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648 Cards in this Set
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Mental status
|
Object characterization of current psychiatric state
general description, speech, mood, thought process, thought content, cognition, insight, judgement |
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General description during a mental status exam
|
Appearance
Behavior (facial expression, pyschomotor, movements, attitude toward you) |
|
Pyschomotor agitation
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Motor restlessness
Can reflect inner restlessness ie anxiety |
|
Pyschomotor retardation
|
Body is slowed down
eg depression |
|
Mannerisms and tics
|
Repeated, purposeless movements
grimacing, orofacial dyskinesias |
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Catatonia
|
Hypoactive to immobile
Often with abnormal posturing |
|
Speech evaluation in a psychiatric exam
|
Rate
Volume Idiosyncrasies of speech |
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Blunted affect
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severely reduced expression of feeling
|
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Flat affect
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absent expression of feeling
|
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Labile affect
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unstable, rapidly fluctating affect
|
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Inappropriate affect
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laughing at a funeral
|
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Mood congruent
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Affect matching mood
Depressed patient appears depressed |
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Affect
|
Objective evaluation of a patient's display of their feeling
|
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Goal directed thought process
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Logical, coherent, easy to follow
Normal |
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Loosening of association
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disconnections between thoughts
|
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Flight of ideas
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Patient moves quickly from one thought to the next
|
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Circumstantiality/Circumfrentiality
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Patient strays from the point but eventually returns
|
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Tangentiality
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Patient gets derailed form the topic never comes back
|
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Thought blocking
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Interruption of a train of thought before the idea is complete
|
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Perservation
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Repeating words phrases or sentences in a relatively meaningless way
|
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Delusions
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Fixed false beliefs not held by society/culture
|
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Paranoid/persecutory delusion
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"The FBI is out to get me"
|
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Grandiose delusion
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"I am the president"
|
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Referential delusion
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"The television is sending me messages"
|
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Somatic delusion
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"My heart is gone"
|
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Thought broadcasting delusions
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"My thoughts are being played over the intercom"
|
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Thought insertion delusions
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"Someone is making me think about hurting my mother"
|
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Hallucinations
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Sensory perceptions in the absence of stimuli
Audio - almost always pyschiatric Visual - sometimes pyschiatric Smell, taste, touch -- usually neurologic |
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Illusions
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Misperceptions of benign stimulus
|
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Depersonalization
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Feeling of having lost ones sense of personal identity
Feel strange or unreal |
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Derealization
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Feeling that everything around oneself is unreal or strange
|
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Disorientation
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Time, place, person
Time is most easily disturbed, person least Common in delirium, mod/sever dementia |
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Attention
|
Ability to focus and direct cognitive processes
Without this, rest of cognitive testing (fnc) cannot occur |
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Concentration
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Ability to sustain attention over time
Can be impaired in depression, anxiety, AD, also with poor effort Tests - world, serial 7s |
|
Registration
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Capacity for immediate recall of new learning, last a few seconds
Repeating back 3 words |
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Short term memory
|
Recall lasting seconds to minutes
"Working memory" Recall of 3 words after 1 to 5 minutes |
|
Long term memory
2 types |
Semantic - general knowledge bank (name last 4 presidents)
Episodic - important personal events, usually best preserved |
|
Construction
|
Ability to make 2 or 3 dimensional objects
Involves visuospatial/visuomotor skills |
|
Abstraction test
|
Similarity
Proverbs |
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Insight/judgement
|
insight -- knowledge involved in decision making
judgement -- opinion or conclusion arrived at |
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Mood
|
Subjective state patient expresses about their feeling
Typically state in patients words |
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Components of cognition
|
Orientation
Attention and Concentration Memory Visuospatial Abstraction Insight and Judgement |
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Digit span
|
Test of attention
Slowly read set of numbers to patient and the have then repeat back |
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Patient characteristics psychiatric emergencies
|
Young adults
Lower SE class Chronic issues w/ acute exacerbation |
|
Behaviors prompting emergent pyschiatric evaluation and treatmetn
|
Suicidal, violent, agitate/extremes of affect, withdrawn
|
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Suicide
|
Attempt to escape an unbearable anguish
Sometimes chronic/somtimes transient Not always associated with psychiatric diagnoses Mood disorders, schizophrenia, substance abuse |
|
Risk factors for completing a suicide attempt
|
Male
Increasing age (to 50 for women, 75 for men), also adolescents Previous attempts Single marital status Unemployed/recent job loss (esp professional) Psychiatric disoder Medical problems |
|
Suicidality evaluation
|
Intentionality -- expressed level of desire to die
Lethality -- how lethal is the plan Means -- does patient have means to carry out plan Viability -- what is the patients ability to accept help |
|
Suicide "gesturer"
|
Plan unlikely to succeed
Acute interpersonal conflict Often 20-40 women, younger people with personality disoders |
|
Hospitalization of a suicidal patient
|
Needs to occur when plan is lethal, desire to die is high, viability is low, or external support is unavailable
Not always possible to do voluntarily |
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Violent or combative patients
|
Typically have history of violence
Typically men 15-30 (also elderly w/ dementia) Low self esteem, embittered Disinhibition by drug/alcohol common Often become violent after embarrassment or losing face |
|
Organic states resulting in violent behavior
|
Drug (esp PCP)/alcohol
Delirium Dementia Partial complex seizures - rarely |
|
Psychiatric diagnoses associated with violent behavior
|
Schizophrenia
Mania Paranoia Character disturbances |
|
Medication in the violent or combative patient
|
Use of neuroleptic and benzodiazapines
Halperidol 5-10 mg w/ lorezapam 1-2mg available IM Newer - IM ziprasidone |
|
Tenets of pyschosocial model of development
|
1. Most kids are normal
2. Development has consistency, but also variations 3. Most parents are trying and will be "good enough" parents 4. Changes in development always set off a cascade of change 5. Intervention should be based in strengths not weaknesses |
|
Erikson stage I
Age Crisis Outcome |
First year of life
Trust vs Mistrust Trust and optimism Need consistent nurturing |
|
Erikson stage II
Age Crisis Outcome |
Second year of life
Autonomy vs Shame/Doubt Sense of self, control and mastery Need to avoid overly critical or hovering parents |
|
Erikson stage III
Age Crisis Outcome |
3-5 yrs
Initiative vs guilt Purpose and direction, ability to initiate children start to form relationships with others |
|
Erikson stage IV
Age Crisis Outcome |
6- puberty
Industry vs inferiority Competence in intellectual, physical, social skills Competition also enters |
|
Erikson stage IV
Age Crisis Outcome |
Adolescence
Identity vs role confusion Integrated sense of unique self |
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Erikson stage V
Age Crisis Outcome |
Early adulthood
Intimacy vs Isolation Close and lasting relationships, career development |
|
Erikson stage VI
Age Crisis Outcome |
Middle adulthood
Generation vs self absorption Concern for family, future generations |
|
Erikson stage VII
Age Crisis Outcome |
Aging years
Integrity vs despair Sense of fulfillment, leaving a legacy |
|
Risk factors for mental health problems in kids
|
Chronic medical problems (self or family)
Brain damage Temperament (aggressive, uninhibited) Genetics Family Stress |
|
Mental age
|
Intellectual age of a child
Can be assessed using Stanford Binet |
|
Neurologic development during childhood
|
Nerve proliferation until 11 (girls) 12 (boys)
Pruning organizes things during adolescence Prefrontal cortex develops last -- normal for adolescents to be somewhat impulsive |
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6 week developmental milestone
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Social smile
|
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2 month developmental milestone
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Head upright and steady
|
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4 month developmental milestone
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Roll over
|
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6 month developmental milestone
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Sits alone
|
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8-10 month developmental milestone
|
Stranger anxiety
Pulls to stand |
|
12 months developmental milestone
|
Walks
Uses cup |
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12-24 months developmental milestone
|
Talking
Single words, 2 word phrases |
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18 month developmental milestone
|
Throws ball
|
|
3-4 years developmental milestone
|
Draws closed circle
|
|
4 years developmental milestone
|
Hops on one foot
Dresses self with help |
|
Temperament in infant
|
Consistent style or pattern of behavior
Activity level Rhythmicity Approach/withdrawal Adaptability Intensity Response threshold Mood Distractibility Attention span Persistance |
|
"easy, difficult, slow-to-warm-up" temperament clusters in infants
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Easy - positive mood, adaptable, regular, approachable, low/moderate expressiveness
Difficult - negative mood, not adaptable, irregular, highly expressive, highly active Slow to warm up-- not adaptable, not approachable, low expressiveness, low activity level |
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Emotional development
|
From general states -- "excited"
to specific emotions -- "anger or delight" Anger -- expressed by frustration often peaks around 2 when autonomy is threatened |
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Attachment
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Affectionate tie between two people
|
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Bonding
|
Selective attachment that is maintained event when there is no contact
|
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Attachment behavior
|
Behavior in infant that promotes proximity or contact with attachment figure
|
|
Phases of attachment
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Undiscriminating social responsiveness 0-3 months
Discriminating social responsiveness 3-7 months Actively seeking proximity and contact: 7 months - 3 years Goal directed partnership 3 years + |
|
Mahler infant/mother dynamics theory
|
First symbiosis - infant sees mother as part of self (normally up to 5 months)
-- social smile Separation-individuation -- infant develops distance from mother |
|
Mahler subphase: differentiation
|
5-10 months
Infant begins to move away physically Stranger anxiety |
|
Mahler subphase: practicing
|
10-16 months
More physical distance -- walking More exploration Separation anxiety occurs |
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Mahler's third subphase: Raprochment
|
16 to 24 months
Self awareness ---> anxiety and conflict Wants to stay close AND wants to explore |
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Mahler's fourth subphase: Object constancy
|
24 to 36 months
Child able to retain internal representation of mother Tolerates separations with knowledge of reunion |
|
Basis of attachment behavior (bowbly)
|
Survival of infant
Needs attention Will persist even in the face of maltreatment |
|
Disturbing attachment process?
|
Leaves the infant insecure as an adult
|
|
Strange situation
|
A test of attachment
Mother leaves infant and stranger approaches Mother reappears Infant goes toward mother and is readily soothed = strong attachement |
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Better attachment leads to what in kids
|
Reliance on parents for help -- 18 months
Better liked by peers More independent in preschool Less problem behaviors in school |
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Insecure-avoidant attachment
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In Strange Situation, infant ignores mother on return and focuses on toys
|
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Insecure-resistant attachment
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In Strange Situation, infant seeks mother on return but cannot be comforted. Show signs of anger
|
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Insecure-disorganized attachment
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In Strange Situation, easily startled, approach parent with head down, disoriented and freezing behavior
|
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Failure to thrive in infancy
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Disorder related to attachment
Abscence/lack of attachment Growth failure and poor health "hospitalism" |
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Separation Anxiety Disorder
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Attachment related disorder
Normal in infants/toddlers Not normal in school aged children Symptoms of depression, difficulty concentrating |
|
Reactive Attachment Disorder
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Inhibited -- withdrawn, unresponsive
Disinhibited -- inappropriate approach to stranger Treat with facilitated 1:1 with primary care giver |
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Chronic exposure to stress in a child
|
Disrupts attachement
Changes brain -- HPA axis, morphology, memory disruption Constant, moderate -- resiliance Unpredicatable, chronic --vulnerability |
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Effects of severe abuse and neglect on childhood behavior
|
Aggressive
Distrustful Impulsive Isolating |
|
Schema's of Piaget
and effect of new knowledge |
Way to organize knowledge
New knowledge is assimilated in or causes accommodation of existing or creation of new schema |
|
Sensorimotor stage
Piaget |
0-2
Perceive and manipulate No reasoning Language begins Object permanence obtained |
|
Preoperational stage
Piaget |
2-7
Symbolic thought Egocentrism Lack of concept of conservation |
|
Where does thought fail with concept of conservation?
