PsychSpring_1
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| Clinical disorders & other conditions that may be a focus of clinical attention a)Axis I b)Axis II c)Axis III d)Axis IV e)Axis V | A
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| Personality Disorders & mental retardation a)Axis I b)Axis II c)Axis III d)Axis IV e)Axis V | B
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| General Medical Conditions a)Axis I b)Axis II c)Axis III d)Axis IV e)Axis V | C
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| Psychosocial & Environmental Problems that may affect the dx, tx & prognosis of Axis I & II diagnoses a)Axis I b)Axis II c)Axis III d)Axis IV e)Axis V | D
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| Global Assessment of Functioning (GAF) useful in planning tx, predicting outcome, & tracking clinical progress a)Axis I b)Axis II c)Axis III d)Axis IV e)Axis V | E
_Should NEVER take into account physical limitations here.
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| Alertness or state of awareness of the environment | Level of consciousness
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| Hypoactive motor behavior might a sign of this | Psychomotor Retardation
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| Sustained emotion that affects a person's view of the world. Pt's subjective description of his or her emotional state in his or her own words | Mood
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| An observable feeling or tone expressed through voice, facial expression & demeanor. Shows emotional responsiveness | Affect
_Normal, blunt, exaggerated, flat, constricted, labile
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| Ability to focus or concentrate over time on one task or activity | Attention
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| Childhood memories a_Remote memory b_recent remote memory c_recent memory d_immediate retention & recall | A
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| Current events within past few months a_Remote memory b_recent remote memory c_recent memory d_immediate retention & recall | B
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| What pt had for breakfast a_Remote memory b_recent remote memory c_recent memory d_immediate retention & recall | C
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| Sensory awareness of objects in environment and interrelationships. Also refers to internal stimuli. | Perception
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| False sensory perception not associated with external stimuli. a)Hallucination b)Illusion c)Depersonalization d)Derealization e)Formication | Hallucinations
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| Misperception or interpretation of a real external stimuli a)Hallucination b)Illusion c)Depersonalization d)Derealization e)Formication | Illusions
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| Person's subjective sense of being unreal, strange or unfamiliar a)Hallucination b)Illusion c)Depersonalization d)Derealization e)Formication | Depersonalization
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| Subjective sense that environment is strange or unreal a)Hallucination b)Illusion c)Depersonalization d)Derealization e)Formication | Derealization
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| Feeling of bugs crawling on or under skin a)Hallucination b)Illusion c)Depersonalization d)Derealization e)Formication | Formication
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| Awareness that sx or disturbed behaviors are normal or abnormal. Pt's awareness/understanding of own illness | Insight
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| Process of comparing & evaluating alternatives when deciding on a course of action | Judgement
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| Fixed, false personal beliefs that are not shared by other members of the person's culture. Cannot be corrected via reasoning. _Paranoid, grandeur, nihilistic, ideas of reference, ideas of influence, persecution | Delusions
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| Recurrent, uncontrollable thoughts, images or impulses a_Obsessions b)Compulsions | A
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| Repetitive behaviors or mental acts that a person feels driven to perform a_Obsessions b)Compulsions | B
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| Persistent, irrational exaggerated fear of a specific stimulus or situation accompanied by a desire to avoid the stimulus | Phobia
_Acrophobia: fear of heights
_Agoraphobia: fear of OPEN spaces
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| 3-10% school aged children, typically in males & more common in 1st degree bio relatives of children with ADHD | ADHD
_From DEC dopamine & NE in brain
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| Persistent pattern of INATTENTION a/o HYPERACTIVITY-IMPULSIVITY that is more frequently displayed & more severe than is typically observed in individuals @comparable devo level. | ADHD
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| Fidgets Leaves seat when sitting in seat is expected Runs/climbs excessively at wrong times Difficulty playing in leisurely activities quietly “On the go” Talks excessively Blurts out answers prematurely Diffic awaiting turn Interrupts or intrude | Hyperactivity-Impulsivity
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| >6 sx of inattention or hyperactivity that's occured >6mos _Sx BEFORE age 7! (though hard to dx if <5 since may be appropriate if kids are active) _Sx w/assoc impairment in >2 settings | Dx criteria for ADHD
_Sx not better accounted for with another disorder & clinically impairs social, academic or occupational functioning
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| Most common type of ADHD | ADHD Combined type
_Meets inattentive & hyperactive-impulsive sx
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| Comprehensive medical, developmental educational, & psychosocial evaluation is needed for this | To confirm ADHD sx, show functional complications, exclude other explanations for symptoms, ID comorbid psych conditions
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| Rating scales for ADHD should be completed when & by whom | At time of dx, during medical titration & at regular med F/U.
