Psychiatry - Pathology (2)

Question 1

Specific phobia

• Definition
• Treatment
• Social anxiety disorder
  
  • Definition
  • Treatment
• Agoraphobia

Answer 1

• Definition
  
  • Fear that is excessive or unreasonable and interferes with normal function.
  • Cued by presence or anticipation of a specific object or situation.
  • Person recognizes fear is excessive.
• Treatment
  
  • Can treat with systematic desensitization.
• Social anxiety disorder
  
  • Definition
    
    • Exaggerated fear of embarrassment in social situations (e.g., public speaking, using public restrooms).
  • Treatment
    
    • SSRIs.
• Agoraphobia
  
  • Exaggerated fear of open or enclosed places, using public transportation, being in line or in crowds, or leaving home alone.

Question 2

Generalized anxiety disorder

• Definition
• Treatment
• Adjustment disorder

Answer 2

• Definition
  
  • Pattern of uncontrollable anxiety for at least 6 months that is unrelated to a specific person, situation, or event.
  • Associated with sleep disturbance, fatigue, GI disturbance, and difficulty concentrating.
• Treatment
  
  • SSRIs, SNRIs, buspirone, cognitive behavioral therapy.
• Adjustment disorder
  
  • Emotional symptoms (anxiety, depression) causing impairment following an identifiable psychosocial stressor (e.g., divorce, illness) and lasting < 6 months (> 6 months in presence of chronic stressor).

Question 3

Obsessive-compulsive disorder

• Definition
• Treatment
• Ego dystonic
• Body dysmorphic disorder

Answer 3

• Definition
  
  • Recurring intrusive thoughts, feelings, or sensations (obsessions) that cause severe distress
  • Associated with Tourette disorder.
• Treatment
  
  • Relieved in part by the performance of repetitive actions (compulsions)
  • SSRIs, clomipramine.
• Ego dystonic
  
  • Behavior inconsistent with one’s own beliefs and attitudes (vs. obsessive-compulsive personality disorder)
• Body dysmorphic disorder
  
  • Preoccupation with minor or imagined defect in appearance, leading to significant emotional distress or impaired functioning
  • Patients often repeatedly seek cosmetic surgery.

Question 4

Post-traumatic stress disorder

• Definition
• Treatment
• Acute stress disorder

Answer 4

• Definition
  
  • Persistent reexperiencing of a previous traumatic event (e.g., war, rape, robbery, serious accident, fire).
  • May involve nightmares or flashbacks, intense fear, helplessness, or horror.
  • Leads to avoidance of stimuli associated with the trauma and persistently increased arousal.
  • Disturbance lasts > 1 month, with onset of symptoms beginning anytime after event, and causes significant distress, negative cognitive alterations, and/or impaired functioning.
• Treatment
  
  • Psychotherapy, SSRIs.
• Acute stress disorder
  
  • Lasts between 3 days and 1 month.

Question 5

Malingering

Answer 5

• Patient consciously fakes, profoundly exaggerates, or claims to have a disorder in order to attain a specific 2° (external) gain (e.g., avoiding work, obtaining compensation).
• Poor compliance with treatment or follow-up of diagnostic tests.
• Complaints cease after gain (vs. factitious disorder).

Question 6

Factitious disorders

• Definition
• Munchausen syndrome
• Munchausen syndrome by proxy

Answer 6

• Definition
  
  • Patient consciously creates physical and/or psychological symptoms in order to assume “sick role” and to get medical attention (1° [internal] gain).
• Munchausen syndrome
  
  • Chronic factitious disorder with predominantly physical signs and symptoms.
  • Characterized by a history of multiple hospital admissions and willingness to receive invasive procedures.
• Munchausen syndrome by proxy
  
  • When illness in a child or elderly patient is caused by the caregiver.
  • Motivation is to assume a sick role by proxy.
  • Form of child/elder abuse.

Question 7

Somatic symptom and related disorders

• Definition
• Somatic symptom disorder
• Conversion disorder
• Illness anxiety disorder (hypochondriasis)

Answer 7

• Definition
  
  • Category of disorders characterized by physical symptoms with no identifiable physical cause.
  • Both illness production and motivation are unconscious drives.
  • Symptoms not intentionally produced or feigned.
  • More common in women.
• Somatic symptom disorder
  
  • Variety of complaints in one or more organ systems lasting for months to years.
  • Associated with excessive, persistent thoughts and anxiety about symptoms.
  • May co-occur with medical illness.
• Conversion disorder
  
  • Sudden loss of sensory or motor function (e.g., paralysis, blindness, mutism), often following an acute stressor
  • Patient is aware of but sometimes indifferent toward symptoms (“la belle indifférence”)
  • More common in females, adolescents, and young adults.
• Illness anxiety disorder (hypochondriasis)
  
  • Preoccupation with and fear of having a serious illness despite medical evaluation and reassurance.

