Psychiatry - Anxiety, Personality d/o, Cognitive d/o

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Psychiatry - Anxiety, Personality d/o, Cognitive d/o
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2013-07-27 18:31:45
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Anxiety and adjustment disorders
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  1. Anxiety disorders
    types
    epidemiology
    • Epidemiology:
    • -women 30% lifetime prevalence, men 19% lifetime prevalence.
    • -More frequently in higher socioeconomic groups

    • Types:
    • -Panic disorder
    • -Agoraphobia
    • -Specific and social phobias
    • -Obsessive-compulsive disorder
    • -Post-traumatic stress disorder
    • -Acute stress disorder
    • -Generalized anxiety disorder
    • -Anxiety disorder secondary to generalized medical condition
    • -Substance-induced anxiety disorder
  2. Medical causes of anxiety disorders
    • hyperthyroidism
    • vitamin B12 deficiency
    • Hypoxia
    • Neurological disorders (epilepsy, brain tumors, MS)
    • Cardiovascular disease
    • Anemia
    • Pheochromocytoma
    • Hypoglycemia
  3. Medication- or Substance-induced anxiety disorders
    • Caffeine intake and withdrawal
    • Amphetamines
    • Alcohol and sedative withdrawal
    • mercury or arsenic toxicity
    • organophosphate or benzene toxicity
    • Penicillin
    • Sulfonamides
    • Sympathomimetics
    • Antidepressants
  4. Panic attacks
    criteria
    • - Attacks peak in several minutes and subsides within 25 minutes. Rarely last > 1 hour
    • - Attacks may be unexpected or provoked by specific triggers

    • Criteria: at least 4 of the following
    • -Palpitations
    • -Sweating
    • -Shaking
    • -Shortness of breath
    • -Choking sensation
    • -Chest pain
    • -Nausea
    • -Light-headedness
    • -Depersonalization (feeling detached from oneself)
    • -Fear of losing control or "going crazy"
    • -Fear of dying
    • -Numbness or tingling
    • -Chills or hot flashes
  5. PANIC (mnemonic)
    • Palpitations
    • Abdominal distress
    • Numbness, nausea
    • Intense fear of death
    • Choking, chills, chest pain, sweating, shaking, shortness of breath
  6. Panic disorder
    criteria
    Experiencing panic attacks accompanied by persistent fear of having additional attacks

    • 1. Spontaneous recurrent panic attacks with no obvious precipitant
    • 2. At least one attack has been followed by minimum 1 month of:
    • -persistent concern about having additional attacks
    • - worry about implications of attack
    • - significant change in behavior related to the attacks

    with or without agoraphobia (fear of being alone in public places)
  7. Panic disorder
    epidemiology
    • Lifetime prevalence: 2 to 5%
    • Females:males 2-3:1
    • Strong genetic component
    • Onset: late teens to early thirties
  8. Panic disorder
    associated conditions
    • Major depression (depressive symptoms found in 40 to 80% of patients)
    • Substance dependence (found in 20 to 40% of patients)
    • Social and specific phobias
    • Obsessive-compulsive disorder
  9. Panic disorder
    course and prognosis
    • Variable, but often chronic
    • Relapses are common with discontinuation of therapy
    • 10 to 20% of patients continue to have significant symptoms that interfere with daily functioning
    • 50% continue to have mild symptoms
    • 30 to 40% remain free of sx after treatment
  10. Panic disorder
    treatment
    • Acute initial treatment of anxiety: benzodiazepines, which should be tapered as SSRI is instituted
    • Maintenance: SSRIs (especially paroxetine and sertraline), typically take 2 to 4 weeks to become effective
    • - can also use clomipramine, imipramine, or other antidepressants
    • - treat for at lesat 8 to 12 months
    • Other: relaxation, biofeedback, cognitive therapy, insight-oriented psychotherapy, family therapy
  11. Agoraphobia
    • fear of being alone in public places, often develops 2/2 panic attacks due to apprehension about having subsequent attacks in public places where escape may be difficult
    • 50 to 75% of patients have coexisting panic disorder
    • Treatment: SSRIs, behavioral therapy
  12. Specific and social phobias
    • phobias are the most common mental disorders in the US
    • 5 to 10% of the population is afflicted
    • Women:men 2:1 for specific phobias
    • Women:men 1:1 for social phobia
  13. Obsessive-compulsive disorder
    • Obsession: recurrent and intrusive thought, feeling, or idea
    • Compulsion: conscious repetitive behavior linked to an obsession that, when performed, functions to relieves anxiety caused by the obsession
    • Axis I disorder; patients are generally aware of their problems, realize that their thoughts and behaviors are irrational
  14. OCD
    criteria
    • 1. Obsessions or compulsions (75% of patients have both obsessions and compulsions)
    • 2. Person is aware of obsessions and compulsions as unreasonable and excessive
    • 3. Obsessions cause marked distress, time consuming, significantly interfere with daily function
  15. OCD
    epidemiology
    treatment
    • Lifetime population prevalence: 2 to 3%
    • Onset: early adulthood
    • Men:women 1:1
    • OCD is associated with MDD, eating disorder, other anxiety disorders, OCPD
    • Treatment: high dose SSRIs (first-line), TCAs
  16. PTSD
    • Having experienced or witnessed a traumatic event
    • Persistent reexperience of the event (dreams, flashbacks, etc.)