Completed by parents AND teachers
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| Tx for ADHD | Therapy (Psychotherapy & Family)
Behavior Modification
Educational Intervention
Environment Manipulation
Pharm agents
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| FIRST LINE Tx of ADHD | Stimulants which release catecholamines to INC dopa & NE in brain
=Methylphenidate & Dextroamphetamine
-Adderall is a mixed amphetamine salt
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| Short acting formulation of ADHD drugs | Ritalin, Methylin, Focalin, Dexedrine, Adderall
_Must take BID-TID
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| Long acting formulation of ADHD drugs | Methylphenidate-SR, Ritalin-SR & LA, Metadate CD & ER, Concerta, Focalin XR, Daytrana, Adderall XR, Vyvanase
_Dosed Qday but side effects can extend longer
_More expensive
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| ~70% of patients with stimulant use will have this | DEC in hyperactivity & INC in attention. If patients do not have positive results or have signif side effects try another agent
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| Side effects of stimulant use in ADHD | Anorexia, appetite disturbance
Sleep disturbance
Wt Loss
INC HR/BP
SUDDEN CARDIAC DEATH
HA
Social Withdrawal
Nervousness
Irritability
Stomach Pain
Tics
Contact Dermatitis
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| Selective NE reuptake inhibitor. NOT a controlled substance, less abuse potential. MORE expensive than methyphenidate & dextroamphetamine | Atomoxetine (Straterra)
_Dyspepsia, Severe liver injury, INC suicidal thinking, cardiac risk
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| Other pharmacological agents used if cannot use Strattera or Stimulants in ADHD | Antidepressants (Tricyc or Dopa reuptake inhibitors)
Alpha2 adrenergic Agonists (Clonidine, Guanfacine)
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| ADHD patient with hx of substance abuse, you may want to consider using this instead of stimulants | Atomexetine (Straterra)
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| Acute, rapidly progressive change in cognition with INATTENTION & DISTURBANCE where sx fluctuate over 24hrs. -Altered level of arousal -Memory Impaired -Disoriented -Perceptual Disturbance -Language Disturbance/Incoherent Speech | Delirium
_Risk Factors: Cognitive impairment, age >70, poor functional status, hearing/visual probs, dehydration, sleep deprivation, metabolic derangement
_May INC risk of cardiac events, mortality rates & length of stay
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| 48% of Delirium is what? | A mix of HYPERactive and HYPOactive symptoms
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| What's the least common type of symptom in delirium? | Hypoactive:
_Inattention, sedation, depressed, withdrawn, loss of appetite
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| Usually NOT helpful in dx delirium | EEG, CT, cultures w/o known source, lumbar puncture
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| Should you use a CT scan to dx delirium? | It's controversial. The incidence of stroke presenting as delirium is about 3% w/o focal findings. A normal neuro exam has a high predictive value (97%)
_Use clinical judgement, if no other focal deficits, look elsewhere first
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| Which of these are not typically involved in mental status testing with Delirium patients a)CAM b)CT scan c)MMSE/Kokmen d)Adjunct Tests | B
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| Asseses 5 Delirium Features: 1)course fluctuation 2)acute 3)inattention 4)disorganized thinking 5)Altered consciousness What would be a positive test? | CAM (Confusion Assessment Method)
_Use as screening tool then to follow improvement/progression.
