Behavioral Dynamics Exam 3 Cards Flashcards
(341 cards)
1
Q
Somatization
A
Physical symptoms that may not be fully explained by a known medical dx after appropriate workup and cause significant distress and functional impairment
2
Q
Somatization in actual medical conditions
A
Often severity of pain/symptoms is out of proportion to the disease
3
Q
3 factors that can influence somatoform disorder development
A
Family member with chronic illness
History of abuse or sexual trauma
Comorbid psych disorder
4
Q
Somatic symptom disorder (Somatization)
A
Multiple unexplained physical symptoms - often in patients accompanied by a sense of urgency with unstable or dyfunctional families
5
Q
Classic patient for somatic symptom disorder
A
Pt. describes being sickly their whole life and has had multiple invasive studies/diagnostics
6
Q
Criteria for Somatic symptom disorder
A
1+ symptom that causes significant distress or disruption
Persistent thoughts, anxiety, or energy focused on concerns
Symptoms present for over 6 months
7
Q
Mild somatic symptom disorder
A
1 of the three criteria (thoughts, anxiety, energy)
8
Q
Moderate somatic symptom disorder
A
2+ of the three criteria (thoughts, anxiety, energy)
9
Q
Severe somatic symptom disorder
A
2+ of the three criteria (thoughts, anxiety, energy) and multiple complaints or one SEVERE complaint
10
Q
Treatment for somatic symptoms disorder
A
Consolidate care to ONE provider
Have frequent follow up visits
Only order tests objectively
Treat comorbid psych disorders
11
Q
Functional Neurological Symptom Disease (Conversion disorder)
A
Altered VOLUNTARY motor or sensory function with no underlying biological cause apparent
12
Q
Etiology of functional neurological symptom disease
A
May be a result of physical trauma or an impaired ability to communicate distress
13
Q
Presentation of functional neurological symptom disease
A
Neurologic symptoms that do not correlate with exam findings - (ie. DTRs in a paralyzed leg, seizures with normal brain activity)
14
Q
Hoover’s sign
A
Hip extension is weak when tested directly but normal when asked to flex the opposite hip
15
Q
Criteria for Functional Neurologic Symptom Disorder
A
1+ deficits that are incompatable with a recognized neurological condition, not explained better by another illness and cause significant distress or impairment
16
Q
Treatment for functional neurological symptom disorder
A
Psychotherapy - don’t tell patients what it’s imaginary
17
Q
Illness anxiety disorder (Hypochondriasis)
A
Preoccupation with serious illness with minimal to no somatic symptoms to support this concern
18
Q
Classic presentation of illness anxiety disorder
A
Misinterpretation of benign symptoms, give extremely detailed hx, unswayed by objective findings
19
Q
Criteria for illness anxiety disorder
A
Preoccupation that is excessive or disproportionate to the symptoms, anxious about health status, more than 6 months, Excessive participation or avoidance of healthcare
20
Q
Management for Illness anxiety disorder
A
Avoid psych referral
Have frequent meetings
Only do objective diagnostic studies
21
Q
Body dysmorphic disorder
A
Classified with OCD, preoccupation with perceived appearance defects not readily visible to others
22
Q
Clinical presentation of body dysmorphic disorder
A
Vague complaints about body parts, obsession or avoidance of mirrors and avoidance of public interaction
23
Q
Criteria for body dysmorphic disorder
A
Preoccupation with 1+ perceived defect, Repetitive behaviors tied to that defect, causes impairment and is not better explained by another condition (ie. anorexia)
24
Q
Treatment for body dysmorphic disorder
A
Correction almost never helpful, off lable SSRI use, psychotherapy
25
Somatic symptom disorder with predominant pain (pain disorder)
Abnormal response, usually to pain that is part of an existing medical condition
26
Classic presentation of somatic symptom disorder with predominant pain
history of med/surg care, state that life would be good without the pain, psych plays a major role in pain which is not feigned
27
Criteria for somatic symptom disorder with predominant pain
1+ somatic symptoms predominantly involving pain that causes distress or disruption of daily life, leads to persistent thoughts and takes up excessive time and energy for over 6 months
28
Treatment for somatic symptom disorder with chronic pain
NSAIDS first line anelgesics, avoid opioids
Cymbalta is indicated for chronic pain, TCAs or SSRIs also helpful
29
2 things to rule out when considering a diagnosis of a somatic symptom or related disorder
Actual medical problem
Substance use
30
Factitious disorder (formerly Munchausen syndrome)
Intentionally faking symptoms to appear ill without motivation to gain rewards (insurance money, etc.)
