Anxiety Disorder Flashcards
<p>Social anxiety disorder (social phobia)</p>
<p>a. characterized by a fear of one or more social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others.
<br></br>b. The individual is afraid of acting in a way that would be embarrassing.
<br></br>c. Exposure to the situation almost always causes anxiety,
<br></br>d. and the person is aware that the fear is excessive.
<br></br>e. Social anxiety disorder is characterized by a fear or anxiety surrounding social situations in which individuals are exposed to possible scrutiny by others.
<br></br>f. The criteria center around the patient's anxiety or fear in specific social situations and does not include other specific symptoms such as irritability, decreased concentration, or sleep disturbance</p>
<p>Not a common comorbidity associated with social phobia?</p>
<p>a. Disorders that are frequently comorbid with social phobia
<br></br>i. other anxiety disorders,
<br></br>ii. Affective disorders,
<br></br>iii. and substance abuse disorders.
<br></br>iv. About one-third of patients with social phobia will meet criteria for MDD
<br></br>b. There is no significant comorbidity with the somatoform disorders in general and conversion disorder in particular</p>
<p>When treating social anxiety disorder,</p>
<p>a. combining CBT and pharmacotherapy does not show a clear benefit over using just one or the other for most initial treatments.
<br></br>b. There is evidence, however, that there are some refractory cases that do
<br></br>respond better to a combination of both.</p>
<p>Tend to have</p>
<p>a. fewer friendships,
<br></br>b. lower levels of education,
<br></br>c. higher rates of suicide,
<br></br>d. and less success in career advancement.
<br></br>e. poorer marital function.</p>
<p>An important differential to consider would be avoidant personality disorder.</p>
<p>a. In this disorder there is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. It leads to the avoidance of other people unless the sufferer is sure that he or she is going to be liked.
<br></br>b. Avoidant personality disorder leads to restraint of intimate relationships for fear of being shamed or ridiculed.
<br></br>c. These patients often view themselves as socially inept or personally unappealing.
<br></br>d. They avoid jobs with significant interpersonal contact. Very importantly,
<br></br>e. they desire the closeness and warmth of relationships but avoid them for fear of rejection.</p>
<p>Borderline personality disorder</p>
<p>characterized by a pattern of instability of interpersonal relationships, self-image, and affect, as well as marked impulsivity.</p>
<p>OCD</p>
<p>defined by a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.</p>
<p>Narcissistic personality disorder is</p>
<p>defined by a pattern of grandiosity, need for admiration, and lack of empathy.</p>
<p>Dependent personality disorder</p>
<p>defined by a pervasive need to be taken care of that leads to submissive and clinging behavior and fears of separation.</p>
Anxiety disorders: highest prevalence
Over 30 million people in the United States have an anxiety disorder. About 17.5 million have depression. About 2 million have schizophrenia. About 5 million have dementia. About 12.8 million use illicit drugs.
Panic attack
complaints of palpitations, sweating, shortness of breath, chest pain, and nausea, trembling, choking sensations, dizziness, fear of losing control, fear of death, paresthesias, chills, or hot flushes.
Myxedema madness
is a depressed and psychotic state found in some patients with hypothyroidism.
Mad Hatter syndrome
presents as manic symptoms resulting from chronic mercury intoxication.
Agoraphobia
feeling anxious about being in places or situations from which escape may be difficult or in which help may not be available should the patient begin to panic.
avoids various situations because of these fears
Acute stress disorder
occurs after a person is exposed to a traumatic event.
2 days to 4 weeks,
Major symptom clusters for both disorders include intrusion symptoms, avoidance symptoms, negative alterations in cognition and mood, and alterations in arousal and reactivity.
patient then feels anxiety, detachment, derealization, feelings of being “in a daze,” dissociative amnesia, and numbing.
Flashbacks and avoidance of stimuli can occur.
The symptoms do not last longer than 4 weeks, and occur within 4 weeks of the traumatic event
PTSD
Sx must last for 4 weeks or more
Most people do not experience PTSD symptoms, even when faced with severe trauma.
lifetime prevalence of PTSD is about 6.7%, as per the National Comorbidity Study.
As per that same study about 60% of males and 50% of females had experienced some significant trauma.
Evidence points to a “dose–response” relationship between the degree of trauma and the likelihood of symptoms. The subjective meaning of the trauma to the individual is also extremely important.
The predisposing vulnerability factors in PTSD are as follows:
Presence of childhood trauma.
Borderline, paranoid, dependent, or antisocial personality disorder traits.
Inadequate family or peer supports.
Female gender.
Genetic predisposition to mental illness.
Recent life stressors.
Perception of an external locus of control to the trauma (natural cause) as opposed to an internal one (human cause).
Recent alcohol abuse.
experienced actual or threatened death or serious injury, which leads to symptoms of intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. “Alterations in arousal and reactivity” include irritability, poor concentration, and sleep disturbance.
Major symptom clusters for ASD and PTSD disorders include
intrusion symptoms, avoidance symptoms, negative alterations in cognition and mood, and alterations in arousal and reactivity.
In dissociative amnesia
the patient has one or more episodes of inability to recall important personal information usually of a traumatic or stressful nature.
The patient maintains intact memory for other information.
