Escolar Documentos
Profissional Documentos
Cultura Documentos
Semester Review
1
DSM-IV Classifications
Axis I: Clinical Disorders and other conditions that would be the focus of clinical attention
Disorders first diagnosed in infancy/childhood/adolescence (not M.R)
Cognitive Disorders
Mental Disorders due to general medical condition
Substance Related Disorders
Schizophrenia, Psychotic Disorders
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious Disorders
Dissociative Disorders
Sexual & Gender Identity Disorders
Eating Disorders
Sleeping Disorders
Impulse Control Disorders
Adjustment Disorders
Axis III: Physical disorder or general medical condition present in addition to a mental
disorder
Axis IV: Psychosocial and environmental problems that contribute to the development or
exacerbation of the disorder
2
Anatomy and Biochemistry of Behavior
Right side of brain (nondominant)spatial relations, musical ability, facial recognition, social
cue perception
Left side of brain (dominant) language function
Dopamine=a catecholamine
Blockade of dopamine=elevated prolactin levels
HVA = metabolite of dopamine
Norepinephrine=role in sleep-wake cycle, arousal, anxiety, learning, memory, pain
MHPG=metabolite of norepinephrine
VMA= metabolite of norepinephrine
Serotonin=anxiety and violence, affective disorders, sleep
Increased serotonin=decreased sexual activity
5-HIAA=metabolite of serotonin
GABA=presynaptic inhibition of CNS
Decreased GABA activityepilepsy, anxiety
Loss of GABAHuntington’s, Parkinson’s
3
Neuropeptide Psychopathology
Cholecystokinin Schizophrenia, eating / movement disorders
Neurotensin Schizophrenia
Somatostatin Huntington’s, Alzeheimer’s, Mood disorders
Substance P Pain, Huntington’s Mood disorders
Vasopressin Mood disorders
Vasoactive Intestinal Peptide Dementia, Mood disorders
Life Cycle
Pregnancy:
Pseudocyesis = false pregnancy
50% of unmarried moms are teenagers
Ave. age of 1st intercourse=16yrs
Predisposing factors of teenage pregnancy=depression, low academic achievement/goals, poor
future planning, divorced parent
Childbirth:
Low SEShigh infant mortality
Mortality Rate: blacks highest, Native Americans, Americans
Prematurity=gestation<34 weeks or birth weight<2500g
Mother-Child Bonding adversely affected by low birth weight, child’s illness, separation from
mom after delivery, problems in mom-dad relationship
Post partum blues (baby blues) develops in 1/3-1/2 of women, a result of changes in hormone
levels, stress of childbirth, awareness of responsibility, disappointment over child’s appearance,
fatigue
5-10% of women suffer from Major Depression after childbirth, .1-.2% of which will develop
postpartum psychosis
Factors related to long-lasting postpartum reactions=lack of child care experience, lack of social
support
Piaget:
Sensorimotor 0-2 years: mastery of environment comes from assimilation
(understanding new things) and accommodation (altering behavior b/c of new
things), “object permanence”-maintain internal representations 12-24mo
Preoperational 2-7 years: child begins to think in symbolic terms
Concrete Operational 7-11 years: capacity for logical thought
4
Formal Operations 11-20 years: abstract reasoning
Erikson:
Childhood
Trust vs. Mistrust 0-1 years: to establish trust, child’s basic needs must
be met consistently
Autonomy vs. Self-doubt 1-3 years: child resolves internal desires for
independence with parental control, “autonomy”
Initiative vs. Guilt 3-5 years: child begins to take risks, w/ fear of
punishment and sense of guilt
Industry vs. Inferiority 6-11 years: acquires sense of competence or
incompetence in interactions w/ world
Adolescence
Identity vs. Diffusion 11-20 years: develop sense of independent self
Adulthood
Intimacy vs. Isolation 20-40 years: inability to have intimate relationship
will lead to emotional isolation
Generativity vs. Stagnation 40-65 years: maintenance of sense of
productivity or develops sense of emptiness and stagnation
Ego Integrity vs. Despair 65+: either a satisfaction and pride in one’s
accomplishments or sense of worthlessness
5
Formation of the personality
Strong sexual impulses, hormonal changes
Attempts at independence
Development of morals/ethics
Identity crisis, if incorrectly handledidentity diffusion, role confusion
Early Adulthood: 20 – 40 years
Social role defined, Independent self develops
Age 30=period of reappraisal
Main responsibility=develop intimate relationship
Middle Adulthood: 40 – 65 years
Middle adulthood=positions of power/authority
“Mid-Life Crisis”inability to change life pattern that individual finds unendurable,
panic about what hasn’t been accomplished in life
Predisposing Factors: problems w/parents, low self-esteem, anxiety, impulsivity,
