1.
Indicators of prognosis in psychiatric disorders (e.g.
schizophrenia, bipolar disorder).
Schizophrenia – the following are associated with a good prognosis:
- mood symptoms
-
positive symptoms (hallucinations, delusions, loose
associations, strange behavior, talkativeness; as
opposed to negative symptoms, which include flat affect, thought blocking,
deficiencies in speech content, cognitive disturbances, poor grooming, lack of
motivation, social withdrawal)
- good social and work relationships
- older age of onset, less of a childhood prodrome (see below)
- absence of neurologic symptoms
Bipolar disorder – I apologize, I couldn’t find any prognostic factors in any of my texts!
- depressive episode is self-limited and successfully treated in 75% of patients
- risk of suicide increases as patient begins to recover from depression. (Patients with severe depression don’t have the energy to commit suicide)
- depression can be rated using Hamilton, Raskin, and Zung scales
2.
Genetic components of common psychiatric disorders
(e.g. schizophrenia, bipolar disorder)
Schizophrenia –strong genetic component (40-60% monozygotic concordance; 10% dizygotic). Hypothesis: schizophrenia is a developmental disorder.
- mothers of schizophrenics have more gestational, labor, and delivery problems
- linked to second-trimester influenza exposure
- children who become schizophrenic have more emotional problems, neuromotor deficits, attention and cognition difficulties
- brains cells have abnormal cytoarchitecture, suggesting a developmental insult
Associated with genetic markers on chromosome 6
- familial (40% monozygotic concordance; 10% dizygotic)
- no genetic markers have been identified
- strongly familial (monozygotic concordance 60%; dizygotic 20%)
- associated with genetic markers on X chromosome (but occurs equally in males and females)
3.
Diseases associated with different personality types
(Personality Disorders)
- personality traits are deviant => personal and interpersonal difficulties
- lifelong; diagnosed only in adults
- bother other people, not the patient (egosyntonic, not egodystonic)
Paranoid PD – suspicious, mistrusting, concerned with hidden motivations of others, “fringe social groups”
Schizoid PD – indifferent to feelings of other people; “loners”
Schizotypal PD – emotionally cold and aloof with few friends; magical thinking, ideas of reference, recurrent perceptual illusions, depersonalization, suspiciousness, or delusional beliefs; tend to join unconventional social/political organizations; “weird people”
(Schizoid and schizotypal are thought to represent mild forms of schizophrenia)
Histrionic PD – shallow, dramatic behavior, exaggerated affect; demand continuous attention and reassurance; vain, self-centered, dependent. More common in women.
Narcissistic PD – grandiose sense of self-importance, alternating with feelings of unworthiness; preoccupied with unrealistic goals; seek constant attention and admiration; sense of entitlement; lack of empathy for the feelings of others; manipulative.
Antisocial PD – more common in men. Disregard for and violation of the rights of others; deceitful, impulsive, reckless, irresponsible, and remorseless. May have delinquency, lying, substance abuse, poor school/work performance, poor relationships. Associated with childhood conduct disorder (fire setting, cruelty to animals, and enuresis). Rarely seen after age 55.
Antisocial, histrionic, and narcissistic personality disorders are often seen in the same families, along with substance abuse.
Borderline PD – problems with identity (gender identity, values), anger, and impulse control. Self-destructive behavior; may be manipulative; have trouble being alone and may be self-abusive (mutilation, suicide gestures); long for but sabotage close personal relationships. Overlap with mood disorders.
Avoidant PD – fear of rejection; hypersensitive to criticism; low self-esteem.
Dependent PD – lack of self-confidence; allow others to assume responsibility for major decisions; give more attention to the priorities of others. More common in women.
Obsessive-Compulsive PD – rigid, conformist, perfectionist style of behavior; “work-a-holics” who are unable to relax.
Not otherwise specified; no longer part of main clusters
in DSMIV:
Passive-aggressive PD – difficulty asserting themselves and expressing anger appropriately; act out anger indirectly by passively sabotaging social or occupational tasks (i.e., “forgetting” to do something for a boss).