|
Centration - focus on one dimension
Irreversibility of thought -- cannot imagine things going in other direction |
|
Concrete operational
|
7-12
Increasingly logical Understanding of mental operations Categorization and classification Less egocentric Able to think abstractly/hypothetically |
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Formal operational
|
12-adulthood
Hypothetico-deductive reasoning Adolescent egocentrism show by personal fable and imaginary audience |
|
Critique of Piaget
|
Underestimates kids abilities
Overestimates differences in thought Vague about process of change Underestimates environment Lack of evidence |
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Language development
|
Newborns can differentiate sounds
Babble up to 6 weeks Filler syllables to 5 months Consonants from 5 mo - year Words 8-18 months 200 words by age 2 Pronouns by 2 Rules of grammar by 4 |
|
Gender identity
|
Parents tend to gender infants
By 1 infants can tell difference in faces By 2 gender id By 3 gender categories 3-6 gender stereotyped play 6-7 gender segregated groups |
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Repression
Ego Defense Mechanism |
Preventing painful or dangerous thoughts from entering consciousness
|
|
Sublimation
Ego Defense Mechanism |
Working off unmet desires or inappropriate thoughts through activities
Changing an unacceptable instinct into a socially acceptable one |
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Denial
Ego Defense Mechanism |
Protection from unpleasant reality by refusing to perceive it
|
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Rationalization
Ego Defense Mechanism |
Substituting socially acceptable reasons
|
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Intellectualization
Ego Defense Mechanism |
Ignoring emotional aspects of an painful experience by focusing on abstract thoughts, words, ideas
|
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What are ego defense mechanism for?
|
Distorting reality to avoid failing to satisfy both the id (pleasure) and superego (society)
|
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Projection
Ego Defense Mechanism |
Transferring unacceptable motives or impulses to others
|
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Reaction formation
Ego Defense Mechanism |
Refusing to acknowledge unacceptable feelings, urges, thoughts by exaggerating the opposite of them
|
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Regression
Ego Defense Mechanism |
Reacting to a threatening situation in a way appropriate for an earlier age or level of development
|
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Displacement
Ego Defense Mechanism |
Substituting a less threatening object for the original object or impulse
|
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Social development sequence
|
Born - regards face
1 month - spontaneous smile 2 months - responsive smile 5 months - work for toy 8 months - wave bye 10 months - communicate want with pointing 12 months - pat-a-cake: joint attention |
|
Language development sequence
|
1 month- respond to bell
2 months- ooh/ahh 4 months - laugh 6 months - turn to voice 9 months - mama/dada -- babble 12 months - mom/dad specific |
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DDx for being non verbal
|
Hearing problems/Auditory processing disorders
Oromotor dyspraxia Cerebral palsy Selective mutism Autism spectrum Downs, fragile x, klinefelters |
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Austism
3 features |
Impaired communication
Impaired social functions Repetitive behavior |
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Autism cognition
|
40-60% have impairment
|
|
Autism gender ratio
|
4:1
Boys: girls |
|
Genetics of Autism
|
Twins/siblings associated with increased risk
A number of genes identified Associated with tuberous sclerosis, fragile X, pku, congenital rubella, thalidomide Fathers>40 6x more likely that Fathers<30 |
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DSM of Autism
|
Abnormal function/delay prior to 3 of
A. Social fnc B. Language as communication C. Repetitive behaviors Not Rhett's or childhood disintegrative |
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Autism loss of social fnc criteria
|
Need 2
Impaired use of non verbal communication - eye contact, facial expression, posturing Failure to develop peer relationships Lack of spontaneous seeking to share interests (no bringing, pointing) Lack of social/emotional reciprocity, not wanted to play social games, ec |
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Autism communication impairment critera
|
Need 1
Failure to develop verbal language without compensation with gesture With language, but difficulty conversing Stereotyped or repetitive language Lack of imagined play, social mimicry |
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Autism repetitive behaviors criteria
|
Need 1
Encompassing preoccupation with activity that is inappropriate in intensity or focus Inflexible adherence to rituals Sterotyped, repetitive motor mannerisms Persistent preoccupation with parts of objects |
|
Treatments in autism
|
Applied Behavior Analysis
Teaches appropriate behavior Antecedent, behavior, consequence 30 hours a week may change behavior Occ therapy - sensory Physical therapy Speech therapy (augmented comm) |
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General patterns in early gross motor development
|
Cephalad to caudal
Flexion to extension |
|
DDx for delay in walking
|
Problems in
Brain Spinal cord Peripheral nerve Muscle Bone |
|
Fine motor task progression
|
0-6 months going from flexed hands to extended hands
7-12 bringing hands together, mastering thumb finger |
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Cerebral palsy
|
Non progressive motor function deficit
See echodensities in periventricular white matter Not related to birth trauma 1-5/1000 50% have global developmental delay |
|
Treatment of cerebral palsy
|
Braces, assist devices
PT/OT Surgery to release a limb Meds to decrease tone/ improve fnc |
|
What defines adolescence?
|
Appearance of secondary sexual characteristics
|
|
Who experiences peer group issues related to puberty the most?
|
Early maturing girls
Late maturing boys |
|
Growth spurt first or sexual maturation?
Boys or girls first? |
Growth spurt by a year
Girls by 2 years within a family |
|
Peer group development in adolescence
|
Early - same sex
Middle - mixed groups Late - pairing |
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Appearance development in adolescence
|
Part of self exploration
early - neglect middle -- take on appearance of a group late - individualization |
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Affiliations development in adolescence
|
Family
Groups, clubs, teams Close peers, self-define friendships |
|
Sexuality development in adolescence
|
Abhorrent but fascinating
Experimentation Continued relationship development |
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Early adolescence
|
11-13
Physical changes begin Same sex peer groups Neglect appearance Crushes Conflicts between parents and friends |
|
Middle adolescence
|
14-16
Abstract thinking begins Mixed peer groups Sexual exploration Rejection of parental values --often initially adopt extreme values (idealism) Appearance important |
|
Late adolescence
|
16+
Good abstract thinking Argue Still challenge parental values Idealism blends with pragmatism Relationships become more serious Decreased importance of appearance |
|
Unsuccessful outcome of identity vs identity diffusion (adolescence)
|
Identity confusion
Psychological dependence Social isolation Impulsivity and aggression |
|
Successful outcome of identity vs identity diffusion (adolescence)
|
Cohesive sense of self
Goals for future Identity separate from family Self-confidence within peer group |
|
Risk and teenage mind
|
Trial and error is going to happen
Risk assessment is difficult |
|
Increased likelihood of living to be 100
|
Lean
Non smoker Old relatives Handle stress above average Most have avoided chronic medical conditions |
|
Predictors of health at 70-80 in Valliant Harvard Study
|
No or moderate smoking
No alcohol abuse No depression Humor and ability to anticipate Warm marriage Good physical health |
|
Nun's study--protective factors for aging well vs developing Alzheimer's
|
High idea density as teens - 85% predictive
Staying mentally active Avoiding strokes, head injuries Diet high in folic acid Positive outlook expressed in teen had longer overall survival |
|
Modifiable factors in aging
|
Exercise
Diet Coping skills Social support With the exception of extreme longevity, genetics have <50% effect on aging |
|
Exercise while aging?
|
Those who started during midlife had almost as much protection from disability as life long exercisers
|
|
Participating in cultural activities does what for the elderly?
|
Great physical health assessment
Fewer doctors visits Less meds Fewer falls Less loneliness Greater total involvement in activity --controlled trial |
|
What does social engagement do in nursing homes?
|
increases survival
|
|
Selective Optimization with compensation
|
Successful aging strategy based on experience
Risk activities to a few domains Optimize reserves, choices Compensation with technology |
|
Neurobiological explanations of wisdom
|
Myelin continuous production (peak at 50)
Reduction in hemispheric asymmetry Reduction in amygdala activation (more able to cope with stress) |
|
Mature coping skills
|
Humor
Altruism Sublimation Anticipation Suppression |
|
Prevalence of pyschiatric diagnosis in US children and adolescents
|
14-20%
1 in 4 receive treatment Comorbitiy is the rule |
|
Cardinal features of ADHD
|
Inattention
Hyperactivity Impulsivity Girls more likely to have inattentive subtype |
|
Major depressive disorder in kids epi
|
More common in adolescents than kids
7.7% of 14-18s Boys=Girls in childhood Girls 2x more likely as adolescents |
|
Major depressive disorder presentation in kids
|
May not acknowledge depressed mood
Oppositional Irritable Physical complaints Aggression |
|
Major depressive disorder diagnosis in childhood increases chance of being diagnoses with
|
Bipolar disorder
>25% chance |
|
Treatment of child/adolescent major depression
|
Multimodal
Pyschotherapy, social interventions, meds Pharma is controversial Suicidality assessment is very importat |
|
OCD features
|
Obsessions -- recurrent thoughts, urges, impulses
Compulsions -- repetitive behaviors or mental acts Causing distress and inferring with fnc |
|
OCD prevalence in children
|
1-2%
Initially more boys than girls, then evens |
|
Comorbid psychiatric disease with OCD
|
Tourette's
other anxiety disorders major depression vocal/motor tics |
|
Treatment of OCD
|
SSRI + CBT with exposure/response
80% improve but 40-70% still meet criteria |
|
Projective testing
|
Testing drive, conflict, intrapsychic defense structure
Uses highly unstructured stimuli |
|
Risk factors for kids developing psychiatric illness
|
Chronic health problems
Brain damage Temperament (aggressive, behaviorally inhibited) Genetics Family factors Psychosocial factors/Stress |
|
Suicide attempt prevalence in adolescents
|
9% overall
12% of females 5% of males |
|
SSRIs and suicide in teens
|
Conflicting evidence
Suicide attempts on trials Suicide attempts in untreated depression Thought that serotonin might be activating a previously depressed individual to at out behaviors |
|
FDA approved SSRIs for OCD in kids
|
Sertraline >6
Fluoxamine >8 Fluoxetine >7 Anafril > 12 |
|
FDA approved SSRI for depression in pedi patients
|
Fluoxetine >8
|
|
Behavioral inhibition
|
A temperament, about 20% of Caucasians
Shy, Fearful Novelty avoidance Consistent over time Long latency to verbal response Sympathetic activation |
|
Anxiety begets anxiety
|
Kids with anxiety (GAD, SAD) are more likely to have parents with panic disorder (21%) or other (81%)
Parents with depression/anxiety are more likely to have kids with SAD, inhibition, school phobia |
|
Anxiety prevalence in pedi patients
|
10-20% meet criteria
Often goes undiagnosed |
|
What makes worry pathologic
|
Intensity, pervasiveness, time consuming, debilitating
|
|
Prognosis in anxiety spectrum disorders in children?
