1
Q
2 components of anxiety
A
- Awareness of the psychological sensations (Palpations and sweating)
- Awareness of being nervous or frightened
2
Q
Psychoanalytic anxiety
A
Things that happen during childhood may contribute to how you function as an adult
3
Q
Behavioral anxiety
A
A conditioned response to a specific environmental stimulus.
4
Q
Existential anxiety
A
No specifically identifiable stimulus exists, chronically feeling anxious.
5
Q
Panic Disorder definition
A
Acute, intense attack of anxiety associated with personality disorganization; overwhelming and accompanied by feelings of impending doom.
6
Q
Panic Disorder clinical presentation
A
- Attack often begins within a 10 minute period of rapidly increasing symptoms.
- Signs Include tachycardia, palpitations, dyspnea, sweating, dizziness, trembling, chest pain/discomfort, nausea and depersonalization.
7
Q
Panic Disorder ddx
A
MI, anemia, angina, hyperventilation, tumor, hyperthyroidism, cocaine, alcohol/drug withdrawal, systemic infection
8
Q
Panic Disorder DSM 5 criteria
A
- Recurrent unexpected panic attacks with >4 symptoms
- At least 1 of the attacks has been followed by 1 month of one of the following:
- Persistent concern or worry about additional panic attacks
- Significant maladapted change in behavior related to the attacks.
9
Q
Social anxiety disorder definition
A
Intense of persistent fear of social situations, including situations that involve scrutiny or contact with strangers.
10
Q
Social anxiety disorder clinical presentation
A
- Anxiety is preventing an individual from participating in desired activities of causes marked distress during such activities.
- Social settings causes intense fear, will avoid completely.
- Feels their fear is excessive or unreasonable.
11
Q
Social anxiety disorder ddx
A
- Appropriate fear or shyness
- Agoraphobia, panic disorder, avoidant personality, MDD, schizoid personality.
12
Q
Social anxiety disorder DSM-5 criteria
A
- Mark fear/anxiety about social situations where possible scrutiny by others as an option
- Fear he/she act in a way/show anxiety symptoms and will be negatively evaluated
- Social situations always provoke fear/anxiety
- Social situations avoided/endured with intense fear/anxiety
- Fear of anxiety out of proportion to actual threat of social situations
- Fear/anxiety/avoidance is persistent for > 6 months
- Significant distress/ impairment and social/occupation/other areas of functioning
13
Q
GAD definition
A
Excessive anxiety/ worrying about several events/activities for most days of at least a 6 mo period.
14
Q
GAD ddx
A
- Neurological, endocrinological, metabolic, and medication related
- Other anxiety disorders such as panic disorder, phobias, OCD, and PTSD.
15
Q
GAD DSM-5 Criteria
A
- Anxiety and worrying associated with 3 or more of the following 6 symptoms
- Restlessness or feeling keyed up or on edge
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbances (falling or staying asleep)
- Anxiety/worrying/physical symptoms cause significant distress/impairment in social, occupational, or other areas of functioning.
16
Q
Sexual assault: historical elements.
A
- Age and identifying information for both victim and assailant.
- Date, time, location of alleged assault = emergency contraception (most effective w/in 72 hr).
- Circumstances of assault
- Obtain details of the assault itself.
- Actual or attempted–vaginal/anal/oral and w/ assailants penis/ finger/tongue/object.
- Condom or lubricant use?
- Ejaculation? If so where? Inside or outside of body?
- Did they urinate?
- Injuries on victim or on assailant that resulted in bleeding? Was the assailant scratched?
- Were physical restraints used? Weapons? Drugs? EtOH?
- Allergies or medications.
- Activities after victim was assaulted = change clothing?, bathing? Douching? Dental hygiene?, urination/defecation?
- Gynecological history
- LMP
- Contraception use
- Pregnancy hx
- Last voluntary sexual encounter.
- Recent episode of gynecological infection
- Previous pelvic surgeries
17
Q
Sexual assault: forensic evidence
A
- Clothing–each article separately packaged in paper bag
- Known blood sample of patient
- Toxicology testing of blood and urine
- Oral swabs/smear–up to 24 hours post assault.
