Lecture 2: Major Disorders Flashcards
Psychiatric Disorders (3)
- Mood disorders
- Anxiety disorders
- Psychotic disorders
Disorder
disruption in normal functioning of a body part or system
Disease
pathophysiological response to external or internal factors
Mood Disorder (3)
- change in mood that is persistent
- accomp. by physical, emotional, and functional deficits
- may be intrinsic or related other factors like stressors, illness, or substance abuse
Quality of Mood
- exists on spectrum
- evaluated in discrete episodes that usually represent a clear departure from “normal”
Mania > euthymia (cheerfullness/tranquility) > depression
Major Depressive Episode overview
depresses, irritable on most days
anhedonia= lack of pleasure in previously pleasureable activities
anhedonia
lack of pleasure in previously pleasurable activities
Major depressive episode signs
- significant appetite disturbance or weight change
- sleep disturbance
- psychomotor agitation or retardation
- loss of energy/fatigue
- feelings of worthlessness
- decreased concentration or cognitive abilities
- recurrent thoughts of death or suicide
- self-rejection/better off dead
Dx major depresive disorder (6)
- symptoms of MDE for at least 2 weeks
- symptoms cause significant social, occupational, or interpersonal functioning
- exclude drug use, bereavement, or other primary mental disorders
- rate severity-mild, moderate, severe
- note psychotic features: hallucinations, negativisitc delusions, or paranoia
- note peri-partum onset (post partum depression)
Persistent Depressive Disorder (3)
- chronic depression without complete remission for 2 years or more
- Dysthymia/ melancholia
- includes episodes of major depression with incomplete remission between episodes
Adjustment disorder
- mood change in reaction to a stressor (job loss, illness, etc. )
with mild functional impairment - Symptoms are brief in duration, less than criteria for full disorders
- Generally do not require pharmacology except for symptomatic approach
- brief psychotherapy if beneficial
Manic Episode (11)
- elated, euphoric, giddy
- inflated sense of self-esteem or grandiosity
- though process races but goal-directed although tengentiality is common
- thought can be excessively focused on religion, business, sexuality, specialness, or persecution.
- speech pressured, difficult to interrupt
- lacks need for sleep
- excessive goal-directed activity with high risk behaviors (spending, sec, business or financial misadventures, chaotic relationships)
- impulsive, easily angered, can lash out physically
- mood lasts for 7 days, may be dx earlier if hospitalized
- may be triggered by medication, stress, drug use-or spontaneous
- significant functional impairment, causes chaos in family and workplace
Hypomanic episode
- similar to symptoms of manic episode but os less intensity and duration
- minimal functional impairment
Mixed specifier
- during either depressive or manic episode, at least 3 diagnostic criteria for the opposite mood episode are also present
- increase complexity of correct diagnosis and treatment
Bipolar I disorder (4)
- at least one documented manic episode
- major depressive episodes not common but not required
- dx may be difficult or delayed
- tx for depression may result in “flip” to mania
Bipolar (II) Disorder (2)
- at least one major depressive episode and at least one episode of hypomania
- no hx full manic episodes
Bipolar Disorders, DX tips (5)
- r/o substance induced origin
- r/o origin due to medical conditions
- r/o other mental disorders
- note psychotic freatures spcifier
- note anxious distress specifier
Mood Disorder Tx steps (4)
- diagnosis, include severity
- discuss tx modes with patient
- choose specific tx
- follow up and monitor
Treating Depression
1st line
2nd line
3rd line
- 1st line treatments: SSRI, SNRI w/ therapy
- 2nd line: atypical antidepressants, TCAs, mood stabilizer, augmentation, TMS
- 3rd line: MAOIs, ECT
Antidepressant pharmacology
SSRIs: fluoxetine, citalopram, sertraline, paroxetine, fluvoxamine, escitalopram, vilazodone, vortioxetine
SNRIs: venlafaxine, duloxtine, levomilnacipran
SGAs: ariprazole, quetiapine, lurasidone
Mood Stabilizers: lithium carbonate, divalproex, cabamezepine
SSRI (4)
Selective, Serotonin reuptake inibitor
- 1st line tx for depression
- ease of dosing, minimal toxicity in OD
- generally well tolerated
- patient preferences, past responses, or family responses considered in selection
SNRI
Serotonin and Norepinephrine Reuptake Inhibitor
- tx option that come clinicians consider first line with SSRIs
- NE receptor binding can help treat anxious distress of concentration issues assoc. with depression
- Duloxetine also indicated for anxiety and neuropathic pain disorders, increasing utility in patients with comorbid issuea
TCAs
tricyclic antidepressants
older class of ad.= impiramine, amitryptyline, doxepin
MAOIs
momamine oxidase inhibitors
react with high amnt. of tyramine to create potentially dangeroud hypertension
req. carefully controlled diet
Atypical antidepressants (4)
bupropion, mirizapine, nefazodone, trazodone
TMS
transcranial magnetic stimulation
stimulates ares of left frontal cortex assoc. with mood.
