Rob's Psychiatry

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USMLE Step 1 Psychiatry from first aid

stanford-binet

calculates IQ as mental age/chronological age x 100

What is the mean IQ and SD

100, 15

What is the criteria for mental retardation

IQ<70

What is severe and profound MR

<40 and <20

repeated stimulation leads to dec response

habituation, simple learning

repeated stimulation lead sot inc response

sensitization

learning in which a natural response is elicited by a conditioned, or learned stimulus that previously was presented in conjuction with an unconditioned stimulus

classical conditioning, pavlov's dogs

learning in which a particular ation is elicited because it produces a reward

operant conditioning

desired reward produces action, mouse presses button for food

positive reinforcement

removal of aversive stimulus elicits behavior, mouse presses button to avoid shock

negative reinforcement

application of aversive stimulus extinguishes unwanted behavior

punishment

discontinuation of reinforcement eliminates behavior

extinction

reward received after every response, rapidly extinguished - vending machine

continuous reinforcement schedule

reward received after random number of responses, slowly extinguished, slot machine

variable ratio reinforcement schedule

patient projects feelings about formative or other important persons onto physician

transference

doctor projects feelings about formative or other important persons onto patient

countertransference

What is the central goa of freudian psychoanalysis

to make the patient aware of what is hidden in their unconcious

primal urges, freud

Id, subconcious - I want it

mediator between primal urges and accepted behavior

Ego - take it and you will get in trouble

Moral values, conscience can lead to self blame and attacks of ego

superego, you know you can't have it, taking it is wrong

behavior achieved following reward of closer and closer approximations of desired behavior

shaping (social learning)

behavior acquired by watching others and assimilating actions into one's own repetoire

modeling (social learning)

What is the goal of the ego defenses

unconcious mental processes to resolve conflict and prevent feelings of anxiety and depression

tantrums

acting out

temporary, drastic changes in personality, memory or conciousness or motor behavior to avoid emotional stress

dissociation - can lead to multiple personality disorder

avoidance of awareness of a some painful reality

denial - can occur in new AIDS or cancer diagnosis

process whereby avoided ideas and feelings are transferred to some neutral person or object

displacement - mom places blame on kid because she's mad at husband

partially remaining at more childish level of development

fixation, men fixating on sports games

modeling behavior after another person is more powerful, though not necessarily admired

identification, abused models abuser

Separation of feelings from ideas and events

isolation of affect, describing murder in graphic detail with no emotional response

an unacceptable internal impulse is attributed to an external source

projection, a man who wants another women thinks his wife is cheating on him

proclaiming logical reasons for actions actually performed for other reasons, to avoid self blame

rationalization, after getting fired saying the job wasn't that important anyway

process whereby a warded off idea or feeling is replaced by an unconsiously derived emphasis on its opposite

reaction formation, a patient with libidinous thoughts enters a monastery

turning back the maturational clock and going back to earlier modes of dealing with the world

regression, seen in children under stress and in patients on dialysis (crying)

involunatary withholding of an idea or feeling from conscious awareness

repression, not remebering a conflictual or traumatic experience

belief that people are either all good or all bad at different times due to intolerance or ambiguity

splitting, a pt that says all nurses are nice and all doctors are bad

guilty feelings alleviated by unsolicitied generosity towards others

altruism, mafia boss makes a large donation to charity

appreciating the amusing nature of an anxiety provoking or adverse situation

humor, nervous med student jokes about boards

process whereby one replaces an unacceptable wish with a course of action that is similar to the wish but does not conflict with ones value system

sublimation, actress using an experience of abuse to enhance her acting

voluntary withholding of an idea or feeling fromk concious awareness

supression, not thinking about the USMLE until the week of the exam

What are the 4 W's of deprived babies?

Weak, wordless, wanting, and wary - dec muscle tone, poor language skills, poor socialization skills, lack of basic trust, anaclitic depression, weight loss, physical illness

How long can infant deprivation last before it leads to irreversible changes

6 months

depression in an infant attributable to continued separation from caregiver, infant beceomes withdrawn and unresponsive - disorder and prognosis

anaclitic depression, can be reversible or lead to FTT, or developmental disturbances

what are pieces of evidence of physical child abuse

healed fractures on xray, cigarrette burns, sudbural hematomasm multiples bruises, retinal hemorrhage or detachment

What are pieces of evidence for sexual child abuse

genital/anal trauma, STDs and UTIs

Who is the typical abuser in physical child abuse

female primary caregiver

Who is the typical abuser in sexual abuse

male, known to the victim

what is the epi of physical child abuse

3000 deaths/yr in the US

What is the epi of sexual abuse

peak incidence 9-12 years of age

What is child neglect

failure to provide adequate food, shelter, supervision, education and/or affection - most common form of child maltreatment

What is the evidence for child neglect

poor hygeine, malnutrition, withdrawal, impaired social/emotional development, FTT