    • Avoid stimuli associated with the trauma
    • Numbing of responsiveness (constricted affect, feeling detachment)
    • Persistent symptoms of increased arousal (difficulty sleeping, outbursts of anger, startle response)
    • Symptoms must be present for >1month
  17. PTSD
    prognosis, treatment
    • 1/2 patients remain symptom free after 3 months of treatment
    • Treatment: TCAs, SSRIs, MAOIs, Anticonvulsants (flashbacks and nightmares)
    • Other: psychotherapy, relaxation, support groups
  18. Acute Stress disorder
    • people experience major traumatic event but have anxiety symptoms for only a short duration
    • - Event occurred <1 month ago
    • - Symptoms last <1 month
  19. Generalized Anxiety Disorder
    • persistent, excessive anxiety and hyperarousal for at least 6 months
    • Worry about general daily events
    • Anxiety is difficult to control
  20. GAD
    criteria
    • Excessive anxiety and worry about daily events and activities for at least 6 months
    • Difficult to control the worry
    • Must be associated with of the following: Restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
  21. GAD
    epidemiology, comorbidities
    • Lifetime prevalence: 45%
    • Women:Men is 2:1
    • Onset: before age 20 (usually)
    • 50-90% of pts with GAD have coexisting mental disorder (esp. major depression, social or specific phobia, panic disorder)
    • Prognosis: chronic, fluctuating sx in 50% of patients
  22. GAD
    treatment
    • Most effective: psychotherapy and pharmacotherapy
    • Buspirone
    • Benzodiazepines (clonazepam or diazepam) -- should taper off asap due to risk of tolerance and dependence 
    • SSRIs
    • Venlafaxine (extended release)
  23. Adjustment disorders
    criteria
    • (Not anxiety disorders)
    • Maladaptive behavioral or emotional symptoms develop aafter a stressful life event
    • Sx begin within 3 months after the events, end within 6 months
    • Cause significant impairment in daily function or interpersonal relationships
    • *Symptoms are not those of bereavement
    • Stressful ivent is not life threatening
  24. Personality disorder
    criteria
    Ego-syntonic: patients lack insight about their problems

    • 1. Pattern of behavior/inner experience that deviates from the person's culture, manifests in two or more of the following ways:
    • Cognition
    • Affect
    • Personal Relations
    • Impulse control

    • 2. The pattern:
    • - Is pervasive and inflexible in a broad range of situations
    • - Is stable and as an onset no later than adolescence or early adulthood
    • - leads to significant distress in functioning
    • - Not accounted for by another mental/medical illness or substance use
  25. Clusters
    • Weird, Wild, Worried
    • Cluster A: schizoid, schizotypal, paranoid
    • Cluster B: antisocial, borderline, histrionic, narcissistic
    • Cluster C: avoidant, dependent, obsessive-compulsive
    • Personality disorder NOS: passive-aggressive personality disorder
  26. Paranoid Personality Disorder
    criteria
    • Pervasive distruss and suspiciousness of others, interpret motives as malevolent
    • At least 4 of the following:
    • 1. Suspicion that others are exploiting or deceiving him or her
    • 2. Preoccupation with doubts of loyalty or trustworthiness of acquaintances
    • 3. Reluctance to confide in others
    • 4. Interpretation of benign remarks as threatening or demeaning
    • 5. Persistence of grudges
    • 6. Perception of attacks on his or her character that are not apparent to others; quick to counterattack
    • 7. Recurrence of suspicions regarding fidelity of spouse or lover