weak/absent same-sex parent
Late Adulthood: 65 years – death
80% of people in US reach age 60+
Life expectancy: white female=80, w male=73, black female=74, b male=65
Depression is the most common psychiatric illness in elderly (15%)
Associated factors of dep.=loss of loved ones, loss of prestige, loss of health, TX: ECT
Longevityfamily history, physically active work, 6-9 hrs sleep/night, advanced
education, suburban living, marriage, strong social supports, calm personality,
occupational activity
Stages of Death: 1.Denial 2.Anger 3.Bargaining 4.Depression 5.Acceptance
Normal grief=1-2 years
Childhood Disorders
Most childhood problems have a familial pattern
More childhood psychological problems occur in males
6
Most common metabolic chromosomal abnormalities: Down’s, Fragile X, Phenylketonuria
Stuttering, 1% prevalence
• Disturbance in normal fluency and time patterning of speech with
one or more of the following: sound and syllable repetitions, sound prolongations,
interjections, broken words, audible or silent blocking, circumlocutions (word
substitutions), words produced with and excess of physical tension, monosyllabic
whole-word repetitions
Autistic Disorder, 5 children per 10,000 births (.005%), more common in boys
AT LEAST 6 OF THE FOLLOWING:
7
• Impairment in social interaction as manifested by 2 of the
following:
Marked impairment in the use of multiple nonverbal behaviors
Failure to develop age-appropriate peer relationships
Lack of spontaneous seeking to share enjoyment w/ others
• Impairments in communication as manifested by at least 1 of the
following:
Delay in, or lack of, development of spoken language
In those w/ speech, impairment in ability to initiate or sustain
conversation
Stereotyped, repetitive use of language or idiosyncratic language
Lack of varied, age-appropriate, spontaneous make-believe or
parallel play
• Restricted, repetitive and stereotyped patterns of behavior,
interests, and activities as
manifested by at least 1 of the following:
Stereotyped, repetitive patterns of interest that is abnormal in
intensity and/or focus
Inflexible adherence to specific, nonfunctional routines or rituals
Stereotyped, repetitive motor mannerisms
Preoccupation w/ parts of objects
• Delays, abnormal functioning in at least 1 of the following
areas(w/onset prior to 3yrs):
Social interaction
Language as used in social communication
Symbolic or imaginative play
Rett’s Disorder
• ALL OF THE FOLLOWING:
Apparently normal prenatal and perinatal development
Apparently normal psychomotor development through the first 5
mo. after birth
• Onset of the following after the period of normal development:
Deceleration of head growth between ages 5 and 48 months
• Loss of previously acquired purposeful hand skills between 5-30
months, w/ development of stereotyped hand movements
Loss of social engagement early in course
Appearance of poorly coordinated gait or trunk movements
Severely impaired expressive and receptive language development
Severe psychomotor retardation
8
Asperger’s Disorder
• Impairment in social interaction as manifested by AT LEAST 2 OF
THE FOLLOWING:
• Impairment in the use of multiple nonverbal behaviors (eye-eye
gaze, facial expression, body posture, social gestures)
• Failure to develop age appropriate peer relations
• Lack of spontaneous seeking to share joy, interests, achievements
w/ others
• Lack of social, emotional reciprocity
• Restricted, repetitive, stereotyped patterns of behavior, interests,
and activities, as
manifested by AT LEAST 1 OF THE FOLLOWING:
Encompassing preoccupation with 1 or more stereotyped and restricted
patterns of interest that is abnormal in intensity of focus
Apparently inflexible adherence to specific, nonfunctional routines/rituals
Stereotyped and repetitive motor mannerisms
Persistent preoccupation with parts of objects
Attention Deficit / Hyperactivity Disorder (ADHD), 3-5% of children btwn 5-12 yrs
• Symptoms must have persisted FOR AT LEAST 6 MONTHS
• Either 6 OR MORE of the following symptoms of INATTENTION:
Fails to give close attention to details or makes careless mistakes
Has difficulty sustaining attention in task or play
Does not seem to listen when spoken to directly
Does not follow through on instructions, fails to finish work/duties
Has difficulty organizing tasks/activities
Avoids, dislikes, reluctant to engage in tasks requiring sustained mental
effort
9
Loses things needed for tasks/activities
Easily distracted by extraneous stimuli
Forgetful in daily activities
Or 6 OR MORE symptoms of HYPERACTIVITY-IMPULSIVITY:
• Fidgets w/ hands or feet or squirms in seat
• Leaves seat in classroom or other situations when sitting is expected
