Psychiatric disorders

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Author:
jknell
ID:
194205
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Psychiatric disorders
Updated:
2013-01-23 00:43:31
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MBB II
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Psychiatric disorders covered in MBB II
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  1. Hallucination
    sensory experience ('perception') that occurs without external stimulation

    Psychotic vs nonpsychotic (does the patient think the perception is real)
  2. Delusion
    specific false belief that is firmly held despite evidence to the contrary; not endorsed by members of the individual's culture
  3. Psychosis
    Loss of reality testing

    • NOT likely to be primary disorder if...
    • 1. Onset at >45 years of age
    • 2. No family hx
    • 3. No psychiatric premorbid behaviors
    • 4. Risk factors for causative neurologic disorders
    • 5. Neurological signs and symptoms
    • 6. Rapid onset or resolution, fluctuations
    • 7. Resistance or unusual response to treatment
  4. Schizophrenia
    Dx, subtypes, treatment
    • Sustained psychosis, long term functional deterioration
    • Dx: 2 or more of the Pos sx for 1 month
    • 6 months of one or more of the negative sx

    Positive sx: Delusions, hallucinations, disorganized speech, disorganized or catatonic behavior

    • Negative sx: (4 A's)
    • Affect - flattening or blunting
    • Alogia - decrease in spontaneous speech
    • Avolition - loss of goal-directed behavior
    • (Anhedonia) - inability to experience pleasure

    Subtypes: Paranoid (most common), disorganized, catatonic, undifferentiated, residual

    • Tx:
    • - 1st generation antipsychotics; D2 blockers; motor side effects
    • -2nd generation antipsychotics; D2 and 5-HT blockers; metabolic syndrome
  5. schizophrenia
    treatment (specifics)
    • 1st generation: D2 blockers
    • -Haloperidol
    • -Risperidone
    • -Olanzapine
  6. Schizophrenia
    • Premorbid phase (odd or eccentric behavior)
    • Prodromal phase (before onset of psychosis) mid to late teens; can have suspiciousness, misinterpretations, odd/eccentric, unusual beliefs, social withdrawal, anxiety/depression, poor sleep, decreased hygiene...
    • Acute (active) phase
    • Recuperative (recovery) - improvement of some of the symptoms of the acute phase
    • Residual phase - nonpsychotic residua of the disease
    • Chronic illness phase
  7. schizophrenia
    complications
    • suicide - 30% attempt; 5-10% successfully commit suicide
    • Depression - half have significant depression
    • Homelessness
    • Violence - 4X increased
    • Substance dependence seen in 40% of schizophrenics
    • Medical problems - insulin tolerance, osteoporosis, poor nutition, increased pain tolerance, polydipsia
    • Early death - 10 years shorter than average
  8. Schizophrenia
    causes
    Multiple hit disorder

    genetic predisposition + one or more environmental factors

    • Neurodevelopmental factors
    • Dopamine hypothesis
  9. Schizophrenia
    Treatment principles
    • Early treatment --> better function, improved function
    • Medical evaluation - r/o medical causes, drugs, etc.
  10. Schizoaffective disorder
    episodes of depression or mania concurrent with symptoms such as bizarre dilusions
  11. Delusional disorder
    • rare. middle to late adult life
    • delusions do not often respond to antipsychotics

    • 1. Systematized - delusions fit into a scheme that makes logical sense to the patient
    • 2. Non-bizarre - delusions are technically possible
    • 3. Encapsulated - pt behaves normally, other than the delusions
  12. Axis 1
    Axis 2
    Axis 3
    Axis 4
    Axis 5
    Axis 1 - major psychiatric disorders and syndromes, including substance use disorders

    Axis 2 - personality disorders and mental retardation

    Axis 3 - general medical conditions

    Axis 4 - psychosocial and environmental problems and stressors

    Axis 5 - global assessment of function
  13. Episodes
    • major depression
    • mania
    • hypomania
    • mixed
  14. Major depressive episode
    (MDE)

    SIGECAPS
    >5 for more than two weeks ... must significantly distress or impair social, occupational or other areas of function


    • Depression +
    • S - sleep problems
    • I - Interest
    • G - Guilt or worthlessness
    • E - Energy
    • C - Concentration
    • A - Appetite change; weight change
    • P - Psychomotor slowing
    • S - suicide
  15. Bereavement
    Normal psychological process

    sx should last less than 2 months
  16. Major depressive disorder

    MDD
    dx: major depressive episode not due to

    -schizophrenia, psychotic disorder, other mood disorder

    May be single or recurrent

    • MDD does NOT increase risk for drug/alcohol abuse
  17. MDD 
    epidemiology
    course
    Lifetime prevalence: 15%

    Mean age of onset: 26 yrs (rare before puberty); Many 30+

    episodes last (average) 4 to 9 months

    Pts will have 2 to 3 episodes during their lifetime

    *earlier onset tends to have more severe disease

    Females >> Males (2:1)

    10% of severely depressed patients (successfully) commit suicide
  18. Mood disorder due to general medical condition

    Mood disorder due to a substance
    Both: significant distress or impairment of function as a direct consequence of...