|
>80% remit
1/3 develop a new adult disorder |
|
Positive reinforcement
|
Turning on a positive stimulus in response to a behavior
|
|
Negative reinforcement
|
Turning off a positive stimulus in response to a behavior
|
|
Punishment
|
Turning on a negative stimulus in response to behavior
|
|
Extinction
|
Turning off a positive stimulus in response to behavior
|
|
Success, failure, pseudo in the 20-30
|
Committed love
Self-absorption Absorption into other |
|
Success in Career vs self absorption
|
Career w/ competence, compensation, commitment, and contentment
Childrearing |
|
Success in generativity vs stagnation
|
Accept death, wisdom (vs power), guide/mentor role
Reconcile personal successes and failures Focus is on community |
|
Failure in generativity vs stagnation
|
Chronic depression
Midlife crisis |
|
Factors that might alter progression through stags
|
Delay from physcial illness
Culture |
|
General pattern of development
|
From self -- primary love object-- community -- world
|
|
Domains of symptoms of mood disorder
|
Mood state
Pyschomotor Psychiatric Physical |
|
Unipolar disorder
Define and diseases within |
Pts who moods only deviate towards depression
Adjustment disorder with depressed mood Dysthymic disorder Major depressive disorder +/-pyschosis |
|
Bipolar disorder and subtypes
|
Experience of depression and mania
Type I - Mania +/- depression Mixed state - very rapid cycling Type II - Depression with hypomania Type III - NOS |
|
Mood symptoms of a depressive disorder
|
Sadness, apathy, irritability
Anhedonia Loss of self-esteem Feeling worthless/useless Guilty |
|
Physical symptoms of a depressive disorders
|
Weight loss
Weight gain (in atypical, SAD) Sleep disturbance with early morning or midcycle awakening Decreased libido Fatigue |
|
Physical symptom associated with severity of depression
|
Amount of weight loss
|
|
Movement symptoms associated with depressive disorders
|
Psychmotor retardation
-everything gets slower Psychomotor agitation - increased risk of suicide with severe agitation |
|
Cognitive symptoms associated with depressive disorders
|
Lack of concentration
Suicidal ideation |
|
Adjustment disorder with depressed mood
|
Development of distressing emotional or behavior symptoms linked to an identifiable stressor within three months of onset
Significant functional impairment Not bereavement |
|
Adjustment disorder with depressed mood prevalence and treatment
|
Most common unipolar depression
Often untreated Can be treated with brief psychotherapy, meds if situation in ongoing and not likely to resolve, short-term use of hypnotics for anxiety/insomnia |
|
Dysthymia diagnosis
|
Depressed mood for most of the day on most days for two years
2/6: Poor appetite or overeating Insomnia or hypersomnia Low energy Low self-esteem Poor concentration/difficult with decisions Feelings of hopelessness Not MDD, never been manic, not organic |
|
Double depression
|
Dysthymia diagonsis
Followed by an MDD diagnosis Poor prognosis |
|
Dysthymia treatment
|
Pyschotherapy
Meds if not return to euthymia Response to antidepressants less robust than MDD |
|
Dysthymia specifications
|
Primary -- no other chronic Axis I or III diagnoses
Secondary -- chronic diagnoses Early (<21) or late (>21) onset |
|
Major depression epi
|
20% of US adults at one point in their life
Fall and winter prevalence increase Genetic component |
|
Psychotic symptoms that can be seen with severe major depression
|
Severe delusional thought content
Perceptual distortion Auditory hallucinations of persecutory nature |
|
Major depression criteria
|
5 everyday for two weeks
Depressed mood Anhedonia Worthless feelings, guilt Diminished concentration/thought Weight loss/gain, poor appetite Pyschomotor agitation/retardation Insomnia/hypersomnia Suicidial thoughts |
|
SIGECAPSS
|
Criteria symptoms of depression
Sad, interested, guilty, concentration, appetite, psychomotor, sleep, suicide |
|
MSE in Depression
|
General -- Unkempt, agitation/retardation, poor eye contact
Affect-- constricted, teary Mood --depressed/irritable Speech -- slow, limited, quiet Thought - hopeless, guilty, preoccupied with somatic complaints, delusional Cognitive- distracted, difficulty concentrating Insight -- impaired because of feelings of worthlessness |
|
Somatic preoccupations often seen in depression
|
Cardiac
GU Chronic pain |
|
Mood disorders and suicide
|
50% of people who commit suicide are clinically depressed
15% of people with mood disorders commit suicide |
|
Tricyclic antidepressents
|
Imipramine, desipramine, amitryptyline, nortryptylline, doxepin
Very effective Lethal in overdose May cause arrythmias even at low blood levels |
|
MAOIs
|
Phenelzine, trancyclopromine
Effective Need to avoid certain foods (wine, cheese, avocados) Many SEs |
|
Second gen antidepressants
|
Amoxapine, Maprotiline, Trazadone
Have many side effects Trazadone used for sleep |
|
Venlafaxine is used for ...
|
FDA approved for anxiety/depression
|
|
Mertazipine is used for...
|
Anxiety, increasing appetite
|
|
Duloxetine is used for...
|
Pain
|
|
What's better about the SSRIs and other new meds vs older meds
|
Safety profile
Few SEs Better adherence |
|
ECT
|
electroconvulsive therapy
Inducing a seizure under anesthesia Mechanism for depression treatment unknown |
|
ECT indications
|
Major depression
Bipolar depression Psychotic depression Mania/depression during pregnancy Depression in elderly Mania Refractory schizophrenia Neuroleptic malignant syndrome Status epilepticus |
|
ECT side effects
|
HA, nausea
Amnesia retrograde - 6 months anterograde during treatment 0.3% chance of permanent memory loss |
|
Repetitive transcranial magnetic stimulation
|
Approved for refractory depression
Weak magnetic fields induced in brain by rapidly changing electric fields Some risk of seizure in pts with epilepsy |
|
CBT in depression
|
Cognitive behavior therapy
Interactive with therapist, homework assignments Short term Works on hopelesses about self/past/future Good evidence base |
|
Interpersonal therapy
|
Specific short term therapy for non-bipolar, nonpyschotic outpatient depression
Works on current interpersonal relationships Changing interactions will get different results from world |
|
Criteria for Mania
|
Dramatically elevated, expansive or irritable mood lasting for at least one week (or until hospitalization)
3+ Grandiosity Decreased need for sleep Talkative/pressured speech Flight of ideas Distractability Increase in goal driven behavior Excessive pleasure seeking with high risk |
|
DIGFAST
|
Mania symptoms
Distractibility Indiscretion (about consequences) Grandiosity Flight of ideas Activity increase Sleep, lack of need Talkative |
|
General appearance of someone with mania in interview
|
Psychomotor agitation
Seductive/colorful dress Intrusive grooming Entertaining Bizarre Threatening |
|
Criteria for hypomania
|
4+ days of elevated mood and mania symptoms without significant impairment or need for hospitalization
|
|
What's important in characterizing a bipolar disorder
|
Mania ever -- biopolar I
Hypomania AND depression -- bipolar II |
|
Biopolar rapid cycling
|
Mania/depression cycle in 2-3 days
May be difficult to treate |
|
Cyclothymic disorder
|
Hypomania/depression alternating two years
Substance use common Treatment of choice--lithium |
|
Lithium in bipolar
|
Best choice for preventing the depression
80% response rate in type I Acute mania can be managed with antipsychotics/ECT |
|
Long term SE of lithium
|
Kidney failure
|
|
AED's in biopolar
|
If lithium is ineffective in controlling manias, adding an AED
topirimate, valproate, carmazepine, lamotrigine |
|
Antidepressants in bipolar
|
Caution: may precipitate mania
Buproprion and paroxetine less so May lower suicide risk |
|
Lifetime suicide risk with bipolar disorder
|
19%
|
|
Pyschotherapy in biopolar
|
Lithium + pyschotherapy is better than either
Group, family, CBT Not indicated during mania |
|
Symptom cluster in Schizophrenia
|
Positive
Negative Disorganization Cognitive deficit Mood symptoms |
|
General appearance of schizophrenic
|
Neglect of hygiene
Social withdrawn Impaired cue response Apathy Amotivation Impaired functioning Behavioral disturbance Catatonia |
|
Speech characteristics in schizophrenic
|
Inappropriately loud
Slowed Pressured Mechanical |
|
Mood in schizophrenic
|
Depressed
Manic Anhedonic Flat, without mood |
|
Affect in schizophrenia
|
Inappropriate
Flat Pyschmotor agitation/retardation |
|
Thought process of schiozphrenic
|
Latency
Thought blocking Loose associations, tangential, word salad, Incoherence Delusions Ideas of reference Magical thinking |
|
Erotomanic delusion
|
A celebrity is my lover
|
|
Somatic delusion
|
Implanted device is listening in to my brain
|
|
Perceptions of schizophrenic
|
Hallucinations
Auditory or auditory + Most often persecutory voices Ilusions Disortions |
|
Cognition in schizophrenic
|
Impaired memory
Impaired executive fnc Impaired motor planning Impaired insight Disorientation |
|
Criteria for Schizophrenia
|
2+ for most of a month total >6 months
Hallucinations Delusions Disorganized speech Negative symptoms Disorganized behavior AND Social/occupational dysfunction AND No mood or medical condition explaining |
|
How to buy a diagnosis of schizophrenia with only one symptom
|
Bizarre delusions
or Hallucinations that are of running commentary or Hallucinations that are of 2 voices conversing |
|
With pervasive developmental disorders what symptoms must be present for diagnosis of schizophrenia?
|
Hallucinations and delusions
|
|
Schizoaffective disorder
|
Major depressive, manic, or mixed symptoms
+ Schizophrenia symptoms Delusions/hallucinations must persist for 2 weeks outside of mood episode Mood should be present for substantial portion of duration Substance abuse, medical exclusion |
|
Delusional disorder
|
Non bizarre delusions >1 month
Never meet schizo criteria Functioning, behavior not markedly impaired Mood symptoms absent or brief Exclude substance use, medical |
|
Schizophreniform disorder
|
Meets criteria for schizophrenia except duration (impairment also not necessary)
Duration includes prodrome, active, residual |
|
Brief psychotic disorder
|
Delusions, hallucinations, disorganized behavior or speech
Completely resolved by 1 month At higher risk for developing schizophrenia |
|
Brief psychotic disorder subtypes
|
By onset
Marked Stressor Without marked stressor Post partum |
|
Shared psychotic disorder
|
Developing the same delusion as a close relationship partner holds
|
|
Mood disorders with psychotic features, why not schizoaffective?