POS: 1-3 and EITHER 4 or 5
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| Includes eval of orientation, recall, registration, attention, concentration & language. Questions have point value, 30 is best. What would an abnormal score be? What's the test? | Mini Mental State Exam
<24 is abnormal
_Cons: not sensitive, cannot differentiate between delirium & dementia, may miss subtle cases, copyrighted
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| Examines orientation, attention, learning, CALCULATION & recall. Includes CLOCK drawing under "construction" component. Was initially validated in Alz pt's. what's test, abnormal? | Kokmen Short Test of Mental Status
_Abnormal <35
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| Would like a sensitive test for detecting patients with mild cognitive impairment. Which is better to detect cognition changes in people "normal" at baseline? a)Kokmen b)MMSE | Kokmen Short Test of Mental Status
_Abnormal <35
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| Should you use restraints when trying to control a delirious patient? | AVOID restraints!!!
_ID at risk meds being used instead and inform family/caregivers
_Replace hearing aids/glasses. Get private room w/around the clock watching. Reorient & reestablish a sleep/wake cycle.
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| When should you use pharmacologic agents when dealing with delirium? | Severe agitation, combative behavior or behavior that severely interferes with care
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| DOC for Delirium (use if severe, combative or behavior influences proper care) | Haloperidol (Haldol)
_Start with VERY LOW doses (NOT psych doses)
-Extrapyramidal side effects & long QT may occur
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| Atypical antipsychotics used in delirium carry a BLACK BOX & used if much needed. What are they? | Quetiapine
Risperidone
Olanazapine
"Start low & go slow."
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| Over prescribed and often will cause delirium. Use for Alcohol/Drug Delirium | Benzodiazepines
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| Special considerations for delirium patients include all but this: a)Pre-op delirium b)Post-op delirium c)Alcohol withdrawal d)Sundowning precipitated by hospitalization, sensory deprivation, meds | A
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| Non-specific early sx of EtOH withdrawal sx: | tachy, diaphoresis, HTN
_The underlying HYPERadrenergic drive causes the complications
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| Medical emergency during EtOH withdrawal where see EXTREME autonomic HYPERactivity with delirium. Later signs will involve confusion, psychosis, agitation & seizures. Mainly see in heavy & long standing drinkers w/prior detox, seizures or DT's | Delirium Tremens
_Kindling Effect: Prior detox may lead to increased susceptibility for delirium tremens
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| Tx of alcohol withdrawal | Benzos, adjunct meds
_Do NOT use EtOH to treat
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| Acquired, chronic, progressive decline consisting of memory impairment & one or more of following: Aphasia Apraxia Agnosia Disturbance in executive function | Dementia
_Deficits are severe enough to cause functional impairment.
_Delirium NOT present
_IRREVERSIBLE!
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| Primary cause of dementia (~50%) a_Vascular dementia b_Alzheimers c_Neurodegen like Lewy body dz, Parkinsons, Pick's d_Medical: Huntingtons, trauma, infections, anoxia, Creutzfeldt-Jakob, HIV | B
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| All dementia dx can come with or without this: | Behavioral Disturbance
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| Typically starts <50 (If under 65=Early Onset), Progressive (lose 3pts/yr on MMSE), higher rates in ppl w/trauma & Downs, myoclonus & gait=late finndings | Alzheimer's Dementia
_CT, MRI, Histopath
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| 20-60% of Parkinson's patients. Exacerbated by depression Tremor, rigid, bradykinesia, posture unstable. COGWHEEL, micrographia, slow movements. | Parkinson's Dementia
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| Change in personality/behavior disinhibition. Prominent primitive reflexes on exam. Type of neurodegenerative dementia a_Parkinson's b_Lewy Body c_Pick's Disease | C
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| Vascular risk factors+neuro deficit. Dx via imaging. | Multi Infarct Dementia
_Dx via Imaging
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| Triad of dementia, involuntary movements, periodic EEG activity. Caused by prions (transmission of corneal transplant, HGH). 40-60w/o. Handling of CSF. _Devos RAPID over wks to mos. | Creutzfeldt-Jakob Disease
_No Tx
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| Autosomal dominant gene with onset late 30s to 40s. Associated movement disorder. BOXCAR VENTRICLES on imaging | Huntington's Dementia
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| HIV may cause dementia. What might be a precipitating cause? | Infection
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| Normal pressure hydrocephalus, B12 defic, HYPOthyroid, depression & syphilis all cause what | Reversible Dementias
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| Memory complaints (subjective) & mild memory impairment (objective) but still preserve cognitive funciton & intact ADLs. INC risk of ALL types of dementia. | Pre-dementia
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| Are there any confirmatory tests for Alzheimer's CLINICALLY? | No. Will need pathologic eval of brain to confirm
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| BEST way to diagnose dementia | History which is often the only way to differentiate between dementias.
