustration leads to formation of...[12]
* Mimicing...[13]
* Maladaptive pattern of...[14]
* Genetic:
* ...[15] that are diagnosed with anxiety disorder have first degree relative with the same diagnosis
1. Autonomic, sympathetic tone
2. REM latency
3. 4th step
4. GABA
5. Serotonin
6. Dopamine
7. Temporal cortex
8. Locus ceruleus
9. Amygdala
10. Loss of loved object
11. Physical injury
12. Conditioned reaction
13. Parents
14. Cognitive thinking
15. 50%
65
Panic disorder - epidemiology
* Prevalence of PD...[1], while of panic attacks is...[2]
* ...[3] times more common in...[4] gender
* Peak of incidence is in the age of...[5]
* The anxiety disorder that have the strongest...[6] component
* Identified triggers include...[7] and...[8]
* 25% have focal slowing in the...[9] lobe
* Kids to parents with anxiety disorder have...[10] times higher risk for developing a disorder
1. 1-4%
2. 3-5.6%
3. 2-3
4. Female
5. 25
6. Genetic
7. Divorce
8. Separation
9. Temporal
10. 4-8
66
Panic attack - criteria (DSM-5)
1. Time period of intense fear of restlessnesss, during this time there is at least 4 of the following symptoms, that develop rapidly and reach peak in 10 minutes:
1. Palpitations
2. Sweating
3. Shaking
4. Dyspnea
5. Feelings of choking
6. Chest discomfort
7. Nausea
8. Dizziness
9. Chills or heat sensations
10. Parasthesias
11. Derealization/depersonalization
12. Fear of losing control
13. Fear of dying
67
Panic disorder - diagnosis (DSM-5)
1. Recurrent, unexpected panic attacks
2. At least 1 of the attacks has been followed by at least 1 month of 1 or both of the following:
1. Persistent concern about panic attacks of their consequences
2. Significant maladaptive behavior related to the attacks
3. Not due to substance abuse or GMC
4. Not better explained by other mental disorder
68
Panic disorder - co-morbidities
* ...[1] have psychiatric co-morbidity
* 33% have...[2], before presentation
* 66% experience PA...[3] or...[4], their...[5] diagnosis
* 15% have...[6] or...[7]
* 2-20% have...[8]
* 15-30% have...[9]
* 20% have...[10]
* Another co-morbidities include...[11-13]
1. 91%
2. MDD
3. During
4. After
5. MDD
6. SAD
7. Social phobia
8. Specific phobia
9. GAD
10. PTSD
11. Ilness anxiety disorder
12. Personality disorder
13. Substance abuse
69
Panic disorder - progression and prognosis
* ...[1] and...[2] progression
* After treatment:
* ...[3] will be without symptoms
* ...[4] will have some symptoms
* ...[5] will have active symptoms
* ...[6] complicates the disease in...[7]
* High risk for...[8]
* Substance and alcohol abuse in...[9]
* Patients may develop...[10]
* ...[11] pre-morbid condition and...[12] duration of symptoms indicate good prognosis
1. Chronic
2. Variable
3. 30-40%
4. 50%
5. 10-20%
6. MDD
7. 40-80%
8. Suicide
9. 20-40%
10. Good
11. Short
70
Panic disorder - treatment
1. CBT
2. Drugs
* Conservative approach
* 2nd line
* Treatment failure
1. More efficient in inducing long term remission
2. Paroxetine and alprazolam
* Start with SSRI (paroxetine) and if needed also BZD
* TCA (impramine/clomipramine) or MAOi
* When there is no reaction to one drug family. It is possible to add mood stablizer
71
Agoraphobia - epidemiology
* Prevalence of...[1]
* About...[2] also have...[3]
* Most of the times it is realted to...[4]
* Prognosis is better when it is combined with...[5]
1. 0.6-6%
2. 75%
3. Panic disorder
4. Traumatic life event
5. Panic disorder
72
Agoraphobia - diagnosis (DSM-5)
1. Marked fear/anxiety about 2 of the following:
1. Public transportation
2. Open spaces
3. Enclosed spaces
4. Stading in line/being in crowd
5. Being outside of home
2. Fear/avoidance due to the fear that if the patient will develop panic symptoms, there will be no way to escape
3. Agoraphobic situations provoke fear/anxiety
4. Agoraphobic situations are actively avoided
5. more then 6 months
6. Fear/anxiety are out of proportion to the danger imposed
7. Distress or decrease in function
8. If another medical condition is present fear/anxiety/avoidance is clearly excessive
9. Not due to another mental disorder
73
Agoraphobia - treatment
* Psychotherapy
* Drugs
* Supportive, CBT
* 3 options:
* Benzodiazepines
* SSRI's
* TCA's
74
The 5 general features of phobia
