Exam 4 Deck 2 Flashcards
(284 cards)
1
Q
What are diagnostic criteria for the trauma in PTSD?
A
Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
- direct experienceing the traumatic event
- witnessing the event as it occured to others
- learning the traumatic event occured to close family member or friend
- experiencing the repeated or extreme exposure to aversive details of the event
2
Q
What are intrusion symptoms of PTSD required for diagnosis??
A
One or more of:
1) Recurrent & intrusive distressing memories of event
2) Recurrent distressing dreams of event
3) Dissociative reactions (eg, flashbacks) in which
feel or act as if event were recurring
4) Intense psychological distress at exposure to cues that symbolize/resemble aspect of event
5) Physiological reactivity on exposure to cues
3
Q
What are avoidance symptoms needed for a PTSD diagnosis?
A
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, as indicated by 1 or both of the following:
1) Avoid distressing memories, thoughts or feelings associated with trauma
2) Avoid external reminders (activities, places, people, conversations that arouse distressing memories, thoughts or feelings about the trauma
4
Q
What are negative alterations in cognitions and mood needed for a PTSD diagnosis?
A
As evidenced by 2 (or more of the following):
1) Can’t recall important aspect of trauma
2) Negative beliefs or expectations about oneself, others or the world
3) Distorted cognitions about the cause or consequences of the trauma that lead individual to blame self or others
4) Persistent negative emotional state (fear, horror, anger, guilt, shame)
5) Decreased interest/participation in activities
6) Feel detached or estranged from others
7) Inability to experience positive emotions
5
Q
What are alterations in arousal and reactivity needed for a PTSD diagnosis?
A
As evidenced by ≥ 2 of the following:
1) Irritability or outbursts of anger
2) Reckless or self destructive behavior
3) Hypervigilance
4) Exaggerated startle response
5) Problems with concentration
6) Sleep disturbance
6
Q
What are diagnostic criteria for PTSD diagnosis?
A
Exposure to trauma
Intrusion symptoms
Avoidance of stimuli associated with trauma
Negative alterations in cognition or mood
Alterations in arousal or activity
> 1 month of symptoms
Impaired functioning
7
Q
What are some common symptoms seen in PTSD (that aren’t in the diagnostic criteria)?
A
Guilt
Depression
Anxiety
Panic attacks
Shame
Rage
Substance abuse
Self injurious behavior
Suicide attempts
Impaired relationships
Explosive or impulsive behavior
Difficult with trust
Somatic complaints
Hyperadrenergic sx
Psychosis
8
Q
What is acute stress disorder?
A
Exposure to traumatic event with presence of 9 or more symptoms from any of the following categories:
Intrusion (memories, dreams, flashbacks)
Negative mood (can’t experience positive emotions)
Dissociation (altered sense of reality, can’t recall important aspect of trauma)
Avoidance (of memories, thoughts, feelings, external reminders)
Arousal (insomnia, irritability/anger, hypervigilance, poor concentration, exaggerated startle)
Impaired function, significant distress
Duration of symptoms: 3 days-1month after trauma
9
Q
What are common comorbid psychiatric disorders with PTSD?
A
OCD
Panic disorder
GAD
MDD
Substance use disorders
Borderline personality disorder
10
Q
What are predictors of worse outcomes?
A
More symptoms
Comorbid medical illnesses
Childhood trauma
Additional trauma
Psychiatric history
Female
Alcohol abuse
11
Q
More trauma is associated with a […] rate of PTSD
A
More trauma is associated with a higher rate of PTSD
12
Q
What role does the type of trauma have in the rates of PTSD development?
A
Those that are more personal physical affronts have higher rates (physical attack, threat wiht weapon, rape, …)
13
Q
What are important factors related to the trauma that are risk factors for PTSD development?
A
Degree of controllability, predictability, perceived threat, and extent of injury
14
Q
What are premorbid sociodemographic risk factors for PTSD?
A
Female, younger age, minority, lower education
15
Q
What are premorbid historical risk factors for PTSD?
A
Prior trauma
Psychiatric history
Family history of anxiety disorder
Neurological compromise
16
Q
What are premorbid psychological risk factors for PTSD?
A
Disrupted parental attachments
Personality disorder
Self-criticism
Cognitive appraisal of trauma
17
Q
What are premorbid characteristics of trauma exposure that are risk factors for PTSD?
A
Type
Amount/severity
Age at exposure
18
Q
What are premorbid characteristics of the recovery environment that are risk factors for PTSD?
A
Low social support
Stressful life events
New traumas
19
Q
What is “failure to recover” with respect to PTSD?
A
Normal stress response occurs to a trauma
Typically it shuts off, but there is a subset of people who do not recover
20
Q
What are neurobiological models of PTSD?
A
ANS, noradrenergic system
HPA axis, cortisol
Serotonergic system
Neuroanatomy and neurocircuitry
Genetics
21
Q
What is the role of cortisol on the fight-or-flight response?
A
Feeds back and shuts it down
22
Q
What findings are seen in the noradrenergic system in PTSD patients?
A
Sustained hyperactivity of sympathetic nervous system (increased urinary excretion of NE, Epi and metabolites; Increased HR, BP, increased plasma NE)
Increased CNS NE activity/reactivity (Increased CSF NE levels and responses to stressors; α2 receptor antagonist causes flashbacks and increased autonomic responses)
23
Q
What can potentially be a predictor of PTSD in trauma survivors?
A
HR at ER presentation
24
Q
What do you see on dexamethasone suppression test in PTSD patients?
A
Exaggerated suppression of the HPA axis
25
What HPA axis findings do you see in PTSD?
Decreased cortisol
Increased CRF (don't worry, its paradoxical)
Exaggerated suppression upon dexamethasone suppression test
Increased negative feedback sensitivity
Increased glucocorticoid receptor sensitivity
26
What are consequences of "low cortisol" in acute aftermath of trauma?
