Psych – Flashcard Answers
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Psychiatric History (components)
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1. History of the present illness (HPI) 2. Past psychiatric history 3. Psychosocial/Family history
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HPI
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History of Present Illness: -Chronological description of the current episode of illness -Why has the patient come for help now?
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Past Psychiatric History
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-Previous episodes of psychiatric illness -Treatment and outcome -Pertinent negatives (i.e. illness or symptoms that are NOT present)
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Psychosocial/Family History
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-Childhood and adolescent development -Education and work history -Relationships -Loss and trauma -Culture, including ethnic/religious background -Profiles of significant family members -Psychiatric illness in family members -Parallel history
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Community Mental Health Act (CMHA, 1963)
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-Passed in 1963 by JFK and led to deinstitutionalization of mental health to more community-based (outpatient) treatment centers -Provided funding and benchmarks for mental health research and treatment under the NIMH.
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Psychiatric Assessment (components)
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-Identifying information (ID) -Chief complaint (CC) -History -Findings: Physical exam, mental status exam -Impression: Case summary, Differential diagnosis -Treatment plans -Prognosis
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Identifying Information (ID)
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-Age -Relationship/marital status -Occupation/source of support
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Chief Complaint (CC)
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-Reason for seeking help -In patient's own words
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Findings
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-Physical exam should be objective, current (NO historical information) -Mental status exam should be objective, current (NO historical information) and be based on speech and behavior -Labs and other tests
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Case summary
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Case summary includes: -Symptoms (subjective reporting of CC and history) -Signs (objective, from PE and MSEs)
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Physician Stance (components)
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-Curious and inquisitive AND empathetic and supportive -Professional: empathetic, respectful, curious
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Interviewing guidelines
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1. Begin with open-ended questions 2. Follow up with focused questions 3. Avoid technical terms 4. Make use of silence 5. Provide periodic summaries 6. Ask for clarification 7. Attend to emotional responses 8. Empathize without offering false reassurance
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Mental Status Examination (MSE)
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1. Appearance, behavior, speech, attitude 2. Mood and affect 3. Thought process and content; perception 4. Cognitive 5. Insight/judgment
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Appearance, Behavior, Speech, Attitude
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-Clothing and grooming -Motor behavior (PMA, PMR) -Speech rate, volume, modulation -Interactions with the interviewer
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Motor Behavior
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-Psychomotor agitation (PMA): noticeable and marked increase in body movements, e.g. hand wringing, pacing -Psychomotor retardation (PMR): significant slowing of speech and body movements, lack of usual fidgetiness
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Mood and Affect
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-Mood: Subjective feeling state sustained over much of the interview; need to ask patient -Affect: Objective feeling state as observed by physician
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Mood descriptors
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-Normal = Euthymic -Abnormal: Depressed/Dysthymic, Sad, Irritable, Expansive (i.e. enthusiastic), Euphoric (i.e. feeling great, as if they just won the lottery), Nervous
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Affect descriptors
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-Normal = Full Range -Abnormal: Constricted (normal amplitude, restricted range), Blunted (decreased amplitude), Flat (virtually complete absence of affective expression), Inappropriate (emotions expressed incongruent with content), Labile (unpredictable shifts)
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Thought Process - Organized
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-Normal = coherent and goal directed -Tangential: occasional lapses such that the patient suddenly changes the subject and never returns to it -Circumstantial: organized but overly inclusive, eventually gets to the point in a painstakingly slow manner -Flight of ideas: flow of thoughts is extremely rapid but connections remain intact
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Thought Process - Disorganized (formal thought disorder)
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-Loosening of associations: frequent lapses between thoughts, disorganized -Word salad: incomprehensible due to lapses in connections even within a single sentence; incoherent (a "tossed salad" of ideas) -Blocking: patient loses train of thought; by definition must confirm patient's subjective experience -Neologism: a created word with an idiosyncratic meaning
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Though Content - Delusion
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-Fixed (i.e. reality testing is NOT intact) -False -Not shared by members of the patient's culture
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Reality Testing
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-Able to consider the possibility that the belief is incorrect, e.g. "Is it possible...?"
