✅ 🧠 Psychiatry Flashcards
Mental Status
Mental Status – Are there any cognitive or behavioral modifications you intend to use to cope? What kinds of things are important to you? Plans? Are there any important relationships you have? “Not discussed” “Typical”
COMMON COMPONENTS:
General Chunk
- General : 🤵 General appearance, grooming (“moderately”),dress (“casually”), 👁🗨 eye contact (good, fair, poor).
- Behavior: Level of cooperation (e.g. “cooperative”, superficially [hard time], uncooperative, hostile).
- Motor: Movements (Increased/decreased), agitation (increased movement), “frequent fidgeting”), Psycho Motor Agitation (PMA) / Retardation (“slowed“).
🌞
- Mood: Internal subjective experience “how are you feeling?” (i.e. How patient feels; typically in quotes) “tell me what that means to you” “depressed, anxious”
Climate
- Affect: Interviewer’s experience of patient (how they express (intonation, body language, facial expression) 😵“euphoric”, 🥰“bright”, 😊 ”full range”, “restricted range” [lower baseline / fluxuation], 🙂“blunted” (range) [>], 😐“flat” (range) [< variation], “labile”, “explosive (get punchy), “expansive”, “Mood incongruent”,“irritable”, Ambivalence? [depressed, low, euthymic]
🧠
- Thought Process: [How] Rate, organization, “disorganized”, “goal orientated”, “concrete”, abstract, “perseveration” (loop),
- Thought Content: [What] Obsessions (there or not), Delusions (e.g. paranoia, grandeur), hallucinations, Suicidal / homicidal Ideation (all-or-none), “Ideas of reference” (news just for you (messages)
- Associations: How thoughts are linked together (e.g. linear, intact, logical, 😵 “loose” = “psychotic” (doesn’t make sense), “circumstantial” (extra circumstances) [get back], tangential (associations) = “manic” [rapid] ; “flight of ideas”,
Specifics under thought process
Loop (perseveration, rumination) -> thought process
- Speech: [Mechanics] “Rate, rhythm, volume, and tone”, articulation, spontaneity, interruptible vs “pressured” (cannot interrupt, talks over). “echolia”
- Language: [Symbolic] symbolic understanding and use of words / vocabulary (expressive, receptive; “typical for age”); neologism (new words), word approximation, “Intact”
- Cognition: proverbs, serial 7s, etc (“abstract vs. concrete”), Attention
- Fund of Knowledge: Expected knowledge compared to peer group (e.g. average for age), “Aware of current events”,
- Memory: Recent, remote, working memory, “Grossly intact”
- Orientation: Person, place, time and situation (“Oriented X 4”), “fully oriented”
- Concentration: Ability to stay on task, “Intact”, “Easily distracted”
- Insight: Understanding of current state (e.g. intact, good, fair, poor, absent)
- Judgment: Ability to make decisions (good, fair, poor, impaired, very impaired)
Suicidal Ideation
Evaluate ideation
- 🌠 Wish to die, 😴 not wake up (passive)
- Thoughts of 🔪 killing self (active)
- ⏲ Frequency, duration, 📊 intensity, 🎮 controllability
Evaluate intent
- Strength of intent to attempt suicide; ability to control impulsivity
- Determine how close patient has come to acting on a plan (rehearsal, aborted attempts).
Evaluate plan
- Specific details: Method, time, place, access to means (eg, weapons, pills), preparations (eg, gathering pills, changing will)
- Lethality of method
- Likelihood of rescue
Active suicidality is associated with intent AND plan for self-harm.
SAD PERSONS
- Sex (Male)
- Age (elderly)
- Depression
- 💪🏾 Previous suicide attempt, Self-injorious behaviors (SIB) Psychiatric disorder
- EtOH (Substance abuse, impulsivity)
- Rational thought loss (psychosis)
- Social Support lacking
- Organized Plan
- No spouse or SO, Non-suicidal self injury
- Sickness or Injury
Anxiety, hopelessness, and disturbed sleep patterns, and 👨👩👦👦 family history / discord, access to firearms, are additional clinical risk factors.
Protective factors:
- Social support/family connectedness
- Pregnancy
- Parenthood
- Religion & participation in religious activities
🔫 Homicide risk factors
- Young male (15-24)
- Unemployed
- Impoverished (low socieoeceonomic)
- 💪🏾 Access to firearms
- Substance abuse
- Antisocial personality disorder
- History of violence or criminality
- History of childhood abuse
- Impulsivity
- overt stressor
Tx:
High imminent risk (Ideation, intent, and plan)
- Ensure safety: Hospitalize immediately
- Remove personal belongings and objects that may present self harm risk
- Constant observation and security may be required
High non-imminent risk (Ideation, intent, but no plan)
- Ensure close f/u
- Treat modificable risk factors (underlying depression, psychosis, substance abuse, pain)
- Recruit family or friends for support
- Reduce access to potential means
- Safety plan (concrete, behavioral modifications, coping strageties)
- Normalization
👨🏾⚕️ Psychotherapy
Brief individual insight-oriented psychotherapy is characterized by a limited, predetermined number of sessions and the fact that the focus of the treatment remains on specific problematic areas in the life of the patient.
Psychoanalytic psychotherapy (months)
Interpretations are the cornerstone and are explanatory statements made by the analyst that link a symptom, a behavior, or a feeling to its unconscious meaning. Ideally, interpretations help the patient become more aware of unconscious material that has come close to the surface. Confrontation and clarification are also used in psychoanalytic psychotherapy. In confrontation, the analyst points out to the patient something that the patient is trying to avoid. Clarification refers to putting together the information the patient has provided so far and reflecting it back to him or her
in a more organized and succinct form.
Psychodynamic psychotherapy (years) traces problems back to their origins in childhood, daily life, replicative and unconscious conflict, may provide the patient with insight; emphasizes the role of unconscious mental processes in producing symptoms with the goal of developing insight.
- Higher functioning
- Personality disorders
- Builds insight into unconscious conflicts & past relationships
- Uses transference
- Breaks down maladaptive defenses
- Strongly motivated patient who can tolerate a great deal of frustration and
has a good capacity for insight.
Psychodynamic group therapy
Cognitive-behavioral therapy (CBT) is an evidence-based, standardized modality of psychotherapy that targets persistent maladaptive thought patterns and behaviors.
- Depression
- Generalized anxiety disorder
- PTSD
- Panic disorder
- OCD
- Eating disorders
- Negative thought patterns
- Combines cognitive & behavioral therapy
- Challenges maladaptive cognitions
- Targets avoidance with behavioral techniques (relaxation, exposure, behavior modification)
- Used as monotherapy or in combination with medication.
- Combines cognitive approaches and social skills training.
Treatment is generally time limited (approximately 5-20 sessions) and structured, and involves homework. Therapists work with patients to identify and change cognitive distortions, such as overgeneralization (eg, believes nothing ever works out) and catastrophizing (eg, assumes the worst outcome). Behavioral techniques such as graded exposure target the avoidance behaviors that stem from these distortions.
