Board Review-Psychiatry-Pathology

Dec muscle tone
Poor language skills
Poor socialization skills
Lack of basic trust
Anaclitic depression
Wt Loss
Physical Illness

if severe can result in death

irreversible change

Hospitalism

Depression attributable to continued separation from caregiver
Sx's: withdrawn, unresponsive, initially reversible, but can lead to all the other sx's of deprivation

ADHD
Conduct disorder
Oppositional Defiant Disorder
Tourette's
Separation Anxiety Disorder

Limited attention span
poor impulse control
hyperactivity
motor impairment
emotional lability
Normal intelligence

methylphenidate (ritalin)
amphetamines (dexedrine)

Repetitive and pervasive behavior violating social norms

Antisocial Personality Disorder

and jail time

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

lifelong disorder characterized by multiple motor/vocal tics

OCD

< 18

Antipsychotics (haloperidol)

overwhelming fear of separation from home or loss of attachment figure

7-8

Autistic Disorder
Asperger's
Rett's
Childhood Disintegrative disorder

Severe Language impairment
Poor social interactions
Repetitive behavior
usually below normal intelligence
RARELY have unusual abilities (savants)

boys

behavioral and supportive therapy to improve communication and social skills

milder form of autism
Restricted interests
repetitive behavior
social problems
normal intelligence
Intact verbal and cognitive skills (no language impairment)

Progressive, X-linked disorder almost exclusively seen in girls

Affected males die in utero or shortly after birth

Loss of development
MR
Loss of verbal abilities
Ataxia
Stereotyped hand-wringing

Marked regression in multiple areas of functioning after at least 2 years of apparently normal development.

Loss of expressive or receptive language skills
loss of social skills or adaptive behavior
Loss of bladder/bowel control
Loss of play and motor skills

Onset between 3 and 4
More common in boys

healed fractures on x-ray
cigarette burns
subdural hematomas
multiple bruises
retinal hemorrhage or detachment

Female
Primary Caregiver

3000

genital/anal trauma
std's
uti's

Known to victim
usually male

9-12

Neglect

Inc NE
Dec GABA
Dec 5-HT

dec NE
dec 5-HT
dec DA

dec ACh

dec GABA
dec ACh

Inc DA

Dec DA
Inc ACh

1st: time
2nd: place
3rd: person

Retrograde
Anterograde
Korsakoff's
Dissociative

inability to remember things that occurred before CNS insult

inability to remember things that occurred after a CNS insult

Anterograde amnesia caused by Thiamine deficiency
---> Bilateral destruction of Mammillary bodies
Can also lead to Retrograde amnesia

inability to recall important personal information
usually subsequent to severe trauma or stress

Waxing and Waning level of consciousness
Rapid dec in attention span and level of arousal
Acute changes in mental status
Disorganized thinking
hallucinations
illusions
misperceptions
disturbance to sleep-wake cycle
cognitive dysfunction

drugs w/ anticholinergic effects

Dementia has a gradual onset
Dementia pts have no change in level of consciousness
Normal EEG (Delirium has abnormal EEG)

Hallucinations: perceptions in the absence of external stimuli
Illusions: misinterpretations of actual external stimuli
Delusions: false beliefs not shared w/ other members of culture/subculture that are firmly maintained in spite of obvious proof of the contrary
Loose associations: disorders in the form of thought (the way ideas are tied together)

Visual
Auditory
Olfactory
Gustatory (rare)
Tactile
Hypnagogic
Hypnopompic

Visual: delirium
Auditory: schizophrenia
Olfactory: as an aura of psychomotor epilepsy

Alcohol withdrawal: ants crawling on skin
Cocaine abusers

hypnaGOgic is when you're GOing to sleep

hypnopompic is while you're waking from sleep

Periods of psychosis and disturbed behavior w/ a decline in functioning lasting > 6 months
Increase DA activity

2 or more of the following:
Delusions +
Hallucinations +
Disorganized Speech +
Disorganized/Catatonic Behavior +
Negative Sx's = flat affect, social withdrawal, lack of motivation, lack of speech or thought

< 1 month
usually stress related

1-6 months

At least 2 weeks of a stable mood w/ psychotic sx's
+
major depressive, manic, or mixed episode

Bipolar
Depressive

Paranoid (delusions)
Disorganized (w/ regard to speech, behavior, affect)
Catatonic (automatisms)
Undifferentiated (elements of all types)
Residual

