Behavioral Flashcards
(153 cards)
1
Q
how many weeks gestation is considered premature and v. premature?
A
- premature birth: <37 weeks
- very premature birth: <32 weeks
2
Q
what is the APGAR score and how is it used?
A
- used to predict the likelihood of immediate survival of a newborn
- Appearance
- Pulse
- Grimace (reflex irritability)
- Activity (muscle tone)
- Respiration
3
Q
developmental milestones: infancy to 18 months
A
- social smile: 12 weeks
- stranger anxiety: 9 months
- separation anxiety: late in first year following object permanence
4
Q
developmental milestones: 3-6 years
A
- cooperative play: at 4 years
- strong fear of bodily injury
- curiosity about body
5
Q
developmental milestones at 6 years
A
- development of child’s conscious: superego
- sense of morality
- learns that lying is wrong
- understands the finality of death, associated with fears of losing loved ones
6
Q
stages of dying
A
- not necessarily sequential:
- denial
- anger
- bargaining
- depression
- acceptance
7
Q
diagnostic criteria for schizophrenia
A
- psychosis is hallmark symptom, no clouding of consciousness
- 2+ of the following during 1 mo. period: delusions, hallucinations, grossly diorganized or catatonic behavior, negative symptoms (flat affect, alogia, avolution), disorganized speech (frequent derailment or incoherence)
- social/occupational dysfunction
- continuous signs of disturbance persist for at least 6 mos; must include at least 1 mo of symptoms
- symptoms cannot be due to another illness (schizoaffective and mood disorder) or due to substance use or medical disorder
8
Q
positive symptoms of schizophrenia
A
- additional to expected behavior:
- delisions
- hallucinations
- aditation
- talkativeness
- though disorder
- responds well to most traditional and atypical antipsychotic agents
9
Q
negative symptoms of schizophrenia
A
- missing from expected behavior
- lack of motivation
- social withdrawal
- flattended affect/emotion
- cognitive disturbance
- poor grooming
- poor/impoverished speech
- sometimes has a better response with atypical antipsychotics
10
Q
course of schizophrenia
A
- prodromal: prior to first psychotic break (late teens, early 20s)
- psychotic/active: loss of touch with reality (associated with positive symptoms)
- residual: period between psychotic episodes, in touch with reality but does not behave normally (associated with negative symptoms)
11
Q
demographics of schizophrenia
A
- 1/100 prevalence
- occurs equally in men and women
- age of onset: 15-25 in men, 25-35 in women
- women respond better to antipsychotic meds; have a greater risk of tardive dyskinesia
- role of genetics (concordance in twins) and environment (viruses? 3rd tri use of diuretics?)
12
Q
neurologic abnormalities in schizophrenia
A
- hypofrontality (decreased use of glucose in prefrontal cortex)
- hyperactive mesolimbic pathway: positive symptoms
- hypoactive mesocortical pathway: negative symptoms
- lateral and third ventricle enlargement, decreased volume of hippocampus, amygdala, parahippocampal gyrus
- loss of cerebral asymmetry
- abnormal EEGs
13
Q
NT abnormalities in schizophrenia
A
-
glutamate hypothesis: NMDA receptor hypoactivity? Glu is major excitatory NT and antagonists of NMDA subtype of Glu receptors aggravate and create psychosis while agonists experimentall relieve symptoms
- normal: Glu-GABA-Glu-DA
-
dopamine hypothesis: disturbed and hyperactive dopaminergic signal transduction
- normal: Glu-GABA-Glu-GABA-DA
14
Q
DDx of schizophrenia
A
- psychotic disorder by general medical condition: B12/folate delicienct, temporal lobe epilepsy, steroid-induced
- manic phase of bipolar
- substance-induced psychotic disorder: cocaine, meth, stimulants, PCP, LSD, bath salts
- other psychotic disorders
- brief psychotic disorder
- schizophrenidorm disorder
- schizoaffective disorder
- delusional disorder
- shated psychotic disorder
15
Q
Tx of schizophrenia
A
- all effective antipsychotics block D2 receptors in mesolimbic DA pathway
- treatment is often lifelong
- first line therapy: atypical second generation antipsychotics
- psychotherapy: LT support for patient and family, fosters compliance with drug regimen
- suicide prevention: >50% attempt suicide
16
Q
diagnostic criteria for ADHD (neurodevelopmental disorder)
A
-
6 inattention symptoms for 6 mo (5+ if older than 17)
- poor attention to details→mistakes
- cannot sustain attention/is distracted
- does not listen
- does not follow through
- does not organize
- avoids tasks
- loses things/is forgetful
-
6 hyperactive/impulsive symptoms for 6 mo (5+ if older than 17)
- fidgets
- leaves seat
- runs/climbs
- not quiet/talks alot/blurts out/interrupts
- cannot wait turn
- several symptoms prior to age 12
- symptoms in 2+ settings
- symptoms reduce quiality of life
17
Q
course of ADHD
A
- most often apparent at young age where age appropriate norms for paying attention and delaying gratification are not met
-
milder and more inattentive cases may not be noticed until later in life when demands are greater
- inattentiveness tends to persist more than hyperactivity/impulsivity
18
Q
etiology of ADHD
A
- at least 76% heritable (one of the most biological illnesses)
- environmental factors: cigarette use/alcohol use in pregnancy, Pb poisoning, head injuries
19
Q
neurologic abnormalities in ADHD
A
- hypoactive anterior cingulate
20
Q
NT abnormalities in ADHD
A
- NE: low tonic NE firing in prefrontal cortex
- DA: low tonic DA firing in prefrontal cortex
- 5-HT: ?? controls locomotion and behavior and cognitive impulsivity
21
Q
management of ADHD
A
-
medication is more effective than therapy
- stimulant class has greatest efficacy: risk of addiction, stunts growth, weight loss
- non stims have less efficacy: no risk of addiction, often sedating, may lower BP
- psychotherapy: behavior modification and training
- work with adults not child to help train child
22
Q
risk triad of suicidality
A
- ideation: how often? how pervasive?
