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
Substance Use Disorder
Severity
- mild: 2-3 criteria met
- moderate: 4-5 criteria met
- severe: 6+ criteria met
Substance Use Disorders
specifiers
- in early remission: no criteria met for 3+ mo but less than 12 mo (except cravings)
- in sustained remission: no criteria for 12+ mo (except cravings)
Alcohol Use Disorder
Risk Factors
- Family history of alcohol use disorder and other substance use disorders
- Availability of alcohol
- Heavy alcohol use
- Binge drinking
- Permissive societal attitudes towards alcohol use
- History of childhood abuse
- History of conduct or mood disorder in childhood
- Having mental health conditions such as depression or post-traumatic stress disorder
- Impulsivity
Alcohol Use Disorder
at risk drinking vs binge drinking
At Risk Drinking
* men: > 4 drinks/day or > 14 drinks/wk
* women: > 3 drinks/day or > 7 drinks/wk
* any gender > 65 yrs: > 3 drinks/day or > 7 drinks/wk
Binge Drinking
* men: 5+ drinks in 2-3 hr period
* women: 4+ drinks in 2-3 hr period
Alcohol Use Disorder
Complications
- Gastritis
- Stomach/duodenal ulcers
- Liver cirrhosis
- Pancreatitis
- Esophageal and stomach cancer
- Hypertension
- Cardiomyopathies, hypertriglyceridemia, elevated LDL
- Myopathies
- Severe memory impairment
- Degenerative changes in the cerebellum
- Thiamine deficiency → Wernicke-Korsakoff Syndrome
Alcohol Use Disorder
Lab markers
- BAC, or blood alcohol concentration: (>200mg/dL in any non-tolerant pt should demonstrate severe intox)
- GGT (gamma-glutamyltransferase): normal to high value; about 70% of patients with elevated GGT are persistently heavy drinkers (8+ per day)
- CDT (carbohydrate-deficient transferrin): levels of > 20 units can be useful in identifying individuals who drink/abuse alcohol regularly
- MCV: normal to high; not a good predictor of abstinence due to long lifespan of RBC’s
- LFT: AST:ALT ratio > 2:1 is indicative of heavy alcohol use
Opioid Use Disorder
opioids
10
- Morphine
- Heroin
- Meperidine
- Methadone
- Propoxyphene
- Oxycodone
- Hydrocodone
- Hydromorphone
- Diphenoxylate
- Fentanyl
Opioid Use Disorder
Risk Factors
- Access to and availability of opioids
- Previous exposure to substance use (e.g., having friends or family who use substances)
- Current or past substance use disorder
- Family history of substance use disorder
- Having mental health conditions such as depression or post-traumatic stress disorder
- History of abuse during childhood
- History of conduct disorder as a child or adolescent
Stimulant Use Disorder
what drugs?
- cocaine
- methamphetamine
- amphetamine
- ADHD meds
Sedative/Hypnotic Anxiolytic Use Disorder
which meds are included in this?
- Xanax
- Valium
- Ativan
- Lunesta
- Ambien
- Belsomra
- Rozerem
- Halcion
Phencyclidine Use Disorder
which drugs?
3
- PCP
- Angel Dust
- Ketamine
Hallucinogen Use Disorder
what drugs?
3
- LSD
- Peyote
- Psilocybin
Inhalant Use Disorder
what drugs?