• Runs about or climbs excessively in situations when it’s inappropriate
• Difficulty playing or engaging in leisure activities quietly
• Often “on the go” or often acts as if “driven by a motor”
• Talks excessively
• Blurts out answers before questions have been completed
• Difficulty waiting turn
• Interrupts or intrudes on others
• Some hyperactive-impulsive or inattentive symptoms were present
before 7yrs
• Some symptoms present in 2 or more settings (school, work,
home)
Oppositional-Defiant Disorder
Pattern of negativistic, hostile and other defiant behavior lasting AT LEAST 6 MONTHS
During which 4 OR MORE OF THE FOLLOWING:
Loses temper
Argues with adults
Actively defies or refuses to comply w/ adult requests/rules
Deliberately annoys people
Blames others for his/her mistakes/misbehavior
Touchy, easily annoyed by others
Angry and resentful
Spiteful or vindictive
Conduct Disorder
Repetitive, persistent pattern of behavior in which either the basic rights of others
or major age-appropriate societal norms are violated. Manifested by 3 OR MORE OF
THE FOLLOWING, present in the PAST 6 MONTHS:
Aggression to people and animals
• Bullies, threatens, intimidates others
• Initiates physical fights
10
• Used a weapon that can cause harm to others
• Been physically cruel to people or animals
• Stolen while confronting victim
• Forced someone into sexual activity
Destruction of property
Deliberately engaged in fire setting w/ intent of damage
Deliberately destroyed others’ property
Deceitfulness or theft
• Broken into another’s house, bldg, car
• Lies to obtain goods/favors or to avoid obligation
• Stolen items of nontrivial value w/out confronting victim
Serious violation of rules
Stays out at night despite parental rules (beginning before
13yrs)
Has run away from home overnight at least 2X
Truant from school (beginning before 13yrs)
Pica
Eating of nonnutritive substances for a period of at least 1 MONTH
Rumination
Regurgitation and rechewing of food for a period of at least 1 MONTH
11
Enuresis, 7% male prevalence, 3% female
• Repeated voiding of urine into bed or clothes involuntarily or intentional
• AT LEAST 2X / WEEK FOR 3 MONTHS
• At least 5 yrs old
Schizophrenia
Childhood onset is rare, 2 per 100,000
Associated w/ low IQ, symptom of autism
TX: Social skills training, Clozapine (best)
Sleep Disorders
Normal Sleep:
6-9 hours a day, restorative
Stage 1-4 NonREM sleep: peacefulness, slowed pulse & respiration, decreased blood
pressure, episodic body mvmts
Stage 3-4 (delta sleep) Deepest, most relaxed, bed-wetting, night terrors
REM Sleep: increased pulse, inc. respiration, inc. blood pressure, inc. brain oxygen use,
penile/clitoral erection, muscle paralysis, DREAMS
REM Latency= 90 minutes after falling asleep, every 90 minutes thereafter, last 1/3 of
night
Newborns 50% REM, Adults 25% REM
Sleep deprivationego disorganization, hallucinations, delusions
REM deprivation lead to irritability and lethargy
12
Dysomnias: 33% lifetime prevalence
Primary Insomnia: 30% prevalence, MOST COMMON DYSOMNIA
• Difficulty initiating or maintaining sleep FOR AT LEAST 1 MONTH
Sleep Apnea
Central airflow and respiratory efforts stop
Parasomnias:
Sleep Terror Disorder, 1-6% of children, most common in boys
• Recurrent episodes of abrupt awakening from sleep with a panicky scream,
during first 3rd of sleep episodes
• Intense fear, Autonomic arousal
• Unresponsive to comfort
TX: Benzodiazapines
Nightmare Disorder
• Repeated awakening from the major sleep period or naps w/ detailed recall of
frightening dreams
Sleepwalking Disorder
Repeated rising from bed
Occurs during NonRem Stages 3 and 4
13
Eating Disorders
More common in women than men
14
Excessive accumulation of fat in the body (20% over ideal body weight)
50% of US adults are obese
More common in low SES, women
Binge Eating
• Episodes of binge eating that occur AT LEAST 2X A WEEK FOR 6 MONTHS
• No inappropriate compensatory behavior (vomiting, laxatives, enemas, etc)
Sexual Dysfunctions
Normal Sexual Response Cycle:
Desire-appetitive phase, strictly psychological: fantasies and desires
Excitement-psychological and physiological stimulation, subjective sense of pleasure, penile
tumescence/vaginal lubrication
Orgasm-peaking of sexual pleasure, release of sexual tension, rhythmic contraction of
muscles/pelvic organs
Resolution-body returns to resting state
Treatment for most Sexual Dysfunctions: Dual Sex Therapy (male & female therapists),
hypnosis, behavior therapy (systematic desensitization, assertiveness training), group therapy,
biofeedback, analytically oriented (psychoanalytic) sex therapy-**most effective**
15
• Women exhibit variability in type/intensity of stimulation that triggers orgasm.
Diagnosis must take this into account.
