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Psychiatry Notes 1. Mental status exam a. General behavior b. Thought c. Mood d. Delusions e. Hallucinations f. Obsessions com!ulsions g. Phobias h.

"uicidal homicidal thoughts #. Psychiatry is medicine a. Psychiatric diseases are disabling$ chronic illnesses b. %ni!olar de!ression is the most fre&uent cause of disability in the 'orld c. ()* of !atients res!ond to antide!ressants +. Psychiatric thera!utics a. Disease i. ,hat a !atient has ii. -im to cure b. Dimension i. ,hat a !atient is ii. -im to guide c. .ehavior i. ,hat a !atient does ii. -im to interru!t d. /ife story i. ,hat a !atient ex!eriences encounters ii. -im to rescri!t e. Treatment can be su!!ortive$ sym!tomatic$ em!iric$ or rational 0. The !sychiatrist1s !roblem a. Mnemonic for the !ers!ectives2 i. H3D4 b. Disease5the logic of categories i. 4tiology!athological entityclinical syndrome ii. Delirium$ dementia$ a!hasia$ bi!olar disorder$ schi6o!hrenia c. Dimensions5the logic of gradations and &uantifications i. Potential!rovocationres!onse ii. "ubo!timal cognitive ability 7mental retardation8$ affective vulnerabilities 7neuroticism$ extreme extraversion or introversion$ lo' conscientiousness8$ immaturity d. .ehaviors5the logic of teleology and goals i. -lcohol de!endence$ drug de!endence$ !ara!hilia$ anorexia bulimia$ slee! disorders e. /ife story5the logic of narrative i. "ettingse&uenceoutcome9 ii. Demorali6ation$ grief$ :ealosy$ hysteria

;. -ffective disorders a. Mood states i. De!ression 1. "3G<4<=-P" a. "lee! b. 3nterest c. Guilt d. 4nergy e. =oncentration f. -!!etite g. Psychomotor retardation h. "uicide ii. Mania 1. 4lated$ ex!ansive or irritable mood #. 3nflated self<esteem or grandiosity +. Decreased need for slee! 0. Pressured s!eech ;. >acing thoughts ?. Distractability b. Ma:or de!ression i. /o' mood and 0 sym!toms during same # 'ee@ !eriod ii. De!ressive e!isodes only$ no manic !hases iii. -ffects 1)<1;* of 'omen and ;<1#* of men c. .i!olar disorder i. .oth de!ressive and manic e!isodes ii. 1* of !o!ulation$ e&ually in men and 'omen d. Treatment i. De!ression5goal is to elevate mood bac@ to baseline ii. .i!olar5goal is to stabili6e mood ?. -nxiety and anxiety disorders a. Aer@es<Dodson /a' i. O!timal arousal im!roves !erformance ii. Hy!er<arousal diminishes !erformance b. Bear is a normal state or nervous arousal in res!onse to a real threat i. -bnormal is degree of arousal !revents ta@ing a!!ro!riate action c. Bear res!onse is caused by a sym!athetic surge d. Pathological fear i. Panic$ com!ulsion$ !hobia$ hy!erreactiveness$ tension e. -nxiety disorders i. 4xcessive fear ii. %nstimulated angst iii. 3na!!ro!riate fear (. Grief a. "tress can come from good and bad things i. Death of s!ouse$ divorce$ :ail$ marriage$ retirement$ gaining ne' family member

b. Grief is not !athological c. Ty!ical course i. 3ntense sym!toms for 1<# months ii. Ongoing sym!toms for 1 year iii. Pattern of varying intensity iv. Decrease in overall sym!tom intensity over time d. "igns of acute grief i. "omatic distress ii. Preoccu!ation 'ith the deceased iii. Guilt iv. Hostility v. 3nterru!tion in the ability to function !ositively e. Cubler<>oss stages of grief i. Denial and isolation ii. -nger iii. .argaining iv. De!ression v. -cce!tance f. "tages of bereavement i. -larm ii. Numbness iii. Pining iv. De!ression v. >ecovery and reorgani6ation g. =ommon elements of !redictable course and !rogression of sym!toms h. Differences bet'een grief and de!ression i. Grief has an intense but brief time course$ de!ression has sustained sym!toms ii. Grief rarely has suicidal thoughts$ de!ression often does iii. Grief has transient hallucinations lin@ed to the deceased$ de!ression has mood congruent hallucinations iv. Grief has 'aves of sym!toms$ de!ression has continuous sym!toms v. Grief usually leaves self<attitude intact$ de!ression decreases self< attitude D. "uicide a. -bnormal because it has an abnormal goal b. Not a motivated behavior$ but an unnatural drive arising from an abnormal mood state c. /ethality and intent i. Gun in motel room vs. 'rist scratch in front of boyfriend d. Bemales attem!t 0 time more than men e. Man com!lete suicide + times more than 'omen f. Older !eo!le are more successful g. "uicide rate in those 'ith affective disorders is hundreds of time higher than in normal !o!ulation

