Term
| What are the definitions of personality disorder? |
|
Definition
Patterns of inflexible and maladaptive personality traits that cause subjective distress and significant impairment in social or occupational functioning
Multiple traits deviate markedly from cultural expectations manifesting in cognition, affectivity, impulse control, and empathy
Deviations are stably present, enduring, since adolescence or early adulthood, and pervasive |
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Term
| How common are personality disorders? |
|
Definition
30%-50% of psychiatric outpatients
15% of psychiatric inpatients are
General population with 10%-13% prevalence |
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Term
| How doe personality disorders impact treatment? |
|
Definition
Affect prognosis and treatment response of Axis I disorders
Often respond less well to treatment
Associated with poor compliance
Characteristics are manifested in the treatment relationship |
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Term
| What biochemical abnormalities are common in personality disorders? |
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Definition
Increased dopaminergic function
High percent of family history of schizophrenia
Abnormalities in serotonin appears to mediate behavioral inhibition, borderline and antisocial personalities
Much higher concordance in monozygotic twins
Often associated with a hxof sexual and physical abuse |
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Term
| How are personality disorders diagnosed? |
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Definition
Patients generally come into treatment with another complaint
Need a thorough personal and social history
Look for problems in several domains of life
Get collateral information
Do not rush to make a diagnosis |
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Term
| How are personality disorders treated? |
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Definition
Traditionally believed to be resistant to change
Quite variable in their course
Cognitive-behavioral therapy
Identifying internal mental schemes which misidentify situations or aspects of themselves and modifying them
Pharmacotherapy |
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Term
| What is included in cluster A of personality disorder patients? |
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Definition
Considered eccentric (“Weird”)
Paranoid
Schizoid
Schizotypal |
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Term
| What is included in cluster B of personality disorder patients? |
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Definition
Considered dramatic (“Wired”)
Antisocial
Borderline
Histrionic
Narcissistic |
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Term
| What is included in cluster C of personality disorder patients? |
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Definition
Considered anxious (“Worried”)
Avoidant
Dependent
Obsessive-Compulsive |
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Term
| What are the characteristics of paranoid personality disorder? |
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Definition
Long history, rarely seek treatment
Usually manages to appear together and undistressed
Central feature a pervasive and unwarranted mistrust of others
DDX: paranoid schizophrenia, delusional disorder, schizotypal personality |
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Term
| What causes paranoid personality disorder? |
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Definition
Psychoanalytic theories suggest person was object of excessive parental rage or repeatedly humiliated by others leading to feelings of inadequacy and vulnerability
Hostility and rage projected onto others
Some genetic evidence of a relation to Delusional disorder |
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Term
| What is the primary defense mechanism in paranoid personality disorder? |
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Definition
| Primary defense mechanism of Projection |
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Term
| How is paranoid personality disorder treated? |
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Definition
Mistrust usually leads to avoidance of psychiatric treatment
Maintain a respectful, straightforward and non-intrusive style
Aim at building trust
Apologize when accused of a fault
Avoid being overly warm or excessively interested
Group and cognitive-behavioral therapies are generally resisted
Antipsychotic medications if patient decompensates into psychosis |
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Term
| What are the characteristics of Schizoid personality disorder? |
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Definition
Characterized by a profound defect in the ability to relate to others
Little or no desire for relationships with others
Socially isolated
Often retreat into elaborate fantasy world
Associated with schizotypal disorder, M>F
Medical illness very upsetting, may deny treatment |
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Term
| What causes Schizoid personality disorder? |
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Definition
Noted in adults who experienced cold, neglectful and ungratifying relationships in early childhood
Constitutional factors may include childhood pattern of shyness and may be inherited
May also be in the genetic spectrum with schizophrenia |
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Term
| How is Schizoid personality disorder treated? |
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Definition
Rarely seek treatment
Do not see the value of a relationship with a therapist
May come for treatment of depression or brought by others
May only tolerate a supportive type therapy aimed at a resolution of a crisis
Alliance facilitated by an interested and caring attitude
Avoid early interpretation or confrontation
Cognitive-behavioral to encourage social involvement
Group therapy possible with focus on social skills |
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Term
| What are the characteristics of Schizotypal personality disorder? |
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Definition
Cognitive and perceptual distortions: ideas of reference, bodily illusions, unusual telepathic and clairvoyant experiences
Behave in an eccentric manner
Speech is often odd and idiosyncratic
Affect constricted or inappropriate
Socially uncomfortable and isolated with few friends
Tend to be suspicious |
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Term
| What causes Schizotypal personality disorder? |
|
Definition
Increased incidence of each other in families
Increased ventricular to brain ratio on CT
Increased CSF volume
Higher CSF homovanillic acid levels
Impaired smooth-pursuit eye movements
Impaired performance on tests of executive function suggesting altered precortical function |
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Term
| How is Schizotypal personality disorder treated? |
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Definition
Usually avoid psychiatric treatment
May be brought in when they become depressed or overtly psychotic
Difficult to establish an alliance or tolerate exploratory techniques
Supportive relationship that counters cognitive distortions and ego-boundary problems may be useful
Emphasis on social skills
Low dose anti-psychotics may help with anxiety and psychosis-like features |
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Term
| What are the characteristics of antisocial personality disorder? |
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Definition
Long-standing pattern of socially irresponsible behaviors that reflects a disregard for the rights of others
Lack of remorse over the harm they cause others
Impulsivity or failure to plan ahead
Irritability and aggressiveness
Must be 18 years with Conduct Disorder before age 15
A subgroup takes sadistic pleasure in being harmful
Associated with a high rate of substance abuse |
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Term
| What causes antisocial personality disorder? |
|
Definition
Twin and adoption studies indicate genetic predisposition
Impulsive and aggressive behaviors may be mediated by abnormal serotonin transport
Early family life often consisted of absent, assaultive or inconsistent parenting
Families often have substance abusing and/or antisocial members
Men>Women, symptoms lessen with age
Tend to die early due to suicides, accidents, homicides, and substance abuse |
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Term
| How is antisocial personality disorder treated? |
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Definition
Important to recognize antisocial individuals to avoid uncritical acceptance and disruptive behaviors
Little evidence for successful treatment
Little evidence for successful treatment
Highly structured group residences
Some may be able to form a therapeutic alliance
Mood stabilizing drugs and antidepressants
Avoid addictive substances
Some may have ADHD, treat carefully
Cognitive-behavior therapy for motivated |
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Term
| What are the characteristics of borderline personality disorder |
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Definition
Demanding search for nurturance
Instability and dysfunction in affective, behavioral and interpersonal domains
Severely impaired capacity for attachment
Maladaptive behavior patterns related to separations
Alternate between idealization and devaluation in intense relationships
Intense abandonment fears lead to rage, self-destructive behavior, guilt tripping, suicide attempts |
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Term
| What causes borderline personality disorder? |
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Definition
Psychoanalytic theories focus on early parent-child interaction
Maternal mismanagement at ages 2-3
Prevent efforts to become autonomous
Exaggerated maternal frustration
Inattention to the child’s emotions and attitudes
Traumatic early abandonment
Physical abuse and sexual abuse in the context of sustained neglect
Development of enduring rage and self-hatred
Lack of secure attachment
Twin studies show 69% heritability with traits
Abnormal serotonin probably involved |
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Term
| How is borderline personality disorder treated? |
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Definition
High utilizers of psychiatric and emergency services
Extremely difficult to treat
Frequent idealization and devaluation “splitting”
Therapists often develop intense countertransference
Intense psychotherapy has been method of choice
Pharmacological management aimed at specific problems
Avoid benzodiazepines
Cognitive-behavioral interventions and group therapy frequently helpful
Dialectical behavior therapy (DBT) combines behavioral weekly treatment with twice a week group therapy |
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Term
| What are the characteristics of histrionic personality disorder? |
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Definition
Central is over-concern with attention and appearance
Underlying insecurity about their value Inappropriate seductive behavior or provocative dress
Flamboyant acts or self-dramatizing behaviors
Effusive but labile and shallow range of emotions
Overly impressionistic and given to hyperbolic descriptions that are lacking in detail or facts
Can be very suggestible and easily influenced by others
Consider relationships to be more intimate than they are |
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Term
| What causes histrionic personality disorder? |
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Definition
Psychoanalytic theory:
Originates in the oedipal phase of development
An overly eroticized relationship with the opposite sex parent is unduly encouraged
Child fears the loss of or retaliation by the same sex parent
Research suggests there is a biogenetically determined temperament |
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Term
| How is histrionic personality disorder treated? |
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Definition
