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B & B Exam 4, Part 1

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eem8u's version from 2016-10-22 19:13

Introduction to Psychiatry / Mood disorders

Question Answer
how are psychiatric disorders are classified in the DSM-5descriptive/symptom-based, rather than an etiologically based system
one of these two symptoms is required to make MDD over HOW MANYY weekssad mood /anhedonia (one of these is present among at least 5 of a laundry list)
mood vs affect in MMSEmood (stated) vs affect (observed expression of emotions, range, appropriateness, intensity)
time frame for diagnosis of depression vs mania2-week diagnostic period vs 1-week
SIG E CAPS for MDD(Depressed mood) Sleep disturbance ƒ/ Loss of Interest (anhedonia) ƒ/ Guilt or feelings of worthlessness /ƒ Energy loss and fatigue /ƒ Concentration problems /ƒ Appetite/weight changes ƒ Psychomotor retardation or agitation /ƒ Suicidal ideations
DIG FAST for Manic episodesDistractibility ƒ/ Irresponsibility—seeks pleasure without regard to consequences (heavy spending) / ƒ ƒ Grandiosity—inflated self-esteem / Flight of ideas—racing thoughts ƒ / INCREASE in goal-directed Activity+psychomotor (hedonistic) Agitationƒ  / decreased need for Sleep ƒ /Talkativeness or pressured speech
review role of mental status exambserving and describing a patient's current state of mind, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight and judgment.
** Diagnostic Criteria for bipolar 1≥1 wk of elevated, expansive, or irritable mood and ≥ 3 of the following sx (DIG FAST): Distractability , Impulsivity, Grandiosity, Flight of ideas, Activity (goal-directed), Sleep (decreased need), Talkative (more)
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Major epidemiological differences between MDD vs Bipolar I Disorder
Question Answer
lifetime prevalence15% vs 1%
gender1/4 women (1/8 men) vs EQUAL gender risk
mean age of onsetlate 20s-peak in 3rd/7th decade vs mean 21 (range 18-44, younger!) OR AFTER PREGANCY
geneticsBPD has much stronger genetic link (65% v 37% heritability)
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Theories of MDD
Question Answer
Psychodynamicdisturbance in infant/mother reln > damaged self esteem > inward anger > tx = symptom relief
cognitivecognitive distortion / “cognitive triad” of negative views (“mind of mood” theory”
monamine deficiency(based on success of NE/5HT reuptake inhibitor drugs) relative deficiency of 5ht/ne/da and secondary neuroplastic changes
neuroendocrine dysregulation HPA axis changes - lack of normal CORTISOL SUPPRESSION > chronic stress > hippocampal damage
immune dysfunction/inflammationelevated pro-inflammatorycytokines (Il-6, TNFa, CRP) due to chronic stress, coinciding with increased risk of inflammatory illnesses > damage neuronal plasticity and neurogenesis (KETAMINE TX) theory of MDD
neuropath changes1 = reduction in glial cell density > glutamate toxicity, 2 = reduction in volume and fx of LIMBIC SYSTEM (esp DL prefrontal cortex and hippocampus)
impairments in neuroplasticitydue to decrease in neurotrophic factors (esp hippocampus)
Genetic vulnerability of MDD50% concordance amongst MZ twins
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Schizophrenia

Question Answer
environmental risk factorsPrenatal viral infection (rubella, influenza), Obstetrical complications (Rh incompatibility, hypoxia), Maternal/nutritional deficiency during pregnancy (famine), Season of birth (winter), Place of birth (urban), Head Injury, Drug use (cannabis, LSD, amphetamine), Non-inherited genetic: paternal age
diagnostic criteria-time frame1-MONTH period of at least 2 of the listed criteria / disturbance for at least 6 months!
diagnosis, criteria A symptomsat least 2 of the following - “present for significant portion of at least 1 month” - delusion / hallucination / disorganized speech / catatonic behavior / negative sx
3 positive sxhallucinations, delusions, formal thought disorder
4 negative sxavolition, anhedonia, alogia, blunted affect
4 cognitive symptomsimpaired attention, encoding, working memory and verbal fluency
epidemiology-Social determinantsHIGHER prevalence in lower SES less likely to be employed/married, more likely to be homeless, increased suicide/increased rate of substance use
typical age of onset18-25 (younger in male)
genetic risk factors (Family)60% concordance in MZ, 5-10x risk with 1st degree relative (complex/polygenic disease w/ “threshold-liability/2hits” model of multiple genetic factors )
genetic risk factors (concurrence )shares risk factors with bipolar disorder and autism
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Pathologic changes in Schizophrenia
Question Answer
Patho changes - Dopamine hypothesisexcess of dopamine (mesolimbic pathway) - positive psychotic symptoms // decrease in MESOCORTICAL pathway --->DA maybe modulator of symptoms
Patho changes - Glutamate(based on PCP/other NMDA blockers) decreased levels in CSF - decreased excitatory modulation of GABA inhibition —> excessive release of glutamate —> neural damage and subsequently lower glut levels
Patho changes - GABAdecreased GABA interneurons in prefrontal cortex
Patho changes - brain fxHYPOFRONTALITY - decreased prefrontal cortical fx / white matter abnormalities = decreased conduction
Patho changes - oligodendrocytesoligodendrocyte and myelin/white matter abnormalities
Path changes- macro brain changesenlarged ventricles, lower weight and volume, shrunken superior temporal gyro (hallucinations/thought disorder?), decreased white matter coherence, decreased grey matter, decreased cortex
Path changes- micro brain changes (2)hippocampal changes, Increased cortical cell density
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Anxiety Disorders