Cognitive-behavioral therapy based on exposure and response prevention (ERP) and/or ERP therapy involves repeated exposure to thoughts, images, and situations that provoke obsessional fears followed by prevention of the accompanying compulsion.
Supportive psychotherapy is a broadly applicable approach that helps to reduce stress, improve coping skills, and maintain hope. Duration evidence lacking?
- No interpretations; concrete suggestions
- Used to reinforce a patient’s ability to cope with stressors and is commonly used for low-functioning patients or those in crisis who are at risk of decompensation.
- Lower functioning; psychotic disorders
- Patients in crisis
- Maintains hope; provides encouragement
- Reinforces coping skills, adaptive defenses
- Normalization, Validation, problem solving, psychoeducation.
- Behavioral Chain Analysis (RCA)
Dialectical behavioral therapy was developed for borderline personality disorder that integrates standard cognitive-behavioral therapy techniques with principles of mindfulness, distress tolerance, and emotion regulation.
- Borderline personality disorder
- Improves emotion regulation, distress tolerance, mindfulness
- Decreases self harm; builds skills
Interpersonal psychotherapy is an evidence-based therapy primarily used for depression that focuses on the interplay between depressive symptoms and interpersonal stressors.
- Depression
- Links symptoms to current relationship conflicts & interpersonal skill deficits
Motivational interviewing is commonly used to treat substance abuse and involves the therapist assuming a nonjudgmental stance, acknowledging ambivalence, focusing on the patient’s motivation for change, and tolerating resistance to change.
- Substance use disorders
- Nonjudgmental; acknowledges ambivalence & resistance
- Enhances intrinsic motivation to change
Behavioral therapy focuses on decreasing or ameliorating people’s maladaptive behavior without theorizing about their inner conflicts. Behaviorists look for observable factors that have been learned or conditioned and can therefore be unlearned.
Biofeedback involves using signals from the body (ie, heart rate, muscle tension, skin temperature, blood pressure) as indicators of emotional distress. Patients are taught to identify and control their responses to various stimuli.
- Prominent physical symptoms; pain disorders
- Improves control over physiological reactions to emotional stressors
Eye movement desensitization and reprocessing (EMDR) Based on the concentration necessary to watch the therapist’s laterally moving finger helps create a state of deep relaxation, during which traumatic events can be worked through.
Eclectic/Integrated therapy
- History of sexual abuse and the long-standing history of these symptoms
👩👩👧👦 Family therapy (psycho-dynamic, solution-oriented, narrative, systemic, strategic, structural, and transgenerational, to name only a few). Each school focuses on a particular aspect of the family dynamics and uses different techniques to obtain the desired results. For example, the structural school focuses on patterns of engagement-enmeshment and on
family boundaries and hierarchies. The solution-oriented approach focuses on solutions and minimizes the importance of problems.
Acute Psychosis
Grossly 🔀 disorganized speech and behavior, probable hallucinations 😵.
The acute onset of psychosis in a child or adolescent is rare, and it is essential to rule out medical or substance-induced conditions that are potentially reversible:
CNS Injury
- Trauma
- Space-occupying lesion
- Infection
- Stroke
- Epilepsy
- Cerebral hypoxia
Metabolic Electrolyte disturbances
- Urea cycle disorders
- Acute Intermittent porphyria
- Wilson Disease
- Kidney/liver failure
- Hypoglycemia
- Sodium/Calcium/Magnesium disturbance
Systemic Disorders
- SLE
- Tyroiditis
Illicit Substance
- 🍄 Hallucinogens
- Marijuana
- Sympathomimetics
- Alcohol Withdrawl
- Bath Salts
Medications
- Intoxication
- Anticholinerics: Many over-the-counter cold preparations 🤧 contain antihistamines (eg, diphenhydramine, doxylamine) that decrease nasal discharge but also have anticholinergic properties that can cause confusion and hallucinations.
- Serotonin Syndrome 🙂
- Amoxicillin/erythromycin/clairitromycin
- Anticonvulsants
- Corticosteroids: High-dose 🌑 glucocorticoids, often given for allergic, inflammatory, or autoimmune conditions, may cause glucocorticoid-induced psychosis.
- Isoniazid
- Alpha-adrenergic agents 🕯 (eg, phenylephrine, pseudoephedrine) constrict blood vessels, decreasing nasal congestion, but can result in agitation and psychosis via their sympathomimetic properties.
Withdrawl
- Baclofen
- Benzodiazepines
Dx: Basic medical workup for new-onset psychosis commonly includes a complete physical and mental status examination, metabolic panel, complete blood count, and urine toxicology screen; it may also include a screen for syphilis, HIV, vitamin B12 levels, thyroid function tests, and antinuclear antibody imaging and neuroimaging depending on specific findings and risk factors.
Tx:
1st generation antipsychotics: High-potency (😇 haloperidol and 🌟fluphenazine, being low in anticholinergic side effects and less likely to cause postural hypotension, are preferred to low-potency medications such as 🎨 chlorpromazine in elderly patients with cardiovascular problems and prostatic hypertrophy.
Second-generation antipsychotics (🙂 serotonin- dopamine antagonists) are often chosen [first-line] due to their lower risk of extrapyramidal side effects and tardive dyskinesia compared with first-generation antipsychotics.
All are associated with 🍭 metabolic adverse effects:
- Weight gain
- Dyslipidemia
- Hyperglycemia (including new-onset diabetes)
✔ Ziprasidone (Geodon) has a low metabolic risk profile; QT 📈 prolonging
Highest-risk drugs (avoid in T2DM)
- ❗ Clozapine
- ❗ Olanzapine (Zyprexa) 🥈
- Quetiatpine
Monitoring guidelines
- Baseline & regular follow-up
- BMI
- Fasting glucose & lipids
- Blood pressure
- Waist circumference
q3 months, and then annually. Earlier and more frequent monitoring is recommended for patients with diabetes or those who have gained >5% of initial weight.
Quetiapine (Seroquel) low-potency antipsychotic with minimal dopamine-2 receptor antagonism.
🚪 Clozapine (Clozaril) is a second-generation antipsychotic used in 💪🏾 treatment-resistant schizophrenia [🥇gold standard] and schizoaffective disorder (ie, patients who have failed ≥2 antipsychotic trials). Minimal dopamine-2 receptor antagonism. It is associated with risk of neutropenia. Life-threatening agranulocytosis (ie, complete absence of neutrophils) has been reported in approximately 1% of patients treated, but this rate has been reduced with regular blood monitoring. Patients must participate in a computer-based registry that requires regular monitoring of the absolute neutrophil counts (ANCs) before dispensing of the drug.