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Delusion - Types (5)
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1. Grandiose: exaggerated view of one's importance 2. Paranoid: suspiciousness of others' motives 3. Somatic: relating to one's body 4. Religious: relating to religion 5. Reference: misinterpretation of external events as having particular meaning for the individual
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Thought Content - Overvalued Idea
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-Firmly held BUT reality testing is intact -False -Not shared by members of the patient's culture -Examples: paranoid ideation, ideas of reference
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Though Content - Descriptors (not delusion or overvalued ideas) (4)
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1. Obsession (intrusive and ego-dystonic idea with intact reality testing) 2. Phobia (a specific fear that results in avoidance despite realization that the fear is irrational) 3. Suicidal ideation 4. Homicidal ideation
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Perception - Descriptors (4)
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-Illusion: misinterpretation of a sensory stimulus in any modality -Hallucination: perceiving a sound, sight, smell, taste, or touch in the absence of external sensory stimulation that seems indistinguishable from such an experience in reality (auditory, visual, olfactory, tactile) -Depersonalization: the sense that one is outside oneself -Derealization: a vague sense of unreality in one's perception of the external world
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Psychosis
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1. Formal thought disorder OR 2. Delusion OR 3. Hallucination
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Insight and Judgment
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-Insight: individual's understanding of himself/herself in the context of wanting/needing help -Judgment: Behavior related to illness; impulsivity -For both: explain with examples; Normal = intact/excellent, Abnormal = fair/impaired
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MSE Guidelines (7)
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1. Concise/Current/Objective 2. Clear and unique to patient 3. Detailed with examples/quotes 4. Systematic 5. ID positive findings/psychopathology 6. Mention pertinent negatives 7. Always assess the following: Suicidal Ideation, Homicidal Ideation, Delusions, Hallucinations
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Major Depressive Episode - Criteria (symptoms) (9)
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"People Who Are Depressed Cry And Feel So Sad" 1. Depressed Mood 2. Anhedonia 3. Change in appetite 4. Change in sleep 5. Psychomotor agitation/retardation 6. Fatigue 7. Poor concentration/indecisive 8. Worthless/guilty 9. Suicidal ideation
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Major Depressive Episode - Criteria (symptom requirements)
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1. Must have Anhedonia OR Depressed mood 2. Must have 4 additional criteria (Polythetic) 3. Lasts longer than 2 weeks 4. Change from previous functioning 5. Symptoms present most of the day every day 6. Causes significant distress 7. Not due to: Another medical condition, a substance (either recreational drug use or prescription)
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Depressed Mood
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-Sad, down, hopeless -Complicated by "alexithymia": inability to experience emotions -Obtained in history -Observed in mental status exam
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Anhedonia
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-Loss of interest -Loss of pleasure (include libido) -Obtained in history
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Appetite Change
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-Increase OR decreased -With or without weight gain -Obtained in history
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Sleep Change
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-Insomnia: middle night awakening (MNA); early morning awakening (EMA); difficulty falling asleep (DFA, though this is NONSPECIFIC) -Hypersomnia -Characteristic sleep architecture changes observed on EEG (i.e. decrease REM latency) -Obtained in history
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Psychomotor Change
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-PMA -PMR -Obtained in history -Observed in MSE
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Fatigue
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-May be related to sleep changes (EMA, MNA, DFA, sleep architecture), though doesn't have to be -Obtained in history
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Poor Concentration/Indecisive
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-"Pseudodementia" -Obtained in history -Observed in MSE
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Worthlessness/Guilt
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-Obtained in history -Observed in MSE -May be an overvalued idea -May be delusion
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Suicidal Ideation
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-Obtained in history -Observed in MSE -Passive (no intent/plan) -Active (intent/plan present) -Does not have to be present every day
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Major Depressive Disorder - Epidemiology
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-Age of onset is typically 20s -General population prevalence: Current 5% (Primary Care Population 10%); Lifetime 17% (women 20-25%, men 7-12%);
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Mania
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1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood + 3 other symptoms if elevated, +4 if irritable. AND 2. Abnormally and persistently increased goal-directed activity or energy
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Hypomania vs. Mania
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Mania: Patient is severely impaired or psychosis is present for at least 1 week or episode results in hospitalization Hypomania: No severe impairment and no psychosis, but an unequivocal change in functioning that in uncharacteristic is observed for at least 4 consecutive days.