- plan: specific? well planned?
- intention
23
Q
what are some symptomatic precursors to suicidality?
A
- anxiety
- panic attacks
- insomnia
- restlessness
- hopelessness
- helplessness
24
Q
demographics of suicide
A
- almost always due to mental illness (usually depression)
- gender: women attempt more, men are more successful
- religion: highest completion in protestants
- race: white americans have higher rates, gap is narrowing
- age: teens and elderly are at greatest risk
25
genetic risks for suicide
* 5HTT gene polymorphism (resilience gene)
* ss short allele for serotonin transporter (reuptake pump) seems to convey poor resilience, incresed MDD, and suicide risk when faced with stress
* ll long allele seems protective
26
diagnostic criteria for MDD
* **5+ during the same 2 week period** and represent change from previous functioning; at least **one symptom is either depressed mood or loss of interest/pleasure**
* significant weight loss or decreased appetite
* insomnia or hypersomnia
* phsychomotor agitation or retardation
* fatigue or loss of energy
* feelings of worthlessness or excessive/inappropriate guilt
* diminished ability to think or concentrate or indecisiveness
* recurrent thoughts of death, recurrent suicidal ideation
* symptoms cause significant distress/impairment in functiong
* not attributable to another condition or medication
27
SMIGECAPS
* Sleep disturbance
* Mood
* Interest/pleasure reduction
* Guilt/worthlessness
* Energy loss/fatigue
* Concentration/attention
* Appetite changes
* Psychomotor symptoms
* Suicidal ideation
28
DDx of MDD
* hypothyroidism
* cushing's syndrome
* vitamin deficiency
* obstructive sleep apnea
29
etiology of MDD
* ratio of monoamines and receptors is off
* **monoamine receptor excess theory: leading theory**
* monoamine deficiency: low levels of dopamine, serotinin, norepi
30
neurologic abnormalities in MDD
* stress→high glucocorticoids and low BDNF→ atrophy/death of neurons
* regain function through interventions that increased 5HT and norepi
* hypoactive dorsolateral prefrontal cortex and hyperactive amygdala
31
demographics of MDD
* women\>men
* low estrogen= low serotinin
* MAOa gene is on X chromosome
* comorbidity of substance abuse and generalized anxiety
32
Tx for MDD
* medications (4-6 weeks to turn on gene and build up enough protein to make a difference)
* front line agents: SSRIs, SNRIs, NDRIs
* MAOIs: v. effective but dangerous side effects
* tricyclics: v. effective but side effects and easy to OD on
* augmenting strategies: lithium, thyroid hormone, atypical antipsychotics (best data but high side effects)
* ECT: 80-90% effective
* therapy
33
diagnostic criteria for oppositional defiant disorder
* 4+ symptoms with 1+ non-sibling \>6 mo
* **angry/irritable mood:** loses temper, touchy/easily annoyed, angry/resentful
* **argumentative/defiant behavior:** argues with authority figures, defies/refuses to comply with rules, deliberately annoys, blames others for his/her mistakes/behaviors
* **vindictiveness:** spireful or vindictive 2x in past 6 mo
* associated with **distress in individual or others or negatively impacts functioning**
* **mild= 1 setting, moderate= 2 settings, severe= 3+ settings**
34
Tx for ODD
* problem-solving skills training: focus on cognitive process (children with ODD have hostile attribution bias)
* behavioral parent training: bug in ear approach
35
diagnostic criteria for conduct disorder
* pattern of bhavior in which basic rights of others or major age-appropriate societal norms/rues are violates
* 3+ in past year and 1+ in past 6 mo
* aggression to people and animals
* destruction of property
* deceitfulness or theft
* serious violations of rules
* behavior causes clinically significant impaitment in functioning
* if 18+ years old, critera are not met for antisocial personality disorder
36
Tx for conduct disorder
* multisystemic therapy
* multidimensional treatment foster care
* functional family therapy
37
autism spectrum disorders
* severe and pervasive impairment in several areas of development
* abnormal/impaired development in social interaction and communication
* restricted repertoire of interests: obsessions, repetitive beavhior, extreme food selectivity
* v. subjective diagnosis, accurate diagnosis based on observation
* 4x more prevalent in boys
38
Tx for autism
* **descrete trial instruction:** most effective method of acquiring new behavior
* reinforcement based treatments are more effective for decreasing problematic heavior
* antipsychotic meds and stimulatns commonly prescribed for associated behaviors
* medication use increases with age: stimulants are most common
39
diagnostic criteria for intellectual disability
* 3 criteria
* subaverage intellectual function (IQ \<70)
* most are mild (50-55 IQ; 6th grade level)
* 2+ deficits in adaptive functioning
* communication, self care, social skills, self-direction, academics, work, safety
* onset before 18 y.o.