Other adverse effects of clozapine include weight gain, metabolic syndrome, seizures, 💩 ileus, myocarditis, hypotension and ☕ 🃏 anticholinergic effects. Compared to other antipsychotics, clozapine is the least likely to cause extrapyramidal symptoms and has not been shown to cause tardive dyskinesia. Clozapine is also indicated in schizophrenic 😵 and schizoaffective patients with recurrent 🔪 suicidality. 🚬 smoking 1A2, 2D6, 3A4 receptor and SIP enzyme. The occurrence of seizures during clozapine treatment is dose related and increases considerably with dosages greater than 400 mg/day. 💈Phenobarbital is considered the safest and the best-tolerated anticonvulsant for patients taking clozapine who experience seizures.
Risperidone (Risperdal) is a commonly used second-generation antipsychotic (SGA) that has mixed serotonin-dopamine antagonist activity with binding at both serotonin 2A and dopamine D2 receptors. [known for 💪🏾stronger dopamine receptor antagonism relative to other second-generation antipsychotics.] The addition of serotonin antagonism to dopamine antagonism is believed to contribute to the comparatively decreased risk of extrapyramidal side effects when compared with first-generation antipsychotics that primarily block D2 receptors. 🍼 Breast formation.
💉 Long-acting injectable (LAI) (depot) antipsychotics are administered intramuscularly every 2-4 weeks, eliminating the need to take oral medication daily. Both first-generation (haloperidol, trifluoperazine [“An angel with a halo will tri to fly”] fluphenazine, perphenazine, chlorpromazine) and second-generation (risperidone, paliperidone (INVEGA) SUSTENNA®]{234 mg on day one followed by another deltoid injection of 156 mg one week later; maintenance dose of 117 mg is begun four weeks after the second injection; Initiation of paliperidone 12-week-LAI may occur only after a patient has been established on monthly paliperidone-LAI for a period of at least four months,}, olanzapine, aripiprazole) antipsychotics are available in LAI formulations.
Patients with unstable illnesses who live alone and have poor social support systems, poor insight, and frequent medication nonadherence are good candidates for LAI antipsychotics. These medications can be administered on an outpatient basis with the support of assertive community treatment programs (eg, clinician can administer the drug in the patient’s home, or facilitate the patient’s adherence to scheduled medication appointments).
🧠 Pathways
The tuberoinfundibular dopamine pathway projects from the hypothalamus to the pituitary gland. Normally, neurons in the tuberoinfundibular pathway secrete dopamine, which inhibits prolactin release from the anterior pituitary gland. Most antipsychotics act as dopamine antagonists, 👇🏾 decreasing activity in this pathway by preventing dopamine from binding to D2 receptors. When dopamine is blocked in the tuberoinfundibular pathway, the production of 🍼 prolactin increases, which can result in galactorrhea, gynecomastia, menstrual irregularities, infertility, and sexual dysfunction.
The antipsychotics with the highest potential for increasing prolactin are high-potency, first-generation medications (eg, ❗ haloperidol, ❗ fluphenazine) and the second-generation agents ❗ risperidone and ❗ paliperidone (a metabolite of risperidone).
Among second-generation antipsychotics, ✔ aripiprazole (a partial D2R agonist) and ✔ quetiapine (a low-potency D2R antagonist) are two of the least likely drugs to produce hyperprolactinemia
The mesolimbic pathway extends from the ventral tegmental area to the limbic system. Decreased dopamine activity in this pathway accounts for the therapeutic effects of antipsychotics. Increased dopamine activity in the mesolimbic pathway accounts for the euphoria that accompanies drug use, as well as the delusions and hallucinations experienced in schizophrenia.
Cx:
Medications that block the dopamine (D2) receptor may cause 🔺 extrapyramidal symptoms (EPS). The most common offending agents include first-generation antipsychotics (eg, haloperidol), second-generation antipsychotics (eg, risperidone) to varying degrees, and antiemetics (eg, metoclopramide). The onset of extrapyramidal symptoms in antipsychotic toxicity occurs in the following timeframes (mnemonic: ADAPT):
Hours to days: Acute dystonia: Sudden, sustained contraction of the 👨🏽neck, mouth, tongue & eye muscles; torticollis
Tx: 🚗 Benztropine (anticholinergic), 🐝 Diphenhydramine
Days to months: 💺 Akathisia: Subjective restlessness, inability to sit still; moving doesn’t help (vs RLS)
Tx: 🎺 Beta blocker (propranolol), Benzodiazepine (lorazepam), 🚗 Benztropine
Secondary Parkinsonism: Gradual-onset tremor, rigidity, bradykinesia
Tx: 🚗 Benztropine, 🐟 Amantadine (a dopaminergic medication, and a weak N-methyl-D-aspartate receptor antagonist)
Months to years: Tardive dyskinesia: Gradual onset after prolonged therapy (> 6️⃣ months): Dyskinesia of the 👄 mouth 🐇 (rabbit syndrome), face (orofacial), trunk & extremities [typically occurs after prolonged (>6 months)], Limb dyskinesia (dystonic postures, foot tapping, chorea), trunk dyskinesias (rocking, thrusting, shoulder shrugging). The pathophysiology of TD is thought to involve dopamine D2 receptor UPREGULATION and supersensitivity resulting from chronic blockade of dopamine receptors. Other hypotheses include an imbalance between dopamine D1 receptor and dopamine D2 receptor effects in the basal ganglia as well as excitotoxic destruction of GABA neurons in the striatum. Typical antipsychotic medications (such as perphenazine) and, in particular, high-potency drugs carry the highest risk of TD. Atypical antipsychotics are thought to be less likely to cause this disorder.
Tx:
- Valbenazine or deutetrabenazine, reversible inhibitors of the vesicular monoamine transporter 2 (VMAT2) recently approved by the FDA for use in TD.
- Switching (cross-tapering) to an antipsychotic with a lower tendency to cause TD, such as quetiapine or 🚪 clozapine.
Neuroleptic malignant syndrome (NMS) is a rare, idiosyncratic, and potentially life-threatening complication of treatment with antipsychotics. Although it is more commonly associated with the use of high-potency, first-generation antipsychotics (eg, haloperidol), NMS can occur with every class of antipsychotics, including second-generation drugs (eg, olanzapine). It may occur at any time but usually develops within the first 2 weeks of treatment. Hx: The cardinal features of NMS include severe hyperthermia, autonomic instability, muscular (lead-pipe) rigidity, and altered sensorium. Laboratory findings include elevated creatine phosphokinase level and white blood cell count. Rhabdomyolysis, followed by myoglobinuria that can cause acute renal failure, is a known complication. Dx: Creatine kinase level and white blood cell count may be elevated. Tx: Treatment of NMS includes prompt ❌ discontinuation of the offending agent (the antipsychotic) followed by supportive care (ie, aggressive cooling, antipyretics, fluid and electrolyte repletion). Dopaminergic agents that can reverse dopamine blockade, such as 🧹bromocriptine or 🐟 amantadine, can be considered in patients who do not respond to supportive care and withdrawal of medication. Dantrolene, a direct-acting muscle relaxant, has also been used.
Fu: Patients that have remained symptom free on her medication for over 3 years should be discontinued from antipsychotic medication. In addition, it is recommended that the patient and family be encouraged to develop early intervention strategies prior to medication discontinuation, should a relapse occur.