Premature Ejaculation
• Persistent, recurrent ejaculation w/ minimal sexual stimulation before, on,
or shortly after penetration, and before intending to
Dysparenueria
• Recurrent, persistent genital pain associated w/ sexual intercourse in male
or female
Vaginismus
• Recurrent, persistent involuntary spasm of the musculature of outer 1/3 of
vagina that interferes w/ sexual intercourse
Paraphilia- Unusual fantasies or sexual urges/behaviors that are recurrent and sexually
arousing. Must occur for AT LEAST 6 MONTHS. The following are examples of:
Exhibitionism
• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the
exposure of one’s genitals to an unsuspecting stranger
Fetishism
• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the
use of nonliving objects
Frotteurism
• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving
touching and rubbing against a nonconsenting person
Pedophilia
• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving
sexual activity with a prepubescent child or children (generally age 13 or younger)
Sexual Masochism
• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the
act (real, not stimulated) of being humiliated, beaten, bound, or otherwise made to suffer
16
Sexual Sadism
• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts
(real, not stimulated) in which the psychological or physical suffering (including
humiliation) of the victim is sexually exciting to the person
Voyerism
• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the
act of observing an unsuspecting person who is naked, in the process of disrobing, or
engaging in sexual activity
Transvestic Fetishism
• In a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or
behaviors involving cross-dressing
with gender dysphoria if the person has persistent discomfort w/ gender role or identity
17
Intense desire to participate in the stereotypical games and pastimes of the
other sex
Strong preference for playmates of the other sex
• In adolescents and adults, the disturbance is manifested by symptoms such as
stated desire to be the other sex, frequent passing as the other sex, desire to live or
be treated as the other sex, or conviction that he/she has the typical
feelings/reactions of the other sex
Persistent discomfort w/ his/her sex or sense of inappropriateness in the gender role of
that sex. In children: males->assertion that penis or testes are disgusting or will disappear
or assertion that it would be better not to have a penis or aversion toward rough and
tumble play and rejection of male stereotypical play/toys. Females-> reject urinating
sitting, does not want to grow breasts or menstruate, marked aversion toward normative
female clothing. In adolescents and adults: Preoccupation w/ getting rid of primary and
secondary sex characteristics or belief that he/she was born the wrong sex.
Physiologic Abnormalities:
Turner’s (XO) Female, Fibrous or absent ovaries, short stature, webbed neck
Klinefelter’s (XXY) Male, Small testes, breast development
Androgen Insensitivity/Testicular Feminization (XY) Female, Body cells
unresponsive to androgen, undescended testicles
Congenital Adrenal Hyperplasia (XX) Female w/ masculinized genitalia, Adrenal
gland cannot produce adequate cortisone, excessive androgen secreted prenatally
Mood Disorders
Mood=internal emotion
Affect=how mood is expressed
Mood disorders occur more frequently in single, divorced, and separated people
**When diagnosing a mood disorder, it is important to look at mood/affect over time**
18
Mood congruent delusions are common: guilt, worthlessness, failure, persecution
Dopamine hypoactivity (decreased), Decreased MAO activity
70% of 1st episodes have a life stressor component
½ - ¾ of individual who suffer from a major depressive episode have a 2nd
Mean age of individual 40 yrs., Increased age = increase in frequency and length of episodes
Most individuals have 5-6 episodes over a 20-year period
Untreated episode lasts 6-12 months, Treated lasts 3 months
TX: 75% success rate, drugs/ECT, 4-6 wk trial of antidepressants (fluoxetine)
Nonpsychiatric causes of depression: cancer, thyroid, mono, pneumonia, AIDS, lupus, arthritis,
M.S, Parkinson’s, stroke, steroids, oral contraceptives, drugs
Manic Episode
• Period of abnormally, persistently elevated, expansive or irritable mood FOR 1WEEK
• During the disturbance, THREE OR MORE OF THE FOLLOWING:
Inflated self-esteem or grandiosity
Talkative
Flight of ideas, racing thoughts
Distractibility
Increase in goal-directed activity or psychomotor agitation
Excessive involvement in pleasurable activities w/ potential for painful
consequences
Hypomanic Episode
• Period of persistently elevated, expansive or irritable mood THROUGHOUT 4 DAYS
• During the disturbance, THREE OR MORE OF THE FOLLOWING:
Inflated self-esteem or grandiosity
Talkative
Flight of ideas, racing thoughts
Distractibility
Increase in goal-directed activity or psychomotor agitation
Excessive involvement in pleasurable activities w/ potential for painful
consequences
Manic episode has rapid onset, untreated lasts 3 months, 6-9 months between episodes
1st manic episode usually occurs after 3 major depressive episodes
15% of patients only exhibit mania
40% of individuals have more than 10 episodes of mania
Increased incidence in higher SES
Prognosis worse than that of depression
50% of individuals w/ bipolar have a parent w/ a history of mood disorder
19
TX: Lithium
Dysthymic Disorder
• Depressed mood for most of the day, for more days than not FOR 2 YEARS
• Presence of 2 OR MORE OF THE FOLLOWING:
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness
Anxiety Disorders
20
Fear=normal reaction to known, environmental source of danger
Anxiety=source of danger unknown and/or unrecognized
Neurotransmitters involved=GABA, norepinephrine, serotonin
@ locus ceruleus, raphe nuclei
21
Panic Attack (not a codable disorder)
• Palpitations, pounding heart, sweating, trembling, shaking, shortness of breath, feelings
