Psychology Flashcards
(166 cards)
1
Q
Psychiatric Exam: Signs and Symptoms
Self-Report measures of mood
A
Beck Anxiety Inventory
Beck Depression Inventory
Symptom Checklist-90-Revised
2
Q
Psychiatric Exam: Signs and symptoms
Clinician-Rated Measures
A
Hamilton Rating Scale for Depression
3
Q
Mental Status Examination (MSE)
A
Establishes the reliability of self report, informs rest of exam. Establishes neuro cognitive baseline. Ranges in breadth and depth depending on patient. Data relevant to MSE is available through the clinical encounter (formal MSE may be brief)
4
Q
Mental Status Exam: Orientation
A
Self (do they know their name), Place (where they are), Time (day month year), Purpose (why they are here)
Notation patient is oriented x3 (self place time)
Patient is oriented to self, place, time, purpose
5
Q
Mental Status Exam: Speech and Language
A
Assessment: amount, rate, tone, volume, fluency, articulation, spontaneity.
Dysprosodic (rhythm), dysarthria (poor articulation of phonemes), dysfluent (can’t find the right words), pressured, slow…
Assument of language: comprehension - direct and simple commands
Expression? - paraphrasais (phonemic or semantic)
6
Q
MSE: Thought Process and Form
A
Normal thought is logical and goal directed.
Disordered can be:
Tangential, circumstantial (indirect, winding, tedious), derailed (no connections), flight of ideas, perseverative, clanging, neologistic (making up words combining words), Blocked (going black v often)
7
Q
DSE: Thought Content
A
Disordered thought can be
Ruminative (preoccupation)
Obsessive (unwanted concerns)
Delusional (at odds with convention)
8
Q
MSE: Insight and Judgment
A
Insight: what brings you here, what is the problem
Judgment: appropriate decisions, if a building were on fire, what would you do?
9
Q
MSE: Cognition
A
Attention, concentration distractibility
Memory (short and life)
Intellectual (current president etc)
10
Q
MSE Categories
A
ASEPTIC
Appearance, attitude, accessibility, behaviour
Stream of mental activity (inferred from speech)
Emotion, mood affect suicidality homocidality
Psychotic symptoms (hallucinations, delusions)
Thought (and language)
Insight and Judgment
Cognition, orientation, concentration, memory
11
Q
MSE: Risk Assessment
A
Suicidality - “What stops you” behavioural control
Chronic or acute?
Risk factors:Prior attempts is the STRONGEST PREDICTOR,psychiatric symptoms (esp BPD and PTSD)
Homocidality - anger?
Protective factors: ie social support, responsibility, coping.
12
Q
Conditions for involuntary Hospitalization
A
Patient can be hospitalised without consent by one or two physicians for a time limited period before court hearing.
Conditions: danger to themselves, danger to others.
13
Q
“Provisional” as a diagnostic descriptor
A
Used AFTER the name of the specific diagnosis.
Used if one presumes that the criteria will be met but
Patient info is unavailable (and expected to be confirmed upon inquiry)
Required symptoms are present, but the duration criterion is NOT YET (but expected to be) met.
14
Q
“Unspecified” as a diagnostic descriptor
A
Patient definitely does NOT meet criteria for a specific disorder, but has significant symptoms within a given diagnostic category
Insert word “unspecified” BEFORE the name of the category
15
Q
Fluoxetine
A
Prozac, SSRIs
16
Q
Venlafaxine (effexor)
A
SNRI, similar side effects as SSRIS
17
Q
Side effects of TCAs
A
Postural hypotension, tachycardia (cardiac side effects)
18
Q
Treatment of MDD
A
CBT, TCAs, ECT (ELECTRO, frontotemporal), TMS (transcranial magnetic, for prefrontal cortex), vagus nerve stimulation (VNS, electrical stim).
19
Q
ECT Contraindications (ELECTROconvulsive therapy)
A
Vascular disease, due to blood pressure increase during a seizure, not preventative
Procedure: frontotemporal, unilateral, seizure for 30s
Side effectsL cardiac arrhyth, headache and confusion, some mesmory loss around session but usually goes away
20
Q
Patients bill of Rights
A
(1972)
Right to receive complete information
Right to refuse treatment
Right to know about a hospital’s financial conflicts of interest
21
Q
Patient Self-Determination Act
A
1991
Patients must be given written information about their health care decision making rights and the institutional policy on advance directives (living will and power of attorney)
22
Q
Benefits of informed patients
A
Greater sense of control, associated with
Greater ability to tolerate pain, faster recovery, enhanced adjustment, decreased hospital stay
23
Q
Transference
A
Relationships schemas (beliefs, expectations, perceptions from the past informing the presence). Unconscious - ie patient transfers feelings onto the physician, can be positive (affectionate) or negative (hostile), or ambivalent.
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Q
Countertransference
A
Physician projecting his relationship schemas onto patient. Ie treat an elderly patient as your own grandmother.
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Objectification/dehuminization
Using patient as a teaching tool in direct view of patient, discussing case with colleagues in listening range of the patient
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Barriers to treatment adherence
1. Poor physician relationship - anger at the physician, unapproachable physician
2. Believing time and costs outweigh benefits
3. Symptom resolution (ie seizures stop, BP normalises)
4. Complex treatment schedule'
5. Fears - loss of bodily integrity from side effects, dependency on others, loss of masculinity, loss of work time, fear of losing livelihood.
