Psych Final

Anxiety

Common with other mental disorders

Person feels apprehensive, uneasiness, uncertainty, and dread- despite things being good

• This indicates it is a neurochemical disorder

Is a real or perceived to be real

Deep level affects self esteem and worth

Normal feeling, becomes disorder when it interferes with function of living

Mild anxiety

Easy functioning

Tension of day-to-day living

Increased alertness/awareness/focus

Wide perception

Tends to motivate learning and creativity

Only causes slight discomfort and slight physical symptoms, often seen fidgeting

Moderate anxiety

More disturbing, knows something is wrong

Pt is nervous and agitated

Focuses on immediate concerns, not worried about the future as much

Narrows perceptual field as a person sees, hears, and grasps less

Selective inattention- only certain things are seen and heard unless something else is pointed

• Can learn and problem solve, just not as well- needs direction

Physical symptoms tend to become apparent, including increased muscular tension, restlessness, increased HR, RR, sweating, mild somatic (gastric discomfort, headache, urinary agency)

Severe anxiety

Impairs functioning of life

Client can only focus on 1 specific detail and nothing else

Attention span extremely limited: difficulty completing tasks, learning, think, problem

Tend to feel dazed and confused

Increased physical and emotional symptoms: headache, nausea, dizzy, insomnia, trembling, hyperventilation, impending doom / dread

Panic

Dread and terror- fight, flight, and freeze

Person unable to communicate or function effectively

No learning or comprehension, unable to focus on even 1 detail

May lose contact with reality (psychosis) and may experience hallucinations or delusions

Worsens somatic symptoms

Screaming, running, pacing, shouting, extreme withdrawal, increased vital signs

Anxiety Defense Mechanisms

Automatic coping styles that protect from anxiety

Can be unconscious

Adaptive or maladaptive- depends on the frequency, intensity, and duration

Compensation defense mechanism

Covers up perceived weakness by strongly emphasizing a feature one considers more desirable

Denial defense mechanism

Avoidance of disagreeable realities by ignoring or refusing to recognize them

Displacement defense mechanism

Shift of emotion from a person or object to another, usually less dangerous person or object

Dissociation defense mechanism

The separation of a group of mental or behavioral processes from the rest of the person’s consciousness or identity

Identification defense mechanism

A person tries to become like someone he or she admires by taking on thoughts, mannerisms, or tastes of that person

Intellectualization

Excessive reasoning or logic is used to avoid disturbing feelings

Introjection defense mechanism

Intense identification where a person incorporates qualities or values of another person into their personality

Ex: 8 year old tells 3 year old brother “Don’t scribble” because that is what his parents told him

Isolation defense mechanism

Splitting off of emotional components of a thought, which may be temporary or long term

Projection defense mechanism

Attributing one’s thoughts or impulses to another person

Rationalization defense mechanism

Offering a socially acceptable or apparently logical explanation to justify things

Reaction formation defense mechanism

Development of conscious attitudes and behaviors that are opposite of what one really feels or would like to do

Ex: a married woman who is attracted to her husband’s friend is rude to him

Regression defense mechanism

Retreat to a behavior characteristic of an earlier level of development

Repression defense mechanism

Exclusion of thought from awareness

Primary ego defense

Involuntary

Splitting defense mechanism

Viewing people as all good or all bad

Sublimation defense mechanism

Acceptance of socially approved substitute goal for a drive whose normal channel of expression is blocked

A man is normally impulsive and aggressive, so he joins the football team and becomes the star tackle

Suppression defense mechanism

Intentional exclusion of material from consciousness

Voluntary

Undoing defense mechanism

Act or communication that partially negates a previous one

Anxiety risk factors pathological

Genetic

Panic/OCD- abnormality in gene that controls proteins chocysotkinin, causing panic attacks

Social anxiety

Specific phobias

Pregnancy and stress- new factors

Neurotransmitters + receptor sites- decrease in GABA, increase in norepinephrine, and decrease in serotonin subtypes

Amygdala/limbic system, hippocampus

Anxiety risk factors psychological

Psychodynamic (Freud)- unconscious childhood conflicts- repressed

• Unsatisfactory parent-child relationship (conditional love)

Interpersonal (Sullivan)- early needs go unmet, anxiety early in life then is the model for anxiety later in life