The prepared test-taker should be able to distinguish this from TGA, which is a reversible anterograde and retrograde memory loss with retention of basic biographic information,
which usually occurs in elderly or middle-aged men,
lasting several hours,
and is likely to be related to a transient ischemic attack.
Central serous chorioretinopathy
is a disease leading to detachment of the retina and has nothing to do with anxiety.
Carcinoid syndrome
can mimic anxiety disorders and is accompanied by hypertension and elevated urinary 5-hydroxyindoleacetic acid (5-HIAA).
Hyperthyroidism
presents with anxiety in the context of elevated T3 and T4 and exophthalmos
Hypoglycemia
presents with anxiety and fasting blood sugar under 50 mg/dL.
Signs and symptoms of diabetes may also be present with hypoglycemia (polyuria, polydipsia, and polyphagia).
Hyperventilation syndrome
presents with a history of rapid deep respirations, circumoral pallor, and anxiety.
It responds well to breathing into a paper bag.
Most important step in treating separation-anxiety disorder in an 11-year-old
Treatment of children with separation-anxiety disorder should be multimodal.
It should involve individual therapy for the child,
medication to reduce anxiety,
family therapy and education,
and return to school,
which is graded if necessary (i.e., start with 1 hour per day, then increase to 2 hours, then to 3 hours, etc.).
The parental education should focus on giving the child consistent support but maintaining clear boundaries about the child’s avoidant behaviors toward anxiety-provoking situations
Most common Anxiety disorder?
Specific phobia
It is the most common mental disorder among women
and the second most common among men (after substance abuse).
This fact takes many psychiatrists by surprise, however, because most patients with specific phobia do not seek medical attention.
Which anxiety disorders has equal rates in both males and females?
obsessive–compulsive disorder
most anxiety disorders the rates are higher for women than for men
substance-induced anxiety disorder in DSM 5 include
“with onset during intoxication,”
“with onset during withdrawal,”
and “with onset after medication use.”
Irritability, poor concentration, and poor sleep seen in
Generalized anxiety disorder,
Sx :restlessness, fatigue, difficulty concentrating, irritability, muscle tension, or sleep disturbance
Criteria
excessive anxiety and
worry must occur more days than not,
for at least 6 months,
about a number of events or activities.
The individual finds it difficult to control the worry.
The worry is associated with symptoms such as
restlessness,
fatigue,
difficulty concentrating,
irritability,
muscle tension,
or sleep disturbance.
It causes impairment in social or occupational functioning.
It is not attributable to substance abuse or another mental disorder.
MDD,
depressed or irritable mood, decreased interest in activities, poor concentration, sleep disturbance, and changes in appetite.
premenstrual dysphoric disorder, Sx are same as MDD
depressed or irritable mood, decreased interest in activities, poor concentration, sleep disturbance, and changes in appetite.
and PTSD
Treatment for Panic disorder
Studies support CBT as the best therapy for panic disorder.
SSRIs are also considered first line because of their effectiveness, safety, and low side effect profile.
Studies also support the fact that CBT plus an SSRI will deliver better results than either treatment given alone
benzodiazepine to a patient on an SSRI for panic disorder will lead to a more rapid resolution of the anxiety.
The SSRI will take 2 to 4 weeks to work in most cases.
Benzodiazepine can effectively control the patient’s symptoms until the SSRI is fully working.
The other choices (Buspar, Gabapentin, Topiramate) will take longer to titrate or become effective
are not good choices for rapid resolution of panic symptoms
DSM criteria for panic disorder
must have recurrent attacks of which at least one attack is followed by 1 month or more of persistent concern about having more attacks, or worry about the implications of the attack or its consequences, or a significant change in behavior related to the attacks.
Propranolol is indicated only
for performance anxiety and should not be used in other anxiety disorders.
Cyclothymic disorder
does not involve psychotic symptoms, although these symptoms may be found in bipolar disorder.
Cyclothymia is a less severe form of bipolar with alternation between hypomania and moderate depression.
Symptoms must exist for 2 years to make the diagnosis.
It is equally common in men and women.
Substance use often coexists.
The onset is usually insidious and occurs in late adolescence or early adulthood.
must have 2 years with periods of hypomania and depressive symptoms that do not meet criteria for major depressive disorder (MDD).
MDMA (ecstasy) intoxication
Ecstasy is a serotonin reuptake inhibitor that is toxic to nerve cells.
At low doses it causes feelings of closeness and empathy.
At high doses it causes anxiety and paranoia.
Other symptoms that point toward ecstasy use would be bruxism and hyperthermia.
When hyperthermia induced by ecstasy is combined with increased physical activity it can lead to death.
Bipolar Disorder
Agitated, acts seductively, wears colorful clothes that are bizarre in appearance, has an excessive amount of makeup on, and vacillates between being entertaining, hyperexcited, and threatening
classic description of the appearance of a patient in the manic phase of bipolar disorder.
equal prevalence of bipolar disorder in women and men.
Bipolar I disorder in women most often starts with depression.
rapid cycling specifier in bipolar disorder,
the patient must present with at least four mood episodes over the past 12 months.
The mood episodes must meet criteria for a major depressive, manic, mixed, or hypomanic episode.
