mental health

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mental health
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  1. Schizophrenia
    • Chronic, devastating mental Illness
    • usually strikes in young adulthood.
    • High risk of suicide
    • Costs society over $100 billion per year
    • Costs to patients and families incalculable
    • Recognized since Arateus of Cappadocia and Hippocrates
    • Psychosis is the hallmark of schizophrenia
  2. Schizophrenia Epidemiology
    • 1% in US population
    • Lifetime prevalence 1-1.3% (world wide)
    • ½ obtain tx
    • M=F
    • Peak age of onset: 10-25 M; 25-35 2nd >40F
    • Occurs >45, late onset
    • Onset rare <10 and >60 years old
  3. Schizophrenia comorbidity
    • High w. general med problems
    • 80% concurrent med illnesses
    • 50% undiagnosed
    • Higher mortality frm accidents/illness
    • high substance abuse (50%drugs; 90 tobacco)
    • 40% etoh abuse
    • >50 cannabis uses=6x > likelihood x
    • Amphetamines and cocaine can increase psychotic symptoms
  4. Schizophrenia etiology bio
    • 1) alterations in brain structure and function
    • ~Enlarged cerebral ventricles
    • ~Altered cellular structure and function
    • ~Altered patterns of blood flow
    • 2) Neuro-developmental findings
    • Higher in incidents of perinatal complications
    • Birthdates cluster in winter months-viral theory
  5. Schizophrenia biochem etiology
    • 1) Dopamine Hypothesis: there is increased dopamine activity
    • Excessive dopamine linked to psychosis
    • Dopamine antagonists decrease psychosis
    • 2) Glutamate Hypothesis:
    • glutamate antagonism produces acute symptoms
    • PCP and other drugs of abuse can cause psychosis
  6. Schizophrenia genetic etiology
    • Genes contribute to vulnerability
    • Other factors involved in expression of phenotype
  7. Schizophrenia dx
    • r/o other causes of psychosis:
    • CBC, Chem 7, LFTs, TFTs, RPR/VRDL
    • serum and urine toxicology screens
    • Head CT or MRI if other neurological signs
    • Ceruloplasmin, Lyme titer, B12/folate
    • EEG if clinical suspicion indicates
  8. Schizophrenia Clinical findings:
    • Positive symptoms- phenomena not normally present
    • Negative symptoms- absence of phenomena normally present
    • Cognitive impairment (memory, organization)
    • Neurologic soft signs
    • (fine motor impairment, primitive reflexes, altered ocular pursuit)
  9. Positive symptoms of schizo
    • Hallucinations
    • Delusions
    • Disorganization
  10. Hallucinations schizo
    • perception of things not present
    • visual, auditory, olfactory, gustatory, or tactile.
    • Most commonly auditory (noises, music, or voices).
  11. Schizophrenia delusions
    • fixed, false beliefs not consistent with the person's cultural norms and background
    • Common themes:
    • grandiose
    • nihilistic
    • persecutory
    • somatic
    • religious
    • sexual
  12. Schizophrenia delusion types
    • Thought broadcasting-broadcasting ones thoughts
    • Thought withdrawal - belief others are taking thoughts out of one's mind
    • Thought insertion - belief others are putting (literally inserting) thoughts into one's mind
    • Thought control - outside forces are controlling what the patient thinks or feels
  13. Schizophrenia Disorganization (disordered thoughts)
    • Tangentiality
    • Circumstantiality
    • Loose associations
    • Derailment
    • Flight of ideas
    • Perseveration
    • Echolalia
    • Clang association
    • Neologisms
    • Word salad
  14. Tangentiality
    starts, then off on a tangent
  15. Circumstantiality
    talks all around the topic; (not main point)
  16. Loose associations
    little connection between thoughts
  17. Derailment
    little connection between thoughts
  18. Flight of ideas
    some logical connections but hard to follow
  19. Perseveration
    repetition of a word or idea
  20. Echolalia
    patient repeats back what is said to them
  21. Clang association
    words are associated by sound
  22. Neologisms
    made up words or phrases used for real ones
  23. Word salad
    random words
  24. Schizo Negative Symptoms
    • (Bleuler's 4 A's)
    • Alogia: poverty of speech (content and amount)
    • Affective flatttening: decreased emotional expression
    • Anhedonia: inability to feel pleasure
    • Avolition: inability to initiate goal directed activity
  25. Schizophrenia Cognitive Impairment
    • Degree of x is the best predictor of functional outcome.
    • Gradual deterioration throughout dz
    • Defects in working memory
    • Defects in filtering extraneous sensory input
  26. Schizophrenia tx
    • often more than one form
    • Hospitalization; Pharmacotherapy
    • ECT; Skills Training; Family Therapy
    • Case Management; Assertive Community Treatment (ACT)
    • Group Therapy; Cognitive Behavioral Therapy
    • Individual Psychotherapy; Personal (Interpersonal) Therapy
    • Dialectic Behavioral Therapy; Vocational Therapy
    • Art Therapy;Cognitive Training
  27. Pharmacotherapy for Schizophrenia
    • Antipsychotics:
    • 1st generation chlorpromazine (Thorazine)
    • Then other dopamine receptor agonists
    • 2nd generation, aka atypical:clozapine (Clozaril)
    • risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, & paliperidone
  28. Schizophrenia Course of illness
    • Prodomal: Social withdrawal, depression, anxiety, eccentricity
    • Active/acute: Active psychosis, diagnosis often made
    • Residual phase: + (psychotic) sx less; - sx persist
    • Exacerbations: usually occur
  29. Schizophrenia Prognosis
    • 20% do well long term; very few symptom free
    • downward drift in cognitive fx & SES
    • women better than men (later onset and better premorbid)
    • good social support+regular schedule=do better
    • Estimated 15-45% of American homeless
    • 5% suicide rate (especially early in illness)
  30. Schizoaffective Disorder Overview
    • mood disorder integrated w/ active phase schizo sx
    • bipolar type or depressive type
    • Episode, remission, and severity specifiers
    • Not due to substance or medical condition
    • Major suicide risk
  31. Schizoaffective Disorder Epidemiology
    • Lifetime prevalence <1%
    • M=F in bipolar type
    • F>M in depressive type
    • Female later than male
    • Bipolar type more common yng adl
    • Depressive type more common older adults
  32. Schizoaffective Disorder Etiology
    • unknown
    • similar to schizophrenia with mood symptoms
    • , mood disorder with psychotic symptoms
    • , or concurrent expression of both.
    • Perhaps a group of heterogenious disorders.
    • likely variable and multifactorial
  33. Schizoaffective Disorder Treatment:
    • Like Mood Disorders and Schizophrenia
    • both pharm & psycho etc therapy
    • Pharm-multi: antipsychotics, antidepressants, mood stabilizers, etc.
    • In some cases, ECT
  34. Schizoaffective Disorder Course and Prognosis:
    • similar to mood disorder, according to type
    • or to schizophrenia, if positive psychotic symptoms are prominent.
    • Prognosis generally better than Schizophrenia but worse than mood disorder.
  35. Schizophreniform Disorder: Clinical Features
    • Schizophrenia sx duration is 1-6 months.
    • r/o psychosis caused by substances or medical condition.
    • High comorbidity with mood and anxiety disorders.
  36. Schizophreniform Disorder Treatment
    • Hospitalization often necessary
    • ECT may be indicated for depressed, catatonic patients
    • Respond quicker to antipsych than schiphren pt
    • 3-6 month course of antipsychotic medication.
    • Psychotherapy
  37. Schizophreniform Disorder: Course and Prognosis
    • Time limited episode with significant symptoms
    • 60-80 additional episodes & progress to schizophrenia disorder.
    • Some experience 2-3 episodes (usually with a declining level of functioning)
    • Only few experience a single episode
  38. Delusional Disorder - overview
    Primarily a thought content disorder
  39. The delusion, (fixed false belief) is usually systematized and possible (not bizarre and impossible like in schizophrenia)
  40. Common delusions include:
    • being loved by a celebrity, being persecuted, being infected/poisoned, unfaithful partner
    • Be careful not to assume that all unlikely situations are delusions.
  41. Delusional Disorder Epidemiology
    0.2-0.3% prevalence in US
  42. Delusional disorder Risk factors
    • elderly, sensory impairment,
    • isolation, recent immigration, lower socioeconomic status
  43. Rarely seek treatment
    • Men more likely to have paranoid delusions
    • Women more likely to have delusions of love
    • Mean age of onset >40
    • F>M slightly
  44. Delusional Disorder
    • etiology unknown but likely to have both biological and psychosocial factors.
    • A psychosocial stress may occur at the onset of a delusional disorder.
    • Need to rule out substances, neurological disorders, and other medical causes for mental status change with delusions.
  45. Delusional Disorder Treatment
    • Generally regarded as treatment resistant
    • Focus on managing the impact of the delusion on the patient's life.
    • Medical intervention, antipsychotic medication, and hospitalization as needed.
    • If there is a shared delusional disorder, those who share the delusion must be seperated
    • Individual psychotherapy
  46. Delusional Disorder Course and Prognosis
    • Sudden onset common (often accompanied by psychosocial stressor)
    • Patients with delusional disorder usually experience an increase in their delusion over time.
    • They seek help from police, FBI, lawyers, medical and surgical physicians for help with what they believe rather than mental health professionals because of their belief that the delusion is truth rather than a mental disorder.
  47. Brief Psychotic Disorder
    • Sudden onset of psychotic condition
    • Lasts one day to one month
    • Most common in young adults
    • More common in women than men
    • May be seen in patients with certain personality disorders who may have biological and psychological predisposition
    • histrionic, narcissistic, paranoid, schizotypal, and borderline personality disorder
  48. Brief Psychotic Disorder Diagnosis:
    • Psychotic symptoms for at least one day but less than one month
    • Not associated with mood disorder
    • Not caused by substance or medical disorder
  49. Three subtypes:
    • 1. presence of a stressor
    • 2. absence of a stressor
    • 3. postpartum onset
  50. Brief Psychotic Disorder
    • If symptoms persist longer than a month consider other diagnosis:
    • Schizophreniform disorder
    • Schizophrenia
    • Schizoaffective disorder
  51. Delusional disorder
    • Mood disorder with psychotic features
    • Psychotic disorder- unspecified
    • Psychotic disorder- substance induced
  52. What is Domestic Violence?
    • pattern of abusive behaviors
    • used to manipulate and control an intimate partner or other family member
    • pattern (behavior is repeated)
    • object is to gain power and control
    • types of abusive behaviors
  53. Elder abuse
    • Only 1 in 4 reported
    • DV grown old
    • w/ new partner
    • b/c increasing vulnerability
    • financial gain(may not be initimate partner)
    • *Distinguish from caregiver abuse (remorseful)
  54. Healthcare Provider Barriers
    • Lack of awareness of prevalence
    • Not in MY practice
    • Fear of offending patient
    • Disbelief - calm abuser seems more credible
    • Unsure what to do once identified
    • Feel Helpless, Frustrated
    • Difficult patient (lies, self medicates, appears crazy)
    • Time constraints
  55. Prevalence of dv
    • 85% of victims are female
    • 15% male victims, some are victims of same sex assaults.
    • leading cause of injury to women in the US
    • up to 1/3 ER visits-battered women
    • 25% of female suicides
    • 25% of women seeking emergency psychiatric help
    • 58% of women over 30 who have been raped.
  56. Prevalence of DV battered women
    • Kill selves >killed by partner(~2k/yr suicide)
    • 1 in 5 sexually assaulted by their partners
    • Preg/recent preg >homicide vitime
    • 40% of girls ages 14 - 17 report knowing someone
  57. Patient barriers
    • May not receive regular medical care
    • May be uninsured or partner may not permit
    • May fear for own and others safety
    • Shame
    • Wishful thinking
    • Distrust - If provider treats abuser, as well
    • May not identify experience as "abuse"
  58. Battered Women Do NOT Need:
    • To be taught to make better choices
    • Therapy
    • A cure
    • To be educated
    • To be better wives
    • To be punished
  59. Battered Women DO Need:
    • To be treated for the physical and psychological damage of abuse
    • To be believed
    • To be assured that being abused is not their fault
    • To be advised of options and resources
    • To be supported in their decisions
  60. Barriers women face
    • Batterer Tactics/ Danger
    • Children; Money
    • Isolation; Lack of Transportation
    • Accessibility to shelter/services
    • Lack of edu
    • Religion; culture
    • Fear of unknown; love
  61. Risks of seeking help
    • Death; Retaliation
    • Harm to children
    • Arrest; Losing home
    • Losing control of her life
  62. Separation is the Most Dangerous Option
    • 75% of all dv assaults occur during or after separation
    • Victims who leave are 75% more likely to be killed than those who stay
  63. Screening for Domestic Violence:
    • When screen? EVERY TIME a patient is seen!
    • Who screened? ALL adolescent and adult patients!
    • In private
    • As part of face-to-face encounter and in written questionnaires
    • With a neutral interpreter, if an interpreter is needed
    • Repeatedly
  64. Strategies
    • Ask partner to leave for part of exam
    • Send partner to do paperwork
    • Approach patient on way to restroom
    • Send patient for x-ray
    • Admit patient
  65. Screening for Domestic Violence:Provider Response
    • How to ask the question:
    • Literature should be kept visible in waiting/exam room
    • Take a direct approach
    • Use open-ended questions
  66. What to Do When a Patient Discloses Domestic Violence
    • Model a positive response that victims may experience from other systems partners
    • Listen, be supportive and nonjudgmental:
    • Don't deserve it; have right to be safe
    • Concerned for your and childrens safety
    • Not alone; help available
  67. Behavioral Signs:
    • Partner accompanies & does most of the talking
    • Partner displays irrational jealousy
    • Patient reluctant to speak or disagree in front of partner
    • Patient checks partner's response while answering questions
    • Patient seems evasive, ashamed, embarrassed, guilty, depressed, ambivalent, angry, and/or fearful
    • Patient avoids eye contact (be aware of cultural differences)
  68. Behavioral Signs med hx
    • Limited access to routine or emergency medical care
    • Missed appointments
    • May not be allowed to obtain or take medication
    • Lack of independent transportation, finances, inability to communicate by phone
    • Failure to use condoms or contraception
    • Complaints with no findings
  69. Med Indicators
    • Frequent injuries - the patients with the thickest charts
    • Delay between injury and presentation
    • Chronic pain
    • Physical symptoms related to stress, anxiety disorders or depression
    • History of multiple miscarriages
    • Suicidal attempts or gestures
    • Substance abuse - drug seeking
  70. Physical Exam Indicators:
    • Injuries to trunk, head, and neck
    • Spongy scalp-pulled by hair
    • Burns in unusual places
    • Injuries at multiple sites
    • Injuries in various stages of healing
  71. Injuries during pregnancy
    • Breasts
    • Abdomen
    • Genitals
    • Complications
  72. Strangulation
    • Injuries visible only 15% of the time
    • Swelling, redness, bruising, abrasions, rope/cord burns, ligature marks
    • Petechiae
    • Neck pain, sore throat, difficulty swallowing
    • Raspy voice; Speaking in spurts
    • Dizziness, fainting, unconsciousness
    • Nausea, vomiting, coughing up blood
    • Miscarriage
  73. Abuse Treatment Plan
    • Empower victims - provide information
    • Domestic violence always escalates
    • Referral to DV Hotline - 222-SAFE
    • Artemis Services
    • Shelter
    • Safety plan for victim who chooses to stay with batterer
    • i.e., avoid kitchen, bathroom and garage
    • Safety plan for victim who chooses to leave
    • Pack safety bag and important documents
    • Plan where to go
  74. Don'ts
    • Don't report against the patient's wishes when reporting is not required
    • Don't assume leaving is the answer
    • Avoid directive language "You should..."
    • Avoid overwhelming the patient with too much information
  75. Reporting
    • Laws vary from state to state
    • Ohio law mandates reporting:
    • Child abuse
    • Elder abuse (60 yrs and older, if physical or mental impairment to elder)
    • Gunshot wounds
    • Stab wounds
    • Second and third degree burns
    • Severe injuries
    • OH requires healthcare providers to document suspected domestic violence
  76. Medical Evidence
    • Domestic violence is a serial crime
    • Medical records can be subpoenaed in criminal and civil cases
    • Evidence based prosecution allows cases to proceed without the victim's participation
    • Include everything - inadmissible information can be used for plea bargaining, persuading witnesses to cooperate, etc.
  77. documenting
    • Establish a paper trail
    • Document date and time patient was seen
    • Include patient history, as stated, and by whom it was given
    • Include detailed information about each injury and your judgment about type of weapon used
    • Document patient's emotional state and demeanor
    • Include direct quotes (i.e., "I was afraid he would kill me" or "My boyfriend kicked me")
    • Document how patient says injury occurred (If necessary, state: "Injuries inconsistent with patient explanation.")
    • Document LEGIBLY
  78. Take Photos
    • Keep a disposable camera in the office
    • Get patient's written consent first
    • Always include photo of victim's face
    • Include close-up, mid-range and long-range views of injuries
    • Include a ruler to provide scale
  79. You CAN Help
    • Screen repeatedly for domestic violence
    • Listen, be supportive and non-judgmental
    • Report if required or patient consents
    • Document thoroughly and legibly
    • Refer patient to domestic violence agency
    • Safety plan with patient
  80. Suicide
    • The Primary Emergency in Mental Health
    • major focus in mental health assess& tx
    • risk is an important focus in the DSM-5
  81. Suicide
    completed act of intentionally killing one's self
  82. Suicide attempt
    • completed act which had the intention of killing one's self
    • did not result in death (may result in various degrees of injury)
  83. Suicidal gesture
    act which looks to be a suicide attempt but intent is questioned (?)
  84. Suicidal plan and/or intent
    • method has been thought of
    • may or may not intend to carry it out in a specific timeframe
  85. Suicidal thoughts
    ideas about ending one's life
  86. Suicidal wish
    hoping or wishing or feeling one would be "better off" if he or she were dead
  87. Parasuicidal behavior
    • intentional self-injury, self-mutilation (e.g. cutting) n
    • ot trying to kill themselves
    • serves some other psychological purpose.
  88. Suicide Epidemiology
    • 35,000 deaths per year in US
    • ~100 per day in the US (~20 per day are vets)
    • Estimated 25:1 suicide attempts to suicide
    • Ranked 10th most common cause of death
    • The Golden Gate Bridge in San Francisco
    • Over 1,600 suicides committed there since 1937
  89. Suicide Prediction
    • impossible to predict.
    • Studies show health professionals are not any better than the general population in prediction.
    • Some people act impulsively, others think and plan it for days, months, or even years.
    • There are some known risk factors
    • F attempt/ideation 3x > M
    • M complete suicide 4x > F
  90. Risk Factors suicide
    • Age: Rare before puberty; teens rising
    • Age 15-24: 3rd highest cause of death (1st accidents, 2nd homicides)
    • Age 35-65: highest rate overall
    • Men peak age after 45; Women peak rate after 55
    • Older attempt less but complete more often
    • Race: Caucasian 2-3x > African American
    • Inner city youth, some Native Americans & Native Alaskan groups, and immigrants have higher rates.
  91. Suicide risk occupation & marriage
    • Marital status: marriage decreases risk
    • Never married 2x > married
    • Divorced: increases risk in both but 2x more M:F
    • Death of spouse increases risk (anniversary of death)
    • Rates in unemployed > employed: generally work is protective however:
    • Higher socioeconomic status and drop in SES increases rate
    • Professional, esp. physicians, have highest rates.
    • Other high risk occupations: police, dentists, artists, mechanics, lawyers, insurance agents.
  92. Suicide risk Physical Health/Illness:
    • Illness is considered an important contributing factor in ½ of all suicides
    • disfigurement, chronic pain, dialysis, cirrosis
    • Meds: e.g. corticosteroids, anti-HTN, chemotherapy
    • loss of mobility,relationships, & work from illness
    • 1/3 of all people who commit suicide-medical visit in the 6 months prior to suicide
  93. Suicide risk Mental Illness:
    • 95% of suicides and suicide attempts occur in people with a mental illness
    • 80% dx of depressive disorder
    • delusional depression -highest risk
    • 10% dx of schizophrenia
    • 5% dx of dementia or delirium
    • personality, anxiety, and substance-related disorders
    • Dual diagnosis w/ substance use- high risk
    • Previous psychiatric hospitalization- high risk
    • Past attempts strongest indicator of increased risk:
    • 40% of depressed pt. have previously attempted often in 3 mo.
