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Psych: stuff looked up / learned

General Psych
Axes (DSM) Axis I: Clinical syndromes Axis II: Developmental (MR, etc) / Personality disorders (cluster A/B/C) o Cluster A (the " eird"): paranoid, schi!oid/schi!otypal o Cluster B (the " ild"): antisocial, "orderline, histrionic, narcissitic o Cluster C (the " orried"): avoidant, dependent, #CD Axis III: Physical conditions ($%&, A%Ds, "rain in'ury, other med conditions that could "e contri"utin() Axis IV: Psychosocial stressors Axis V: $i(hest level o) )unctionin( in last year and level no (ho is li)e a))ected)

Personality disorders
Cluster A Schi oid: *oner, )lat a))ect, restricted emotions, indi))erent to interpersonal relationships, no psychotic symptoms, not (ood ith personal interaction, computer nerd+ ,se a lo -.ey, technical approach hen discussin( care+ Schi otypal: odd, eccentric, ma(ical thin.in(, paranoid, not psychotic+ Pro'ection, re(ression, )antasy are de)enses+ /tay non'ud(mental as therapist Paranoid: distrust)ul / suspicious0 constricted a))ect+ Pro'ection is de)ense+ 1ry to )orm alliance ith patient+ 2o true delusions / hallucinations or.in(

Cluster ! "istrionic: e3cessively emotional, attention-see.in(, theatrical, over"lo n speech, seductive manner+ Reaction )ormation is de)ense #arcissistic: sel)-important, needs admiration, dismisses others4 )eelin(s, secretly lo sel)esteem+ %) they see. treatment, it4s pro"a"ly "ecause they4re an(ry that they4re not (ettin( the credit that they deserve, etc+ Antisocial: no empathy, actin( out, a((ressive, conduct disorder as child, usually starts up "y a(e 56, need to "e $% y/o for dx Conduct disorder: 7 s3 in last 58 mo, 5 in last 9 mo o): a((ression to ard people / animals, destruction o) property, the)t / deceit)ulness, rule "rea.in( (can have more than 5 in a cate(ory), need to "e youn&er than a&e $% (enerally Can develop so'ati ation disorders

!orderline: impulsive, unsta"le relationships, a))ective insta"ility, can "e transiently psychotic+ /plittin(, pro'ection are de)enses+ Dialectical (eha)ioral therapy is speciali!ed co(nitive therapy )or BPD

Cluster C *CPD: per)ectionistic control )rea., really into order, no o"sessions or compulsions, may "e really into or.+ Reaction )ormation is de)ense A)oidant: hypersensitive to criticism / re'ection, socially uncom)orta"le, see.s interpersonal relationships "ut uncom)orta"le doin( so, may"e a very )e close )riends Dependent: su"missive, clin(y, needs to "e ta.en care o), :(o De)enses Pro+ection: pt attri"utes their thou(hts to another (an(ry ith therapist; accuse therapist o) "ein( an(ry at you<) ,eaction for'ation: deal ith emotional con)lict "y su"stitutin( the opposite (e+(+ an(ry at hus"and; coo. him a nice dinner<) So'ati ation: e3press your pro"lems as physical complaints ()orm o) re(ression - e+(+ (et headache hen you4re upset ith therapist) Ideali ation: attri"ute e3a((erated positive =ualities to others to deal ith con)lict De)aluation: opposite o) ideali!ation0 e3a((erated ne(ative =ualities Isolation of affect: separate ideas )rom )eelin(s (lose touch ith )eelin(s a"out an event "ut retain descriptive details) ,ationali ation: deal ith emotional con)lict / stressors "y concealin( true motivations -ndoin&: use ords or "ehavior to ne(ate / sym"olically ma.e amends )or unaccepta"le thou(hts / )eelin(s / actions (realistically or ma(ically associated ith con)lict - e+(+ don4t step on crac.s to avoid ""rea.in( mother4s "ac.") Actin& out: use actions rather than re)lections / )eelin(s to (uard a(ainst stressors / con)licts (e+(+ an(ry; start a )i(ht at a "ar<) Dissociation: deal ith con)lict / stressors "y "rea.do n o) normal consciousness splittin( o)) (e+(+ )eel li.e events are "ein( told to someone else a)ter son .illed in car crash) ,epression: distur"in( stu)) (ets pulled into unconscious (can4t remem"er hat trou"lin( thin(s ere said, etc) Suppression: don4t deal ith )eelin(s / ideas, "ut still in conscious a areness (actively tryin( to )or(et) Denial: don4t ac.no led(e con)lict / stressors - ar(uin( that they don4t e3ist instead o) dealin( ith them Displace'ent: ta.e out impulses on less threatenin( tar(et (e+(+ dad as alcoholic, dtr no has con)lict ith "oy)riends) Su(li'ation: actin( out impulses in socially accepta"le ay (e+(+ a((ressive; "e a "o3er<) ants others to ma.e decisions