- nitrous
- spray paint
- butane
- markers
- glue
- cleaning solutions
- air conditioning refrigerant
Autism Spectrum Disorder
risk factors
- advanced maternal age
- low birth wt
- exposure to depakote
- family hx
Personality Disorders
generally describe
- Patterns of behaviours and inner experiences that deviates significantly from the expectations of an individual’s culture
- Pervasive and inflexible
- Typically present in adolescents to early adulthood and is life-long
- Causes impairment but not necessarily destress
Personality Disorders
Risk Factors
3
- neglect
- childhood abuse
- genetic factors (twin studies)
Personality Disorders
egosyntonic vs egodystonic
- EGOSYNTONIC: behaviors, values, and ideas that are aligned with the ideal self & current self image (most here)
- EGODYSTONIC: behaviors, values, ideas that aren’t aligned w/ the ideal self
Personality Disorders
tools for assessment
- million clinical multiaxial inventory (MCMI): self administered, true/false inventory of 344 items
- minnesota multiphasic personality inventory (MMPI): used to assess pt more globally (500+ items)
Personality Disorders
Cluster A vs B vs C
- A: odd/eccentric; schizoid, schizotypical, paranoid
- B: dramatic/emotional/impulsive; histrionic, narcisssistic, borderline, antisocial
- C: anxious/fearful; avoidant, dependent, obsessive-compulsive
Schizoid Personality Disorder
summary
A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings
Schizotypal Personality Disorder
summary
A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior
Paranoid Personality Disorder
Summary
A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts
Histrionic Personality Disorder
summary
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts
Borderline Personality Disorder
summary
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts
Narcissistic Personality Disorder
summary
A pervasive pattern of grandiosity, need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts
Anti-Social Personality Disorder
summary
- asa psychopathy (born) vs sociopathy (made)
- A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years
Avoidant Personality Disorder
Summary
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning in early adulthood and present in a variety of contexts
Dependent Personality Disorder
Summary
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation
Enuresis
describe
- Involuntaryloss of urine in children
- Can occur in the daytime, at night, or both
Enuresis
Risk Factors
- younger age
- male sex
- family hx enuresis (1 parent = 44%; 2 parents = 77%)
- psychiological stress (divorce, birth of sibling)
Enuresis
pathophys options
Multi-Factorial
* Decreased arousal from sleep in response to a full bladder
* Delayed bladder maturation
* Decreased ADH (vasopressin) production or alteration in circadian release
* Decreased functional capacity of the bladder
Encoporesis
generally describe
Involuntary or unintentional passage of feces in inappropriate situations in children older than 4 years of agein the absence of neuromuscular disease
Encopresis
classsifcation/subclasses
Classified as:
* Retentive: associated w/ constipation, secondary overflow and leakage of stool around the obstruction (80% of cases)
* Non-Retentive: w/out constipation
Subclasses
* Primary: fecal continence has never been achived
* Secondary: fecal incontinence returns after successful toilet training; marked by higher level of stressors/psychological disorders
Encopresis
associated sx of renentive vs non-retentive vs both
Retentive
- large stool volume with BM
- painful defecation
- abd pain
- careful diet hx (excessive diary, insufficient fiber)
Non-Retentive
- no evidence of retention
Both
- hx concurrent behavior problems or recent change in school performance
- potentially traumatic changes at home
Encopresis
what does nocturnal incontinence indicate?
SEVERE FECAL IMPACTION IN RECTUM
Suicide
Ideation vs attempt vs successful attempt
- Ideation: thoughts of hurting oneself (can range from plan to fleeting consideration); does not necessarily include the final act of suicide
- Attempt: non-fatal, self directed, injurious behavior w/ the intent to die; may not result in injury/death
- Successful Attempt: death caused by self directed, injurious behavior w/ intent to die
Suicide
epidemiology
- 10th most common cause of death
- 2nd leading cause of death among individuals aged 10 -24 (after unintentional injuries)
- One death every 11 minutes
- Women attempt suicide 3–4x more often than men
- Men are 4x more likely to complete suicide (Men aged 85 and older have the highest rateof suicide)
Suicide
Suicide and Crisis Lifeline #
988
Suicide
Risk Factors
- Prior attempt (greatest risk factor)
- Access to a firearm
- Men > 65 years old
- Positivefamily history
- RURAL areas of US (highest rates in WY, MT, AK)
- Modifiable risk factors: Mental illness, Chronic medical illness, Substance use disorder, Life stressors (unemployment, financial stressors, homelessness, divorce)
- Ethnic groups: American Indian/Alaska Native population and Non-Hispanic whites
- Special groups: Military personnel, Healthcare workers, First responders, Mining/construction workers, Lesbian, gay, or bisexual young people
Suicide
Protective Factors
- Reflective and deep-thinking skills
- Participation in programs to help with mental illness and substance use disorder
- Access to psychiatric help
- Support from friends and family
- Cultural programs discouraging suicide
- Religious beliefs (faith in God and religious activities)
- Constructive activities (sports or artistic pursuits)
Suicide
methods of suicide
Firearms
* 50%
* Most common method of completed suicide
* More commonly used by men
Other Methods
* Hanging/suffocation – 28%
* Poisoning – 11%- (Prescription medications are used more than illicit substances; More commonly used by women)
* Self-inflicted trauma
Suicide
Risk assessment
- Process of making close observations, evaluations, and estimations of an individual’sprobability to commit suicide
- Includes evaluating a patient’s suicidal ideation, plan, and intent
Screenings
* Columbia-Suicide Severity Rating Scale (C-SSRS)
* Beck Scale for Suicide Ideation (BSI)
* Suicidal Ideation Attributes Scale (SIDAS)
* Patient Health Questionnaire-9 (PHQ-9)
Alert signs
* Patient created a clear plan
* Patient started writing a will, funeral plan, or suicide note
* Unexpected visiting friends and family members
* Recent visit to the primary care physician
* Patient is in severe, acute, immediate stress
* Recent suicide attempt was a highly lethal method (deep, cutting wounds)
Suicide
Active vs Passive Suicidal Ideation
Active
* Experiencing current, specific, suicidal thoughts
* Conscious desire to inflict self-harming behaviors
* Level of desire, above zero, for death to occur
* Example of an Active SI assessment: “Over the past day or two, when you have thought about suicide, did you want to kill yourself? How often? Do you want to kill yourself now?”
