PSYCH - Panic, Anxiety, Mood Disorders Flashcards
Define mood disorders
disorders in which extreme variatons in mood (either high or low) are the primal feature
in most cases, these variations are maladaptive
Mood disorders can be broken into two moods which are:
mania
depression
*note: these typically occur separately but sometimes can occur simultaneously and create rapidly alternating moods
Define: Mania
intense and unrealistic feelings of excitement and euphoria
Define: Depression
feelings of extraordinary sadness and dejection
Unipolar vs Bipolar disorders
Unipolar: where a person only experiences depressive episodes
Bipolar: where a person experiences both depressive and manic episodes
Manic episode (and criteria/symptoms)
- markedly elevated, euphoric or expansive mood, usually with intermittent bursts of intense irritability or sometimes violence
- Must persist for >1 week and show 3 or more additional symptoms in the same time period
- Inflated self-esteem or feelings of grandeur
- Decreased need for sleep
- More talkative than normal, feels pressure to keep talking
- Racing thoughts/ideas
- Distracted
- Increase in goal directed activity (work, sex, socially) or psychomotor agitation
- Excessive involvement in high risk activities (sexual indiscretions, spending large amounts of money, etc.) - due to inability to see future consequences
What is the most common form of mood episode that people present with?
Major depressive episode
Major depressive episode (and criteria)
- markedly depressed for majority of the day, most days, for >2 weeks
- must exhibit at least 3 or 4 other symptoms (or 5?) (different than normal functioning)
- One symptom must include depressed mood or loss of pleasure
- Depressed mood
- Diminished interest in pleasure in activities
- Decreased ability to think, concentrate
- Feelings of worthlessness or inappropriate/excessive feelings of guilt
- Recurrent thoughts of death, suicide
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Significant weight loss or gain
- Fatigue
- Cause clinically ++distress
If a patient experiences a major depressive episode or a manic episode but not both, do they meet the criteria for mixed episode?
no
Signs and symptoms of a manic episode can cause disturbances that can result in what negative impacts?
- social or occupational activities
- require hospitalization to prevent harm to self, others
- psychotic features
Major mood disorders occur ______x more frequently than schizophrenia.
_____________ is the most common form, and rates are (higher/lower) in women than men.
15-20x
Unipolar major depression
higher in women than men (2:1)
Lifetime risk of developing bipolar disorder is ______%
Is there any difference between sexes?
0.4-2.2% (2006)
no discernable difference between sexes (not a genetic trait, may have predispositions x environmental factors)
What types of depression aren’t considered mood disorders?
- depression that results from recent stress
- dealing with death, grieving
- postpartum depression
What are specifiers?
different patterns of symptoms or features
Specifiers of Major Depression
1) Atypical symptoms:
- Leaden paralysis (heavy feelings in arms or legs)
- Acutely sensitive to interpersonal rejection for long periods
- Brightens to positive events
- More often female than male, respond better to monoamine oxidase inhibitors (MAOI)
2) Melancholic symptoms:
- early morning awakenings
- depressed more in the morning
- more often connected to genetic factors
3) Psychotic symtpoms:
- Mood-congruent delusions or hallucinations
- Tx usually requires antipsychotic meds in addition to antidepressants
- Poorer LT prognosis
Biological Factors that contribute to Unipolar Mood Disorders
Genetic influences:
- prevalence 3x higher among blood relatives w/ Dx than general population
- Monozygotic twins with one twin who meets diagnosis is 2x more likely than dizygotic twins
- Sx such as depressed mood do not appear to be heritable, but symptoms such as loss of libido and/or appetite do
- UMD occurred 7x more often in biological relatives of severely depressed adoptees than control
- Gene-environmental interaction
Neurochemical: increases in NE activity, very little understood
Hormone Regulatory Systems: increased cortisol levels (feedback loop from HPA axis), failure of feedback mechanisms, thyroid irregularities (hypothyroidism common in depressed people)
Neurophysiological & neuroanatomical: stroke studies
Sleep and Biological Rhythms
Psychosocial factors that contribute to Unipolar Mood Disorders
1) Stressful life events
2) Diathesis-stress models: Personality and cognitive predispositions, early adversity and parental loss
3) Psychodynamic: Threats to self-esteem and developmental needs
4) Behavioural
- Depression resulting from either negative reinforcement increases or positive reinforcement decreases
- Not typically very reliable
5) Interpersonal Effects: Lack of social support; Marriage and family life
Differences in sex in regard to unipolar mood disorders
Women:
- 2x as likely to develop unipolar mood disorders than men
- Rumination more prominent in women
- Women statistically have more “negative” interpersonal events
- Evidence that development of secondary sex characteristics harder psychologically for females than males
Men:
- Among school children, boys equally or more likely to be diagnosed
- Men statistically engage in “distracting” activities
Both/neither
- Few exceptions in developing countries such as Nigeria and Iran
- In North America, these differences start in adolescence and continue ~65
- Hormonal factors not very reliable
- Sex differences in neuroticism
- Social factors
Bipolar disorders are distinguished from unipolar disorders by the presence of __________ or __________ symptoms.