Mood Disorders

Depression
.SI/ 0 CAPS. - Depression )eatures

Sleep Interest (decreased) /uilt

0ner(y

Concentration Appetite Psychomotor retardation Suicidal ideation

Suicide: .SAD P0,S*#S. (most at ris.) Se3 (male) A(e less than 5> or (reater than ?6 years Depression (patient admits to depression or decreased concentration, sleep, appetite and/or li"ido)

Previous suicide attempt or psychiatric care 03cessive alcohol or dru( use ,ational thin.in( loss: psychosis, or(anic "rain syndrome Separated, divorced, or ido ed *r(ani!ed plan or serious attempt #o social support Sic.ness, chronic disease

Bipolar Disorder
Mania: .DI/ 1AS2. Distracti"ility Indiscretion (D/M-%&4s "e3cessive involvement in pleasura"le activities + + + ") /randiosity

1li(ht o) ideas Activity increase Sleep de)icit (decreased need )or sleep) 2al.ativeness (pressured speech)

AD / De'entia / etc

De'entia: multiple co(nitive de)icits ith 'e'ory (often short3ter' lost $st) and one o) aphasia / apraxia / a&nosia / exec fxn ith )unctional impairment o @ithout the other co(nitive de)icits, it4s 'ust amnesia

AD AP*04: associated ith increased (83;) ris. o) late-onset AD (A9B y/o) APP (chr 85), presenilin 5-8: aut-dom )orms, early onset AD cortical atrophy, enlar(ed ventricles

Pick disease: )rontotemporal, pic. "odies, preferential frontote'poral atrophy Vascular de'entia: deep hite-matter lacunar in)arcts

Procedures
0C2: ,nilateral C less con)usion / delirium a)ter ards0 Bilateral C more po er)ul )or s3 "ut more con)usion / delirium R+ sided unilateral helps preserve lan(ua(e )unctionin( a)ter ards $old meds "e)orehand: anticonvulsants (mechanistic) and anythin( that can contri"ute to delirium

Meds
#ld patients may need lo er doses "ut similar "lood levels )or antidepressants (less meta"olism)

%n hepatic disease, use "en!os meta"oli!ed outside the liver (oxa epa'5 te'a epa'5 lora epa') actually meta"oli!ed "y the liver via (lucuronidation, hich isn4t dependent on "liver )unction" (ta.es a lot o) liver )3n loss to lose (lucuronidation capacity)

Sedation 6 the A&itated Patient

Physical restraints are "ad: increased rate o) sentinel events (death / harm / etc) Chemical restraints: thin. !378 o !enadryl 79 '& o 7 '& "aldol o 8 '& Ati)an (lora epa')

!ro'ocriptine C dopaminer(ic a(onist+ Can "e used D/- dantrolene (muscle rela3ant) in treatment o) #MS

2hiorida ine (lo vision)

potency typical antipsychotic) can cause retinitis pi&'entosa (loss o) ni(ht

!eta (lockers (li.e Propranolol) can "e used to treat a.athisia, per)ormance an3iety Bradycardia, hypotension, asthma e3acer"ation can "e side-e))ects

!uspirone (!uspar): selective serotonin type 5A receptor a(onist+ As e))ective as dia!epam in treatin( an3iety+

Anticholiner&ics ((en tropine5 trihexylphenidyl) used as 5st line in neuroleptic3induced parkinsonis'5 acute dystonia+ Diphenhydra'ine (antihistamine ith anticholiner(ic properties) - as a"ove D nonspeci)ic sedation 1hese are C2/ muscarinic anta(onists0 side e))ects (peripheral anticholiner(ic action) "lurry vision (cyclople(ia), constipation, urinary retention, (central action) - sedation, delirium

1lu'a enil is a (en o anta&onist used in emer(ent "en!o #D0 can precipitate se)ere :ithdra:al (dan(erous)

Sti'ulants )or AD$D: atch out )or decreased appetite (incl+ slo ed (ro th), insomnia at )irst, irrita"ility, dysphoria, headache, tics sometimes0 rapid action Ato'oxetine is a selecti)e #0 reuptake inhi(itor, used in AD$D, especially i) su(stance a(use in )amily (not a"usa"le) or tics (doesn4t orsen tics) or comor"id an3iety disorders

Pe'oline has stimulant action too, "ut has rare heptatotoxicity ((et "aseline A*1, =8 .s)