Individual psychodynamic psychotherapy or analysis remains the cornerstone
Aim at helping increase awareness
Stay with here and now rather than reconstruction of childhood experiences
Idealization and eroticism brought into therapy
Caregivers should be supportive and allow for affective ventilation |
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Term
| What are the characteristics of narcissistic personality disorder? |
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Definition
Grandiose self-esteem and importance
Intense reactions when self-image is damaged
When self-image damaged react by becoming devaluative or rageful
May become depressed leading to seeking help
Often distant in relationships, try to appear self-sufficient and often exploit others
DSM-IV focuses on the arrogant, socially conspicuous forms
Lack empathy and unwilling to recognize or identify with the feelings or needs of others |
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Term
| What causes narcissistic personality disorder? |
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Definition
Little scientific evidence
Psychoanalytic theories propose develops in persons who have had their fears, failures or dependency needs responded to with criticism, disdain or neglect during childhood
Leads to becoming contemptuous of such reactions in themselves and others and therefore unable to see others as sources of comfort or support |
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Term
| How is narcissistic personality disorder treated? |
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Definition
Individual psychodynamic psychotherapy
Aim at conveying empathy for patient’s sensitivity and disappointments
Allows for a positive idealized transference
Vulnerability should be addressed early and directly
Very difficult as they resist self-reflection
Entitlement feelings get in the way |
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Term
| What are the characteristics of avoidant personality disorder? |
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Definition
Excessive anxiety and discomfort in social situations and intimate relationships
Strongly desire relationships but fear being ridiculed, criticized, rejected or humiliated
Low self-esteem and hypersensitivity to negative evaluation by others
Lead constricted lives and avoid new activities |
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Term
| What causes avoidant personality disorder? |
|
Definition
Develops from parental rejection and censure
From early life experiences that lead to an exaggerated desire for acceptance or an intolerance of criticism
Children as young as 21 months can show physiological arousal and avoidant traits in social situations |
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Term
| How is avoidant personality disorder treated? |
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Definition
May be difficult to engage
Psychotherapy with supportive techniques and sensitivity to protective defenses
Be aware of potential countertransference reactions
Assertiveness and social training may be helpful
Cognitive techniques to gently challenge beliefs
Group therapy
May see some improvement with SRI’s
Short term use of low dose anxiolytics |
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Term
| What are the characteristics of dependent personality disorder? |
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Definition
Excessive need to be cared for by others
Submissive and clinging behaviors and fears of separation
Doubt their abilities and judgment
View others as stronger and more capable
Low self-esteem and self-doubt lead them to avoid positions of responsibility
Great effort to maintain dependent relationships |
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Term
| What causes dependent personality disorder? |
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Definition
May result from either over or under indulgence during oral phase (birth to age two)
Subsequently more support for under-indulgence
No specific association between feeding or other oral habits and dependent behavior in adulthood
Perhaps more from prohibition of independent behaviors
Twin studies have monozygotic twins more similar on scales measuring submissiveness than dizygotic
Cultural and social factors |
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Term
| How is dependent personality disorder treated? |
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Definition
Often present with depression or anxiety related to loss of a dependent relationship
Respond well to various forms of psychotherapy
Exploration of fears of independence
Encourage increased self-esteem, assertiveness and independent functioning
Desire to help may reinforce dependence
Group and cognitive-behavioral therapies
Couple and family therapy may be helpful |
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Term
| What are the characteristics of obsessive-compulsive personality disorder? |
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Definition
Excessively orderly, neat, punctual, organized and overly conscientious
Extreme perfectionism which interferes with task completion and delegation
Over-work at the expense of leisure activities and relationships
Severe superego, “I should”
Overly concerned with control including their emotions and others
Difficulty expressing emotions, appear distant
Difficulty discarding worn-out or worthless objects
Miserly toward self and others |
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Term
| What causes obsessive compulsive personality disorder? |
|
Definition
Related to autonomy
Excessive parental control
Criticism and shaming
Constitutional factors such as excessive rage leading to power struggles with others are possible |
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Term
| How is obsessive compulsive personality disorder treated? |
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Definition
Difficult to treat:
Excessive intellectualization
Difficulty expressing emotion
Often respond to psychoanalytic type therapies
Therapists must be active
Avoid being drawn into interesting but affectless discussions
Focus on feelings that are being avoided
Power struggles offer opportunities to address the excessive need for control
Cognitive techniques to diminish need for control and perfection
Dynamically oriented groups that focus on feelings |
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Term
| What are the characteristics of normal anxiety? |
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Definition
Fear resulting from the perception of an external environmental danger
Alerts the individual to prepare for defense
Provides motivational force
Anxiety arising from internal impulses that are a threat to the person’s sense of well-being |
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Term
| What are the characteristics of pathological anxiety? |
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Definition
Ineffective adaptation to a naturally occurring threat
Becomes pathological when functioning is disrupted
Worry, demoralization
Can manifest as cardiac, respiratory, gastrointestinal or neurological symptoms |
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Term
| What biologic findings are common in patients with panic or phobic disorders? |
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Definition
Greater cardiac and respiratory reactivity during sleep
Sodium lactate infusion and breathing CO2 may induce respiratory alkalosis and exaggerated brain elevations of brain lactate and elicit panic attacks
Dopamine receptors in the prefrontal cortex may be involved in avoidance conditioning
Serotonin system may be dysregulated in panic disorder |
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Term
| What is the relay center for the body's alarm system? |
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Definition
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Term
| How is the Hypothalamic-Pituitary-Adrenal Axis involved in anxiety? |
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Definition
Acute stress triggers release of Corticotrophin Releasing Factor (CRF) from the paraventricular nucleus of the hypothalamus
CRF increases Adrenocorticotrophic Hormone (ACTH) and cortisol levels
Cortisol helps orchestrate the body's stress response |
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Term
| Which endocrine disorders can cause anxiety? |
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Definition
Pheochromocytoma
Thyroid dysfunction
Pituitary dysfunction
Adrenal disorders |
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Term
| Which neurological disorders can cause anxiety? |
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Definition
Head trauma
Neurosyphilis
Seizure disorder
CNS neoplasms |
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Term
| What toxic and metabolic disorders can cause anxiety? |
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Definition
Alcohol or sedative withdrawal
Stimulant intoxication
Sympathomimetic agents
Cannabis
B12 deficiency
Hypoxia
Ischemia
Anemia |
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Term
| What autoimmune disorders can cause anxiety? |
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Definition
Systemic lupus erythematosis
Temporal arteritis
Polyarteritis nodosa |
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Term
| What complications are associated with anxiety disorders? |
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Definition
Men with panic disorder have twice the expected death rates, mostly cardiovascular and suicide
Overall increased rate of alcoholism
Social phobias
Decreased educational attainment
Higher rate of teenage pregnancy
Higher rate of marital violence |
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Term
| What is classical conditioning? |
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Definition
| A person learns to associate a neutral object or situation with something that naturally results in a fear response |
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Term
| What is operant conditioning? |
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Definition
A response is rewarded or punished by the environment and thus results in an increase or decrease of that response
Uses positive or negative reinforcement |
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Term
|
Definition
Unacceptable thoughts, impulses or desires are kept out of conscious reach
When the psychic energy attached to these elements becomes too great to hold back, they find there way into awareness in disguised form, leading to anxiety and panic |
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Term
| What are the basic guidelines for screening for anxiety disorders? |
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Definition
Get a good description of the anxiety symptoms
Inquire about associated symptoms
Take a life history
Ask about patient’s theories about symptoms
Obtain a complete medical history
Maintain a calm, reassuring demeanor
Avoid expressing irritation or impatience with the patient |
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Term
| How is anxiety disorder associated with depression? |
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Definition
Symptoms often overlap
High rate of comorbidity |
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Term
| What are the criteria defining a panic attack? |
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Definition
A discrete period of intense fear or discomfort, in which 4(+) of the following develop abruptly & peak w/in 10 min:
Palpitations, accelerated HR, Sweating, Trembling or shaking, Sensations of shortness of breath or smothering, Feeling of choking, Chest pain or discomfort, Nausea or abdominal distress, Feeling dizzy, unsteady, lightheaded, or faint, Derealization or depersonalization, Fear of losing control or going crazy, Fear of dying, Parasthesias, Chills or hot flushes |
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Term
| What are the characteristics of agoraphobia? |
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Definition
Anxiety about places from which escape might be difficult or where help might not be available in the event of a panic attack