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Manic Co-Morbidity
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More 90% of patients who have a manic episode will eventually have a depressive episode
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Bipolar Disorder
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1. If MANIA occurs, then by definition, diagnosis is Bipolar I 2. If hypomania occurs, then by definition, diagnosis is Bipolar II
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Mania/Hypomania - Additional Symptoms
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1. Grandiosity 2. Decreased need for sleep 3. Pressured speech 4. Racing thoughts 5. Distractibility 6. Increased activity 7. Poor judgment
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Psychiatric Exclusion Criteria
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Not due to: 1. Another medical condition 2. A substance (recreational or prescription drugs)
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Grandiosity
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-Inflated sense of abilities -Can be overvalued idea -Can be delusional -Usually observed (i.e. MSE) rather than reported
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Decreased Need for Sleep
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-Patients tend not to complain of insomnia -Feel rested despite less sleep than usual -Can be dramatic, e.g. virtually no sleep for days -Very specific questioning is required
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More Talkative/Pressured Speech
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-More talkative than usual can be reported (i.e. history) -Pressured speech (i.e. difficult to interrupt) can be observed (i.e. MSE)
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Racing Thoughts/FOI
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-Subjective experience of thoughts going too fast can be reported (i.e. history) -Flight of ideas can be observed (i.e. MSE)
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Distractibility
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-Can be reported (i.e. history) -Can be observed (i.e. MSE)
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Increased Activity
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-Can be reported if goal-directed (i.e. history) -Can be observed if purposeless and non-goal directed (i.e. psychomotor agitation on MSE)
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Poor Judgment
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-Excessive involvement in risky activities -Often involve money and sex -Increased impulsivity
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Mania with Psychotic Features
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-Mood congruent psychosis: grandiose or paranoid delusions -Mood incongruent psychosis (any other form) -By definition, diagnosis is MANIA if psychosis is present
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Mania/Hypomania - Epidemiology
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-Lifetime prevalence: 2% -Male:Female = 1:1 -Onset is typically in 20s
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Differential Diagnosis of Psychosis
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-Brief psychotic disorder -Delusional disorder -Manic episode with psychotic features -Major depressive episode with psychotic features -Schizophrenia -Schizophreniform disorder -Schizoaffective disorder
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Brief Psychotic Disorder
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-Delusions, hallucinations, or formal thought disorder are present for at least 1 day and at most 1 month -Patients return to full premorbid functioning after the episode -Typically associated with emotional turmoil and lability, confusion, and severe impairment -Can occur with or without a marked stressor (if a marked stressor exists, also called brief reactive psychosis)
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Delusional Disorder
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-The presence of one or more delusions for at least 1 month -Hallucinations can be present but are not prominent and are related to the delusional theme -Exclusion criteria: formal thought disorder, disorganized and catatonic behavior, and negative symptoms -Functioning is not markedly impaired, apart from direct impact of delusions -If mood episodes occur, they are brief relative to overall duration of the delusional periods
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Catatonia
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Defined as a marked decrease in reactivity to environment including: -Stupor (not actively relating to environment) -Catalepsy (passive induction of posture against gravity) -Waxy flexibility (slight resistance to positioning) -Mutism (no verbal response) -Negativism (opposition to instructions) -Posturing (maintenance of posture against gravity) -Mannerism (odd caricature of normal actions) -Stereotypy (repetitive, frequent, non-purposed moves) -Agitation -Grimacing -Echolalia (mimicking another's speech) -Echopraxia (mimicking another's movements)
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Negative Symptoms (5 A's)
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1. Diminished emotional expression: flat affect; reduced movements of head, hands, and body; lack of variation in speech pitch, volume, rhythm, and intonation. 2. Avolition: decrease in motivated self-initiated purposeful activities 3. Alogia (diminished speech output) 4. Asociality (lack of interest in social interactions) 5. Anhedonia
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Delusional Disorder - Classifications
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1. Erotomanic - conviction that another person is in love with the individual 2. Grandiose - conviction of having great talent or insight, having made an important discovery, having a special relationship with a prominent person 3. Jealous - conviction of having an unfaithful partner 4. Persecutory - conviction of being conspired against, cheated, spied on, followed, poisoned, maliciously maligned, harassed, obstructed in pursuit of goals 5. Somatic - conviction of abnormalities of bodily functions or sensations 6. Mixed Can be "bizarre" - clearly implausible or out of the realm of possibility