Female patients are more likely than men to have rapid cycling bipolar disorder.
There is no evidence to suggest that rapid cycling is a heritable phenomenon in bipolar disorder.
It is therefore likely to be a result of external factors such as stress or medication.
Bipolar II disorder
is characterized by at least one major depressive episode and at least one hypomanic episode during the patient’s lifetime.
Hypomania
DSM criteria for hypomania specifically state
no psychotic features.
If psychosis exists then the mood episode would be considered mania
There are no full manic episodes in bipolar II disorder.
If criteria for a manic episode are met then the correct diagnosis is bipolar I disorder.
Psychotic features can be found in bipolar I disorder during mania or depression
but in bipolar II will occur only associated with depression as full mania is not present in bipolar II.
EX of bipolar II disorder
describes episodes of distractibility, racing thoughts, increased goal-directed activity, and elevated mood. These episodes last for 4 days and she is having one currently. She also describes past episodes lasting 3 to 4 weeks in which her mood is depressed, and she experiences loss of appetite, fatigue, poor concentration, and suicidal thoughts.
meets criteria for hypomania as well as major depressive episodes.
To qualify for mania one needs symptoms for at least a week.
If the core symptom is euphoria, three additional symptoms are needed.
If the core symptom is irritability, four additional symptoms are needed.
Additional symptoms can include grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal-directed activity, or excessive involvement in pleasurable activities.
One must demonstrate impairment in social or occupational functioning, need for hospitalization, or presence of psychosis as part of the picture of mania.
Hypomania lasts for at least 4 days. The same criteria for symptoms apply, but the patient does not experience disturbance in social or occupational functioning, require hospitalization, or become psychotic as part of the symptom picture.
Bipolar I disorder
has equal prevalence for men and women
Major depression
is more common in women than in men.
There is no correlation between socioeconomic status and frequency of depression.
There is a correlation between hypersecretion (not hyposecretion) of cortisol and increased depression.
Only about 50% of those with major depressive disorder receive specific treatment
Patient comes to you and reports recurrent hypomanic episodes but denies any depressive symptoms
To meet criteria for bipolar I the patient must have at least one manic episode.
So bipolar I is out in this case.
For bipolar II, the patient must have one hypomanic episode and one episode of MDD.
So bipolar II is out in this case because we have no depressive symptoms.
To meet cyclothymic disorder one must have hypomanic symptoms as well as depressive symptoms that do not meet criteria for major depression and that go on for at least 2 years.
This patient has no depressive symptoms so cyclothymic disorder is out.
Other specified bipolar and related disorder,
which includes patients with clear bipolar symptoms who do not meet criteria for any specific bipolar disorder.
Amok
Malaysian cultural syndrome
sudden rampage including homicide and/or suicide,
which ends in exhaustion and amnesia.
Koro
Asian
delusion that the penis will disappear into the abdomen and cause death.
the greatest comorbidity with pathological gambling?
Major Depressive Disorder
Also: panic, OCD, and agoraphobia, but the association MDD is greater
Criteria for pathological gambling
a. preoccupation with gambling,
b. gambling increased sums of money to obtain excitement,
c. being unsuccessful at stopping or cutting back,
d. gambling to escape dysphoric mood,
e. lying to significant others about gambling,
f. loss of important relationships over gambling,
g. committing illegal acts to be able to gamble,
h. relying on others to pay the bills because of money lost gambling,
i. a desire to keep going back to break even.
Tourettes Disorder
a. involves both motor and vocal tics.
b. onset is usually around 7 years of age,
c. may come as early as 2 years.
d. Motor tics
i. usually start in the face and head and progress down the body.
e. Vocal tics
i. not done intentionally to provoke others,
ii. but are the result of sudden, intrusive thoughts and urges that the
patient cannot control.
iii. intrusive thoughts may involve socially unacceptable subject
matter or obscenity.
ADHD, diagnosed
a. by six or more symptoms of inattention
1. failure to pay close attention to tasks,
2. failure to sustain attention,
3. not listening,
4. not following through on tasks,
5. problems organizing tasks,
6. forgetfulness,
7. being easily distracted by extraneous stimuli.
b. or six or more symptoms of hyperactivity–impulsivity
1. fidgeting,
2. inability to remain seated when expected,
3. running or climbing excessively,
4. difficulty playing quietly,
- acting as if driven by a motor,
- talking excessively,
- blurting out answers,
- difficulty awaiting turn,
- and interrupting others
c. that persist for 6 months or more.
d. Several inattentive or hyperactive–impulsive symptoms should be present
prior to age 12.
e. Several symptoms of impairment must be present in more than one setting to
make the diagnosis.
treatment of tics in Tourettes syndrome?
a. Severe motor tics in Tourette’s syndrome
i. are best treated by neuroleptics,
1. haloperidol and pimozide.
2. atypical neuroleptics because of their superior safety profiles,
a. risperidone,
b. quetiapine,
c. olanzapine,
d. ziprasidone,
e. and clozapine.
3. Fluphenazine, molindone, and other conventional antipsychotics
are also acceptable treatment choices.
4. Clonidine
a. is also a frequently used and effective treatment of tics
b. is particularly favored by pediatric neurologists for its
excellent safety profile.