Question 8

Personality

• Personality trait
• Personality disorder

Answer 8

• Personality trait
  
  • An enduring, repetitive pattern of perceiving, relating to, and thinking about the environment and oneself.
• Personality disorder
  
  • Inflexible, maladaptive, and rigidly pervasive pattern of behavior causing subjective distress and/ or impaired functioning
  • Person is usually not aware of problem.
  • Usually presents by early adulthood.
  • Three clusters, A, B, and C
    
    • Remember as Weird, Wild, and Worried based on symptoms.

Question 9

Cluster A personality disorders

• Definition
• Disorders

Answer 9

• Definition
  
  • Odd or eccentric
  • Inability to develop meaningful social relationships.
  • No psychosis
  • Genetic association with schizophrenia.
  • “Weird” (Accusatory, Aloof, Awkward).
• Disorders
  
  • Paranoid
  • Schizoid
  • Schizotypal

Question 10

Cluster A personality disorders

• Paranoid
• Schizoid
• Schizotypal

Answer 10

• Paranoid
  
  • Pervasive distrust and suspiciousness
  • Projection is the major defense mechanism.
• Schizoid
  
  • Voluntary social withdrawal, limited emotional expression, content with social isolation (vs. avoidant).
  • Schizoid** = distant.**
• Schizotypal
  
  • Eccentric appearance, odd beliefs or magical thinking, interpersonal awkwardness.
  • Schizotypal = magical thinking.

Question 11

Cluster B personality disorders

• Definition
• Disorders

Answer 11

• Definition
  
  • Dramatic, emotional, or erratic
  • Genetic association with mood disorders and substance abuse.
  • “Wild” (Bad to the Bone).
• Disorders
  
  • Antisocial
  • Borderline
  • Histrionic
  • Narcissistic

Question 12

Cluster B personality disorders

• Antisocial
• Borderline
• Histrionic
• Narcissistic

Answer 12

• Antisocial
  
  • Disregard for and violation of rights of others, criminality, impulsivity
  • Males > females
  • Must be > 18 years old and have history of conduct disorder before age 15.
  • Conduct disorder if < 18 years old.
  • Antisocial = sociopath.
• Borderline
  
  • Unstable mood and interpersonal relationships, impulsiveness, self-mutilation, boredom, sense of emptiness
  • Females > males
  • Splitting is a major defense mechanism.
• Histrionic
  
  • Excessive emotionality and excitability, attention seeking, sexually provocative, overly concerned with appearance.
• Narcissistic
  
  • Grandiosity, sense of entitlement
  • Lacks empathy and requires excessive admiration
  • Often demands the “best” and reacts to criticism with rage.

Question 13

Cluster C personality disorders

• Definition
• Disorders

Answer 13

• Definition
  
  • Anxious or fearful
  • Genetic association with anxiety disorders.
  • “Worried” (Cowardly, Compulsive, Clingy).
• Disorders
  
  • Avoidant
  • Obsessive-compulsive
  • Dependent

Question 14

Cluster C personality disorders

• Avoidant
• Obsessive-compulsive
• Dependent

Answer 14

• Avoidant
  
  • Hypersensitive to rejection, socially inhibited, timid, feelings of inadequacy, desires relationships with others (vs. schizoid).
• Obsessive-compulsive
  
  • Preoccupation with order, perfectionism, and control
  • Ego-syntonic: behavior consistent with one’s own beliefs and attitudes (vs. OCD).
• Dependent
  
  • Submissive and clinging, excessive need to be taken care of, low self-confidence.

