Spec Dis Psych

What is the orthogenetic principle?

States that development moves from undifferentiated and stereotypical towards greater complexity and individualized responses (Ex: infant responds to everyone the same way -> toddlers respond in certain ways to certain people)

Define adaptation/competence in the context of psych d/o development

Level of performance by an individual in meeting demands of their environment to the degree that is expected given the individual's circumstances

What 2 types of change are required and must be in balance for successful adaptation to occur?

i. Assimilation = incorporation of challenge into exisiting organizational structures

ii. Accommodation = reorganization of our structures to meet demands of environment

Differentiate the types etiologies of psych d/o: multifinality and equifinality

i. Multifinality = one etiologic factor causes many different outcomes

ii. Equifinality = many causes result in one disorder

True/False: due to diverse biopsychosocial interactions, not every person who has suffered the same maltreatment/life event will have the same adverse outcomes

True

True/False: context of one's situation, such as cultural/societal views, can influence whether or not they develop psych d/o

True

Give some examples of major transition points

i. Entry to schooling

ii. Puberty

iii. High school graduation and entry into work world

iv. Marriage

v. Birth of children

vi. Death of loved ones

What are the 10 types of Adverse Childhood Experiences (ACEs) that negative impact future health and well-being (there are 3 main categories)?

i. Abuse: emotional, physical, and sexual

ii. Household challenges: mother treated violently, substance use in household, mental illness in household, parental separation, incarcerated household member

iii. Neglect: emotional or physical

Experiencing how many ACEs significantly increases risk for many adverse outcomes including alcoholism, drug use, depression, suicide, physical inactivity, obesity, ischemic heart dz, etc?

4+

What type of behavioral intervention consists of reframing an interaction of an organism with an external stimuli that results in a simple reflex arc in response to the stimuli?

Classical conditioning

What types of d/o can classical conditioning be used to tx?

Phobias and anxiety-based d/o

What is the difference between the types of classical conditioning: traumatic conditioning vs counterconditioning?

i. Traumatic conditioning: can cause phobic reactions (Ex: loud gong rung every time a baby sees a rat to create a conditioned response of fear and avoidance)

ii. Counterconditioning = used to eliminate phobic reactions

What is progressive relaxation and what type of d/o is it used to tx?

Alternately tense and relax different muscle groups in systematic fashion to alleviate anxiety-based disorders

What is systematic desensitization?

Successive degrees of exposure to feared object or stimulus for phobias and anxiety-based disorders

Instrumental learning and operant learning both cause behavior change. What is the difference between the two methods?

a. Instrumental Learning = causes behavior change by teaching organism that a certain behavior is instrumental to gaining reward using a conditioned stimulus

b. Operant Learning = causes behavior change by allowing organism to operate on its environment to get rewards; no conditioned stimulus

What are the 5 levels to Maslow's Hierarchy of Needs?

i. Basic needs

- Safety

- Physiological

ii. Psychological Needs

- Esteem

- Belongingness and love

iii. Self-fulfillment

- Self-actualization

What type of psych intervention is based on idea that organisms are not just passive recipients of stimuli but instead interpret and try to make sense out of their worlds?

CBT

What is the ABC model, associated with CBT?

It is not just what happens to someone that determines how they feel and what they will do, but also how the person interprets those events according to their beliefs

1. Activating event

2. Beliefs about the event

3. Consequences

True/False: the behavior of an individual referred for behavioral/cognitive therapy is always of concern

False: inappropriate behavior may just be an adaptation to an impossible situation

What type of psych intervention is described as structured encounters with a trained individual who can influence the mental state of another to decrease suffering and/or increase healthy psychological, interpersonal, and behavioral options of patient?

Psychotherapy

What are the 3 main types of psychotherapy?

Dynamic, experimental-humanistic, and cognitive-behavorial

Which type of psychotherapy is based on the idea that our life experiences explain why we behave a certain way, yet we often do not recognize this connection; And so its goal is to gain understanding of behavior ti consciously make better choices in relationships and vocations?

Dynamic

Which type of psychotherapy helps decrease defense mechanisms such as displacement, repression, sublimation, and regression?

