Psychiatry: Anxiety, Personality, Other Psychiatric and Substance Disorders
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| A feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome | Anxiety
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| T/F: 1/4 will experience some sort of anxiety disorder in their life | True
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| Female, FH, personality temperament, environmental influences | RF of anxiety disorders
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| 2 principle components of anxiety and an example or two about them? | 1) Psychological: tension, fears, apprehension, difficulty concentrating 2) Somatic: Both tachys, palpitations, tremor, sweating
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| 3 aspects of developing anxiety disorder | 1) Life experiences (trauma) 2) Ongoing psychsocial stressors 3) Biological (genetic)
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| What 3 NT abnormalities are found w/ anxiety disorders? | 1) Serotonin deficit 2) Norepinephrine hyperactivity 3) GABA deficit
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| Fearful or anxious about separation from an attachment figure(s). Often develops after a life stressor or loss. Dx? | Separation Anxiety; Dx: Lasts 4+ weeks in children and 6+ months in adults
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| Consistent failure to speak in social situations in which there is an expectation to to do so, yet speaks in other situations. Excessive shyness, social embarrassment, isolation, withdrawal. Can interfere w/ educational/occupational achievement. Dx? | Selective Mutism; Dx: Lasts 1+ month(s) and usually begins before 5 yo.
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| Characterized by excessive fear or anxiety that results in avoidance of a specific object or situation. May be after traumatic event. Actively avoided or endured w/ intense anxiety. Fainting/near fainting and SNS arousal. Dx? 4 subtypes? | Specific Phobia; Dx: Lasts 6+ months. 4 subtypes: Animal, Blood-injection, Natural environment, Situational
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| Environmental RF for specific phobia (4). What risk is higher in this population. | 1) Parental over-protectiveness 2) Parental loss/separation 3) Physical/sexual abuse 4) Traumatic encounter w/ feared situation/object; Suicide is higher in this population
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| Fearful or anxious about or avoidant of social interactions and situations that involve the possibility of them being scrutinized. Onset usually 13 yo, higher in females, and often follows stressful or humiliating experience. Dx? | Social Anxiety Disorder; Dx: present 6+ months
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| Common comorbidities w/ social anxiety disorder? (3) | 1) Other anxiety disorders 2) MDD 3) Substance use disorders
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| Recurrent, unexpected panic attacks of intense fear, discomfort, or anxiety w/ at least 4 Sx: Palpitations, Choking, Sweating, Trembling, Feeling SOB, CP, Nausea, Dizzy, Chills/heat, Paresthesias, Derealization, Fear of losing control, Fear of dying Dx? | Panic Disorder; Dx: 1+ month worrying about more panic attacks or maladaptive changes in behavior due to attacks
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| Most at risk for panic disorder? What else is at higher risk? | Females, 20-24 yo, abused in childhood, genetic component. Suicide at highest risk in 12 months after attack
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| T/F: Panic attacks and panic disorder are synonymous | FALSE, Panic attack is not a mental disorder by itself, but rather can occur in any context of another psychiatric disorder
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| Females, Onset: adolescence, chronic and persistent, STRONGEST association w/ genetics. Marked fear/anxiety about 2+/5: 1) public transportation 2) open places 3) enclosed spaces 4) standing in line/crowds 5) being alone outside of home Dx? | Agoraphobia; Lasts 6+ months or more and causes significant distress/impairment. Note: Independent Dx of Panic Disorder
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| 2 comorbidities secondary to agoraphobia? | MDD and alcohol use disorder
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| Anxiety and worry associated w/ 3 of the following: 1) Restlessness 2) Difficulty concentrating 3) Irritability 4) Muscle tension 5) Sleep disturbances. Interferes significantly and they've "always had this". Dx? How do many pts present? | General Anxiety Disorder (GAD); Dx: worrying more days than not for 6+ months. Often present w/ somatic complaints
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| Who most commonly presents w/ GAD? (6) | Females, onset: 30, no environmental stressor, genetics, MDD comorbid, chronic illnesses
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| Short acting benzo? | Alprazolam (Xanax)
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| Moderate acting benzo? | Lorazepam (Ativan)
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| Long acting benzo (2)? | Clonazepam (Klonopin) and Diazepam (Valium)
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| 3 things to monitor w/ benzo use? | 1) Respiratory depression 2) Rebound/withdrawal anxiety 3) Paradoxical agitation especially in geriatrics
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| Acute management of GAD | Benzodiazepines
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| Gold standard of maintenance therapy for GAD? An alternative? | SSRIs (Paroxetine [Paxil], Escitalopram), alternative: SNRIs (Duloxetine/Cymbalta)
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| Acute Tx of Panic Disorder? First line maintenance? Non-pharm approach? | Acute: Benzos (short acting: Xanax); Main: SSRIs; Non-pharm: CBT
