First Aid: Psychiatry Clerkship – Flashcards
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What are delusions?
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Fixed, false beliefs that cannot be altered by rational arguments and cannot be accounted for by the cultural background of the individual 1. Delusions of persecution/paranoid delusions 2. Ideas of reference 3. Delusions of control 4. Delusions of grandeur 5. Delusions of guilt 6. Somatic delusions
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What are delusions of persecution/paranoid delusions?
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Irrational belief that one is being persecuted CIA is after me and tapped my phone
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What is ideas of reference?
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Belief that cues in the external environment are uniquely related to the individual Jesus is speaking to me though TV characters
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What are delusions of control?
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Includes thought broadcasting (belief that ones thoughts can be heard by others) and thought insertion (belief that other people thoughts are being placed in ones head)
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What are delusions of grandeur?
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Belief that one has special powers beyond those of a normal person I am the all powerful son of god and I shall bring down my wrath on you if I don't get my way
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What are delusions of guilt?
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False belief that one is guilty or responsible for something I am responsible for all the worlds wars
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What are somatic delusions?
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False belief that one is infected with a disease or has a certain illness
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What is an illusion?
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Misinterpretation of an existing sensory stimulus (mistaking a shadow for a cat)
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What are hallucinations? Types?
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Sensory perception without an actual external stimulus 1. Auditory - schizophrenic 2. Visual - drug intoxication, drug or alcohol withdrawal, delirium 3. Olfactory - aura associated with epilepsy 4. Tactile - drug abuse or alcohol withdrawal
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What are the medical causes of psychosis?
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1. CNS disease 2. Endocrinopathies 3. Nutritional and vitamin deficiency states
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What is the difference between delusion, illusion, and hallucination?
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Delusion - false belief Illusion - misinterpretation of an external stimulus Hallucination - perception in the absence of an external stimulus
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What medications and substances cause psychosis?
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Corticosteroids, antiparkinsonian agents, anticonvulsants, antihistamines, anticholinergics, beta blockers, digitalis, methylphenidate, fluoroquinolones Alcohol, cocaine, hallucinogens (LSD, ecstasy), marijuana, benzo, barbiturates, pcp
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What are the five A's of schizophrenia? (Negative symptoms)
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Anhedonia, affect (flat), alogia (poverty of speech), avolition (apathy), attention (poor)
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What is paranoid schizophrenia?
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Higher functioning Older age of onset Preoccupation with one or more delusions or frequent auditory hallucinations No predominance of disorganized speech, disorganized, or catatonic behavior, or inappropriate affect
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What is disorganized schizophrenia?
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Poor functioning type, early onset Disorganized speech, behavior, flat or inappropriate behavior
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What is catatonic schizophrenia?
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Characterized by rigid posture, inappropriate or repetitive and purposeless movements, echolalia (repeating what someone else says), echopraxia (copying easy someone else does)
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What is undifferentiated schizophrenia?
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Characteristic of more than one subtype or none of the subtypes
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What is residual schizophrenia?
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Prominent negative symptoms (flattened affect or social withdrawal) with only minimal evidence of positive symptoms (hallucinations or delusions)
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What are positive symptoms?
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Hallucinations, delusions, bizarre behavior, disorganized speech Respond to current antipsychotic medications
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What are negative symptoms?
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Blunted affect, anhedonia, apathy, alogia, lack of interest in socialization Treatment resistant and contribute significantly to social isolation of schizophrenic patients
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What are cognitive symptoms?
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Impairments in attention, executive function, working memory Leads to poor work and school performance
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What are the three phases of schizophrenia?
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1. Prodromal - decline in functioning that precedes the first psychotic episode, patient may become socially withdrawn and irritable, new found interest in religion occult 2. Psychotic - perceptual disturbances, delusions, disordered thought process/content 3. Residual - occurs between episodes of psychosis, marked by flat affect, social withdrawal, odd thinking or behavior (negative symptoms)
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What is the criteria for schizophrenia?
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Two or more of the following must be present for at least one month: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms (flattened affect) Only one of the above symptoms are required if delusions are buzzard or hallucinations consist of a voice keeping up a running commentary on the persons behavior or thoughts, or two or more voices conversing with each other Duration of illness for at least 6 months
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What are the time frames for brief psychotic disorder, schizophreniform, and schizophrenia?
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Brief psychotic disorder - 1 month Schizophreniform - between 1 and 6 months Schizophrenia - greater than 6 months
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What are some epi characteristics of schizophrenia?
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Men - present by 20; more negative symptoms and impaired social functioning Women - present at 30 People born in winter and early spring have higher incidence Downward drift - low levels of function results in shift to low socioeconomic group
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What are the dopamine pathways affected in schizophrenia?
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Prefrontal mesocortical - inadequate dopaminergic activity responsible for negative symptoms Mesolimbic - excessive dopaminergic activity responsible for positive symptoms
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What are the dopaminergic pathways affected by neuroleptics?
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Tuberoinfundibular - blocked by neuroleptics, causing hyperprolactinemia (gynecomastia, galactorrhea, menstrual irregularities) Nigrostriatal - blocked by neuroleptics, causing extra pyramidal side effects such as tremor, slurred speech, akathisia, dystopia, other abnormal movements
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What are the neurotransmitter abnormalities implicated in schizophrenia?