31
Factious disorder by proxy
Form of ABUSE
Inducing symptoms on others to make them appear sick
32
Clinical presentation of factitious disorder
Multiple facilities, multiple providers, frequent moves and vague hx
Patients have rare disorders and want a comprehensive workup
33
4 Common symptoms with factitious disorder
Poor wound healing, , hypoglycemia, GI symptoms, adverse to psychiatric consult
34
Severe factitious disorder
Wandering with aliases from hospital to hospital - can become aggressive, get admitted and then leave AMA
35
Signs of factitious disorder imposed on another
S/S worsen when perpetrator is around or when patient has testing or is scheduled for discharge
S/S improve when perpatrator is not around - they show disregard for the patients actual health and are surprisingly agreeable to invasive procedures
36
Malingering
Faking an illness or symptoms for personal gain - avoids excessive diagnostic tests. S/S improve once goal is acheived
37
Treatment for malingering
Treat underlying conditions, and avoid manipulation
38
Treatment for factitious disorders
REPORT by proxy
Be compassionate in discussing diagnosis and try to keep them with one provider2
39
6 symptoms that can point to psychosis
Hallucinations, Delusions, Disorganized or incoherent speech, disorganized or catatonic behavior, Abnormal emotions, Cognitive difficulties
40
Hallucination
Sensory perceptions in the absence of any external stimuli - not JUST sight
41
Illusions
Misperceptions of actual external stimuli - not JUST sight
42
Delusions
Fixed false beliefs that persist in the face of contrary evidence - cannot be shared by a religion, family, or subculture
43
Schizophrenia
Chronic or recurrent psychosis that is severely disabling - social and occupational dysfunction for at least 6 months
44
Clinical presentation of Schizophrenia
No pathognomic symptom or sign
Take a good thorough history and pay attention for unkempt patient presentation
45
One possible cause of psychosis that must be ruled out
Drug use
46
Positive symptoms of Schizophrenia
Exaggeration of normal processes due to increased dopamin activity
Hallucinations
Delusions
Disorganization
47
1 disease with a similar presentation to schiophrenia
Alzheimer's
48
Negative symptoms of schizophrenia
Diminution of normal processes, thought to be due to decreased dopamine activity
49
Most common type of hallucinations for schizophrenic pts
Auditory
50
Delusion that everyone is "judging me" or "out to get me"
Delusions of persecution
51
Exaggerated perception of one's own abilities and importance - thinks they are a famous person
Delusions of Grandeur
52
The belief that one does not exist or has died
Cotard/Nihlistic delusion
53
Delusion that someone is in love with the patient
Erotomania
54
Belief that insignificant remarks, events, or objects have personal meaning or significance - radio is speaking to me
Delusions of reference
55
Belief that an external force controls one's own thoughts
Delusion of control (Withdrawal, insertion, broadcasting)
56
Belief that one's body is diseased or infested
Somatic delusions
57
Speech that begins in a goal directed manner but gradually deviates to consistently off topic answers
Tangentiality
58
Speech is goal oriented but the pt gets to the answer in a roundabout way
Circumstantiality
59
Speech starts out coherent and goal oriented but shifts rapidly between topics with no logical connection
Derailment
60
Creation and use of new nonsensical words
Neologisms
61
Incomprehensible speech - word sals
Incoherence
62
Words are used for how they sound rather than what they mean
Clanging
63
Inability to use abstract thinking (can't do similarities or parable)
Concrete speech
64
Consistent return to one specific topic despite movemet of conversation to different topics
Perseveration of ideas
65
Disorganized behavior
Positive symptom of schizophrenia - may be childlike, aimless, inappropriate, or bizarre
66
Negative catatonia
Abnormally decreased movement - Mutism, Waxy Flexibility, Negativism, Staring
67
Positive Catatonia
Positive catatonia - Teeth clicking, Rocking, Echolalia, Echopraxia
68
Is catatonia a positive or negative symptom?
