Mental Health Disorders Flashcards
Neurotransmitters that affect mood
- Norepinephrine
- Serotonin and GABA
- Dopamine
How does serotonin and GABA affect the body?
- Well-being
- Calmness
- Decrease impulsivity
- Decrease aggression
- Helps with sleep
- Decreases sex drive
- Increases appetite
How does norepinephrine and dopamine affect the body?
Enhances:
- Concentration
- Ambition
- Productivity
Major Depressive Disorder: What is it?
- A constellation of signs and symptoms that have multifactorial causes, including life circumstances, biological predisposition, and epigenetic influences. Disturbances in cognitive, emotional, behavioral, and somatic regulations are common features of depression.
Major Depressive Disorder: Diagnostic Criteria
- In adults, diagnostic criteria includes anhedonia or depression and any four or more of the following:
1. Change in appetite
2. Change in sleep pattern
3. Fatigue
4. Psychomotor retardation or agitation
5. Poor self-image
6. Concentration difficulty
7. Suicidal ideation
What is anhedonia?
Is a loss of pleasure or interest in things that previously provided joy or pleasure. To be diagnosed with depressive disorder, depression and/or anhedonia must be present with other specifiers.
Major Depressive Disorder: Etiology
- Still not well understood
- Impaired synthesis and/or metabolism of norepinephrine, serotonin, dopamine, and/or other neurotransmitters
- Evidence indicates genetic predisposition (30-40%)
- 60-70% of cases are related to specific environmental factors including adverse childhood events and ongoing or recent stress due to interpersonal adversities
Major Depressive Disorder: Risk Factors
- Psychosocial stressors
- Postpartum period
- Physical or chronic illness, especially migraines and back pain
- Prior episodes of depression and suicide attempts
- Family history of suicide
- Alcohol or substance abuse
- Children with a history of being bullied or abused
- Retirement, aging
- Significant loss (death of a spouse, loss of job, divorce)
- Isolation
- Comorbidities
Major Depressive Disorder: Assessment Findings in Children
- Anorexia
- Sleep disturbance
- Apathy and sluggishness
- Developmental delay
- Anxiety, irritability, cries easily, restlessness
- Aggression, hyperactivity
- School problems
- GI or other somatic complaints
- Poor self-esteem
- Cognitive dulling
- Suicidal thoughts or self-injury
- Withdrawal or increased clinging behaviors
Major Depressive Disorder: Assessment Findings in Adolescents
- Similar to adults
- Impulsivity
- Fatigue
- Hopelessness
- Substance abuse
Major Depressive Disorder: Assessment Findings in Adults
- Depressed mood for 2 weeks or longer and/or anhedonia (at least one must be present)
- Decreased or increased appetite
- Weight loss or gain
- Sleep disorder
- Psychomotor agitation or retardation
- Fatigue, loss of energy
- Feelings of worthlessness, inappropriate guilt
- Recurrent thoughts of death
- Difficulty thinking/concentrating or indecisiveness
Major Depressive Disorder: Non-Pharmacologic Management
- Identify suicidal risk, plan, lethality, availability and intent
- Establish safe environment
- Provide community resources
- Psychoeducation
- Psychotherapy
- Electroconvulsive therapy (ECT)
- Light therapy
- Transcranial magnetic stimulation (TMS)
- Vagus nerve stimulation (VNS)
Major Depressive Disorder: Psychoeducation
- Ongoing information about illness, symptoms, prognosis, and therapy
- Include interpersonal relationships, work, and other health-related needs
- Discourage major life changes while in a depressive state
- Help set realistic, attainable, concrete goals
- Educate about importance of avoiding alcohol
Major Depressive Disorder: Psychotherapy
- Treatment of choice with or without pharmacologic interventions in mild to moderate depression
- Pharmacologic treatment works best when accompanied with psychotherapy
- Establish and maintain a supportive therapeutic relationship
- Remain available during times of crisis
- Maintain vigilance for signs of destructive impulses
- Strengthen expectations of help and hope for the future
- Enlist support of others in patient’s social network
Major Depressive Disorder: Electroconvulsive therapy (ECT)