Increased catecholamines (NE) leading to overconsolidation or pairing of memories and distress
Causes traumatic reminders to be destressing, which leads to increased fear and development of maladaptive cognitive responses to the trauma
Causes failure of habituation and extinction, which induces a state of perpetual fear; PTSD symptoms and dysfunction perpetuated
27
Can glucocorticoids prevent PTSD?
Preliminary data shows that it may play a role in protection
But there are many side effects
28
What drugs are effective in the treatment of PTSD?
SSRIs
29
What is the role of the serotonergic system in PTSD?
SSRIs are effective in treatment
Modulatory effects on affective and stress responses
Coordinates with CRF and NE systems
Potential role in pathophysiology of impulsivity, hostility, aggression, depression, hypervigilence, and suicidality
30
What neuroanatomical/neurocircuitry findings do we see in PTSD?
Smaller hippocampus
Smaller anterior cingulate with decreased reactivity
Increased reactivity of the amygdala
31
What are the genetics of PTSD?
Complex with genetic and environmental risk factors
Parental PTSD appears to be a risk factor for PTSD
- lower cortisol levels in children of PTSD patients
32
What is the cognitive model of PTSD?
People respond to traumatic events based on how they interpret these events
Cognitive appraisal during and after the event is critical to understanding who develops chronic symptoms
PTSD becomes persistent when individuals process the trauma in a way that leads to a sense of serious and current threat (e.g. "all men are rapists")
33
What are individual differences in cognitive appraisal that can be linked to greater chance of PTSD?
Degree of perceived controllability and predictability
Feelings of shame, humiliation, guilt
Feeling that one could have prevented what happened
Subjective interpretation of event
Gender
Social support
Pre-traumatic "history"
34
How do we treat PTSD pharmacologically?
Antidepressants (SSRIs, Tricyclic, MAOIs, SNRIs)
Adrenergic blockers (propranolol, clonidine, prazosin)
Anticonvulsants/Mood stabilizers
Atypical antipsychotics
35
What are psychotherapies for PTSD?
Education, crisis intervention
Supportive counseling
Cognitive and Behavioral Therapies (exposure therapy, relaxation techniques, cognitive restructring therapy, stress management)
Group therapy
36
What defines a personality disorder in DSM V?
An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture
Manifested in two or more of the following areas:
Cognition
Affectivity
Interpersonal Functioning
Impulse control
37
What are FDA approved drugs for Axis II disorders?
NONE!
Psychotherapy most helpful
38
What are the clusters of personality disorder in DSM-5?
Cluster A = odd or eccentric disorders
Cluster B = dramatic, emotional, or erratic disorders
Cluster C = anxious or fearful disorders
39
What are the cluster A personality disorders??
Paranoid - irrational suspicions and mistrust of others
Schizoid - lack of interest in social relationships
Schizotypal - characterized by odd behavior or thinking
40
What are the cluster B personality disorders??
Antisocial - pervasive disregard for law and rights of others
Borderline - extreme black and white thinking. instability in relationships, self image, identity and behavior leading to self-harm and impulsivity
Histrionic - pervasive attention-seeking behavior, inappropriately seductive behavior
Narcissistic - grandiosity, need for admiration, lack of empathy
41
What are the cluster C personality disorders??
Avoidant - social inhibition, avoidance of social interaction
Dependent - pervasive psychological dependence on others
Obsessive-compulsive - rigid conformity to rules, moral codes, and excessive orderliness
42
What are characteristics of schizotypal personality disorder?
Magical thinking (aura, destiny, telepathy, ...)
Disturbances in working memory
Ideas of reference
Unusual perceptual experiences
Odd thinking and speech/odd or perculiar behavior and/or appearance
Suspicious, lack of close friends, excessive social anxiety
Inappropriate or extremely reserved emotional responses
43
What treatments are available for schizotypal personality disorder?
Social skills training
Low dose antipsychotic medications
44
What is the neurobiological basis behind schizotypal personality disorder?
Runs in family with schizophrenia
Similar abnormalities in working memory and in various neurophysiological measures including eye-tracking abnormalities
Reduced volume of the superior temporal gyrus with relative preservation of frontal lobe volume
45
What are characteristics of borderline personality disorder?
Extreme emotional instability, especially anger
Hypersensitivity to interpersonal interactions - especially perceived rejection
Self-injury to relieve emotional pain
Dissociateive symptoms
Impulsivity; especially impulsive aggression: verbal and physical
Unstable intense interpersonal relationships
Chronic feelings of emptiness, identity disturbance
Onset in adolescence, but symptoms evident from young childhood
46
What is the heritability of borderline personality disorder?
~0.7 (high)
Substantial evidence for gene x environment interaction for BPD
47
What is the role of childhood trauma in borderline personality disorder?
High rates **reported** and it seems to be almost ubiquitous
Not universal
Not all abused children develop BPD; not all BPD patients have childhood trauma, etc.
48
What is a relatively objective way of measuring emotionality?
Startle Eye Blink Modification
Emotion can influence the intensity; negative emotion in healthy controls enhances intensity
49
What is the neurobiological basis for borderline personality disorder?
Amygdala hyperactivity to emotional stimuli: prefrontal amygdala imbalance
Poor self monitoring of emotion
Social cognition dysfunction
50
What happens to an individual with borderline personality disorder when they drink alcohol or take benzodiazepines?
Further decreased prefrontal activity - become more emotional
The tearful drunk, the sad person in the corner of the party that may be crying or suicidal
51
What are the characteristics of cluster c personality disorders?
Tied closely to social anxiety disorders
Longstandign feelings of inadequacy, subjective sense of being socially inept
Extreme sensitivyt to what others think about them; hypersensitivity to criticism, blushing easily
Sensitivity results in inhibition, not aggressive response as in BPD or ASPD
Behavioral avoidance of work, school, and any activities that involve socializing or interacting with others
Social isolation, w/ restricted interpersonal contacts
52
What can you see in brain imaging in avoidant personality disorder?
