3. Psychiatric History?
• Psychiatric History
–Identification
–Chief Complaint
–History of Present Illness
–Past Psychiatric and Medical History
–Family History
5. Early Childhood Hx?
• Early Childhood - Quality of mother-child
interactions during feeding /toilet training
• Sleep patterns
• Human constancy and attachments
• Personality as a child
6. Middle Childhood Hx?
• Middle Childhood- gender identification,
punishments used in the home, early school
experiences
• Early patterns of assertion, impulsiveness,
aggression, passivity, anxiety, or antisocial
behavior
7. Later Childhood Hx?
–Peer Relations
–School History
–Cognitive and Motor Development
–Emotional/Physical Problems
–Psychosexual History – them or their friends
sexual activity, common at younger and younger
ages. The younger they are has been shown to
commonly cause depression
–Religious Background – strong, pressures, none
8. Adulthood Hx?
–Occupational History
–Social Activity – too little, too much – pressure to
do too much
–Adult Sexuality – in a relationship, previous
relationships, healthy? Children?
–Military History – big insite into psych disorders,
discharged honorably?
–Value system – what do they hold as important?
Power, money, family, stability – will give you a
huge insight into the person.
9. What is Neuropsychiatric Assessment?
• Neuropsychiatric Assessment
– Assessment of multiple areas of functioning
that may impact performance in the
classroom, with peers, at home or in the
job.
12. Mental Status Exam Components?
• Mental Status Examination (MSE)
– General Description
– Mood and Affect
– Speech Characteristics
– Perception
– Sensorium and Cognition
– Impulsivity
– Judgment and Insight
13. Mini Mental Status ExamWhen is it used?
What is normal?
• Used as a screening tool and to follow patients
for advancing dementia, etc.
• Normal ranges vary based on education level
and age.
14. Psychoanalysis- Goals?
Goals of traditional psychoanalysis
• Symptom relief
• Increased self awareness
• Objective capacity for self observation
15. Psychoanalysis- Treatment Methods?
Limitations?
Treatment Methods
– Free Association
– Transference - common
– All are meant to discover the unconscious
defenses or personality of the patient
Limitations –
Countertransference – must guard against
4-5 times a wk./ 3-5 yrs.
16. Behavior therapy techniques?
• Behavioral Techniques
– Relaxation Training
– Hierarchy Construction
– Desensitization of the Stimulus
– Hypnosis
18. Behavioral/Cognitive therapy
techniques?
• Cognitive Behavioral Techniques
– Scheduling activities
– Mastery and pleasure
– Graded task assignments
– Cognitive rehearsal
– Self-reliance training
– Role playing
– Diversion techniques
19. What are the axes in DSM-IV?
• Axis I
– Clinical diagnosis and those diagnosis needing clinical
attention
• Axis II
– Personality disorders and mental retardation
• Axis III
– General medical conditions
• Axis IV
– Psychosocial and environmental problems
• *Axis V
– Global assessment of functioning scale
20. Psychiatric Nosology
• Axis I
– 296.23: Major depressive disorder, single episode, severe without
psychotic episode
– 305.00: Alcohol abuse
• Axis II
– 301.6: Dependent personality disorder
– Frequent use of denial
• Axis III
– Hypertension
• Axis IV
– Threat of job loss
• Axis V
– GAF: 35
21. Psychiatric Report components?
• Includes psychiatric history and MSE
– Written
– Includes final summary of both positive and
negative finding and interpretation of the data.
24. CAGE questionnaire?
• Screening tools — A simple screening tool for problems of
alcohol use is the CAGE questionnaire, which has been
modified for screening for drug use and is known as the CAGEAID questionnaire (AID = Adapted to Include Drugs)
– C — Have you ever tried to cut down on your alcohol or
drug use?
– A — Do you get annoyed when people comment about
your drinking or drug use?
– G — Do you feel guilty about things you have done while
drinking or using drugs?
– E — Do you need an eye-opener to get started in the
morning?
25. Define Alcohol Abuse.
• Alcohol abuse — Alcohol abuse is defined as a
maladaptive pattern of alcohol use associated with
one or more of the following:
– Failure to fulfill role obligations (eg, at work, school or
home)
– Recurrent substance use in physically hazardous situations
– Recurrent legal problems related to substance use
– Continued use despite alcohol-related social or
interpersonal problems
26. Define Alcohol Dependence.
• Alcohol dependence — Alcohol dependence is
defined as a maladaptive pattern of use associated
with three or more of the following:
–
–
–
–
–
–
–
Tolerance
Withdrawal
Substance taken in larger quantity than intended
Persistent desire to cut down or control use
Time is spent obtaining, using, or recovering from the substance
Social, occupational, or recreational tasks are sacrificed
Use continues despite physical and psychological problems
27. Definition of Intoxication?
• Quantity of alcohol ingested exceeds
individuals tolerance producing physical
and/or behavioral changes
28. Describe Absorption of Alcohol
• Absorption
– 20% stomach
– 80% jejunum
– Increase time in stomach, decreases peak BAC
29. Describe Metabolism of Alcohol
• Metabolism
– 90% in liver via ADH (alcohol dehydrogenase)
– 5% excreted by lungs
• Basis of Breathalyzer
– 5% excreted in urine
30. Mechanism of Action of Alcohol?
• Ethanol binds postsynaptic GABA(A)
receptors (inhibitory neurons)
• Ethanol inhibits excitatory NMDA (N -methyl
D –aspartate) receptors
• Ethanol affects opioid binding
31. Further Describe Mechanism of Action
of Alcohol?
• Alcohol consumption results in the release of
the body’s naturally occurring opiates,
endorphins both in the brain and in the
periphery.
– If opiates are consumed simultaneously with
alcohol the exogenous and endogenous opioid
effects can be additive.
32. Standard Drink?
• Standard “drink” consists of 10 g EtOH
– 12 oz of beer (3.2%)
– 4-5 oz of wine (12 %)
– 1.5 oz liquor ( 80 proof)
• Average person metabolizes 10 g / hr
– Approx 1 drink / hr
33. Blood Alcohol Level?
• Expressed in mg/dl
• 100 mg/dl = 1 part EtOH in 1000 parts blood
= 0.1%
• Legal limit in most states is between 0.08%
and 0.1%
34. Alcohol Overdose Clinical
Presentation?
– BAC > 600 mg/dl often fatal
– Progressive obtundation, decreases in respiration, BP
and temp
– Urinary incontinence or retention
– Reflexes markedly decreased or absent
– Death occurs from loss of airway protective reflexes
(with subsequent airway obstruction by the flaccid
tongue), pulmonary aspiration of gastric contents or
from respiratory arrest from profound CNS
depression.
35. Alcohol Overdose Management?
– Supportive:
• Protect airway – prevent respiratory depression
• Administer IV thiamine and glucose
• Alcohol is rapidly absorbed, so induction of emesis or
gastric lavage / activated charcoal not effective
• Enhancement of elimination via hemoperfusion and
forced diuresis not effective
• Currently no pharmacological “alcohol antagonist”
• Assess pt for ingestion of other drugs
36. Definition of withdrawal?
• A withdrawal syndrome is a predictable
constellation of signs and symptoms
following abrupt discontinuation of, or rapid
decrease in, the intake of a substance that
has been used consistently for a period of
time.
37. Pathophysiology of Alcohol
Withdrawal?
• CNS depressant
• Alcohol (normally) simultaneously enhances
inhibitory tone and inhibits excitatory tone
• With abrupt abstinence from alcohol deficiencies in
inhibitory influences and excesses in excitatory
influences create withdrawal phenomena.
• The withdrawal symptoms last until the body
readjusts to the absence of the alcohol and
establishes a new equilibrium.
38. DSM IV Diagnostic Criterion of
Withdrawal?