6. Denial/avoidance
7. Regression
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Sick Role
Parsons, 1951
Sanctioned deviance - sick person exempt from normal social roles, not responsible for condition, work toward return to health
1980s: onus moved to patient, obligation to behave think and feel healthily, sick leave de-legitimised. Responsible for your own care.
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ICD 10 Post-Concussional Syndrome
history of head trauma with LOC preceding symptom onset by max of 4 weeks
3 or more: headache, dizziness, malaise, fatigue
Irritability
Self reported cog difficulties with no evidence of impairment on formal testing
Insomnia
Reduced alcohol too
Pre-occupation with symptoms, adoption of sick role
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Nocebo effect
Various inherently inert factors that may create negative expectancies for recovery, and therefor impede a given patient's progress and recover
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SPIKES - 6 step protocol for conveying bad news to patients
S - setting up the interview - privacy, so's, eye contact, silence pager
P - reception of the patient - find out what patient understands, determine thinking, expectations
I - invitation - find out how would like to receive diag, detail wanted, offer to answer qs, talk to relatives
K - knowledge - prepare patient for bad news, give positive news first, bad news clearly, info in small doses, nontechnical, avoid conveying hopelessness
E - emotion/empathy - connect emotion and reason, tolerate discomfort, ask if need someone called.
S - strategy/summary - ask if ready to disc treatment, evaluate understanding and hopes, share decision making, understand goals ie pain ctrl, state plans, schedule follow ups.
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Medical Interview
Start with open-ended questions, add direct questions. Avoid leading questions, or compound questions.
Interruption: redirecting patient if rambling, restructuring.
Transition - politely changing topics to gather relevant info
Reflection - paraphrasing to show understanding
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3 key components of medical encounter
History
Signs (physical exam)
Symptoms (physical exam)
/ lab tests
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Clinical Decision making (6 steps)
1. Define the problem - problem list, hypotheses, iterative refinement to diagnosis
2. Define outcome goals - desired condition after treatment
3. General alternative treatment solutions - consider how to alter bio fnxn, modify behaviour, changes in enviro, utilise social resources
4. Finalize treatment plan - optimal interventions, priorities, clear goals, confirm understanding and commitment, oral and written comm.
5. Implement treatment plan - establish method for comm unexpected obstacles to implement ie side effects, insurance denial, follow-up appt to review progress
6. Evaluate outcome - symptoms resolved/reduced?
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SOAP Note
Subjective - incl chief complaint "stomach pain for 3 days". HPI (if first visit), status of existing or new sympas, status of health behaviours (sleep, diet)
Objective - vital signs, measurement, physical exam findings, lab tests, medication list
Assessment - summary, differential diag, rule out
Plan - labs ordered, referrals, procedures performed, mess given, eduacation provided, treatment goals, monitoring parameters
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Obstacles that can arise in psychiatric interviewing
1. Poor insight - don't realise they have a disorder
2. Positive impression management
3. Self-deception - ie in denial
4. Symptoms as adaptations
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MSE: Orientation
Oriented to self, place, time, and purpose.
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Dyskenisias
Unable to perform voluntary movement (part of motor behaviour of MSE)
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Dystopias
Part of Motor Behaviour of MSE - weak muscle tone and posture
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MSE: Mood
Sustained subjective emotional state as reported by patient
| Time scale: weeks
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MSE: Affect
Observed emotional state
Time scale: minutes
Assess: appropriate, fluctuate, broad range
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Dysprosodic speech
Disruption of prosody (rhythm, body, intonation, pauses, stresses) of speech
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Dysarthric speech
Slurred slow speech, difficult to understand. Commonly nervous system disorders
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Dysfluent speech
Stuck, unable to move ahead in speech/ Can't find the words, stutter
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Phonemic paraphasia
Substitution of a word with nonproductive that preserves at least half of the segments and or number of syllables of intended word.
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Semantic Paraphasia
Sub of one word for another on the basis of a meaning relationship between the two.
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ASEPTIC (MSE)
Appearance, attitude, accessibility, behaviour
S - stream of mental activity
E - emotion, mood, affect, suicidality, homocidality
P - psychotic symptoms
T - thought and language
I - insight and judgment
C - ignition, orientation, concentration, memory
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V Code conditions
Other conditions that may be a focus of clinical attention, but are not mental disorders
Ie V61.7 problems related to unwanted preg
Exposure to disaster, war
Problems related to release from prison
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DSM 5 conditions for further study
Proposed criteria sets for 8 disorders ie internet gaming
| Common language for studying, NOT for clinical use, research guid future DSM decisions.
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Unspecified Disorders
Diagnosed when a patient definitely does NOT meet criteria for a specific disorder, but has significant symptoms within a given diagnostic category. Insert word unspecified BEFORE the name of the category.
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Anxiety Disorders
```
Panic Disorder
Agoraphobia
Specific Phobia
Social anxiety disorder
Generalised anxiety
Separation anxiety
Selective mutism
```
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Panic Disorder
Recurrent and unexpected panic attacks (number not specified)
For > 1 MONTH shows fear of future panic attacks, or sig change in behaviour related
Can be learned by classical conditioning - physical symptom alone can now trigger full fear response
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Agoraphobia
>or equal to 2 of these situations are feared/avoided:
using public transp, open spaces, enclosed spaces, standing in line or being in crowd, being outside of home alone
-- feared because of thoughts that escape might be difficult if embarrassing symptoms develop
-- Agoraphobia often develops in PD patients.