Positive
69
4 Negative symptoms of schizophrenia
Decrease or absence of normal psych processes - Anhedonia, Flat affect, Alogia, Loss of hygene
70
Deficit schizophrenia
Mostly negative symptoms and more likely to have positive outcomes
71
Most commonly used substance in schizophrenic patients
Nictotine
72
Percent of schizophrenic patients that attempt and successfully commit suicide
20-50 and 10%
73
2 Neuro findings potentially in schizophrenia
Agraphesthesia and astereognosia
74
Average age of onset for schizophrenia
10-25 for men
25-35 for women
75
Incidence of schizophrenia
1% internationally
76
7 risk factors for schizophrenia
1st degree relative with schizophrenia
Male gender
OB complications
Infections and birth during winter/early spring
Inflammation/Autoimmune
Cannabis use
Immigrant status
77
Familial risks of schizophrenia
50% if monozygotic twin
40% if both parents
10% if a first degree relative
78
Why can cannabis be a risk factor for schizophrenia development
It can induce psychotic episodes
79
Dopamine hypothesis of schizophrenia
More dopamine causes positive symptoms of schizophrenia while less dopamine causes positive symptoms of schizophrenia
80
Dopamine receptors that all antipsychotics block
Dopaminergic/ D2 receptors
81
Serotonin hypothesis of schizophrenia
Excess of serotonin causes it - not widely believed as the main theory
82
Glutamate hypothesis of schizophrenia
Believed to be a potential lack of function of the glutamate receptor
Glutamate is an excitatory neurotransmitter
83
GABA hypothesis of schizophrenia
Decreased function or synthesis of GABA with is an inhibitory neurotransmitter
84
Acetylcholine hypothesis of schizophrenia
Developed based on the affinity for smoking in schizophrenic patients - unsure how much of a role nicotinic receptors play
85
Structural brain abnormalities of schizophrenia
Decreased tissue with larger ventricle - less gray matter (similar to alzheimers disease)
86
Functional brain abnormalities of schizophrenia
Cognitive defects are often present before positive symptoms
87
Response of schizophrenia symptom categories to antipsychotics
Positive symptoms respond well while negative symptoms generally do not
88
Pre-treatment screenings for schizophrenia -General health
BMI, waist, HE, BO, EKG
89
Special pre-treatment screening for schizophrenia
AIMS score for movement disorder
90
4 labs for pre-treatment screening of schizophrenia
CBC, CMP fasting, Lipids, and TNFs
91
Minimum trial period for an antipsychotic for schizophrenia
6 weeks - can try high dose therapy afterwards
92
2 low potency first gen antipsychotics
Know brand OR generic for each
Chlorpromazine (thorazine)
Thioridazine (Mellaril)
93
2 high potency first gen antipsychotics
Know brand OR generic
Haloperidol (Haldol)
Prochlorperazine (Compazine)
94
1st generation antipsychotics - general description
TYPICAL
Dopamine receptor agonists that are good for positive symptoms and have more side effects
95
2nd generation antipsychotics
ATYPICAL
Dopamine/5HT antagonists with less side effects that treat positive AND negative symptoms
96
7 Side effects of antipsychotics
Neuroleptic Malignant Syndrome
FALTER
Fever
Arms (stiff)
Leukocytosis
Tremors
Elevated CPK
Rigidity
97
Antipsychotics that might cause hyperprolactinemia
Typicals, Risperidone, also high dose olanzipine or ziprasidone
98
Antipsychotics that might cause anticholinergic side effects or sedation
low potency typicals and clozapine
may see with high dose olanzapine or quetiapine
99
4 extrapyramidal symptoms that may be seen with antipsychotics
Pseudoparkinsonism
Akathasia (restlessness)
Dystonia (spastic muscle contractions)
Tardive dyskinesia (involuntary movements that disappear during sleep)
100
Most common antipsychotics for extrapyramidal symptoms
High potency typicals
101
Antipsychotics likely to cause hypotension
Low potency typicals and clozapine
Rapid titration of risperidone and quetiapine
102
Antipsychotic that comes with a risk of agranulocytosis
Clozapine - weekly CBC for 6 months then biweekly, them monthly
103
Antipsychotic that is given once per month after tapering
Abilify
104
Antipsychotic that sedates and can be useful for end of life
Haldol
105
Antipsychotic that can cause severe nausea and vomiting
Campozine
106
2 antipsychotics most commonly associated with cardiac arrythmia and prolonged QT
Thioridazine and Ziprasidone
107
2 worst antipsychotics for metabolic syndromes
Clozapine and Olanzipine
108
5 best antipsychotics for metabolic problems
Aripirazole, brexpiprazole, cariprazine, ziprasidone, High-potency typicals
109
1 antipsychotic that is good for not gaining weight
Lurasidone
110
4 antipsychotics that cause dyslipidemia
Low potency typicals, Clozapine, Olanzapine, Quetiapine
111
Schizophrenia prognosis
10% recover
20% have a good outcome but not full recovery
30-35% have a stable but intermediate outcome
112
5 things that lead to a good schizophrenia prognosis
Later onset
Positive symptoms
Female sex
Mood symptoms
Acute onset
113
Schizophrenia that persists for less than 1 month
Brief psychotic disorder
114
Schizophrenia for 1-6 months that often turns into schizophrenia
Schizophreniform disorder
115
Psychosis with another probable cause
Secondary psychotic disorder
116
Schizophrenia with a mood disorder
Schizoaffective disorder
117
Delusions without other "crazy" stuff
Delusional disorder
118
Criteria for brief psychotic disorder
One or more psychotic symptoms for 1 day to 1 month
Often associated with a life stressor
119
Treatment for brief psychotic disorder
May try an antipsychotic for 1-3 months following symptom remission
120
Diagnostic criteria for schizophreniform disorder
2+ psychotic symptoms for 1-6 months
121
Treatment for schizophreniform disorder
Second generation antipsychotic with hospitalization if needed
122
Signs that a patient may have a secondary psych disorder
Patient has been using a substance or symptoms are only present in tandem with another psych disorder
123
Diagnostic criterion for schizoaffective disorder
At least one 2 week period with hallucinations or delusions in the absence of a prominent mood episode
124
Prognosis of schizoaffective disorder
Better with bipolar and worse with depression
125
Presentation of delusional disorder
Delusions in a high functioning person that last at least 1 month and are typically non-bizarre
126
Delusions that another person usually of higher status is in love with the patient
Erotomanic delusion
127
Delusion of inflated worth, power, knowledge, identity, or special relationship with a deity or famous person
Grandiose Delusion
128
Delusion that the pt's sexual partner is unfaithful
Jealous type delusion
129
Delusions that the patient is being treated malignantly in some way
Persecutory type delusion
130
Delusion that the patient has physical defect or medical condition
Somatic type delusion
131
Prognosis for delusional disorder
Two thirds recover significantly while 20% have persistent and treatment resistant symptoms
132
Body dissatisfaction
Chronic Negative perception of one's body
133
What makes body dissatisfaction different than an eating disorder?
