J Psych CM

T/F: by consensus a formal diagnosis of a “Personality Disorder” can NOT be made before the age of 18

T

1st line tx for paranoid personality

psychotherapy

differences b/w PPD and schizophrenia

PPD: suspicious, NO active delusions (false, fixed ideas) or auditory hallucinations. NO impaired reality testing

People with PPD may experience brief, mini-psychotic like episodes when under significant stress though

difference between schizoid (SPD) and schizotypal (STPD) personality disorder

SPD: avoid social interactions/lack interest. do NOT have cognitive distortion/eccentricities. emotional flatness.

STPD: desire relationships but struggle w/ anxiety, bizarre/idiosyncratic thinking, beliefs, behaviors. DO have cognitive distortions and eccentricities (magical thinking). have anxiety, paranoia, possible intimidation or aggression to others

how to distinguish between Borderline Personality Disorder and Histrionic Personality Disorder?

Borderline patients are generally more depressed and suicidal

Histrionic patients are generally more functional and want praise

how to distinguish between Dependent Personality disorder (PD) and Avoidant PD?

Avoidant PD patients are slow to get into relationships

Dependent PD patients aggressively seek relationships out

OCPD vs. OCD

OCPD: NO obsessions.compulsions. unaware of or don’t care they have “Problems”. MAY respond to SSRIs.

OCD: HAVE recurrent obsessions/compulsions. aware and distressed by problems. OFTEN respond to SSRIs

avoidant PD affects men and women _

equally

overt parental deprecation OR overprotection; phobias in parents

distinguish between Social Anxiety Disorder and Avoidant PD

• Avoidant PD is fear of rejection and affects more areas of life

• Social Anxiety Disorder is fear of embarrassment in a particular setting (such as giving a public presentation)

when was prolonged grief disorder was placed in the “Trauma & Stressor Related Disorders” category?

2023

what is useful in tx of OCD and social anxiety?

SSRIs/SNRIs

benzo role, when are they used, when not and why?

enhance, augment GABA type A receptors

→ only used if severe/acute life threatening emergency otherwise NOT 1st line d/t potential for addiction

what should you do when an individual has anxiety and separate unrelated medical condition?

ALWAYS r/o possible organic etiologies

You can begin treatment for a severe anxiety disorder while still working up other causative or contributory medical factors

1st line tx for specific phobias

Exposure / desensitization therapy is first-line treatment here

tx for social anxiety disorder and its SE

Tricyclic antidepressants (TCAs)

antichol, can be fatal in overdose, not as effective as SSRIs

PTSD sx manifestations

within a week of the traumatic event,

OR years after the event, being triggered by a similar event, sound, sight, etc.

What is the difference between Acute Stress Disorder and Adjustment Disorder?

Acute Stress Disorder: exposure to actual death, injury, violence. has at least 9 sx of PTSD. lasts few days to less than a month

Adjustment Disorder": identifiable nonthreatening stressors (job loss, divorce) within 3 months of stressor → distress but max 6 mos

risk factors for suicide and _ of depressed patients will ultimately die by suicide

discharge from psych inpatient

• 15+% of depressed patients will ultimately commit suicide (closest # to 15% would be accurate)

tx for atypical depression (first line and other)

TOC: MAOIs (monoamine oxidase inhibitor) 1st line

SSRIS (not FDA approved for this preferred because they are safer)

before starting antipsychotic medications, what do you do?

get a baseline:

EKG

Blood glucose

Lipids

BMI and waist circumference

Factitious Disorder, primary goal, another name?

• mental illness is real

• pain and suffering is manufactured by pt → gets taken care of (primary goal)

• bona fide mental illness/somatic sx related disorder

illness anxiety disorder, when can you make this diagnosis?

SEVERE PREOCCUPATION with having a serious, undiagnosed medical illness

You can only make these diagnoses when ALL other testing has proven negative consistently

(feels pain)

FUNCTIONAL NEUROLOGIC SYMPTOM DISORDER, how to test?

NEUROLOGICAL symptoms that are found to be incompatible with neurologic pathophysiology

Testing by different methods, look for inconsistencies in PE

(feels pain)

factitious disorder - pain, psych, name, purpose of lying?

• no pain, real psycho-pathology

• bona fide mental illness

• purpose of lying: to be treated/to be cared/pitied by medical staff

malingering - pain, mental disorder, purpose?