manic, hypomanic
Hypomanic
person experiences abnormally elevated, expansive or irritable mood for at least 4 days
- similar symptoms as mania, but to a lesser degree
- less impairment on social, occupational function
- hospitalization not required
Cyclothymic disorder (and symptoms between depressive and hypomanic episode)
Cyclothymic disorder: cyclical mood changes less severe than bipolar. Ppl do not experience delusions and do not show marked impairment caused by manic or major depressive episodes
Cyclothymic depressive episode: dejected, distinct loss of pleasure in activities, low energy, social withdrawal, feelings of inadequacy
Cyclothymic hypomanic episode: spark in creativity and production, increased mental and physical energy
Define:
Bipolar I disorder
Mixed episodes
distinguish from MDD by at least one episode of mania or mixed episode
mixed episode: sx of both full blown manic and major depressive episodes for at >1 week. These can be intermixed or rapidly alternating
Bipolar II
person does not experience full-blown manic episodes but does experience hypomanic episodes and major depressive episode
- more common than Bipolar I
Prevalence/Risks in developing Bipolar I and II
- combined ~3% of population will have either
- equal occurrence in men and woman
- most will experience periods of remission, relatively Sx free
- 20-30% experience significant occupational/interpersonal impairment
- ~60% have chronic occupational/interpersonal impairment between episodes
- ~10-13% of people who have initial major depressive episode will later have manic or hypomanic episode
Causal Factors in Bipolar Disorder
Biological: genetic influences, neurochemical, other brain and thyroid abnormalities
Psychosocial factors: stressful life events, others
Cultural variations
Biological Causal factors of Bipolar Disorder
Genetic influences
- 8-9% of first-degree relatives of those who have bipolar disorder can be expected to receive a diagnosis (~1% in gen. pop.)
- Concordance rates for monozygotic twins (~60%) significantly higher than dizygotic(~12%)
- Genes account for 80-90% variance in the likelihood to develop bipolar disorder
Biological Causal factors of Bipolar Disorder
Neurochemical
- Evidence suggests that increased dopamine activity is linked to manic symptoms, particularly hyperactivity, grandiosity, and euphoria
- Possible that sodium ions have difficulty being transported across neural membranes (evidenced by role of Lithium in tx)
Biological Causal factors of Bipolar Disorder
Other
- Abnormalities in thyroid function
- Shifting patterns in brain activity and blood flow
- Basal ganglia and amygdala enlarged in bipolar disorder
- Increased activation in emotional processing areas of the brain
Psychosocial factors for Bipolar Disorders
- Stressful life events: important in predisposition
-
Other:
- low social support
- personality and cognitive variables
- striving and increased sensitivity to reward in the environment predicts increases in manic symptoms
- pessimistic attributional style (someone who is always negative)
Cultural Variations in unipolar and bipolar mood disorders
- Western countries see higher rates of depression
- Non-Western countries have more somatic manifestations of depression, vs more psychological manifestations in Western countries
- Cultural beliefs about autonomy and independence (more common in Western cultures) attributed to greater psychological (internal) manifestations
- Some cultures show signs of outwards transgression towards others instead of feelings of guilt or self-deprecation
- Very little is understood about the prevalence discrepancies between countries
- In Canada, depression higher among Aboriginals
- Research indicates rates of unipolar depression are inversely proportional to socioeconomic status
- Research indicates that bipolar disorder is more directly proportional to socioeconomic status
Treatment options and recovery time in mood disorders
- Majority of patients will recover without treatment (often only temporarily) within <1 year
- more than half of people with mood disorders receive inadequate or no treatment at all
- Types of treatment:
- Meds (antidepressants, antipsychotics)
- Lithium and other mood-stabilizers (anti-manic and anti-depressant effects)
- Electroconvulsive therapy (usually for immediate & serious suicidal risk)
- Transcranial Magnetic Stimulation (brief, intense magnetic fields that induce electrical activity in certain parts of the brain)
- CBT & BA
- Interpersonal Therapy (not widely available)
- Family and Marital Therapy