- Indicated for depression in which a rapid antidepressant response is imperative: depression coupled with psychotic features, catatonic stupor, mania, severe suicidality, suicidality in pregnancy, or severe nutritional compromise
- Indicated for patients who prefer this method of treatment, or who have responded unsatisfactorily to antidepressant medication in the past
- High rate of therapeutic success
- Chief side effects are transient postictal confusion and memory impairment that resolve in a few days
Major Depressive Disorder: Light Therapy
- Particularly effective for seasonal affective disorder
- Exposure to bright white artificial light for 30 minutes or more in morning and/or evening
- May be used along with pharmacotherapy
Major Depressive Disorder: Transcranial magnetic stimulation (TMS)
- Use in resistant depression
- Side effects are significantly reduced
- Treatment is 4-5 times per week for 4-6 weeks
Major Depressive Disorder: Vagus nerve stimulation (VNS)
- Approved for adult patients with long-term or recurrent major depression
- Requires surgical implantation of a stimulator that runs from collarbone to vagus nerve
Major Depressive Disorder: Pharmacologic Management
- Determine coexisting substance use disorders and general medical conditions
- SSRIs are first-line treatment
- SNRIs
- Novel antidepressants
- TCAs
- MAOIs are not used first or second-line due to food and drug interactions. These drugs are usually prescribed by psychiatric specialists
- Atypical antipsychotics may be used to augment poor response to antidepressants alone. When used, these medications should be monitored for side effects common with all antipsychotics
Selective Serotonin Reuptake Inhibitors (SSRIs)
- Fluoxetine
- Citalopram
- Escitalopram
- Paroxetine
- Sertraline
- Vilazodone
Selective and Neuroepinephrine Reuptake Inhibitors (SNRIs)
- Duloxetine
- Venlafaxine
- Desvenlafaxine
Tricyclic Antidepressants (TCAs)
- Amitriptyline
Norepinephrine and Dopamine Inhibitors
- Bupropion
Serotonin Antagonists and Reuptake Inhibitors (SARI)
- Trazodone
Noradrenaline and Specific Serotonergic Agents (NaSSAs)
- Mirtazapine
Multimodal Antidepressants
- Vortioxetine
Anxiety: What is it?
Psychic and physical experience of dread, foreboding, apprehension, or panic in response to emotional or physiologic stimuli; may be acute or chronic. Many anxiety disorders develop in childhood and tend to persist if untreated.
Anxiety: Etiology
- Behavioral theory: anxiety is the conditioned response to specific environmental stimuli
- Genetic component (first-degree relative increases likelihood eigthtfold)
- Biologic theories:
1. Norepinephrine, serotonin, and gamma-aminobutyric acid (GABA) are poorly regulated
2. The autonomic nervous system inappropriately responds to stimuli
3. Functional cerebral pathology causes anxiety disorder symptoms
4. Hypothalamic pituitary adrenal (HPA) axis highly implicated
Anxiety: Assessment Findings in Children
- Excessive anxiety about separation after age 3-4 years
- Note: DSM-5 states that separation anxiety may be present in adulthood
- Unrealistic worry about harm to self or family
- Persistent worry about past behavior, competence, or future events
Anxiety: Assessment Findings in Adults
- Complaints of apprehension, restlessness, edginess, distractibility
- Insomnia
- Somatic complaints:
- Fatigue, headaches
- Paresthesia, near syncope, derealization, dizziness, diaphoresis
- Palpations, tachycardia, chest pain/tightness
- Dyspnea, hyperventilation
- Nausea, vomiting, diarrhea,
- Excessive rumination
Anxiety: Diseases that Masquerade as Anxiety
- Angina, arrhythmias, MI
- Anemias
- Hyperthyroidism
- Hypoglycemia
- Essential tremor
- Asthma, COPD, PE
- Carcinoid syndrome
Anxiety: Drugs that Masquerade as Anxiety
- Caffeine, cocaine
- Pseudoephedrine
- Theophyline
- Drug withdrawal (BNZs, EtOH)
- Benadryl
- TCAs
- Dopaminergics
Anxiety: Non-Pharmacologic Management
- Psychotherapy
- Regular exercise and healthy diet
- Adequate sleep and limit caffeine intake
- Serial office visits
** Advise patients to avoid alcohol consumption because it increases risk of drug interactions and is associated with high rates of abuse and rebound anxiety
Anxiety: Psychotherapy