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| First line Tx for Social Anxiety Disorder? | SSRIs and SNRIs (Effexor/venlafaxine) & CBT
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| Gold standard Tx for Specific Phobia? | CBT: Exposure and response prevention therapy
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| thoughts, impulses, or images that are recurrent; they are persistent; intrusive; and recognized as a product of their own mind. | Obsessions
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| behaviors (rituals) or mental acts that are repetitive, purposeful, and intentional. Behaviors are aimed at reducing anxiety or preventing some dreaded event | Compulsions
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| checking, cleaning, washing, counting, hoarding, collecting, ordering, arranging, and repeating | Compulsions
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| Contamination, illness, violent images, fear of harming self/others, forbidden sexual thoughts, exactness, religious | Obsessions
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| Know behavior is abnormal but still have belief that something bad will happen if they don’t do it. | Egodystonic (OCD)
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| Think everyone else is abnormal for not doing it this way | Egosyntonic
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| Dx of OCD | Obsessions/compulsions are time consuming (>1 hr/day) or cause clinically significant impairment
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| What is problem is high with OCD? What other comorbidities often come w/ OCD? | SI (50%) and SA (25%); 76% have anxiety disorders and 63% have depressive/bipolar disorders
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| Have you been bothered by unpleasant thoughts and have you been driven to perform certain acts over and over again? | OCD; Must have both obsessions AND compulsions.
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| First line Tx for OCD? What else works? What should you understand about OCD Tx? | SSRIs first line; CBT (exposure and response prevention); Reduction of Sx is much lower than you would expect than say MDD
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| Preoccupation with one or more perceived defects of flaws in physical appearance that are not observable or appear only slightly to others. Comes on around 15 yo. Most common comorbidity? | Body Dysmorphic Disorder; Comorb: MDD
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| Persistent difficulty discarding or parting with possessions, regardless of their actual value. RF: indecisive temperament, traumatic life events, genetics. Most prevalent and severe in what population? | Hoarding Disorder; Often in older population
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| Recurrent pulling of one’s own hair resulting in hair loss. More common in females, w/ onset at puberty | Trichotillomania
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| Recurrent picking of one’s own skin resulting in skin lesions, more common in females w/ onset at puberty | Excoriation Disorder
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| 1) Exposure to actual or threatened death, injury, sexual violence 2) Intrusion Sx 3) Avoidance of stimuli 4) 2+ negative alterations in cognition or mood 5) Marked alterations in arousal/reactivity. Dx? What NTs are elevated? | Post Traumatic Stress Disorder (PTSD); Dx: Disturbances must last 1+ month(s) and characterized by 1) re-experiencing trauma 2) avoiding reminders 3) increase physiologic arousal; NTs: Increased dopamine and norepinephrine
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| Top 5 events most likely to cause PTSD | 1) Physical Torture 2) Rape 3) Severe physical assault 4) Other sexual assault 5) Shooting/stabbing
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| What comorbidities should you monitor for w/ PTSD? (4) | Depressive, bipolar, anxiety, but especially substance use disorder
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| PTSD Tx? Non Pharm? | First line: SSRIs especially sertraline and paroxetine. CBT: Exposure therapy and/or group therapy
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| Tx for PTSD w/ anger management/impulsivity | Carbamazepine (mood stabilizer/anti-convulsant)
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| Tx for PTSD w/ nightmares | Prazosin (alpha blocker)
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| Similar Sx to PTSD but only lasting 3 days to 1 month. Prognosis/caveat? | Acute Stress Disorder; 50% who have PTSD initially had Acute Stress Disorder
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| consistent pattern of inhibited, emotionally withdrawn behavior towards an adult caregiver. Persistent social and emotional disturbance, evident before 5 yo | Reactive Attachment Disorder
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| Pattern where child actively approaches and interacts w/ unfamiliar adults. | Disinhibited Social Engagement Disorder
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| habitual patterns of behavior that result in individual differences | Traits
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| Long-standing, for the most part, stable behaviors termed traits | Personality
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| Occur when traits become maladaptive and inflexible that it negatively impacts the patient’s social life, work life, and/or causes significant distress. | Personality Disorder
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| T/F: You can Dx PDs on the first visit | False