Passive
* General wish to die
* No plan of inflicting lethal self-harm to kill oneself
* Often received less attention from clinicians
* Example of a Passive SI assessment: “In the past month, have you ever wished you were dead?”
Studies have shown that prediction of suicide attempt based on reported passive SI verses active SI shows no significant difference
Suicide
CBT vs DBT
Cognitive behavioral therapy:
* Problem-oriented strategy that focuses on current problems and finding solutions
* Strongly recommended for patients with a recent history of self-directed violence to reduce future incidents
* Patient satisfaction with CBT focused on suicide prevention is generally high
Dialectical behavior therapy:
* Incorporates CBT elements, skills training, and mindfulness techniques
* Aims to develop skills in emotion regulation, interpersonal effectiveness, and distress tolerance
* Suggested for individuals with borderline personality disorder (BPD) who have recently engaged in self-directed violence
PMS & PMDD
pathophys
Cyclic changes in hormones
* Signs and symptoms of premenstrual syndrome change with hormonal fluctuations (progesterone) and disappear with pregnancy and menopause
Chemical changes in the brain
* Fluctuations of serotonin, a neurotransmitter that is thought to play a crucial role in mood states, could trigger premenstrual mood symptoms
* Insufficient amounts of serotonin may contribute to premenstrual depression, fatigue, food cravings and sleep problems
Postulated that PMS/PMDD symptoms develop because of a decline of progesterone in the late luteal phase
Premenstrual Syndrome (PMS)
describe
- Recurrent luteal-phase disorder characterized by a variable cluster of psychological and physical symptoms
- Symptoms are occurring with the hormonal fluctuations of the menstrual cycle (~7-10 days before onset of menstruation)
PMS
relationship between EtOH and PMS
Alcohol consumption is associated with a moderate increase in the risk of development
Premenstrual Dysphoric Disorder (PMDD)
general describe
A severe form of premenstrual syndrome (PMS) characterized by mood, behavioral, and physical symptoms causing significant distress and/or functional impairment
PMDD
risk factors
- History of traumatic events
- Comorbidanxietydisorders
- Smoking
- Obesity- linear relationship of BMI and risk of incident PMS
Postpartum Disorders
describe the postpartum period
- The time after giving birth when a woman’s body returns to its pre-pregnant state
- Usually lasts six to eight weeks, but can last longer
- Common time for the emergence or exacerbation of psychiatric disorders
Three most common disorders:
* Postpartum blues
* Postpartum depression
* Postpartum psychosis
Postpartum psychiatric disorders are not distinct entities in the DSM-V
* Use a “with peripartum onset” modifier if the onset of symptoms occur during pregnancy or within 4 weeks postpartum
Postpartum Disorders
Pathophys
Hormonal factors
* Drastic changes in hormonal levels (↓ estrogen, progesterone, and cortisol) within 48 hours after delivery
* Estrogen levels can have an effect on serotonin and dopamine levels → affective and psychotic symptoms
* Estrogen promotes synthesis, prevents degradation, and inhibits reuptake of serotonin
* Estrogen decreases the release of GABA, the main inhibitory neurotransmitter in the brain, promoting increased dopamine transmission
Psychosocial factors
* Women who report inadequate social supports, marital discord or dissatisfaction, or recent negative life events are more likely to experience postpartum depression
Biologic vulnerability
* Women with a prior history of depression or family depression of a mood disorder are at increased risk
* Women with a prior history of postpartum depression or psychosis having 90% risk of recurrence
Postpartum Disorders
Risk Factors
- Young age (< 25 years)
- History of psychotic illnesses (anxiety and depression)
- Previous episode of postpartum psychiatric disorder (up to a 90% recurrence rate)
