CM Psych I

jmanderson's version from 2016-02-22 01:53

1 Psych History


Question Answer
Benjamin rushfather of biological psychiatry
Philippe pinelhumane treatment of psych pts
Chlorpromazine1st antipsychotic
Adolf Meyerpersonalities and psych

2 Psych HPI


Question Answer
Healthy confrontationto point something bad out (e.g., suicide attempts)
Biopsychosocial modelGeorge Engel, biology-psychology-sociology
Transferencewhat pt expects from doctor
Countertransferencewhat doc expects from pt (e.g., reaction to transference)
Pertinent positives HPIdepressed mood, lack of interest, dec sleep/appetite, suicidal ideations
Pertinent negatives HPIno guilt feelings, no wt loss
Suicide attemptsnever miss this, get fam hx too
Social hxnormal, but add legal issues
Polypharmacyleading cause of neuropsychiatric symptoms

3-4 Psych exam and MMSE


Question Answer
Axis Imajor mental disorders
Axis IIdevelopmental/personality disorders
Axis IIIgeneral medical disorders
Axis IVpsychosocial stressors
Axis Vglobal assessment of functioning (social, occupational, school)
Phenomenological dx approachdx from clinical findings, list of sx, probability models (inclusion/exclusion criteria)
Global assessment functioningyour judgment of individuals overall level of functioning. 100 good  10 bad (dangerous)
Pt unable to give infoutilize family/caregiver, pt confidentiality is the matter of importance
Concentrationsustained attention (test by spelling ‘world’ backwards)
Mental status examgeneral appearance, sensorium, orientation, motor, mood, affect, speech, thought process, thought content, judgment, insight, intellect, cognition
Moodpts description of their own feeling
Affectdocs description of how the pt is feeling (normal, constricted, blunted, or flat)
Associationsconnectors of thoughts
Logiclinking simple thoughts together to make a complex one
Tangential communication disorderthought wanders out of focus and never returns
Circumstantial communication disorderthought wanders out of focus, but comes back to the point
Delusionsunshakeable false beliefs
Hallucinationsfalse perception without stimulus
Illusionsfalse perception with stimulus
MC hallucination in schizophreniaauditory
MC hallucination in drug overdosevisual
First cognitive thing that diminishes in dementiaabstract thinking
Only time to use close-ended questionssuicidal ideation (plan, intent), homicidal thoughts, thoughts that s/he is not in control or being controlled by outside forces
Judgmentpredict outcomes via imaginary situations
Insightdegree of understanding about being ill
Decisional capacitydetermined by judgment and insight; decided by physician
Competencydetermined by court of law
Learninglimbic structures (medial temporal lobes, fornix, dorsomedial thalamic nuclei, mammillary bodies)
Repetitionform of comprehension; test by repeating sentences (lesions = left perisylvian)
Visuospatial/calculation skillsone of the most sensitive indicators of brain dysfunction
Dyscalculiadominant parietal lobe lesion
Subjective Assessmentsensitive indicator of cognitive function
Objective Assessmentselective indicator of cognitive function
Folstein Mini Mental State Examalzheimer’s, 30 pts, valid
Mini Mental State Examless validated in other dementias, poor cognitive coverage
Draw a clock testtests a narrow range of cognitive functioning, complimentary to MMSE (visuospacial, executive, abstraction)
Montreal Cognitive Assessment Toollike MMSE (30 pts), wider range of cognitive functioning, items individually validated
Mini-Cogmemory (name 3 things) + clock-drawing test + recall (rename 3 things); assesses dementia
0 mini-cogdementia
1-2 w/ abnormal clock mini-cogdementia
1-2 w/ normal clock mini-cognot dementia
3 mini-cognot dementia

5 Hallucinations, Illusions, Delusions, and Loose Associations


Question Answer
Hallucinationfalse perception w/o external stimulus
Delusionsfixed false belief based on incorrect inference about reality
Illusionexternal stimulus misperceived/misinterpreted
Loose Associationdisturbance of thinking shown by speech
Most common hallucinationsauditory and visual
Always rule ….. out with hallucination ptsubstance/medication induced
Hypnagogic hallucinationspt GOing to sleep
Hyponopompic hallucinationpt waking up
Charles Bonnet syndromevisual hallucinations of blind folks
Negative symptomsdiminished emotional expression; reductive emotional response/spontaneity; avolition (dec. direction following), alogia (dec. speech), anhedonia (dec. pleasure)
Delusional disorder dx> 1 delusion for > 1 mo; functioning not markedly impaired; behavior not markedly bizarre/odd
PimozideRx for somatic subtype of delusional disorder (MOA, dopamine blocker)