TMS course of tx
- 6-8 weeks at therapeutic dose considered adequate to assess response
- after response determines, may proceed with dose increase, augmentation, or change to new agent
- continuation of tx for 9 months is recommended to achieve durable remission
Tx bipolar disorder (4)
- SGAs and divalporex are considered 1st line treatments
- monitor metabolic parameters due to rx of increased lipids and metabolic syndrome
- antidepressants avoided if possible, but if needed must be combined with SGA or mood stabilizer
- ongoing tx recommended to prevent furutre episodes
Lithium Carbonate
- classic tx for bipolar mania
- can be used for antidepressant supplementation
- long term risk of renal impairment, thyroid impairment, tremor, others
- req. blood monitoring for serum levels and has tight therapeutic window
- toxicity can cause disorientation, psychosis, and my be fatal
Cognitive Behavioral Therapy
type of psychotherapy that focuses on interaction between core beliefs, thoughts, and feelings and guides patient to reformulate these connections to improve mood and reduce distress
Psychoanalytic Therapy
type of psychotherapy-explores childhood experiences and long-standing paradigms of thought
Anxiety Disorders
- state of increases worry, fear, and concern, especially for future events
- assoc. with physical symptoms of agitation, increased heart rate, respiratory rate, and tension
- may include avoidance behaviors and fears of losing it or going crazy
Panic Attack
- sudden, rapidly escalating onset of fear and anxiety, sometimes without provocation
- physical symptoms include: rapid heart rate, paplitations, sweating, trembling, dizziness, chest or abdominal pain, chokin sensation, cold or hot flashes
- emotional symtpoms include: fear of death, fear of going crazy, derealization
Panic Disorder
- sudden recurrent onset of panic attacks
- up to 25% patients experiences nocturnal panic attacks that may awaken them from sleep
- for at least one month afterwards, patient experiences fear of recurrence and experiences increased anxiety over the possibility of further attacks
- patient engages in avoidance behaviors to prevent future attacks-isolates, change jobs or relationships, etc.