Morbid fear of weight gain coupled with the belief that one cannot be too thin
134
Anorexic families
Usually rigid, controlling, or organized
135
Bullimic families
Usually chaotic, critical and conflicted
136
Parenting style that often leads to eating disorders
Parents who respond to non-hunger needs like anxiety with food
137
Alexthymia
Lack of feelings
138
4 forms for eating disorders
SCOFF
ESP
EAT
PHQ - Depression
139
Classic presentation of a restrictive eating disorder
Underweight child (average BMI - 16) comorbid anxiety and decreased bone mineral density
140
Diagnostic criteria for an eating disorder
Avoiding or restricting intake due to lack of interest, sensory issues, or averse experience
Weight loss, deficiency, need for supplements and parenteral nutrition, or Impaired social functioning
141
Bimodal onset of Anorexia Nervosa
12-15 or 17-21
142
2 characteristics of Anorexia Nervosa
Intense fear of weight gain and Distorted perception of body index
143
BMI cutoffs for Mild, Moderate, Severe, and Extreme Anorexia nervosa
Mild - 17+
Moderate - 16-17
Severe - 15-16
Extreme - Under 15
144
2 subtypes of anorexia nervosa
Binge eating (smaller binges than bullimia)
with purging
Restrictive with no binges
145
5 ROS findings for Anorexia Nervosa
Depression, Bone pain, Amenorrhea, Constipation, Hair loss
146
2 PE findings for
Russel's sign, lanugo
147
Russel's sign
Scars on knuckles from self gagging to purge - (also look at dental erosion)
148
Lanugo
Hair usually found on babies - grown in anorexia due to body fat loss
149
5 cardiac complications from anorexia
Decreased heart mass, Dysrhythmias, CHF, mitral valve prolapse, Orthostatic hypotension
150
3 major causes of death in anorexia nervosa
Starvation, suicide, electrolyte imbalance
151
2 workups for ALL suspected anorexia nervosa patients
ECG and UA
Draw labs
152
5 Labs to draw for AN
CMP, INR, CBC, Phosphorus, Magnesium
153
Management approach to AN
Nutritional rehabilitation (SLOWLY) and Psychotherapy
Meds are not first line though Prozac may help
154
5 levels of refeeding
Enough
Macronutrient balance
Micronutrient balance
Variety
Challenge (hard to eat) foods
155
AN prognosis
50% good
25% intermediate
25% poor
6x higher all cause mortality
156
Classic bullimia patient
Adolescent white female
157
Characteristic bullimic presentation
Recurrent binge eating with inappropriate compensation at least once a week for 3 months
158
2 subtypes of bullimia
Purging and Non-purging
159
Behavioral pattern of bullimia
Eat and compensate in secret with more control over timing of behaviors
160
3 cardiac abnormalities of bullimia
Hypotension, Tachycardia, Peripheral edema
161
Difference of bullimia from anorexia
Body weight is within the normal range
162
Common complications of bullimia
Loss of gag reflex, esophageal tears, parotid gland hypertrophy
163
Bullimia management
CBT works unlike annorexia
SSRI such as prozac is helpful
164
When to admit and eating disorder patient
Unstable, Suicidal, Refusing treatment and likely to become suicidal
165
Bulimia prognosis
2x increase in all cause mortality
Often comobid with psych disorders such as PTSD, depression, substance us, and personality disorders
166
Median age of onset for binge eating disorder
23 - more common in women, less researched despite higher prevalence
167
Number of episodes per week for mild, moderate, severe, and extreme BED
Mild - 1-3
Moderate - 4-7
Severe - 8-13
Extreme - 14+
168
Clinical presentation of binge eating disorder
Use food for coping or comfort, continue eating after they are full, Eat quickly (inhale food), Have feelings of shame, Try to hide their eating habits
169
3 complications of BED
High risk of Cancer, Obesity, Dyspnea
170
Therapy for BED
CBT - first line
Behavioral weight loss therapy
SSRIs but NOT weight loss drugs
171
Antipsychotic that causes weight loss
Olazepine
172
Definition of ADHD
Diminished sustained attention and high levels of hyperactivity that are present before the age of 12
173
2 major types of ADHD
Hyperactive/Impulsive and Inattentive
174
Gender mor prone to ADHD
Males - more skewed for hyperactive impulsive
175
Biological component of ADHD
Impaired catecholamine metabolism in the brain (dopamine and norepinephrine)
Likely also hereditary
176
Diagnostic criteria for ADHD
6+ symptoms from one of two categories (inattentive or hyperactive) for at least 6 months, before 12 in 2+ settings and inconsistent with developmental level
177
ADHD behavioral interventions
Preferred for preschool age children but adjunct for older children and teens
178
Cognitive therapy for ADHD
Not recommended as monotherapy may be an adjunct for comorbid conditions
179
Dietary modifications for ADHD
Generally not recommended - ensure child is receiving adequate nutrition
180
2 classes of stimulants for ADHD
Methylphenidate and Amphetamines
181