  94. Suicide Etiology
    • Many theories
    • Freud: aggression turned inward
    • Menninger: wish to kill, wish to be killed, and wish to die
    • Contemporary suicidologists: acting out on suicide fantasies (e.g. revenge, power, control, punishment, atonement, sacrifice, escape, rescue, reunion, rebirth)
    • Aaron Beck: showed "hopelessness" most accurate indicator of long-term suicide risk
    • Genetic factors may play a role in suicidal behavior
  95. Suicide Risk Reduction
    • Treatment of underlying illness: mental ill ie MDD
    • Achieve and maintain sobriety- AA has saved many
    • Reverse risks which are reversible: Increase social supports
    • Regular assessment and intervention in high risk populations and individuals
  96. Suicide Assessment
    • Universally in psychiatric assessments
    • If any indication of risk in general medical
    • ~~violence, etoh, pain
    • Thorough MSE and direct questions as indicated
    • ask questions directly and specifically in a logical progression.
    • Begin with questions about patient's feelings about their life and living.
    • Ask specifically about thoughts about death, self-harm, or suicide.
  97. Suicide Assessment (continued)
    • For those who have had thoughts of self-harm or suicide, ask more about those thoughts.
    • Have they thought of a plan?
    • Assessment of reality of the plan.
    • Assessment of intent to carry out the plan.
    • Hx: get hx of event
    • Ask about hallucinations and delusions.
    • Command auditory hallucinations about self-harm are very high risk symptoms.
    • Consider asking if the patient has thought of harming others in addition to themselves.
  98. Intervention and Treatment
    • Suicide prevention hotlines: may be helpful for some patients
    • Select appropriate setting: Level of restriction, intensity of intervention
    • tx underlying condition: depression, anxiety, psychosis, substances etc
    • Treatment of other medical issues
    • Assist with social/economic needs
  99. Suicide Aftercare
    • Not all suicides are preventable.
    • Support and treatment may be needed for others impacted by a patient's suicide.
    • The toll on loved ones may be greater with suicide than other causes of death.
    • Support groups and supportive psychotherapy may be helpful as those affected attempt to make sense of what happened.
  100. Other psychiatric emergencies
    • Often involve serious but reversible effects of medications or other substances.
    • E.g. Neuroleptic Malignant Syndrome:
    • E.g. Wernike's encephalopathy
    • Delirium
  101. Neuroleptic malignant syndrome
    • life threatening complication of antipsychotics
    • rare
    • sx: rigidity, dystonia, mutism
    • akinesia, obtundation,
    • fever, diaphoresis
    • agitation
    • develops quick and may be mistaken for agitation/psychosis
  102. neuroleptic malignant syndrome dx/tx
    • increased WBC, CPK, liver enzymes
    • plasma myoglobin( myoglobinurea & liver failure)
    • medical support: dantrolene or bromocriptine
  103. PTSD and Acute Stress Disorder
    • increased stress & anxiety after exposure to a traumatic or stressful event such as:
    • Accident, Violent Crime or Assault, Combat, Natural Disaster
    • Stressor must be enough to affect almost everyone to some degree
    • Not everyone who is expose will develop a disorder
  104. Acute stress diff ptsd
    • Symptoms similar but starts immediately after
    • last from 3 days to 1 month.
  105. PTSD diff acute
    symptoms last more than one month.
  106. PTSD Epidemiology:
    • Lifetime prevalence 8% overall; 10% for Females; 4% for Males
    • Females: trauma usually assault; Males: usually combat
    • Up to 30% for veterans who experience combat
    • 13% of veterans of the Iraq & Afghanistan wars diagnosed
  107. PTSD higher risk
    • SEVERITY, DURATION & PROXIMITY of pt exposure 2 trauma
    • single, divorced, widowed
    • socially isolated, low socioeconomic status
  108. Comorbidity PTSD
    • Depressive, bipolar, anxiety, and substance-use disorders
    • These comorbid disorders also increase risk
  109. PTSD Etiology
    • trauma or is the prime causative factor in the development
    • Not everyone who experiences the same trauma develops
    • trauma alone is not the only factor
    • trauma must provoke intense fear or horror in them.
  110. PTSD etiology Other considerations:
    • preexisting biological and psychosocial factors;
    • previous trauma; and the events just prior to and after the trauma.
    • If members of a group who survive together, may do better.
    • If others died, the survivor may experience feelings of guilt that can predispose to, or exacerbate
  111. PTSD Clinical Features
    • Intrusive re-experiencing (flashbacks), memories, dreams
    • Dissociative reactions
    • Psychological distress
    • Avoids internal and external reminders
    • Self-devaluation, guilt, or shame
    • Amnesia for some or all of the event
    • Detachment or withdrawal in relationships
    • Anhedonia: not feeling pleasure
    • Symptoms last longer than one month
  112. Treatment for PTSD and Acute Trauma DO
    • Initial treatment: support, talk, education about coping
    • Pharm: SSRIs 1st line; TCA antidepressants also supported
    • Psychotherapy: focus on support, education, development of coping skills, and acceptance of event
    • Psychodynamically oriented psychotherapy
    • Behavior therapy
    • Cognitive therapy
    • Group and Family therapies
  113. Other treatment modalities PTSD & acute stress
    • Hypnosis
    • Exposure
    • Relaxation and stress management
    • Eye movement desensitization and reprocessing (EMDR)
  114. EMDR
    • Relatively new, somewhat controversial
    • Patient focuses on the lateral movement of the clinician's finger while maintaining a mental image of the trauma allowing the patient to work through the trauma while in a state of deep relaxation. It is supported by patients and clinicians who have used it successfully.
  115. PTSD Course
    • Sx develop in as short as 1 week
    • may take up to decades
    • last at least 1 month, but often much longer.
    • Symptoms can fluctuate & intensify during times of stress.
    • Untreated: 30% recover, 40% mild, 20% moderate, 10 % remain unchanged or worsen.
  116. PTSD prognosis
    • Good prognosis: rapid onset and short duration (<6 mo),
    • good premorbid function, good social support
    • absence of other psychiatric, medical, or substance use disorders.
    • Very young and very old have more difficulty with trauma.
  117. Adjustment Disorder
    • This diagnosis is widely used in clinical practice.
    • characterized by an emotional response to a stressful event
    • stress often financial or social
  118. Adjustment d/o epi/eti
    • 2-8% of general population
    • F 2x > M
    • Single women are at the highest risk
    • Frequently diagnosed in adolescents (male and female)
    • School problems, family issues, parental divorce
    • Etiology: stressor(s) involved, by definition.
    • Psychodynamic, Family, and Genetic factors also contribute (biopsychosocial)
  119. Adjustment d/o Clinical Features
    • Appearance of emotional or behavioral symptoms
    • after, but within 3 months, of a stressor.
    • Sx don't always subside after the stress resolves.
    • If stressor continues, the disorder may become chronic.
    • Can occur at any age.
    • Physical symptoms most common in children and the elderly.
    • Symptoms vary considerably.
    • Depressed, anxious, and mixed features are common in adults.
  120. Treatment for Adjustment Disorder
    • 1Psychotherapy: Primary treatment
    • 2Group therapy: similar stressor(s); e.g. cancer groups
    • 3Crisis intervention:
    • ~~With hospitalization is suicidality is high
    • ~~With frequent contact outpatient; may involve case management
    • 4Pharmacotherapy: Only for tx of specific sx for brief times.
    • CAM: in pt resisting psych intervention
  121. Adjustment d/o Course and Prognosis
    • Txd pts return to normal level fx w/in 3m
    • Some develop mood disorders or substance use: mc teens
    • Risk for suicide is high in adolescents
    • 50% had suicide attempts just prior to hospitalization
    • 60% during hospitalization
    • Comorbid substance use disorders and personality disorders increase risk for suicide
  122. Dissociation
    • unconscious defense mechanism
    • segregate any group of mental or behavioral processes from the rest of the person's psychic activity.
    • can disrupt memory, perception, consciousness, or motor fx
  123. Amnesia
    • memory loss; the inability to recall something previously known.
    • Coded differently based on cause
  124. Dissociative fugue
    • sudden, unexpected travel with the inability to recall some or all of one's past,
    • may be accompanied by confusion about one's identity or assumption of a new identity.
  125. Depersonalization
    persistent or recurrent feeling of detachment or estrangement from one's self.
  126. Derealization
    feelings of unreality or of being detached from one's environment.
  127. Dissociative Amnesia
    • inability to recall important personal information
    • too severe to be explained by normal forgetfulness.
  128. Dissociative amnesia Epi/eti
    • reported in 2-6% of the general population
    • M=F;
    • usually reported in late adolescence and adults
    • Etiology: Psychosocial with high emotional or conflictual circumstances.
    • May be related to trauma, betrayal, or other psychosocial stress.
  129. Dissociative amnesia Classic Presentation
    • dramatic, overt, florid presentation
    • brought quickly to medical attention
    • May include somatic or conversion symptoms, altered consciousness, depersonalization, derealization, trance, or age regression.
    • Depression and suicidal ideation are common.
    • History of abuse or trauma, often.
  130. Dissociative amnesia Nonclassic Presentation
    • present with depression, mood swings, anxiety, ED, PD, or other problems .
    • may be experienced for self-harm/violent episodes.
    • Ie don't remember cutting self
  131. MSE Questions to ask for dissociative amnesia
    • Do you ever have blackouts, blank spells, or memory lapses?
    • Do you ever "lose time" or have gaps in time?
    • Have you ever traveled a significant distance and not remembered getting there?
    • Do people tell you things you said or did that you don't recall?
    • Do you find objects in your possession that you don't remember acquiring?
    • Have you ever been told you have talents or abilities you do not know you have?
    • Do your preferences for food, music, clothes, etc. fluctuate?
    • Do you have gaps in your memory of major events or times in your life?
    • Do you notice that you tune out, not hearing all or part of what's said?
  132. Dissociative Amnesia: Treatment
    • 1 Cognitive Therapy: Identifying the cognitive distortions based in trauma may provide entry for the patient into the lost memory.
    • 2Hypnosis: Used to contain, modulate, and titrate the intensity of symptoms; to aid controlled recall of dissociated memories; to provide support and ego strengthening ; and finally to promote working through and integration of the dissociated material.
    • 3Somatic Therapies: no known pharmacotherapy however pharmacologically facilitated interviewing, done carefully, may be helpful in some cases.
    • 4Group Psychotherapy: helpful in cases associated with PTSD
  133. Dissociative Amnesia Course & prognosis
    • frequently resolves spontaneously when the person is removed from the traumatic or overwhelming circumstances and feels safe.
    • Chronic forms of generalized, continuous, or severe localized amnesia can occur and they can be profoundly disabling and require high levels of social support with intensive family caretaking or extended care facility.
    • If lost memories can be restored to consciousness , it is less likely the repressed memory will form a nucleus in the unconscious around which future amnestic episodes might develop.
  134. Depersonalization/Derealization Disorder Epidemiology
    • unknown for the disorder
    • transient experiences are extremely common in both clinical and general populations.
    • 19% of general population in 1 year prevalence survey
    • Common after life threatening experiences, head injury without loss of consciousness, and during some meditation practices.
    • Also common in seizure, migraine, and substance use.
  135. Deperson/real Etiology
    Traumatic stress (up to 50% of patients, with this disorder, report history of significant trauma); psychodynamic (childhood defense mechanism brought into adulthood) and neurobiological factors.
  136. Dp/dr do Clinical Features
    • Patients have difficulty expressing what they are experiencing, but say things like:
    • "I feel dead."; "Nothing seems real."
    • "I'm standing outside myself."; "It's all foggy."
    • "It feels like I'm walking around in a dream and I'm watching myself in it."
  137. Dp/dr do Differential Diagnosis
    • thorough medical and neurological evaluation is essential,
    • including standard labs, EEG, and any indicated drug screens
    • Substances including marijuana, cocaine, hallucinogens & psychostimulants can cause symptoms , transient or persistent.
    • Neurological disorders including: seizures, brain tumors, post concussive syndrome, and others.
    • Medical conditions including: metabolic abnormalities, migraine, vertigo, and others.
  138. Dp/dr do Treatment
    • SSRIs may be beneficial.
    • A variety of psychotherapies have been used including:
    • psychodynamic, cognitive, CBT, hypnotherapy, supportive
    • Other: stress manage; distraction; relaxation; exercise
  139. Dp do Course and Prognosis
    • after traumatic experiences or intoxication commonly resolve spontaneously.
    • If sx of mood, psychotic, or anxiety disorder-remits w/ tx of primary do
    • may have an episodic, relapsing and remitting, or chronic course.
    • often refractory to treatment.
  140. Dissociative Identity Disorder
    • two +distinct identities or personality states (alters, self-states, alter identities, or parts).
    • can experience all of the symptoms of the other dissociative disorders (amnesia, fugue, depersonalization, derealization, and others).
    • Distinct IDs recurrently assume control of the person's behavior, mood, thoughts
    • each may have a specific age, gender, and other distinguishing characteristics.
  141. Dissociative Identity Disorder epi/eti
    • Considered extremely rare, little epidemiological data exists. However it is estimated:
    • Female to Male ratio is anywhere from 5-9:1
    • Etiology: strongly linked to severe early childhood trauma,
    • usually physical or sexual abuse, reported in 85-97% of cases.
    • No evidence currently of genetic factors.
  142. Dissociative Identity Disorder sx
    • >1 distinct personalities
    • wide variety of other symptoms including symptoms also found in PTSD, mood, somatic, anxiety , psychotic and obsessive-compulsive disorders.
    • Mental Status- many findings similar to other (above) disorders
    • Memory and Amnesia- lost time, black out spells, gaps in knowledge of personal history
    • Dissociative Alterations in Identity- "we" or "they" or "the angry one" or "the wife" or "the son" (rather than "my son")
  143. Dissoci id Differential
    • Affective disorders; Psychotic disorders
    • Anxiety disorders; PTSD
    • Personality DO; Neurocognitive DO
    • Neuro/seizure DO
    • Somatic Symptom; Factitious DO
    • Malingering
    • Other Dissociative; Deep-trance
  144. Dissociative id Treatment
    • Psychotherapy: requires a therapist comfortable with a range of interventions including:
    • psychoanalytic psychotherapy, cognitive therapy, behavioral therapy, hypnotherapy, and treatment of trauma survivors
    • Pharm: by sx/comorbid including antidepressants, anticonvulsants, and BZDs.
    • Electroconvulsive therapy (ECT): for some patients with refractory mood symptoms.
    • Adjunct therapies: group, family, self-help groups, art, music, occupational therapies and Eye Movement Desensitization and Reprocessing (EMDR)
  145. Dissociative id Course and Prognosis
    • Little is known of the course of untreated
    • Some are thought to continue to live in a traumatic culture
    • Many are believed to die by suicide or as a result of high risk behavior.
    • Prognosis is particularly poor if patient has comorbid psychotic serious medical, refractory substance use, or eating disorder, antisocial personality features, current criminal activity, or ongoing abuse.
  146. Normal Sleep
    • Reqr by all animals for normal brain fx
    • Adults req 6-9/24 hours
    • restorative, homeostatic, thermoregulation, & energy conservation
    • active, not passive process-high amt brain activity
    • phases quantitatively and qualitatively different from each other
    • unique characteristics, functions, & regulatory mechanisms
    • relevant to mental health-can have mental ill sx
    • sometimes involved in the etiology, exacerbation, or tx
    • disturbances can be a side effect of medications
  147. Primary Sleep Disorders
    • Insomnia
    • Hypersomnolence
    • Narcolepsy
  148. Hypersomnolence Disorder:
    • excessive, but unsatisfying, sleep (>9 hours/night)
    • 3 nights/week for at least 3 months
  149. Narcolepsy:
    • irresistible need to sleep during the day with at least 1 of following:
    • episodes of cataplexy, hypocretin deficiency, REM latency during sleep
    • 3 times/week for at least 3 months
  150. Cataplexy
    • Lose voluntary control bilaterally
    • Collapse but maintain consciousness
    • if long may fall asleep
  151. Sleep d/o Epidemiology
    • 60 million in the US report problems with sleep
    • Most commonly: insomnia
    • Followed by: sleep apnea
    • Followed by: restless leg/ circadian rhytm /other
  152. Sleep d/o Morbidity and Mortality
    • Untreated or chronic can increase risk of:
    • heart disease
    • metabolic and weight problems
    • memory problems; mood symptoms
    • thought disorder; hallucinations
    • delusions; accidents; death
  153. Insomnia
    • Difficulty initiating or maintaining sleep, or early wakening
    • May be transient, persistent, or recurrent
    • It may be an independent condition, co-occuring, symptom, or side effect
    • 3 nights/week for at least 3 months
  154. Insomnia epi/eti
    • 33% of US population have several bouts yearly
    • 9% chronic
    • Etiology
    • many factors can lead to insomnia
  155. Insomnia - Treatments
    • 1) Pharm: BZD & hypnotics; OTC sleep aids
    • BZD & hypnotics- use with care; short term; short acting for initial insomnia (trouble falling asleep), long acting for maintaining sleep
    • OTC sleep aids: sedating antihistamines, protein precursors (L-Triptophan), or hormone (Melatonin)
    • 2) Cognitive-Behavioral Therapies:
    • Universal Sleep Hygiene (Table 16.2-5)
    • Stimulus Control
    • Sleep Restriction Therapy
    • Relaxation and Biofeedback
    • Cognitive Training
  156. Hypersomnolence Disorder
    • Excessive sleep and sleepiness is hypersomnia
    • Serious, debilitating, potentially life threatening
    • Significantly affects the patient, family, peers, & society
    • Sleep onset can occur without warning
    • adversely affects attention, memory, concentration, and higher-order cognitive functioning
    • dx after >1m of excessive sleep/sleepiness
  157. Hypersomnolence etiology
    • Excessive sleepiness can be a consequence of
    • insufficient sleep,
    • dysfunction of CNS sleep regulation system,
    • or disruption of sleep/or circadian rhythm
  158. Hypersomnia Treatments
    • increasing sleep time and improving sleep quality with good sleep hygiene.
    • Pharm: PROVIGIL(MONDAFINIL)-first line
    • wake-promoting substance
    • psychostimulants if mondafinil fails
  159. Narcolepsy
    • excessive sleepiness
    • & sx caused by intrusion of aspects of REM sleep while awake.
    • Characterized by "sleep attacks" lasting 20-30 minutes which leave the patient feeling refreshed briefly.
    • 50% of patients also experience cataplexy (lose muscle tone)
    • Onset at any age but usually before age 30.
    • progresses slowly or reaches a plateau
  160. Treatment of Narcolepsy
    • No cure but symptom management is possible
    • A regimen of forced naps may control symptoms
    • In addition to forced naps, medications may be needed
    • Provigil (modafinil) approved by FDA
    • ~reduce number of sleep attacks
    • ~improve psychomotor control in narcolepsy
    • ~patients need to be monitored closely as tolerance can develop
    • ~TCAs and SSRIs can also reduce cataplexy because they surpress REM sleep
    • Even with medications, schedules naps, lifestyle adjustment, and counseling should be part of the plan.
  161. Good sleep hygiene
    • Go to bed & wake @ same time daily
    • Regular ex schedule
    • 2 hr unwind b4 bed (no tv/computer)
    • Cool, dark quiet bedroom
    • Warm bath/shower can help trigger temp dec-promotes sleep
    • Void alcohol, tobacco and caffeine b4 bed
    • Bedtime routine or rituals can be helpful
  162. Accurate diagnosis
    • Appropriate treatment relies on accurate diagnosis.
    • Meds/dz may manifest as change behavior/feeling
    • Psych illness may have sx suggesting medical dz
  163. Reducing the risk of misdiagnosis
    • Be aware and explore psych and med causes
    • Expand your knowledge. Be curious. Use resources.