of choking, check pain or discomfort, nausea, abdominal distress, dizziness, faintness,
derealization or depersonalization, fear of losing control/going crazy, fear of dying,
paresthesias, chills, hot flashes
Specific Phobia
• Persistent fear cued by the presence or anticipation of a specific object or situation
• Exposure to the stimulus always provokes anxiety response
• Person recognizes that fear is excessive and unreasonable
Social Phobia
• Persistent fear of one or more social or performance situations. Fear being embarrassed or
humiliated
• Exposure to the feared social situation always provokes anxiety response
22
Psychotic Disorders:
1.5% prevalence, men=women
Bleuler’s 4As: Autism (lack of communication),
Affect (flat),
Associations (loose),
Ambivalence (uncertain)
Schizophrenia: 1% prevalence
*2 or more of the following DURING A 1 MONTH PERIOD, PERSISTING FOR 6 MONTHS*
• Delusions
• Hallucinations
• Disorganized Speech
• Disorganized or catatonic behavior
• Negative symptoms (flat affect, alogia-speech deficiencies, avolition) D1
receptor
• Positive symptoms (loose associations, strange behavior, hallucinations, talkative)
D2,3 receptors
Good Prognosis=Late onset, precipitating factors, acute onset, good premorbid history of
functioning, mood disorder symptoms, married, family history of mood disorders, good support
symptoms, positive symptoms
Poor Prognosis=Young onset, no precipitating factors, insidious onset, poor premorbid
functioning, withdrawn, autistic behavior, single, divorced, family history of schiz., poor support
system, negative symptoms, multiple relapses, “High Expressed Emotion” (pressures in family)
23
Short arm 9, X
TX: Behavioral, Family, and Individual Therapy, Antipsychotics/Neuroleptics, Side Effects of
Neuroleptics: weight gain, impotence, extrapyramidal signs, Extrapyramidal (tremor, akinesia,
rigidity, muscle spasms, tardive dyskinesia)
**Clozapine-no extrapyramidal signs**
Schizophreniform Disorder
• The criteria for schizophrenia are met FOR AT LEAST 1 MONTH BUT < 6
MONTHS
Shizoaffective Disorder
• Major depressive episode, manic episode, or mixed episode with Schizophrenia
• Delusions or hallucinations for AT LEAST 2 WEEKS W/OUT MOOD SYMPTOMS
Simple Schizophrenia
• Decline in functioning, gradual appearance and deepening of negative symptoms, no
other schizophrenic symptoms met
24
• BEGINNING IN EARLY ADULTHOOD, 4 OR MORE OF THE FOLLOWING:
Suspects that others are exploiting, harming or deceiving him/her
Preoccupied with unjustified doubts about the loyalty of friends/family
Reluctance to confide in others
Reads hidden meaning into benign remarks or events
Persistently bears grudges
Perceives attacks on character or reputation not apparent to others
Recurrent suspicions, w/out justification, regarding fidelity of partner
25
TX: Psychotherapy: Patients have peculiar patterns of thinking, therapists must not ridicule or
judge these thoughts/activities, antipsychotic
Crisis Addict, often attempt suicide for attention, to manipulate others, and accidentally succeed
Poor prognosis
TX: Psychotherapy: Problems: patients regress easily, act out impulses, transference, splitting,
therefore, reality-oriented approach is most common. They do best in hospital setting.
Antipsychotics, antidepressants, MAOIs
26
Interactions w/ others is sexually seductive/provocative
Rapidly shifting, shallow expressions of emotion
Use of physical appearance to draw attention to self
Style of speech is excessively impressionistic and lacking in detail
Self-dramatic, theatrical, exaggerated expression of emotion
Easily influenced by others or circumstances
Considers relationships to be more intimate than actually are
TX: Psychotherapy: As these patients are unaware of their own feelings, clarification of their
inner feelings is important
TX: Individuals are chronic, difficult to treat b/c treatment=blows to their narcissism, Lithium
and antidepressants
TX: Psychotherapy: depends on solid alliance w/ patient, trust and acceptance, encourage risk-
taking despite fear of humiliation/rejection, Beta Blockers
27
Dependent Personality Disorder, more common in females
• Pervasive, excessive need to be taken care of that leads to submissive, clinging behaviors
and fears of separation
• BEGINNING IN EARLY ADULTHOOD, 5 OR MORE OF THE FOLLOWING:
Difficulty making everyday decisions w/out advice and reassurance from
others
Needs others to assume responsibility for most areas of his/her life
Difficulty expressing disagreement w/ others for fear of loss of
support/approval
Difficulty initiating projects or doing things on his/her own (not lack of
energy)
Goes to excessive lengths to get nurturance and support from others
Uncomfortable or helpless when alone b/c exaggerated fears of inability to
care for self
When a close relationship ends, urgently seeks another for source of
care/support
Unrealistically preoccupied w/ fears of being left to take care of self
TX: Psychotherapy: often successful, w/ support of therapist the patient becomes more
independent, self-reliant, assertive. Beware of how this will affect pathological relationships
TX: Psychotherapy: often aware of suffering, seek treatment on their own. Free association and
non-directive therapy, Benzodiazepines (Clonazepam)
28
Sullen, argumentative
Unreasonably criticizes and scorns authority
Envy and resentment toward those more fortunate
Voices exaggerated, persistent complaints of personal misfortune
Alternates between hostile defiance and contrition
Somatoform Disorders
These individuals truly believe that they are sick
TX: Difficult to treat, Individual and group psychotherapy, anxiolytics, hypnosis, consistent
physician who views symptoms as communications and helps patient see link w/ psychology
RepressionConversionPhysical Symptom
TX: 90% cure in < month, insight-oriented supportive or behavioral therapy, hypnosis,
anxiolytics, relaxation exercises, lorazepam, amytal