Question 15

Schizo-

• -id vs. -typal vs. -phrenic vs. -affective
• Schizophrenia time course

Answer 15

• Schizoid < Schizotypal < Schizophrenic < Schizoaffective
  
  • Schizotypal = schizoid + odd thinking
  • Schizophrenic = greater odd thinking than schizotypal
  • Schizoaffective = schizophrenic psychotic symptoms + bipolar or depressive mood disorder
• Schizophrenia time course
  
  • < 1 mo—brief psychotic disorder, usually stress related
  • 1–6 mo—schizophreniform disorder
  • > 6 mo—schizophrenia

Question 16

Eating disorders

• Anorexia nervosa
  
  • Definition
  • Findings
• Bulimia nervosa
  
  • Definition
  • Findings

Answer 16

• Anorexia nervosa
  
  • Definition
    
    • Excessive dieting +/− purging
    • Intense fear of gaining weight, body image distortion, and increased exercise, leading to a body weight well below ideal (≈ BMI < 17 kg/m2).
    • Seen primarily in adolescent girls
  • Findings
    
    • Associated with decreased bone density.
    • Severe weight loss, metatarsal stress fractures, amenorrhea, lanugo (fine body hair), anemia, and electrolyte disturbances.
    • Osteoporosis caused in part by decreased estrogen over time.
    • Commonly coexists with depression.
• Bulimia nervosa
  
  • Definition
    
    • Binge eating +/− purging
    • Often followed by self-induced vomiting or use of laxatives, diuretics, or emetics.
    • Body weight often maintained within normal range.
    • Seen predominantly in adolescent girls
  • Findings
    
    • Associated with parotitis, enamel erosion, electrolyte disturbances, alkalosis, dorsal hand calluses from induced vomiting (Russell sign).

Question 17

Gender dysphoria

• Definition
• Transsexualism
• Transvestism

Answer 17

• Definition
  
  • Strong, persistent cross-gender identification.
  • Characterized by persistent discomfort with one’s sex assigned at birth, causing significant distress and/or impaired functioning.
  • Affected individuals are often referred to as transgender.
• Transsexualism
  
  • Desire to live as the opposite sex, often through surgery or hormone treatment.
• Transvestism
  
  • Paraphilia, not gender dysphoria.
  • Wearing clothes (e.g., vest) of the opposite sex (cross-dressing)

Question 18

Sexual dysfunction

• Includes:
• Differential diagnosis includes:

Answer 18

• Includes:
  
  • Sexual desire disorders (hypoactive sexual desire or sexual aversion)
  • Sexual arousal disorders (erectile dysfunction)
  • Orgasmic disorders (anorgasmia and premature ejaculation)
  • Sexual pain disorders (dyspareunia and vaginismus).
• Differential diagnosis includes:
  
  • ƒƒDrugs (e.g., antihypertensives, neuroleptics, SSRIs, ethanol)
  • ƒƒDiseases (e.g., depression, diabetes, STDs)
  • Psychological (e.g., performance anxiety)

Question 19

Sleep terror disorder

Answer 19

• Periods of terror with screaming in the middle of the night
• Most common in children.
• Occurs during slow-wave sleep.
  
  • Occurs during non-REM sleep (no memory of arousal) as opposed to nightmares that occur during REM sleep (memory of a scary dream).
• Cause unknown, but triggers may include emotional stress, fever, or lack of sleep.
• Usually self limited.

Question 20

Narcolepsy

• Definition
• Also associated with:
• Treatment

Answer 20

• Definition
  
  • Disordered regulation of sleep-wake cycles
  • 1° characteristic is excessive daytime sleepiness.
  • Caused by decreased orexin production in lateral hypothalamus.
  • Strong genetic component.
• Also associated with:
  
  • ƒƒHypnagogic (just before sleep) or hypnopompic (just before awakening) hallucinations.
    
    • Hypnagogic—going to sleep
    • Hypnopompic—post-sleep
  • ƒƒNocturnal and narcoleptic sleep episodes that start off with REM sleep.
  • Cataplexy (loss of all muscle tone following a strong emotional stimulus, such as laughter) in some patients.
• Treatment
  
  • Daytime stimulants (e.g., amphetamines, modafinil) and nighttime sodium oxybate (GHB).

Question 21

Substance use disorder

Answer 21

• Maladaptive pattern of substance use defined as 2 or more of the following signs in 1 year:
  
  • Tolerance—need more to achieve same effect
  • ƒƒWithdrawal
  • Substance taken in larger amounts, or over longer time, than desired
  • Persistent desire or unsuccessful attempts to cut down
  • Significant energy spent obtaining, using, or recovering from substance
  • Important social, occupational, or recreational activities reduced because of substance use
  • Continued use in spite of knowing the problems that it causes
  • Craving
  • Recurrent use in physically dangerous situations
  • Failure to fulfill major obligations at work, school, or home due to use
  • Social or interpersonal conflicts related to substance use

Question 22

Stages of change in overcoming substance addiction

Answer 22

1. Precontemplation
   
   • Not yet acknowledging that there is a problem
2. Contemplation
   
   • Acknowledging that there is a problem, but not yet ready or willing to make a change
3. Preparation/determination
   