  164. partial differential for symptoms of anxiety
    • Cv: MI, angina; Mitral valve prolapse
    • Pulmonary: Asthma; Pulmonary embolus
    • Neurological: CVA, TIA, tumor; Migraine; Infection
    • Endocrine:hyperT; hypopara; DM; addisons;
    • Systemic: electolytes; infection; heavy metal poison
    • Drug withdrawal/intoxication
  165. partial differential for amnesia
    • Head injury
    • Brain Tumor
    • Seizure Disorder
    • Side effect of medication
    • Substance Use
    • Psychiatric: Depression;Stress; somatic; dissociative; delirum; malingering
  166. Ddx medical complications of alcohol use
    • Wernike-Korsakoff syndrome
    • Liver disease
    • GI disease
    • Cardiomyopathy
    • Arrhythmias
    • Respiratory Depression: hypoxia
    • Anemia
    • Leukopenia
    • Thrombocytopenia: hemorrhages
  167. Suspect medical cause for mental disorder symptoms if:
    • Acute onset
    • First episode
    • Geriatric age
    • Currently medically ill or hospitalized
    • Non-auditory hallucinations
    • Neurologic symptoms
    • Mental status changes in alertness, orientation, concentration, memory
    • Changes in speech, gait, or movement
    • Constructional apraxia: Difficulty drawing
  168. Somatic Symptom Disorder (Hypochondriasis)
    • Preoccupation w/ fear of having dz
    • X6+ months w/out medical evidence
    • Or General, non-delusional fear of having serious dz
    • Based on misinterpretation of bodily sx (have dz)
  169. Somatic sx d/o Epidemiology:
    • Ranges from 4%-15% of population
    • Men and women equally affected
    • More common between 20-30 y/o
    • Somatic Symptom Disorder
    • Etiology unknown - several theories
  170. Somatic sx Differential Diagnosis
    • Delusional Disorder: belief is clearly delusional
    • Body Dysmorphic Disorder: distress restricted to appearance
    • Depression, Anxiety, Conversion, Factitious
    • A difficult to diagnose non-psychiatric medical condition
  171. Somatic Symptom Disorder Clinical findings
    • No physical exam to correlate with complaints
    • Focus on fear/belief that dz present>sx
    • Belief continues even when dx test negative
    • Can have depression, anxiety
  172. Somatic Symptom Disorder PE.dx
    • Unexplained physical symptoms
    • ~Not intentional or under voluntary control
    • ~Believed by family and patient to have a medical cause
    • ~Patients resent implication of psychiatric diagnosis
    • ~No physical exam findings to explain symptoms
    • Normal Diagnostic Tests
    • Continues to fear / believe something is wrong
  173. Somatic Sx -pmh
    • Long complex medical hx
    • "thick chart sign"
    • Numerous invasive dx or tx procedure
    • Multisystem c/o
  174. Somatic Sx- Treatment
    • Single health care provider
    • Regularly scheduled appointment
    • Long term strategy
    • Resist psych tx
    • Med setting focus on stress red/edu helps
    • Meds not effective unless used for co-morbid psych dx like anxiety or depression
  175. Somatic SX Disorder Complications
    • Failure to ID medical cause for s/s
    • Use of unnecessary & invasive dx or surgical tx
    • Adverse effects of multiple medications
    • Rx drug abuse
    • Can lead to helpless and dependent lifestyle
  176. Somatic Sx Disorder Course
    • Course is usually episodic
    • Episodes last months to years
    • 1/3-1/2 of all patients eventually improve significantly
    • Good prognosis associated with:
    • High socioeconomic status
    • Treatment responsive anxiety or depression
    • Sudden onset of symptoms
    • Absence of personality disorder
    • Absence of non-psychiatric medical condition
  177. Illness Anxiety Disorder
    • DSM-5 differentiates this disorder (although it is similar to/and perhaps a form of hypochondriasis) from Somatic Symptom Disorder.
    • Applies when few-no somatic sx
    • "primarily concerned with the idea they are ill."
    • It may be fear based
  178. Illness Anxiety Disorder Clinical Features:
    • Believe have undx serious illness
    • belief persists despite negative medical evidence to the contrary and absence of sx.
    • Their preoccupation with fear of illness interferes with their normal life.
  179. illness anxiety d/o Treatment
    • resist psych tx
    • office: stress reduc/ du on cope w/ chronic
    • Group therapy may help.
    • Frequent/regular physical examinations may or may not be helpful.
    • Antianxiety meds offer only temporary relief.
  180. Functional Neurological Symptom Disorder/Conversion Disorder
    • Symptoms/deficits affecting voluntary motor or sensory functions
    • ~~suggests a medical condition
    • ~~due to psychological factors
    • ~~illness is preceded by conflicts or other stressors
  181. Conversion disorder epi
    • 5-15% hospitalized patients; 25-30% VA admissions
    • Women> men (up to 10:1)
    • Men may have military experience; antisocial PD
    • Onset:Late childhood up to early adulthood
    • Before age 10; after 35 look for organic disease
  182. Conversion Disorder demographic
    • Most commonly found in
    • Rural populations
    • Lower IQ
    • Less educated
    • Lower socioeconomic groups
    • Military with combat experience
  183. Conversion d,o Co-morbidity
    • Depressive and Anxiety Disorders
    • Medical, particularly neurological, disorders
    • Personality Disorders
  184. Conversion Disorders Etiology
    • psychodynamic theory
    • repression of unconscious intrapsychic conflict
    • conversion of anxiety into a physical symptom
    • Examples
    • Symptom allows patient to avoid confronting the problem
    • Vaginismus- unable to have sexual intercourse; rape in personal hx
    • Blindness- patient observed traumatic experience
  185. Conversion Disorders sx
    • Common: Motor symptoms, sensory deficits, visceral symptoms
    • Distinctive PE findings (Table 13.4-2)
    • must have a neurological component
    • affects a voluntary motor or sensory function
    • cannot be explained by physical exam
  186. Conversion Disorder Clinical Findings
    • Mimics dysfunction in voluntary motor or sensory system:
    • ~~Blindness, deafness, mutism, most common
    • ~~Paralysis and anesthesia (sensory) also common
    • Motor involvement
    • ~~Abnormal movements, gait abnormalities, weakness, paralysis
    • ~~Could have tics, tremors
    • Exam doesn't correlate
    • ~~DTRs present in paralyzed patient
  187. Psychodynamics conversion d/o
    • Primary gain: blindness prevents dealing with trauma
    • Secondary gain: pt. benefits from illness
    • La belle indifference: lack of appropriate concern for severe symptoms
    • ~~not pathognomonic, may or may not be present
    • Identification: patient may take on characteristics of person important to them
    • Patient may exhibit s/s of deceased parent
  188. Conversion Disorder Differential Dx
    • Must r/o medical disorder
    • Up to 25-50% of pts diagnosed w/conversion disorders later have a medical dx of neurological disease
    • If s/s disappear with either suggestion, hypnosis, amobarbital (Amytal) or lorazepam (Ativan) = conversion disorder
  189. Conversion Disorder Prognosis
    • Can recur
    • 20-25% recur w/in first year of first episode
    • Need to make sure true disease is not overlooked
    • Ex: MS
    • Failure to consider conversion disorder as dx can lead to continued treatment=permanent invalid
  190. Conversion Disorder Treatment
    • Usually patient have spontaneous resolution
    • Best when good rapport with therapist
    • Meds: benzos and antidepressants
    • Psychological: insight/behavior therapy
  191. Pain Disorder Epidemiology
    • common
    • 6 month prevalence 5%
    • Lifetime prevalence 12%
    • Etiology: multifactorial
    • Psychodynamic
    • Interpersonal
    • Behavioral
    • Biological
  192. Pain Disorder
    • DSM-5:considered a variant of Somatic sx do
    • Pain is the symptom of focus.
    • Dx&tx focus on importance of psych factors & impairment d/2 pain
    • In DSM-5 it is called "Unspecified Somatic Symptom Disorder"
  193. Pain Disorder Clinical findings
    • MUST have a psychological component to the pain symptoms
    • Helpless, hopeless attitude re: pain
    • Disrupted social relationship due to pain
    • Remember that symptoms are real to the patient
  194. Pain Disorder course and prognosis
    • Pain onset is abrupt
    • Severity/intensity increases steadily weeks to months
    • Prognosis
    • Generally better with acute vs chronic
  195. Pain Disorder Treatment
    • Meds: Antidepressant, SSRIs (most effective)-cymbalta
    • ~~Avoid using narcotics for pain due to abuse risk
    • Psychotherapy
    • Cognitive therapy
    • Biofeedback
  196. Factitious Disorder
    • Patient intentionally produces signs of illness
    • Objective is only to become a patient;
    • NO external incentive; no secondary gain
    • Known as Munchausen disorder if present with physical complaints
  197. Facticious d/o epi/eti
    • Occurs more in men>women (66%)
    • White, middle-aged, unemployed, single no social/family relationships
    • Hospitalization may be intended outcome
    • Can be found in medical profession
    • Etiology may be illness as a child,
    • ~~hx abuse/rejection=attention as an adult
  198. Factitious Disorder Clinical Findings
    • May present with nausea, vomiting, pain
    • Patient may take poison in small amounts to give s/s
    • Put blood in feces or urine, artificially elevate temperature
    • Multiple hospital admissions, surgeries (look for multiple abdominal scars)
    • Munchausen by proxy: parent induces/lies-RARE
  199. Treatment of Factitious DO
    • Minimize risk of morbidity/mortality
    • Minimize harm
    • Interdisciplinary meetings with tx team
    • Self-hypnosis or biofeedback
    • Treat underlying psychopathology
    • Appoint primary tx gate keeper
    • Involve risk management and bioethics
    • Consider appointment of guardian
  200. Factitious DO by proxy tx
    • Pediatrician as gatekeeper
    • Involve/report child protective services as needed and required
    • Keep child safe
    • Family and individual psychotherapy
  201. Malingering
    • exaggerates symptoms for external gain;
    • seeking diagnosis for secondary gain.
    • deliberate behavior for a known external purpose.
    • Not mental illness
    • MC goal in ER=obtain drugs/shelter
    • MC goal clinic=financial compensation
  202. Malingering suspect
    • In presence of any combination of the following:
    • Medicolegal presentation (eg, an attorney refers patient, a patient is seeking compensation for injury)
    • Marked discrepancy between the claimed distress and the objective findings
    • Lack of cooperation during evaluation and in complying with prescribed treatment
    • Presence of an antisocial personality disorder
  203. gender dysphoria
    • incongruence between expressed/experienced gender and birth gender
    • but wont necessarily ID self as other gender
  204. gender identity
    the sense one has of being male or female
  205. transgender
    identifies with a gender different from the one they were assigned at birth
  206. gender dysphoria epidemiology
    • 1 in 500 adults fal on the transgender spectrum.
    • DSM-5 reports prevalence rates much lower.
    • 3-5 male(IDF) assigned patients for every 1 F (ID M)
    • male to female dysphoria is higher than female to male dysphoria.
  207. Gender dysphoria etiology
    • unknown-
    • bio studied: prenatal hormone & genetics
    • Psychosocial factors theorized:
    • ~~postnatal life events
    • ~~reward and punishment
    • ~~defense mechanisms
  208. Gender dysphoria comorbidities
    • depressive disorders, anxiety disorders,
    • substance use disorders, self-harm behaviors, and suicide.
  209. Gender dysphoria Diagnostic Features
    • Incongruence between expressed and assigned gender
    • Associated with clinically significant distress/impairment
    • 2 of 6 criteria for min 6 months
    • Persistent discomfort with sexual characteristics
    • Desire to be rid of one's sexual characteristics
    • Desire for sexual characteristics of other gender
    • Strong desire to be the other gender
    • Strong desire to be treated as the other gender
    • Conviction that one has typical feelings/reactions of the other gender
  210. Gender dysphoria Treatments
    • Psychotherapy- exploration of gender issues
    • Hormonal treatments- testosterone for transgender men
    • estrogen, progesterone, and/or testosterone blockers for transgender women
    • Surgical treatments- less common than hormonal for a variety of reasons
  211. DSM III & DSM IV
    • Multi-axial system of diagnosis
    • Although eliminated in DSM-5 still important:
    • Axis I: psychiatric diagnoses (except those on axis II)
    • Axis II: personality disorders, intellectual disabilities, life long problems
    • Axis III: medical or neurological problems
    • Axis IV: psychosocial stressors
    • Axis V: Global Assessment of Functioning (GAF)
  212. Significant Changes in the DSM-5
    • The multi-axial system was eliminated
    • Introduction of severity scales
    • Respect for gender, culture, and age
    • New emphasis on children
    • New emphasis on suicide risk
    • "Principle Diagnosis" concept introduced
    • Focus on quest for diagnostic validity
    • Specifically ruling out other disorders
  213. Organization of DSM-5
    • Section 1: The Introduction
    • Section 2: The Twenty Classifications and other
    • conditions that may be the focus of clinical attention
    • Section 3: Assessments & diagnostics for further study
  214. The Severity Scales
    • DSM-5 added severity scales: four application:
    • Cross Cutting Symptom Measures
    • WHODAS 2.0
    • Clinician Rated Symptom Severity
    • Individual Severity Index which is diagnostic specific
  215. Diagnostics is Art & Science
    • It is a process - we are always learning more...
    • Avoid the rush to certainty.
    • An accurate treatment requires accurate diagnosis.
    • Rule out expected reactions.
    • Dystonic conditions: cause distress to the patient.
    • Syntonic conditions: patient is resigned, has benefit, lacks insight, and may be resistant to treatment.
  216. Approach to diagnosis using DSM-5
    • 1. Rule out malingering and factitious disorder
    • 2. Rule out substance etiology
    • 3. Rule out a disorder due to a general medical condition
    • 4. Determine the specific primary disorder(s)
    • 5. Differentiate adjustment disorders from the residual other specified, or unspecified disorders
    • 6. Establish the boundary with no mental disorders
  217. Diagnosis of Mental Illness
    • Important because:
    • It determines the treatment
    • It helps the patient make sense of their experience
    • It informs family and other care providers how they can be helpful to the patient
  218. Psychiatric Assessment
    • Patient Interview
    • History
    • Mental Status Exam
  219. Psychiatric Patient Interview
    • Introduce yourself
    • Determine the reason for the interview
    • Establish consent
    • Review confidentiality and the exceptions
  220. Establishing an effective patient-provider relationship
    • Professionalism: Appearance and Manner
    • Respect and Rapport: Joint Venture
    • Unconditional Positive Regard
    • Empathy
    • Listening
  221. Mental Status Exam
    • Appearance and Behavior
    • Motor Activity; Speech
    • Mood; Affect
    • Thought Content
    • Thought Process
    • Perceptional Disturbances
    • Cognition; Abstract Reasoning
    • Insight; Judgment
  222. Motor Activity
    • described.
    • For examples: normal, slowed, fast, agitated, etc.
    • The presence or absence of any abnormal involuntary movements such as tics, tremor, lip smacking, or tongue protrusions should be noted.
  223. Speech
    • Are they fluent in their speech or incoherent?
    • Do they have an abundance or paucity of speech?
    • Describe their rate, tone, and volume of speech.
    • Example: The patient's speech was fluent, normal in amount, rate, tone, and volume.
    • Example: The patient's speech was slurred, using minimal words, slowly in a deep tone and low volume.
  224. Affect
    • how the patient appears to feel or how the clinician assesses their mood based on their appearance.
    • Elements of affect include:
    • Quality (happy, euthymic, dysphoric, angry, agitated, flat, sad, tearful, etc.)
    • Quantity or intensity
    • Range
    • Appropriateness
    • Congruence with mood or thought content
  225. Thought Content
    • What kind of thoughts occur to the patient?
    • Obsessional thoughts are unwanted and intrusive.
    • Delusional thoughts are fixed, false beliefs that are not shared by others. These may be either bizarre or non-bizarre.
    • Suicidal thoughts
    • Homicidal thoughts
  226. Thought Process
    • Flight of ideas; Tangentiality
    • Circumstantiality
    • Clang associations
    • Loose associations
    • Derailment; perseveration
    • Thought blocking; neologisms
    • Word salad
  227. Hallucinations
    • perceptions without causative stimuli
    • Auditory (most common in psychiatric illness)
    • can also occur in other senses:
    • visual, tactile, olfactory (smells), & gustatory (taste)
  228. Illusions
    misperception of stimuli
  229. Depersonalization
    feeling that one is not themself
  230. Derealization
    feeling one's environment has changed
  231. Cognition
    • Alertness; Orientation
    • Concentration; Memory
    • Calculation
    • Fund of knowledge
    • Abstract reasoning
    • Insight; judgment
  232. Anxiety
    • A. Marked X about min 1 social situation where they may exposed to scrutiny by others.
    • B. Fear others will see & judge negatively->humiliation or embarrassment
    • C. The social situation almost always causes X
    • D. the social situation is either avoided or endured with extreme X
    • E. out of proportion to the actual threat or is more extreme than culturally normal
    • F. Persists more than 6 months
    • G-J: impairment; not attrib to substance, medical/mental
  233. Anxiety r/o
    • Panic d/o
    • Body dysmorphic
    • Autism spectrum
  234. GAD DSM-5 Diagnostic Criteria
    • A. Excessive anxiety/worry or apprehensive expectation more days than not for at least 6 months about several events or activities.
    • B. Difficult to control this worry
    • C. The anxiety/worry is associated with at least 3 of the following 6 symptoms in adults (only 1 of 6 required in children)
    • D-F impairment; not attributable
  235. GAD r/o
    • Panic Disorder; SAD; OCD; separation anxiety
    • PTSD; Anorexia Nervosa; Somatic Symptom Disorder
    • Body Dysmorphic Disorder; Illness Anxiety Disorder
    • Schizophrenia; Delusional Disorder
  236. GAD criteria
    • 1. restlessness or feeling on edge/keyed up
    • 2. being easily fatigued
    • 3. difficulty concentrating/mind goes blank
    • 4. irritability
    • 5. muscle tension
    • 6. sleep disturbance
  237. OCD
    • A. Presence of obsessions, compulsions, or both
    • B. Obsessions/compulsions are time consuming and cause significant distress or impairment in important areas of functioning.
    • C. Condition not caused by a substance or another medical condition.
    • D. Not better explained by the symptoms of another mental disorder.
  238. Obsessions
    • Recurrent and persistent thoughts, urges, or images that are experienced, at least sometimes, as intrusive and unwanted and are usually cause anxiety or distress.
    • Attempts to ignore/suppress these thoughts, urges, or images or to neutralize them with some other thought or action
  239. Compulsions
    • Repetitive behavior or mental act driven to perform in response to obsession.
    • Aimed at preventing or reducing anxiety/distress or preventing a dreaded outcome (not rationally related).
  240. OCD r/o
    • Hoarding Disorder
    • Body Dysmorphic Disorder
    • Specific Phobia
    • Social Anxiety Disorder
    • Delusional Disorder
    • Illness Anxiety Disorder
    • Hair Pulling or Skin Picking Disorder
  241. OCD Specify if
    • With good or fair insight
    • Recognizes the thoughts are not/probably not true
    • With poor insight
    • Thinks the thoughts are probably true
    • With absent insight/delusional beliefs
    • Convinced the beliefs are definitely true
    • Specify if:
    • Tic related: current or past history of tics
  242. MDD
    • A. At least 5 of 9 criteria for at least 2 weeks
    • b-d. r/o; signif impair; not attribu
    • E. There has never been a manic or hypomanic episode.