6-7 Schizophrenia and Psychotic Disorders


Question Answer
Psychosisimpaired sense of reality with emotional/cognitive disabilities that compromise functioning
Genetics of schizophrenia% chance is higher w/ schizophrenic siblings (10%), parents (46%), identical twins (46%), fraternal twins (14%), children (5%) and one parent (17%)
Biology of schizophreniadopamine hypothesis (increase # or sensitivity of receptors, increase DA from dec. breakdown, low function of NMDA receptorsr in glutamate system); Transmethylation hypothesis (breakdown of DA, NE, and 5-HT produced methtylated hallucinatory derivatives)
Prevalence of schizophrenia1% worldwide, M=F
Age of onset of schizophrenia18-25 yo M; 21-30 yo F; almost always <40 yo
Schizophrenia dxsx for > 6 mo
Schizoaffective disorder dxschizophrenic sx + depression/mania for > 2 weeks
Brief psychotic disorder dxsx for >1 day but <1 mo
Schizophreniform disorder dxsx for >1 mo but <6 mo
Delusional disorder dxno disorganized thought, delusions are circumscribed and non-bizarre, in 40-50 yo
For acute threatening behavior of psychotic pts … RxHaloperidol 10 mg at a time prn
1st gen antipsychotics (typical) MOApotency based on D2 receptor blockade
1st gen antipsychotics (typical) AEalpha-block, long QT, extrapyramidal sx, movement dysorders (TARDIVE DYSKINESIA)
2nd gen antypsychotics (atypical) MOAless D2 potency but varying levels of 5-HT receptor blockade
2nd gen antypsychotics (atypical) examplesclozapine, olanzapine, quetiapine, rlsperidone, aridiprazole, ziprasadone
2nd gen antypsychotics (atypical) AEsless than 1st gen (typical), SEROTONIN SYNDROME with MAOIs, METABOLIC SYNDROME (glucose, A1c, lipids), aplastic anemia, CVA risk with dementia, long QTc

8-9 Mood Disorders


Question Answer
Manic v. Hypomanic episode?Manic = 7 d w/ impairment; Hypomanic = 4 d w/o impairment
Major Depressive Disorder and Bipolar Disorder epidemiology?depression is 2x more common in F during reproductive years
Depression and Sleep?difficulty falling asleep, early morning awakening; early REM latency, increase REM density
Tx for depressive episode?cognitive behavioral therapy (CBT) +/- SSRIs
Electroconvulsive Therapy (ECT) relative contraindications?space occupying lesion in brain, recent MI or CVA
34 yo F on SSRI begins taking tramadol and SNRI for pain has HTN, sweats, myoclonus, hypotonia, HA?Serotonin Syndrome
Rapid cycling with bipolar disorder?> 4 episodes per year
Tx bipolar disorder?mood stabilizer (e.g., valproate, lithium) with discussion of AEs and monitoring is first line
How long pt takes antidepressant before clinical effects?4-6 wk
Which mood disorder is most genetically susceptible?bipolar disorder

