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Behavioral Medicine
Y2S1B2
| Question | Answer |
|---|---|
| Confusional states (delirium, dementia, amnesia) are all characterized by: | cognitive disturbances such as confusion, memory impairment, speech/language difficulties, impairment of executive functions |
| Acute Confusional State | sudden onset of congnitive impairment; "organic" - physiologic in causation |
| Acute Confusional State: young people | think intoxication/withdrawal |
| Acute Confusional State: Older people | think cerebrovascular, tumor or medication |
| Acute Confusional State: children | think metabolic problems |
| Delirium | clouding of consciousness, impaired cognition, short/fluctuating course; NOT dementia; general medical conditions or substances most common (incl. prescriptions/steroids); pt can be ok during daylight and bad at night/morning dt few sensory distractions |
| Delirium-associated features | sleep/wake cycle disturbances; phsychomotor behavior disturbance (extremes of strength or weakness/catatonia); emotional disruption; EEG abnormalities often diagnostic (delta wave disturbance - deep unconscious); evidence of med condition/substance abuse |
| Delirium is often a/w the following medical conditions: | systemic infxns/inflam; metabolic derangement; hepatic failure or disease; renal failure or disease; seizures; head trauma |
| Tx depends on Dx | correct identification of underlying problem is essential; addressing this prob is curative; while work-up proceeds, treat pt w/calm reassurance in a quiet well-lit room; frequently re-orient pt; if severely agitated use anti-psychotics (restraints rarely |
| Antipsychotic medications | Ziprexa (olalanzapine, dissolvable Zydis); Rispadol (risparadone, dissolvable M-tab) |
| Dementia | delirium lasting longer than 6 months (DSM-IV); cognitive impairment should be apparent even w/clarity of consciousness; memory impairment (esp short term) is HALLMAR, but other impairments are needed for Dx |
| Aspects of Dementia: | aphasia, apraxia, agnosia, frontal/executive funtional impairments |
| Aphasia | problem w/speech or language (ex: stroke from a language ctr in temporal area, bizarre speach, jargon aphasia) |
| Apraxia | loss of ability to perform a taks (ex: combing hair) |
| Agnosia | loss of knowledge; unable to recognize common objects/faces by sight or feel |
| "Frontal" or "Executive" functional impairments | cannot organize, plan or execute complex activities; judgement becomes poor; loss of problem-solving ability |
| Types of dementias: Cortical vs. Subcortical | aphasia may help discriminate cortical; this is a histological difference |
| Types of dementias: Neurodegenerative | Alzheimers type is most common (no one understands its genesis, it is a genetically linked cluster of neurofibrillary tangles) |
| Types of dementias: Infectious | PNL (viral infxn giant white patches of demyelination in brain of HIV pts); Prion Diseases (CJ - spongiform encephalopathy makes holes where brain tissue was; Kuru, Mad Cow) |
| Types of dementias: Cerebrovascular | strokes, aneurysms, and other intracranial problems |
| Types of dementias: Substance-induced | alcohol is most common; poisoning (migrant workers from insecticides; lead poisoning in kids) |
| Dx of Dementias leads to Tx | correctly differentiating from other conditions guides Tx; medications include: antipsychotics/anti-cholinergics/avoid sedatives; Involve a family member/caregiver; access as many community services as possible for support |
| Amnestic Disorders | Impaired memory only; confusion/confabulation; emotional change; R/O dissociative disorders; bilateral damage to brain structures required; "age-related cognitive decline" - major memory probs can't be attributed to normal aging (consider drugs, hormones) |
| Mini Mental Status Exam: Score of 0-22 | suggestive of an organic syndrome |
| Mini Mental Status Exam: Question 1 | what is the year (season, date, day, month); 0-5 points |
| MMSE: Question 2 | Where are we? (state, country, town, hospital, floor); 0-5 points |
| MMSE: Question 3 | I'd like to test your memory, please say these 3 words (ex: pencil, door, clock); 0-3 points |
| MMSE: Question 4 | Begin with 100 and count backwards by 7 (100, 93, 86, 79, 72, 65...); 0-5 points |
| MMSE: Question 5 | Can you name the 3 objects I named before? 0-3points |
| MMSE: Question 6 | Can you identify these 2 objects? 0-2 points |
| MMSE: Question 7 | Repeat the following: "No ifs, ands or buts;" 0-1 point |
| MMSE: Question 8 | Take this paper in your right hand, fold it in half and put it on the floor; 0-3 points |
| MMSE: Question 9 | Please read and obey the following statement: "Close your eyes;" 0-1 point |
| MMSE: Question 10 | Please write a sentence for me; 0-1 point |
| MMSE: Question 11 | Please copy this drawing of 2 interlocking pentagons; 0-1 point |
| Personality Disorders | divided into clusters; ingrained pattern of behavior that lasts for years (pt cannot "snap out of it"); They can learn to make their disorder adaptive (except borderline and antisocial); May not be diagnosed bf 16-18yo (be cautious w/adolescents) |
