Behavioral exam i

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  • - Later childhood- Peer RelationsSchool HistoryCognitive and Motor DevelopmentEmotional/Physical ProblemsPsychosexual History – them or their friends sexual activity, common at younger and younger ages. The younger they are has been shown to commonly cause depressionReligious Background – strong, pressures, none- Adulthood - Occupational HistorySocial Activity – too little, too much – pressure to do too muchAdult Sexuality – in a relationship, previous relationships, healthy? Children?Military History – big insite into psych disorders, discharged honorably?Value system – what do they hold as important? Power, money, family, stability – will give you a huge insight into the person.
  • Addiction is an equal-opportunity afflictionMarked findings of this report are (a) a 94 percent increase in the number of drug-related ED visits overall between 2004 and 2010, and (b) large increases in the involvement of a wide range of pharmaceuticals (e.g., prescription drugs, over-the-counter medications, supplements) over that period. It is likely that there are multiple causes contributing to these increases. Some portion of these increases may be associated with the greater number of prescriptions being written and with more people taking multiple prescription drugs, often in combination with over-the-counter preparations, as part of their long-term medical care
  • Behavioral exam i

    1. 1. Behavioral Exam I
    2. 2. Introduction to Psychiatry Paula DeMaro MHS, PA-C
    3. 3. Psychiatric History? • Psychiatric History –Identification –Chief Complaint –History of Present Illness –Past Psychiatric and Medical History –Family History
    4. 4. Psychiatric Assessment –Personal History • Early Childhood (age 3) • Middle Childhood (age 3-11) • Later Childhood (puberty through adolescence) • Adulthood
    5. 5. Early Childhood Hx? • Early Childhood - Quality of mother-child interactions during feeding /toilet training • Sleep patterns • Human constancy and attachments • Personality as a child
    6. 6. Middle Childhood Hx? • Middle Childhood- gender identification, punishments used in the home, early school experiences • Early patterns of assertion, impulsiveness, aggression, passivity, anxiety, or antisocial behavior
    7. 7. Later Childhood Hx? –Peer Relations –School History –Cognitive and Motor Development –Emotional/Physical Problems –Psychosexual History – them or their friends sexual activity, common at younger and younger ages. The younger they are has been shown to commonly cause depression –Religious Background – strong, pressures, none
    8. 8. Adulthood Hx? –Occupational History –Social Activity – too little, too much – pressure to do too much –Adult Sexuality – in a relationship, previous relationships, healthy? Children? –Military History – big insite into psych disorders, discharged honorably? –Value system – what do they hold as important? Power, money, family, stability – will give you a huge insight into the person.
    9. 9. What is Neuropsychiatric Assessment? • Neuropsychiatric Assessment – Assessment of multiple areas of functioning that may impact performance in the classroom, with peers, at home or in the job.
    10. 10. Neuropsychiatric Assessment Components? »Arousal »Sensory »Attention and concentration »Memory »Language »Executive Functioning »Behavior, emotions, personality
    11. 11. Mental Status Exam Components? • Mental Status Examination (MSE) – General Description – Mood and Affect – Speech Characteristics – Perception – Sensorium and Cognition – Impulsivity – Judgment and Insight
    12. 12. Mini Mental Status ExamWhen is it used? What is normal? • Used as a screening tool and to follow patients for advancing dementia, etc. • Normal ranges vary based on education level and age.
    13. 13. Psychoanalysis- Goals? Goals of traditional psychoanalysis • Symptom relief • Increased self awareness • Objective capacity for self observation
    14. 14. Psychoanalysis- Treatment Methods? Limitations? Treatment Methods – Free Association – Transference - common – All are meant to discover the unconscious defenses or personality of the patient Limitations – Countertransference – must guard against 4-5 times a wk./ 3-5 yrs.
    15. 15. Behavior therapy techniques? • Behavioral Techniques – Relaxation Training – Hierarchy Construction – Desensitization of the Stimulus – Hypnosis
    16. 16. Cognitive Therapy techniques? • Cognitive Techniques – Eliciting automatic thoughts – Testing automatic thoughts – Identifying maladaptive assumptions – Testing the validity of maladaptive assumptions
    17. 17. Behavioral/Cognitive therapy techniques? • Cognitive Behavioral Techniques – Scheduling activities – Mastery and pleasure – Graded task assignments – Cognitive rehearsal – Self-reliance training – Role playing – Diversion techniques
    18. 18. What are the axes in DSM-IV? • Axis I – Clinical diagnosis and those diagnosis needing clinical attention • Axis II – Personality disorders and mental retardation • Axis III – General medical conditions • Axis IV – Psychosocial and environmental problems • *Axis V – Global assessment of functioning scale
    19. 19. Psychiatric Nosology • Axis I – 296.23: Major depressive disorder, single episode, severe without psychotic episode – 305.00: Alcohol abuse • Axis II – 301.6: Dependent personality disorder – Frequent use of denial • Axis III – Hypertension • Axis IV – Threat of job loss • Axis V – GAF: 35
    20. 20. Psychiatric Report components? • Includes psychiatric history and MSE – Written – Includes final summary of both positive and negative finding and interpretation of the data.
    21. 21. Introduction to Drugs and Alcohol Paula DeMaro MHS, PA-C
    22. 22. Alcohol Intoxication, Overdose and Acute Withdrawal
    23. 23. CAGE questionnaire? • Screening tools — A simple screening tool for problems of alcohol use is the CAGE questionnaire, which has been modified for screening for drug use and is known as the CAGEAID questionnaire (AID = Adapted to Include Drugs) – C — Have you ever tried to cut down on your alcohol or drug use? – A — Do you get annoyed when people comment about your drinking or drug use? – G — Do you feel guilty about things you have done while drinking or using drugs? – E — Do you need an eye-opener to get started in the morning?
    24. 24. Define Alcohol Abuse. • Alcohol abuse — Alcohol abuse is defined as a maladaptive pattern of alcohol use associated with one or more of the following: – Failure to fulfill role obligations (eg, at work, school or home) – Recurrent substance use in physically hazardous situations – Recurrent legal problems related to substance use – Continued use despite alcohol-related social or interpersonal problems
    25. 25. Define Alcohol Dependence. • Alcohol dependence — Alcohol dependence is defined as a maladaptive pattern of use associated with three or more of the following: – – – – – – – Tolerance Withdrawal Substance taken in larger quantity than intended Persistent desire to cut down or control use Time is spent obtaining, using, or recovering from the substance Social, occupational, or recreational tasks are sacrificed Use continues despite physical and psychological problems
    26. 26. Definition of Intoxication? • Quantity of alcohol ingested exceeds individuals tolerance producing physical and/or behavioral changes
    27. 27. Describe Absorption of Alcohol • Absorption – 20% stomach – 80% jejunum – Increase time in stomach, decreases peak BAC
    28. 28. Describe Metabolism of Alcohol • Metabolism – 90% in liver via ADH (alcohol dehydrogenase) – 5% excreted by lungs • Basis of Breathalyzer – 5% excreted in urine
    29. 29. Mechanism of Action of Alcohol? • Ethanol binds postsynaptic GABA(A) receptors (inhibitory neurons) • Ethanol inhibits excitatory NMDA (N -methyl D –aspartate) receptors • Ethanol affects opioid binding
    30. 30. Further Describe Mechanism of Action of Alcohol? • Alcohol consumption results in the release of the body’s naturally occurring opiates, endorphins both in the brain and in the periphery. – If opiates are consumed simultaneously with alcohol the exogenous and endogenous opioid effects can be additive.
    31. 31. Standard Drink? • Standard “drink” consists of 10 g EtOH – 12 oz of beer (3.2%) – 4-5 oz of wine (12 %) – 1.5 oz liquor ( 80 proof) • Average person metabolizes 10 g / hr – Approx 1 drink / hr
    32. 32. Blood Alcohol Level? • Expressed in mg/dl • 100 mg/dl = 1 part EtOH in 1000 parts blood = 0.1% • Legal limit in most states is between 0.08% and 0.1%
    33. 33. Alcohol Overdose Clinical Presentation? – BAC > 600 mg/dl often fatal – Progressive obtundation, decreases in respiration, BP and temp – Urinary incontinence or retention – Reflexes markedly decreased or absent – Death occurs from loss of airway protective reflexes (with subsequent airway obstruction by the flaccid tongue), pulmonary aspiration of gastric contents or from respiratory arrest from profound CNS depression.