|
Psychosis resolves when mood does
|
|
What runs in families that have schizophrenia
|
Schizotypal personality disorder
|
|
Substance induced psychotic disorder
|
Prominent hallucination/delusions
-more than typical of withdrawl or intoxicaiton Onset w/in month of use or cessation Not better explained by other pysch diagnosis Symptoms do not exist purely in delirium |
|
Psychotic disorder due to general medical condition
|
Prominent delusions or hallucinations
Direct consequence of medical condition Not better accounted for by other psychotic disorder Not just during delirium Ex pyschosis from herpes encephalitis |
|
Delirium
|
Disturbance of consciousness
and perception Frequently have non auditory hallucinations |
|
Dementia and psychosis
|
Often happens
|
|
Paranoid subtype of schizophrenia
|
Preoccupation with delusions or auditory hallucinations
Not disorganized or catatonic |
|
Disorganized subtype of schizophrenia
|
Disorganized speech, behavior
Inappropriate or flat affect |
|
Catatonic schizophrenia
|
Extreme physical immobility, stupor
or excessive activation Extreme negativism Posturing Sterotyped movement Echolalia --decreasing in frequency |
|
Residual schizophrenia
|
Attenuated delusions, hallucinations, disorganization or catatonia
|
|
Schizophrenia epi
|
1% of population
0.5% population -- schizoaffective Increased risk with lower SES, childhood trauma, exposure to stress in first trimester Not just a genetic disease |
|
Onset of schizophrenia
When to treat? |
Onset typically teens-20s
Rare after 45 Initial episode response best to treatment Longer untreated psychosis leads to overall poor treatment response, psychosis is toxic |
|
Brain changes in progression of schizophrenia
|
Ventricular enlargement
Anterior hippocampal loss |
|
Gender difference in schizophrenia
|
Women have later onset
Better response to traditional antipsychotics Estrogen has neuroprotective effects and inhibits D2 |
|
Course of schizophrenia
|
Prodrome -- social, cognitive deficits for years
First episode-- treatment responsive Active phase -- full syndrome, 3-4 decades Residual phase -- 1/3 remission, 1/3 reduced symptoms in old age Dopamine decreases at around 50 |
|
Effectiveness of treatment?
|
Get into a remission and stay on antipsychotics:
3% relapse rate |
|
Suicidality in schizophrenia
|
20-40% attempt
10% complete Usually in first decade of illness, in between psychotic episodes |
|
Violence risk in schizoprenia?
|
When psychotic
|
|
Clozapine in schizophrenics
|
Can reduce sucidality and violence
|
|
Schizophrenia and lifespan
|
10-20 shorter
Worst if untreated Suicide Lung cancer - smoking rate Poor self care Chronic disease rates high Med effects (weight gain, sudden cardiac death, neuroleptic malignant syndrome) |
|
Reward deficiency syndrome
|
Schizophrenics are not getting enough reward from normal behaviors
Easier to get addicted to substances 50% lifetime, 25% at any time point 3-5x rate of substance abuse disorder Can easily destabilize the schizophrenia |
|
Effect of drug use on schizophrenia
|
Poorly med compliance
Higher relapse rate Earlier onset Poorer med response Greater brain loss Increase risk of violence, disease |
|
Nicotine and caffeine use in schizophrenia
|
90% smoke
Shown to help with cognitive deficits A form of self medicating |
|
Histology of schizophrenia
|
Some atrophy, enlarged ventricles
Reduction in caudate, hippocampus Disordered neuronal migration and connection |
|
fMRI of schizophrenic
|
Deficits in hippocampus, prefrontal cortex
|
|
Pathophysiology of schizophrenia
|
Dopamine
Hyperactivity in mesolimbic system Hypoactivity in mesocortical (cognitive and mood symptoms |
|
Drugs that inhibit NMDA receptors in normals can produce?
|
Schizophrenia symptoms
A dopiminergic pathway is not be stimulated? |
|
Schizophrenia genetics
|
50% coincidence in monozygotic twins
5% in parents of 10% in children, sibs of Genes involved with GABA/glutamte/dopamine balance, learning, memory, neuronal plasticity |
|
COMT variant in schizophrenia
|
COMT metabolized dopamine in prefrontal
Hyperactive COMT associated with schizo Cannabis increases risk in this genotype |
|
Neurodevelopment model of schizophrenia cause
|
Early brain abnormality (probably mesial temporal)
Hypofrontality develops Mesolimbic system later becomes hyperactive |
|
Neurodegenerative model
|
Glutamate dysregulation leads to neuronal apoptosis
Antipsychotics can protect rats during PCP (NMDA-antagonist) trials Psychosis toxicity could be glutamate excitotoxicity as well |
|
First generation antipsychotics
|
D2 antagonists
Clorpromazine, halperitold Parkinsonian side effects |
|
Second generation antipsychotics
|
D2,5HT antagonists
clozapine, atypical antipsychotics |
|
Third gen antipsychotics
|
D2 partial agonists
aripiprazole |
|
Effects of antipsychotics
|
Reduce acute symptoms
Prevent relapse into those symptoms Some reduce neg symptoms and cognitive impairments 10-20% remission rate |
|
What helps reduce relapse in schizophrenia other than meds?
|
Personal therapy
Supported work Family intervention treatment -- esp |
|
Treatment of dual diagnoses
|
Substance abuse + schizophrenia response rates better with integrated care of both problems by same team
|
|
Suppression
Ego defense |
Conscious decision to postpone or avoid an emotionally troubling issue
|
|
Altruism
Ego defense |
Addresses an emotional conflict through constructive attention to the needs of others, rather than self
|
|
Passive aggression
Ego defense |
Anger expressed indirectly through passivity or inaction
|
|
Turing against self
|
Passive aggression that involves hostile feelings towards another directed toward self
|
|
Dissociation
|
Splitting off a portion of an experience
(consciousness, memory, identity, perception, or a combo) that would normally be integrated with other parts of the conscious self |
|
Hypochondriasis (somatization)
Ego defense |
Transfer of emotional conflict or painful feelings to somatic symptoms or complaints
Not malingering |
|
Fantasy
Ego defense |
Creation of self contained fantasies as means of restoring emotional equilibrium
|
|
Splitting
Ego defense |
Inability to tolerate ambivalence
Involves concrete, typically intense black and white thinking and emtions that can shift back and forth depending on emotional state Idealization and devaluation |
|
Having less mature ego defenses is associated with
|
Axis I and II diagnoses
|
|
Mature ego defenses
|
Sublimation
Suppression Altruism Humor |
|
Neurotic defenses
|
Associated with symptom formation, maladaptive character traits
Repression, displacement, isolation of affect, reaction formation |
|
Immature defenses
|
Dissociation, acting out, fantasy, projection, hypochondriasis, splitting
|
|
Narcissistic (psycotic) defenses
|
Denial
|
|
What delays development in Fruedian model?
|
Conflict between a conscious desire and an unconscious desire/fear
Individual is perplexed by associated discomfort Anxiety forms, defense activates and if its a bad one -- symptoms |
|
Psychic determinism
|
All behavior is motivated
|
|
Epigentic development of personality
|
Experience is cumulative over time
|
|
Elements of personality
|
Character traits -- enduring patterns of expression
Coping style Stress tolerance/management Vulnerabilities |
|
In most of the country what is the percentage of patients with serious psychiatric illness receiving no treatment?
|
50%
|
|
Goals of community based care
|
Help complete their life goals
Stable housing Competitive employment Symptom management Freedom from addiction Avoidance of hospitalization |
|
Big problem with chronic mental illness and emotion/mentation?
|
Sense of hopelessness
Illness defined self |
|
Supported housing
|
Regular community housing with optional mental health services
Studies show works as well as more structured for most people with chronic mental illness |
|
What responds better to treatment positive or negative symptoms?
|
Positive
|
|
Med compliance among the chronically mentally ill
|
About 50%
Pts as likley to use alcohol/street drugs as psychiatric meds |
|
Work desire and employment rate in chronically mentally ill
|
75% want to work
Unsupported- 15% are working |
|
Presentation of anxiety
|
Subjective feeling of unease, apprehension, fear
Signs of sympathetic arousal : dry mouth, trembling, SOB, palpitations, urinary hesitancy, GI distress, unsteadiness, paresthesias |
|
Common presentation of major depressive disorder in the elderly?
|
Anxiety
|
|
General medical conditions causing anxiety disorders
|
Hypoxia
COPD delirium hyperthyroidism acidosis hypoglycemia |
|
Substance induced anxiety disorder culprits
|
Caused by exposure or withdrawl
Caffeine Alcohol Benzos Amphetamines Cocaine Other adrenergics |
|
Areas of brain that have been implicated in anxiety
|
Locus coruelus -- panic disorder
Amygdala - normal fear Orbitofrontal-basal ganglia network OCD |
|
Neurotransmitters involved with anxiety
|
NE, serotonin, gaba
|
|
Behavior of anxiety
|
Conditioned response from pairing of unconditioned stimulus with conditioned stimulus
Fear where there is not danger |
|
Cognition of anxiety
|
Catastrophizing
|
|
Lifetime prevalence of an anxiety disorder
Gender |
25%
Women 2x men This data excluded PTSD and OCD |
|
Treatment success in anxiety disorders
|
Not as good as MDD
May mitigate but not get rid of symptoms |
|
Panic attack
|
Discrete period of intense fear
Physical symptoms develop abruptly and resolve in less than an hour palpitations, sweating, trembling, feel SOB, feel choking, chest pain, dizziness, separation from reality, fear of dying, paresthesias, chils/hot flashes |
|
Panic disorder
|
Recurrent unexpected panic attacks
At least one is followed by a month+ of fearing more attacks, fearing implications of attacks, changing behaviors to avoid Not explained by medical other pyschological diagnosis |
|
Agoraphobia
|
Fear of situations which are difficult to escape/ get help for a panic attack
and Restriction of activities/distress doing activities and Not better explained by social phobia, etc |
|
What is feared in panic disorder?
|
Physical symptoms
|
|
Anxiety sensitivity
|
Level to which someone fears the panic attack, can make a difference in developing panic disorder
|
|
Behavioral action tendencies in anxiety
|
Escape and avoidance
Procrastination Jittery behaviors Safety checks |
|
CBT in anxiety
|
Psychoeducation
Modification of unhelpful stimuli Exposure to phobic stimuli Less focus on self-regulation because people are already spending too much time thinking about inner workings |
|
Treating panic disorder with agoraphobia
|
Consider starting with some drugs
--if you can't think you can't do CBT CBT with progressive exposure interoceptive, naturalistic, in vivo |
|
Fear is maintained by
|
Avoidance behaviors
- feel relief by avoiding - also prevents any new learning Faulty cognitions persist |
|
Exposure therapy
|
Extinction of fear stimulus
Negative consquence (physical arousal) decreases over time with behavior |
|
Panic disorder exposure
|
Fear is of the bodily sensations
Make run in place, feel racing heart Challenging misinterpretations racing heart does not equal MI De-catastrophizing |
|
Social phobia, what is the fear?
|
Embarassment
|
|
Social phobia
|
Marked and persistent fear that social performance with strangers will lead to embarassment
AND Feared situation provokes anxiety AND Fear is self-recognized as excessive AND Avoidance/pained endurance AND Interferes with functioning |
|
Specific phobia
|
Marked and excessive fear cued by presence or anticipation of specific stimulus
AND Exposure evokes anxiety AND Recognition of excess AND Avoidance/pained endurance of phobia AND Interferes with fnc/distress about phobia |
|
What is feared in Generalized Anxiety Disorder?