Acetylcholinesterase inhi(itors ; donepe!il, (alantimine, rivisti(mine, tacrine0 all reversi"le inhi"itors+ E% upset, cholinomimetic e))ects ("radycardia, increased (astric acid secretion) can result+ Me'antine used in AD too, #MDA anta&onist (less neuroto3icity) ,se hi&h potency antipsychotics in demented individuals to decrease a(itation (lo -potency have more anticholiner(ic / orthostatic side e))ects) !en os Short hal)-li)e (8-5B h) Inter'ediate hal)-li)e (5B56h) te'a epa'= (Restoril) dia epa' (Valiu') tria ola' ($alicon) oxa epa'= (/era3) lora epa'= (Ativan) clora epale (1ran3ene) alpra ola' (>anax) flura epa' (Dalmane) hala epa' (Panipam) pra epa' (Centra3) Side 0ffects of neuroleptics Dystonic r3n: hours - days, treat Par.insonism: days - .s A.athisia: days - .s 1ardive dys.inesia: years 2M/: anytime ith anticholiner(ics / antihistamines <on& hal)-li)e (F 5dD) chlordia epoxide (*i"rium)

A'pheta'ines: (enerally used )or AD"D5 narcolepsy5 depressi)e disorders Dexedrine (de3troamphetamine), Desoxyn (methamphetamine)5 ,italin (methylphenidate) a))ect dopa'iner&ic syste' Desi(ner amphetamines (ecstasy, etc) have serotoner&ic effects too

Basic Science & Anatomy


"ypothala'ic nuclei *ateral C drive to eat &enteromedial C satiety center (dama(ed in Prader-@illi) Anterior C se3 Posterior C levels o) arousal (lesion C lethar(y, somnolence) Paraventricular, supraoptic C vasopressin, o3ytocin

?lu)er3!ucy syndro'e: "ilateral amy(dala dama(e (a"sence o) )ear, hyperorality, hyperse3uality, etc)

Neurotransmitters & stuff

#uclei #ucleus (asalis - co(nitive )unctions, memory0 de(enerates in Al! D! Su(stantia ni&ra (dopamine) - de(enerates in PD ,aphe nuclei: serotonin, mood/pain/a(ression <ocus ceruleus: ma'or noradrener(ic nucleus0 arousal / attention / autonomic tone, connects to amy(dala (threats)

#eurotrans'itters:

Sleep:

/erotonin: depression, #CD Dopamine: psychosis, :P/ Acetylcholine: co(nitive )3n, memory 2orepi: an3iety disorders

Polysomno(raphy: ::E, :#E, :ME+ /ta(e 5: theta aves, rela3ed muscle tone, "noddin( o))" /ta(e 8: G comple3es, sleep spindles0 no eye movements, noddin(-o)) Delta-sleep: *o )re=uency, hi(h volta(e ::E aves0 sta(es 7-? here ,0M: lo , )ast ::E volta(e0 no 'uscle tone (cataplexy), very rapid eye movements

Sleep disorders: Dyssomnia: too much / too little sleep (#/A, narcolepsy, poor hy(eine) Parasomnias: durin( sleep or on arousal (sleep terrors, sleep al.in(, rhythmic movement disorder, etc)

Dia(nostic tests MMPI: personality test (minnesota multiphasic) Pro'ective tests: am"i(uity o Rorshach: in. "lots o 1hematic apperception tests (1A1) - motivation (ma.e a story a"out a picture) o /entence completion (My (reatest )ear is+++) %ntelli(ence tests: @A%/ (@eschelr Adult %ntelli(ence /cale) is most common 2europsych tests o @isconsin card sortin(: a"stract reasonin(, )le3i"ility (sort cards) - a"nl in )rontal lo"e dys)3n o @eschelr memory (various memory tests)

&isuomotor (Bender visual-motor (estalt)

#ther medical conditions H psychiatry Pancreatic cancer lin.ed to depressive symptoms classically Psychosis in deliria, dementias, severe hypothyroid, hyperCa, syphilis, su"stance a"use (esp PCP) Anxiety in Eraves, P:, hyperthyroid, /'o(ren, some sei!ures o /'o(ren: @BC attac. moisture-producin( (lands+ dry eyes @ dry 'outh D other or(ans+ ?M in ,/A/yr+ o Eraves: up to 9BI meet EAD criteria o Pheochromocytoma: can mimic panic attac.s o A aitin( heart transplant: more noradrener(ic tone0 hi(h incidence o) panic disorder o "ypo&lyce'ia can loo. li.e an3iety too Mania-li.e states: corticosteroids, levodopa, cocaine+ PA#DAS: Pediatric autommune neuropsych disorders a/ strep in)ections0 includes *CD3 type "ehavior o Eet antistrep A" titer (antistreptolysin # - AS* - titer rises A3B :ks a)ter in)ection, antistrep D2Aase B - antiD#se-! - titer rises B3% .s later) o ,se SS,I @ C!2 )or compulsive "ehaviors+ ;A"3 use to prevent recurrence; Cardiac sur&ery is a "i( ris. )or delirium (>BI o) pts), also old a&e (9BI nursin( home residents), hosp (5B-7BI)

DSM Junk, etc.