    34. 34. Alcohol Overdose Management? – Supportive: • Protect airway – prevent respiratory depression • Administer IV thiamine and glucose • Alcohol is rapidly absorbed, so induction of emesis or gastric lavage / activated charcoal not effective • Enhancement of elimination via hemoperfusion and forced diuresis not effective • Currently no pharmacological “alcohol antagonist” • Assess pt for ingestion of other drugs
    35. 35. Definition of withdrawal? • A withdrawal syndrome is a predictable constellation of signs and symptoms following abrupt discontinuation of, or rapid decrease in, the intake of a substance that has been used consistently for a period of time.
    36. 36. Pathophysiology of Alcohol Withdrawal? • CNS depressant • Alcohol (normally) simultaneously enhances inhibitory tone and inhibits excitatory tone • With abrupt abstinence from alcohol deficiencies in inhibitory influences and excesses in excitatory influences create withdrawal phenomena. • The withdrawal symptoms last until the body readjusts to the absence of the alcohol and establishes a new equilibrium.
    37. 37. DSM IV Diagnostic Criterion of Withdrawal? • Two (or more) of the following, developing within several hours to a few days after cessation – autonomic hyperactivity (e.g. sweating or pulse rate greater than 100) – increased hand tremor – insomnia – nausea and vomiting – psychomotor agitation – transient visual, tactile, or auditory hallucination or illusions – anxiety – grand mal seizures
    38. 38. Clinical Picture of Alcohol Withdrawal? • Stage I: Early withdrawal consists of mild anxiety and alcohol craving • Stage II: Intermediate severity, usually between 24-36 hours, characterized by excessive adrenergic effects • Stage III: This stage consists of tonic-clonic seizures and occurs typically between 12-48 hours
    39. 39. Stage 4 Alcohol Withdrawal Clinical Picture? • Stage IV: This stage consists of DTs, often occurring immediately following a seizure, typically within 48-72 hours after alcohol intake stops.
    40. 40. Hallucinations- how many alcohol abusers? • Up to 25% of patients with a prolonged history of alcohol abuse experience alcoholic hallucinosis • Occur with an otherwise clear sensorium
    41. 41. Describe the Hallucinations in alcohol withdrawal? • Mild to moderate – lights too bright, sounds too loud and startling. Tactile “pins and needles”. • Severe – visual hallucinations most common, frequently involving animal life. Auditory hallucinations begins as clicks or buzzing and can progress to formed voices. Tactile – bugs and insects
    42. 42. Withdrawal Seizures? • Alcohol withdrawal seizures ("rum fits") are experienced by up to 33% of patients with significant alcohol withdrawal • Usually brief, generalized, tonic-clonic, without an aura, in clusters of 1-3, short postictal period • Incidence peaks at 24 hours following most recent ingestion
    43. 43. Delirium Tremens- How many? When? • Only 5% of pts with ethanol withdrawal progress to DTs • Occurs usually between 48-96 hours after the last drink
    44. 44. What is Delirium Tremens? • Classic presentation; all the early and intermediate symptoms of alcohol withdrawal plus a profoundly altered sensorium
    45. 45. Delirium Tremens- Physical Signs? • Severe autonomic derangements are commonly present • Significant dehydration due to intense diaphoresis, hyperventilation, and restricted oral intake
    46. 46. Delirium Tremens- Mortality? • Patients at greatest risk for death are those with extreme fever, fluid and electrolyte imbalance, or intercurrent illness such as pneumonia, hepatitis or pancreatitis • Mortality rate is as high as 35% if untreated but less than 5% with early recognition and treatment
    47. 47. Management of Alcohol Withdrawal? • Alcohol Withdrawal – Clinical assessment of severity – CIWA scale – Evaluate for the presence of both acute and chronic medical and psychiatric conditions. – Pertinent labs include CBC, electrolytes, Mg, Ca, Phos, LFTs, UDS, preg, BAC, lipase, EKG. – Benzodiazepines
    48. 48. Management of Alcohol Withdrawal Seizures? • Alcohol Withdrawal Seizures – Diagnosis of a withdrawal seizure should be made only if there is a clear history of a marked decrease or cessation of drinking in the previous 24 to 48 hours – Parenteral rapid acting benzodiazepines (diazepam, lorazepam) to prevent future episodes
    49. 49. Management of Alcohol withdrawal delirium? • Alcohol Withdrawal Delirium – Cross-tolerant sedative-hypnotics reduce mortality in DTs but do not reverse delirium or reduce its duration – Narcoleptics should not be used alone to treat DTs because they can lower the seizure threshold – Sedate pt. to point of light sleep to control agitation, prevent self and/or staff injurious behavior and allow the administration of supportive medical care
    50. 50. What are the components of Wernicke-Korsakoff Syndrome? • In 1881, Carl Wernicke first described an illness that consisted of the triad of opthalmoplegia, ataxia and the abrupt onset of an acute confusional state
    51. 51. Pathophysiology of WernickeKorsakoff Syndrome? • Thiamine deficiency – Alcoholism is the most common cause (though any condition that results in a poor nutritional state can lead to W-K syndrome) – Alcohol decreases active GI transport of thiamine – Liver disease decreases thiamine activation and storage – 1 to 3% in pts with alcoholism
    52. 52. Clinical Picture-Wernicke • Weakness or paralysis of lateral rectus muscles leading to internal strabismus and diplopia • Nystagmus • Wide-based stance with uncertain short stepped gait • Global confusional state characterized by apathy, inattentiveness and indifference to surroundings
    53. 53. Clinical Picture –Korsakoff? • Korsakoff amnestic state occurs in a small number of pts and is characterized by both persistent anterograde and retrograde amnesia. ( anterograde > retrograde). – Confabulation to fill in gaps in memory. – http://www.youtube.com/watch?v=UbSlLtsJfUY
    54. 54. Morbidity/Mortality of WernickeKorsakoff Syndrome? • Generally full recovery of ocular function occurs • 40% completely recover from ataxia • Only 20% eventually recover from amnestic (Korsakoff psychosis) deficit – may take one or more years and depends on abstinence from alcohol • Mortality rate is 10 – 20% • Most common etiologies are infectious or hepatic failure
    55. 55. Treatment of Wernicke-Korsakoff Syndrome? • Wernicke encephalopathy is a medical emergency. • IV thiamine 100 mg is the initial treatment of choice. • Continue daily doses of thiamine 50 – 100 mg IV / IM / po depending on status. • IV glucose can exhaust malnourished pts supply of thiamine precipitating WernickeKorsakoff. – Administer thiamine prior to glucose infusion.
    56. 56. Treatment of alcohol dependence? • Naltrexone – can be initiated while the individual is still drinking • Disulfiram - (which by intent leads to adverse effects when combined with alcohol intake) should only be used by abstinent patients in the context of treatment intended to maintain abstinence
    57. 57. Opioids Intoxication, Overdose and Acute Withdrawal
    58. 58. Definition-Use? • Use — Sporadic consumption of alcohol or drugs with no adverse consequences of that consumption.
    59. 59. Definition- Abuse? • Abuse — Although the frequency of consumption of alcohol or drugs may vary, some adverse consequences of that use are experienced by the user.
    60. 60. Definition- Physical Dependence? • Physical dependence — A state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation or rapid dose reduction of a drug, or by administration of an antagonist.
    61. 61. Definition- Psychological Dependence? • Psychological dependence — A subjective sense of a need for a specific psychoactive substance, either for its positive effects or to avoid negative effects associated with its abstinence.
    62. 62. Definition- Addiction? • Addiction — A primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addiction is characterized by behaviors that include impaired control over drug use, compulsive use, continued use despite harm, and craving
    63. 63. Opioid Intoxication according to DSM-IV? • DSM-IV criteria – Recent use of an opioid – Clinically significant maladaptive behavioral or psychological changes (e.g. euphoria, followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment, or impaired social or occupational functioning) that develop during, or shortly after, opioid use.
