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Psych 1 Exam

Clinical Medicine: Psychiatry: Intro, Mood Psychotic, ADHD and Eating Disorders

A study of the human mind and its functions (mental processes) and behaviors. Psychology
A medical specialty that diagnoses, treats, and prevents mental and emotional disorders. Psychiatry
A syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes. Mental Disorder
Treatment of mental disorders through verbal and non-verbal (pet therapy, recreational therapy, art, music etc.) communication. Psychotherapy
Treatment that aims to make the unconscious, conscious. Psychoanalysis
3 types of psychotherapy? Which ones are still used? Cognitive, Behavioral, Psychoanalysis; Cognitive and behavioral are still used
Addresses dysfunctional emotions, maladaptive behaviors, cognitive processes and contents. What are the 3 Rs? Cognitive Behavioral Therapy; Recognize, Reconstruct, Repeat
What does DSM stand for? Diagnostic and Statistical Manual of Mental Disorders
Prevalence of mental disorders? 1/5
Percentage of mental health care provided in primary care? 75%
Primary Care Psychiatric ROS AMPS: Anxiety, Mood, Psychosis, Substance
What takes the place of a PE? MSE (mental status examination)
What is included in MSE: Orientation (4) 1) Person 2) Time 3) Place 4) Situation
6 things in MSE: Appearance and Behavior 1) Grooming status 2) Hygiene 3) Looks compared to age 4) Eye contact 5) Attitude 6) General behavior
2 things in MSE: Motor activity 1) Body posture and movement 2) Facial expressions
6 things in MSE: Speech 1) Quantity 2) Rate 3) Volume 4) Tone 5) Fluency/Rhythm 6) Coherency
level and stability of consciousness Sensorium
Attention, concentration, memory Cognition
Patient’s awareness and understanding Insight
Ability to ID consequences of actions Judgement
What must the patient have in order to have the right to consent or refuse medical treatment? A sound mind
3 steps to get involuntary commitment 1) Determine that pt is an imminent risk to self or others 2) Send signed affidavit and petition for Involuntary Commitment (IVC) to court magistrate 3) Once granted, a different provider must evaluate w/in 24 hours
What is a temporary commitment? Holds a patient for 72 hrs w/o a court hearing if it is deemed an emergency
What is a civil commitment? Adopted by various states in the setting of sexual predators
T/F: Capacity is a legal issue decided in court not by health professionals False, Competency
Looks at the individuals thought processes, insight, and judgment to determine if they have the mental ability to make informed, autonomous decisions Capacity
T/F: Aggression is the most common reason for physical restraints on the medical/surgical floors False, Delirium most common on med/surg floor; Aggression most common reason on psych floors
What do the use of physical restraints require from a provider? Face-to-face assessment by provider w/in 1 hour
What is Duty to Warn? Must warn anyone that a serious threat has been made against
2 situations where breach in confidentiality is okay 1) Suspected child abuse 2) Suspected adult/elder abuse
Shifts the focus of care away from a mere diagnosis and treatment to include views of an illness from a patient’s perspective with respect to his/her preferences and needs Patient-Centered Care
3 steps to deal w/ difficult pts 1) ID difficult pt 2) View behavior as “useful clue” to illness 3) Look for a way to respond therapeutically to pt
Loss of a parent before age of 11, loss of spouse, disturbance of infant-mother relationship, psych co-moribidities, other GMC (general medical conditions) Risk factors for Mood disorders
4 types of mood EPISODES Depressive, Manic, Hypomanic, Mixed
Avg. age of onset is 30-35 y/o, Women 2x more likely, +FH is clear risk factor (1st degree), Higher in those unemployed, Higher mortality rate (6% lifetime risk of suicide) Depressive Disorders
What neurotransmitter alterations seen in mood disorders (3) 1) Serotonin 2) Dopamine 3) Norepinephrine
Pathophys of NT alterations When levels are LOW, membrane receiving neuron channels DON’T open and nerve messages cannot be passed through neurons
helps regulate sleep, appetite, and mood and inhibits pain Serotonin
constricts blood vessels, raising blood pressure. It may trigger anxiety and be involved in some types of depression. It also seems to help determine motivation and reward Norepinephrine
essential to movement. It also influences motivation and plays a role in how a person perceives reality; involved w/ substance abuse/reward system Dopamine
3 areas of brain affected by depression and a how they affect 1) Amygdala: overactive in depression 2) Hippocampus: smaller in depressed 3) Thalamus: may be associated w/ bipolar
Dx criteria for a depressive episode 1) Depressed mood or loss of interest/pleasure for at least a 2 week period PLUS 2) 4 or more other Sx (appetite, sleep, psychomotor disturbances, fatigue, worthlessness, inability to concentrate, SI)
Loss of interest or pleasure (clinical term) Anhedonia
Evaluation of major depressive disorder SIG E CAPS
SIG E CAPS Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidal thoughts
Best therapy for major depressive disorder? Pharmacotherapy and Psychotherapy combo
How can you tell which SSRI is the best for the situation? CAN’T…if there are two options on the exam, you EXCLUDE both of them!
