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Behavioral Dynamics > Behavioral Dynamics Exam 3 Cards > Flashcards

Behavioral Dynamics Exam 3 Cards Flashcards

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

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2
Q

Somatization in actual medical conditions

A

Often severity of pain/symptoms is out of proportion to the disease

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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

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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

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5
Q

Classic patient for somatic symptom disorder

A

Pt. describes being sickly their whole life and has had multiple invasive studies/diagnostics

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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

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7
Q

Mild somatic symptom disorder

A

1 of the three criteria (thoughts, anxiety, energy)

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8
Q

Moderate somatic symptom disorder

A

2+ of the three criteria (thoughts, anxiety, energy)

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9
Q

Severe somatic symptom disorder

A

2+ of the three criteria (thoughts, anxiety, energy) and multiple complaints or one SEVERE complaint

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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

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11
Q

Functional Neurological Symptom Disease (Conversion disorder)

A

Altered VOLUNTARY motor or sensory function with no underlying biological cause apparent

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12
Q

Etiology of functional neurological symptom disease

A

May be a result of physical trauma or an impaired ability to communicate distress

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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)

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14
Q

Hoover’s sign

A

Hip extension is weak when tested directly but normal when asked to flex the opposite hip

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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

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16
Q

Treatment for functional neurological symptom disorder

A

Psychotherapy - don’t tell patients what it’s imaginary

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17
Q

Illness anxiety disorder (Hypochondriasis)

A

Preoccupation with serious illness with minimal to no somatic symptoms to support this concern

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18
Q

Classic presentation of illness anxiety disorder

A

Misinterpretation of benign symptoms, give extremely detailed hx, unswayed by objective findings

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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

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20
Q

Management for Illness anxiety disorder

A

Avoid psych referral
Have frequent meetings
Only do objective diagnostic studies

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21
Q

Body dysmorphic disorder

A

Classified with OCD, preoccupation with perceived appearance defects not readily visible to others

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22
Q

Clinical presentation of body dysmorphic disorder

A

Vague complaints about body parts, obsession or avoidance of mirrors and avoidance of public interaction

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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)

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24
Q

Treatment for body dysmorphic disorder

A

Correction almost never helpful, off lable SSRI use, psychotherapy

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25
Q

Somatic symptom disorder with predominant pain (pain disorder)

A

Abnormal response, usually to pain that is part of an existing medical condition

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26
Q

Classic presentation of somatic symptom disorder with predominant pain

A

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

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27
Q

Criteria for somatic symptom disorder with predominant pain

A

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

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28
Q

Treatment for somatic symptom disorder with chronic pain

A

NSAIDS first line anelgesics, avoid opioids
Cymbalta is indicated for chronic pain, TCAs or SSRIs also helpful

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29
Q

2 things to rule out when considering a diagnosis of a somatic symptom or related disorder

A

Actual medical problem
Substance use

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30
Q

Factitious disorder (formerly Munchausen syndrome)

A

Intentionally faking symptoms to appear ill without motivation to gain rewards (insurance money, etc.)

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31
Q

Factious disorder by proxy

A

Form of ABUSE
Inducing symptoms on others to make them appear sick

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32
Q

Clinical presentation of factitious disorder

A

Multiple facilities, multiple providers, frequent moves and vague hx
Patients have rare disorders and want a comprehensive workup

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33
Q

4 Common symptoms with factitious disorder

A

Poor wound healing, , hypoglycemia, GI symptoms, adverse to psychiatric consult

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34
Q

Severe factitious disorder

A

Wandering with aliases from hospital to hospital - can become aggressive, get admitted and then leave AMA

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35
Q

Signs of factitious disorder imposed on another

A

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

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36
Q

Malingering

A

Faking an illness or symptoms for personal gain - avoids excessive diagnostic tests. S/S improve once goal is acheived

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37
Q

Treatment for malingering

A

Treat underlying conditions, and avoid manipulation

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38
Q

Treatment for factitious disorders

A

REPORT by proxy
Be compassionate in discussing diagnosis and try to keep them with one provider2

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39
Q

6 symptoms that can point to psychosis

A

Hallucinations, Delusions, Disorganized or incoherent speech, disorganized or catatonic behavior, Abnormal emotions, Cognitive difficulties

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40
Q

Hallucination

A

Sensory perceptions in the absence of any external stimuli - not JUST sight

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41
Q

Illusions

A

Misperceptions of actual external stimuli - not JUST sight

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42
Q

Delusions

A

Fixed false beliefs that persist in the face of contrary evidence - cannot be shared by a religion, family, or subculture

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43
Q

Schizophrenia

A

Chronic or recurrent psychosis that is severely disabling - social and occupational dysfunction for at least 6 months

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44
Q

Clinical presentation of Schizophrenia

A

No pathognomic symptom or sign
Take a good thorough history and pay attention for unkempt patient presentation