   • Getting ready to change behavior
4. Action/willpower
   
   • Changing behaviors
5. Maintenance
   
   • Maintaining the behavior change
6. Relapse
   
   • Returning to old behaviors and abandoning new changes

Question 23

Nonspecific depressants

• Type of drug
• Intoxication symptoms
• Withdrawal symptoms

Answer 23

• Type of drug
  
  • Psychoactive drugs: depressants
• Intoxication symptoms
  
  • Nonspecific: mood elevation, decreased anxiety, sedation, behavioral disinhibition, respiratory depression.
• Withdrawal symptoms
  
  • Nonspecific: anxiety, tremor, seizures, insomnia.

Question 24

Alcohol

• Type of drug
• Intoxication
  
  • Symptoms
  • Labs
• Withdrawal
  
  • Symptoms
  • Treatment

Answer 24

• Type of drug
  
  • Psychoactive drug: depressant
• Intoxication
  
  • Emotional lability, slurred speech, ataxia, coma, blackouts.
  • Labs
    
    • Serum γ-glutamyltransferase (GGT)—sensitive indicator of alcohol use.
    • Lab AST value is twice ALT value.
• Withdrawal
  
  • Symptoms
    
    • Mild alcohol withdrawal: symptoms similar to other depressants.
    • Severe alcohol withdrawal can cause autonomic hyperactivity and DTs (5–15% mortality rate).
  • Treatment for DTs: benzodiazepines.

Question 25

Opioids (e.g., morphine, heroin, methadone) * Type of drug * Intoxication * Symptoms * Treatment * Withdrawal * Symptoms * Treatment

Answer 25

* Type of drug * Psychoactive drugs: depressants * Intoxication * Euphoria, respiratory and CNS depression, decreased gag reflex, pupillary constriction (pinpoint pupils), seizures (overdose). * Treatment: naloxone, naltrexone. * Withdrawal * Sweating, dilated pupils, piloerection (“cold turkey”), fever, rhinorrhea, yawning, nausea, stomach cramps, diarrhea (“flu-like” symptoms). * Treatment: long-term support, methadone, buprenorphine.

Question 26

Barbiturates * Type of drug * Intoxication * Symptoms * Treatment * Withdrawal symptoms

Answer 26

* Type of drug * Psychoactive drugs: depressants * Intoxication * Low safety margin, marked respiratory depression. * Treatment: symptom management (assist respiration, increase BP). * Withdrawal symptoms * Delirium, life-threatening cardiovascular collapse.

Question 27

Benzodiazepines * Type of drug * Intoxication * Symptoms * Treatment * Withdrawal symptoms

Answer 27

* Type of drug * Psychoactive drugs: depressants * Intoxication * Symptoms * Greater safety margin. * Ataxia, minor respiratory depression. * Treatment: supportive care; consider flumazenil (competitive benzodiazepine antagonist). * Withdrawal symptoms * Sleep disturbance, depression, rebound anxiety, seizure (can be triggered by reversal with flumazenil).

Question 28

Nonspecific stimulants * Type of drug * Intoxication symptoms * Withdrawal symptoms

Answer 28

* Type of drug * Psychoactive drugs: stimulants * Intoxication symptoms * Nonspecific: mood elevation, psychomotor agitation, insomnia, cardiac arrhythmias, tachycardia, anxiety. * Withdrawal symptoms * Nonspecific: post-use “crash,” including depression, lethargy, weight gain, headache.

Question 29

Amphetamines * Type of drug * Intoxication symptoms * Withdrawal symptoms

Answer 29

* Type of drug * Psychoactive drugs: stimulants * Intoxication symptoms * Euphoria, grandiosity, pupillary dilation, prolonged wakefulness and attention, hypertension, tachycardia, anorexia, paranoia, fever. * Severe: cardiac arrest, seizure. * Withdrawal symptoms * Anhedonia, increased appetite, hypersomnolence, existential crisis.

Question 30

Cocaine * Type of drug * Intoxication * Symptoms * Treatment * Withdrawal symptoms

Answer 30

* Type of drug * Psychoactive drug: stimulant * Intoxication * Impaired judgment, pupillary dilation, hallucinations (including tactile), paranoid ideations, angina, sudden cardiac death. * Treatment: benzodiazepines. * Withdrawal symptoms * Hypersomnolence, malaise, severe psychological craving, depression/suicidality.