Neuroleptic malignant syndrome (NMS)
A rare but potentially lethal adverse reaction to antipsychotic medications. Both first-generation (eg, haloperidol) and second-generation antipsychotics can cause NMS. It may occur at any time but usually develops within the first 2 weeks of treatment.
The cardinal features of NMS include severe hyperthermia, autonomic instability, muscular (lead-pipe) rigidity, and altered sensorium. Laboratory findings include elevated creatine phosphokinase level and white blood cell count. Rhabdomyolysis, followed by myoglobinuria that can cause acute renal failure, is a known complication.
Treatment of NMS includes prompt discontinuation of the offending agent (the antipsychotic) followed by supportive care (ie, aggressive cooling, antipyretics, fluid and electrolyte repletion). Dopaminergic agents that can reverse dopamine blockade, such as bromocriptine or amantadine, can be considered in patients who do not respond to supportive care and withdrawal of medication. Dantrolene, a direct-acting muscle relaxant, has also been used.
Delirium
is characterized by the acute onset of mental status changes that wax and wane. It may present as impaired awareness, easy distraction, confusion, and/or disturbances of perception such as: illusions, misinterpretations, and visual hallucinations. Recent memory is usually impaired, and speech may be rambling, perseverating, nonsensical, pressured, or incoherent. Patients may also be agitated or obtunded. Keep in mind that one of the most important features of delirium is that it is reversible. Patients’ degree of awareness of their condition may fluctuate with time.
Delirium is characterized by:
Rapid decrease in attention span and level of arousal
Disorganized thinking, cognitive dysfunction
Hallucinations, illusions, misperceptions
Disturbance in sleep-wake cycle
Several causes of delirium include (AEIOU TIPS):
Alcohol
Electrolytes or metabolic disturbances
Iatrogenic (anticholinergics, anticonvulsants, antihypertensives, anti-Parkinson drugs, antibiotics, benzodiazepines, disulfiram, H2receptor blockers, hypoglycemics, insulin, narcotics, NSAIDs, steroids)
Oxygen hypoxia (bleeding, pulmonary disease, carbon monoxide poisoning)
Uremia and/or Urinary/fecal retention
Trauma
Infection
Poisons
Substance abuse/withdrawal
Physical examination or laboratory studies usually reveal some organic cause for the delirium. Common causes of delirium include intoxication, occult infection, head trauma, seizure, mania, thyrotoxicosis, renal failure, hepatic failure, neoplasm, stroke, and shock. When delirium is diagnosed, the underlying causes should be sought and treated. Components of delirium management include supportive therapy and pharmacologic management with short-acting neuroleptics (risperidone, haloperidol).
The treatment of delirium consists of the following:
Identify underlying cause
Oxygen, hydration, pain control
Haloperidol (with agitation)
Benzodiazepines (for alcohol withdrawal)
Major depressive Disorder MDD
“recurrent”, “single episode”; mild, moderate, severe
Dx: Depressed mood must be present most of the day, almost every day for > 2️⃣ weeks:
≥ 5 of 9 symptoms: Depressed mood + SIGECAPS
💤 Sleep changes: increase during day or decreased sleep at night.
Interest (loss): of interest in activities that used to interest them
Guilt (worthlessness): depressed persons may devalue themselves
Energy (lack): common presenting symptom (fatigue)
Cognition/Concentration: reduced cognition and/or difficulty concentrating
🍗 Appetite (weight loss); usually declined, occasionally increased
Psychomotor: agitation (anxiety) or lethargic
🔪 Suicide/preoccupation with death
Hopelessness is one of the most accurate indicators of long-term suicidal risk.
No lifetime history of mania
👶🏾
Pediatric depression often presents with symptoms of irritability rather than depressed mood. Treatment is warranted if they have resulted in a marked change from baseline as well as significant academic and social impairment. Depressed preschoolers tend to be irritable, aggressive, withdrawn, or clingy instead of sad.
Psychotic symptoms are common in depressed children, most commonly one voice that makes depreciative comments and mood-congruent delusional ideations. Up to one-third of children diagnosed with major depression receive a diagnosis of bipolar disorder later in life.
School-age children may experience a significant loss of interest in friends and school.
Adolescents present more similar to adults.
Older adults with depression initially present to primary care providers and focus more on somatic complaints than on subjective changes in mood and interest.
Tx:
Major depressive disorder is a highly recurrent illness for most patients.
Continuation phase = 6️⃣ months following remission
Due to the high risk of recurrence, patients with ≥2 episodes are candidates for Maintenance antidepressant treatment Other indications for maintenance therapy (due to high risk of recurrence) include early age of onset (≤18), persistent residual depressive symptoms, and comorbid psychiatric disorders. Maintenance therapy can be continued for 1-3 years.
However, patients with a history of highly recurrent illness (eg, ≥3 lifetime depressive episodes), chronic episodes (≥2 years), severe ongoing psychosocial stressors, or severe episodes (eg, suicide attempts) are candidates for maintaining antidepressant treatment indefinitely.
Doses of antidepressants should generally be raised to their maximal doses and kept there for 4 to 5 (6️⃣)weeks before a drug trial is considered unsuccessful. Patients with minimal to no improvement with initial antidepressant treatment can be switched to another antidepressant.
Patients with anxiety disorders are especially sensitive to activating effects of antidepressants. They should generally be started at lower doses than are typically used to treat depression (eg, half the normal starting dose) with a gradual increase to a therapeutic level over several weeks.
Rx:
Selective serotonin reuptake inhibitors (SSRIs) are frequently used as first-line treatment for depressive and anxiety disorders due to their efficacy, tolerability, and general safety in overdose. Common early side effects of SSRIs include nausea, diarrhea, headache, increased anxiety, and insomnia or somnolence. These effects most commonly occur shortly after initiation and diminish or resolve over time for most patients. Sexual dysfunction (retarded ejaculation?) is the most common long-term side effect and is more likely to be persistent.
Selective serotonin reuptake inhibitors (SSRIs) are used as first-line treatments after an acute MI because they are generally well tolerated and less likely to cause adverse cardiac effects compared with other classes of antidepressants. Among the SSRIs, 💗 sertraline (Zoloft) and escitalopram (Lexapro) are preferred because they carry a very low risk of drug interactions, especially with cardiac medications.
🏙 Citalopram is generally avoided in patients with a recent MI due to its potential for dose-dependent QT prolongation
🦜 Paroxetine has a potential for anticholinergic effects, drug-drug interactions through inhibition of cytochrome P-450 enzymes, and weight gain.
✈ Fluoxetine (Prozac) is considered the medication of choice for 👶🏾 pediatric depression; has the least potential to cause ❌ weight gain.
🚲 Tricyclic antidepressants such as amitriptyline can slow cardiac conduction by inhibition of fast sodium channels. Amitriptyline is associated with a great tendency to gain weight.