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1. Elevated serotonin - atypical antipsychotics like risperidone and clozapine antagonize serotonin and weakly antagonize dopamine 2. Elevated NE - decreased activity of noradrenergic neurons. 3. Decreased GABA - decreased expression of enzyme necessary to create GABA in the hippocampus 4. Decreased levels of glutamate receptors - schizophrenic patients have fewer NMDA receptors, correlates with psychotic symptoms observed with NMDA antagonists like ketamine
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What do CT scans of patients with schizophrenia show?
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Enlargement of ventricles and diffuse cortical atrophy
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What factors are associated with better prognosis in schizophrenia?
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Later onset, good social support, positive symptoms, mood symptoms, acute onset, female sex, few relapses, good premorbid functioning
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What factors are associated with worse prognosis in schizophrenia?
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Early onset, poor social support, negative symptoms, family history, gradual onset, male sex, many relapses, poor premorbid functioning, comorbid substance abuse
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What is a predisposing factor to paranoid psychosis?
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Deafness
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What is neologism?
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Use of words that have meaning only to the person who uses them and is different than the orthodox meaning of the word
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What are the first generation antipsychotic medications?
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Chlorpromazine, thioridazine, trifluoperazine, haloperidol Dopamine antagonists More effective against positive symptoms, minimal impact on negative symptoms Side effects - extra pyramidal symptoms, neuroleptic malignant syndrome, tardative dyskinesia
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What are the second generation antipsychotic medications?
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Risperidone, clozapine, olanzapine, quetipine, aripiprazole, ziprosidine Antagonize serotonin receptors (5HT2) and dopamine receptors More effective than older antipsychotic medications Much lower incidence of extrapyramidal side effects Increased risk of metabolic syndrome (screen waist circumference, BMI, fasting blood glucose, lipid assessment, blood pressure) Medications taken for at least four weeks before efficacy is determined Clozapine is reserved for patients who have failed multiple antipsychotic trials due to increased risk of agranulocytosis
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What are the side effects of antipsychotic medications?
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EPS - high potency traditional: dystonia of face, neck, tongue; parkinsonism (resting tremor, rigidity, bradykinesia), akathisia (restlessness) Anticholinergic symptoms (low potency traditional and aytpical) - dry mouth, constipation, blurred vision Metabolic Syndrome (second generation antipsychotics): increased BP, insulin levels, body fat around waist, abnormal cholesterol, risk of CV, stroke, DM 2 Tardive dyskinesia (high potency): darting or writhing movements of face, tongue, and head NMS (high potency) - change in mental status, autonomic changes (high fever, elevated BP, tachycardia), lead pipe rigidity, sweating elevated CPK, leukocytosis, metabolic acidosis Prolonged QT Hyperprolactinemia - gynecomastia, galactorrhea, amenorrhea, diminished libido, impotence
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What is the treatment for extrapyramidal symptoms?
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antiparkinsonian agents (benztropine, diphenhydramine), benzo, beta blockers (indicated for akathisia)
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What are the weight neutral second generation antipsychotics?
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Aripiprazole Ziprasidone
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What is the adverse effect of clozapine?
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agranulocytosis
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What is the adverse effect of thioridazine?
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retinitis pigmentosum
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What is the adverse effect of chlorpromazine?
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corneal deposits
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What two medications exacerbate psychosis in predisposed individuals?
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Digoxin Beta blockers
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What is the diagnostic criteria for schizophreniform disorder?
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Symptoms of schizophrenia for between 1-6 months Two or more of the following must be present for at least one month: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms (flattened affect) Only one of the above symptoms are required if delusions are buzzard or hallucinations consist of a voice keeping up a running commentary on the persons behavior or thoughts, or two or more voices conversing with each other
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What is the diagnostic criteria for schizoaffective disorder?
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Meet criteria for depressive episode, manic episode, mixed episode (during which criteria for schizophrenia are also met) Had delusions or hallucinations for 2 weeks in the absence of mood disorder symptoms (this condition is necessary to differentiate schizoaffective disorder from mood disorder with psychotic features) Have mood symptoms present for substantial portion of psychotic illness Have symptoms not due to general medical condition or drugs
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What is the criteria for brief psychotic disorder?
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Patients with psychotic symptoms as defined for schizphrenia that last 1 day to 1 month often due to extreme stress such as bereavement, sexual assault
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What is the criteria for delusional disorder?
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More often in older patients (after age 40), immigrants, and hearing impaired Nonbizzare, fixed delusions for 1 months Does not meet criteria for schizophrenia Functioning in life is not significantly impaired
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What is an erotomanic type delusion?
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Delusion revolves around love
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What is a grandiose delusion?
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inflated self worth
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What is a somatic delusion?
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physical delusion
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What is a persecutory delusion?
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delusions of being persecuted
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What is a jealous delusion?
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delusions of unfaithfullness
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What is a mixed delusion?
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more than one of the following: erotomanic, grandiose, somatic, persecutory, jealous
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Compare and contrast schizophrenia and delusional disorder
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Schizophrenia: bizzare delusions, daily functioning impaired, must have two or more of the following - delusions, hallucinations, disorganized speech, disorganized behavior, negative symptoms Delusional: nonbizzare delusions (never bizzare), daily functioning not significantly impaired, does not been criteria for schizophrenia
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What is the criteria for shared psychotic disorder?