- agoraphboia “fear of marketplace”
Generalized Anxiety Disorder
- characterized by excessive, intrusive worries about everyday situations that causes significant distress and functional impairment
- Accompanied by physical symtpoms of anxiety: muscle tension, restlessness, insomnia, GI disturbances, chronich headaches, fatigure and difficulty concentrating
- may have epidoses of increased anxiety resembling panick attacks
Selective mutism
form of anxiety disorder
refusal to speak due to increased anxiety- more common in children
social anxiety disorder
debilitating anxiety in social situations and avoidance of socialization
Specific Phobia
avoidance of a specific situation of object that causes debilitating anxiety
Acrophobia
fear of heights
chiroptophobia
fear of bats
coimetrophobia
fear of cemeteries
enochlophobia
fear of crowds
geletophobia
fear of being laughed at
nomophobia
fear of being out of cell phone range
nosocomophobia
fear of hospitals
pogonophobia
fear of beards
tomophobia
fear of medical procedures
tx for anxiety
- rx (4)
- clinic tx
- personal
- SSRIs, SNRIs, Buspirone, Benzodiazepines
- CBT, mindfulness
- phsyical activity, structured social activity
Anxiety Pharmacology
- SSRI= effective for anxiety
SSNRI= effective for anxiety, not for panic disorder - Buspirone= non-addictive tx for GAD and other anxiety disorders- ineffective for panic disorder
- benzodiazepines= effective short-term, carry long term rx dor dependence, sedation, mental clouding, increased mortality
Psychotherapy for anxiety
- CBT helps manage anxious thoughts, increase functionality, reduce panic and anxiety attacks
- mindufllness practices proven to help reduce clinical anxiety
- structured activities help patient gradually resume normal psychosocial functioning
- exposure therapy-effective but intensive and time consuming
Psychotic disorders
- characterized by significant disorders of though process and content
- like mood, psychosis is considered a spectrum of though disorders
Psychosis symptoms (5)
- delusions
- hallucinations
- disorganized speech
- disorganized or catatonic behavior
- negative symtpoms
*defining symptoms of schizophrenia and other psychotic disorders, can be present in other disorders
Delusions
fixed, false believes that persist in the face of negative evidence
may be persecutory, erotomanic, paranoid, or other types
fragmentary delusions seen in psychotic disorders but some patients present with sustained, complex, and organized delusional systems
resistant to pharmacology and psychotherapy
Delusional Content (4)
- persecution= becomes increasingly specific over time
- erotomanic= belief that one is loved by another
- technological= invastion or control my machines, electronics, unseen forces
- medical-belief in illness not diagnosable by current techqniues
Hallucinations
any sensory modality-auditory, visual, olfactory, tactile, gustatory
auditory and visual-most common in psychotic disorders
patient appears distracted, not following conversation
may respond directly to unseen stimuli
Hallucinatory content (3)
- voices- single or multiple, sometime overlapping, occasionally music or crowd noise
- visions- usually normally sized ppl in psychotic disorders more disorganized in medication or drug induced states
- tactile-ants crawling on skin, body sensations misinterpreted as technological or intrusive
Disorganized speech (4)
- cannot stay on topic
- suddenly stops or blocks mid sentence
- non-sequitur responses
- nonsensical responses
Disorganized (4)
- bizarre posturing
- excessive or inaproppriate clothing and grooming
- lack of reponsiveness to environment
- inapropriate emtional responses
Negative symptoms (6)
- monotonic speech with minimal content
- flat, unresponsive focail expressions
- slow, labored thought processes
- lack of motiviation and inability to start simple projects
- lack of spontaniety
- lack of interest in social and interpersonal interactions
Schizophrenia (6)
- characterized by 2 or more of the 5 psychotic symptoms
- at least one of the symptoms must be delusions, hallucinations, or disorganized speech
- significant impairment in social, occupational, or self-care activities since onset of psychosis
- psychotic symtpoms present for at least one month and syndrome lasts at least 6 motnhs
- no better explained by mood disorder or autistic spectrum
- frequent onset in late teen to early adult years
schizophrenia assoc. featues (8)
- inappropriate affect
- dysphoric mood
- erratic sleep pattern
- poor insight
- anxiety and phobias, sometimes obsessive
- feelings of derealization and depersonalization
- difficulty with social cues and interactions
- psychosis may cause hostility and aggression
Delusional Disorder (3)
- presence od persisten delusions
2. other psychotic symptoms usually not present
Schizoaffective Disorder (2)
- characterized by presence of both psychotic and mood disorder symptoms
- mood symtpoms and psychotic symptoms persist in the absence of the other
a. mood symptoms in at least 50%
b. psychotic symptoms in absence of mood symptoms
Brief psychotic disorder (3)
- presence of psychotic symptoms in prevous non-psychotic patient
- resolves within one month with full return to baseline level of functioning
- not related to drug use or medical ilness
Antipsychotic tx (3)
- first gen tx- thorazine, haldol, prolixin
- second gen- risperdal, seroquel, zyprexa, abilify, latuda
- clozapine
Supplementary antipsychotic tx (4)
- antidepressants-common in schizophrenia (5% suicide rate)
- socialization-group therapy, group community, living, day programs
- primary care- medical illnesses common
- case management- asst. with acess to resources, transportation, housing, daily living