    • This exclusion does not apply if the previous manic or hypomanic symptoms were substance induced or due to another medical condition
  243. MDD 9 criteria
    • depressed mood,
    • decreased interest/pleasure,
    • weight loss/decreased appetite,
    • insomnia/hypersomnia,
    • psychomotor agitation/retardation,
    • fatigue,
    • worthlessness/guilt,
    • decreased concentration,
    • recurrent thoughts of death/suicide
    • At least one symptom is either (1) depressed mood or (2) loss of interest or pleasure
  244. MDD rule outs
    • Schizoaffective Disorder
    • Schizophrenia
    • Schizophreniform Disorder
    • Delusional Disorder
    • other specified or unspecified schizophrenia spectrum or other psychotic disorder
  245. MDD specify
    • Specify if single episode or recurrent
    • Specify severity (mild, moderate, or severe)
    • Specify if with psychotic features
    • Specify if in partial or full remission
    • Specify if "unspecified"
    • Specify with:
    • anxious distress,
    • mixed features,
    • melancholic,
    • atypical,
    • mood-congruent/mood-incongruent
    • psychotic features,
    • catatonia,
    • peripartum onset,
    • seasonal pattern (recurrent episode only)
  246. r/o dmdd
    • pediatric bipolar
    • oppositioanl defiant
    • neurodevelopmental d/o
    • intermittent explosive
  247. Dysthymia criteria
    • Depressed mood 2 of 6
    • Poor appetitie/overeating
    • Insomnia/hypersomnia
    • Low energy/fatigue
    • Low self-esteem
    • Poor concentration/difficulty making decisions
    • Feeelings of hopelessness
  248. Schizophrenia
    • A. 2 of 5 criteria for at least 1 month if untreated
    • B. dec fx in 1+ work, school etc
    • C. last min 6 months
    • D. r/o
    • E. not attributable to substance/medical
  249. schizophrenia criteria
    • 1. Delusions
    • 2. Hallucinations
    • 3. Disorganized speech
    • 4. Grossly disorganized or catatonic behavior
    • 5. Negative symptoms (e.g. diminished emotional expression)
    • At least one of the symptoms has to be 1.), 2.), or 3.)
  250. schizophrenia required r/o
    schizoaffective and mood disorders w/ psychotic sx
  251. Schizoaffective Disorder
    • A. Episode of Major Depression or Mania, concurrent with criterion A of schizophrenia
    • b. min 2w of delusions/hallucinations w/out major mood disorder
    • c. Mood symptoms present for majority of the total duration of the illness
    • D. Not due to substance or other medical illness
  252. Anorexia Nervosa
    • A. "Restriction of energy intake...leading to significantly low body weight..."
    • B. "Intense fear of gaining weight...or persistent behavior that interferes with weight gain..."
    • C. "Disturbance in the way...one's body weight or shape is experienced...or lack of recognition of seriousness of the current low body weight"
  253. Anorexia Nervosa Specify:
    • 1) Restricting: no bing/purg in prior 3 m; use diet/fast/exercise
    • 2) Binge-eating/purging type: bing/purge past 3 m
    • 3) Partial or full remission
  254. anorexia severity
    • Mild: BMI > 17
    • Moderate: BMI 16-16.99
    • Severe: BMI 15-15.99
    • Extreme: BMI <15
  255. Bulimia Nervosa
    • A. Recurrent episodes of binge eating
    • B. Recurrent behaviors to prevent weight gain
    • C. Binging and Purging min 1/week x3 m
    • D. "Self-evaluation is unduly influenced by body shape and weight."
    • E. "...does not occur exclusively during episodes of anorexia nervosa."
  256. Bulimia Nervosa Specify if:
    • Partial/full remission
    • current severity: based on avg purges/week
    • Mild: 1-3 episodes/week
    • Moderate: 4-7 episodes/week
    • Severe: 8-13 episodes/week
    • Extreme: 14 or more episodes/week
  257. Binge Eating Disorder DSM-5 criteria
    • A. Recurrent episodes: lrg amt; feel out of control
    • B. episodes associated with:
    • eating rapidly, until uncomfortable, when not hungry, alone (feeling embarrassed), and feeling disgusted, or guilty after binge
    • C. Marked distress
    • D. at least once a week for 3 months
    • E. not associated with compensatory behaviors (purging)
  258. Binge Eating Disorder specify
    • Partial/full remission
    • current severity:
    • Mild: 1-3 binges/week
    • Moderate: 4-7 binges/week
    • Severe: 8-13 binges/week
    • Extreme: 14 or more binges/week
  259. Avoidant/Restrictive Food Intake Disorder
    • A. Persistent failure to meet nutritional needs associated with at least 1 of 4:
    • 1. significant weight loss, or lack of gaining weight
    • 2. significant nutritional deficiency
    • 3. dependence on enteral feeding or oral supplements
    • 4. marked interference with psychosocial function
    • B. Not better explained by a lack of available food or culturally normal practice.
    • C. Does not meet criteria for AN, BN, or Body Dysmorphic Disorder.
    • D. Not attributable to a current medical condition or other mental disorder.
  260. Substance Use disorders
    • Term applied, naming the specific substance,
    • at least 2 of 11 criteria are met within 12 months.
    • 1. recurrent use->failure to meet major obligations
    • 2. recurrent use in hazardous situations (e.g. driving)
    • 3. continued use despite adverse social or relationship consequences
    • 4. tolerance: (a.) incr amts needed for effect or (b.) diminished effect from same amount
    • 5. withdrawal: (a.) experience characteristic withdrawal symptoms or (b.) a similar substance is taken to avoid
    • 6. substance used in larger amounts or longer time than intended
    • 7. persistent desire or unsuccessful attempts to cut down or control substance use
    • 8. much time is spend in obtaining, using, and recovering from use of the substance
    • 9. give up important recreational/social/work activities in order to continue use
    • 10. continue use despite known physical or emotional problems related to use
    • 11. craving/strong desire/ urge to use substance
  261. DSM-5
    • The Diagnostic Dilemma of Dual Diagnosis
    • (Co-occuring Disorders)
  262. Determine if the substance is used to manage, control, or eliminate mood, psychotic, or anxiety symptoms (significant risk factor for suicide)
  263. Determine if the substance use causes or exacerbates symptoms of mood, psychotic, or anxiety disorder.
  264. Cannabis Use Disorder
    • DSM-5 defines this as a problematic use of cannabis leading to clinically significant impairment or distress, with at least 2 of 11 listed criteria occurring in a 12 month period.
    • Specify if in early or sustained remission
    • Specify if in a controlled environment (without access to the substance)
    • Specify current severity:
    • mild: 2-3 symptoms
    • moderate: 4-5 symptoms
    • severe: 6 or more symptoms
  265. Cannabis intoxication
    • A. recent use of cannabis
    • B. clinically significant problematic changes that developed during or shortly after use:
    • motor coordination impaired, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal
    • C. 2 or more of the following within 2 hours of use:
    • conjunctival injection, increased appetite, dry mouth, tachycardia
    • D. signs & symptoms not attributable to another medical condition or better explained by another mental disorder, including intoxication of another substance
    • Specify if with perceptual disturbance: hallucinations with intact reality testing or illusions in the absence of delirum
  266. Cannabis withdrawal
    • A. Cessation of heavy or prolonged cannabis use.
    • B. 3 or more of the following develop 1 week after:
    • 1. irritability/anger/aggression
    • 2. nervousness/anxiety
    • 3. sleep difficulty (insomnia, disturbing dreams)
    • 4. decreased appetite or weight loss
    • 5. restlessness
    • 6. depressed mood
    • 7. at least of of the following: abdominal pain, tremors, sweating, fever, chills, or headache
    • C. The signs and symptoms in B. cause clinically significant distress or impairment in important areas of functioning
    • D. Not attributable to another medical disorder or better explained by another mental disorder including intoxication or withdrawal from another substance.
  267. Opioid Use Disorder:
    • Problematic use with significant impairment or distress, with at least 2 of 11 criteria in 12 months.
    • Specify if: in early or sustained remission
    • Specify if: on maintenance therapy (e.g. methadone)
    • Specify current severity:
    • mild: 2-3 symptoms
    • moderate: 4-5 symptoms
    • severe: 6 or more symptoms
  268. Opioid Intoxication:
    • Recent use
    • Clinically problematic changes- initial euphoria then apathy, dysphoria, impaired judgment
    • Pupillary constriction and 1 or more of drowsiness, slurred speech, impairment in attention or memory
    • Not due to another medical/mental disorder or another substance.
    • Specify if with perceptual disturbance
  269. Opioid Withdrawal:
    • Cessation or reduction of use or administration of an opioid antagonist after use
    • 3 or more of the following:
    • dysphoric mood, nausea or vomiting,
    • muscle aches, lacrimation or rhinorrhea,
    • pupillary dilation/piloerection/sweating,
    • diarrhea, yawning, fever, insomnia.
    • clinically significant distress or impairment
    • Not better explained by another cause
  270. Stimulant=related Clinical Features
    • pattern of use leading to clinically significant impairment or distress
    • With at least 2 of 11 criteria in a 12 month period
    • Specify if in full or partial remission
    • Specify if in controlled environment
    • Specify current severity
    • mild: 2-3 symptoms
    • moderate: 4-5 symptoms
    • severe: 6 or more symptoms
  271. Stimulant Intoxication criteria:
    • Recent use which leads to clinically significant problematic behavior or psychological changes (e.g., euphoria, or affective blunting, anxiety, hypervigilance, tension, anger, impaired judgment)
    • Two or more of the following during/soon after use:
    • 1. tachycardia/bradycardia, 2. pupillary dilatation,
    • 3. high or low BP, 4. perspiration/chills,
    • 5. nausea/vomiting, 6. weight loss,
    • 7. psychomotor agitation/retardation,
    • 8. muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias,
    • 9. confusion, seizures, dyskinesias, dystonias, or coma.
    • Not attributable to another medical or mental condition, including intoxication with another substance.
    • Specify specific intoxicant & if perceptual disturbance
  272. Delusional Disorder
    • A. Presence of at least one delusion for at least one month.
    • B. Criteria A for Schizophrenia has never been met.
    • C. Except for the consequences of the delusions, function is not impaired and behavior is not bazarre
    • D. If mood disorders have occurred, they have been brief relative to the delusions.
    • E. Not due to substance or other medical condition and not better explained by another mental disorder (i.e. body dysmorphic disorder or OCD)
  273. Delusional Disorder Specify Type:
    • Erotomanic- another person in love with them
    • Grandiose- delusion of greatness
    • Jealous- delusional belief partner is unfaithful
    • Prosecutory- conspired against, cheated, poisoned
    • Somatic- delusions involving bodily function
    • Mixed- no one delusional theme predominates
    • Unspecified- can not be clearly identified
  274. Major Neurocognitive impairment
    • highlight cognitive decline, with significant impairment of ADLs;
    • not only with delirium or better explained by another mental disorder.
    • Specifiers: due to, with or without behavioral disturbance, and current severity
  275. Paranoid PD
    • pervasive distrust/suspiciousness of others
    • such that their motives (4 or more)
    • 1) Others are exploiting, harming, or deceiving him/her
    • 2) Friends or associates are untrustworthy
    • 3) Information confided to others will be used maliciously against him or her
    • 4) Reads hidden demeaning or threatening meanings into benign remarks or events
    • 5) Bears grudges
    • 6) Perceives personal attacks that aren't seen by others
    • 7) Suspicions, without justification, spouse is unfaithful
    • Does not occur exclusively during the course of schizophrenia
  276. Schizoid PDA pervasive pattern of detachment from social relationships
    • restricted range of expression of emotions in interpersonal settings
    • begins by early adulthood
    • present in a variety of contexts, as indicated by 4 (or more):
  277. schizoid PD criteria
    • Doesn't desire or enjoy close relationships, including family
    • Chooses solitary activities
    • Little interest in having sexual experiences
    • Takes pleasure in few, if any, activities
    • Lacks close friends other than first-degree relatives
    • Appears indifferent to the praise or criticism of others
    • Shows emotional coldness, detachment, or flattened affectivity
  278. Schizotypal PD
    • Pervasive social and interpersonal deficits
    • indicated by 5 (or more) of the following:
    • 1Ideas of reference (believes that public messages are directed personally to them)
    • 2Odd beliefs or magical thinking
    • 3 Unusual perceptual experiences (including bodily illusions)
    • 4Odd thinking and speech
    • 5Suspiciousness or paranoid ideation
    • 6Inappropriate or constricted affect
    • 7Odd, eccentric, or peculiar behavior/appearance
    • 8No close friends/confidants except first-degree relatives
  279. Antisocial PD
    • Pervasive disregard for and violation of rights of others and society norms since age 15
    • Need 3 of following
    • 1Repeated violations of the law
    • 2Repeated lying, alias, "con-men"
    • 3Impulsivity
    • 4Physical aggressiveness (fights/assaults)
    • 5Reckless disregard for safety of self/others
    • 6Consistent irresponsibility; in work/family
    • 7Lack of remorse
    • Must be at least 18
    • Evidence of conduct disorder onset<15y/o
    • Not due to schizophrenia or mania
  280. Borderline PD
    • pervasive pattern of unstable/intense interpersonal relationship, self-perception, and moods
    • Need 5 of the following:
    • 1Frantic efforts to avoid abandonment
    • 2Unstable & intense interpersonal relationships
    • 3Markedly & persistently unstable self-image
    • 4Impulsivity in at least 2 self-damaging areas (sex, substance abuse, reckless driving, etc)
    • 5Recurrent suicidal behaviors/threats; self-mutilation
    • 6Affective instability
    • 7Chronic feelings of emptiness
    • 8Inappropriate and intense anger
    • 9Transient paranoia or dissociation
  281. Histrionic PD DSM-5 (table 22-6)
    • Excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts (5 or more of the following 8)
    • 1Needs to be center of attention
    • 2Inappropriate sexually seductive or provocative behavior
    • 3Rapidly shifting and shallow expression of emotions
    • 4Consistently uses physical appearance to draw attention to self
    • 5Speech is excessively impressionistic and lacking in detail
    • 6Shows self-dramatization, theatricality, and exaggerated expression of emotion
    • 7Is suggestive, i.e. easily influenced by others or circumstances
    • 8Considers relationships to be more intimate than they actually are
  282. Narcissistic PD DSM-5 (Table 22-7)
    • Grandiose thoughts or behaviors, need for admiration, lack of empathy (needs 5)
    • 1Has a grandiose sense of self-importance
    • 2Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
    • 3Believes that he or she is "special" and unique
    • 4Requires excessive admiration
    • 5Sense of entitlement
    • 6Takes advantage of others
    • 7Lacks empathy
    • 8Envious of others or believe others envy them
    • 9Arrogant
  283. Avoidant PD DSM-5 (Table 22-8)
    • A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, (need 4)
    • 1Avoids activities involving interpersonal contact, due to fears of criticism, disapproval, or rejection
    • 2Unwilling to get involved with people unless certain of being liked
    • 3shows restraint within intimate relationships because of a fear of being shamed or ridiculed
    • 4Preoccupied w/being criticized/rejected in social situations
    • 5Inhibited in new interpersonal situations due to feelings of inadequacy
    • 6Views self as socially inept, personally unappealing, or inferior to others
    • 7Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
  284. Dependant PD DSM-5 (Table 22-9)
    • A pervasive/excessive need to be taken care of; submissive, clinging behavior & fears of separation, begins early adulthood; (needs 5)
    • 1 Difficulty making everyday decisions
    • 2 Needs others to assume responsibility for most major areas of his or her life
    • 3Difficulty expressing disagreement with others
    • 4Has difficulty doing things on his or her own because of a lack of self-confidence
    • 5Excessive lengths to obtain nurturance and support from others
    • 6Discomfort or helpless when alone
    • 7Urgently seeks another relationship when a close relationship ends
    • 8 Is unrealistically preoccupied with fears of being left to take care of himself or herself
  285. OC PD DSM-5 Criteria (Table 22-10)
    • A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, begins early adulthood; presents several contexts, (need four):
    • 1Perfectionist; interferes w/task completion
    • 2Preoccupied with details, rules, lists, order, organization, or schedules; major point of the activity is lost
    • 3Excessively devoted to work and productivity; excludes leisure activities/friendships
    • 4Inflexible about matters of morality, ethics, or values
    • 5Unable to discard worn-out or worthless objects
    • 6Reluctant to delegate tasks or to work with others
    • 7Adopts a miserly spending style toward both self and others
    • 8Shows rigidity and stubborness
  286. Somatic Symptom Disorder
    • A. At least one somatic symptom that is distressing and results in disruption of life
    • B. Excessive thoughts, feelings, or behaviors related to the symptom with at least 1 of
    • 1) Disproportionate & persistent thoughts of it
    • 2) Persistent high anxiety about it
    • 3) Excessive time and energy spent on it
    • C. Although any 1 symptom may not be continuously present, the state of being symptomatic is, usually > 6 months
  287. Illness anxiety disorder DSM-5 Criteria (Table 13.3-1)
    • A. Preoccupation with having or acquiring a serious illness
    • B. Somatic sx are absent or if present , mild.
    • C. High level of anxiety about health
    • D. Performs excessive health related behaviors or exhibits maladaptive avoidance
    • E. Preoccupation last > 6 months
    • F. not better explained by another disorder
  288. insomnia
    • A. Dissatisfaction with sleep quality or quantity with
    • B. Causes clinically significant distress or impairment
    • C. Occurs at least 3 nights/week
    • D. Present for at least 3 months
    • E. Occurs despite adequate opportunity for sleep
    • F. -H not caused by other disorder, substances etc
    • Specifiers (see Table 16.2-4 for complete criteria)
  289. hypersomnolence DSM-5 Diagnostic Criteria
    • A. Self-reported excessive sleepiness despite sleeping 7 hours
    • and at least one of the following:
    • 1. Recurrent periods of sleepiness or lapses into sleep with in the same day
    • 2. Prolonged main sleep episode > 9 hours that is nonrestorative
    • 3. Difficulty being fully awake after abrupt awakening
    • B. Occurs at least 3x/week for at least 3 months
    • C. Significant distress or impairment
    • D. -F not other causes/explanation
    • Specify: if with another condition; if acute, subacute, or persistent; current severity (mild, moderate, or severe)
  290. Narcolepsy DSM-5 Criteria (Table 16.2-7)
    • A. Recurrent irrepressible need for sleep, lapsing into sleep, or napping in the same day; 3x/week; 3 months
    • B. The presence of at least one of the following:
    • 1. cataplexy, either a. or b., at least a few times a month
    • 2. hypocretin deficiency (measured in cerebral spinal fluid)
    • 3. REM latency (measured on nocturnal sleep polysomnograph)
    • Specifiers for above (see DSM-5) w/ or w/out above
    • Specify current level of severity
  291. Cataplexy type a&b
    • a. in longstanding dz, brief episodes of sudden bilateral loss of muscle tone, maintained consciousness, precipitated by laughing or joking
    • b. in children, or within 6 mo. onset, grimaces, jaw-opening with tongue thrusting, or global hypotonia, without any emotional triggers
  292. PTSD
    • Exposure to actual/threatened death, serious injury or sexual violence by:
    • ~~direct experience
    • ~~witnessing it as it occurred to others
    • ~~learning of violent or accidental trauma to family member or friend
    • ~~repeated or extreme exposure to details (such as experienced by 1st responders)
    • Four symptom clusters (required symptoms from each) >1month :
    • 1) Re-experiencing (at least one): flashback/dream/memory
    • 2) Avoidance & numbing (at least one)
    • 3) Negative alterations in mood and cognition (at least two)
    • 4) Alterations in arousal (at least two) jumpy etc
  293. Acute Stress Disorder Criteria
    • Exposure to actual or threatened death, serious injury, or sexual violation
    • (in one of 4 ways-same as PTSD).
    • 9 or more (of 14) symptoms from any of 5 categories
    • 1)Intrusive symptoms
    • 2)Negative mood
    • 3)Dissociative symptoms
    • 4)Avoidance symptoms
    • 5)Arousal symptoms
    • Duration of disturbance is 3 days to one month
    • It causes clinically significant distress or impairment
  294. Adjustment Disorder
    • A. Development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
    • B. Symptoms are clinically significant with marked distress
    • and/OR significant impairment in functioning
    • C. not meet criteria for other d/o; not exacerbation
    • D. Not normal bereavement.
    • E. sx don't persist>6m after stress/consequence stopped
    • Specify if: depressed, anxious, mixed, disturbance of conduct, emotions and conduct, or unspecified.
  295. Dissociative Amnesia
    • Inability to recall important autobiographical information,
    • usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. (usually either localized for specific events or generalized for identity or life history)
    • B. Causes clinically significant distress or impairment in important areas of function
    • C. Not attributable to the effects of a substance or a neurological /medical condition
    • D. Not better explained by dissociative identity disorder, PTSD, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.
    • Specify if with dissociative fugue
  296. Dissociative fugue
    apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or other important autobiographical information.
  297. Depersonalization/derealization
    • Presence of persistent or recurrent experiences of depersonalization, derealization, or both.
    • 1. depersonalization- feeling detached from one's self
    • (perceptual alterations, time distortion, emotional/physical numbing)
    • 2. derealization- feeling detached from one's environment (dream-like)
    • B. During these experiences, reality testing remains intact.