Heightened amygdala response to fear inducing stimuli, with reduced prefrontal modulation
Decreased connectivity b/w prefrontal cortex and amygdala
53
What prenatal test can help predict future avoidant personality disorder?
Non-stress test
Duration of elevation of fetal HR predicts future inhibited temperament
54
How does the mortality of a schizophrenic patient compare to that of the general population?
8x higher
55
What is schizophrenia?
In schizophrenia, all of the normal mental processes - sensation, perception, language, emotion, interpersonal relationships - appear to go completely awry. People with the disorder lose touch with the real world. They hear voices that are not there, speak a language that does not exist, laugh for no reason, or sit motionless for hours on end. The entire human personality is laid waste, and the psychological and social building blocks of every day life are crushed, often beyond recognition.
56
What are the positive symptoms of schizophrenia?
Hallucinations
Delusions
Formal thought disorder
Behavioral disorganization
57
What are hallucinations?
False perceptions through hearing, touch, taste, smell or vision
58
What are delusions?
False beliefs inexplicable in terms of patient's cultural background
59
What is formal thought disorder?
illogical and often disjointed but fluent speech
Seen in schizophrenia
60
What is behavioral disorganization?
Bizarre behavior
seen in schizophrenia
61
What are the negative symptoms of schizophrenia?
Alogia
Affective blunting
Avolition
Anhedonia
62
What is alogia?
Poverty of speech per se, or of speech content
63
What is affective blunting?
Impairment in emotional expression reactivity and feeling
Inability to react in an appropriate way
64
What is avolition?
Characteristic lack of energy drive and interest
65
What is anhedonia?
Difficulty in experiencing interest or pleasure
66
What are cognitive symptoms of schizophrenia?
Difficulty paying attention
Difficulty encoding new information (working memory)
Contstructional apraxia (difficulty copying simple diagrams, intersecting pentagons)
Difficulty with verbal fluency
67
What do you need for a diagnosis of schizophrenia?
2 symptoms from positive and negative symptom groups
Have to interfere markedly with work, interpersonal relationships, self care
Need to be present for 6 months with 1 month of active symptoms
68
What is the natural history/progression of schizophrenia?
69
What happens to the positive vs negative symptoms of schizophrenia over time?
Negative symptoms increase
Positive symptoms decrease
70
When in the course of schizophrenia do patients respond best to pharmacotherapy?
Earlier (first episode)
71
What is the rate of suicide in schizophrenics?
4-13%
More common in men
72
Which gender commits suicide at a higher rate in schizophrenia?
Men
73
What factors may increase the risk of suicidality in schizophrenia?
Comorbid depression and alcoholism
74
Which demographic of schizophrenics tend to commit suicide?
Younger men with good premorbid functioning with high self-expectations for performance
75
What is the prognosis for schizophrenia compared with other psychiatric disorders?
Poor
76
What is the occupational status in schizophrenic compared with other psychiatric disorders?
Worse
77
What is the ability to hold relationships (marital status) in schizophrenics compared to other psychiatric illnesses?
Worse
78
What is the largest risk factor for the development of schizophrenia?
Positive family history
79
Is schizophrenia a mendelian disorder?
NO
80
What is the neurodevelopmental hypothesis for schizophrenia?
Suggests the etiology of schizophrenia may involve pathologic processes, caused by both genetic and environmental factors, that begin before the brain approaches its adult anatomical state in adolescence
81
What is the "two hit" hypothesis for schizophrenia?
Within the neurodevelopmental theory in which maldevelopment during two critical time points (early brain development and adolescence) combines to produce the sympotms associated with schizophrenia
82
What are some external factors that increase the risk of development of schizophrenia?
Viral infections
10-20x risk of devleoping schizophrenia following prenatal exposure to **rubella**
Prenatal exposure to **influenza** in the 1st trimester increases 7x and infection in early to midgestation increases 3x
Maternal antibodies to **toxoplasma gondii** lead to 2.5x risk
83
What are maternal infetions that can increase the risk of schizophrenia?
Rubella (10-20x)
Influenza (3-7x)
Toxoplasma gondii (2.5x)
84
Which psychiatric disorders does schizophrenia share genetic risk factors for?
Bipolar disorder
Autism
85
What are the shortcomings of the pathophysiologic hypothesis of schizophrenia?
None account for the involvement of Dopamine, Glutamate, GABA; integrate series of macro and microscopic changes, and account for genetic and environmental factors
None are all-encompassing
86
What are the two most implicated pathophysiological mechanisms of schizophrenia?
Stuctural brain abnormalities and abnormal brain neurochemistry
87
What are structural brain changes seen in schizophrenia?
Enlarged ventricles, shrunken temporal gyri, decreased coherence of white matter tracts
Hippocampal changes, increased cortial cell density
88
In these two twins, which is more likely to have schizophrenia?
On the right
89
In these two twins, which is more likely to have schizophrenia?
On the right
90
What brain region is associated with the psychotic symptomsm of schizophrenia?
Temporal lobe - perhaps associated with temporal lobe epilepsy
Decreased temporal cortical thickness and thought disorder and hallucinations
auditory cortex activation thought to be implicated in auditory hallucinations
91
What is the role of the prefrontal cortex in schizophrenia?
Hypofrontality is observed in schizophrenics
92
What is the role of dendritic spines in schizophrenia?
Decreased spines result in a thinner cortex that is more densely packed
93
What macroscopic changes do post-mortem studies show in schizophrenics?
Smaller volumes of hippocampus, parahippocampal gyrus, amygdala, and cerebellar vermis
Enlarged lateral ventricles
Lower brain weight
94
What histolocial changes are seen in schizophrenics?