10 Anaclitic Depression and Early Childhood Development


Question Answer
Anaclitic depressionimpairment of infant/s physical, social, and intellectual development from absence of mothering
NT involved with attachmentoxytocin
Attachmentchild’s affective relationship with parents
Bondingparents affective relationship with child
Lay still on belly1-2 mo
Scooting on belly3-4 mo
Roll over4-5 mo
Sit5-6 mo
Back straight6-7 mo
Stand with object8-9 mo
Crawl9-10 mo
Walk10-12 mo
Kicks ball, walk stairs, stack 6 blocks, draw lines2 y
climb steps w/ alt feet, broad jump, stack 8 blocks, draws circle3 y
Hops on one foot, copies + draws person w/ 3 body parts4 y
Skips, heal-toe walks, copies square5 y
balance on each foot for 6 s, copies triangle, draw person w/ 6 parts6 y
Sensorimotor stagestranger anxiety, object permanence (birth-2y)
Preoperational stagemagical thinking, animism, egocentrism (2-7y)
Concrete operational stagelogic, conservation of #/length, cause-effect, death, no more santa clause (7-11y)
Formal operationsabstract thinking, imaginary audience (>11y)
Assimilationobjects related to experience they have already encountered (“hot food burns”)
Accommodationadjusts to a new function (newly constructed schemes to fit old/new experiences into uniform reality)
Stages of psychosocial developmenttrust/mistrust  autonomy v. shame/doubt  initiative/guilt  industry/inferiority  identity/role-confusion  intimacy/isolation  generativity/stagnation  integrity/despair
Stages of personality developmenttrust/mistrust  hope  will  purpose  competence  fidelity  love  care
Psychosocial oral stagepleasure from stuff in mouth (birth-1y)
Psychosocial anal stagepleasure from holding body waste (1-3y)
Psychosocial phallic stagepleasure from own sex organs (3-6y)
Psychosocial latency perioddenies attraction for opposite sex parent, prefers same sex parent (6-11y)
Psychosocial genital stagesexuality and heterosexual desire (adolescence)

11-12 Child Psychiatry


Question Answer
Fetal alcohol syndromesmall eye opening, smooth philtrum, thin upper lip, MCC of preventable mental retardation
Autism spectrum disorderbefore age 3, delay in functioning of 1) social interaction, 2) language, 3) symbolic/imaginative play
Expressive languagehow person communicates their wants/needs
Receptive languagethe comprehension of language
Enuresisrepeated urination on self 2x/wk for > 3 mo at > 5yo; bell and pad is gold standard tx
Encopresisrepeated feces in inappropriate places for > 3 mo; may be secondary to TRUAMA
Tourette’stics for >1y w/o tick free period of more than 3 consecutive mo
Reactive attachment disorderinappropriate social relatedness in most contexts <5yo
What to ask if you suspect reactive attachment disordercaregivers in 1st 5 y of life (e.g., more common in foster kids) – lack of selectivity in choice for attachment figures
1st line tx for OCDCBT +/- meds (fluoxetine, clomipramine, fluvoxamine, sertraline)
PTSD stressor criterion with reaction sx must last how long for dx?at least one month
Most common initial presentation of depression in kidsIRRITABILITY
Conduct disorderlack of empathetic behavior in kids (fire setting, animal abuse, theft)
Autism irritable behavior RxAbilify (aripriprazole) and Risperdal (risperidone)
ADHD Rxmeds (stimulants, alpha agonists) + community interventions
Stimulant (amphetamines, methylphenidate) AEsstunted growth, tics, dec. appetite, rebound irritability, priapism, SUDDEN DEATH (esp. w/ fam hx of CVD)
Tourette’s Rxbehavioral is first line; alpha agonists in severe cases, antipsychotics
Atypical antipsychotic AEsMETABOLIC SYNDROME (wt gain, DM, hyperlipidemia), cataracts, sexual AEs, prolonged QTc, myocarditis, EXTRAPYRAMIDAL sx
Depression RxSSRIs, TCAs
TCA/SSRI black box warningchildren on antidepressants correlated with higher suicide rate than placebo
ADHDpersistent inattention or hyperactivity w/ more frequency/severity than typical (at least two settings); clear evidence of impaired functioning (school, social, occupational)
ADHD sx must be present before age7 yo
Manic episodeelevated, expansive, irritable mood lasting at least ONE WEEK – grandiosity, dec. sleep, pressure to keep talking, flight of ideas, distractible, psychomotor agitation, excess pleasure activities
Anorexia Rxmultidisciplinary, SSRIs (olanzapine), catch early
Bulemia nervosa sxswollen parotid gland, discoloration of teeth, broken vessels in eyes/face, callus on back of hands/knuckles (self-induced vomiting), sore throat, heartburn/reflux
Bulemia nervosa Rxfluoxetine
Children ages 10 to 14 suicide rate0.9 per 100,000
Adolescents ages 15 to 19 suicide rate6.9 per 100,000
Young adults ages 20 to 24 suicide rate12.7 per 100,000