5. Botulinum toxin type A
a. can be effective for blepharospasm and eyelid motor tics
b. FDA-approved for this indication.
- Protriptyline and the other antidepressants
a. may be effective for associated obsessive–compulsive symptoms,
b. not useful for treatment of tics.
criterion for kleptomania
a. Kleptomania is found within the larger heading of impulse control disorders.
i. increased sense of tension.
ii. repeated stealing of objects that he or she does not need, Recurrent
failure to resist stealing objects.
iii. sense of tension before the act
iv. the sense of pleasure or relief afterward
v. theft is not done to express anger
Pyromania
a. is included in the impulse control disorders.
b. sets fires repeatedly because of the tension before the act and the relief after.
c. There is also a fascination with fire and its various uses.
d. If the patient is setting fires for gain such as money or to make a political
statement, then it is not a case of pyromania.
e. One cannot make the diagnosis
i. in the presence of conduct disorder, mania, or antisocial personality
disorder.
following a fight with police. Upon examination the psychiatrist finds that the patient
has a history of several discrete assaultive acts. His aggression in these situations
was out of proportion to what one would consider normal. The patient has no other
psychiatric disorder and no history of substance abuse. He has no significant medical
history.
a. intermittent explosive disorder.
i. discrete episodes of failure to resist aggressive impulses that lead to
extreme physical aggression directed toward people and/or property.
ii. The degree of aggression is completely out of proportion to any
particular psychosocial stressor that may trigger such an episode.
iii. Episodes are unpredictable and often arise without cause or
particular trigger and remit as spontaneously as they begin.
iv. There are no signs or symptoms of aggressivity noted in
between these discrete episodes.
v. more common in men than in women.
vi. Predisposing psychosocial factors include
1. an underprivileged or tempestuous childhood,
2. childhood abuse,
3. and early frustration and deprivation.
vii. Biological predisposing factors
1. decreased cerebral serotonergic transmission,
2. low CSF levels of 5-hydroxyindoleacetic acid,
3. and high CSF levels of testosterone in men.
viii. There is strong comorbidity
1. fire setting,
2. substance use,
3. and the eating disorders.
ix. Treatment of intermittent explosive disorder
1. mood stabilizers such as lithium, carbamazepine, divalproex
sodium, and gabapentin.
2. SSRIs and tricyclic antidepressants can also be effective in
reducing aggression
- Temporal lobe seizures
a. aggression,
i. most often interictally,
Conduct disorder
a. shows a pattern whereby the rights of others and societal rules are violated.
i. presents as
ii. bullying other children,
iii. using weapons,
iv. physical fighting,
v. cruelty to animals,
vi. stealing,
vii. fire setting,
viii. destroying property,
ix. truancy,
x. or running away from home.
Depression
a. children can become very irritable, withdraw, and not wish to socialize.
b. They may even act out as a result of how badly they are feeling.
c. However, this is different from a long-standing pattern of actively trying to
carry out violence or do property damage regardless of mood state.
In bipolar disorder children
a. may break rules and have behavioral difficulties during manic and depressive
episodes.
b. clear cycling pattern to their moods (and other symptoms), which
corresponds to the times when their behaviors become problematic.
One of the other important distinctions to make is between conduct disorder and
oppositional defiant disorder (ODD).
a. In ODD there is a pattern of
i. negativistic, hostile, or defiant behavior directed at adults or authority
figures.
ii. ODD behaviors are therefore more targeted and have less of a wide-
ranging destructive nature than those of conduct disorder.
1. may include
a. temper tantrums,
b. arguing with adults,
c. actively defying adults’ requests or rules,
d. deliberately annoying people,
e. blaming others for one’s own mistakes or misbehavior,
f. being easily annoyed by others,
g. being angry and resentful,
h. or being spiteful or vindictive.
Primary treatment for ODD is
a. therapy for the child and parental training to give
parents management skills.
i. Often behavioral therapy will be used to reinforce
good behavior while ignoring or not reinforcing
bad behavior
b. In conduct disorder
i. the negative behavior is directed at all others regardless of whether
they are authority figures or not.
Kleine–Levin syndrome
a. is a rare condition.
i. marked by
1. periods of hypersomnia with periods of normal sleep in
between.
a. During the periods of excessive sleep the patients wake
up
i. experience apathy, irritability, confusion,
voracious eating, loss of sexual inhibitions,
disorientation, delusions, hallucinations, memory
impairment, incoherent speech, excitation, and
depression.
ii. onset of the illness
1. 10 and 20 years of age,
a. and it goes away by the time in his/her 40s.
ADHD Treatment
a. Methylphenidate and amphetamine
i. preparations are dopamine agonists.
b. Methylphenidate has been shown to be effective in about 75% of all children
with ADHD.
i. Common side effects of the stimulants are headaches, GI discomfort,
nausea, and insomnia.
ii. Of course stimulants also suppress appetite and can induce weight
loss.
iii. Some children experience a rebound effect following the
wearing-off of the stimulant, during which period they become irritable
and hyperactive.
iv. Motor tics can also be exacerbated by the use of stimulants,
which warrants caution when the medications are given in this specific
population of children.
v. Methylphenidate is also associated with growth stunting or
suppression.
vi. This effect seems to be offset when children are given drug
holidays during the summer months when they are not in school.
vii. About 75% of students on stimulant medications demonstrate
improvement in attention as measured by objective tests of their
academic performance.
c. Dextroamphetamine and dextroamphetamine/amphetamine salt combinations
(Adderall)
i. are generally the second choice when methylphenidate fails.