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| How long do you have to have Sx to be Dx w/ a PD? | 1 year more...Antisocial cannot be Dx until 18 and still requires 1 year for Dx
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| What PD gets better as you age? Worse? | Better: Borderline; Worse: Schizoid
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| Providers thoughts/feelings towards the patient. | Countertransference
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| Enduring pattern of inner experience and behavior that deviates from the expectations of the individual’s culture, inflexible and pervasive, w/ significant distress/impairment, that is stable and of long duration (not due to other MD, substance, GMC) | Personality Disorder
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| Odd/eccentric behavior, "mad", overlap w/ psychotic D/O | Cluster A
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| Isolation, desires and comfortable w/ solitude, don't present until super severe, negative Sx of schizophrenia Dx? Cluster? | Schizoid PD; Dx: Detachment w/ restricted range of emotions and 4 others(neither desires nor enjoys relationships, apathy for sex, activities that don't involve others, few activities, indifferent to praise/criticism, emotional coldness) Cluster A
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| Self-important, always looking out for #1, name drops, thinks they are better than everyone else. M>F, high risk of suicide/depression. Often masking insecurity. Dx? Cluster? | Narcissistic PD; Grandiosity/need for admiration, lack of empathy plus 5 (inflated sense of self, overly concerned w/ fantasies, belief they are special, excessive admiration, sense of entitlement, takes advantage, lacks empathy, jealous, arrogant). C: B
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| Eccentric, individuality and thinks outside the box, asking for bizarre Tx, positive Sx of schizophrenia. Cluster? | Schizotypal PD Dx: Social and interpersonal deficits and cognitive/perceptual distortions and eccentricities of behavior plus 5 others (odd beliefs, odd thinking/speech, suspicious/paranoid ideations, odd behavior or appearance, lack of close friend. C: A
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| Concerned with appearances, seductive, exaggerating emotions, desires attention. Need to differentiate from Bipolar. F>M. Dx? Cluster? | Histrionic PD; Dx: Excessive emotionality, attention seeking plus 5 (discomfort when not center of attention, inappropriate behavior, rapidly shifting emotions, use of appearance to draw attention, dramatic, influence-able. Cluster: B
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| Suspicious, hypervigilance towards environment, like schizophrenia but not as much dysfunction. More often female>male, substance abuse, OCD, depression more common. Dx? | Paranoid PD; Dx: Distrust and suspiciousness w/ 4 others (suspect w/o basis, preoccupied w/unjustified doubts, reluctant to confide, reads hidden demeaning, perceives attacks, infidelity). Cluster A
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| Law and rule breaking, consistently taking advantage, Hx of conduct disorder, very charming, pathological liar, lacking remorse. 20-50% of inmates. M>F. Dx? Cluster? | Antisocial PD; Disregard for violation of rights of others plus 3 (failure to conform to social norms, deceitfulness, impulsiveness, irritability/aggresion, disregard for safety of all, consistent irresponsibility, lack of remorse. Cluster: B
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| Black and white reasoning of good and bad...no in between. Instability in mood and relationships, impulsive, avoids abandonment, self-inflicted injuries. DSM criteria? Dx? Cluster? | Borderline PD; AEIOUS (Affect, Emptiness, Impulsivity, paranOia, Unstable, SI; Dx: Instability and impulsivity plus 5 (avoid abandonment, ID disturbance, SI, emptiness, anger, dissociative Sx, changes in mood/emotion). Cluster: B
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| Dramatic, emotion, erratic behavior, "bad", overlaps w/ mood disorders, SI/high-risk | Cluster B
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| Anxious/fearful behavior, "sad", overlaps w/ anxiety disorders, less compliant w/ Tx | Cluster C
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| M>F, lonely, carefulness in social situations, must differentiate from schizoid. Dx? Cluster? | Avoidant PD; Dx: social inhibition, inadequacy, hypersensitivity to negative evaluation plus 4 (avoids work-related activities involving social activities, unwilling to involve w/ people, fears of shame, overly concerned w/ criticism etc). Cluster C
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| Needy, need to be attached to something or someone, insecure, difficulty making decisions. Be careful about countertransference. Dx? Cluster? | Dependent PD; Dx: Need to be taken care of , submissive, fears of separation plus 5 (difficulty making daily decisions, need others to assume responsibility, difficulty disagreeing, difficulty starting projects etc); Cluster C
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| Detailed and organized, rule follower, plans, inability to delegate, controlling, inflexible, perfectionist, attention to detail. F>M. Differentiate from OCD (how do you do this???) Dx? Cluster? | Obsessive Compulsive PD (OCPD); OCD is egodystonic while OCPD is egosyntonic; Dx: orderliness, perfectionism, mental control + 4 (overly concerned w/ detail, unable to complete projects b/c overly strict standards, emphasis on work, inflexible) C: C
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| Gold Standard Tx for ALL personality disorders? What is the one exception? How do you Tx it? | DBT or Dialectical Behavioral Therapy (consists of individual and group psychotherapy). Doesn't work for anti-social PD. We hope they will grow out of it...