Question Answer
Panic disorder-diagnostic time frame & criteria1) recurrent unexpected panic attacks 2) **anticipatory anxiety (with at least 1 month of concern) 3) +/- agoraphobia
cardinal symptom of panichyperventilation
Panic disorder -txSSRI (+ benzo at the beginning) - based on low 5ht1a binding in cingulate cortex
GAD-diagnostic time frame & criteriaexcessive anxiety & worry at least 6 months w/ at least 3 of the following -- restlessness/poor concentration/muscle tension/easy fatigue/irritable/sleep disturbance
Social Phobia-diagnostic time frame & criteriafear of social or performance situation >> anxiety OUT OF PROPORTION >> situation avoidance / duration 6 MONTHS
relevance of classical conditioning in anxiety disordersfearful response to conditioned stimulus
key structures of the fear networksensory afferents > sensory thalamus > insula and AMYGDALA > HPA axis via hippocampus and fear response via brain stem nuclei (w/ modulation via medial PRC & cingulate)
fear network theory in pain disorderpotential deficit in cortical processing —> inappropriate activation of network // abnormal sensitivity of all structures involved
panic disorder & NE systemincreased NE activity and density from locus ceruleus (increased NE levels)
GABA receptors & panic disorderfewer rectors or decreased sensitivity of GABA-A receptors & lower concentrations of cortical GABA
Anxiety Disorders-tx (general)SSRI > TCA/MAOI > benzo > anticonvulsants
Epi of Panic- prevalence/gender/ age of onset/assc disorders4.7%, 2-3F/1M, 3rd -6th decades/ correlation w/ suicide
Epi of GAD5.7% prevalence / F>M/ early 20’s / 25% develop panic (anxiety disorders are the most prevalent mental disorder)
Epi of Social Phobia3-12% / M=F / acute or insidious onset
Serotonergic Dysfunction in Panic Disorderdecreased 5ht-1a receptor binding
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PTSD
Question Answer
PTSD - trauma criteriaexposure to trauma via 1) direct experience 2) witness event 3) learning of event occurring to loved one 4) experience extreme/repeated exposure to details of event
trauma, defined in DSMactual or threatened death/serious injury/sexual violence
****PTSD - symptom clusters (4)Intrusion, Avoidance, negative alterations in mood/cognition, alterations in arousal/activity
PTSD - time frame for dxmore than ONE Month (less is categorized as acute stress disorder)
Intrusion symptoms, 2 examplesrecurrent & distressing dreams/memories,flashbacks, physiologic reactivity on exposure to cues
Avoidance symptoms, 2 examplesavoiding memories/thoughts // avoiding external reminders provoke thoughts/memories
Negative alterations in cognition/mood symptoms, 2 examplescan’t recall aspects of trauma, negative beliefs about oneself or world (“i won’t live long”), feeling detached/estranged from others
Alterations in arousal/reactivity symptoms, 2 examplesanger/irritability outbursts, self-destructive behavior, hyper vigilance, sleep disturbance
Childhood Trauma & HPA axis development>>DYSregulation in limbic-HPA axis >> disturbance in stress response system >> psychological/behavioral/learning problems
PTSD risk factorsamount of trauma / type of trauma / degree of controllability/predictability in trauma / preparedness
HPA dysregulation hypothesiscortisol levels lower indicating blunted cortisol response > inability to mount sufficient cortisol = inability to shut down stress response —> hyper-arousal & hyperresponsive to stress and the effects of cortisol.
Dexamethasone Suppression Test results in MDD vs PTSDPTSD - exaggerated suppression of cortisol in response to low dose dexamethasone vs reduced cortisol suppression in MDD ( dexamethasone binds to glucocorticoid receptors in the anterior pituitary gland for negative feedback of ACTH/cortisol)
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