Clinical psychiatry

syndrome characterized by significant disturbance in an individual's COGNITION, EMOTION REGULATION, or BEHAVIOR that reflects a dysfunction in psychological, biological, or developmental processes underlying mental functioning. Associated with SIGNIFICANT DISTRESS OR DISABILITY IN SOCIAL, OCCUPATION, OR OTHER IMPORTANT ACTIVITIES

1) General appearance and behavior2) Mood and affectivity3) Speech characteristics4) Thoughts5) Perception6) Sensorium and Cognition7) Judgement and Insight

Part of MSElook for:1) Appearance2) Behavior3) Psychomotor activity4) Attitude

Part of MSElook for:1) Mood 2) affect3) appropriateness (to situation, does face match what is being said?)4) Range5) Mobility6) Reactivity

Part of MSElook for:1) speech characteristics2) Thought process (ex: formal thought disorder)3) Though content (ex: delousions)4) Depressive cognitions, anxiety, phobias, obsessions, SI

What the person says does not make sense compared to the normal thought process which is logical and goal oriented. EX:Loosening of associations (no connection between sentences)Tangentiality (goes on tangent)Derailment (shift in speak)Word Salad / incoherence (speak gibberish)Circumstantiability (gives tedious details about everything)

Part of MSE1) Hallucinations2) Illusions

Part of MSElook for:1) level of consciousness2) Attention and concentration3) Orientation and memory4) language, reading, writing5) Visuospatial ability6) Abstraction7) General Fund of information

Part of MSE:Test judgement / social judgement / clinical judgement Grades of insight (what is person's understanding of known illness)

an immediate expression of emotion (ex: it is the weather, where as mood is the climate)

1) Blunted - reduction in expression2) Flat - absent expression3) Inappropriate - discordance between expression and content of speech4) Labile - abnormal variability with rapid shifts

emotional experience over a more prolonged period of time (ex: mood is climate where as affect is weather)

Involves:IncoherenceLoose associationsTangentialityDerailmentCircumstantialityFlight of ideas

A firm and fixed false belief that is held with firm conviction in spite of evidence of the contrary and not in keeping with the person's religious and/or cultural beliefs

1) Bizarre2) Jealousy3) Erotomanic4) Grandiose5) Persecutory (most common)6) Somatic (feelings on body parts)7) Thought insertion (think others put thoughts in their head)8) Thought broadcast (think others know about my thoughts)

Perception in the absence of external stimulus

1) Auditory (most common)2) Visual (inorganic brain disease)3) Tactile4) Olfactory (inorganic brain disease)5) Gustatory 

Apprehensive anticipation of future danger or misfortune accompanied by a feeling of worry, distress and/or somatic symptoms of tension

Discrete periods of sudden onset of fear or terror, often associated with FEELINGS OF IMPENDING DOOM

Recurrent, persistent, thoughts, urges or images that are experienced as INTRUSIVE AND UNWANTED, and it causes ANXIETY

Repetitive behaviors or mental acts that the individual feels driven to perform in response to obsession.These are done to reduce anxiety produced by obsessions.

"As if" phenomenonFeeling detachedFeeling like an outside observer

persistent fear of a specific object, activity or situation THAT IS OUT OF PROPORTION TO THE ACTUAL DANGER posed by the specific object, activity or situation and a compelling desire to avoid it. Impacts the person life

1) Delirium2) Major Neurocognitive Disorders3) Mild Neurocognitive Disorders

Characterized by disturbance in ATTENTION (reduced ability to direct, focus, sustain and shift attention) and AWARENESS (reduced orientation to the environment) that develops over a short period of timeAcute onset, fluctuating course, impairment of attention is associated with global impairment of cognitive functions (memory deficits, disorientation, language and perception)

substance withdrawal deliriummedication-induced deliriumdue to another medical conditiondue to multiple etiologiesif acute: hours to daysif persistent: weeks to months (not common)

CNS disorderMetabolic disorderCardiopulmonary disorder (oxygenation deficit to brain)Sepsis/ infectionsystemic illness

1)Hyperactive- hyperactive level of psychomotor activity may be accompanied by mood lability, agitation, and/or refusal to cooperate with medical care2)Hypoactive - Most common; hypoactive level of psychomotor activity that may be accompanied by SLUGGISHNESS AND LETHARGY that approaches to stupor. 3) Mixed level of activity - individual has normal level of psychomotor activity even though attention and awareness are disturbed. Activity levels may also rapidly fluctuate. 