What Tx for neurogenic pain and MMD? Cymbalta (Duloxetine)
Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertaline, Vilazodone SSRIs
Desvenla-faxine, Duloxetine, Levomilnacipram, Venlafaxine SNRIs
Bupropion NDRI
Adverse of SSRI/SNRI N/V/D/C, sexual dysfunction, HA, activation
Serotonin Syndrome causes neurologic, autonomic and muscular changes; FEVER (Fever, Encephalopathy, Vital signs unstable, Enzymes (elevated CPK), Rigidity)
Amitriptyline, Clomipramine, Desipramine, Imipramine, Nortriptyline, Trimipramine TCAs
Isocarboxazid, Phenelzine, Selegiline, Tranylcypromine MAO-Is
Adverse of TCA and MAO-I TCA: Anticholinergic and sedation; MAO-I require diet restrictions (basically anything good)
Acute phase length? Continuation phase length? Discontinuation? Maintenance phase? AP: 4-8 weeks, CP: 4-9 months, Discontinuation: taper down, Maintenance: continue indefinitely…3 or more episodes or risk factors for recurrence.
Tx Resistance? 5 steps 1) increase dose 2) change w/in same class 3) Switch classes 4) augment w/ another med class 5) ECT (last line)
Chronic feeling of “being down in the dumps” or “feeling low” most of the day for more days than not, for at least 2 years Persistent Depressive Disorder
Persistent Depressive Disorder criteria Must have 1) Depressed mood PLUS at least 2 others (poor appetite, insomnia/hypersomnia, fatigue, low self-esteem, poor concentration, feelings of hopelessness). These must occur for 2 years and cannot go w/o Sx for more than 2 months at a time
First-line for Tx of Persistent Depressive Disorder Psychotherapy alone. If that doesn’t work: Psychotherapy and Pharmacotherapy
Substance/Medication-Induced Depressive Disorder timing occurs 1 month after substance intoxication or withdrawal
Recurrent Brief Depression: presence of 4 or more sx and depressed mood for 2-13 days at least once a month for at least 12 months
Short-Duration Depressive Episodes: presence of 4 more sx and depressed mood for 4-13 days
Depressive Episode w/ Insufficient Symptoms: depressed mood and least one of the other 8 sx that persists for at least 2 weeks
Symptoms are characteristic of a depressive d/o that causes significant distress/impairment but does not meet the full criteria of any of the disorders in the depressive d/o diagnostic class. Unspecified Depressive Disorder
Emotional or behavioral Sx in response to an identifiable stressor occurring within 3 months of the onset of the stressor. Adjustment Disorder
Marked distress out of proportion to severity of stressor AND/OR significant impairment in social, occupational, or other areas of functioning Adjustment Disorder
How long should you persist with treatment after stressor has been resolved with Adjustment Disorder? no longer than 6 months
What is important for making a diagnosis of a mood disorder in regards to GMCs? Must rule everything else out
Who should you screen for mood disorders? Everyone! (recall AMPS)
Labs for mood disorders (5) 1) TSH 2) CBC 3) B12 4) CMP 5) UA
What gender has higher prevalence of bipolar 1? Bipolar 2? 1: Gender neutral 2: F>M
T/F: Genetic influence much stronger in depression than in bipolar False, Bipolar has stronger genetic component; considered the most heritable mental illness
3 dysfunctions of bipolar 1) Too much cortisol: depression; Too little cortisol: mania 2) Frontal cortex to limbic system  chaotic presentation of bipolar 3) Disrupted neurotransmission of NTs
Abnormally elevated, increased goal-direction lasting 1+ week, causing significant impairment that is not contributed to another substance or condition Manic episode
Evaluating Mania DIGFAST (Distractibility, Injudiciousness, Grandiosity, Flight of ideas, Activities (lots), Sleep, Talkativeness
Activated, distractible, pleasure-seeking behaviors, impulsive, impaired, loud speech, tangential thought process Mania
Abnormally elevated, expansive, increased energy, lasting 4 consecutive days. Not severe enough to cause significant impairment. Evaluation? Hypomanic episodes; Eval still DIGFAST (What does that stand for again?)
