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Axis I:
Mental illness, including substance abuse and developmental disorders
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Axis II
Personality disorders, mental retardation
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Axis III
General medical conditions
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Axis IV
Psychosocial and environmental problems (homelessness, divorce, etc.)
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Axis V
- Global Assessment of Function (GAF)
- 1-10: Persistent DTS or DTO, inability to maintain minimal personal hygiene
- 11-20: Gross impairment in communication, some DTO or DTS, suicide attempt without clear expectation of death
- 21-30: Behavior is considerably influenced by delusions or hallucinations, inability to function in almost all areas
- 31-40: some impairment in reality testing, major impairment in several areas
- 41-50: Serious symptoms, any serious impairment in areas...
- 51-60: Moderate symptoms, moderate difficulty in areas...
- 61-70: Some mild symptoms, some difficulty in areas...
- 71-80: Transient symptoms, expectable reactions to psychosocial stressors
- 81-90: Absent or minimal symptoms, mild anxiety before an exam, good function in all areas
- 91-100: no symptoms, superior functioning in wide range of activities
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IQ
- >130: very superior
- 120-129: superior
- 110-119: high average
- 90-109: average
- 80-89: low average
- 70-79: borderline
- 50-70: Mild MR
- 35-49: Moderate MR
- 25-34: Severe MR
- <25: Profound MR
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Disordered thought
-content
-process
- content: patient's belief, ideas, interpretations of surroundings (paranoid delusions, ideas of reference, loss of ego)
- process: manner in which the patient links ideas and words (tangentiality, circumstantiality, loosening of associations, thought blocking, perseveration)
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psychosis
- break from reality involving delusions, perceptual disturbances, and/or disordered thinking
- i.e. schizophrenia, substance-induced psychosis
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Delusions
- Paranoid delusions: irrational belief that one is being persecuted
- Ideas of reference: belief that some event is uniquely related to the individual
- Thought broadcasting: belief that one's thoughts can be heard by others
- Delusions of grandeur: belief that one has special powers
- Delusions of guilt: false belief that one is guilty or responsible for something
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Hallucinations
- Auditory: most commonly exhibited by schizophrenic patients
- Visual: commonly seen with drug intoxication
- Olfactory: associated with epilepsy
- Tactile: secondary to drug abuse or alcohol withdrawal
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DDx of psychosis
- psychosis 2/2 general medical condition
- substance-induced psychotic disorder
- delirium/dementia
- bipolar disorder
- major depression with psychotic features
- brief psychotic disorder
- schizophrenia
- schizophreniform disorder
- schizoaffective disorder
- delusional disorder
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Medical causes of psychosis
- 1. CNS disease: cerebrovascular disease, MS, neoplasm, PD, Huntington's choria, temporal lobe epilepsy, encephalitis, prion disease
- 2. Endocrinopathies: Addison's/Cushing's disease, thyroid, hypo/hypercalcemia, hypopituitarism
- 3. Nutritional/Vitamin deficiency states: B12, folate, niacin
- 4. Other: CT disease (SLE, temporal arteritis), porphyria
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Schizophrenia
positive vs negative symptoms
phases
- Schizophrenia: abnormalities in thinking, emotion, behavior.
- Positive symptoms: hallucinations, delusions, bizarre behavior, thought disorder
- Negative symptoms: blunted affect, anhedonia, apathy, inattentiveness
- Phases:
- - Prodromal: decline in functioning, socially withdrawn and irritable
- -Psychotic: perceptual disturbances, delusions, and disordered thought process/content
- -Residual: occurs between episodes of psychosis, flat affect, social withdrawal, odd thinking or behavior (negative symptoms)
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Schizophrenia
strongest predictor of function
- Negative symptoms are the strongest predictor of function (more so than positive ones)
- Treatment is more aimed at positive symptoms
- Men tend to have more negative symptoms; schizophrenia is more severe in men than women
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Schizophrenia
criteria
- ≥2 of the following for 1 month:
- 1. Delusions
- 2. Hallucinations
- 3. Disorganized speech
- 4. Grossly disorganized or catatonic behavior
- 5. Negative symptoms (i.e. flattened affect)
Duration of illness for at least 6 months, must cause significant social or occupational functional impairment
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Schizophrenia
subtypes
- Paranoid type: highest functioning, older age of onset
- -preoccupation with one or more delusions
- -no predominance of disorganized speech, disorganized or catatonic behavior
- Disorganized type: poor functioning type, early onset
- -Disorganized speech, behavior
- -Flat or inappropriate affect
- Catatonic type: rare, ≥2 of the following
- -Motor immobility
- -Excessive purposeless motor activity
- -extreme negativism or mutism
- -peculiar voluntary movements or posturing
- -Echolalia or echopraxia
Undifferentiated type: multiple or no characteristics of subtypes
- Residual type: predominant negative symptoms
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Schizophrenia
epidemiology
- 1% of people over their lifetimes
- Men = women
