Psychiatry - psychotic and mood disorders

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Psychiatry - psychotic and mood disorders
2013-07-23 22:21:15
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Psychotic and mood disorders
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  1. Axis I:
    Mental illness, including substance abuse and developmental disorders
  2. Axis II
    Personality disorders, mental retardation
  3. Axis III
    General medical conditions
  4. Axis IV
    Psychosocial and environmental problems (homelessness, divorce, etc.)
  5. 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
  6. 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
  7. Disordered thought
    • 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)
  8. psychosis
    • break from reality involving delusions, perceptual disturbances, and/or disordered thinking
    • i.e. schizophrenia, substance-induced psychosis
  9. 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
  10. 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
  11. 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
  12. Medical causes of psychosis
    • 1. CNS disease: cerebrovascular disease, MS, neoplasm, PD, Huntington's choria, temporal lobe epilepsy, encephalitis, prion disease
    • 2. EndocrinopathiesAddison's/Cushing's disease, thyroid, hypo/hypercalcemia, hypopituitarism
    • 3. Nutritional/Vitamin deficiency states: B12, folate, niacin
    • 4. OtherCT disease (SLE, temporal arteritis), porphyria
  13. Schizophrenia
    positive vs negative symptoms
    • 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)
  14. 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
  15. Schizophrenia
    • ≥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
  16. Schizophrenia
    • 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
  17. Schizophrenia
    • 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
  18. 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
  19. 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)
  20. Other dopamine pathways affected by neuroleptics
    • Tuberoinfundibular: blocked by neuroleptics, causing hyperprolactinemia
    • Nigrostriatal: blocked by neuroleptics, cuasing extrapyramidal side effects
  21. Schizophrenia
    • typical neurolepticschlorpromazine, thioridazine, trifluoperazine, haloperidol
    • -D2 antagonists
    • -Side effects: EPS, neuroleptic malignant syndrome, tardive dyskinesia

    • atypical neurolepticsRisperidone, 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
  22. 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
  23. 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
  24. 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
  25. 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
  26. 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
  27. 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
  28. 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)
  29. 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
  30. 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
  31. Major depressive episode
    • ≥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
  32. Suicide and major depressive episodes
    Risk of committing suicide after hospitalization for a major depressive episode, 15%
  33. SIG E CAPS
    • Sleep
    • Interest
    • Guilt
    • Energy
    • Concentration
    • Appetite
    • Psychomotor activity
    • Suicidal ideation
  34. 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
  35. DIG FAST
    • Distractability
    • Insomnia
    • Grandiosity
    • Flight of ideas
    • Activity/agitation
    • Speech
    • Thoughtlessness
  36. 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
  37. Major Depressive Disorder (MDD)
    • 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
  38. Seasonal affective disorder
    • Subtype of MDD in which episodes occur only during winter months
    • Tx: light therapy
  39. MDD
    • 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%
  40. MDD
    • 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
  41. MDD
    risk factors
    • 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
  42. MDD
    • 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
  43. 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
  44. Bipolar I disorder
    • 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
  45. Bipolar I disorder
    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
  46. Bipolar I disorder
    • 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
  47. Bipolar II disorder
    H/o one or more major depressive episodes and at least one hypomanic episode
  48. Bipolar II disorder
    • Lifetime prevalence: 0.5%
    • Slightly more common in women then men
    • Onset usually before age 30
  49. Bipolar II disorder
    etiology, treatment
    • Same as bipolar I disorder
    • course, prognosis: chronic, requiring long-term treatment
  50. Dysthymic disorder
    • Chronic, mild depression most of the time with no discrete episodes
    • rarely need hospitalization
  51. Dysthymic disorder
    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
  52. Dysthymic disorder
    • lifetime prevalence: 6%
    • two to three times more common in women
    • onset before age 25 in 50% of patients
  53. Dysthymic disorder
    course and prognosis
    • 20% develop MDD
    • 20% will develop bipolar disorder
    • >25% will have lifelong symptoms

    • Treatment:
    • -CBT
    • -Antidepressant medications (SSSRIs, TCAs, MAOIs)
  54. Cyclothymic disorder
    • 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
  55. 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
  56. Minor depressive disorder
    • episodes of depressive symptoms that don't meet MDD criteria
    • euthymic periods are also seen
  57. Recurrent brief depressive disorder
  58. Premenstrual dysphoric disorder
  59. Mood disorder due to a general medical condition
  60. Substance-induced mood disorder
  61. Mood disorder not otherwise specified