Both Sx of MDE and manic episode persisting for 7+days. HIGH risk of SI or self-injurious behaviors (SIB) Mixed episode
T/F: Much more time is spent in depression than hypomania or mania True
T/F: 60% of manic episodes occur directly after a major depressive episode False, occur immediately before
How many manic episodes are required for a Dx of Bipolar? Which Bipolar? Only 1 episode for Dx of BIPOLAR 1!
Dx for Bipolar 1 (2 options) 1) If mood disturbance is euphoria: 3+ DIGFAST Sx. 2) If mood disturbance is irritability: 4+ Sx.
Onset mid 20s usually with a MDE first, with Sx decreases as the person ages. RF: genetics highest among mood disorders. 1/3 report SA in lifetime Bipolar 2 Disorder
T/F: Bipolar 2 disorder usually has 1 comorbidity of another mental disorder. False, majority have at least 3 co-occurring mental disorders
Bipolar 2 disorder criteria 4 days of hypomanic episodes (DIGFAST criteria) where hypomania doesn’t cause significant impairment AND 2 weeks of MDE criteria (5 Sx 1 being depression or anhedonia, others SIGECAPS)
4 or more mood episodes over 12 month period Rapid-Cycling Specifier
Begins in teens/early adulthood with a high likelihood -> Bipolar disorder. Many episodes of hypomanic Sx and depressive Sx that do not meet criteria occurring over 2 years. Cannot be w/o Sx for 2 months and causes significant impairment to functioning Cyclothymic Disorder
T/F: Substance/Medication-Induced Bipolar and Related Disorder is associated with delirium FALSE
Sx are characteristic of bipolar and related disorders but do not meet full criteria Other Specified Bipolar & Related Disorder
Gold standard for Bipolar Disorder. A few other options? Mood stabilizers like Lithium. Others: anti-convulsants (Valproic Acid, carbamazepine, Lamotrigine)
Why don’t we use anti-depressants in treating Bipolar? Can switch them from a depressed state to a manic state.
What is the only thing shown to break an acute manic cycle? Sleep
What Tx do you use for an acute mixed episode? Same medications as acute mania: Mood stabilizers
What mood stabilizer is especially effective in acute mixed episode if the predominant Sx is depression? Lamotrigine
Side effects of Lithium Ebstein anomaly formation in pregnancy, hypothyroidism, lithium toxicity
Side effects of Valproic acid Thrombocytopenia, elevation in LFTs
Side effects of Carbamazepine SJS and thrombocytopenia
Side effects of Lamotrigine lacy rash and SJS
Leading cause of ED visits and hospital admission for those 35 and younger? Suicide attempts (SAs)
Veterans, widowed/divorced/single, Caucasian, age extremes, less religious, comorbid psychiatric disorders High risk groups for suicide
T/F: In 2013, there were as many veteran suicides as servicemen killed in Iraq/Afghanistan war that year False, there were as many suicides in that one year as troops killed the entire war
T/F: 50% of pts who completed suicide saw their PCP within 1 month of their death True
Management for passive SI, no plan, good support system Treat outpatient
Management for active SI, plan Admit to inpatient behavioral health unit and Tx underlying psych/substance disorder ASAP
Loss of reality testing often accompanied by delusions, paranoia, and hallucinations Psychosis
Disruption of thought, mood, and overall behavior Schizophrenic disorder
fixed beliefs that are not going to change even with conflicting evidence. Delusions
perception-like experiences that occur without an external stimulus Hallucinations
thought process often driven by anxiety and fear that results in irrational or delusional beliefs (state of thinking driven by fear and anxiety that are irrational, leading to delusions) Paranoia
Bizarre no way it could be possible. (internal organs replaced w/o scarring)
Non-Bizarre can be possible. I believe I’m being followed by the police
Usually inferred from one’s speech. May switch from topic to topic (derailment or loose associations), answers may be unrelated (tangential) or nearly incomprehensible (word salad or incoherence) Disorganized thinking
can manifest in many ways from childlike silliness to unpredictable agitation which often affects ability to carry out ADLs. Disorganized or Abnormal Motor Behavior
marked decrease in reactivity to the environment Catatonia
purposeless and excessive motor activity w/o obvious cause Catatonic excitement
4 As of Psychosis; What kind of Sx are these? 1) Autism 2) Attention 3) Affect 4) Association; Negative Sx
Assessing a patient with Psychosis? PSYCHOSIS (Psychotropics, Safety, Psychotic Sxs, Caring, Home, Other conditions, Suicide, Impairment, Substance misuse)
Social withdrawal, auditory hallucinations, loose associations,, delusions, flat affect, hypersensitivity, depersonalization Sx of Psychotic disorder
What NT abnormalities are associated with Psychotic disorder? What are the 2 other pathophysiologies? Glutamate and Dopamine excess; Genetic and Environmental causes
