Psych Pathophys Flashcards
Major Depressive Disorder
Epidemology
- 7% of US population
- 18-29 yrs, females most common
Major Depressive Disorder
Risk Factors
- family hx (2-4x higher risk if first degree relative has)
- concurrent DM, obesity, CVD
- Poor interpersonal relationships (divorced, isolated)
SOCIOECONOMIC STATUS NOT A RISK FACTOR
Neurotransmitters
Adrenaline/Epinephrine
- fight or flight
- produced in stressful situations, increases heart rate/blood flow, leads to physical boost w/ heightened awareness
Neurotransmitters
noradrenaline/norepinephrine
- concentration
- affects attention & responding actions in the brain
- contracts blood vessel, increases blood flow
Neurotransmitters
dopamine
- pleasure
- feelings of pleasure, movement, motivation
- people repeat behaviors that lead to dopamine release
Neurotransmitters
serotonin
- mood
- contributes to well being and happiness
- helps sleep cycle and digestive system regulation
- affected by exercise
Neurotransmitters
Serotonin Side Effects
- n/v/d
- HA, dizziness
- induces mania/hypomania
- increased bleeding risk (because there are serotonin receptors on platelets)
- bone fx
- sexual dysfunction (reduced libido, inability to climax)
Neurotransmitters
GABA
- calming
- calms firing nerves in the CNS
- high levels improve focus
- low levels cause anxiety
Neurotransmitters
acetylcholine
- involved in thought, learning, and memory
- activates muscle action in the body
Neurotransmitters
glutamate
- memory
- involved in learning and memory
- regulates development and creation of nerve contacts
Neurotransmitters
Endorphins
- euphoria
- released during exercise, excitement, sex
- produces sense of well being and pain reduction
Escalation of Treatment Resistant Depression
- Level I: Begin with an adequate trial of a first-line antidepressant (usually a generic formulation of an SSRI or SNRI)
- Level II: Switch to another first-line antidepressant (some favor switching to a different type of medication, eg, mirtazapine)
- Level III: Patented antidepressants, combinations and adjuncts or older antidepressants (ie, TCAs or MAOIs)
- Level IV: Neuromodulation strategies (TMS or ECT), ketamine infusions or intranasal esketamine
- Level V: VNS or unproven or experimental strategies
Psychotic Disorders
what is psychosis?
- Delusions
- Hallucinations
- Disorganized speech
- Grossly Disorganized or catatonic behavior
- Negative symptoms
Psychosis
Delusions describe
- Fixed beliefs that one holds despite evidence to the contrary
- cognitive distortion
- Various themes
- The distinction between a delusion and a strongly held idea is sometimes difficult - delusions typically cannot be broken
Ex. A patient has delusions that she won a house, she fully believes this despite lack of evidence. She packs her things, tells her family she is moving, etc.
Psychosis
describe hallucinations & types
- Perception-like experiences that occur without an external stimulus.
- sensory based
- Vivid, clear, with the full force and impact of normal perceptions, and not under voluntary control
- Be sure to distinguish Inner dialogue (intrusive thoughts) vs perceived sounds
- Hallucinations while falling asleep or waking up are normal (Hypnagogic Hallucinations)
Types
* Auditory is most common in psychotic disorders - usually in the form of a voice, not just a noise
* Others include: visual, tactile. Olfactory and gustatory typically medical cause involving temporal lobe.
Psychosis
Disorganized Thinking/Speech
- Disorganized thinking is typically seen in the presentation of disorganized speech
- Symptoms must be severe enough to impair effective communication, but may be mild if in prodromal or residual phases of psychosis
Types
* Derailment - switching from topic to topic with no logical connection
* Thought blocking - sudden and involuntary interruption
* Tangentiality - answers to questions are seem to be unrelated and gradually deviate
* Incoherence - unintelligible sounds that may or may not be words
* Word salad - mix of seemingly random words strung together in a “sentence”
Psychosis
Grossly Disorganized Behavior
- Behavior that seems bizarre, without purpose or inappropriate.
- Ex: childlike silliness, unprovoked agitation, pacing aimlessly, inappropriate giggling, poor hygiene
- Included catatonic behavior, which is marked decrease in reactivity to the environment
Can range from….
