o   Syndrome

§  Major domains – psycholic, cognitive, affective, anxiety, substance related, somatoform, paraphilias, sleep disorders, impulse control disorders, dissociative disorders

·         Childhood vs. adult

·         Abnormal vs. normal based on functional impairment

o   Personality Disorders, Mental Retardation

§  Fixed, maladaptive qualities acquired by otherwise “normal” people

o   Medical Conditions

§  Recognition of secondary disorders

§  May limit treatment/affect outcome

§  PMH may be related psychologically or pathophysiologically

o   Stressors

§  Psychological factors, causal

§  May complicate/constrain treatment

o   Global Assessment of Function

§  Quantitative

§  If in hospital almost always <50

o   pairing a neutral (conditioned) stimulus with one that evokes a response (unconditioned stimulus) such that the neutral stimulus eventually comes to evoke the response

o   Sleep disorder

o   Interest deficit (anhedonia)

o   Guilt

o   Energy deficit

o   Concentration deficit

o   Appetite disorder

o   Psychomotor retardation/agitation

o   Suicidality

§  Quantity

§  Rate

§  Volume

§  Articulation

§  Fluency

·         Word comprehension

·         Repetition

·         Naming

·         Reading

·         Writing

§  external expression of emotion visible to the clinician

·         Emotion in responses and body language, hyper-emotional, responses changing, appropriate responses, eye contact

§  ask the patient how they are feeling

·         Labile, intensity, suicidal, appropriate mood

·         false, fixed personal beliefs not shared by others in community

o   Persecution, grandiosity, delusion of being controlled externally, somatic delusions, jealousy

·         can patient learn something new and repeat it back

o   3 words

·         correctly remember things that happened today

·         focus enough to be able to perform tasks

o   Serial sevens, spell world backwards

·         apparent intelligence by degree to which are informed, vocabulary

o   What happened in Washington last January?

o   Proverbs – interpret a commonly used proverb

o   Similarities – tell how two things are alike

§  ability to evaluate a situation and form an appropriate response

·         Propose solution to current situation

·         Propose solution to hypothetical situation – stamped and addressed envelope

§  ability to understand and acknowledge illness or situation

o   An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable overtime, and leads to distress and impairment.

§  repression, dissociation, intellectualization, displacement, reaction formation

§  altruism, humor, sublimation, anticipation

odd or eccentric

paranoid PD

schizoid PD

schizotypal PD

§  unwarranted suspiciousness and a tendency to misinterpret the actions of others as threatening or deliberately harmful, stereotype of hate group

·         < 1% lifetime risk

§  deficits in interpersonal relationships and distortions in both cognition and perception, the clairvoyant mystic

·         2-3% lifetime risk

·         Chronic low form of psychosis

dramatic, emotional, erratic

narcissistic PD

antisocial PD

histrionic PD

borderline PD

§  grandiosity, lack of empathy and a need for admiration, wealthy realestate tycoon who enjoys firing people

·         < 1% lifetime risk, men 3x more likely than women

§  guiltless, exploitative and irresponsible behavior with the hallmark being conscious deceit of others, stereotype of the cold and callus criminal

·         3% lifetime risk in males, 1% in females

§  excessive emotional expression and attention seeking behavior

·         2-3% lifetimerisk

§  pervasive instability in moods, interpersonal relationships, self-image, and behavior, often disrupts family and work life, long-term planning, and the individuals sense of self identity.  Often impulsive, risky behavior, vollitile relationships, suicidal behavior

·         2% lifetimerisk

·         High rate of completed suicide after many attempts

anxious or fearful

obsessive compulsive PD

avoidant PD

dependent PD

§  rigidity, perfectionism, orderliness, indecisiveness, interpersonal control and emotional constriction

·         1% lifetime risk; more common in male, associated with OCD, anxiety disorder, nonmelancholic depression

·         Do not usually act on obsessions. Usually unaware of their disorder and does not bother them but bothers others.

§  inhibition, introversion and anxiety in social situations; highly sensitive to criticism; want to have relationships

·         1% lifetime risk

§  submissive behavior and excessive needs for emotional support

·         < 1% lifetime risk

§  submissive behavior and excessive needs for emotional support

·         < 1% lifetime risk

o   harm avoidance; tendency to inhibit behavior when faced with novelty, punishment, or nonreward

§  Serotonin – fight/flight system

o   reward dependence; tendency to be conditioned andtomaintain behaviors associated with reward and non-punisment

§  Norepinephrine – homeostasis system

3 or less drinks per week

o   a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) or the following occurring within a 12 month period:

·         Resulting in failure to fulfill major role obligations

·         Resulting in situations in which it is physically hazardous

·         Resulting in recurrent substance-related legal problems

·         Resulting in persistent or recurrent social or interpersonal problems

§  Never met criteria for substance dependence

o   a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12 month period:

·         Tolerance – need for increased amount to achieve intoxication/desired effect; diminished effect with continued use of same amount

·         Withdrawal – characteristic withdrawal symptoms of the substance; same or related substance taken to relieve withdrawal symptoms

·         Substance often taken in larger amounts or over a longer period of time than intended

·         Persistent desire or unsuccessful efforts to cut down

·         Great deal of time spent on activities necessary to obtain, use, recover from effects

·         Important social, occupational, or recreational activities are given up or reduced

·         Continued use despite knowledge of persistent or recurrent physical or psychological problems

§  With physiological dependence – evidence of tolerance or withdrawal

§  Without physiological dependence – no evidence of tolerance or withdrawal

o   C – have you felt the need to cut down on your drinking?

o   A – have you felt annoyed by criticism of your drinking?

o   G – have you felt guilty about your drinking?

o   E – have you felt the need for an eye opener in the morning?

o   One positive or defensive response = alcohol problem likely

o   autonomic hyperactivity, increased hand tremor, insomnia, nausea or vomiting, transient visual, tactile, or auditory hallucinations or illusions, psychomotor agitation, anxiety, grand mal seizures

§  Differential Dx:  thyrotoxicosis, hypoglycemia, anticholinergic drug poisoning, amphetamine or cocaine use, CNS infection or hemorrhage, withdrawal from other sedative-hypnotic agents

§  GABA reduces brain excitability and is stimulated by alcohol; excitatory NT glutamate depressed by alcohol

§  alcohol blocks thiamine absorption

·         Thiamine key to many neurologic processes, particularly with regard to memory

·         Vision changes, gait changes, confabulation

·         Weirnicke’s prevention – multivitamins and thiamine provided during treatment for alcohol withdrawal