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45
Q

One possible cause of psychosis that must be ruled out

A

Drug use

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46
Q

Positive symptoms of Schizophrenia

A

Exaggeration of normal processes due to increased dopamin activity
Hallucinations
Delusions
Disorganization

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47
Q

1 disease with a similar presentation to schiophrenia

A

Alzheimer’s

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48
Q

Negative symptoms of schizophrenia

A

Diminution of normal processes, thought to be due to decreased dopamine activity

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49
Q

Most common type of hallucinations for schizophrenic pts

A

Auditory

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50
Q

Delusion that everyone is “judging me” or “out to get me”

A

Delusions of persecution

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51
Q

Exaggerated perception of one’s own abilities and importance - thinks they are a famous person

A

Delusions of Grandeur

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52
Q

The belief that one does not exist or has died

A

Cotard/Nihlistic delusion

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53
Q

Delusion that someone is in love with the patient

A

Erotomania

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54
Q

Belief that insignificant remarks, events, or objects have personal meaning or significance - radio is speaking to me

A

Delusions of reference

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55
Q

Belief that an external force controls one’s own thoughts

A

Delusion of control (Withdrawal, insertion, broadcasting)

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56
Q

Belief that one’s body is diseased or infested

A

Somatic delusions

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57
Q

Speech that begins in a goal directed manner but gradually deviates to consistently off topic answers

A

Tangentiality

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58
Q

Speech is goal oriented but the pt gets to the answer in a roundabout way

A

Circumstantiality

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59
Q

Speech starts out coherent and goal oriented but shifts rapidly between topics with no logical connection

A

Derailment

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60
Q

Creation and use of new nonsensical words

A

Neologisms

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61
Q

Incomprehensible speech - word sals

A

Incoherence

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62
Q

Words are used for how they sound rather than what they mean

A

Clanging

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63
Q

Inability to use abstract thinking (can’t do similarities or parable)

A

Concrete speech

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64
Q

Consistent return to one specific topic despite movemet of conversation to different topics

A

Perseveration of ideas

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65
Q

Disorganized behavior

A

Positive symptom of schizophrenia - may be childlike, aimless, inappropriate, or bizarre

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66
Q

Negative catatonia

A

Abnormally decreased movement - Mutism, Waxy Flexibility, Negativism, Staring

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67
Q

Positive Catatonia

A

Positive catatonia - Teeth clicking, Rocking, Echolalia, Echopraxia

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68
Q

Is catatonia a positive or negative symptom?

A

Positive

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69
Q

4 Negative symptoms of schizophrenia

A

Decrease or absence of normal psych processes - Anhedonia, Flat affect, Alogia, Loss of hygene

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70
Q

Deficit schizophrenia

A

Mostly negative symptoms and more likely to have positive outcomes

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71
Q

Most commonly used substance in schizophrenic patients

A

Nictotine

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72
Q

Percent of schizophrenic patients that attempt and successfully commit suicide

A

20-50 and 10%

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73
Q

2 Neuro findings potentially in schizophrenia

A

Agraphesthesia and astereognosia

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74
Q

Average age of onset for schizophrenia

A

10-25 for men
25-35 for women

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75
Q

Incidence of schizophrenia

A

1% internationally

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76
Q

7 risk factors for schizophrenia

A

1st degree relative with schizophrenia
Male gender
OB complications
Infections and birth during winter/early spring
Inflammation/Autoimmune
Cannabis use
Immigrant status

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77
Q

Familial risks of schizophrenia

A

50% if monozygotic twin
40% if both parents
10% if a first degree relative

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78
Q

Why can cannabis be a risk factor for schizophrenia development

A

It can induce psychotic episodes

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79
Q

Dopamine hypothesis of schizophrenia

A

More dopamine causes positive symptoms of schizophrenia while less dopamine causes positive symptoms of schizophrenia

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80
Q

Dopamine receptors that all antipsychotics block

A

Dopaminergic/ D2 receptors

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81
Q

Serotonin hypothesis of schizophrenia

A

Excess of serotonin causes it - not widely believed as the main theory

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82
Q

Glutamate hypothesis of schizophrenia

A

Believed to be a potential lack of function of the glutamate receptor
Glutamate is an excitatory neurotransmitter

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83
Q

GABA hypothesis of schizophrenia

A

Decreased function or synthesis of GABA with is an inhibitory neurotransmitter

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84
Q

Acetylcholine hypothesis of schizophrenia

A

Developed based on the affinity for smoking in schizophrenic patients - unsure how much of a role nicotinic receptors play

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85
Q

Structural brain abnormalities of schizophrenia

A

Decreased tissue with larger ventricle - less gray matter (similar to alzheimers disease)