40
course and etiology of intellectual disability
* chronic disease
* 2x common in males
* 30-40%: cause unknown
* 30% due to chromosomal abnormalities
41
challenging behavior in autism
* **self-injurious behavior**
* pica: 3 criteria (persistent eating of non-nutrient 1+mo, eating is inappropriate for developmental level eating is not culturally sanctioned)
* **destructive behavior:** physical harm to another person or immediate environment
42
CAM in psychology
* **folates, SAMe:** low level RCT data support as effect depression treatment
* effects 1 carbon cycle and methylation; increases NTs
* **St. John's Wart:** RCT and meta analysis support its effect over placebo
* mindfulness: reasonable data for anxiety control
* yogic breathing: reasonable data for PTSD and depressive symptoms
* **light therapy:** v. good for seasonal depression
43
psych genes
* **DRD4, 5:** mutations can lower DA (ADHD);
* **COMT, DAR:** mutation can lower DA and NE (hypofrontal; schizo)
* **5HTPPLR:** mutation can lower 5HT (hyperlimbic; MDD)
44
diagnostic criteria for personality disorder
* enduring pattern of inner experience and behavior
* cognitive, emotional, interpersonal, and behavioral commponents
* leads to distress/impairment
* pervasive and inflexible
* onset in adolescence or early adulthood
45
Cluster A Personality Disorder
* **paranoid:** pervasive distrust and suspiciousness of others
* **schizoid:** detachment from relationships and restricted range of expression/emotions
* **schizotypal:** interpersonal deficits marked by cognitive or perceptual distortions and eccentricites of behavior
* treatment: psychopharm has modest efficacy, esp mood stabilizers
46
personality disorder cluster types
* cluster A: psychotic-like
* cluster B: behavioral (dreaded disorders)
* cluster C: anxious
47
Cluster B Personality Disorder
* **antisocial:** disregard for and violation of rights of others since 15 y.o.; evidence of condct disorder with onset before 15
* **histrionic:** excessively emotionality and attention seeking
* **narcissistic:** grandiosity (in fantasy and behavior), need for admiration, lack of empathy, sense of entitlement
* **borderline:** instability of relationships, self-image/affects and marked impulsivity; 5+ needed:
* frantic efforts to avoid abandonment; unstable relationships; persistent unstable self-image; impulsivity; recurrent suicidal behavior; mood lability; chronic feelings of emptiness; frequent/intense anger outbursts; transient paranoia
* treatment: psychotherapy esp in borderline
48
Cluster C Personality Disorder
* **avoidant:** pervasive social inhibition because of feelings of inadequacy; hypersensitive to criticism or rejection
* **obsessive-compulsive:** preoccupied with details, rules, lists, schedules; interfers with task completion
* **dependent:** excessive need to be taken care of; indecisive; submissive and clingy
* treatment: CBT and psychodynamic therapy; psychopharm for avoidant
49
demographics of personality disorder
* paranoid, avoidant, and dependent: more prevalent in women
* antisocial: more prevalent in men
* risk factors: unmarried, impoverished, poorly educated
50
etiology of personality disorder
* early maternal deprivation reduces CNS serotonin levels
* some degree of genetic involvement
* certain parenting behaviors correlate to offspring personality disorder
51
diagnostic criteria for mania
* distinct, abnormal, elevated, expansive (or irritable) mood \> 7 days
* 3+ symptoms for 2 weeks:
* increased self esteen/grandiosity, decreased sleep, increased speech, racing thoughts, distractibility, increased goal directed activity, increased dangerous impulsivity
* hypomania is milder and lasts 4-7 days; not severe enough to cause marked impairment
* cyclothymia: chronic hypomania
52
bipolar 1 vs bipolar 2
* bipolar 1: mania + major depressive episode; women = men
* bipolar 2: hypomania + major depressive episode women \> men
53
etiology of bipolar disease
* high level of monoamines, low # of receptors
* kindling hypothesis: too much neuronal limbic firing; antiepilepsy drugs via Na2+ blockade
54
Tx for bipolar disorder
* avoid antidepressants (increase monoamines, elevate mania)
* atypical antipyschotics: uniquely suited to treat both sides of bipolarity; block D2 receptor and 5HT2a
* **pyschotherapy is good for bipolar depression but not mania**
* Li: promotes neuronal health and protective factors
55
TBI
* injury to head arising from blunt/penetrating trauma or from acceleration/deceleration forces and leads to:
* decreased level of consciouness
* amnesia
* objective neurologic or neuropsych abnormalities
* skull fractures
* diagnosed intracranial lesions
* head injury listed as cause of death
* highest rates men and elderly; MCC falls
* alcohol is greatest risk factor
56
pathophysiology of TBI
* **primary: diffuse axonal injury due to shearing/torsional force on brain tissue**, vascular tear, forcal cortical contusions, hemorrhage
* **secondary (evolves over time):** ischemia/hypoxia, vasospasm, edema, necrosis, inflammation, seizure
57
glasgow coma scale
* eye opening, verbal responsiveness, best motor response