Disarray of pyramidal cells in CA1 and CA2 of hippocampus
Increased neuronal density in PFC
95
What is the foundation of the dopamine hypothesis of schizophrenia?
All antipsychotic neuroleptic drugs block dopamine receptors
Dopaminergic drugs can mimic or worsen some schizophrenic symptoms
96
What are the dopaminergic pathways in the brain?
Nigrostriatal
Mesolimbic
Mesocortical
Tuberoinfundibular
97
What is the problem with the dopaminergic model of schizophrenia?
There is a delayed onset of activation
There is nonresponsivity in some schizophrenic patients
There are resuidual symptoms in patients on antidopaminergic drugs
98
What is the take-home message with the dopamine hypothesis of schizophrenia?
Dopamine alone is not the etiologic event in schizophrenia
Dopamine is a modulator of symptom severity
(we're talking elevated dopamine here)
99
What is the basis for glutamatergic hypothesis of schizophrenia?
PCP and ketamine are NMDA receptor antagonists and produce similar behaviors
Also decreased CSF glutamate in schizophrenics
GWAS data
100
What is the PCP model of schzophrenia?
PCP blocks NMDA receptor of GABA-inhibitory interneurons
leads to decreased excitatory modulation of inhibitory GABA-R
Excessive glutamate release at initial stages
Glutamatergic excitotoxicity and neuronal damage with subsequent reduced glutamate in later stages
101
What is the activity of glutamic acid dearboxylase in schizophrenics relative to controls?
Lower
102
What is the role of GABA in schizophrenia?
Decreased GABA interneurons in PFC
Decreased glutamic acid decarboxylase activity
Decreased release of GABA by interneurons
Decreased GABA transporter
103
What non-neuron CNS cells have been implicated in schizophrenia?
Oligodendrocytes
Injury may affect the numerous cells for which one oligodendrocyte provides myelin
104
What are differences seen in oligodendrocytes in schizophrenics vs controls?
Total number of oligodendrocytes in layer III and in white matter are decreased in schizophrenics
105
What are shared characteristics of somatic symptom and related disorders?
Prominence of somatic symptoms associated with significant distress and impairment
Typically present medically rather than psych
Medically unexplained symptoms are present to various degrees (can accompany diagnosed medical disorders)
Have strong disease conviction
Often include affective, cognitive, behavioral
106
What was Freud's take on somatic symptom and hysteria?
Traumatic experience leads to unconscious physical symptom formation
Uncovering traumatic incident is key to symptom relief
Psychoanalysis sort of grew out of this
107
What are the DSM-5 Somatic Symptom and Related Disorders?
Somatic Symptom disorder
Illness anxiety disorder
Conversion disorder (Functional neurological symptom disorder)
Psychological factors affecting other medical conditions
Factitious Disorder
108
109
110
111
What defines Somatic Symptom Disorder?
1+ somatic symptoms (including pain) that are distressign or result in significant disruption of daily life
Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns (persistent thoughts, high anxiety, fear the worst, don't trust doctors, devote time and attention to symptoms/health concerns)
Typically more than 6 months
112
What are some common behaviors of individuals with Somatic Symptom Disorder?
High levels of worry about illness, even with evidence to the contrary
Health concerns assume a central role in the individual's life
High level of medical care utilization
Often unresponsive to medical interventions, and new ones may only exacerbate symptoms
113
Who presents with Somatic Symptom Disorder more commonly?
Women, perhaps more common in lower socioeconomic groups
114
What typically happens to individuals with Somatization Disorder (what ist he course of the illness)?
Symptoms begin in adolescence, and criteria satisfied in mid 20s
Complications are common due to unnecessary medical procedures (surgeries)
May develop drug dependence, marital separation/divorce, iatrogenic disease
115
What are other diseases you must think of when you are considering Somatization Disorder?
Multiple Sclerosis
Systemic Lupus Erythematosus
Acute Intermittent Porphyria
Hemochromatosis
Other psych disorders (mood, anxiety, schizo, factitious, personality)
Malingering
116
What are some theories on the origins/etiology of Somatization Disorder?
Unconscious need to be ill that can be attributed to chaotic life, lesser education, history of abuse
Can be a learned behavior (used as a way to communicate, express emotion, be taken care of)
May be genetic, or have difficulty with information processing
Patients often fully believe their problems to be physical and have great faith in powers of aggressive medical intervention
117
How do you treat a patient with Somatization Disorder?
Goal is to prevent adoption of sick role and chronic invalidism
Recognize it!
Adjust expectations of treatment
Proper workup, but don't perform unnecessary tests/order unnecessary drugs
118
What is the overall goal of Somatization Disorder?
To prevent the adoption of the sick role and chronic invalidism
119
22 year old man who develops atypical chest pain on the anniversary of his father’s death from an MI. Admitted to CCU, where he can grieve and at same time be excused from the demands of his ongoing life. What do you think?
Conversion Disorder
120
35 year old woman who presents with acute onset blindness after walking in on husband with another woman. What do you think?
Conversion disorder
121
How do you diagnose Conversion Disorder?
One or more symptoms of altered voluntary motor or sensory function
Clinical findings provide evidence of incompatibility between the symptom and the recognized neurological or medical conditions
Symptom or deficit are not better explained by other medical/mental disorder
Symptom or deficit causes significant distress or impairment in the patient's life
122
What are typical symptoms seen in Conversion Disorder?
Motor weakness or paralysis, abnormal movements, gait or limb posturing abnormalities
Altered sensation, vision, or hearing
Episodes of abnormal generalized limb shaking w/ apparent loss of consciousness
Episodes of unresponsiveness
Sensation of lump in throat
May show indifference to symptoms
123
Are the symptoms of conversion disorder intentionally produced?
No they are involuntary
124
What is la belle indifference?
