Test 1 Flashcards
Emil Kraepelin
- Studied disease classification for mental disorders
- Origins of current biological psychiatry
Sigmund Freud
- Developed ego model
- Used psychoanalysis as treatment
Aaron Beck
Developed cognitive behavioral therapy.
Mental disorders characterized by
- alterations in thinking, mood, or behavior
- an association with distress and/or impaired functioning
Surgeon general recommendations
- efficacy of mental health treatment is well documented
- range of treatment exists for most disorders
- seek help if you have mental health problem or symptoms of a disorder
mental health prevalence
- 1 in 5 US adults experience mental illness
- of the 50% who seek treatment, 25% will quit treatment within a year
suicide statistics
- 1 suicide every 11 minutes
- 10th leading cause of death for all ages
- 2nd leading cause of death ages 10-34
serotonin
- Helps control mood, appetite, and sleep.
- Low levels associated with depression.
- Most receptors are in GI system.
norepinephrine
- Controls alertness
- Implicated in the regulation of emotion and cognition.
- fight or flight stress response
- Low level associated with depression
Dopamine
- involved in controlling movement
- linked to reward systems in the brain and areas influencing emotion
- low levels can result in movement disorders (parkinsons)
- problems utilizing dopamine linked to schizophrenia
GABA
- major inhibitory neurotransmitter
- abnormal levels linked to anxiety and depression
acetylcholine
- enables muscle action, learning, and memory
- Ach producing neurons deteriorate as alzheimer’s progresses
- most abundant neurotransmitter in the brain
glutamate
- increases the chance that a neuron will fire
- important role in early brain development
- may assist in learning and memory
- high levels may produce seizures or migraine
DSM-V classification
main diagnosis with multiple specifiers
remission
- partial 3-12 months
- full greater than 12 months
laboratory tests in psychiatry
- rule out underlying medical causes
- rule out substance abuse
- aid in selection of treatment
- monitor side effects
screening lab tests
CBC, CMP, thyroid panel, urine toxicology, brain imaging (if needed)
lab tests to establish baseline before treatment
pregnancy, A1C (or FBS), lipid panel, ECG
along with screening labs
special case lab tests
HIV/hepatitis, neurosyphilis, OD, GGT, folate, B12, magnesium, endocrine
GGT is like A1C for EtOH
Lithium monitoring
- narrow therapeutic index
- level every 3 days until stable and then every 3 months
- desirable range 0.5-1.5 but in practice 0.8-1.2 mEq/L
- 1st line drug for bipolar
- toxic to kidneys at high dose
clozapine monitoring
- risk of agranulocytosis (decreased WBC)
- CBC with differential weekly for first 6 months and then every 2 weeks
obstacles to mental health care
- stigma
- fear
- cost
- access
depression screening
Sleep Interest Guilt Energy Concentration Appetite Psychomotor Suicidal Ideation
diagnose MDD
- constant symptoms for at least 2 weeks
- 5 of the SIGECAPS and one must be lost of interest
past psych history 3 questions
- previous psych hospital admissions
- outpatient treatment
- prior medications
CAGE questionnaire
Cut down on drinking
Annoyed when asked about drinking
Guilty about drinking
Eye opener in the morning
level one screening
- general symptom measures
- new patient or long time between psych evaluations
level two screening
- specific disorders
- symptomatic
cognitive assessment
- help in early diagnosis of cognitive function
- helpful for documenting progression of dementia
- do not distinguish between dementia and delirium
- consider age and education when interpreting
cognitive assessment tools
- mini mental state exam
- montreal cognitive assessment
- mini-cog
- addenbrooke’s cognitive exam
appearance
describe general appearance and anything unusual or specific
mood
patient’s description of their mood
affect
outward manifestation of mood
thought form
how is the patient thinking
tangential
going on a tangent to 1 other subject
circumstantial
going on multiple tangents
flight of ideas
manic state
thought content
what is the patient thinking
obsessions, delusions, SI, HI
hallucination
something not real that is experienced through one of the 5 senses
illusions
misrepresentation of a real object
misperceptions
an incorrect interpretation
fund of knowledge
-estimate of intelligence and ability of concrete/abstract reasoning
proverb interpretation
- abstract reasoning
- concrete reasoning
- bizarre reasoning
insight