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| People are under significant psychosocial stress and instead of acting out verbally or emotionally the symptoms are manifested physically. Refractory to Tx. Believe concretely they have medical (not psychiatric problem). Are these Sx intentional? | Somatic Sx Disorder; Sx are NOT intentional, but develop as part of unconscious process.
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| RF of Somatic Sx Disorder (4) | 1) Genetic vulnerability 2) Past experiences 3) Learned behaviors 4) Cultural/social norms
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| F> M, older age, lower education/socioeconomic status, experienced stressful events, coexist w/ other med and psych conditions frequently. Dx? | Somatic Symptom Disorder; Dx: 1+ somatic Sx that are distressing, excessive thoughts/behaviors and at least 1 (disproportionate/persistent thoughts about seriousness of Sx, high anxiety about Sx, Excessive energy devoted to Sx), & 6+ months
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| Tx of Somatic Sx Disorder? | Pharmacotherapy only aimed at Tx comorbid psych illness, psychotherapy (CBT) beneficial
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| Formerly called hypochondriasis, onset early to middle childhood, triggered by major life stress, chronic and relapsing condition. Dx? (6) | Illness Anxiety Disorder; 1) Preoccupation acquiring serious illness 2) Somatic not present 3) High anxiety about health 4) Excessive health behaviors 5) Present 6+ months 6) Not another mental disorder, substance abuse, GMC
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| Subtype of illness anxiety d/o: will avoid so they won’t “get illness” at clinic | Care-avoidant type
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| Subtype of illness anxiety d/o: smallest thing bother them | Care-seeking type
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| Difference in Tx between Somatic Sx Disorder and Illness Anxiety Disorder | Nothing
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| F>M, onset throughout life span, onset typically abrupt w/ stress/trauma. Trying to resolve or express unconscious conflict. Aspects? (4) | Conversion Disorder; 1) 1+ Sx of altered voluntary motor or sensory function 2) Nothing supports neuro Dx despite Sx 3) No explained by something else 4) Causes significant distress or impairment
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| Pseudoseizure, syncope, blindness, diplopia, deafness, paralysis, mutism, altered articulation, globus (feel like something in their throat), falling, gait problems | Typical conversion Disorder complaints
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| Tx for Conversion disorder (2) | 1) Spontaneous resolution 2) Psychotherapy (CBT)
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| Onset: early adulthood, internal incentive, appear like psych or medical condition to assume "sick role", often in medical field. Aspects? | Factitious disorder (Munchausens); 1) Falsification of physical or psychological signs 2) Presents to others as ill 3) Deceptive behavior in absence of obvious external rewards 4) Not better explained
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| Tx for Facticious disorder (3) | 1) Tx whatever self-induced illness 2) Tx underlying psych comorbidities 3) CBT
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| Intentionally produce symptoms in order to obtain both the “sick” role and further external incentives. Common in psych population. Specific demands and can rapidly escalate into dangerous behaviors. Tx/Approach (3)? | Malingering; Tx: 1) Tx comorbid psych illnesses 2) Don’t reward request 3) Don’t accuse patient
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| Characterized by a disruption of &/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body, motor control, & behavior. Post-trauma. Intrusions into awareness, inability to access info/control mental fns | Dissociative Disorder(s)
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| Presence of 2 or more distinct personality states (alters) or experience of possession, recurrent episodes of amnesia. Relapsing/remitting course w/ poor prognosis. High incidence of SI/SIB. Tx? | Dissociative Identity Disorder; Tx: Psychotherapy
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| Inability to recall important personal information, usually of a traumatic or stressful nature (not explained by forgetfulness) | Dissociative Amnesia
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| Sense of detachment or estrangement from oneself; often accompanied by derealization (the surrounding world appears strange, foreign, or dream-like) | Depersonalization/Derealization
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| Combination of DID and Dissociative Amnesia. Essential Feature: sudden travel away from one’s home and inability to recall some or all of one’s past. | Dissociative Fugue
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| Behaviors that manifest in violating the rights of others and/or bring the individual significant conflict with societal norms or authority figures. M>F, Onset usually in childhood | Disruptive, Impulse-Control & Conduct disorders
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| Frequent and persistent pattern of angry/irritable mood, defiant behavior, vindictiveness. May be confined to one setting. 6+ months of Sx | Oppositional Defiant Disorder
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| Aggressive (verbal or physical) outbursts that have a rapid onset and last less than 30 minutes. Not premediated (can’t control impulse/self-control). Rxn out of proportion. Must be 6 yo. | Intermittent Explosive Disorder
