Clinical Medicine: Psychiatry: Intro, Mood Psychotic, ADHD and Eating Disorders
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| A study of the human mind and its functions (mental processes) and behaviors. | Psychology
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| A medical specialty that diagnoses, treats, and prevents mental and emotional disorders. | Psychiatry
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| 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
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| Treatment of mental disorders through verbal and non-verbal (pet therapy, recreational therapy, art, music etc.) communication. | Psychotherapy
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| Treatment that aims to make the unconscious, conscious. | Psychoanalysis
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| 3 types of psychotherapy? Which ones are still used? | Cognitive, Behavioral, Psychoanalysis; Cognitive and behavioral are still used
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| Addresses dysfunctional emotions, maladaptive behaviors, cognitive processes and contents. What are the 3 Rs? | Cognitive Behavioral Therapy; Recognize, Reconstruct, Repeat
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| What does DSM stand for? | Diagnostic and Statistical Manual of Mental Disorders
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| Prevalence of mental disorders? | 1/5
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| Percentage of mental health care provided in primary care? | 75%
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| Primary Care Psychiatric ROS | AMPS: Anxiety, Mood, Psychosis, Substance
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| What takes the place of a PE? | MSE (mental status examination)
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| What is included in MSE: Orientation (4) | 1) Person 2) Time 3) Place 4) Situation
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| 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
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| 2 things in MSE: Motor activity | 1) Body posture and movement 2) Facial expressions
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| 6 things in MSE: Speech | 1) Quantity 2) Rate 3) Volume 4) Tone 5) Fluency/Rhythm 6) Coherency
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| level and stability of consciousness | Sensorium
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| Attention, concentration, memory | Cognition
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| Patient’s awareness and understanding | Insight
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| Ability to ID consequences of actions | Judgement
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| What must the patient have in order to have the right to consent or refuse medical treatment? | A sound mind
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| 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
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| What is a temporary commitment? | Holds a patient for 72 hrs w/o a court hearing if it is deemed an emergency
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| What is a civil commitment? | Adopted by various states in the setting of sexual predators
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| T/F: Capacity is a legal issue decided in court not by health professionals | False, Competency
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| Looks at the individuals thought processes, insight, and judgment to determine if they have the mental ability to make informed, autonomous decisions | Capacity
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| 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
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| What do the use of physical restraints require from a provider? | Face-to-face assessment by provider w/in 1 hour
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| What is Duty to Warn? | Must warn anyone that a serious threat has been made against
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| 2 situations where breach in confidentiality is okay | 1) Suspected child abuse 2) Suspected adult/elder abuse
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| 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
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| 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
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| 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
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| 4 types of mood EPISODES | Depressive, Manic, Hypomanic, Mixed
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| 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
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| What neurotransmitter alterations seen in mood disorders (3) | 1) Serotonin 2) Dopamine 3) Norepinephrine
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| Pathophys of NT alterations | When levels are LOW, membrane receiving neuron channels DON’T open and nerve messages cannot be passed through neurons
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| helps regulate sleep, appetite, and mood and inhibits pain | Serotonin
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| 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
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| essential to movement. It also influences motivation and plays a role in how a person perceives reality; involved w/ substance abuse/reward system | Dopamine
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| 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
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| 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)
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| Loss of interest or pleasure (clinical term) | Anhedonia
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| Evaluation of major depressive disorder | SIG E CAPS
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| SIG E CAPS | Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidal thoughts
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| Best therapy for major depressive disorder? | Pharmacotherapy and Psychotherapy combo
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| 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!