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86
Q

Functional brain abnormalities of schizophrenia

A

Cognitive defects are often present before positive symptoms

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87
Q

Response of schizophrenia symptom categories to antipsychotics

A

Positive symptoms respond well while negative symptoms generally do not

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88
Q

Pre-treatment screenings for schizophrenia -General health

A

BMI, waist, HE, BO, EKG

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89
Q

Special pre-treatment screening for schizophrenia

A

AIMS score for movement disorder

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90
Q

4 labs for pre-treatment screening of schizophrenia

A

CBC, CMP fasting, Lipids, and TNFs

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91
Q

Minimum trial period for an antipsychotic for schizophrenia

A

6 weeks - can try high dose therapy afterwards

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92
Q

2 low potency first gen antipsychotics
Know brand OR generic for each

A

Chlorpromazine (thorazine)
Thioridazine (Mellaril)

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93
Q

2 high potency first gen antipsychotics
Know brand OR generic

A

Haloperidol (Haldol)
Prochlorperazine (Compazine)

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94
Q

1st generation antipsychotics - general description

A

TYPICAL
Dopamine receptor agonists that are good for positive symptoms and have more side effects

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95
Q

2nd generation antipsychotics

A

ATYPICAL
Dopamine/5HT antagonists with less side effects that treat positive AND negative symptoms

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96
Q

7 Side effects of antipsychotics

A

Neuroleptic Malignant Syndrome
FALTER
Fever
Arms (stiff)
Leukocytosis
Tremors
Elevated CPK
Rigidity

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97
Q

Antipsychotics that might cause hyperprolactinemia

A

Typicals, Risperidone, also high dose olanzipine or ziprasidone

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98
Q

Antipsychotics that might cause anticholinergic side effects or sedation

A

low potency typicals and clozapine
may see with high dose olanzapine or quetiapine

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99
Q

4 extrapyramidal symptoms that may be seen with antipsychotics

A

Pseudoparkinsonism
Akathasia (restlessness)
Dystonia (spastic muscle contractions)
Tardive dyskinesia (involuntary movements that disappear during sleep)

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100
Q

Most common antipsychotics for extrapyramidal symptoms

A

High potency typicals

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101
Q

Antipsychotics likely to cause hypotension

A

Low potency typicals and clozapine
Rapid titration of risperidone and quetiapine

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102
Q

Antipsychotic that comes with a risk of agranulocytosis

A

Clozapine - weekly CBC for 6 months then biweekly, them monthly

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103
Q

Antipsychotic that is given once per month after tapering

A

Abilify

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104
Q

Antipsychotic that sedates and can be useful for end of life

A

Haldol

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105
Q

Antipsychotic that can cause severe nausea and vomiting

A

Campozine

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106
Q

2 antipsychotics most commonly associated with cardiac arrythmia and prolonged QT

A

Thioridazine and Ziprasidone

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107
Q

2 worst antipsychotics for metabolic syndromes

A

Clozapine and Olanzipine

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108
Q

5 best antipsychotics for metabolic problems

A

Aripirazole, brexpiprazole, cariprazine, ziprasidone, High-potency typicals

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109
Q

1 antipsychotic that is good for not gaining weight

A

Lurasidone

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110
Q

4 antipsychotics that cause dyslipidemia

A

Low potency typicals, Clozapine, Olanzapine, Quetiapine

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111
Q

Schizophrenia prognosis

A

10% recover
20% have a good outcome but not full recovery
30-35% have a stable but intermediate outcome

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112
Q

5 things that lead to a good schizophrenia prognosis

A

Later onset
Positive symptoms
Female sex
Mood symptoms
Acute onset

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113
Q

Schizophrenia that persists for less than 1 month

A

Brief psychotic disorder

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114
Q

Schizophrenia for 1-6 months that often turns into schizophrenia

A

Schizophreniform disorder

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115
Q

Psychosis with another probable cause

A

Secondary psychotic disorder

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116
Q

Schizophrenia with a mood disorder

A

Schizoaffective disorder

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117
Q

Delusions without other “crazy” stuff

A

Delusional disorder

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118
Q

Criteria for brief psychotic disorder

A

One or more psychotic symptoms for 1 day to 1 month

Often associated with a life stressor

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119
Q

Treatment for brief psychotic disorder

A

May try an antipsychotic for 1-3 months following symptom remission

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120
Q

Diagnostic criteria for schizophreniform disorder

A

2+ psychotic symptoms for 1-6 months

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121
Q

Treatment for schizophreniform disorder

A

Second generation antipsychotic with hospitalization if needed

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122
Q

Signs that a patient may have a secondary psych disorder

A

Patient has been using a substance or symptoms are only present in tandem with another psych disorder

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123
Q

Diagnostic criterion for schizoaffective disorder

A

At least one 2 week period with hallucinations or delusions in the absence of a prominent mood episode

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124
Q

Prognosis of schizoaffective disorder

A

Better with bipolar and worse with depression

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125
Q

Presentation of delusional disorder

A

Delusions in a high functioning person that last at least 1 month and are typically non-bizarre

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126
Q

Delusions that another person usually of higher status is in love with the patient

A

Erotomanic delusion

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127
Q

Delusion of inflated worth, power, knowledge, identity, or special relationship with a deity or famous person

A

Grandiose Delusion

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128
Q

Delusion that the pt’s sexual partner is unfaithful

A

Jealous type delusion

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129
Q

Delusions that the patient is being treated malignantly in some way

A

Persecutory type delusion

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130
Q

Delusion that the patient has physical defect or medical condition

A

Somatic type delusion

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131
Q

Prognosis for delusional disorder

A

Two thirds recover significantly while 20% have persistent and treatment resistant symptoms

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132
Q

Body dissatisfaction

A

Chronic Negative perception of one’s body

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133
Q

What makes body dissatisfaction different than an eating disorder?