- how aware a person is of their own mental state
- self awareness of a problem
pathological anxiety
- due to its intensity and/or duration it is deemed an inappropriate response to a given situation
- when the anxiety significantly interferes with a person’s academic, occupational, or social functioning
biological basis of anxiety
- serotonin (require higher SSRI dose), NE, GABA, CRH
- amygdala increased response
- prefrontal cortex inhibited response
genetic basis of anxiety
-50% with panic disorder have at least 1 affected relative
generalized anxiety disorder epidemiology
- 1 yr prevalence 3-8%
- more than 50% of those diagnosed have another mental disorder
- female : male = 2 : 1
- patients normally start treatment in their 20s
GAD clinical features
- anxiety, motor tension, fatigue, impaired concentration, and cognitive vigilance
- chronic condition that can worsen with life stressors
- worries about multiple aspects of life
- may seek medical attention for somatic symptoms
GAD course and prognosis
- tends to be chronic and may be lifelong
- up to 25% will eventually develop panic disorder
- significant percentage likely to have comorbid depression
GAD treatment
- best results combine psychotherapy and pharmacotherapy
- CBT focuses on identifying/changing dysfunctional though patterns; ways of coping with stressors
- SSRIs are 1st line
- other options SNRIs, TCA, buspirone
- benzos short term
SSRIs
fluoxetine (prozac) paroxetine (paxil) citalopram (celexa) fluvoxamine (luvox) sertraline (zoloft) escitalopram (lexapro)
AE: feeling “on edge”/nausea (early), sexual dysfunction (late)
panic attack
- discrete period of intense fear or discomfort accompanied by at least 4 somatic or cognitive symptoms
- reaching a peak within 10 minutes
- palpitations / chest pain
- sweating, trembling, paresthesia
- SOB, choking
- nausea, dizziness
- derealization (fear of losing control / of dying)
panic disorder
- recurrent, unexpected panic attacks (2 or more)
- concern about additional attacks
- worry about the implications of the attack or significant change in behavior related to the attacks
panic disorder epidemiology
- female to male = 2-3 : 1
- mean age of onset 25
panic disorder etiology
- theories include ANS dysregulation
- genetic association
- psychosocial factors
panic disorder treatment
- SSRIs are first choice
- benzodiazepine (simultaneous with SSRI then taper)
- TCAs (alternative but more AE and lower safety profile)
treat 8-12 months after symptoms controlled
phobia
irrational fear that produces a conscious avoidance of the feared subject, activity, or situation
Most commons are animals, heights, social/space
specific phobia
strong, persisting fear of an object or situation
phobia clinical feature
- arousal of severe anxiety when the patient is exposed or the anticipation of exposure
- patients recognize fear is excessive and go to great lengths to avoid the stimulus
phobia treatment
exposure therapy with gradual exposure and desensitization
Obsessions
- something you think about
- recurrent and intrusive thoughts, feelings, ideas, or sensations
compulsions
- something you do
- conscious, distressing, and recurring pattern of behaviors such as counting, checking, ordering, and cleaning
- safety oriented behaviors
OCD etiology
- serotonin dysregulation
- strong genetic component
- may have comorbid depression
OCD course and prognosis
- more than half have sudden onset of symptoms
- for 50-70% onset occurs after a stressful event
- many delay seeking treatment due to embarrassment
OCD treatment
-SSRIs are first choice but higher dosages are commonly required
obsessive compulsive disorder personality
commonly confused with OCD, but not life altering
specific obsessive disorders
- hoarding
- trichotillomania (hair pulling)
- excoriation disorder (skin picking)
separation anxiety
- developing inappropriate and excessive fear and anxiety concerning separation from those whom the individual is attached
- persistent for >4 weeks in children & >6 months in adults
- more likely to develop in adults after loss of a close loved one
selective mutism
- consistent failure to speak in situations where there is an expectation of speaking
- occurs for >1 month
- child is able to speak but is silent/inaudible
- often due to fear of the situation
social anxiety disorder
- strong, persistent fear of social situations in which embarrassment can occur along with fear of not being able to leave the situation
- equally common in both sexes with peak age of onset in the teens
social anxiety treatment