Condition not better accounted for by another psychiatric disorder |
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Term
| What are the criteria for agoraphobia without panic disorder? |
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Definition
The presence of agoraphobia related to fear of developing panic-like symptoms
Criteria have never been met for panic disorder |
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Term
| What are the criteria for panic disorder? |
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Definition
Recurrent unexpected Panic Attacks
At least 1 of the attacks has been followed by 1(+)mo of 1(+) of the following:
Persistent concern about having another attack
Worry about the implications of the attack or its consequences
Significant change in behavior related to the attacks |
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Term
| How often do panic attacks occur in panic disorder? What does it often present with? |
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Definition
Highly variable
Several panic attacks per day to twice per year
Often comorbid with Major Depressive Disorder and other anxiety disorders, arrhythmias, hyperthyroidism, asthma, COPD, irritable bowel syndrome
Increased prevalence of mitral valve prolapse, thyroid disease
Higher concordance in monozygotic twins |
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Term
| What are the most common symtoms in panic disorder? |
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Definition
Palpitations*
Fatigue
SOB
Nervousness
Chest pain
Siging
Dizziness, fainting, apprehensiveness
Headache, parasthesias |
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Term
| What does panic disorder usually appear? |
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Definition
Onset late adolescence to mid 30’s
Usually chronic, but waxing and waning
First-degree relatives have 8x risk of PD |
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Term
| What are the different patterns of anxiety? |
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Definition
Panic attacks
Anticipatory anxiety
During panic; worry about dying, losing control, having a heart attack
Dyspnea, palpitations, lightheaded
Avoid closed spaces or being alone. Seek reassurance |
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Term
| How are panic disorders treated? |
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Definition
Primary: relaxation training, cognitive behavioral pyschotherapy, SSRI's and SNRI's
Secondary: TCA's, benzodiazepines
Tertiary: MAOI's, anticonvulscants
Adjuncts: Buspirone, beta blockers |
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Term
| What relaxation techniques can be used to treat panic disorders? |
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Definition
Visual Imagery
Diaphragmatic Breathing
Autogenic training (relaxing your body through suggestion, focus a body part to relax it)
Progressive Muscle Relaxation (focus on tension to relaxation)
Yoga
Meditation |
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Term
| What does cognitive therapy address when used to treat panic disorders? |
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Definition
Negative automatic thoughts/cognitive distortions that help to maintain the anxiety
Catastrophizing: exaggerating a potential problem into a catastrophe
Generalization
Overestimating the probability of a negative outcome |
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Term
| What are the criteria for specific phobia? |
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Definition
Marked and persistent excessive or unrealistic fear, cued by the presence or anticipation of an object or situation
Exposure to the phobic stimulus provokes an immediate anxiety response
The person recognizes that the fear is excessive or unreasonable
In children, the duration is at least six months
More common in lower socioeconomic classes and unmarried |
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Term
| How are specific phobias treated? |
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Definition
First-line: Cognitive-behavioral therapy
Second-line: PRN Benzodiazepines |
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Term
| What are common somatic complaints associated with social anxiety disorder? |
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Definition
Stuttering
Blushing
Palpitations
Sweating
Shaking/trembling |
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Term
| What are the characteristics of social anxiety/phobia disorder? |
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Definition
Comorbid anxiety disorders, substance abuse, major depressive disorder common
Marked and persistent fear of one or more social or performance situations
Exposure to the feared social situation provokes an anxiety response
The person recognizes that the fear is excessive or unreasonable
In children, the duration is at least six months |
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Term
| How is social anxiety disorder associated with considerable impairment? |
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Definition
| Lowers potential wages, probability of college graduation, and of professional, technical or managerial employment |
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Term
| What are the patterns of anxiety in social anxiety disorder? |
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Definition
Panic attacks
Anticipatory anxiety
Fear of embarrassment and negative evaluation
Blushing, sweating, trembling
Avoid public speaking or social interaciton |
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Term
| How is social anxiety disorder managed? |
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Definition
Primary: Psychotherapy - systematic desensitization, flooding, cognitive therapy. SSRI’s and SNRI’s
Secondary: MAOI’s, Benzodiazepines, Beta blockers (performance anxiety) |
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Term
| How is cognitive therapy used to treat social anxiety disorder? |
|
Definition
Addresses negative automatic thoughts/cognitive distortions which:
Help to maintain the anxiety
Catastrophizing: exaggerating a potential problem into a catastrophe
Generalization: if one person doesn’t like my lecture I’ll never be a good speaker”
Overestimating the probability of a negative outcome |
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Term
| OCD is often comorbid with what other conditions? |
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Definition
Major Depressive Disorder
M = F but onset earlier in men |
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Term
| What are the criteria for OCD? |
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Definition
Either obsessions or compulsions
At some point, the person recognizes that the obsessions or compulsions are excessive or unreasonable (does NOT apply to children)
The obsessions or compulsions cause marked distress, are time consuming
If another Axis I disorder is present, the content of the obsessions or compulsions are not restricted to it |
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Term
| What defines an obsession? |
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Definition
Recurrent thoughts, impulses or images that are experienced, at some time during the disturbance, as intrusive and inappropriate, and that cause marked anxiety or distress
The thoughts, impulses or images are not simply excessive worries about real life problems
The person attempts to ignore or suppress such thoughts, impulses or images, or to neutralize them with some other thought or action
The person recognizes that the thoughts, impulses or images are a product of his own mind |
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Term
| What defines a compulsion? |
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Definition
Repetitive behaviors or mental actions that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
The behaviors or mental acts are aimed at preventing or reducing stress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way |
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Term
| What kind of biological findings are often present in OCD patients? |
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Definition
Dysfunction of the Corticostriatal circuit
Orbitofrontal cortex
Caudate nuclei
Globus pallidus
Symptoms may occur in neurological disorders that involve the basal ganglia (Huntington’s disease) |
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Term
| What is the pattern of anxiety in OCD patients? |
|
Definition
Panic attacks
Anticipatory anxiety
Obsessive fears of contamination, causing harm to others, not doing something “just right”
Washing/cleaning, checking, ordering, avoiding contaminants, etc. |
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Term
|
Definition
First-line:
SSRI’s
Clomipramine
Cognitive-behavioral therapy (Exposure therapy, fear and avoidance hierarchy)
Family therapy
Second line: Atypical antipsychotic augmentation |
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Term
| What are the characteristics of generalized anxiety disorder? |
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Definition
Female>male
Usually chronic course, though severity fluctuates
Psychiatric treatment uncommon
Complications include major depression, substance abuse, panic disorder, associated with significant impairment
Excessive anxiety and worry, occurring more days than not for at least six months, about a number of events or activities
The person finds it difficult to control the worry |
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Term
| What are the criteria for generalized anxiety disorder? |
|
Definition
The anxiety and worry are associated with 3(+) of the following (one item in children):
Restlessness or feeling keyed up
Being easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbance |
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Term
| What is the pattern of anxiety in generalized anxiety disorder? |
|
Definition
Panic attacks
Anticipatory anxiety
Worries about money, safety, future, relationships
Tension, insomnia, restlessness
Avoid reminders of worry, seek reassurance |
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Term
| How is generalized anxiety disorder treated? |
|
Definition
First-line:
SNRI’s and SSRI’s
Cognitive-behavioral therapy
Second-line:
Benzodiazepines
Buspirone
TCA’s
Antihistamines (hydroxyzine) |
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Term
| What are the characteristics of PTSD? |
|
Definition
Men usually combat-related; women usually related to assault or rape
Symptom severity fluctuates; usually worse w/stress
Outcome better in patients with rapid symptom onset, good premorbid functioning, strong social support, and no psychiatric or medical comorbidity
Comorbid anxiety disorders, major depression, and substance abuse common |
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Term
| What are the diagnostic criteria for PTSD? |
|
Definition
The person has been exposed to a traumatic event in which both of the following were present:
Event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
The person’s response involved intense fear, helplessness or horror
The traumatic event is persistently re-experienced in various ways
The traumatic event is persistently re-experienced in 3(+) ways
Persistent symptoms of increased arousal (not present before the trauma) in 2(+) ways
Duration of symptoms is more than one month |
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Term
| What are the different types of PTSD? |
|
Definition
Acute: duration of symptoms less than 3 months
Chronic: duration of symptoms 3 months or more
Delayed onset: onset of symptoms is at least six months after the trauma |
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|
Term
|
Definition
First-line
SSRI’s and SNRI’s
Group therapy
Family therapy
Cognitive-behavior therapy
Second-line
Benzodiazepines
Prazosin (nightmares and hypervigilance) |
|
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Term
| What are the criteria for acute stress disorder? |
|
Definition
The person has been exposed to a traumatic event in which both of the following were present:
The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
The person’s response involved intense fear, helplessness or horror
Either while experiencing or after experiencing the distressing event, the individual has 3(+) dissociative symptoms
The traumatic event is persistently reexperienced
Marked symptoms of anxiety or increased arousal
The disturbance lasts for a minimum of two days and a maximum of four weeks and occurs within four weeks of the traumatic event |
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Term
| How is acute stress disorder treated? |
|
Definition
80 % progresses to PTSD
Relaxation training
Short course of benzodiazepine
Possible beta-blockers |
|
|
Term
| What are the characteristics of separation anxiety disorder? |
|
Definition
May be precursor to panic disorder
May be related to academic problems, or problems with athletic or social skills
Approximately 3% schoolchildren |
|
|
Term
| What are the diagnostic criteria for separation anxiety disorder? |
|
Definition
Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by 3(+) manifestations
The duration of the disturbance is at least 4 weeks
The onset is before age 18. |
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Term
| How is separation anxiety disorder managed? |
|
Definition
Identify thoughts about anxiety
Cognitive restructuring to patient’s worries
Parental interventions
Educate about anxiety
Effect of overprotection in maintaining anxiety
Parent management techniques
Application of exposure hierarchies |
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Term
| How does sexuality change with aging? |
|
Definition
Sexual interest does not decline significantly with aging
Best predictor of sexual activity in the elderly is availability of a partner
Physical changes associated with aging can impact sexual activity
Older patients may be uniformed about STD’s |
|
|
Term
| What endocrine disorders can cause sexual dysfunction? |
|
Definition
Hypothyroidism, hypogonadism, diabetes
Causes low libido, impotence, dec vaginal lubrication |
|
|
Term
| What vascular disorders can cause sexual dysfunction? |
|
Definition
Hypertension, atherosclerosis, stroke, venous insufficiency, sickle cell disorder
Causes impotence |
|
|
Term
| What neurological disorders can cause sexual dysfunction? |
|
Definition
| Neuropathy, spinal cord injury, brain injury, multiple sclerosis, temporal lobe epilepsy |
|
|
Term
| What surgeries have a higher chance of causing sexual dysfunction? |
|
Definition
| Prostectomy, colostomy, vaginal repair, episiotomy, amputation |
|
|
Term
| What cardiovascular drugs can cause sexual dysfunction? |
|
Definition
Methyldopa
Thiazide diuretics
Clonidine
Propanolol
Digoxin
Clofibrate |
|
|
Term
| Which GI drugs can cause sexual dysfunction? |
|
Definition
|
|
Term
| What anxiolytics cause sexual dysfunction? |
|
Definition
|
|
Term
| Why do antipsychotics cause sexual dysfunction? |
|
Definition
Hyperprolactinemia
Seen in thioridazine, haloperidol, and quetiapine |
|
|
Term
| What are predisposing factors to sexual dysfunction? |
|
Definition
Lack of information/experience
Unrealistic expectations
Negative family attitudes to sex
Sexual trauma, rape, incest |
|
|
Term
| What are maintaining factors of sexual dysfunction? |
|
Definition
Interpersonal issues
Family stress
Work stress
Financial problems
Depression
Performance anxiety
Gender identity conflicts |
|
|
Term
| What are the phases of the human sexual response cycle? |
|
Definition
Desire phase
Excitement phase (foreplay)
Plateau phase (period prior to orgasm)
Orgasmic phase
Resolution phase |
|
|
Term
| What is the definition of a sexual desire disorder? |
|
Definition
Persistent or recurrent deficiency in or the absence of sexual fantasies and desire for sexual activity
Often accompanied by social uneasiness, and lack of self-confidence
More common in women |
|
|
Term
| What is the definition of sexual aversion disorder? |
|
Definition
Persistent and recurrent aversion to and avoidance of genital contact with a sexual partner
Some persons have been sexually victimized in the past |
|
|
Term
| How do you treat sexual desire disorder? |
|
Definition
Testosterone
CBT
Sensate focus exercises (nondemand pleasuring techniques)
Erotic material
Masturbation training
Marital therapy |
|
|
Term
| How do you treat sexual aversion disorder? |
|
Definition
CBT
Sensate focus exercises (nondemand pleasuring techniques)
Erotic material
Masturbation training
For phobic/panic symptoms, use antidepressant/antianxiety medications |
|
|
Term
| What are the characteristics of male erectile disorder? |
|
Definition
| Can be primary (rare) or secondary (25% of men), more common with age |
|
|
Term
| What are the characteristics of female sexual arousal disorder? |
|
Definition
Partial or complete failure to attain or maintain the lubrication/swelling response characteristic of the excitement stage or the complete lack of sexual excitement and pleasure
1/3 of married women
May be associated with lack of sexual desire and anorgasmia
May result in painful intercourse sexual avoidance |
|
|
Term
| How is erectile dysfunction treated? |
|
Definition
Phosphodiesterase-5 inhibitors: sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis)
Enhance effect of nitric oxide, which relaxes smooth muscles in the penis, increasing blood flow to the penis
Sildenafil short-acting, vardenafil lasts up to a day, tadalafil lasts up to 3 days
Alprostadil: synthetic prostaglandin E |
|
|
Term
| How common is premature ejaculation disorder? |
|
Definition
|
|
Term
| How is female orgasmic disorder treated? |
|
Definition
Self-stimulation
Use of fantasy materials
Kegel vaginal exercises (contraction of pubococcygeus muscles)
Female controlled intercourse |
|
|
Term
| How is premature ejaculation treated? |
|
Definition
SSRI’s
Stop-start technique
Squeeze technique |
|
|
Term
|
Definition
Genital pain associated with sexual intercourse in men or women
Rare in men
Not diagnosed when pain is from vaginismus |
|
|
Term
|
Definition
Recurrent or persistent involuntary muscle contractions of the perineal muscles surrounding the vagina when penetration by a penis, finger, tampon, or speculum is attempted
Muscle contractions may occur even when penetration is anticipated
Sexual desire and orgasmic potential may be unimpaired
More common in younger women |
|
|
Term
| How are sexual pain disorders treated? |
|
Definition
Ensure sufficient lubrication
Treat any underlying gynecological problem
Training to have orgasm by masturbation
Psychotherapy
Relaxation techniques
Hegar dilators for vaginismus |
|
|
Term
| What are psychological causes of sexual dysfunction? |
|
Definition
Chronic stress
Anxiety or depression
Fear of impregnation
Fear of rejection by partner |
|
|
Term
|
Definition
Usually involves couples
Education about normal sexual functioning
Understanding attitudes and improving communication
Sensate focus exercises
A series of assignments to be carried out in private
CBT to correct dysfunctional beliefs |
|
|
Term
|
Definition
| Recurrent, intense sexually arousing fantasies, sexual urges or behaviors occurring over a period of at least six months generally involving either nonhuman objects, suffering or humiliation, or children or other nonconsenting partners |
|
|
Term
|
Definition
Deviant patterns of arousal become paired with masturbation
Can occur in brain injuries or dementia, poor impulse control
Dilation of temporal horns seen in pedophilia |
|
|
Term
| How do Paraphilias progress? |
|
Definition
Usually established in adolescence
Most persons are heterosexual
Persons may have > 1 paraphilia
Co-occurring psychiatric disorders common
Tend to be chronic but tend to vary in frequency of expression and severity
May have normal sex lives with partner or spouse aside from paraphilia |
|
|
Term
|
Definition
Exposure of one’s genitals to a stranger
1/3 of sexual offenders referred for treatment
Person masturbates while exposing his genitals
Generally no attempt at having sexual activity with the stranger
May occur during dementia |
|
|
Term
|
Definition
Sexual arousal from a physical object (not a vibrator)
Often rubber garments, women’s underclothing, and high-heeled shoes as objects of gratification
Contact with the object produces arousal, which is followed by masturbation
Person may spend considerable time seeking desired objects |
|
|
Term
|
Definition
Touching or rubbing against a nonconsenting person
May involve rubbing genitals against victim’s thighs or buttocks or touching genitals or breasts with hands
Tends to occur in crowded places from which the person can readily escape
Most common in 15- to 25- year age group |
|
|
Term
|
Definition
Sexual activity with a prepubescent child, generally age 13 or younger
Individual must be 16 yo and at least 5 years older than the child
Pedophiles generally report an attraction to children of a particular age
Experiencing distress about thoughts and fantasies is not required for the diagnosis
Tends to begin in adolescence and to be chronic |
|
|
Term
| What is Transvestic fetishism? |
|
Definition
Cross-dressing by a man in women’s clothing
Begins at puberty
Early on, person experiences cross-dressing as sexually stimulating
As person gains confidence, clothes may be worn in public
Tends to have chronic course |
|
|
Term
|
Definition
Act of observing unsuspecting persons, usually strangers, who are naked, in the act of disrobing, or engaging in sexual activity
The looking is for sexual excitement and no sexual contact with the observed person is sought
Often an expression of sexual curiosity in adolescents and typically has onset before 15 years of age
Tends to have chronic course |
|
|
Term
| What is sexual masochism and sexual sadism? |
|
Definition
Masochism involves sexual fantasies, urges, or behaviors of being humiliated, bound, or otherwise made to suffer, causes significant distress or impairment
Sadism involves sexual fantasies, urges or behaviors in which psychological or physical suffering (including humiliation) of a victim is sexually exciting to the person. The person has acted on the urges with a nonconsenting person, or the urges or fantasies cause marked distress or interpersonal difficulty |
|
|
Term
|
Definition
| Paraphilia involving feces |
|
|
Term
|
Definition
| Paraphilia involving desire to achieve altered state of consciousness secondary to hypoxia |
|
|
Term
|
Definition
| Paraphilia involving behaving as though one were an infant |
|
|
Term
|
Definition
| Paraphilia involving dead persons |
|
|
Term
|
Definition
| Paraphilia involving enemas |
|
|
Term
|
Definition
| Paraphilia involving focusing on oral-genital contact to the exclusion of intercourse |
|
|
Term
|
Definition
| Paraphilia involving focusing on one part of the body to the exclusion of all else (e.g., feet) |
|
|
Term
| What is telephone scatologia? |
|
Definition
| Paraphilia involving obscene phone calls |
|
|
Term
| How are paraphilias managed? |
|
Definition
Masturbatory satiation (boring the pt with his own deviant fantasies)
Covert sensitization (replacing fantasies with unpleasant images)
Masturbatory conditioning
Social skills conditioning
Relaxation training
CBT
Some meds, none are FDA-approved |
|
|
Term
| What is gender identity disorder (transexualism)? |
|
Definition
A strong and persitent cross-gender identification
Often a desire to become a member of the opposite sex
Individuals have a sense of inappropriateness about their assigned gender
Usually begins in childhood
Prevalence 1 in 30000 men and 1 in 100000 women
Mood disorders, substance abuse and personality disorders are frequently comorbid
Many seek hormonal treatment and request sex reassignment surgery |
|
|
Term
| What factors lead to good adjustment after sex-change surgery in people with gender identity disorder? |
|
Definition
Lifelong cross-gender identification
Ability to “pass” convincingly as a member of opposite sex
Good social support
Education and steady job |
|
|
Term
| What are the purposes served by monogamy? |
|
Definition
Preserves couples mental, physical, social, and economic health
Preserves family structure to facilitate children’s emotional development
Preserves continuity of families lives |
|
|
Term
| What is noncommercial problematic sex? |
|
Definition
Love affairs
Hookups
Friends with benefits
Swinging |
|
|
Term