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| Fluctuations in cognitive function with SUDDEN onset of Parkinson's a_Lewy Body b_Alzheimers c_Vascular Dementia d_Picks disease e_Creutzfeldt Jakob | A
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| Progressive decline in function a_Lewy Body b_Alzheimers c_Vascular Dementia d_Picks disease e_Creutzfeldt Jakob | B
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| Signs of previous stroke with dementia a_Lewy Body b_Alzheimers c_Vascular Dementia d_Picks disease e_Creutzfeldt Jakob | C
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| Progressive NON-fluent aphasia a_Lewy Body b_Alzheimers c_Vascular Dementia d_Picks disease e_Creutzfeldt Jakob | D
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| Rapid/Progressive, involuntary movements a_Lewy Body b_Alzheimers c_Vascular Dementia d_Picks disease e_Creutzfeldt Jakob | E
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| Is neuroimaging very predictive for dementia? | Low predictive value but a noncontrast head CT or MRI in the routine initial eval of all patients with dementia is recommended.
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| When is a neuropsych eval best in dementia? | When performed on an increased risk population
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| Pharm management of Dementia | Cholinesterase Inhibitors
NMDA Antagonists
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| Donepezil, Rivastigmine, Galantamine are all approved for this | Mild to moderate Alzheimers
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| Approved for tx of severe Alzheimers | Donepezil
_SE: symptomatic bradycardia, syncope
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| Rivastigmine is also indicated for this (besides mild-->mod Alzheimers) | Moderate dementia w/parkinson's
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| Cholinesterase inhibitor RARELY used | Tacrine (Cognex)
_Hepatotoxic
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| Prevention in mild uncharacterized cognitive impairment, multi-infarct dementia, Lewy body dementia are all NON-labelly tx with this | Cholinesterase Inhibitors
_with other dementia not listed, no data to support use
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| Side effects of cholinesterase inhibitors used in the tx of dementia | N, V, D
Donepezil-symptomatic bradycardia, syncope
Galantamine has MORE side GI side effects & INC mortality with MCI
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| Can be used in combo w/cholinesterase inhibitors. Often used in VASCULAR dementia & Alzheimers. Acts on glutamate receptors in the brain. | NMDA Antagonist=Memantine
_Dizzy, HA, hallucination, extrapyramidal SE
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| Would you expect to see disturbance of consciousness, sx fluctuation & attention deficit in EITHER dementia or delirium??? | Delirium
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| In order to dx amnestic disorders (confusion, disorientation, confabulation) what must not occur with | In the setting of delirium or dementia
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| Abrupt loss of ability to recall events or remember new info lasting 6-24hrs. Memory will return except for amnesic gap | Transient Global Amnesia
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| Opthalmoplehia, Ataxia, Nystagmus | Wernecke's Encephalopathy caused by EtOH
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| Thiamine deficiency associated with prolonged EtOH use. Irreversible. | Korsakoff's Syndrome
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| “Loss of contact with reality” Delusions: false beliefs Hallucinations: auditory and/or visual* Disorganized thoughts & speech Disorganized or catatonic behavior | Psychosis
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| Lifetime prevalence ~1% worldwide (2.5 million in U.S.*) 1 affected 1st degree relative ~10x higher than gen. pop. Males will develop sx earlier while females have bimodal onset | Schizophrenia
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| Chronic May have abrupt onset, or may have prodrome Negative symptoms often prominent earlier than positive Complete remission is uncommon Some studies have shown decreased life expectancy * must have signs of illness for 6 mos. (criterion C) | Schizophrenia