Where is child neglect reported

CPS

Under what conditions do children regress to younger patterns of behavior

stress of physical illness, punishment, birth of a new sibling, fatigue (bedwetting in a previously toilet trained child when hospitalized

limited attention span and poor impulse control - hyperactivity, motor impairment, emotional lability

ADHD

What is the age of onset of ADHD

before 7

In ADHD, what is typical intelligence and school performance

normal intel, trouble in school

What gross neurological finding is associated with ADHD

dec frontal lobe volumes

What are the treatments for ADHD

methylphenidate, amphetamines, atomoxetine

repetitive and pervasive behavior violating social norms, disorder, and name change after 18

conduct disorder <18, antisocial personality disorder > 18

enduring pattern of hostile, defiant behavior towards authority figures in the absence of serious violations of social norms

oppositional defiant disorder

sudden rapid, recurrent, nonrhythmic stereotyped motor movements or vocalizations that persist for >1 yr

Tourrette's

What is lifetime prevalance of tourrette's in the gen pop, and what is the chance of coprolalia

.1-1% of gen pop, 20% of obscene speech

What other psychiatric disorder is associated with tourrettes, and what is the treatment

OCD, haloperidol

overwhelming fear of separation from home or loss of attachment figure that can lead to factitious physical complaints to avoid going to school

separation anxiety disorder

When does separation anxiety disorder usually present

7 to 9

severe language impairment and poor social interactions, greater focus on objects than people, repetitive behavior, below normal intelligence

autism

autism with unusual abilities

savant

in which gender is autism more common

boys

milder form of autism with normal intel, repetitive behavior and problems with social relationships, no language impairment

aspergers

x-linked disorder in girls, sx apparent 1-4, regression, MR, loss of verbal abilities, ataxia, and hand wringing

Rett's disorder

marked regression in multiple areas of fxn after at least 2 years of nl development, loss of expressive or receptive language skills, social, adaptive behavior, bowel or bladder control, more common in boys

childhood disintegrative disorder

In what disease does NE inc, GABA dec, and 5HT dec

anxiety

In what disease does NE dec, 5HT dec and DA dec

depression

in what disease is ACH dec

alzheimers

In what disease is GABA dec and ACH dec

huntingtons

In what disease is DA inc

schizophrenia

in what diseaese is DA dec, 5HT inc, and inc ACH

parkinsons

patients ability to know who he or she is, what date and time is and wht his or her present circumstances are

orientation

What are the common causes of lack or orientation

EtOH, drugs, fluid/lytes imbalance, head trauma, hypoglycemia, nutritional def

What is the order of loss of orientation

time then place then person

inability to remember things that occurred before CNS insult

retrograde amnesia

inability to remember things that occurred after CNS insult

anterograde amnesia

anterograde amnesia caused by thiamine deficiency

korsakoff's amnesia

what can korsakoff's amnesia lead to, who do you see it in and what is it also associated with

bilateral destruction of mammilary bodies, some retrograde amnesia, alcholics, and assoc with confabulations

inbability to recall important personal information, usually subsequent to severe trauma or stress

dissociative amnesia

waxing and waning level of conciousness with acute onset leading to rapid dec in attention span/level of arousal, acute changes in mental status, disorganized thinking, hallucinations etc

delirium

Drugs with what kind of affect can lead to a state of delirium

anticholinergic

What is the most common psychiatric illness on medical and surgical floors and what is the most common cause of this pyschiatric disorder

delirium/secondary to other illness

Gradual change in cognition with no change in level of conciousness, memory deficits, aphasia, apraxia, loss of abstract thought

dementia

What are the EEG findings in dementia

nl

in elderly patients who present with dementia, what is the concern

depression

Causes of dementia

inc incidence with age, then alzheimers, vasc thrombosis, hemorrhage, HIV, pick's disease, CJD

perceptions in the absence of external stimulus

hallucination

misinterpretations of actual external stimulus

illusion

false beliefs not shared with other members of culture/subcutlure that are firmly maintained in spite of obvoius proof to the contrary

delusions

disorders in the form of through, the way ideas are tied together

loose associations

where a visual hallucinations common

delirium

where are auditory hallucinations common

schizophrenia

where are olfactory hallucinations common

aura of psychomotor epilepsy and in brain tumors

where are gustatroy hallucinations common

there are rare

where are tactile hallucinations common

EtOH withdrawal, cocaine abusers

when do hypnagogic hallucinations take place

while going to sleep

When to hypnopompic hallucinations take place

occurs while waking up

Chronic mental disorder with periods of pyschosis, disturbed behavior and though and decline in fxn that lasts > 6 months

schizophrenia

What are the 5 types of schizophrenia

paranoid, disorganized, catatonic, undifferentiated, residual

What drug is a risk factor for schizophrenia in teens

weed

Diagnosis requres 2 of 5 of which sx

delusions, hallucinations, disorganizaed speech, disorganized or catatonic behavior and negative sx