Cognitive- fault, distorted, counterproductive thinking and perceiving

Behavioral- learning (anxiety is contagious), passive (unknowingly staying away) + active avoidance (engage in behaviors that provide relieve bc you can’t avoid)

Separation anxiety disorder

Normal at 8 months, peaks at 18 months then declines

Abnormal if there is developmentally inappropriate level of concern of being away from other

• Concern is that the separation will be permanent

Risk factors: previous significant loss through death, change in environment, physical or sexual assault, genetics

Panic attacks

Sudden onset

Rapid, intense, escalating anxiety, apprehension, fear, terror, feelings of impending doom, and intense physical discomfort

Is unpredictable, does not occur immediately before or on exposure to situation that creates anxiety

Must have 4 or more symptoms present- palpitations, sweating, tremors, SOB, feeling of choking, chest pain, abdominal distress, lightheadedness, paresthesias, chills, hot flashes, derealization/depersonalization, fear of dying, fearing of losing control

Panic disorder

Episodes of panic attacks

Can be recurrent or unexpected

Followed by 1 month or more of consistent concern about having another attack, worried about consequences about having another attack, changing behavior due to fear of attacks

Often lead to other symptoms, such as phobias

Varying degrees of anxiety between attacks

Specific phobias

Persistent, irrational fear cued by presence or anticipation of a specific object, activity, or situation

Exposure or just a thought causes immediate anxiety response or panic attack

Persists even if a person knows it is unreasonable

Person tries to avoid restricts life and gets in the way of functioning

Ex: Agoraphobia, social anxiety disorder, selective mutism

Has subtypes: animals, natural environment, blood injection, situation

Generalized anxiety disorder (GAD)

Chronic, unrealistic, excessive anxiety and worry

Occurs more days than not, lasts for 6 months or longer

Causes significant impairment in functioning- person can’t control or focus it

Depression, restless, easy fatigue, difficulty concentrating, irritable, muscle tension, sleep

Obsessive-compulsive disorder

Obsessions- unwanted, recurrent, intrusive, and persistent ideas, thoughts, impulses, or images that cannot be dismissed from the mind, causing anxiety and distress

Compulsions- unwanted repetitive ritualistic behavior patterns or mental acts that are performed repeatedly

Goal of preventing or relieving anxiety and distress caused by obsessions or to prevent a dreaded situation

Severe, occurs more than 1 hour per day

Recognizes that thoughts and actions are unreasonable or excessive, but continues because it provides relief

PANDAS

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections

Acute onset of OCD and/or food restriction and multiple neuropsychiatric symptoms

Symptoms: OCD, severe food restriction, anxiety, emotional liability, depression, irritability, aggression, regressions ect.

Trichotillomania

Hair pulling disorder

Trichophagia- secret swallowing of pulled hair, causing rapunzel syndrome

Dermatillomania

Skin picking disorder

Excoriation disorder

Usually picking face, head, cuticles, back, arms, legs, hands/feet

Leads to pain, sores, scars, and infections

Sense of tension, then full or pick releases and caused gratification

Risk factors: correlation with abuse and neglect, body dysmorphia disorder, and is hereditary

Hoarding disorder

Persistent difficulties discarding or parting with possessions regardless of value

May have excessive need for acquiring items

Gets more severe with age

Associated with perfectionism, indecisiveness, anxiety, depression, and difficulty planning and organizing tasks

Treat with therapy and SSRIs

Body dysmorphic disorder

An exaggerated belief that body is deformed or defective in some specific way

Repetitive behaviors present (mirror checking, camouflage)

Insight varies, pt may know this is exaggerated

High suicide risk, response to tx limited

Common w a history of abuse or neglect

If has to do with weight, causes eating disorder

Anti anxiety medications treatment

Antidepressants (1st line): SSRI, SNRI

Noradrenergic agents/ Antihypertensive: Beta blockers, Alpha 2 receptor agonists

Antianxiety agents: Anxiolytics, Benzodiazepines, Nonbenzodiazepine, antihistamines,

Anxiolytics

Depress levels of the CNS, increases GABA (calming)

Do not give with other CNS depressants, if pregnant or lactating

Interacts with alcohol, narcotics, herbal depressants, Kava Kava and Valerian Root

Benzodiazepines

Quick onset, can cause drowsiness, confusion, lethargy, ataxia, reduced motor coordination, sedation, hangover effects, orthostatic hypotension, paradoxical excitement, dry mouth, N/V