* Resistance to instructions (negativism)
* Maintaining a rigid, inappropriate or bizarre posture (waxy flexibility)
* Complete lack of verbal and motor response (mutism and stupor)
* Purposeless and excessive motor activity without obvious cause (catatonic excitement)
Psychosis
Negative Symptoms
- lacking “something”
- Diminished emotional expressions - reductions in the expression of emotions in the face, eye contact, intonation of speech and movements of the hand, head, and face that normally give an emotional emphasis to speech
- Avolition - decrease in motivated self-initiated purposeful activities
- Alogia - diminished speech output
- Anhedonia - lack of interest, happiness
- Asociality - apparent lack of interest in social interactions
- Account for a substantial portion of the morbidity associated with psychotic disorders
Psychosis
Delusional Disorder types:
* erotomanic
* grandiose
* jealous
* persecutory
* somatic
- Erotomanic: delusion that another person is in love with the indivudal
- Grandiose: delusion or conviction of having an undiscovered talent
- Jealous: delusion that spouse/partner is unfaithful
- Persecutory: delusion that one is being conspired against
- Somatic: delusions involving bodily functions
Schizophreniform Disorder
Specifiers
* w/ good prognostic features
* w/out good prognostic features
* w/ catatonia
W/ good prognostic features
* 2+ of the following:
* onset of prominent psychotic symptoms within 4 weeks of the first noticeable change;
* confusion/perplexity;
* good premorbid social and occupational functioning;
* absence of blunted or flat affect
w/out good prognostic features
* when 2+ of abvoe aren’t met
w/ catatonia (self explanatory)
Psychosis
typical vs atypical antipsychotics
Typicals
* 1st gen
* reduce dopamine
* work best on positive sx
* risk of EPS and anti-HAM sx
Atypicals
* 2nd gen
* decrease dopamine; increase serotonin
* works on pos and neg sx
* risk of metabolic side effects
Bipolar Disorders
Epidemiology of 1 vs 2
Bipolar 1
* 0.6% population
* M=F but men have manie and women have depression/cycling
Bipolar 2
* 0.8% of population
* F > M
* avg onset mid 20s
no relationship between life events, personality, childhood experiences, or race
Bipolar Disorders
Risk Factors/Complications 1 vs 2
Bipolar 1
* 6-7% die from suicide w/ highest risk immediately after hospital discharge
* very heritable (73-79%)
Bipolar 2
* hypomanie causes less impariment but depressive episodes are severe
* 33% attempt suicide with 6-7% dying
* 5-15% have manic episode and lead to bipolar 1 dx
Bipolar
diagnostic clinical tips for bipolar
- If patient states they have bipolar, still ask full mania hx to confirm
- Mood changing by the hour and situation related → think BPD
- If SSRIs are not working → consider bipolar
- If SSRI’s trigger mania → Bipolar
- Depressive episodes in childhood/adolescence → keep bipolar on your radar. ⅔ of bipolar patients have a major mood disorder in childhood/adolescence
- Can be hard to distinguish as it can look like and occur simultaneously with drug use, ADHD and BPD. (and even NPD… very had to distinguish)
Bipolar Diosrder
clinical tx tips
- Acute mania → think lithium and/or depakote +/- SGA
- Depression → think lamotrigine (off label) + approved antipsychotic
- Rapid cycling → Seroquel is a good option
- Augment with antipsychotics, they work faster!
- Bipolar II can sometimes be treated with SSRIs + mood stabilizer
- You may need to tx other conditions such as ADHD, anxiety, SUD.
Bipolar Disorder
Tx Takeaways
- Almost all SGAs will treat mania. Choose based on side effects, comorbidities and past med trials.
- Seroquel will treat mania, maintenance and depression
- Vraylar will treat mania, mixed and depression.
- Only bipolar depression tx include: Seroquel, Latuda, Vraylar and Symbyax (olanzapine/fluoxetine).
Why not SSRIs/SNRIs??
* Not typically effective and can trigger mania in some patients
* Will sometimes with in bipolar II with concurrent mood stabilizer
Anxiety Disorders
Anxiety Epidemiology
- more common in women than men
- age of onset late teens/20’s and in elderly
- important to know how patient is coping (EtOH, drugs, rx, ED, cutting, exercise, therapy)
- high co-morbidity in presence of phobia, substance abuse, panic disorders
BATHE Model for Mental Health Interviewing
- Background: “what has been going on”
- Affect: “how do you feel about that”
- Trouble: “what troubles you the most”
- Handle: “how are you handling this”
- Empathy: “this must be difficult for you”
- compressed therapy/limited
- focuses on the present NOT the past
- make connections between thoughts and actions/choices to change your thinking/behaviors (ultimately chaning emotions)
- highly structured w/ clear goals/practical techniques
- pt may have homework
- empowers patient to make choices
similar effectiveness compared to meds but better long term outcomes
Psychotherapy/Psychodynamic Therapy
- unlimited time (pt decides when to stop)
- rooted in Freud
- less structure, no homework
- Pt leads sessions
- Transference (discuss the past & how it affects the present)
- explores unconscious thoughts & past experiences to gain insight into present thoguhts/emotions
- goal is to better understand self/health emotional wounds
Exposure Response Therapy
- used a lot in PTSD & phobias
- based on habituation (desensitization)
- exposure to a fear for a set amount of time & they learn that they are safe
EMDR
- PTSD therapy
- processing the trauma while stimulating different areas of brain w/ light, vibration, or sound (thought to disrupt stored trauma by dual stimulation)
- helps people dissociate form feelings of the event and introduce more logic to the event
Non-Pharm tx for Anxiety
- TLC: stress management techniques, yoga, exercise, relaxation therapy, mindfullness time
Somatic Therapy for Anxiety Disorders
- Transcranial Magnetic Stimulation (TMS): noninvasive procedure that delivers magnetic pulses to the brain to alter nerve cell activity in specific areas of the brain ( usually cerebral cortex) that regulate mood; indicated for anxiety, ocd, ptsd- non painful. Treatment is 4-5 times a week for 4-6 weeks x 40 minutes