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folie a deux Patients develops delusions as someone he/she is in a close relationship with (family members) Rx: separate patient from source of delusions
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Cultural specific psychosis: koro
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patient believes penis is shrinking and will disappear causing his death Asia
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Cultural specific psychosis: amok
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sudden unprovoked outbursts of violence of which the person has no recollection Person commits suicide afterwards Malaysia, Southeast Asia
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Cultural specific psychosis: brain fag
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Headache, fatigue, visual disturbances in male students Africa
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What is the prognosis from best to worst of psychotic disorders?
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Mood disorder > brief psychotic disorder (less than one month) > schizoaffective disorder > schizophreniform disorder (1-6 months) > schizophrenia (greater than 6 months)
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Describe the distinguishing features of psychotic disorders
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Schizophrenia - lifelong psychotic disorder Schizophreniform - schizophrenia for less than 6 months Schizoaffective - schizophrenia + mood disorder Schizotypal - personality disorder, paranoid, odd, or magical beliefs, eccentric, lack of friends, social anxiety. criteria for true psychosis are not met schizoid - withdrawn, lack of enjoyment from social interactions, emotionally restricted
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What is the criteria for major depressive episode?
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Depressed mood, anhedonia (loss of interest in pleasurable activities), change in appetite or body weight, feelings of worthlessness or excessive guilt, insomnia, hypersomnia, diminished concentration, psychomotor agitation or retardation (restlessness, slowness), fatigue or loss of energy, recurrent thoughts of death or suicide SIGECAPS
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What is the criteria for manic episode?
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Abnormally elevated, expansive, or irritable mood for at least one week At least three of the following (four if mood is irritable):distractible, inflated self esteem or grandiosity, increased in goal directed activity (socially, at work, or sexually), decreased need for sleep, flight of ideas, more talkative or pressured speech, excessive involvement in pleasurable activities with high risk of negative consequences (shopping, sexual indiscretions) DIGFAST Manic episode is a psychiatric emergency
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Compare and contrast mania and hypomania
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Mania - lasts 7 days, causes severe impairment in social or occupational functioning, may necessitate hospitalizations to prevent harm to self or others May have psychotic features Hypomania - lasts at least 4 days, no marked impairment in social or occupational functioning, does not require hospitalization, no psychotic features
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What is a mixed episode?
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Criteria met for both manic episode and major depressive episode Present nearly every day for at least one week Psychiatric emergency
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What are the medical causes of depressive episode?
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cerebrovascular disease (stroke, MI) endocrinopathies (DM, cushing, addison, hypoglycemia, thyroid disease, hyper/hypoprolactinemia Parkinsonsviral illness (mono)carcinoid syndromecancer (lymphoma, pancreatic ca)collagen vascular disease (SLE)
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What are the medical causes of manic episode?
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Metabolic (hyperthyroidism) Neurological disorders (temporal lobe seizures, MS) Neoplasms HIV infection
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What are the medication/substances that induce depressive episodes?
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ETOH AntiHTN Barbituates Corticosteroids Levodopa Sedative-hypnotics Anticonvulsants Antipsychotics Diuretics Sulfonamides Withdrawal from psychostimulants (cocaine, amphetamines)
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What are the medication/substances that induce manic episodes?
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Antidepressants Sympathomimetics Dopamine Corticosteoids Levodopa Bronchodilators
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What is the criteria for major depressive disorder?
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At least one major depressive episode No history of manic or hypomanic episodes
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What are the sleep problems associated with major depressive disorder?
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multiple awakeningsinitial and terminal insomnia hypersomnia rapid eye movement (REM) sleep shifted to earlier in night and stages 3 and 4 decrease
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What is the etiology of depression?
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Decreased brain and CSF levels of serotonin and 5HIAA Abnormal regulation of beta adrenergic receptors Drugs that increase serotonin, NE, and dopamine alleviate symptoms High cortisol: hyperactivity of HPA axis as shown by failure to suppress cortisol levels in dexamethasone suppression test Abnormal thyroid axis: thyroid disorders are associated with depressive symptoms GABA and endogenous opiates may have a role Psychosocial/life events - better prognosis with stable family and social functioning Genetics: first degree relatives have increased risk, loss of parent before age 11
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What is the Hamilton Rating Score?
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standard measure of depression severity that is used in research to assess the effectiveness of therapies
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What are the adverse effects of SSRI?
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Headache GI disturbance Sexual dysfunction Rebound anxiety
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What are the adverse effects of TCAs?
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Sedation, weight gain, orthostatic hypotension, anticholinergic effects Prolonged QT
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What are the adverse effects of MAOIs?
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Useful for treatment of refractory depression Risk of hypertensive crisis when used with sympathomimetics or ingestion of tyramine rich foods (wine, beer, aged cheeses, liver, smoked meats), orthostatic hypotension
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What is serotonin syndrome?
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Autonomic instability, hyperthemia, seizures, coma/death
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What are the adjunct medications for depression?