DISTURBANCE IN ATTENTION OR AWARENESSacute onset, fluctuating symptomsConfusion, disorientation, illusions/hallucinations, emotional disturbance (apathy, anxiety, fear), emotional disturbance may manifest calling out, screaming, shouting, disturbed sleep awake cycle

Evidence of significant cognitive decline from previous level of performance in one or more of the 6 cognitive domains, based on history and neuropsychological testing:1) complex attention (sustained, divided and selective attention + processing speed)2) Executive function (planning, decision making, inhibition, mental flexibility)3) Learning and Memory (immediate, recent, remote, new learning, declarative, implicit)4) Language5) Perceptual motor (visual perception, visuo-constructual, praxis, diagnosis)6) Social cognition (behavior i out of norm, difficulty recognizing emotions)COGNITIVE DEFICITS MUST INTERFERE WITH EVERYDAY ACTIVITIES!!and not due to delirium and not explained by another medical disorder

Alzheimer's, Vascular Disease, FTLD, TBI, Lewy Body disease, Parkinson's, HIV infection, Substance Use, Huntington's Disease, Prion Disease

Major Neurocognitive Disorders impair activities of daily living (ADLs) and instrumental activities of Daily Living

Disturbance in the SIX domainsInsidious onsetgradual progressionPatients are adept at minimizing their symptomsCollateral history is importantALWAYS assess ADLs and IADLs

CT headTSHRPRB12, Folate levels

Alertness- awake and fully aware of stimuliLethargy - not fully alert, drifts to sleep when not actively stimulatedObtundation - difficult to arouse and when aroused patient is confusedStupor - patient responds only to vigorous stimulationComa - completely unarousableAssess with Glasgow Coma Scale

ability to attend to a specific stimulus w/o being distracted by extraneous stimuli

ability to sustain attention over a sustained period of time

Digit repetitionRandom letter test serial subtractionspell "world" backwardsAnatomical localization: ascending reticular activating system

1) Level of consciousness2) Attention3) Language4) Memory5) Constructional ability6) higher cognitive function (fund of information, calculation, proverb interpretation)

disorder of articulation

loss of speech melody (ex: monotone)

impaired production / comprehension of spoken language

loss of reading ability in a previously literate person

acquired disturbance of writing

handednessspontaneous speechcomprehensionrepetition (no ifs ands or buts)namingreadingwriting

word or syllable substitution

Error in comprehension and production of speech

disproportionate deficit in repetition; lesion in arcuate fasciculus and left parietal region

intact repetition; disruption of language functions

inability to name

process that allows an individual to store information for later recall3 stages: registration, encoding, recall

1) Immediate, short term2) Recent3) Remote

Digit repetition (immediate memory)New learning ability (short term)recent memory (orientation)Remote memory (historical facts about patient experiences)

any condition in which there is impaired attention (ex: encephalopathy)

mamillary bodies, medial temporal lobe, hippocampus, dorsal medial thalamic nuclei

Association cortex

ability to draw or construct two or three dimensional figures or shapesconstructional tasks are extremely sensitive in detecting organic brain disease

copying geometric shapesdrawing on command3D block construction

Parietal lobeRight Parietal Lobe lesions produce higher incidence and greater severity of defect than left parietal lobe lesions

Fund of informationCalculation (parietal)Proverb interpretation (frontal)Social judgement (frontal)

acquired disorder of learned, skilled, sequential movements that cannot be accounted for by elementary disturbances of strength, coordination or lack of comprehension or attention.INABILITY TO CARRY OUT MOTOR COMMANDS IN THE ABSENCE OF ANY GROSS MOTOR DEFICIT

1) Finger agnosia2) Right-Left disorientation3) Dysgraphia4) DyscalculiaParietal lobe lesions- dominant or bilateralANGULAR GYRUS

ADVascularLewy Body

characterized by a persistent disturbance of eating or eating related behavior that results in altered consumption or absorption of food and significantly impairs physical health or psychosocial functioning (patients judge how they look)

PicaRumination DisorderAvoidant/Restrictive Food intake Disorder

Anorexia NervosaBulimia NervosaBinge Eating Disorder

persistent eating of nonnutritive, non food substances for over a period of 1 monthEx: paper, soap, cloth, chalk, hair, stringInappropriate to developmental levelNot culturally supportedOften associated with Intellectual Disability