h. -lcoholics have higher suicide rate i. %nstable extroverts have higher rate of suicide E. Demorali6ation a. -n emotional state characteri6ed by discouragement$ a feeling of being over'helmed and ho!elessness b. Prevalence is + times higher in the medically ill$ but not all ex!erience it c. /ife story !ers!ective allo's for em!athy 1). Dimensions a. -ttributes re!resented as continua along 'hich 'e are all arrayed i. Height$ 'eight$ blood !ressure$ intelligence$ !ersonality traits b. Neurotic !aradigm i. Neuroticism ii. O!enness iii. 4xtraversion iv. -greeableness v. =onscientiousness 11. Personality disorders a. The same situations re!eatedly cause distress in a !erson i. Traits are inflexible and non<ada!tive to ex!erience b. The !erson1s traits cause difficulty in all or most domains of life5'or@$ school$ sex$ and relationshi!s c. Provocations leading to distress are usually minor d. Personality disorders i. Paranoid$ schi6oid$ schi6oty!al 1. =luster ii. Histrionic$ narcissistic$ antisocial$ borderline$ avoidant$ de!endent$ obsessive<com!ulsive 1. =luster . 1#. =hild develo!ment a. =an be considered continuous or stage<based$ also can be considered to occur stereoty!ically or idiosyncratically b. Normal rituals and su!erstitions vs. obsessions and com!ulsions 1+. "chi6o!hrenia a. - neurodevelo!mental disorder characteri6ed by hallucinations$ delusions$ disorgani6ed thin@ing and s!eech$ !assivity ex!eriences$ cognitive decline$ and social 'ithdra'l i. Positive sym!toms and negative sym!toms b. Occurs in 1* 'orld'ide c. 4&ually affects males and females i. Male onset 1(<#($ female onset 1(<+( d. Higher rates in !oor communitiesF do'n'ard drift e. D)* have no first degree relative 'ith schi6o!hrenia$ ?)* have no family history f. =ourse i. Prodromal !haseactive !haseremission residual !haserela!se

ii. =an have a single e!isode$ be !eriodic$ have !eriods 'ith no return to baseline$ or be escalating g. Treat 'ith anti!sychotics and !sychological su!!ort 10. -utism a. Pervasive develo!mental disease umbrella i. -s!erger1s symdrome$ PDD<NO"$ -utism$ =DD$ >ett1s symdrome b. - brain disorder that occurs during the 1st trimester i. 3nvolves the cerebellum and the amygdala c. 3m!airment of reci!rocity i. 3m!airment of nonverbal behaviors$ don1t develo! !eer relationshi!s at the develo!mental level d. 3m!airment in communication i. Delay in language develo!ment ii. "tereoty!ed and re!etitive use of language e. /ac@ a theory of mind i. Don1t understand others1 intents and beliefs f. 1 1?? have autism s!ectrum disorder$ 1 #;) have autism i. -ffects 0 males !er female 1;. "exual disorders a. "ex relates to all 0 !ers!ectives b. "ex is somatic c. Physiological changes in 'omen and men 'ith aging i. ,omen2 delayed vaginal lubrication$ vaginal atro!hy$ decreased clitoral res!onse$ briefer orgasm$ briefer resolution !hase ii. Men2 erection slo'er and less tumescence$ increased orgasmic latency$ briefer orgasm$ reduced e:aculate$ s'ifter resolution d. Medicali6ation of sex through somatic treatments li@e Giagra e. -bout #;* of 'omen admit !roblems 'ith orgasm i. Orgasm is often a learned ex!erience for 'omen f. +)* of men admit !remature e:aculation i. May be !art of the normal curve g. Peo!le 'ith sexual disorders often are neurotic$ highly o!en to fantasy$ lo' in agreeableness$ and lo' in conscientiousness h. "to!!ing un'anted sexual behaviors through grou! thera!y and use of antiandrogens i. Bocus on antecedents$ behaviors and conse&uences 1?. Beeding a. - driven behavior serving the organism1s energy homeostasis i. - large inta@e of food correlates 'ith a small inta@e # days later b. Peer modeling can affect ho' much a !erson eats i. ,omen are more affected by this than men ii. "ocial cues c. Hungerfood ac&uisitionfood consum!tionsatietyhunger d. =ontrol of feeding is overdetermined i. Ghrelin$ NPA$ orexins$ beta<endor!hin$ etc. increase inta@e