MDD: Most o) the time )or at least 8 :ks, 6D symptoms, 8D episodes )or recurrent 6B-JBI recurrence, 56I suicide rate, usually 9-58mo episodes &s nor'al (erea)e'ent: usually C 8'o a)ter loss, diminishin( ith time, can even have hallucinations o) deceased person (children / adolescents) "ut reassurin( / com)ortin( vs accusatory PMD hallucinations Psychotic MD: taper antipsychotic hen psychotic s3 resolve, at least 9-> mo or more o) antidepressant ithin A 'onths of stressor, don4t last

Ad+ust'ent disorder: emotional response (mood s3) lon(er than B 'o after stressor resol)ed

can "e an3iety, depressed mood, conduct distur"ance, mi3es+ #)ten so'atic co'plaints in .ids / irrita(ility in .ids H adolescents 1reat ith psychotherapy ((roup i) possi"le, individual, (enerally not meds e3cept actue sleep help) ee., less severe than depression, present in 793%9D pts,

Postpartu' (lues: several days - a resolves in K 5?d, no treatment

Postpartu' depression: 96I o) all

omen e3perience )irst MDD in 5st year a)ter delivery+

1reat ith SS,I5 Can (ive antidepressant prophylaxis )or ne3t pre(nancy (prior episode is L5 ris. )actor )or postpart depression)

Postpartu' psychosis: con)usion, e3treme mood la"ility, 5-8/5BBB deliveries, 'edical e'er&ency (hosp 'o' E (a(y) SS,I ((enerally sa)e) @ antipsychotic, also consider 0C20 1CAs not (ood

Dysthy'ic disorder: depressed )or most o) day, more days than not )or at least 8 yrs ($ yr )or children /adolescents), not more than 8 'o ithout symptoms, no MDD Cyclothy'ia: "et een dysthymia H hypomania over 8 yrs !ipolar disorder5 'anic episode: need at least 5 . o) manic symptoms or hospitali!ation

MBI MN vs 8BI DN #)ten psychotic )eatures i) manic in children+ DD3 vs AD$D D #DD or CDD BP-%: )ull mania, BP-%%: hypomania (don4t meet )ull criteria0 "rie)er0 milder0 ?dD) Rapid-cyclin(: 4@ episodes in $8 'o

Schi ophrenia: 8D symptoms )or 5 mo or one i) "i!arre delusions / commentin( auditory hallucinations / conversin( voices, at least B 'o ith so'e sx (incl+ ne(ative symptoms) 5I li)etime prevalence, MCO, 8B-?BI attempt suicide, 5BI complete, M present 5J-86 yo, O present 86-76 yo0 omen have "etter outcome 1hou(ht-"loc.in(: havin( one4s train o) thou(ht curtailed a"solutely, unpleasant Ideas of reference: )alse "elie)s that people tal.in( a"out pt (o)ten+ via 1&, radio, etc) .s

Schi oaffecti)e disorder: psychotic symptoms li.e acute schi!, also must "e around )or 8 ithout mood symptoms as ell as ith mood symptoms+ 1reat ith antipsychotics, o)ten lon(-term (usually atypicals)+ Can use 'ood sta(ili ers i) manic mani)estations+

Schi ophrenifor' disorder: schi!ophrenia that doesnFt last for B 'onths and no social ithdra al+ Resolves or pro(resses to "ipolar / schi!ophrenia Delusional disorder: non-"i!arre delusions, other ise normal, at least $ 'onth, o)ten mid-li)e, OAM !rief psychotic disorder: o)ten a)ter stress or postpartum, $ day to $ 'onth Panic disorder: panic attac.s (?D panic symptoms, out o) the "lue, episodic), recurrent, $ 'o o) "ehavior chan(e / orry as result+ 1reat ith //R%s / 1CAs / MA#i D CB10 "en!os short term only

/AD: more chronic an3iety, not attac.s+ A least B 'o o) symptoms )or ma'ority o) the day+ Also irrita"le, )ati(ued, sleep distur"ed+ 2eed 7 s3+ OAM 1reat ith SS,Is/)enlefaxine @ C!2G Also "uspirone, avoid "en!os lon(-term+