Repeated regurgitation of food over a period of at least 1 month (bringing up their food without effort)Regurgitated food is swallowed or spit outNot due to medical conditionNOT OCCURRING EXCLUSIVELY during Anorexia, Bulimia, or BED

Avoiding food due to lack of interest in eating / avoiding food based on sensory characteristics (color, taste, texture)Weight loss / nutritional deficiency / dependence of enteral supplementsDoes not occur exclusively during AN or BNTHERE IS NO BODY IMAGE DISTURBANCEOften associated with Intellectual Disability, Autistic Spectrum Disorder, and phobias about choking

Restriction of energy intake leading to SIGNIFICANTLY LOW BODY WEIGHTIntense fear of gaining weight or becoming fat, even though underweightDisturbance in the way in which the body is shaped (patient always checks their weight)Two subtypes

1) Restrictive - worst prognosis2) Binge-eating / purging type - binge and then try laxatives or purgingDistribution is 50-50 and there is crossoverSeverity of illness is based on BMI

High risk group is adolescent girls and young women10-20 X more common in women, more frequent in professions that require thinnessmore frequent in caucasians

1) self-induced starvation to a significant degree2) relentless drive for thinness or a morbid fear of fatness3) presence of medical signs and symptoms resulting from starvation

pts control what they eatdrastic reduction in food intakerefuse to eat with families or in public spacesPreoccupation with food - cooking, collecting recipesPeculiar behaviors - hiding food, carrying candy in pocketsRitualistic behaviorsbinging followed by self-induced vomiting, diuretic and laxative abuse

HypothyroidismHypothermiaLoss of cardiac muscle, PVC, bradycardiaConstipation, abdominal painamenorrhea, low LH and FSHLanugo (thin hair in back of neck), dry skinOsteoporosis (IRREVERSIBLE)Abnormal tasteMild cognitive impairment

Electrolye abnormalities (low K, hypochlormemic alkalosis, low Mg)Salivary gland and pancreatic inflammation, increase in amylase (swelling of parotid glands)Erosion of dental enamelSeizures

course is variableRestrictive type has poor prognosisamong highest mortality rates of all mental illnessesMortality rates are high 

Nutritional Rehab (weight gain 2-3 lbs per week)Psychotherapy  (CBT, family therapy, self help groups)Pharmacotherapy (Cyproheptadine and other antihistamines, limited role of antidepressants like mirtazepine, TCA, fluozetine

Bulimia- means binge eatingdistinguishing feature from AN is that ATTEMPTS TO RESTRICT FOOD ARE PUNCTUATED BY BINGES COMPENSATED BY PURGING AND/OR LAXATIVE ABUSEThere is loss of control over eating and is followed by guilt

Recurrent episodes of binge eating: 2 hr period of excessive food intake and loss of control while eating. Recurrent inappropriate compensatory behaviorAbove occurs once a week for at least 3 mosself evaluation influenced by body shapedoes not occur exclusively during episodes of anorexiaSeverity is defined in terms of episodes of compensatory behavior per week

more prevalent than ANonset in adolescence or young adult hoodmost patients are within normal weight range or slightly overweightmenstrual irregularitiesmedical complications due to purging or laxative abusecross over between AN and BNPATIENTS REGARD BEHAVIOR AS MORE EGO DYSTONIC

less heritability than ANincreased childhood and parental obesityearly menarcheparental alcoholismincreased Hx of childhood abuse

Mostly secondary to purging or laxative abuseElectrolyte imbalancearrhythmiasdental erosions

depressionsubstance abuseimpulse control disordersBipolar affective disorderDissociative disorders

1) CBT is effective2) antidepressants have anti-bulimic effect

recurrent episodes of binge eating (eating food that is definitely larger than what most people would eat over a discrete period of time plus a sense of lack of control)most common eating disordereating more rapidly / eating til uncomfortably full / eating when not hungry / eating alone or embarrassment / guiltAT LEAST ONCE A WEEK FOR 3 mos; NO COMPENSATORY BEHAVIOR