High risk of abuse

Must wean off

Ex: Xanax, Valium, Ativan, Librium, Serax

Nonbenzodiazepine

Buspirone (BuSpar)

Does not depress CNS

A serotonin receptor/ partial agonist

Long term tx, taken regularly, 2-4 week onset of action

No potential for abuse

Can cause dizziness, orthostatic hypotension, headache, drowsiness, nausea, paradoxical excitement, dry mouth

Antihistamines

Hydroxyzine (Vistaril), diphenhydramine (Benadryl)

Safe, nonaddictive

Can cause drowsiness, confusion, lethargy

Nonbenzodiazepine medications

Sedative-hypnotic

Zaleplon (sonata), Zolpidem (Ambien)

Fast onset, taken before bed

Short term use as a sleep aid, usually taken few days to 2 weeks

Stopping use suddenly can cause withdrawal

Can cause strange sleep-wake states, binge eating, sleep walking, driving while asleep

Can cause hallucinations, abnormal behavior, severe confusion, suicidal thoughts, vivid or abnormal dreams, daytime drowsiness, dizziness, ataxia, double vision or other vision problems, agitation

Anorexia nervous

Highest mortality rate of all mental illnesses

Chronic, at 1 year, relapse rate is at 50%

Mostly females (12-30 years)

Refusal to maintain normal weight for age and height (less than 85% expected/ BMI <17.5)

Extreme fear of obesity and weight gain even though underweight or emaciated

Pt usually denies seriousness of disorder

Gross distortion of body image, preoccupation with food and handling

Different types- restricting or binge eating/purging types

Can cause electrolyte imbalances, EKG changes, deadly arrhythmias, bradycardia, hypothermia, hypotension, hypoglycemia, metabolic changes (amenorrhea, abnormal thyroid functioning), peripheral neuropathy, acrocyanosis, lymphocytosis, osteoporosis, elevated cholesterol, proteinuria, depression, anxiety, OCD

Bulimia nervosa

Late adolescence or early adulthood

Repeated uncontrolled compulsive rapid ingestion of large quantities of food over a short period of time (binging) followed by inappropriate compensatory behaviors to rid body of excess calories (purging)

Once a week for 3 months

Severity based on how many times a week purging occurs

Can be with MDD, bipolar, anxiety, personality disorder, substance abuse

Can cause weight fluctuations, dehydration, electrolyte imbalance, EKG changes, arrhythmias, tooth enamel erosion, dental caries, loss of dental arch, tears in esophagus, enlarges parotid glands, increased amylase levels, gastric dilation/rupture, abdominal calluses from fingers, loss of gag reflex, aspiration pneumonia, frequent heartburn/indigestion, cardiomyopathy

Russell’s sign

Risk factors for anorexia and bulimia

Unknown, linked to chromosomes 1, 2, and 13

Can be possibly due to hypothalamic dysfunction (hypothalamus regulates body’s ability to detect hunger)

Impaired dopamine regulation (dopamine release triggers anxiety rather than pleasure)

Endogenous opioids in spinal fluid (some gain weight when given narcan, which is an opioid antagonist)

Loss of serotonin and norepinephrine (SSRIs help)

Binge eating disorder

Repeated episodes of uncontrolled binge eating with significant distress

Does not use compensatory behaviors

Leads to obesity

Genetic link

Feeding disorders

Common in young children

Pica- persistent eating of substance with no nutritional value (dirt, paint, paper clips)

• Objects undigested and become dangerous + cause intestinal blockage

Rumination disorder- undigested food being returned to mouth, then rechewed, reswallowed, or spit out

Diabulimia

Eating disorder where someone with T1D withholds insulin to lose weight

Increase risk of death and escalation of diabetes complications

Eating disorder treatment

#1-restore nutritional status (careful or else refeeding syndrome)

Behavior modification

Cognitive therapy- confront ED brain

Family therapy

Individual therapy

Refeeding syndrome

Imbalance of electrolytes and fluid shifts

Rapid discharge of insulin causes a decrease in phosphorus

Can cause weakness, swelling legs/feet, difficulty breathing, altered mental status, seizures, heart failure

Can lead to death, need to refeed slowly and supplement electrolytes

Dialectical behavior therapy (DBT)