Genetic factors outweigh environmental factors

Men present earlier (teens and 20s) that women (late 20s to early 30s)

Fixed, persistent, nonbizarre belief system lasting > 1 month
Functioning otherwise not impaired
Self-limited

development of delusions in a person w/ a close relationship w/ someone w/ a delusional disorder
usually resolves upon separation

Dissociative Identity Disorder
Depersonalization Disorder
Dissociative Fugue

Presence of 2 or more distinct identities or personality states

formerly known as multiple personality disorder

women
previous h/o sexual abuse

Persistent feeligns of detachment or estrangement from oneself

Abrupt change in geographic location w/ inability to recall past, confusion about identity, or assumption of a new identity
Leads to significant distress or impairment

Often associated w/ traumatic circumstances (natural disasters, war, trauma)
Not due to substance abuse or a general medical condition

Distinct period of abnormally and persistently elevate, expansive, or irritable mood lasting at least 1 week
Often disturbing to pt

3 or more of:
1. Distractibility
2. Irresponsibility (seeks pleasure w/o regard for consequences)
3. Grandiosity (inflated self esteem)
4. Flight of ideas (racing thoughts)
5. inc in goal-directed Activity/psychomotor agitation
6. dec need for Sleep
7. Talkativeness or pressured speech

DIG FAST

Like manic episode, but mood disturbance isn't severe enough to cause marked impairment in social/occupational functioning to necessitate hospitalization
no psychotic features

At least 1 manic (bipolar 1) or hypomanic (bipolar 2) episode.
+
Depressive sx's always occur eventually
Mood and functioning return to normal between episodes

Antidepressants---> inc mania
Lithium
Valproic acid
Carbamazepine
Atypical Antipsychotics

Milder form of Bipolar lasting at least 2 years

at least 5 of SIG E CAPS for 2 weeks

Sleep disturbances
loss of Interest**
Guilt or feeling worthless
loss of Energy
loss of Concentration
Appetite/wt changes
Psychomotor retardation/agitation
Suicidal ideations
Depressed mood***

2 or more episodes w/ a sx-free interval of 2 months

milder form of depression lasting at least 2 years

associated w/ winter
improves in response to full-spectrum light exposure

Rx option for major depressive disorder refractory to other Rx
Produces painless seizure
SE's: disorientation, anterograde and retrograde amnesia

Dec slow-wave sleep
dec REM latency
inc REM early in sleep cycle
inc total REM sleep
Repeated nighttime awakenings
Early morning awakenings

Atypical

Hypersomnia
Overeating--->wt gain
Mood reactivity (experiences improved mood in response to positive events vs persistent sadness)
Sensitive to rejection

MAO inhibitors
SSRI's

Sex (male)
Age (teenage or elderly)
Depression
Previous attempt
Ethanol or drug use
loss of Rational thinking
Sickness
Organized plan
No spouse (divorce, widow, single, esp if childless)
Social support lacking

SAD PERSONS

Presence of recurrent periods of intense fear and discomfort peaking in 10 minutes w/ sx's

4 or more:
Palpitations
Paresthesias
Abd distress
Nausea
Intense fear of dying/losing control
Lightheadness
Chest Pain
Chills
Choking
disConnectedness
Sweating
Shaking
Shortness of Breath

Cognitive behavioral therapy
SSRIs
TCAs
Benzodiazepines

Fear that is excessive, unreasonable, and interferes w/ normal fxn
Cued by presence or anticipation of a specific object or situation
Person recognizes fear is excessive

systematic desensitization

exaggerated fear of embarassment in social situations

Recurring, Intrusive thoughts, feelings, or sensations that cause severe distress
Relieved in part by the performance of repetitive actions
Ego Dystonic: behavior inconsistent w/ one's own beliefs and attitudes (distinguishes from OC personality disorder)

SSRI's
Clomipramine

Persistent reexperiencing of a previous traumatic event
May involve nightmares, flashbacks, intense fear, helplessness, or horror
Lasts > 1 month ---> significant distress and/or impaired fxning

Psychotherapy
SSRIs

lasts between 2 days and 1 month

Pattern of uncontrollable anxiety for at least 6 months that is unrelated to a thing
Sleep disturbed
Fatigued
Difficulty concentrating

Benzodiazepines
Buspirone
SSRI's

Emotional Sx's (anxiety, depression) causing impairment following identifiable psychosocial stressor (divorce, illness) and lasting < 6 months (> 6 if chronic stressor