Pho(ias are H$ co''on mental disorder in ,/A (6-5BI population), specific A social, :o'en A men, late childhood / early adulthood, chronic+ Desensiti!ation or e3posure, //R%s / "en!os / venla)a3ine / "usipirone+ Beta-"loc.ers 'ust "e)ore (propanolol, atenolol)

Separation anxiety (a childhood disorder) $ard to treat0 o)ten develop depression / psychotic disorders+ 5J-6BI develop panic disorderG ,se SS,Is )or mood / an3iety D rela3ation D (raded separation+ :arlier treatment "etter+ Don4t homeschool (rein)orces) At least 4 :ks5 onset (efore a&e $%, inappropriate an3iety a"out separatin( )rom home / care ta.er Can have so'atic sx, especially in .ids+

*CD: 8-7I li)etime0 5BI o/p psych visits, 8B-7BI have tic history (6I 1ourette4s)+ 1reat ith (eha)ioral therapy (0xposure3response pre)ention) and SS,Is (clomipramine 8nd line, 1CA mostly actin( on serotonin, "ut side e))ects)

AD"D 3 needs to "e present in 'ore than one settin& and start (efore I yrs old, B@ sx Inattenti)e5 hyperacti)e5 and co'(ined types ,se si'ulants5 ato'oxetine (2: reupta.e inhi"itor, less tics associated), also "uproprion, imipramine / nortriptyline / pemoline Comor"id *DD / CD is common0 meds can only help i) child ants to do the ri(ht thin(< MB-JBI respond to stimulants+ 2ourette Disorder: both motor H vocal tics (don4t have to "e at same time), )or at least $ yr ithout A 'onths )ree o) tics, a&e C $%5 causes distur"ance o o o Coprolalia C potty mouth ?/6/5B,BBB, more common in "oys+ ,sually motor "y a(e M, vocal "y a(e 55+ Runs ith #CD / AD$D 1reat ith alpha3adrener&ic 'edicine (clonidine5 &uanfacine) + %) it doesn4t or., try atypical antipsychotic (esp risperidone) Clonidine: alpha-8 a(oniost, decrease 2: "y actin( on locus ceruleus Euan)acine: activates postsynaptic pre)rontal alpha-adrener(ic receptors Both also used in AD$D to reduce s3 - &ood for co'or(id condition P2SD: acute i) K 7mo, chronic i) A 7 mo+ Acute o)ten resolve on their o n0 i) it lasts lon(er than 7 mo, pro"a"ly needs intervention+ 1reat ith SS,I (esp+ sertraline, paro3etine) D psychotherapy (C!2), social interventions+ Can use alpha38 a&onists (clonidine, pra!osin) )or symptoms+ Ben!os not help)ul H ris. )or su"stance a"use+

Acute Stress Disorder (shortly a)ter event0 in first four :eeks5 lastin( )or at least 8 days) o)ten resol)es on its o:n

$ave dissociati)e sy'pto's (7 o) num"ness / detatchment / lac. o) emotion, decreased a areness o) surroundin(s, dereali!ation, dissociative amnesia) ith a)oidance Ma'or treatment is 'o(ili in& social support !eta3(lockers can help s3, may help prevent pro(ression to P1/D0 can use short-term hypnotic )or insomnia

So'atifor' disorders 3 ta.e concerns seriously0 re(ularly scheduled (not PR2) visits, no inappropriate tests+ "ypochondriasis: all a"out the disease Pain disorder: 5D sites, primary complaint, psycholo(ical )actors play role (initiate / orsen pain), at least B 'onths, may "e tri((ered past trauma o &alidate pt e3perience, e3plain psych )actors in pain, consider antidepressants (2CAs / SS,Is) D (iofeed(ack, pain is chronic so )ocus on &radual i'pro)e'ent of function o Anal&esics usually don4t help, really avoid narcotics So'ati ation disorder: ?D pain s3 at di))erent sites, 8 E% s3, one se3 / repro pro"lem, one pseudoneurolo(ic0 all over course o) illness, no e3planation o 2eeds to (e&in (efore a&e A9, last )or se)eral years, H cause impairment Con)ersion disorder: 5D sensory / motor de)icits su((estin( neuro / medical illness0 preceded "y con)lict / stress, not 'ust pain / se3 dys)3n, not part o) somati)orm disorder+ o La belle indifference: pt unconcerned a"out his symptoms o Can recur0 reassure that it ill resolve on its o n ith time, pt not )a.in( - tell pt ""ody responds in unusual ays" to stress sometimes