1. Anxiety and stress
2. Provoked
3. Ego-dystonic
4. Avoidance
5. Anticipation
75
Specific phobia - epidemiology
* Prevalence of...[1]
* The most common disorder in...[2]
* The 2nd most common disorder in...[3]
* In the ages of...[4] the most common phobias are injections, blood, injury, nature
* While in the age of...[5] the most common phobias are of situations and cicumstances
* It is...[6] more common in...[7]
* In...[8] there is co-morbidity with...[9],...[10] and...[11]
1. 10%
2. Females
3. Males
4. 5-9
5. 20's
6. Twice
7. Females
8. 50-80%
9. Depression
10. Anxiety
11. Substance abuse
76
Specific phobia - diagnosis (DSM-5)
1. Marked fear/anxiety aboud specific object/situation
2. Almost always provokes immediate fear/anxiety
3. Phobic object is actively avoided or endured with intesnse fear
4. Fear/anxiety is out or proportion to the actual danger
5. Fear/anxiety/avoidance is at least 6 months
6. Significant distress or decrease in function
7. Not better explained by other mental disorder
Specify: type of phobia
77
Specific phobia - treatment
* CBT
* Psychotherapy
* Drugs
* Most effective - systemic desensitization, flooding, intensive exposure
* Insight oriented
* Benzodiazepines, beta blockers
78
Social anxiety disorder - epidemiology
* Also termed social phobia
* Prevalence of...[1]
* Peak incidence is in...[2]
* More common in...[3]
* Co-morbidity with other...[4] disorders and also with...[5] disorders
* ...[6] of the patients diagnosed with...[7]
* Also, co-morbidity with...[8]
* There is high association with...[9]
1. 3-13%
2. Teens
3. Females
4. Anxiety
5. Affective
6. 33%
7. MDD
8. Bulemia nervosa
9. Substance abuse
79
Social anxiety disorder - diagnosis (DSM-5)
1. Marked fear/anxiety about 1 or more social situations, in which the individual is exposed to possible scrutiny by others
2. Fear that he/she will act in a way that will be negatively evaluated
3. Social situations almost always provoke fear/anxiety
4. Social situations are avoided
5. Fear/anxiety is out of proportion
6. For 6 months or more
7. Distress or decrease in function
8. Not due to drugs of GMC
9. Not better explained by other mental disorders
10. If other medical condition the fear/anxiety/avoidance is clrealy unrelated or excessive
Specify: performance only
80
Social anxiety disorder - treatment
1. Psychotherapy
2. Pharmacotherapy
1. CBT, social skill training
2. First line are SSRI's
* Also venlafaxine, BZD's or buspirone
* In severe cases - phenelzine (MAOi)
* SSRI effect starts later than MDD treatment - within 12-14 weeks
* For performance disorders - BB's or short/intermediate BZD's can be given
81
GAD - epidemiology
* Prevalence of...[1]
* ...[2] more common in...[3]
* ...[4] of ...[5] are also effected
* Onset is usually in...[6]
1. 5%
2. Twice
3. Females
4. 25%
5. First degree relatives
6. Adolescense/early adulthood
82
GAD - diagnosis (DSM-5)
1. Excessive anxiety and worry occuring at least 6 months abount number of activities
2. The individual finds it difficult to control the worry
3. Anxiety and worry are associated with at least 3 of the following:
1. Restlessnesss
2. Easily fatigued
3. Difficulty concentrating
4. Irritability
5. Muscle tension
6. Sleep disturbances
4. Significant distress or decrease in function
5. Not due to substance or abuse or GMC
6. Not better explained by another mental disorder
83
GAD - co-morbidity
* The mental disroder that have the highest rate with other mental disorders, this occurs in...[1] of the patients
* Usually...[2],...[3],...[4] or...[5]
1. 50-90%
2. Social phobia
3. Specific phobia
4. Panic disorder
5. Depressive disorder
84
GAD - treatment
* Psychotherapy
* Drugs
* CBT - insight oriented, and supprotive therapy
* Few options:
1. Benzodiazepines - 75% response. 2-6 weeks therapy
2. SSRI - to patinets with comorbid depression (not fluoxetine, because it increases anxiety)
* Combine with BZD
* 60-80% have relapse in the first year after stopping the therapy
3. Buspirone - more effective in reducing congnitive symptoms
4. SNRI (venlafaxine) - good for patients with insomnia, poor concentration, distress and muscle rigidity
85
Substance induced anxiety disorder - diagnosis (DSM-5)