• Two (or more) of the following, developing within several
hours to a few days after cessation
– autonomic hyperactivity (e.g. sweating or pulse rate
greater than 100)
– increased hand tremor
– insomnia
– nausea and vomiting
– psychomotor agitation
– transient visual, tactile, or auditory hallucination or
illusions
– anxiety
– grand mal seizures
39. Clinical Picture of Alcohol
Withdrawal?
• Stage I: Early withdrawal consists of mild
anxiety and alcohol craving
• Stage II: Intermediate severity, usually
between 24-36 hours, characterized by
excessive adrenergic effects
• Stage III: This stage consists of tonic-clonic
seizures and occurs typically between 12-48
hours
40. Stage 4 Alcohol Withdrawal Clinical
Picture?
• Stage IV: This stage consists of DTs, often
occurring immediately following a seizure,
typically within 48-72 hours after alcohol
intake stops.
41. Hallucinations- how many alcohol
abusers?
• Up to 25% of patients with a prolonged
history of alcohol abuse experience alcoholic
hallucinosis
• Occur with an otherwise clear sensorium
42. Describe the Hallucinations in alcohol
withdrawal?
• Mild to moderate – lights too bright, sounds
too loud and startling. Tactile “pins and
needles”.
• Severe – visual hallucinations most common,
frequently involving animal life. Auditory
hallucinations begins as clicks or buzzing and
can progress to formed voices. Tactile – bugs
and insects
43. Withdrawal Seizures?
• Alcohol withdrawal seizures ("rum fits") are
experienced by up to 33% of patients with
significant alcohol withdrawal
• Usually brief, generalized, tonic-clonic, without an
aura, in clusters of 1-3, short postictal period
• Incidence peaks at 24 hours following most
recent ingestion
44. Delirium Tremens- How many?
When?
• Only 5% of pts with ethanol withdrawal
progress to DTs
• Occurs usually between 48-96 hours after the
last drink
45. What is Delirium Tremens?
• Classic presentation; all the early and
intermediate symptoms of alcohol
withdrawal plus a profoundly altered
sensorium
46. Delirium Tremens- Physical Signs?
• Severe autonomic derangements are
commonly present
• Significant dehydration due to intense
diaphoresis, hyperventilation, and restricted
oral intake
47. Delirium Tremens- Mortality?
• Patients at greatest risk for death are those
with extreme fever, fluid and electrolyte
imbalance, or intercurrent illness such as
pneumonia, hepatitis or pancreatitis
• Mortality rate is as high as 35% if untreated
but less than 5% with early recognition and
treatment
48. Management of Alcohol Withdrawal?
• Alcohol Withdrawal
– Clinical assessment of severity – CIWA scale
– Evaluate for the presence of both acute and
chronic medical and psychiatric conditions.
– Pertinent labs include CBC, electrolytes, Mg,
Ca, Phos, LFTs, UDS, preg, BAC, lipase, EKG.
– Benzodiazepines
49. Management of
Alcohol Withdrawal Seizures?
• Alcohol Withdrawal Seizures
– Diagnosis of a withdrawal seizure should be
made only if there is a clear history of a marked
decrease or cessation of drinking in the previous
24 to 48 hours
– Parenteral rapid acting benzodiazepines
(diazepam, lorazepam) to prevent future
episodes
50. Management of Alcohol withdrawal
delirium?
• Alcohol Withdrawal Delirium
– Cross-tolerant sedative-hypnotics reduce mortality
in DTs but do not reverse delirium or reduce its
duration
– Narcoleptics should not be used alone to treat DTs
because they can lower the seizure threshold
– Sedate pt. to point of light sleep to control
agitation, prevent self and/or staff injurious
behavior and allow the administration of
supportive medical care
51. What are the components of
Wernicke-Korsakoff Syndrome?
• In 1881, Carl Wernicke first described an
illness that consisted of the triad of
opthalmoplegia, ataxia and the abrupt onset
of an acute confusional state
52. Pathophysiology of WernickeKorsakoff Syndrome?
• Thiamine deficiency
– Alcoholism is the most common cause (though
any condition that results in a poor nutritional
state can lead to W-K syndrome)
– Alcohol decreases active GI transport of thiamine
– Liver disease decreases thiamine activation and
storage
– 1 to 3% in pts with alcoholism
53. Clinical Picture-Wernicke
• Weakness or paralysis of lateral rectus
muscles leading to internal strabismus and
diplopia
• Nystagmus
• Wide-based stance with uncertain short
stepped gait
• Global confusional state characterized by
apathy, inattentiveness and indifference to
surroundings
54. Clinical Picture –Korsakoff?
• Korsakoff amnestic state occurs in a small
number of pts and is characterized by both
persistent anterograde and retrograde
amnesia. ( anterograde > retrograde).
– Confabulation to fill in gaps in memory.
– http://www.youtube.com/watch?v=UbSlLtsJfUY
55. Morbidity/Mortality of WernickeKorsakoff Syndrome?
• Generally full recovery of ocular function occurs
• 40% completely recover from ataxia
• Only 20% eventually recover from amnestic
(Korsakoff psychosis) deficit
– may take one or more years and depends on abstinence
from alcohol
• Mortality rate is 10 – 20%
• Most common etiologies are infectious or hepatic
failure
56. Treatment of Wernicke-Korsakoff
Syndrome?
•
Wernicke encephalopathy is a medical
emergency.
•
IV thiamine 100 mg is the initial treatment of
choice.
•
Continue daily doses of thiamine 50 – 100 mg
IV / IM / po depending on status.
•
IV glucose can exhaust malnourished pts
supply of thiamine precipitating WernickeKorsakoff.
– Administer thiamine prior to glucose infusion.
57. Treatment of alcohol dependence?
• Naltrexone – can be initiated while the
individual is still drinking
• Disulfiram - (which by intent leads to adverse
effects when combined with alcohol intake)
should only be used by abstinent patients in
the context of treatment intended to maintain
abstinence
59. Definition-Use?
• Use — Sporadic consumption of alcohol or
drugs with no adverse consequences of that
consumption.
60. Definition- Abuse?
• Abuse — Although the frequency of
consumption of alcohol or drugs may vary,
some adverse consequences of that use are
experienced by the user.
61. Definition- Physical Dependence?
• Physical dependence — A state of adaptation
that is manifested by a drug class-specific
withdrawal syndrome that can be produced by
abrupt cessation or rapid dose reduction of a
drug, or by administration of an antagonist.
62. Definition- Psychological Dependence?
• Psychological dependence — A subjective
sense of a need for a specific psychoactive
substance, either for its positive effects or to
avoid negative effects associated with its
abstinence.
63. Definition- Addiction?
• Addiction — A primary, chronic, neurobiologic
disease, with genetic, psychosocial, and
environmental factors influencing its
development and manifestations. Addiction is
characterized by behaviors that include
impaired control over drug use, compulsive
use, continued use despite harm, and craving
64. Opioid Intoxication according to
DSM-IV?
•
DSM-IV criteria
– Recent use of an opioid
– Clinically significant maladaptive
behavioral or psychological changes (e.g.
euphoria, followed by apathy, dysphoria,
psychomotor agitation or retardation,
impaired judgment, or impaired social or
occupational functioning) that develop
during, or shortly after, opioid use.
65. Signs of Opiate Intoxication?
•
Pupillary constriction (or papillary dilation
due to anoxia from severe overdose) and
one (or more) of the following signs,
developing during, or shortly after, opioid
use
– Drowsiness or coma
– Slurred speech
– Impairment in attention and memory
66. Opiates interact with what receptors?
•
Involve opioid receptors specifically in the
CNS
– Mu
– Kappa
– Delta
71. Opiate Overdose- Management
General Support?