|
Bad things happening
|
|
GAD criteria
|
Excessive worry for most days for >6 months
AND Worry in more than one domain AND Difficult to control worry AND 3+ fatigue/restlessness, impaired concentration, muscle tension, sleep disturbance AND Impairment NOT other pysch/med diagnosis |
|
GAD predisposers
|
Parental modeling
Uncontrollable negative events as child |
|
What do people worry about in GAD
|
normal stuff
but too intensely, too often, out of control, focused on small matters too much |
|
Process of worry
|
Mostly thought, verbal
Not imagined Sympathetic arousal (which reduces emotions) |
|
CBT theory of GAD
|
Worry is like avoidance
Worry inhibits emotional processing by focusing on verbal rather than imagined |
|
Treatment of GAD
|
Education
Somatic relaxation Reduction of avoidance Worry exposure |
|
What is feared in OCD?
|
The intrusive thought
|
|
OCD criteria
|
Obsessions or compulsions
AND Recognition of excess AND Distress, time consuming >1hr/day NOT related to another Axis I, or medical |
|
Obsessions
|
Recurrent and persistent thoughts, images, impulses that are intrusive and cause anxiety
Not simply excess of real life issues Pt attempts to ignore, suppress or neutralize these thoughts Thoughts are recognized as internal not inserted |
|
Compulsions
|
Repetitive behaviors or mental acts that person feels compelled to perform in response to an obsession or as part of a strict rule
Behaviors are aimed at neutralizing a thought or avoiding a feared event, but are not causally linked to that event |
|
OCD treatmetn
|
Meds
Exposure and response prevention CBT |
|
Personality
|
Pattern of cognition, behavior, emotion with which an individual interacts with the world and thinks of self
Individual has many character traits, usually flexible to fit situation |
|
Personality disorder
|
Inflexible personality traits resulting in social/occupational/interpersonal problems
Lifelong |
|
Personality disorders affect on ego
|
Usually ego syntonic
Problem is with others, not self |
|
When are personality disorders easiest to notice?
|
High stress and interpersonal relationships
|
|
Personality disorders prone to pyschotic episodes with stress
|
Boderline
Schizotypal |
|
Base pathology in personality disorders
|
Distorted internal representation of self and others
|
|
Where do aberrant behaviors originate from in personality disorders
|
Ego defenses
Usually immature ones Trying to prevent harm in a hostile internal environment |
|
Etiology of personality disorder
|
Many dysfunctional/abusive families
-although not necessary or sufficient Genetic factors Develop view of world: unstrustworthy, unpredictable, overly demanding or dangerous |
|
Acquired personality disorders?
|
From
Frontal lobe trauma MS Seizures Dementing processes |
|
Cluster A
|
Odd, Eccentric
Difficulty interpreting of environment, social cues, connecting with others Paranoid, schizoid, schizotypal |
|
Paranoid personality disorder
|
Suspects without evidence that others are exploiting, harming, tricking
Is preoccupied with doubting others Avoids confiding in others Reads hidden meaning into benign statements Is unforgiving/grudge holding Reacts angrily to perceived attacks on character/self Is not pyschotic during symptoms |
|
Paranoid personality disorder epi
|
Men>women
0.5% - 2.5% On schizophrenia spectrum |
|
Paranoid personality disorder ego dense
|
Frequent use of projection
|
|
Schizoid personality
|
Nether desires nor enjoys close relationships
Chooses solitary activities Has little to no sexual interest Get pleasure from few activities Lack friends/confidants Indifferent to praise/disdain of others Flat affect, emotional coldness Not psychotic or explained by pervasive developmental disorde |
|
Schizoid personality disorder epi
|
<1%
Male 3: Female 1 ? relationship to schizophrenic disorders |
|
Schizotypal personality disorder
|
Odd beliefs and magical thinking outside of subcultural norms
Ideas of reference Paranoid ideation Odd behavior Lack of close friends outside family Inappropriate or constricted affect Social anxiety not remitting with familiarity 2/2 paranoia Unusual perceptions like bodily illusions Not during course of psychosis |
|
Schizotypal personality disorder epi
|
3%
Associated with schizophrenia, relatives with schizophrenia |
|
Cluster B
|
Dramatic, emotional cluster
Affective dysregulation, impulsivity, distorted sense of self Borderline, antisocial, narcissistic, histrionic |
|
Borderline personality disorder
|
Frantic effort to avoid real/imagined abandonment
Intense, unstable relationships characterized by idealization and devaluation Identity disturbance Impulsivity with danger potential Chronic feelings of emptiness Recurrent suicidalilty, parasuicidal behavior Affective instability Inappropriate and difficult to control anger Stress related paranoia, dissociation |
|
Borderline personality disorder epi
|
1-2% of population
10+% of psychiatric admissions 2 females: 1 male Increased prevelance of MDD, alcohol dependence/abuse, substance abuse (also in 1st degree relatives) |
|
Etiology of borderline
|
80% reported significant childhood trauma
Genetic component -- mothers with borderline, increase in affective disorders in first degree relatives |
|
Histrionic personality disorder
|
Uncomfortable out of center of attention
Interactions often sexual/provocative Rapid, shallow emotions Uses body to draw attention to self Speech is impressionistic Behavior is dramatic Considers relationships more intimate than they are |
|
Histrionic personality disorder epi
|
2-3%
F > M |
|
Histrionic personality disorder DDx
|
Somatiform
Convergence |
|
Narcissitic personality disorder
|
Grandiose sense of self-importance
Preoccupied with schemes of ultimate success Belief in own uniqueness, need to be around other high fncing Require excessive admiration Entitled Exploitive Lacking empathy Envious/perceives envy of self Arrogant, haughty behaviors |
|
Suicide and narcissism
|
High rates of suicide
Usually after a narcissistic injury - wife leaving |
|
Narcissistic PD epi
|
1%
Can be high functioning |
|
Antisocial PD
|
Failure to adhere to social norms like laws
Deceitful Impulsive Irritable and aggressive (fights) Reckless with self-others Consistent irresponsibility Lack of remorse |
|
Antisocial PD epi
|
3% men, 1% women
Genetic and correlated link with EtOH dependence High population in prisons |
|
Antisocial PD brain
|
Differences seen
Inability to process negative reinforcement? |
|
Cluster C
|
Fearful, anxious
Avoidant, Obsessive compulsive, Dependent |
|
Avoidant personality disorder
|
Avoids significant interpersonal contact for fear of rejection, humiliation
Unwilling to get involved until assured of liking Restraint in intimate relationships, inhibited socially Preoccupied with rejection in social situations Views self as inept, inferior, unattractive Reluctant to take risks |
|
Difference between avoidant and schizoid PD
|
Avoidants very much desire the personal relationships
|
|
Avoidant personality
Epi Treatment |
1% of population
Treat with exposure/group |
|
Dependent personality disorder
|
Has difficult with decision making
Needs others to assume most responsibility for his/her life Difficulty disagreeing Difficult initiating projects b/c lack of self confidence Goes to great lengths to obtain nurture (volunteer for unpleasant) Feels helpless/uncomfortable when alone Urgently seeks another relationship when one ends Preoccupied with being left alone to take care of self |
|
Dependent personality disorder epi
|
1.5%
F>M High medical comorbidity/obesity |
|
Obsessive compulsive personality disorder
|
Preoccupied with details, lists, rules to the point that activity purpose is lost
Perfectionism interferes with completion Devotion to work in exclusion of leisure/friendships Inflexible morals, values Unable to discard objects, even without meaning Reluctant to delegate Miserly (hoard for doomsday) Rigid and stuborn |
|
Obsessive compulsive PD epi
|
1%
NOT OCD |
|
Treating personality disorders
|
Many do not seek treatment (exception: borderline)
CBT, DBT (+eastern philos) Gives skills need to fnc Treat Axis I Sometimes pharma is helpful |
|
Characteristics of a successful physician in counseling
|
Non judgmental
Supportive Knowledgable Encourages/educates about coping Socially sanctioned for healing |
|
Supportive therapies
|
Help pts cope
Supportive therapy, crisis intervention, mutual self help groups |
|
Expressive therapies
|
Focus on gaining insight
Need to have higher fnc Psychoanalysis/psychodynamic therapy Insight oriented -generally focused on present |
|
Behavioral therapies
|
Focused on changing behaviors rather than understanding the problem
Relaxation, social skills training, exposure/response, contingency management Mood, anxiety, substance abuse, psychotic |
|
Cognitive therapy
|
Focused on changing the thoughts associated with disorder
Often combined with behavioral |
|
What is CBT used in?
|
Mood
Panic GAD bulemia PTSD anger problems others |
|
Behavior therapy particularly useful when?
|
There is a behavior to change
OCD Eating disorders Substance abuse |
|
Behavioral therapy sequence
|
Explanation of rational
Identification of pt issues Model new behavior Practice new behavior Give pt homework |
|
Relaxation train useful in
|
Mood, anxiety, anger, substances , pain
Slow breathing with conscious muscle relaxation |
|
Social skills training
|
Allows for better relationships, more intrinsically rewarding interactions
Better abilities to refuse |
|
Contingency management
|
Use rewards for behavior that is inconsistent with disorder
Helps with operant behavior disorders--drug use Also childhood disorders Can be very effective |
|
Schemata
|
Deeply ingrained belief that can engender automatic thoughts and behaviors
"I am only lovable if I am think" I must lose weight Vomitting |
|
Cognitive restructuring
|
Replace maladaptive thought with a more realistic one
|
|
Common maladaptive thought processes
|
All or none
Generalization Catastrophe Must, should, never Emotional reasoning Fortune telling Labeling |
|
Challenging automatic thoughts
|
ID distortion
Examine evidence Shades of gray Double standard -- what would you tell friend? Experimentation -- let's ask someone Cost benefit analysis |
|
Patient improves on a medical treatment, why?
