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217 terms

Rob's Psychiatry

USMLE Step 1 Psychiatry from first aid
STUDY
PLAY
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
How long does the disturbance last in PTSD
>1month
pattern of uncontrollable anxiety for at least 6 months - associated with sleep disturbances, fatigue, GI distirbance, difficulty concentrating
generalized anxiety disorder
What is the tx for GAD
BDZ, busiprone, SSRIs
emotional symptoms causing impairment following an identifiable stressor (divorce, illness) and lasting <6 months
adjustment disorder
patient conciously fakes or claims to have a disorder in order to gain a specific secondary gain and avoids medical treatmen, complaints cease after gain
malingering
patient conciously creates physical and or psychological symptoms in order to assume the sick role and get medical attention - primary gain
factitious disorder
chronic factitious disorder with physical signs and symptoms, mutliple hospital admissions and invasive procedures
munchausen's syndrome
illness in a child is caused by a caregiver, motivation is to assume sick role by proxy
munchausen's syndrome by proxy
both illness and motivation are subconcious, sx not intentionally produced or feigned
somatization disorders
variety of complaints in multiple organ symptoms - pain, GI, sexual, pseudo neurologic over years
somatization disorder
sudden loss of sensory or motor fxn often following an acute stressor, pt is aware but indifferent
conversion disorder
preoccupation with a fear of having a serious illness despite medical evaluation and assurance
hypochondriasis
preoccupation with minor or imagined defect in appearance leading to significant emotional distress or impaired functioning
body dysmorphic disorder
prolonged pain with no physical findings - psychosocial factors play an important role in severity exacerbation or maintenance
pain disorder
an enduring repetitive pattern of perceiving, relating to, and thinking about about the environment and oneself
personality trait
inflexible, maladaptive, and rigidly pervasive pattern of behavior causing subjective distress and/or impaired functioning - persons usually not aware of problem, presents early in adulthood
personality disorder
odd or eccentric; inability to develop meaningful social relationships
cluster A personality disorder
What are the various types of cluster A personality disorder
paranoid- pervasive distrust, schizoid - voluntary social withdrawal, schitzotypal - eccentric appearance and magical thinking, interpersonal awkwardness
dramatic, emotional or erratic
cluster B personality disorder
what are the types of cluster B personality disorder
antisocial - disregard for others, borderline - unstable, histrionic - excessive emotionality, narcissistic - grandiosity, sense of entiltlement, lacks empathy
anxious, fearful
cluster C personality disorder
what the 3 types of cluster C personality disorder
avoidant - hypersensitive to rejection, timid, obsessive/compulsive - preoccupation with order, ego syntonic, dependent - submissive and clinging
excessive dieting +/- purging, intense fear of gaining weight, body image distortion, inc exercise
anorexia nervosa
less than what percentage of ideal body weight is common in anorexia nervosa
85 percent
what are the complications/associations of anorexia nervosa
dec bone density, severe weight loss, metatarsal stress fractures, amenorrhea, anemia, lytes disturbances, depression
bing eating +/- purging self induced vomiting, use of laxatives, diuretics or emetics
bulimia nervosa
Is body weight maintained within nl range in bulimia nervosa
yes
what are the associations/complications of bulimia nervosa
parotitis, enamel erosion, lytes disturbances, alkalosis, dorsal hand calluses from inducing vomit
strong persistant cross gender identification
gender identity disorder
desire to live as the opposite sex, through surgery or hormone tx
transsexualism
whering clothes of the opposite sex
transvestism
maladaptive pattern of substance use with 3 or more of these 7 criteria
substance dependence - tolerance, withdrawal, substance taken in larger amounts over longer time than desired, persistant desire or unsuccesful attempts to cut down, lots of energy spet obtaining, using or recovering from substance, important social, occupational or recreational activities reduced because of substance use, continued in spite of knowing problems it causes