Pathological gambling,
a. neurobiological determinant in pathological gamblers’ risk-taking behaviors
i. Theories have focused on both serotonergic and noradrenergic
receptor systems.
ii. Evidence supports the probability that male pathological
gamblers have low plasma MHPG concentrations,
iii. as well as increased CSF MHPG concentrations
iv. and increased urinary output of norepinephrine.
v. Chronic gamblers also have
1. decreased platelet MAO activity,
a. which is a marker of serotonergic dysfunction,
i. which is linked to difficulties with inhibition and
impulse control.
b. Epidemiologic studies point to a prevalence rate of a
i. 3% to 5% of problem gamblers in the general population
ii. 1% who meet criteria for pathological gambling.
c.
d. an individual must present with persistent and recurrent maladaptive
gambling that causes economic problems and significant disturbances in
personal, social, or occupational functioning with at least five of the following
symptoms:
1. Preoccupation: The subject has frequent thoughts about gambling
experiences, whether past, future, or fantasy.
2. Tolerance: As with drug tolerance, the subject requires larger or more
frequent wagers to experience the same “rush”.
3. Withdrawal: Restlessness or irritability associated with attempts to
cease or reduce gambling.
4. Escape: The subject gambles to improve mood or escape problems.
5. Chasing: The subject tries to win back gambling losses with more
gambling.
6. Lying: The subject tries to hide the extent of his or her gambling by
lying to family, friends, or therapists.
7. Loss of control: The person has unsuccessfully attempted to reduce
gambling.
- Illegal acts: The person has broken the law to obtain gambling money
or recover gambling losses. This may include acts of theft,
embezzlement, fraud, or forgery. - Risked significant relationship: The person gambles despite risking or
losing a relationship, job, or other significant opportunity. - Bailout: The person turns to family, friends, or another third party for
financial assistance as a result of gambling.
Conduct disorder
a. repetitive and persistent pattern of behavior in which the basic rights of
others or major age-appropriate societal norms or rules are violated,
i. as manifested by the presence of three (or more) of the following
criteria
ii. in the past 12 months,
iii. with at least one criterion present in the past 6 months:
1. Aggression to people and animals
a. often bullies, threatens, or intimidates others
b. often initiates physical fights
c. has used a weapon that can cause serious physical harm
to others (e.g., a bat, brick, broken bottle, knife, gun)
d. has been physically cruel to people
e. has been physically cruel to animals
f. has stolen while confronting a victim (e.g., mugging,
purse snatching, extortion, armed robbery)
g. has forced someone into sexual activity
- Destruction of property:
a. has deliberately engaged in fire setting with the
intention of causing serious damage
b. has deliberately destroyed others’ property (other than
by fire setting) - Deceitfulness or theft:
a. has broken into someone else’s house, building, or car
b. often lies to obtain goods or favors or to avoid
obligations (i.e., “cons” others)
c. has stolen items of nontrivial value without confronting a
victim (e.g., shoplifting, but without breaking and
entering; forgery) - Serious violations of rules:
a. often stays out at night despite parental prohibitions,
beginning before age 13 years
b. has run away from home overnight at least twice while
living in a parental or parental surrogate home (or once
without returning for a lengthy period)
c. is often truant from school, beginning before age 13
years
a. The disturbance of behavior causes clinically significant impairment in social,
academic, or occupational functioning. Many biopsychosocial factors
contribute to the manifestation of childhood conduct disorder.
b. Some of these factors include
i. harsh, punitive parenting;
ii. family discord;
iii. low socioeconomic status;
iv. lack of proper parental supervision;
v. and lack of social competence.
c. The problems must begin to manifest before 13 years of age.
d. In some children with conduct disorder,
i. low plasma levels of dopamine-β-hydroxylase have been found.
1. supports the notion of decreased noradrenergic functioning in
conduct disorder.
2. Canadian study demonstrated greater right frontal EEG activity
at rest correlated with violent and aggressive behavior in
children.
3. There is also little doubt that children chronically exposed to
violence and abuse have a higher risk for being violent
themselves.
Anorexia nervosa.
a. Tests to Order
i. Electrolytes
1. one of the most important tests is the serum potassium level.
a. develop a hypokalemic hypochloremic alkalosis
i. have cardiac complications including arrhythmias
and sudden death.
ii. renal function tests,
iii. thyroid function tests,
iv. glucose,
v. amylase,
vi. complete blood count,
vii. electrocardiogram,
viii. cholesterol,
1. Cholesterol is often increased in these patients,
2. not urgent
ix. dexamethasone suppression test,
x. and carotene
b. Osteoporosis
i. can be found in anorexic patients,
1. but a bone scan is not a vital initial procedure.
c. Delayed gastric emptying
i. can occur with eating disorders,
ii. but a study to prove such is not urgent.
Piblokto
occurs in female Eskimos of northern Greenland.