A

Morbid fear of weight gain coupled with the belief that one cannot be too thin

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134
Q

Anorexic families

A

Usually rigid, controlling, or organized

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135
Q

Bullimic families

A

Usually chaotic, critical and conflicted

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136
Q

Parenting style that often leads to eating disorders

A

Parents who respond to non-hunger needs like anxiety with food

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137
Q

Alexthymia

A

Lack of feelings

138
Q

4 forms for eating disorders

A

SCOFF
ESP
EAT
PHQ - Depression

139
Q

Classic presentation of a restrictive eating disorder

A

Underweight child (average BMI - 16) comorbid anxiety and decreased bone mineral density

140
Q

Diagnostic criteria for an eating disorder

A

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
Q

Bimodal onset of Anorexia Nervosa

A

12-15 or 17-21

142
Q

2 characteristics of Anorexia Nervosa

A

Intense fear of weight gain and Distorted perception of body index

143
Q

BMI cutoffs for Mild, Moderate, Severe, and Extreme Anorexia nervosa

A

Mild - 17+
Moderate - 16-17
Severe - 15-16
Extreme - Under 15

144
Q

2 subtypes of anorexia nervosa

A

Binge eating (smaller binges than bullimia)
with purging
Restrictive with no binges

145
Q

5 ROS findings for Anorexia Nervosa

A

Depression, Bone pain, Amenorrhea, Constipation, Hair loss

146
Q

2 PE findings for

A

Russel’s sign, lanugo

147
Q

Russel’s sign

A

Scars on knuckles from self gagging to purge - (also look at dental erosion)

148
Q

Lanugo

A

Hair usually found on babies - grown in anorexia due to body fat loss

149
Q

5 cardiac complications from anorexia

A

Decreased heart mass, Dysrhythmias, CHF, mitral valve prolapse, Orthostatic hypotension

150
Q

3 major causes of death in anorexia nervosa

A

Starvation, suicide, electrolyte imbalance

151
Q

2 workups for ALL suspected anorexia nervosa patients

A

ECG and UA
Draw labs

152
Q

5 Labs to draw for AN

A

CMP, INR, CBC, Phosphorus, Magnesium

153
Q

Management approach to AN

A

Nutritional rehabilitation (SLOWLY) and Psychotherapy
Meds are not first line though Prozac may help

154
Q

5 levels of refeeding

A

Enough
Macronutrient balance
Micronutrient balance
Variety
Challenge (hard to eat) foods

155
Q

AN prognosis

A

50% good
25% intermediate
25% poor
6x higher all cause mortality

156
Q

Classic bullimia patient

A

Adolescent white female

157
Q

Characteristic bullimic presentation

A

Recurrent binge eating with inappropriate compensation at least once a week for 3 months

158
Q

2 subtypes of bullimia

A

Purging and Non-purging

159
Q

Behavioral pattern of bullimia

A

Eat and compensate in secret with more control over timing of behaviors

160
Q

3 cardiac abnormalities of bullimia

A

Hypotension, Tachycardia, Peripheral edema

161
Q

Difference of bullimia from anorexia

A

Body weight is within the normal range

162
Q

Common complications of bullimia

A

Loss of gag reflex, esophageal tears, parotid gland hypertrophy

163
Q

Bullimia management

A

CBT works unlike annorexia
SSRI such as prozac is helpful

164
Q

When to admit and eating disorder patient

A

Unstable, Suicidal, Refusing treatment and likely to become suicidal

165
Q

Bulimia prognosis

A

2x increase in all cause mortality
Often comobid with psych disorders such as PTSD, depression, substance us, and personality disorders

166
Q

Median age of onset for binge eating disorder

A

23 - more common in women, less researched despite higher prevalence

167
Q

Number of episodes per week for mild, moderate, severe, and extreme BED

A

Mild - 1-3
Moderate - 4-7
Severe - 8-13
Extreme - 14+

168
Q

Clinical presentation of binge eating disorder

A

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
Q

3 complications of BED

A

High risk of Cancer, Obesity, Dyspnea

170
Q

Therapy for BED

A

CBT - first line
Behavioral weight loss therapy
SSRIs but NOT weight loss drugs

171
Q

Antipsychotic that causes weight loss

A

Olazepine

172
Q

Definition of ADHD

A

Diminished sustained attention and high levels of hyperactivity that are present before the age of 12