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| What Tx for neurogenic pain and MMD? | Cymbalta (Duloxetine)
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| Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertaline, Vilazodone | SSRIs
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| Desvenla-faxine, Duloxetine, Levomilnacipram, Venlafaxine | SNRIs
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| Bupropion | NDRI
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| Adverse of SSRI/SNRI | N/V/D/C, sexual dysfunction, HA, activation
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| Serotonin Syndrome | causes neurologic, autonomic and muscular changes; FEVER (Fever, Encephalopathy, Vital signs unstable, Enzymes (elevated CPK), Rigidity)
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| Amitriptyline, Clomipramine, Desipramine, Imipramine, Nortriptyline, Trimipramine | TCAs
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| Isocarboxazid, Phenelzine, Selegiline, Tranylcypromine | MAO-Is
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| Adverse of TCA and MAO-I | TCA: Anticholinergic and sedation; MAO-I require diet restrictions (basically anything good)
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| 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.
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| 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)
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| 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
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| 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
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| First-line for Tx of Persistent Depressive Disorder | Psychotherapy alone. If that doesn’t work: Psychotherapy and Pharmacotherapy
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| Substance/Medication-Induced Depressive Disorder timing | occurs 1 month after substance intoxication or withdrawal
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| 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
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| Short-Duration Depressive Episodes: | presence of 4 more sx and depressed mood for 4-13 days
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| Depressive Episode w/ Insufficient Symptoms: | depressed mood and least one of the other 8 sx that persists for at least 2 weeks
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| 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
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| Emotional or behavioral Sx in response to an identifiable stressor occurring within 3 months of the onset of the stressor. | Adjustment Disorder
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| Marked distress out of proportion to severity of stressor AND/OR significant impairment in social, occupational, or other areas of functioning | Adjustment Disorder
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| How long should you persist with treatment after stressor has been resolved with Adjustment Disorder? | no longer than 6 months
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| What is important for making a diagnosis of a mood disorder in regards to GMCs? | Must rule everything else out
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| Who should you screen for mood disorders? | Everyone! (recall AMPS)
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| Labs for mood disorders (5) | 1) TSH 2) CBC 3) B12 4) CMP 5) UA
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| What gender has higher prevalence of bipolar 1? Bipolar 2? | 1: Gender neutral 2: F>M
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| T/F: Genetic influence much stronger in depression than in bipolar | False, Bipolar has stronger genetic component; considered the most heritable mental illness
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| 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
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| Abnormally elevated, increased goal-direction lasting 1+ week, causing significant impairment that is not contributed to another substance or condition | Manic episode
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| Evaluating Mania | DIGFAST (Distractibility, Injudiciousness, Grandiosity, Flight of ideas, Activities (lots), Sleep, Talkativeness
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| Activated, distractible, pleasure-seeking behaviors, impulsive, impaired, loud speech, tangential thought process | Mania
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| 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?)
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| Both Sx of MDE and manic episode persisting for 7+days. HIGH risk of SI or self-injurious behaviors (SIB) | Mixed episode
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| T/F: Much more time is spent in depression than hypomania or mania | True
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| T/F: 60% of manic episodes occur directly after a major depressive episode | False, occur immediately before
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| How many manic episodes are required for a Dx of Bipolar? Which Bipolar? | Only 1 episode for Dx of BIPOLAR 1!
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| Dx for Bipolar 1 (2 options) | 1) If mood disturbance is euphoria: 3+ DIGFAST Sx. 2) If mood disturbance is irritability: 4+ Sx.
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| 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
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| T/F: Bipolar 2 disorder usually has 1 comorbidity of another mental disorder. | False, majority have at least 3 co-occurring mental disorders
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| 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)
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| 4 or more mood episodes over 12 month period | Rapid-Cycling Specifier
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| 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
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| T/F: Substance/Medication-Induced Bipolar and Related Disorder is associated with delirium | FALSE
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| Sx are characteristic of bipolar and related disorders but do not meet full criteria | Other Specified Bipolar & Related Disorder
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| Gold standard for Bipolar Disorder. A few other options? | Mood stabilizers like Lithium. Others: anti-convulsants (Valproic Acid, carbamazepine, Lamotrigine)
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| Why don’t we use anti-depressants in treating Bipolar? | Can switch them from a depressed state to a manic state.