Indifference to symptoms often seen in Conversion Disorder
Patients not concered about their symptoms, fully confident doctor's will fix it
125
Who generally presents with Conversion Disorder (which populations)?
Females, low socioeconomic status, low education, lack of psychological sophistocation, rural setting
126
What happens to patients with Conversion Disorder (what is the course of illness)?
Manifests in late adolesence but can have onset throughout lifespan
Generally acute and self limited
May be associated with stress/trauma
20-25% relapse within 1 year
Typically include one symptom at a time
127
What other things must stay on your differential for Conversion Disorder?
Neurological illnesses (MS, Myasthenia Gravis, Periodic Paralysis, Epileptiform Seizure, Polymyositis, Other Myopathies, Guillain-Barre)
Comorbid physical illness + conversion
Other psychiatric disorder
Factitious Disorder or Malingering
128
What are psychogical factars that may explain Conversion Disorder (etiology)?
Occur in setting of stress
Conversion of an unconscious psychological conflict into a physical symptom that leads to a reduction of anxiety
Choice of symptom may be symbolically important
Associated w/ maladaptive personality traits
Seconary benefits: attention, avoid noxious activities
129
How do you treat Conversion Disorder?
Exclude physical illness
Reassure, relax pt
May try hypnosis, amobarbital interview (rarely)
Behavioral therapy
Suggestion
Direct confrontation not recommended
130
What are long-term management options for Conversion Disorder?
Support or psychotherapy
Try to gain appreciation for relationships between conflicts/stressors and symptoms
131
What is Factitious Disorder?
Feigning or production of physical and/or psychological symptoms without underlying pathology
Motivation is presumed to be unconscious and is related to the desire to assume the sick role
132
What is Malingering?
Feigning or production of physical and/or psychological symptoms without underlying pathology
Viewed as the intentional production or reporting of symptoms for a specific purpose associated with some secondary gain
133
What distinguishes Factitious Disorder from Malingering?
Distinguished by motivation for symptom production
Factitious - unconcsious and related to desire to assume sick role
Malingering - viewed as intentional for specific purpose (secondary gain)
134
What defines Factitious Disorder?
Falsification of physical or psycholigical signs or symptoms or induction of injury or disease associated with identified deception
Presents him/herself to others as ill, impaired or injured
Deceptive behaviro is evident even in absence of obvious external rewards
Not better explained
135
What are these examples of?
Factitious Disorder
136
What is Munchausen's Syndrome?
Subtype of Factitious Disorder
Simulation of disease with Peregrination/Wandering
Psudologia fantastica - grandiose often
Usually male, single, 40s, antisocial PD or cluster B traits
Discharged against medical advice, or disappear when discovered.
137
What is the typical course of factitious disorder?
Often unrecognized or untreated
Chronic with significant morbidity
Usually intermittent episodes and reject psych interventions
Some stop behaviors on their own due to lifestyle/life changes
138
What are some factors that suggest a diagnosis of Factitious Disorder?
Discrepancies between objective findings/inconsistenceis between them and other clinical history or symptomatology
Atypical illness course
Failure to respond to usual therapies
Unusually receptive to invasive tests/treatment
Resistant to releasing medical records
Unexplained medical paraphernalia or meds in room
139
What is thought to be the basis (etiology) of Factitious Disorder?
Motivation to assume sick role and is presumed to be **unconscious**
Desire to receive empathic supoprt and be subject to reduced expectations
Disturbances in self and sense of reality
Early childhood abuse, emotional deprivation
Recent stressor, loss or relationship/sexual problem
140
What is Factitious Disorder Imposed on Another?
(Munchausen's by Proxy)
Falsification of physical or psychological signs or symptoms or induction of injury or disease in another, associated with identified deception
Presents someone else as ill, impaired, or injured
Deceptive behavior evident even in absence of obvious external rewards
Not better explained
141
How do you manage Factitious Disorder?
Acute - asses negative reactions, behavior towards patient; psych eval; don't overlook comorbid illness; confirm diagnosis
Chronic - collaborative treatment, communication; pharmacotherapy for comorbid disorders; psychotherapy
142
Is malingering a psychiatric disorder?
Technically no
143
How do you evaluate Malingering patients?
Obtain collateral info
Obtain past Med and Psych records
Psych testing is often useful
Look for motive to malinger
Observe discrepancies and look for inconsistenceis
144
What is "give away" weakness?
Muscle is strong and then suddenly weak (arm suddenly drops, for instance)
Typical of Functional illness (i.e. Conversion Disorder)
145
What is the "Arm Drop" Test?
Hold patient's affected arm above the patient's face and the arm is dropped.
In non-organic weakness the hand always misses the face
Look for jerky descent
146
What are characteristics of a dragging monoparetic gait?
Leg dragged like a sack of potatoes
No external rotation, circumduction
Normal reflexes, no Babinski
147
What is Hoover's Sign?
Based on principle that flexion at one hip is accompanied by involuntary extension of the contralateral joint
Test includes examiner testing hip extension at the heal both voluntarily and involuntarily (after asking for hip flexion). Look for discrepancy
148
What do we see here?
Forcefully trying to close left eye - pseudoptosis
149
What is a general feature of Functional (non-organic) muscle weakness/gait disturbances/ tremor/ etc?
Disappear with distraction
150
What is a test to check if blindness is functional (non-organic)?
Ask to bring fingers together or to sign name (don't really need vision for this)
Pupillary reaction
Opticokinetic nystagmus
Normal opthalmoscopy
151
What can help you identify non-organic (Functional) monocular blindness?
Prism bar - will help you see if the 'blind' eye sees anything
152
What is the demographic that gets psychogenic non-epiletic seizures?
Women more common than men
20-30 year olds most common
Sexual/physical abuse, or bereavement
Can be seen in patients with diagnosed epilepsy
153
What are features of PNES (Psychogenic Non-Epileptic Seizures)?