  27. Paranoid personality disorder vs paranoid schizophrenia
    PPD do not have any fixed delusions and are not frankly psychotic
  28. Schizoid personality disorder
    criteria
    • social withdrawal, often perceived as eccentric and reclusive; no desire for close relationships
    • 4 or more of the following:
    • 1. Neither enjoying nor desiring close relationships
    • 2. Generally choosing solitary activities
    • 3. Little interest in sexual activities
    • 4. Taking pleasure in few activites
    • 5. Few close friends or confidants
    • 6. Indifference to praise or criticism
    • 7. Emotional coldness, detachment, or flattened affect
  29. Schizoid PD vs Paranoid schizophrenia vs schizotypa PD
    • Schizoid PD do not have any fixed delusions
    • Schizoid PD do not have the same eccentric behavior or magical thinking seen in patients with schizotypal PD
  30. Schizotypal PD
    criteria
    • pervasive pattern of eccentric behavior and peculiar thought patterns
    • Five or more of the following:
    • 1. Ideas of reference
    • 2. Odd beliefs or magical thinking, inconsistent with cultural norms
    • 3. Unusual perceptual experiences
    • 4. Suspiciousness
    • 5. Inappropriate or restricted affect
    • 6. Odd or eccentric appearance or behavior
    • 7. Few close friends or confidants
    • 8. Odd thinking or speech
    • 9. Excessive social anxiety
  31. Antisocial personality disorder
    criteria
    • Pts refuse to conform to social norms and lack remorse for their actions; impulsive, deceitful, often violate the law
    • Must be at least 18 years old with history of conduct disorder3 or more of the following:
    • 1. Failure to conform to social norms by committing unlawful acts
    • 2. Deceitfulness/repeated lying/manipulating others for personal gain
    • 3. Impulsivity/failure to plan ahead
    • 4. Irritability and aggressiveness/repeated fights or assaults
    • 5. Recklessness and disregard for safety of self or others
    • 6. Irresponsibility/failure to sustain work or honor financial obligations
    • 7. Lack of remorse for actions
  32. Borderline PD
    criteria
    • BPD pts have unstable moods, behaviors, interpersonal relationships
    • At least 5 of the following:
    • 1. Desperate efforts to avoid real or imagined abandonment
    • 2. Unstable, intense interpersonal relationships
    • 3. Unstable self-image
    • 4. Impulsivity in at least two potentially harmful ways
    • 5. Recurrent suicidal threats or attempts or self-mutilation
    • 6. Unstable mood/affect
    • 7. General feeling of emptiness
    • 8. Difficulty controlling anger
    • 9. Transient, stress-related paranoid ideation or dissociative symptoms
  33. Histrionic PD
    Criteria
    • Attention-seeking behavior and excessive emotionality; dramatic, flamboyant, extroverted
    • At least 5 of the following:
    • 1. Uncomfortable when not the center of attention
    • 2. Inappropriately seductive or provocative behavior
    • 3. Uses physical appearance to draw attention to self
    • 4. Has speech that is impressionistic and lacking in detail
    • 5. Theatrical and exaggerated expression of emotion
    • 6. Easily influenced by others or situations
    • 7. Perceives relationships as more intimate than they actually are
  34. Narcissistic PD
    criteria
    • Sense of superiority, need for admiration, lack of empathy; "Special"
    • At least 5 of the following:
    • 1. Exaggerated sense of self-importance
    • 2. Preoccupied with fantasies of unlimited money, success, brilliance
    • 3. Believes that he or she is "special" or unique
    • 4. Needs excessive admiration
    • 5. Has sense of entitlement
    • 6. Takes advantage of others for self-gain