ii. /e!tin$ 3nsulin$ ==C$ etc. decrease inta@e 1(. 4ating disorders a. -norexia nervosa5).1<1* of 'omen i. "yndrome of self<starvation ii. HD;* of ideal 'eight iii. Bear of fatness iv. .ody image dissatisfaction v. -menorrhea vi. May include binge !urge behavior b. .ulimia nervosa51<+* of 'omen i. .ingeeating ii. "ense of loss of control over eating iii. =om!ensation of binging by !urging iv. Bear of fatness and body dissatisfaction c. =ognitive disturbance of an overvalued idea 7morbid fear of fatness8 leads to a behavioral disorder$ 'hich reinforces the cognitive disorder d. Dieting associated 'ith2 i. Decreasing 'eight goals ii. 3ncreasing criticism of the body iii. 3ncreasing social isolation iv. -menorrhea v. 4vidence of !urging e. E)* female f. Mean age of onset 10<#) i. -ssociated 'ith menarche and increase in body fat content g. "ymbolic meaning of thinness h. -dolescent dieting is a ris@ factor for both eating disorders and obesity i. "tages in develo!ment and maintenance of an eating disorder i. Predis!osing factors!reci!itating factorsmaintaining factors :. Peo!le are highly ambivalent about changing 'hat they do @. ;<1)* long term mortality i. I suicide$ I medical com!lications 1D. "lee! a. T'o !rocesses regulate slee!<'a@e cycle i. Homeostatic !rocess 1. .alance of slee! and 'a@e in a #0 hour !eriod #. 1 + slee!$ # + 'a@e ii. =ircadian !rocess 1. 4ntrained and synchroni6ed cycle of !hysiologic systems #. 3nfluences the timing of slee!iness !romoted by the endogenous circadian cloc@ +. >einforced by the daily !hoto!eriod a. Melano!sin system goes to ganglion cells that !ro:ect to the su!rachiasmatic nucleus in the hy!othalamus 0. "lightly longer than #0 hours

;. Pea@ slee!iness at 0<; a.m. ?. Pea@ 'a@efulness at (<D !.m. b. "tages of slee! i. N>4M slee! 1. "tage 1$ #$ +$ and 0 #. (;<D;* of the time ii. >4M slee! 1. Decreased muscle toneF dreamingF !enile tumescence #. 1;<#;* of the time c. Disturbances i. 3nsomnia 1. Most common slee! !roblem ii. 4xcessive slee!iness 1. Most li@ely to see@ medical hel! iii. Parasomnia 1E. Obsessive<=om!ulsive disorder a. Obsessions are intrusive ideations$ urges or images b. =om!ulsions are re!etitive$ ritualistic behaviors !erformed in a rigid manner c. These are ego<dystonicF they are un!leasant i. 3f ego<syntonic$ the !erson has obsessive<com!ulsive !ersonality disorder d. 4arly age of onset 7D)* before age 1D8 e. 0th most common !sychiatric disorder i. -ffects 1<#* of !o!ulation f. Do not need multi!le sym!toms i. =ontamination fears cleaning ii. -ggressive religious sexual obsessions iii. Need for symmetry$ ordering$ other sensory sym!toms iv. Hoarding g. >ituals are normal in children #<0 years old i. Obsessions and com!ulsions re<emerge later in childhood ii. Onset is earlier in boys than girls h. Thought to arise from dysfunction in cortical<basal ganglia circuits i. .ehavior modification can change brain function of these regions ii. Tics also arise from this region 1. O=D thought to be related to Tourette1s and autism i. O=D is often familial :. O=D treated 'ith cognitive behavior thera!y #). "omati6ation disorder a. Previously called hysteria b. - behavior of com!laining 'ith the com!laining dominated by things medical c. 3t is a behavior$ not a disease i. -ntecedentsres!onsesconse&uences

