Psych Pathophys Flashcards
Nina’s Deck for Child Abuse!
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Major Depressive Disorder
Epidemology
- 7% of US population
- 18-29 yrs, females most common
Major Depressive Disorder
Risk Factors
- family hx (2-4x higher risk if first degree relative has)
- concurrent DM, obesity, CVD
- Poor interpersonal relationships (divorced, isolated)
SOCIOECONOMIC STATUS NOT A RISK FACTOR
Major Depressive Disorder
Criteria for “with anxious disease”
At least 2+ sx for a majority of days w/ MDD:
* feeling keyed up/tense
* feeling unusually restless
* difficulty concentrating due to worry
* fear that something awful may happen
* feeling that the individual might lose control of themself
Major Depressive Disorder
Major Depressive Disorder
Major Depressive Disorder
Major Depressive Disorder
Major Depressive Disorder
Major Depressive Disorder
Major Depressive Disorder
Major Depressive Disorder
Major Depressive Disorder
Major Depressive Disorder
Major Depressive Disorder
Major Depressive Disorder
Major Depressive Disorder
Major Depressive Disorder
Major Depressive Disorder
Neurotransmitters
Adrenaline/Epinephrine
- fight or flight
- produced in stressful situations, increases heart rate/blood flow, leads to physical boost w/ heightened awareness
Neurotransmitters
noradrenaline/norepinephrine
- concentration
- affects attention & responding actions in the brain
- contracts blood vessel, increases blood flow
Neurotransmitters
dopamine
- pleasure
- feelings of pleasure, movement, motivation
- people repeat behaviors that lead to dopamine release
Neurotransmitters
serotonin
- mood
- contributes to well being and happiness
- helps sleep cycle and digestive system regulation
- affected by exercise
Neurotransmitters
Serotonin Side Effects
- n/v/d
- HA, dizziness
- induces mania/hypomania
- increased bleeding risk (because there are serotonin receptors on platelets)
- bone fx
- sexual dysfunction (reduced libido, inability to climax)
Neurotransmitters
GABA
- calming
- calms firing nerves in the CNS
- high levels improve focus
- low levels cause anxiety
Neurotransmitters
acetylcholine
- involved in thought, learning, and memory
- activates muscle action in the body
Neurotransmitters
glutamate
- memory
- involved in learning and memory
- regulates development and creation of nerve contacts
Neurotransmitters
Endorphins
- euphoria
- released during exercise, excitement, sex
- produces sense of well being and pain reduction
Escalation of Treatment Resistant Depression
- Level I: Begin with an adequate trial of a first-line antidepressant (usually a generic formulation of an SSRI or SNRI)
- Level II: Switch to another first-line antidepressant (some favor switching to a different type of medication, eg, mirtazapine)
- Level III: Patented antidepressants, combinations and adjuncts or older antidepressants (ie, TCAs or MAOIs)
- Level IV: Neuromodulation strategies (TMS or ECT), ketamine infusions or intranasal esketamine
- Level V: VNS or unproven or experimental strategies
Psychotic Disorders
what is psychosis?
- Delusions
- Hallucinations
- Disorganized speech
- Grossly Disorganized or catatonic behavior
- Negative symptoms
Psychosis
Delusions describe
- Fixed beliefs that one holds despite evidence to the contrary
- cognitive distortion
- Various themes
- The distinction between a delusion and a strongly held idea is sometimes difficult - delusions typically cannot be broken
Ex. A patient has delusions that she won a house, she fully believes this despite lack of evidence. She packs her things, tells her family she is moving, etc.
Psychosis
describe hallucinations & types
- Perception-like experiences that occur without an external stimulus.
- sensory based
- Vivid, clear, with the full force and impact of normal perceptions, and not under voluntary control
- Be sure to distinguish Inner dialogue (intrusive thoughts) vs perceived sounds
- Hallucinations while falling asleep or waking up are normal (Hypnagogic Hallucinations)
Types
* Auditory is most common in psychotic disorders - usually in the form of a voice, not just a noise
* Others include: visual, tactile. Olfactory and gustatory typically medical cause involving temporal lobe.
Psychosis
Disorganized Thinking/Speech
- Disorganized thinking is typically seen in the presentation of disorganized speech
- Symptoms must be severe enough to impair effective communication, but may be mild if in prodromal or residual phases of psychosis
Types
* Derailment - switching from topic to topic with no logical connection
* Thought blocking - sudden and involuntary interruption
* Tangentiality - answers to questions are seem to be unrelated and gradually deviate
* Incoherence - unintelligible sounds that may or may not be words
* Word salad - mix of seemingly random words strung together in a “sentence”
Psychosis
Grossly Disorganized Behavior
- Behavior that seems bizarre, without purpose or inappropriate.
- Ex: childlike silliness, unprovoked agitation, pacing aimlessly, inappropriate giggling, poor hygiene
- Included catatonic behavior, which is marked decrease in reactivity to the environment
Can range from….