combination of SSRIs (long term), benzodiazepine (short term), beta blockers (PRN), and psychotherapy
PTSD diagnosis
- set of typical symptoms that develop after a person is exposed to a traumatic event
- person reacts with fear and hopelessness, persistently relives the event, and tries to avoid reminders
- symptoms >1 month
- symptoms <1 month = acute stress disorder
PTSD clinical feature
ERASE Experience a trauma Relive the trauma Avoidance of reminders Sympathetic nervous system Excitement (hypervigilance, exaggerated startle response)
SNRIs
Duloxetine (cymbalta)
Venlafaxine (effexor)
Desvenlafaxine (pristiq)
Monitor their BP
bupropion (wellbutrin)
- atypical antidepressant
- anxiety, ADHD
- wary of seizure Hx (lowers threshold)
trazodone (desyrel)
- low dose = sleep aid
- higher dose = antidepressant
- AE: priapism
lithium
- first line bipolar
- NTI
- AE: hand tremors, teratogenic (Ebstein’s anomaly), hypothyroidism, diabetes insipidus, renal function
clozapine
- schizophrenia (most effective, but not first line due to AE)
- agranulocytosis
PTSD treatment
- SSRIs first line
- TCAs alternative
- prazosin for night terrors
- psychotherapy (CBT, eye movement desensitization)
adjustment disorder
- external stressful event linked to development of new symptoms
- occurs within 3 months of event
mood disorder
syndrome consisting of a cluster of signs and symptoms sustained weeks-months which represent a marked departure from a person’s functioning and tend to recur often in a periodic or cyclical fashion
mood disorders epidemiology
- more women get MDD
- men and women equal for bipolar I (more manic men and more depressed women)
- higher risk if no close relationships
- commonly comorbid with anxiety and substance abuse
mood disorders psychosocial factors
- life events: event most associated with developing depression is losing a parent before age 11
- environmental stress: loss of spouse most likely to cause depression
- personality types: OCPD, histrionic, and borderline more likely to develop depression
cognitive triad of depression
- low self-perception, self-esteem
- tendency to experience the world as hostile and demanding
- expectation of suffering and failure
views lead to learned helplessness
MDD diagnostic criteria
- symptoms for same 2 week period that are a change from previous functioning
- must have depressed mood and anhedonia
persistent depressive disorder
- chronic state of subclinical depression exhibited by a depressed mood for most of the days for at least 2 years
- can’t go more than 2 months without symptoms
- no previous manic episodes
- don’t meet criteria for MDD
pre-menstrual dysphoric disorder
- 1st line treatment SSRIs
- more severe form of PMS
- higher risk for post partum depression
post partum blues
- mild depressive symptoms
- 40-80% of women
- symptoms usually peak on day 5 and resolve in 2 weeks
post partum depression
- 8-15% of women
- 0.9% get psychosis
manic episode
distinct period of abnormal and persistently elevated, expansive, or irritable mood lasting at least 1 week (or any duration if hospitalization is needed)
manic episode mnemonic
DIG FAST Distractibility Indiscretions Grandiosity Flight of ideas Activity increase Sleep deficits Talkativeness
hypomania episode
- distinct period different from usual non-depressed mood lasting at least 4 days
- does not impair functioning and no psychotic features
Bipolar I criteria
- at least one manic episode
- symptoms not explained by another disorder
- psychosis, marked impairment daily life, hospitalization
Bipolar II criteria
- one hypomania
- one major depressive episode
- symptoms not explained by another disorder
- no psychosis or life altering impairement
bipolar prognosis
50% of patients attempt suicide
cyclothymic disorder
- for at least 2 years (1 yr kids)
- numerous periods of hypomanic symptoms that don’t meet hypomania criteria
- numerous periods of depressive episodes that don’t meet MDD criteria
- symptoms present at least half the time and not absent for more than 2 months
MDD pharmacotherapy
- SSRIs
- SNRIs
- atypical antidepressants as adjunct
- TCAs
MDD resistant to Rx
- esketamine (special K)
- adjunctive psychotherapy
- ECT last resort
treatment of acute mania
- haldol, risperidone, and olanzapine are best
- short term benzo if needed
- continue or restart established med if bipolar diagnosed
bipolar 1st line treatment
- lithium 1st line monotherapy
- valproate alternative
bipolar 2nd line treatment
-dual therapy first line drug with a 2nd generation antipsychotic