🍷 Phenelzine is a monoamine oxidase inhibitor (MAOI) that is not used as a first-line antidepressant due to its unfavorable side effect profile and required dietary restrictions. At therapeutic doses, MAOIs commonly cause hypotension, not hypertension. Hypertensive crisis refers to severe hypertension that can occur after patients on MAOIs ingest foods containing the sympathomimetic tyramine. Tyramine metabolism is inhibited in the presence of MAOIs, causing an increased sympathomimetic (ie, adrenergic) effect that can result in severe hypertension. This commonly presents first as a headache but can lead to intracranial bleeding, stroke, and death. Foods to be avoided by patients on MAOIs include tyramine-rich foods such as aged cheese, salami, 🍕pepperoni, sausage, overripe fruit, liquors, red wine, pickled fish, sauerkraut, and brewer’s yeast. Chocolate, coffee, tea, beer, and white wine can be consumed in small quantities.
🎺 Trazodone, a serotonin-modulating antidepressant, is extremely sedating. It is used primarily at low dose for sleep induction rather than for its antidepressant effects. Its orthostatic effects are problematic in the elderly. [vilazodone]
📠 Venlafaxine (Effexor); Duloxetine (Cymbalta) a serotonin-norepinephrine reuptake inhibitor, is associated with tachycardia and has been associated with dose-dependent hypertension. At lower doses, venlafaxine primarily inhibits the reuptake of serotonin. As the dose is increased, the drug also inhibits norepinephrine reuptake with the potential effect of increasing systolic and diastolic blood pressure. The hypertensive effect is dose dependent and is especially significant at doses above 300 mg daily, where the incidence may be >10%.
🤡 Mirtazapine (Remeron) is a first-line antidepressant medication whose side effects include stimulation of appetite, weight gain, and somnolence.
⚡ Electroconvulsive therapy is generally indicated for patients with very severe depressive symptoms (eg, persistent suicidality, malnutrition/dehydration), major depression with psychotic features, or failure to respond to multiple medication trials. ECT is a safe procedure with very few contraindications (recent myocardial infarcts, increased intracranial pressure, aneurysms, bleeding disorders, and any condition that disrupts the blood-brain barrier). Unilateral electrode placement is less efficacious than bilateral electrode placement but is associated with less cognitive side effects, including short-term memory impairment and confusion.
🏀 Bupoprion (Wellbutrin, Zyban): Side effects most common include headache, insomnia, dry mouth, tremor, and nausea. Severe anxiety and panic disorder can be worsened by bupropion. Can worsen psychosis and delirium due to dopaminergic activity. Have seen severe psychosis with use of bupropion in pregnancy. Seizure risk is 2% with 600 mg and 0.1% with 300-450 mg .
🚩 Half-lives
Fluvoxamine: 15.6 hours
🦜 Paroxetine: 21 hours
Escitalopram: 27-32 hours
Citalopram: 35 hours
✈ Fluoxetine: 4-6 days (9.3 days for active metabolite)
Cx:
Antidepressant discontinuation syndrome Sudden onset of dysphoria, fatigue, insomnia, and myalgias. Other physical symptoms may include dizziness, flu-like and gastrointestinal symptoms, tremor, and neurosensory disturbances (eg, ⚡ “electric shock” and “rushing” sensations in the head, paresthesias, hyper-responsivity to light and noise, vivid dreams). Symptoms typically begin within 2-4 days of the medication being abruptly stopped or rapidly tapered. Serotonergic antidepressants with a shorter elimination half-life (eg, 🦜 paroxetine, venlafaxine), higher doses, and longer duration of treatment are associated with more severe discontinuation symptoms.
Tx: The best approach to manage discontinuation syndrome is to re-institute the same antidepressant and taper the dose gradually over 2-4 weeks (or longer in severe cases).
In 2007 the US Food and Drug Administration extended its warning that all patients age <25 should be informed about the small risk of becoming suicidal during initial antidepressant treatment. The warning was based on studies showing a slightly increased risk of suicidal thoughts and behaviors (not completed suicide) among a small group of child and adolescent patients treated with antidepressants compared with placebo.
😠Serotonin syndrome is characterized by hyperthermia 🔥(although fevers are not as high as in NMS), autonomic instability, mental status changes, prominent gastrointestinal symptoms, and neuromuscular irritability (including hyperreflexia and myoclonus).
Antidepressant-induced mania: All antidepressants carry the risk of inducing mania in susceptible patients, and many patients who experience this are ultimately diagnosed with a bipolar spectrum disorder. If manic symptoms persist despite discontinuing the antidepressant, treatment with a mood stabilizer (eg, lithium, valproate) or an antipsychotic should be considered.
🧠 Hyperactivity of the hypothalamic-pituitary-adrenal axis, resulting in increased 🌑cortisol levels, has been associated with depression. The neurocytotoxic effects of hypercortisolemia may play an important role in the pathogenesis of depressive symptoms and associated cognitive deficits. These effects may also explain the association of stress and 🚑 trauma with an increased risk for the development of depression.
Positron emission tomography (PET) scan has consistently demonstrated a decrease in blood flow and metabolism in the frontal lobe of depressed patients.
Other findings in depressed patients include decreased hippocampal and frontal lobe volumes
💤 Sleep architecture: REM sleep latency (the time from sleep onset until the start of the first REM sleep period) and slow-wave sleep are both decreased in depression Patients with major depressive disorder have increased REM sleep (duration) ???
MDD w/ psychotic features
In this severe subtype of unipolar major depression, the depressive episode is accompanied by delusions and/or hallucinations, typically with depressive themes (eg, deserving punishment, worthlessness, nihilism).
The diagnosis is differentiated from psychotic disorders in that the psychotic symptoms are present only during the episode of major depression. Identification of psychotic features has important implications as effective treatment of major depressive disorder with psychotic features requires the combination of an antidepressant and antipsychotic or electroconvulsive therapy.
Tx: 🥇 First-line treatment of major depressive disorder with psychotic features is combination pharmacotherapy with an 😢 antidepressant AND 😵 antipsychotic (sertraline and risperidone) or ⚡ electroconvulsive therapy (ECT). Because ECT is generally faster than pharmacotherapy, it is used to achieve a rapid response in depressed elderly patients who are unable to eat and drink, psychotic, or actively suicidal. ECT involves inducing a 30- to 60-second generalized tonic-clonic seizure. Hemodynamic changes are brief and cardiac complications are rare. Methohexital (barbiturate) is commonly used for anesthesia prior to ECT.
Persistent depressive disorder (Dysthymia)
Can be thought of as a chronic, low-grade depression that lasts for years.
Clinical Features:
- Persistent depressive symptoms for > 2️⃣ years (1 year in adolescents)
- No symptom-free period for for > 2 months 📆📆 at a time.