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Social Anxiety Disorder
Excessive, persistent, and unrealistic fear of social situation involving possible scrutiny by other due to fear of negative evaluation.
Specify "performance only" if fear is restricted to speaking or performing in public.
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Generalised Anxiety Disorder
Persistent uncontrolled anxiety about multiple events for >6 months.
Accompanied by sypmtmos such as: restless, decreased conc, muscle tension, fatigued, irritable, insomnia.
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Separataion anxiety disorder
```
Developmentally inappropriate and excessive concerning separation from major attachment figures
Marked distress (mental and physical) about anticipated or actual separataion, harm befalling attachment figures, going out because of separation fears
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Selective Mutism
Refusal to speak in specific situations despite fluent speech in other contexts - written comm and social play may also be affected
Symptoms persist for >1 month (not the first month of school)
NOT due to lack of language of comm disorder ie stuttering.
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Neuroanatomical Correlates of Anxiety
Amyglda - initiates fear response via activation of hypothalamic - Pituitary - adrenal axis
Prefrontal cortex - SHOULD inhibit amygdala when fear response is no longer necessary
Hippocampus - should track the context in which a fear response is learned and help to suppress fear when in safe contexts
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Treatment of anxiety disorders
1. CBT - modifying thought (cognitive), using exposure techniques (behavioural)
2. Anxiolytics - Try CBT first or use together. Benzos (GABA agonists), antidepressants (monoamine agonists)
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OCD
Recurrent obsessions or compulsions
1. Obsessions: intrusive recurrent thoughts, urges, or images that increase distress
Compulsions: repetitive behaviours/mental acts performed to decrease distress. Not always logically related to obsession
2. Obsessions/compulsions are time consuming, disrupt fuel
3. Not explained by another Disorders (ie weight in eating d)
- - OCD with absent insight (delusional beliefs). - convinced their OCD beliefs are true.
- -etiology: cortico-striato-thalamo-cortical (CSTC) circuit OVERACTIVITY - cingulate to striatum to thalamus to orbital frontal loop, serotonin def
Treatment: Behavioural ERP - exposure and response prevention - expose to obsession without allowing to engage in compulsion
SSRIs
If refractory: cingulotomy, capsulotomy
Deep brain stimulation - electrical
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PANDAS
Rare case, OCD beings suddenly after streptococcal infections
Paediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal infections
Hyp: autoimmune run affects neurons in basal ganglia, activating CSTC loop (cortico-striato-thalamo cortical path)
Treat w antibiotics and OCD treatment
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Yale Brown OC Scale (Y-BOCS)
Objective scale used after OCD Diagnosis to:
Qualify and quantify symptoms and severity
Monitor changes in symptoms over time
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Hoarding Disorder
Difficulty parting with possessions. Hoarding causes distress/impairment and is not better explained.
Specify whether HD is "with absent insight (delusional beliefs) - ie certain that HD beliefs are not problematic despite contrary evidence.
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Body Dysmorphic Disorder
Preoccupation with perceived flaw in physical appearance (flaw is minimal, on-observable). Repetitive behaviours, mental acts performed in response.
Preoccupation not better accounted for by an eating disorder. Must cause functional impairment (ie sequestering oneself), otherwise considered normal vanity
* specify if with "muscle dysphasia" - preocc belief that body is too small or too little muscle
* or with absent insight (delusional beliefs) - convinced that BDD beliefs are true
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Excoriation Disorder
Recurrent skin picking resulting in lesions
Attempts to stop
Picking results in distress/impairment
Not better explained by another disorder
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Trichotillomania
Recurrent pulling out of one's hair - episodes vary in freq, duration, and intensity
Attempts to stop hair pulling,
Pulling causes distress/impairment
Pulling is not better explained by another disorder
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PTSD
Exposure to traumatic stressor
>orequalto 1 symptom from EACH of the 4 categories.
(4 symptoms or more)
1. Intrusion symptoms - dreams, recollections, feeling event reoccur, psych distress when encounter symbols
2. Avoidance symptoms - avoid thoughts, places, convos, that are reminders
3. Negative alterations in cognition and mood - persistent neg beliefs, emotion, inability to exp positive emotion, diminished interest, detachment, dissociative amnesia.
4. Alterations in arousal and activity - sleep disturbance, irritable outbursts, reckless self destructive, concentration probs, hypervigilance, exag starte response.
>1 month. Usually beigin within 3 months of trauma but can be ANYTIME.
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ASD (Acute stress disorder)
Exposure to traumatic stressor
Numerous PTSD like symptoms must develop from the four categories.
Duration is 3 days to 1 month post trauma exposure
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PTSD/ASD neuroanatomical correlates
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Hyperresponsive amygdala (fear)
Unresponsive prefrontal cortex (failure to suppress)
Reduced volume and dysfunction of hippocampus (failure to suppress fear when in safe contex)
```
Likely underlies intrusion symptoms and alterations in arousal and reactivity when seen.