1. Clinical signs of anxiety or panic attack
2. There is clues from history taking, clinical examination and lab:
1. Symptoms developed during/immediatley after/during posioning/rehab.
2. The drug is known to induce anxiety
3. Rule out another mental etiology:
1. Symptoms appeard before the use of drug
2. Present at least 1 month after stoping the drug
3. Clues of mental disroder that is not related to the drug
4. Is not present only in delirium
5. Significant distress or decrease in function
86
Anxiety disorder due to another medical condition - diagnosis (DSM-5)
1. Clinical signs of anxiety or panic attack
2. There are clues in history/physical examination/lab that the disturbance is directly due to another medical condition
3. Rule out another mental disorder
4. Is not only in the time of delirium
5. Significant distress or decrease in function
87
Kleptomania - clinical features
* Prevalence of...[1]
* ...[2] times more common in...[3]
* The age of apperance in males is...[4], while in females is...[5]
* May appear in...[6]
* Co-morbidity with...[7-12]
* Usually does not effect...[13]
1. 0.6%
2. 3
3. Females
4. 50
5. 35
6. Childhood
7. Mood disorders
8. Anxiety
9. Gambling disorder
10. Substance abuse
11. Excessive shopping
12. Eating disorders
13. Normal function
88
Kleptomania - diagnosis (DSM-5)
1. Failure to resistent the impulse to steal objects which are not needed and not due to their value
2. High tension before cofessing the theft
3. Feeling of satisfcation/relief while confessing about the theft
4. The act does not express anger/revenge and not due to hallucinations or delusions
5. Is not better explained by other mental disorder
89
Kleptomania - treatment
* Psychotherapy
* Drugs
* Few options:
* Dynamic treatment and CBT
* Insight oriented psychotherapy
* Behavioral therapy - desensitizaton, reverse conditioning
* SSRI's is the drug of choice
* In addition mood stabilizers
* ECT is also an option
90
Pyromania - clinical features
* Male:female ratio is...[1]
* Comorbidity with...[2-6]
* In kids it is highly associated with...[7]
* Associated with...[8]
* Possible association with...[9]
* If the disorder starts...[10] there is a good prognosis
1. 8:1
2. Mild retardation
3. Substance abuse (mainly alcohol)
4. MDD/bipolar disorder
5. Other impulse disorders
6. Personality disorders (borderline, anti-social)
7. ADHD and learning disability
8. Animal abuse
9. Enuresis
10. Early
91
Pyromania - diagnosis (DSM-5)
1. More then 1 case of premaditated or deliberate fire setting
2. Tension or arousal before the act
3. High intrest in fire or related situations
4. High satisifaction while setting the fire or while watching/taking part in fire setting
5. Fire setting is done without other motives, not due to delusions or hallucinations and not due to states of impaired judgement
6. Is not better explained by other mental disorder
92
Pyromania - treatment
* Psychotherapy
* Drugs
* The treatment is psychotherapy alone but there is no established method
93
Intermittent explosive disorder - epidemiology
* More common in...[1] gender, which accounts for...[2]
* Usually appears in...[3]
* In most cases the severity decrease in...[4]
* For diagnosis the chronologic age must be at least of...[5]
1. Male
2. 80%
3. Young age
4. Adulthood
5. 6 years old
94
Intermittent explosive disorder - etiology
* Psychodynamic...[1]
* Psycho-social...[2]
* Biologic...[3]
* Genetics...[4]
1. Defense mechanisms by narcssistic assault
2. Dependent men, rough childhood
* Perinatal trauma, head injuries, encephalitis, hyperactivity
3. Decreased serotonin
4. First degree relative with MDD, addictions, impulse control disorders
**הפרעה פיזיולוגית במוח, במיוחד במערכת הלימבית**
95
Intermittent explosive disorder - diagnosis (DSM-5)