Not stereotyped
Side-to-side head or body turning
Asynchronous body movements
Slow down at end
Pelvic thrusting/sexual postures often seen
Prolonged body flaccidity
EEG negative!!! Can see similar symptoms in frontal lobe seizure
154
What part of the tongue is often bitten in a pseudoseizure (PNES) vs in seizures?
Pseudoseizures often seen with **tip** of tongue biting
Seizures often bite the sides of tongue
155
What are ways to determine if a person is psychogenically unresponsive vs coma.
Eylids flutter and close actively
Pupils small and reactive
Variable tone, bizarre posturing (potentially)
Sternal rub
Opticokinetic testing positive
Oculocalorics (fast component present)
EEG!!!!
156
What is the most important part of the treatment experience in psychiatric illnesses? And the part that contributes most to positive outcomes for patients?
Doctor-Patient relationship
157
What is psychotherapy?
A talking- and relationship-based treatment that affects the midn and brain
Not a "hired friendship", hand holding or babysitting.
Target organ is the BRAIN
Goal is to increase range of behaviors available to the patient, and in this way relieve symptoms and alter problematic problems
158
What is psychotherapy useful for?
Psychiatric symptoms and/or syndromes (mood, anxiety, psychosis, etc)
Specific problems (relationships, stresses, phase of life concerns)
General problems (self-esteem, inhibitions, ..)
159
How effective is psychotherapy?
75-80% of patients show benefit
Many maintain their gains after completion
160
What factors contribute to the success of psychotherapy?
Patient
Psychotherapist
Treatment method
Context
**Most importantly, the relationship between therapist and patient**
161
Is psychotherapy generally preferred to psychopharmacology?
Limited data to show efficacy differences, since they are often used together
But patients report 3x preference for psychotherapy
162
What is psychoanalysis/psychodynamic therapy?
Range of methods
Process of self-reflection, self-exploration, and self-discovery that takes place in the context of relationshpi between therapist and patient
Everyone has an unconscious that largely determines behaviors, thoughts, and feelings
Make the past alive in the present
163
How does psychoanalytic/psychodynamic therapy genearlly go down?
Frequency ranges from 1x - 5x per week
May be time limited or open ended, brief or long term
+/- the couch
164
What is the general technique of psychoanalysis/psychodynamic therapy?
Allow pt to free associate
Interpret transference
Interpret defense mechanisms, dreams
Focus on present, but listen for past experiences
165
Which patients are going to be successful in using psychoanalysis/psychodynamic therapy?
Patients who are able to tolerate negative emotions and the feelings they will feel towrads the therapist
Those who will be able to delineate transference reactions from reality and maintain their therapeutic alliance despite ebb and flow of transference
166
What are goals of psychoanalytic/psychodynamic therapy?
Increase insight
Understand relationship of present symptoms to developmental antecedents
Expand conscious emotional awareness of unconscious influences so can correct maladaptive patterns and better manage reality
Resolve intrapsychic conflict
Understand "truth" about oneself and one’s motivations
Enhance feeling of meaning in one's life
Improve capacity to seek out and maintain appropriate relationships
Minimize vulnerability for recurrence of symptoms
167
What are distinguishing features of psychodynamic therapy?
Focus on affect and the expression of emotion
Exploration of attempts to avoid distressing thoughts and feelings
Identification of recurring themes/patterns
Discussion of past experience
Focus on interpersonal relations and on the therapy relationship
Exploration of fantasy life, unstructured
Goals include but extend beyond symptom remission
168
What are cognitive and behavioral therapies based upon?
Learning theory
Related to stimulus-response paradigms
169
What is the goal of behavioral and cognitive-behavioral therapies?
To unlearn maladaptive and relearn adaptive behavioral and thinking patterns
170
How does behavioral and cognitive-behavioral therapies go down?
Structured, often manualized (with handouts, etc)
Typically short-term with "here and now" problems
Therapist is active, a directive teacher with the patient being an active student
171
What is the role of the therapist in behavioral and cognitive-behavioral therapies?
Active teacher
172
What are active ingredients in behavioral therapy?
Specific exposures to things the patient may be scared of
173
What are targets in behavioral therapy?
Specific conditioned responses that are looked to be extinguished
174
What is aversive conditioning?
Used to reduce appeal of undesired behaviors
Patient is exposed to unpleasant stimulus while engagingi n targeted behavior
To create aversion to the behavior
(useful in nail biting, sex addiction, other habits)
175
What is exposure therapy used for?
Specific phobias and PTSD
176
What is systematic desensitization?
Removing a negative association/irrational fear that can extinguish conditioned fear response
Slowly and gradually increase doses of the feared stimulus, with relaxing stimuli until stimulus can be tolerated
(Much slower than flooding)
177
What is flooding?
Actual full-on exposure without negative consequences to extinguish a fear or phobia
178
What is exposure with response prevention?
Useful treatment for OCD, phobias
Expose to anxiety producing stimulus but cannot perform associated anxiolytic ritual
Must practice at all times, not jut during session
Pavlovian extinction
179
What is token economy?
Behavioral therapy that looks to increase target behaviors
Reinforce the good, do not punish the bad
Operant conditioning - learning based on rewarding consequences
Useful in severely ill people or children
180
What is biofeedback?
For physical/psychosomatic disorders
Physiological parameter is measured (BP, HR, etc) in real time to allow patient to learn how to alter that by relaxation
181
What are the basic concepts of cognitive behavioral therapy?
Directed primarily at identifying and modifying distorted or maladaptive cognitions and associated emotional reactions and behavioral dysfunction
Adapted for use in many conditions
182
What is the role of a therapist in CBT?
Very active, teacher
Structured sessions, psychoeducation, give patient homework
183
What are automatic thoughts in CBT?
Cognitive errors
184
What are CBT schemas?
Adaptive or maladaptive
185
What are illnesses in which CBT is useful?