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Stimulates (methylphenidate) Antipsychotics Liothyronine, levothyroxine, lithium, l-tryptophan
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What is electroconvulsive therapy?
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Performed by premedication with atropine, followed by general anesthesia, and administration of muscle relaxant Generalized seizure induced by passing a current of electricity across the brain (unilateral or bilateral) - seizure lasts less than 1 minute Eight treatments administered over 2-3 week period Retrograde and anterograde amnesia is common side effect (disappears within 6 months) Side effects: headache, nausea, muscle soreness
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What are the characteristics of melancholic depression?
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Anhedonia, early morning awakenings, psychomotor disturbance, excessive guilt, anorexia
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What are the characteristics of catatonic depression?
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catalepsy (immobility), purposeless motor activity, extreme negativism, mutism, bizarre postures, echolalia Responsive to ECT Applied to bipolar disorder
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What are the characteristics of atypical depression?
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Hypersomnia, hyperphagia, reactive mood, leaden paralysis, hypersensitivity to interpersonal rejection
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What are the characteristics of psychotic depression?
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Presence of delusions or hallucinations
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What are the five stages of grief (Kubler Ross model)?
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1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance
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What is normal grief?
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Illusions common Suicidal thoughts are rare Lasts <2 months
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What is the criteria for Bipolar I?
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One manic or mixed episode (manic episode lasts 3 months) Psychotic features (delusions or hallucinations) during major depressive or manic episodes onset - before age 30 Highest genetic link of all psychiatric disorders
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What is rapid cycling?
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Four or more mood episodes in one year
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What are the side effects of lithium?
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weight gain, tremor, GI disturbance, fatigue, cardiac arrythmias, seizures, goiter/hypothyroid, leukocytosis, coma, polyuria (nephrogenic diabetes insipidus), polydipsia, alopecia, metallic taste
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What are the treatment options for Bipolar I?
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Lithium - mood stabilizer, low therapeutic index Anticonvulsants (carbamazepine, valproic acid) - useful for rapid cycling bipolar disorder and mixed episodes, increased risk of suicide Atypical antipsychotics (olanzapine, quetiapine, ziprasidone) - acute mania Antidepressants discouraged as monotherapy due to concerns of activating mania or hypomania ECT - refractory or life threatening acute mania or depression
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What is the criteria for bipolar II?
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major depressive disorder and at least one hypomanic episode more common in women misdiagnosed at unipolar depression
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What are the symptoms of dysthymic disorder?
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Poor concentration or difficulty making decisions Feelings of hopelessness Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem
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What is the criteria for dysthymic disorder?
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Depressed mood for most days for at least 2 years (children/adolescents for at least 1 year) At least two of the following: poor concentration, Feelings of hopelessness, Poor appetite or overeating, Insomnia or hypersomnia , Low energy or fatigue, Low self-esteem During the two year period: person has not been without above symptoms for >2 months at a time, no major depressive episode, no manic or hypomanic episode 2 years, 2 listed criteria, never asymptomatic for >2months Rx: cognitive therapy and insight oriented psychotherapy are most effective
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What is the criteria for cyclothymic disorder?
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Hypomanic symptoms and periods with depressive symptoms for at least 2 years Never been symptom free for >2 months during those 2 years No hx of major depressive episode or manic episode coexist with borderline personality disorder
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What is seasonal affective disorder?
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2 consecutive years of two major depressive episodes during the same season Triad: irritability, carb craving, hypersomnia
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What is postpartum depression?
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Onset within 4 weeks of delivery
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What is the criteria for adjustment disorder?
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Symptoms begin 3 months after stressful life event that is not life threatening and end within 6 months after stressor has terminated Symptoms are not those of bereavement
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What are the symptoms of anxiety?
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Palpitations, tachycardia, HTN SOB, choking sensation Dizziness, light headedness, hyperreflexia, mydriasis, tremors, tingling in the peripheral extremities Restlessness Sweating, GI, urinary urgency and frequency
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What is the criteria for panic attack?
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Palpitations Abdominal distress Numbness, nausea Intense fear of death Choking, chills, chest pain Sweating, shaking, SOB Peak within 10 min and lasts <25min Associated with MVP, asthma, pulmonary embolus, angina, anaphylaxis
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What are medical causes of anxiety disorder?
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Hyperthyroidism Vit B12 deficiency Hypoxia Neurological disorders (epilepsy, brain tumors, MS, cerebrovascular disease) CV disease Anemia Pheochromocytoma Hypoglycemia
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What are the medication/substance induced anxiety disorders?
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Caffeine Theophylline Amphetamines Alcohol/sedative withdrawal Mercury/arsenic toxicity Organophosphate or benzene toxicity Penicillin Sulfonamides Sympathomimetics Antidepressants
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What is the neurotransmitter imbalances in anxiety?
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Increased activity of NE Decreased activity of GABA and serotonin
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What is the criteria for panic disorder?
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recurrent panic attacks with no obvious precipitant last 20-30min anticipitory anxiety about having another attack between episodes At least one of the attacks must be followed by a min of 1 month of: persistent concern about having additional attacks, worry about implications of attack, significant change in behavior related to attacks specify with or without agoraphobia PANICS - palpitations, abdominal distress, numbness, nausea, intense fear of death, chocking, chills, chest pain, sweating, shaking, SOB
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What is agoraphobia?