| Cluster A Personality Disorders | schizoid, paranoid, schizotypal |
| Schizoid Personality Disorder | Cluster A; people who want to be left alone; loners; don't socialize; not psychotic; job is technical w/o interactions w/people; no friends or support system; don't interact enough to get things done that they need, but they don't mind living this way |
| Paranoid Personality Disorder | main thing is to distinguish from paranoid psychosis, quasi delusions; reality testing intact, thoughts are clear |
| Schizotypal Personality Disorder | people who are the "hippie chicks" and do the crystals...in touch with the animal spirit; a little weird w/belief systems just outside of the mainstream; can become a problem if they become quasi delusionsal |
| Cluster B Personality Disorders | the "bad" ones; Borderline, Histrionic, Narcissistic, Antisocial |
| *Borderline | B;Focus Hx on relationships; empty feeling inside/hurt all the time; self injury (arms w/tracks); many bad relationships/end abruptly w/partner running away; get inappropriately attached early; can never be happy/blame others/suicide attempts (overdose); |
| more facts about borderline people | drug abuse not common; 12-15% of people; common ER pts; more common in females; emotional vampires |
| Histrionic Personality Disorder | B; very demonstrative and elaborate; bright loud colors, dramatic, exaggerative; becomes a problem when you cannot believe what they say anymore |
| Narcissistic Personality Disorder | B; "entitled people;" demand the top person; want the best of everything; put others down to feel better about self; best way to deal with these pts is to let them put you down |
| Antisocial Personality Disorder | do not feel bound to abide by the rules of regular society; repeatedly violate rights/laws of other people; shallow; may have kids they don't talk to; must be >18yo; lack empathy/callous/manipulative; frustrated/violent |
| Cluster C Personality Disorders | benign; hardly ever seen; Avoidant, Dependent, Obsessive-Compulsive |
| Avoidant Personality Disorder | C; the librarian type that doesn't interact outside comfort zone; they want relationships (diff from schizoid); desperately lonely but have no skills/courage to get out and interact w/people |
| Dependent Personality Disorder | C; "as if" personalities; don't have substance of their own; they ride along someone else's life; crisis happens when "host" abandons them and they are left adrift |
| Obsessive-Compulsive Personality Disorder | C; a little bit is OK; thorough, check, don't miss things; too much means you cannot leave house because pt is washing hands for 2hrs |
| Normal phases of sexual arousal | Desire, excitement, orgasm, resolution |
| Desire phase | stimulation usu visual/mental imagery, physical sensation or spont physiological response (ex: morning erection); changes in blood flow/lubrication; initiated in the brain |
| Sources of sexual arousal | men primarily visual; women use other senses too, incl smell; normal men aroused by women >14yo; either sex may be aroused by members of same sex |
| Excitement phase | brain decides to commit to sexual response; measurable physiologic changes dt arousal; erectile engorgement, inc HR/BP/RR; women can be less aware |
| Excitement escalation | one point where deviation can occur; time from excitement to climax usu longer for women; fantasy is usueful; upward trending curve of hyperarousal that may be painful |
| Plateau stage | maximal excitement; scrotum tightens and penis may arch w/hyper-engorgement; Cowper's gland secretions contain viable sperm (premature ejaculation - tell teens); Clitoris is hypersensitive, vagina tightens/lengthens; sensation of imminent orgasm |
| Orgasm - women | perineal platform structure contracts rhythmically in women (thick, dark, full of blood); controversy over "clitoral" vs. "vaginal" bc different areas of stimulation results in different types of orgasm; anal stimulation in women does not produce orgasm |
| Orgasm - men | men experience sensation of ejaculation at onset; prostate, seminal vesicles, urethra contract rhythmically to emit semen; some meds cause painful retrograde ejaculation |
| Priapism | ususually painful and prolonged erection (usu penile) > 4hrs; emergency bc tissues can necrose dt lack of blood flow; Tx w/ice water enema or detumescence w/needle to drain corporis cavernosum |
| Resolution phase | males experience refractory period of varying length, during which time erection can't occur; younger men have shorter periods/better ability for rearousal; women may proceed to another orgasm |
| Disorders of Sexuality | don't want to, want but can't; poor control or it hurts; want too much or too often; want something/one that is not a natural sex partner (paraphilias - fetishes if required for arousal) |
| Hypoactive Desire: who decides what is too low? | Dr takes into account a person's life, stress/demands; in some situations sex is considered disposable; may be dt time constraints or other life stressors |