Dynamic

What is the defense mechanism, sublimation?

Boxing/exercising to get out aggression

Which type of psychotherapy is based on the idea that psychopathology is from failure of caregivers to provide empathy or compassion necessary for successful and adaptive development of the self?

Experiential-humanistic

Which type of psychotherapy is based on the idea that psychopathology is from distorted thoughts and resulting maladaptive behaviors?

Cognitive-behavioral psychotherapy

True/False: cognitive-behavioral therapy attempts to explain the etiology of distorted beliefs to help patients overcome them

False: does not attempt to explain etiology of beliefs, but does challenge them and more adaptive beliefs are suggested and supported

What 3 hormones affect mood and are associated with MDD?

Serotonin, NE, and dopamine

What is the average age of onset of MDD and in what age group are the highest rates found?

Onset: mid-teens to late 20s

Highest rates: 25-44

What is the DSM-5 criteria for MDD?

5+ of the SIGE CAPS Sxs for at least 2 weeks causing clinically sig distress or impairment in social, occupational, or other areas of life and NO manic episodes(one of the Sxs must be depressed mood or loss of interest/pleasure)

What does SIGE CAPS stand for?

- Sleep changes

- Interest

- Guilt

- Energy

- Concentration

- Appetite changes

- Psychomotor changes

- Suicidal ideation

What is anhedonia?

Loss of interest/pleasure

What is masked depression?

No depressed mood but social withdrawal or decreased activity

Is weight loss or gain more common with MDD?

Weight loss (decreased appetite)

Do patients with MDD more commonly have hypersomnia or insomnia?

Insomnia

What comorbid conditions are MC associated with MDD?

Anxiety d/o

When is risk of suicide highest for MDD patients?

After initiation of tx and 6-9 month period following recovery

What is the difference between depression and grief?

Grief is different from an MDE in the sense that grief is directed at an external factor whereas MDD is an internal conflict

What are the PHQ-9 score categories?

- 5-9 = mild depression

- 10-14 = moderate

- 15-19 = mod/severe

- 20-27 = severe

What are the general tx needs for mild, mod/severe, and severe/intractable depression?

(1) Mild: psychotherapy alone can be done

(2) Mod/severe: meds and psychotherapy

(3) Severe/intractable: hospitalization and ECT

For how long should antidepressant therapy be maintained to avoid relapse of MDD?

At least 6 months

What class of antidepressants are the mainstay of tx for MDD?

SSRIs

What are some common SEs of SSRIs?

GI, HA, insomnia, sexual dysfunction

What class of antidepressants are good for MDD with concurrent pain syndromes?

SNRIs

What class of antidepressants are not used much anymore for MDD due to the need for a strict low-tyramine diet?

MAOIs

What % of patients treated for MDD will relapse in the first 6 months of remission?

25% (prevent this by keeping on meds at least 6 months)

After how many tx failures should MDD be referred to psych?

3

What is the DSM-5 criteria for dysthymia (persistent depressive disorder)?

Clinically significant depressed mood for most of the day, for more days than not, for at least 2 years with 2+ of the following and has not been without symptoms for more than 2 months:

(1) Poor appetite/overeating

(2) Insomnia

(3) Low energy

(4) Low self-esteem

(5) Poor concentration

(6) Feelings of hopelessness

*basically same as MDD but only only 2 symptoms needed (vs 5) and 2 years (vs 2 weeks)

What depressive symptoms are less common with dysthymia compared to MDD?

Vegetative sxs: insomnia, change in appetite, decreased libido, and psychomotor symptoms

*More mood-related symptoms with dysthymia

Tx for dysthymia?

SSRIs, CBT

Does MDD or dysthymia respond better to antidepressants?

MDD

What % of suicides are a result of MDD?

50%

What % of people who commit suicide saw a healthcare provider within 2 weeks of their death?

80%

What is the most widely used screening tool for suicide risk assessment?

Columbia Suicide Severity Rating Scale

What hormone is associated with increases in mania and decreases in depression?

NE

What is the DSM-5 criteria for Bipolar I?