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| What is the only thing shown to break an acute manic cycle? | Sleep
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| What Tx do you use for an acute mixed episode? | Same medications as acute mania: Mood stabilizers
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| What mood stabilizer is especially effective in acute mixed episode if the predominant Sx is depression? | Lamotrigine
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| Side effects of Lithium | Ebstein anomaly formation in pregnancy, hypothyroidism, lithium toxicity
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| Side effects of Valproic acid | Thrombocytopenia, elevation in LFTs
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| Side effects of Carbamazepine | SJS and thrombocytopenia
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| Side effects of Lamotrigine | lacy rash and SJS
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| Leading cause of ED visits and hospital admission for those 35 and younger? | Suicide attempts (SAs)
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| Veterans, widowed/divorced/single, Caucasian, age extremes, less religious, comorbid psychiatric disorders | High risk groups for suicide
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| 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
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| T/F: 50% of pts who completed suicide saw their PCP within 1 month of their death | True
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| Management for passive SI, no plan, good support system | Treat outpatient
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| Management for active SI, plan | Admit to inpatient behavioral health unit and Tx underlying psych/substance disorder ASAP
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| Loss of reality testing often accompanied by delusions, paranoia, and hallucinations | Psychosis
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| Disruption of thought, mood, and overall behavior | Schizophrenic disorder
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| fixed beliefs that are not going to change even with conflicting evidence. | Delusions
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| perception-like experiences that occur without an external stimulus | Hallucinations
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| 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
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| Bizarre | no way it could be possible. (internal organs replaced w/o scarring)
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| Non-Bizarre | can be possible. I believe I’m being followed by the police
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| 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
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| can manifest in many ways from childlike silliness to unpredictable agitation which often affects ability to carry out ADLs. | Disorganized or Abnormal Motor Behavior
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| marked decrease in reactivity to the environment | Catatonia
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| purposeless and excessive motor activity w/o obvious cause | Catatonic excitement
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| 4 As of Psychosis; What kind of Sx are these? | 1) Autism 2) Attention 3) Affect 4) Association; Negative Sx
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| Assessing a patient with Psychosis? | PSYCHOSIS (Psychotropics, Safety, Psychotic Sxs, Caring, Home, Other conditions, Suicide, Impairment, Substance misuse)
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| Social withdrawal, auditory hallucinations, loose associations,, delusions, flat affect, hypersensitivity, depersonalization | Sx of Psychotic disorder
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| What NT abnormalities are associated with Psychotic disorder? What are the 2 other pathophysiologies? | Glutamate and Dopamine excess; Genetic and Environmental causes
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| 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
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| DSM criteria for Schizophrenia | Continuous disturbance that persists for >6 months, including active-phase Sx for at least 1 month
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| Preoccupation w/ 1 or more delusions, related to persecution, disorganized speech or behavior | Paranoid type Schizophrenia
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| Disorganized speech, disorganized behavior, flat/inappropriate affect | Disorganized type Schizophrenia
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| Mutisim, excessive motor activity, extreme negativism, weird voluntary movement like perching, echolalia (parroting) or echopraxia (repetition of movement) | Catatonic type Schizophrenia
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| 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
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| Presence of 1+ delusions for at least 1 month w/o meeting criteria for schizophrenia | Delusional Disorder
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| Erotomanic Delusions | another person, usually of higher status, is in love with them (usually celebrity)
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| Grandiose Delusions | inflated worth, power, knowledge, identity, or special relationship with a famous person
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| Jealous Delusions | convinced of infidelity
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| Persecutory Delusions | being spied on, conspired against, followed, poisoned, or manipulated
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| Somatic Delusions | bodily sensations or functions
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| Mixed Delusions | multiple themes exist w/o one being predominant
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| Unspecified Delusions: no clear theme is identifiable |
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| Delusional paracytosis | imagined bug infestation.