| What is commercial problematic sex? |
|
Definition
Prostitutes
Lap dancers/strippers
Masseuses with “happy endings” |
|
|
Term
| How psychotherapy for sexual diseases approached? |
|
Definition
Initial, from substance abuse
Addiction is a disease, not a moral failing
Subsequent
Personal responsibility for better choices and impulse control, expressing feelings and coping
Focus on understanding the motivations for the behaviors
Learning new ways of dealing with life issues |
|
|
Term
| What drugs can be used to treat excess sex drives? |
|
Definition
SSRI
Gonadotrophin-release factor inhibitor (leuprolide)
Progesterone |
|
|
Term
| What are the diagnostic criteria for adjustment disorders? |
|
Definition
The development of emotional or behavioral symptoms in response to an identifiable stressor occurring within three months of the onset of the stressor
Symptoms cause marked distress that is in excess of what would be expected from exposure to the stressor or significant impairment in functioning |
|
|
Term
| What is the difference between acute and chronic adjustment disorders? |
|
Definition
Acute = >6mo
Chronic = <6mo in response to a chronic stressor or to a stressor that has enduring consequences
When disturbance is longer than six months, should presumably meet criteria for another disorder |
|
|
Term
| What are the subtypes of adjustment disorders? |
|
Definition
Can be associated with:
Depressed mood
Anxiety
Mixed anxiety/depressed mood
Disturbance of conduct
Mixed disturbance of emotions and conduct
Unspecified: ex. for a person who is having difficulty functioning at work |
|
|
Term
| What are the characteristics of adjustment disorders? |
|
Definition
Typically lasts days to weeks
43% of adolescents with adjustment disorders later are diagnosed with other psychiatric illness
Adolescents more likely to be suicidal
Clinicians may have a bias toward diagnosing adjustment disorders in adolescents
If the symptoms meet criteria for another Axis I psychiatric disorder, it would be the correct diagnosis, even in the presences of a stressor
Adjustment disorders more likely to occur in patients with maladaptive styles, such as those with personality disorders |
|
|
Term
| What are the common stressors causing adjustment disorders in children? |
|
Definition
Illness
Parental divorce
Moves
Birth of a sibling
Poverty |
|
|
Term
| What are the common stressors causing adjustment disorders in adults? |
|
Definition
Illness
Marital problems
Moves/placements
Job problems
Legal problems
Cancer patients: about 25% have persistent anxiety and depressive symptoms for weeks to months |
|
|
Term
| What do you do when an adjustment disorder is comorbid for depression? |
|
Definition
| Depression should be treated, do not underestimate the morbidity caused by depression |
|
|
Term
| How are adjustment disorders managed? |
|
Definition
Individual psychotherapy, typically supportive psychotherapy
Group psychotherapy
Symptomatic treatments:
Hypnotic for insomnia
Short course of benzodiazepine for anxiety |
|
|
Term
| What mental health factors during pregnancy influence infant outcomes? |
|
Definition
Exposure to illness during pregnancy
Impact of illness during pregnancy on obstetrical outcome
Exposure to treatment during pregnancy
Impact of illness on infant
Exposure to treatment during breastfeeding |
|
|
Term
| How are medication use decided during pregnancy? |
|
Definition
Medications used when risk to mother and fetus from disorder outweigh the risks of pharmacotherapy
No decision is risk free |
|
|
Term
| What are potential effects of maternal anxiety during pregnancy on infant outcome? |
|
Definition
Prematurity
Low birth weight
Low Apgar scores
High cortisol levels in children |
|
|
Term
| What are potential effects of maternal depression during pregnancy on infant outcome? |
|
Definition
Low birth weight
Intrauterine growth retardation
Childhood IQ negatively associated with duration of depression in pregnancy |
|
|
Term
| What are potential effects of maternal psychosis during pregnancy on infant outcome? |
|
Definition
High risk pregnancy in many ways
Thought and behavioral disorganization
May have delusions about fetus/infant
Suicide |
|
|
Term
| What is the treatment of choice for mild to moderate depression during pregnancy? |
|
Definition
Psychotherapy
May be especially important during first pregnancy and women with limited support systems |
|
|
Term
| What is required to detect teratogenesis with medication? |
|
Definition
| Must exceed 3% baseline and/or must have distinctive pattern |
|
|
Term
| What are the FDA pregnancy categories? |
|
Definition
A= Absence of risk
B= No risk in animals or risk in animals not shown in human controlled studies
C= risk in animals, no human controlled studies; or no studies available
D= need for drug justifies known risk
X= Contraindicated in pregnancy |
|
|
Term
| What drugs carry a low risk of teratogenesis? |
|
Definition
Typical antipsychotics: thioridizine, perphenazine, trifluoperazine, fluphenazine, haloperidol
Antidepressants: TCA’s, most SSRI’s, bupropion, mirtazapine, venlafaxine
Mood stabilizing medication: lamotrigine <3% risk of cleft palate |
|
|
Term
| What risk is associated with the use of atypical antipsychotics during pregnancy (clozapine, olanzapine, quetiapine, risperidone, aripiprazole, ziprasidone)? |
|
Definition
Concerns regarding gestational diabetes, weight gain, infant birth rate
May be associated with lower motor skills and reflexes at six months after birth |
|
|
Term
| Lithium has what known teratogenic effects? |
|
Definition
|
|
Term
| Carbamazepine has what known teratogenic effects? |
|
Definition
| Cranial-facial defects, spina bifida |
|
|
Term
| Valproic acid has what known teratogenic effects? |
|
Definition
| Cranial-facial defects, spina bifida, autism?, diminished cognition |
|
|
Term
| What are the consequences of untreated maternal depression during pregnancy? |
|
Definition
Untreated maternal depression = diminished body and head growth
SSRI-treated depression = less depressive symptoms, no effect on body growth, but diminished head growth
SSRIs have no association with stillbirth or neonatal mortality |
|
|
Term
| How does lithium affect labor and delivery? |
|
Definition
| Can cause obstructed labor due to goiter in the baby |
|
|
Term
| How do benzodiazepines affect labor and delivery? |
|
Definition
| Can cause sedation in neonate |
|
|
Term
| How do SSRI’s/SNRI’s affect labor and delivery? |
|
Definition
| Potential for discontinuation syndrome (paroxetine, venlafaxine); persistent pulmonary hypertension associated with late trimester exposure to an SSRI; increased risk of prematurity? |
|
|
Term
| What are the long-term neurobehavioral effects of prenatal exposure to an antidepressant? |
|
Definition
Though limited data, no clear effects noted
In small study, no significant effects on muscle tone, reflexes or motor skills at six months |
|
|
Term
| When should you consider discontinuing antidepressant therapy during pregnancy? |
|
Definition
Only one episode
At least six months of good functioning
No strong family history
No current stressors
Good support system
Avoid switching meds during pregnancy, depression during pregnancy strongest predictor of postpartum depression |
|
|
Term
| How do you treat bipolar disorder during pregnancy? |
|
Definition
If mild to moderate: consider tapering from mood stabilizers prior to pregnancy, reintroduce as needed or during 2nd trimester
Lithium may be safest alternative for women dependent on mood stabilizers |
|
|
Term
| What are the long-term neurobehavioral effects of prenatal exposure to an antipsychotic? |
|
Definition
At six months:
Lower muscle tone
Less-developed motor skills
Reduced reflexes |
|
|
Term
| What should be screened for when suspecting postpartum depression? |
|
Definition
Anemia
Thyroid disease
Bipolar disorder
Psychosis
Delirium |
|
|
Term
| What are the risk factors for postpartum depression? |
|
Definition
Past history of psychiatric disorder or subsyndromal disease
Affective instability during pregnancy coupled with clinical roughening during third trimester
History of mood cycling |
|
|
Term
| What should be kept in mind when treating postpartum disorders with medication? |
|
Definition
All psychotropic medications pass into milk
Infant levels are a fraction of maternal levels
Long-term effects are unknown |
|
|
Term
| How does illness affect breast feeding? |
|
Definition
Cortisol readily excreted into breast milk
Unknown impact on IgA, IgM, and other constituents of breast milk
If breast milk is altered by illness, benefits may not be the same |
|
|
Term
| What are the risks of not treating postpartum disorders? |
|
Definition
Poor infant care/impaired synchrony
Rejection of infant/impaired attachment
Suicide/homicide
Guilt
Poor eating/ maternal self-care |
|
|
Term
| What meds show no harm during breastfeeding? |
|
Definition
SSRI’s
TCA’s
Bupropion
Venlafaxine
Trazadone
Atypical antipsychotics |
|
|
Term
|
Definition
| Related to thinking, memory, judgment, perception |
|
|
Term
| What are some examples of ADLs (activities of daily living)? |
|
Definition
| Hygiene, ambulation, toileting eating, dressing |
|
|
Term
| What are some examples of IADLs (instrumental activities of daily living)? |
|
Definition
| Shopping, housekeeping, accounting, food/meds, technology |
|
|
Term
|
Definition
Objective acquired cognitive dysfunction
Displays a dysfunction in ADLs (or IADLs) |
|
|
Term
| What is mild cognitive impairment? |
|
Definition
Objective cognitive dysfunction
No impairment in ADLs
50% develop dementia in 5 years |
|
|
Term
| What are the risk factors for dementia? |
|
Definition
Increasing age, esp over 65
Low level of education
Family history
Gene mutations
Vascular risk factors: Obesity, Lack of exercise, Diabetes, Hypertension |
|
|
Term
| What is the most common cause of dementia? |
|
Definition
Alzheimer Disease (50%)
Prevalence doubles every 5 years after age 65 |
|
|
Term
| What are the core features of Alzheimer disease? |
|
Definition
Impaired episodic memory
Visuospatial dysfunction
Language difficulties |
|
|
Term
| What makes up plaques in Alzheimer Disease? Where are they found? |
|
Definition
| Extracellular Beta-amyloid deposits |
|
|
Term
| What makes up tangles in Alzheimer Disease? Where are they found? |
|
Definition
| Phspho-tau found intracellularly |
|
|
Term
| What are the three major subtypes of frontotemporal dementia? |
|
Definition
Behavioral
Progressive nonfluent aphasia
Semantic dementia |
|
|
Term
| What are the characteristics of behavioral frontotemporal dementia? |
|
Definition
Disinhibition
Loss of volition
Distractibility
Emotional blunting
Irritability
Poor insight |
|
|
Term
| What are the characteristics of progressive nonfluent aphasia frontotemporal dementia? |
|
Definition
Impaired language production
Effortful speech
Poor grammar
Reading and writing may be affected
Eventual mutism
Other functions generally spared |
|
|
Term
| What are the characteristics of semantic frontotemporal dementia? |
|
Definition
Impaired language comprehension
Difficulty naming
Fluent speech and normal grammar
Reading usually unaffected |
|
|
Term
| How does Alzheimer Disease appear in neuroimaging? |
|
Definition
| Generalized brain atrophy, hippocampal atrophy on CT, abnormal FDG on PET scan |
|
|
Term
| How does Frontotemporal Demential appear on neuroimaging? |
|
Definition
| Atrophy of the frontal lobe, visible in the frontal lobe on a CT scan, abnormal FDG PET scan |
|
|
Term
| What causes vascular dementia? |
|
Definition
|
|
Term
| What are the characteristics of cerebral infarctions that lead to vascular edema? |
|
Definition
Single event with residual symptoms
Progressive decline due to multiple events
Preventable
Often associated with other dementias |
|
|
Term
| How does vascular dementia appear on neuroimaging? |
|
Definition
| Infarctions are visible, may be multiple and tiny or few and large. Placement determines effect |
|
|
Term
| What are the tangible complications of dementia? |
|
Definition
Increased morbidity and mortality
Higher costs of living
Nursing home and ALF placement |
|
|
Term
| What are the intangible complications of dementia? |
|
Definition
Lost productivity
Family/caregiver stress |
|
|
Term
|
Definition
| Formal assessment of cognition interpreted in the context of other psychological, social and health factors |