    64. 64. Signs of Opiate Intoxication? • Pupillary constriction (or papillary dilation due to anoxia from severe overdose) and one (or more) of the following signs, developing during, or shortly after, opioid use – Drowsiness or coma – Slurred speech – Impairment in attention and memory
    65. 65. Opiates interact with what receptors? • Involve opioid receptors specifically in the CNS – Mu – Kappa – Delta
    66. 66. Neuropharmacology- Mu? • Mu – Supraspinal analgesia – Respiratory depression – Miosis – Euphoria
    67. 67. Neuropharmacology- Kappa? • Kappa – Spinal analgesia – Sedation – Sleep – Miosis – Limited respiratory depression
    68. 68. Neuropharmacology- Delta? • Delta – Interacts with mu receptors via endogenous substances including endorphins
    69. 69. Opiate Overdose- Clinical Presentation? • Clinical Presentation – Classically characterized by pinpoint pupils, respiratory depression, hypotension and coma
    70. 70. Opiate Overdose- Management General Support? • Management – General support • Assess and clear airway • Support ventilation (if needed) • Assess and support cardiovascular system • Give IV fluids
    71. 71. Opiate Overdose ManagementPharmacologic? • Management – Pharmacologic therapy • Naloxone (Narcan) hydrochloride and Opioid antagonist: 0.4 to 0.8 mg IV initially, repeat q 2 –3 mins as necessary up to 2 mg per dose to a max of 10 mg
    72. 72. Opiate Withdrawal Symptoms WHEN? • Symptoms usually begin within 12 hours of last use, peak within 1 – 3 days and gradually subside over a period of 5 –10 days for a short acting opioid (i.e. heroin)
    73. 73. Opiate Tolerance? – Tolerance • Heroin induces tolerance quickly, increasing the euphoric dose while keeping the lethal dose constant • Death occurs during intoxication and not during withdrawal
    74. 74. Opiate Withdrawal according to DSM-IV Criteria? • DSM-IV criteria – Cessation of (or reduction in) opioid use that has been heavy and prolonged (several weeks or longer) – Administration of an opioid antagonist after a period of opioid use
    75. 75. Opiate Withdrawal Symptoms? • Three (or more) of the following, developing within minutes or several days after above criterion: • Dysphoric mood • Nausea or vomiting • Muscle ache • Lacrimation or rhinorrhea • Pupillary dilation, piloerection, or sweating • Diarrhea • Yawning • Fever • Insomnia
    76. 76. What drugs are used for opiate withdrawal? • • • • Methadone Clonidine Buprenorphine Benzos
    77. 77. Opiate Withdrawal ManagementMethadone? • Methadone – Based on the principal of cross-tolerance, in which one opioid is replaced with another longer acting opioid and then slowly withdrawn
    78. 78. Opiate Withdrawal ManagementClonidine? • Clonidine – A central acting alpha-2 agonist that diminishes norepinephrine therefore suppressing autonomically mediated signs and symptoms of withdrawal – Suppresses cardiovascular signs of withdrawal and has some anxiolytic effect
    79. 79. Opiate Withdrawal ManagementBuprenorphine? • Buprenorphine – A partial opioid agonist and potent opioid antagonist – Provides an effective and comfortable withdrawal – Binds to various opioid receptors, producing agonist and antagonist effects
    80. 80. Opiate Withdrawal ManagementBenzos? • Benzodiazepines – As an adjuvant therapy for agitation, insomnia and muscle cramps
    81. 81. PHARMACOLOGY AND CELLULAR TOXICOLOGY of Amphetamines? • Cause release of neurotransmitters – dopamine, serotonin, and norepinephrine and may also inhibit their reuptake • Stimulation of alpha and beta adrenergic receptors is primarily responsible for the acute effects – Hyper-alertness, mydriasis – HTN, diaphoresis – Tachycardia, hyperthermia
    82. 82. Cocaine Intoxication, Overdose and Acute Withdrawal
    83. 83. Cocaine and Emergency Visits? – Aside from alcohol or tobacco related diseases, cocaine is the most common single cause of drug-related emergency department visits in the US. – The combined use of alcohol and cocaine is the most frequent reason for drug-related emergency department visits in the US and may be the major cause of drug-related deaths
    84. 84. Physiology of Cocaine Intoxication? • Pharmacology / Neurobiology – dopaminergic re-uptake inhibition – large increases in extracellular dopamine in the nucleus accumbens – activates mid-brain reward pathway associated with survival behaviors such as feeding and sexual motivation
    85. 85. Cocaine Intoxication Signs? • • • • • • • • euphoria increased energy enhanced mental acuity increased sensory awareness (sexual, tactile, auditory, visual) anorexia increased anxiety and suspiciousness decreased need for sleep increased self-confidence, egocentricity
    86. 86. Physical Signs of Cocaine Intoxication? • physical symptoms of a generalized sympathetic discharge – – – – – increased heart rate increased blood pressure pupillary dilation perspiration nausea
    87. 87. Routes of Administration of Cocaine • Inhalation (7 s onset, 1-5 min peak, 20 min duration, 40-60 min half-life) • IV (15 s onset, 3-5 min peak, 20-30 min duration, 40-60 min half-life) • Nasal (3 min onset, 15 min peak, 45-90 min duration, 60-90 min half-life) • Oral (10 min onset, 60 min peak, 60 min duration, 60-90 min half-life)
    88. 88. Cocaine OverdoseCardio effects? • Cardiovascular – Hypertensive crisis – Cardiac arrhythmias (both atrial and ventricular) – Myocardial ischemia and infarction via aadrenergic mediated vasoconstriction – Myocarditis • cocaethylene
    89. 89. Cocaine OverdoseCNS effects? • Central Nervous System – Seizures (grand mal/epileptic) – CVA – Coma – Hyperthermia
    90. 90. Cocaine OverdosePsychiatric Effects? • Psychiatric – acute panic – psychosis – Paranoia – Agitated delirium • also known as excited delirium (ED), is a common presentation in patients dying of cocaine toxicity.
    91. 91. Cocaine OverdosePulmonary Effects? Renal Effects? • Pulmonary – Pneumonitis – Pulmonary edema and hemorrhage – Pneumothorax • Renal – Rhabdomyolysis
    92. 92. Cocaine Overdose Symptom Treatment? • Cornerstone is sedation and the close monitoring of vital signs. – Benzodiazepines (hypertension, tachycardia, tachypnea) – Mist fan / ice baths (hyperthermia) – Fluid resuscitation (renal function)
    93. 93. Cocaine Overdose Pharmacologic Treatment? • Morphine / sedation –Nitrites –Aspirin –B-blockers contraindicated »Unopposed a-adrenergic mediated vasoconstriction.