173
Q

2 major types of ADHD

A

Hyperactive/Impulsive and Inattentive

174
Q

Gender mor prone to ADHD

A

Males - more skewed for hyperactive impulsive

175
Q

Biological component of ADHD

A

Impaired catecholamine metabolism in the brain (dopamine and norepinephrine)
Likely also hereditary

176
Q

Diagnostic criteria for ADHD

A

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
Q

ADHD behavioral interventions

A

Preferred for preschool age children but adjunct for older children and teens

178
Q

Cognitive therapy for ADHD

A

Not recommended as monotherapy may be an adjunct for comorbid conditions

179
Q

Dietary modifications for ADHD

A

Generally not recommended - ensure child is receiving adequate nutrition

180
Q

2 classes of stimulants for ADHD

A

Methylphenidate and Amphetamines

181
Q

3 non-stimulants for ADHD

A

Atomoxetine, A2 Adrenergic Agonists (Clonidine and Guanfacine), Antidepressants

182
Q

Criteria for starting children on ADHD medication

A

Full diagnostic assessment completed, Child is at least six, School will cooperate, No household substance use concerns
Pharm is 1st line

183
Q

Schedule for stimulant drugs

A

Schedule II

184
Q

Methylphenidate and Amphetamine

A

Block catecholamine reuptake - Amphetamines also stimulate dopamine release

185
Q

Extended release stimulants

A

Helpful to treat in multiple settings - can reduce adverse effects at peak and crash when drug is cleared

186
Q

Dosing of stimulants

A

Start low and go slow - drug holidays can help reduce desensitization

187
Q

6 side effects of stimulants

A

Reduced appetite, Insomnia or nightmares, Jittery, Emotional lability, weight loss, Tics

188
Q

Titration for stimulants for ADHD

A

Titrate up to 50% resolution of symptoms

189
Q

Cardiac side effects and 2 other contraindications of stimulants

A

Increased HR and BP, Palpitations

CI in hx of mania or Tourette syndrome

190
Q

Management of mood lability for stimulants

A

Use XR formulations

191
Q

How long is needed between an MAOI and a Stimulant

A

14 days

192
Q

4 brand names of methylphenidate

A

Ritalin, Focalin, Concerta, Methylin

193
Q

Use of methylphenidates

A

Equally effective but preferred for preschool age children as they are better tolerated
Reduced weight loss and increased priapism associated

194
Q

4 brands of amphetamines

A

Adderall, Vyvanse, Mydayis, Zenzedi

195
Q

Use preference for amphetamines

A

Generally more side effects, associated with slightly more weight loss

196
Q

Atomoxetine

A

SNRI for use if stimulants cannot be used for ADHD

197
Q

Onset of action of Atomoxetine

A

Takes 1-2 weeks

198
Q

Side effects of atomoxetine

A

Similar to stimulants with less cardiac danger, Liver injury

199
Q

4 CIs for atomoxetine

A

Use within 14 days of an MAOI, Glaucoma, Pheochromocytoma, Severe heart disease

200
Q

Use us alpha adrenergic receptor agonists for ADHD

A

Pts who fail to respond to stimulants or atomoxetine - not controlled

201
Q

2 Alpha adrenergic agonists used for ADHD

A

XR Clonidine
XR Guanfacine

202
Q

XR clonidine for ADHD

A

Sedating effect for aggressive agitated patients, can add to avoid jacking up stimulant dose, PO BID

203
Q

XR guanfacine for ADHD

A

Fewer side effects than Clonidine with once daily dosing

204
Q

Antidepressants that can be used with ADHD (2)

A

TCAs
Buproprion

205
Q

3 characteristics of autism spectrum disorder

A

Deficits in social interaction and communication
Restrictive and repetitive patterns of behavior
Present in early development

206
Q

Gender with more prevalence of ASD

A

More common in males

207
Q

3 associated conditions with ASD

A

Intellectual disability, ADHD, seizures

208
Q

Three factors that might contribute to ASD

A

Increased parental age, Poor peri/neonatal health, Maternal metabolic conditions

209
Q

Usual age for autism diagnosis

A

2 years

210
Q

Severe autism

A

Often mute with severe behavioral problems

211
Q

Mild Autism

A

Verbal capacity with unusual interests impaired social skills

212
Q

5 social signs of autism

A

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
Q

Stereotyped behaviors

A

Repetitive movements such as rocking, fidgeting

214
Q

2 restrictive behaviors of ASD

A

Insistence on sameness and difficulty with changes
Focus on restricted interests with a persistent preoccupation

215
Q

Sensory perception of ASD patients

A

Hyposensitivity, hypersensitivity, or paradoxical responses seen in 99% of patients

216
Q

Intellectual impairment of ASD patients

A

Stronger in nonverbal tasks with marked deficit in verbal cognition

217
Q

2 other common factors in ASD patients

A

Motor deficit, Macrocephaly

218
Q

Milestones missed in autism

A

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
Q

Screening tool for autism

A

M-CHAT-R/F - early detection leads to better outcomes

220
Q

4 follow ups for children who test positive for autism

A

Referral to a specialist
Hearing screening
Serum lead level
Genetic testing

221
Q

Pharmacology for ASD

A

Do not treat but can help behaviors
Stimulants for hyperactivity
Antipsychotics for maladaptive behaviors
SSRI for Mood and Anxiety symptoms