Uses concepts of cognitive, behavioral, and eastern mindfulness practices to target problem behaviors and increase ability to manage distress

Autism spectrum disorder

Alteration in communication and behavior

Occurs before age 3, ranges in severity

Deficits in social communication and interaction, relationships, and verbal matters

Stereotypical restricted/repetitive behavior (movements, speech, rituals, routines, fixated interests, hyporeactivity or hyper reactivity to sensory imput)

Exact cause unknown, genetic abnormality, having a sibling with disorder, having certain genetic conditions (Downs, fragile x, and Rett), low birth weight

Early intervention with therapeutic programs is key to treat, ensure structure in rules,

Autism spectrum disorder medication treatment

Recommended for short term treatment of aggressive behavior such as temper tantrums and self injurious behaviors

Risperidone (Risperdal)- age 5 and older

Aripiprazole (Abilify)- age 6 and older

SSRIs- mood and anxiety

Stimulants- hyperactivity, impulsivity, inattention

Balovaptan (RG7314)- break through therapy,

Attention-deficit-hyperactivity disorder (ADHD)

Inappropriate degree of inattention, impulsiveness, and hyperactivity

Symptoms appear before age 12, and last at least 6 months to be diagnosed

Has a genetic link, increase in dopamine, norepinephrine, and serotonin, RED 40

ADHD medications

Stimulants- amphetamines (adderall)

Nonstimulants- atomoxetine (Strattera)

Antidepresssants- bupropion (Wellbutrin)

Antipsychotics- divalproex (depakote)

Meds can cause insomnia, anorexia, upset stomach

Ensure drug holidays (summer)

Oppositional defiant disorder (ODD)

Angry and irritable mood

Defiant/argumentative, passive aggressive behavior

Vindictive behavior-spiteful

Social issues, conflicts with authority, academic issues

Sees others as making unreasonable demands, does recognize others have rights and there are rules

Commonly with ADHD

May become conduct disorder later on

Personality disorder

When personality traits become inflexible and rigid, causing maladaptive patterns of behavior and functional impairment

Divided into 3 clusters (A,B,C)

Can co-occur with depression, anxiety, eating + substance use disorders, ect.

Personality disorder clusters

Cluster A- odd or eccentric traits (paranoid, schizoid, schizotypal)

Cluster B- dramatic, emotional, or erratic traits (antisocial, borderline, histrionic, narcissistic)

Cluster C- Anxious or fearful traits (avoidant, dependent, Obsessive-compulsive)

Borderline Personality Disorder

Emotionally unstable personality disorder

Emotional instability, troubled relationships, and shifting self-image

Impulsivity, recurrent suicidal behavior, emotional dysregulation/lability

• Treat wounds in matter of fact way, do not offer sympathy

Usually a trauma response, can be genetic or due to a decrease in serotonin

Primary defense mechanism

Splitting- cannot view a person with negative or positive aspects, all or nothing, good or bad, no middle ground

Borderline personality disorder treatment

Teamwork and safety

No medications, only off-label uses

CBT, DBT, schema-focused therapy

Anti-social personality disorder (sociopaths)

Diagnosis reserved for adults but has aspects since age 15

Deceitful/manipulative for personal gain

Hostile if needs are blocked

Lack of remorse, no empathy, callousness

Can be due to genetics, low serotonin and high dopamine, and childhood abuse/ACE

Treat with CBT, DBT, and MBT (recongize and understand mental states)

Paranoid personality disorder

Longstanding mistrust and suspiciousness

Believes others are exploiting, harming, deceiving, or taking advantage

Pt is on guard, hypervigilant, tense, irritable

Pt will avoid others, test their honesty, is envious and hostile toward others with success

Over sensitive, misinterprets cues in environment, magnify and distorts them

Caused by genetics, parents (antagonism and harassment)

Histrionic personality disorder

Colorful, dramatic, and extroverted behavior, excitable and emotional

Difficult maintaining long-lasting relationships

Require constant affirmation and acceptance, can’t provide other with sustained affection

Attention seeking, seductive/flirtatious, manipulate and exhibitionistic

Somatic complaints

Can cause psychosis if extreme stress

Narcissistic personality disorder

Exaggerated sense of self worth (grandiose), arrogant, sense of entitlement

Lack of empathy, hypersensitive to evaluation of others

Deserve special consideration to needs, exploits others and impairs relationships