• NO pain

• deliberate manipulation

• NOT a mental disorder

• purpose of lying: to get something (money, comp, drugs)

does social (pragmatic) communication disorder have behavioral problems? what do they struggle with?

No behavioral problems (as we would see in Autistic Spectrum Disorder (ASD))

communication difficulties

ABC: The triad of clinical features associated with Autism:

A SOCIAL

B BEHAVIORALLY RESTRICTED

C OMMUNICATION IMPAIRED

Treatments for Autistic Spectrum Disorder, most effective

• multidisciplinary support

• most effective: behavioral tx (autism specialists, language path, audiologists)

• remediation and psychotherapy

What is the difference between Autistic Spectrum Disorder (ASD) & Social [Pragmatic] Communication Disorder (SCD)?

• ASD: struggle w social communication AND behavior

  • repeated/disruptive movements (flapping, rocking)

  • obsessive fixation on routine/rituals

  • putting things in order

primary sxs for ADHD (IHI)

• Inattention

• Hyperactivity

• Impulsivity

T/F: neuroimaging is diagnostic for ADHD

F

ADHD dx

clinical

Tx for ADHD (non-pharm)

• Psychotherapy: Early intervention works best; behavioral interventions should be tried first

  • Behavioral therapy

  • Social skills training

  • School-based interventions.

pharm tx for ADHD - when is it done, what is first line?

only when behavioral intervention insuff/cleared indicated

#1 line: CNS stimulates (ritalin, adderall, dextroamphetamine)

#2: SNRI (strattera - not a controlled substance), wellbutrin, or venlafaxine (SNRI)

advantage for strattera (ADHD)

not a controlled substance

venlafaxine MOA

increases 5HT & NE levels in the CNS

dextroamphetamine MOA

effect on DA => more DA availability

MOA of buproprion, risk?

NRDI

INC in dopamine

can lower seizure threshold

SE of CNS stimulants for ADHD

Appetite suppression,

insomnia,

dysphoria,

irritability,

VS & BP fluctuations 

oppositional defiant disorder - can be defined by? what is it? how long?

• Can be identified by age 3, (up to age 5)

• A pattern of defiant, angry, negative behavior for >6 months

intermittent explosive behavior - identified by, definition, a “hallmark”?

• Can be identified by age 6 (up to age 12)

• Recurrent behavioral outbursts; a failure to control aggressive impulses.

• Verbal aggressions: such as temper tantrums are followed by physical aggression toward property, animals, people

conduct disorder - definition, age, after 21?

• Aggression and violation of the rights of others: bullying, threatening or intimidating others => sometimes a precursor to adult Antisocial Personality Disorder

• Can be identified by age 13, (up to age 18

• After 21, => antisocial personality disorder

• A repetitive pattern of antisocial behavior, physical aggression, cruelty to animals, verbal abuse, violence, promiscuity, theft, deceit, lack of remorse or regret

most common cause of intellectual developmental disorders

down syndrome (Trisomy 21)

down syndrome classifications

causes of intellectual disabilities

1. Tay-Sach’s Disease

2. Phenylketonuria

3. Fragile X chromosome

4. Prader-Willi syndrome

5. Rett’s disorder

6. Lesch-Nyan syndrome

cause of tay sach’s disease (Phenylketonuria)

inborn errors of metabolism

cause of down syndrome

3 chromosome

genetic etiology of fragile X syndrome

mutation of X chromosome

genetic etiology for prader-willi syndrome?

Deletion fragment, chromosome 15

genetic etiology for rett’s disorder?

cerebroatrophic hyperammonemia

genetic etiology for lesch-nyan syndrome?

enzyme deficiency for purines

Strongest predictor of biological risk for health problems

Having a lower level of neighborhood “affluence” in childhood or adolescence

sleep wake disorder is assoc with a lack of

orexin

severity of a personality disorder depends on 3 things

Frequency (of the manifestations), intensity, and duration

Styles → Traits → Disorders

Cluster A (ODD & Eccentric): PSS (personality disorder)

Paranoid PD

Schizoid PD

Schizotypal PD

Cluster B (dramatic, emotional, unpredictable, erratic): BAHN (personality disorder)

• Borderline PD

• Antisocial PD

• Histrionic PD

• Narcissistic PD

Cluster C (anxious, scared, fearful): DOA *personality disorder cluster)