    • 7. Lacks empathy
    • 8. Envious of others or believes others are envious of him or her
    • 9. Arrogant or haughty
  35. Avoidant PD
    criteria
    • social inhibition and an intense fear of rejection. Patients desire companionship, but are shy and easily injured
    • At least 4 of the following:
    • 1. Avoids occupation that involves interpersonal contact due to a fear of criticism and rejection
    • 2. Unwilling to interact unless certain of being linked
    • 3. Cautious of intrapersonal relationships
    • 4. Preoccupied with being criticized or rejected in social situations
    • 5. Inhibited in new social situations because of feelings of inadequacy
    • 6. Believes he or she is socially inept and inferior
    • 7. Reluctant to engage in new activities for fear of embarrassment
  36. Dependent PD
    criteria
    • Poor self-confidence and fear separation
    • At least 5 of the following:
    • 1. Need reassurance from others regarding everyday decisions
    • 2. Need others to assume responsibility for most areas of life
    • 3. Cannot express disagreement b/c of fear of loss of approval
    • 4. Difficulty initiating projects
    • 5. Goes to lengths to obtain support from others
    • 6. Feels helpless when alone
    • 7. Urgently seeks another relationship when one ends
    • 8. Preoccupied with fears of being left to take care of self
  37. obsessive-compulsive PD
    criteria
    • pattern of perfectionism, inflexibility, and orderliness
    • At least 4 of the following:
    • 1. Preoccupation with details, rules, lists, organization such that the major point of the activity is lost
    • 2. Perfectionism that is detrimental to completion of task
    • 3. Excessive devotion to work
    • 4. Excessive conscientiousness and scrupulousness about morals and ethics
    • 5. Will not delegate tasks
    • 6. Unable to discard worthless objects
    • 7. Miserly
    • 8. Rigid and stubborn
  38. Cognitive disorders
    categories
    • Cognitive d/o affect memory, orientation, attention, and judgement
    • Dementia
    • Delirium
    • Amnestic disorders
  39. Dementia
    • Dementia is an impairment of memory and other cognitive function without alteration in the level of consciousness
    • Most progressive and irreversible
    • Memory, cognition, language skills, behavior, personality
  40. Dementia
    epidemiology
    • Incident increases with age
    • 20% of people > age 80 have severe form of dementia
    • Delusions and hallucinations occur in approximately 30% of demented patients
    • Depression and anxiety seen in 40 to 50% of patients
  41. Delirium
    • waxing/waning of consciousness
    • high mortality if untreated
    • 1. Quiet: patient may seem depressed or exhibit symptoms similar to failure to thrive
    • 2. Agitated: obvious pulling out lines; may hallucinate
  42. Delirium vs dementia
    • Delirium vs Dementia
    • Clouding of consciousness vs loss of memory/intellectual ability
    • Acute onset vs Insidious onset
    • Lasts 3 days to 2 weeks vs months to years
    • Orientation impaired
    • Immediate/recent memory impaired vs remote and recent memory impaired
    • Usually reversible vs 15% reversible
    • EEG changes vs No EEG changes
  43. Alzheimer's disease
    epidemiology
    • Most common dementia (80% of all dementias)
    • 5% of all people > 65
    • 15 to 25% of all people >85
    • Women>men
    • Average life expectancy: 8 years after diagnosis
    • 40% have family history of Alzheimer's
  44. Alzheimer's disease
    Clinical manifestations, criteria
    • Gradual progressive decline of cognitive function, especially memory and language.