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PTSD ASD Treatment
Psychotherapy - Supportive therapy, behavioural therapy to address problem behaviour (avoidance)
Medications to reduce emotion: antisepsis, benzos
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Adjustment Disorder
Development of disproportional emotional/behavioural symptoms - due to identifiable stressor (often ordinary life experience but not necessarily)
Acute onset
Brief duration (expected to resolve within several months of stressor)
*subtypes: with depressed mood
With anxiety
With disturbance of conduct(externalising behaviour)
Can also be mixed or unspecified
If sufficient symptoms after stressor that another criteria are met, NOT adjustment disorder. ONLY diag if causal stressor and NO OTHER DISORDER explains
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Reactive Attachment Disorder (RAD)
Inhibited and emotionally-withdrawn behaviour toward adult caregivers.
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DSED (Disinhibited Social Engagement Disorder)
Overly familiar behaviour with relative strangers
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Dissociative Amnesia (Psychogenic amnesia)
Memory loss for autobiographical information, not due to another disorder
Can be
Localised - during circums period
Selective - some limited recall of memories during a circumscribed time
Generalised - loss of personal memory of entire life up to and including event
* specify if with dissociative fugue - purposeful travel, bewildered wandering - brief, unobtrusive life, spontaneous term of amnesia, rare
* differential during MSE - det if organic (hard time learning new info),or if psychological (dissociative) basis - patient learns new info well only retrograde memory loss.
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Dissociative Identity Disorder (DID)
Greater than or equal to 2 distinct personality states
1. The primary (host) and an alter
2. Inability to recall personal information (frequent memory gaps when alter in ctrl)
Amnesia with "mistaken identity" experiences and unexpected changes in personal possessions - clues
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Depersonalization/Derealization Disorder
Either or both of
Depersonalisation; unreality, detachment, feel as an outside observer wrt one's thoughts, feelings, body etc
Derealization: unreality or detachment wrt to surroundings (objects seem dreamlinke)
Reality testing remains intact (knows its a misperceptions)
Symptoms result in functional impairment
Metabolic , neurological causes etc eliminated as causal.
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Treatment of dissociative disorders
Some form of psychotherapy (CBT)** gold standard
| Hypnosis may be used, but cautiously due to false memory syndrome
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MDD Major Depressive Disorder "unipolar Depression"
1. Must experience >Oreq 1 MDE
2. NO history of mania or hypomania
* with melancholic features - severe anhedonia, lack of mood reactivity, profound despondency and guilt, depression worse in morning, sig app lost
* with atypical features - mood reactivity, weight and sleep increase, leaden paralysis
* with psychotic features - mood congruent and incongruent
* with catatonia - mutism, immobility, waxy flex, stéréotypies, abnormal postures
* with anxious distress
* with peripartum onset
* with seasonal pattern (aka SAD)
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MDE Major Depressive Episode
MUST HAVE EITHER OF Anhedonia or depressed mood (affective)
AT LEAST TWO WEEKS, but gen last 6-12 months.
PLUS 4 or more of
Neurovegetative, cognitive ie
SIGECAPS - Sleep change, Interest loss, Guilt, low Energy, Concentration decline, Appetite change, Psychomotor changes, Suicidal Ideation
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MDD Neurobiology
Increased amygdala activity
Increased HPA Axis activity
--increased cortisol, increased cytokines (sickness behaviour)
Decreased hippocampus volume (bc of hypercotisolemia?)
Decreased prefrontal cortex activity/volume (dorsolateral)
Multifac, 30% if monozygous twins, higher if MDD more severe
Reduced monoaminergic transmission
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MDD Treatment
1. Psychothérapies (ie CBT)
2. Antidepressants, SSRIs and SNRIs(venlafaxine ie effexor)
3. TCAs (less agonism relative to ssris?), cardiac side effects incl postural hypotension, tachycardia.
4. MAOis - diet restrictions ie tyramine-induced hypertension, less widely used
5. Electroconvulsive Therapy (ECT) - electrical induction of generalised seizures. Pre treat with muscle relaxant - CONTRAIND: vascular disease.
6. TMS - transcranial magnetic stimulation
7. Vagus Nerve Stimulation
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Electroconvulsive therapy
Frontotemporal electrode placement, unilateral
CONTRAINDICATED: vascular disease
Gen. seizure gr than 30 s
3 treatments/week for 10-12 treatments
Initial side effects: cardiac arrhythmias, headache and confusion, some memory loss for recent long-term mem and some encoding difficulty surrounding sessions. Usually returns to baseline
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TMS Transcranial Magnetic Stimulation
magnetic pulses generated and used
40 mins, 5x per week for 4-6 weeks
Not as effective as ect but maybe less side effects? Dont really know
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Schizophrenia Spectrum Disorders - 5 domains
Each diagnosis involves one or more of the 5 domains ( 1 2 and 3 are CORE domains)
1. Delusions
2. Hallucinations
3. Disorganised Speech
4. Disorganised behaviour
5. Negative symptoms
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Delusions (1 of psychotic symptom domains)
Fixed belief that is not amenable to change, even with conflicting evidence
1. Grandiose
2. Persecution (paranoid)
3. Of Control (external force controlling behaviour)
4. Of Reference (an outside action refers directly to the person)
5. Thought broadcasting delusion (thoughts transmitted to others)
Etc..
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Hallucination (psychotic symptom domains, 2)
Sensory perception with NO external stimulus
| Typical features: auditory, single voice multiple voice etc, derogatory
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Disorganized Thinking (3 of psychotic symptom domains) (speech) (differential diagnosis)
Ie formal thought disorder (speech)
Tangentiality, flight of ideas, derailment (loose associations), clang association, word salad.