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| Repetitive and persistent pattern of behavior in rights of others are violated. 1) Bullies, cruelty, violence vs animals or people 2) Property loss or damage 3) Deceitfulness or theft 4) Serious violations of rules | Conduct Disorder
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| Multiple episodes of deliberate and purposeful fire setting, fascination, interest, pleasure, gratification when setting fires. Not done for monetary gain or to conceal criminal activity | Pyromania
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| Recurrent failure to resist impulses to steal objects that are not needed for personal use or for monetary value | Kleptomania
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| Tx for Oppositional Defiant Disorder? | Use of stimulants, anti-psychotics, alpha agonists
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| Tx for Impulse Explosion Disorder? | Fluoxetine
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| Tx for Conduct disorder? | Lithium
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| Tx for all Disruptive, Impulse-Control and Conduct disorder? | Psychotherapy effacious
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| 4 RF for substance abuse disorder | 1) Male 2) American indian/Alaskan 3) Caucasian 4) Unemployed
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| Most common comorbidity of substance abuse disorder | MDD
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| T/F: Those w/ substance abuse disorder are 10x more likely to die from suicide than rest of population | False, 20x!!!
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| DSM Dx criteria for Substance Abuse Disorder | Maladaptive pattern of substance use leading to clinical impairment manifested by 2/4 occurring w/in 12 months (failure of obligations, hazardous situations, social problems, tolerance, withdrawal, inability to cut back, excessive time spent using etc.)
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| use of a drug, usually by self-administration in a manner that deviates from approved social or medical patterns | Abuse
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| 3rd largest health problem in US today | Alcohol Related Disorders
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| 3 causes of alcoholism | Genetics, environment, familial
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| Hepatomegaly, jaundice, ascities, telangtesia, rhinophymo | Findings of alcoholism on physical exam
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| What is Korsakoff's Syndrome | Chronic encephalopathy due to Thiamine deficiency
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| What is Wernicke's Syndrome | Acute encephalopathy due to Thiamine deficiency
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| What is important to prevent during alcohol withdrawal? | DTs
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| What should be given with alcohol withdrawal? What scale can be used to assist w/ alcohol withdrawal? | Benzos: diazepam (valium) and loraezpam (ativan). Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar)
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| inhibits alcohol metabolism, causes nausea and vomiting, flushing, sweating, tachycardia if alcohol ingested, warn can effect for weeks after use, no mouthwash or alcohol in foods | Disulfiram
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| blocks opioid receptors, results in reduced craving and reduced reward in response to drinking (must be free of opioids for at least 10 days, check UDS) Check LFT’s | Naltrexone
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| unclear action but decreases craving, abstinence before prescribing | Acamprosate
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| Caffeine intoxication at ____mg. Rambling speech and cardiac arrhythmias at ____ __. Gen seizures, resp failure and death at _____. Tx? Patho? | 250 mg, 1 gm, 10 gm; Tx: Analgesics; P: Cerebral vasoconstriction
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| Most widely used illegal drug in the world. Euphoric effects w/in minutes, peak at 30 min, lasts 2-4 hours. Chemical responsible for psychoactive effects? How long is it detectable in urine? Hair? | Cannabis; THC or Tetrahydrocannabinal. Urine: 4 weeks; Hair: 8 weeks
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| Examples of hallucinogens? Tx? | Ex: LSD, MDMA, PCP, Ketamine, mushrooms; Tx: Dopamine antagonists (Haldol, benzos)
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| Ex of inhalant and Tx? | Ex: solvents for glues, adhesives, aerosols. CNS depressant. Tx: Haldol. Don't use Benzos
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| Ex of opioids and Tx (OD and dependence)? | Ex: Demerol, oxycontin, percoset, vicodin, fentanyl, heroin. Tx: Narcan for overdose. Tx for dependence: Methadone gold standard
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| anxiety, dysphoria, intolerance for bright lights and loud noises, nausea, sweating, muscle twitching, seizures, insomnia, tachycardia, elevated BP, restlessness, tremor, perceptual disturbances. Dangerous or just painful detox? | Benzodizepines; Dangerous! This and alcohol are the only withdrawals that can kill you.
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| Ex of stimulants | Methamphetamine, cocaine, ritalin, MDMA, LSD
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| Most prevalent, deadly, and costly of all substance disorders? Tx? | Tobacco; Nicotine replacement, Bupropion, clonidine
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