- Education about diagnosis, treatment plan, and prognosis
- Support and empathetic listening
- First line treatment for children and adolescents
- Relaxation techniques
- Cognitive behavioral therapy
- Reconditioning: exposure to feared stimuli in controlled setting to develop tolerance and eventually eradicate the anxiety response
Anxiety: Pharmacologic Management
- First-line SSRIs
- SNRIs
- Buspirone (slow onset)
- Benzodiazepines (GABA)
Benzodiazepines
- Alprazolam
- Clonazepam
- Diazepam
- Lorazepam
** For Anxiety
** Should be of limited duration, with intent of allowing patient to benefit from behavioral treatments
** These drugs reduce - not eradicate - symptoms
Post Traumatic Stress Disorder (PTSD): What is it?
A constellation of symptoms that persist for more than 30 days after exposure to a traumatic event. Traumatic events that induce PTSD include combat, serious injury, or violence that occurs through direct experience or exposure, witnessing, the testimony of a close friend or family member, or through repeated/extreme exposure to the event details (such as with first responders).
** PTSD is associated with an increased risk for the abuse of alcohol and other sedating substances in an attempt to attenuate PTSD symptoms
Post Traumatic Stress Disorder (PTSD): Etiology
- Dysregulation of the hypothalamic pituitary axis, resulting in an overactive stress response
- Corticotrophin-releasing factor is overactive, causing increased norepinephrine in the brain and resulting in hyperarousal, re-experiencing and anxiety symptoms
- Serotonin is not as effective in attenuating the stress response in the brain
Post Traumatic Stress Disorder (PTSD): Risk Factors
- Adverse childhood experiences (ACEs)
- Limited coping mechanisms
- Alcohol or substance abuse
- Limited psychosocial support systems
- Previous exposure to trauma
- Psychosocial stressors
Post Traumatic Stress Disorder (PTSD): Assessment Findings
- PTSD occurs after exposure to a traumatic event and symptoms are clustered into four areas:
1. At least one intrusion symptom (e.g., dreams, memories, or dissociative reactions)
2. At least one avoidant symptom (e.g., avoiding reminders or thoughts)
3. At least two negative alterations in cognition and mood (e.g., inability to remember aspects of the trauma, negative emotional state, or diminished interest)
4. At least two marked alterations in arousal and reactivity (e.g., hypervigilance, exaggerated startle response, sleep disturbance, or problems with concentration)
Post Traumatic Stress Disorder (PTSD): Assessment Findings in Children
- Bedwetting
- Irritability
- Replaying the event during play
- Sleep disturbance and upsetting dreams
- Disruptive behavior
- Emotional detachment
- Socially isolative
- Loss of interest in activities
- Acting younger than their age
- Increased alertness to the environment
- Physical symptoms such as headaches and stomachaches
- Worry about dying
Post Traumatic Stress Disorder (PTSD): Assessment Findings in Adults and Adolescents
- Sleep disturbance (initiation and maintenance)
- Low frustration threshold
- Socially isolative
- Panic symptoms
- Difficulty with focus and concentration
- Low energy
- Loss of interest
- Feelings of emotional detachment from others
- Decreased performance at work and/or school
- Avoidance of places, people, or situations that are reminders of the event
- Feelings of guilt related to the event
- Increase in risk-taking behaviors
- Suicidal thoughts
Post Traumatic Stress Disorder (PTSD): Non-Pharmacologic Management
** First-line treatment is trauma-focused psychotherapies
- Provide community resources
Post Traumatic Stress Disorder (PTSD): Pharmacologic Management
- Manage sleep difficulty
- In general, avoid benzodiazepines due to increased risk for substance use disorders and making of underlying anxiety symptoms
- SSRIs indicated for PTSD treatment: paroxetine and sertraline
- If chronic pain is present, a SNRI may be helpful for both mood and pain symptoms
- Prazosin is an alpha-1 antagonist that can be helpful for trauma-related nightmares
Post Traumatic Stress Disorder (PTSD): Should TCAs be used for treatment?