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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)
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| Why can psychosis/schizophrenia resolve or improve with age? | Glutamate and dopamine levels decrease as we age (excess amounts cause said psychosis)
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| Tx for Psychotic patient? | Anti-psychotics, specifically, ATYPICAL as they have a lower side effect profile
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| Thorazine, prolixin, Haldol | Typical anti-psychotics
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| Clozapine, risperidone, olanzapine, quietipaline, ziprasidone, aripiprazole | Atypical anti-psychotics
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| Risperidone is most likely to | raise prolactin levels
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| Clozapine may cause | agranulocytosis
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| Olanzapine is least likely to | increase QT prolongation
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| Quietiapine has been known to cause _________ in dogs | cataracts
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| Ziprasidone is most likely to | increase QT prolongation
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| Ariprprazole is least likely to cause | wt gain
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| Which typical anti-psychotic has a lower likelihood of EPS and sedation and autonomic adverse? | Thorazine
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| 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
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| What is NMS? Tx? | Neuroleptic Malignant Syndrome; FEVER (Fever, Encephalopathy, Vital sign instability, Elevated CPK, Rigid muscles); Tx: Symptomatic: dantroline helps reduce fever
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| Tx of aggressive/violent patient (5) | remove weapons, reduce stimulation, never turn back, Benzodiazepine Zyprexa in acute crisis is first line
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| What should be given with typical anti-psychotics? | Benadryl
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| Chronic Behavior and Developmental condition of inattention and distractibility with or without hyperactivity | ADHD
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| T/F: 2-4x more frequent in girls and 50% have another significant psychiatric comorbidity | False, more common in BOYS
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| Do inattentive or hyperactive Sx improve w/ age? | Hyperactive Sx decrease!
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| 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
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| 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
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| 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
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| Percentage of children that continue having Sx of ADHD as adults | ~50%
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| What labs are routine when assessing for ADHD? | NONE
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| First line therapy for ADHD. 2nd line? | Central stimulants; 2nd: Atomoxetine(SNRI), alpha agonists, anti-depressants
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| Adverse of stimulants (6) | wt loss, abd pain, HA, irritability, sleep disturbances, tic development
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| Black box warning for atomoxetine | Increased risk of SI
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| Alpha agonists (clonidine/guanfacine) main adverse (3) | 1) Skin rxns 2) Somnolence 3) Drowsiness
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| Adjunctive Tx to pharmaceuticals (3) | 1) High protein diet 2) Exercise 3) Good sleep habits
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| 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
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| What may anorexia nervosa coincide w/? | Separation from home or after a loss
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| 3 comorbidities w/ anorexia nervosa | Depression, anxiety, OCD
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| 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
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| pale or yellow tinged (carotenemia), fine lanugo hair, acrocyanosis, dryness, ankle edema, bradycardia, HypoTN, hypothermia | signs of starvation
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| 2 main effects of purging | 1) Parotid gland enlargement 2) Dental carries/erosion of enamel
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| 3 things to screen for w/ anorexia nervosa evaluation? | 1) SI 2) Depression 3) Anxiety
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| What is recommended if a pt is amenorrheic for 6+months? | Bone density scan
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| 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
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| Hypokalemia w/ alkalosis suggests? What does acidosis suggest? | vomiting or diuretic abuse. Acidosis: laxative abuse
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| 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
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| When is hospitalization for eating disorders required? | suicidal ideation, major electrolyte or cardiac disturbances, severe malnutrition
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| What is the good approach for treating adolescents w/ anorexia? | FAMILY THERAPY w/ Maudsley Approach (training parents)
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| What drug is contraindicated in eating disorders and why? | Buproprion due to increased potential of seizures w/ eating disorders
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| Rx Tx of Bulimia | SSRIs (mainly) and TCAs
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| Rx Tx of Anorexia | Atypical anti-psychotics
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| Rx Tx of Binge-Eating disorder | SSRIs
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Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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Created by:
crward88
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