- Head hair combings
- Fingernail scrapings (DNA)
- Foreign material collection
- Swabs of bite marks or areas where assailant’s mouth touched the patient
- Pubic hair combings–15 to 20 hairs
- External genital swabs
- Vaginal swabs/smears–Cx sampling (96 to 120 hrs post assault)
- pap smear
- woods lamp (used to detect semen)
- use only saline w/speculum
- Perianal swabs
- Anorectal swabs/smears–up to 24 hours post assault
- Forensic photography–3 views per injury–one w/ruler for scale
18
Q
Sexual assault: what do you prescribe to prevent pregnancy?
A
- levonorgestrel 1.5 g po x 1 (plan B)
19
Q
Sexual assault: what do you prescribe to prevent gonorrhea?
A
- ceftriaxone 250 mg IM or cefixime 400 mg po x 1
20
Q
Sexual assault: what do you prescribe to prevent chlamydia?
A
- azithromycin 1 g po x 1 or doxycycline 100 mg po bid x 7 days(may cause nausea)
21
Q
Sexual assault: what do you prescribe to prevent trichomonas and BV?
A
- Flagyl 2 g po x 1 (may cause nausea)
22
Q
Sexual assault: what do you prescribe to prevent Hep B?
A
- Vaccine x 1 w/ 2nd and 3rd vaccines (4 w and 6 mo) or hepatitis B immune globulin
23
Q
Sexual assault: what do you prescribe to prevent tetanus?
A
- Td toxoid 0.5 mL IM x 1
24
Q
Sexual assault: what do you prescribe to prevent HIV?
A
- Zidovudine 200 mg po TID x 4 w
or - lamivudine 150 mg po BID x 4 w
and consult w/ infectious dz specialist
25
Define Psychological
| dependency
- Craving and the behavior involved in procurement of a drug
26
Define Physiologic
| dependency
- Withdrawal symptoms on discontinuance of the drug
27
Define abuse
- Use of any drug, usually by self administration, in a manner that deviates from approved social or medical patterns
28
Define Misuse
Similar to abuse, but usually applies to drugs prescribed by physicians that are not properly used.
29
define addiction
- The repeated and increased use of substance that deprivation of which gives rise to symptoms of distress and an irresistible urge to use the agent again which leads to physical and mental deterioration.
30
define intoxication
- A reversible syndrome caused by a specific substance that affects one of more of the following mental functions: memory, orientation, mood, judgement, and behavioral, social or occupational functioning
31
define withdrawal
- A substance-specific syndrome that occurs after stopping or reducing the amount of the drug or substance that has been used regularly over a prolonged period of time. The syndrome is characterized by psychological signs and symptoms in addition to psychological changes such as disturbances in thinking, feeling, and behavior.
32
define tolerance
- The need to increase the dose to obtain desired effects.
33
define cross-tolerance
- The ability of one drug to be substituted for another, which usually produce the same physiological and psychological effects
34
define neuroadaptation
- Neurochemical or neurophysiologic changes in the body that result from the repeated administration of a drug.
- It accounts for the phenomenon of tolerance.
35
define codependence
- Behavioral patterns of family members or have been significantly affected by another family members substance use or addition
36
Explain alcohol absorption
- 10% of consumed alcohol is absorbed from the stomach the remainder from the small intestines.
- If the [ ] of alcohol in the stomach becomes too high, mucus is secreted and the pyloric valves close. This slows the absorption and keeps alcohol from passing into the small intestine. This small amount of alcohol can remain in the stomach for hours, results in pylorospasm causing n/v.
37
Explain alcohol metabolism
- About 90% of absorbed alcohol is metabolized through oxidation in the liver, the remaining 10% is excreted unchanged by the kidneys and lungs.
- Alcohol is metabolized by two enzymes: alcohol dehydrogenase (ADH) and aldehyde dehydrogenase.
38
What tool is used to screen pts with alcohol abuse?
AUDIT
39
Describe what AUDIT is
- Consist of questions on the quantity and frequency of alcohol consumption, on alcohol dependence symptoms and on alcohol related problems.
- Cost effective and efficient diagnostic tool for routine screening of alcohol use disorders in primary care setting.
40
Number of drinks a day for men to be considered alcoholic?
>4 drinks per day
41
Number of drinks a day for women to be considered alcoholic?
>3 drinks per day
42
define allodynia
- Pain resulting from a stimulus which would not normally provoke pain.
43
define analgesia
-any group of drug used to relieve pain
44
define anesthesia
-usually long lasting and is used to block pain.
45
define dysesthesia
unpleasant or abnormal sense of touch.
46
define hyperalgesia:
increased sensitivity to pain.