    94. 94. Cocaine OverdoseTreatment of CNS effects? • CNS –Benzodiazepines (tremors/seizures) –Phenobarbital (status epilepticus) –CT for all seizures (intracranial pathology common)
    95. 95. Cocaine WithdrawalSymptoms? • • Classic physical withdrawal symptoms do not occur Symptoms often seen after binge periods include: – Intense unpleasant feelings of marked anergia, dysphoria, irritability, impulsivity and depression - generally requiring several days of rest and recuperation
    96. 96. Cocaine Withdrawal according to DSM-IV? • DSM-IV criteria – B. Dysphoric mood and two (or more) of the following: • • • • • (1) fatigue (2) vivid, unpleasant dreams (3) insomnia or hypersomnia (4) increased appetite (5) psychomotor retardation or agitation
    97. 97. Cocaine Withdrawalpsychiatric effects? • Depression with suicidal ideation or behavior are generally the most serious symptoms of cocaine withdrawal dysphoric state • Structured setting for stabilization
    98. 98. Marijuana CANNIBUS
    99. 99. Preparations of Cannabis? • All parts of Cannabis sativa contain psychoactive cannabinoids, of which 9-THC is most abundant • The cannabis plant is usually cut, dried, chopped, and rolled into cigarettes (commonly called “joints”), which are then smoked • Plant contains more than 400 chemicals
    100. 100. Neuropharmacology of Cannabis? • 9-THC is rapidly converted to 11-hydroxy-9THC, the metabolite that is active in the CNS • The cannabinoid receptor is found in highest concentrations in the basal ganglia, the hippocampus, and the cerebellum, with lower concentrations in the cerebral cortex
    101. 101. Tolerance and Psychological Dependence of Marijuana? • Tolerance has been found, although the evidence for psychological dependence is not strong
    102. 102. Cannabis Withdrawal? • Withdrawal symptoms in human are limited to modest increases in irritability, restlessness, insomnia and anorexia and mild nausea; all of these symptoms appear only when a person abruptly stops taking high doses of cannabis
    103. 103. Routes of Administration of Cannabis? • When cannabis is smoked, the euphoric effects appear within minutes, peak in about 30 minutes, and last 2-4 hours. • Can be taken orally when it is prepared in food, such as brownies and cakes but it takes 2-3 times as much to be as potent as smoking it
    104. 104. Physical Effects of Cannabis? • Most common physical effects are dilation of the conjunctival blood vessels (red eye) and mild tachycardia • At high does, orthostatic hypotension may appear • Increased appetite (“the munchies”) and dry mouth are common effects of cannabis intoxication
    105. 105. Adverse Effects of Cannabis Use? • No documented case of death caused by cannabis intoxication alone which reflects the substance’s lack of effect on the respiratory rate • The most serious potential adverse effects are those caused by inhaling the same carcinogenic hydrocarbons present in conventional tobacco
    106. 106. Treatment of Cannabis Intoxication and Addiction? • DSM-IV-TR diagnostic Criteria for Cannabis Intoxication – Tables 9.5-1 & 9.5-2 in Kaplan & Sadock’s • Treatment rests on the same principles as tx of other substances of abuse – abstinence and support – Education – Possible anti-anxiety drugs
    107. 107. Anxiety, Panic Attacks, and Obsessive-Compulsive Disorders LMU-DCOM Rex Hobbs, MPAS, PA-C
    108. 108. Anxiety Disorders Prevalence National Comorbidity Survey (N=8,098) Lifetime (%) Social phobia OCD PTSD Agoraphobia without PD Panic disorder GAD 13.3 2.5 8.0 5.3 3.5 5.1
    109. 109. Anxiety Disordershow many ppl? • Most common psychiatric illnesses in America • > 23 million people affected each year • About 1/3 of total US mental health costs
    110. 110. Anxiety Disorders DSM Classifications- Types? • Panic disorder (w/wo agoraphobia) • Agoraphobia (w/o a history of panic disorder) • Generalized anxiety disorder (GAD) • Obsessive-compulsive disorder (OCD) • Social phobia • Other specific phobia • Post traumatic stress disorder • Acute stress disorder
    111. 111. Anxiety and Physical Illness New Anxiety Symptoms? Rule Out: • Endocrine problems – Thyroid disease • Pulmonary disease – Asthma – COPD • Medications – Bronchodilators – Thyroid replacement – Decongestants (ex: Sudafed) – Excessive Caffeine (energy drinks)
    112. 112. AnxietySubstance Abuse Causes? • Psychostimulants – Cocaine – Methamphetamine • Alcohol abuse • Benzodiazepine misuse – Borrowing spouse’s Rx • Discontinuation
    113. 113. Panic Disorder- Epidemiology? • Epidemiology – 1 to 3 % of general population – Women twice as likely to develop – Onset is between ages 25-30 – Little differences between race in US
    114. 114. Describe Panic ATTACK? • • Panic Attack= a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached peak within 10 minutes; generally no trigger (although sometimes there is) • • • • • • • • • • • • Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feeling of choking Chest pain discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint Serialization (feelings of unreality) or depersonalization (being detached from oneself) Fear of losing control or going crazy Fear of dying Parasthesias (numbness or tingling sensations) Chills or hot flushes
    115. 115. Panic Disorder- Epidemiology? • Most frequent presentations: – Neurological (trouble concentrating, loss of touch with reality)…………..44% – Cardiac………………..39% – Gastrointestinal..……...33% • One year prevalence of 1% - 2% • Twice as common in women than men • 60% - 90% comorbid depression • Often complicated by: – Agoraphobia (30-40%) – Major depression (40-70%) • Suicide risk – Substance abuse (30-40%)
    116. 116. What is Agoraphobia? • Intense, irrational fear of open spaces, characterized by marked fear of being alone or of being in public places where escape would be difficult or help might be unavailable – Dorland’s Illustrated Medical Dictionary 30th Edition. Saunders 2004
    117. 117. Panic Disorder- Biological Factors? • Etiology: Biological Factors – Major neurotransmitters involved are norepinephrine, serotonin, and GABA (can be excess, or more often than not, deficit) – Imaging has found pathology in temporal lobes possibly due cerebral vasoconstriction; over excitation and activation of the limbic system – Strong genetic component with panic disorder that is associated with agoraphobia
    118. 118. Panic Disorder- Psychosocial Factors? • Etiology: Psychosocial Factors – CBT: Panic is a learned response from either parental behavior or classic conditioning (fear of internal sensations). – Psychoanalytic: Panic attacks arise from environmental triggers that usually have unconscious meaning. • Parental loss in childhood • Adulthood loss • Abandonment
    119. 119. Panic Disorder- Diagnosis? • Diagnosis: – Recurrent unexpected panic attacks – One attack followed by 1 month of: • Persistent concern about having additional attacks • Worry about the implications of the attack of the consequences (e.g., losing control, having a heart attack, “going crazy”) • Significant change in behavior related to attack (ex: “I’m not going to take that job because I’d have to travel, and I don’t want to have an attack on an airplane…”)
    120. 120. Panic DisorderDrug Treatment? – *SSRI’smost effective, least SE • Citalopram (Celexa) • Fluoxetine (Prozac) • Paroxatine (Paxil) • Sertraline (Zoloft) – TCAs • Clomipramine (Anafranil) • Imipramine (Tofranil) – Benzodiazepines (PRN) • Alprazolam (Xanax) • Clonazepam (Klonopin) - SNRI’s- avoid in pure panic disorder because of the NE effect - Venlafaxine (Effexor XR) Withdrawal: Stop any of these drugs abruptly, nausea will occur. Especially with Paxil. *SSRIs should be taken with food because high first pass metabolism.
    121. 121. Panic DisorderCBT Tx? Psychotherapy? • Treatment: CBT – Relaxation techniques (breathing, imagery) – Exposure in vivo • Treatment: Psychotherapy – Shown not to be as effective as CBT, Pharmacotherapy, or combination of both
    122. 122. Social PhobiaWhat is it? • Persons with social phobias (also called social anxiety disorder) have excessive fears of humiliation or embarrassment in various social settings (speaking in public).
    123. 123. Social Phobia- Epidemiology? • Epidemiology: – Phobias are most common mental disorder in US with 8-13% affected at some point in life – Women more than men – Peak onset in teen years, but range is 5-35 years – Comorbidity very high (panic disorder, avoidant personality disorder, substance abuse)
    124. 124. Social Phobia- Biological Factors? • Etiology: Biological Factors – Those with performance phobias release more norepinephrine (increased sensitivity). Beta adrenergic receptor antagonist. – Possible increased NE or increased sensitivity to NE. – Social phobia due to decreased dopaminergic reuptake site density. – First degree relatives of individuals with social phobias are 3 times more likely to have social phobia.
    125. 125. Social Phobia- Psychosocial Factors? • Etiology: Psychosocial Factors – Classic conditioning in childhood (Pavlovian). – Early environmental stressors (humiliation and criticism from siblings/parents, parental conflicts, separation from parents) – Shame and embarrassment are principle affect states
    126. 126. Social PhobiaCBT Tx? • Treatment: CBT – Commitment to treatment – Clearly identified problems – Available alternative ways to cope with feelings/fears
    127. 127. Social Phobia- Psychotherapy Tx? • Treatment: Psychotherapy – Some recognition that source of phobia happened in early development, but improvement of condition best if coupled with CBT.
    128. 128. Social PhobiaPharm Therapy? • Treatment: Pharmacotherapy – Social Phobias (performance situations): • Beta adrenergic receptor antagonist (propranolol) – Social Phobias: • SSRI’s (considered first line) • Benzodiazepines (only as additive, only over symptoms, not underlying neurotransmitter imbalances) • MAOI’s (phenelzine) • Beta Blocker (propanolol) for test anxiety
    129. 129. Obsessive-Compulsive Disorder- Epidemiology? • Epidemiology – Recently thought to be 2.5% within the general population – Age of onset is 15-35 – Males and females have equal occurrences overall, but women onset usually older, while males more commonly present in adolescence – Complete resolution of symptoms is rare
    130. 130. Obsessive-Compulsive DisorderBiological Factors? • Etiology: Biological Factors – Believed to be a strong correlation with dysregulation of serotonergic system. (SSRI’s) – Unlike other disorders of anxiety, OCD is associated with corticostriatal pathways (frontal lobes and basal ganglia) more than with the amygdala. – Strong genetic component – 35% of OCD first-degree relatives also are affected with the disorder – Some correlation between Tourette’s disorder, motor tics, and OCD.