- Family history of psychiatric illnesses
- Stressful life events (during pregnancy or near delivery)
- Unintended pregnancy
- Poor social support
- Financial difficulties
- History of intimate partner violence or sexual abuse
- Cesarean sections, traumatic birth experience, or other perinatal complication (gestational diabetes)
- Difficulties with breastfeeding
- Women with infants having health problems and/or infants admitted to the NICU
- Childcare stress (inconsolable crying infant)
Postpartum Disorders
Epidemiology
Prevalence
* Postpartum blues: very common, up to 80% of pregnancies
* Postpartum depression: often underdiagnosed, approximately 10%–25% of pregnancies
* Postpartum psychosis: rare, < 1–2 per 1000 births
Impact
Maternalsuicide
* One of the leading causes of maternalmortality
* Rates of maternalmortality due tosuicide are similar tomortality from infection
Infanticide
* Killing of a child within a year of its birth
* ~300 in the US each year
Negative effects on children
* Untreated postpartum mood disorders in mothers are associated with long-term effects on cognitive, behavioral, and emotional development in childhood through adolescence
Somatic Disorders
general info
- physical sx with an unknown cause that lead to mental distress
- AKA: hysteria or somatization
- unintentional, unconscious sx
Eating Disorders
general
persistent disturbance of eating behavior that impairs health or psychosocial functioning
Eating Disorders
pathophys
- multi-factorial (combination of biological, sociocultural, and psychological factors)
- genetic (biologic) risk is strongest for anorexia
Eating Disorders
prevalence?
- 5% females; 2% males
- highest among individuals w/ obesity
Eating Disorders
Biological Risk Factors
- close relative w/ an eating disorder (parent/sibling)
- close relative w/ mental health condition
- hx of dieting
- T1 diabetes
Eating Disorders
psychological risk factors for eating disorders
- perfectionism
- cognitive inflexibility
- impulsivity
- body image dissatisfaction
- personal hx of mental health conditions
- personal hx of substance use disorder
Eating Disorders
social risk factors for eating disorders
- wt stigma
- teasing/bullying
- limited social networks
- personal experiences of trauma
Eating Disorders
SCOFF Questionnaire
- do you make yourself Sick because you feel uncomfortably full?
- do you worry you have lost Control over how much you eat?
- have you recently lost more than One stone (14 lbs, 6.35 kg) in a 3-mo period?
- do you believe yourself to be Fat when others say you are too thin?
- would you say that Food dominates your life?
“yes” to 2+ = pos screen
Anorexia Nervousa
how does anorexia lead to amenorrhea?
reduced LH & FSH
Anorexia Nervousa
Russell Sign
scars/calluses on the hand from contact with the teeth
Anorexia Nervosa
complications
- malnutrition
- delayed puberty
- amenorrhea
- osteoporosis
- electrolyte imbalances
- CV manifestations (cardiomyopathies, prolonged QT syndrome, bradycardia)
Anorexia Nervosa
Refeeding Syndrome
- Constellation of critical acid-base and electrolyte disturbances that may occur due to refeeding of malnourishedpatientswho are persistently starved
- sudden reintroduction of caloric intake (carbs) leading to increased insulin (sudden shift of fluid/electrolytes into cells), electrolyte imbalances lead to arrhythmias, salt & H2O retention leads to edema)
Prevention
* slow introduction of calories
* vitamin supplementation
Bulimia Nervosa
epidemology + pathophys
Epi
* women 18-35 most affected
* prevalence: 1%
Pathophys
* hunger & satiety states not accurately recognized by anterior insula
* alterations in hormones and neuropeptides 9ghrelin and leptin)
Bulimia Nervosa
ghrelin vs leptin
- ghrenlin: stimulates appetite & signals brain when time to eat
- regulates energy balance by suppressing hunger & promoting feelings of fullness
Binge Eating Disorder
epidemology
- women more affected than men
- median age = 21 yrs
- more common in obese pts