- Acupuncture: Stimulating specific points seeks to balance energy flow through meridians; positive data in PTSD and GAD
Complimentary Therapies for Anxiety Disorders
- yoga
- counting method
- power therapies (focus on trauma while getting acupuncture)
Anxiety Disorders
Rx for anxiety
- SSRIs (sub: SNRI): first line for GAD/Panic Disorder, few SE
- TCAs
- MAOIs (not typical to see in modern day)
- Benzos (see largely in older ladies; caution due to addiction)
- Anxiolytic (Buspirone- takes 2-3 mo to have noticable effect, should be used w/ SSRI)
Misc Meds
* Beta Blockers (controls physical sx)
* Benzos (last resort)
* Anti-Histamines (sedating)
Anxiety Disorders
Unapproved/Emerging Therapies
- Ketamine: dissociative psychedelic; affects glutamate which regualtes pain perception, emotion, learning
- D-Cycloserine: acts on NMDA and glutamate receptors
- MDMA: affects dopamine, serotonin, norepi, oxytocin, cortisol, prolactin, vasporessin
- Sirolimus
OCD
types
5
- contamination: hand washing/cleaning
- pathologic doubt/safety: worry about things = repetitive checking
- intrusive thoughts: obsessive thoughts w/out compulsions
- symmetry: rearranging items in extremely slow/precise methods
- misc: nail biting, picking, religious obsession, hair pulling
Hoarding
specifiers
4
- With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space. (Approximately 80 to 90 percent of individuals with hoarding disorder display this trait.)
- With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.
- With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.
- With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.
trauma/stress & the brain
- The most primal function of the brain is to keep us alive. Trauma affects the brain
- Limbic brain: “reptilian brain”, develops in utero, located in the brain stem, tells us to cry, void, eat; shape in response to experience- emotions, safety, pleasure, threat
- Traumatized people perceive the world differently
- After trauma, the brain and nervous system have altered sense of risk and safety
- Cortisol levels remain elevated in a person who has been exposed to stress or trigger
- MRI of people with trauma look different ( activated right hemisphere (intuitive, emotional, visual, spatial, and tactual brain- carries feelings related to an experience) and deactivated left hemisphere ( linguistic, sequential, and analytical- does the talking)
- Leads to people being “stuck” in fight or flight. You cannot process an event if you are overwhelmed by it- stuck in R brain thus cannot be logical (L brain); remains “raw and undigested”
3 pathways of stress response in the brain
- social engagement (call for help/support or comfort)
- fight/flight
- freeze/collapse
Substance Abuse Disorders
pathophys of the “reward” pathway in the brain for drug use
- In a “normal brain” dopamine is released from the ACC to the NC when we do things that promote survival (drinking water, eating food, having sex, and sleeping) as a positive reinforcement mechanism.
- Various substances, including all of the most commonly abused substances, hijack this system by releasing significantly higher levels of dopamine from the ACC into the NC, and for a greater duration of time. After this occurs, victims are now much more likely to repeat the behavior as nothing else is able to produce that type of euphoria - their reward center has been introduced to a new threshold of pleasure
Substance Abuse Disorders
pathophys of the “frontal lobe/cortex” pathway in the brain for drug use
Frontal lobe is responsible for:
* Storing negative consequences to avoid poor actions in the future
* Inhibiting impulsivity and appropriately delay gratification
Patients with addiction have a severely underdeveloped frontal lobe. Meaning high impulsivity and difficulty recognizing consequences of poor choices.
Substance Abuse Disorders
pathophys of the “memory” pathway in the brain for drug use
Addiction also affects neurotransmission and interactions between….
* The cortical and hippocampal circuits and the nucleus accumbens, such that the memory of previous exposures to rewards (such as heroin) leads to a biological and behavioral response to external cues → triggering craving and/or engagement in addictive behaviors.
Substance Abuse Disorders
pathophys summary
- inactive frontal lobe (reduced impulse control, reduced ability to utilize learned social behavior/logic)
- Hyperactive reward center (has new/high stanards for gratification)
those together = pt w/ very little control over their drug use
Substance Use Disorders
genetic components
- Resiliencies which the individual acquires (through parenting or later life experiences) can affect the extent to which genetic predispositions lead to the behavior and other manifestations of addiction
- Patients can be born with underlying biological deficits in the function of reward circuits resulting in a exaggerated reward response within the NA
Substance Abuse Disorders
DSM Criteria (for any substance disorder)
a problematic pattern of “substance” use leading to clinically significant impairment or distress characterized by 2+ within 12 mo period:
* Substance is taken in larger amounts or over a longer period than was intended
* There is a persistent desire or unsuccessful efforts to cut down or control substance use.
* A great deal of time is spent in activities necessary to obtain, use, or recover from it’s effects
* Craving, or a strong desire or urge to use the substance
* Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
* Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
* Important social/work/ rec activities are given up or reduced because of use
* Recurrent use in situations in which it is physically hazardous
* Use is continued despite knowledge of having a persistent or recurrent physical or psych problem that is likely to have been caused or worsened by substance
* Tolerance
* Withdrawal