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Schizophrenia - Diagnostic Criteria (Active Phase/Criterion A)
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At least 2 of the following for a significant portion of 1 month (or less if treated successfully): 1. Delusions 2. Hallucinations 3. Formal Thought Disorder 4. Grossly disorganized or catatonic behavior 5. Negative symptoms At least one symptom must be 1-3. Delusion/Hallucination are also referred to as "positive symptoms"
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Schizophrenia - Functional Impairment
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Level of functioning must be: 1. Impaired in at least 1 major area (work, interpersonal relationships, self-care) 2. Markedly below the level achieved prior to onset 3. Impaired for a significant portion of time since onset
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Schizophrenia - Duration
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Diagnosis is made IF: 1. Continuous signs of illness are present for at least 6 months 2. At least 1 month of active phase symptoms 3. May include periods of prodromal or residual symptoms
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Schizophrenia - Prodromal/Residual Symptoms
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1. Negative symptoms 2. Attenuated "quasi-psychotic" experiences and thoughts: -Overvalued ideas -Unusual perceptual experiences (illusions) -Odd thinking and speech -Odd behavior that is not grossly disorganized
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Schizophrenia - Time Course of Prodromal/Residual Symptoms
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-By definition, prodromal symptoms occur prior to the onset of the disorder (therefore determined in retrospect) -Prodromal symptoms can persist for several years -By definition, residual symptoms occur after the resolution of the active phase -Residual symptoms tend to last as long as the disorder is present
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Schizophreniform Disorder - Key differences from Schizophrenia
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-Duration is >1 month and <6 months -Social or occupational impairment is not required -Prognosis: 1/3 make complete recovery; 2/3 ultimately diagnosed with schizophrenia or schizoaffective disorder
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Psychotic Features in Mood Disorders
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-Delusion/Hallucinations -Mood congruent for Mania (grandiose/paranoid) -Mood congruent for Depression (depressive themes of personal inadequacy; guilt; disease; death; nihilism; or deserved punishment) -Mood incongruent -Formal thought disorder only with mania, NOT major depression
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Manic Episode with Psychotic Features
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-In the moment, i.e. cross-sectionally can be indistinguishable from brief psychotic disorder as well as the active-phase of schizophreniform disorder -Past history and future course are crucial to distinguishing among these disorders
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Prevalence of Psychotic Disorders
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-Brief Psychotic Disorder: 0.1% -Deulsional Disorder: 0.2% -Schizophrenia: 1% -Schizophreniform Disorder: 0.2% -All 1:1 gender ratio
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Major Depressive Disorder Risk Factors
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-Genetic: 2-4 times the risk if 1st degree relative with major depression; Common genetic variation accounts for 21% of depression; Evidence from twin and family studies estimate total heritability at 37% -Environment: particularly early childhood loss/stress -Adverse life events may precede an episode but do not impact the course and prognosis
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Major Depressive Episode - Course
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-Persists 6-9 months without treatment -1/3 of untreated patients will develop chronic depression, i.e. persistent depressive disorder -One episode increases risk for recurrent episodes, but many patients have only a single lifetime episode -If >1 episode, likely 4-5 over lifetime
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Persistent Depressive Disorder
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-Depressed mood for at least 2 years and never without symptoms for >2 months -Accompanied by at least 2 other symptoms Change in appetite, change in sleep, fatigue, low self-esteem, poor concentration/indecisive, hopeless
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Major Depressive Disorder - Morbidity and Mortality
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-Functional impairment including: parenting; time away from work -Suicide -Increased incidence of cardiovascular disease -Increased risk of death after myocardial infarction
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Depressive Disorder - Specifiers
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-Psychotic features (higher suicide risk; more common in bipolar disorder) -Melancholic features (more severe, often associated with psychosis) -Anxious pattern (higher suicide risk) -Seasonal pattern (recurrent fall/winter depressions) -Atypical (increased appetite/sleep) -Peripartum onset (more common in bipolar disorder) -Catatonia
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Major Depressive Episode - Treatment
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Anti-depressants: -SSRIs are first line -Also dual uptake inhibitors, tricyclics -Duration 6 months for first episode -Long-term prophylactic use if recurrent Add anti-psychotics if psychosis is present ECT: particularly for psychotic and melancholic subtypes Bright lights (for seasonal pattern) Psychotherapy alone and in combination with medication is very effective