Definition of suicide
The act of taking one’s own life
Demographics and prevalence for suicide
- 1 in 10 leading causes of death in most Western countries
- Approximately one person attempts suicide every 31 seconds
- Experts believe actual suicide numbers are 2-4x higher than reported numbers due to self-inflicted death being attributed to “other” causes
- ~40 to 60% of those who commit suicide do so during a depressive episode/during the recovery phrase
- Depressed people are 50x more likely to commit suicide
- ~90% of suicide patients have some psychiatric disorder (~60% of these ppl have a mood disorder)
- Estimates suggest that 20-25% of pts who commit suicide have attempted suicide in the past. Those who have made attempts are higher risk for actual suicide
- Rates of completed suicide are highest among those aged between 45-54, equally high rate for the elderly (80 and over)
- Elderly patients are ~50% more likely to commit suicide than the nation as a whole
- 80% of students who die by suicide have never contacted a mental health professional
- Aboriginals and Caucasian Americans have the highest rates of suicide
- Among pts who were hospitalized for suicidal ideation or intent, ~80% denied suicidal ideation the last time they spoke with a clinician
- Additionally, 50% of those who committed suicide did so while on 15-minute suicide watch or 1:1 observation
Risk factors for suicide attempts
- female, young, undereducated, unmarried/divorced, mental disorders
- 1.5 : 1 ratio W:M - suicide attempts
- Men (typically older males) are 4x more likely to commit the act
- partially attributed to stats re: methods of suicide
- Males: choose quickly, more lethal methods (firearms, hanging)
- Females: OD on drugs
What three factors are interrelated that contribute to a patient following through with suicide?
1) suicidal ideation
2) suicidal plan
3) attempted suicide attempts
____ % of people who have suicidal ideation will continue to suicidal plans and attempts in the following year.
~60%
Which population of people have the higher risk of suicide?
Those with mood disorders (15%)
The average risk of suicide in the general population is ~ ____%
1.4
Health care professionals are at a (lower/higher) than average risk of suicide.
higher
Factors affecting suicide
- Generally attributed to hopelessness about the future (also in YAs because they can’t see consequences of the future)
- Linked to childhood psychopathology, child maltreatment & family instability
- Low self-esteem
- Poor problem solving skills
- Reduced serotonin functioning
- Race/ethnicity- Aboriginals have significantly higher levels of suicide
- Religious taboos/beliefs
- Unemployment
True or False. Most people do not wish to die, they just want to end their suffering.
True
True or False. Months leading up to a person’s suicide, they often communicate clear thoughts about suicidal intent or have engaged in discussions aboure death or dying
True
Warning signs/behaviours of suicide
- Sleep issues
- Feelings of hopelessness
- Severe sadness or mood changes
- Withdrawal
- Sudden calmness - euphoric phase because they are at peace
- Changes in personality/appearance- sudden disinterest/care about appearance
- Dangerous or self-harming behaviours
- Recent trauma/life crisis
- Making preparations- Setting up a will, clearing bank accounts, giving away personal possessions, etc.
- Threatening or discussing self-harm, suicide
Factors to consider as a paramedic when responding to suicide calls
- Consider your body language - getting to a patient’s level tells them you see them as an equal and allows for better and more honest communication
- Ask clear, direct questions - suicidal ideations, plan, have they gathered needed resources for that plan, have they considered suicide in the past
- Refer to the MHA - Once a pt threatens suicide (seemingly harmless or not) they must be transported under the MHA. If pt does not come willingly, contact police
- Be cognizant of your language - Keep things simple. Do not allow the pt to direct the conversation. Be mindful of how you are saying things and remain calm.
- Take the threat seriously - Even if a pt says they were worked up, or have changed their mind, this should not change plans for transportation
- Be patient-focused - Avoid bringing in personal experience. Communicate solely about the patient and express your concern for their well-being
- Be prepared - Suicidal patients may become agitated or unpredictable. Always be mindful of your surroundings and have an exit strategy.