* not prognostic but helps to give idea about course of illness
58
ranchos los amigos levels of cognitive function
1. no response: coma
2. generalized response: vegetative state; evidence of sleep/wake
3. localized response: minimally conscious state; localizes pain, inconsistent response to environment
4. confused/agitated: v. disruptive; rule out delerium from UT, additional fall; address participating factors (pain, overstimulation)
5. confused/inappropriate
6. confused/appropriate
7. purposeful, appropriate, stand-by assistance
8. purposeful, appropriate, stand-by assistance on request
9. purposeful, appropriate, modified independent
59
psychiatric manifestations s/p TBI
* personality changes: frontal-subcortical circuits modulate complex human emotional expression and behavior
* depression
* PTSD: screen because it may complicate recovery
* substance misuse
60
DDx of anxiety
* organic (medical causes): hyperthyroidism, hypoglycemia, pheochromacytoma
* often presents as anxiety: acute MI, PE, COPD, asthma attack
* psych disorders: depression, schizo, personality disorders
61
diagnostic critera for generalized anxiety disorder
* excessive anxiety/worry, occuring more days than not 6+ mo, about 1+ event/activity
* difficult to control worry
* associated with 3+:
* restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance
62
Tx for GAD
* CBT is most evidence-based therapy
* SSRis, SNRIs
* Buspirone (5HT1 receptor agonist): initially lowers 5HT activity but eventually renders them inactive allowing for increased output
* Benzos (2nd line due to risk of addiction, falls, apnea)
63
diagnostic critera for panic attack
* abrupt surge of intense fear or discomfort, peaks within minutes, that is unexpected with 4+ of the following:
* palpitations; sweating; shaking; choking feeling; chest pain; nausea; dizziness; chills/heat; paresthesias; derealization; fear of losing control; fear of dying
64
diagnostic criteria for panic disorder
* recurrent unexpected panic attacks
* 1+ attack followed by 1+ mo of 1+ of the following:
* concern about additional panic attacks or consequences
* significant maladaptive change in behavior related to attacks
65
diagnostic criteria for agoraphobia
* fear/anxiety about 2+ for 6 mo.
* using public transport, being in open spaces, being in enclosed spaces, standing in line/crowd, being outside home alone
* fear of not being able to escape situation
* situation almost always produces fear/anxiety
* avoid situations
* fear/anxiety out of proportion to actual danger
66
Tx for panic disorder
* CBT; systemic desensitization
* medications: LT: SSRI/SNRI, benzos
67
diagnostic criteria for phona
6+ mo of marked fear/anxiety about specific object/situation; object/situation almost always provokes fear/anxiety, actively avoids object/situation; fear/anxiety out of proportion or actual danger
68
diagnostic criteria for social anxiety disorder
6+ months of marked fear/anxiety when exposed to social situation with possible scrutiny by others; fear of acting in ways that will ne negatively scrutinized; social situatons provokes fear, avoids social situations, fear/anxiety out of proportion to actual threat
69
Tx for social anxiety disorders and phobias
* **social anxiety disorder:** SSRI/SNRI is 1st line
* performance anxiety: ßblocker; benzo PRN as needed
* **specific phobia:** therapy is 1st line
70
diagnostic criteria for OCD
* **obsessions:** recurrent/persistent thought, urges, or images; intrusive and unwanted; **patient tries to ignore/suppress or neutralize**
* **compulsions:** repetitive behavior in response to obsession or set of rules; undoes/reduces anxiety
* obsessions and compulsions are time consuming (\>1 hr/day) or cause significant distress
71
demographics for OCD
* **men and women are equally effected**
* 50-70% have onset after a stressful event
72
Tx for OCD
* **CBT (as effective as pharmacotherapy):** exposure and response prevention
* pharmacotherapy: SSRIs (higher dose/duration than MDD)→ TCA→ antipsychotics
73
DDx for OCD
* tourette's: vocal and motor tics, OCD is common comorbidity
* temporal lobe epilepsy: repetitive motor movements (may look like compulsion)
* OCD PD: patients with OCD have insight into their behavior, OCD PD patients do not
74
diagnostic criteria for PTSD
* symptoms \>1 mo
* criteria A: exposure to actual or threatenng traumatic event
* criteria B: intrusion symptoms (reliving of event; flashblacks)
* criteria C: avoidance of stimuli associated with traumatic event
* criteria D: negative changes in cognition and mood associated with event (dissociative amneia, exaggerate beliefs, negative emotional state, decreased interest, detachment, inability to experience positive emotions)
* criteria E: alterations in arousal/reactivity
75
diagnostic criteria for acute stress disorder
* PTSD except criteria B-D must persist for 3 days - 1 mo
* precursor to PTSD
* best time to treat
76
demographics of PTSD and ASD
* women \> men
* prognosis is better if rapid onset of symptoms, good pre-morbid functioning, no other psychiatric co-morbities
* untreated, by 1 yr: 50% will recover