    131. 131. Obsessive-Compulsive DisorderPsychosocial Factors? • Etiology: Psychosocial Factors – Marked by extreme emotional ambivalence triggered by strong feelings of both love and hate toward an object, especially in children. This leads to emotional paralysis in the face of choices. – Increased incidence with stressful situations (pregnancy, childbirth, or prenatal care of children).
    132. 132. Obsessive-Compulsive Disorder- Pharm Tx? • Treatment: Pharmacological – SSRI’s (if warranted) • Fluoxetine (Prozac) • Fluvoxamine (Luvox)- not used often anymore, risk of serotonin syndrome • Paroxetine (Paxil) • Sertraline (Zoloft)
    133. 133. Obsessive-Compulsive Disorder- CBT therapy? • Treatment: CBT – Exposure of patient to feared object or obsession and prevented from doing anxiety-reducing rituals – Estimates of up to 90% effectiveness in reducing the symptoms of disorder
    134. 134. Obsessive-Compulsive DisorderPsychotherapy? • Treatment: Psychotherapy – Believed to be more effective in the treatment of obsessive-compulsive personality disorder than of obsessivecompulsive disorder.
    135. 135. Posttraumatic Stress Disorder- At what point are symptoms diagnostic of acute stress disorder? • Situation where symptoms last less than 1 month after traumatic event is termed “acute stress disorder”.
    136. 136. Combat Honeymoon Phase? • Combat Honeymoon Phase: coupe weeks home with no symptoms, symptoms begin later
    137. 137. Posttraumatic Stress DisorderEpidemiology? • Epidemiology – Prevalence of PTSD is 8-9% in general population (increasing). – Women twice as likely to have PTSD than men. – Directly linked to the epidemiology trauma: 25-30% of victims of trauma go on to develop PTSD – Men; military combat or witnessing injury/death – Women; rape, sexual molestation, and assault. – Some studies have shown PTSD in persons post-MI or after high risk surgeries (this is especially common in children).
    138. 138. Posttraumatic Stress DisorderBiological Factors? – Noradrenergic systems, endogenous opiate systems, and HPA axis are hyperactivity. – Higher urine epinephrine concentrations in soldiers and abused female children with PTSD. – Soldiers demonstrate narcan-reversable analgesic response to combat stimuli suggesting hyperregulation of opioid system. – Lower serum cortisol and urinary free cortisol concentrations in patients with PTSD suggests hyper-regulation of cortisol.
    139. 139. Posttraumatic Stress DisorderPsychosocial Risk Factors? – Risk Factors: • Childhood trauma or abuse • Borderline, paranoid, dependent, or antisocial personality disorder traits • Inadequate support system • Female gender • Family history of psychiatric illness • Recent stressful life changes • External locus of control • Substance abuse • Some studies show genetic linkage increasing risk • Some small studies of combat vets show certain racial groups are more likely than others.
    140. 140. Posttraumatic Stress Disorder- Pharm Tx? • Treatment: Pharmacological – SSRI’s (first line) • Sertraline • Paroxetine – Tricyclics • Imiparmine • Amitriptyline
    141. 141. Posttraumatic Stress DisorderPsychotherapy? – Combination of CBT, psychotherapy, and hypnosis – Group Therapy – No time limit in the beginning – Individualized as re-experiencing trauma may present different therapeutic needs – All patients tend to improve with time regardless of severity or treatment (5-10 years); small percentage may still have symptoms 25-30 years post event.
    142. 142. Generalized Anxiety DisorderBiological Factors? • Etiology: Biological Factors – Likely to occur with other medical and/or psychiatric conditions – Occipital Lobes (most benzodiazepine receptors, altered activity) – Limbic system
    143. 143. Generalized Anxiety Disorder- CBT? • Etiology: Psychosocial Factors – CBT: • Patients respond to inaccurately and incorrectly perceived dangers • Selective attention to negative details • Distortions in information processing • Negative view of individual’s ability to cope
    144. 144. Generalized Anxiety DisorderPsychoanalytic Theory? • Etiology: Psychosocial Factors – Psychoanalytic • Generalized anxiety is symptom of unresolved unconscious conflicts (but this is not always the case) • Hierarchy of anxieties related to various developmental levels
    145. 145. Generalized Anxiety DisorderClinical Presentation? – Distorted cognitive processing • Poor concentration, unrealistic assessment of problems, worries • Difficulty in moving short term memories into long term memory – Poor coping strategies • Avoidance, procrastination, poor problem-solving skills – Excessive physiologic arousal • Muscle tension, irritability, fatigue, restlessness, insomnia
    146. 146. Generalized Anxiety Disorder- What are the anxiety symptoms? • Anxiety symptoms – 3 or more of the following: • Restlessness or feeling keyed-up or on edge • Fatigability • Trouble concentrating • Irritability • Muscle tension • Sleep disturbance
    147. 147. Generalized Anxiety Disorder- Pharm tx? – SSRIs, SNRIs • SSRI burnout after 5 years, • SSRIs can cause increased prolactin levels, increased dopaminergic effects of brain and nullifies effects of serotonin; poss. switch to diff SSRI or an SNRI – Benzodiazepines • Alprazolam (Xanax) • Chlordiazepoxide (Librium)- more for EtOH withdrawal • Diazepam (Valium) • Lorazepam (Ativan)- Status Epilepticus*
    148. 148. Generalized Anxiety Disorder- CBT? – Cognitive therapy helps patients to limit cognitive distortions by viewing concerns more realistically. – Learn effective ways to solve their problems – Relaxation techniques decrease physiologic symptoms – Has not been shown to be truly effective as monotherapy; possibly in combination with SSRI
    149. 149. Personality Disorders LMU-DCOM Physician Assistant Studies Rex Hobbs, MPAS, PA-C
    150. 150. What leads to the Development of Personality Disorders? • Personality – Pattern of defenses against internal drives and external environment – Personality vs. ego • Thinking and feeling • Exaggerated development of defenses at the expense of others at a given developmental stage – Mastery/repression of anxiety, anger, shame, guilt • Internal Object Relations – Failure to meet needs arrests development and how an individual relates to internalized objects – Continues patterns of relating to internal objects into adulthood
    151. 151. Personality DisordersDSM-IV definition? • DSM-IV Definition – Axis II disorder • Commonly have Axis I disorder as well – Enduring subjective experiences and behavior that deviate from cultural norms – Rigidly pervasive – Onset in adolescence or early adulthood – Stable through time – Lead to unhappiness or impairment in social, occupational and relational settings
    152. 152. What are the personality disorder CLUSTERS? • CLUSTER A= odd and eccentric • CLUSTER B= dramatic and emotional • CLUSTER C= anxious or fearful
    153. 153. Cluster A Disorders? • Paranoid • Schizoid • Schizotypal
    154. 154. Cluster B Disorders? • Antisocial • Borderline • Histrionic
    155. 155. Cluster C Disorders? • Avoidant • Dependent • Obsessive-Compulsive
    156. 156. Hallmark of Paranoid Personality Disorder? • Pervasive distrust and suspiciousness of others.