    • Personality changes and mood swings are very common
    • Memory impairment plus at least 1 of the following:
    • Aphasia: disorder of language affecting speech and understanding
    • Apraxia: inability to perform purposeful movements
    • Agnosia: inability to interpret sensations correctly (visual, inability to recognize a previously known object)
    • Diminished executive function
  45. Alzheimer's 
    neurophysiology
    • decreased levels of acetylcholine (locus ceruleus)
    • decreased levels of norepinephrine (basal nucleus of Meynert)
    • Pathology: diffuse atrophy, enlarged ventricles
    • Neurofibrillary tangles derived from Tau proteins
  46. Alzheimer's treatment
    • No cure or effective treatment
    • NMDA receptor antagonists: memantine
    • Cholinesterase inhibitors help slow progression:
    • -Tacrine (Cognex)
    • -Donepezil (Aricept)
    • -Rivastigmine (Exelon)
  47. Vascular dementia
    clinical manifestation
    • Microvascular disease in the brain ⇒ multiple small infarcts
    • IDENTICAL to Alzheimer's: memory impairment plus at least one of the following
    • 1. Aphasia
    • 2. Apraxia
    • 3. Agnosia
    • 4. Diminished executive function
  48. Vascular dementia vs Alzheimer's
    • Vascular dementia:
    • -focal neurological symptoms
    • -onset is more abrupt
    • -preservation of personality
    • -Can reduce risk by modifying risk factors (smoking, hypertension, diabetes)
  49. Pick's disease
    aka Frontotemporal dementia (FTD)
    • RARE cause of slowly progressing dementia
    • Hallmarks: aphasia, apraxia, agnosia
    • Pathology: atrophy of frontotemporal lobes; Pick bodies
  50. Pick's bodies
    intraneuronal inclusion bodies (necessary for diagnosis of FTD)
  51. Huntington's disease
    • Autosomal dominant genetic disorder
    • progressively disabling cognitive, physical, and psychological functioning
    • death after approx. 15 years
  52. Huntington's disease
    clinical manifestations
    • Onset: 35 to 50 years
    • Progressive dementia
    • Choreiform movements
    • Muscular hypertonicity
    • depression and psychosis very common
  53. Huntington's disease
    pathology, diagnosis, treatment
    • Pathology: trinucleotide repeat of short arm of chrom 4; basal ganglia
    • MRI: caudate atrophy
    • genetic testing is diagnostic
    • Treatment: none!
  54. Parkinson's disease
    • prominent neuronal loss in substantia nigra (provides dopamine to basal ganglia) causing physical and cognitive impairment
    • Approx 30% of patients with PD develop dementia
  55. Parkinson's disease
    clinical manifestation
    • Bradykinesia
    • Cogwheel rigidity
    • Resting tremor - "pill-rolling" tremor most common
    • Masklike facial expression
    • Shuffling gait
    • Dysarthria (abnormal speech)
  56. Parkinson's disease
    Etiology
    • Idiopathic (most common)
    • Traumatic (Muhammad Ali)
    • Drug- or toxin-induced
    • Encephalitic
    • Ramilial (rare)
  57. Parkinson's disease
    treatment
    • Levodopa: degraded by dopamine by dopadecarboxylase
    • Carbidopa: peripheral dopadecarboxylase inhibitor prevents levodopa from being converted to dopamine
    • Amantadine: mechanism unknown
    • Anticholinergics: help relieve tremor
    • Dopamine agonists (bromocriptine, etc.)
    • Monoamine oxidase (MAO)-B inhibitors (selegiline): inhibit break-down of dopamine
  58. Creutzfeldt-Jakob disease
    • Rapidly progressive, degenerative disease of the CNS caused by prion
    • Clinical manifestations: rapidly progressive dementia 6 to 12 months after onset of sx
    • 90% have myoclonus
    • Extrapyramidal signs, ataxia, lower motor neuron signs are also common
  59. Other prion diseases
    • Kuru
    • Gerstmann-Straussler syndrome
    • Fatal familial insomnia
    • Bovine spongiform encephalopathy ("mad cow disease")
  60. Normal pressure hydrocephalus
    • NPH is a reversible cause of dementia
    • Enlarged ventricles with increased CSF pressure
    • Clinical triad: gait disturbance, urinary incontinence, dementia
    • Wet, wabbling, weird (dementia)
    • Treatment: relieve increase pressure with shunt
  61. Delirium
    • rapid onset of symptoms
    • periods of altered levels of consciousness
    • potential reversal of symptoms
    • Fluctuating course with lucid intervals
    • Patients are often anxious, incoherent, unable to sleep normally
  62. Delirium
    Etiology
    • CNS injury or disease
    • Systemic illness
    • Drug abuse/withdrawal
    • Hypoxia
    • Fever
    • Sensory deprivation
    • Medications (anticholinergics, steroids, antipsychotics, antihypertensives, insulin)
    • Postop
    • Electrolyte imballances
  63. Amnestic disorders
    • impairment of memory without other cognitive problems
    • Always occur 2/2 an underlying medical condition
    • Etiology: hypoglycemia, systemic illness, hypoxia, head trauma, brain tumor, CVA, seizures, multiple sclerosis, herpes simplex encephalitis, substance use

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