47
define nociceptive pain
- Caused by somatic injury
- Sharp, local radiating well defined areas.
- Typically does respond to NSAIDs and opioids
- Ex. Post operative and post traumatic pain
- A delta fibers
48
define neuropathic pain
- Caused by damage to actual nerve
- Tingling, shooting, electric, numbness, radiating, allodynia.
- Typically does NOT respond to NSAIDs or opioids
- DOES respond to TCAs and SNRIs.
- C Fibers
49
define visceral pain
- Distention of a hollow viscous
- Typically nonspecific, feel pain away from the actual source/cause
- Sympathetic fibers
- Ex. Pancreases, appendicitis, nephrolithiasis.
50
Define chronic pain
- May be perpetuated
- Pathogenically and physically remote from the originating cause
- Low levels of underlying pathology that does not respond to the presence of extent of the pain experienced.
- Total eradication may be unrealistic
51
Define acute pain
- Elicited by the injury of body tissues and activation of nociceptive transducers at the site of local tissue damage
- Typically resolves after the injury is healed
- Acute pain can last anywhere from seconds to up to a year
52
What are some challenges with chronic pain in primary care setting?
- Time, knowledge, experience, awareness, treatment modalities, sympathy, professional patients, examination/diagnosing, when/what to prescribe, patient care/customer service.
- Knowing what to treat, or not to treat
- Opiates vs your license
- Several providers have lost DEA or state license resulting in not being able to prescribe or practice
- No sufficient training in prescribing opioid pain relievers.
53
Epidemiology of paranoid personality disorder?
- 2 to 4 % of population
- Rarely seek tx themselves rather spouse/employer bring them in
- Increased likelihood for relative of schizophrenia patient
- M > W
54
Diagnostic criteria of paranoid personality disorder?
- 4 or more of the following:
- Pathologically jealous, distrust, suspicious of others, believes others out to get them
- Recurrent suspicions w/o justification of fidelity of spouse/sexual partner
- Persistently bears grudges
- Suspects w/o backing that others are exploiting, harming, or deceiving them
- Preoccupied w/ unjustified doubts regarding loyalty/ trustworthiness of friends/associates
55
DDx of paranoid personality disorder?
- Delusion
- Schizophrenia
- Borderline
- antisocial
- Schizoid
56
Course and prognosis of paranoid personality disorder?
- Have lifelong problems working/ living w/others.
57
Tx for paranoid personality disorder?
- Psychotherapy: therapist
| - Management anxiety (diazepam) and agitation (haloperidol)
58
Diagnostic criteria of schizoid personality disorder?
- 4 or more of the following:
- No desire/enjoyment w/close relationships including family
- Almost always chooses solitary events
- Little/no interest in sexual experiences
- Little pleasure in few activities
- No close friends/ confidants other than first degree relatives
- Emotional coldness, detachment, flattened affect.
59
DDx for schizoid personality disorder?
- schizophrenia
- delusional
- paranoid
- autistic or aspergers
60
Course and prognosis for schizoid personality disorder?
- Onset = early adulthood/adolescence
| - Long-lasting but not necessarily lifelong.
61
Tx for schizoid personality disorder?
- Psychotherapy: development of trust w/therapist important
- Pharmacotherapy: small doses of antipsychotics, antidepressants, and psycho stimulants can be beneficial;
- benzos may diminish interpersonal anxiety;
- serotonergic agents may make patient less sensitive to rejection
62
Epidemiology of schizotypal personality?
- Frequent in female w/fragile X syndrome
- M > W
- Increased risk among families of schizophrenic patient
63
Diagnostic criteria of schizotypal personality?
- 5 or more of the following:
- Ideas of reference
- Odd beliefs of magical thinking influencing behavior inconsistent w/subcultural norms
- Unusual perceptual experiences
- Odd thinking/speech
- Suspiciousness/paranoid ideation
- Inappropriate or constricted affect
- Behavior/appearance which is odd/ eccentric/ peculiar
- Lack of close friends/confidants
- Excessive social anxiety that doesn’t go away w/familiarity associated w/paranoid fears rather than negative judgments about self
64
DDx for schizotypal personality?
- Schizoid
- Avoidant
- Schizophrenia
65
Course and prognosis for schizotypal personality?
- Premorbid personality of schizophrenic patient
| - 10% commit suicide
66
Tx for schizotypal personality?
- Psychotherapy
| - Antipsychotic meds and antidepressants (if depressive component)
67
Epidemiology of antisocial personality disorder?