4. Clinical features and treatment of phobias.
A. Phobia: Definition and Clinical Features
1. Fear that is excessive or unreasonable, cued by presence or anticipation of a specific object or entity. Fear interferes with normal routine. (First Aid)
2. Irrational fear of specific objects or social or environmental situations; because of the fear, the patient avoids the object or social situation. (HY Behavioral Science)
3. Anxiety is seen with exposure to the feared object or place. (BRS Behavioral Science)
B. Examples: (First Aid)
1. gamophobia à fear of marriage
2. algophobia à fear of pain
3. acrophobia à fear of heights
4. agoraphobia à fear of open places
5. claustrophobia à fear of closed areas
C. Treatment:
1. Systemic Desensitization, (Kaplan USMLE Step I Lecture Notes)
a. Based on classic conditioning in which the counter-conditioning or reciprocal inhibition of anxiety responses is developed.
1. Step 1: Hierarchy of fear-eliciting stimuli is created, building from least to most stressful.
2. Step 2: Therapist teaches the technique of muscle relaxation, a response that is incompatible with anxiety.
3. Step 3: Patient is taught to relax in the presence, real or imagined, of each stimulus on the hierarchy from least to most stressful
b. When the person is relaxed in the presence of the feared stimulus, objectively, there is no more phobia.
c. Note that this works by replacing anxiety with relaxation, an incompatible response.
2. Family Therapy (HY Behavioral Science)
3. Psychotherapy (HY Behavioral Science)
4. MAO inhibitors and B-adrenergic antagonists (e.g. propanolol) are useful adjuncts to psychotherapeutic treatment of phobias. (BRS Behavioral Science)
5. Clinical features of child abuse (e.g. shaken-body syndrome).
A. Child Abuse: Definition and Characteristics (BRS Behavioral Science)
1. Child abuse includes physical and sexual abuse as well as emotional neglect such as harsh rejection and severe withholding of parental love and attention.
2. Parents typically perceive the children they abuse as slow, different, bad, or difficult to control.
3. Sexual abuse predisposes child to later anxiety, phobias, depression, and an inability to deal with his own and other’s aggression.
B. Physical Abuse (First Aid, BRS Behavioral Science)
1. Evidence: subdural hematomas, retinal hemorrhage (both specific for shaken baby syndrome), old healed fractures, cigarette burns, bruises over buttocks or lower back, belt marks
2. Abuser: usually female and the primary care giver
3. Risk Factors: poverty, social isolation, substance abuse, parents abused as children, prematurity, hyperactivity
4. Epidemiology: approximately 3000 deaths per year
C. Sexual Abuse (First Aid, BRS Behavioral Science, HY Behavioral Science)
1. Evidence: genital/anal trauma, STD’s, UTI’s, initiation of sexual activity with friends, specific knowledge about sexual acts
2. Abuser: usually male and known to the victim
3. Risk Factors: single parent home, marital problems, substance abuse, sick mother, crowded living conditions
4. Epidemiology: peak incidence 9-12 years of age
6. Clinical features of common learning disorders (e.g., dyslexia, mental retardation).
A. Mental Retardation (Kaplan USMLE Step I Review Series)
1. Criteria for diagnosis
a. Subaverage intellectual functioning, defined as an IQ that falls at least two standard deviations below the mean on an individually administered intelligence tests, i.e. and IQ of 70 or less
b. Deficits in adaptive behavior. The degrees to which the individual is able to function independently and to meet culturally imposed demands regarding social responsibility are impaired relative to other individuals of the same age
2. Classification
a. Mild (IQ 50-70) à usually not apparent until child enters school
b. Moderate (IQ 35-49) à trainable; as adults, able to attend sheltered workshops
c. Severe (IQ 20-34) à may be able to communicate basic needs; need constant supervision
d. Profound (IQ below 20) à very limited self-care and communication skills; need nursing care
B. What Are the Types of Learning Disabilities? (National Institute of Mental Health website)
1. Not all learning problems are necessarily learning disabilities. Many children are simply slower in developing certain skills. Because children show natural differences in their rate of development, sometimes what seems to be a learning disability may simply be a delay in maturation. To be diagnosed as a learning disability, specific criteria must be met.
2. The criteria and characteristics for diagnosing learning disabilities appear in the Diagnostic and Statistical Manual of Mental Disorders. Learning disabilities can be divided into three broad categories:
a. Developmental speech and language disorders
b. Academic skills disorders
c. "Other," a catch-all that includes certain coordination disorders and learning handicaps not covered by the other terms
C. Developmental Speech and Language Disorders à Speech and language problems are often the earliest indicators of a learning disability. People with developmental speech and language disorders have difficulty producing speech sounds, using spoken language to communicate, or understanding what other people say. Depending on the problem, the specific diagnosis may be:
1. Developmental Articulation Disorder à Children with this disorder may have trouble controlling their rate of speech. Or they may lag behind playmates in learning to make speech sounds. Developmental articulation disorders are common. They appear in at least 10 percent of children younger than age 8. Fortunately, articulation disorders can often be outgrown or successfully treated with speech therapy.