222
Q

Bruxism

A

Grinding teeth

223
Q

Gene mutation that causes Rett syndrome

A

MECP2 gene - almost exclusively in females

224
Q

Clinical presentation of rett syndrome

A

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
Q

3 supportive treatments for Rhett disorder

A

Good nutrition, Monitor QT, PT/OT for motor problems

226
Q

NREM sleep

A

Peaceful and relaxed sleep that is comprised of 4 stages

227
Q

REM sleep

A

Sleep that involves high levels of brain activity including dreams

228
Q

How does early sleep differ from later sleep

A

Starts out with more NREM and less REM
Changes to more REM and less NREM

229
Q

Order of sleep stages

A

Go through stages 1-4 and then REM

230
Q

NREM stage 1

A

Easily awakened - may have twitches (hypnic myoclonia) or feelings of falling in this stage

231
Q

NREM stage 2

A

Light sleep with periods of muscle tone and muscle relaxation as the body prepares for deep sleep

232
Q

NREM stages 3&4

A

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
Q

Delta waves

A

Longest brain waves 1-3.99 Hz

234
Q

REM sleep characteristics

A

Physiologic activity is increased, Paralysis, Erection, and dreaming

235
Q

NREM dreams

A

Usually more abstract and surreal than REM dreams

236
Q

Effect of serotonin on sleep

A

Less serotonin = less sleep

237
Q

Effect of norepinephrine on sleep

A

More norepinephrine = less sleep

238
Q

Effect of melatonin on sleep

A

Less melatonin = less sleep

239
Q

Effect of dopamine on sleep

A

More dopamine = less sleep

240
Q

Changes in REM sleep as we age

A

80% as an infant, 20-25% from 10 through adulthood, Under 20% after 65
Stage 4 NREM also decreases

241
Q

Elderly sleep pattern character

A

Less deep without as much stage 3/4 or REM, frequent awakenings and daytime drowsiness

242
Q

3 sleep disturbances seen in depressed patients

A

Insomnia
Hypersomnia - less common than insomnia
Longer and more frequent periods of wakefulness

243
Q

6 things to ask about when taking a sleep related history

A

Falling vs. Staying asleep
Daytime sleepiness
Abnormal sleep behavior
Abnormal sleep-wake timing
Life stressors
Sleep environment

244
Q

Insomnia criteria

A

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
Q

Transient, Acute, and Chronic

A

Transient - under 7 days
Acute - 7-30 days
Chronic - over 30 days

246
Q

3 causes of secondary insomnia

A

Depression or Anxiety
Breathing related sleep disorder
Substance abuse or medications

247
Q

Alcohol and effect on sleep

A

Acute - decreased sleep latency with vivid dreams and awakening
Chronic - Increased stage 1 and decreased REM
Withdrawal - Delay in onset with awakening

248
Q

Insomnia management

A

Treat underlying causes, Non-pharm treatment should be first line (relaxation, meditation, sleep hygiene, etc.)

249
Q

6 classes of drugs that can be used for insomnia management

A

OTC 1st gen antihistamines
Benzodiazepine receptor agonists
Melatonin agonists
Benzodiazepines
Dual orexin receptor agonists
Antidepressants

250
Q

3 things to do for proper sleep hygeine

A

Establish a regular sleep schedule
Cut down on excess time in bed
Make bedroom confortable

251
Q

Time gap between exercise and bedtime

A

6 hours min
Definitely not within 90 minutes

252
Q

Time gap between caffeine and bed

A

after lunch - 4 hour half life

253
Q

Time gap between eating and sleep

A

2 hours for heavy meals

254
Q

Onset age for narcolepsy

A

20s

255
Q

4 potential secondary causes of narcolepsy

A

Brain tumor, cerebrovascular insufficiency, head trauma, encephalopathy

256
Q

Classic narcolepsy tetrad

A

Recurrent irresistible attacks of daytime sleepiness, Cataplexy, Hallucinations, Sleep paralysis

257
Q

Irresistible attacks of daytime sleepiness criteria

A

Daily for at least 3 months, unexpected and inappropriate

258
Q

Cataplexy criteria

A

Bilateral loss of muscle tone often associated with emotional trigger - can be systemic or localized

259
Q

2 types of narcoleptic hallucinations

A

Hypnagogic - on falling asleep
Hypnopompic - on waking up

260
Q

Diagnostic tool for narcolepsy

A

Multiple sleep latency test - record naps to see how fast patient enters REM cycles

261
Q

3 treatment options for narcolepsy
1 non-pharm
2 pharm with 2 drugs each

A

Forced naps during the day
Stimulants - modafinil (less abuse), Methylphenidate
SSRI or SNRI for symptomatic treatment