    157. 157. Paranoid Personality Disorder Diagnostic Criteria? • Diagnostic Criteria (4 or more) – Suspects exploitation or deception from others without sufficient basis – Preoccupied with unjustified doubts regarding loyalty of others – Will not confide in other for unwarranted fear information will be used against them maliciously – Will assign demeaning or threatening meaning to benign remarks – Persistently bears grudges, unforgiving for slights or insults – Perceives attacks on character (not apparent to others) and is quick to retaliate – Consistently questions, without justification, the fidelity of spouse or sexual partner
    158. 158. Paranoid Personality DisorderEpidemiology? – 0.5-2.5% of general population; ~20% of inpatient psychiatric settings – Higher incidence with relatives diagnosed with schizophrenia – More common in men – Believed to be more common in minority or immigrant groups
    159. 159. Paranoid Personality DisorderTreatment? – Psychotherapy – Pointers: • Should not be overly warm • Should be consistent (and apologize when not) and honest • Do not offer to ‘take control’ if not willing to do so • Expect: belittling comments, accusations and litigious threats
    160. 160. Hallmark of Schizoid Personality Disorder? • Detachment from social relationships
    161. 161. Schizoid Personality Disorder Diagnostic Criteria? • Diagnostic Criteria (4 or more) – No desire for or enjoyment of close relationships – Always chooses solitary activities – Little or no interest in sexual relationship – No pleasure in activities – Lacks close friends or confidants other than family – Indifferent to praise or criticism
    162. 162. Schizoid Personality Disorder- How is this different from Schizophrenia? – Capable of recognizing reality
    163. 163. Schizoid Personality DisorderEpidemiology? – Perhaps 7.5% of general population; ~15% in the homeless population – 2 to 1 male to female – Tend to be isolated individuals
    164. 164. Schizoid Personality Disorder Treatment? – Psychotherapy – Pointers: • Should avoid aggression (group therapy) • Consistency and patience; tolerate odd beliefs • Avoid over involvement in personal or social issues • Generally will become involved with therapy and reveal fantasy
    165. 165. What is hallmark of Schizotypal? • Discomfort with relationships, cognitive and perceptual eccentricities
    166. 166. Schizotypal Personality Disorder Diagnostic Criteria? Diagnostic Criteria (5 or more) Magical thinking that influences behavior Unusual perceptual experiences Odd thinking or speech (vague, overelaborate) Paranoid ideation Inappropriate/constricted affect Eccentric appearance or behavior Lack of close friends Social anxiety that does not diminish with familiarity and tend to be paranoid
    167. 167. Schizotypal Personality Disorder Epidemiology? – 3% of the general population – Sex ratio unknown – Higher incidence with relatives with schizophrenia (monozygotic 33%, dizygotic 4%)
    168. 168. Schizotypal- what other diagnosis quite possible to have? • Borderline
    169. 169. Schizotypal Personality Disorder Treatment? – Psychotherapy – Antipsychotics or mood stabilizers? – Pointers: • Patience and consistency • Do not show judgment with odd interests or behavior • Will be sensitive to anger/aggression
    170. 170. Hallmark for antisocial? • Disregard and violation of the rights of others
    171. 171. Antisocial Personality Disorder Diagnosis? • Diagnostic Criteria (3 or more) – Failure to conform to social norms as evidenced by arrests – Lying or conning others for personal gain – Impulsiveness – Aggressiveness as evidenced by frequent physical fights – Reckless disregard for self or others – Irresponsibility as evidenced by inability to keep job/pay bills – Lack of remorse: rationalization for actions against others
    172. 172. Other requirements for antisocial diagnosis? • Must be 18 years old • Evidence of conduct disorder before 15 years of age • Antisocial behavior not occurring in psychotic episode
    173. 173. Antisocial Personality Disorder Epidemiology? – 3% in men, 1% in women – Boys from larger families in poor urban areas – 75% of prison populations – Higher incidence with positive family history
    174. 174. Antisocial Personality Disorder Treatment? – Inpatient settings more effective – Group therapy can be effective – Antidepressants and atypical antipsychotics may be helpful – Limits will be essential – Aware of patient’s fear of intimacy and selfdestructive behavior
    175. 175. Hallmark for Borderline? • Marked impulsivity, unstable interpersonal relationships and selfimage
    176. 176. Borderline Personality Disorder Diagnosis? • Diagnostic Criteria (5 or more) – Frantic efforts to avoid abandonment – Unstable relationships with idealization/devaluation pattern – Unstable self image – Impulsivity (gambling, sex, substance abuse) – Recurrent suicidal threats or self-mutilation – Affect instability – extreme mood swings – Chronic feelings of emptiness – Inappropriate intense anger (tantrums, fights) – Stress related paranoid ideation and dissociative symptoms
    177. 177. Borderline Personality Disorder Clinical Presentation? Always in a state of crisis Feelings of hostility and dependency Numerous troubled interpersonal relationships Erratic mood swings Self destructive acts (cutting, attempted suicide) Substance abuse, sexual promiscuity Complaints of feeling empty
    178. 178. Borderline Personality Disorder Epidemiology? – 1-2% of general population – 2 to 1 female to male – Increased incidence in families with major depressive disorder and alcohol use disorders
    179. 179. Borderline Personality Disorder Treatment? – Pharmacotherapy • Second gen. antipsychotics, antidepressants and omega3 fatty acids – Psychotherapy • One of the most difficult to treat – because of projective identification and countertransference • In-patient therapy (up to a year) • Combination group therapy
    180. 180. Hallmark for Histrionic? • Excessive emotionality and attention seeking
    181. 181. Histrionic Personality Disorder Diagnosis? • Diagnostic Criteria (5 or more) • Uncomfortable if not the center of attention • Interactions marked with inappropriate sexual seduction/provocative behavior • Rapid shifting, shallow emotions • Physical appearance used to draw attention • Speech impressionistic and lacks detail • Self dramatization, exaggerated emotion • Easily influenced • Considers relationships more intimate than they are
    182. 182. Histrionic Personality Disorder Epidemiology? – 2-3% of general population – More women than men – 10-15% in-patient Psychiatric population – Higher incidence in somatization disorder and alcohol use disorders
    183. 183. Histrionic Personality Disorder Treatment? – Psychotherapy – Pointers: • Clarification of patient’s feelings important • Group or individual therapy show equal effectiveness • Boundaries/limits important!!
    184. 184. Hallmark of Narcissistic? • Grandiosity, need for admiration; lack of empathy
    185. 185. Narcissistic Personality Disorder Diagnosis? • Diagnostic Criteria (5 or more) – Exaggerated sense of self-importance without commensurate accomplishments – Fantasies of unlimited success, beauty, love – Believes they are special and can only be understood by special people – Excessive need for admiration – Sense of entitlement – Interpersonally exploitative – Lacks empathy – Envious of others while believing others are envious of them – Demonstrates arrogant behavior/attitude
    186. 186. Narcissistic Personality Disorder Epidemiology? – <1% of general population – 16% of clinical population – Number of cases increasing – Higher incidence with children of parents with narcissistic personality disorder
    187. 187. Narcissistic Personality Disorder Treatment? – Psychotherapy • Difficult, as therapy often involves perceived criticism • Group therapy may help develop empathetic response • ‘Narcissistic Wound’
    188. 188. What is Hallmark for Avoidant? • Feelings of inadequacy, hypersensitive to negative evaluations
    189. 189. Avoidant Personality Disorder Diagnosis? • Diagnostic Criteria (4 or more) – Avoids occupational activities for fear of criticism or rejection – Won’t get involved with people unless certain of being liked – Restraint in interpersonal relationships for fear of rejection – Preoccupation with rejection in social situations – Inhibited in new relationships because of feelings of inadequacy – Views self as inept, socially unappealing, and inferior – Reluctant to take personal risks for fear being embarrassed
    190. 190. Avoidant Personality Disorder Epidemiology? – 10% of general population – No clear gender ratio – Children with ‘timid’ temperament may have higher incidence
    191. 191. Avoidant Personality Disorder Treatment? – Psychotherapy – Pointers: • Establish trust and safety • Caution with exposures that may be humiliating • Assertiveness training will help with expression of needs
    192. 192. Hallmark for Dependent? • Submissive, clinging, fear of separation
    193. 193. Dependent Personality Disorder Diagnosis? • Diagnostic Criteria (5 or more) – Cannot make decisions without excessive advice and reassurance from others – Desires others take responsibility for major areas of their life – Will not disagree for fear of loss of approval/support – Will not take initiative – May volunteer for unpleasant tasks to secure/solicit the support of others – Uncomfortable with being alone for fear of not being able to take care of themselves – Will seek another relationship soon after another ends – Preoccupied with unrealistic fears of being left to take care of themselves
    194. 194. Dependent Personality Disorder Clinical Presentation? • Clinical Presentation – Patterns of submissive behavior – Cannot complete tasks unless accompanied by another – May have history of tolerating abusive situations – Pessimistic affect – Prolongation of illness and other behaviors to continue to obtain attention
    195. 195. Dependent Personality Disorder Epidemiology? – More common in women than men – Common in young children – Higher incidence in children with chronic childhood illness
    196. 196. Dependent Personality Disorder Treatment? – Psychotherapy • Successful if insight-oriented • Group therapy also successful • Must be tolerant of patient’s need for relationship security even if abusive
    197. 197. What is hallmark for obsessive compulsive personality disorder? • Preoccupation with control/orderliness/perfection
    198. 198. Obsessive-Compulsive Personality Disorder Diagnosis? • Diagnostic Criteria (4 or more) – Preoccupation with rules, lists, details till the purpose of activity is lost – Perfectionism that interferes with task completion – Obsession with work tasks to the exclusion of friends and leisure – Rigid and inflexible about matters of ethics and morals – Unable to discard worn-out objects regardless of sentimental value – Will not delegate unless sure tasks will be performed their way – Miserly spending style – saves for catastrophes – Stubbornness
    199. 199. Obsessive-Compulsive Personality Disorder Clinical Presentation? – No sense of humor – Jobs generally routine without change – Limited interpersonal relationships as unwilling to compromise – If having any major life changes, may experience anxiety
    200. 200. Obsessive-Compulsive Personality Disorder Epidemiology? – Unknown prevalence – More men than women – Higher incidence with first degree relative with OCPD – Higher incidence if childhood characterized by harsh discipline
    201. 201. Obsessive-Compulsive Personality Disorder Treatment? – Pharmacotherapy: Klonopin or SSRIs to help reduce symptoms – Psychotherapy • Most likely to seek therapy on their own • Free association / non-structured
    202. 202. Introduction to Psychiatric Assessment Mental Illness can be explained as a disorder of Mood,Thought or of Anxiety or any combination of the 3! Jeff Mann D.O.