    - physiological consequence of general medical condition

    -consequence of substance intoxication or withdrawal (within 1 month)
  19. MDE/MDD related to medical conditions
    Pts at increase risk of death post myocardial infarction
  20. MDD

    causes
    Unknown...

    Genetics - 2x increased risk in people with first degree relatives with MDD

    Environment/stress...
  21. MDD
    treatment
    goal: restore wellness

    1. Cognitive behavioral therapy (CBT): address pt's views of self, world, and future

    2. Interpersonal therapy

    • 3. Antidepressant drugs
    • - Tricyclic antidepressants (TCA)
    • - SSRI; not any faster or better, but fewer side effects

    Side effects: anticholinergic, drowsiness, nervousness, insomnia...

    Pharmaceuticals either 1) increase NE, 2) increase 5-HT, 3) both, or 4) increase DA

    • Marked improvement in 70% of patients
    • *drugs should be continued for 4 to 9 months after the resolution of the depression

    • 4. Electroconvulsive therapy (ECT)
    • - most effective treatment for MDD: works within days
    • -primarily used for pts that are unresponsive to Rx
  22. Dysthymic disorder
    small font
    depressed mood for most of the day, for more days than not, for at least 2 years... impairs function

    Not as severe as MDD
  23. Manic episode

    DIG FAST
    distinct period of elevated, expansive or irritable mood lasting at least 1 week during which patient has >3 of the following...

    • D- Distractible
    • I - Impulsive - pleasurable activities w/ high risk for painful consequences
    • G - Grandiosity
    • F - Flight of ideas
    • A - Activity (increase in goal-directed activity)
    • S - Sleep decreased (need decreased)
    • T - Talkative
  24. Hypomanic episode
    • only 4 days, manic-like
    • Not psychotic
    • Not markedly impaired function
  25. Mixed episode
    Pt meets criteria for MDE and mania nearly every day for at least 1 week
  26. Bipolar I disorder
    Dx
    dx: one or more manic or mixed episode (not due to primary psychotic disorder

    Pts will often have one or more MDE
  27. Bipolar II disorder
    Dx: one or more MDEs and at least one hypomanic episode
  28. Cyclothymic disorder
    (don't diagnose)

    2 years with numerous periods of hypomanic symptoms and numerous periods of depressive symptoms...significant distress/impairment of function
  29. Bipolar I disorder
    natural history/epi
    • 1 % of the population (lifetime prevalence)
    • 4x risk in first degree relatives; 70% heritability

    Onset: 15 to 30 years (younger than MDD)

    Male ~ Female

    Frequent episodes: 4/life

    Bipolar DOES increase risk for alcohol/drugs
  30. Bipolar I disorder
    Tx
    • Mood stabilizers: for the treatment of manic episodes
    • - lithium
    • - divalproex
    • - carbamazepine

    *concern for treating depressive episodes aggressively for fear that pt will go into manic state*
  31. Lithium
    • Mechanism: unknown (mood stabilizer)
    • Indication: Bipolar (manic episodes)
    • onset: takes 5 to 7 days

    Excretion: renal; follow plasma levels

    AEs: cognitive impairment, tremor, diarrhea, hypothyroidism, elevated PTH and hypercalcemia, weight gain, edema, increase thirst, polyuria, nephrogenic diabetes insipidus, acne
  32. Divalproex
    • Mechanism (as a mood stabilizer): unknown
    • - antiepileptic drug: blocks voltage gated sodium channels

    AEs: cognitive effects, tremor, nausea, diarrhea, weight gain, hair loss, hepatotoxicity, pancreatitis, teratogenicity (neural tube defects)
  33. Carbamazepine
    mechanism: unknown; also an anticonvulsant

    75% protein bound; metabolized in liver

    AEs: sedation, rash, hepatotoxicity, hyponatremia, common leucopenia (but rare aplastic anemia), increased metabolism of oral contraceptives, teratogenicity
  34. Maintenance therapy for pts with bipolar I disorder
    Mood stabilizers... (lithium +/- anticonvulsants)

    if pts has 2-3 episodes in last 2-3 years; keep them on it for several years

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