|
Disease just got better
Placebo Specific effects |
|
Enhancing power of a medication
|
MD - make right diagnosis, use right dose, educate, be optimistic
Med - SEs Pt-- adhere |
|
Somatic disorders
|
Physical symptoms or concern about physical symptoms
No medical diagnosis to explain Symptoms are not intentionally produced--Unconscious Symptoms cause distress/impairment |
|
Malingering
|
Not a diagnosis
Process of intentionally faking symptoms get desired response (ie narcotics) |
|
Factitious disorder
|
Conscious to attempt to simulate or stimulate illness
|
|
Thought processes of somatiform disorders
|
Masochism
Guilt Dependency Hostility Anger Illness as punishment |
|
Somatization disorder
|
Multiple physical complaints w/o medical cause
Must be from 4 different systems Pain, GI, sexual, quasi-neurologic Onset before 30 Lasts years AKA Briquet's, Hysteria |
|
Somatization disorder epi
|
F>M
0.2-2% population, more in hospital Varies by culture? |
|
Somatization disorder etiology
|
Somatization of unconscious processes
Expression of social needs Frontal lobe dysfunction Relationship with hyponotizability 80% were highly hypnosable 40% had DID |
|
Somatization disorder associations
|
Axis II, MDD, Panic, Substances
Childhood abuse Families with somatiform, substances, antisocial personality |
|
Somatization disorder management
|
Work up any possible organic illness
Consistent brief visits w/ PCP -psych consult may help minimize cost Pyschologic -- move away from physical to emotional pains CBT improved physical symptoms 5-10% recovery Pharma antidepressent trials |
|
Undifferentiated somatiform disorder
|
Physical symptoms without medical cause
>1, lasting > 6 months AKA Subsyndromal somatization disorder, abridged somatization |
|
Undifferentiated somatoform disorder epi
|
5-10%
20% in general med populations |
|
Conversion disorder
|
1+ deficits is voluntary motor or sensory fnc with no medical cause
Excludes pain, sexual dysfunction L>R Sometimes preceeded by stressor AKA Hysterical neurosis, conversion type |
|
Conversion disorder epi
|
1-3% mental health outpatients
25% of medical and pysch inpatient 5-40% epilepsy pts F>M Increases with lower SES, rural populations |
|
Conversion disorder associated diagnoses
|
MDD, dissociative disorders, histrionic, antisocial, dependent
Some familial association with conversion, antisocial PD |
|
Pathogenesis of conversion disorder
|
Resolution of some unconscious conflict
primary and secondary gain may not be distress by symptom because of resolution of pysch symptoms Decreased blood flow to contralateral thalamus/basal ganglia during episode Self hypnosis? Predisposition from having an organic illness |
|
Conversion disorder treatment
|
Workup for organic cause
recently shown 0-3% Confrontation Suggestion of rapid recovery Hypnosis - not very supported Amytal interview -- access unconscious issues Recovery is about 90% |
|
Pain disorder
|
Pain without medical cause
Evidence of psychologicl factors Can be associated with general medical condition or not |
|
Pain disorder epi
|
Prevalence unclear up to 50% of pain has no known cause
|
|
Pain disorder associations
|
Mood disorders, anxiety disorders
Familial with pain disorder, mood disorder, ETOH dependence |
|
Pain disorder etiology
|
? decreased tolerance
? conditioned behavior ? social/culture factors Social exclusion -- neurally similar to physical pain : activation of anterior cingulate) |
|
Pain disorder treatment
|
Maintain activity - PT/OT
CBT Hypnosis CAM NSAIDs - not opiates Antidepressants, antiepileptics TENS |
|
Hypochondriasis
|
Preoccupation with having a serious illness despite reassurance
Preoccupation is not delusional, not about appearance >6 months |
|
Hypochondriasis epi
|
5-10%
M=F (F get help more) Onset in early adulthood Chronic Many more with intermittent worry |
|
Hypochondriasis association
|
Axis I
Anxiety and Depressive disorders ? increased somatization, anxiety in families |
|
Hyochondriasis pathognesis
|
Somatization/alexathymia
Misinterpretation of bodily sensations Defense manifestations related to perceived internal threat Learned Serotingergic deficit -- esp with overvalued thoughts |
|
Hypochondriasis treatment
|
? frequent visits
SSRI if anxious CBT does not work especially well |
|
Body dysmorphic disorder
|
Excessive preoccupation with perceived deficit in physical appearance
AKA dysmorophophobia |
|
BDD prevalence
|
2% of pop
12% psych outpatients 7-15% of those seeking cosmetic surgery |
|
BDD onset and associations
|
Onset usually in adolescence, usually chronic
80% have MDD, 40% have OCD, associated with other anxiety, axis II If insight ranges to delusion --> delusion disorder, somatiform type |
|
BDD etiology
|
Serotinergic deficit
Social ideal influence ?OCD varient ?eating disorder viarent |
|
BDD treatment
|
CBT, group
SSRI, clomipramine Levetiracetam Severe - neuroleptic, buspirone, gabepentin ?ECT, cosmetic surgery |
|
Pseudomalingering
|
Pretending to have a disease and then getting it
|
|
Factitious disorder, who are the pts
|
F, 20-40, health care worker
M, middle aged, socially isolated |
|
Factitious disorder treatment
|
Nothing good really
Confront pt in face saving way....if this is a physical diagnosis, this treatment will work Give space for psychological expression |
|
Factitious disorder by proxy
|
Proxy is usually child <4, mother is usually perpetrator (76%)
22 months from onset -- diagnosis 6% dead, 7% long term injury at diagnosis 25% have dead siblings, 61% of siblings had suspicious symptoms |
|
Self mutilation and the opioid system
|
Theory
Endogenous opioid system occurs as a result of adequate attachment Serves to self sooth during distress With poor attachment this system may be underactive and require hyperstimulation |
|
Relative prevalence of various types of child abuse
|
Physical
Sexual Emotional Medical Neglect |
|
Most common cause of PSTD in women in US?
|
Sexual abuse
|
|
Attachment and trauma
|
Security of attachment bond is greatest mitigating factor against trauma induced disorganization
80% of traumatized kids have disorganized attachment |
|
What best predicts severe symptoms from trauma?
|
Victim feeling that he/she had no one to turn to with whom he/she woul dbe safe
|
|
Age and child abuse
|
Younger the child the worse the consequence, generally
|
|
Trauma experience
|
Threat of life or wellbeing to self or others that cannot be escaped
Experienced or observed |
|
Disorganization of defense system
|
Autonomic arousal with no ability to escape or fight
Gets overwhelmed and disorganized Fear state persists |
|
Dissociation
|
Separation of normally integrated functions
Ex. Memory but no emotion |
|
Coping with abuse parents
|
Children must find a way not to blame parents
Repression and dissociation are most common |
|
Psychiatric patients with a history of sexual abuse?
|
2/3
|
|
What has highest correlation with early childhood sexual abuse?
|
Somatizaton disorder -- 90+% correlation
|
|
Biology of dissociation
|
Glutamate mediated?
Ketamine is an NMDA receptor antagonist -deactivation of large, association fibers |
|
PET during flashback
|
Shows deactivation of language and communication areas
|
|
Dissociation as a child
|
Seems to be adaptive for survival of trauma
Predisposes to development of PTSD |
|
Dissociative identity disorder
|
Presence of two or distinct, enduring personalities
AND At least two of the states recurrently take control AND Inability to recall information too extensive for forgetfulness AND Not 2/2 substance/medical condition |
|
Not all abused kids develop diagnoses, what's different?
|
Neurobiologic change
Genetics FKBP5 variant with altered glucocorticoid pathway activation |
|
Neurobiologic changes seen in abuse sufferers--->PTSD
|
Long term changs in HPA axis
Changes in hippocampal morphology Changes in hippocampal based memory Increased ventricular volume and decreased brain volume |
|
Abuse in childhood, adolescence and self harm
|
Abuse in childhood correlates with increase in all self harm behaviors
Abuse in adolescence, increases risk of suicide, anorexia only |
|
Lifetime effect of childhood abuse
|
Increased lifetime psychopathology
Physical = sexual Eating disorders correlation is not a strong |
|
Most powerful predictor of self destructive behavior?
|
Neglect
|
|
PTSD is a disorder of
|
Reactivity, rather than basal state
|
|
Psychological outcomes of trauma
|
PTSD
New onset substance abuse Anxiety disorder |
|
Lifetime incidence of PTSD in US
|
7%
F 2: M 1 40% in combat veterans -combat is worst male trauma |
|
Components of the generalized stress response
|
HPA
Locus coruleus Immune system |
|
Structural changes in PTSD
|
Decrease hippocampal volume
Decrease in medial prefrontal cortex -fear extinction Increase in orbital prefrontal cortex - fear extinction |
|
Psychiatric responses to domestic violence
|
Women - anxiety disorders
Men - substance abuse |
|
Sexual vs nonsexual crime
|
Sexual violence victims 2x as likely to get PTSD
|
|
How does PTSD effect life?
|
More suicide attempts
More medical illnesses Worse physical health Less employment Negative impact on personal relationships |
|
Pregnancy with PTSD
|
Higher rates of
ectopics, miscarriages, hyperemesis, preterm labor, excessive fetal growth |
|
Highest levels of post traumatic stress with
|
Female gender
Marital separations Pre-event depression or anxiety disorder Physical illness Intensity of exposure Early diengagement from coping |
|
Criteria for PTSD
|
Exposure to trauma: experienced or witnessed
AND Respond with intense fear, helplessness, horror AND Rexperiencing, Avoidance/numbing, and Hyperarousal AND Impairment/Distress Lasting > 1 month |
|
Re-experiencing criteria of PTSD
|
Persistent experience of 1+:
Distressing recollections Distressing dreams Acting/feeling event recurring Distress at cues resembling event Reactivity at cues resembling event |
|
Avoidance/numbing criteria of PTSD
|
3+ of
Avoid thoughts, feelings, convos related Avoid people, places, activities related Unable to recall parts of trauma Decreased interest in activities Estrangement from others Restricted range of affect Foreshortened vision of future |
|
Arousal criteria of PTSD
|
2+
Sleep difficulties Outbursts of anger or irritability Difficulty concentrating Hypervigilance Exaggerated startle response |
|
Comorbities with PTSD
|
Alcohol abuse
Depression Social phobia |
|
PTSD first line treatment
|
CBT
--cognitive processing --prolonged exposure Eye movement desensitization and reprocessing SSRIs |
|
PTSD first line meds
|
SSRIs
sertraline, paroxetine, fluoxetine SNRIs venlafaxine |
|
Prazosin
|
Minipress
Promising PTSD Used to stop nightmares, now also during day |
|
Anxiolytics in PTSD
|
Don't really work
|
|
Cognitive processing therapy in PTSD
|
Psychoeducatoin
Written exposure write about impact of trauma on thoughts of self/othrs interpretations of event Challenge interpretations Restructure beliefs disrupted by trauma |
|
What therapy has long lasting improvements with PTSD
|
Cognitive processing therapy
Prolonged exposure therapy Have about 80% reduction in criteria meeting at 5 years |
|
Eating disorders epi
|
4% prevalence
9 females: 1 male Onset is usually adolescence |
|
Eating disorders risk factors
|
Genetics
AN - families with eating disorder or affective disorder Bulemia -- families with eating disorder, affective disorder, or substance abuse Twin study concordance |
|
Eating disorders comorbidity
|
Depression 50-75%
OCD 25% AN Substance abuse 12-18% BN Personality disorder 40-70% AN |
|
Anorexia Nervosa criteria
|
Refusal to maintain body weight above minimum for height and age (85%, BMI18.5)
and Intense fear of getting fat and Disturbance in perception of body, undue influence of body weight on self-image, or denial of seriousness of underweight and Ammenorrhea when applicable |
|
Anorexia Nervosa subtypes
|
Restricting
Binge/purge |
|
Bulemia Nervosa criteria
|
Recurrent episodes of binge eating
Excess consumption Feeling unable to stop Recurrent inappropriate compensatory behavior At least twice and week for three months Self evaluation is unduly influenced by shape/weight |
|
Bulemia subtypes
|
Purging - vomitting, laxatives
Nonpurging - excercise, fasting |
|
Eating disorder NOS
|
Most are subsyndromal anorexia or bulemia
Also binge eating disorder |
|
Binge Eating Disorder
|
Binge eating in absence of compensatory behaviors
Commonly overweight, but not always Body dissatisfaction, depression, low self esteem |
|
Anorexia tardiva
|
Anorexia diagnosed after 25
|
|
Anorexia onset
|
As young as 7-12 (often with OCD)
Typically in adolescence |
|
Bulemia associated with what childhood disorder
|
Pica
Rare is bulemia seen in <12 |
|
Binge Eating Disorder onset
|
Adulthood
|
|
Binge eating disorder gender ratio
|
More common in men
|
|
BDD genders
|
M=F
Men often have muscle dysmorphism -- Adonis complex |
|
Female athlete triad
|
Disordered eating
Ammenorhea Osteopenia |
|
Sports and eating disorders
|
Female high school athletics is protective
Female college athletics is a risk factor Body building/wrestling risk for bulemia |
|
Personality disorder and eating disorder
|
AN -- cluster C
BN -- clusters B and C Association of borderline and long term bulemia |
|
Childhood disorders associated?