- Presence of 2 of the following:
- Poor appetite or overeating
- insomnia / hypersomnia
- Low energy or fatigue
- Low self-esteem
- Poor concentration or difficulty making decisions
- Feelings of hopelessness
Specifiers
“Pure dysthymic syndrome”: criteria for major depressive episode never met
Dysthymia with “intermittent” major depressive episodes
Dysthymia with “persistent” major depressive episodes: criteria for major depressive episode met throughout previous 2 years
Tx: Antidepressants, psychotherapy, or a combination of these.
Acute stress disorder
Acute stress disorder is characterized by symptoms of reexperiencing (intrusive memories and flashbacks), avoidance, negative mood, dissociation, and hyperarousal lasting from 3 days to 1 month 📆 following a traumatic event.
Can follow trauma related to threatened death, serious injury, or sexual violation. Symptoms of acute stress disorder can be broken down into 5 categories which include intrusive thoughts, negative mood, dissociation, avoidance, and arousal.
Patients with ASD may have difficulty recalling part or all of a specific traumatic event; this does not require a comorbid diagnosis of dissociative amnesia unless the amnesia extends beyond the immediate time of the trauma.
Although ASD will remit in some individuals without intervention, others can benefit from treatment designed to alleviate symptoms and prevent development of post-traumatic stress disorder (diagnosed when symptoms persist for ≥4 weeks). The best initial approach is to provide education on symptoms and the course of acute and post-traumatic stress disorders, as well as to encourage the patient to seek help if the symptoms persist. Normalizing the stress response, while explaining that symptoms can sometimes cause distress and impairment, would be helpful.
Adjustment disorder
An adjustment disorder involves emotional or behavioral symptoms (eg, anxiety, depression, disturbance of conduct) developing within 3 months of an identifiable stressor and lasting no longer than 6 months once the stressor ceases.
- Depressive symptoms develop within 3️⃣ months of the onset of an identifiable stressor.
- Marked distress out of proportion to the stressor and/or impaired social or occupational functioning.
- ❗ Does not meet criteria for another DSM-5 disorder
❓ What is ther worst thing that has ever happened to you ❓
The treatment of choice for adjustment disorder is psychotherapy, which focuses on developing coping mechanisms and improving the individual’s response to and attitude about the stressful situation.
Atypical depression
Another variant of major depressive disorder, is characterized by mood reactivity ⛅ (ie, feeling better in response to positive events), self-pity, excessive sensitivity to rejection, reversed diurnal mood fluctuations (patients feel better in the 🕗 morning), and reversed vegetative symptoms (🍗 increased appetite and 💤 increased sleep), leaden paralysis (patient’s arms and legs feel extremely heavy). Approximately 15% of patients with depression have atypical features.
Tx: 🐁 MAOIs are considered to be more effective than other classes of antidepressants in atypical depression.
Bereavement
(1) guilt about things other than actions taken or not taken by the survivor at the time of the loved one’s death, (2) thoughts of death other than the survivor feeling he/she would be better off dead without the loved one, (3) a morbid preoccupation with worthlessness, (4) marked psychomotor retardation, (5) marked and prolonged functional impairment, and (6) hallucinations other than the survivor believing he/she can hear the voice or see the loved one.
Dysthymia
Characterized by an irritable or depressed mood for at least 1 year
(In adults, the time requirement for the diagnosis would be 2 years)
Venlafaxine and bupropion are generally believed to be the treatments of choice, though there is a subgroup of patients that will respond to the MAOIs as well.
Double depression is diagnosed when a major depressive episode develops in a patient with dysthymic disorder.
Melancholic depression
A variant of major depressive disorder, is characterized by loss of pleasure in all activities (anhedonia), lack of reactivity (nothing can make the patient feel better), intense guilt, significant weight loss, ⏰ early morning awakening, and marked psychomotor retardation. TCAs have been considered to be more effective than other antidepressants in the treatment of melancholic depression.
Postpartum blues
Frequent, with a prevalence estimated between 20% and 40%. Symptoms include tearfulness, irritability, anxiety, and mood lability. Symptoms usually emerge during the first 2 to 4 days after birth, peak between days 5 and 7, and resolve by the end of the second week postpartum.
t is a normal and self-limited response that typically peaks at 5 days postpartum and resolves within 2 weeks.
Anhedonia is NOT seen in postpartum blues.
Tx: Resolves spontaneously, and usually the only interventions necessary are support and reassurance.
Normal stress response
Symptoms are mild rather than excessive given the nature of the stressor; does not meet the full criteria for any disorder; not markedly distressed. Most importantly no impairment of social and occupational functioning, a key feature of psychiatric illness.
- Not excessive or out of proportion to severity of stressor
- No significant functional impairment
Patient continues to function well (eg, still performs at work, enjoys socializing and leisure activities).
Substance-induced depressive disorder
A substance (eg, drug of abuse, medication, toxin) is judged to be etiologically related to the mood disturbance (eg, depressed mood that occurs only during cocaine withdrawal would be diagnosed as cocaine-induced depressive disorder).
Seasonal affective disorder (SAD)
A depressive disorder that is associated with seasonal changes and is worse during winter months.
Patients usually exhibit typical signs and symptoms seasonally, most often during the winter, with symptoms remitting in the spring. 🛌🏾 Hypersomnia and 🍗 hyperphagia (atypical signs of a depression) are classically seen.
Tx: Bright light therapy is typically administered with a 10,000-lux light box shortly after awakening. Most patients experience clinical improvement in 1-4 weeks and continue treatment through the fall or winter until spontaneous remission in the spring or summer. Light therapy alone is a reasonable alternative for patients with mild to moderate SAD.
Normal Grief
Clinical features:
- Normal reaction to loss (bereavement)
- Sadness more specific to thoughts of the deceased
- “Waves” of grief at reminders
- Worthlessness & self-loathing; guilt less common
- Functional decline less severe
- Thoughts of dying involve wish to join the deceased; active suicidality uncommon
Normal grief can last up to 1 year (although DSM IV and especially DSM V seem to be shortening the “allowable” time for grieving and encouraging consideration of a diagnosis of 😢depression after 2 months, or in DSM V, 2 weeks in some patients with additional symptoms of depression). Grief should not be medicated
Persistent complex bereavement disorder (also known as complicated grief, prolonged grief, or complex grief).
>12 months 📅 after the loss
Difficulty accepting the death, persistent yearning for the deceased, and avoidance of reminders of the deceased.
The estimated incidence of complicated grief in bereaved individuals is 7%, with increased risk associated with unexpected or violent death of a loved one and death of a spouse or child. Difficulty envisioning a meaningful life without the deceased, suicidal ideation or wish to join the deceased, and guilty ruminations about the circumstances of the death are also common.
If left untreated, persistent complex bereavement disorder can continue for years or decades after the loss and result in poor quality of life, increased substance use, and increased mortality due to medical conditions or suicide.
Tx: Psychotherapy specifically geared to helping the patient come to terms with the loss and re-engage in a meaningful life without the deceased.