Depression and Anxiety Disorders
186
What is a thought change record/thought record?
Have patients write down their thoughts/emotions in response to an emotion
187
188
189
190
191
192
193
194
195
What is Dialectical Behavioral Therapy (DBT)?
Successful therapy for borderline personality disorder
Combines CBT techniques with concepts of distress tolerance, acceptance and mindfulness derived from Buddhist meditative practice
Therapist is an ally, not adversary
Individual and group components
196
What are core skills of DBT (dialectical behavioral therapy)?
Mindfulness
Distress tolerance
Emotion regulation
Interpersonal effectiveness
197
What is group therapy?
One or more therapists treat a small gropu of clients together as a group
Can refer to any form of psychotherapy or helping process that occurs in a group
198
What is family therapy?
Group therapy with a family
199
What is supportive psychotherapy?
Goals are to ameliorate symptoms and maintain, restore, or improve self-esteem and adaptive/coping skills
Try to increase resilience and strenghten adaptive defenses
200
What changes can be seen in the brain due to psychotherapy?
Several fMRI studies have shown that there are changes in brain activity after psychotherapy
201
How does psychotherapy change brain function?
Don't know exaclty how yet, but functional neuroimaging studies have shown that they do indeed change brain function
202
What are the four stages of child development/
Infancy
Early Childhood
School-Age
Adolescence
203
What are the four developmental lines?
Motor
Language
Cognitive
Social-emotional
204
What are the motor capabilities of a newborn?
Basic reflexes (rooting, sucking, palmar grasp, moro)
Lifts head
Limited purposeful movements
205
What are the basic reflexes of a newborn?
Rooting
Sucking
Palmar grasp
Moro
206
What are the three types of temperament?
Easy
Difficult
Slow-to-warm-up
207
What is the time-scale of language development in a child?
Newborn = minimally responsive, cannot localize sound
Baby can coo by 2-4 months
Can babble by 5-6 months
208
What are the Piaget's Stages?
Sensorimotor stage (0-2 y/o)
Pre-operational stage (3-6 y/o)
Concrete operations (7-12 y/o)
Formal operations (13+ y/o)
209
What is Piaget's sensorimotor stage?
Ages 0-2
Babies don't have language or ability to symbolize, so intelligence consists of exploring the environment through sensing things and learning how to manipulate their bodies
Smart = being able to breastfeed, being able to suck on bottle or thumb
210
What is Piaget's pre-operational stage?
Ages 3-6
Preschool age
Child has language without logic, magical thinking, animism (anything that moves is alive)
No concept of real vs imaginary
211
What is Piaget's Concrete operations stage?
Age 7-12
Onset of logical thought
212
What is Piaget's Formal operations stage?
Ages 13+
Still have logic, but now capable of abstract thought and imagining possibilities
213
When should a baby be able to coo?
2 months
214
When should a baby be able to babble with consonants?
5-6 months
215
When should a baby be able to understand words?
8 months
216
When should a baby be forming their first words?
10-12 months
217
What is Mahler's stages of attachment?
Normal autism - first few weeks
Symbiosis - 2 months
Differentiation - 4-5 months
Practicing - 1 year
Rapprochement - 1-2 years
Object constancy - 2-5 years
218
What is Mahler's normal autism?
First few weeks, baby is in its own world and doesn't interact much with outside world. This is adaptive
219
What is Mahler's symbiosis stage?
By 2 months, the baby is fused with mom and has no sense that the body is separate from mom
220
What is Mahler's differentiation stage?
4-5 months
Baby starts to seperate, discover outside world, look around, attention wanders, finds fingers and toes
More alert; mom becomes a distinct entity, different from strangers
Development of transient stranger anxiety
221
What is Mahler's practicing stage?
1 year
Baby can walk, now can go fast away from mom and end up alone; Hallmark of separation, which is exciting for babies, but can develop seperation anxiety
Desire to be independent and the ongoing need for mothering are conflicting
222
What is Mahler's rapproachment stage?
1-2 years
Child goes out to world, feels anxious, comes back to check with mom
223
What is Mahler's object constancy stage?
2-5 years
Child internalized mother as stable and reliable figure, so they can tolerate separation
Mother is internalized no matter where the kid goes, so they can go to school now
224
What do children with secure attachment styles look like?
They reach object constancy, they cry when a parent leaves but are able to tolerate it and are happy to see them return
225
What do children with insecure attachment styles look like?
They can be avoidant and disengaged and may treat the mother and strangers equally
If parents leave them in room with stranger, they show minimal distress and avoid parent upon return
226
What are Freud's psychosexual stages?
Oral (0-1 years)
Anal (1-3 years)
Genital (3-5 years)
227
What motor tasks should a baby be able to perform by 4 months?
Rolls over
228
What motor tasks should a baby be able to perform by 5-6 months?
sits unsupported
229
What motor tasks should a baby be able to perform by 8-9 months?
crawls
230
What motor tasks should a baby be able to perform by 12 months?
walks
231
When shoud a child be able to roll over by?
4 months
232
When should a child be able to sit unsupported by?
5-6 months
233
When should a child be able to crawl by?
8-9 months
234
When should a child be able to walk by?
12 months
235
When should a child be able to deveop a social smile?
2 months
236
When should a child develop stranger anxiety?
8 months
237
When should a child develop seperation anxiety by?
10 months
238
What social/emotional milestone should a child hit by 2 months?
social smile
239
What social/emotional milestone should a child hit by 8 months?
stranger anxiety
240
What social/emotional milestone should a child hit by 10 months?
seperation anxiety
241
What are language milestones of toddlers 18-36 months?
18 months: knows one body part
24 months: two-word combinations
30 months: uses pronouns
36 months: uses grammar
242
What are cognitive milestones by 24 months?
Preoperational thought
Can sort shapes and colors
243
What are motor milestones for 18-36 months?