    • C. Causes clinically significant distress or impairment.
    • D. Not attributable to the effects of a substance or other condition.
    • E. Not better explained by another mental disorder such as schizophrenia, panic disorder, major depressive disorder, PTSD, acute stress disorder, or another associative disorder. (these must be specifically ruled out)
  298. Dp/dr r/o
    • as schizophrenia, panic disorder
    • major depressive disorder,
    • PTSD, acute stress disorder
    • another associative disorder
  299. Dissociative ID disorder
    • A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession.
    • involves marked discontinuity in sense of self and sense of agency,
    • accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning.
    • may be observed by others and reported by the individual.
    • B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
    • C. The symptoms cause clinically significant distress or impairment in functioning.
    • D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.
    • E. Not attributable to the effects of a substance or another medical disorder.
  300. Amnesia
    impairment in memory
  301. cognition
    thinking and it's many domains: attention, executive function, learning, memory, language, perceptual-motor, and social
  302. delirium
    • acute, life threatening, potentially reversible disorder of the CNS
    • characterized by a change in cognition and decline in the level of consciousness.
  303. major neurocognitive disorders
    serious cognitive impairment that disrupts performance of daily activities
  304. dementia
    neurocognitive disorder which involves multiple cognitive deficits
  305. minor neurocognitive disorders
    • cognitive impairment w/ mild-moderate dec in fx
    • does not impair daily functioning
    • (some consider the cognitive changes of normal aging to fall in this category).
  306. Nerocog d/o Clinical Evaluation
    • Detailed history: (multiple sources if possible)
    • Physical Exam and screening lab tests
    • Detailed Mental Status Exam
    • EEG, CT, and MRI when indicated
    • Brain biopsy by steriotactic needle - rarely
    • Neuropsychological testing - initial assessment and reevaluation of cognitive abilities
  307. Delirium
    • acute onset & time limited
    • change in cognition and confusion
  308. Delirium subtypes based on etiology
    • 1. general medical condition (e.g. infection, electrolytes)
    • 2. substance induced (e.g. stimulants, opioids, LSD)
    • 3. multiple causes (e.g. head trauma and renal disease)
    • 4. other (e.g. sleep deprivation)
  309. Delirium Epidemiology
    • Common in the elderly at some time
    • 1% community >55; 13% community > 85
    • 60% of nursing home patients at some time
    • 5-10% of elderly visiting emergency departments
    • 15-21% of elderly at time of hospital admission
    • 5-30% admitted free of delirium, develop in hospital
    • 70-87% in intensive care units
    • Common with other medical illnesses
    • 10-15% of general surgical patients; 30% if open heart
    • patients with hip fractures, burns, and HIV
    • multiple predisposing and precipitating factors
  310. delirium Etiology
    • CNS disorders (seizures, tumors, head trauma, TIA, CVA)
    • Metabolic disorders (electrolytes, blood glucose)
    • Systemic illnesses (infection, altitude, burns, pain)
    • Medications (prescribed, OTC, herbal supplements)
    • Drugs of abuse (intoxication and withdrawal)
    • Cardiac, pulmonary, hematologic, renal, & hepatic abnormalities
    • any systemic or cerebral dysfunction can cause delirium
  311. delirium Diagnosis
    • diagnosed at the bedside"
    • mental status exam/neurologic signs used
    • document confusion and change in mental status.
    • PE, labs, and other studies used to find etiology and determine appropriate treatment.
  312. Delirium f/u
    • must be followed closely
    • worsening is a sign that treatment may not be effective and further evaluations may be indicated.
  313. Differential Diagnosis
    • delirium verses dementia: attn; timing (fluc & short)
    • delirium verses schizophrenia or depression
    • psychotic symptoms more consistent with schizophrenia
    • EEG shows general slowing with delirium not usually seen in depression
  314. Delirium Treatment
    • Treat the underlying cause
    • Provide support to prevent accidents
    • Avoid sensory deprivation and overstimulation
    • Provide familiar people and objects when possible
    • Provide regular orientation to person, place, and time.
    • calendar and clock
    • greet them by name and remind them where they are
  315. delirium Course and Prognosis
    • May be a prodromal phase of fearfulness/restlessness.
    • Active phase: rapid onset last til cause reversed
    • After identification and correction of etiology, symptoms usually resolve in 3-7 days;
    • may take longer in people who are older and in people who had symptoms for a longer duration.
    • High mortality rates can be related to seriousness of underlying causes.
  316. Major Neurocognitive Impairment
    • Serious impairment in 1+ area of cognition
    • Areas: attention, executive function, learning,
    • memory, language, perceptual-motor, and social
    • Does not manifest solely in the course of delirium
    • Dementia refers to X in multiple area
  317. Major NCI Epidemiology
    • Prevalence is rising with the aging of the population
    • 5% of the general population > 65
    • 20-40% > 85
    • 15-20% outpatients; 50% in extended care facilities
    • 50-60% Alzheimer's type dementia F > M
    • 15-30% have vascular dementia M > F
  318. Major NCI Etiology > 65
    • most common causes are:
    • 1. Alzheimer's Disease,
    • 2. vascular
    • 3. mixed Alzheimer's and vascular diseases
  319. Major NCI etiology
    • Lewy body, Pick's disease, Parkinson's disease
    • Huntington's disease, Wilson's disease
    • normal pressure hydrocephalus, MS, HIV
    • syphilis, other infections of CNS, drugs and toxins
    • chronic psychiatric illnesses such as depression, schizophrenia (cognitive decline)
  320. major NCI Diagnosis
    • Based on clinical exam, MSE,
    • info from family, friends, other sources.
    • Cog decline w/ impaired ADLS
  321. Major NCI sx
    • Personality changes (particularly in person > 40)
    • hallucinations/delusions; depression/anxiety
    • Agitation secondary to subjective awareness of decline.
    • Attempt 2 compensate for deficit (humor/change subj)
    • If impaired judgment:crude jokes/language; neglect hygiene and ignore social norms of modesty and behavior.
  322. Major NCI Differential Diagnosis
    • Transient Ischemic Attacks (TIAs)
    • Delirium
    • Depression
    • Factitious Disorder
    • Schizophrenia
    • Normal Aging
  323. Major NCI Treatment
    • Verify the diagnosis
    • Treat what's treatable (diet, exercise, BP, blood sugar)
    • Psychosocial therapies (supportive and educational)
    • Family intervention and support
    • Pharmacotherapies
    • Aricept, Exelon, Remiryl, & Cognex - cholinesterase inhibitors used to treat Alzheimer's disease
    • In general, avoid meds with high anticholinergic activity
  324. Major NCI Course and Prognosis
    • Classic course usually begins in 50s-60s
    • Gradual deterioration in the case of Alzheimer's disease eventually leading to death.
    • Incremental worsening in cases of vascular dementia.
    • Stable dementia in cases of head trauma or single episode causes.
    • Symptom regression is possible in reversible dementias (brain tumor, NPH, etc.)
  325. Cluster A Personality Disorder
    • (odd, eccentric)
    • Paranoid PD
    • Schizoid PD
    • Schizotypal PD
  326. Cluster B
    • (dramatic, impulsive, erratic)
    • Antisocial PD
    • Borderline PD
    • Histrionic PD
    • Narcissistic PD
  327. Cluster C
    • (anxious, fearful)
    • Avoidant PD
    • Dependent PD
    • Obsessive-Compulsive PD
    • PD: General Considerations
  328. Personality disorder
    • pattern of inflexible and maladaptive personality traits
    • causing significant impairment or personal distress to patient.
    • Perception, thought, and response are fixed & inflexible
    • Behavior unpredictable
    • Deviate from cultural norms
    • Usually long term conditions that are difficult to change
    • significant distress in social, occupational, or other areas
    • Previously on Axis II
    • Majority of patients will meet criteria for >1
    • Mood disorders common
  329. Personality d/0 epidemiology
    • Affect 10-15% of adults in US
    • Diagnosis not made until after patient is 18y/o
    • Cluster A: schizoid men>women
    • Cluster B: antisocial& narcissistic men>women; borderline women3x>men
    • Cluster C: obsessive-compulsive PD men 2x>women
  330. Personality d/o Etiology
    • controversial
    • Transference and countertransference reactions are common.
    • ~~Rxn 2 person based upon another person/experience
  331. Transference
    Unconsciously & inappropriately displacing onto individuals in his/her current life those patterns of behavior & emotional rxns that origniante with figures from earlier in life
  332. Countertransference
    Provider unconsciously displaces onto the pt patterns of behavior or emotional rxn as if he/she were a significant figure from earlier in the provider's life
  333. PD dx
    • Toxicology screen
    • HIV screen/STIs: poor impulse control, impulsivity
    • Minnesota Multiphasic Personality Inventory (MMPI)
  334. PD Treatment
    • Psychotherapy, CBT, group therapy
    • Meds: not curative, most useful for borderline
    • ~~SSRIs not as effective as with MDD
    • ~~Don't use tricyclic 2˚to OD potential
  335. PD Disposition
    • Hospitalization for those at risk of self-harm
    • Continue OP therapy after discharge
  336. PD Cx
    • suicide, substance abuse,
    • accidents, depression
    • homicide (paranoid, antisocial PD)
  337. PD Prognosis
    • Lifelong condition
    • Cluster A, B decreases in intensity by middle age
    • Cluster B prone to sub abuse, impulse control, suicide threats
    • Cluster C characteristics exaggerate in later life
  338. Paranoid PD
    • Pervasive distrust/suspiciousness of others
    • Grudges; read hidden meaning in remarks
    • Believe others untrustworthy
    • Perceive personal attacks
  339. Paranoid PD Epidemiology
    • 0.5-2.5% of population
    • Usually referred for tx by family member
    • Affects men>women
  340. Paranoid PD Etiology
    • uncertain;
    • genetic link between PPD and schizophrenia
  341. paranoid pd ssx
    • Speech is goal directed, logical
    • Mental status exam: persecutory ideation
    • No thought disorder
    • Risk for agoraphobia, MDD, OCD, substance abuse
    • Appear cold, unemotional
  342. Paranoid PD Diagnosis
    • Hallmark: EXCESSIVE suspiciousness and distrust of others
    • Internal expectation they will be taken advantage of
    • Difficulty keeping friends, intimate relationships
  343. Paranoid pd DDX:
    • paranoid schizophrenia,
    • other Cluster A PD
  344. Paranoid PD Course/Prognosis
    • Usually life-long
    • Can be precursor of schizophrenia
    • Difficulty with working and personal relationships
  345. Paranoid pd Treatment
    • Psychotherapy treatment of choice
    • Meds: antianxiety can be used for anxiety, agitation;
    • Orap (antipsychotic) has good results with some patients
  346. Schizoid PD
    • Detachment from social rlt
    • Restricted range of expression fo emotion
    • Begin in early adulthood
    • Choose solitary
    • Little interest in sexual
    • Coldness, detached
  347. Schizoid PD Epidemiology
    • Occur up to 7.5% in general population
    • Rarely distresses the patient because they withdraw internally
    • Uncommon in clinical setting
  348. Schizoid pd Etiology
    ?lack of emotional nurturing, ?genetic
  349. Schizoid pd sx
    • Appears uneasy, little eye contact, aloof
    • Speech goal directed, sensorium intact,
    • memory and abstract thinking appropriate
  350. schizoid PD Dx
    • Preference for solitary life;
    • no intimate relationships, socially detached;
    • flat and unresponsive personality,
    • inability to demonstrate anger
    • Reality based
  351. Schizoid pd DDx:
    • Schizophrenia, delusional disorder,
    • affective disorder w/psychotic features
  352. Schizoid PD Course/Prognosis
    • Onset early childhood; long-lasting (not always life-long)
    • Disinterest in socializing magnifies isolation
    • less anxiety or depression than other pd
  353. schizoid pd Treatment
    • Psychotherapy treatment of choice : group difficult
    • Meds:No specific med indication
    • some pts benefit from antipsychotics, antidepressants, SSRIs, benzodiazepines if anxious
  354. schizotypal pd
    • social & interpersonal deficits
    • Eccentric, but more pronounced than Schizoid
    • Based on oddities of thinking, speech, behavior, and appearance
    • Unusual thought processes and content do not reach psychosis
    • Psychosis may occur during high stress, but it temporary
    • Socially isolated
    • Hx taking is difficult secondary to patients communication
  355. Schizotypal PD Epidemiology
    • 3% in general population
    • No gender difference known
    • Etiology
    • Probable genetic link w/schizophreniz
  356. Schizotypal PD DDx:
    • Schizoid, avoidant PD
    • ~~Sx more pronounced in thinking, perception, communication
  357. Schizotypal pd Course and Prognosis:
    • 10% commit suicide
    • Associated with schizophrenia
  358. Schizotypal pd Treatment
    • Psychotherapy: proceed with care;
    • patients often in cults, the occult, bizarre religious practices.
  359. Antisocial PD
    • Major feature is disregard for rights, feelings of others
    • Chronic lying, hx problems w/ the law,
    • irresponsible, impulsive, aggressive
    • Shows no remorse
    • Externalize blame
    • May appear to be very normal;
    • hx is + for ↑ episodes of poor social interactions.
    • Substance abuse may be common
    • Known as sociopaths or psychopaths by laypersons
  360. Antisocial PD Epidemiology
    • 3% men; 1% women
    • Conduct disorder onset before age 15
    • 75% of prison population
  361. Antisocial PD Etiology
    • ↑risk if father antisocial, or alcoholic
    • ↑risk if antisocial pd in family members (?genetic)
  362. Antisocial PD Course & Prognosis:
    • Course usually unremitting
    • Highest during adolescence
    • Prognosis highly variable
    • May decrease slightly as grow older
  363. Antisocial pd Treatment
    • Psychotherapy: good in hospital setting; group therapy better in jails
    • Meds: treat symptoms
  364. Borderline PD
    • Pattern of unstable/intense interpersonal relationship, self-perception and moods
    • Characteristic Office behavior
    • ~Atypical medical presentation
    • ~Unexplained, incomplete recoveries
    • ~Pressuring for meds
    • ~Recurrent medication sensitivity
    • ~Crisis
    • ~Seduction
    • Interpersonal relationships-both dependent & hostile
  365. Borderline PD Gunderson Criteria
    • PISIA
    • P = PSYCHOTIC/QUASI-PSYCHOTIC EPI
    • Transient, depersonalization, rage reaction, unusual reaction to drugs
    • I = IMPULSIVITY
    • Longstanding, includes self-regulation difficulties and self-destructive behaviors
    • S = SOCIAL ADAPTATION
    • Superficially intact veneer
    • I = INTERPERSONAL RELATIONSHIPS
    • Chaotic, unsatisfying; personal- intense, manipulative, dependent
    • A = AFFECT
    • Dysphoric, labile, primarily anxiety, anger, depression, and/or emptiness
  366. Borderline PD Epidemiology
    • 2% population
    • Affects women 2x>men
    • Etiology
    • ?disturbances in normal separation dev of child/mother; child abuse
    • ?genetics: occur more often in families of patients with the disorder
  367. Borderline PD DDx:
    • Schizophrenia
    • X has only transient paranoia
  368. BPD Course and Prognosis
    • Change little over time
    • 10% suicidal over 20 year period
  369. Borderline PD Treatment
    • Difficult
    • Have consistent medical care provider
    • Define treatment plan
    • Maintain conservative medical approach
    • Avoid high-risk behavior: Watch RX, OD
    • Consider using SSRI, neurontin, atypical antipsychotics
    • Avoid BZD: increase impulsivity, prone to addiction
  370. Histrionic PD
    • Cardinal feature: deliberate use of excessive, superficial emotionality to draw attention, evade unpleasant responsibilities and control others
    • Concern with physical appearance, dress in seductive or provocative manner.
    • Mental status: La belle indifferénce
  371. Histrionic PD Epidemiology
    • 2-3% in general population: more frequently diagnosed in women; may be overlooked in men
    • Etiology
    • ?problems in parent/child relationship leading to low self-esteem
    • ?seductive & authoritarian attitudes by fathers
  372. Histrionic pd DDx:
    • Other Cluster B PDs
    • Bipolar, eating disorders, substance abuse
  373. Histrionic PD Course/Prognosis
    • Prognosis is relatively good
    • Patients are usually well accepted in social settings
    • Patients gradually improve with age
  374. Histonic pd Treatment
    • no meds for the personality disorder
    • If have co-morbid MDD or anxiety, use meds for these dx
    • Group therapy effective as is CBT
  375. Narcissitic pd sx
    • Grandiose thoughts, need admiration, lack empathy
    • Classic hallmark findings
    • *grandiosity
    • *extreme lack of empathy
    • *lack of consideration of others.
    • Little insight into their behavior
  376. Narcissistic PD Epidemiology
    • < 1% in general population
    • Etiology
    • ?lack of parental appreciation of accomplishments; defense against low self-esteem
  377. Nacissitic pd DDx:
    • Hypomania, anti-social PD
    • substance abuse, hypochondriasis
  378. Narcissitic pd Treatment
    • Chronic, difficult to treat
    • Medications: treat other symptoms (Lithium for mood swings)
    • psychotherapy is challenging. Therapist must avoid either joining the patient in his self-appreciation or criticize the patient.
  379. Avoidant pd
    • Pervasive pattern of social inhibition
    • Feelings of inadequacy
    • Hypersensitivity to neg eval
  380. Avoidant PD Epidemiology
    • 1-10% of general population
    • Women>men
    • Etiology
    • ?
  381. Dx:
    • Most important is anxiety shown during interview
    • DSM-IV-TR patient is extremely socially withdrawn
  382. Avoidant pd DDx:
    Social phobia (present in specific settings)
  383. Avoidant PD Course and prognosis
    • Many able to function well, marry, have children etc
    • Successful primarily with supporting family
  384. Avoidant pd Treatment
    • Psychotherapy, group therapy
    • Meds Tx depression, anxiety
  385. Dependant PD
    • Hallmark is lifelong interpersonal submissiveness
    • Pervasive/excessive need to be taken care of
    • Submissive/clinging behavior
    • Fears separation
  386. Dependant PD Epidemiology
    • 2-3% in general population; women>men
    • Seen often in mental health facilities
    • Etiology
    • Major theories suggest childhood
  387. Dependent pd DDx:
    • Many Axis I;
    • panic disorder, agoraphobia
  388. Dependent pd Treatment
    • Good prognosis if no co-morbid dx
    • Psychotherapy: patients usually receptive to treatment
    • Meds: treat specific symptoms
  389. OC PD
    • Preoccupation w/ orderliness, perfectionism
    • And mental/interpersonal control
    • during interview, pt appear rigid, stiff,
    • formal in demeanor, doesn't see he has a problem
    • may be very controlling of others
  390. Obsessive-Compulsive PD Epidemiology
    • Prevalence unknown; men>women
    • Etiology
    • stagnated in "anal stages" of development;
    • may need control as a defense against shame or powerlessness
  391. OC PD DDx:
    • OCD: obsessive compulsive disorder
    • Difference: OCD know there is a problem;
    • OCPD doesn't see a problem with their behavior
  392. Ocpd Treatment
    Group and cognitive behavior
  393. Proposed changes found in section 3 of DSM-5 for PD
    • 1. Core impairments in personality fx (self and interpersonal)
    • 2. Pathological Personality Traits
    • ~~negative affectivity, detachment, antagonism, disinhibition or compulsivity, and psychoticism
    • 3. Overall measure of severity
    • ~~very little, mild, moderate, or extreme
  394. Anxiety
    • normal& adaptive phychological/biological rxn
    • lack cld=> carelessness and danger.
    • Too much/@ inappropriate times-pathological& dangerous
  395. Anxiety Disorders
    • Panic Disorder
    • Agoraphobia
    • Specific Phobia
    • Social Anxiety Disorder
    • Generalized Anxiety Disorder
  396. Panic Disorder
    • intense, acute attacks
    • accompanied by fear of impending doom
    • coupled w/ physical sx ie CP, SOB & diaphoresis
    • followed by maladaptive behavior and/or fear of another panic attack.