ii. >is@ factors of !ersonal vulnerabilitiesF life events !lay a roleF co< morbid mental illness !lays a role d. Peo!le 'ith somati6ation disorder are sub:ect to unnecessary treatments$ 'hich often have harmful side effects or com!lications e. =ultural factors create a niche for it to occur i. "ee@ to ta@e on the Jsic@ roleK f. ).1<).(* occurrence i. Bemales outnumber males 1) to 1<+ ii. Diagnosis is biased to'ards 'omen g. "omati6ation is not malingering h. Have !ersonalities that are anxious 7harm avoidance8 and histrionic i. To !atient$ the visit is more im!ortant than any treatment i. Ma@e sure that !atient feels that she is more im!ortant than any sym!toms she has ii. -void medicating #1. =hildhood behavior !roblems a. Po'er struggles bet'een children and !arents i. >eci!rocal interactions 1. 4ach child behavior and each adult behavior elicits a res!onse by the other #. Tit for tat ii. 4scalation of behavior 1. Try ne' interventions 'hen the old ones no longer 'or@ #. =oercive behaviors a. Not 1))* effective over time b. Bor !arents$ !hysical and emotional abuse are considered Jend stageK coercive behaviors c. Bor children$ suicide gestures and running a'ay can be considered Jend stageK coercive behaviors d. -ttending to malada!tive behaviors increases the li@elihood that they 'ill recur b. Negative reinforcement i. ,hen a behavior is successful in decreasing a noxious stimulus$ it is more li@ely to occur the next time the stimulus is !resent c. Positive reinforcement i. ,hen a behavior is follo'ed by an ex!erience that ma@es it more li@ely that the behavior 'ill reoccur ii. - reinforcer is !erson s!ecific and can be anything d. Monitoring i. "u!ervision 1. /eads to @no'ledge of child and !arental self<a'areness #. Hel!s recogni6e !atterns of behavior +. Poor su!ervision !roblems a. 4arly =hildhood5fires and accidents b. -dolescence5substance abuse$ early sexual activity$ delin&uent behavior

e. Po'er struggles and lac@ of su!ervision facilitate the develo!ment of malada!tive behavior f. Decreasing or !reventing !roblem behaviors in children is de!endent u!on decreasing !o'er struggles and increasing effective su!ervision ##. -ddiction a. >e!eated use of a !sychoactive drug b. -n a!!arent Jloss of controlK c. The continued use of the drug$ and the effort it ta@es to get it$ !roduces !roblems that 'ould motivate a reasonable !erson to sto! d. >is@ factors i. 4veryone is at some ris@ ii. 3ncreased if there is a family history iii. T'ice as many men than 'omen are addicts iv. "eems to be increasing in !revalence e. 3ncreased ris@ of death and disease f. 3ncreased crime i. ;)* of violent crimes are associated 'ith alcohol intoxication g. Poor educational achievement and unem!loyment h. Doesn1t really fit in the disease model i. "ufferer see@s the !athogen ii. "ufferer acts as if he 'ants to be sic@ iii. ,hen !ro!erly motivated$ addicts can choose not to use drugs iv. Disorder is strongly influenced by social attitudes i. /i@e sex$ addiction to drugs can be considered a driven behavior i. .ehaviors are mutually inhibitory because there is limited time in the day 1. O!!ortunity costs ii. Positive and negative conse&uences influence the behavior extensively iii. The drive is ac&uired through !ractice and habituation iv. ,ith drugs$ the system is ex!osed to something it 'as not designed to handle :. Drugs have reinforcing !ro!erties because the user ex!eriences !leasure through neural re'ard !ath'ays @. Highly addictive drugs have a ra!id onset$ are !otent$ and ra!idly offset so that there are fre&uent training sessions i. =rac@ cocaine is extraordinarily addictive l. Physical de!endence i. Tolerance and 'ithdra'l m. =lasses of drugs i. "edatives hy!notics ii. "timulants iii. O!iods iv. Hallucinogens v. =annabis derivatives vi. 3nhalants