DIfferential diagnosis: Disorganised speech in post-stroke aphasia
presence of phonemic paraphasic errors - additions/deletions of syllables, are more likely seen in stroke patients. Ie clotch
Pronunciation is good in psychotic patients - problem is with logical connection.
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4. Grossly disorganized or catatonic behaviour (psychotic symptom domains)
Disorganized: non goal-oriented behaviour - unable to take care of activities of daily living
Catatonia: multiple motor/behaviour abnormalities that reflect diminished reactivity to the environment ie posturing, waxy flexibility, stereotypies, non-responsiveness, mutism.
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5. Negative Symptoms (Psychotic symptom domains cont)
Diminished emotional expression (verb and non verb)
Avolition (decrease in self initiated purposeful activities)
Alogia (diminished speech output)
Anhedonia
```
Negative symptoms: thoughts behaviours perceptions that normally exist and are now absent/diminished
Positive symptoms (categories 1-4) - thoughts behaviours perceptions that are distorted or in excess of normal function
```
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**Schizophrenia
An Active Phase for >or eq to 1 month, defined as
- at LEAST 2 psychotic domain symptoms, with at least ONE being a core symptom (1-3)
1. Delusions 2. Hallucinations 3. Disorganized Speech 4. Grossly disorganized behavriour 5. Negative symptoms
- At LEAST ONE symptom persists for > or eq to 6 MONTHS
Timeline: Signs of disturbance > 6 months
Ie prodromal phase, active phase (must be >1 month), residual phase
Prodromal and residual often only negative and or psychotic symptoms in subthreshold forms
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Schizophrenia other interest points
Subtypes - DSM no longer subtypes it except to specify with catatonia
But the presentation varies depending on symptoms
Differential: substance induced psychosis
Associated features: low SES attainment (downward drift), nicotine addiction (comorbid), suicide risk and aggressive tendencies (ie if command hallucinations, or feels threatened)
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Schizophrenia Epidemiology, Onset, and course
Approx 1%, no gender bias
Typical onset: late teens, slightly later in women
Late onset: >40 years, more likely female with positive symptoms and less severe course
Childhood onset: <13 years, severe form with notable neurodegeneration
Course: chronic with slow gradual decline or fluctuating symptoms, moderate to severe disability with episodic hosp. Not always like this but not good progrnostics.
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Schizophrenia outcome predictors
```
Better if
Age of onset is older
Rapidity of onset is faster
Type of symptoms are positive
Mood symptoms are present
Gender is female
```
Worse if all of the above are opposite.
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Hypotheses of schizophrenic symptoms - Dopamine Hypothesis
1. Positive symptoms: Overactivity of Mesolimbic DA (VTA to basal forebrain)
2. Negative symptoms: underactivity of mesocortical DA (VTA to prefrontal cortex)
Insufficient - other neurotransmitters are dysregulated
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Neuropathology of schizophrenia - changes
Neurostructural:
enlarged lateral ventricles (Ventriculomegaly)
Cortical and hippocampal atrophy
Decreased volume of thalamus
Neurofunctional changes : hypofrontality (decreased prefrontal metabolism)
Neurocognitive effects: impairment in multiple areas incl attention, memory, executive functions etc.
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Neurodevelopmental theory of schizophrenia
A lesion occurs during early brain development
No immediate effects, seen as affected structures come on line with brain maturation, effects also influenced by impact of environmental factors.
Evidence for a lesion: hippocampal cellular disorganisation, increased neurological soft-signs, increased minor physical anomalies.
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Treatment of schizophrenia
Antipsychotics - mainstay ie neuroleptic, tranquillisers
All are dopamine (D2) receptor antagonists (DA2)
But some block DA2 receptors more potently, some block additional types
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Chlorpromazine (thorazine, 1954), also haloperidol ie aldol
1st antipsychotic drug used for schizophrenia
Another example of antipsychotic is haloperidol (Haldol)
DA2 antagonist
Improves positive symptoms
Side effects: Extrapyramidal syndrome (EPS) due to nigrostriatal DA2 blockade -
EPS: dystonia (often within first week), parkinsonism (1st few months), akathisia(1st few months, restless), tardive dyskinesia (years, repetitive involuntary mvmt)
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Extrapyramidal symptoms (EPS) from Da2 antagonists block of nigrostriatal pathway
Dystonia: sustained muscle contractions (head neck) dvlp within first week
Parkinsonianism: first few months
Akathisia: first few months, excessive movements due to inner restlessness
Tardive dyskinesia: long term side effect (years) repetitive, involuntary, purposeless movements often in face and extremities.
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Neuroleptic malignant syndrome (NMS)
Antipsychotic side effects. Fast drop in DA
Tachycardia, HTN, rapid resp, fever, extreme rigidity, delirium death
WIthin two weeks of starting or changing dose
Likely a Precipitous drop in DA affecting hypothalamic functioning
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Atypical antipsychotics
Clozaril (clozapine) (2% agranulocytosis risk)
Risperidone (risperdal), olanzapine (zyprexa)
mechanism: antagonists of Da2 3 4 and 5HT 2A receptors
Improves positive and negative symptoms
Decreased risk of EPS
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Additional side effects of all antipsychotics
Weight gain, sedation, sexual dysfunction
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Schizophreniform Disorder
At least one month of ACTIVE PHASE symptoms
| Signs of the disturbance last less than 6 months.