- Onset: men ~ 20yrs; women ~30yrs. rarely before age 15 and after 45
- Genetics: strong predisposition
- - 50% concordance among monozygotic twins
- - 40% risk of inheritance if both parents have schizophrenia
- - 12% risk if one first-degree relative if affected
- Lower socioeconomic groups have higher rates of schizophrenia
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Schizophrenia
pathophysiology
- Dopamine hypothesis: increased dopamine activity in certain neuronal tracts
- -most treatment (antipsychotics) are dopamine receptor antagonists
- -cocaine and amphetamines increase dopamine activity and can lead to schizophrenic-like symptoms
- Prefrontal cortical: negative symptoms
- Mesolimbic: positive symptoms
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Prognostic factors
- Better prognosis:
- -late onset
- -good social support
- -positive symptoms
- -mood symptoms
- -acute onset
- -female sex
- -few relapses
- -good premorbid functioning
- Worse prognosis:
- -Early onset
- -poor social support
- -negative symptoms
- -family history
- -gradual onset
- -male sex
- -many relapses
- -poor premorbid functioning (social isolation)
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Other dopamine pathways affected by neuroleptics
- Tuberoinfundibular: blocked by neuroleptics, causing hyperprolactinemia
- Nigrostriatal: blocked by neuroleptics, cuasing extrapyramidal side effects
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Schizophrenia
treatment
- typical neuroleptics: chlorpromazine, thioridazine, trifluoperazine, haloperidol-D2 antagonists
- -Side effects: EPS, neuroleptic malignant syndrome, tardive dyskinesia
- atypical neuroleptics: Risperidone, clozapine, olanzapine, quetiapine, aripiprazole, ziprosidone
- -Serotonin receptor and dopamine receptor antagonists
- -Side effects: fewer EPS, "better" at treating negative symptoms
behavioral therapy, family therapy, group therapy
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antipsychotic side effects
- 1. EPS (especially high potency typicals): dystonia (spasm), parkinsonism, akathisia (restlessness). Tx: antiparkinsonian agents (benztropine, amantadine, etc.), benzodiazepines
- 2. Anticholinergic symptoms: dry mouth, constipation, blurred vision
- 3. Tardive dyskinesia (high potency): darting or writhing movements of face. Tx: dc offending agent, benzos, beta blockers, cholinomimetics. most often in older women after at least 6 months of medications; 50% experience spontaneous remission
- 4. Neuroleptic malignant syndrome (high potency): confusion, high fever, elevated BP, tachycardia, "lead pipe" rigidity, sweating, elevated CPK. 20% mortality rate. most common in men who have recently begun medication
- 5. weight gain, sedation, orthostatic hypotension, ECG changes, hyperprolactinemia, hematologic effects (agranulocytosis), ophthalmologic conditions
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Schizophreniform disorder (aka attenuated psychosis syndrome)
criteria, prognosis, treatment
- criteria: same criteria as schizophrenia, but only lasting between 1 and 6 months
- prognosis: 1/3 patients recover completely
- treatment: hospitalization, 3- to 6-month course of antipsychotics, psychotherapy
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Schizoaffective disorder
criteria, prognosis, treatment
- -Meet criteria for major depressive episode, manic episode, or mixed episode (during which criteria for schizophrenia are also met)
- -Have delusions or hallucinations for 2 weeks in the absence of mood disorder symptoms
- -Have mood symptoms present for substantial portion of psychotic illness
- Prognosis: better than schizophrenia, worse than mood disorder
- Treatment: hospitalization, antipsychotics (short-term control of psychosis); mood stabilizers, antidepressants, ECT for mania or depression
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Brief psychotic disorder
criteria, prognosis, treatment
- psychotic symptoms lasting less than 1 month
- Rare: less common than schizophrenia
- Prognosis: 50 to 80% recovery rate; 20 to 50% may eventually be diagnosed with schizophrenia or mood disorder
- Treatment: brief hospitalization, course of antipsychotics for psychosis itself and/or benzodiazepines for agitation
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Delusional disorder
epidemiology, criteria, types, prognosis, tx
- epidemiology: more often in older patients (>40yr), immigrants, hearing impaired
- criteria: nonbizarre, fixed delusion for at least 1 month; does not meet criteria for schizophrenia; functioning in life not significantly impaired
- - Erotomanic type: delusion revolves around love
- - Grandiose type: inflated self-worth
- - Somatic type: physical delusions
- - Persecutory type: delusions of being persecuted
- - Jealous type: delusions of unfaithfulness
- - Mixed type: more than one of the above
- Prognosis: 50% full recovery, 20% decreased symptoms, 30% no change
- Treatment: psychotherapy, trial of antipsychotics
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shared psychotic disorder
folie a deux
- shared delusional symptoms, often in family members or close relationships
- prognosis: 20 to 40$ will recover upon removal from the inducing person
- Treatment: separate the patient from person who is the source of the delusion, antipsychotics if the sx don't improve in 1 to 2 weeks
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Cultural-specific psychosis
- Koro: patient blieves that his penis is shrinking and will disappear, causing his death (Asia)
- Amok: sudden unprovoked outbursts of violence with no recollection (Malaysia, Southeast Asia)
- Brain fag: headache, fatigue, visual disturbances in male students (Africa)
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schizo...