- In general, avoid TCAs in this population because they are associated with an increased risk for suicide due to lethality in overdose
Post Traumatic Stress Disorder (PTSD): What kind of medications should be avoided?
- TCAs, due to lethality in overdose
- Avoid antipsychotics and anticonvulsants (quetiapine, olanzapine, divalproex, risperidone, lamotrigine, topiramate) because the harms of these medications outweigh the benefits
Obsessive-Compulsive Disorders (OCD): What is it?
- A chronic neuropsychiatric disorder characterized by time-consuming, distressing, or maladaptive obsessions, compulsions (or both) that are not a direct result of a medical condition or substance use.
- The patient with OCD spends an hour or more per day trying to avoid or control the obsessions, which cause distress in social and occupational functioning. Patients with OCD typically experience obsessions and related compulsions in themes and patterns.
- OCD occurs across the lifespan. Obsessions and compulsions associated with OCD can disrupt work and relationships. Shame and fear may prevent the patient from mentioning the obsessions and compulsions. The astute provider can routinely inquire and be attuned to health consequences of the disorder. Early recognition and intervention may prevent further comorbidities and reduce suffering.
Obsessive-Compulsive Disorders (OCD): Obsessions Definition
- Are repetitive, intrusive, unwanted thoughts, urges, or images that frequently are associated with anxiety and/or avoidance behaviors. They are usually recognized as illogical by the patient.
Obsessive-Compulsive Disorders (OCD): Compulsions Definition
- Are repetitive thoughts or behaviors that the patient feels driven to perform in response to an obsession in order to alleviate anxiety. Compulsive behaviors are often rigid and/or repetitive in their execution.
Obsessive-Compulsive Disorders (OCD): Etiology
- Neurobiologic contributing factors suggest a reduction in serotonin synthesis in the prefrontal cortex and caudate
- This disregulation can be further impacted by altered function among the orbital frontal cortex, caudate, and thalamus
- Dysregulation along the cortico-striatal-thalamic tract that connects the orbitofrontal cortex, anterior cingulate, basal ganglia, and thalamus are hypothesized to be impacted in this disease
Obsessive-Compulsive Disorders (OCD): Risk Factors
- Genetic and Epigenetic: Genetic vulnerabilities and stressful life events, coupled with limited social support and ineffective coping abilities, can place a person at risk for developing OCD
- Infectious: Pediatric autoimmune neuropsychiatric disorder associated with Group A Streptococcal (PANDAS) infection or pediatric acute onset neuropsychiatric syndrome (PANS)
Obsessive-Compulsive Disorders (OCD): Common Obsession Themes
- Cleanliness or avoiding contamination (disgust)
- Persistent doubt
- Symmetry and order
- Intrusive thoughts (forbidden or taboo, aggressive or violent in nature)
- Religious obsessions (concerning religion, morals, sin, or guilt)
- Superstitious
Obsessive-Compulsive Disorders (OCD): Common Compulsions for Cleanliness
Handwashing: excessive showering or changing clothes; not leaving home
Obsessive-Compulsive Disorders (OCD): Common Compulsions for Persistent Doubt
Repeated checking of door locks or ensuring stove is turned off
Obsessive-Compulsive Disorders (OCD): Common Compulsions for Symmetry and Order
Being overly precise while arranging items or completing tasks (specific/repetitive)
Obsessive-Compulsive Disorders (OCD): Common Compulsions for Intrusive Thoughts
Usually without compulsion, often shameful to the patient (may confess to religious clergy or law enforcement)
Obsessive-Compulsive Disorders (OCD): Common Compulsions for Religious Obsessions
Variable; compulsive prayer or religious rituals
Obsessive-Compulsive Disorders (OCD): Common Compulsions for Superstitions