  397. Panic Disorder epidemiology
    • 1-4% lifetime prevalence
    • 2-3x more common in woman than men
    • May be under diagnosed in men
    • Any age; MC=YNG ADULT (25 mean age)
    • Contributing social factors: Recent divorce/ separation
  398. Panic disorder Comorbidity
    • 91% least one other mental health disorder
    • 33% Major Depression prior to dx
    • 66% during/ after the onset of Major Depression
    • 15-30% also have Social Anxiety Disorder
    • 15-30% also have Generalized Anxiety Disorder (GAD)
    • 30% also have Obsessive-Compulsive Disorder (OCD)
    • 2-20% have Specific Phobias
    • 2-10% have Post Traumatic Stress Disorder (PTSD)
  399. Panic attacks Biological Factors
    • Studies indicate a range of abnormalities in brain structure and function
    • Central Nervous System - brainstem
    • ~~Noradrenergic neurons - locus ceruleus
    • ~~Serotonergic neurons - median raphe nucleus
    • ~~GABA receptors
    • Central Nervous System - temporal lobes
    • Peripheral Nervous System - autonomic
    • ~~Sympathetic nervous system- fight or flight
  400. Panic attacks Genetic Factors
    • 4-8x higher risk w/ 1st degree relative with dx vs w/ 1st degree relative w/ other psych
    • Monozygotic twins concordant > dizygotic twins
    • No known specific chromosome location
    • No known specific mode of transmission
  401. Panic attack Psychosocial Factors
    • > #stressful event in prior to onset than control
    • Childhood physical and sexual abuse: 60%F vs 31 F in other dz
    • Psychodynamic Themes:
    • ~~Physical or emotional separation
    • ~~increased work responsibility
    • ~~Chronic sense of feeling trapped
  402. Panic attacks Clinical Features
    • last minutes to hours
    • First often spontaneous.
    • Major sx= intense fear of death or doom
    • usually can't ID source of fear
    • often feel confused, and difficulty concentrating.
    • physical: tachycardia, dyspnea or hyperventilation,
    • diaphoresis, and heart palpitations.
  403. Panic attack History
    • HOPI: attn 2 preced events ie caffeine, alcohol, nicotine, or change in sleeping or eating habits.
    • Past History: Depression/Trauma or abuse
    • Family History: Depression or anxiety
  404. DSM-5 Panic Disorder
    • a. recurrent unexpected attacks
    • b. 1+ attack followed by 1+ m of ...
    • c. not attributable 2 physilogical effect of substance
    • d. not better explained by other disorder
  405. A. Recurrent unexpected panic attacks.
    • come on quickly (minutes)
    • From either a calm or anxious state
    • Criteria: need 4 of 13 symptoms:
  406. Panic attack criteria dsm-5
    • 1. heart palpitations 8. feeling dizzy/faint
    • 2. sweating 9. chills or heat sensations
    • 3. trembling/shaking 10. paresthesias (numb/tingling)
    • 4. shortness of breath 11. derealization/depersonalization
    • 5. feeling of choking 12. fear losing control/going crazy
    • 6. chest pain/discomfort 13. fear of dying
    • 7. nausea/abdominal distress
  407. B. One or more of the panic attacks is followed by one month or more of:
    • 1. Persistent concern or worry of having
    • more panic attacks or their consequences
    • and/or
    • 2. Significant or maladaptive change in behavior
    • due to the panic attacks
  408. DSM-5 Panic Disorder criteria (continued)
    • C. The condition is not attributable to the physiological effects of a substance or another medical condition.
    • For example: drugs of abuse or other medications; hyperthyroidism or cardiopulmonary disease
    • D. The condition is not better explained by another mental disorder.
    • For example: social anxiety disorder, specific phobia, obsessive-compulsive disorder, or separation anxiety disorder
  409. Panic attack Treatment
    • Cognitive and behavior therapy
    • Avoid/decrease identifiable precipitating factors
    • (caffeine, nicotine, alcohol, work stress, ect.)
    • Pharmacotherapy
    • Antidepressants- prevent attacks: ssri; TCA; MAOI
    • Benzodiazepines- acute treatment
  410. TWO FDA APPROVED DRUGS panic attack tx
    • 1)Alprazolam (Xanax) - a benzodiazepine
    • 2)Paroxetine (Paxil) - a SSRI antidepressant
    • Benzos w/ssri started then benzo tapered off
  411. Cognitive Therapy for Panic Disorder
    • Instruction on misinterpretation of body sensations
    • Information helps pt recog sx as less dreadful than prior
    • Pharmacotherapy plus CBT is more effective than either alone.
  412. Panic attack Course
    • Generally a chronic disorder which requires ongoing treatment
    • variable; # of attacks can fluctuate in severity and frequency
    • Comorbid depression 40-80% of cases and increases suicide risk
    • Alcohol/substance dependence in 20-40%
  413. Panic attack Prognosis
    • Long term follow up studies indicate:
    • 30-40% symptom free
    • 50% continue to experience mild symptoms
    • 10-20% continue to have serious symptoms
    • Most patients have significant relief with treatment.
    • Patients with good premorbid function and brief symptoms have the best prognosis.
  414. Agoraphobia
    • Anxiety / avoidance of places/situations impossible 2 escape
    • Fear of the market place
    • Out of proportion fear of place difficult to escape
    • Sufferers alter lives to stay home 2 avoid fear/anxiety
  415. Agoraphobia Epidemiology
    • Estimates vary widely
    • 2-6% lifetime prevalence in community
    • Higher in psychiatric settings due to comorbidity with panic disorder
  416. Agoraphobia Comorbidity
    • 75% also have panic disorder
    • d/2 assoc w/ panic dz may have those comorbid also
  417. Agoraphobia Etiology
    • Unknown etiology
    • Many begin after traumatic event.
    • Most thought to be caused by panic disorder
  418. Agoraphobia Clinical Features
    • strictly avoid situations from which escape is difficult
    • impairs edu, vocational, employment, & social fx
  419. Agoraphobia History
    • Listen for a hx of anxiety sx every time the patient leaves places they feel safe, such as their home.
    • They manage this anxiety by not leaving home whenever possible.
    • They seek help when they can no longer manage their life this way.
  420. DSM-5 criteria for agoraphobia
    • A. Marked fear/anxiety in 2 of 5 situations:
    • 1. using public transportation
    • planes, trains, cars, buses, ships
    • 2. being in open spaces
    • parking lots, long bridges, parks,
    • 3. being in enclosed places
    • movie theaters, shops, others' homes
    • 4. standing in a line or being in a crowd
    • 5. being outside of their home alone
    • DSM-5 criteria for agoraphobia
    • B. Fear and avoidance of these situations because of thoughts that escape might be impossible or help might not be available if they experience panic or embarrassing symptoms
    • C. Their particular agoraphobic situation almost always produces fear/anxiety for them
    • DSM-5 criteria for agoraphobia
    • D. Their agoraphobic situations are actively avoided, require someone with them, or are endured with great fear or anxiety.
    • E. The fear/anxiety is out of proportion to any actual danger.
    • F. The fear/anxiety/ avoidance is persists usually greater than 6 months.
    • DSM-5 criteria for agoraphobia
    • G. The fear/anxiety/avoidance causes clinically significant impairment in social, occupational, or other areas of important areas of functioning.
    • H. If another medical condition is present, the fear/anxiety/ avoidance is clearly excessive to what would be expected.
    • Examples:
    • IBS (fear of incontinence)
    • Parkinson's (fear of falling)
    • DSM-5 criteria for agoraphobia
    • I. The fear/anxiety/avoidance is not better explained by another mental disorder:
    • not confined to a specific phobia
    • not confined to only social situations
    • not related exclusively to obsessions
    • not related only to perceived physical deficits
    • not related only to reminders of trauma
    • not related only to fear of separation
  421. Treatment of Agoraphobia
    • Pharm: Similar to Panic D(Benzos, SSRI, TCA)
    • Psychotherapy: supportive, insight, behavior, cognitive, virtual
  422. Agoraphobia Course and Prognosis
    • If caused by panic and panic d tx=> x improves
    • without panic disorder it is often chronic
    • comorbidly w/ depression or substance abuse
    • =>course complicated/prognosis worse
  423. Specific Phobia
    • Excessive fear of a particular or specific object, situation or circumstance
    • Fear Causes intense anxiety
    • may panic when exposed to object/situation
  424. specific phobia Examples:
    • Specific animals (snakes, spiders, dogs)
    • Natural Environments (heights, storms, lakes)
    • Medical procedures (injections, surgery)
    • Situations (enclosed places like airplanes & elevators)
  425. Specific Phobia Epidemiology
    • USA 5-10%
    • 10% lifetime prevalence
    • MC MENTAL DISORDER IN WMN
    • 2ND MC IN MEN ( behind substance-use disorders)
    • Peak age of onset varies by type
  426. Specific phobia Comorbidity
    • Rates of comorbidity range from 50-80%
    • other anxiety disorders
    • mood disorders 1/3 of pt w/ x
    • substance-related disorders espec ETOH
  427. specific phobia behavioral factors etiology
    • Conditioned Emotional Reactions
    • Classic Stimulus Response Theory
    • Operant Conditioning Theory
  428. Operant conditioning specific phobia
    • anxiety motivates us to move away from pain
    • avoidance becomes fixed as it protects the person from anxiety.
  429. Spec phob Conditioned Emotional Reactions
    • (John Watson, 1920)
    • traditional pavlovian stimulus response model of conditioned reflex
  430. Classic Stimulus Response Theory
    attenuation of the response to the stimulus does not occur.
  431. Specific phobia Etiology psychoanalytic
    • Freud's formulation :Little Hans case history of 5 year old boy's fear of horses
    • Three combined defense mechanisms involved
    • 1)Repression
    • 2) Displacement
    • 3) Symbolization
    • Other theories are hypothesized ie separation anxiety
  432. Specific phobia Etiology
    • As in most mental disorders there is not clear specific etiology
    • combination of genetic constitution and environmental factors.
    • Genetic factors: tend to run in families
    • particularly the blood-injection-injury type of phobias.
  433. Specific phobia Clinical Features
    • Severe anxiety/panic when exposed/anticipate exposure
    • Avoidance of stimulus: Taking back roads instead of highway on long drives
    • Findings on Mental Status Exam
    • ~~Irrational and ego-dystonic fear of stimulus
    • ~~Depressed mood in 1/3 of these patients
  434. Spec phob History
    • anxiety when exposed/anticipate/think of stimulus.
    • avoidance of stimulus sometimes going to great lengths.
    • May have a family history
  435. DSM-5 criteria for Specific Phobia
    • A. Marked fear or anxiety related to a specific object or situation. (In children may expressed by crying, freezing, clinging, or tantrums.)
    • B. The phobic object or situation almost always results in immediate fear/anxiety.
    • C. It is actively avoided or endured with intense fear/anxiety if not avoided.
    • DSM-5 criteria
    • D. Fear/anxiety out of proportion to the actual danger
    • E. Fear/anxiety/avoidance is persistent, typically lasting more than 6 months.
    • F. Fear/anxiety/avoidance causes clinically significant distress or impairment of social, occupational, or other important areas of functioning
    • DSM-5 criteria
    • G. It is not better explained by another mental disorder such as:
    • agoraphobia
    • obsessive compulsive disorder
    • separation anxiety disorder
    • social anxiety disorder
    • Coding of Specific Phobias
    • DSM-5
    • Specify code based on phobic stimulus
    • Example:
    • 300.29 (F40.218) animal
    • ICD 10
    • Select specific code
    • Example:
    • F40.230 fear of blood
  436. Specific phobia Treatment
    • Behavior Therapy
    • virtual therapy
    • other therapies: hypnosis, supportive, family
  437. Behavior therapy spec phobia tx
    • Most studied and most effective tx
    • Techniques: Systematic Desensitization;Intensive Exposure
    • Key factors for success:
    • 1)Patient commitment
    • 2)Clearly identifiable problems and objectives
    • 3) Alternative coping strategies
  438. Virtual Therapy spec phobia
    • cutting edge of computer programs
    • computer generated virtual simulations of stimuli
    • Success has been variable.
  439. Specific phobia Course and Prognosis
    • Limited data
    • People with specific phobias rarely present for treatment
    • Without treatment it is often chronic
  440. Social Anxiety Disorder (Social Phobia)
    • Fear d/2 anxiety related to scrutiny/ judgment
    • May be specific (eating or speaking in front of others)
    • or vague, nonspecific fear of embarrassing oneself in front of others.
    • general anxiety related to fear of embarrassment in social situations.
  441. Social anxiety Epidemiology
    • Lifetime prevalence 3-13%
    • 6 month prevalence 2-3%
    • In community samples F>M
    • treatment settings M>F
    • peak age : teens but begins ages 5-35.
  442. Social anxiety Comorbidity
    • Other Anxiety Disorders
    • Mood Disorders
    • Substance Related Disorders
    • Bulimia Nervosa
  443. Social anxiety Etiology
    • Genetic: 1st degree relative 3x more likely
    • Neurochemical:Adrenergic & dopaminergic theories
    • Psychosocial Factors:
    • Theory that rejecting, careless, as well as, overprotective parenting may contribute
  444. Social anxiety Clinical Features
    • See DSM-5 Diagnostic Criteria
    • marked fear/anxiety in one + social situations where one is exposed to possible scrutiny by others.
    • Fear others will notice their anxiety leading to feelings of humiliation, rejection, and embarrassment.
    • some degree of x and self-consciousness is common
  445. Social anxiety Treatment
    • Combo pharmacy & psychotherapy best
    • Pharma:SSRIs, benzodiazepines, venlafexine, buspirone
    • PsychoT: combo behavioral & cognitive methods
    • ~~including cognitive retraining, desensitization, and rehearsing.
  446. Social anxiety Course and Prognosis
    • Onset tends to be in late adolescence or early adulthood
    • Typically chronic
    • Untreated-y affect school/job performance & social development.
  447. Generalized Anxiety Disorder (GAD)
    • Anxious about almost everything
    • Worry about events that are unlikely
    • Worry about things that would be considered out of the ordinary
    • Excessive anxiety/worry about several events or activities for most days for at least 6 months
    • Worry is difficult to control & associated with somatic symptoms
  448. GAD Epidemiology
    • Common
    • 3-8% one year prevalence
    • F>M by 2:1
    • In anxiety disorder clinics 25% of patients
    • Also high prevalence in primary care settings
    • Onset usually in late adolescence or early adulthood with another spike in older adults
  449. GAD Comorbidity
    • Common
    • 50-90% of patients with GAD have another mental disorder
    • Social phobia
    • Specific phobia
    • Panic disorder
    • Depressive disorders
    • Substance related disorders
  450. GAD Etiology
    • A certain amount adaptive and normal
    • can be difficult to identify cause of excessive
    • Probably a combo of bio & psychosocial factors
    • similar to other anxiety disorders.
    • May be proceeded by several negative life events.
  451. GAD Treatment
    • Most effective: psycho/pharmo therapy and social supportive.
    • Time consuming; rqr commitment and good therapeutic relat
  452. GAD Course and Prognosis
    • Age of onset difficult to establish
    • Usually chronic condition
    • can see improvement with combination therapy.
    • Only 1/3 of patients seek tx from mental health
    • Most see primary care providers or specialists such as cardiologists, pulmonologists or gastroenterologists for somatic symptoms.
  453. Anxiety Disorders Attributable to Another Medical Condition
    • Many medical conditions are associated with anxiety symptoms.
    • Signs and symptoms of anxiety due to the physiological effects of the medical illness.
    • Why dsm-5 has r/o as part of dx criteria
  454. Substance Induced Anxiety Disorder
    • Anxiety as a direct result of a toxic substance
    • Drugs of abuse
    • Rx or OTC medications
    • Poisons
    • Alcohol
  455. Mood
    "pervasive and sustained emotion or feeling tone that influences a person's behavior...colors perception..."
  456. Affect
    • expression of mood;
    • what mood appears to be;
    • may be congruent or incongruent with stated mood
  457. Adjectives used to describe mood:
    • depressed, sad, distressed, irritable, elated, euphoric, empty, anxious and many others
    • labile (fluctuating from one extreme to another over a short period of time)
    • stable (generally consistent over time)
  458. Mood Disorders separated into
    • Depressive
    • Bipolar and related
  459. Depressive Disorders
    • extremely ego-dystonic (suicide risk)
    • noted correlation to substance use
    • strong correlation to suicide if self medicating
  460. Bipolar and Related Disorders
    • manic and depressive episodes
    • may vary between ego-syntonic/ego-dystonic
    • risk of accidental death>suicide when manic
  461. Depressive Disorders types
    • Disruptive Mood Dysregulation Disorder
    • Major Depressive Disorder, single episode
    • Major Depressive Disorder, recurrent
    • Persistent Depressive Disorder
    • Premenstrual Dysphoric Disorder
    • Substance Induced Depression
    • Depression due to Medical Conditions
  462. Disruptive Mood Dysregulation Disorder
    • onset is after age 6 but before age 18.
    • Temper outbursts (verbal or behavioral)
    • grossly out of proportion to the circumstances.
    • Outbursts occur >3x/week for at least 12 consecutive months.
    • Overall mood of irritability
    • r/o pediatric bipolar, oppositional defiant, neurodevelopmental disorders, and intermittent explosive
  463. Disruptive Mood Dysregulation Disorder tx
    • Cognitive-behavioral therapy + Meds(relief of irritability)
    • Requires specialists in child/adolescents
    • Studies show mindfulness training works well particularly with adolescents.
  464. Major Depressive Disorder (MDD)
    • occurs without a history of manic, mixed or hypomanic episode.
    • Meets 5 of 9 criteria for at least 2 weeks (DSM-5 criteria):
    • Specify severity of mild, moderate, or severe impairment or pain/distress
    • Specify if psychotic features, partial remission, full remission, Unspecified
    • Major correlation to suicide in the United States
    • Bereavement exclusion has been eliminated in DSM-5
  465. Mdd dsm-5 criteria 9
    • depressed mood,
    • decreased interest/pleasure,
    • weight loss/decreased appetite,
    • insomnia/hypersomnia,
    • psychomotor agitation/retardation,
    • fatigue,
    • worthlessness/guilt,
    • decreased concentration,
    • recurrent thoughts of death/suicide
  466. MDD Rule out:
    • expected sadness,
    • normal grief, bipolarity,
    • ADHD, substance induced,
    • general medical conditions,
    • adjustment reaction
  467. MDD: acronym
    • Sleep
    • Interest
    • Guilt
    • Energy
    • Concentration
    • Appetite
    • Psychomotor agitation or slowing
    • Suicidality
  468. Epidemiology: Major Depressive Disorder (MDD)
    • 5-17% lifetime prevalence
    • Female 2x > Male -all countries & cultures
    • Mean age of onset 40
    • 50% of cases onset 20-50 years old
    • Can also occur in children & elderly
    • No correlation - socio-economic status
    • Lower reported rates - AfricanAmericans
    • More common in rural than urban areas
  469. Comorbidity: MDD
    • higher risk for:
    • Substance Use Disorder (M>F)
    • Anxiety Disorders (F>M)(panic, ocd, social)
    • Eating Disorders (F>M)
    • substance use or anxiety disorders, higher risk for mood disorders
  470. Etiology: MDD
    • Multifactorial: interaction of multiple variables
    • Biological: genetic, endocrine, brain abnorm; neurtotransmitter
    • Personality: passive, high harm, sociotrophy; automony
    • Socio-cultural: negative life effect, social support, culture
    • Cognitive:
  471. Biological etiology MDD
    • Genetic factors: relative 2-3x more likely mood disorder
    • Endocrine system: Chronically elevated serum cortisol
    • ~~Reduced regulation of the HPA axis
    • Brain structure abnormalities: Reduced hippocampal volume related to disease duration
    • Neurotransmitters:
    • Reduced serotonin & norepinephrine availability at the synapse
    • Dopamine activity may be reduced in depression (high in mania)
    • Final common pathway may involve glutamate
  472. MDD etiology-Personality Styles
    • 1) Passive personality style: hurt expressed out(anger); in (depression)
    • 2) High harm avoidance style: fear-> w/drawl & inc risk
    • 3) Sociotrophy (Beck): define self worth by approval/ acceptance of other incr risk of depression
    • 4)Autonomy (Beck): concern w/ achiev, indep, self-actualization and control may be protective
  473. Etiology: MDD Socio-cultural factors
    • Negative life events: Trauma, loss, chronic criticism
    • Social support: friends and family (2x single>married)
    • Culture: lower A.A.