•
Management
– General support
• Assess and clear airway
• Support ventilation (if needed)
• Assess and support cardiovascular
system
• Give IV fluids
72. Opiate Overdose ManagementPharmacologic?
•
Management
– Pharmacologic therapy
• Naloxone (Narcan) hydrochloride and
Opioid antagonist: 0.4 to 0.8 mg IV
initially, repeat q 2 –3 mins as
necessary up to 2 mg per dose to a max
of 10 mg
73. Opiate Withdrawal Symptoms
WHEN?
• Symptoms usually begin within 12 hours of
last use, peak within 1 – 3 days and gradually
subside over a period of 5 –10 days for a
short acting opioid (i.e. heroin)
74. Opiate Tolerance?
– Tolerance
• Heroin induces tolerance quickly,
increasing the euphoric dose while
keeping the lethal dose constant
• Death occurs during intoxication and not
during withdrawal
75. Opiate Withdrawal according to
DSM-IV Criteria?
•
DSM-IV criteria
– Cessation of (or reduction in) opioid use that
has been heavy and prolonged (several weeks
or longer)
– Administration of an opioid antagonist after a
period of opioid use
76. Opiate Withdrawal Symptoms?
• Three (or more) of the
following, developing
within minutes or several
days after above criterion:
• Dysphoric mood
• Nausea or vomiting
• Muscle ache
• Lacrimation or
rhinorrhea
• Pupillary dilation,
piloerection, or
sweating
• Diarrhea
• Yawning
• Fever
• Insomnia
77. What drugs are used for opiate
withdrawal?
•
•
•
•
Methadone
Clonidine
Buprenorphine
Benzos
79. Opiate Withdrawal ManagementClonidine?
•
Clonidine
– A central acting alpha-2 agonist that diminishes
norepinephrine therefore suppressing
autonomically mediated signs and symptoms of
withdrawal
– Suppresses cardiovascular signs of withdrawal
and has some anxiolytic effect
80. Opiate Withdrawal ManagementBuprenorphine?
•
Buprenorphine
– A partial opioid agonist and potent opioid
antagonist
– Provides an effective and comfortable
withdrawal
– Binds to various opioid receptors, producing
agonist and antagonist effects
82. PHARMACOLOGY AND CELLULAR
TOXICOLOGY of Amphetamines?
• Cause release of neurotransmitters –
dopamine, serotonin, and norepinephrine and
may also inhibit their reuptake
• Stimulation of alpha and beta adrenergic
receptors is primarily responsible for the acute
effects
– Hyper-alertness, mydriasis
– HTN, diaphoresis
– Tachycardia, hyperthermia
84. Cocaine and Emergency
Visits?
– Aside from alcohol or tobacco related diseases,
cocaine is the most common single cause of
drug-related emergency department visits in the
US.
– The combined use of alcohol and cocaine is the
most frequent reason for drug-related
emergency department visits in the US and may
be the major cause of drug-related deaths
85. Physiology of Cocaine
Intoxication?
• Pharmacology / Neurobiology
– dopaminergic re-uptake inhibition
– large increases in extracellular dopamine
in the nucleus accumbens
– activates mid-brain reward pathway
associated with survival behaviors such as
feeding and sexual motivation
86. Cocaine Intoxication Signs?
•
•
•
•
•
•
•
•
euphoria
increased energy
enhanced mental acuity
increased sensory awareness (sexual, tactile,
auditory, visual)
anorexia
increased anxiety and suspiciousness
decreased need for sleep
increased self-confidence, egocentricity
87. Physical Signs of Cocaine
Intoxication?
•
physical symptoms of a generalized
sympathetic discharge
–
–
–
–
–
increased heart rate
increased blood pressure
pupillary dilation
perspiration
nausea
88. Routes of Administration of
Cocaine
• Inhalation (7 s onset, 1-5 min peak, 20 min
duration, 40-60 min half-life)
• IV (15 s onset, 3-5 min peak, 20-30 min
duration, 40-60 min half-life)
• Nasal (3 min onset, 15 min peak, 45-90 min
duration, 60-90 min half-life)
• Oral (10 min onset, 60 min peak, 60 min
duration, 60-90 min half-life)
89. Cocaine OverdoseCardio effects?
• Cardiovascular
– Hypertensive crisis
– Cardiac arrhythmias (both atrial and ventricular)
– Myocardial ischemia and infarction via aadrenergic mediated vasoconstriction
– Myocarditis
• cocaethylene
91. Cocaine OverdosePsychiatric Effects?
• Psychiatric
– acute panic
– psychosis
– Paranoia
– Agitated delirium
• also known as excited delirium (ED), is a common
presentation in patients dying of cocaine toxicity.
95. Cocaine OverdoseTreatment of CNS effects?
• CNS
–Benzodiazepines (tremors/seizures)
–Phenobarbital (status epilepticus)
–CT for all seizures (intracranial
pathology common)
96. Cocaine WithdrawalSymptoms?
•
•
Classic physical withdrawal symptoms do
not occur
Symptoms often seen after binge periods
include:
– Intense unpleasant feelings of marked anergia,
dysphoria, irritability, impulsivity and
depression - generally requiring several days of
rest and recuperation
97. Cocaine Withdrawal according
to DSM-IV?
• DSM-IV criteria
– B. Dysphoric mood and two (or more) of
the following:
•
•
•
•
•
(1) fatigue
(2) vivid, unpleasant dreams
(3) insomnia or hypersomnia
(4) increased appetite
(5) psychomotor retardation or agitation
98. Cocaine Withdrawalpsychiatric effects?
• Depression with suicidal ideation or
behavior are generally the most serious
symptoms of cocaine withdrawal
dysphoric state
• Structured setting for stabilization
100. Preparations of Cannabis?
• All parts of Cannabis sativa contain
psychoactive cannabinoids, of which 9-THC is
most abundant
• The cannabis plant is usually cut, dried,
chopped, and rolled into cigarettes (commonly
called “joints”), which are then smoked
• Plant contains more than 400 chemicals
101. Neuropharmacology of Cannabis?
• 9-THC is rapidly converted to 11-hydroxy-9THC, the metabolite that is active in the CNS
• The cannabinoid receptor is found in highest
concentrations in the basal ganglia, the
hippocampus, and the cerebellum, with lower
concentrations in the cerebral cortex
103. Cannabis Withdrawal?
• Withdrawal symptoms in human are limited to
modest increases in irritability, restlessness,
insomnia and anorexia and mild nausea; all of
these symptoms appear only when a person
abruptly stops taking high doses of cannabis
104. Routes of Administration of Cannabis?
• When cannabis is smoked, the euphoric
effects appear within minutes, peak in about
30 minutes, and last 2-4 hours.
• Can be taken orally when it is prepared in
food, such as brownies and cakes but it takes
2-3 times as much to be as potent as smoking
it
105. Physical Effects of Cannabis?
• Most common physical effects are dilation of
the conjunctival blood vessels (red eye) and
mild tachycardia
• At high does, orthostatic hypotension may
appear
• Increased appetite (“the munchies”) and dry
mouth are common effects of cannabis
intoxication
106. Adverse Effects of Cannabis Use?
• No documented case of death caused by
cannabis intoxication alone which reflects the
substance’s lack of effect on the respiratory
rate
• The most serious potential adverse effects are
those caused by inhaling the same
carcinogenic hydrocarbons present in
conventional tobacco
107. Treatment of Cannabis
Intoxication and Addiction?
• DSM-IV-TR diagnostic Criteria for Cannabis
Intoxication
– Tables 9.5-1 & 9.5-2 in Kaplan & Sadock’s
• Treatment rests on the same principles as tx of
other substances of abuse – abstinence and
support
– Education
– Possible anti-anxiety drugs
109. Anxiety Disorders Prevalence
National Comorbidity Survey (N=8,098)
Lifetime (%)
Social phobia
OCD
PTSD
Agoraphobia without PD
Panic disorder
GAD
13.3
2.5
8.0
5.3
3.5
5.1
110. Anxiety Disordershow many ppl?
• Most common psychiatric illnesses in
America
• > 23 million people affected each year
• About 1/3 of total US mental health costs
111. Anxiety Disorders
DSM Classifications- Types?