| Absence of fantasy/interest in any sexual behavior | be comfortable w/your own sex life; men and women have different arousal cycles - compromise; pt may be depressed |
| Sexual Aversion | pt wants sexual feelings w/o contact w/another's genitals; dt control distress like panic attacks, OCD, germ-related |
| Masturbation | women are less likely to do it & usu have less experience w/what they are supposed to feel; can be used to differentiate averse person from low desire; teach women/couples as therapy; |
| Excess masturbation | clue to certain MR (inappropriate times/places; overaroused); Excess = problematic incl blisters, distracted in school; teen boys think of ways to take desire away (ex: mom in underwear); social probs can occur if done in public |
| Erectile Dysfunction | a symptom of a physiological OR psychological/emotional problem; can be a red flag about probs in relationship; Plethysmograph or postage stamps can be used to detect erection during the night (3-5 cycles usu occur) |
| Orgasmic disorders | mid-aged men or women who never experienced orgasm; determine if this is a new event v. lifelong problem; check meds; sex therapy to give partner pleasure from places other than genitals |
| Premature ejaculation | a problem if it creates a problem w/partner; difficult topic ask about sexual performance/satisfaction; suggest a way to help; chronic probs may lead to sex aversion in men |
| Dyspareunia | painful sexual intercourse; usu dt medical disorder or drug side effects; psychotherapy may help esp if a traumatic sexual event was experienced |
| Sex and drugs: SSRIs | notoriously reduce libido/impair orgasms; |
| Sex and drugs: anticholinergic or antihistaminic | drying, vaginal drying, painful intercourse |
| Sex and drugs: Trazodone/Desyrel | antidepressant sedating and slightly antihistaminic; males experience priapism |
| Sex and drugs: alcohol | dose-related; small amount reduces inhibitions and facilitate a better experience; higher blood EtOH = more impairment |
| Sex and drugs: cocaine | does NOT heighten sex |
| Sex and drugs: ecstasy | increases libido in males and females |
| Paraphilias | recurrent intense fantasies, urges, behaviors w/non-human objects, suffering, kids, other non-consenting people; their only satisfactory experience/perferred method of sex; more common than not |
| Common paraphilias | entirely different from sexual orientation; exhibitionism, fetishism, transvestic fetishism, frotteurism/frottage, voyeurism, sadism, masochism, sadomasochism |
| Exhibitionism | sexually aroused by displaying genitals in public; desired effect is to stun people; may be male/female; women usu exhibit breasts to get social approval not usu for sexual arrousal |
| Fetishism | when a person has an unusual sexual arousal linked to a particular object (ex: feet, high-heeled shoes, things that are furry or tactiley interaesting) |
| Transvestic Fetishism | people sexually aroused by dressing in clothing of opposite gender; usu men in women's clothes...not an indicator of sexual orientation |
| Frotteurism/frottage | rubbing genitalia on someone unsuspecting; people usu in crowded subway/concert; victim doesn't know if they are doing it on purpose or not |
| Voyeurism | aroused by watching others have sex or seeing their bodies when they are not aware of being observed |
| Sadism | tend to be psychopaths or extreme personality disorders; involved physical or psychological harm to victim to heighten sexual experience; often becomes murder from repeated torture |
| Masochism | > 6 months; recurrent intense sexual fantasies involving personal suffering; can cause significant impairment in social, occupational functioning |
| Sadomasochism | as a non-pathological concept, people who engage in these activities do so interchangeably; role-playing w/2+ partners, one person is mildly tormented by the others |
| Pedophilia | probably born that way; not really curable; aroused by children <14yo; most common is male only arousal; can be only female or both; limited to incest; exclusive = only kids; non-exclusive = gets involved w/single parent to abuse kids; usu age-specific |
| things about the pedophile | must be 16yo to be diagnosed (bf 16 there may be general sexual confusion); <50% of pedophiles were sexually abused as kids; identification w/the aggressor - mastering own victimization by acting out on others; no effective treatment (anti-androgens) |
| zoophilia | sex w/animals |
| telephone scatologia | phone sex |
| necrophilia | arousal by having sex w/dead bodies; some people will kill to gain access to dead bodies |
| coprophilia/urophilia | excrement needed for sexual arousal; "golden showers" |
| amputation-related paraphilia | use amputated stump for sex or use another person's amputated stump for sex |
| Partialism | sexual fixation on a part of the body (ex: feet); they may actually remove the part from a victim for a collection |