* Resistance to instructions (negativism)
* Maintaining a rigid, inappropriate or bizarre posture (waxy flexibility)
* Complete lack of verbal and motor response (mutism and stupor)
* Purposeless and excessive motor activity without obvious cause (catatonic excitement)
Psychosis
Negative Symptoms
- lacking “something”
- Diminished emotional expressions - reductions in the expression of emotions in the face, eye contact, intonation of speech and movements of the hand, head, and face that normally give an emotional emphasis to speech
- Avolition - decrease in motivated self-initiated purposeful activities
- Alogia - diminished speech output
- Anhedonia - lack of interest, happiness
- Asociality - apparent lack of interest in social interactions
- Account for a substantial portion of the morbidity associated with psychotic disorders
Psychosis
Delusional Disorder types:
* erotomanic
* grandiose
* jealous
* persecutory
* somatic
- Erotomanic: delusion that another person is in love with the indivudal
- Grandiose: delusion or conviction of having an undiscovered talent
- Jealous: delusion that spouse/partner is unfaithful
- Persecutory: delusion that one is being conspired against
- Somatic: delusions involving bodily functions
Schizophreniform Disorder
Specifiers
* w/ good prognostic features
* w/out good prognostic features
* w/ catatonia
W/ good prognostic features
* 2+ of the following:
* onset of prominent psychotic symptoms within 4 weeks of the first noticeable change;
* confusion/perplexity;
* good premorbid social and occupational functioning;
* absence of blunted or flat affect
w/out good prognostic features
* when 2+ of abvoe aren’t met
w/ catatonia (self explanatory)
Psychosis
typical vs atypical antipsychotics
Typicals
* 1st gen
* reduce dopamine
* work best on positive sx
* risk of EPS and anti-HAM sx
Atypicals
* 2nd gen
* decrease dopamine; increase serotonin
* works on pos and neg sx
* risk of metabolic side effects
Bipolar Disorders
Epidemiology of 1 vs 2
Bipolar 1
* 0.6% population
* M=F but men have manie and women have depression/cycling
Bipolar 2
* 0.8% of population
* F > M
* avg onset mid 20s
no relationship between life events, personality, childhood experiences, or race
Bipolar Disorders
Risk Factors/Complications 1 vs 2
Bipolar 1
* 6-7% die from suicide w/ highest risk immediately after hospital discharge
* very heritable (73-79%)
Bipolar 2
* hypomanie causes less impariment but depressive episodes are severe
* 33% attempt suicide with 6-7% dying
* 5-15% have manic episode and lead to bipolar 1 dx
Bipolar
diagnostic clinical tips for bipolar
- If patient states they have bipolar, still ask full mania hx to confirm
- Mood changing by the hour and situation related → think BPD
- If SSRIs are not working → consider bipolar
- If SSRI’s trigger mania → Bipolar
- Depressive episodes in childhood/adolescence → keep bipolar on your radar. ⅔ of bipolar patients have a major mood disorder in childhood/adolescence
- Can be hard to distinguish as it can look like and occur simultaneously with drug use, ADHD and BPD. (and even NPD… very had to distinguish)
Bipolar Diosrder
clinical tx tips
- Acute mania → think lithium and/or depakote +/- SGA
- Depression → think lamotrigine (off label) + approved antipsychotic
- Rapid cycling → Seroquel is a good option
- Augment with antipsychotics, they work faster!
- Bipolar II can sometimes be treated with SSRIs + mood stabilizer
- You may need to tx other conditions such as ADHD, anxiety, SUD.
Bipolar Disorder
Tx Takeaways
- Almost all SGAs will treat mania. Choose based on side effects, comorbidities and past med trials.
- Seroquel will treat mania, maintenance and depression
- Vraylar will treat mania, mixed and depression.
- Only bipolar depression tx include: Seroquel, Latuda, Vraylar and Symbyax (olanzapine/fluoxetine).
Why not SSRIs/SNRIs??
* Not typically effective and can trigger mania in some patients
* Will sometimes with in bipolar II with concurrent mood stabilizer
Anxiety Disorders
Anxiety Epidemiology
- more common in women than men
- age of onset late teens/20’s and in elderly
- important to know how patient is coping (EtOH, drugs, rx, ED, cutting, exercise, therapy)
- high co-morbidity in presence of phobia, substance abuse, panic disorders
BATHE Model for Mental Health Interviewing
- Background: “what has been going on”
- Affect: “how do you feel about that”
- Trouble: “what troubles you the most”
- Handle: “how are you handling this”
- Empathy: “this must be difficult for you”
- compressed therapy/limited
- focuses on the present NOT the past
- make connections between thoughts and actions/choices to change your thinking/behaviors (ultimately chaning emotions)
- highly structured w/ clear goals/practical techniques
- pt may have homework
- empowers patient to make choices
similar effectiveness compared to meds but better long term outcomes
Psychotherapy/Psychodynamic Therapy
- unlimited time (pt decides when to stop)
- rooted in Freud
- less structure, no homework
- Pt leads sessions
- Transference (discuss the past & how it affects the present)
- explores unconscious thoughts & past experiences to gain insight into present thoguhts/emotions
- goal is to better understand self/health emotional wounds