• Panic disorder (w/wo agoraphobia)
• Agoraphobia (w/o a history of panic
disorder)
• Generalized anxiety disorder (GAD)
• Obsessive-compulsive disorder (OCD)
• Social phobia
• Other specific phobia
• Post traumatic stress disorder
• Acute stress disorder
114. Panic Disorder- Epidemiology?
• Epidemiology
– 1 to 3 % of general population
– Women twice as likely to develop
– Onset is between ages 25-30
– Little differences between race in US
115. Describe Panic ATTACK?
•
• Panic Attack= a discrete
period of intense fear or
discomfort, in which four
(or more) of the following
symptoms developed
abruptly and reached
peak within 10 minutes;
generally no trigger
(although sometimes
there is)
•
•
•
•
•
•
•
•
•
•
•
•
Palpitations, pounding heart, or accelerated
heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath or
smothering
Feeling of choking
Chest pain discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded, or faint
Serialization (feelings of unreality) or
depersonalization (being detached from
oneself)
Fear of losing control or going crazy
Fear of dying
Parasthesias (numbness or tingling
sensations)
Chills or hot flushes
116. Panic Disorder- Epidemiology?
• Most frequent presentations:
– Neurological (trouble concentrating,
loss of touch with reality)…………..44%
– Cardiac………………..39%
– Gastrointestinal..……...33%
• One year prevalence of 1% - 2%
• Twice as common in women than men
• 60% - 90% comorbid depression
• Often complicated by:
– Agoraphobia (30-40%)
– Major depression (40-70%)
• Suicide risk
– Substance abuse (30-40%)
117. What is Agoraphobia?
• Intense, irrational fear of open spaces, characterized by
marked fear of being alone or of being in public places where
escape would be difficult or help might be unavailable
–
Dorland’s Illustrated Medical Dictionary 30th Edition. Saunders 2004
118. Panic Disorder- Biological Factors?
• Etiology: Biological Factors
– Major neurotransmitters involved are norepinephrine,
serotonin, and GABA
(can be excess, or more often than not, deficit)
– Imaging has found pathology in temporal lobes possibly
due cerebral vasoconstriction; over excitation and
activation of the limbic system
– Strong genetic component with panic disorder that is
associated with agoraphobia
119. Panic Disorder- Psychosocial Factors?
• Etiology: Psychosocial Factors
– CBT: Panic is a learned response from either
parental behavior or classic conditioning (fear of
internal sensations).
– Psychoanalytic: Panic attacks arise from
environmental triggers that usually have
unconscious meaning.
• Parental loss in childhood
• Adulthood loss
• Abandonment
120. Panic Disorder- Diagnosis?
• Diagnosis:
– Recurrent unexpected panic attacks
– One attack followed by 1 month of:
• Persistent concern about having additional attacks
• Worry about the implications of the attack of the
consequences (e.g., losing control, having a heart
attack, “going crazy”)
• Significant change in behavior related to attack (ex:
“I’m not going to take that job because I’d have to
travel, and I don’t want to have an attack on an
airplane…”)
121. Panic DisorderDrug Treatment?
– *SSRI’smost effective, least SE
• Citalopram (Celexa)
• Fluoxetine (Prozac)
• Paroxatine (Paxil)
• Sertraline (Zoloft)
– TCAs
• Clomipramine (Anafranil)
• Imipramine (Tofranil)
– Benzodiazepines (PRN)
• Alprazolam (Xanax)
• Clonazepam (Klonopin)
-
SNRI’s- avoid in pure panic
disorder because of the NE
effect
- Venlafaxine (Effexor XR)
Withdrawal: Stop any of
these drugs abruptly,
nausea will occur.
Especially with Paxil.
*SSRIs should be taken
with food because high
first pass metabolism.
122. Panic DisorderCBT Tx? Psychotherapy?
• Treatment: CBT
– Relaxation techniques (breathing, imagery)
– Exposure in vivo
• Treatment: Psychotherapy
– Shown not to be as effective as CBT,
Pharmacotherapy, or combination of both
123. Social PhobiaWhat is it?
• Persons with social phobias (also called social
anxiety disorder) have excessive fears of
humiliation or embarrassment in various
social settings (speaking in public).
124. Social Phobia- Epidemiology?
• Epidemiology:
– Phobias are most common mental disorder in US
with 8-13% affected at some point in life
– Women more than men
– Peak onset in teen years, but range is 5-35 years
– Comorbidity very high (panic disorder, avoidant
personality disorder, substance abuse)
125. Social Phobia- Biological Factors?
• Etiology: Biological Factors
– Those with performance phobias release more
norepinephrine (increased sensitivity). Beta
adrenergic receptor antagonist.
– Possible increased NE or increased sensitivity to
NE.
– Social phobia due to decreased dopaminergic
reuptake site density.
– First degree relatives of individuals with social
phobias are 3 times more likely to have social
phobia.
126. Social Phobia- Psychosocial
Factors?
• Etiology: Psychosocial Factors
– Classic conditioning in childhood (Pavlovian).
– Early environmental stressors (humiliation and criticism
from siblings/parents, parental conflicts, separation from
parents)
– Shame and embarrassment are principle affect states
127. Social PhobiaCBT Tx?
• Treatment: CBT
– Commitment to treatment
– Clearly identified problems
– Available alternative ways to cope with
feelings/fears
128. Social Phobia- Psychotherapy Tx?
• Treatment: Psychotherapy
– Some recognition that source of phobia happened
in early development, but improvement of
condition best if coupled with CBT.
129. Social PhobiaPharm Therapy?
• Treatment: Pharmacotherapy
– Social Phobias (performance situations):
• Beta adrenergic receptor antagonist (propranolol)
– Social Phobias:
• SSRI’s (considered first line)
• Benzodiazepines (only as additive, only over
symptoms, not underlying neurotransmitter
imbalances)
• MAOI’s (phenelzine)
• Beta Blocker (propanolol) for test anxiety
130. Obsessive-Compulsive
Disorder- Epidemiology?
• Epidemiology
– Recently thought to be 2.5% within the general
population
– Age of onset is 15-35
– Males and females have equal occurrences
overall, but women onset usually older, while
males more commonly present in adolescence
– Complete resolution of symptoms is rare
131. Obsessive-Compulsive DisorderBiological Factors?
• Etiology: Biological Factors
– Believed to be a strong correlation with dysregulation of
serotonergic system. (SSRI’s)
– Unlike other disorders of anxiety, OCD is associated with
corticostriatal pathways (frontal lobes and basal ganglia) more
than with the amygdala.
– Strong genetic component – 35% of OCD first-degree relatives
also are affected with the disorder
– Some correlation between Tourette’s disorder, motor tics, and
OCD.
132. Obsessive-Compulsive DisorderPsychosocial Factors?
• Etiology: Psychosocial Factors
– Marked by extreme emotional ambivalence triggered
by strong feelings of both love and hate toward an
object, especially in children. This leads to emotional
paralysis in the face of choices.
– Increased incidence with stressful situations
(pregnancy, childbirth, or prenatal care of children).
133. Obsessive-Compulsive Disorder- Pharm
Tx?
• Treatment: Pharmacological
– SSRI’s (if warranted)
• Fluoxetine (Prozac)
• Fluvoxamine (Luvox)- not used often
anymore, risk of serotonin syndrome
• Paroxetine (Paxil)
• Sertraline (Zoloft)
134. Obsessive-Compulsive Disorder- CBT
therapy?