    203. 203. Hypomania vs. Mania • We could then further describe this person as having Hypomania where they feel great but exist in a state of excitedness above “Normal” yet are functional or unbelievably excited where it’s hard to be in their presence and they are experiencing a state of Mania where they are not functional
    204. 204. Dysthymia, Adjustment Disorder, Euthymia? • A third person might seem “bummed out” or very irritable and we might say that they were suffering from Dysthmia • A 4th person might have had a breakup or lost a job and be sad as they adjust to the loss for a time and has an Adjustment Disorder • Lastly a 5th person seems to have a “normal” mood and we would refer to them as being in a state of Euthymia or being Euthymic
    205. 205. What is Affect? • Affect is our perception of how a person feels • Affect is based upon our observations of a person’s posture, gait, dress, appearance, eye contact and speech • A flat affect could be our description of a person with little to no facial expression, poor conversation, disinterest or a distant gaze
    206. 206. What is Delusional? • A person who is convinced that pigs can fly and nothing you can say will change their mind is Delusional
    207. 207. What can cause hallucinations? • SEIZURES
    208. 208. Mental Status Exam Components (1 of 1)? • Orientation Can you tell me your name? Person Can you tell me where we are? Place Can you tell me the month,year or day? Time • Recent Memory Can you tell me who is the president now? • Intermediate Memory Can you tell me the president before him? • Longer Term Memory Can you tell me the president before that one?
    209. 209. Mental Status Exam- Components (2 of 2)? • Cognitive Function Can you spell the word World? • Testing Concentration Can you spell the word World backward? Can you count backward from 100 by 7? Stop at 65 • Testing Abstract Thinking How are an apple and orange are alike? How are are a dog and a cat alike? How are a knife and fork alike? How are a fly and a tree alike?
    210. 210. SAMCELS? • The Big 6 plus 1 SAMCEL(S) Plus ID 1. Sleep How are you sleeping? 2. Appetite How are eating? 3. Memory Any trouble remembering? 4. Concentration Any trouble staying on track? 5. Energy How is your get up and go? 6. Libido How is your interest in sex? 7. Suicide Any thoughts of hurting anyone?
    211. 211. PLUS ID? • Plus ID 1. Loss of interest in life activities;loss of joy or pleasure (anhedonia) 2. Depressed mood
    212. 212. The Big 3? • The Big 3- If yes to any, find out when or plan!! 1. Are you having any hallucinations? 2. Have you thought about hurting or killing someone? 3. Have you thought about hurting or killing yourself?
    213. 213. Verbigeraton? Word Salad? Verbigeration • Stereotyped and meaning- less repetition of words and phrases ;seen in some cases of schizophrenia Word Salad • A meaningless mix of words and phrases characteristic of advanced schizophrenia
    214. 214. New Terms Dysphoria Excessive pain, anguish, agitation; disquiet, restlessness or malaise Euphoria An exaggerated feeling of physical or mental wellbeing not justified by external reality
    215. 215. New Terms Aphasia A group of speech disorders involving a defect or loss of the power of expression by speech or writing or of comprehending spoken or written language Alexia The loss of the ability to understand written language
    216. 216. New Terms Agraphia Impairment or loss of the ability to write Neologisms New words whose meaning are known only to the person using them
    217. 217. New Terms Echolalia Repetition of another person’s words or phrases Coprolalia Compulsive,stereotyped use of obscene,filthy language
    218. 218. New Terms Clanging A pattern of speech in which sound rather than sense governs word choice Flight of ideas A nearly continuous flow of rapid speech that jumps from topic to topic; often heard in manic episodes
    219. 219. New Terms Circumstantiality A disturbed pattern of speech or writing characterized by a delay in getting to the point Tangentiality A pattern of speech characterized by oblique,irrelevant or digressive replies to questions without ever getting to the point
    220. 220. What is Adjustment Disorder? • Failing an exam, losing a job, experiencing a divorce or losing a loved one can disrupt your outlook on life • A stressor like one of the above is readily identified as occurring within 3 months of the decline in mood but the person remains functional • Without a chronic stressor, the person returns to their normal within 6 months
    221. 221. What is Dysthymia? What is required for diagnosis? • A long term mild to moderate decline in mood lasting for most of the day,every day,for two years or more • In children or adolescents should suspect if one year of decreased mood or irritabilty • Diagnosis requires decreased mood plus 2of the these: 1. Change in appetite 2. Change in sleep pattern 3. Decrease in concentration or memory 4. Decrease in energy 5. Decrease in self esteem 6. Feelings of hopelessness
    222. 222. Major Depressive EpisodeDiagnosis Requirements? • To have this diagnosis, a person must have 5 of 9 of the symptoms below for most of the day,every day for 2 weeks 1. Agitation or retardation in motor functioning 2. Changes in sleep pattern(more or less) 3. Change in weight(loss or gain) 4. Depressed mood* 5. Disturbance in concentration or memory 6. Feelings of worthlessness,guilt or shame 7. Loss of energy 8. Loss of interest in life’s activities* 9. Thoughts of dying including suicidal thoughts * These 2 must be present
    223. 223. Typical vs. Atypical Depression? • Typical 1. Person sleeps less or doesn’t sleep 2. Person doesn’t eat or eats much less • Atypical 1. Person sleeps much more 2. Person eats all the time
    224. 224. Hypomania and ManiaWhat is it? Diagnosis? • Involves an elevation in mood or irritability for 4 days for hypomania or more for mania with at least 3 of the behaviors below: 1. Subjective feelings of racing thoughts 2. Disturbance in concentration or focus 3. Inappropriately elevated self esteem 4. Uncharacteristic risk taking behavior 5. Increased motor activity 6. Increase in pursuing goals and tasks 7. Increase in talkativeness 8. Less need for sleep
    225. 225. What are the Types of Bipolar Disorder? • Three types : • Type I. Mania with or without a major depressive episode • Type II. At least one major depressive episode with at least one episode of hypomania • Mixed. Symptoms of depressed mood and agitation/mania simultaneously
    226. 226. Cyclothymic Disorder- what is it? Diagnosis? • Persons with this experience at least 2 years of numerous episodes of hypomanic symptoms and numerous episodes of depressive symptoms that do not meet the criteria for mania or major depressive disorder
    227. 227. Schizoaffective Disorder- What is it? • This is a combination of thought disturbance and mood disorder with an acceptance that it is a comorbidity of bipolar disorder or major depressive disorder and schizophrenia
    228. 228. Delusional Disorder- what are some false beliefs? • The person believes falsely 1. They are being deceived by a spouse 2. They are being followed or stalked 3. They are infected by a disease 4. They are loved by someone distant 5. They have been poisoned
    229. 229. Schizophrenia- Diagnosis? • The person must experience 1 of these: 1. Suffer from bizarre delusions 2. Hear voices that either maintain a running commentary of the person’s thoughts or have 2 or more voices talking with each other • If neither of those are present,they must have • At least 2 of these: 1. Delusions 2. Disorganized behavior or catatonia 3. Disorganized speech 4. Hallucinations 5. Flat affect;less speech;withdrawal;less motivation
    230. 230. Substance Abuse- diagnosis requirements? • A person must have 1 of the following: 1. Use impairs ability to perform important daily activities at work,school or home 2. Use occurs in places and situations that are risky to their and other’s safety (driving) 3. Use results in legal consequences 4. Use persists despite the problems caused at work,school or home
    231. 231. What is the most commonly used objective personality test? • Minnesota Multiphasic Personality Inventory 2
    232. 232. What is the other personality test? • Personality Assessment Inventory (PAI)
    233. 233. Beck Depression Inventory • A behavior rating scale • Aids in diagnosing depression • Measures the severity of self-reported depressive symptoms, and describes the particular manifestation of depression in a given patient (are symptoms more physiological, cognitive or mood-oriented in nature?)