Fragile self esteem, sensitive to criticism

Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

Caused in early childhood, needs were met with criticism of neglect

• Parents were narcissistic and over-indulged

Avoidant personality disorder

Sensitive to rejection, socially withdrawn life

Avoids all situations that require interpersonal contact

Not antisocial, has a strong desire for companionship

Awkward and uncomfortable in social situations, view others as critical, betraying, and humiliating

Speech is slow and constrained, frequent hesitations and fragmented thoughts

Pt has depression, anxiety, and anger

Cause is hereditary, by parental rejection

Dependent personality disorder

Extreme dependency, excessive need to be taken care of

Submissive/clinging behavior, fear of separation

Feel helpless and lacks self confidence

Tolerates mistreatment, lets others make decisions or needs excessive amounts of reassurance

Overly generous and underplays self

Avoids disagreements dt fear of loss of support or approval

Cause is due to dependent temperament, stimulation/nurturance exclusively from one source, parent overprotective and discourage independence

Somatic symptom disorder

Physical symptoms present but has no organic pathology found

Excessive concern with persistent thoughts and fear about seriousness of symptoms- high anxiety getting in way of life

Sx include chest pain, fatigue, dizziness, headache, swelling, back pain, shortness of breath, insomnia, abdominal pain, numbness

Client feels misunderstood and does not perceive self as having a psych issue

Illness anxiety disorder

Excessive worry or fear of the possibility of having a disease

Causes frequent scanning of body, very in touch with body sensations

Unrealistic or inaccurate interpretation of physical sensation feeds into preoccupation or fear or having a serious disease

Fear disabling despite reassurance

Has no pathology only obsessive and intrusive thoughts

Actual symptoms are minimal or absent

Care seeking type of care avoidant type

Conversion disorder

AKA functional neurological disorder

Pseudoneuological= symptoms with no diagnosis

Loss of or voluntary sensory functions resulting from a psych conflict or stressor

NO MEDICAL CAUSE

Paralysis, blindness, deafness, movement or gait disorders, numbness, episodes resembling epilepsy

Primary (reduction of anxiety by converting it to physical symptom) and secondary (external benefits or advantages from being sick) gains

La belle indifference

Factitious disorder

Munchausen syndrome

Conscious and intentional, can be physical or psychological

Dramatic presentation with medical terms, often demanding

Negative test results, usually new symptoms

Pt doctor shops

Munchausen syndrome by proxy

Malingering

Conscious/intentional

Exaggeration of symptoms for secondary gains, disability compensation, insurance fraud, evading military service, reduced prison sentence

Often with antisocial/borderline personality disorders

Post traumatic stress disorder

Exposure to actual or threatened event that person responded with intense fear, helplessness, or horror

Can be brought on by indirect exposure

Persistent re-experiencing of event

Flashbacks

Pt avoids stimuli associated with trauma

Pt has cognitive issues, hyperviglience and exaggerated startle response

Symptoms must be present for more than 1 month

Reactive attachment disorder

Inhibited- emotionally withdrawn behavior

Does not seek comfort when distressed

Caused by a lack of bonding with primary caregiver by 8 months old

Disinhibited social engagement disorder

Remarkably friendly and confident

No fear of strangers

No boundaries with strangers

Unfazed by separation w adult caregivers

Attaches to everyone but not truly with anyone

Adverse childhood experiences (ACE)

Events that disrupt a child’s brain development

Allostatic overload causes exaggerated inflammatory responses in the brain

Can change DNA and cause cancer

Kids- No meds, SSRI may help

Adults- SSRIs

Derealization disorder

Depersonalization

Characterized by persistent feelings of unreality, detachment, 3rd person POV

Has intact sense of reality

Treat with antidepressants, mood stabilizers, anticonvulsants, antipsychotics

Dissociative amnesia

Inability to remember important personal info that is too extensive to be due to normal forgetfulness or condition

Localized-unable to recall incidents associates w traumatic events

Selective- can recall only certain parts associated with event

Generalized- relating to identity and life history

Dissociative fague

Person suddenly and unexpectedly wanders away and has memory loss

Can’t recall past or ID

Assumption of new ID common

Dissociative identity disorder (DID)

Two or more distinct personalities

Switching- transition from one personality to another, usually sudden, often dramatic, and usually precipitated by stress

One personal usually dominant

Defense mechanism