Bipolar, anxiety Flashcards
What are bipolar and related d/o?
Episodic mood shifts into
- mania,
- MDD,
- hypomania
- mixed mode states
What treatments are used for acute mania/hypomania?
Mood stabilizers
- lithium
- valproic acid (1st line)
Antipsychotics
- used as a bridge for lithium
What makes valproic acid the 1st line?
No blood monitoring (unlike lithium)
bipolar I vs bipolar II
bipolar I
- Manic episodes
- Followed by depression
Bipolar II
- hypomanic episodes
- w/o frank mania
Describe a manic episode
- elation w hyperactivity
- over involvment in life’s activities
- increased irritability
- flight of ideas
- easy distractibility
- little need for sleep
- rash things ($$, gabling, sex)
What are some atypical symptoms of mania?
- Gross delusions
- Paranoid ideation
- Auditory hallucinations
What is a rapid cycler?
4+ mania episodes per year
What is cyclothymic d/o?
- Episodes of Sub-syndromal depression and hypomania
- must have 2+ yr duration
Meds that can cause bipolar?
- Reserpine
- Corticosteroids
- Oral contraceptives
- Antihypertensives (methyldopa, guanethidine, clonidine)
- Antiparkinson (levodopa)
- Interferon
- Stimulants (when withdrawn)
- ETOH, sedatives, opoids and psychodellics are all depressants
Can medical conditions cause bipolar?
Any illness (severe or mild) can cause sig depression but especially common in
- cancer
- RA
- major chronic diseases
What are anxiety d/o’s?
Persistent excessive anxiety or chronic fear and associated behavioral disturbances
Can be psychologic or somatic
Lack of structure contributes to it
What is separation anxiety?
Inappropriate and excessive fear or anxiety concerning separation from something
Minimum of 3 of:
- recurrent excessive distress w/ anticipation or experience of separation
- persistent and excessive worry about loss of ____
- persistent and excessive worry about untoward event (kidnapping etc)
- refusal to go to ___ b/c of fear of separation
- cant sleep away from home
- nightmares about separation
- physical symptoms from separation
How long must separation anxiety continue to be diagnosed?
Children - 4 weeks
Adults - 6 months
Ddx for separation anxiety?
GAD Panic d/o Agoraphobia Conduct d/o Social anxiety d/o PTSD Illness anxiety d/o Bereavement Depressive/bipolar Oppositional defiant d/o Psychotic d/o Personality d/o Comorbidity
What are specific phobias?
A fear of a specific object
- lasting 6 mo or more
Pharm tx for specific phobias?
SSRI’s - paroxetine, sertraline, flovoxamine
SNIR’s - venlafaxine
Gabapentin - anxiolitic action
Beta-blocker
How are beta blockers given for specific phobias?
They are preemptive
- give 1 hr prior to known exposure
Behavior tx for specific phobias?
Relaxation techniques
Desensitization
talk tx for specific phobias?
CBT
Group therapy
Support groups
Prognosis for specific phobias?
- Long standing and difficult to treat
Vary by age:
Childhood/adolescence - tend to wax and wane
Persist into adulthood - unlikely to remit
What is social anxiety (social phobia)?
Fear or anxiety about one or more social situation
- worry about scrutiny of others
- fears will be negatively evaluated by others
6 months or more
What is panic d/o?
Panic attacks that include chronic fear of the recurrence and avoidance of triggers
At least 1+ month of:
- worry about panic attack
- maladaptive change in behavior (avoiding things etc)
Clinical findings with panic d/o?
Panic attacks
Agoraphobia
Anticipatory anxiety
Sleep panic attacks
Tx for panic d/o?
Antidepressants are mainstay
- SSRI (fluoxetine, paroxetine sertraline)
- SNRI (venlafaxine)
Benzo’s (be careful with them)
- use as a bridge
What is a panic attack?
Recurrent unpredictable episode of intense surges of anxiety w physiologic manifestations
With trigger - expected panic attack
No trigger - unexpected panic attack
Panic attack vs anxiety?