262
Q

Presentation and etiology of somnambulism

A

Semi purposeful behavior during stages 3 and 4 of NREM sleep - difficulty waking patient up with no memory of episodes

263
Q

Treatment for somnambulism

A

Avoid fatigue
Minimize interventions
Lead patient back to bed
Provide a safe sleep environment
Lock doors and windows

264
Q

Clinical presentation of sleep related bruxism

A

Involuntary, non-functional forcefull clenching, grinding and rubbing of teeth, have headaches and TMJ disorders

265
Q

Treatment for sleep related bruxism

A

Occlusive splints to reduce mechanical wear
Control anxiety

266
Q

Complication of sleep related bruxism

A

Wearing down of the tooth enamel

267
Q

Circadian rhythm disorder

A

Misalignment between the environment and an individual’s sleep-wake cycle

268
Q

6 types of circadian rhythm disorders

A

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
Q

Sleep apnea

A

Breath cessation for at least 10 seconds

270
Q

Hypopnea

A

4% drop in oxygen saturation accompanied by decreased airflow

271
Q

Central apnea

A

Absent ventilatory effort during apneic episode

272
Q

Obstructive apnea

A

Present ventilatory effort during apneic episode

273
Q

Mixed apnea

A

Absent ventilatory effort followed by obstruction during episode

274
Q

5 risk factors for obstructive sleep apnea

A

Anatomically narrowed upper airways
Ingestion of alcohol or sedatives before sleeping
Nasal obstruction
Hypothyroidism
Smoking

275
Q

Classic sleep apnea patient

A

Obese and middle aged
“Bull neck” appearance

276
Q

Lab finding for sleep apnea

A

erythrocytosis

277
Q

3 patient reported symptoms of sleep apnea

A

Daytime somnolence
Recent weight gain
Morning sluggishness and headaches

278
Q

3 bed partner reported symptoms of sleep apnea

A

Loud cyclical snoring
Thrashing of the extremities
Personality changes or poor judgement

279
Q

2 Diagnostic tools for obstructive sleep apnea

A

Home overnight pulse oximetry
Overnight polysomnography - look for cardiac electrical abnormalities

280
Q

3 Treatments for obstructive sleep apnea

A

CPAP
Weight loss 10-20%
Surgical repair

Supplemental O2 can lengthen apneas while providing relief

281
Q

micrognottia

A

Sunken/Small jaw

282
Q

4 pharmacotherapy options for sleep disorders

A

Benzodiazepine receptor agonists
Melatonin receptor agonists
Dual orexin receptor agonists
Stimulants

283
Q

MOA of benzo receptor agonists

A

Facilitate GABA-mediated inhibition of cell firing

284
Q

Difference between Benzos and benzo receptor agonists

A

Less addictive and don’t reduce deep sleep
Not anxiolytic

285
Q

3 benzodiazepine receptor agonists for sleep disorders

A

Zaleplon (Sonata)
Zolpidem (Ambien)
Eszopiclone (Lunesta)

286
Q

Zaleplon

A

BZD receptor agonist
Can cause headache
Very short half life and less effective with fatty meals

287
Q

Zolpidem

A

Longer half life with IR and XR forms
XR better for sleep maintainance but can cause grogginess - SEs of headache, dizziness, drowsiness

288
Q

Eszopiclone (Lunesta)

A

Butterfly of DEATH
Metallic taste and headache longest half life and do not take with meals

289
Q

Schedule of BZD receptor agonists

A

Schedule IV medication
BBW for complex sleep related disorders

290
Q

Effect of prolonged exogenous melatonin use

A

Desensitization of receptors

291
Q

Ramelteon

A

Melatonin receptor agonists that binds with a higher affinity than melatonin itself
Cannot be used with fluvoxamine
Better for sleep onset insomnia

292
Q

SSRI that causes a prolonged QT

A

Lexapro

293
Q

Why is melatonin contraindicated with seizures

A

It can make anticonvulsants less effective

294
Q

MOA of Dual Orexin Receptor Antagonists

A

Antagonize orexin receptors and thereby decrease the wake drive

295
Q

System that promotes and stabilizes wakefulness

A

Orexin/Hypocretin system

296
Q

Suvorexant

A

Dual Orexin receptor antagonist
Don’t take with CYP3A4 inhibitors/inducers
Schedule IV
12 hr half life for both insomnias

297
Q

Lemborexant

A

DORA
Long half life of 17-19 hours - maintainance and onset insomnia
Schedule IV

298
Q

Daridorexant

A

New DORA approved in 2022
Only 8 hour half life

299
Q

Contraindication for orexin receptor agonists

A

Narcolepsy

300
Q

Modafinil

A

Stimulant to treat narcolepsy taken first thing in the morning or taken for night shifts
Schedule IV drug

301
Q

Sodium Oxybates

A

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
Q

Cluster A personality disorders (3)

A

Usually odd and eccentric
Paranoid, Schizoid, and Schizotypal

303
Q

Cluster B personality disorders (4)