|
|
Term
| How is neuropsychology used when treating patients suspected with dementia? |
|
Definition
Provides a diagnostic aide
A useful baseline to evaluate treatments/progression
Can be useful in guiding competency decisions and design interventions. Can be applied in clinical trials |
|
|
Term
| What clinical cognitive assessments are used physicians? |
|
Definition
Mini-Mental State Examination (MMSE)
Montreal Cognitive Assessment (MoCA) |
|
|
Term
| What clinical cognitive assessments are used neuropsychologists? |
|
Definition
Various styles, “off the shelf” batteries
Usually eclectic mix to assess different domains |
|
|
Term
| What clinical cognitive assessments are used clinical trialists? |
|
Definition
ADAS-Cog
Neuropsychological Test Battery
Severe Impairment Battery |
|
|
Term
| What cognitive domains are tested during assessment? |
|
Definition
Premorbid IQ
Orientation
Attention
Processing Speed
Memory
Language
Visuospatial Skills
Executive skills |
|
|
Term
| What is it important to assess various domains? |
|
Definition
Different diseases have their own cognitive “signatures”
Some parts of the brain are more vulnerable to certain diseases |
|
|
Term
| Alzheimer's disease targets what parts of the brain first? How does it progress? |
|
Definition
Limbic networks responsible for episodic memory
Attacks the hippocampus and entorhinal cortex, causes anterograde amnesia
Progresses to association cortices, cascades neuropsychological impairment by region |
|
|
Term
| How does memory change in Alzheimer's disease? |
|
Definition
Word learning tests show loss of free recall ability and reduced recognition with cues
Impaired consolidation (not ineffective retrieval)
Free recall and recognition further impacted by increased sensitivity to interference
Reduced semantic clustering affects learning |
|
|
Term
| What is evaluated in the neuropsychological evaluation? |
|
Definition
Estimation of baseline IQ
Various domains: M-S-A-L-V-E
Memory
Speed of processing
Attention
Language
Visuospatial functiong
Executive functioning |
|
|
Term
| How is the the neuropsychological evaluation interpreted? |
|
Definition
Heirarchical in nature
If no attention, or severely reduced speed, needs to be taken into account for interpretation
Language and understanding has a major impact
Must be flexible in approach |
|
|
Term
| A patient's clinical history during a neuropsychological evaluation should strive to include input from what other source? |
|
Definition
Partner's report
However, sometimes it is important to separate the accounts |
|
|
Term
| What type of assessment tools are available for neuropsychological evaluations? |
|
Definition
Standardized tests commercially available
Free tests of cognition and questionnaires |
|
|
Term
| What are non-standardized aspects of neuropsychological evaluations? |
|
Definition
| Remembering clinician’s name, evidence of fluctuation during assessment, remembering way back to waiting room |
|
|
Term
| How should neurophsychological tests be standardized? |
|
Definition
Should use appropriate norms
Test performance differs by age but also cultural background, and education level
Sometimes, normative information is not enough, must screen closely for actual retention or the nature of the naming difficulty
Environmental and examiner relationship/rapport are also factors |
|
|
Term
| What is prodromal/mild cognitive impairment Alzheimer's Disease? |
|
Definition
| Some memory loss may occur years prior to the onset of dementia |
|
|
Term
| What mental faculties are usually spared with Alzheimer's Disease? |
|
Definition
Digit span forward
Vocabulary
Information
Comprehension
Similarities |
|
|
Term
| A decline in cognition coincides with what other change? |
|
Definition
|
|
Term
| What are common neuropsychiatric symptoms associated with Alzheimer's? |
|
Definition
| Depression, anxiety, irritability among most frequent |
|
|
Term
| What pathologies might resemble Alzheimer's Disease but do not display the specific deficit in retrieval necessary for diagnosis? |
|
Definition
Depression
Normal pressure hydrocephalus
Sleep deprivation |
|
|
Term
| What is Lewy body dementia? |
|
Definition
| A "subcortical" dementia characterized by Parkinsonism, hallucinations, fluctuating cognition, and neuropsychological deficits |
|
|
Term
| What neuropsychological deficits are present with Lewy body dementia? |
|
Definition
Visuospatial
Executive
Attention
Memory deficit less severe than in AD, qualitatively different, better recall and recognition but deficit in learning |
|
|
Term
| Vascular dementia usually presents with impairments in what functions? |
|
Definition
Executive functions
Visuoconstructional impairment |
|
|
Term
| What functions are spared in vascular dementia? |
|
Definition
|
|
Term
| Frontotemporal dementia causes what changes? |
|
Definition
Primarily affects behavior and/or language
Memory spared in early stages
Can be difficult to test memory due to prominent aphasia or behavioral indifference/disinhibition |
|
|
Term
| What biomarkers predict the conversion from mild cognitive impairment to Alzheimer's disease? |
|
Definition
Best prediction of conversion seen on MRI
Aβ pathology implies clinical progression but absence does not classify it as benign |
|
|
Term
| What are potential reasons Alzheimer's disease is so underdiagnosed? |
|
Definition
The goals of treatment may not be clearly understood
Lack of understanding of the importance of treating AD
Early signs of AD are subtle and easily missed by physicians
Cholinesterase inhibitor therapy can reduce cognitive and functional decline in patients with AD
Lack of definitive screening and diagnostic tests
Reluctance to acknowledge signs and symptoms |
|
|
Term
| What are risk factors for Alzheimer's Disease? |
|
Definition
Age
Hypertension
Hypercholeterolemia
Head injury |
|
|
Term
| What type of patients should be evaluated for Alzheimer's Disease? |
|
Definition
Patients with identified risk factors
Patients with memory or cognitive impairment
People brought to attention through an informal complaint
Depressed or anxious patients with or without cognitive complaints |
|
|
Term
| What are the DSM IV criteria for Alzheimer's Disease? |
|
Definition
Memory impairment
Impairment in one other domain (aphasia agnosia, apraxia, executive dysfunction)
Occupational and social dysfunction
Gradually progressive |
|
|
Term
| What are the limitations of the DSM criteria for Alzheimer's disease? |
|
Definition
Low specificity
40% of non-AD dementia dx are actually AD
Requires presence of dementia prior to diagnosis
Many behavioral symptoms precede diagnosis by months or years |
|
|
Term
| What are often the first signs and changes associated with Alzheimer's disease that can precede diagnosis by months to years? |
|
Definition
Social withdrawal
Depression
Day/night reversals |
|
|
Term
| What is the informant assessment/AD8? |
|
Definition
An 8-item questionnaire that probes for changes from the patient’s previous level of functioning
Only minimally affected by age, gender, race, education, or relationship of informant |
|
|
Term
| How is the informant assessment/AD8 administered? |
|
Definition
Can be done at home by informants
Yes/No format, 2 or more positive answers correlate strongly with dementia |
|
|
Term
| Why are extensive lab studies recommended as a part of the assessment of dementia? |
|
Definition
Necessary to identify causes of dementia and coexisting conditions that are common in the elderly
Depression, vitamin B12 deficiency, and hypothyroidism commonly occur in the elderly, and particularly in patients with suspected dementia |
|
|
Term
| What are some causes of memory problems other than dementia? |
|
Definition
Depression
Drugs
Tumors
Infection
Subdurals |
|
|
Term
| Abnormal TSH and B12 levels found during the assessment of suspected dementia indicates what? |
|
Definition
|
|
Term
| Focal signs found during the assessment of suspected dementia indicates what? |
|
Definition
|
|
Term
| Parkinsonism found during the assessment of suspected dementia indicates what? |
|
Definition
| Dementia with Lewy bodies |
|
|
Term
| Tactless and impulsive behavior found during the assessment of suspected dementia indicates what? |
|
Definition
|
|
Term
| Amnestic memory defects found during the assessment of suspected dementia indicates what? |
|
Definition
|
|
Term
| What are the benefits of early recognition and treatment of dementia? |
|
Definition
Identify entities that would be treated differently
Treatments may slow down functional decline
Opportunity to participate in research
Capacity to decide one’s fate and treatment by the patient |
|
|
Term
| What is the original amyloid cascade hypothesis? |
|
Definition
| Alzheimer’s is the cumulative product of a series of pathological events that may begin with the deposition of beta-amyloid in the brain |
|
|
Term
| What is required for a research diagnosis of Alzheimer's Disease (including pre-dementia)? |
|
Definition
Documented and progressive episodic memory impairment
At least 1 biomarker evidence of Alzheimer's disease such as mild temporal atrophy, biparietal hypometabolism, amyloid signals on PET, decreased Aß and increased tau/p-tau int he CSF, or a first degree relative with a APP or PS mutation |
|
|
Term
|
Definition
A legal action to recover money or property, enforce or protect a civil right, prevent or redress a civil wrong
The “opposite” of a criminal action |
|
|
Term
|
Definition
A legal process for admitting a mentally ill person to a psychiatric treatment program, usually involuntarily
Involves a court or judicial procedure |
|
|
Term
| What are other terms that refer to a civil commitment? |
|
Definition
Legal 2000
L2K
Involuntary Hold
Involuntary treatment
Involuntary
Committed
72 hour hold |
|
|
Term
| After a patient is brought into the ER by EMS, what is the following process of civil commitment in Nevada? |
|
Definition
Initial evaluation to establish whether or not they meet criteria and whether they are medically clear
Discharged if no criteria are met and medically clear
If medically clear but meet criteria, Legal 2000 is completed and they are transferred to a mental health facility. If medically not clear, admitted first to hospital and not committed |
|
|
Term
| What is the definition of mental illness according to Nevada? |
|
Definition
| Any person whose capacity to exercise self-control, judgement, and discretion in the conduct of his/her affairs and social relations or to care for personal needs is diminished as a result of mental illness to the extent that they present a clear and present danger to self or others, but does not include any person whose capacity is diminished by epilepsy, mental retardation, dementia, delirium, intoxication, addiction, unless a diagnosable mental illness is also present |
|
|
Term
| A mental hospital should be reserved for what type of patients? |
|
Definition
| The seriously mentally ill who are in an acute crisis situation and for whom a treatment is available |
|
|
Term
| What is considered "serious mental illness"? |
|
Definition
Schizophrenia and schizoaffective disorders
Bipolar disorder, particularly while manic
PTSD with exacerbations from stressors
Severe personality disorder, particularly borderline and antisocial disorder
Major depression with psychotic symptoms, extreme negativity, and suicidal impulses
All can be under the influence of drugs or severe stress |
|
|
Term
| What is Criteria A for serious mental illness? |
|
Definition
Unable to care for self
Sometimes known as “gravely disabled”
Can be subsumed under a broad definition of dangerousness to self |
|
|
Term
| What is Criteria B for serious mental illness? |
|
Definition
Suicidal actions, threats or intent
High risk illnesses include schizophrenia, major depression, bipolar disorder, substance abuse/dependence and personality disorders |
|
|
Term
| What are static risk factors for Criteria B? |
|
Definition
| Male, single, increasing age, White and Native Americans, prior suicide attempts and family history of suicide |
|
|
Term
| What causes Criteria B serious mental illness? |
|
Definition
Psychosocial stresses
Younger more likely about relationship problems and legal problems
Older populations frequently related to declining health and physical illness
Other issues relate to financial ruin or shame and failure |