3 non-stimulants for ADHD
Atomoxetine, A2 Adrenergic Agonists (Clonidine and Guanfacine), Antidepressants
182
Criteria for starting children on ADHD medication
Full diagnostic assessment completed, Child is at least six, School will cooperate, No household substance use concerns
Pharm is 1st line
183
Schedule for stimulant drugs
Schedule II
184
Methylphenidate and Amphetamine
Block catecholamine reuptake - Amphetamines also stimulate dopamine release
185
Extended release stimulants
Helpful to treat in multiple settings - can reduce adverse effects at peak and crash when drug is cleared
186
Dosing of stimulants
Start low and go slow - drug holidays can help reduce desensitization
187
6 side effects of stimulants
Reduced appetite, Insomnia or nightmares, Jittery, Emotional lability, weight loss, Tics
188
Titration for stimulants for ADHD
Titrate up to 50% resolution of symptoms
189
Cardiac side effects and 2 other contraindications of stimulants
Increased HR and BP, Palpitations
CI in hx of mania or Tourette syndrome
190
Management of mood lability for stimulants
Use XR formulations
191
How long is needed between an MAOI and a Stimulant
14 days
192
4 brand names of methylphenidate
Ritalin, Focalin, Concerta, Methylin
193
Use of methylphenidates
Equally effective but preferred for preschool age children as they are better tolerated
Reduced weight loss and increased priapism associated
194
4 brands of amphetamines
Adderall, Vyvanse, Mydayis, Zenzedi
195
Use preference for amphetamines
Generally more side effects, associated with slightly more weight loss
196
Atomoxetine
SNRI for use if stimulants cannot be used for ADHD
197
Onset of action of Atomoxetine
Takes 1-2 weeks
198
Side effects of atomoxetine
Similar to stimulants with less cardiac danger, Liver injury
199
4 CIs for atomoxetine
Use within 14 days of an MAOI, Glaucoma, Pheochromocytoma, Severe heart disease
200
Use us alpha adrenergic receptor agonists for ADHD
Pts who fail to respond to stimulants or atomoxetine - not controlled
201
2 Alpha adrenergic agonists used for ADHD
XR Clonidine
XR Guanfacine
202
XR clonidine for ADHD
Sedating effect for aggressive agitated patients, can add to avoid jacking up stimulant dose, PO BID
203
XR guanfacine for ADHD
Fewer side effects than Clonidine with once daily dosing
204
Antidepressants that can be used with ADHD (2)
TCAs
Buproprion
205
3 characteristics of autism spectrum disorder
Deficits in social interaction and communication
Restrictive and repetitive patterns of behavior
Present in early development
206
Gender with more prevalence of ASD
More common in males
207
3 associated conditions with ASD
Intellectual disability, ADHD, seizures
208
Three factors that might contribute to ASD
Increased parental age, Poor peri/neonatal health, Maternal metabolic conditions
209
Usual age for autism diagnosis
2 years
210
Severe autism
Often mute with severe behavioral problems
211
Mild Autism
Verbal capacity with unusual interests impaired social skills
212
5 social signs of autism
Delay in language development
Lack of social reciprocity
Lack of desire to share enjoyment with others
Nonverbal communication is difficult
Fail to develop and maintain peer relationships
213
Stereotyped behaviors
Repetitive movements such as rocking, fidgeting
214
2 restrictive behaviors of ASD
Insistence on sameness and difficulty with changes
Focus on restricted interests with a persistent preoccupation
215
Sensory perception of ASD patients
Hyposensitivity, hypersensitivity, or paradoxical responses seen in 99% of patients
216
Intellectual impairment of ASD patients
Stronger in nonverbal tasks with marked deficit in verbal cognition
217
2 other common factors in ASD patients
Motor deficit, Macrocephaly
218
Milestones missed in autism
Babbling by 9 months
Pointing or orientation to name by 12 months
No words by 16 months
Lack of pretend play by 18 months
No meaningful two word phrases by 24 months
219
Screening tool for autism
M-CHAT-R/F - early detection leads to better outcomes
220
4 follow ups for children who test positive for autism
Referral to a specialist
Hearing screening
Serum lead level
Genetic testing
221
Pharmacology for ASD
Do not treat but can help behaviors
Stimulants for hyperactivity
Antipsychotics for maladaptive behaviors
SSRI for Mood and Anxiety symptoms
222
Bruxism
Grinding teeth
223
Gene mutation that causes Rett syndrome
MECP2 gene - almost exclusively in females
224
Clinical presentation of rett syndrome
Uneventful pregnancy with sudden deceleration of head growth at 2-3 months and loss of fine motor skills and communication at 12-18 months
225
3 supportive treatments for Rhett disorder
Good nutrition, Monitor QT, PT/OT for motor problems
226
NREM sleep
Peaceful and relaxed sleep that is comprised of 4 stages
227
REM sleep
Sleep that involves high levels of brain activity including dreams