|
AN and OCD
BN and social phobia |
|
Effects of vomiting/overexercise
|
Relief of tension
Emotional anesthetic High similar to cutting |
|
Effects of low weight
|
Starvation
Food obsession, ritualization Depression, anxiety, irritability, mood swings Social withdrawal Decreased concentration, poor judgement Apathy |
|
Hunger level of anorexics
|
Extremely high
Eating takes them down to where most people peak |
|
Early physical signs of AN
|
Hair thinning
Feeling cold Complaints of bloating or nausea Amenorrhea |
|
Anorexia nervosa -- other ways to present
|
Low sex drive
Depression/anxiety Weakness, fatigue Chest pain, palpitations Sports injury, stress fracture |
|
Physical findings in anorexia
|
thin, pale
dependent edema reduced muscle mass bradycardia <50 arrythymias hypotension abdominal pain on exam |
|
Lab finding in anorexia
|
Usually come on late in weight loss
Hypokalemia, metabolic acidosis -- laxative Metabolic alkalosis -- vomiting Rare hypoglycemia Ca, Mg down, amylase up |
|
DDx with anorexia
|
Malabsorption syndrome
Endocrine Malignancy Anxiety Depression Psychotic |
|
AN treatment goals
|
Restore healthy weight
Educate Prevent relapse |
|
AN Nutritional rehab
|
2-3 lb/week inpt, 0.5-1/week out
Goal is 90%, better success at 95% Normalize eating patterns Reunderstand hunger and satiety Correct malnutrition |
|
AN therapy after weight has been restored
|
Understanding
Identify antecedents Secondary gain issues Avoid relapse How to deal with stress better |
|
Where to treat a pt with AN
|
>85% IBW - outpatient
>90% intensive outpt 85-75% - partial hospitalization, residential treatment <75% Inpatient Also check: medical status, suicidal, motivation, stressors, amt of support needed |
|
What kind of therapy in AN
|
Family - Maudlsey - young children
CBT and DBT individually Group, esp CBT based 12-step programs Meds |
|
Medicaitons in AN
|
Not in used much in acute phase
SSRIs may prevent relapse after weight recovery |
|
AN medical issues in recovery
|
Dermatologic
Cardiac GI Endocrine - ammenorhea, hypothermia Muscoloskeletal - osteopenia/porosis, fractures Cognitive Reproductive - arrest sexual development, infertility, neonatal complicaitons Heme - anemia, neutropenia |
|
Refeeding syndrome
|
Too rapid feeding of the severely malnourished <70%
Down P, Ca, Mg, Thiamine Fluid retention, cardiac arrythmias, cardiac failure, respiratory insufficiency, red cell dysfunction, seizures, delerium, death |
|
Non eating related sign of bulemia
|
Difficulty managing money and time
|
|
BN physical signs
|
Fluctuating weight
Menstrual irregularities Swollen salivary/parotids Dental problems Abdominal discomfort, anxiety, depression, palpitations |
|
BN physical exam
|
Range of weights
Poor skin turgor Dental decay Inflamed oral mucosa, oropharynx Arrythmias Cardiomyopathy |
|
Abnl labs in bulemia
|
Metabolic alkalosis and decrease K with vomiting
Metabolic acidosis with laxative use Increased amylase from vomiting Increased LFTs late 2/2 fatty degeneration UA with increased specific gravity |
|
BN DDx
|
Malignancy
GI illness Hyperthyroidism Anxiety disorder (somatoform) OCD Personality disorders (additional self-harm behaviors) |
|
Bulemia stabilization
|
Restore electrolyte balance
Rehydrate Typically followed by outpt treatment |
|
Meds for bulemia
|
Fluoxetine shown 50-75% reduction in binge eating/vomiting rates
|
|
Bulemia medical risks
|
GI - tears, ruptures, reflux, stomatitis
CV - arrythmias Renal failures Tooth loss Frequent relapse |
|
Eating disorder prognosis
|
10% overall mortality
33% of AN have full recov, more partial 75% of BN have full recov |
|
Dementia criteria
|
Multiple cognitive deficits
Memory impairment (amnesia) with Aphasia, agnonsia, apraxia, or loss of executive fncing Impairment from previous level |
|
Most common dementias
|
AD
Mixed (AD with vascular) Lewy body Vascular (multiinfarct) Frontotemporal Parkinson's associated |
|
Factors that may encourage earlier onset of AD
|
Hypertension
Obesity Hypercholesteremia Diabetes |
|
Meds that can worsen symptoms of AD
|
Anticholingergics
Lots of others -- including opiods, steroids, sleeping pills |
|
Lab tests to work up AD
|
CBC, lytes, B12, folate, LFTs
|
|
CSF in AD
|
Low beta mayloid, high tau
|
|
Progression of AD
|
Mild - trouble with money, navigating, word finding, starting things
Moderate - trouble with recognition, safety, appearance declines, needs help with ADLs Severe Gibberish, no recognition of self/family, groans and moans when touched, total assistance with ADLs |
|
Antidementia meds
|
Cholinesterase inhibitors : donepezil, rivastigmine, galantamine
NMDA receptor antagonist Memantine Modest, symptomatic relief -- slow cognitive decline, preserve fnc, decrease mood/behavior problems |
|
Affects of psychological intervention with caregiver of Alzheimer's pt
|
Benefits caregiver
Slows nursing home placement |
|
Behavioral symptoms in dementia
|
90% of pts get significant behavior symptoms at some point
No meds approved -- atypical antipsychotics have black box on dementia |
|
Racial difference in AD preference
|
Hispanics 1.5 x whites
Blacks 2 x whites Probably mediated by HTN, hypercholesterolemia, diabetes, etc |
|
Genetic risks of AD %s
|
With 1 parent -- 2.5x
With both parents -- 20-25% risk |
|
Peak behavioral problems based on stage of AD
|
Mild -- apathy
Moderate - delusions Severe - agitation Depression, anxiety, restlessness fairly high throughout |
|
Eating disorder prognosis
|
10% overall mortality
33% of AN have full recov, more partial 75% of BN have full recov |
|
Dementia criteria
|
Multiple cognitive deficits
Memory impairment (amnesia) with Aphasia, agnonsia, apraxia, or loss of executive fncing Impairment from previous level |
|
Most common dementias
|
AD
Mixed (AD with vascular) Lewy body Vascular (multiinfarct) Frontotemporal Parkinson's associated |
|
Factors that may encourage earlier onset of AD
|
Hypertension
Obesity Hypercholesteremia Diabetes |
|
Meds that can worsen symptoms of AD
|
Anticholingergics
Lots of others -- including opiods, steroids, sleeping pills |
|
Making diagnosis of AD
|
Dementia
Other causes ruled out Gradual and progressive decline |
|
Delirium
|
Disturbance of consciousness with reduced ability to sustain attention
and Change in cognition/perception and Develops quickly and fluctuates not Better explained by dementia |
|
Delirium AKA
|
Altered mental status
Acute confusional state Toxic/metabolic encephalopathy Acute brain failure |
|
Signs of delirium
|
Change in consciousness: stupor -- hyperarousal
Hallucinations, illusions Parnoid delusions Altered sleep-wake Change in activity level Emotional/cognitive changes |
|
Most common diagnosis of pts referred to psych consult for crying
|
Delirium
|
|
Cognitive disturbances with delirium
|
Disorientation
Short term memory impairment Incoherent speech Trouble naming Impaired construction |
|
Hyperactive vs hypoactive delirium
|
Agitation vs lethargy
Hallucination vs confusion Hypoactive is probably more common but underdiagnosed Hypo- mistaken for depression Hyper - pyschotic disorders |
|
Prevalence of delirium
|
50% of elderly admitted acutely
40-90% in ICU Post op 10% of elderly for any surgery 25-35% CT surgery 40-50% hip fracture repair |
|
Delirium in kids/young adults
|
Increased rate w/ MR. seizure disorder, previous brain surgery
Often med induced (diphenhydramine) |
|
Risk factors for delirium
|
Increasing age
Dementia Medical illness H/o brain injury H/o alcohol abuse Male Sensory impairment Malnourished, dehydrated |
|
What's so bad about delirium in hospital
|
Increases length of stay/infections
Increases chance of death w/in 2 years of hospitalization Increased institutionalization at discharge Stay delirious on discharge - worse |
|
Etiology of delirium
|
Medical not psychologic
|
|
EEG in delirium
|
Diffuse slowing
|
|
Exam in delirium
|
non focal
general dysfunction in cortical/subcortical structures, more on non-dominant side |
|
Neurotransmitter theory
|
Too much dopamine
dopamingergics can mimic d Not enough AcH anticholinergics can mimic Reports of altered glutamate, GABAs, serotonin, histamine |
|
I WATCH DEATH
|
Causes of Delirium
Infection Withdrawal Acute metabolic (acidosis, renal fail) Trauma CNS pathology Hypoxia Deficiencies Endocrinopathies Acute vascular Toxins/drugs Heavy metals |
|
Drugs associated with delirium
|
Opiods
Anticholinergics Corticosteroids Benzodiazapines Others |
|
DDx for delirium
|
Mania
Schizophrenia Dementia Depression Way to differentiate -- fluctuating impairment of the sensorium |
|
Best test for delirium
|
Confusions assessment method
1. Acute onset and fluctuating course 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness 1 + 2 +3/4 = delirium |
|
Treatment of delirium
|
Treat underlying medical cause
Remove potentially delirious meds Support safety |
|
Behavioral treatments for delirious pts
|
Orient -- clock, calendar
Glasses and hearing aids Regular sleep-wake Mobilize as soon as possible Avoid restraints when possible |
|
Pharmacological treatment of delirium
|
Typical antipsychotics
(like halperidol --IV/IM/PO) Atypical antipyschotics not as well establish resperidone, olanzapine Non-benzodiazapine anxiolytics trazadone -- nice and safe gabepentin |
|
What not to give to delirious pt?