103
Brief psychotic Disorder
At least 1 CORE psychotic domain symptom
1. Delusions 2. Hallucinations 3. Disorganized Speech
Episode lasts < 1 month (less than)
Person returns to full premorbid functioning
Specify "with marked stressor" or "without marked stressor" (based on trigger of episode)
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Delusional Disorder
Presence of a delusion
Must last > or eq to 1 month
No other psychotic domain symptoms
No functional impairment aside form the direct impact of the delusion
Subtypes: persecutory, grandiose, erotomanic, jealous type, somatic type (parasitoses, malodorous, organ gone), unspecified type
For somatic type, if delusion is appearance related then it is "BDD with absent insight (delusional belief)"
Specify: if with bizarre content (non-bizarre could happen , bizarre is aliens etc.)
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Schizoaffective Disorder
Active phase of schizophrenia occurs CONCURRENTLY with a major mood episode (MDE or manic episode)
EXTRA Active phase lasts > or eq to 2 weeks WITHOUT mood symptoms
Mood symptoms are present for the majority of the total duration of symptomatic periods of the illness
IE SCHIZO PLUS MDE OR MANIA, TWO WEEKS ONLY SCHIZO AF, PLUS ACTIVE PHASE WITH MDE OR MANIA
Subtypes: bipolar type (if mania) or depressive type (if depression experienced but not mania)
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Erik Erikson Psychosocial Development
Each stage of life has its own psychosocial task
Epigenetic principle: each builds on the previous one
Resolution of each crisis = maturation
WIth maturation, lower stages acquire new meanings`
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Erikson's stages Birth-1
Hope - trust vs mistrust
| If needs are dependably met, infants develop a sense of basic trust
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Eirkson's stages 1-3 years
WILL Autonomy vs shame and doubt
| Toddlers learn to exercise will and do things for themselves, or they doubt their abilities
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Erikson;s stages 3-6 years
PURPOSE
Initiative vs guilt
Preschoolers learn to initiate tasks and carry out plans, or they feel guilty about efforts to be independent
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Somatic Symptom Disorder (SSD)
>Eq to 1 distressing/disruptive somatic symptom AND at least ONE indicator of excessive thoughts/feelings behaviours about the symptom
Diagnosis relies on abnormal behaviours thoughts feeling in response to the distressing somatic symptom focus NOT on whether there is a medical explanation. Could have an explanation and STILL have SSD
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Illness Anxiety Disorder (IAD)
Preoccupation with having/acquiring an illness
Somatic symptoms are NOT present, or if they are they are mild
Patient performs excessive health related behaviours or maladaptively avoids health care
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Comparison of SSD to IAD
SSD ; patient has distressing physical complaint with EXCESIVNESS in response
IAD: patient does NOT have distressing complaint but still worries about health
113
Differentials for SSD and IAD
Delusion Disorder (DD), somatic type
BDD (Body dysmorphic disorder)
1. In DD the belief is held with delusional intensity, more severe
2. In BDD concern is about appearance not symptom or health
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Conversion Disorder (Functinoal neurological symptom)
Altered voluntary motor or sensory function
Evidence of incompatibility between the symptom and neurological conditions - key, that it is not compatible with neurological disease
Onset: typically sudden after major stress
Often LA BELLE INDIFFERENCE REACTION to their disability
115
Fictitious Disorders
2a. Munchausen's syndrome - fictitious disorder imposed on self, patient feigns symptoms in oneself, for no obvious external reward
2b) factitious disorder imposed on another (munchausens syndrome, by proxy) - feigns symptoms in another person
*pseudologia fantastica
NOT malingering
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Anorexia Nervosa
Restriction of food that leads to being significantly underweight (based on BMI)
18.5 BMI is lower limit of normal
Adults less than 17 clearly below, 18.5 grey zone
Children 2-18 years: BMI < 5th percentile
1. intense fear of weight gain
2. Body image disturbance
Subtypes: binge eating/purging type - one or both - purge = vomiting, laxatives, diuretics, enemas.
Restricting type - weight loss through dieting, fasting, exercise
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Indicators of excessive vomiting
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Calloused knuckles (russel's sign)
Dental enamel erosion, salivary gland inflammation (chipmunk cheeks), subconjunctival hemorrhage, hypokalemia
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Vomiting commonly occurs in anorexia and bulemia, but not an essential symptom of either
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Bulimia Nervosa
1. Recurrent binge eating
- eating a large amount in a discrete period - eating is out of control during episode
2. Recurrent inappropriate compensatory behaviour for binge - purging, or non-purging ie fasting, excessive exercise.
3. Bine/inapp compensatory behaviours MUST OCCUR > 1 /WEEK FOR 3 MONTHS
4. Self eval is unduly influenced by body shape and weight
~ low serotonin assoc.
~ typically seeks treatment unlike anorexia, bc disorder is distressing
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Binge Eating Disorder (BED)
1. Binge eating at least 1/week for 3 months
2. Binge eating associated with : rapid eating, uncomfortable full, when not hungry, alone due to shame, feeling disgusted and guilty
3. NO inappropriate compensatory behaviour
Often associated with obesity.