228
How does early sleep differ from later sleep
Starts out with more NREM and less REM
Changes to more REM and less NREM
229
Order of sleep stages
Go through stages 1-4 and then REM
230
NREM stage 1
Easily awakened - may have twitches (hypnic myoclonia) or feelings of falling in this stage
231
NREM stage 2
Light sleep with periods of muscle tone and muscle relaxation as the body prepares for deep sleep
232
NREM stages 3&4
Delta wave sleep - time of mending of the body with repair and regeneration
Enuresis, Somambulance and night terrors occur here. Patients are usually disoriented
233
Delta waves
Longest brain waves 1-3.99 Hz
234
REM sleep characteristics
Physiologic activity is increased, Paralysis, Erection, and dreaming
235
NREM dreams
Usually more abstract and surreal than REM dreams
236
Effect of serotonin on sleep
Less serotonin = less sleep
237
Effect of norepinephrine on sleep
More norepinephrine = less sleep
238
Effect of melatonin on sleep
Less melatonin = less sleep
239
Effect of dopamine on sleep
More dopamine = less sleep
240
Changes in REM sleep as we age
80% as an infant, 20-25% from 10 through adulthood, Under 20% after 65
Stage 4 NREM also decreases
241
Elderly sleep pattern character
Less deep without as much stage 3/4 or REM, frequent awakenings and daytime drowsiness
242
3 sleep disturbances seen in depressed patients
Insomnia
Hypersomnia - less common than insomnia
Longer and more frequent periods of wakefulness
243
6 things to ask about when taking a sleep related history
Falling vs. Staying asleep
Daytime sleepiness
Abnormal sleep behavior
Abnormal sleep-wake timing
Life stressors
Sleep environment
244
Insomnia criteria
Difficulty initiating or maintaining sleep
Non-restorative or poor quality sleep
Early morning awakening
At least one month despite adequate opportunity and circumstances
Deficits in daytime function
245
Transient, Acute, and Chronic
Transient - under 7 days
Acute - 7-30 days
Chronic - over 30 days
246
3 causes of secondary insomnia
Depression or Anxiety
Breathing related sleep disorder
Substance abuse or medications
247
Alcohol and effect on sleep
Acute - decreased sleep latency with vivid dreams and awakening
Chronic - Increased stage 1 and decreased REM
Withdrawal - Delay in onset with awakening
248
Insomnia management
Treat underlying causes, Non-pharm treatment should be first line (relaxation, meditation, sleep hygiene, etc.)
249
6 classes of drugs that can be used for insomnia management
OTC 1st gen antihistamines
Benzodiazepine receptor agonists
Melatonin agonists
Benzodiazepines
Dual orexin receptor agonists
Antidepressants
250
3 things to do for proper sleep hygeine
Establish a regular sleep schedule
Cut down on excess time in bed
Make bedroom confortable
251
Time gap between exercise and bedtime
6 hours min
Definitely not within 90 minutes
252
Time gap between caffeine and bed
after lunch - 4 hour half life
253
Time gap between eating and sleep
2 hours for heavy meals
254
Onset age for narcolepsy
20s
255
4 potential secondary causes of narcolepsy
Brain tumor, cerebrovascular insufficiency, head trauma, encephalopathy
256
Classic narcolepsy tetrad
Recurrent irresistible attacks of daytime sleepiness, Cataplexy, Hallucinations, Sleep paralysis
257
Irresistible attacks of daytime sleepiness criteria
Daily for at least 3 months, unexpected and inappropriate
258
Cataplexy criteria
Bilateral loss of muscle tone often associated with emotional trigger - can be systemic or localized
259
2 types of narcoleptic hallucinations
Hypnagogic - on falling asleep
Hypnopompic - on waking up
260
Diagnostic tool for narcolepsy
Multiple sleep latency test - record naps to see how fast patient enters REM cycles
261
3 treatment options for narcolepsy
1 non-pharm
2 pharm with 2 drugs each
Forced naps during the day
Stimulants - modafinil (less abuse), Methylphenidate
SSRI or SNRI for symptomatic treatment
262
Presentation and etiology of somnambulism
Semi purposeful behavior during stages 3 and 4 of NREM sleep - difficulty waking patient up with no memory of episodes
263
Treatment for somnambulism
Avoid fatigue
Minimize interventions
Lead patient back to bed
Provide a safe sleep environment
Lock doors and windows
264
Clinical presentation of sleep related bruxism
Involuntary, non-functional forcefull clenching, grinding and rubbing of teeth, have headaches and TMJ disorders
265
Treatment for sleep related bruxism
Occlusive splints to reduce mechanical wear
Control anxiety
266
Complication of sleep related bruxism
Wearing down of the tooth enamel
267
Circadian rhythm disorder
Misalignment between the environment and an individual's sleep-wake cycle
268
6 types of circadian rhythm disorders
Delayed sleep phase type - night owl
Jet lag type - Eastward travel worse than westward
Shift work type - Night shift causes insomnia
