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BEHAVIORAL DYNAMICS 2 - Coggle Diagram

- - - - restricting type
      - binge-eating/purging type
  - - - eating more rapidly than normal
      - eating until feeling uncomfortably full
      - eating large amounts when not physically hungry
      - eating alone b/c feeling embarassed about quantity
      - feeling disgusted with oneself, depressed or very guilty after
      - distress during episode
      - medications: fluoxetine, fluvoxamine, sertraline, citalopram, topiramate, orlistat, sibutramine
  - - - Do you eat large amounts of food until you are uncomfortably full, even when you are not hungry?
      - Do you feel embarrassed or disgusted with yourself after eating?
      - Are you distressed about eating or your body?
- - - - Inadequate Sleep Hygiene - a sleep disorder due to performance of daily living activities that are inconsistent with the maintenance of good quality sleep and full daytime alertness
      - Insufficient Sleep Syndrome - a sleep disorder in an individual who persistently fails to obtain nocturnal sleep required to support normally alert wakefulness because of voluntary chronic sleep deprivation
      - Psychophysiological Insomnia - excessive worry about the inability to sleep, rumination & inability to "clear the mind", negative conditioning to the bed & bedroom, can fall asleep when not trying, increased muscle tension at bedtime, extreme tiredness
      - Limb Movement Disorders:
        
        Restless Legs Syndromes - overwhelming urge to move the legs, usually supine, at sleep onset; crawling sensations in the legs
        
        Periodic Limb Movement Disorder - leg twitches, jerks and kicks which occur regularly during sleep and are usually noticed by the bed partner as opposed to the pt
        
        made worse by stimulants, some meds (antidepressants, antipsychotics, CCBs, lithium, etc.), some medical conditions (anemia, diabetes, ESRD, pregnancy, arthritis, OSA, vitamin deficiency)
        
        more prevalent with advancing age
        
        treatment: treat comorbid conditions, reduce/stop offending products, dopamine agonists, benzodiazepines, anticonvulsants, opioids, alpha-2 agonists
      - Circadian Rhythm Sleep Disorder - a mismatch between the individual's biological rhythm and the environmentally required schedule
      - Shift-Work Sleep Disorder - similar to circadian rhythm sleep disorder, but induced by work requirements
      - Insomnia due to chronic pain, psychiatric illness, medical illness
      - Idiopathic Insomnia - a lifelong inability to obtain adequate sleep that is due to an abnormality of the neurological control of the sleep-wake system
  - - - Obstructive Sleep Apnea Syndrome - most common
      - Central Sleep Apnea Syndrome - more common in severe COPD & neuromuscular conditions
      - Upper Airway Resistance Syndrome - milder form of OSA
      - Primary Snoring - snore arousals without disrupted breathing
      - symptoms: loud snoring, frequent awakening with choking/gasping, witnessed apnea, morning dry mouth, morning headaches, excessive daytime sleepiness, unrefreshing sleep
      - RF: obesity, middle age or older, male, low set soft palate &small airway, micrognathia or retrognathia
      - comorbidities: HTN, heart disease, stroke, depression, sexual dysfunction
      - treatments: positive airway pressure, weight loss, oral appliances, surgeries, positioners, drugs, avoid CNS depressants & alcohol, avoid driving or operating dangerous equipment, extend & regularize sleep, avoid supine position, treat nasal allergies & congestion aggressively
    - - excessive daytime sleepiness, cataplexy, hypnogogic hallucinations, sleep paralysis
      - diagnosis: interview, full night PSG sleep study, multiple sleep latency test
      - treatment: stimulants, anticataplectics
- - - - boys: previous suicide attempt, depressive/mood disorder, substance abuse, disruptive behavior
      - immediate risk: agitation, prior attempts, male, mood disorders
      - other: behavioral characteristics (impulsivity & substance use), race, presenting symptoms of depression, psychosis, or mixed bipolar state, suicidal behaviors/past suicidal behaviors, diagnosed psychiatric disorders, stressors, access (to firearms esp.) & treatment changes, history (personal, family)
      - girls: MDD/mood disorders, previous suicide attempt
    - - internal: coping skills, religion, frustration tolerance
      - external: dependents (children, pets), positive relationships, social supports
    - - ideation
      - plan
      - history
      - intent
  - - - is this age appropriate anxiety/behavior?
      - is the degree of distress (un)realistic given the developmental stage and situation?
      - does the distress interfere with daily life and functioning?
      - is the child able to recover from distress when the event is not present?
  - - - unknown cause
      - 65% of children with ADHD will have persistent and impairing ADHD symptoms in adulthood
      - symptoms: attention switched easily, inattention, impulsivity, restlessness, emotional volatility, hyperactivity
      - treatment: alpha agonists, wellbutrin, stimulants (gold standard)
      - diagnosis: 6+ symptoms for 6+ months, symptoms present <12yo, 2+ settings, specifiers
    - - diagnosis: onset in the developmental period, deficits confirmed by clinical assessment & standardized intelligence testing, intellectual deficits, adaptive functioning deficits, specifiers
    - - diagnosis:
        