BIPOLAR
“current episode”, “most recent episode”; manic, depressed, mixed
Acute mania:
Clinical features
- Elevated, irritable, labile mood, Distractability, Impulsivity
- Increased energy & Activity (increased goal-directed activity / psychomotor agitation), decreased need for Sleep
- Talkativeness / Pressured speech, racing thoughts (Flight of Ideas), distractibility
- Grandiosity, Impulsivity (high-risk behavior [spending, sexual])
- Marked impairment, may have 😵 psychotic symptoms
- 1️⃣ week unless hospitalized
- Marked impariement in social or occupational functioning or hospitilization necessary.
Management
- Antipsychotics (first- & second-generation)
- Lithium (avoid in renal disease)
- Valproate (avoid in liver disease)
- Combinations in severe mania (eg, antipsychotic plus lithium or valproate)
- Adjunctive benzodiazepines for insomnia, agitation
Brief auditory hallucinations are likely related to the manic phase. In fact, auditory hallucinations are seen in a variety of psychiatric disorders. It has been estimated that around 75% of patients with schizophrenia experience auditory hallucinations. These hallucinations are also relatively common in bipolar disorder (20% to 50%), major depressive disorder with psychotic features (10%), and in posttraumatic stress disorder (40%).
Hypomania is differentiated from mania by a lesser degree of severity and functional impairment and the absence of psychosis. Patients experiencing hypomania exhibit a noticeable change in behavior but are often very productive despite requiring less sleep. Hypomanic patients are often able to work and are rarely hospitalized.
≥ 4️⃣ days (consecutive)
- Unequivocal, observable change in functioning from patient’s baseline
- Symptoms not severe enough to cause marked impairment or necessitate hospitalization
- No psychotic features
Bipolar I disorder is diagnosed in patients who experience 1 or more lifetime manic episodes (irritable mood, hyperactivity, pressured speech, decreased need for sleep, and grandiose delusions). Major depressive episodes are common but ⛔ NOT required for diagnosis.Delusions, if present, are often mood congruent and have manic themes (eg, grandiose themes involving special talent and powers).
Tx: It is a lifelong illness that requires maintenance pharmacotherapy to reduce the risk of recurrent mood episodes. Most patients require maintenance for many years, and lifelong maintenance is indicated for those with a severe course (eg, frequent episodes, suicide attempts, severe symptoms, hospitalization). A strong therapeutic alliance, psychoeducation, and adjunctive psychotherapy can help the patient accept the chronic nature of the illness and enhance adherence.
Bipolar II disorder involves hypomanic episodes (less severe than mania, no psychosis) AND 😢 one or more major depressive episodes.
Tx: Maintenance treatment to delay or prevent recurrence of new mood episodes.
❓ Have there been times, lasting at least a few days when you felt the opposite of depressed, where you were very cheerful or happy and this felt different from your normal self ❓
💊 Rx: Evidence-based maintenance monotherapy options for bipolar disorder include lithium, valproate, quetiapine, and lamotrigine. However, those with severe illness (ie, psychosis, aggression, frequent episodes/hospitalization), often require combination therapy to maintain stability.
😵 Acute mania:
🔘 Lithium OR valproate combined with a second-generation antipsychotic (eg, quetiapine) is 🥇 first-line combination therapy.
First- and second-generation antipsychotics are effective in managing mania and associated acute behavioral agitation. 2nd [quetiapine and lurasidone]
Olanzapine can be administered intramuscularly and has more rapid onset of action.
Antipsychotics and benzodiazepines should be discontinued as soon as the patient is in a stable state, given the risk of movement disorders and dependence, respectively.
🐑 Lamotrigine (anticonvulsant)🥈 [second-line] has the greatest efficacy in treating bipolar depressive (not manic) episodes. The most significant adverse effect is rash that can develop into a life-threatening mucocutaneous reaction (ie, Stevens-Johnson syndrome)(<10% body surface area skin detachment) and toxic epidermal necrolysis (>30% detachment) occur at a rate of 0.1% (10%-30% detachment is known as Stevens-Johnson syndrome/toxic epidermal necrolysis overlap). in approximately 0.1% of patients.
Long-term maintenance:
Valproate (Depacote)[first line] : Periodic monitoring of liver function tests and platelets is necessary due to the medication’s rare association with hepatotoxicity and thrombocytopenia.
🐄 Drug-induced liver injury: Patients receiving valproate should have liver tests prior to therapy and regularly thereafter. In addition to hepatotoxicity, valproate is also associated with tremor, thrombocytopenia, and alopecia.
🔘 Lithium [first line]
Indications
- Acute mania, bipolar maintenance
❌ Contraindications
- Chronic kidney disease
- Heart disease
- Hyponatremia or diuretic use
Baseline studies
- Blood urea nitrogen (BUN)[yearly], creatinine, calcium, urinalysis
- TSH (Thyroid function tests) q6 months; T3RU (yearly)
- ECG in patients with coronary risk factors
☠ Adverse effects
Acute
- Tremor, ataxia, weakness
- Polyuria, polydipsia
- GI: Nausea, vomiting, diarrhea 💩
- Cognitive impairment (confusion, agitation)
Chronic
- Nephrogenic diabetes insipidus: lithium antagonizes the effects of ADH in the distal kidney. The primary treatment is discontinuation of treatment or addition of 🦵 HCTZ (thiazide diuretic). Thiazides, in addition to effects on Na in the proximal kidney, increase expression of distal aquaporins, thus reversing the effects of lithium. Because HCTZ decreases NA reabsorption, it ultimately leads to increased lithium absorption (a positive ion) and can be associated with lithium toxicity. Thus lithium coadministered with HCTZ must be decreased in dose.
- Chronic kidney disease
- 🎀 Thyroid dysfunction: Approximately 25% of patients treated with lithium will develop hypothyroidism (fatigue, constipation, myalgias, and bradycardia). A much smaller percentage will experience hyperthyroidism. Tx: Patients who develop hypothyroidism are generally managed symptomatically with addition of T4 (eg, levothyroxine) rather than discontinuation of lithium.
- Hyperparathyroidism
Weight gain, metallic taste, acne, and polyuria,
Drug interactions
- 🦵 Thiazide diuretics can cause a decrease in the renal clearance of lithium and lead to lithium toxicity. The risk of lithium toxicity is higher in patients with dehydration from any cause (eg, vomiting, diarrhea, fever, diuresis) and in elderly patients due to a lower glomerular filtration rate and reduced volume of distribution.
- NSAIDs (not aspirin)
- ACE inhibitors
- Tetracyclines, metronidazole
ECG is also recommended in patients with coronary artery disease risk factors (eg, diabetes, hypertension, smoking) as lithium may cause dysrhythmias in these patients. These studies should also be reassessed periodically after starting the medication.