Question 31

Caffeine * Type of drug * Intoxication symptoms * Withdrawal symptoms

Answer 31

* Type of drug * Psychoactive drug: stimulant * Intoxication symptoms * Restlessness, increased diuresis, muscle twitching. * Withdrawal symptoms * Lack of concentration, headache.

Question 32

Nicotine * Type of drug * Intoxication symptoms * Withdrawal * Symptoms * Treatment

Answer 32

* Type of drug * Psychoactive drugs: stimulants * Intoxication symptoms * Restlessness. * Withdrawal * Irritability, anxiety, craving. * Treatment: nicotine patch, gum, or lozenges; bupropion/ varenicline.

Question 33

PCP * Type of drug * Intoxication * Symptoms * Treatment * Withdrawal symptoms

Answer 33

* Type of drug * Psychoactive drug: hallucinogen * Intoxication * Belligerence, impulsiveness, fever, psychomotor agitation, analgesia, vertical and horizontal nystagmus, tachycardia, homicidality, psychosis, delirium, seizures. * Treatment: benzodiazepines, rapid-acting antipsychotic. * Withdrawal symptoms * Depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep.

Question 34

LSD * Type of drug * Intoxication symptoms * Withdrawal symptoms

Answer 34

* Type of drug * Psychoactive drug: hallucinogen * Intoxication symptoms * Perceptual distortion (visual, auditory), depersonalization, anxiety, paranoia, psychosis, possible flashbacks. * Withdrawal symptoms * None

Question 35

Marijuana (cannabinoid) * Type of drug * Intoxication symptoms * Withdrawal symptoms

Answer 35

* Type of drug * Psychoactive drug: hallucinogen * Intoxication symptoms * Euphoria, anxiety, paranoid delusions, perception of slowed time, impaired judgment, social withdrawal, increased appetite, dry mouth, conjunctival injection, hallucinations. * Prescription form is dronabinol (tetrahydrocannabinol isomer): used as antiemetic (chemotherapy) and appetite stimulant (in AIDS). * Withdrawal symptoms * Irritability, depression, insomnia, nausea, anorexia. * Most symptoms peak in 48 hours and last for 5–7 days. * Generally detectable in urine for 4–10 days.

Question 36

Heroin addiction * Definition * Treatments * Methadone * Naloxone + buprenorphine * Naltrexone

Answer 36

* Definition * Users at increased risk for hepatitis, abscesses, overdose, hemorrhoids, AIDS, and right-sided endocarditis. * Look for track marks (needle sticks in veins). * Treatments * Methadone * Long-acting oral opiate * Used for heroin detoxification or long-term maintenance. * Naloxone + buprenorphine * Partial agonist * Long acting with fewer withdrawal symptoms than methadone. * Naloxone is not active when taken orally, so withdrawal symptoms occur only if injected (lower abuse potential). * Naltrexone * Long-acting opioid antagonist used for relapse prevention once detoxified.

Question 37

Alcoholism * Definition * Complications * Treatment

Answer 37

* Definition * Physiologic tolerance and dependence with symptoms of withdrawal (tremor, tachycardia, hypertension, malaise, nausea, DTs) when intake is interrupted. * Complications * Alcoholic cirrhosis, hepatitis, pancreatitis, peripheral neuropathy, testicular atrophy. * Treatment * Disulfiram (to condition the patient to abstain from alcohol use), naltrexone, supportive care. * Alcoholics Anonymous and other peer support groups are helpful in sustaining abstinence.

Question 38

Wernicke-Korsakoff syndrome * Definition * Findings * Treatment

Answer 38

* Definition * Alcoholism * Caused by thiamine deficiency. * Findings * Triad of confusion, ophthalmoplegia, and ataxia (**Wernicke encephalopathy**). * May progress to irreversible memory loss, confabulation, personality change (**Korsakoff psychosis**). * Associated with periventricular hemorrhage/necrosis of mammillary bodies. * Treatment * IV vitamin B1 (thiamine).

Question 39

Mallory-Weiss syndrome * Definition * Findings

Answer 39

* Definition * Alcoholism * Longitudinal partial thickness tear at the gastroesophageal junction caused by excessive vomiting. * Findings * Often presents with hematemesis. * Associated with pain (vs. esophageal varices).

Question 40

Delirium tremens (DTs) * Definition * Findings * Treatment

Answer 40

* Definition * Life-threatening alcohol withdrawal syndrome that peaks 2–5 days after last drink. * Symptoms in order of appearance * Autonomic system hyperactivity (tachycardia, tremors, anxiety, seizures) * Psychotic symptoms (hallucinations, delusions) * Confusion * Treatment * Benzodiazepines.