Onset between 20-30 years of age, more common in blacks than whites
TX: Patients are usually resistant to treatment, group psychotherapy, frequent regularly
scheduled physical exams provide reassurance that doctor has not abandoned patient
29
Body Dysmorphic Disorder
• Preoccupation w/ imagined defect in appearance
Age of onset 15-20 years, more common in women than men, unmarried
Comorbidity w/ major depressive episode, anxiety disorder, psychotic disorder
TX: SSRIs, tricyclics, MAOs
Pain Disorder
• Pain in one or more anatomical sites
• Psychological factors are judged to have a role in onset, severity, exacerbation and
maintenance of pain
• Pain is not intentionally produced
Factitious Disorders
Factitious Disorder, more frequent in men
• Intentional production of physical or psychological signs or symptoms
• Motivation is to assume the sick role
• External incentives for the behavior are absent
Dissociative Disorders
Defense against trauma and anxiety
Important differentials for all dissociative disorders: Dementia, Delirium, ECT, Epilepsy,
Head trauma, Substance abuse
30
Dissociative Fuge
• Sudden, unexpected travel away from home or customary place of work, w/
inability to recall one’s past
• Confusion about personal identity or assumption of new identity
Usually occurs during or right after personal crisis, lasts for a few hours/days (recurrence rare)
Individuals w/ borderline, histrionic personalities are more prone
TX: Supportive treatment understanding of cause, hypnosis, amital
Causes: sensory deprivation, brain tumors, emotional trauma, substances, anxiety, depression
TX: Anticholinergic drugs, barbituates
Cognitive Disorders
Caused primarily by abnormalities in brain chemistry, structure, and/or physiology
Delirium
• Disturbance of consciousness (reduced clarity of awareness of environment) w/ reduced
ability to focus, sustain, or shift attention
• Change in cognition (memory deficit, disorientation, language disturbance)
• Disturbance develops over a short period of time (hours to days) and tends to fluctuate
during the course of a day
31
Often visual illusions and/or hallucinations
3 Month mortality rate: 23-33%
Causes: cerebral, somatic, external, pharmacologic, CNS dysfunction
Major neurotransmitteracetylcholine, Neuroanatomical areareticular formation
Most common psychiatric disorder seen in patients admitted to medical/surgical units
1/3 of ICU/Surgical patients are suffering from delirium
TX: identify and remove causative factors, recedes in 3-7 days, if psychosis: Haloperidol, if
insomnia: benzodiazepines w/ short ½ lives
Dementia
• Development of multiple cognitive deficits manifested by memory impairment and
cognitive disturbances (aphasia, apraxia, agnosia, disturbance of executive functioning)
32
Polysubstance Dependence=Repeated use of at least 3 types of psychoactive drugs for at least 6
months
Psychiatric Emergencies
10% of ER visits are psychiatric emergencies
Presentation may be overt or covert, significant disturbance of cognition or mood (suicidal,
depressed, severe obsessional thoughts, acute anxiety, phobias)
Suicide
8th leading cause of death in the US, 30,000 deaths per year
2nd leading cause of death among 15-24 year olds
Men commit suicide 3X more often than women
Women attempt suicide 4X more often than men
25% of suicides are by the elderly
80% of suicides are secondary to depression
33
Cancer patients tend to commit suicide w/in first year after diagnosis
Indicators of high risk: age > 45 yrs, male sex, single/divorced/widowed, unemployed,
chaotic/conflicted family/personal relationships, alcohol/drug abuse, prior suicide
attempts (highest indicator), hypochondriachal, psychosis, severe personality disorder,
strong wish to die, available methods, plan for suicide, family history, poor achievement,
poor insight, social isolation,
Whites commit suicide more frequently, as do Jews & Protestants vs. Catholics
Professionals, esp. psychiatrists, dentists, law enforcement, lawyers, musicians greater
risk
Hospitalize ifimpulsive, lack social support, presence of specific plan
Violence
Outwardly or inwardly directed destructive behavior
Environment, biology and psychology interplay, to cause distress for individual
Risk factors: past history of violence, forensic history, childhood history of abuse,
possession/access to weapon, history of psychosis, current psychotic state,
alcohol/substance abuse, cognitive state, physical illness
TX: haldol, benzodiazepines, amobarbital, lithium
Treatment/Therapy
Psychoanalytic Theory: Sigmund Freud
Forces motivating behavior are derived from unconscious mental processes, sexual and
aggressive drives motivate activities of the mind
Repression=force that keeps unconscious processes out of consciousness
Unconscious mind=repressed thoughts and feelings, primary process thinking (primitive
drives, wishes and pleasure
Preconscious mind=secondary process thinking (logical, associated w/ reality)
Conscious mind=operates w/ preconscious, no access to unconscious
Id=sexual and aggressive drives, pleasure principle
Ego=maintains relationship to outside world, controls expression of instinctual drives to
adapt to external reality
34
Superego=moral values and conscience, controls id impulses
Defense mechanisms=unconscious mental techniques used to decrease anxiety, and
maintain self-esteem, safety, equilibrium (acting out, denial, displacement, dissociation,
identification, intellectualization, isolation of affect, projection, rationalization, reaction
formation, regression, repression, splitting, altruism, humor, sublimation, suppression)
Psychotherapy
Classical Psychoanalysis-
Based on Freud’s Psychoanalytic Theory
3-6 years, 4 times per week, 45-50 minute sessions
Purpose to recover and integrate into an individual’s personality, those experiences
repressed in the unconscious
Major technique is free association (say whatever comes to mind), couch promotes f.a.