vii. ,eird stuff n. Polydrug abuse gives a 'orse !rognosis o. =an sto! drug abuse by getting rid of the drive$ increasing negative conse&uences and introducing other behavior #+. .ehavioral disorders a. =onditioned behavior !aradigm i. 4nvironmental ex!osure leads to a behavior$ 'hich leads to an environmental res!onse 1. The environmental res!onse can be !ositive or negative$ 'hich then influence the li@elihood of the behavior being re!eated b. =lassical conditioning<<Pavlov i. .ehavior elicited by a !reviously neutral stimulus that has been !aired 'ith another stimulus that 'ould elicit that behavior c. O!erant conditioning5"@inner i. Positive stimulus 1. 3f delivered 'hen the behavior occurs$ there is !ositive reinforcement #. 3f 'ithdra'n 'hen the behavior occurs$ the behavior is extinguished ii. Negative stimulus 1. 3f delivered 'hen the behavior occurs$ there is !unishment #. 3f 'ithdra'n 'hen the behavior occurs$ there is negative reinforcement d. =ontinuous !ositive reinforcement increases the rate and !robability of a behavior e. 3ntermittent !ositive reinforcement increases the !robability and longevity of a behavior f. =ore conce!ts of addiction i. Tolerance ii. De!endence iii. >einforcement #0. -DHD a. =an be treated very effectively 'ith stimulants li@e >italin b. "ubty!es i. =ombined ii. Predominantly inattentive iii. Predominantly hy!eractive<im!ulsive c. "ym!toms begin before age ( i. Pea@ onset ;<( years old d. 3m!airment in # or more settings e. "ignificant im!airment is social$ school or 'or@ functioning f. Diagnosis is made clinically g. Prevalence is +<(* i. Males outnumber females 021 h. 3t is undertreated

#;. Dementia a. "ym!tom is difficulty thin@ing i. =ognitive disorder ii. -dult onset iii. Multi!le sym!toms iv. Normal level of alertness v. %sually !ermanent b. -lmost al'ays occurs in the elderly 7L?)8 c. =ortical dementia i. Normal early motor exam ii. -mnestic 1. >ecognition doesn1t hel! iii. -!hasia iv. 3nitiative is normal early d. "ubcortical dementia i. -bnormal early motor exam 1. "lo' ii. Memory is slo' 1. >ecognition im!roves memory iii. Dysarthria iv. -!athy occurs early e. -l6heimer1s disease i. "lo'ly !rogressive 1. Birst stage a. Memory im!airment b. Personality changes #. "econd stage a. =ortical signs i. -!hasia ii. -!raxia iii. -gnosia +. Third stage a. Physical decline i. 3ncontinence ii. Gait disorder iii. Muteness iv. Beeding difficulty ii. -mnesia iii. -!hasia iv. -!raxia v. -gnosia vi. Peo!le 'ith Do'n1s syndrome get -D around age 0) 1. -PP gene on chromosome #1 vii. >is@ factors 1. female #. 3ncreasing age

+. Bamily history 0. Head in:ury f. =auses i. -l6heimer1s disease accounts for # + of dementia ii. Gascular dementia accounts for #)<#;* #?. Mental retardation a. 3M () or less i. # standard deviations belo' normal ii. -bout #* of the !o!ulation b. Deficits in ada!tation i. /ife demands and !ersonal inde!endence as modified by culture$ !ersonality$ etc. c. -!!ears during develo!ment d. Mild M> 7D;* of M>8 i. ()<;; 3M e. Moderate M> 71)* of M>8 f. "evere M> 7+<0* of M>8 g. Profound M> 71<#* of M>8 h. =auses i. =ongental ii. Perinatal iii. Post<natal or ac&uired i. M> is lo' 3M and deficits in ada!tation at less than 1D years :. M> is not a !sychiatric disorder$ but is a vulnerability i. Need to differentiate M> from autism @. Do'n syndrome is most common form of M> #(. Delirium a. ,axing and 'aning decreases in consciousness b. - state of fluctuating inattentiveness c. Often is 'orse at night 7sundo'ning8 d. -bru!t onset e. 3t is a sym!tom of other serious !roblems f. Hy!eractive$ agitated delirium i. Hy!erarousal$ hallucinations$ delusions$ disorientation$ agitation ii. ##* of delirium g. Hy!oactive$ disoriented delirium i. Hy!oarousal$ lethargy$ confusion$ sedation ii. #?* of delirium h. 0#* of delirious !atients are mixed hy!eractive and hy!oactive i. Ne' onset hallucinations in adults are almost al'ays delirium :. Occurs commonly i. 1)* in those !resenting to 4D ii. 1)<1;* of surgical in!atients iii. 0;* of elderly 'ith cognitive im!airment iv. D;* of terminally ill @. -cetylcholine hy!othesi6ed to be the ma:or NT affected



n. o.

i. -nticholinergic drugs often cause delirium ii. -lmost all !sychiatric drugs have some anti<cholinergic effects >is@ factors2 i. -ge 7old or young8 ii. Dehydration iii. Pre<existing brain damage iv. -dvanced medical illness 4tiology i. Medications ii. 3nfections iii. Toxic metabolic disturbances iv. "ubstance abuse Mini<mental state exam is D#* sensitive for delirium Delirium is a clinical diagnosis