• Dependent PD

• Obsessive Compulsive PD

• Avoidant PD

Paranoid Personality - SUSPECTS

S - suspicious of others

U - unforgiving and bears grudges

S - spousal fidelity questioned for cheating

P - perceives attackers

E - envious and jealous

C - cold affect; criticism disliked very much

T - trust in others is minimal, if any

S - self referential, “everything that’s going on is about me”

Schizoid Personality - DISTANT

D - detached from other with a flat affect

I - indifferent to praise or criticism, “don’t care,” nothing matters

S - sexual drive, libido very reduced

T - tasks done alone by choice

A - absence of close friends by choice

N - no emotional responsiveness

T - takes very little pleasure in doing anything

Schizotypal Personality - RECS

R - reduced capacity for love or close relationships

E - eccentric behavior marked; identifiable to anyone

C - cognitive and perceptual “magical” distortions, severe and prominent, occasional staring, threatening looks

S - strikingly odd appearance, face may appear threatening

Borderline Personality - AM SUICIDE

abandonment is extremely feared

M - mood instability

S - suicidal/parasuicidal behaviors, mostly attention seeking

U - unstable relationships

I - impulsivity

C - control of anger/emotions extremely poor

I - intensely ambivalent relationships

D - disturbed sense of self and personal identity

E - emptiness feeling that is chronic, and can never get fulfilled

Antisocial Personality - CORRUPT

C - callous

O - others are always to blame

R - reckless disregard for others

R - remorseless

U - underhanded

P - poor planning/impulsive

T - /tendency to violate the rights of others for personal gain

Histrionic Personality - PRAISE

P - provocative behaviors

R - real concern for physical attractiveness

A - attention seeking even during solemn events (i.e. wearing red to a funeral)

I - influenced easily

S - shallow, seductive and very inappropriate

E - exaggerated emotions, egocentric and vain

Malignant Narcissism

Narcissistic Personality Disorder + Antisocial Personality Disorder

Not a formal diagnosis but a term frequently used for an extreme blended personality disorders, more dramatic, even public, destructive for everyone

Dependent Personality - RELIANCE

• R - reassurance required at all times

• E - expressing disagreement is difficult

• L - lack of any self confidence

• I - initiating conversations or projects is difficult

• A - abandonment is feared

• N - needs others to assume responsibilities

• C - constant companionship sought

• E - exaggerated fears

Obsessive-Compulsive PD - LAW FIRMS

• L - loses the point of an activity or relationship due to preoccupation with detail

• A - ability to complete anything is compromised due to perfectionism

• W - workaholic at the expense of others

• F - fussy can’t see the big picture

• I - inflexible

• R - rigid, unyielding even when proven wrong

• M - meticulous attention to detail to the point of not getting anything finished

• S - stubborn

Avoidant Personality - CRIES

• C - certainty/guarantee of being liked before becoming involved with anyone 

• R - restriction to lifestyle in order to maintain security

• I - inadequacy felt

• E - embarrassment potentially prevents involvement in new activities

• S - social inhibition, slow to get into relationships, shy

Adjustment Disorders

excessive emotional or behavioral overreaction to a specific life stressor, like a breakup or job loss.

The symptoms must begin within 3 months of the stressor and completely resolve within 6 months after the stressor ends.

Generalized Anxiety Disorder, pertinent negatives

•It is NOT episodic (as seen in panic disorder)

•It is NOT situation-specific (as seen in specific phobias)

•It is NOT focalized to one place or time

•It is NOT due to an underlying medical illness

•It is NOT due to substance intoxication or withdrawal

Tx for GAD - benzos?

Benzodiazepines (BZDs), for very short-term or urgent adjunct use ONLY (so to avoid *habituation, tolerance and dependence).

BZDs are NOT considered to be a first-line choice. They are useful in emergency situations or until the SSRI becomes effective

GAD - WATCHERS

• W = worry,

• A = autonomic hyperactivity

• T = tension in muscles/tremors

• C = concentration difficulty/chronic aches

• H = headaches/hyperventilation

• E = energy loss

• R = restlessness

• S = startles easily/sleep disturbance

panic attack - how long does it last?

• only one SYMPTOM of a “PANIC DISORDER”.  It is NOT a DSM diagnosis by itself.  

• A panic attack is a rapid-onset episode of extremely intense anxiety that develops abruptly, usually PEAKS WITHIN 10 MINUTES and usually LASTS <60 MINUTES.