It involves anxiety, depression, confusion, depersonalization, and derealization,
ending in stuporous sleep and amnesia.
Wihtigo
Native American Indians
is a delusional fear of being turned into a cannibal through possession by a supernatural monster, the Wihtigo.
Mal de ojo
Mediterranean descent
is a syndrome involving vomiting, fever, and restless sleep
caused by the evil eye.
Ataque de nervios
is a culture-bound anxiety syndrome associated with those from Latin-American cultures. headache, insomnia, anorexia, fear, anger, despair, diarrhea.
Japanese culture
it is customary to minimize distress in front of an authority figure.
Chinese culture
often presents with more somatic complaints and less focus on mood symptoms.
Very often Chinese patients will come to the primary care physician or emergency room
with somatic symptoms that are somewhat nonspecific
are found to be driven by an underlying depressive disorder.
Culture
correlates most with ethnicity.
People can be of the same race, age, gender, or nationality
have very different cultures.
Completed suicide
is most often associated with depression,
not bipolar disorder.
Adolescents most frequently commit suicide with guns,
not by hanging.
In recent years the suicide rate has gone up dramatically among adolescents,
not among middle-aged adults.
Previous suicide attempts are the best predictor of future risk of suicide.
Men successfully commit suicide three times more often than women.
Another factor contributing to completed suicides is age.
For men, the highest risk period is after 45 years of age.
For women, the highest risk period is after 55 years of age.
Married people are less likely to commit suicide than single or widowed people.
As far as religion is concerned,
rates of suicide among Roman Catholics are less than those for Protestants or Jewish people.
With race,
whites are more likely to commit suicide than others,
especially white males.
Physical health may play a role.
Thirty-two percent of people who commit suicide have seen a doctor within the past 6 months.
With regard to occupation, the higher a person’s social status, the higher the rate of suicide.
A fall in social status also increases the risk.
The best legal protection for a psychiatrist treating a suicidal patient is thorough regular documentation of a suicide assessment.
No-suicide contracts signed by the patient offer no legal protection, though they may demonstrate the existence of a therapeutic relationship between doctor and patient.
Children who are depressed
can often present with irritability instead of, or in addition to, depressed mood.
Prepubertal children can report somatic complaints, psychomotor agitation, and mood-congruent hallucinations.
Depressed children can also fail to make expected weight gains.
Other signs of depression that children can present with include school phobia and excessive clinging to parents.
Teens with depression
often report poor school performance, substance abuse, promiscuity, antisocial behavior, truancy, and running away from home.
They can withdraw from social activities and be grouchy and sulky.
SAD is a non-DSM term used to describe a seasonal pattern specifier
a depression that sets
in during the fall and winter and resolves during the spring and summer.
often characterized by hypersomnia, hyperphagia, and psychomotor slowing.
added to the diagnoses of
bipolar I and II disorders,
and major depressive disorder.
It is associated with depressive symptoms that occur at a certain time of year,
with complete remission of symptoms at other times of the year.
One must show a pattern of two episodes during the same season of the previous 2 years to make the diagnosis.
In addition, the seasonal depressive episodes must substantially outnumber any non-seasonally related depressive episodes during the patient’s lifetime.
The treatment is light therapy.
Treatment involves exposure to bright artificial light for 2 to 6 hours each day during the fall and winter months.
It is thought to be related to abnormal melatonin metabolism.
often associated with carbohydrate cravings,
that light therapy is most effective in the morning,
and that light therapy can precipitate hypomania in bipolar patients.
Disinhibited behavior
is more characteristic of mania than it is of depression.
Patients with depression
have disrupted rapid eye movement (REM) sleep,
including shortened REM latency, (1 hour or less).
increased percentage of REM sleep,
and a shift in REM distribution from the last half to the first half of the night.
Acetylcholine is associated with the production of REM sleep.
most typical effect of depression on sleep is early morning awakening.
How long should a patient remain on antidepressant medication after having experienced four major depressive episodes in the past 5 years?
Depression tends to be a chronic, relapsing disorder.
The percentage of patients who recover following repeated episodes diminishes over time.
About one-quarter of patients have a recurrence within the first 6 months after initial treatment.
This figure rises to about 30% to 50% in the first 2 years and even higher to about 50% to 75% within 5 years.
It has been proven than ongoing antidepressant prophylaxis helps to lower relapse rates.
As a patient experiences more depressive episodes over time, the time between episodes decreases and the severity of the episodes worsens.
Dysthymic disorder is
characterized by decreased mood
over a period of 2 years
with poor appetite or overeating, sleep problems, fatigue, low self-esteem, poor concentration, and feelings of hopelessness.
Violent or aggressive behavior is associated with
Karolinska Institute has shown in numerous studies that diminished central serotonin plays a role in suicidal behavior.
low levels of CSF 5-HIAA are associated with suicidal behavior.
It has also been shown that low 5-HIAA levels predict future suicidal behavior
and that low 5-HIAA levels have been shown in the CSF of adolescents who kill themselves.
Keys to normal bereavement
are that suicidality is rare,
it improves with social contacts,
and it lacks global feelings of worthlessness.
In depression
one finds anger and ambivalence toward the deceased,
suicidality is common,
and social contacts do not help, thus the person isolates.