1. Recurrent outburst as manifested by 1 of the following:
1. Verbal or physical aggression occuring 2 a week for at least 3 months. Physical aggression does not result in damage.
2. 3 outbursts involving damage or destruction and physical injury to other, occuring within 12 months
2. Agressiveness during the outbursts is out of proportion to the provocation
3. Outbursts are not premeditataed and not committed to achieve any objective
4. Leads to significant distress or decrease in function or associated with financial or leagal consequences
5. Chronological age is at least 6 years
6. Not better explained by other mental disorder and not due to GMC
96
Intermittent explosive therapy - treatment
* Psychotherapy
* Drugs
* ...[1] are not recommended
* Personal psychotherapy is the treatment of choice - difficult because the patient is non compliant
* SSRI's
* Mood stabilizers (lithium, carbamazepine, valproate)
* BB's
1. Benzodiazepines
* Paradoxical reaction
97
Oppositional defiant disorder - epidemiology
* Prevalence of...[1]
* Starts by the age of...[2]
* Before puberty...[4], while after puberty...[5]
1. 2-16% of school aged children
2. 10
3. M \> F
4. M = F
98
Oppositional defiant disorder - diagnosis (DSM-5)
1. Pattern of defiant/angry/irritable behavior/mood for at least 6 months, with at least 4 of the following happening during interaction with a person which is not a sibling
1. Angry/irritable mood:
1. Loses temper
2. Easily annoyed
3. Angry and resentful
2. Defiant behvior:
1. Argues with authority
2. Defies/refuses to comply with authority requests
3. Delibrately annoys others
4. Blames others for his behaviors/mistakes
3. Vindictiveness:
1. Vindictive for at least 2 times in the past 6 months
2. Cause significant distress to the kid and his family and decrease function
3. Does not occur in the psychosis or in affective disorder
99
Oppositional defiant disorder - clinical features
* Risk factors include...[1-2]
* ...[3] of the patients will have remission
* Other will eventually develop...[4]
1. Child abuse/neglect
2. Strict parenthood
3. 25%
4. Conduct disorder
100
Oppositional defiant disorder - treatment
* Psychotherapy
* Drugs
* First line treatments include parent guidance and family treatment
* Reinforce positive behavior and narrow down negative behavior
* Pharmacotherapy is not indicated
101
Conduct disorder - epidemiology
* More common in...[1] gender
* The prevalence in males...[2], while the prevalence in females is...[3]
* Higher frequency in children to parents with..[4] personality disorder and...[5]
* Avarage onset in boys...[6], while the avarage onset in girls...[7]
* Classified into 3 type...[8-10]
1. Male
2. 6-16%
3. 2-9%
4. Antisocial
5. Alcohol dependance
6. 10-12
7. 14-16
8. Onset before the age of 10
9. Onset after the age of 10
10. Onset in unknown age
102
Conduct disorder - etiology
* Cultural-social factors...[1]
* Psychological...[2]
* Neurologic...[3]
1. Frequent in areas with high population
* Low SES, avoidance from social acitivty, increased exposure to alcohol and drugs
2. Diffculties in regulation of emotions and lack of impulse control
3. Decrease in grey matter in the limbic system
* Increased serotonin levels
* Decreased levels of dopamine beta-hydroxylase
Could be associated with the gene monoamineoxidase A
103
Conduct disorder - clinical features
* Risk factors:
* Child...[1] and...[2]
* ...[3] parenthood
* Exposure to...[4]
* ...[5] IQ and...[6] school performance
* Good prognosis when:
* Happens only within...[7]
* ...[8] onset
* No other...[9]
* ...[10] IQ
1. Abuse
2. Neglect
3. Strict
4. Alcohol
5. Low
6. Low
7. Family
8. Late
9. Psychopathology
10. Normal
104
Conduct disorder - diagnosis (DSM-5)
1. Repatitive behavior in which the basic rights of others or major social norms/rules are violated. Manifested by at least 3/15 in the past 12 months, and 1 of these is present for at least 6 months:
1. Agression:
1. Bullies
2. Initiate physical fights
3. Used a weapon
4. Physically cruel to people
5. Physically cruel to animals
6. Stolen while confronting a victim
7. Forced someone into sexual activity
2. Destruction of property:
1. Engaged in fire to cause serious damage
2. Destroyed others property
3. Deceitfulness/theft:
1. Broken into someone else house/car
2. Lies to obtain goods/favors or to avoid obligations
3. Stolen items of nontrivial value without confronting the victim
4. Violations of rules:
1. Stays out at night despite prohibitions, before the age of 13
2. Run away from home overnight at least 2 times, or once without returning to lengthy period
3. Truant from school, before the age of 13
2. Causes significant impairment in function
3. If the patient is older than 18, criteria are not met for antisocial personality disorder
105
Conduct disorder - specifiers
* With limited prosocial emotions:
* Lack of remorse/guilt
* Lack of empathy
* Unconcerned about performance
* Shallow/deficient affect
106
Conduct disorder - treatment
* Psychotherapy
* Pharmacotherapy
* CBT, parent guidance and child guidance
* Antipsychotics - beneficial in prevention of the disease and decrease symptoms