Advanced sleep phase - Early bird elderly
Irregular rhythm type - lack of defined rhythm
Non-24-hour type - Blind patients
269
Sleep apnea
Breath cessation for at least 10 seconds
270
Hypopnea
4% drop in oxygen saturation accompanied by decreased airflow
271
Central apnea
Absent ventilatory effort during apneic episode
272
Obstructive apnea
Present ventilatory effort during apneic episode
273
Mixed apnea
Absent ventilatory effort followed by obstruction during episode
274
5 risk factors for obstructive sleep apnea
Anatomically narrowed upper airways
Ingestion of alcohol or sedatives before sleeping
Nasal obstruction
Hypothyroidism
Smoking
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Classic sleep apnea patient
Obese and middle aged
"Bull neck" appearance
276
Lab finding for sleep apnea
erythrocytosis
277
3 patient reported symptoms of sleep apnea
Daytime somnolence
Recent weight gain
Morning sluggishness and headaches
278
3 bed partner reported symptoms of sleep apnea
Loud cyclical snoring
Thrashing of the extremities
Personality changes or poor judgement
279
2 Diagnostic tools for obstructive sleep apnea
Home overnight pulse oximetry
Overnight polysomnography - look for cardiac electrical abnormalities
280
3 Treatments for obstructive sleep apnea
CPAP
Weight loss 10-20%
Surgical repair
Supplemental O2 can lengthen apneas while providing relief
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micrognottia
Sunken/Small jaw
282
4 pharmacotherapy options for sleep disorders
Benzodiazepine receptor agonists
Melatonin receptor agonists
Dual orexin receptor agonists
Stimulants
283
MOA of benzo receptor agonists
Facilitate GABA-mediated inhibition of cell firing
284
Difference between Benzos and benzo receptor agonists
Less addictive and don't reduce deep sleep
Not anxiolytic
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3 benzodiazepine receptor agonists for sleep disorders
Zaleplon (Sonata)
Zolpidem (Ambien)
Eszopiclone (Lunesta)
286
Zaleplon
BZD receptor agonist
Can cause headache
Very short half life and less effective with fatty meals
287
Zolpidem
Longer half life with IR and XR forms
XR better for sleep maintainance but can cause grogginess - SEs of headache, dizziness, drowsiness
288
Eszopiclone (Lunesta)
Butterfly of DEATH
Metallic taste and headache longest half life and do not take with meals
289
Schedule of BZD receptor agonists
Schedule IV medication
BBW for complex sleep related disorders
290
Effect of prolonged exogenous melatonin use
Desensitization of receptors
291
Ramelteon
Melatonin receptor agonists that binds with a higher affinity than melatonin itself
Cannot be used with fluvoxamine
Better for sleep onset insomnia
292
SSRI that causes a prolonged QT
Lexapro
293
Why is melatonin contraindicated with seizures
It can make anticonvulsants less effective
294
MOA of Dual Orexin Receptor Antagonists
Antagonize orexin receptors and thereby decrease the wake drive
295
System that promotes and stabilizes wakefulness
Orexin/Hypocretin system
296
Suvorexant
Dual Orexin receptor antagonist
Don't take with CYP3A4 inhibitors/inducers
Schedule IV
12 hr half life for both insomnias
297
Lemborexant
DORA
Long half life of 17-19 hours - maintainance and onset insomnia
Schedule IV
298
Daridorexant
New DORA approved in 2022
Only 8 hour half life
299
Contraindication for orexin receptor agonists
Narcolepsy
300
Modafinil
Stimulant to treat narcolepsy taken first thing in the morning or taken for night shifts
Schedule IV drug
301
Sodium Oxybates
CNS depressant - Metabolite of GHB (Date rape drug)
Schedule III - respiratory depression is possible
Works on GABA receptors
Avoid use with EtOH and sedatives
Can be good for narcolepsy
302
Cluster A personality disorders (3)
Usually odd and eccentric
Paranoid, Schizoid, and Schizotypal
303
Cluster B personality disorders (4)
Emotional
Antisocial, Borderline, Histrionic, Narcissistic
304
Cluster C personality disorders
Fearful
Avoidant, Dependant, Obsessive-compulsive
305
Personality disorder
Personality traits that are inflexible and maladaptive enough to cause distress and impairment of functioning
306
Demographic for personality disorders
Male, young, Poor education, Unemployed
307
4 risks of personality disordered patients
Reckless behavior
Psychiatric comorbidities
Functional impairment
Noncompliance
308
2 screening tools for personality disroders
Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF)
Millon Clinical Multiaxial Inventory-III (MCMI-III)
309
Clinical relationship with type A personality disorders
Only seek treatment for acute complaints
Mistrust of healthcare
Strong affirmation and careful handling can help
310
Clinical relationship with type B personality
Push limits, engage in power struggles, Be careful with boundaries
311
Clinical relationship with type C personality