In addition others find the depressed person irritating or annoying,
whereas the bereavement patient evokes sympathy from others.
In depression the patient may feel that he or she is worthless,
which is not the case in bereavement
period of grief or mourning
typically lasts about 6 months to 1 year.
Some symptoms and signs of mourning may persist for a longer period, even up to 2 years or more.
In most cases, the acute symptoms of grief improve over a period of about 1 to 2 months, after which time the individual returns to a more normal level of functioning.
Suicide rate for
adolescents has quadrupled since 1950.
Suicide accounts for 12% of deaths in the adolescent age group.
The suicide rate has gone up more in this group than in any other group over the same time period.
Pancreatic cancer
associated with a high rate of depression.
Present with apathy, decreased energy, and anhedonia.
It should be a consideration in the clinician’s mind whenever seeing middle-aged depressed patients.
Of patients with cancer, 50% often have comorbid psychiatric diagnoses,
with adjustment disorder, major depressive disorder, and delirium being the most common.
postpartum period.
40% of mothers may experience mood or cognitive symptoms during the
Postpartum blues (or maternity blues) is a
normal state of sadness, dysphoria, tearfulness, and dependence,
which may last for several days
and is the result of hormonal changes and the stress of being a new mother.
Postpartum depression
is more severe and involves neurovegetative signs and symptoms of depression and potential suicidality.
Postpartum psychosis
can involve hallucinations and delusions,
as well as thoughts of infanticide.
Content of thought
delusions, preoccupations, obsessions, compulsions, phobias, suicidality, homicidality common mistake to put hallucinations in the thought content Hallucinations are false sensory perceptions and fall under the category of perception.
The categories of the mental status examination are
appearance, psychomotor activity, attitude, mood, affect, speech, perception, thought content and process, consciousness, orientation, memory, concentration, attention, reading and writing, visuospatial ability, abstract thought, information and intelligence, impulsivity, judgment and insight, reliability.
Depression
increased awakening during the second half of the night
increased length of the first REM sleep episode.
EEG can be used to evaluate sleep, but in clinical psychiatry,
used to separate temporal lobe seizures from pseudoseizures
to distinguish dementia from pseudodementia caused by depression.
Tumor
unrelated to sleep changes and could potentially show up on an EEG as a seizure focus,
Petit mal epilepsy
has a classic 3-per-second spike and wave pattern,
Hepatic encephalopathy
would cause a delirium
EEG patterns in delirium would show generalized slow activity, that is, theta and delta waves, with possible areas of hyperactivity.
Hepatic encephalopathy often shows on EEG
as bilaterally synchronous triphasic slow waves
Best method to diagnose depression
is the standard psychiatric interview.
Psychiatric interviews serve two functions:
to find and classify symptoms
and to find psychological determinants of behavior.
Interviews can be either insight or symptom oriented.
The MMPI
is a self-report inventory used to assess personality traits
The dexamethasone suppression test
used to demonstrate abnormal activity of the hypothalamic–pituitary–adrenal axis,
which can be found in 50% of major depression patients.
test has limited clinical usefulness because of the frequency of false positive and negative test results.
Logorrhea
is uncontrollable, excessive talking.
Alexithymia
is a difficulty in recognizing and describing one’s emotions.
Echolalia
is the imitative repetition of the speech of another.
Flight of ideas
is rapid shifting from one topic to another.
Stilted speech
is a formal stiff speech pattern.
Suicidal ideation
is part of the thought content of the depressed patient.
It is possible to find it in the manic bipolar patient,
but is more likely during the depressed phase of the illness and is not part of the thought process
Thought content
Obsessions delusions, ideas of reference, phobias, suicidal or homicidal thoughts, depersonalization, derealization, neologisms,
Thought process
word salad, flight of ideas, circumstantiality, tangentiality, clang associations, perseveration, goal-directed ideas.
ECT
no absolute contraindications to ECT.
Pregnancy is not a contraindication for ECT.
Fetal monitoring is considered important only if the pregnancy is high risk or complicated.
Brain tumors increase the risk of ECT, especially of brain edema and herniation after ECT.
If the tumor is small, complications can be minimized by administration of dexamethasone prior to ECT
and close monitoring of blood pressure during the treatment.
Aneurysms, vascular malformations, or increased intracranial pressure
are at greater risk during ECT because of increased blood flow during the induction of the seizure.
This risk can be decreased by careful control of blood pressure during the seizure.
Epilepsy and prior neuroleptic malignant syndrome are not problematic with the administration of ECT.
Recent myocardial infarction is another risk factor,
but the risk decreases markedly 2 weeks after the infarction and even further 3 months after the infarction.
Hypertension, if controlled and stabilized with antihypertensive medication,
does not pose an increased risk during ECT
Patients at high risk during ECT include the following:
space-occupying lesions in the CNS, increased intracranial pressure, at risk for cerebral bleed, have had a recent myocardial infarction, with uncontrolled hypertension. no absolute contraindications for ECT
Right unilateral placement of the electrodes in ECT
has been shown to minimize cognitive impairment and memory deficits.