• Treatment: CBT
– Exposure of patient to feared object or obsession
and prevented from doing anxiety-reducing rituals
– Estimates of up to 90% effectiveness in reducing
the symptoms of disorder
136. Posttraumatic Stress Disorder- At
what point are symptoms
diagnostic of acute stress
disorder?
• Situation where symptoms last less than 1
month after traumatic event is termed
“acute stress disorder”.
137. Combat Honeymoon Phase?
• Combat Honeymoon Phase: coupe weeks
home with no symptoms, symptoms begin
later
138. Posttraumatic Stress DisorderEpidemiology?
• Epidemiology
– Prevalence of PTSD is 8-9% in general population
(increasing).
– Women twice as likely to have PTSD than men.
– Directly linked to the epidemiology trauma: 25-30% of
victims of trauma go on to develop PTSD
– Men; military combat or witnessing injury/death –
Women; rape, sexual molestation, and assault.
– Some studies have shown PTSD in persons post-MI or after
high risk surgeries (this is especially common in children).
139. Posttraumatic Stress DisorderBiological Factors?
– Noradrenergic systems, endogenous opiate systems,
and HPA axis are hyperactivity.
– Higher urine epinephrine concentrations in soldiers
and abused female children with PTSD.
– Soldiers demonstrate narcan-reversable analgesic
response to combat stimuli suggesting hyperregulation of opioid system.
– Lower serum cortisol and urinary free cortisol
concentrations in patients with PTSD suggests
hyper-regulation of cortisol.
140. Posttraumatic Stress DisorderPsychosocial Risk Factors?
– Risk Factors:
• Childhood trauma or abuse
• Borderline, paranoid, dependent, or antisocial
personality disorder traits
• Inadequate support system
• Female gender
• Family history of psychiatric illness
• Recent stressful life changes
• External locus of control
• Substance abuse
• Some studies show genetic linkage increasing risk
• Some small studies of combat vets show certain racial
groups are more likely than others.
142. Posttraumatic Stress DisorderPsychotherapy?
– Combination of CBT, psychotherapy, and hypnosis
– Group Therapy
– No time limit in the beginning
– Individualized as re-experiencing trauma may present
different therapeutic needs
– All patients tend to improve with time regardless of
severity or treatment (5-10 years); small percentage
may still have symptoms 25-30 years post event.
143. Generalized Anxiety DisorderBiological Factors?
• Etiology: Biological Factors
– Likely to occur with other medical and/or
psychiatric conditions
– Occipital Lobes (most benzodiazepine
receptors, altered activity)
– Limbic system
144. Generalized Anxiety Disorder- CBT?
• Etiology: Psychosocial Factors
– CBT:
• Patients respond to inaccurately and incorrectly
perceived dangers
• Selective attention to negative details
• Distortions in information processing
• Negative view of individual’s ability to cope
145. Generalized Anxiety DisorderPsychoanalytic Theory?
• Etiology: Psychosocial Factors
– Psychoanalytic
• Generalized anxiety is symptom of
unresolved unconscious conflicts (but this
is not always the case)
• Hierarchy of anxieties related to various
developmental levels
146. Generalized Anxiety DisorderClinical Presentation?
– Distorted cognitive processing
• Poor concentration, unrealistic assessment of
problems, worries
• Difficulty in moving short term memories into long
term memory
– Poor coping strategies
• Avoidance, procrastination, poor problem-solving skills
– Excessive physiologic arousal
• Muscle tension, irritability, fatigue, restlessness,
insomnia
147. Generalized Anxiety Disorder- What
are the anxiety symptoms?
• Anxiety symptoms
– 3 or more of the following:
• Restlessness or feeling keyed-up or on edge
• Fatigability
• Trouble concentrating
• Irritability
• Muscle tension
• Sleep disturbance
148. Generalized Anxiety Disorder- Pharm
tx?
– SSRIs, SNRIs
• SSRI burnout after 5 years,
• SSRIs can cause increased prolactin levels, increased
dopaminergic effects of brain and nullifies effects of serotonin;
poss. switch to diff SSRI or an SNRI
– Benzodiazepines
• Alprazolam (Xanax)
• Chlordiazepoxide (Librium)- more for EtOH withdrawal
• Diazepam (Valium)
• Lorazepam (Ativan)- Status Epilepticus*
149. Generalized Anxiety Disorder- CBT?
– Cognitive therapy helps patients to limit cognitive
distortions by viewing concerns more realistically.
– Learn effective ways to solve their problems
– Relaxation techniques decrease physiologic symptoms
– Has not been shown to be truly effective as
monotherapy; possibly in combination with SSRI
151. What leads to the Development of
Personality Disorders?
• Personality
– Pattern of defenses against internal drives and external
environment
– Personality vs. ego
• Thinking and feeling
• Exaggerated development of defenses at the expense of
others at a given developmental stage
– Mastery/repression of anxiety, anger, shame, guilt
• Internal Object Relations
– Failure to meet needs arrests development and how an
individual relates to internalized objects
– Continues patterns of relating to internal objects into
adulthood
152. Personality DisordersDSM-IV definition?
• DSM-IV Definition
– Axis II disorder
• Commonly have Axis I disorder as well
– Enduring subjective experiences and behavior that
deviate from cultural norms
– Rigidly pervasive
– Onset in adolescence or early adulthood
– Stable through time
– Lead to unhappiness or impairment in social,
occupational and relational settings
153. What are the personality disorder
CLUSTERS?
• CLUSTER A= odd and eccentric
• CLUSTER B= dramatic and emotional
• CLUSTER C= anxious or fearful
157. Hallmark of Paranoid Personality
Disorder?
• Pervasive distrust and suspiciousness
of others.
158. Paranoid Personality Disorder
Diagnostic Criteria?
• Diagnostic Criteria (4 or more)
– Suspects exploitation or deception from others without
sufficient basis
– Preoccupied with unjustified doubts regarding loyalty of
others
– Will not confide in other for unwarranted fear information
will be used against them maliciously
– Will assign demeaning or threatening meaning to benign
remarks
– Persistently bears grudges, unforgiving for slights or
insults
– Perceives attacks on character (not apparent to others)
and is quick to retaliate
– Consistently questions, without justification, the fidelity of
spouse or sexual partner
159. Paranoid Personality DisorderEpidemiology?
– 0.5-2.5% of general population; ~20% of
inpatient psychiatric settings
– Higher incidence with relatives diagnosed
with schizophrenia
– More common in men
– Believed to be more common in minority or
immigrant groups
160. Paranoid Personality DisorderTreatment?
– Psychotherapy
– Pointers:
• Should not be overly warm
• Should be consistent (and apologize when
not) and honest
• Do not offer to ‘take control’ if not willing to do
so
• Expect: belittling comments, accusations and
litigious threats
161. Hallmark of Schizoid Personality
Disorder?
• Detachment from social relationships
162. Schizoid Personality Disorder
Diagnostic Criteria?
• Diagnostic Criteria (4 or more)
– No desire for or enjoyment of close
relationships
– Always chooses solitary activities
– Little or no interest in sexual relationship
– No pleasure in activities
– Lacks close friends or confidants other than
family
– Indifferent to praise or criticism
165. Schizoid Personality Disorder
Treatment?
– Psychotherapy
– Pointers:
• Should avoid aggression (group therapy)
• Consistency and patience; tolerate odd
beliefs
• Avoid over involvement in personal or
social issues
• Generally will become involved with
therapy and reveal fantasy
166. What is hallmark of
Schizotypal?
• Discomfort with relationships,
cognitive and perceptual eccentricities
167. Schizotypal Personality Disorder
Diagnostic Criteria?
Diagnostic Criteria (5 or more)
Magical thinking that influences behavior
Unusual perceptual experiences
Odd thinking or speech (vague, overelaborate)
Paranoid ideation
Inappropriate/constricted affect
Eccentric appearance or behavior
Lack of close friends
Social anxiety that does not diminish with
familiarity and tend to be paranoid
170. Schizotypal Personality Disorder
Treatment?