Typically emerges in males first, then females at a later age, suicide is a major risk in this disease as are comorbidities. DSM criteria? Acute phase of Schizophrenia; 2+/5 Sx present for a month: 1) Delusions 2) Hallucinations 3) Disorganized speech 4) Disorganized behaviors 5) Negative Sx
DSM criteria for Schizophrenia Continuous disturbance that persists for >6 months, including active-phase Sx for at least 1 month
Preoccupation w/ 1 or more delusions, related to persecution, disorganized speech or behavior Paranoid type Schizophrenia
Disorganized speech, disorganized behavior, flat/inappropriate affect Disorganized type Schizophrenia
Mutisim, excessive motor activity, extreme negativism, weird voluntary movement like perching, echolalia (parroting) or echopraxia (repetition of movement) Catatonic type Schizophrenia
Those who have had an episode in the past that meets criteria for a schizophrenic diagnosis but at present are not actively psychotic. Residual type Schizophrenia
Presence of 1+ delusions for at least 1 month w/o meeting criteria for schizophrenia Delusional Disorder
Erotomanic Delusions another person, usually of higher status, is in love with them (usually celebrity)
Grandiose Delusions inflated worth, power, knowledge, identity, or special relationship with a famous person
Jealous Delusions convinced of infidelity
Persecutory Delusions being spied on, conspired against, followed, poisoned, or manipulated
Somatic Delusions bodily sensations or functions
Mixed Delusions multiple themes exist w/o one being predominant
Unspecified Delusions: no clear theme is identifiable
Delusional paracytosis imagined bug infestation.
Why is Tx difficult w/ delusional patients? Tx? Lack of insight into their delusion and convinced of accuracy causes a “fixed” mindset. Tx: anti-psychotics
Female>males, mid 30s, after traumatic event with high rate or relapse, where duration only lasts less than a month, delusions, hallucinations, disorganized speech, disorganized/catatonic behaviors. Prognosis? Brief Psychotic Disorder; Full recovery eventually to baseline
More common in developing countries, 2+/5 for more than 1 month but less than 6 months: delusions, hallucinations, disorganized speech, disorganized behavior, negative Sx; prognosis? Schizophreniform Disorder; 1/3 recover in first 6 months, 2/3 go on to develop schizophrenia/schizoaffective disorder
Early adulthood onset, females/males, RF: genetics, 2+/5 (delusions, hallucinations, disorganized speech/behavior, negative Sx), with major mood episode (mania or depression) for at least 2 weeks Schizoaffective disorder
Typical pattern of schizoaffective disorder Hallucinations/delusions prior to MDE or mania then Sx are present at same time, eventually mood Sx resolve but psychosis still present (psychosis always comes before mood episode in Schizoaffective disorder
Name and describe the 2 subtypes of Schizoaffective disorder 1) Bipolar: manic/mixed episode w/psychosis (which came first) 2) Depressive: MDE w/ psychosis (which as always, comes first)
Why can psychosis/schizophrenia resolve or improve with age? Glutamate and dopamine levels decrease as we age (excess amounts cause said psychosis)
Tx for Psychotic patient? Anti-psychotics, specifically, ATYPICAL as they have a lower side effect profile
Thorazine, prolixin, Haldol Typical anti-psychotics
Clozapine, risperidone, olanzapine, quietipaline, ziprasidone, aripiprazole Atypical anti-psychotics
Risperidone is most likely to raise prolactin levels
Clozapine may cause agranulocytosis
Olanzapine is least likely to increase QT prolongation
Quietiapine has been known to cause _________ in dogs cataracts
Ziprasidone is most likely to increase QT prolongation
Ariprprazole is least likely to cause wt gain
Which typical anti-psychotic has a lower likelihood of EPS and sedation and autonomic adverse? Thorazine
4 categories of EPS and first line Tx 1) Akathasia (need for constant motion): Benzodiazepine 2) Dystonia (odd muscle contractures): Diphenhydramine 3) Drug-induced Parkinsonism: irreversible 4) Tardive Dyskinesia (abnormal repetitive involuntary movements of face/mouth/tongue: no Tx
What is NMS? Tx? Neuroleptic Malignant Syndrome; FEVER (Fever, Encephalopathy, Vital sign instability, Elevated CPK, Rigid muscles); Tx: Symptomatic: dantroline helps reduce fever
Tx of aggressive/violent patient (5) remove weapons, reduce stimulation, never turn back, Benzodiazepine Zyprexa in acute crisis is first line
What should be given with typical anti-psychotics? Benadryl
Chronic Behavior and Developmental condition of inattention and distractibility with or without hyperactivity ADHD
T/F: 2-4x more frequent in girls and 50% have another significant psychiatric comorbidity False, more common in BOYS
Do inattentive or hyperactive Sx improve w/ age? Hyperactive Sx decrease!