  474. Etiology: MDD Cognitive
    • 1)distortions
    • ~~Depression may be the result of negative interpretations
    • ~~Errors in thinking
    • ~~Automatic negative thoughts
    • ~~Negative interpretations about self, future, and the world
    • ~~Overgeneralization, magnification, or minimization
    • 2 styles
    • ~~Learned helplessness (Seligman)
    • ~~Negative cognitive styles (Beck)
    • ~~~~~"maladaptive thinking and negative appraisals of life circumstances contribute to the development of depression"
  475. MDD: Another Important Factor
    • Sleep!
    • Sleep/wakefulness important factor-onset and tx
    • and component, of mood disorders-both depressive and bipolar.
    • normal healthy circadian rhythm is important to mood stability and euthymia.
  476. Tips for Diagnosing MDD
    • depressed mood/ loss of interest => ask SIG-E-CAPS (at least 4 or more).
    • Have the symptoms lasted at least 2 weeks?
    • Areas affected, how, and to what extent
    • (impairment of functioning and level of severity).
    • R/o effects of a substance (alcohol/drugs or medications)
    • r/o other medical illness (e.g., thyroid disease) as the cause of symptoms.
  477. Treatment MDD
    • Antidepressant: SSRIs*, TCAs, MAOIs, etc
    • ~~Mood stabilizers and antipsychotics if indicated
    • PsychoT: Cognitive, Behavioral, Insight Oriented, etc
    • Modern Electroconvulsive: effective but underutilized
    • ~~Performed under anesthesia
    • ~~Major side effect is short term memory loss
    • Hospitalization (suicidal or catatonic)
    • Phototherapy (MDD & SAD)
  478. Course and Prognosis MDD
    • Most have long course & tend to relapse
    • Early tx-prevent worsening
    • Untreated episodes last 6-13 months
    • Treated episodes last an average of 3 months.
    • Takes time; if tx works-cont to dec risk of relapse
    • 5-10% manic episode later=change dx
  479. Persistent Depressive Disorder (Dysthymia)
    • Poor concentration/difficulty making decisions
    • Feelings of hopelessness
    • More days than not, for at least 2 years
    • No evidence of mania, no bipolarity
    • Major correlate to suicide and self-mutilation
    • DEPRESSED MOOD W/ AT LEAST 2 of 6:
    • Poor appetite or overeating
    • Insomnia or hypersomnia
    • Low energy or fatigue
    • Low self-esteem
  480. Persistent Depressive Disorder (Dysthymia) ETIOLOGY
    • 12 month prevalence: 2%
    • complex and may include:
    • Genetics, substance abuse
    • interpersonal or personality issues,
    • endocrine and neurochemical factors,
    • history of trauma, and more.
  481. PDD Treatment
    • often complex D/2 multi factor and chronic
    • may require multiple approaches
    • with both antidepressants and forms of psychotherapy.
  482. Premenstrual Dysphoric Disorder
    • 7-10 days/month
    • begin in luteal phase
    • improve or remit in follicular phase
    • physical/mental sx more severe/debilitating
    • Mood swings, irritability, depression, anxiety
    • anger, decreased energy/interest/concentration,
    • changes in appetite and sleep, pain, swelling, and bloating.
  483. Premenstrual Dysphoric Disorder ddx
    • Short cyclic course differs from persistent depressive disorder.
    • The chronic nature is frustrating and causes significant impairment.
  484. PMDD Treatments
    • hormonal treatment
    • antidepressant and antianxiety medications
    • psychotherapies, diet, exercise, and support groups.
  485. Bipolar and Related Disorders
    • Characterized by variations in mood, energy, and ability to function
    • Common and recurrent
    • Often debilitating and sometimes fatal
    • Include: Bipolar I Disorder; Bipolar II Disorder; Cyclothymia
    • Substance & Medical Illness Induced
  486. Bipolarity (what is it?)
    • Episodes of Depressive Symptoms
    • Episodes of manic symptoms
  487. Depressive symptoms bipolar
    • Sadness,
    • decreased interest,
    • feelings of guilt,
    • decreased energy,
    • impaired concentration,
    • decreased pleasure,
    • suicidal thoughts (possible).
  488. Episodes of Manic Symptoms bipolar
    • Euphoria,
    • expansive or irritable mood,
    • increased energy and activity,
    • inflated self- esteem,
    • grandiosity, decreased need for sleep,
    • excessive rate and amount of speech,
    • racing thoughts, increased risk taking,
    • psychosis (possible).
  489. Bipolar I Disorder
    • experience at least 1 manic episode.
    • Manic episodes are severe
    • Manic last min 1w. (n unless hospitalized)
    • elevated, expansive, or irritable mood
    • along with increased energy/activity
    • at least 3 (4 if mood is irritable) of sx
  490. bipolar I disorder min 3 (4 if irritable)
    • Inflated self esteem or grandiosity
    • Decreased need for sleep (feels rested with 3 hours)
    • Increased speech; pressured speech
    • Racing thoughts or flight of ideas or thought disorder (psychosis)
    • Distractibility; decreased attention to details
    • Increased goal directed activity or psychomotor activity
    • Impulsivity, engagement in activities with risk of harmful consequences
  491. Course: Bipolar I Disorder
    • Usually starts with Major Depression
    • Most both depression and mania
    • 10-20% experience only manic episodes.
    • Manic: usually quick develop (hr-days)
    • 90% go on to have another episode after a first
    • time betwn episodes decreases them stabilizes (charting is helpful)
    • 5-15% have rapid cycling (>3 episodes/year)
  492. Prognosis: Bipolar I Disorder
    • Overall worse prognosis than MDD
    • Overall better prognosis than Schizophrenia
    • Usually lifelong-relapsing/remitting
    • Long term fx worse
    • Early aggressive tx: 50-60% stabilize
  493. Bipolar II Disorder
    • 1 hypomanic & 1 major depressive
    • NO MANIC EPISODES
    • hypomanic=No psychosis, hospitalization or severe impairment of functioning.
    • Hypomanic : shorter minimum duration of 4 days (not 7).
    • MAJOR DEPRESSIVE EPISODE CRITERIA
  494. Bipolar II Disorder Major Depressive Episode (at least one)
    • Sadness (depression) or
    • Loss of interest (anhedonia) plus
    • Weight change
    • Sleep disturbance
    • Psychomotor agitation or retardation
    • Poor energy
    • Poor self esteem/guilt
    • Poor concentration
    • Suicidal thoughts
    • At least 5 of the above pervasively for at least 2 weeks
  495. Course: Bipolar II Disorder
    • Chronic disorder with relapsing/ remitting course
    • Once dx, likelyto have same dx 5 yrs later
    • Long term treatment is recommended
  496. Cyclothymic Disorder
    • Min 2yrs(1ped) mood disorder sx
    • -chronic&fluctuating between hypomanic & depressive sx
    • Chornic but less severe than bipolar I &II
    • Never meet criteria for mania or major depressive
  497. Bipolar Spectrum Disorders
    DSM-5 criteria for Bipolar Disorders is extensive and can be found on pages 358 &359 of Kaplan & Sadock's Synopsis of Psychiatry.
  498. Comorbidity: Bipolar Disorders
    • >80% of patients also have a substance use disorder
    • this is a significant clinical problem
    • can precipitate mood episodes and worsen compliance
  499. Bipolar Spectrum Disorders Epidemiology
    • Prevalence of Bipolar I is <1%
    • Prevalence of all Bipolar Disorders >2%
    • Female=Male
  500. Bipolar Etiology
    • multifactorial
    • have biological, psychological & social factors
    • Evidence for circadian rhythm abnormalities
  501. TX: Bipolar Spectrum Disorders
    • Pharm w/ mood stabilizers in every phase of the illness
    • Mood stabilizers: Lithium & anticonvulsants
    • ~~(valproic acid, carbamazepine, oxcarbazepine, & lamotrigine)
    • ECT- effective in severe depression or mania (not for psychosis)
    • Pharm w/ antidepressants as necessary for symptom control.
  502. Substance Related Disorders Major Features:
    • Physical, Cognitive, Behavioral, & Psychological symptoms
    • Continued use despite significant consequences
  503. Change in brain chemistry substance
    • Changes in brain chemistry persist
    • Can lead to cravings, relapse, and chronic mood change
  504. Classes of substances in this group:
    • Alcohol Inhalants Anxiolytics
    • Caffeine Opioids Stimulants
    • Cannabis Sedatives Tobacco
    • Hallucinogens Hypnotics Steroid
  505. Substance abuse types
    • 10% have a substance related disorder (22 million)
    • 15 million alcohol only
    • 4.5 million illicit drugs without alcohol
    • 2.8 million both alcohol and illicit drugs
    • Additional surveys show abuse/dependence:
    • 669,000 heroin
    • 4.3 million marijuana
    • 1million cocaine
    • 2 million pain medications
  506. Substance abuse epidemiology
    • 18-25 highest (19%)
    • 26-65 (7%)
    • 12-17 (6%)
    • >65 (1%)
    • M>F
    • Younger initial use is associated with higher rates of dependence, particularly with alcohol.
    • Native Americans>Caucasians>African Americans
    • Unemployed>Employed
  507. Sub. Abu. Etiology
    • Multifactorial
    • Genetic:strong evid in etoh; others less conclusive
    • Self-med: etoh-control anxiety; opioids-pain; amphet-depression
    • Learning & conditioning: reinforced by consequences (relief of uncomfortable feelings or withdrawal symptoms, good feelings, peer pressure)
    • Neurochemical: opioid receptors, brain reward circuitry
  508. S.A. Comorbidity
    • 50% have another psychiatric illness
    • antisocial personality disorder is common in illicit
    • depressive/anxiety disorders- with alcohol use
    • major risk factor for suicide! 20x more
    • 15% of people with alcohol use disorder - suicide
    • self-medication for untreated mental illness is the most significant risk for suicide in the United States
  509. Terminology
    • see Table 20.1-1 in Synopsis of Psychiatry
    • Know the definitions of all these terms.
    • Also be aware that the DSM-5 has moved away from the abuse and dependency and has incorporated both into substance use disorders and then specify if there is tolerance, withdrawal, or compulsive use and apply a severity index. (ICD 10 has retained the terms of abuse and dependence)
  510. Substance Related Disorders types
    • Substance Use Disorders
    • Substance Intoxication
    • Substance Withdrawal
    • Substance Induced Disorders
  511. Substance Use disorders
    • Term applied, naming the specific substance,
    • at least 2 of 11 criteria are met within 12 months.
    • 1. recurrent use->failure to meet major obligations
    • 2. recurrent use in hazardous situations (e.g. driving)
    • 3. continued use despite adverse social or relationship consequences
    • 4. tolerance: (a.) incr amts needed for effect or (b.) diminished effect from same amount
    • 5. withdrawal: (a.) experience characteristic withdrawal symptoms or (b.) a similar substance is taken to avoid
    • 6. substance used in larger amounts or longer time than intended
    • 7. persistent desire or unsuccessful attempts to cut down or control substance use
    • 8. much time is spend in obtaining, using, and recovering from use of the substance
    • 9. give up important recreational/social/work activities in order to continue use
    • 10. continue use despite known physical or emotional problems related to use
    • 11. craving/strong desire/ urge to use substance
  512. Cage
    • 2 Y =investigate further
    • "needed to Cut down on your drinking?"
    • " Annoyed you by criticizing your drinking?"
    • "Have you ever felt Guilty about drinking?"
    • "Eye-opener) to steady your nerves or to get rid of a hangover?"
  513. Substance intoxication
    • ssx of recent intake of a particular substance and includes:
    • development of reversible substance-specific syndrome
    • significant maladaptive behavioral or emotional changes due to the effects of the substance on the CNS developing during or shortly after use
    • symptoms not due to or better explained by a general medical condition or mental disorder
  514. Substance Withdrawal
    • substance-specific syndrome due to reduction or cessation of substance
    • => significant distress or impairment in social, occupational, or other functioning
    • sx not d/2 general med or mental d/o
    • symptoms are not due to or better explained by a general medical condition or mental disorder
  515. Substance Induced Disorders
    • This is a major "rule out" in many of the other disorders!
    • Alcohol induced depressive disorder
    • LSD induced psychotic disorder
  516. alcohol induced depressive disorder
    some people who have abused alcohol in the past but have been sober for years can have ongoing depressive symptoms which were caused by neurobiological changed due to their past alcohol use.
  517. LSD induced psychotic disorder
    some people who abuse hallucinogens develop psychotic (mood or anxiety) disorders
  518. Prognosis
    • guarded because relapse is common.
    • 75% of people with Alcohol Use Disorders with severe dependence will relapse within 1 year of early remission.
  519. Alcohol
    • 2 million injuries/year; including 22,000 deaths
    • causes acute neurochemical changes: depression, anxiety, and psychosis can result
    • causes chronic medical complications: potentially fatal withdrawal; liver, heart, nutritional, etc.
    • causes significant social consequences: broken relationships, loss of jobs, homelessness
  520. alcohol Epidemiology
    • 90% of US population drinks
    • >40% have temporary problems related to alcohol
    • >10% of Males - abuse
    • >5% of Females - abuse
    • 10% of Males - dependence
    • 3-5% of Females - dependence
    • 20-30% of psychiatric patients - abuse or dependence
  521. Alcohol Etiology
    • Genetic Factors may account for 60% of the risk
    • Environmental Factors may account for 40%
    • Again we see a combination of nature and nurture.
    • Fhx=more at risk
  522. Alcohol use Comorbidity
    • other substance related disorders (often more than one drug is used)
    • Antisocial Personality Disorder M>F
    • Mood Disorders (30-40%) F>M
    • Anxiety Disorders (25-50%)
    • Phobias, Panic Disorder, Generalized Anxiety Disorder
    • Suicide (10-15%)
    • risk is high if MDD, undiagnosed mental illness, weak social support, socially isolated, serious medical illness, unemployment
  523. etoh Clinical Features
    • CNS depression
    • Behavioral effects based on blood levels:
    • 0.05% thought, judgment, & restraint loosened
    • 0.1% clumsy voluntary motor actions
    • 0.2% motor function depressed & emotions affected
    • 0.3% confusion & stupor
    • 0.4-0.5% coma, if higher, death due to respiratory depression
    • Sleep: fall asleep faster but decreases REM and deep sleep and increases sleep fragmentation leading to more and longer times of awakening
  524. ETOH Clinical Features
    • Liver: enlarged: alcoholic hepatitis/hepatic cirrhosis
    • Gastrointestinal: esophagitis, gastritis, ulcers, esophageal varices (which are an emergency if rupture), pancreatitis, mal-absorption
    • Cardiovascular: HTN, increased MI risk
    • Cancer: increased risk for head/neck/esophageal cancers, stomach, liver, colon, and lung cancers
    • Labs: elevated MCV, uric acid, triglycerides, AST, ALT
    • Drug interactions: can be fatal with other drugs that depress CNS or interact with liver metabolism
  525. Signs of Alcohol Intoxication:
    • Slurred Speech Dizziness Incoordination
    • Unsteady gait Nystagmus (involuntary eye movement)
    • Double Vision Attention/Memory Impairment
    • Stupor or Coma (Death is possible)
  526. Signs of Alcohol Withdrawal:
    • Agitation
    • Tremors
    • Seizures
    • Hallucinations
    • Delirium Tremens- a medical emergency-BENZOS
  527. Conditions that may exacerbate withdrawal:
    Fatigue, malnutrition, medical illness, depression
  528. Treatment of Acute Alcohol Withdrawal:
    • chlordiazepoxide, diazepam, lorazepam
    • mild tremor, agitation, hallucinosi: oral benzos titrated
    • agitation, withdrawal seizures,& (DT)=IV
    • symptoms resolve then titrate
  529. steps to treatment of Alcohol Use Disorder:
    • Intervention- if patient is in denial
    • Detoxification- if patient has dependence
    • Rehabilitation and Relapse Prevention- support and 12 step groups like AA, individual and/or group counseling or therapy, and medications if indicated.
  530. Cannabis-related Disorders
    • Epidemiology: most widely used illegal drug worldwide
    • demographic Correlates vary by age:
    • Over age 25: M 2x > F
    • Ages 12-17: M = F
    • Ages 12-17: Caucasians > African Americans
    • Over age 35: Caucasians = African Americans
  531. Cannabis use etiology
    • A specific receptor has been found:
    • basal ganglia, hippocampus, cerebellum, & cerebral cortex
    • leading to effects in mood
    • not found in the brain stem- less effect on respiration
  532. cannabis sx
    • Tolerance & psychological dependence
    • Euphoria peak 30 min last 2-4 hr; motor/cog 5-12 hr
    • physical effects: dilated blood vessels (eyes),
    • mild tachycardia, orthostatic hypotension,
    • increased appetite ("the munchies")
  533. Clinical Features adverse effects
    • inhaling the some of the same carcinogens as smoking tobacco
    • increased risk of chronic respiratory disease
    • increased risk of lung cancer
  534. Cannabis in food
    • higher doses needed for desired effect
    • has become a problem in some instances with accidental ingestion and overdose
    • With recent legalization in some states additional data on cannabis use, both inhaled and ingested, will likely be collected.
  535. Cannabis Induced disorders
    • Cannabis Intoxication Delirium
    • Cannabis Induced Psychotic Disorder
    • Cannabis Induced Anxiety Disorder
    • Unspecified Cannabis Related Disorders
  536. Other cannabis related issues:
    • Flashbacks
    • Cognitive impairment
    • Amotivational Syndrome
  537. Cannabis Treatment and Rehabilitation
    • Requires a motivated patient :Patient education
    • Relies of abstinence and support
    • Abstinence: in/out pt w/ monitoring
    • Support: individual, family, group therapies
    • Medications: antianxiety short 4 withdrawal
    • antidepressants if indicated for underlying depression
  538. Hallucinogen-related disorders
    • Botanical-social and religious rituals
    • Synthetic-more potent& assoc w/ panic attacks, flashbacks, delirium, psychosis, mood disturbance and anxiety. e.g. LSD,PCP (angel dust), MDMA (ecstasy)
    • Schedule 1=no med use & high abuse
  539. hallucinogenEpidemiology
    • 10% age 12 and older report some lifetime use
    • LSD > MDMA > PCP
    • More common among young people
    • More common in the southern US
    • Caucasian 2x > African Americans
    • M > F
    • Long term use is not common
  540. Hallucinogen Use Disorder:
    • Long term use of PCP can lead to a syndrome with:
    • dulled thinking, impaired memory & concentration,
    • decreased reflexes impulse control, lethargy, & depression
    • Psychological dependence can occur but is rare.
  541. Pcp etc Use Disorder criteria DSM-5.
    • use that causes impairment or distress
    • behavioral changes and clinical signs/symptoms
    • not better explained by another medical/mental disorder
  542. hallucinogen Clinical Features
    • behavioral symptoms:
    • belligerence, assaultive, impulsive, unpredictable, agitated
    • psychiatric symptoms:
    • geometric hallucinations, flashes of color, false perceptions of movement, trails of images, halos around objects, etc.
    • physical symptoms:
    • numbness, ataxia, muscle rigidity, palpitations, etc.
  543. Hallucinogen Induced Disorders
    • Hallucinogen Intoxication Delirium
    • Hallucinogen-Induced Psychotic Disorder
    • Hallucinogen-Induced Mood Disorder
    • Hallucinogen-Induced Anxiety Disorder
    • Unspecified Hallucinogen-Related Disorder
  544. Hallucinogen Treatment
    • acute intoxication symptoms:
    • reassurance and support
    • quiet environment
    • intense anxiety may respond to 20 mg of diazepam
  545. hallucinogen Treatment to abstain:
    education, support, individual & group therapies
  546. hallucinogen Treatment of persisting symptoms
    • palliative
    • meds: if have stopped but persistent perceptive disorder
    • long acting benzodiazepines or mood stabilizers
  547. Opioid-Related disorders
    • used medically for pain relief
    • drugs of abuse for their psychoactive effects.
  548. Synthetic opioids include:
    • Demerol or meperidine
    • Dolophine or methadone
    • Talwin or pentazocine
    • Darvon or propoxyphene
  549. Opioid Epidemiology
    • Prevalence Fluctuates; dec price->inc use
    • Estimated 600,000-800,000 opiate users in the US.