– Psychotherapy
– Antipsychotics or mood stabilizers?
– Pointers:
• Patience and consistency
• Do not show judgment with odd interests
or behavior
• Will be sensitive to anger/aggression
172. Antisocial Personality Disorder
Diagnosis?
• Diagnostic Criteria (3 or more)
– Failure to conform to social norms as evidenced by
arrests
– Lying or conning others for personal gain
– Impulsiveness
– Aggressiveness as evidenced by frequent physical
fights
– Reckless disregard for self or others
– Irresponsibility as evidenced by inability to keep
job/pay bills
– Lack of remorse: rationalization for actions against
others
173. Other requirements for
antisocial diagnosis?
• Must be 18 years old
• Evidence of conduct disorder before 15
years of age
• Antisocial behavior not occurring in
psychotic episode
174. Antisocial Personality Disorder
Epidemiology?
– 3% in men, 1% in women
– Boys from larger families in poor urban areas
– 75% of prison populations
– Higher incidence with positive family history
175. Antisocial Personality Disorder
Treatment?
– Inpatient settings more effective
– Group therapy can be effective
– Antidepressants and atypical antipsychotics
may be helpful
– Limits will be essential
– Aware of patient’s fear of intimacy and selfdestructive behavior
177. Borderline Personality Disorder
Diagnosis?
• Diagnostic Criteria (5 or more)
– Frantic efforts to avoid abandonment
– Unstable relationships with idealization/devaluation
pattern
– Unstable self image
– Impulsivity (gambling, sex, substance abuse)
– Recurrent suicidal threats or self-mutilation
– Affect instability – extreme mood swings
– Chronic feelings of emptiness
– Inappropriate intense anger (tantrums, fights)
– Stress related paranoid ideation and dissociative
symptoms
178. Borderline Personality Disorder
Clinical Presentation?
Always in a state of crisis
Feelings of hostility and dependency
Numerous troubled interpersonal relationships
Erratic mood swings
Self destructive acts (cutting, attempted suicide)
Substance abuse, sexual promiscuity
Complaints of feeling empty
179. Borderline Personality Disorder
Epidemiology?
– 1-2% of general population
– 2 to 1 female to male
– Increased incidence in families with major
depressive disorder and alcohol use
disorders
180. Borderline Personality Disorder
Treatment?
– Pharmacotherapy
• Second gen. antipsychotics,
antidepressants and omega3 fatty acids
– Psychotherapy
• One of the most difficult to treat – because
of projective identification and
countertransference
• In-patient therapy (up to a year)
• Combination group therapy
182. Histrionic Personality Disorder
Diagnosis?
• Diagnostic Criteria (5 or more)
• Uncomfortable if not the center of attention
• Interactions marked with inappropriate sexual
seduction/provocative behavior
• Rapid shifting, shallow emotions
• Physical appearance used to draw attention
• Speech impressionistic and lacks detail
• Self dramatization, exaggerated emotion
• Easily influenced
• Considers relationships more intimate than they
are
183. Histrionic Personality Disorder
Epidemiology?
– 2-3% of general population
– More women than men
– 10-15% in-patient Psychiatric population
– Higher incidence in somatization disorder and
alcohol use disorders
184. Histrionic Personality Disorder
Treatment?
– Psychotherapy
– Pointers:
• Clarification of patient’s feelings important
• Group or individual therapy show equal
effectiveness
• Boundaries/limits important!!
186. Narcissistic Personality Disorder
Diagnosis?
• Diagnostic Criteria (5 or more)
– Exaggerated sense of self-importance without commensurate
accomplishments
– Fantasies of unlimited success, beauty, love
– Believes they are special and can only be understood by special
people
– Excessive need for admiration
– Sense of entitlement
– Interpersonally exploitative
– Lacks empathy
– Envious of others while believing others are envious of them
– Demonstrates arrogant behavior/attitude
187. Narcissistic Personality Disorder
Epidemiology?
– <1% of general population
– 16% of clinical population
– Number of cases increasing
– Higher incidence with children of parents with
narcissistic personality disorder
188. Narcissistic Personality Disorder
Treatment?
– Psychotherapy
• Difficult, as therapy often involves perceived
criticism
• Group therapy may help develop empathetic
response
• ‘Narcissistic Wound’
189. What is Hallmark for Avoidant?
• Feelings of inadequacy, hypersensitive
to negative evaluations
190. Avoidant Personality Disorder
Diagnosis?
• Diagnostic Criteria (4 or more)
– Avoids occupational activities for fear of criticism or
rejection
– Won’t get involved with people unless certain of being
liked
– Restraint in interpersonal relationships for fear of
rejection
– Preoccupation with rejection in social situations
– Inhibited in new relationships because of feelings of
inadequacy
– Views self as inept, socially unappealing, and inferior
– Reluctant to take personal risks for fear being
embarrassed
192. Avoidant Personality Disorder
Treatment?
– Psychotherapy
– Pointers:
• Establish trust and safety
• Caution with exposures that may be
humiliating
• Assertiveness training will help with
expression of needs
194. Dependent Personality Disorder
Diagnosis?
• Diagnostic Criteria (5 or more)
– Cannot make decisions without excessive advice and
reassurance from others
– Desires others take responsibility for major areas of
their life
– Will not disagree for fear of loss of approval/support
– Will not take initiative
– May volunteer for unpleasant tasks to secure/solicit the
support of others
– Uncomfortable with being alone for fear of not being
able to take care of themselves
– Will seek another relationship soon after another ends
– Preoccupied with unrealistic fears of being left to take
care of themselves
195. Dependent Personality Disorder
Clinical Presentation?
• Clinical Presentation
– Patterns of submissive behavior
– Cannot complete tasks unless accompanied
by another
– May have history of tolerating abusive
situations
– Pessimistic affect
– Prolongation of illness and other behaviors to
continue to obtain attention
197. Dependent Personality Disorder
Treatment?
– Psychotherapy
• Successful if insight-oriented
• Group therapy also successful
• Must be tolerant of patient’s need for
relationship security even if abusive
198. What is hallmark for obsessive
compulsive personality disorder?
• Preoccupation with
control/orderliness/perfection
199. Obsessive-Compulsive Personality
Disorder
Diagnosis?
• Diagnostic Criteria (4 or more)
– Preoccupation with rules, lists, details till the purpose
of activity is lost
– Perfectionism that interferes with task completion
– Obsession with work tasks to the exclusion of friends
and leisure
– Rigid and inflexible about matters of ethics and
morals
– Unable to discard worn-out objects regardless of
sentimental value
– Will not delegate unless sure tasks will be performed
their way
– Miserly spending style – saves for catastrophes
– Stubbornness
200. Obsessive-Compulsive Personality Disorder
Clinical Presentation?
– No sense of humor
– Jobs generally routine without change
– Limited interpersonal relationships as
unwilling to compromise
– If having any major life changes, may
experience anxiety
204. Hypomania vs. Mania
• We could then further describe this person as
having Hypomania where they feel great but
exist in a state of excitedness above “Normal”
yet are functional or unbelievably excited
where it’s hard to be in their presence and
they are experiencing a state of Mania where
they are not functional
205. Dysthymia, Adjustment Disorder,
Euthymia?
• A third person might seem “bummed out” or
very irritable and we might say that they were
suffering from Dysthmia
• A 4th person might have had a breakup or lost
a job and be sad as they adjust to the loss for
a time and has an Adjustment Disorder
• Lastly a 5th person seems to have a “normal”
mood and we would refer to them as being in
a state of Euthymia or being Euthymic
206. What is Affect?
• Affect is our perception of how a person feels
• Affect is based upon our observations of a
person’s posture, gait, dress, appearance, eye
contact and speech
• A flat affect could be our description of a
person with little to no facial expression, poor
conversation, disinterest or a distant gaze
207. What is Delusional?
• A person who is convinced that pigs can fly
and nothing you can say will change their
mind is Delusional
209. Mental Status Exam Components
(1 of 1)?