- Schizophrenia—lifelong psychotic disorder Schizophreniform—schizophrenia for < 6 months Schizoaffective—schizophrenia + mood disorder
- Schizotypal (personality disorder)—paranoid, odd or magical beliefs, eccentric, lack of friends, social anxiety. Criteria for true psychosis are not met
- Schizoid (personality disorder)—withdrawn, lack of enjoyment from social interactions, emotionally restricted
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Mood episodes/disorders
- Mood episodes:
- -Major depressive episode
- -Manic episode
- -Mixed episode
- -Hypomanic episode
- Mood disorders:
- -Major depressive disorder (MDD)
- -Bipolar I disorder
- -Bipolar II disorder
- -Dysthymic disorder
- -Cyclothymic disorder
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Major depressive episode
criteria
- ≥5 of the following for at least 2 weeks, not due to substance use or medical condition:
- 1. Depressed mood
- 2. Anhedonia
- 3. Change in appetite or body weight
- 4. Feelings of worthlessness or excessive guilt
- 5. Insomnia or hypersomnia
- 6. Diminished concentration
- 7. Psychomotor agiatation or retardation
- 8. Fatigue or loos of energy
- 9. Recurrent thoughts of death or suicide
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Suicide and major depressive episodes
Risk of committing suicide after hospitalization for a major depressive episode, 15%
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SIG E CAPS
- Sleep
- Interest
- Guilt
- Energy
- Concentration
- Appetite
- Psychomotor activity
- Suicidal ideation
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Manic episode
- period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week. ≥3 of the following, ≥4 if mood is irritable:
- 1. Distractibility
- 2. Inflated self-esteem or grandiosity
- 3. Increase in goal-directed activity
- 4. Decreased need for sleep
- 5. Flight of ideas or racing thoughts
- 6. More talkative or pressured speech (rapid and uninterruptible)
- 7. Excessive involvement in pleasurable activities that have high risk of negative consequences
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DIG FAST
- Distractability
- Insomnia
- Grandiosity
- Flight of ideas
- Activity/agitation
- Speech
- Thoughtlessness
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Hypomanic episode
- distinct period of elevated, expansive, or irritable mood that includes at least three of symptoms listed for the manic episode:
- -Lasts at least 4 days
- -No marked impairment in social or occupational functioning
- -Does not require hospitalization
- -No psychotic features
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Major Depressive Disorder (MDD)
definition
- Marked by episodes of depressed mood associated with loss of interest in daily activities:
- - At least one major depressive episode
- - No history of manic or hypomanic episode
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Seasonal affective disorder
treatment
- Subtype of MDD in which episodes occur only during winter months
- Tx: light therapy
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MDD
epidemiology
- Lifetime prevalence: 15%
- Onset at any age, average age of onset at 40
- Women:Men (2:1)
- No ethnic or socioeconomic differences
- Prevalence in elderly from 25 to 50%
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MDD
etiology
- Serotonin/Catecholamines:
- 1. decreased levels of serotonin and 5-hydroxyindolacetic acid (main metabolite)
- 2. Drugs that increase available serotonin, norepinephrine, and dopamine often alleviate symptoms of depression
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MDD
risk factors
Prognosis
- Risk factors:
- -Loss of parent before age 11: increased risk
- -Stable family, social functioning: better prognosis
- -First-degree relative with MDD: 2-3x more likely to develop MDD (genetics)
- Course and prognosis:
- -untreated, episodes usually last 6 to 13 months
- -episodes occur more frequently as the disorder progresses
- -risk of subsequent episodes is 50% within the first 2 years after that first episode
- -treatment, approximately 75% are treated successfully with medical therapy
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MDD
treatment
- 1. Antidepressants
- - SSRIs: safer and better tolerated than other classes of antidepressants. side effects: headache, GI disturbance, sexual dysfunction, rebound anxiety
- - TCAs: most lethal in overdose. side effects: sedation, weight gain, orthostatic hypotension, anticholinergic effects. can aggravate prolonged QTC syndrome
- - MAOIs: used for refractory depression. side effects: risk of hypertensive crisis with sympathomimetics or ingestion of tyramine-rich foods (wine, beer, aged cheeses, liver). risk of serotonin syndrome. Orthostatic hypotension
- 2. Adjuvant Medications
- - Stimulants (methylphenidate)
- - Antipsychotics
- - Liothyronine (T3), levothyroxine (T4), lithium, L-tryptophan
- 3. Psychotherapy
- - CBT, DBT
- 4. Electroconvulsive therapy (ECT)