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fear of being alone in public places
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What are common social phobias?
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Public speaking eating in public using public restrooms
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What is the best treatment option for panic disorder?
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SSRI - paroxetine, sertraline Clomipramine, Imipramine Continue treatment for 8-12 months as relapse in common in discontinuation of therapy
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What is the treatment for performance anxiety?
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Beta blockers
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What is systemic desensitization?
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Gradual exposure of a patient to the feared object or situation while teaching relaxation and breathing techniques
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What is flooding?
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Confronting patient with their full fear
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What is the criteria for specific phobias?
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Excessive fear brought on by specific situation or object Exposure to situation brings about an immediate anxiety response Pt recognizes that fear is excessive Situation is avoided when possible or tolerated with intense anxiety If person is under age 18, duration must be at least 6 months Short course of benzos or beta blockers may be used during desensitization to help autonomic symptoms
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What are the four components of malpractice?
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Deviation (neglect) from Duty that was the Direct cause of Damage 1. Physician had duty to care 2. Physician breached duty by practice that did not meet standard of care 3. Patient was harmed 4. Harm was caused by physician negligence
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What is the Tarasoff duty?
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Obligation of a physician to report patients who are potentially harmful to others
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What are the four elements of informed consent?
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Reason for treatment Risks and benefits Reasonable alternatives Refused treatment consequences
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What is an emancipated minor?
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self supporting military married have children
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What is capacity?
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Clinical term Assessed by physicians
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What is competence?
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Legal term Decided by judge
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What is decisional capacity?
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Task specific Fluctuates over time In order for pt to have decisional capacity, pt must be able to: understanding relevant info about treatment, appreciate impact of decision, logically manipulate info to make decision, communicate a choice
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What is the m'naghten test?
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Addresses whether patient comprehends measure and quality of his/her actions and whether he/she knows that his/her actions are wrong Establish whether or not person is competent in understanding risks and benefits of medical treatment being offered
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What legal principles support involuntary commitment?
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Police power (protecting citizens from each other) Parens patriae (protects citizens who can't care for themselves)
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What are the three insanity defense standards?
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1. M'Naghten - person does not understand what he was doing or its wrongfulness; most stringent test 2. American Law Institute Model Penal Code - person could not appreciate right from wrong or could not control actions (irresistible impulse test) 3. Durham - person's criminal act has resulted from mental illness; most lenient test and is rarely used
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What are the risk factors for violence?
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History of violence Specific threat with a plan History of impulsivity Psychiatric diagnosis Substance abuse
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What are the expert witness standards?
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Frye (1923) - evidence must be generally accepted by the appropriate scientific community Daubert (1993) - judge decides if evidence is based on relevant and reliable science
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What is mental impairment?
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loss, loss of use, derangement of mental function
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What is mental disability?
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alteration of an individual's capacity to meet personal, social, occupational demands due to mental impairment To assess whether an impairment is also a disability, consider four categories: activities of daily living, social functioning, concentration, persistence, pace, deterioration or decompensation in work settings
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What is competence?
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Capacity to understand, rationally manipulate, and apply information to make a reasoned decision on a specific issue To stand trial, defiant must: understand the charges against him/her, be familiar with courtroom personnel, have the ability to work with an attorney and participate in his/her trial, understand possible consequences
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What is the 6th amendment?
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right to counsel and confront witnesses
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What is the 14th amendment?
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right to due process of law
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What is malingering?
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Feigning or exaggerating symptoms for secondary gain: financial gain, avoid school, work, responsibility, obtain meds of abuse (benos, opiods), avoid legal consequences Signs to detect malingering - atypical presentation, textbook description of illness, history of working in medical field, symptoms only present during observation, history of substance abuse or antisocial personality disorder
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What are obsessions?
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Recurrent and persistent intrusive thoughts or impulses that cause marked anxiety and are not simply excessive worries about real problems Person attempts to suppress thoughts Person realizes thoughts are product of his or her own mind
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What are compulsions?
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Repetitive behaviors that the person feels driven to perform in response to an obsession Behaviors are aimed at reducing distress but there is no realistic link between the behavior and the distress
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What are the common patterns of obsessions and compulsions?
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Obsessions about contamination followed by excessive washing or compulsive avoidance of feared contaminant Obsessions of doubt (forgetting to turn off the stove, lock the door, etc) followed by repeated checking to avoid potential danger Obsessions about symmetry or order - compulsively slow performance of a task (eating, showering, lining items exactly in place) Intrusive thoughts with no compulsion (sexual or violent thoughts) Somatic obsessions that cause people to view parts of their body, wastes, or secretions as abnormal
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What is the criteria for OCD?
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Either obsessions or compulsions Person is aware that obsessions and compulsions are unreasonable and excessive Obsessions cause marked distress, are time consuming, or significantly interfere with daily functioning Axis I disorder Pt have insight and are ego-dystonic
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What conditions is OCD associated with?
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Major depressive disorder, eating disorder, anxiety disorder, OCPD Higher rates in Tourette syndrome
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What are the causes of OCD?
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Abnormal regulation of serotonin Genetics ASsociated with head injury, epilepsy, basal ganglia disorders, postpartum conditions Stressful life trigger
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What are the treatment options for OCD?