Must meet criteria for at least 1 manic episode - period of abnormally and persistently elevated, expansive, or irritable mood and persistently increased activity/energy for at least 1 week with 3+ of the following symptoms:

i. Increased self-esteem

ii. Decreased need for sleep

iii. More talkative than usual

iv. Flight of ideas

v. Distractibility

vi. Increased goal-directed activity or psychomotor activity

vii. Risky behaviors

True/False: criteria for at least 1 MDE must be met for a Bipolar I dx

False; just need manic/hypomanic criteria

*50-60% of cases have depressive episode immediately before or after manic episode

True/False: criteria for at least 1 MDE must be met for a Bipolar II dx

True! (unlike Bipolar I)

What is the DIG FAST acronym for mania symptoms?

- Distractability

- Irresponsibility

- Grandiosity

- Flight of ideas

- Activity increase

- Sleep decrease

- Talkativeness

What are some of the clinical presentations of Stages 1-3 mania?

1. Stage 1 = euphoria, grandiose, increased rate of speech, irresponsibility

2. Stage 2 = increased dysphoria and depression, flight of ideas, disorganized cognition, increased psychomotor activity

3. Stage 3 = panic-stricken, incoherent associations, delusions, frenzied psychomotor activity

How many manic episodes are required to be considered rapid cycling Bipolar?

4+

Management of mild/mod mania?

Antipsychotic monotherapy

Tx for severe mania/rapid cycling?

Combo therapy (lithium/valproic acid + antipsychotic) and probs need hospitalization

Tx fr acute manic episode?

- Lithium: less likeely to have recurrence and reduces intensity/# of future episodes

- Valproic acid

- Antipsychotics: work quicker than lithium

- Carbamazepine

What are some examples of mood destabilizers in Bipolar d/o?

EtOH, steroids, antidepressants

What type of antidepressants are one of the worst mood destabilizers in Bipolar d/o?

TCAs

Tx of acute depressive episodes in Bipolar d/o?

Lamotrigine, quetiapine, olanzapine +/- SSRIs

How are hypomanic episodes different from manic episodes?

Basically the same but hypomanic episodes don't cause social impairment

- Vocation not interrupted

- No psychotic symptoms (delusions/hallucinations)

- No need to hospitalize

The DSM-5 criteria for Bipolar I vs II are very similar with 3 major exceptions. What are they?

- Bipolar I must have Sxs for 7+ days vs Bipolar II is 4+ days

- Bipolar I causes social/vocational interruption whereas Bipolar II does not (hypomania vs mania)

- Bipolar II requires at least 1 MDE whereas Bipolar I does not

What is the preferred first line monotherapy for Bipolar II?

SGAs (risperidone or olanzipine)

*Same as mild/mod Bipolar I

What is cyclothymia?

Less severe depressive and hypomanic episodes than Bipolar II

Which mood d/o is associated with mood cycling that occurs within hours as opposed to weeks or months?

Cyclothymia

True/False: at least 1 hypomanic episode and at least 1 MDE are required for a cyclothymia dx

False: can't have either

What is the DSM-5 criteria for cyclothymia?

Clinically significant periods of hypomanic symptoms without meeting criteria for hypomania and episodes of depressive symptoms not meeting criteria for MDE for at least 2 years and individual has not been without symptoms for more than 2 months

Does REM or SWS start earlier in the night?

SWS; REM

What structure in the hypothalamus is responsible for responding to light and darkness to control cortisol/melatonin release and our circadian rhythms?

Suprachiasmatic nucleus

What are zeitgebers?

Time cues such as social activities, bright lights, exercise, and meals that enhance circadian rhythms

Which hormones are the arousal hormones?

- Serotonin

- Dopamine

- NE

- Ach

- Histamine

- Orexin

- Glutamate

What are the functions of the various arousal hormones?

i) Ach turns on REM sleep and initiates wake cycle

ii) NE, serotonin, and histamine turn off REM sleep and keep us awake

iii) Orexin stabilizes wake/sleep switch and reinforces wake cycle

Which hormones are the sleep hormones?