77
Tx for PTSD and ASD
* psychotherapy: follow model of crsis intervention
* pharmacotherapy: SSRI→ TCAs→ MAOi
* **prazosin for nightmares**
78
diagnostic criteria of insomnia
* **dyssomnia:** dissatisfaction with sleep quantity or quality, associated with either difficulty initiating or maintaing sleep, early morning awakening with inability to return to seep
* sleep disturbance causes distress or impairment
* disturbance occurs at least 3x/ week for 3+ mos
79
endogenous etiology of insomnia
* excitatory NTs in excess at night
* NE from locus ceruleus
* 5HT from raphe nucleus
* DA from venral pegmental area
* Hist: from tuberomammillary nucleus
* inhibitory NT deficiency at night
* loss of GABA tone
* loss of melatonergic tone
* loss of adenosinergic tone
80
Tx of insomnia
1. diagnosis, informed consent and education
2. behavioral counseling (sleep hygiene, stimulus control)
3. sleep restriction therapy, cognitive therapy, behavioral therapy
4. pharmacotherapy: OTC→ Rx
81
diagnostic criteria for anorexia
* restriction of E intake requirements→ low body weight
* fear of gaining
* body dysmorphism
* restrictive vs. binge/purge
* severity based on BMI
82
demography of anorexia
* midteens-20s
* female \> male (20x)
* personality profile: rigid (barrier to treatment), controlling, high achieving, lower addiction rates
* 50% depresion comorbidity
83
etiology of anorexia
* low NE
* high endogenous opiate
* delusions?
84
symptoms of anorexia
* **lanugo hair**
* weight loss
* electrolyte imbalance
* edema (not enough protein to keep H2O in blood)
85
Tx of anorexia
* hospitalization: force tube feed if MDs/judge feels patient is incompetant (delusions)
* therapy: hard reduction approach; programing
* meds: no FDA approvals, treat comorbidies to facilitate tx of anorexia
86
diagnostic criteria of bulimia
* recurrent binge eating (atypical portion in discrete period of time; loss of control); **1x/week for 3 mo**
* compensatory behaviors: insight into what they are doing
* purging vs. non purging
87
demography of bulimia
* greater prevalence than anorexia
* female \> male (10x)
* more personality disorder and substance abuse
* dysfunctional family, less rigid and more conflicted
88
symptoms of bulimia
* **russell's sign (abraided knuckles);** poor dentition
* low PO4, low Mg, high amylase (salivary enlargement)
* esophagitis/tears
89
Tx of bulimia
* better than anorexia
* meds: SSRIs are FDA approved
* therapy: thorough psych eval (more comorbities with bulimia)
90
bulimia vs. binge eating disorder
binge eating disorder= binging, lack of control, ego dystonic; 1x/wk for 3 mo **BUT no purges or compensations**
91
delusional disorders
* usually a crystallized, single delusion
* no hallucinatons or thought disorders (like in schizophrenia)
* Tx
* **be non judgemental, empathic**
* antipsychotics are sometimes effective
* psychotherapy: help cope, lower anxiety, agitation
92
capgras delusion
delusion where patient feels someone has been replaced by an imposter
93
fregoli delusion
delusion that different people are in fact a single person who changes appearance or is in disguise
94
psychopathic cannibalism
antisocial personality, psychopathy, sociopathy with delusions
95
folie a deux
* syndrome in which symptoms of delusion are transmitted from one individual to another
* "madness of many"
* imposee: has the delusion
* simultanee: incorporates the delusion into their life
96
cotard's delusion
* somatic delusion that one is dead/does not exist/missing organs
* vs. depersonalization-derealization disorder: disconnected from one's physicality (out of body experiences; surreal experiences)
97
krokodil
heroin-like drug that rots flesh and bone
98
morgellons/delusional parasitosis
* somatic delusion/paranoid delusion
* patient believes they are infested, can see/feel parasites in or on them
* often middle ages women
99
erotomanic delusions
* affect person believes that another person (usually a stranger, high-status or famous person) is in love with them
* extreme stalker
100
age associated cognitive changes
* **no functional impairment**
* difficulty retrieving words
* slower processing speed
* can't multitask
* learning something new takes bigger effort
101
mild cognitive impairment
* memory complaint corroborated by informant
* objective memory impairment for age/edu
* preserved general cognition (good judgement and executive function)
* normal ADLs
102
amnestic MCI
* **may be earliest phase of AD**
* memory loss not meeting criteria for dementia, progresses to AD at 10-15%/ year vs. 1-3% incidence in general population
103
diagnostic criteria for neurocognitive disorder
* decline in memory, complex atention, executive function, learning/memory, language, perceotual/motor, social cognition
* cognitive deficits impact social and occupational function
* **major: not capable of independent living**
104
risk factors for early onset AD
* abnormal presenilin 1, 2
* abnormal APP (down syndrome has high rates of AD)
105
risk factors for late-onset AD
* associated with HTN, diabetes, high cholesterol
* **ApoE4 allele**
* females (estrogen?)