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Subclinical eating problems - ie Unspecified eating disorder
Ie woman BMI = 22 frequently purges but does not binge eat
| Woman with BMI = 25 binges and purges but does so only once per month
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Erikson's stages 6-12 years
COMPETENCE
Industry vs inferiority
Children learn the pleasure of applying themselves to tasks, or they feel inferior
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Erikson's stages 12-20
FIDELITY
Identity vs role confusion
Teenagers work at refining a sense of self by testing roles and then integrating them to form a single identity, or they become confused about who they are
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Erikson's stages 20-40
LOVE
Intimacy vs isolation
Young adults struggle to form close relationships and to gain the capacity for intimate love, or they feel socially isolated
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Erikson's stages 40-60
CARE
Generativity vs stagnation
The middle-aged discover a sense of contributing to the world, such as through family and work, or they may feel a lack of purpose
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65+ eirkson's
WISDOM
Integrity vs despair
When reflecting on his or her life, the older adult may feel a sense of satisfaction or failure
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Leading causes of adolescent mortality (15-19, UNITED STATES)
1. Accidents - unintentional injuries (motor vehicle)
2. Suicide - males 3-4x females
3. Homicide - males 4x females
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Leading cause of adolescent mortality (GLOBAL)
1. Road injury
2. HIV
3. Suicide
4. Lower respiratory infections
5. Interpersonal vitamin
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Kohlberg's Theory of Moral reasoning (three levels)
1. Preconventional - reasoning based on personal benefit
2. Conventional - reasoning based on fulfilling the expectations of others, incl. following rules
3. Postconventional - reasoning based on strict adherence to personal principles
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Kohlberg's Stages of oral reasoning
Preconventional:
1. Punishment orientation - obey rules to avoid punishment
2. Reward orientation - conform to obtain rewards and favours
Conventional:
3. Good boy/girl - conforms to avoid disaproval
4. Authority orientation - upholds social rules to avoid censure and guilt
Postconventional
5. Social contract orientation - guided by commonly agreed principles essential to public welfare - upheld to retain respect of peers and self-respect
6. Ethical principle orientation - actions guided by self-chosen ethical principles whic h usually value justice, dignity, and equality - upehld to avoid self-condemnation.
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Decline in cognitive abilities ages 74-84 from greatest to least
1. Memory (steady decline)
2. Speed *
3. Everyday cognition*
4. Reasoning*
5. Vocabulary*
* = precipitous decline from 79-80
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Crystallized intelligence
Increases with age. Accumulated knowledge as reflected in vocabulary and analogies tests
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Fluid intelligence
Decreases with age (ability to reason speedily and abstractly when solving novel logic problems.
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Leading causes of death in US ages 25-44
1. Unintentional Injuries
2. Cancers
3. Heart disease
4. Suicide
5. Homicide
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Leading causes of death in US ages 45-64
1. Cancers
2. Heart Disease
3. Unintentional injuries
4. Chronic lower respiratory disease
5. Diabetes
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Leading causes of death in US ages 65+
1. Heart Disease
2. Cancers
3. Chronic lower respiratory disease
4. Cerebrovascular disease
5. Alzheimer's disease
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Leading cause of death in US ages 85+
1. Heart disease
2. Cancer
3. Stroke
4. Alzheimer's
5. Chronic lower resp disease
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Kubler-Ross 5 stages of dying
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
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Intellectual Disability
1. Intelligence Deficit >2 SDs below mean
And 2. Deficits in ADAPTIVE function in conceptual, social practical
AND 3. Onset DURING development
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Global Development Delay
A. Fails several milestones of intellectual function
B. Severity CANNOT be reliably assessed
C. DIagnosis ONLY for children <5 years
D. Reassessment required
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Language Disorder
1. Persistent difficult acquisition and use - decr. Vocal, limited sentence, impaired discourse
2. Substantially BELOW age expectations
3. Early developmental onset
4. Not attributed to sensory, motor, or other dysfunction.
Diagnosis < 4 yo may be unreliable.
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Intellectual disability (ID) subtypes
Based on ADAPTIVE function
Mild (85%) - 6th grade level
Moderate (10%) - 2nd grade level
Sever (3-4%) limited vocab, pre-academic skills (alphabet, colours)
Profound (1-2%) associated with severe handicaps, dependent.
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Speech Sound Disorder
A. Persistent diff. W/speech sound production interference w intelligibility and verbal communication
B. Limitations in communication, interferes with social, academic
C. Early developmental onset
D. NOT due to congenital, accquired, medical, neuro, hearing loss, brain injury (speech should be intelligible by 3-4).
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Social pragmatic communication disorder
A. Social use of verbal and non-verbal comm 1. Deficits using 2. Impaired context matching 3. Following rules 4. Undrerstanding implicit meaning
B. Functional limitation, interfering with social, academic, occupation.
C. Early developmental onset
D. NOT due to word structure, grammar, abilities, medial cond. Rarely make diagnosis before 4-5
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Autism Spectrum Disorder
A. Persistent deficits in social communication and interaction incl social emotional reciprocity, non verbal comm probs ie eye contact, relationships
B. Restricted, Repetitive Behaviour ie >2 of
1. Stereotyped movements 2. Adherence to routines 3. Fixated interestes 4. Sensory hypo/hyperreactivity or unusual sensory interest
C. Symptoms usually early developmental period (usually by 2)
D. Cause significant impairment social, occupational etc.
Severity levels 1, 2, 3
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Intellectual Disability
A. Deficits in intelligence - as measured by clinical assesment
B. Deficits in ADAPTIVE function - limit funcitoning one or more daily life activity
C. Onset DURING DEVELOPMENTAL PERIOD
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Intelligence Tests
Weschler Adult Intelligence Scale (WAIS) M 100 SD 15
Weschler Intelligence Scale for Children (WISC) M 100 SD 15
Stanford-Binet Intelligence Scale M 100 SD 16
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Personality Disorders Onset and Course, Treatment
Childhood-adolescence, behaviours solidifying with age.