maladaptive pattern leading to clinically significant impairment or distress
substance abuse
behavioral, physiologic, cognitive state caused by cessation or reduction of heavy and prolonged substance use, what are clinical signs
substance withdrawal, signs are often opposite of intoxication
What are the stages of change in overcoming substance addiction
precontemplation, contemplation, preparation, action, maintenance, relapse
depressant intoxication - nonspecific
mood elevation, dec anxiety, sedation, behavior disinhibition, respiratory depression
depressant withdrawal - nonspecific
anxiety, tremor, seizures, insomnia
intox - emotional liability, slurred speech, ataxia, coma, blackouts. Withdrawal - severe is delerium tremens
alcohol
What are the serum markers of alcohol use
gamma glutamyltransferase - GGT - AST 2x ALT
What is the treatment for EtOH intox and withdrawal
naltrexone and BDZ
intox = CNS depression, N/V, constipation, pup cxn, seizures withdrawal = sweating, pup diltaed, piloerection, rever, rhinorrhea, N, stomach cramps, diarrhea
opiods
What is the tx for opiod intox and withdrawal
naloxone, naltrexone, and symptomatic for withdrawal sx
intox is marked respiratory depression, intox = delerium, life threatening CV collapse
barbituates
intox = ataxia, minor respiratory depression
BDZ
what is the tx for BDZ intox - MOA
flumazenil - competitive GABA antagonist
what are the non specific signs of stimulant intox and withdrawal
intox = mood elevation, psychomotor agitation, insomnia, cardiac arrhythmias, tachycardia, anxiety. Withdrawal = post use crash, depression, weight gain, lethargy, HA
intox = impaired judgement, pup dilation, prolonged wakefulness and attention, delusions, hallucinations, fever. Withdrawal = stomach cramps, hunger, hypersomnolence
amphetamines
intox = impaired judgement, pup dilation, hallucinations (tactile), paranoid ideations, angina, sudden cardiac death. Withdrawal = suicidality, hypersomnolence, malaise, severe psychological craving
cocaine
intox = restlessness, inc diureis, muscle twitching
caffeine
intox = restlessness. Withdrawal = irritability, anxiety, craving
nicotine
What are potential tx for nicotine withdrawal
patch, gum, losenge, buproprion, varenicline
intox = belligerence, impulsiveness, fever, psychomotor agitation, vertical and horizontal nystagmus, tachycardia, homicidality, psychosis, delirium. Withdrawal = depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep
PCP
intox = marked anxiety or depression, delusions, visual hallucinations, flashbacks and pup dilation
LSD
intox = euphoria, anxiety, paranoid delusions, perception of slowed time, impaired judgment, social withdrawal, inc appetite, dry mouth hallucinations. Withdrawal = irritability, depression, insomnia, N, anorexia
marijuana
How long is marijuana detectable in the urine after last use
1 month
What are heroin users at increased risk of
hepatitis, abscesses, OD, hemorrhoids, AIDS, right sided endocarditits
Long acting oral opiate for heroine detox or long term maintenance
methadone
what is suboxone and what is the rational of adding an antagonist
naloxone + buprenorphine - naloxone not active when taken orally only when injected, withdrawal sx only occur if injected cuts down abuse
What is the definition of alcoholism
physiologic tolerance and dependence with symptoms of withdrawal when intake is interrupted
What are the complications of alcoholism
alcoholic cirrhosis, hepatitis, pancreatitis, peripheral neuropathy, testicular atrophy
what causes wernicke-korsakoff syndrome
thiamine deficiency
What is the triad of Wernicke's encephalopathy
confusion, opthalmoplegia, and ataxia
What is Korsakoff's psychosis
irreversible memory loss, confabulation, personality change
What neurologic outcome is associated with W-K syndrome
periventricular hemorrhage/necrosis of mamillary bodies
What us the tx of W-K syndrome
vit B1, thiamine
Longitudinal lacerations of the gastroesophogeal junction caused by excessive vomiting
mallory weiss syndrome
what is the tx for alcoholism
disulfiram and supportive care
delerium tremens symptoms
autonomic system hyperactivity, psychotic symptoms, confusion