    • HIV transmission with IV use- public health concern
    • Smoking, snorting, and oral intake have increased
    • Oxycodone (OxyContin) use has increased
    • Heroin use M 3x > F
    • ER visits for heroin doubled from 1990-1995
  550. Opioid Clinical Features
    • addictive because of the euphoric effect
    • particularly felt IV
    • Associated symptoms: warmth, facial flush & itch,
    • dry mouth, heaviness of extremities.
    • Initial euphoria followed by sedation, sleep, nausea.
  551. Opioid Physical effects
    • respiratory depression, pupillary constriction,
    • constipation, changes in vital signs.
    • Track marks and "skin poppers" from chronic abscesses
  552. Opioid Adverse effects
    • transmission of hepatitis and HIV
    • allergic, & drug interactions.
  553. Opioid Use Disorder:
    • Problematic use with significant impairment or distress, with at least 2 of 11 criteria in 12 months.
    • Specify if: in early or sustained remission
    • Specify if: on maintenance therapy (e.g. methadone)
    • Specify current severity:
    • mild: 2-3 symptoms
    • moderate: 4-5 symptoms
    • severe: 6 or more symptoms
  554. Opioid Intoxication:
    • Recent use
    • Clinically problematic changes- initial euphoria then apathy, dysphoria, impaired judgment
    • Pupillary constriction and 1 or more of drowsiness, slurred speech, impairment in attention or memory
    • Not due to another medical/mental disorder or another substance.
    • Specify if with perceptual disturbance
  555. Opioid Withdrawal:
    • Cessation or reduction of use or administration of an opioid antagonist after use
    • 3 or more of the following:
    • dysphoric mood, nausea or vomiting,
    • muscle aches, lacrimation or rhinorrhea,
    • pupillary dilation/piloerection/sweating,
    • diarrhea, yawning, fever, insomnia.
    • clinically significant distress or impairment
    • Not better explained by another cause.
  556. Opioid Overdose treatment:
    • Antagonists:
    • Narcan (naloxone)
    • ReVia (naltrexone)
    • Adequate airway and respiratory support are primary in overdose
  557. Opioid Treatment
    • Medically Supervised Withdrawal and Detoxification
    • Psychotherapy: individual, behavioral, CBT, family, support groups (e.g. Narcotics Anonymous[NA]), social skills training
    • Therapeutic Communities: residences for people in recovery, abstinence is the rule
    • Education
    • Methadone Maintenance Clinics
    • Needle Exchange Programs- controversial
  558. Sedative-,Hypnotic-, or anxiolytic-related disorders Epidemiology:
    • 6% report illicit use
    • 24-36 year olds - highest prevalence
    • 25-33% of all substance related ER visits
    • F 3x > M
    • Caucasian 2x > African American
    • Some use BZD alone
    • Some use BZD to reduce withdrawal sx of cocaine, enhance euphoria of opioids, or reduce anxiety of stimulants, hallucinogens, other drugs.
  559. Sedative/Hypnotic/Anxiolytic Related Use Disorder:
    • A. Problematic pattern of use -distress/impair w/ 2of 11 in12m
    • Specify if in early or sustained remission
    • Specify if in a controlled environment
    • Code based on current severity:
    • mild
    • moderate
    • severe
  560. Sedative/Hypnotic/Anxiolytic Intoxication:
    • A. Recent use
    • B. Maladaptive behavior/psychological changes
    • C. One or more of the following:
    • 1. slurred speech
    • 2. incoordination
    • 3. unsteady gait
    • 4. nystagmus
    • 5. impairment in cognition (e.g. attention or memory)
    • 6. coma or stupor
    • D. Not better explained by another condition.
  561. Sedative/Hypnotic/Anxiolytic Withdrawal
    • Two+ sx developing several hrs-days after cerssation following prolonged use:
    • 1. autonomic hyperactivity (sweating, tachycardia), 2. tremor, 3. insomnia, 4. nausea or vomiting, 5. transient hallucinations or illusions, 6. agitation, 7. anxiety, 8. seizures
    • Symptoms cause significant distress or impairment.
    • Not better accounted for by another condition.
    • Specify if: with perceptual disturbances (hallucinations with intact reality testing or illusions in the absence of delirium)
  562. Treatment and Rehabilitation BZD
    • Withdrawal can take several weeks.
    • To prevent seizures and other symptoms, gradually reduce dose.
    • Carbamazepine (Tegretol) may be helpful.
    • Withdrawal from barbiturates must follow clinical guidelines to prevent death.
  563. Sed/hallu Overdose
    • life threatening, treat with gastric lavage,
    • activated charcoal, induce vomiting,
    • hospitalization for monitoring,
    • support of airway, respiration, hydration, etc.
  564. sed/hallu Treatment and Rehabilitation
    • Similar to treatment of Alcohol Use Disorders:
    • Inpatient for withdrawal/detox/early recovery prn
    • Long term outpatient treatment for abstinence and for relapse prevention
    • Psychotherapies: individual, group, family, supportive living environment, 12 step program.
    • Treatment of co-occuring disorders
  565. Amphetamines Use:
    • methamphetamine doubled 1995-2012
    • many in law enforcement describe it as the greatest drug threat
  566. Cocaine:
    • Became a US epidemic in the 1980s (currently declining)
    • In 2012, 0.6% over age 12 had used it in the past month; 0.4% met criteria for abuse or dependence in past year.
    • 1.5% among 18-24 year olds had used in the past month; 0.9% met criteria for abuse or dependence in past year.
    • M 2x > F
  567. Stimulant-Related Disorders Comorbidity:
    • Mood disorders (MDD, Bipolar II, and Cyclothymia)
    • alcohol related disorders often follow the onset
    • Antisocial PD, anxiety disorders, and ADHA often precede
  568. Stimulant=related Clinical Features
    • pattern of use leading to clinically significant impairment or distress
    • With at least 2 of 11 criteria in a 12 month period
    • Specify if in full or partial remission
    • Specify if in controlled environment
    • Specify current severity
    • mild: 2-3 symptoms
    • moderate: 4-5 symptoms
    • severe: 6 or more symptoms
  569. Stimulant Intoxication criteria:
    • Recent use which leads to clinically significant problematic behavior or psychological changes (e.g., euphoria, or affective blunting, anxiety, hypervigilance, tension, anger, impaired judgment)
    • Two or more of the following during/soon after use:
    • 1. tachycardia/bradycardia, 2. pupillary dilatation,
    • 3. high or low BP, 4. perspiration/chills,
    • 5. nausea/vomiting, 6. weight loss,
    • 7. psychomotor agitation/retardation,
    • 8. muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias,
    • 9. confusion, seizures, dyskinesias, dystonias, or coma.
    • Not attributable to another medical or mental condition, including intoxication with another substance.
    • Specify specific intoxicant & if perceptual disturbance
  570. Stimulant Treatment
    • Withdrawal from cocaine can take weeks but no pharmacologic intervention is required.
    • Patients experience fatigue, dysphoria, insomnia, and cravings.
    • May require inpatient or intensive outpatient setting with drug monitoring to achieve abstinence.
    • Psychosocial Therapies: Individual- focus on dynamics which lead to use
    • Group- group therapy, support groups, & NA
    • Family- address past and future issues
  571. Other Substance Use disorders
    • Caffeine
    • Tobacco
    • Other non-substance "addictions"
    • ~~gambling
    • ~~internet
    • ~~pornography/sex
  572. Obsessive-Compulsive and Related Disorders
    • DSM-5 New Grouping of disorders which share:
    • symptoms of repetitive thoughts
    • signs of repetitive behaviors
    • 3. common pathophysiology
    • 4. common etiology (theory)
    • 5. high comorbidity
    • 6. high prevalence in 1st degree relatives
    • 7. share similar approach to treatment
  573. Obsessive-Compulsive and Related Disorders
    • Obsessive-Compulsive Disorder (OCD)
    • Body Dysmorphic Disorder
    • Hoarding Disorder
    • Hair-Pulling Disorder (Trichotillomania)
    • Excoriation (Skin-Picking) Disorder
    • r/o substance induced & other med dz
  574. obsessive-Compulsive Disorder
    • Recurrent, persistent, intrusive thoughts
    • thoughts may be bizarre or unreasonable
    • thoughts are not psychotic
    • Patient is aware these thoughts are not rational.
    • managed /suppressed by compulsive acts (washing, safety checks)
    • MOST, but not all, have both thought & acts
    • Dystonic (uncomfortable, painful, unwanted)
    • Major impairment in functioning
  575. OCD Comorbidity
    • Major Depression - 67%
    • Social Phobia - 25%
    • Alcohol Use
    • Generalized Anxiety Disorder
    • Panic Disorder
    • Eating Disorders
    • Personality Disorders
  576. OCD Epidemiology
    • 4th most common psychiatric illness
    • (phobias, substance related disorders, major depression)
    • 2-3% general population lifetime
    • 10% of mental health clinic outpatients
    • Adults: M=F Adolescents: M>F
    • Mean age of onset: M-19; F-22
  577. OCD Etiology
    • Bio-psych-social combination
    • Biological Factors: neurotransmitters
    • ~~(serotonin & norepinephrine)
    • Brain Imaging Studies: PET scans: metab changes
    • (frontal lobes, basal ganglia, and cingulum)
    • Genetics: signif 3-5x family>control
    • Behavioral Factors
    • Obsessions are conditioned stimuli
    • Compulsions develop when dec anxiety assoc w/ obsess
  578. OCD Clinical Features
    • MC=obsess CONTAMINATION=>compulsive WASHING/avoidance
    • 2nd MC: DOUBT/fault=> COMPULSIVE CHECKING
    • 3) INTRUSIVE thoughts W/OUT compulsive behavior
    • 4) obsessive SYMMETRY=>behaviors 2 DO things in perfect symmetry.
  579. OCD presentation
    • often present to dr d/2 effects of compulsions
    • Dermatologist for chapped hands
    • Pediatrician for parent's concern about behaviors
    • Dentist for gum lesions tooth erosion from excessive oral hygiene
  580. OCD Treatment
    • Pharm/behavioral Therapy or combo=most
    • many reluctant to take medications or accept behavioral therapy.
  581. OCD pharmacotherapy
    • SSRIs, clomipramine, mood stabilizers
    • Symptoms return when meds stopped
  582. OCD Behavior Therapy
    • Exposure and Response Prevention
    • As effective as meds and the results may last longer.
    • Patient motivation essential!
  583. OCD Psychotherapy
    May help improve compliance with other treatments if patient is resistant.
  584. OCD Course and Prognosis
    • Onset usually sudden and prior to age 30.
    • 50-70% have onset after stressful event
    • (such as childbirth or family death)
    • Many keep their symptoms secret for several years prior to evaluation.
    • 20-30% significantly improve
    • 40-50% moderately improve
    • 20-40% remain same or get worse
  585. Body Dysmorphic Disorder
    • Preoccupation w/ nonexistent defect that causes severe impairment
    • If actual abnormality-concern about it is excessive
    • included in Obsessive Compulsive Related Disorders in DSM-5
    • b/c obsessional nature of the concern about the perceived defect
    • &often compulsive behaviors that sometimes occur to address it
    • such as seeking multiple plastic surgeries.
  586. Body Dysmorphic Disorder sx
    • Onset, gradual or abrupt, usually in adolescence.
    • Yrs btwn onset and mental health eval
    • Chronic and difficult to tx
    • ~~Medications may have some benefit.
    • ~~Comorbid illnesses ie depression should be tx
  587. Hoarding Disorder
    • Acquire & cant discard possessions
    • Regardless of usefulness/value
    • Must cause signif distress/ impaired social, rec, vocation of fx
    • Behavior must not be due to psychosis, depression, OCD, PTSD, or brain injury.
  588. Hoarding Disorder
    • Results in excessive clutter of living space
    • can lead to safely and health issues
    • Poor sanitation (particularly with animals)
    • Risk of tripping and falling
    • Effects on sleeping, eating, and hygiene
  589. Hoarding Disorder etiology
    • Usually begins in adolescence and persists
    • Affects 2-5% of population (perhaps 14%)
    • M=F
    • Single>Married
  590. Hoarding comorbidity
    • High w/ OCD and personality disorders
    • Dependent
    • Avoidant
    • Schizotypal
    • Paranoid
  591. Hoarding Disorder tx
    • Difficult to treat unless motivated patient
    • Most effective treatment is CBT
    • ~~Training in decision making and categorizing
    • ~~Exposure and habituation to discarding
    • ~~Cognitive Restructuring
    • ~~Requires office and in home treatment
  592. Common Eating Disorders
    • Anorexia Nervosa: Restricting and Binge/Purge Subtypes
    • Bulimia Nervosa
    • Binge Eating Disorder
    • Avoidant/Restrictive Food Intake Disorder (new)
  593. Other Feeding and Eating Disorders
    • Pica- eating nonfood substances for >1 month
    • Rumination: regurg, re-chew, re-swallow/spit out x> 1 month
    • Other Specific Eating or Feeding Disorders
  594. Anorexia Nervosa
    • Behavior: self-induced starvation
    • Psychopathology: extreme drive to be thin/ fear of being fat
    • Physiological symptoms: medical signs and symptoms of starvation;
    • medical consequences; medical complications pg 512
  595. Anorexia Nervosa Epidemiology
    • 10-20x> in Females;
    • Homo M>het M
    • usually onset age 14-18;
    • more in developed countries & professions requiring thinness
    • (models, dancers, acting; wrestlers have increased incidence during competition)
  596. Anorexia Etiology
    • No known specific etiology: genetic&social factors.
    • 5% in 1st degree relatives
    • Increased incidence in sisters: nature and/or nurture
    • Psycho-social factors: emphasis on thinness and appearance
    • family dynamics, professional/athletic expectations, and sexual orientation
  597. Anorexia Nervosa Comorbidity
    • 65% also have depression
    • 34% also have social phobia
    • 26% also have OCD
  598. Anorexia Nervosa Clinical Features/Presentation
    • Extreme low weight & medical ssx
    • Signs: emaciation, lanugo, dry skin-fine hair on face
    • Symptoms: hypothermia, hypotension, bradycardia, dependent edema
    • Consequences/findings: metabolic changes, electrolyte abnormalities (hypokalemic alkalosis), amenorrhea, cardiac abnormalities, and even death are possible
    • Initially denial, flat affect;
    • may be hostile, aloof, and/or uncooperative to clinician.
  599. Anorexia Nervosa Treatment
    • Hospitalization if critical/unstable; in &out pt
    • Medical treatment and monitoring of complications.
    • Psychotherapies: cbt, psychodynamiac, family
    • Pharmacotherapy: no med cures; help specific sx(Prozac)
  600. Anorexia Nervosa Course and Prognosis
    • varies greatly:
    • Some recover without treatment
    • Some recover with treatment
    • Treatment outcomes in US: (10 years)
    • 25% recover completely
    • 50% improved and well functioning
    • 25% symptomatic, poor functioning, significant morbidity/mortality
    • Some:Lifelong relapses/deterioration-> death
  601. Bulimia Nervosa
    • binge eating min 1/w x3m
    • eat L amt food, quickly
    • stop when physically uncomrfortable (N/abd pain)
    • Purging behaviors to reduce consequences of overeating- weight gain.
    • Physical pain/nausea
    • Guilt of overeating/fear of weight gain
    • Weight is not severely lowered: fear wt gain
  602. Bulimia Nervosa Epidemiology
    • More common than Anorexia Nervosa
    • Age of onset slightly older than AN
    • 1-4% prevalence of young women in US
    • 20% of college women have some symptoms
    • Hispanic & African Americans > Caucasian
    • 90% F>M
    • May be normal weight; oft obesity hx
  603. Bulimia Nervosa etiology
    • unknown, likely multifactorial
    • Biological Factors: Serotonin& norepinephrine possibly
    • Social Factors: Family conflicts, social pressures
    • Psychological Factors: Hx depression, anger, impulse control issues
  604. Bulimia Nervosa Comorbidity:
    • Depressive Disorders
    • Substance Abuse
  605. Bulimia Nervosa ssx
    • Often normal weight, may be overweight
    • history of obesity/dieting/weight fluctuations
    • Affect spontaneous and engaging
    • Less guarded, more cooperative, seeking help
    • Preoccupation with weight & appearance
    • History of GI distress: constipation, bloating
    • Irregular menstrual cycles
  606. Bulimia Nervosa Physical Exam Findings:
    • Abdominal distention
    • Edema
    • Evidence of self-induced vomiting:
    • Dental problems- enamel erosion, caries (cavities)
    • Pharynx irritated
    • Parotid glands swollen
    • Chapped lips
    • Calluses on dorsal aspects of fingers
  607. Bulimia Nervosa Lab work:
    • Electrolytes
    • Amylase
    • Magnesium
    • Bun/creatinine
  608. Bulimia Nervosa Medical complications:
    • Metabolic- hypokalemic alkalosis or acidosis
    • Renal- kidney failure
    • Cardiovascular- arrhythmias, cardiomyopathy
    • Dental- loss of enamel (lingual surfaces), caries
    • Gastrointestinal- swollen parotid glands, gastric distention, elevated serum amylase, IBS
    • Musculoskeletal- cramps
  609. Bulimia Nervosa tx
    • Usually out pt
    • Pharm: antidepressents (same doses) except Prozac higher@(60-80 mg/day)
    • Psychotherapies: CBT-indicated(interruption and alter beliefs)
    • Psychodynamic Therapy- less effective than CBT
  610. Bulimia Nervosa Course and Prognosis
    • Better prognosis than Anorexia Nervosa
    • 40% fully recover with treatment
    • Mortality rate reported 2% per decade
    • More willing to accept treatment
    • Treated have better outcome than not treated
    • Long illness and/or a history of substance abuse- poorer prognosis
  611. Binge Eating Disorder
    • 1. eating, more rapidly than normal, to the point of feeling uncomfortably full
    • 2. eating large amounts of food even when not hungry
    • 3. eating in private
    • 4. feeling guilty or upset after
    • Not purging
  612. Binge Eating Disorder Epidemiology
    • The most common eating disorder.
    • Found in 25% of patients seeking treatment for obesity.
    • Found in 50-75% of those with severe obesity
    • BMI > 40
    • More common in F (4%) over M (2%)
  613. Binge Eating Disorder Etiology
    • Cause is unknown.
    • May occur during periods of stress
    • Food may be used to decrease anxiety/depression
    • Risk increased: Impulsive, extroverts, hx of low cal diet
  614. Binge Eating Disorder Comorbidity
    • 50% also have obesity
    • Obese patients -earlier onset of obesity
    • more likely to have weight fluctuations
    • insomnia, early menarche, chronic pain, and metabolic disorder
  615. Binge Eating Disorder Treatments
    • 1) Psychotherapy:CBT & interpersonal
    • 2) Self-Help Groups like Overeaters Anonymous (OA)
    • 3) Pharm: antidepressants/amphetamines short term
    • Combo more effective than solitary
  616. Avoidant/Restrictive Food Intake Disorder
    • Significant weight loss
    • Nutritional deficiencies
    • Medical consequences
    • Need to pay attention to triglycerides, cholesterol, electrolytes, EKG, etc.
    • Cardiac complication->risk premature death in F <19
    • Often correlated to early childhood trauma involving swallowing
  617. Obesity
    • not included in the DSM-5.
    • (62% overweight, 26% obese)
    • affect many psychiatric patients.
    • Pt don't usually see mental health provider
  618. Body Mass Index (BMI) Classifications
    • <18 underweight
    • 18.5-24.9 normal weight
    • 25-29.9 overweight
    • 30-39.9 obese
    • >40 morbidly or extremely obese
  619. Obesity Etiology
    • More complicated than once thought.
    • Calories in vs calories out valid but other factors
    • Hormones, neurochemistry, and genetics also have roles
    • Likely an interplay of bio-psycho-social factors
  620. Obesity TX
    • important b/c significant morbidity and mortality
    • Diet- the amount, type, and quality of food are all important factors
    • Lifestyle habits
    • Behavior modification/support groups
    • Exercise- with medical supervision
    • Pharmacotherapy: medications used to lose weight
    • Surgery- many procedures now available

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