Treatment: CBT, medications may be use adjunct. Treatment difficult due to patient disinterest and difficulty in unlearning behaviours
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Paranoid Personality Disorder (Cluster A)
Theme: Distrust and Suspiciousness
Differential: DD (persecutory type). In DD the paranoid thought is believed with certianty. in PPD paranoid thought is suspected. PPD symptom onset is gradual, and starts in childhood with pervasive paranoia. DD is middle age, sudden onset, single delusion
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Schizoid Personality Disorder (Cluster A)
Theme: Interpersonal detachment, l
| ie lacks desire for close relations, prefers solitary, indifference
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Schizotypal Personality Disorder (cluster A)
Theme: Eccentric - social and interpersonal deficits, odd speech, beliefs in paranormal phenomenon, odd appearance/behaviour.
In the schizophrenia spectrum - DON'T have psychotic symptoms (delusions hallucinations), but MAY eventually develop them ie could be the premorbid personality of schizophrenia.
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Histrionic personality Disorder (cluster B)
Theme: excessive emotaionlity
Needs to be ctr of attention, physical appearnace for attention, inappropriate behaviour, shallow rapidly shifting emotions
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Borderline Personality Disorder (Cluster B)
Relationships: unstable, intense with alt idealization and devaluation (splitting), avoids abandonment. Emotions: intense uncontrolled anger, reactivity of mood, chronic emptiness. Unstable self, self-damaging impulsiveness, suicidal, self mutilation, transient stress relatione
Theme: instability
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Narcissistic Personality Disorder
Theme: Grandiosity
Grandiose sense, preoccupied with success, req admiration, entitlement, interpersonally exploitative, lacks empathy. A narcissistic injury (blow) may result in rage reaction.
Differntials: DD grandiose type (in DD person has a single belief of delusional proprotion, NPD is general arogance. DD patients have an abrupt and older age of onset.
BP I: involves a mood disturbance with more symptoms than grandiosity.
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Antisocial Personality Disorder (ASPD)
Theme: pervasive disregard for other;s rights
Repeated unlawful acts, decietful, irritable, reckless disregard, irresponsible, lack of remorse
Not even on kohlberg's spectrum
Must be at least 18 yo
Must be evidence of conduct disorder before age 15
Assoc with lack of physioligcal reactivity to stressors (amygdlaa?)
Psychopath/sociopath - often used synonymously, but is only a research subset of ASPD
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PDD Persistent Depressive Disorder
Chronic depressed mood for greq to 2 years. Depressed mood is either a long lasting MDE OR dysthymia (>/2 of poor appetite or overeating, insomnia/hypersomnia, low energy, low self esteem, trouble concentrating making decisions, feelings of hopelesssness
Specifiers: with pure dysthymic
with persistent MDE
with intermittent MDEs
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Treatment for PMDD (premenstrual)
Several SSRI's are approved for treatment
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DMDD (Disruptive mood dysregulation disorder)
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SEvere temper outburts at least 3x per week.
Sad irritable or angry mood almost daily
Reaction disprop to situation
Symptoms present in multiple settings
Child must be at least 6 yo
SYmtpoms must begin before age of 10
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Conduct Disorder
Repeated, serious violation of rights/societal norms. Multiple symptoms in/across - aggressive conduct, deliberate property destruction, deceit/theft, serious rule violation.
Childhood onset (<10 yrs) : mostly boys, often ODD history, increased ASPD risk
Adolescent onset (> or eq 10 yrs): less boy bias, "serious violation of rules"
multifactoiral - temperament and parenting
Treat with anger management, parent education
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IED Intermittent Explosive DIsorder
Recurrent outburts, failure to control, manifest either as
- verbal aggression or non damaging physical aggressions FREQUENTLY
OR
- damaging physical aggression infrequently.
Aggression disporortionate, impulsive, normal mood usually and feel guilty after
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Neurological Correlates for impulsivity
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Decreased serotonin (decreased prefrontal impulse control)
Increased dopamine (reward centres)
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Cataplexy
Sudden loss of muscle tone, typically precipitated by emotions, considered an aberrant manifestation of REM sleep.
Other REM related behaviours might be present but are NOT diagnostic criteria: sleep paralysis, hypnagogic (upon falling asleep) hallucinations
hypnopompic (upon awakening) hallucinations
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Hypocretin (orexin) deficiency
Spinal tap needed
| hypothalamic neuropeptide, deficiency may be autoimmune.
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Gender Dysphoria
Marked incongruence between assigned and experienced gender. Clin significant distress/impairment. Symptoms at least 6 months.
Etiology: XY not androgenized at typical time (female identity dvlp)
XX is androgenized (male ident dvlp)
Atypical size of INAH 3, bed nucleus of stria terminalis
Smaller nuclei in females (and trans females)
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Dyspareunia
Genital pain during intercourse
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Vaginismus
Vaginal contraction upon attempted coitus causing penetration difficulties/pain
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Megan's law
Personal information about some registered sex offenders is available publicly.