Resources for addressing suicide ideations/attempts
- suicide hotlines
- Speaking to a trusted doctor/clinician or MH professional
- contacing teacher/supervisor
- online forums
- asking for help, expressing your concener
- MH resources within your service (such as EAP)
Anxiety Disorders
a group of disorders that are characterized by symptoms of fear and anxiety
Neuroses
psychological disorders that are characterized by anxiety, depression and unhappiness that does not correspond to the pt’s life circumstances
Neurotic Behaviour
mental, emotional and/or physical reactions that are drastic and irrational
Fear/Panic
- basic emotion that invokes the sympathetic nervous system’s fight or flight response
-
Fear: near instantaneous reaction to any imminent threat (has an adaptive value)
- distinguish from anxiety
Anxiety
fear or apprehension about the future (immediate or long term)
a complex mix of unpleasant emotions/cognitions that is more diffuse and oriented to the future than fear
Anxiety disorders affect ~ ____% of Canadians.
In 2005, estimated that ______% of the population will be affected by anxiety disorders in their lifetime
4.6%
25-30%
Anxiety disorders can result in various problems that are ___________ in nature.
a) personal
b) economic
c) health-care related
d) all of the above
d) all of the above
Anxiety disorders include what conditions?
- Phobic disorders
- Panic disorders
- Generalized Anxiety Disorder (GAD)
- Obsessive-Compulsive Disorder (OCD)
- PTSD
All disorders on a sliding scale/spectrum
Panic Attack
- when fear/panic response occurs in the absence of obvious external danger S&S of panic attack are similar to fear but also include:
- Sense of impending doom
- Are broken into three components
- Cognitive/subjective - “feeling” afraid
- Physiological - Increased HR, BP
- Behavioural - stronge urge to escape
What are the three components that make up anxiety?
1) Subjective/Cognitive: feelings of fear/out of control, -ve mood, self-preoccupation, worries of possible threat/danger, difficulty concentrating
2) Physiological: increased HR and BR, state of tension/over-arousal, higher oxygen demands, diaphoresis
3) Behavioural: Avoidant behaviour, no immediate urge to flee or escape
Phobia
persistent and disproportionate fear of some specific object or situation that presents little to no legitimate danger, yet produces avoidant behaviours
3 main categories: specific phobias, social phobias, agoraphobia
Specific phobias - definition, behaviours, and treatment
- strong and persistent fear that is excessive and/or unreasonable, triggered by a specific object or event
- When encountering phobic stimulus, often elicits a panic response
- avoidance of stimulus (ex: heights, blood, snakes, enclosed spaces)
- lifetime prevalence 12%
- age of onset varies, more predominant in women
- results from traumatic conditioning
- common tx: exposure therapy
Social phobias - definitions, behaviours, demographics, tx
- aka social anxiety disorder
- characterized by disabling fears of one or more specific social situations
- 3 - 7.2% meet criteria in any given year
- more common in women > men
- most common form: fear of public speaking
- usually begins in adolescence or early adulthood
- ~1/3 abuse alcohol to reduce their anxiety
- learned from classifical conditioning, evolutionary fear of others, cognitive vulnerability to rejection
- Tx: CBT, meds
Agoraphobia
- fear of public spaces
- most commonly avoided: streets, malls, movie theatres, stores
- attributed to panic attacks in one or more of these settings
- often frightened by own bodily reactions that will cause arousal
- usually expands from one setting to generalized settings
- 0.7% affected in Canada
- usual onset between 15-24
- much more common in women
- results from biochemical + anatomical abnormalities, social factors
- Tx: meds, CBT
Panic disorder
characterized by the occurrence of “unexpected” panic attacks that often seem unprecedented
Panic Attack: Cognitive S&S
Cognitive:
- Depersonalization: feeling of being detached from one’s body
- Derealizatoin: feeling that external world is not real
- Fear of death/dying
- Fear of “going crazy”, losing control
Panic Attack: Physical S&S
- increased HR, palpitations
- diaphoresis
- shaking/trembling
- feeling of choking
- feeling SOB or “smothered”
- CP or chest tightness
- N/V or abdo pain
- feelings of lightheadedness, dizziness, faint
- chills, hot flashes
- paresthesia
- dilated pupils
How long do panic attacks last?
- brief and intense, typically reaching peak intensity at 10 min mark
- usually subside afer 20-30 minutes, rarely lasting longer than 1 hour
Why would patients who experience panic attacks seek emergency medical attention?
Because physical nature of panic attacks can be alarming (like chest pain, diaphoresis), 8% will seek medical attention.