2. Developmental Expressive Language Disorder à Some children with language impairments have problems expressing themselves in speech. Their disorder is called, therefore, a developmental expressive language disorder. For example, a child who often calls objects by the wrong names, has an expressive language disorder. Of course, an expressive language disorder can take other forms. A 4-year-old who speaks only in two-word phrases and a 6-year-old who can't answer simple questions also have an expressive language disability.
3. Developmental Receptive Language Disorder à Some people have trouble understanding certain aspects of speech. It's as if their brains are set to a different frequency and the reception is poor. There's the toddler who doesn't respond to his name, a preschooler who hands you a bell when you asked for a ball, or the worker who consistently can't follow simple directions. Their hearing is fine, but they can't make sense of certain sounds, words, or sentences they hear. They may even seem inattentive. These people have a receptive language disorder. Because using and understanding speech are strongly related, many people with receptive language disorders also have an expressive language disability. Of course, in preschoolers, some misuse of sounds, words, or grammar is a normal part of learning to speak. It's only when these problems persist that there is any cause for concern.
D. Academic Skills Disorders à Students with academic skills disorders are often years behind their classmates in developing reading, writing, or arithmetic skills.
1. Developmental Reading Disorder à This type of disorder, also known as dyslexia, is quite widespread. In fact, reading disabilities affect 2 to 8 percent of elementary school children.
a. However, there is more to reading than recognizing words. If the brain is unable to form images or relate new ideas to those stored in memory, the reader can't understand or remember the new concepts. So other types of reading disabilities can appear in the upper grades when the focus of reading shifts from word identification to comprehension.
2. Developmental Writing Disorder à Writing, too, involves several brain areas and functions. The brain networks for vocabulary, grammar, hand movement, and memory must all be in good working order. So a developmental writing disorder may result from problems in any of these areas. A child with a writing disability, particularly an expressive language disorder, might be unable to compose complete, grammatical sentences.
3. Developmental Arithmetic Disorder à Arithmetic involves recognizing numbers and symbols, memorizing facts such as the multiplication table, aligning numbers, and understanding abstract concepts like place value and fractions. Any of these may be difficult for children with developmental arithmetic disorders. Problems with numbers or basic concepts are likely to show up early. Disabilities that appear in the later grades are more often tied to problems in reasoning.
a. Many aspects of speaking, listening, reading, writing, and arithmetic overlap and build on the same brain capabilities. So it's not surprising that people can be diagnosed as having more than one area of learning disability. For example, the ability to understand language underlies learning speak. Therefore, any disorder that hinders the ability to understand language will also interfere with the development of speech, which in turn hinders learning to read and write. A single gap in the brain's operation can disrupt many types of activity.
E. "Other" Learning Disabilities à The DSM also lists additional categories, such as "motor skills disorders" and "specific developmental disorders not otherwise specified." These diagnoses include delays in acquiring language, academic, and motor skills that can affect the ability to learn, but do not meet the criteria for a specific learning disability. Also included are coordination disorders that can lead to poor penmanship, as well as certain spelling and memory disorders.
1. Attention Disorders
a. Nearly 4 million school-age children have learning disabilities. Of these, at least 20 percent have a type of disorder that leaves them unable to focus their attention.
b. Some children and adults who have attention disorders appear to daydream excessively. And once you get their attention, they're often easily distracted.
c. In a large proportion of affected children--mostly boys--the attention deficit is accompanied by hyperactivity. Dennis is an example of a person with attention deficit hyperactivity disorder--ADHD. They act impulsively, running into traffic or toppling desks. Like young Dennis, who jumped on the sofa to exhaustion, hyperactive children can't sit still. They blurt out answers and interrupt. In games, they can't wait their turn. These children's problems are usually hard to miss. Because of their constant motion and explosive energy, hyperactive children often get into trouble with parents, teachers, and peers.
d. By adolescence, physical hyperactivity usually subsides into fidgeting and restlessness. But the problems with attention and concentration often continue into adulthood. At work, adults with ADHD often have trouble organizing tasks or completing their work. They don't seem to listen to or follow directions. Their work may be messy and appear careless.
e. Attention disorders, with or without hyperactivity, are not considered learning disabilities in themselves. However, because attention problems can seriously interfere with school performance, they often accompany academic skills disorders.