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| Characteristic symptoms, at least 1 mo.*, 2+ of: 1.Delusions 2.Hallucinations 3.Disorganized speech 4.Disorganized or catatonic behavior 5.Neg sx B. 1+ area of social/occupational dysfunction c: 1 month criterion A sx+Prodrom | Schizophrenia
_Must R/O schizoaffective disorder & mood disorder. Also make sure not caused by subatance
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| If pt autistic or PDD how would you dx with schizophrenia. | Must have prominent delusions/hallucinations for at least 1 month
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| Negative Symptoms (5As) of Schizophrenia | Affective flattening
Alogia
Avolition/apathy
Anhedonia/asociality
Attention
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| Paranoid Schizophrenia | 1+ delusion or frequent AH
Not prominent: disorganized speech/behavior, inappropriate affect
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| Prominent disorganized speech & behavior and flat/inappropriate affect. NOT catatonic. Type of schizophrenia | Disorganized Schizophrenia
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| At least 2: motoric immobility, catalepsy/waxy flexibiliy, stupor excess motor activity(purposeless) extreme negativism(resistance against movement), mutism Bizarre posturing, stereotypies, prominent mannerisms or grimacing echolalia or echopraxia | Catatonic Schizophrenia
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| Meets criteria for schizophrenia, but NOT any subtype | Undifferentiated Schizophrenia
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| Absence of prominent hallucinations, delusions, or disorganized speech/behavior or catatonia Presence of negative symptoms, or 2+ attenuated positive symptoms | Residual Schizophrenia
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| Prognosis for Schizophrenia better if: | Female
Later age of onset
Acute onset, with precipitating factor
Brief duration, early intervention & compliance
Positive symptoms
Mood disturbance, family hx of mood d/o
High SES, married, good support system
Good premorbid functioning
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| Essentially identical to Schizo: Delusions, hallucinations, disorganized speech, catatonic behavior, neg sx Shorter: btwn 1 and 6 mos Social fcn may or may not be impaired 1/3 recover, & dx is final 2/3 progress to Dx of Schizophrenia or Schizoaffec | Schizophreniform Disorder
_Criteria A, D, E met but NO schizoaffective or mood probs
_Episode(prodrome+active+residual phases) last at least 1 month, but LESS than 6!!
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| Sudden onset of at least 1 pos sx Lasts btwn 1 day & 1 month, w/return to normal Emotional, labile, confused Onset in late 20s to early 30s, may be w/marked stressor or postpartum onset Dx rarely seen clinically High suicide risk | Brief Psychotic Disorder
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| High Risk of Suicide Associated with this dx: a)Schizophrenia b)Schizophreniform Disorder c)Brief Psychotic Disorder | C
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| Presence of 1 or more: 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized or catatonic behavior B. Duration: at least 1 day, BUT <1 month, with eventual full return to premorbid level of functioning | Brief Psychotic Disorder
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| Schizophrenia+Mood Disorder Delusions/Hallucinations for 2+wks with no mood sxs Bipolar or Depressive types Women>Men Less common than schizo, better prognosis. Early Adulthood INC risk of schizophrenia & mood disorders in 1st degree relative | Schizoaffective Disorder
_Meet Criteria A for schizo(Pos Sx) & ALSO has major depressive, manic or mixed episode
_Muse have @least 2 wks delusions/hallucinations w/o prominent mood sx. Mood sx are present though for a signif portion of illness
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| NON-Bizarre delusions (could actually be true) for at least 1 month, does NOT meet Criteria A for Schizo (pos sx). Hallucinaitons could be related to delusional theme. Psychosocial function NOT impaired. Poor insight. | Delusional Disorder
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| Another person is in love with pt. Usually person of higher status (celeb). Type of delusional disorder a_Erotomanic b_Grandiose c_Jealous d_Persecutory e_Somatic | A