If unilateral electrode placement fails to improve the patient’s symptoms after four to six treatments
the placement may be switched to bilateral,
which can be more effective but carries a higher risk of side effects
Lithium
can prolong seizure activity during ECT
and should be discontinued.
Antipsychotics
are fine during ECT,
with the exception of clozapine,
which causes late-appearing seizures during ECT.
Tricyclic antidepressants (TCAs) and MAOIs
re fine to continue during ECT.
require 6 to 12 ECT treatments to treat depression.
Some cases may require as many as 30 treatments,
but these are the exception rather than the rule.
Treatments are often given three times per week
with one seizure per treatment.
The use of more than one seizure per episode has no proven advantages.
The preference is for unilateral electrode placement
because it lessens memory impairment from the procedure.
If a patient fails to improve after six unilateral treatments
then bilateral electrode placement should be considered.
Cingulotomy
a surgical treatment for OCD.
successful in treating about 30% of otherwise treatment-resistant patients.
Some patients who fail medication, and then subsequently fail surgery, will respond to medication after surgery.
Complications of cingulotomy include
seizures,
managed with anticonvulsants.
Biofeedback
therapy in which instruments are used to measure autonomic parameters
Pt’s are provided with “real-time” feedback from the instrumentation about their bodily physiologic processes.
enables patients to control their own physiologic functions
alter them in positive ways to alleviate symptoms using operant conditioning techniques.
Feedback is provided to the patient by measuring physiologic parameters
heart rate,
blood pressure,
galvanic skin response,
and skin temperature.
The measurement is translated into a visual or auditory output signal that patients can rely on to gauge their responses.
Patients can alter the tone by using guided imagery, breathing techniques, cognitive techniques, and other relaxation techniques.
The modality is useful for
anxiety disorders,
migraine,
tension-type headache
Relaxation training
a form of behavior therapy encompasses techniques meditation yoga to help patients to dispel anxiety by tapping into their own physiologic parameters such as heart rate and breathing rate.
Guided mental imagery
helps patients to enter a relaxed state of mind.
Behavior therapy
global term used to describe various therapeutic modalities
that employ either operant or classical conditioning techniques
to help patients overcome their fears, phobias, and anxieties.
Flooding,
systematic desensitization,
aversion
Desensitization
helps patients gradually overcome their fears, phobias, and anxieties
by graded exposure to the very stimulus that is the source of their fears.
patient is exposed to more and more anxiety-provoking stimuli,
Alogia
is a lack of speech that results from a mental deficiency or dementia.
Akinesia
Poverty of movement
“flat affect.”
Poverty of emotion
26-month-old child into the doctor’s office. The child has not spoken any words yet.
child who is not speaking should first have his or her hearing checked.
Phonological disorders are characterized by a child’s inability to make age-appropriate speech sounds.
The child cannot be diagnosed if the deficits are being caused by a structural or neurological problem; therefore these things must first be ruled out.
Phonological disorder may present as substitutions of one sound for another or omissions such as leaving the final consonant off of words.
The treatment of choice is speech therapy,
recovery can be spontaneous in some children.
Speech therapy is indicated if the child cannot be understood,
if the child is over 8 years of age,
when self-image and peer relationships are being affected,
when many consonants are misarticulated,
and when the child is frequently omitting parts of words
Transcranial magnetic stimulation (TMS)
Left dorsolateral prefrontal cortex, where treatment in applied
is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain.
electromagnetic induction to induce weak electric currents using a rapidly changing magnetic field;
this can cause activity in specific or general parts of the brain with minimal discomfort,
allowing the functioning and interconnections of the brain to be studied.
A variant of TMS
repetitive TMS (rTMS),
has been tested as a treatment tool for various neurological and psychiatric disorders
migraines,
strokes,
PD,
dystonia,
tinnitus,
depression,
auditory hallucinations.
The treatment protocol involves the application of electromagnetic stimulation to the standardized treatment location,
over the left prefrontal cortex,
determined by moving the TMS coil 5 cm anterior to the motor threshold location along a left superior oblique plane with a rotation point about the tip of the patient’s nose.
Treatment for depression involves 20 to 30 sessions of about 40 minutes each over a 4- to 6-week period
NeuroStar TMS Therapy
is indicated for the treatment of major depressive disorder in adult patients
who have failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode.
noninvasively stimulates the left prefrontal cortex of the brain
to treat the symptoms of major depression.
4 to 6 weeks of treatment.
is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain.
uses electromagnetic induction to induce weak electric currents using a rapidly changing magnetic field;
this can cause activity in specific or general parts of the brain with minimal discomfort,
allowing the functioning and interconnections of the brain to be studied.
In 2008 Neuronetics, Inc.,
a privately held company in the United States,
received FDA clearance for its NeuroStar TMS Therapy device for the in-office treatment of major depressive disorder.
SCID (Structured Clinical Interview for DSM)
does not include functional impairment covers the following topics: general overview (demographics and medical, psychiatric services, and medication use histories), mood episodes, psychotic symptoms, psychotic disorders differential, mood disorders differential, substance use, anxiety disorders, somatic disorders, eating disorders, adjustment disorders.
SCAN (Schedule for Clinical Assessment in Neuropsychiatry)
Covers functional impairment
give a broader assessment of psychosocial function than the SCID.