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Bipolar Disorder - Risk Factors
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-Greater genetic contribution to etiology than depression: Common genetic variation accounts for 25% of bipolar disorder; Evidence from twin and family studies estimate total heritability at 75% -Less role for environment and psychosocial factors
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Bipolar Disorder - Course
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-Lifelong, episodic -Euthymic between episodes -Decreasing cycle length with age -Rapid cycling (at least 4 distinct episodes within 12 months)
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Cyclothymic Disorder
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-Milder form of Bipolar Disorder -Symptoms of hypomania and dysthymia
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Bipolar Disorder - Mixed Features
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-Simultaneous depressive and manic symptoms -Dysphoric mania -Psychosis -High suicide risk -Less responsive to standard treatment
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Manic Episode - Treatment
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-Mood stabilizers: Lithium; Anticonvulsants (valproic acid, carbamazepine) -Antipsychotics -ECT
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Bipolar Disorder - Treatment
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-Mood stabilizers (lithium, anticonvulsants: carbamazepine, valproic acid) -Antipsychotics -TRY TO AVOID antidepressants -Adjunctive psychotherapy -Interpersonal and social rhythm therapy -Ongoing medication often necessary
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Schizoaffective Disorder - Criteria
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-A major depressive or manic episode is present concurrently with the active-phase symptoms of schizophrenia -Delusions or hallucinations must be present WITHOUT mood symptoms for at least 2 weeks -Episodes of depression or mania are present for the majority of the illness's total duration -Specify whether depressive or bipolar type
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Schizoaffective Disorder - Prevalence
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-0.3% overall, female>male (particularly depressive type) -Social and occupational dysfunction is associated but is not required (in contrast to schizophrenia) -Often chronic course but overall prognosis is generally better than for schizophrenia
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Neurocognitive Disorders - Criteria
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-Primary clinical deficit is in cognitive function -The core features of the disorder are cognitive -The cognitive deficit is acquired, not developmental -Impaired cognition represents a decline from previously attained level of functioning.
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MSE: Cognitive
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-Attention & Orientation -Memory -Complex functions and language -Abstract thought
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Attention & Orientation
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-Attention: able to direct, focus, sustain, and shift attention -Awareness: Orientation to the environment (usually reported in 3 spheres: Person, Place, and Time)
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Memory
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-Immediate = 3 objects -Short-term = 3 objects -Intermediate: Recall breakfast, recent current events -Long-term/fund knowledge: Personal history, Presidents
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Assessment of Complex Functions and Language
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-Serial 7s or 3s -WORLD spelled backwards -Money calculations -Word-finding and naming
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Abstract Thought
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-Concrete: no capacity for abstract thought -Formal testing: Comparisons/proverbs -Observation during interview
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Neurocognitive Disorders - Delirium
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Brainstem (i.e. more primitive functions of attention) -Disturbances in attention and awareness -Additional disturbance in cognition (e.g. memory or language deficit) or presence of perceptual disturbance -Develops over short time period, represents a change from baseline attention and awareness, and fluctuates in severity during the course of the day -Evidence that the disturbance is direct physiological consequence of another medical condition, a substance intoxication or withdrawal, or exposure to a toxin
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Neurocognitive Disorders - Major and Minor
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Cerebral Cortex (i.e. higher level "executive" functions)
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Neurocognitive Disorders - Delirium, Epidemiology
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-Children and the elderly at highest risk -10-30% of hospitalized patients -A life-threatening emergency until proven otherwise -Course depends on etiology
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Neurocognitive Disorders - Major
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-Significant cognitive decline in at least one domain: Attention, Executive functions (planning/decision making), Learning and Memory, Language, Perceptual & Motor, Social cognition (empathy, social cues) -Cognitive deficits interfere with independence in everyday activities -Not exclusively in the context of delirium
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Neurocognitive Disorders - Minor
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-Modest cognitive decline in one or more cognitive domains -Cognitive deficits do not interfere with independence in everyday activities, although greater effort or compensatory strategies may be required.