|
|
Term
| What is Criteria C for serious mental illness? |
|
Definition
Self-mutilation
Some will report converts psychic pain into physical pain which is a relief and gives a sense of control
Most common in borderline personality
Frequently has a manipulative aspect |
|
|
Term
| What is Criteria D for serious mental illness? |
|
Definition
Danger to others
Past history of violence is the best predictor of future violence
Obtain as much history as possible and use multiple sources |
|
|
Term
| What demographic has a higher risk of Criteria D serious mental illness? |
|
Definition
| Slightly increased risk of violence in the mentally ill |
|
|
Term
| What mental illnesses are most commonly associated with violence? |
|
Definition
Schizophrenia
Bipolar mania
Personality disorders
Alcohol and other substance abuse |
|
|
Term
| What are common characteristics in patients under Criteria D serious mental illness? |
|
Definition
Recent stressors are relationship issues and economic problems such as job loss
History of abuse, victimization and family violence predispose
Affect states are most important to assess such as fear, anger, confusion and humiliation |
|
|
Term
| What is required by the state of Nevada to classify a Criteria D serious mental disorder? |
|
Definition
Threats or previous actions must be within 30 days
Clinician must judge the dangerousness of the threats or acts rather than the degree of danger represented by the patient’s mental state |
|
|
Term
| Why is it the responsibility of the mental health system to attempt to treat antisocial personalities, particularly those classified under Criteria D serious mental disorder? |
|
Definition
| Police are unlikely to arrest someone for verbal threats |
|
|
Term
| What are non-committable patients? |
|
Definition
Patients who are intoxicated will resolve much of their suicidal and homicidal ideation once sober
Patients experiencing acute crisis due to environmental stressors, will usually calm down
Some patients with mental illnesses off their meds
Some patients should be referred for detox or substance abuse treatment if they will go voluntarily |
|
|
Term
| How often do patients presenting to local ER’s with the initial part of Legal 2000 completed actually receive inpatient care at SNAMHS? |
|
Definition
Only about 23%
Most others have other problems, are ultimately considered non-committable patients |
|
|
Term
| What is the function of medical clearance? |
|
Definition
| Establishes that patient does not have a medical problem that is causing or significantly contributing to the psychiatric symptoms and that any other medical problem is stable enough for the patient to be admitted to a mental health facility |
|
|
Term
| A medical clearance should include what tests? |
|
Definition
Pregnancy test in females
Urine toxicology screen and BAC |
|
|
Term
| What are the possible outcomes for a patient that a physician determines requires commitment and for whom a Legal 2000 has started? |
|
Definition
Psychiatric consultation determines:
No underlying psychiatric illness
Psychiatric symptoms are due to substance disorder, refer to substance abuse program when stable
Psychiatric diagnosis generates treatment recommendations that are successful
Psychiatric treatment does not lead to improvement before medical clearance, page B of Legal 2000 is completed, committed to a mental health facility |
|
|
Term
|
Definition
| A legal state and refers to the degree of mental soundness necessary to make decisions about a specific issue or to carry out a specific act |
|
|
Term
| When can you assume someone is competent? |
|
Definition
| All adults are presumed competent unless adjudicated otherwise by a court |
|
|
Term
|
Definition
| An individual’s ability to make an informed decision |
|
|
Term
| Who can make a determination of capacity? |
|
Definition
Any licensed physician
Frequently done by forensic psychiatrists for many issues such as stand trial or make a will |
|
|
Term
| What happens if a person is determined to be lacking capacity? |
|
Definition
| They may need to be referred for a competency hearing or need to have a guardian appointed |
|
|
Term
| Competence is specific to what? |
|
Definition
| A specific issue in question such as competency to stand trial |
|
|
Term
| What competency issues often become points of dispute following an individuals death? |
|
Definition
| Competency to make a will or enter into a contract such as marriage or real estate |
|
|
Term
| What are common causes of a patient's refusal to receive medical treatment? |
|
Definition
Patient’s poor understanding of proposed treatment
Mental illness may also impair capacity |
|
|
Term
| What is informed consent? |
|
Definition
Written consent needed for procedures, treatments with risk and research protocols
In psychiatry may be for ECT or psychotropic medications |
|
|
Term
| What is required for someone to make informed consent? |
|
Definition
Comprehension
Free or voluntary choice
Reliability
Requires that the patient has knowledge, is competent and consent is voluntary |
|
|
Term
|
Definition
Whether or not a patient demonstrates an understanding of their condition and proposed treatments
Educate if necessary and at a language level appropriate to the patient. Patient must know the risks and benefits of treatment |
|
|
Term
|
Definition
Decision to accept or reject treatment must be voluntary
May be forced due to coercion, unrealistic fears, denial, or mental illness |
|
|
Term
|
Definition
The patient’s ability to make a decision and stick to it
Some psychiatric conditions such as anxiety or depression may cause indecision and may respond to treatment |
|
|
Term
| What are exceptions to informed consent? |
|
Definition
Emergency
Incompetence or lack of capacity to make decisions that must be made without benefit of the court
Consent obtained from a guardian or substitute decision maker
Waiver
Therapeutic privilege |
|
|
Term
| What are potential interruptions that can deny communicating choice and consent? |
|
Definition
Impairment of consciousness
Mutism
Thought disorder
Disruption of short memory
Severe ambivalence
Severe aphasia with inability to write as an alternative |
|
|
Term
| What concept of competence is most often referred to in legal cases and statutes? |
|
Definition
|
|
Term
| What is relevant information? |
|
Definition
Refers to capacities include memory for words, phrases, ideas and sequences of information
Must comprehend the fundamental meaning and that they have a critical part in decision making |
|
|
Term
| What is involved in appreciating the situation and its consequences? |
|
Definition
| Appreciating the existence of illness, the probable consequences of a treatment or its refusal, and the likelihood of each of a number of consequences |
|
|
Term
| What must be distinguished when appreciating the situation and its consequences? |
|
Definition
| A realistic evaluation of the situation and the reasonableness of the decisions made |
|
|
Term
| What can cause a deficiency in the ability to appreciate the situation and its consequences? |
|
Definition
Pathological distortion or denial of reality
Delusional perceptions of the illness, the treatment or motivations of caregivers |
|
|
Term
| What is rational manipulation of information? |
|
Definition
Ability to use logical processes to compare the benefits and risks of various treatment options
Process of weighing information, frequently multiple options simultaneously, to reach a decision |
|
|
Term
| What can impede rational manipulation of information? |
|
Definition
Psychotic thought disorder
Delirium and dementia
Extreme phobia, panic or anxiety
Euphoria or mania
Depression
Anger |
|
|
Term
| What determines the level of competence? |
|
Definition
Varies with the risk/benefit ratio
More favorable the risk/benefit ratio, the lower the standard of competence to consent and the higher the standard to refuse |
|
|
Term
| What situations require a particularly high level of competence? |
|
Definition
Participation in research studies
Refusal of disfiguring surgeries such as amputation may require a court intervention
Very unfavorable risk/benefit ratio |
|
|
Term
| Who is qualified to evaluate capacity? |
|
Definition
Most evaluations can be performed by the attending physician who must be:
Conversant in the evaluation of mental status in the medically ill
Familiar with the abilities related to competence
Aware of the medical implications of the illness and proposed treatment |
|
|
Term
| When is a more formal evaluation of capacity required? |
|
Definition
| When patients behave in a way that their competence comes into question, such as refusal of treatment thought beneficial |
|
|
Term
| What is the process of evaluating capacity? |
|
Definition
Gather information related to medical situation and psychiatric history
Assess the patient’s knowledge and understanding
Do a mental status exam focusing on orientation, memory, cognitive skills and presence of delusions and hallucinations
Obtain auxiliary information from family, caregivers and nurses
Treat reversible conditions and reassess
Document thoroughly |
|
|
Term
| What is the function of the court regarding issues of capacity and competency? |
|
Definition
The court will attempt to reach a balance between protecting patients from bad decisions and maintaining their autonomy
In most cases of apparent incompetence, a substitute decision maker is found or appointed and generally the courts will support this approach |
|
|
Term
| Patients with a mental illness and an acute medical problem cannot be civilly committed in Nevada until what? |
|
Definition
| Their medical condition must be stable enough to transfer |
|
|
Term
| What is required in the non-emergent situation for treatment of an incompetent patient? |
|
Definition
| A surrogate decision maker |
|
|
Term
| What are the basic guidelines in the approach to treating an incompetent patient? |
|
Definition
Use the least restrictive treatment alternative
A sitter is generally preferred to physical restraints
Careful documentation for physical restraint when necessary
Chemical restraint is effective but watch for over sedation |
|
|
Term
| Restraint or treatment without a patient’s consent can give rise to liability for what charges? |
|
Definition
Battery which is touching another person without consent or justification
False imprisonment from when patient is denied the right to move around at will by real or perceived methods of confinement |
|
|
Term
| A failure to treat or restrain a patient who is incompetent or behaves in self-injurious fashion leaves you liable for what? |
|
Definition
|
|
Term
| What are the principles of medical ethics specifically applicable to psychiatry? |
|
Definition
A physician shall respect the rights of patients and shall safeguard patient confidences within the constraints of the law
Psychiatric records must be protected with extreme care
Confidentiality is essential to psychiatric treatment
The psychiatrist must be circumspect in the information he/she chooses to disclose to others about a patient |
|
|
Term
| What is required to breach doctor-patient confidentiality? |
|
Definition
Written consent of the patient, though exceptions exist
HIPAA was passed to protect information as the electronic age began to permeate medicine |
|
|
Term
| What is ensured by the Privacy Act of 1974? |
|
Definition
Maintenance of privacy of all information that personally identifies an individual, both patients and employees
Applies to written and verbal disclosure
Patients and individuals acting on their behalf may request in writing to have access to and make corrections to their record
Agencies have “Privacy Officer” or “Release of Information Officer”
Some areas of information such as drug and alcohol abuse, HIV infection and sickle cell anemia have special protection |
|
|
Term
| What is the purpose of HIPAA? |
|
Definition
Encourages efficiency and effectiveness of healthcare systems through development of electronic health information systems
Creates standards to regulate electronic transmission, privacy and security of certain health information
Requires training of individuals |
|
|
Term
| What is considered protected health information (PHI) under HIPAA? |
|
Definition
Identifying information related to past, present or future mental or physical condition