    234. 234. What are Actuarial Assessment Techniques? • Assessment methods based purely on given patient characteristics, demographic information, and historical data that are combined to make probabilistic classifications of patients • Such as risk of violence or likelihood of responding favorably to a given treatment, or suicide risk
    235. 235. Projective Personality Testing examples • Inkblots • Incomplete sentences
    236. 236. Thematic Apperception Test Shown a card, patient asked to give a story about what is going on in the card
    237. 237. What are the most widely used intellectual tests? • The Wechsler tests – Preschool – Childhood – Adulthood
    238. 238. Academic Skills Disorders • Academic skills disorders are defined by DSM as a learning impairment that is associated with significantly worse performance on an academic skill than would be expected based on the patient’s intelligence
    239. 239. What is neuropsychological assessment? • Neuropsychological assessment refers to the application of standardized measurement techniques to determine the relationship between brain impairment and its cognitive and behavioral concomitants
    240. 240. Why can neuropsychological assessment be more useful than MRI? Give example. • MRI techniques detect gross structural damage but not changes at the molecular or cellular level- in these circumstances, neuropsychological testing may provide a more sensitive measurement of brain function • (EX): neuropsychological assessment is useful in distinguishing between early dementia and those symptoms of depression that mimic cognitive impairment
    241. 241. What can be used to assess premorbid function? • Reading ability- reading ability is highly resistant to most acquired cognitive disorders, with the exception of alexia • Reading is thus a good measure of prior function
    242. 242. What is the backbone of many neuropsychological evaluations? • A comprehensive intelligence test- ex the Wechsler test
    243. 243. When might intelligence tests not be indicative of actual patient function? • Early to mid stage alzheimers- intelligence tests don’t take into account memory and executive function very well, and these patients are usually debilitated because of difficulty with executive function and memory
    244. 244. Halsted-Reitan Neuropsychological Test Battery • Very good at distinguishing patients with confirmed brain lesions from control subjects – Ex: stroke, frontal lobe damage, etc. • Most widely accepted global measure of brain dysfunction in neuropsychology
    245. 245. What is the most widely used global memory test? • Wechsler memory scale
    246. 246. What is the most powerful tool for the clinician in identifying malingered disorders? • Thorough knowledge and experience with the disorder in question • REFERRAL to a specialist with knowledge of the disorder in question is important
    247. 247. Tests to look for Malingering • MMPI-2 and PAI- (personality tests) contain scales to detect malingering • Structured Interview of Reported Symptoms (SIRS) • Floor Effects tests- tests that appear to be difficult but in fact are nearly always successfully performed even by individuals with moderate cognitive impairment • Forced Choice Tests- 2 choices; if patient wrong more than 50% of the time, this is not likely to be chance- patient probably malingering – Test of Memory Malingering (TOMM) utilizes this concept
    248. 248. Inception • Interviewer tells the patient what he or she already knows – (ex): “I know your family found your suicide note”
    249. 249. Reconnaissance • Have the patient tell his or her story as spontaneously as possible, with little interruptions • Ask open-ended questions rather than direct yes or no questions • Use the same method when obtaining the detailed inquiry
    250. 250. Transitions • Interviewer should not move abruptly from one topic to another • Change should be signaled- “Okay id like to go on from there to something else”
    251. 251. Standard vs. Discretionary Inquiry • Standard Inquiry- obligatory questions for a patients age, in a specific clinical situation, or as part of minimum database • Rest of interview is discretionary
    252. 252. What supports causation? • Causation is supported if the patient previously had a breakdown when exposed to a similar stress or if the patient’s account of the stress indicates its personal significance
    253. 253. Types of Reliability • Test-Retest Reliability= similar results are obtained on retesting • Interrater Reliability= similar results will be obtained by different observers
    254. 254. What are the sections of the Mental Status Exam? • • • • • • • • Appearance and Behavior Relationship to the Interviewer Affect and Mood Cognition and Memory Language Disorders of Thought Physiological Function Insight and Judgment
    255. 255. What is very important to note in the relationship to the interviewer? • Quality of patient’s eye contact
    256. 256. What is affect? • Affect refers to a feeling or emotion, experienced typically in response to an external event or thought • Affect can be MOMENTARY • Patient’s relationship to the interviewer is a particular manifestation of affect
    257. 257. What is Mood? Example? • Mood refers to an inner state that persists for some time, with a disposition to exhibit a particular emotion or affect • Example- a mood of depression may not prevent an individual from deriving momentary diversion from a joke; however, the expression of gloom, sadness, or desolation returns and prevails
    258. 258. Lability? • Suddenly changing from neutral to excited or from one emotional pole to the other
    259. 259. Inappropriate or Incongruous Affect? • Not keeping with the topic of conversation
    260. 260. Morbid Anger? • Defined by its pervasiveness, frequency, disproportionate quality, impulsiveness, and uncontrollability • Assoc with organic brain disorder
    261. 261. Fear vs. Anxiety • Fear has an object= the need to defend oneself against uncertain odds (ex= car accident) • Anxiety is associated with threat to an essential value (ex= losing someone you love, being successful, etc)
    262. 262. Torpor? • Torpor denotes a lowering of consciousness short of stupor
    263. 263. Hallucinations in Delirium? • Visual more common
    264. 264. Dissociative Fugue State • Delirious patients may wander off in a daze, showing up in an emergency room unaware of his or her name or address
    265. 265. Attention vs. Concentration • Attention is involved when a patient is alerted by a significant stimulus (ex- someone talking to them) and maintains interest in it • Concentration refers to the capacity to maintain mental effort despite distraction (exnoises)
    266. 266. Amnesia vs. Dysmnesia • Amnesia= memory loss • Dysmnesia= distortion of memory
    267. 267. How do we test comprehension? • No tests- evaluated as interview proceeds • (ex): does the patient know why he or she is where they are?
    268. 268. How do we test conceptualization? • Simple levels of conceptualization are assessed by testing the patient’s capacity to discern the similarities and differences between sets of individual words
    269. 269. How do we test abstraction? • Discern the meaning of well known metaphors • (ex): people in glass houses should not throw stones
    270. 270. Flight of Ideas • Thinking is accelerated in flight of ideas, which may reach such a pitch that goal direction is lost and the connection between ideas is governed not by sense but by sound or idiosyncratic verbal or conceptual associations
    271. 271. Insight • Does the patient recognize he or she has a problem? • Does the person identify the problem as personal and psychological in nature? • Does he or she understand the nature and the cause of the illness? • Does he or she want help? And what kind of help?
    272. 272. How do we assess judgment? • Can ask one of the following questions– What would you do if you found a stamped, addressed envelope in the street? – Why are there laws? – Why should promises be kept?
    273. 273. Empathy vs. Sympathy • The deepest affective understanding is empathy, that is, feeling with, or sharing the feelings of the patient • Different from sympathy, which is feeling for the patient
    274. 274. What is transference? Example? • Transference refers to the unreasonable displacement of attitudes and feelings that originated in childhood to the people in the here and now • Example- patient angered because interviewer has a mustache or wears pearls- something is being added to an objectively neutral situation • Example- patient may unconsciously regard the physician as a parent or a sibling, casting hum or her in a caring or antagonistic role
    275. 275. What is countertransference? • When a physician irrationally transfers to a patient his or her attitudes and feelings derived from childhood experiences
    276. 276. Components of Basic Sexual History • Sexual activity & STI’s
    277. 277. Poverty of thought • Reduced or limited number of thoughts
    278. 278. Poverty of speech • General lack of additional, unprompted content seen in normal speech. • As a symptom, it is commonly seen in patients suffering from schizophrenia, and is considered as a negative symptom
    279. 279. Thought Insertion • Abnormal thinking can be experienced by the thinker as invasive, inserted, or controlled by alien forces
    280. 280. Thought Withdrawal • Abnormal thinking can be experienced by the thinker as leaking, stolen, lost
    281. 281. Thought Broadcasting • Abnormal thinking can be experienced by the thinker as broadcast from the mind into the outside world
    282. 282. Alexia • Neurologic disorder marked by loss of the ability to understand written or printed language, usually resulting from a brain lesion or a congenital defect.
    283. 283. Agraphia • An acquired form of aphasia, which is characterized by the loss of a previously possessed ability to write

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