Avoiding working with unlucky numbers, repeating activities the “right” number of times
Obsessive-Compulsive Disorders (OCD): Non-Pharmacologic Management
- Tailor therapy to symptom profile of the patient
- Behavioral techniques for anxiety management training and extinction
- Cognitive Behavioral Therapy (CBT)
- Group therapy
- Psychoeducation
- Involving family in treatment
- Cornerstone of psychological therapies for children is Exposure and Response Prevention (ERP)
Obsessive-Compulsive Disorders (OCD): Pharmacologic Management
- SSRIs are first-line treatment
- Clomipramine, a TCA, is still considered a gold standard for OCD treatment, but it is considered second-line for patients who do not respond to SSRIs. This is due to greater tolerability of SSRIs
- Best to combine pharmacologic management with psychotherapy
- Usual dosage ranges of medications are used to start, but higher doses may be necessary for full effect. Therapeutic effects begin at 4-6 weeks, but 8-12 weeks may be necessary.
An adequate trial of medication at a therapeutic dosage is a minimum of 12 weeks. Serial trials may be required; patient responses vary - SSRI treatment of OCD may require a higher dose and a longer course of treatment than when utilized for other disorders
Attention Deficit/Hyperactive Disorder: What is it?
A complex, highly heritable neurodevelopmental disorder characterized by persistence of shortened attention span, impulsivity, distractibility, and/or hyperactivity that is not within norms for chronological or developmental age and causes clinical impairments. Symptoms may not be evident until patient’s system is challenged beyond their threshold during adolescence and early adulthood.
Attention Deficit/Hyperactive Disorder: Three Subtypes
- Combined type: meets criteria for both inattention and hyperactivity/impulsivity
- Predominantly inattentive type: meets criteria for inattentiveness but not hyperactivity/impulsivity
- Predominantly hyperactive/impulsive type: meets criteria for hyperactive/impulsive type but not inattentive type
Attention Deficit/Hyperactive Disorder: Etiology
- Exact cause unknown
- Studies suggest dysfunction of neurotransmitters (dopamine and norepinephrine) and dysfunction in prefrontal cortex, which influence executive functions
- Many factors seem to contribute: perinatal, behavioral, biochemical, genetic, physiologic, psychosocial, environmental, sensory, and motor functions
Attention Deficit/Hyperactive Disorder: Common Comorbidities
- Autism spectrum disorder
- Anxiety
- Oppositional defiant disorder
- Conduct disorder
- Learning disorders
- Depression
- Tics, Tourette syndrome
- Bipolar disorder
- Substance abuse
- Trauma, adverse childhood events (ACEs)
- In children with ADD/ADHD, 2 out of 3 have a comorbidity; 1 out of 2 has a behavior problem; 1 out of 3 has anxiety
Attention Deficit/Hyperactive Disorder: Incidence
- Estimated to affect 5-11% of school-aged children
- Boys affected at nearly twice the rate of girls; girls often diagnosed later than boys
- Onset < 12 years
- Exists into adolescence and adulthood
Attention Deficit/Hyperactive Disorder: Risk Factors
- Family history and genetic factors explain covariance between hyperactivity and inattention
- Possible association with poor prenatal health (e.g., alcohol or drug abuse, smoking, preeclampsia, prenatal and perinatal stress, low birth weight)
- Traumatic brain injuries, elevated lead levels
- History of ACEs or trauma
Attention Deficit/Hyperactive Disorder: Assessment Findings for ADHD
** Six or more of the following must be present for diagnosis
1. Fidgets, squirms, restless
2. Difficulty remaining in seat
3. Excessive activity
4. Quiet play is difficult
5. Acts as if “motorized”
6. Excessive talking
7. Impatient when forced to wait for turn
8. Blurts out answers to questions before time
9. Interrupts conversation
Attention Deficit/Hyperactive Disorder: Assessment Findings for ADD