Services or treatment provided
Payment information |
|
|
Term
| What are problems with confidentiality under HIPAA? |
|
Definition
The risks of possibly breaching confidentiality in the interest of good care are often overstated
The risks of not providing important patient information to clinicians, or of not obtaining important information from third parties, are usually greatly understated
Clinical-entity-to-clinical-entity communication in a patient’s interest is almost always acceptable |
|
|
Term
| What are exceptions to confidentiality? |
|
Definition
Medical emergencies
Legal actions
Insurance billing
Protection of vulnerable persons, particularly children and the elderly
Reportable infectious diseases: TB, HIV, syphilis, gonorrhea
Potential victims of psychiatric patients – Tarasoff rule |
|
|
Term
|
Definition
A civil tort related to negligence of duty, either by omission or commission
Applies to organizations as well as clinicians, and to organizations’ responsibility for their staff |
|
|
Term
| What are the 4 elements of malpractice? |
|
Definition
Duty
Breach of duty
Damage
Causation: the connection between the breach and the damage |
|
|
Term
| What must be shown in a malpractice suit? |
|
Definition
Duty: arises from a special relationship with the damaged person, such as a doctor-patient, clinic-patient, or hospital-patient relationship
Causation: usually the hardest element for the plaintiff to prove
Damage: must be substantial |
|
|
Term
| What do you do if you or your organization get any communication from a lawyer about a patient, including a request for records? |
|
Definition
Refer it immediately to your lawyer or insurance carrier
Do not respond independently
Do not ignore it |
|
|
Term
| Why are malpractice suits rare for psychiatrists? |
|
Definition
Desire for confidentiality
Less likely to be harmed
Long-term relationships |
|
|
Term
| What are the most common reasons for malpractice suits against psychiatrists? |
|
Definition
Suicide most common reason
Failure to obtain informed consent
Adverse effects from medications or ECT
Abandonment
Sexual relations with patients |
|
|
Term
| What are the basic principles involved in dealing with difficult patients? |
|
Definition
Identify and honor patient’s strengths
Provide structure, goals, boundaries, function of tx
Reassess patient situation
Recognize own limitations
Get help
Take care of your own stress management |
|
|
Term
| What are the principles of effective listening? |
|
Definition
Focus on conversation
Ignore distractions
Don’t interrupt
Control your own emotions
Avoid hasty judgments
Acknowledge patient’s (family’s) perspective |
|
|
Term
| What limits should be set with patients? |
|
Definition
Define what is and is not appropriate behavior
Define what will and will not be tolerated
Treatment and care-giving should be valued |
|
|
Term
| What is the purpose of setting limits? |
|
Definition
Block habitual and maladaptive behavior
Allow for the emergence of newly learned behavior |
|
|
Term
|
Definition
Target maladaptive behavior requiring change
Address consequences of continued inappropriate behavior
Communicate limits with the entire team
Be aware of content and tone of communications
Encourage patient and family to participate in limits
Effective limits should be few in number
The complete team must support the limits once set
Provide patient and family with opportunity to verbalize responses |
|
|
Term
| What are the dynamics of a professional patient-physician relationship? |
|
Definition
Physician agrees to provide medical services to a patient for a fee
Patient trusts physician to act in his/her best interest
Only patient discloses very personal information
Patients may be unaware of the need for professional boundaries; physician is responsible for maintaining boundaries and held accountable in their absence |
|
|
Term
| What are the dynamics of a social relationship? |
|
Definition
Initiated for the purpose of friendship
Mutual needs are met
Communication includes giving advice and meeting basic needs such as lending money
Both are responsible for maintaining the boundaries of the relationship |
|
|
Term
| What is the purpose of boundaries? |
|
Definition
Limits that allow a patient and physician to connect safely in a therapeutic relationship based on the patient’s needs
Protect client vulnerability
Provide legal protection for physician |
|
|
Term
| What are typical areas where boundaries tend to be violated? |
|
Definition
Self-disclosure
Giving or receiving significant gifts
Dual relationships
Becoming friends
Maintaining established conventions (providing treatment in social situation)
Physical contact |
|
|
Term
| What are warning signs of sexual misconduct? |
|
Definition
Gradual erosion of physician neutrality
Perceiving patient as special
Socializing outside of practice
Self-disclosure
Physical contact
End of day or after hours appointments
Free care
Dating |
|
|
Term
| What is considered sexual misconduct? |
|
Definition
| “It is considered sexual misconduct for a physician to have sexual contact with any current patient whom the physician has interviewed and/or upon whom a medical or surgical procedure has been performed.” |
|
|
Term
| How should you approach treating an angry patient? |
|
Definition
Acknowledge anger
Accept the anger by listening
Explore the reason for anger, even if you do not agree with it
Reflect what he or she has been said
Look for contributing factors, may not be obvious
Reach an agreement if possible about what can be done to resolve the issue |
|
|
Term
| What are characteristics of dependent patients? |
|
Definition
May be mildly or severely ill
Have self perception of bottomless needs
Perceive caregivers as inexhaustible
This may result in weary avoidance of the patient |
|
|
Term
| What tactics are usually used by dependent patients? |
|
Definition
Use flattery and unconscious seduction
Extreme gratitude
Feeling of specialness by caregiver |
|
|
Term
| What should be avoided when stamina exhausted with dependent patients? |
|
Definition
A referral for psychiatric evaluation may be put forth in a way the patient perceives as rejection.
Referrals in this context are destined to fail |
|
|
Term
| How should you manage a dependent patient? |
|
Definition
Discuss with patient and families, patient is entitled to good care but there are limits to human knowledge, skill, stamina, and time
Try to avoid saying “goodbye”
Leave reminder of visits such as a card or note |
|
|
Term
| What are characteristics of entitled demanders? |
|
Definition
Very needy
Use intimidation, devaluation, and guilt-induction
May be overtly hostile
Patient is unaware of deep dependency underlying actions
Hostility is born of the terror of abandonment
Patient may be feeling weak, unattractive or unsuccessful |
|
|
Term
| How should you respond to entitled demands? |
|
Definition
Re-channel entitlement
"We can’t give you the good treatment you deserve unless you help. You’ll get the help you deserve if you stop mis-directing your anger at the people trying to help you. You need all the allies you can get" |
|
|
Term
| What type of comfort are entitled demanders seeking? How should you comfort them? |
|
Definition
Feel more comfortable and secure if caregivers fulfill need for him to be acknowledged as a person of achievement
Does not mean denying own medical expertise and skills |
|
|
Term
| How should you approach the treatment of an entitled demander? |
|
Definition
May need to practice some defensive medicine
Good charting
Avoid debates
Remain calm, gentle and firm
Tireless repetition of the theme of acceptance that the patient deserves first-rate medical care |
|
|
Term
| What are characteristics of Manipulative Help-Rejecters? |
|
Definition
Not seductive, grateful, or overtly hostile
Appear to feel no regime of treatment will help
May accept treatment, only to report again and again that it does not work
Pessimism increases in proportion to caregiver’s efforts and enthusiasm
When one symptom improves another appears in its place
Symptoms and illnesses serve to maintain the relationship with the caregiver
Patients frequently deny depression and refuse referral to psychiatry |
|
|
Term
| How do you deal with manipulation? |
|
Definition
Put limits on unrealistic expectations
Put limits on demanding hostility |
|
|
Term
| What are the characteristics of Self-Destructive Care-Refusers? |
|
Definition
No self-destructive intent
Tendency to prize independence
Appeals to the patient’s sturdiness should be attached to the treatment plan
Patient is using the defense of denial to survive
Has given up hope of ever having needs met |
|
|
Term
| How should you approach the treatment of elf-Destructive Care-Refusers? |
|
Definition
Patients respond to medical advice delivered with a lighthearted touch and focused on maintenance of good health
Doomsaying, authoritarian approaches typically fail
Patient easily denies bad news |
|
|
Term
| How do you provide optimal care to Self-Destructive Care-Refusers? |
|
Definition
Psychiatry consult to see if depression exists and/or to evaluate competence
Recognize limits such patients pose for even ideal caregivers
Work with diligence and compassion to preserve the refuser as long as possible, just as one does with any other patient with a terminal illness |
|
|
Term
| What are the characteristics of a compulsive patient? |
|
Definition
Presents with excellent self-discipline
When stressed, reacts by needing as much information as possible as the preferred way of handling anxiety
Striving for intellectual control
Tends to master aggression and satisfy his conscience by hard work
Copes with danger by increasing his efforts to be responsible and orderly
-May seem inflexible and opinionated
-May be hesitant, doubting and indecisive
Tends to suppress emotions |
|
|
Term
| How should you approach a compulsive patient? |
|
Definition
Responds to scientific medical approach
Values sympathetic efficiency and cleanliness
Physician should welcome patients active participation in decisions
Recognize patient’s reasoning and high standards
Encourage patient participation in care |
|
|
Term
| What are the characteristics of an aloof patient? |
|
Definition
Lack of involvement with everyday events and concerns of people
Quiet, seclusive, unsociable
History of solitary interests and noncompetitive jobs
Often oversensitive, fragile and lacking resilience
Aloofness may be protective in avoiding painful experience
Seeks solace and satisfaction within himself |
|
|
Term
| How should you approach an aloof patient? |
|
Definition
| Make few demands for personal involvement with others, but do not permit complete withdrawal |
|
|
Term
| What are characteristics of a Long-Suffering, Self-Sacrificing Patient or Family Member? |
|
Definition
History of repeated suffering, rather from repeated illnesses or disappointments
Inclined to disregard own comfort and be of service to other people
Tendency to display suffering in exhibitionistic way despite overt humility
Striving for love, care and acceptance, but feels too guilty and anxious to accept without self-sacrifice and suffering |
|
|
Term
| How should you approach a a Long-Suffering, Self-Sacrificing Patient or Family Member? |
|
Definition
Express appreciation of the difficulties of illness as they are experienced by the patient
Patients respond better when considering the burden that treatment will carry rather than the relief that health would bring
May have to present recovery as a special additional task for the benefit of others |
|
|
Term
| How do you deal with patients experiencing feelings of aversion? |
|
Definition
|
|
Term
| How do you deal with patients experiencing an impulse to counterattack? |
|
Definition
| Re-channel entitlement into expectation of good medical care |
|
|
Term
| How do you deal with patients experiencing feelings of depression who reject help? |
|
Definition
| Accept pessimism so patient does not feel abandoned |
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Term
| How do you deal with patients experiencing feelings of wishing death? |
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Definition
Consider possibility that patients wishes to die
Uncomfortable feelings not addressed make it more likely that errors in diagnosis and treatment will occur |
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