ADHD criteria 6+ Sx of either inattention or hyperactivity/impulsivity in at least 2 different environments by age of 12 that interfere w/ social, academic, occupational functioning
Inability to be flexible, anticipate needs/problems, goal set, use short term memory, detach emotion from reason, wait in line appropriately Defects in executive function
ADHD pathophysiology (4) 1) Strong genetic component 2) Environmental factors not clearly IDed 3) Disturbance in dopamine, norepinephrine, acyetylcholine 4) abnormalities in frontal and parietal cortex, basal ganglia, cerebellum
Percentage of children that continue having Sx of ADHD as adults ~50%
What labs are routine when assessing for ADHD? NONE
First line therapy for ADHD. 2nd line? Central stimulants; 2nd: Atomoxetine(SNRI), alpha agonists, anti-depressants
Adverse of stimulants (6) wt loss, abd pain, HA, irritability, sleep disturbances, tic development
Black box warning for atomoxetine Increased risk of SI
Alpha agonists (clonidine/guanfacine) main adverse (3) 1) Skin rxns 2) Somnolence 3) Drowsiness
Adjunctive Tx to pharmaceuticals (3) 1) High protein diet 2) Exercise 3) Good sleep habits
Inaccurate self-image regarding weight associated with self-imposed food restriction and exercise to maintain dangerously low body weight (no matter how thin they get); BMI < 17.5 or <85% of expected weight; Fatality? Anorexia Nervosa; 10% fatality
What may anorexia nervosa coincide w/? Separation from home or after a loss
3 comorbidities w/ anorexia nervosa Depression, anxiety, OCD
Prognosis for anorexia nervosa: how many have complete recovery? Which prognosis is associated with a poor outcome? 50% recover fully; Bulimia nervosa associated w/ a poor outcome
pale or yellow tinged (carotenemia), fine lanugo hair, acrocyanosis, dryness, ankle edema, bradycardia, HypoTN, hypothermia signs of starvation
2 main effects of purging 1) Parotid gland enlargement 2) Dental carries/erosion of enamel
3 things to screen for w/ anorexia nervosa evaluation? 1) SI 2) Depression 3) Anxiety
What is recommended if a pt is amenorrheic for 6+months? Bone density scan
Recurrent episodes of binge eating with a sense of lack of control over eating during the episode and recurrent compensatory behavior to prevent weight gain. Scars on dorsum of hand and tooth enamel erosion. How long must it go on for for Dx? Bulimia nervosa; 1+/week for 3+months
Hypokalemia w/ alkalosis suggests? What does acidosis suggest? vomiting or diuretic abuse. Acidosis: laxative abuse
Binge eating disorder. How long must it go on for Dx? What labs are usually abnormal? 1+/week for 3 months. No compensatory mechanisms. PE and labs are usually NORMAL
When is hospitalization for eating disorders required? suicidal ideation, major electrolyte or cardiac disturbances, severe malnutrition
What is the good approach for treating adolescents w/ anorexia? FAMILY THERAPY w/ Maudsley Approach (training parents)
What drug is contraindicated in eating disorders and why? Buproprion due to increased potential of seizures w/ eating disorders
Rx Tx of Bulimia SSRIs (mainly) and TCAs
Rx Tx of Anorexia Atypical anti-psychotics
Rx Tx of Binge-Eating disorder SSRIs
Created by: crward88