** Six or more of the following must be present for diagnosis
1. Realizes careless mistakes when pointed out
2. Exhibits difficulty maintaining attention
3. Difficulty listening
4. Does not finish tasks
5. Organization skills are poor
6. Tasks requiring sustained attention are difficult
7. Forgetful
8. Loses items (shoes, socks, school assignment)
9. Easily distracted
Attention Deficit/Hyperactive Disorder: Non-Pharmacologic Management
Parent, teacher, patient education
Attention Deficit/Hyperactive Disorder: Pharmacologic Management
- Stimulants are first-line treatment; have potential for abuse and addiction
- Other choices are non-stimulants, alpha-2 agonists, antidepressants
- Prescribers must follow state laws
- ADHD medications may exacerbate pre-existing psychiatric illnesses
- Use caution in patients with seizure disorder
Attention Deficit/Hyperactive Disorder: Medications
- Methylphenidate
- Dexmethylphenidate
- Lisdexamfetamine
- Dextroamphetamine-amphetamine
- Methamphetamine HCl
- Atomoxetine
- Guanfacine
- Clonidine
Suicide: Epidemiology
- For attempts: highest in adolescents, then middle-aged
- Highest suicide rates among older men
Suicide: Means
- Firearms (men)
- Hanging (men)
- Poisoning (women)
Suicide: Risk Factors
- Presence of psych disorders
- Hopelessness
- Impulsivity
- History of attempts
- Marital status from highest to lowest:
- Never married
- Widowed
- Separated
- Divorced
- Married without children
- Married with children
Suicide: Important Questions to Ask
- Are you thinking about hurting yourself? (Suicidal ideation, how long?)
- If yes, do you have a plan?
- If yes, do you have the means?
Suicidal Ideation: Non-Pharmacologic Management
- Goals
- Establish safe environment: ensure patient safety in least restrictive environment
- Negotiate contract to do no harm, plus a crisis response plan
- Provide community resources, suicide hotline
Suicide: General Guidelines for Referral
- High suicide risk
- Pregnant or planning to become
- No social support
- Profoundly depressed/disabled by it
- Patients with comorbid conditions
- Children and adolescents
- Patients who do not respond to 1 or 2 trial prescriptions
Suicide: When to Manage in Primary Care
- Moderate to severe symptoms that last more than a month
- Mild to moderate chronic symptoms interfere with life functioning
Autism Spectrum Disorder: What is it?
Neurodevelopmental disorder characterized by persistent social communication deficits and restricted or repetitive patterns of behavior, interests or activities. Autism spectrum disorder is present in the early developmental period and causes varying degrees of functional impairment.
Insomnia: What is it?
A dissatisfaction with sleep quantity or quality resulting in clinically significant distress or impairment in social, occupational, or other important areas of functioning. Among adults with insomnia, the most commonly reported symptoms are difficulty falling asleep or remaining asleep. Many adults with insomnia have a false perception that they are not sleeping at all. Among children with insomnia, caregivers commonly report issues going to bed, difficulty sleeping alone, and/or frequent nighttime awakenings.
- Insomnia is a clinical diagnosis based in part on a detailed sleep history including number and duration of awakenings, duration of problems, and sleep habits.
Domestic Violence: What is it?
Deliberate pattern of intimidation, physical assault, emotional abuse, battery, sexual assault, economic abuse, neglect and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by a family member or one intimate partner against another.
The 4 Types of Child Maltreatment
- Emotional/psychological abuse
- Physical abuse
- Sexual abuse
- Neglect
Adverse Childhood Experiences (ACEs): What is it?
Childhood experiences and exposures that are major risk factors for chronic physical and/or psychological illness