        A -- persistent deficits in social communication & social interaction across multiple contexts, as manifested by the following, currently, or by history: 1. social-emotional reciprocity deficits 2. nonverbal communication deficits 3. deficits in developing, maintaining, and understanding relationships
        
        B -- restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following, currently, or by history: 1. stereotyped or repetitive motor movements, use of objects or speech, 2. insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior 3. highly restricted, fixated interests that are abnormal in intensity or focus 4. hyper-/hyporeactivity to sensory input or unusual interest in sensory aspects of the environment
        
        these symptoms are not better explained by intellectual disability or global developmental delay
        
        red flags: avoids eye contact and prefers to be alone, struggles with understanding other people's feelings, remains nonverbal or has delayed language development, repeats words or phrases over and over, gets upset by minor changes in routine or surroundings, has highly restricted interests, performs repetitive behaviors such as flapping, rocking, or spinning, has unusual or intense reactions to sounds, smells, tastes, textures, lights, colors
  - - - physical injury that results in or is a genuine threat of substantial harm; regardless of whether or not there was an intention to hurt
      - suspect when -- frequent injuries, frequent complaints of pain without obvious injury, burns or bruises in unusual patterns, lack of reaction to pain, unreasonable clothing to hide injuries, behaviors (aggressive, acting out, destructive, etc.)
    - - failure to provide for a child's basic needs necessary to sustain the life or health of the child, excluding failure caused primarily by financial inability
      - suspect when -- obvious malnourishment, lack of personal cleanliness, torn or dirty clothing, stealing/begging for food, child unattended for long periods of time, need for glasses/dental care/other medial attention, frequent tardiness or absence from school
    - - suspect when -- physical signs of STIs, evidence of injury to genital area, pregnancy in young girl, difficulty sitting/walking, extreme fear of being alone with adults of a certain sex, sexual comments/behaviors/play, knowledge of sexual relations beyond what is expect for a child's age, sexual victimization of other children
    - - suspect when -- over compliance, low self-esteem, severe depression/anxiety/aggression, difficulty making friends or doing things with other children, lagging in physical, emotional and intellectual development, caregiver who belittles the child, withholds love, and seems unconcerned about the child's problems
- - - - even though individuals might be forced into a hospitalization against their will, they still have the right to refuse medication unless they are imminently dangerous to themselves or others
  - - - a pattern of being unable, or unwilling, to function well with others to the extent that his/her behavior, by words or action, has the potential to interfere with quality healthcare
  - - - clinicians are required to report clinicians who pose a continuing threat
      - domestic assault/other behaviors not involving pts can warrant TMB report
      - reports can be confidential but not anonymous
      - drug/alcohol problem not affecting pt care need not be reported by self or others
      - TMB refers clinicians with SUD to the Texas physician health program (lots of power, little scrutiny from without; usually an MD has to do everything they ask to have a hope of continuing to practice)
  - - - clinicians are the ones who are responsible for maintaining boundaries, not the pts
      - what constitutes inappropriate behavior is often per the eyes of the recipient
- - - - "rebalancing" the brain
      - neuroendocrine hypothesis - release of pituitary/hypothalamus hormones
      - enhanced expression of neuroprotective proteins
      - changes in brain connectivity
      - decreased metabolic activity in frontal and cingulate cortex
      - stabilization through the anticonvulsant effects expressed by the elevation of seizure threshold
  - - - Magnetic seizure therapy - uses transcranial magnets to induce generalized seizure similar to ECT
      - Focal electrically administered seizure therapy - unidirectional current, control of polarity, and an asymmetric electrode arrangement (with one electrode much larger than the other) in an attempt to induce seizures more efficiently than ECT
      - Transcranial direct current stimulation - uses two scalp electrodes to deliver a constant, low-intensity direct current to specific cortical regions
      - Stellate ganglion blocks - local injection of long-acting anaesthetic into stellate ganglion to block cervical sympathetic chain, reducing physiologic response to PTSD
    - - Vagus nerve stimulation - implanted electrical stimulator attached to vagus nerve
      - Direct cortical stimulation - epidural or subdural electrodes implanted through burr holes or craniotomy to stimulate cortex directly
- - - - healthy men up to 65 --> no more than 4 drinks in a day AND no more than 14 drinks in a week
      - healthy women & healthy men over 65 --> no more than 3 drinks in a day AND no more than 7 drinks in a week
    - - moderate drinking --> up to 1 drink per day for women and up to 2 drinks per day for men
      - binge drinking --> drinking 5 or more alcoholic drinks on the same occasion on at least 1 day in the past 30 days; a pattern of drinking that produces blood alcohol concentrations of >0.08g/dL
      - heavy drinking --> drinking 5 or more drinks on the same occasion on each of 5 or more days in the past 30 days
    - - stage 2 (w/in 24hrs) --> insomnia, marked tremors, nightmares, hallucinations, illusions, agitation
      - stage 1 (w/in 8hrs) --> mild tremors, anxiety, nausea
      - stage 3 (12-48hrs) --> add seizures
      - stage 4 (3-5 days) --> delerium tremens
  - - - short term effects: problems with memory and learning, distorted perception, trouble with thinking and problem solving, loss of motor coordination, increased heart rate
      - long term effects: respiratory, cancer, immune, amotivational syndrome
    - - other effects: powerfully addictive, feel euphoric and energetic, heart attacks, respiratory failure, strokes, seizures, bizarre and violent behavior
      - strong CNS stimulant
      - physical effects: constricted blood vessels, dilated pupils, increased temperature, increased heart rate, increased bp
      - route of administration: increased rate = increased intensity of high but decreased duration of action
      - many many complications
    - - effects: surge of euphoria followed by alternately wakeful and drowsy states and cloudy mental functioning
    - - gateway drugs to heroin
    - - effects: brain damage, confusion, anxiety, paranoia, anger, stroke, high body temperature, convulsions; distinct physical effects
    - - MDMA (Ecstasy), Rohypnol, GHB, Ketamine (Special K)
      - effects: seizures, amnesia, anxiety, tremors, sweating, coma, high body temperature
    - - chemicals that are "huffed" or "sniffed" like paint thinners, gasoline, glue, butane lighters, propane tanks, aerosol sprays, nail polish remover, etc.
      - effects: slows down the body's functioning, loss of body control, passing-out, permanent hearing loss, permanent muscle spasms and twitches, cancer, brain damage, bone damage, liver & kidney damage, heart failure and possible death
    - - LSD, Acid, PCP, Angel Dust, Shrooms --> alter the time, reality and environment around you
      - long term effects: flashbacks, schizophrenia & severe depression
- - - - external force applied to the head --> disruption of brain function; alteration of consciousness at time of event
      - common subset of ABI
      - it is #1 cause of death/disability in children/young adults
      - classification:
        