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Neurocognitive Disorders - Prevalence
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-Major NCD/dementia: 1-2% of the general population at age 65 years, but up to 30% by age 85 -Mild NCD/mild cognitive impairment: 2-10% at age 65 and 5-25% by age 85
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Neurocognitive Disorders - Etiology
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Due to: -Dementia (most commonly due to Alzheimer's Disease, Parkinson's Disease, and Cardiovascular Disease) -Traumatic brain injury -Infection (HIV) -Another medical condition (e.g. brain tumor, endocrine disorder)
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Neurocognitive Disorder - Course
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Depends on etiology: -NCD due to neurodegenerative diseases such as Alzheimer's and Parkinson's with insidious onset and gradual decline -NCD due to cardiovascular disease with step-wise or "stuttering" decline -NCD due to traumatic brain injury with acute change
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Signs and Symptoms Suggestive of a Mental Disorder Due to Another Medical Condition
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-Age >40 years -Inconsistent with usual presentation -Abnormal neurological examination
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Feeding and Eating Disorders
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1. Anorexia Nervosa 2. Bulimia Nervosa 3. Binge Eating Disorder (BED) 4. Avoidant/Restrictive Food Intake Disorder (ARFID) 5. Pica 6. Rumination Disorder NOT OBESITY
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Anorexia Nervosa - Criteria
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1. Persistent caloric restriction -> low weight; 2. Fear of weight gain 2. Disturbance in the way in which one's body weight or shape is experienced
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Anorexia Nervosa - Long-term Outcomes
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1. Full recovery: 1/3 to 1/2 2. Death: 5% per decade of follow-up 3. Alive but not well: the rest 4. Obesity: Rare (if present)
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Bulimia Nervosa - Criteria
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1. Recurrent episodes of binge eating 2. Recurrent inappropriate compensatory behavior to prevent weight gain 3. (1) and (2) occur on average at least weekly for 3 mos 4. Self evaluation is unduly influenced by body shape and weight 5. The disturbance does not occur exclusively during episodes of anorexia nervosa
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Binge Eating - Definition
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1. Eating within a discrete period of time an amount of food that definitely larger than "normal" 2. Accompanied by a sense of lack of control
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Bulimia Nervosa - Complications
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Labs: Hypo-kalemia/chloremia/natremia; alkalosis (vomiting); Acidosis (laxatives); Hyperamylasemia Signs: Irregular menses, enlarged salivary glands, dental erosion, laxative dependence, ipecac toxicity, gastric rupture
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Binge Eating Disorder - Criteria
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1. Recurrent episodes of binge eating 2. Associated with at least 3 of : -Eating rapidly -Eating past comfortable full -Eating large amounts when not hungry -Eating alone due to embarrassment of the amount -Feeling disgusted, depressed, or guilty after binging 3. Distress regarding binging 4. Occurs on average weekly for 3 months 5. Not associated with compensatory behavior
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Binge Eating Disorder - Co-Morbidity
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-Increased frequency of mood and anxiety disorders -Probably, increased risk of weight gain
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Eating Disorder Epidemiology
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1. AN: Low body weight, mid-adolescence presentation, 9:1 F:M, 0.5-1% prevalence in women 2. BN: Normal body weight, adolescence/young adults, 9:1 F:M, 1-2% prevalence in women 3. BED: Usually high body weigh, middle aged, 3:2 F:M, 2-4% lifetime prevalence in general population
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Eating Disorders - Etiology
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1. Pre-disposing factors: female, genes, environment, societal emphasis on thinness 2. Precipitating Factors: stresses of adolescence 3. Perpetuating factors: dieting -> binging -> dieting
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Persistent Behavior
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Behavior that is not innate, but is learned via 2 related, yet distinct processes: 1. Action-outcome learning: operant conditioning, goal-directed 2. Stimulus-Response learning: habit formation
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Eating Disorders - Treatment
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1. AN: Behavioral intervention to restore weight (family-based for younger; supportive/cognitive for older) 2. BN: Cognitive Behavioral Treatment (CBT): SSRIs 3. BED: CBT; SSRIs; Weight loss agents
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Schizophrenia - Epidemiology
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1. Afflicts 1% of Americans 2. Accounts for 25% of all hospital bed days 3. Accounts for 40% of all long-term care days 4. Accounts for 20% of all Social Security benefit days 5. Costs the nation $65B/year
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Emil Kraeplin (1855-1926)
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First described the symptoms for schizophrenia and considered them a single illness. Used the term "dementia praecox" indicating early onset (praecox) and deterioration of intellectual functioning (dementia). Distinguished from bipolar disorder.
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Eugene Bleuler (1857-1939)
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Focused more on nature of symptoms than on course. Identified 4 A's: Autism; Ambivalence, Affect, Association.
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Schizophrenia - Symptoms
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Positive Symptoms: -Hallucinations (auditory, gustatory, visual, olfactory, or tactile). Most commonly auditory/visual. -Cognitive Dysfunction: impairment of any of attention/vigilance, processing speed, reasoning/problem solving, verbal learning/memory, visual learning/memory, working memory, social cognition Heterogeneous presentation (likely 2 or more different diseases). Interpretation of symptoms depends a lot on cultural context.