Fundamental Rule: patient must be completely honest (doesn’t always happen)
Therapeutic Alliance: mutual trust, cooperation, honesty
Intensive focus on transference=patient’s unconscious feelings from the past are
displaced onto and experienced w/ therapist
Countertransference=therapist unconsciously experiences feeling about past w/ patient
Therapist’s (tabula rasa) role is to interpret material produced in free association using
“free-floating attention”
Dreams (roadway into the unconscious): manifest content (what’s reported), latent
content (unconscious meaning)
Analysis of defense mechanisms that fend off awareness of unconscious conflicts
Therapist provides well-timed interpretations, of which transference is major frame of
reference
Indicators: significant suffering (motivation), wish to understand self, tolerance for
frustration/anxiety/strong affect, mature superego (honest), ave. or > IQ, psychologically
minded
Supportive psychotherapy:
Therapist as authority figure during time of illness, turmoil, temporary
decompensation
Therapist as warm, friendly, strong leadership, partial gratification of dependency
needs, help in developing pleasurable activities, rest/diversion
Goal: help patient feel secure, accepted, protected, encouraged, safe, not anxious
Talking is done for relief, not for insight
Brief psychotherapy
Brief in Focus
35
Derived from a combo of psychoanalytic and learning theories
Increased popularity b/c of pressure to contain health care costs
Clear-cut selection/rejection criteria: highly motivated, able to deal w/ psych. concepts,
concentrate on / resolve conflict, develop therapeutic alliance quickly
20-30 sessions to clarify nature of defense/anxiety/impulse
Time-Limited
12 interviews, no explicit candidates
Goal: to resolve present/chronically endured pain & negative self-image
Crisis intervention
Therapeutic and preventative
Crisis Intervention=immediate responses to an immediate situation, as well as long-term
development of psychological adaptation to prevent future problems
Crisis=painful state in response to hazardous events, may last hours-weeks
Crisis 1.anxiety/tension rise
2.problem-solving mechanisms kick in (adaptive/maladaptive)
maladaptivepain intensifies, crisis deepens, regressive deterioration
TX: Rapidly establish rapport, reassurance, suggestion, environmental manipulation,
psychotropic meds
Resolve crisis and build skills to prevent future crisis
Biological Treatments
Psychosurgery
Surgical modification of brain, Lesion-specific brain regions
Used in severely ill patients
Biofeedback
Autonomic nervous system can come under voluntary control through operant
conditioning
Patients get info on involuntary biologic function through instruments, and learn to
regulate
EMG-electric potential of muscle fibers
36
EEG-alpha waves in relaxed state
GRS-galvanic skin response gauge-skin conductivity
Thermistor-skin temp
Applications: asthma, cardiac arrhythmias, encopresis/enuresis, ADHD, epilepsy,
migranes, hypertension
Pharmacology
Antipsychotics (Neuroleptics): Treat Schizophrenia
Antidepressants:
Heterocyclics (Tricyclics):*Primary drugs to treat depression*, Block reuptake of
norepinephrine and serotonin, Also block acetylcholine and histamine receptors to
produce anticholinergic effects (dry mouth, blurred vision, urine retention, constipation,
sedation), Overdose can be fatal.
Imipramine (Tofranil): Strongly anticholinergic, more likely to cause orthostatic
hypotension.
Clincial use: Panic disorder w/ agoraphobia, eneuresis, anorexia nervosa, bulimia.
Clomipramine (Anafranil): Most specific for serotonin.
Clinical use: Obsessive-compulsive disorder .
Desipramine (Norpramin): Least sedating, least anticholinergic.
Clinical use: Depression in the elderly, anorexia nervosa, bulimia.
Amitriptyline (Elavil): Strongly sedating and anticholinergic.
37
Clinical use: Depresion with insomnia.
Nortriptyline (Pamelor): Least likely to cause orthostatic hypotension.
Clincal use: Depression in cardiac patients and the elderly.
Amoxapine (Asendin): Parkinsonian symptoms, galactorrhea, sex dysfunction,
most dangerous in overdose.
Clinical use: Depression w/ psychotic features.
Doxepin (Sinequan, Adapin): Strongly sedating and anticholinergic.
Clinical use: Generalized anxiety disorder, peptic ulcer disease.
Sympathomimetic Agents:
Amphetamines: Used in treatment-resistant individuals at risk from adverse
effects of other antidepressants
Other Antidepressants:
Trazodone (Desyrel): safer antidepressant, used as adjunct to tricyclics
Alprazolam (Xanax): antidepressant activity, but used to treat anxiety
38
Alprazolam (Xanax): Intermediate-acting, also antidepressant, panic disorder,
social phobia.