• Orientation
Can you tell me your name? Person
Can you tell me where we are? Place
Can you tell me the month,year or day? Time
• Recent Memory
Can you tell me who is the president now?
• Intermediate Memory
Can you tell me the president before him?
• Longer Term Memory
Can you tell me the president before that one?
210. Mental Status Exam- Components
(2 of 2)?
• Cognitive Function
Can you spell the word World?
• Testing Concentration
Can you spell the word World backward?
Can you count backward from 100 by 7? Stop at 65
• Testing Abstract Thinking
How are an apple and orange are alike?
How are are a dog and a cat alike?
How are a knife and fork alike?
How are a fly and a tree alike?
211. SAMCELS?
• The Big 6 plus 1 SAMCEL(S) Plus ID
1. Sleep
How are you sleeping?
2. Appetite
How are eating?
3. Memory
Any trouble remembering?
4. Concentration Any trouble staying on track?
5. Energy
How is your get up and go?
6. Libido
How is your interest in sex?
7. Suicide
Any thoughts of hurting anyone?
212. PLUS ID?
• Plus ID
1. Loss of interest in life activities;loss of joy or
pleasure (anhedonia)
2. Depressed mood
213. The Big 3?
• The Big 3- If yes to any,
find out when or plan!!
1. Are you having any hallucinations?
2. Have you thought about hurting or killing
someone?
3. Have you thought about hurting or killing
yourself?
214. Verbigeraton? Word Salad?
Verbigeration
• Stereotyped and
meaning- less repetition
of words and phrases
;seen in some cases of
schizophrenia
Word Salad
• A meaningless mix of
words and phrases
characteristic of
advanced schizophrenia
216. New Terms
Aphasia
A group of speech disorders
involving a defect or loss of the
power of expression by speech
or writing or of comprehending spoken or written language
Alexia
The loss of the ability to
understand written language
217. New Terms
Agraphia
Impairment or loss of the
ability to write
Neologisms
New words whose meaning
are known only to the person
using them
218. New Terms
Echolalia
Repetition of another person’s
words or phrases
Coprolalia
Compulsive,stereotyped use of
obscene,filthy language
219. New Terms
Clanging
A pattern of speech in which
sound rather than sense
governs word choice
Flight of ideas
A nearly continuous flow of
rapid speech that jumps from
topic to topic; often heard in
manic episodes
220. New Terms
Circumstantiality
A disturbed pattern of speech
or writing characterized by a
delay in getting to the point
Tangentiality
A pattern of speech characterized by oblique,irrelevant or
digressive replies to questions
without ever getting to the
point
221. What is Adjustment Disorder?
• Failing an exam, losing a job, experiencing a
divorce or losing a loved one can disrupt your
outlook on life
• A stressor like one of the above is readily
identified as occurring within 3 months of the
decline in mood but the person remains
functional
• Without a chronic stressor, the person returns
to their normal within 6 months
222. What is Dysthymia?
What is required for diagnosis?
• A long term mild to moderate decline in mood lasting
for most of the day,every day,for two years or more
• In children or adolescents should suspect if one year of
decreased mood or irritabilty
• Diagnosis requires decreased mood plus 2of the these:
1. Change in appetite
2. Change in sleep pattern
3. Decrease in concentration or memory
4. Decrease in energy
5. Decrease in self esteem
6. Feelings of hopelessness
223. Major Depressive EpisodeDiagnosis Requirements?
• To have this diagnosis, a person must have 5 of 9 of the
symptoms below for most of the day,every day for 2 weeks
1. Agitation or retardation in motor functioning
2. Changes in sleep pattern(more or less)
3. Change in weight(loss or gain)
4. Depressed mood*
5. Disturbance in concentration or memory
6. Feelings of worthlessness,guilt or shame
7. Loss of energy
8. Loss of interest in life’s activities*
9. Thoughts of dying including suicidal thoughts
* These 2 must be present
224. Typical vs. Atypical Depression?
• Typical
1. Person sleeps less or doesn’t sleep
2. Person doesn’t eat or eats much less
• Atypical
1. Person sleeps much more
2. Person eats all the time
225. Hypomania and ManiaWhat is it? Diagnosis?
• Involves an elevation in mood or irritability for 4 days
for hypomania or more for mania with at least 3 of the
behaviors below:
1. Subjective feelings of racing thoughts
2. Disturbance in concentration or focus
3. Inappropriately elevated self esteem
4. Uncharacteristic risk taking behavior
5. Increased motor activity
6. Increase in pursuing goals and tasks
7. Increase in talkativeness
8. Less need for sleep
226. What are the Types of
Bipolar Disorder?
• Three types :
• Type I. Mania with or without a major
depressive episode
• Type II. At least one major depressive episode
with at least one episode of hypomania
• Mixed. Symptoms of depressed mood and
agitation/mania simultaneously
227. Cyclothymic Disorder- what is it?
Diagnosis?
• Persons with this experience at least 2 years of
numerous episodes of hypomanic symptoms
and numerous episodes of depressive
symptoms that do not meet the criteria for
mania or major depressive disorder
228. Schizoaffective Disorder- What is it?
• This is a combination of thought disturbance
and mood disorder with an acceptance that it
is a comorbidity of bipolar disorder or major
depressive disorder and schizophrenia
229. Delusional Disorder- what are some
false beliefs?
• The person believes falsely
1. They are being deceived by a spouse
2. They are being followed or stalked
3. They are infected by a disease
4. They are loved by someone distant
5. They have been poisoned
230. Schizophrenia- Diagnosis?
• The person must experience 1 of these:
1. Suffer from bizarre delusions
2. Hear voices that either maintain a running commentary of
the person’s thoughts or have 2 or more voices talking
with each other
• If neither of those are present,they must have
• At least 2 of these:
1. Delusions
2. Disorganized behavior or catatonia
3. Disorganized speech
4. Hallucinations
5. Flat affect;less speech;withdrawal;less motivation
231. Substance Abuse- diagnosis
requirements?
• A person must have 1 of the following:
1. Use impairs ability to perform important
daily activities at work,school or home
2. Use occurs in places and situations that are
risky to their and other’s safety (driving)
3. Use results in legal consequences
4. Use persists despite the problems caused at
work,school or home
232. What is the most commonly used
objective personality test?
• Minnesota Multiphasic Personality Inventory 2
233. What is the other personality test?
• Personality Assessment Inventory (PAI)
234. Beck Depression Inventory
• A behavior rating scale
• Aids in diagnosing depression
• Measures the severity of self-reported
depressive symptoms, and describes the
particular manifestation of depression in a
given patient (are symptoms more
physiological, cognitive or mood-oriented in
nature?)
235. What are Actuarial Assessment
Techniques?
• Assessment methods based purely on given
patient characteristics, demographic
information, and historical data that are
combined to make probabilistic classifications
of patients
• Such as risk of violence or likelihood of
responding favorably to a given treatment, or
suicide risk
238. What are the most widely used
intellectual tests?
• The Wechsler tests
– Preschool
– Childhood
– Adulthood
239. Academic Skills Disorders
• Academic skills disorders are defined by DSM
as a learning impairment that is associated
with significantly worse performance on an
academic skill than would be expected based
on the patient’s intelligence
240. What is neuropsychological
assessment?
• Neuropsychological assessment refers to the
application of standardized measurement
techniques to determine the relationship
between brain impairment and its cognitive
and behavioral concomitants
241. Why can neuropsychological assessment be
more useful than MRI? Give example.