A

Emotional
Antisocial, Borderline, Histrionic, Narcissistic

304
Q

Cluster C personality disorders

A

Fearful
Avoidant, Dependant, Obsessive-compulsive

305
Q

Personality disorder

A

Personality traits that are inflexible and maladaptive enough to cause distress and impairment of functioning

306
Q

Demographic for personality disorders

A

Male, young, Poor education, Unemployed

307
Q

4 risks of personality disordered patients

A

Reckless behavior
Psychiatric comorbidities
Functional impairment
Noncompliance

308
Q

2 screening tools for personality disroders

A

Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF)
Millon Clinical Multiaxial Inventory-III (MCMI-III)

309
Q

Clinical relationship with type A personality disorders

A

Only seek treatment for acute complaints
Mistrust of healthcare
Strong affirmation and careful handling can help

310
Q

Clinical relationship with type B personality

A

Push limits, engage in power struggles, Be careful with boundaries

311
Q

Clinical relationship with type C personality

A

More likely to take responsibility for problems, willing to readily engage in dialogue, can be sensitive or stubborn

312
Q

Possible etiology for paranoid personality disorder

A

Parents with irrational outbursts of anger

313
Q

Cardinal symptoms of paranoid personality disorder

A

Generalized distrust or suspiciousness - others motives are malevolent
Defensive and formal on exam

314
Q

Treatment and prognosis for paranoid personality disorder

A

Low dose antipsychotics may help - patients often distrustful of therapy
More adaptive personality that can become overtly psychotic

315
Q

3 potential etiologies for schizoid personality disorder

A

Pregnancy during famine, Autism, Lack of nurturing

316
Q

Cardinal symptoms of schizoid personality disorder

A

Detachment, introversion and restricted range of emotional expression - lack of intimacy aloof and hard to engage on exam
FLAT AFFECT

317
Q

Treatment for Schizoid personality disorder

A

May use antidepressants, family or group therapy may help although patients often do NOT feel distressed or in need of help

318
Q

Schizoid personality disorder prognosis

A

Social detachment but less likely to develop depression

319
Q

Etiology of schizotypal personality disorder

A

Believed to be linked to schizophrenia

320
Q

Cardinal symptoms of schizotypal personality disorder

A

Peculiar thoughts speech and behavior, magical beliefs without hallucinations or delusions
Eccentric and emotional with a constricted affect

321
Q

Therapy and prognosis for schizotypal PD

A

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
Q

Etiology of antisocial personality disorder

A

Genetic and environmental
Abusive or absent parent and low socioeconomic status

323
Q

Cardinal symptoms of antisocial PD

A

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
Q

Treatment and prognosis for antisocial PD

A

Group therapy is the most helpful
Peaks in early adulthood and can lead to alcoholism and late onset depression

325
Q

Etiology and risks of Borderline personality disorder

A

Childhood trauma
HIGH risk of suicide - take very seriously

326
Q

Cardinal symptoms of BPD

A

Impaired relatedness with others, labile mood with impulsive and self-injurious behavior - things are either all good or all bad

327
Q

Physical exam for BPD patients

A

Labile mood, Difficult and demanding with irrational attachment and fear of abandonment

328
Q

Treatment for BPD

A

Lithium, Carbamazepine, Antipsychotics, SSRIs
Group and family therapy can help avoid attachment to therapy

329
Q

Prognosis for BPD

A

More antisocial = poorer prognosis
Better educated = Better prognosis

330
Q

Cardinal symptoms of histrionic personality disorder

A

Excessive superficial emotionality and sexuality to draw attention and control others - seductive and want to be center of attention - Happy but sad

331
Q

Treatment and prognosis for histrionic PD

A

SSRIs often useful maybe MAOIs
Group therapy may also help
Good prognosis if no comorbid cluster B disorders

332
Q

Potential etiology of narcissistic PD

A

Over or under gratification of needs as a child

333
Q

Cardinal symptoms of Narcissistic PD

A

Grandiose with a lack of empathy and sense of entitlement
Hypersensitive to criticism

334
Q

Treatment and prognosis for NPD

A

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
Q

Cardinal symptoms of avoidant personality disorder

A

Persistent pattern of avoidance due to anxiety that causes introversion and a restricted lifestyle
Anxious and shy on exam

336
Q

Treatment and prognosis for avoidant PD

A

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
Q

Cardinal symptoms of dependent PD

A

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
Q

Therapy and prognosis for Dependant

A

SSRIs or TCAs
Considerable benefit with group therapy
Assertiveness and decision making training
Good prognosis if few comorbidities

339
Q

Cardinal symptoms of OCPD

A

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
Q

Difference between OCD and OCPD

A

OCPD has no true obsessions or compulsions and little to no distress - don’t spend as much time in obsessive tasks

341
Q

Treatment and prognosis for OCPD

A

No strong indication for medication
May need to treat family/friends upon whom expectations are being forced
Good prognosis - may develop anxiety and depression

Behavioral Dynamics (3 decks)

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