- Stereotypically Male
- High prevalence among men w/ alcohol use disorder, prison populations
- Onset =prior to age 15
- Familial pattern (5x more likely among first degree relatives of men w/ disorder)
68
diagnostic criteria of antisocial personality disorder?
- 3 or more of the following:
- Failure to conform to social norms w/respect to lawful behaviors
- Deceitfulness, repeated lying, use of a lies or conning others for personal profit/pleasure
- Impulsivity/failure to plan ahead
- Irritability/aggressiveness --> repeated fights/assaults
- Reckless disregard for safety of self/others
- Consistent irresponsibility --> repeated failure sustain consistent work behavior/honor financial obligations
- Lack of remorse
69
Tx for antisocial personality disorder?
- Psychotherapy: when feel they are among peers, they lack motivation to change, need to combat patient’s desire to run from honest human encounters
- Pharmacotherapy: combat sx of anxiety, rage, depression, but be careful as higher incidence of drug use needs to be used carefully
70
Epidemiology of borderline personality disorder?
- Stereotypically female
| - Increase prevalence of MDD, alcohol use, substance abuse in first degree relatives of someone w/borderline disorder
71
diagnostic criteria of borderline personality disorder?
- 5 or more of the following:
- Frantic efforts to avoid real/imagined abandonment
- Pattern of unstable and intense interpersonal relationships
- Identity disturbance–unstable self-image or sense of self
- Impulsivity in at least two areas that are potentially self-damaging
- Recurrent suicidal behavior, gestures, threats, self-mutilation
- Affective instability d/t marked reactivity of mood
- Chronic feeling of emptiness
- Inappropriate intense anger/difficulty controlling anger
- Transient, stress-related paranoid ideation or severe dissociate sxs
72
DDx for borderline personality disorder?
- schizophrenia
- schizotypal
- paranoid
73
Course and prognosis for borderline personality disorder?
- Fairly stable
- High incidence of MDD
- Diagnosed typically prior to age 40
- Unable to deal w/normal stages of life
74
Tx for borderline personality disorder?
- caution: most likely to sue providers
- Pharmacotherapy: antidepressants; MAOI for modulating impulsive behavior;
- benzos (alprazolam) for anxiety and serotonergic for depression;
- anticonvulsants (carbamazepine) improve global function.
75
Diagnostic criteria of histrionic personality disorder?
- 5 of more of the following
- Uncomfortable in situation where not the center of attention
- Interaction w/ other characterized by inappropriate sexually seductive or provocative behavior
- Display rapidly shifting and shallow expression of emotions
- Consistent use of physical appearance to draw attention to self
- Style of speech excessively impressionistic and lacking in detail
- Self-dramatization, theatricality, exaggerated expression of emotion
- Suggestible
- Consider relationships to be more intimate than they actually are
76
DDx for histrionic personality disorder?
- borderline
| - Somatization disorder can occur in conjunction w/ histrionic
77
Course and prognosis for histrionic personality disorder?
- Increase age = fewer sx
| - Sensation seekers = get into trouble w/law, substance abuse, promiscuous
78
Tx for histrionic personality disorder?
- Psychotherapy: unaware of own real feelings --> clarification of their feelings is important
- Pharm: symptomatic tx.
79
Epidemiology of narcissistic personality disorder?
- Impart an unrealistic sense to their children --> offspring = higher risk of developing narcissism as well
80
Diagnostic criteria of narcissistic personality disorder?
- 5 or more of the following
- Grandiose sense of self-importance
- Preoccupied w/fantasies of unlimited success, power, brilliance, beauty, or ideal love
- Believes they are special and unique and only understood/associate w/other special or high-status people
- Require excessive admiration
- Sense of entitlement
- Interpersonally exploitative
- Lack empathy, unwilling to recognize/identify w/feeling and needs of others
- Often envious of others or believes others are envious of them
- Arrogant, haughty behaviors or attitudes
81
DDx for narcissistic personality disorder?
- Borderline
- Histrionic
- Antisocial
82
Course and prognosis for narcissistic personality disorder?
- Aging is handled poorly as patient’s value beauty, strength, youthfulness
- More vulnerable to mid-life crisis
83
Tx for narcissistic personality disorder?
