Psychiatry - psychotic and mood disorders

Mental illness, including substance abuse and developmental disorders

Personality disorders, mental retardation

General medical conditions

Psychosocial and environmental problems (homelessness, divorce, etc.)

• 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

• >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

• 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)

• break from reality involving delusions, perceptual disturbances, and/or disordered thinking
• i.e. schizophrenia, substance-induced psychosis

• 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

• 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

• 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

• 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

• 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)

• 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

• ≥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

• 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

• 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

• 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

• 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)

• Tuberoinfundibular: blocked by neuroleptics, causing hyperprolactinemia
• Nigrostriatal: blocked by neuroleptics, cuasing extrapyramidal side effects

• 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

• 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

• 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

• -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

• 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

• 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

• 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

• 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)

• 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

• 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

• ≥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

Risk of committing suicide after hospitalization for a major depressive episode, 15%

• Sleep
• Interest
• Guilt
• Energy
• Concentration
• Appetite
• Psychomotor activity
• Suicidal ideation

• 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

• Distractability
• Insomnia
• Grandiosity
• Flight of ideas
• Activity/agitation
• Speech
• Thoughtlessness

• 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

• 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

• Subtype of MDD in which episodes occur only during winter months
• Tx: light therapy

• 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%

• 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

• 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

• 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

• 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

• 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

• 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

• 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

H/o one or more major depressive episodes and at least one hypomanic episode

• Lifetime prevalence: 0.5%
• Slightly more common in women then men
• Onset usually before age 30

• Same as bipolar I disorder
• course, prognosis: chronic, requiring long-term treatment

• Chronic, mild depression most of the time with no discrete episodes
• rarely need hospitalization

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

• lifetime prevalence: 6%
• two to three times more common in women
• onset before age 25 in 50% of patients

• 20% develop MDD
• 20% will develop bipolar disorder
• >25% will have lifelong symptoms

• Treatment:
• -CBT
• -Antidepressant medications (SSSRIs, TCAs, MAOIs)

• 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

• 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

• episodes of depressive symptoms that don't meet MDD criteria
• euthymic periods are also seen