* **head injury**
* alcohol abuse
106
pathologic features of alzheimer's disease
* **cerebral and hippocampal atrophy;** occipetal lobe spared
* **ßamyloidopathy**→ plaques, amyloid angiopathy
* **tauopathy**→ intracellular inclusions (NFTs)
* hydrocephalus ex vacuo
107
early symptoms of AD
* cognitive: missed appts, work-finding issues, misplacing objects
* functional: driving difficulties
* behavioral: changes in personality, social withdrawal
108
frontotemporal lobal degeneration
* insidious onset, gradual progression
* characterized by **behavioral abnormalities**, early emotional blunting
* pathologic
* **frontotemperal lobar degeneration,** spares occipetal and parietal
* profound atrophy; knife-edge gyri
* **pick bodies:** rounded tau inclusions
* ghost tangles (outlive cell because tau is so stable)
* FTLD-Tau: MC
* PTLD-TDP
* FTLD-FUS
109
Tx for FTLD
* careful use of atypical antipyschotics
* divalproex for behavioral control (AED)
* SSRIs for irritability, impulsivity
* NO AChEi
110
Tx for AD
* AChEi; donepezil: only drug for all stages of AD
* NMDA receptor antagonists; memantine
* neuropsych disturbances:
* counsel caregiver
* antipsychotics (esp if harm could happen)
* antidepressants and anxiolytics
111
vascular dementia
* 2nd MC dementia
* step-wise progression, can be abrupt after CVA
* pathology
* associated with HTN-related small vessel disease in deep grey/white matter (basal ganglia, internal capsule)
* multi-infarct dementia (depends on region and volume of tissue affected)
* cerebral amyloid angiopathy
* Tx: AChEi, treat cardiovascular risk factors
112
synucleinopathies
* characterized by intracellular **a synuclein deposits (lewy bodies and lewy neurites)**
* **Parkinson's:** if LBs in substantia nigra first; dopaminergic deficit; pallor of substantia nigra, dementia following motor symptoms
* **D****ementia with lewy bodies:**if LBs in cortex first;**memory less affected**, pronounced fluctuations and variations in symptoms;**hallucinations, delusions; REM sleep disorder**
* Tx: AChEi, carbi/levodopa for movement symptoms; clonazepam for sleep; **avoid** antipyschotics
113
MMSE and MoCA
* screening tools
* scoring impacted by age, edu, ethnicity
* MMSE: normal 30-27, mild=30-20
* MoCA: normal \>26, mild=18-26
114
ADLs vs. IADLs
* ADLs: **d**ressing, **e**ating, **a**mbulating, **t**oileting, **h**ygiene
* IADLs: **s**hopping, **h**ousekeeping, **a**ccounting, **f**ood prep, **t**ransportation
115
psychosexual stages of development
* birth-1.5 years: **oral**
* 1.5-3 years: **anal**
* 3-5/6 years: **phallic**
* 6-adolescent: **latent**
* adolescent+: **genital**
116
id vs. ego vs. superego
* **id:** child; fun, gratification
* **superego:** parent; conscience, rules morals, develops based on input from authority/society
* **ego:** adult; growing, evolving
117
level 1 "psychotic" ego defense mechanisms
* healthy in individuals \<5 y.o; adult dreams/fantasy
* **delusional projection:** frank delusions about external reality, paranoia
* **psychotic denial:** denial of external reality ("i am jesus")
* **distortion:** grossly reshaping external reality to suit inner needs; unrealistic megalomaniacal beliefs
118
level 2 immature ego defense mechanisms
* healthy in 13-15 y.o; seen in personality disorders
* **projection:** attributing one's own unacknowledged feelings to others; paranoid PD
* **somatization:** turning an unacceptable impulse into complaints of pain or somatic illness; hypochondriac, psychosomatic disorders
* **acting out:** direct expression of unconscious wish/impulse in order to avoid being conscious of affectthat accompanies it; antisocial PD
* **splitting:** seeing people/events as good vs. evil; borderline PD
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level 3 neurotic ego defense mechanisms
* healthy in 3-90 y.o; neurotic disorder, acute stress
* **denial:** MC
* **displacement:** redirect feelings roward less cathected object
* **dissociation:** temporary but drastic modification of one's character or one's sense of personal identity to avoid emotional distress
* **identification:** unconscious patterning of beavhior after someone else
* **intellectualization:**
* **isolation of affect:** intellectuali knowledge and understanding without experience the feelings
* **rationalization:**
* **reaction formation:** e.g. hating someone you really like
* **regression:** seen in medical crises and when sibling is born
* **undoing:** e.g., superstitious rituals or formal atonement
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level 4 mature ego defense mechanisms
* healthy in 12-90 y.o.