#on3so'atofor' disorders (consciously doin( stu)) to sel))+ 1actitious disorder: intentionally producin( s3 to assume sic. role+ #)ten "orderline+ 1ry to develop therapeutic alliance o Munchhausen is )actitious disorder ith repeated episodes, etc+0 "y pro3y C induced in children "y parents Malin&erin&: intentionally producin( s3 )or secondary (ain omen, usually later onset

!uli'ia #er)osa: 5I prevalence0 "rie) pur(in( in 6-5BI youn( than A#5 even adulthood

Dan(er: parotid (lands / mouth / caries / esopha(eal / E% in'ury, dehydration )rom la3atives, ipecac can cause hypotension5 tachycardia, arrhythmias+ Chec. lytes (hypoCl / hypoG acidosis )rom emesis), amylase, ma(+ 1reat ith nutritional reha(5 C!2 @ &roup D )amily therapy, antidepressant (usually //R%)+ Mortality rate is up to ADG *ots o) relapses

Anorexia ner)osa: hi(h achievers (B2 too), ha)e to (e under:ei&ht (J6I ideal "ody t) and a'enorrheic *anu(o: )ine "ody hair on prepu"ertal .ids, pts ith anore3ia Bi( contri"ution o) society, )amily )unctionin( Al"umin level canhelp )ollo nutritional status+ Blood chem, :CE chan(es need to "e monitored+

Sleep 2errors: :motional / "ehavioral disorders, usually early in ni&htly sleep durin( arousal )rom delta (slo:3:a)e) sleep, no 'e'ory #)ten in .ids (7I vs 5I adults), can "e increased "y fe)er5 sleep depri)ation5 C#S depressants0 (enerally self3li'itin& (use reassurance) #)ten co-occur ith restless le& syndro'e and sleep3disordered (reathin& ho have more

So'na'(ulis': also durin( arousal )rom delta sleep (more common in kids, delta sleep5 H first half of ni&ht) Protect the kid )rom dan(erous "ehaviors

0nuresis - tell the parents to "e supportive, don4t punish child, can use (ell and pad to retrain (alar') - "ut only i) after a&e I, occasionally des'opressin or i'ipra'ine (need :CE monitorin() Primary: never a dry period /econdary: usually ,1% or psycholo(ical stressor (re(ression

ith ne

si")

Inso'nia Primary: at least 5 month, causin( distress+ Bad sleep hy(iene, so )i3 it+ /timulus control ("eds only )or sleepin( H se3, (et up i) can4t )all asleep), rela3ation therapy, ta.e a hot "ath "e)ore "ed+ CB1 can help0 reassure an3iety ,a'elteon: meletonin receptor a(onist, also "en!os (don4t use )or A 8 .s), tra adone

Autis': Poor social reciprocity (ver"al H non-ver"al), sterotyped "ehaviors (purposeless, repetitive - spin toys, hand )lappin() 2eed sx C A y/oJ o)ten d34d hen .ids put in social situations li.e school+ ?BI have MR0 some can have precocity+ A/ tu"erous sclerosis, )ra(ile 3+ *an(ua(e development is "est predictor o) outcome+ Multisystemic treatment: )amily education, "ehavior shapin(, speech therapy, #1, educational trainin( Oocus on (ettin( (asic skills early so child can interact in school, etc+

Aspe(er&er: social impairment, restricted interests / stereotyped "ehavior "ut nor'al lan&ua&e 6 co&nition ,ett: developmental disorder: (irls, normal early, then pro(ressive encephalopathy, loss o) speech, (ait pro"lems, stereotyped movements, microcephaly, poor social interaction

Dissociati)e disorders: (enerally precipitated "y trauma, DD3 vs de'entia in older pts (more common, so'e past 'e'ory spared in dementia<)

Dissociati)e 1u&ue: usually "rie) (hours - days), can last )or months, can "e post-trauma / con)lict, usually rapid spontaneous recovery ith no recurrence+ 2ot a are o) identity0 may create a ne one+ Dissociati)e A'nesia: can4t recall speci)ic in)ormation (usually a"out identity) "ut intact memory a"out (eneral in)ormation0 usually caused "y trauma / stress)ul memory+ no tra)el5 no ne: identity createdG $3 o) head trauma can predispose+ Dissociati)e identity disorder: "multiple personalities" to help deal ith trauma, controversial, 8D identities recurrently ta.in( control /ender Identity Disorder: persistent cross-(ender identi)ication0 usually have to live as opposite (ender A 'o (efore hor'ones5 $ yr (efore sur&ery Intersex Stuff Andro(en %nsensitivity /yndrome: interse30 chromosomally 'ale "ut no andro(en response (develop external fe'ale &enitalia)