Clonazepam (Klonopin): Intermediate-acting, also for seizures, mania, panic
disorder, social phobia.
Lorazepam (Ativan): Intermediate-acting, also for psychotic agitation
Chlordiazepoxide (Librium): Long-acting, also for alcohol withdrawal
Diazepam (Valium): Long-acting, also a muscle relaxant, and analgesia
Flurazepam (Dalmane): Long-acting, also for insomnia
Halazepam (Paxipam): Long-acting
Prazepam (Centrax): Long-acting
Temazepam (Restoril): Long-acting, also for insomnia
Barbiturates-greater potential for abuse (used less frequently), lower therapeutic index,
SE=sedation, respiratory depression, fatal overdose, tolerance and dependence develop
w/ chronic use
Carbamates- great potential for abuse and dependence, used only when unable to use
benzodiazepines
Azaspirodecanediones, unrelated to benzodiazepines, nonsedating, not associated w/
dependence, withdrawal or abuse
Buspirone (BuSpar)
Advantages= short study time, inexpensive, suitable for rare disease, no subject volunteer, small
number of subjects, no attrition problems
Disadvantages=control group susceptible to bias in selection, biased recall possible, can’t
determine incidence
39
Cross-Sectional Studies
Provide info on possible risk factors and health status of a group of individuals at one
specific point in time
Case Report:
Brief, objective report of a clinical characteristic or outcome from a single clinical subject
or event
Provides first report of unexpected findings, hypothesis for testing, definitions for further
study
Relative Risk
Compares incidence rate of disorder of exposed individuals w/ incidence rate of disorder
in unexposed individuals. E.g.
R.R = Incidence rate of cancer among smokers / rate among nonsmokers
Can be calculated ONLY for prospective studies
Attributable Risk
Useful for determining what would happen in a study population if the risk factor was
removed
Incidence rate of the illness in nonexposed individuals is subtracted from those who have
been exposed
A.R= incidence rate of lung cancer in smokers - incidence in nonsmokers
Odds Ratio
Estimate of relative risk when incidence rate is not available
How much higher the risk is in exposed individuals vs. nonexposed
Calculated for retrospective (case-control) studies
40
Validity=measure of whether test assesses what it was designed to test
Sensitivity and Specificity are components of validity
Sensitivity (How well a test identifies truly ill people) = A / A+C
Specificity (How well a test identifies truly well people) = D / B+D
Predictive Value=measure of the percentage of test results that match the actual diagnosis
Positive Predictive Value: (Probability that an individual w/ a positive test actually has the
illness) = A / A+B
Negative Predictive Value (Probability that a person w/ a negative test is actually well)
= D / C+D
Prevalence (Number of individuals in a population who have an illness)
= A+C / GRAND TOTAL (A+B+C+D)
Disease State
Test Results Present Absent Total Patients
Positive A B A+B
True Positive False Positive
Negative C D C+D
False Negative True Negative
Total Patients A+C B+D GRAND TOTAL
A+B+C+D
Statistical Tests
t-test-difference between means of two samples
Analysis of variance-differences between mean of more than two samples
One-way (one variable)
Two-way (two variables)
Chi-squared test-differences between frequencies in a sample
Correlation-mutual relationship between two continuous variables, (-1 and +1)
Multiple regression-relationship between many measures
Hypothesis testing
Null hypothesis: says there is no difference between two groups (postulated to be
different in hypothesis)
Type I error: null hypothesis is rejected although it is true
Type II error: null hypothesis is not rejected and it is false
p (probability): chance of a type I error
p < .05 = type I error unlikely, statistically significant
Psychological Testing
41
Objective Test=Easily scored, statistically analyzed (MMPI)
Minnesota Multiphasic Personality Inventory: hypochondriasis, depression, hysteria,
psychopathology, masculinity/femininity, paranoia, psychastenia(anxiety),
schizophrenia, hypomania, social distance
Projective Test=Subject interprets questions, responses are based on motivational state and
defense mechanisms (Rorschach Inkblot, Thematic Apperception Test, Sentence Completion
Test, Draw-A-Person Test)
Rorschach: though disorders, nature of defenses
Thematic Apperception Test (TAT): make story based on pictureemotions/conflicts
that are out of awareness
Test-Battery=Tests functioning in a number of areas (Halstead-Reitan Battery)
Halstead-Reitan Battery (HRB): presence/location/effect of brain lesions
Luria-Nebraska Neuropsychological Battery (LNNB): left/right cerebral dominance,
specific types of brain dysfunction (i.e. dyslexia)
Intelligence Test=measurement of individual’s ability to reason, manage abstract concepts,
assimilate facts, recall, analyze/organize info, and manage new situations
Stanford Binet Scale: Used to test general intellectual ability btwn 2-18yrs
IQ = mental age:chronologic age X 100
Wechsler Intelligence Tests: Most commonly used IQ test
WAIS-R: Wechsler Adult Intelligence Scale Revised 16-75 years
WISC-R: 6-16 ½ years
WPPSI: 4-6 ½ years
42