* **altruism:** vacarious but constructive and instintually gratifying service to others
* **sublimation:** take troubling role and channel it productively
* **anticipation:** realistic anticipation of/planning for future inner discomfort
* **suppression:** conscious/semiconscious decision to postpone paying attention to conflict
* **humor:** allows one to bear and yet focus on what is too terrible to be borne
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mechanism of endorphin activity
* **on CNS:** inhibits GABA→ disinhibiting DA; descending pain circuit, amygdala
* **on PNS:** primary afferent neurons, peripheral sensory nerves, dorsal root ganglia; inhibis substance P and other tachykinin release
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proposed mechanism of endorphin release
* peripherally mediated by **stress and ACTH corelease**
* centrally mediated by innervation of hypothalamus, midbrain, rostral medulla
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NSAIDs vs opiods
* NSAIDs address cause of **inflammatory pain**
* opiods make patient less concerned about the pain
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neuropathic pain and Tx
* AEDs: lower neuron's ability to fire by hyperpolarization or disallowing depolarization ( Ca2+ and Na2+ influx→ central sensitization and excessive/chronic pain response)
* gabapentin: Ca2+ blocker
* carbamazepine: Na+ blocker
* lamotrigine: Glu blocker
* antidepressants: weak descending NE projections = pain
* SNRIs (duloxetine, venlafaxine)→NE→ inhibitory GABA→ inhibits pain
* amitriptyline (TCA): NE + Na+ blockage
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SBIRT
* **S**creening instrumens
* **B**rief motivational **I**nterventions
* **R**eferral options for substance use **T**reatment
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5 steps of SBIRT
1. build rapport
2. explore pros/cons about addiction
3. provide personalized feedback (ask permission, give info, ellicit reaction)
4. readiness ruler
5. create action plan
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psychoanalysis and psychodynamic therapy
* **unconscious conflicts are repressed and cause difficulty (insight-oriented)**
* aim: make unconscious, conscious; understand conflicts/behaviors
* techniques: free association, analysis of transference and resistance, dream interpretation
* analysis: LT
* dynamic: ST; focuses on present
* treats: depression, anxiety, some PD
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interpersonal therapy
* **problematic attachments early in life predispose one to develop disorders that are expressed through present troubled interpersonal relationships**
* aim: correct interpersonal difficulties
* ST, focus on current relationships
* treats: depression, eating disorders
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family systems therapy
* **identified patient reflects dysfunction in whole family system**
* aim: improve family's relational health (whole family as patient)
* techniques: normalize boundaries, redefine blame
* treats: children with behavior problems, families dealing with conflict, teenagers with eating disorders/substance abuse
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behavioral therapy
* **based on learning therapy**
* aim: relieve symptoms by unlearning maladaptive behaviors
* techniques: based on classical and operant conditioning
* treats: phobias, depression, autism spectrum, psychotic disorders, ODD/ADHD
* e.g. systematic desensitization, flooding, token economy, stimulus control, self-monitoring
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classical conditioning
* pavlovian; what happens before the behavior is important
* usually deals with involuntary responses
* organism learns stimulus discrimination
* **good for addictions treatment and phobias**
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instrumental/operant conditioning
* what happens after the behavior is important
* + reinforcement: stimulus you add in that increases behavior
* - reinforcement: stimulus you remove that increases behavior
* continuous vs. intermittent reinforcement schedule
* **fixed interval, variable interval have most consistant response**
* punishment: unpleasant stimulus or removal of pleasant stimulus
* Does not erase habit but suppresses it; can often be ineffective unless given immediately after response; signals what is bad but doesn't show what is good
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somatization disorder
* 4+ pain issues (2 GI, 1 sexual, 1 neuro) not adequately explained by mdical causes after history, exam, labs, tests
* onset before 30 yo.