Sexual dysfunction :rectile: nor'al nocturnal erections means :D is pro"a"ly psycho(enic0 can also "e medical (CRO, DM, malnutrition, cirrhosis, atherosclerosis, etc) and iatro(enic (antidepressants - classically //R%s, mood sta"ili!ers, antipsychotics) Va&inis'us: involuntary muscle constriction o) outer third o) va(ina, inter)eres ith se3ual intercourse, causes distress

Mental ,etardation A"out 5I prevalence0 see ta"le "elo )or de(rees+ Self3destructi)e (eha)ior can "e response to painful 'ed pro(le's i) child can4t communicate Do:n syndro'e is L5 cause o) moderate to severe MR in ,/A ()acial )eatures, hypothonia, lan(ua(e D motor developmental delay, trisomy 85) 1ra&ile >: L8 common cause o) mental retardation, L5 cause o) herita"le MR, P=8M+7 mutation, 'ales are 'oderate to se)ere MR5 fe'ales less so P?- is another cause, can4t "rea. do n phenylalanine0 dietary restriction is treatment 1etal alcohol exposure too 7B-?BI are un.no n etiolo(y IK Characteristics 1unction Can o)ten li)e/:ork independently / social support Can "e competent at occupational tasks in supportive settin(, need hi&h le)el of super)ision

Se)erity

6B,sually not detected until Mild (J6I 66 to school0 complete hi(h ) MB elementary school level 7BModerate ?B to /ocially isolated in (5BI) 6Belementary school 66 8BSe)ere (7 86 to Minimal speech, poor -?I) 76motor development ?B Profound "elo

#ot independent0 can do some sel)care, need e3tensive supervision

A"sent to minimal speech, 2eed constant nursin& care

(5-8I)

8B86

poor to a"sent motor s.ills throu&hout life

<earnin& Disorders: /peci)ic de)icits in 'ath5 readin&5 or :ritten expression Readin( most common0 all t ice as prevalent in "oys 1reat "y addressin( speci)ic de)icit

/u"stances Dependence (su(stance): need 7D o) tolerance, ithdra al s3, increased use, attempts / )ailure to cut do n, lots o) time spent (ettin( it, less time spent doin( other stu)), still usin( despite .no in( dama(e /u"stance-induced mood disorders: %) they don4t resolve on their o n, treat 4em li.e they4re not su"stance-induced (e+(+ antipsychotics, mood sta"ili!ers, antidepressants) Accordin( to D/M, no canni"is-induced mood disorders

PCP intoxication Phencyclidine, an(el dust, horse tran=, happy lea)+ piperidine li.e .etamine0 ori(inally anesthetic (2MDA receptor "loc.er), lon(-actin( (9h short-term e))ects, )ull e))ect can last several days, varia"le "ehavioral chan(es, unpredicti"le), o)ten ith MQ Dysarthria5 nysta&'us (vertical), (elli&erent, hyperacusis5 ataxia5 'uscle ri&idity5 can cause s / co'a, num"ness, $12 / tachy 1reatment: treat "2#, can acidify urine to increase e3cretion, hospitali e in a Luiet dark roo' Avoid restraints (more muscle "rea.do n), (astric lava(e (emesis / aspiration), typical antipsychotics (anticholiner(ic side e))ects ma.e it orse)+ Ben!os can delay e3cretion, so avoid those too+

Alcohol dependence: 7-6I omen, 5BI men li)etime0 a/ 6BI homicides, 86I suicides *a" tests: elevated li)er transa'inases (particularly (amma-(lutamyl trans)erase, EE1) and 'acrocytic ane'ia Mernicke: acute, reversi"le encephalopathy )rom thia'ine deficiency a)ter chronic :1#$ use: deliriu'5 opthal'ople&ia (typically C29), ataxia o (ive thia'ine (efore &lucose ?orsakoff: usually irre)ersi(le amnesia, antero(rade D retro(rade ith con)a"ulation, a)ter chronic alcohol use (thia'ine de)iciency)

Alcohol :ithdra:al: 1ypical sta(es: tremulousness / 'itteriness (9-Jh), psychosis / perceptual s3 (J-58h), sei ures ($8384h), D2s (843I8h5 up to $ :k) D1s: disorientation, tremors, elevated vital si(ns, )luctuatin( consciousness post-stoppa(e, can "e fatalN DDx vs thyroto3icosis, pheochromocytoma, inappropriate use o) "eta-a(onist inhalers / sympathomimetics+

,se lon&3actin& (en os (chlordia epoxide5 dia epa')G #3a!epam, lora!epam are (ood i) liver )unction may "e compromised