Panic attack is fast
- occurs w/in minutes
- discrete nature
- greater in severity
What is agoraphobia?
Fear places where escape is difficult
Fear of 2 or more of:
- public places
- open spaces (parking lots)
- enclosed spaces
- lines or crowds
- being outside the home
How many pts with anxiety develop generalized anxiety disorder?
About 1/2
What is generalized anxiety d/o?
Anxiety symptoms that re present more days than not for 6 months
Excessive anxiety or worry about a number of events or activities that is “out of proportion”
Clinical findings for GAD?
3 of the following (1 for kids):
- restlessness, keyed up, on edge
- easy fatigue
- difficulty concentrating/ blank mind
- irritability
- muscle tension
- sleep disturbance
DDX for GAD?
Must r/o underlying medical d/o
- cardiac
- endocrine
- etc
Tx for GAD?
Pharm
- SNRI (venlafaxine and duloxetine)
- SSRI (escitalopram and paroxetine)
- TCA/MAOI (3rd line)
- Buspar (makes a good bridge)
When treating GAD dont use?
Bupropion
Other causes of anxiety?
Substance/med-induced anxiety d/o
- happens after meds (give or take away)
- med must be capable of producing anxiety
Anxiety d/o due to medical condition
- caused by psyiologic consequence of med condition (not the med)
Common depression findings are?
- Mood varies from mild sadness to total abandon
- difficulty thinking, concentrating, acting
- loss of interest
- somatic complaints
Severe depression can present w?
- Psychomotor retardation or agitation
- Delusions
- Withdrawal
- Physical symptoms
- SI
With mania you may see?
- Mood varies from euphoria - irritability
- sleep disruption
- hyperactivity
- racing thoughts
- grandiosity/extreme over confidence
Contrast grief and depression
Grief - intact self-esteem
Depression - sense of guilt and worthlessness
4 major types of depression?
- adjustment d/o w depressed mood
- depressive d/o
- bipolar
- mood d/o 2/2 illness/meds
Types of depression in depressive d/o?
MDD
Dysthymia
Premenstrual dysphoric d/o
MDD, atypical depression and seasonal affected disorder typical tx?
SSRI
Bupropion
Melancholic depression tx?
ECT
TCA
SNRI
If a pt has SI they never get?
TCA or MAOI
Tx that is specific to SAD?
Phototherapy
How effective is ECT?
70-85% effective
- especially good in the elderly
What is disruptive mood disregulation d/o?
Sever recurrent temper outbursts manifested verbally or behaviorally in kids age 6-18
- grossly out of proportion to situation
3x per week
Mood between outbursts is irritable or angry
Symptoms must be >12 months
Clinical findings for MDD?
Anhedonia Loss of concentration Fatigue Anxiety Worthlessness Somatic complaints Diurnal variation
MDD can include what types of depression?
MD w atypical features
Melancholic MD
MDD w SAD
MD w peripartum onset
MD w peripartum is found in?
80% of peripartum depression
Pt population for psychotic MD?
Older - 14% more common over 50
MDD must have 5 symptoms from?
Also, must have symptom 1 or 2
- Depressed mood (most of day)
- Markedly diminished interest or pleasure
- Weight change
- Insomina/hypersomnia
- Psychomotor agitation/retardation
- Fatigue or loss of energy
- Feelings of worthlessness
- Diminished ability to think/concentrate
- Thoughts of death
What is persistent depressive d/o?
Chronic depression
- 2+ years w a relatively persistent course
Symptoms are usually milder but dont get better
What is premenstrual dysmorphic d/o?
Depression during the luteal phase
- looks like a duck but it starts around 5 days pre bleed and improves after day 1
What else can cause depression?
Substances and medical d/o
What is unspecified depressive d/o?
Depression that doesnt meet the criteria for the other types
- recurrent brief depression
- short-duration depressive episode
- depressive episodes w insufficient symptoms
What is depression w mixed features?
At least 3 manic/hypomanic symptoms are present
What is melencholic depression?
Depression with an almost complete loss of interest or pleasure in everything