Mostly for neurological, cardiac, and respiratory concerns
Demographics/prevalence for panic disorder
- 4.7% of adult population has had panic disorder at some point in their lives (2005)
- Age of onset primarily between 15-24
- ~ 2x more common in women than men
- 50% have co-morbidities
- 80-90% report first panic attack occurred after negative life event
- Has some genetic and environmental/social causes, not very well understood
Treatment for panic disorders
- medications: benzodiazepines (Xanax, clonazepam)
- quick acting (~30-60 minutes)
- can cause drowsiness, sedation, impaired cog. function & motor performance
- addictive
- antidepressants - particularly SSRIs
- CBT
- exposure therapy
Factors that paramedics should consider when responding to anxiety/panic calls
- Mindful positioning - Ensure you give the pt space but remain in sight for reassurance
- Recognize it - Acknowledge that this is an anxiety disorder and it will pass
- Stay calm
- Give them time - rushing a pt, or pushing them for diagnostics may aggravate symptoms (only do so in life threatening situations, or where pt harm is evident)
- Offer your assistance - attempt to coach breathing, give them the opportunity to state their feelings
- Assume underlying organic causes and rule out medical/traumatic concerns
- Provide supportive care
- Initiate transport based on clinical findings
Generalized Anxiety Disorder (GAD)
disorder where anxiety becomes chronic, excessive, and unreasonable
Presentation of GAD
- Excessive and relatively constant state of future-oriented anxiety
- Pt finds it difficult to cope with worry
- Restlessness
- Chronic fatigue/easily fatigued
- Difficulty concentrating
- Irritability
- Muscle tension
- Sleep disturbances
Prevalence & Age of Onset of GAD
- ~3% of population affected
- 2x as common in women
- Most common anxiet disorder
- Majority of pts manage to function normally
- Pts less likely to seek psychological tx, usually frequent medical complaints
- Age of onset varies
- Often occurs alongside other anxiety, mood disorders
Causal factors in GAD
Psychosocial:
- cognitive biases
- unpredictable/uncontrollable life events
Biological:
- GABA deficiency
- Hormonal imbalances
- Strong attribution to the limbic system (BNST - threat anticipation; Amygdala - threat confrontation)
Tx for GAD
- Benzos typically over- or mis- used for reduction of somatic symptoms - Valium, Lorazepam (Ativan)
- Antidepressants (SSRIs and venlafaxine most common)
- CBT
Obsessive-compulsive disorder (OCD)
the occurrence of unwanted, intrusive thoughts or distressing images. Usually accompanied by compulsive behaviours that are performed to neutralize obsession or to prevent some dreaded event
Obsessions
persistent and recurrent intrusive thoughts, images, or impulses experienced as disturbing and/or inappropriate
Compulsions
- two diff ways:
- repetitive behaviours (handwashing, checking appliances, etc)
- covert mental acts (mantras, counting, praying)
- very rigid rules on how compulsions are performed
- goal is to reduce distress or prevent occurrence of negative event
Vicious cycle of OCD
OCD is common in what population(s)?
1. Obsessive thought - cause marked distressed and interfere with normal functioning/time consuming
2. anxiety
3. compulsive behaviour
4. temporary relief (and then continues in a cycle)
Pt realizes that obsession is excessive and unreasonable but can’t stop (will lead to being late, sores/skin irritations) - common in athletes, performance-based careers
Prevalence & Age of Onset of OCD
- Average lifetime prevalence is ~1.6% (2005)
- 98% of those who seek tx have both obsessions and compulsions
- Divorced (separated), and unemployed people have higher rates of OCD
- Typically begins in late adolescence, early adulthood-can also be seen in young children
- Very little difference in gender
- Most cases have gradual onset- usually becomes chronic & waxes and weans over time
- ~1/3 of OCD pts also experience major depressive episodes
- Most often co-occurs with social phobia, panic disorder, GAD, and PTSD
3 main risk factors that can cause OCD/OCD types
Genetics: those with 1st degree relatives who developed OCD as a child/teen have significantly higher risk of developing OCD
Brain structure: specific areas affected & neurochemical imbalances
Environment: experiencing physical, sexual or emotional abuse at a young age
Treatment of OCD
- behavioural therapy - best when combining exposure and response prevention
- Cognitive therapy
- Medications - primarily affecting serotonin (Prozac, clomipramine)
- Surgery (rare cases)
Sociocultural differences in anxiety disorders
- anxiety manifestations can be different from culture to culture
- Nigeria - fears of witchcraft “feeling of something like water on my brian”
- India - possession by spirits, sexual inadequacy
- China - Koro - fear that genitals or sex reproductive organs are shrinking
- Japan - Taijin Kyofusho - similar to social phobia, fear of embarrassing of offending others