|
Benzos
can have paradoxical effect Do give if its DTs, in antipsychotics are contraindicated -lorazepam |
|
Insomnia define
|
Difficulty initiating or maintaining sleep or early awakening or insufficient sleep
|
|
Excessive sleepiness
|
Intrusive dozing/involuntary dozing
|
|
Circadian rhythm disorder
|
Changes is sleep wake
|
|
Parasomnias
|
Abnormal behaviors, events, or medical disorders related to sleep
|
|
Insomnia epi
|
10-15% report chronic insomnia
35% report occassional sleep disturbances Higher rates in older individuals, women, those w/ medical or psychiatric concerns, substance abuse |
|
Insomnia perception vs reality
|
Report extremely little sleep
Objective changes often mild Something about the sleep is unrestful that they think they are awake |
|
Insomnia fatigue?
|
Fatigue
May report feeling sleepy Have = or greater sleep latency than normals |
|
Insomnia pathogenesis
|
Hyperarousal
Show hyperarousal during day, increased HR, caffeine simulation |
|
Daytime consequences of insomnia
|
Poor cognition, mood, motor fnc, overal fnc/performance
Physical symptoms |
|
Causes of insomnia
|
Psychiatric -40%
Substance induced Circadian shift work, Medical/neuro breathing, restless leg Primary sleep disorder Primary insomnia |
|
Adjustment insomnia
|
Related to acute stress
Usually time limited May become chronic if complicated Treat to prevent development of chronic |
|
MDD and sleep
|
>90% complain of sleep disturbances
Impaired initiation and maintenance Early morning awakening Non restorative sleep, MDD worse in morning |
|
Sleep physiology in MDD
|
Increased latency
Fragmented sleep Diminished slow wave REm onset earlier, more REM |
|
Substances that can induce insomnia
|
Stimulants
Methylxanthines Steroids Alcohol Nicotine Withdrawal from sleep medication Pthers |
|
Circadian disorders
|
Jet lag
Shift work disorder Delayed/advanced phase Irregular sleep/wake rhythm |
|
AD and circadian rhythm
|
Decreased amplitude of melatonin rhythm and total production
Temp cycle intact |
|
Restless leg syndrome
|
Desire to move limbs associated with paresthesias/dysthesias
Motor restlessness Increased at rest/partially relieved by activity Symptoms worse in evening/night |
|
Periodic limb movement disorder
|
Clinical features of light/interupted sleep, daytime sleepiness
Repetitive muscle contractions (last 5 s), may awake or arouse |
|
Periodic limb movement disorder causes
|
Familial/sporadic
Neuropathy/radiculopathy/myelopathy Fe deficiency End stage renal disease RA Substances |
|
Periodic limb movement disorder treatments
|
Dopamimetics
Benzos Opiods Carbmazepine Gabapentin Clonidine |
|
Psychophysiologic insomnia
|
Conditioned insomnia
Tension/anxiety/arousal in response to efforts to sleep Neg expectations surrounding ability to sleep Ability to fall asleep better when not trying Sleep better when not at home Can be initiating/maintaining More fixed over time No other psych diagnosis |
|
Psychophysiologic insomnia treatment
|
Sleep hygiene
CBT Hypnotics Benzos Imidazopyridines Cyclopyrrolones Pyrazolopyrimidines Sedating antidepressants |
|
CBT in pyschophysiologic insomnia
|
Stimulus control
Bed only when sleepy/sex Get up if not sleeping Maintain cycle -- no naps Sleep restriction Keep in bed time to actual sleep time With success increase time in bed, with trouble, decrease it |
|
Sleepiness
|
Increased ability to fall asleep spontaneously
|
|
Causes of excessive sleepiness
|
Low sleep quantity
Bad sleep quality Substances anxiolytics, hypnotics, some AEDs, antipsychotics Sleep/wake Pysch Medical Narcolepsy/idopathic hypersomulence |
|
Narcolepsy
|
Inappropriate manifestations of REM
1/5000 Intrusive drowsiness (sleep attacks) Restorative naps Disturbed noctural sleep |
|
Cataplexy
|
Inappropriate intrusion of REM atonia into wakefulness
Fairly diagnostic of narcoplexy |
|
Narcolepsy tetrad
|
Narcolepsy
Cataplexy Sleep paralysis Hypnogogic hallucinations only 15% have tetrad |
|
Narcolepsy on multiple sleep latency test
|
mean time to sleep <5 minutes
2+ sudden onset REM episodes |
|
Narcolepsy onset
|
10-30
|
|
Narcolepsy pathogenesis
|
Autoimmune?
Associate with HLA type Destruction of hypocretin (orexogenic) neurons in lateral hypothalamus |
|
Hyponcretin (orexogenic neurons)
|
Lateral hypothalmus
Project to cortex, thalamus, basal forebrain, brainstem (dorsal raphe, locus ceruleous, pp tegmentum) Keeps stable sleep wake cycle |
|
Treatment of narcolepsy
|
Naps
Stimulants Modafenil - histamine, alpha 1 agonist, ?hypocretin activation |
|
Narcolepsy treatment of cataplexy, sleep paralysis, hallucinations
|
REM suppressant: SSRi, TCA, SNRI
GHB Support |
|
Idiopathic hypersomulence
|
Chronic drowsiness
Naps do not help Deep/long noctural sleep Sleep drunkeness ?autonomic disturbance Chronic fatigue link Poorly responsive to treatment |
|
Disorders of arousal
What kind of sleep, when, meory |
Stage 3/4
Partial arousal w/ amnesia or partial Extreme autonomic activation First 1/3 of night Stuck between deep sleep and wakefullness |
|
Sleep arousal epi
|
Predominantly kids
2-8, most 4-6 1-2% are problems |
|
Sleepwalking
Sonambulism |
Disorder of arousal
Complex behavior with deep sleep Confusion, incoherence Wide range of behaviors Leading cause of sleep related injury |
|
Night terrors
Parvor nocturnus |
Sudden arousal from deep sleep
Scream/terror Extreme autonomic arousal Variable motor activity - escape imagery |
|
Treating disorders of arousal
|
Safety management
Benzos Psychotherapy |
|
REM Behavior disorder
|
Acting out dream behavior because of loss of REM atonia
Dream related actions Wide range of behaviors talking, walking, violence Last seconds to minutes |
|
REM behavior disorder epi
|
Mostly elderly men
50% with known neuropathology |
|
Can normal people lack atonia in REM
|
Yes, but its much less frequent than in someone with REM behavior disorder
|
|
Markers of REM behavior disorder
|
Loss of smell, loss of color identification
|
|
REM behavior disorder treatment
|
Neurologic evaluation
Safety Clonazapem Melatonin (2nd line) |
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What problems show up in a substance abusers life?
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Relationships
Work/school Social Medical |
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Substance Abuse criteria
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In 12 month span:
Recurrent use resulting in failure to fulfill obligations or Recurrent use in situations where its physically hazardous or Recurrent substance use legal problems or Continued use despite social/interpersonal problems made worse by use |
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Substance abuse or dependence, what's worse?
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Dependence
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Substance dependence criteria
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Maladaptive pattern of use causing distress characterized by 3+ at least once in a year
1. Tolerance 2. Withdrawal 3. Substance taken in larger amounts or over longer than intended 4. Persistent desire to cut back or failed attempts to do so 5. Great deal of time spent obtain, using, recovering 6. Important social/occupational/personal activities given up/reduced because of use 7. Continued use despite knowledge of physical/psychological issue worsened by use |
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Is alcoholism dangerous
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Progressive and potential fatal
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Lifetime prevalence of alcohol disorders, dependence
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Overall 30% and 12%
Men 40%, 25% Women 20%, 8% |
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Lifetime dependence alcohol prevalence by race
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Native Americans -- 22%
White 14% Hispanic 10% Black 8% Asian 6% |
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Groups with higher rates of alcohol dependence
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18-29
Never married No college (6x), some college (3x) Low SES (20K-35K) West and midwest |
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African Americans and alcohol
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More abstain
Those who drink have worse medical consequences |
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How much does alcohol and drugs cost the country a year in treatment/secondary effects?
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Half a trillion dollars
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Worst drug for you physically acutely? longterm?
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Acutely -- cocaine
arrythmias, strokes, seizures, death Long term -- EtOH |
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Liver damage sequence in alcoholism
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Fatty change -- reversible
Hepatitis - mostly reversible Cirrhosis -- not reversible Death by liver failure, esophageal varices |
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Esophageal varices
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Enlarged blood vessels in esophagus
Portal HTN is cause If rupture, can cause very major bleed Liver disease also effects clotting factors production |
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GI damage in alcoholism
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Pancreatitis
Reflux esophagitis Gastritis Diarrhea GI cancers esophageal, mouth, larynx -esp with smoking |
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Alcohol effect on CV system
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HTN -- 3 drinks a day +
Cardiac arrythmias Dilated cardiomyopathy |
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Alcohol effects on reproductive system
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Decreased sexual performance in men
Sperm abnormalities Hypogonadism -- chronic use with liver damage results in higher estrogen levels |
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Fetal alcohol syndrome facial features
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Small head
Epicanthal folds Small palpebral fissues Flattened nasal bridge Smooth philtrum Thin upperlip Short nose Underdeveloped jaw |
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Alcohol effects on hematopoesis
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Macrocytic anemia
Decreased WBC Decreased plts Anemia 2/2 nutritional deficiency |
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Alcohol effects on skin
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facial edema and redness
worsening of conditions like psoriasis |
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Alcohol effects on musculoskeletal sysem
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Asceptic hip necrosis more preavlent
Osteopenia progresses faster Limb compression syndrome -ischemia from passing out in weird position Injuries while intoxicated |
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Alcohol effect on nervous system
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Peripheral neuropathy
--reflex, sensory, motor fibers --bilateral, distal --treated with B vitamins, PT TBI Wernicke-Korsakoff - in a few malnourished alcoholics |
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Wernicke's encephalopathy
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Confusion, ataxia, eye symptoms
-- EOM paralysis and nystagmus Usually impaired consciousness at this point Can be reversible with thiamine |
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Korsakoff's psychosis
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Amnesia and confabulation
Not usually reversible |
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Red flags for alcoholism in occupational history
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Frequent job changes
Tardiness Absenteeism - Monday mornings Work related accidents |
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Effectiveness of treating addiction
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40-60% of treated addicts are continuously abstinent 1 year post treatment
+ 15-30% that have not returned to dependent use |
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Relapse paradox in alcohol as a chronic disease
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In other chronic diseases, relapse is a demonstration of the necessity/effectiveness of treatment
In alcoholism, its considered evidence of treatment failure |
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What is predictive of alcohol dependence
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Genetics
Ethnicity No alcoholic personality |
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Factors that predict successful recovery
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Development of vital interest to replace drinking
Consistent reminders of how bad drinking was Presence of a new intimate relationship |
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Family effect on alcoholism
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Risk of alcoholism is 3x higher with close relatives
More of them is worse A - reward drinkers, mom or dad alcoholis B -- dad is alcoholic, 9x more likely, quickly progressive |
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Twin alcoholic risk
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Doubles risk compared to having fraternal or sibling
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How important is environment on alcoholism development
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Adoption studies show effect of biological parent alcoholism
Environment may have greater effect on women |
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Groups with low rates of alcoholism
High? |
Jews, Asians
Native American, French, Irish |