what is the time frame for brief pyschotic disorder

<1mo, usually stress related

What is the time frame for schizophreniform disorder

1-6 months

at least 2 weeks of stable mood with psychotic sx plus a major depressive, manic or mixed episode

schizoaffective disorder

What are the two types of schizoaffective disorder

dipoloar or depressive

Which factors are most important in the etiology of schizophrenia

genes > environment

Who gets schizophrenia and what is the prev

blacks=whites, males = females, 1.5% lifetime prev

when do men vs women present with schizophrenia

men early 20s, women late 20s early 30s

fixed persistent, nonbizarre belief system lasting >1 month not impaired, self limited

delusional disorder

development of delusions in a person in a close relationship with delusional disorder

shared delusional disorder

presence of 2 or more distinct identities or personality states, most common in women, associated with a history of sexual abuse

dissociative identity disorder

persistant feelings of detachment or estrangement from one's own body, a social situation, or the environment

depersonalization disorder

abrupt change in geographic location with inability to recall past, confusion about personal identity, or assumption of a new identity, associated with traumatic circumstances

dissociative fatigue

distinct period of abnormally and persistently elevated, expansive, irritable mood lasting at least 1 week

manic episdoe

What does DIG FAST stand for and how many do you need for diagnosis

distractability, irresponsibility, grandiosity, flight of ideas, inc in Activity/Agitation, dec need for sleep, talkativeness or pressured speech (at least 3)

what is a hypomanic episode

like manic but without marked impairement in fxning - no pyschotic features

define bipolar disorder and distinguish I from II

presence of at least one manic (I) or hypomanic (II) episode, depressive sx occur eventually

What is the concern with use of antidepressants in pts with bipoloar disorder

inc mania, high suicide risk

What is the tx for bipolar disorder

mood stabilizers, Li, valproic acid, carbamazepine, atypical antipsychotics

what is cyclothymia disorder

dysthymia followed by hypomania

How long do episodes of major depressive episode usually last

6-12 months

What does SIG E CAPS stand for and what is the criteria for dx

sleep disturbances, loss of interest, guilt or feelings of worthlessness, loss of Energy, loss of Concentration, Appetite/weight changes, psychomotor retardation or agitation, suicidal ideations, depressed mood - 5 of 9 with anhedonia/depressed mood

How many major depressive episodes constitute major depressive disorder

2 or more within a symptom free interval of 2 months

milder form of depression lasting at least 2 years

dysthymia

associated with winter season, improves in response to full spectrum light exposure

seasonal affective disorder

hypersomnia, overeating, mood reactivity, weight gain and sensitivity to rejection

atypical depression

What is the tx for atypical depression

MAOi, SSRIs

postpartum depressed affect, tearfullness fatigue, usually resolves within 10 days - disorder + incidence

maternal blues 50 to 85%

postpartum depressed affect, anxiety, poor concentration, lasts 2 weeks to 2 months -disorder + incidence

postpartum depression - 10 to 15%

Postpartum delusions, confusion, unusual behavior, homicidal/suicidal ideations or attempts, lasts 4 to 6 weeks

postpartum psyschosis - .1 to .2%

What is the treatment for maternal blues, depression, psychosis

supprt then antidepressants + psychotherapy then all those + antipsychotics and possible inpatient hospitalization

treatment option for MDD refractory to opther treatment, produces painelss seizure in anesthetized patient - tx and major adverse affects

ECT, disorientation amnesia, usually resolves in 6 months

What does SAD PERSONS stand for

Risk factors for suicide complettion - sex (male), age (teen/elderly), depression, previous attempt, ethanol/drug use, loss of rational thinking, sickness (medical illness 3 or more prescription medications), orgnized plan, no spouse, social support lacking - women try men succeed

intense fear and discomfort peaking in 10 minutes

panic disorder

What does PANICS stand for

palp, parasthesias, abdominal distress, nausea, intense fear of dying or losing control, lIght headedness, chest pain, chills, choking, disConnectedness, sweating, shaking, SOB

What is the tx for panic disorder

CBT, SSRI, TCI, BDZ

fear that is excessive or unreasonable and interferes with with nl fxn, cued by presence or antiicipation of a specific object or situatio - person recognizes fear is excessive

specific phobia

exaggerated fear of embarrasment in social situations- disorder and tx

social phobias - tx SSRIs

recurring, intrussive thoughts, feelings or sensations that cause severe distress - relieved in part by performance of repeititive actions

OCD

What does ego dystonic mean in relation to OCD

behavior inconsistent with ones own beliefs and attitudes, as opposed to OC personality disorder

What is the tx for OCD

SSRIs, clomipramine

persistent re-experiencing of a previous traumatic event

PTSD

What are the common sx of PTSD

flashbacks, nightmares, intense fear, helplessness, or horror - avoidance of stimuli associated with trauma and persistent arousal

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