- Adenosine

- GABA

- Galanin

What are the functions of the various sleep hormones?

i) Adenosine build-up triggers ventrolateral preoptic nucleus to release GABA and galanin

ii) GABA and galanin inhibit arousal areas in hypothalamus and pons to turn on non-REM sleep

A score of what on the Epworth Sleepiness Scale indicates excessive levels of subjective sleepiness?

11+

What is psychophysiologic insomnia?

Disorder of somatosized tension and learned sleep-preventing associations that result in insomnia

What is the DSM-5 criteria for insomnia d/o?

Clinically significant dissatisfaction of sleep quantity/quality at least 3 nights per week, lasting at least 3 months despite adequate opportunity for sleep associated with at least one of the following:

i. Difficulty initiating sleep

ii. Difficulty maintaining sleep

iii. Early-morning awakening with inability to return to sleep

Diagnostics for insomnia d/o?

Polysomnography, labs

Tx for insomnia d/o?

Mainly non-pharm:

- CBT for insomnia (1st line for chronic insomnia in adults)

- Sleep hygiene

- Sleep restriction therapy: set a limit for time in bed

Pharm:

- Benzos: only for short-term use

- Zolpidem: FDA approved

- Ramelteon: melatonin agonist

- Dual orexin receptor antagonists

- Doxepin

Describe the timing of Sxs, motor activity, eyes open vs closed, autonomic activation, and amnesia associated with nightmare d/o

- Timing: last 3rd of night

- Motor activity: none except for jerking awake

- Eyes: closed

- Autonomic: slight activation due to fear

- Amnesia: none (has memory of nightmare)

Describe the timing of Sxs, motor activity, eyes open vs closed, autonomic activation, and amnesia associated with REMm sleep d/o

- Timing: last half of night

- Motor activity: act out complex dreams (can be brief or complex/violent movements)

- Eyes: closed

- Autonomic: associated with REM and motor activity

- Amnesia: none (has memory of event)

Describe the timing of Sxs, motor activity, eyes open vs closed, autonomic activation, and amnesia associated with sleep terror d/o

- Timing: first 3rd of night

- Motor activity: screaming and agitation

- Eyes: open

- Autonomic: extreme with sweating and vocalizations

- Amnesia: yes (no memory of event)

Describe the timing of Sxs, motor activity, eyes open vs closed, autonomic activation, and amnesia associated with sleep walking d/o

- Timing: first 3rd of night

- Motor activity: uhhh yeah

- Eyes: open

- Autonomic: none

- Amnesia: yes (no memory of event)

Are sleep terror and sleepwalking disorders associated with REM or non-REM sleep?

non-REM

What is the DSM-5 criteria for nightmare d/o?

Clinically significant repeated occurrences of extended, dysphoric, and well-remembered dreams that involve threats to survival, security of physical integrity

True/False: PSG is needed for a nightmare d/o dx

False: but can be used to show awakenings from REM sleep

What meds can be used to suppress REM sleep in severe nightmare d/o?

MAOIs or other antidepressants

How can you differentiate REM sleep behavior d/o and sleepwalking d/o in terms of clinical pres?

REM Sleep Behavior D/o

- 2nd half of night

- Wakes clearly and rapidly

- Remembers event

- Eyes closed

Sleepwalking d/o

- 1st half of night

- Wakes confused

- No memory of event

- Eyes open

Which parasomnia d/o is a strong predictor of neurodegeneration in older men?

REM sleep behavior d/o

DSM-5 criteria for REM sleep behavior d/o?

Clinically significant, repeated episodes of arousal during sleep associated with vocalization and/or complex motor behaviors later in the night diagnosed with either sleep study (REM sleep w/out atonia) or concurrent neuro d/o (Parkinson's, eg.)

Patient presents with repeated occurrences of abrupt arousal from sleep with panicked screams, rapid breathing, and sweating. Their partner says they are confused/disoriented upon waking. What is the likely dx and during what phase of sleep do you expect to see arousals on PSG?

Sleep terror d/o; arousals during SWS (non-REM)

True/False: sleep terror d/o and sleepwalking d/o belong to the same DSM-5 dx of Non-REM Sleep Arousal d/o

True

What is the pathophys of narcolepsy?

Loss of orexin-producing neurons in lateral hypothalamus leads to loss of stabilization of wakefulness