- Therapy often makes them worse–get additional ideas on how to manipulate people
- Medications rarely help
- Community of boundaries–create an environment to hold them accountable
- Be careful what behaviors they exhibit are being rewarded
- Susceptible to depression --> antidepressant
- If mood swings, then lithium can be helpful
84
Epidemiology for avoidant personality disorder?
- Timid temperament infants may be more susceptible
85
Diagnostic criteria or avoidant personality disorder?
- 4 or more of the following:
- Avoid occupational activities involving significant interpersonal contact for fear of criticism, disapproval, rejection
- Unwilling to get involved w/people unless certain will be liked
- Restraint w/in intimate relationships d/t fear of being shamed/ridiculed
- Preoccupied w/being criticized or rejected in social situations
- Inhibited in new interpersonal situations d/e feeling inadequate
- Views self as socially inept, personally unappealing, inferior to others
- Usually reluctant to take personal risks or to engage in new activities as they might be embarrassed
86
DDx for avoidant personality disorder?
- Schizoid
- Borderline and Histrionic
- Dependent
87
Course and prognosis for avoidant personality disorder?
- Able to function in protected environment.
| - If support system fails --> depression, anxiety, and anger
88
Describe the subtype of schizophrenia: Paranoid
- Preoccupation w/one + delusions/auditory hallucinations (most commonly delusions of grandeur)
- Less regression of mental faculties, emotions, and behavior
- Tense, suspicious, guarded, reserved, hostile/aggressive, okay w/ social situations, intact intelligence
- Will have onset at older age than older types(late 20s and 30s)
89
Describe the subtype of schizophrenia: Disorganized
- Marked regression to primitive unorganized behavior
- Pronounced thought disorder, poor grip on reality, disheveled personal appearance, social/emotional responses are inappropriate, incongruous grinning/grimacing, described as silly
- Onset prior to age 25
90
Describe the subtype of schizophrenia: catatonic
- Disturbance in motor function = stupor, negativism, rigidity, excitement, posturing
- Can present w/rapid altercation between extremes
- Mutism is common
- Catatonic excitement = careful supervision to prevent self-harm, malnutrition, exhaustion, febrile
91
Gender and peak age for schizophrenia
- Men: 18 to 25 yrs
- Women: Late 20s–30s
- Childhood: is VERY rare (13+)
92
Positive (adding) clinical presentation of schizophrenia?
Hallucinations, delusions, mood disorders, incoherent speech skipping, psychomotor agitation (PMA)
93
Negative (taking away) clinical presentation of schizophrenia?
Actions, psychomotor retardation (PMR), speech, pleasure, volition
94
Describe delusional disorder: persecutory type
- Central theme of he/she being conspired against/cheated, spied on, followed, poisoned/drugged, maliciously maligned, harassed, obstructed in goals.
95
Describe delusional disorder: jealous type
- theme of spouse of love is unfaithful.
| - Often Men w/no prior psychiatric illness
96
Describe delusional disorder: somatic type
- Theme involving bodily functions or sensations
- Infestation (parasites), dysmorphophobia (misshapenness, ugly, exaggerated size of body party), foul body odors/halitosis
97
Describe delusional disorder: grandiose type
- Theme of conviction of having some great unrecognized talent/insight or having made an important discover
98
Clinical presentation of Bipolar disorder
Bipolar disorder consists of episodic mood shifts into mania, MDD, hypomania, and mixed mood states.
99
Bipolar disorder I
an individual has manic episodes.
100
Bipolar disorder II
an individual experiences hypomanic episodes without frank mania, and have at least 1 major depressive episode.
101
Why do pts with bipolar disorder have extreme highs and lows?
- Bipolar may exist by itself or with overlaying depression.
- The mania episodes cause the pr to experience extreme highs while the depressive episodes cause extreme lows.
102
What is the criteria for MDD
- 5 or more of the following
- Depressed most of the day, nearly every day as indicated by subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by subjective account or observation).
- Significant weight loss when not dieting or weight gain (e.g., change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
103
What is seasonal affective disorder?
- Pts tend to experience depressive episodes during a particular season, MC: winter. They will experience these sxs at the same time each year.
104
What is the cause of seasonal effective disorder?
- Dysfunction of circadian rhythm that occurs more commonly in the all winter months and is believed to be d/t decreases exposure to full spectrum light
105
What is the presentation of seasonal effective disorder?
carbohydrate craving, lethargy, hyperphagia and hypersomnia.
106
Tx for seasonal effective disorder?
Phototherapy (light therapy), SSRIs, Bupropion
BHM II
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