        MILD: GCS 13-15, LOC <30 min, PTA <24 hrs
        
        MODERATE: GCS 9-12, LOC 30 min to1 week, PTA 24hrs to <1 week
        
        SEVERE: GCS 3-8, LOC >1 week, PTA >1 week
        
        categorization is based on acute injury severity characteristics: 1. length of LOC, 2. level of consciousness, 3. length of PTA, 4. length of retrograde amnesia, 5. time to follow commands
      - causes: MVA, struck by/against, assaults, falls, self-inflicted, blast, crash, sports
      - MOA: coup (blow), contrecoup (counter blow, contusion, swelling, blood clots), rotational forces (diffuse axonal injury, shearing twisting)
      - most concussion/mild TBI recover within hours to days, with a small proportion taking longer
      - challenges to rehabilitation:
        
        intrinsic factors:
        
        up to 45% of persons with moderate to severe TBI exhibit reduced or complete lack of awareness
        
        physical disturbances: dizziness, balance problems, poor coordination, nausea, noise sensitivity, hearing difficulty, urinary incontinence, seizures, spasticity, arthritic complaints, change in hair/skin, headache, blurred vision, change in taste/smell, nausea, numbness, change in appetite, weight changes, anxiousness, problems falling asleep, problems staying asleep
        
        mental health and reintegration:
        
        risks due to TBI: behavioral changes, increased mood difficulties, increased substance use, increased risk of abuse/neglect, increased burden on others, poor decisions/impulsivity
        
        impaired social communication and poor affective/behavioral functioning are a barrier to good social integration after TBI
        
        personality changes: disinhibition, apathetic, aggressive, paranoia, lability
        
        behavioral disturbances: impulsivity, disinhibition, anger dyscontrol, inappropriate sexual behavior, lack of initiative, change in personality
        
        cognitive disturbances: mood swings, depression, anxiety, anger/irritability, apathy
        
        post-concussive syndrome
        
        extrinsic factors:
        
        driving
        
        physical barriers: lighting, noise, crowds, temperature, climate, terrain, design/layout of home
        
        service barriers: availability of transportation, availability of education and training, lack of additional help in the home, difficulties with technology
        
        policy barriers: government programs, lack of community programs and services, rules of businesses and organizations
        
        attitudes and support barriers: other peoples attitudes at home, other peoples attitudes in the community, lack of support or encouragement from other at home, prejudice or discrimination
        
        legal/criminal activity/being victims of violence, abuse or neglect
      - co-morbidities: dementia, mood disorders, psychotic disorder, anxiety, sleep disorders
- - - - male hypoactive sexual desire disorder
      - female sexual interest/arousal disorder
    - - erectile disorder
      - genito-pelvic pain/penetration disorder
    - - premature ejaculation
      - delayed ejaculation
      - female orgasmic disorder
    - - significant disturbance in sexual functioning which developed during or soon after substance intoxication/withdrawal or exposure to a medication that is capable of producing such effects