| overlapping paraphilias | man in outhouse for 12hrs in rubber suit; aroused by women eliminating waste on top of him |
| Gender Identity Disorder | people feel they were born in wrong body and want it fixed; possible change via hormones/surgery/etc; pt genuinely feels they are the opposite sex w/persistent discomfort in own sex; not simply a desire for perceived advantages or discomfort w/stereotypes |
| Transgenderism | not to be confused w/transvestitism; usu presents in childhood; sexual orientation may be gay/straight/bisexual regardless of perceived gender; complication of gender assignment in sexually ambiguous kids; they feel/act like they are the other sex |
| Making a diagnosis on a sexual dysfunction | to dx a disorder, it has to create significant distress in pt's life; not just a "weirdness;" take good sexual Hx; leave religious, cultural, social values out of assessment; interview partners separately; get over your own inhibitions |
| Suicide | This is the act of voluntarily taking one’s own life. It is a intentional self-inflicted death, whereby the murderer and the victim is the same |
| Suicide Gesture/Suicidal Behavior | Is self-destructive act which is manipulated as attention seeking behavior |
| Suicidal Attempt | A self-destructive act which requires medical or surgical treatment |
| Modes of Death (NASH) | natural, accidental, suicidal, homicidal |
| Limitations of suicide research | unknown suicides, underreporting, misclassification of deaths |
| Rational suicide | the pt wishes to follow thru with this; they are not psychotic |
| Reactional suicide | when a significant loss causes pt to grieve enough to end life |
| Vengeful suicide | pt wants to make someone else “pay” for their death |
| Manipulative suicide | to emotionally influence another person |
| Psychotic suicide | pt has mental disorder; very difficult cases |
| Accidental suicide | attempted suicide may become lethal by virtue of an accident |
| Suicide death rates by state | many western mountainous states...can it be due to isolation? lack of support system; temporary workers |
| Methods of Completed Suicides | >50% by firearms; hanging, solid/liquid poisons, gas poisons, jumping, other.... |
| Highest suicide rate by age and sex: | older than 75; 85+ has highest rate; males are 5x more likely to do it successfully |
| Out of state suicides in Nevada | only 10% |
| Months w/greater suicide events in Nevada | September and February |
| Suicide by Psychological Risk Groups | 60% have Affective Disorders/Depression; 10-15% Schizophrenia; 15-25% dt substance abuse |
| Causes of death in youth | #1: Accidents, #2: Cancer, #3: Suicide |
| The Seriousness of Suicide Attempts | 1 in 4 are successful; pt becomes at risk for life; Consider: likelihood of rescue, precautions against discovery, degree of planning, purpose of attempt (intent), concern for effect on family, proximal life crisis (divorse, bankruptcy, surgery, etc) |
| Survivors of suicide | each suicide intimately affects at least 6 other people; |
| Medical presentation/causes of depression | endocrine disorders (thyroid, diabetes), post-partum, cancer, brain tumors-myomas, HIV, Hep B, Parkinson's, chronic pain, sexual dysfxn; Family Hx |
| Medications that cause depression | antihistamines, steroids, antidepressants, anti-hypertensives |
| Triad of Depression | lonliness/sadness, difficulty sleeping, wt loss OR overeating, oversleeping, hyperactivity |
| Suicide Risk Assessment Tools | suicidal plan, final arrangements, depression, substance abuse, isolation/withdrawal, previous attempts, anxiety,current resourses (emotional/funds), activity fxning, recent losses, disorientation/disorganization, lifestyle, hostility |
| Anxiety level = highly motivated | indicates more succes w/suicidal attempt; as well as someone who has depressed and all of a sudden is more friendly b/c they finally have the energy to carry it out |
| The most consistant risk factor a/w suicidal risk | PRIOR SUICIDAL BEHAVIOR |
| 5 Domains related to youth suicide assessment | characteristic of suicidality (intent, lethality, motivation); Current lifetime psychopathology (mood, subs abuse, eating dis); Psych charach (despair, hostility, aggression, social skills); fam/environ factors; availability of lethal agents |
| When Suicidal Patients Require Hospitalization | pt is acutely/actively psychotic w/poor judgment, command hallucinations; Under influence of drugs; Intoxicated and ER is not equipped to monitor for 12-23hrs of observation; Pt is alone; Mood doesn't change w/intervention; Stressor isn't resolved/at home |
| Risk Management | Consultation; Tx for depression; Level of care/hospitalization; Document (risks, compliance, Sx, info, reasons, fam, contracts, contacts); Competency/scope of practice |
| Enhance Compliance | follow up appt; timely scheduling w/telephone reminder; 24hr back up available for crisis; pursue no-shows w/phone calls or letters; contract btw pt, family, therapist for tx; involve family and significant others |
Created by:
bscaryp