Cocaine intoxication: Behavioral: euphoria, "luted )eelin(s, hypervi(ilance, hypersensitivity, an3iety, poor 'ud(ment, anore3ia Physical: dilated pupils, autonomic insta"ility, chills/s eatin(, n/v, PMA/R, chest pain / arrhythmias, con)usion / s! / stupor / coma, t loss

Cocaine :ithdra:al: can last 8-? days or lon(er, "crash. (dysphoria, irriti"ility, an3iety, hypersomnia, depressi)e sx incl /%)+ %nto3 ithdra al durin( li)etime o) addiction can mimic "ipolar disorder in the history<

A'pheta'ine intoxication: causes adrener&ic hyperacti)ity (tachy, pupils dilated, hypertensive, perspirin(, chills, nausea / vomitin(, anorexia / :t loss, mm ea.ness, can have hallucinations5 resp depression chest pain, arrhythmias, con)usion, s!, dys.inesia, dystonia, coma can result) Meth (ives you (ad dental pro(le's (meth mouth) D paranoia, hallucination / tics / a((ression

A'pheta'ine :ithdra:al: the "crash" (an3iety, tremors, lethar(y, )ati(ue, ni(htmares, headache, e3treme hun&er)

*pioid intoxication: apathy, PMR, constricted pupils, dro siness *pioid :ithdra:al: nausea / vomitin(, muscle aches, )luids )rom all ori)ices, autonomic hyperactivity, )ever, dilated pupils, depressed / an3ious mood, rarely life3threatenin& Eenerally, lon&er3actin& su(stances &i)e less :ithdra:al I(uprofen can help 'uscle aches Can use clonidine )or autonomic hyperactivity in acute-phase D 'ethadone (lon(-actin( opiate)

Psycholo&ical theories 1reud: e(o psycholo(y: id (drives / instincts), supere(o (ri(ht / ron(, )rom societal / parental morality), e(o (resolves con)lict / adapt to an3iety) Drive psychiatry: oral / anal / phallic / latency / (enital sta(es o) development #"'ect relations: relationship to o"'ects / people are more important than drives 0rikson: li)e cycle sta(es+ :ach part o) li)e is con)lict0 pro(ress / development throu(hout o 2rust )s 'istrust (B-5Jmo, child dependin( on careta.ers), autono'y )s sha'e (5J mo - 7 yrs0 "o el / "ladder )unction, al.in(), initiati)e )s &uilt (7-6 yrs, more lan(ua(e / al.in( / e3plore the orld), industry )s inferiority (6-57 yrs, sense o) sel) starts developin( "ased on thin(s created), identity )s role confusion (57-85 yrs, adolescence, appearance to others important), inti'acy )s isolation (85-?B yrs, vulnera"ility o) intimacy vs loneliness), &enerati)ity )s sta&nation (.eep producin( as mem"er o) society or not;), e&o inte&rity )s despair (9B - death, acceptin( li)e course or re(rettin()

Co&niti)e distortions (co(nitive therapy) o Ar(itrary inference: don4t have enou(h evidence o Dichoto'ous thinkin&: all or none o *)er&enerali ation: it as 'ust one event< o Ma&nification / 'ini'i ation: 'ust hat it sounds li.e !eha)ior theory o Modelin&: learn "ased on o"servin( others, imitatin( actions / responses o Classical conditionin&: pair neutral stimulus, natural stimulus, response "ecomes a/ neutral stimulus o *perant conditionin&: environmental events (contin(encies) in)luence ac=uisition o) ne "ehaviors, e3tinction o) e3istin( "ehaviors Positive C (ive stimulus, ne(ative C ta.e stimulus a ay+ Rein)orce C ma.e repeat "ehavior, punish C ma.e stop "ehavior /o "ne(ative punishment" means you ta.e a stimulus a ay to ma.e someone stop a "ehavior, )or instance

*e(al %ssues Malpractice: need ne&li&ence ("ro.e standard o) care)5 duty (had responsi"ility to pt)5 direct causation (ne(li(ence caused pt pro"lem)5 da'a&es (pt had a pro"lem as a result) Infor'ed consent: need to infor' (side e))ects, alternatives, outcome /o treatment), pt must "e co'petent, and pt must (ive )oluntary consent In)oluntary co''it'ent: ri(ht to "e treated H re)use treatment unless declared incompetent 2arasoff decisions: 1araso)) %: need to arn potential victims o) patients ho could do them harm+ 1araso)) %%: need to ta.e reasona"le steps to prevent harm to 7rd party MF#au&hten ,ule: 5J?7, :n(land, mentally ill man tried to assassinate prime minister not held responsi"le i) mentally ill / MR and didn4t understand nature o) act or reali!e that it as ron(0 controversial, "asis o) insanity de)ense+