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SSRI (higher dose than depression treatment) TCA (clomipramine) Behavioral therapy Exposure and response prevention (ERP) - involves prolonged exposure to the ritual eliciting stimulus and prevention of the relieving compulsion (pt must touch the dirty floor without washing his or her hands) Relaxation techniques ECT or surgery (cingulotomy)
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What is cognitive processing therapy?
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Modified form of cognitive behavioral therapy in which thoughts, feelings, and meanings of the event are revisited and questioned
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Compare and contrast PTSD and Acute Stress Disorder
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PTSD - event occurred at any time in the past, symptoms last >1 month Acute stress disorder - event occurred <1 month ago, symptoms last <1 month
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What is the criteria for PTSD?
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Traumatic experience Persistent avoidance Hyperarousal (increased psychological and/or physiological tension) Reexperiencing traumatic event Duration - > 1 month Associated with substance abuse and depression (avoid benzos)
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What is the treatment of PTSD?
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Antidepressants: SSRI, TCA (imipramine, doxepin), MAOI Anticonvulsants (flashbacks and nightmares) Relaxation training CBT Eye movement desensitization and reprocessing
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What is the criteria for general anxiety disorder?
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Excessive anxiety and worry about daily events and activities (difficult to control) for at least 6 months Must be associated with at least three of the following: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance Free floating anxiety Women, before age 20 Associated with major depression, social/specific phobia, panic disorder
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What is the treatment of general anxiety disorder?
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Antidepressants (SSRI, buspirone, venlafaxine) Taper off benzos
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What are the stages of normal sexual response in men and women?
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1. Desire - interest in sexual activity often reflected by sexual fantasies 2. Excitement - begins with fantasy or sexual contact. characterized by erections in men and vaginal lubrication, clitoral erection, labial swelling, and elevation of uterus in women, both men and women have nipple erection and increased pulse/BP 3. Plateau - Men have increased testicular size, tightening of scrotal sac, secretion of seminal fluid; women experience contraction of outer one third of vagina and enlargement of upper one third of vagina, facial flushing, increased pulse/BP, respiration occur in both men and women 4. Orgasm - men ejaculate and women have contractions of the uterus and lower one third of vagina 5. Resolution - muscles relax and CV state returns to baseline. Men have refractory period during which they cannot re-experience orgasm, women have little or no refractory period
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What is hypoactive sexual desire disorder?
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Absence or deficiency of sexual desire or fantasies (more common in women, occurs in 20% of population)
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What is sexual aversion disorder?
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Avoidance of genital contact with sexual partner
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What is male erectile disorder?
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Inability to attain an erection Impotence Primary or secondary (acquired after previous ability to maintain erection) Men who have erections in morning, during masturbation, or other sexual partners have psychological disorder than physical etiology
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What is female sexual arousal disorder?
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Inability to maintain lubrication until completion of sex act
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What is female orgasmic disorder?
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Inability to have an orgasm after a normal excitement phase Prevalence - 30%
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What is male orgasmic disorder?
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Achieves orgasm with great difficulty Prevalence - 5%
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What is premature ejaculation?
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Ejaculation earlier than desired time (before to immediately upon entering vagina) Prevalence -33%
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What is dyspareunia?
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Genital pain before, during, or after sexual intercourse A/w vaginismus
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What is vaginismus?
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Involuntary muscle contractions of the outer third of vagina during insertion of penis or object (speculum) Increased in higher SES, strict religious upbringing
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What is the pharmacologic treatment for erectile disorder?
answer
Phosphodiesterase 5 inhibitors (sidenafil given orally, enhances blood flow to penis) Require sexual stimulation to achieve erection Alprostadil - injected into corpora cavernosa or transurethral, acts locally, produces erection within 2-3 min and works in the absence of sexual stimulation
question
What is the pharmacologic treatment for premature ejaculation?
answer
SSRIs and TCAs prolong the time from stimulation to orgasm
question
What is the pharmacologic treatment for hypoactive sexual desire disorder?
answer
Testosterone as replacement therapy for men with low levels Low doses may improve libido in women Estrogen replacement may improve vaginal dryness and atrophy in hypoestrogenemic women
question
What is the mechanical therapy for male erectile disorder?
answer
Vacuum pumps, constrictive rings, surgical insertion of semirigid or inflatable tubes into corpora cavernosa (end stage impotence)
question
What is the mechanical therapy for male orgasmic disorder?
answer
Gradual progression from extravaginal ejaculation (via masturbation) to intravaginal
question
What is the mechanical therapy for female orgasmic disorder?
answer
Masturbation (with vibrator)
question
What is the mechanical therapy for premature ejaculation?
answer
Squeeze technique - increase threshold of excitability. When man has been excited near ejaculation, sexual partner is instructed to squeeze the glans of penis in order to prevent ejaculation. Gradually gains awareness about sexual sensations and learns to achieve greater ejaculatory control Stop - start technique - cessation of all penile stimulation when the man is near ejaculation
question
What is the mechanical therapy for dyspareunia?
answer
Gradual desensitization to achieve intercourse, starting with muscle relaxation techniques, progressing to erotic massage, finally achieving sexual intercourse
question
What is the mechanical therapy for vaginismus?