Anxiety disordersdepressionsubstance abuseDisorder is more prevalent among those seeking weight loss treatmentCross over not commonMedical complications related to obesity

for Bulima Nervosa and Binge Eating Disorder

Good for adolescent anorexia nervosa

enduring pattern of perceiving, relating, and thinking about the environment and oneself that is seen in a wide range of social and personal situationsIt is: stable, predictable, flexible and adaptable

ENDURING PATTERN OF INNER experiences and behavior that deviate from cultural standards. Manifested as: Cognition, affect, interpersonal functioning, impulse controlPattern is rigidly pervasiveOnset in adolescence and the behavior pattern is stable and of long durationSignificant distress and / or impairment in social, occupational functioning

A: ODD (paranoid, schizoid, schizotypical)B: SAD (antisocial, borderline, histrionic, narcissistic)C: Anxious (avoidant, dependent, obsessive-compulsive)

Person has no psychotic delusions but is suspicious and bears grudgesFeatures: Suspects that he is being exploited or deceived, doubts loyalty or trustworthiness of friends, reluctant to confide, reads hidden meaning, bears grudges, perceives attack on his reputation and is quick to react and counterattack, argumentative, difficult to get along, suspicious about spouses fidelity. Life-long disorder may go on to have schizophrenic breakdownMore common in males, minorities, immigrants, and deaf, patients with schizophreniaDifferential: Schizophrenia, Delusional DisorderTx: Psychotherapy is 1st choice; pharmacotherapy has limited role (antianxiety and neuroleptics)

Person NEITHER DESIRES NOR ENJOYS CLOSE RELATIONSHIPS, always chooses SOLITARY ACTIVITIES, no interest in having a sexual relationship, NO CLOSE FRIENDS, indifferent to praise or criticism, emotional detachment, less likely to be involved in activitiesMore common in males, onset in early childhood, Lifelong courseDifferential: Paranoid PD, Schizotypical PD, SchizophreniaRx: Psychotherapy 1st choice, Neuroleptics, Benzos, SSRI's

Person has a pattern of social interpersonal beliefs with reduced capacity for close relationships AND cognitive and perceptual distortions:Ideas of reference, odd beliefs (UFO's, black magic), Unusual perceptual experiences, odd thinking, suspicious, Inappropriate or constricted affect, Behavior or appearance that is odd (wear all black in hot weather), BRIEF PSYCHOTIC EPISODESmore likely in relatives of schizophrenia, 10% risk of suicide, schizophrenic breakdownDifferential: Schizophrenia, Paranoid PD, Borderline PDRx: Pharmacotherapy (1st  choice, neuroleptics), Psychotherapy is difficult

In cluster B; person has pervasive pattern of DISREGARD FOR RIGHTS OF OTHERS, inability to conform to social norms, multiple and continuous criminal acts, impulsivity or failure to plan ahead, physical fights or aggressiveness, lack of remorse. HISTORY OF CONDUCT DISORDER IN CHILDHOOD IS NEEDED.common in males (FH is 5x more likely), wide spectrum of people and professions, mellow with age, graduate to other psychiatric disorders (depression, substance abuse, somatic symptom disorders)Diffirential: Substance abuse disorders, mania, ADHD, mental retardationRx: Treat co-morbid psychiatric disorders, self help groups, psychotherapy, antiepileptic, B-blockers for aggression

Cluster B; person has a pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by EARLY ADULTHOOD and present in a variety of contexts. IMPAIRED CAPACITY TO FORM STABLE INTERPERSONAL RELATIONSHIPSaffective instability (rapid mood swings), impulsivity, identity disturbance (chronic boredom or emptiness), recurrent manipulative suicidal and parasuicidal behaviors (cutting behavior), idealization/devaluation (splitting- let me tell you something i've never told anyone before), fear of abandonment, brief psychotic episodes under stress

More common in women, genetic factors, adverse childhood events reported, severity of abuse related to severity of symptomsNeurobiological findings in: anterior cingulate cortex, prefrontal cortex, hippocampus, amygdala

Psychotherapy: Dialectical Behavior Thearpy (DBT)Pharmacotherapy: symptom focused- neuroleptics (though disturbances), SSRI's (dysphoria), Valproate (mood swings)

based largely in behaviorist theory with some cognitive therapy elements; weekly individual and group session and available telephone consultations4 essential parts: DBT skills training group, DBT individual therapy, DBT phone coaching, therapy for DBT therapist consultation team and providers