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Schizophrenia - Causes (Neurodevelopmental vs. Neurodegenerative Model)
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- ND postulates schizophrenia is caused by a subtle defect in cerebral development that disrupts late-maturing, high evolved neocortical functions, and fully manifests itself years later in adult life. -NDG also has data supporting it.
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Schizophrenia - Genetics
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-Twin/family studies show a strong genetic link -Linkage studies have identified potential gene locations on chromosomes 1, 6, 8, 13, 15, and 22. -Problems with false positives owing to heterogeneity and small effects of individual genes -All evidence suggest schizophrenia is multifactorial with several genes and environment factors.
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Schizophrenia - Course
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-Occurs in all genders, cultures, races, and religions -Age of onset is usually between 16 and 25, though females tend to present later than ment -Some present acutely, others gradually -Often cause of severe stress to family
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Schizophrenia - Factors Predicting Poor Prognosis
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-Early onset -No precipitating factors/insidious onset -Poor premorbid social, sexual, and work history -Withdrawn, autistic behavior -Family history of schizophrenia -Poor support systems -Negative symptoms -Neurological signs and symptoms
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Schizophrenia - Violence
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-Afflicted are MORE likely to be victim than perpetrator -Some evidence does suggest increased risk of violence by individuals with schizophrenia, but most of the risk is due to substance abuse.
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Schizophrenia - Treatment
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1. Antipsychotic medications (positive symptoms) 2. Cognitive Behaviorally-Oriented Psychotherapy to reduce severity of symptoms 3. Supported employment to assist both in obtaining and maintaining competitive employment 4. Family intervention to reduce rates of relapse and re-hospitalization 5. Assertive community treatment to reduce hospitalization and homelessness
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Schizophrenia - Recovery
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Reflects symptomatic remission and some success in social and occupational functioning. Often implied is no need for further medication and full return to pre-morbid functioning. This should be looked at more holistically.
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Obsessive Compulsive Spectrum Disorders
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1. Obsessive Compulsive Disorder (OCD) 2. Hoarding 3. Body Dysmorphic disorder 4. Trichotillomania (Hair pulling) 5. Excoriation Disorder (Skin picking) 6. OCD secondary to another medical condition 7. Substance-induced OCD
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Obsession
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1. Recurrent thoughts, urges, or images that are intrusive, unwanted (at some point), cause marked distress, and are not simply worrying about life. Examples: taboo (aggressive, sexual, religious); Harm to self or others; contamination (germs, dirt); symmetry 2. The individual tries to ignore, suppress, or neutralized the thoughts, urges, or images.
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Compulsion
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1. Repetitive behaviors (handwashing, ordering, checking) or mental acts (praying, counting, repeating words silently) that the person is driven to perform. 2. Goal of compulsion is to reduce stress (feel "right") or prevent dreaded consequences (usually overvalued)
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Obsessive Compulsive Disorder (OCD) - Diagnostic Criteria
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1. Presence of obsessions, compulsions, or both 2. Obsessions/compulsions are time-consuming (>1 hour/day) or cause marked distress/impairment 3. Not due to physiologic effects of a substance or another medical condition 4. Content is not limited to other disorders, such as anorexia, hoarding, anxiety, depression
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OCD Related Features
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1. Pathologic intolerance of uncertainty 2. Inflated sense of responsibility 3. Pervasive avoidance (overtly risk adverse) 4. Over importance of thoughts
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Other Disorders with Obsessions/Compulsions
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1. Obsessions/Compulsions with a focus: -Body dysmorphic disorder -Eating disorders -Illness Anxiety Disorder (Hypochondriasis) 2. Compulsions without prominent obsessions: -Hoarding -Hair pulling (Trichotillomania) -Excoriation -Tourette's 3. Obsessions without compulsions: -PTSD
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Depressive Ruminations vs. OCD Obsessions
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Distinctions made on content: -Ruminations tend to be negative, pessimistic, and ego-syntonic -Obsessions intrude unrelated to mood Distinctions made on response: -The depressed individual does not try to suppress or ignore the depressive thought
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Generalized Anxiety Disorder vs. OCD Obsessions
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-Worries of GAD are excessive concerns about real-life circumstances that are seen by the person as realistic -Obsessions tend to be more unrealistic or magical and are usually recognized by the individual as inappropriate
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Obsessive Compulsive Personality Disorder
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-Pervasive preoccupation with orderliness, perfectionism, mental and interpersonal control -OCPD is ego syntonic while OCD is ego dystonic -Characteristics: perfectionism (tasks can't be completed), inflexible/rigid/stubborn, Exclusive devotion to work (few friends), so focused on lists/details/rules that major points are lost, reluctant to delegate tasks.