answer
Women may obtain some relief by dilating their vaginas regularly with fingers or dilators
question
What is a paraphilias?
answer
Sexual disorder characterized by engagement in unusual sexual activities and/or preoccupation with unusual sexual urges or fantasies for at least 6 months that cause impairement in daily functioning Most common - pedophilia, voyeurism, exhibitionism Poor prognostic factors - early age of onset, comorbid substance abuse, high frequency of behavior, referral by law enforcement agencies Good prognostic factors - self referral for treatment, guilt, history of normal sexual behavior
question
What is pedophilia?
answer
Sexual gratification from fantasies or behaviors involving sexual acts with children age 13 yrs or younger Person is at least age 16 and at least 5 years older than child
question
What is frotteurism?
answer
Sexual pleasure from touching or rubbing against non-consenting person
question
What is voyeurism?
answer
Watching unsuspecting nude individuals (often with binoculars) in order to obtain sexual pleasure
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What is exhibitionism?
answer
Exposure of one's genitals to strangers
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What is sadism?
answer
Sexual excitement from hurting or humiliating another
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What is fetishism?
answer
Sexual preference for inanimate objects (shoes, pantyhose)
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What is transvestic fetishism?
answer
Sexual gratification in men (heterosexual) from wearing women's clothing (especially underwear)
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What is masochism?
answer
Sexual excitement from being humiliated or beaten
question
What is necrophilia?
answer
Sexual pleasure from engaging in sexual activity with dead people
question
What is telephone scatologia?
answer
Sexual excitement from calling unsuspecting women and engaging in sexual conversation with them
question
What are the treatment options for paraphilias?
answer
Insight oriented psychotherapy - most common, patients gain insight into stimuli that cause them to act as they do Behavior therapy - aversive conditioning used to disrupt the learned abnormal behavior by coupling the impulse with an unpleasant stimulus such as electric shock Pharmacologic therapy - antiandrogens have been used to treat hypersexual paraphilias in men by reducing sexual desire
question
What is the diagnostic criteria for gender identity disorder?
answer
A strong and persistent cross gender identification Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex Clinical distress or impairment in social, occupational, or other important areas of functioning Rx: Therapy, family involvement, sex reassignment
question
What is dissociative fugue?
answer
Sudden, unexpected travel away from home, accompanied by the inability to recall one's identity or one's past Patients may assume an entirely new identity and occupation after arriving in the new location Unaware of their amnesia and new identity (unlike dissociative amnesia) Never recall the period of fugue Show characteristically low anxiety despite their confusion Predisposing factors: heavy use of alcohol, major depression, history of head trauma, epilepsy Onset associated with stressful life event
question
What is dissociative identity disorder (multiple personality disorder)?
answer
Presence of two or more distinct identities At least two of the identities recurrently take control of the person's behavior Inability to recall personal information of one personality when the other is dominant Not due to effects of substance or medical condition Women - 90% Experienced prior trauma (childhood or sexual abuse) High incidence of major depression, anxiety disorder, borderline personality, substance abuse, 1/3 attempt suicide
question
What is depersonalization disorder?
answer
Persistent or recurrent feelings of detachment from one's self, environment (derealization), or social situation Reality testing remains intact during episode Causes social/occupational impairment and cannot be accounted for by another mental or physical disorder More common in women, young adults, comorbid anxiety disorders and major depression Predisposing factor - severe stress Rx: antianxiety agents, SSRIs
question
What is dissociative disorder NOS?
answer
Dissociative disorder presentations without two or more states Primary derealization Cultural bound dissociative trance disorders Loss of consciousness, stupor, or coma not due to medical condition Ganser syndrome (the giving of approximate answers to simple questions such as how many legs do you have?)
question
What is ataque de nervios?
answer
Culturally bound trance disorder common in Puerto Rico that consists of convulsive movements, fainting, crying, and visual problems
question
What is conversion disorder?
answer
At least one neurological symptom Psychological factors associated with initiation or exacerbation of symptoms Not intentionally feigned or produced Cannot be explained by medical condition or substance use Causes significant distress or impairment in social or occupational functioning or warrants medical evaluation Not limited to pain or sexual dysfunction, and not better accounted for by a different mental disorder Common symptoms: shifting paralysis, blindness, mutism, paresthesias, seizures, globus hystericus (sensation of lump in throat) More common in women, adolescence, high incidence of comorbid schizophrenia, major depression, anxiety disorders
question
What is hypochondriasis?
answer
Preoccupation with fear of having or contracting a serious disease, based on misinterpreting bodily symptoms Persists despite medical evaluation and reassurance Not of delusional intensity and not restricted to circumscribed concern about appearance Significant impairment in functioning Persists for at least 6 months Not better accounted for by another mental disorder Men and women affected equally (only somatoform disorder that doesn't have a higher frequency in women) Rx: regularly scheduled visits to PCP, SSRI, CBT Better prognosis - higher SES, treatment responsive anxiety or depression, absence of comorbid medical conditions and personality disorder
question
What is body dysmorphic disorder?
answer
Preoccupation with an imagined defect in appearance or excessive concern about a slight physical anomaly Must cause significant distress in patient's life Not better accounted for by another mental disorder Rx: surgical or derm procedures are routinely unsuccessful in pleasing pt; SSRIs
question
What is pain disorder?