More likely to take responsibility for problems, willing to readily engage in dialogue, can be sensitive or stubborn
312
Possible etiology for paranoid personality disorder
Parents with irrational outbursts of anger
313
Cardinal symptoms of paranoid personality disorder
Generalized distrust or suspiciousness - others motives are malevolent
Defensive and formal on exam
314
Treatment and prognosis for paranoid personality disorder
Low dose antipsychotics may help - patients often distrustful of therapy
More adaptive personality that can become overtly psychotic
315
3 potential etiologies for schizoid personality disorder
Pregnancy during famine, Autism, Lack of nurturing
316
Cardinal symptoms of schizoid personality disorder
Detachment, introversion and restricted range of emotional expression - lack of intimacy aloof and hard to engage on exam
FLAT AFFECT
317
Treatment for Schizoid personality disorder
May use antidepressants, family or group therapy may help although patients often do NOT feel distressed or in need of help
318
Schizoid personality disorder prognosis
Social detachment but less likely to develop depression
319
Etiology of schizotypal personality disorder
Believed to be linked to schizophrenia
320
Cardinal symptoms of schizotypal personality disorder
Peculiar thoughts speech and behavior, magical beliefs without hallucinations or delusions
Eccentric and emotional with a constricted affect
321
Therapy and prognosis for schizotypal PD
Low dose antipsychotics (lamictal) or mood stabilizers such as lithium
Group and in person therapy although patient may make others uncomfortable
10-25% develop schizophrenia
322
Etiology of antisocial personality disorder
Genetic and environmental
Abusive or absent parent and low socioeconomic status
323
Cardinal symptoms of antisocial PD
Recurrent disregard for and violation of the rights and feelings of others - often starts as conduct disorder in childhood
Attempt to be charming with a lack of empathy
324
Treatment and prognosis for antisocial PD
Group therapy is the most helpful
Peaks in early adulthood and can lead to alcoholism and late onset depression
325
Etiology and risks of Borderline personality disorder
Childhood trauma
HIGH risk of suicide - take very seriously
326
Cardinal symptoms of BPD
Impaired relatedness with others, labile mood with impulsive and self-injurious behavior - things are either all good or all bad
327
Physical exam for BPD patients
Labile mood, Difficult and demanding with irrational attachment and fear of abandonment
328
Treatment for BPD
Lithium, Carbamazepine, Antipsychotics, SSRIs
Group and family therapy can help avoid attachment to therapy
329
Prognosis for BPD
More antisocial = poorer prognosis
Better educated = Better prognosis
330
Cardinal symptoms of histrionic personality disorder
Excessive superficial emotionality and sexuality to draw attention and control others - seductive and want to be center of attention - Happy but sad
331
Treatment and prognosis for histrionic PD
SSRIs often useful maybe MAOIs
Group therapy may also help
Good prognosis if no comorbid cluster B disorders
332
Potential etiology of narcissistic PD
Over or under gratification of needs as a child
333
Cardinal symptoms of Narcissistic PD
Grandiose with a lack of empathy and sense of entitlement
Hypersensitive to criticism
334
Treatment and prognosis for NPD
Pharm not very helpful
Therapy can be helpful but it is difficult for the patient to deal with any criticism
Do not usually improve and can become depressed
335
Cardinal symptoms of avoidant personality disorder
Persistent pattern of avoidance due to anxiety that causes introversion and a restricted lifestyle
Anxious and shy on exam
336
Treatment and prognosis for avoidant PD
SSRIs, MAOIs, Beta blockers, Buspirone and BZDs - Antianxiety
Group and individual therapy helps overcome fears - important to establish trust
Often a good prognosis in simple cases
337
Cardinal symptoms of dependent PD
Lifelong interpersonal submissiveness with a fear of abandonment and lack of self confidence - hard for them to make decisions
Engage but withhold for fear of alienating provider
338
Therapy and prognosis for Dependant
SSRIs or TCAs
Considerable benefit with group therapy
Assertiveness and decision making training
Good prognosis if few comorbidities
339
Cardinal symptoms of OCPD
Rigidity and constricted affect inflexible, stubborn and need orderliness and control, want to be a good patient but can seem inflexable and high-strung
Right way and wrong way to do things
340
Difference between OCD and OCPD
OCPD has no true obsessions or compulsions and little to no distress - don't spend as much time in obsessive tasks
341
Treatment and prognosis for OCPD
No strong indication for medication
May need to treat family/friends upon whom expectations are being forced
Good prognosis - may develop anxiety and depression