Patient consciously fakes or claims to have a disorder in order to attain specific gain (avoid work, get drugs)
Avoids Rx by docs
Complaints cease after gain (vs factitious disorder)

Patient consciously creates physical and/or psychological sx's in order to assume sick role and get medical attention

Chronic factitious disorder w/ predominantly physical sx's.
H/o multiple admissions and willingness to undergo invasive procedures

when illness of child is caused by caregiver. Obtain sick role by proxy
Is child abuse

Category of disorders characterized by physical sx's w/ no identifiable physical cause
Both illnessproduction adn motivation are unconscious drives
Sx's not intentionally produced or feigned.

women

Somatization Disorder
Conversion
Hypochondriasis
Body Dysmorphic Disorder
Pain Disorder

variety of complaints in multiple organ systems (at least 4 pain, 2 GI, 1 sexual, 1 pseudoneurologic) over a period of years

motor or sensory Sx's (e..g paralysis, blindness, mutism), often following an acute stressor

Preoccupation w/ and fear of having a serious illness despite medical evaluation and reassurance

preoccupation w/ minor or imagined defect in appearance, leading to significant emotional distress or impaired functioning
Often repeatedly seek cosmetic surgery

prolonged pain w/ no physical findings

an enduring pattern of perceiving, relating to, and thinking about the environment and oneself that is exhibited in a wide range of important social and personal contexts

inflexible, maladaptive, and rigidly pervasive pattern of behavior causing subjective distress and/or impaired functioning
Person is usually not aware of problem
Stable by early adulthood, not usually dx in kids

Odd or Eccentric
Inability to develop meaningful social relationships
No Psychosis
Genetically related to schizophrenia

Paranoid
Schizoid
Schizotypal

Pervasive distrust and suspiciousness
Projection is major defense mech

Voluntary social withdrawal
Limited emotional expression
Content w/ social isolation (hermit) (vs avoidant)

Eccentric appearance
Odd beliefs or magical thinking
Interpersonal awkwardness

Dramatic
Emotional
Erratic
Genetic tie w/ mood disorders and substance abuse

Antisocial
Borderline
Histrionic
Narcissistic

Disregard for and violation of rights of others, criminality
Males>females
= conduct disorder if < 18

unstable mood and interpersonal relationships
Impulsiveness
Sense of emptiness
females>males
Splitting is major defense mech

Excessive emotionality and excitability
Attention Seeking
Sexually Provocative
Overly concerned w/ appearance

Grandiosity
Sense of Entitlement
Lacks empathy and requires excessive admiration
Often demands the best and reacts to criticism w/ rage

Anxious or Fearful
Genetic tie to anxiety disorders

Avoidant
Obsessive-Compulsive
Dependent

hypersensitive to rejection
socially inhibited
timid
feelings of inadequacy
desires relationships w/ other (vs schizoid)

preoccupation w/ order, perfectionism, and control
Ego syntonic
Behavoir consistent w/ one's own beliefs and attitudes (vs OCD)

Submissive and Clinging
Excessive need to be taken care of
Low self-confidence

Cluster A: Weird
Cluster B: Wild
Cluster C: Worried

Schizoid < Schizotypal < Schizophrenic

Schizotypal = schizoid + odd thinking

Schizophrenic = even greater odd thinking

< 1 month = brief psychotic disorder, usually stress related
1-6 month = schizophreniform disorder
> 6 month = schizophrenia

Anorexia Nervosa
Bulimia nervosa

abnormal eating habits
intense fear of gaining wt
body image distortions
Inc exercise
dec bond density
metatarsal stress fractures
amenorrhea
anemia
electrolyte disturbances
usually accompanied by depression

binge eating followed by self-induced vomiting or laxatives, diuretics, or emetics
Body wt usually in normal range
Associated w/ parotitis, enamel erosion, electrolyte disturbances, alkalosis, Russell's sign

dorsal hand calluses from inducing vomiting

Strong, persistent cross-gender identification
Discomfort w/ one's sex
Significant distress and/or impaired functioning

Maladaptive pattern of substance use defined by 3 or more of the following in 1 year:

Tolerance
Withdrawal
Using in larger amounts or over longer time than desired
Persistent desire or unsuccessful attempts to cut down
Significant energy spend getting, using, or recovering
Important social, occupational, or recreational activities reduced
Continued use despite knowledge of problems