* chronic symptoms; remission is rare
* **unconscious; no secondary gain**
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conversion disorder
* sudden and drastic loss of one or more voluntary motor and/or sensory functions suggesting neurologic etiology
* la belle indifference
* usually self-limiting with remission \<1 mo
* **unconscious; no secondary gain**
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illness anxiety disorder (hypochondriasis)
* fear or idea of having serious medical illness based on misinterpretation of bodily symtoms
* part of GAD spectrum
* symptoms must persist 6+ mo
* **unconscious; no secondary gain**
* **Tx: SSRIs**
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body dysmorphic disorder
* preoccupation with imagine problem or insignificant abnormaility in sppearance (usually involves face/head)
* cannot be accounted for by eating disorder
* plastic surgery/medical interventions are common but rarely relieve symptoms
* **unconscious; no secondary gain**
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pain disorder
* removed in DSM 5
* protracted pain severe enough to cause patient to seek help but cannot be explained by physial causes
* acute (\<6 mo) or chronic (\>6 mo)
* typical onset 3-4th decade
* can be disabling and cause dependence on pain meds
* **unconscious; no secondary gain**
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factitious disorder (Munchausen's)
* conscious feigning or production of physical/mental illness in order to recieve attention from medical personnel
* assume sick role
* **primary gain: feel safe/care for**
* **secondary gain: feel expert at solving their medical problem**
* get angry when confronted about it
* more common in medical personnel
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malingering
* not in DSM 5
* not psychiatric (could be a crime)
* **conscious simulation or exaggeration of physical or mental illness to achieve secondary gain**
* ****disability
* drugs
* leave of absence/AWOL
* symptoms improve once secondary gain is obtained
* seen more frequently in incarcerated and people in lawsuits
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cognitive therapy
* **problems develop as a result of errors in thinking**
* aim: correct errors in logic (cognitive distortions) driven by schemas (underlying cognitive construct)
* ST; focus on cognitive restructuring, psychoedu
* treats: depression , anxiety disorders, eating disorders
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cognitive behavioral therapy
* 3 fundamental propositions
* cognitive activity affects behavior (mediational model)
* cognitive activity may be monitored and altered
* desired behavior change may be affected through cognitive change
* 3 major classes of CBT
* coping skills therapies
* cognitive restructuring methods (change beliefs)
* problem solving therapies (combination of the two)
* emphasizes homework and outside session activities
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dependence vs. abuse
* dependence: physiological tolerance + withdrawal
* abuse: psychological
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effects of drugs and addictive behavior on brain
* act on limbic reward pathways to either:
* enhance DA release from VTA
* enhance DA effects in nucleus accumbens or related structures
* drug induced states are important motivators/ reinforces of use
* chronic use→ reward circuitry changes that promot future use (increased limbic function, decreased prefrontal cortex function)
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opiate intoxication and withdrawal
* intoxication: elevated mood, pupil constriction, respiratory suppression
* Rx: **naloxone to reverse**
* withdrawal: **don't die but you wish you would;** restless, water eyes, yawning; cramping
* Rx: methadone (full agonist) or buprenorphine (partial agonist)
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EtOH intoxication and withdrawal
* intoxication: seriously you live this
* Rx: support
* withdrawal: tremor, agitation, **DTs (20-30% mortality),** GI, seizures, hallucinations
* ****Rx: benzos until stable and symptoms normalize
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benzo/barb intoxication and withdrawal
* intoxication: similar to alcohol
* Rx: **flumazenil for benzos**
* ****withdrawal: agitation, tremor, GI, seizures, hallucinations, death
* Rx: benzos until stable and symptoms normalize
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stimulant intoxication and withdrawal
* intoxication: dilated pulis, psychosis
* withdrawal: crash but no death
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hallucinogen intoxication
* perceptual distortion, depersonalization
* PCP/ spike: sedatives better than antipsych because rhabdo
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cannabis intoxication
elevated mood, expansive thought, pupil constriction, red conjunctiva
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stages of change
* **precontemplation**: not yet acknowledging there is a problem
* **contemplation:** acknowledge problem but not willing to make change
* **preparation/determination**
* **action/willpower**
* **maintenance**
* **relapse**
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12 steps of AA
1. admit powerless
2. believe there is power greater than you
3. make the decision to change
4. moral inventory of yourself
5. admit to yourself and another the exact nature
6. be ready to remove these defects of character
7. ask God to revoew shortcomings
8. make a list of person harmed and become willing to make amends
9. make amends
10. continue personal inventory
11. seek to improve conscious contact with God
12. spiritual awakening and promote AA to others
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varenicline
* partial nicotine receptor agonist used for smoking cessation
* avoid most withdrawal
* **best results**
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buproprion
* used for smoking cessation
* blocks reuptake/recycling of NA and DA→ desensitize DA reward circuitry so cigarette is not missed
* boxed warning: anxiety, suicidality esp in \<25 yo.