• MRI techniques detect gross structural
damage but not changes at the molecular or
cellular level- in these circumstances,
neuropsychological testing may provide a
more sensitive measurement of brain function
• (EX): neuropsychological assessment is useful
in distinguishing between early dementia and
those symptoms of depression that mimic
cognitive impairment
242. What can be used to assess premorbid function?
• Reading ability- reading ability is highly
resistant to most acquired cognitive disorders,
with the exception of alexia
• Reading is thus a good measure of prior
function
243. What is the backbone of many
neuropsychological evaluations?
• A comprehensive intelligence test- ex the
Wechsler test
244. When might intelligence tests not be
indicative of actual patient function?
• Early to mid stage alzheimers- intelligence
tests don’t take into account memory and
executive function very well, and these
patients are usually debilitated because of
difficulty with executive function and memory
245. Halsted-Reitan Neuropsychological
Test Battery
• Very good at distinguishing patients with
confirmed brain lesions from control subjects
– Ex: stroke, frontal lobe damage, etc.
• Most widely accepted global measure of brain
dysfunction in neuropsychology
246. What is the most widely used global
memory test?
• Wechsler memory scale
247. What is the most powerful tool for the
clinician in identifying malingered
disorders?
• Thorough knowledge and experience with the
disorder in question
• REFERRAL to a specialist with knowledge of
the disorder in question is important
248. Tests to look for Malingering
• MMPI-2 and PAI- (personality tests) contain scales to
detect malingering
• Structured Interview of Reported Symptoms (SIRS)
• Floor Effects tests- tests that appear to be difficult but in
fact are nearly always successfully performed even by
individuals with moderate cognitive impairment
• Forced Choice Tests- 2 choices; if patient wrong more than
50% of the time, this is not likely to be chance- patient
probably malingering
– Test of Memory Malingering (TOMM) utilizes this concept
249. Inception
• Interviewer tells the patient what he or she
already knows
– (ex): “I know your family found your suicide note”
250. Reconnaissance
• Have the patient tell his or her story as
spontaneously as possible, with little
interruptions
• Ask open-ended questions rather than direct
yes or no questions
• Use the same method when obtaining the
detailed inquiry
251. Transitions
• Interviewer should not move abruptly from
one topic to another
• Change should be signaled- “Okay id like to go
on from there to something else”
252. Standard vs. Discretionary Inquiry
• Standard Inquiry- obligatory questions for a
patients age, in a specific clinical situation, or
as part of minimum database
• Rest of interview is discretionary
253. What supports causation?
• Causation is supported if the patient
previously had a breakdown when exposed to
a similar stress or if the patient’s account of
the stress indicates its personal significance
254. Types of Reliability
• Test-Retest Reliability= similar results are
obtained on retesting
• Interrater Reliability= similar results will be
obtained by different observers
255. What are the sections of the
Mental Status Exam?
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•
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•
•
•
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Appearance and Behavior
Relationship to the Interviewer
Affect and Mood
Cognition and Memory
Language
Disorders of Thought
Physiological Function
Insight and Judgment
256. What is very important to note in the
relationship to the interviewer?
• Quality of patient’s eye contact
257. What is affect?
• Affect refers to a feeling or emotion,
experienced typically in response to an
external event or thought
• Affect can be MOMENTARY
• Patient’s relationship to the interviewer is a
particular manifestation of affect
258. What is Mood? Example?
• Mood refers to an inner state that persists for
some time, with a disposition to exhibit a
particular emotion or affect
• Example- a mood of depression may not
prevent an individual from deriving
momentary diversion from a joke; however,
the expression of gloom, sadness, or
desolation returns and prevails
261. Morbid Anger?
• Defined by its pervasiveness, frequency,
disproportionate quality, impulsiveness, and
uncontrollability
• Assoc with organic brain disorder
262. Fear vs. Anxiety
• Fear has an object= the need to defend
oneself against uncertain odds (ex= car
accident)
• Anxiety is associated with threat to an
essential value (ex= losing someone you love,
being successful, etc)
265. Dissociative Fugue State
• Delirious patients may wander off in a daze,
showing up in an emergency room unaware
of his or her name or address
266. Attention vs. Concentration
• Attention is involved when a patient is alerted
by a significant stimulus (ex- someone talking
to them) and maintains interest in it
• Concentration refers to the capacity to
maintain mental effort despite distraction (exnoises)
268. How do we test comprehension?
• No tests- evaluated as interview proceeds
• (ex): does the patient know why he or she is
where they are?
269. How do we test conceptualization?
• Simple levels of conceptualization are
assessed by testing the patient’s capacity to
discern the similarities and differences
between sets of individual words
270. How do we test abstraction?
• Discern the meaning of well known metaphors
• (ex): people in glass houses should not throw
stones
271. Flight of Ideas
• Thinking is accelerated in flight of ideas, which
may reach such a pitch that goal direction is
lost and the connection between ideas is
governed not by sense but by sound or
idiosyncratic verbal or conceptual associations
272. Insight
• Does the patient recognize he or she has a
problem?
• Does the person identify the problem as
personal and psychological in nature?
• Does he or she understand the nature and the
cause of the illness?
• Does he or she want help? And what kind of
help?
273. How do we assess judgment?
• Can ask one of the following questions– What would you do if you found a stamped,
addressed envelope in the street?
– Why are there laws?
– Why should promises be kept?
274. Empathy vs. Sympathy
• The deepest affective understanding is
empathy, that is, feeling with, or sharing the
feelings of the patient
• Different from sympathy, which is feeling for
the patient
275. What is transference? Example?
• Transference refers to the unreasonable
displacement of attitudes and feelings that
originated in childhood to the people in the here
and now
• Example- patient angered because interviewer
has a mustache or wears pearls- something is
being added to an objectively neutral situation
• Example- patient may unconsciously regard the
physician as a parent or a sibling, casting hum or
her in a caring or antagonistic role
276. What is countertransference?
• When a physician irrationally transfers to a
patient his or her attitudes and feelings
derived from childhood experiences
279. Poverty of speech
• General lack of additional, unprompted
content seen in normal speech.
• As a symptom, it is commonly seen in patients
suffering from schizophrenia, and is
considered as a negative symptom
280. Thought Insertion
• Abnormal thinking can be experienced by the
thinker as invasive, inserted, or controlled by
alien forces
282. Thought Broadcasting
• Abnormal thinking can be experienced by the
thinker as broadcast from the mind into the
outside world
283. Alexia
• Neurologic disorder marked by loss of the
ability to understand written or printed
language, usually resulting from a brain lesion
or a congenital defect.
284. Agraphia
• An acquired form of aphasia, which is
characterized by the loss of a previously
possessed ability to write
Editor's Notes
- Later childhood- Peer RelationsSchool HistoryCognitive and Motor DevelopmentEmotional/Physical ProblemsPsychosexual History – them or their friends sexual activity, common at younger and younger ages. The younger they are has been shown to commonly cause depressionReligious Background – strong, pressures, none- Adulthood - Occupational HistorySocial Activity – too little, too much – pressure to do too muchAdult Sexuality – in a relationship, previous relationships, healthy? Children?Military History – big insite into psych disorders, discharged honorably?Value system – what do they hold as important? Power, money, family, stability – will give you a huge insight into the person.
Addiction is an equal-opportunity afflictionMarked findings of this report are (a) a 94 percent increase in the number of drug-related ED visits overall between 2004 and 2010, and (b) large increases in the involvement of a wide range of pharmaceuticals (e.g., prescription drugs, over-the-counter medications, supplements) over that period. It is likely that there are multiple causes contributing to these increases. Some portion of these increases may be associated with the greater number of prescriptions being written and with more people taking multiple prescription drugs, often in combination with over-the-counter preparations, as part of their long-term medical care