• Panic Attack = Sympathetic Overdrive

panic attack symptoms

Dizziness; trembling; choking sensation; tingling in hands; sweating; shortness of breath; chest discomfort; chills or hot flashes; fear of losing control; fear of dying; palpitations; increased heart rate; nausea; abdominal distress; feeling detached from oneself (depersonalization) or feeling “unreal” (derealization)

greatest RF for panic disorder

FH

tx for panic disorder - first term and emergency?

SSRIs, first-line use and appropriate for long-term, maintenance use

Benzodiazepines for EMERGENCY USE ONLY: SHORT-TERM, ACUTE, URGENT (NOT first line)

OCD summary

anxiety disorder characterized by a combination of intrusive thoughts (obsessions) and intrusive behaviors (compulsions).

Equal in men and women

Recognize their thoughts as their own, recognize the absurdity, cannot stop themselves

if on a ceiling dose of a bzd (esp. xanax), what do you do?

move to hospital for a controlled detox and start med treatment over again

Screen for PTSD - TRAUMA

• T= traumatic event (s)

• R = re-experiencing the event

• A = avoiding behaviors

• U = unable to function, (emotional numbness)

• M = more than 1 month of symptoms

• A = increased arousal patterns (hypervigilance)

Acute stress disorder- symptoms occur _?

Symptoms occur within 1 month of the traumatic event and last only up to 30 days thereafter

prolonged grief disorder (PGD) tx

It should be noted that both Prolonged Grief Disorder and Major Depressive Disorder should be diagnosed if criteria for both are met.

MDD w/ tx and not getting better → check into the hx some more

Would tx MDD w/ SSRI and leave PGD to be tx with psychotherapy

ANHEDONIA

loss of interest in normally pleasurable activities. <<

One of the core symptoms of depression along with low mood (#1)

very high mood

mania

high mood

hypomania

normal mood

euthymia

low mood

dysthymia

very low mood

depression

MDD episode criteria

5 or more depressive sx for at least 2 weeks & representing a change from previous functioning. 

This causes significant impairment in functioning. 

One symptom must be depressed mood  (NOT associated with normal bereavement)

The _ hormone influences many bodily processes, meaning that high levels can cause various symptoms that can also present in depression

T4

relationship between thyroid function and depression

Patients with thyroid disorders are more prone to develop depressive symptoms

- and –

depression may have subtle thyroid abnormalities.

• High T4 (thyroxine) levels

• Low T3

• Blunted TSH response to TRH

risk of suicide with tx of MDD

If a patient's treatment is undertreated (not a high enough dose, wrong medication, or insufficient therapy), their risk of suicide is just as high as someone getting no help at all

suicide in women and women

Men COMMIT - suicide 3x more often than women

Women ATTEMPT - suicide 4x more often than men

suicide methods men vs. women

Men are more VIOLENT AND LETHAL; tend to use firearms, hanging

Women are more PASSIVE AND POSSIBLY LETHAL; tend to use overdose of (psychoactive) drugs, or wrist cutting (not along the course of the artery)

suicide age men vs. women

MEN: suicide rate peaks after 45

WOMEN: suicide rate peaks after 65

*Older persons attempt suicide less often, but if they do, they are more determined and successful.

spousal deaths and suicide relationship

Death of a spouse increases risk of suicide PROFOUNDLY

For women, having young children at home is protective against suicide; BUT this is not true for men

If someone shares this information with you then take the time to truly speak with them

MDD notes

• 66% of depressed patients have serious suicidal ideation

• As energy improves with treatment, patients can become MORE suicidal.

• An untreated depressed episode lasts ~10-11+ months

• 80% of patients have a 2nd episode within the first 6 months

• Average number of major depressive episodes in a lifetime is 5

• With each successive depression, the treatment becomes increasingly difficult.

in Twin studies for MDD, how many (%) is explained by genes?

50-70%

3 neurotransmitters lowered in MDD

norepinephrine

serotonin (5HT)

dopamine

noepinephrine in depression, tx

• downregulated OR decreased sensitivity

• low levels of MHPG (the principle metabolite of NE)

• tx: effexor (venlafaxine) has an noradrenergic effect (inc functional NE)

serotonin deficiency in depression, tx

low levels of 5-HIAA (serotonin metabolite) is assoc with violence, suidicide

SSRIs inhibit the reuptake of serotonin, allowing more to be available at synaptic cleft

dopamine in depression, tx

DA reduced in depression (but INC in mania)

wellbutrin has a dopaminergic effect → INC DA