18 months: runs
24 months: climbs stairs
30 months: jumps
36 months: rides tricycle
244
What are social/emotional milestones of 18-36 months?
18 months: rapprochement
24 months: capable of sympathy
36 months: object constancy
3-4: gender identity
245
When does a child develop gender identity?
3-4 years
246
What age do children first understand that death is irreversible?
7 years old
247
What defines school age?
5-10 years
Also called "latency period"
Child enters society and starts to become contributing member of community
248
What was Erikson's theory of development?
People go through eight conflicts in life
Trust vs mistrust (infancy)
Autonomy vs shame and doubt (toddlers)
Initiative vs guilt (preschool)
Industry vs inferiority (school age)
Identity vs role confusion (adolescence)
Intimacy vs isolation (young adulthood)
Generativity vs stagnation (middle age)
Integrity vs despair (old age)
249
What is the prevailing Eriksonian conflict of school-age children?
Industry vs inferiority
Child attempts to master the basics of industry in society, academic achievement and social competence
Failure to do so results in sense of inferiority
250
What emotional growth occurs during school age?
Child should be able to evaluate him/herself by a composite of his strengths and weaknesses
"What am I good at?", "Can I get the job done?"
Reflected appraisals - competence is determined by the child's evaluation of themselves and others' evaluations of them
**Self evaluation**
251
What is ADHD?
Developmental disorder of inattention and hyperactivity/impulsivity
252
What is a developmental disorder of inattention and hyperactivity/impulsivity?
ADHD
253
What do you need for a diagnosis of ADHD?
254
When do symptoms need to present for a diagnosis of ADHD?
Before age 7
255
Where do the symptoms of ADHD have to present in order to to merit a diagnosis?
In 2 or more settings
256
Does an individual who meets all of the critera for ADHD but is successful and has had straight A's all through school, etc. merit a diagnosis of ADHD?
NO
Must have impaired function
257
What brain areas are implicated in ADHD?
Prefrontal Cortex
Parietal Cortex ("coctail party effect" - tuning noise-to-signal ratio)
Cerebellum
Striatum
258
What is suggested by the genetics of ADHD?
Highly heritable (0.76)
259
What findings are seen in the PFC of children with ADHD?
Smaller PFC volume in children with ADHD
260
What changes are seen in the caudate nucleus in ADHD?
Decreased caudate nucleus volume
261
What are changes seen in the corpus callosum in ADHD?
Reduced corpus callosum area
262
What are changes in the cerebellum seen in ADHD?
Reduced cerebellum volume
263
What percentage of individuals with ADHD respond to treatment with stimulants?
70%
264
What are environmental modifications that are useful in ADHD?
Structure the environment
Simplify communication
Use external aids
Well structured
265
How do stimulants work?
Block reuptake of DA and NE
266
What is adderall? How does it compare to Ritalin?
Mixed amphetamine salt
More potent in a sense, since it blocks presynaptic reuptake, and in the presynaptic vesicles
Ritalin - methylphenidate
267
What is atomoxetine?
Non-stimulant ADHD treatment
ATX blocks the NE transporter resulting in increased NE diffusely, and increased DA in the **prefrontal cortex,** specifically
268
How are antihypertensive drugs helpful in ADHD?
Decrease sympathetic activity
269
What is the traditional triad of autism?
Language impairment - delays, non-verbal
Social impairment - difficulty interpreting world around them or emotions/POV of someone else
Restricted, repetitive behaviors
270
What is the most common comorbid condition with Autism Spectrum Disorders?
Intellectual defecits
271
What is the relationship between epilepsy/seizures and Autism spectrum disorders?
Big overlap. Will have EEG abnormalities often, if not frank seizures
272
What are hte two best prognostic indicators for autism spectrum disorders?
Intellectual ability
Verbal ability
273
What do you need in order to have a diagnosis of autism spectrum disorder?
Persistent deficits in social communication in 3 of 3 symptoms
Restricted repetitive patterns of behavior , at least 2 of 4 symptoms
Must be in early childhood
They limit and impair everyday functioning
274
What are the three social communication defecits required for diagnosis of autism spectrum disorder?
Deficits in social-emotional reciprocity
Deficits in nonverbal communicative behaviors used for social interaction
Deficits in developing and maintaining relationships, appropriate to developmental level
275
What are restricted repetitive behaviors of Austism spectrum disorder? How many do you need for a diagnosis?
Need 2/4 of:
276
What do you find in eye gaze tracking studies of patients with autism spectrum disorders?
They spend more time looking at the mouth of a person than their eyes - it's moving, it's "where the action is"
277
What changes in the neruobiological processing of language do you see in autism spectrum disorder patients?
Decreased activation of Broca's and increased activation of Wernicke's area
278
What are important features of early intervention in autism spectrum disorders?
Intervention by age 3 improves outcome
Behavioral signs are evident by 12 months
Experienced clinicians can reliably identify ASD at 24 months
279
What are some risk alerts for autism spectrum disorder?
Eye contact
Response to name
Joint attention (share attention with someone else)
Response to voice
Mastery motivation
Emotional tone/affection
Interest in other children
Restricted or unusual sensory interests
Expressive language
Receptive language skills
Imitation
Pretend play
Motor sterotypy
280
What are reasons for increased prevalence of autism?
Broadening diagnostic criteria
Younger age of diagnosis
Improved efficiency of case ascertainment
Probably not increased incidence
281
What is thought to be the etiology of autism?
Genetic is thought to be most likely cause
Increased paternal and maternal ages
Some enviornment factors - congenital infetions (rubella)
282
What proportion of the causes of autism can be identified by genetic testing?
15-Oct
283
What pathway do most of the genes implicated in Autism converge on?
Glutamatergic synaptic transmission
284
What determines if a head injury is closed or penetrating?
If the dura is breached = penetrating
If the dura is intact = closed