Maladaptive pattern---> clinically significant impairment or distress
Sx's have NEVER met criteria for substance dependence

Recurrent use---> failure to fulfill responsibilities
Recurrent use in physically hazardous situations
Recurrent substance-related legal problems
Continued use despite of above problems

Behavioral, physiologic, and cognitive state caused by the cessation or reduction in heavy and prolonged substance use

Sx's often opposite of those seen w/ intoxication

Alcohol
Opioids
Barbiturates
Benzodiazepines

Amphetamines
Cocaine
Caffeine
Nicotine

PCP
LSD
Marijuana

Disinhibition
Emotional lability
Slurred speech
ataxia
coma
blackouts

Serum gamma-glutamyltransferase (GGT)

Tremor
Tachycardia
HTN
malaise
Nausea
Seizures
Delirium Tremens
Tremulousness
Agitation
Hallucinations (including tactile)

Life Treatening disorder peaking 2-5 days after last drink
Autonomic hyperactivity (tachycardia, tremors, anxiety)
Psychotic Sx's (hallucinations, delusions)
Confusion

Benzodiazepines

CNS depression
N&V
Constipation
Pupillary Constriction (pinpoint)
Seizures

Anxiety
Insomnia
Anorexia
Sweating
Dilated pupils
Piloeretion (cold turkey)
Fever
Rhinorrhea
Nausea
Stomach Cramps
Diarrhea
Yawning*

Intoxication: Naloxone, Naltrexone

Withdrawal: symptomatic

Low safety margin
RESP DEPRESSION

Anxiety
Seizures
Delirium
Life-threatening CV collapse

Symptomatic (assist respiration, inc BP)

Greater safety margin
Amnesia
Ataxia
Somnolence
Minor Resp Depression
Additive effects w/ booze

Rebound anxiety
seizures
tremor
insomnia

Flumazenil

Psychomotor agitation
Impaired judgement
Pupillary dilation
HTN
Tachycardia
Euphoria
Prolonged wakefulness and attention
Cardiac arrhythmias
Delusions
Hallucinations
Fever

Post-use Crash
Including Depression
Lethargy
HA
Stomach Cramps
Hunger
Hypersomnolence

Euphoria
Psychomotor agitation
Impaired judgement
Tachycardia
Pupillary Dilation
HTN
Hallucinations (including tactile)
Paranoid Ideations
Angina
Sudden Cardiac Death

post-use Crash
Severe depression
Suicidal
Hypersomnolence
Fatigue
Malaise
Severe Psychological craving

Restlessness
Insomnia
Inc Diuresis
Muscle twitching
Cardiac Arrhythmias

HA
Lethargy
Depression
Wt. Gain

Restlessness
Insomnia
Anxiety
Arrhythmias

Irritability
HA
Anxiety
Wt. Gain
Craving

BELLIGERENCE
Impulsiveness
Fever
Psychomotor agitation
Vertical*** and Horizontal Nystagmus
Tachycardia
Ataxia
Homicidality
Psychosis
Delirium

Depression
Anxiety
Irritability
Restlessness
Anergia
Disturbances of thought and sleep

Marked Anxiety and Depression
Delusions
Visual Hallucinations
**Flashbacks
Pupillary Dilation

Euphoria
Anxiety
Paranoid Delusions
Perception of Slowed Time
Impaired Judgement
Social Withdrawal
Inc Appetite
Dry mouth
Hallucinations

Irritable
Depressed
Insomnia
Nausea
Anorexia

Peak in 48 hrs and lasts for 5-7 days

up to 1 month

Hepatitis
Abscesses
OD
Hemorrhoids
AIDS
Right-sided endocarditis

Naloxone
Naltrexone

they competitively inhibit opioids

Methadone

Suboxone
naltrexone + buprenorphine (partial agonist)
Longer acting
Fewer withdrawal sx's unless injected

Cirrhosis
Hepatitis
Pancreatitis
Peripheral neuropathy
Testicular Atrophy
Wernicke-Korsakoff
Mallory-Weiss

Thiamine Def
Wernicke = Confusion, Ophthalmoplegia, Ataxia
Korsakoff = irreversible memory loss, confabulation, personality changes

periventricular hemorrhage/necrosis of mammillary bodies

IV Thiamine

Longitudinal lacerations of G-E jxn caused by excessive puking
Presents w/ hematemesis
It hurts (distinguishes from varices)

Disulfiram
Supportive Care
AA