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| Inflated worth, power, knowledge, identity, special relationship to a deity or famous person. Type of delusional disorder a_Erotomanic b_Grandiose c_Jealous d_Persecutory e_Somatic | B
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| Spouse, significant other, sexual partner is unfaithful. Type of delusional disorder. a_Erotomanic b_Grandiose c_Jealous d_Persecutory e_Somatic | C
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| Being treated malevolently.Conspired against, spied one, followed poisoned.Type of delusional disorder. a_Erotomanic b_Grandiose c_Jealous d_Persecutory e_Somatic | D
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| Physical defect or medical condition. Type of delusional disorder. a_Erotomanic b_Grandiose c_Jealous d_Persecutory e_Somatic | E
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| Tx of Delusional Disorders | Neuroleptic=Antipsychotic=Dopamine Antagonist
_Haloperidol
_Chlorpromazine
_Thioridazine
_Prochlorperazine
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| Atypical Antipsychotics (2nd generation) | Ariprazole
Clozapine
Olanzapine
Quetiapine
Risperidone
Ziprasidone
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| First Generation Conventional Antipsychotics | Haloperiodl
Chlorpromazine
Thioridazine
Prochlorperazine
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| Torticollis, jaw spasms, dysphagia, dysarthria, tongue protrusion, oculogyric crisis, abnormal positioning | Acute Dystonic Rxn (Spasms)
_Form of extrapyramidal sx caused by antipsychotic drug use
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| Parkinsonism, Akathisia (restlessness), Tardive Dyskinesia & Neuroleptic Malignant Syndrome are all what? | Extrapyramidal Symptoms caused by antipsychotic drug use
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| Abnormal involuntary movements Choreiform: rapid, jerky, nonrepetitive Athetoid: slow, sinuous, continual Rhythmic: stereotypies | Tardive Dyskinesia:
Extrapyramidal Symptoms caused by antipsychotic drug use in 20-30% of pts. Worse longer you used. Only 5-40% cases remit.
Use AIMS to screen EVERY 6mos!!!
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| This drug can be used in everything but akathasia to tx extrapyramidal side effects from antipsychotic use. | Benztropine or Diphenydramine
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| How must you treat Akathisia. Only unique drug & cannot use Benztropine or Diphenydramine | Propranolol
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| When would you use amantdine to decrease EPS effects from antipsychotic use | Parkinsonism
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| Severe muscle rigidity + elevated temp* Potentially life threatening! _Mental status change(1st sx), autonomic unstable (INC BP/HR), Leukocytosis, INC CK, Electrolyte probs F-Fever E-Encephalopathy V-Vitals Unstable E-Elevated Enzyme-CK R-Rig | Neuroleptic Malginant Syndrome
@Risk: dehydration, agitation, high dose, rapid increase, IM injection, hx of NMS. +/- hot, humid, Lithium
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| Tx for Neuropeptic Malignant Syndrome | Dantrolene (but in clinic more often supportive)
_**NO neuroleptics for at least 2 wks*
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| Why do you get Parkinson like symptoms as a side effect when using antipsychotics? | They are dopamine antagonists. Remember, Parkinson's is caused by decreased levels of dopamine, therefore an overextension of the effect.
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| INC mortality when tx elderly pts for dementia related psychosis | Black Box warning for antipsychotics (dopamine antagonists)
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| Weight Gain, HYPOtension, QT prolong, Tachy, Hepatic Transaminitis, AGRANULOCYTOSIS, hyperglycemia, dyslipidemia, metabolic syndrome are common side effects of this | Anti-psychotics (dopamine antagonists)
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| Conventional antipsychotics & Risperidone may experience this side effect | hyperprolactinemia & associated gynecomastia, galactorrhea, amenorrhea, decreased libido
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| Pigmentary retinopathy may be caused by chronic use of this antipsychotic | Thioridazine
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| Dose-dependent risk with most conventional antipsychotics & Clozapine | Lowered seizure threshold
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