- - indicated if pt is unresponsive to pharmacotherapy
- - premedicate with atropine, followed by general anesthesia, muscle relaxant
- - 8 treatments over 2- to 3-week period
- - Side effect: retrograde amnesia is a common side effect, usually disappears within 6 months
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Types of depressive disorder
- Melancholic: 40 to 60%, anhedonia, sleep disturbances, psychomotor disturbance, excessive guilt, anorexia
- Atypical: hypersomnia, hyperphagia, reactive mood, leaden paralysis
- Catatonic: catalepsy, purposeless motor activity, extreme negativism or mutism, bizarre postures
- Psychotic: 10 to 25% of hospitalized depressions
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Bipolar I disorder
criteria
- Criteria: one manic or mixed episode
- - 10 to 20% of patients experience only manic episodes
- -between manic episodes, interspersed euthymia, major depressive episodes, dysthymia, or hypomanic episodes
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Bipolar I disorder
Epidemiology
course and prognosis
- Lifetime prevalence: 1%
- Women:Men is 1:1
- Onset usually before age 30
- Genetics: monozygotic twins have 75% concordance
- Course and prognosis:
- -untreated: manic episodes last ~3 months
- -chronic course with relapses, increasing in frequency
- -prognosis: worse than MDD, only 50 to 60% of patients treated with lithium experience significant improvement in symptoms
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Bipolar I disorder
treatment
- Pharmacotherapy
- -lithium
- -anticonvulsants (carbamazepine or valproic acid)—also mood stabilizers
- -Olanzapine—typical antipsychotic
- Psychotherapy
- -Supportice psychotherapy, family therapy, group therapy
- ECT
- - works well in treatment of manic episodes
- - usually requires more treatments than for depression
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Bipolar II disorder
criteria
H/o one or more major depressive episodes and at least one hypomanic episode
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Bipolar II disorder
epidemiology
- Lifetime prevalence: 0.5%
- Slightly more common in women then men
- Onset usually before age 30
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Bipolar II disorder
etiology, treatment
- Same as bipolar I disorder
- course, prognosis: chronic, requiring long-term treatment
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Dysthymic disorder
definition
- Chronic, mild depression most of the time with no discrete episodes
- rarely need hospitalization
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Dysthymic disorder
Criteria
1. Depressed mood for majority of the time of most days for at least 2 years
- 2. At least two of the following:
- -poor concentration or difficulty making decisions
- -feelings of hopelessness
- -poor appetite or overeating
- -insomnia or hypersomnia
- -low energy or fatigue
- -low self-esteem
- 3. During the 2-year period:
- -person has not been without symptoms for >2 months at a time
- -No major depressive episode
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Dysthymic disorder
epidemiology
- lifetime prevalence: 6%
- two to three times more common in women
- onset before age 25 in 50% of patients
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Dysthymic disorder
course and prognosis
treatment
- 20% develop MDD
- 20% will develop bipolar disorder
- >25% will have lifelong symptoms
- Treatment:
- -CBT
- -Antidepressant medications (SSSRIs, TCAs, MAOIs)
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Cyclothymic disorder
criteria
- Alternating periods of hypomania and periods with mild to moderate depressive symptoms
- -numerous periods with hypomanic symptoms and periods with depressive symptoms for at least 2 years
- -no symptom free periods for > 2 months during those 2 years
- -No history of MDE or manic episodes
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Cyclothymic disorder
Epidemiology, course, treatment
- Epidemiology:
- Lifetime prevalence: <1%
- May coexist with borderline personality disorder
- onset usually between age 15 to 25
- Occurs equally in males and females
- Course and prognosis
- -chronic course; 1/3 eventually diagnosed with bipolar disorder
- Treatment
- -Antimanic agents used to treat bipolar disorder
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Minor depressive disorder
- episodes of depressive symptoms that don't meet MDD criteria
- euthymic periods are also seen
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Recurrent brief depressive disorder
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Premenstrual dysphoric disorder
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Mood disorder due to a general medical condition
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Substance-induced mood disorder
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Mood disorder not otherwise specified
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