answer
Pain at one or more anatomic site of sufficient severity to warrant clinical attention Pain causes significant distress or impairment in patient's life Not intentionally produced Not better accounted for by a mental disorder or meet criteria for dyspareunia May have real medical condition but pain symptoms are in excess of disease pathology Women, increased incidence in first degree relatives, blue collar workers, 30-50 Major depression can exacerbate symptoms of pain disorder
question
What is factitious disorder?
answer
Patients intentionally produce signs of physical or mental disorder Produce symptoms to assume sick role Lack of secondary gain distinguishes factitious disorder from malingering No external incentives Intentional, conscious production of physical or psychological signs and symptoms Commonly feigned symptoms: psychiatric - hallucinations, depression, pseudologia fantastica; medical - fever (heating the thermometer), abdominal pain, seizures, skin lesions, hematuria A/w higher intelligence, poor sense of identity, poor sexual adjustment; history of child abuse, higher incidence in healthcare workers Avoid early confrontation
question
What is munchhausen syndrome?
answer
Factitious disorder with predominantly physical complaints
question
What is munchhausen by proxy syndrome?
answer
Intentionally producing symptoms in someone else who is under one's care
question
What is malingering?
answer
Feigning of physical or psychological symptoms in order to achieve personal gain External motivations include avoiding police, receiving room and board, obtaining narcotics, receiving monetary compensation
question
What are the distinguishing features of somatoform disorders, factitious disorders, malingering?
answer
Somatoform disorder - patients believe that they are ill and do not intentionally produce or feign symptoms Factitious disorder - intentionally produce symptoms of real illness because of desire to assume the sick role, not for external rewards Malingering - patients intentionally produce or feign symptoms or external rewards
question
What are the core qualities of impulse control disorders?
answer
Repetitive or compulsive engagement in behavior despite adverse consequences Little control over negative behavior Anxiety or craving experienced prior to engagement in impulsive behavior Relief or satisfaction during or after completion of the behavior
question
What is intermittent explosive disorder?
answer
Recurrent outbursts of aggression that result in assault against people or property Outbursts and aggression are out of proportion to triggering event or stressor Aggression is not better explained by another psychiatric diagnosis Each episode of explosive behavior often remits quickly and spontaneously, often leaving patients feeling remorseful and distressed Men, late teens, hx of child abuse, head trauma, seizures SSRIs, anticonvulsants, lithium, propanolol
question
What is kleptomania?
answer
Inability to resist uncontrollable urges to steal objects that are not needed for personal use or monetary reasons Pleasure or relief is experienced while stealing Intense guilt and shame often reported by those with disorder Objects stolen are given away, returned, hoarded Women, times of stress, a/w mood disorder, eating disorder, OCD, chronic Rx: therapy, SSRIs, naltrexone
question
What is pathological gambling?
answer
Preoccupation with gambling, need to gamble with increasing amount of money to achieve pleasure Repeated and unsuccessful attempts to cut down on gambling Restlessness or irritability when attempting to stop gambling Done to escape problems or relieve dysphoria Return to reclaim losses after gambling Lying to therapist or family members Commit illegal acts to finance gambling Jeopardize relationships or job Rely on others to finance gambling Men, young adults, therapy after 3 months of abstinence
question
What is trichotillomania?
answer
Recurrent, repetitive intentional pulling out of one's hair causing visible hair loss Involves scalp, eye brows, eye lashes, facial and pubic hair Rx - SSRIs, antipsychotics, lithium
question
What is pyromania?
answer
At least one episode of deliberate fire setting to relieve tension typically with feelings of gratification or relief afterward Equal in men and women, late adolescence Rx - therapy, SSRIs
question
What is dissociative amnesia?
answer
At least one episode of inability to recall important personal information, usually involving traumatic or stressful event Women, younger, a/w depression/anxiety Psychotherapy Hypnosis or administration of sodium amobarbital or lorazepam during interview
question
What antidepressant should be used in high suicide risk?
answer
Trazadone, SSRIs, buproprion, venlafaxine
question
What antidepressant should be used in concurrent depression and panic attacks?
answer
Phenelzine, Imipramine, SSRIs
question
What antidepressant should be used in chronic pain with or without depression?
answer
Amitripyline, doxepin, venlafaxine, duloxetine
question
What antidepressant should be used in weight gain on other antidepressants?
answer
Buproprion, SSRIs
question
What antidepressant should be used in sensitivity to anticholinergic side effects?
answer
Trazadone, phenelzine, tranycypromine, bupropion, SSRIs (except paroxetine)
question
What antidepressant should be used in orthostatic hypotension?
answer
Nortriptyline, bupropion, sertraline
question
What antidepressant should be used in sexual dysfunction?
answer
Bupropion, nefazodone
question
What are the treatment options for antidepressant induced inorgasmia?
answer
Reduce SSRI dose Sidenafil Add cyproheptadine
question
What are the treatment options for antidepressant induced apathy/decreased spontaneity?
answer
Reduce SSRI dose Add bupropion
question
What are the treatment options for antidepressant induced weight gain?
answer
Exercise Diet