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Obsessive Compulsive Disorder - Insight
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-Fluctuates from person to person and day to day -Many have good insight; some poor (house will PROBABLY burn) -Nearly 4% have NO INSIGHT (delusional: house will DEFINITELY burn)
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Obsessive Compulsive Disorder - Development
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-Young children (3-5 yrs) like things "just so" or insist on elaborate rituals. These are normal developmental issues about mastery/control and most are gone by age 6-10. -True OCD usually occurs later and appears bizarre to other adults/children and produces dysfunction rather than mastery.
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Obsessive Compulsive Disorder - Epidemiology
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-Relatively common: 1 year prevalence of 1.2/100 -Mean age of onset is 19.5 years with 25% before 14. -Co-Morbidities common: 60-70% have major depression; 35-70% had another anxiety disorder; 20-25% have tics (and vice versa), more often in males and early onset -F:M is 6:4 -Well-understood with effective treatments. -Under-diagnosed
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OCD - Genetic Factors
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-Increased incidence within families -Twin studies suggest concordance -Multiple genes implicated -Heterogeneity can be reduced within certain OCD subtypes (e.g. contamination/cleaning)
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OCD with Autoimmune Etiology (PANDAS)
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-Abrupt onset of tic or OCD -Age of onset is 3 to puberty -Concurrent Group A strep during exacerbations -Neurologic abnormalities often present (95% choreiform piano playing finger movements). -Treat with IVIg, plasmapheresis -Prevent via rapid ABX treatment -Other IFX like lyme also associated with symptoms
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OCD - Treatment
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1. Cognitive Behavioral Therapy 2. Pharmacologic (SSRIs) 3. Neurosurgical 4. Immunologic
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OCD - Cognitive Behavioral Model
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1. Over responsibility for harm 2. Over estimation of threat 3. Intolerance of uncertainty 4. Over importance of thoughts 5. Over valued need to control
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OCD Behavior Therapy
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1. Live confrontations with fear situations/objects 2. Imagined confrontations with feared consequences 3. Ritual prevention Most effective
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OCD - Neurosurgical Therapy
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-Interrupts connections between frontal and subcortical structures -Seen as treatment of last resort
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Body Dysmorphic Disorder
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1. Preoccupation with an imagined or slight defect in physical appearance 2. Causes person at some point to perform repetitive behaviors (mirror checking, grooming) or mental acts (comparing appearance) 3. Causes significant distress/impairment 4. Not restricted to body fat/weight
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Clinical Features of BDD
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-Mean age of 16 years, equal among genders, most never married, 2.4% of adults, relatively common with other disorder (10-35% comorbid with other OC disorders) -Preoccupations usually involve head/face, asymmetry, can be involved for 3-5 hrs/day -Compulsive behaviors: comparing, checking, grooming, camouflaging, reassurance seeking -Psychological impact: shame, suicide common (27.5%), rejection sensitive -Insight poor -> delusions of reference -Delusions can be reduced by SSRIs alone, but antipsychotics are not usually effective.
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Hoarding
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1. Persistent difficulty discarding or parting with possessions, regardless of value 2. Perceived need to save items and/or distress with discarding 3. Results in accumulation of large number of possessions that fill up living areas. 4. Cause clinically significant distress/impairment 5. Not due to another general medical condition, and not restricted to symptoms of another diagnosed mental disorder
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Hoarding Prevalence
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-2-6% lifetime prevalence with no gender difference -3x more common in 55+ age group -Chronic course - rarely waxes or wanes, but may increase in severity over time. -50% of hoarders have a family member who hoards
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Tichotillomania
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-Hair-pulling -1-2% one year prevalence -10:1 F:M -Require clinically significant distress/impairment and repeated attempts to stop or decrease behavior
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Excoriation
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-Recurrent skin picking -Require clinically significant distress/impairment and repeated attempts to stop or decrease behavior