The lithium level considered effective for acute mania is between 1 and 1.5 meq/L. Since the half-life of lithium is about 20 hours, equilibrium is reached after 5 to 7 days of regular intake. Mild lithium toxicity (serum levels below 3 meq/L with symptoms of tremor, mild confusion, and gastrointestinal distress); severe toxicity requires dialysis
💀Toxicity
Neurologic (eg, altered mental status, seizure, fasciculations, tremor) and gastrointestinal (eg, vomiting, diarrhea) signs are common in cases of acute intoxication. Tx: Although mild overdoses can frequently be managed supportively with hydration and monitoring, hemodialysis is the treatment of choice for patients with lithium levels >2.5 mEq/L and prominent signs of toxicity. Patients with levels >4 mEq/L and creatinine >2.0 mg/dL should generally be prescribed dialysis regardless of symptoms.
Because lithium is renally excreted, common precipitants of toxicity include medications that affect the excretion rate (eg, nonsteroidal anti-inflammatory drugs, ACE inhibitors, angiotensin receptor blockers) as well as dehydration by any cause (eg, diuretics, gastrointestinal illness). Intentional overdose should also always be on the differential.
Carbamazepine: can cause 🦴 aplastic anemia, agranulocytosis, thrombocytopenia, and leucopenia. It also has a risk of hepatotoxicity. Because of these possibly side effects, a CBC, platelet count, reticulocyte count, serum electrolytes, SGOT, SGPT, LDH, and a pregnancy test (in appropriate patients, since carbamazepine raises the risk a baby will be born with spina bifida) should all be drawn before treatment with carbamazepine is instituted. SGOT, SGPT, and LDP should be drawn every month for the first 2 months, and thereafter, every 3 months.
Sleep deprivation has an antidepressant effect in depressed patients and may trigger a manic episode in bipolar patients.
The use of a long-acting benzodiazepine will allow patients to return to a normal sleep pattern and generally will abort manic episodes.
❌ Antidepressant monotherapy should generally be avoided in patients with bipolar I disorder due to the risk of precipitating mania.
Medications commonly used in the treatment of acute bipolar depression include the second-generation antipsychotics quetiapine and lurasidone and the anticonvulsant lamotrigine. Lithium, valproate, and the COMBINATION of olanzapine and fluoxetine have also demonstrated efficacy. [If necessary, antidepressants should be used in combination with mood stabilizers (eg, lithium, valproate, second-generation antipsychotics) as these appear to decrease the risk of an antidepressant-induced switch from depression to mania.] Other risks of using antidepressants in patients with bipolar depression include the development of rapid cycling (≥4 mood episodes/year) and increased mood cycle frequency.
Cyclothymia
Involves > 2️⃣ years of numerous periods with hypomanic and depressive symptoms that do not meet the full criteria for hypomanic and depressive symptoms that do not meet the full criteria for hypomanic or major depressive episodes.
Characterized by recurrent periods of mild depression alternating with periods of hypomania.
SCHIZOPHRENIA
Disorganized type
≥ 6️⃣ months (includes ≥1 month of active symptoms, can include prodromal & residual periods), requires functional decline. ≥2 of the following:
- Delusions
- Prominent 👂🏾 auditory or 👁 visual hallucinations
- Disorganized speech (🧵 loosening of associations, nonsensical words)
- Grossly disorganized or catatonic behavior (unpredictable agitation, bizarre behaviors, inappropriate affect), functional impairment, grimacing, silly/odd behaviors and mannerisms.
- Negative symptoms (affective flattening, avolition, alogia [poverty of speech], anhedonia, asociality), 1 of which must be delusions, hallucinations, or disorganized speech. Mood symptoms (meeting criteria for manic or depressive episodes) are absent. These active symptoms must be present for ≥1 month during a period of ≥6 months, with prodromal or residual symptoms occurring the rest of the time.
The psychotic features of schizophrenia typically emerge between the late teens and mid-30s; childhood onset is rare and is associated with a poorer prognosis. 👦🏽Adolescents commonly have a prodromal phase marked by social withdrawal and academic decline, which can last for weeks to years prior to the onset of active psychotic symptoms. Youth with schizophrenia frequently name their hallucinations, which need to be differentiated from imaginary friends. Imaginary friends typically decline in prevalence around age 6 and are not associated with functional decline.
Factors weighting toward ✅ good prognosis in schizophrenia include: late onset of the disease (>25y), obvious precipitating factors/stressors, an acute onset, good premorbid functioning, the presence of mood disorder symptoms, the patient being married, a 👨👩👧👧family history of mood disorders, good support systems, and the presence of positive symptoms (as opposed to negative symptoms).
Patients with schizophrenia can have grandiose delusions that they possess special powers or are related to or have become someone famous. Other common types of delusions include paranoid delusions and delusions of reference (receiving special messages from electronic media).
🧠 Neuroimaging studies have frequently shown loss of cortical tissue volume with ventricular enlargement
Tx: Family interventions that have been shown to be effective in the treatment of schizophrenic patients include teaching the family members about schizophrenia, emphasizing the importance of keeping interpersonal communication at a low emotional quotient (schizophrenic patients tend to relapse when exposed to the intense negative emotions of family members), and helping the family learn more adaptive ways to cope with stress.
Brief psychotic Disorder
😵 Psychotic symptoms (delusions, hallucinations, disorganized speech and behavior, negative symptoms) last at >1 day but <1 month 📆 with full return to premorbid functioning; normal functioning apart from direct impact of delusions
Schizoaffective Disorder
“depressed-type”, “bipolar type”
Diagnostic Criteria:
- Major depressive OR manic episode concurrent with symptoms of schizophrenia
- ➕ Lifetime history of delusions or hallucinations 😵 for ≥2 weeks in the ABSENCE of major depressive or manic episode
- Mood episodes are prominent & recur throughout illness
- Not due to substances or another medical condition
Schizoaffective disorder can be differentiated from schizophrenia and bipolar disorder by assessing the relationship of mood and psychotic symptoms over the course of the illness.
Differential diagnosis
- Major depressive or bipolar disorder with psychotic features: Psychotic symptoms occur exclusively during mood episodes
- Schizophrenia: Mood symptoms may be present for relatively brief periods
Concurrent Mania/mood episode (elevated mood, decreased need for sleep, hypersexuality, grandiose delusions) with a history (at least 2 weeks) of delusions and hallucinations occurring in the absence of a major mood episode (manic or depressive). A lifetime history of psychotic symptoms without significant mood disturbance.
Schizophreniform Disorder
Psychotic symptoms with a duration of > 1 month and < 6️⃣ months
Psychotic symptoms such as auditory or visual hallucinations are common, as is a
premorbid history of being “weird” or a “loner.”
Delusional Disorder
Clinical features:
- ≥1 delusions for ≥ 1️⃣ month
- Other psychotic symptoms absent or not prominent
- Behavior not obviously odd/bizarre; ability to function apart from delusion’s impact
- Subtypes: Erotomanic, grandiose, jealous, persecutory & somatic
Delusional disorder may be subtyped based on delusional themes: persecutory (eg, being poisoned, harassed, plotted against)[pt. is commonly verbally/physically abusive], 💖 erotomanic (false belief that someone of higher status is in love with them), grandiose (great talent, insights, or achievements), jealous (unfaithful partners), and somatic (bodily functions and sensations [eg. odor]), Unspecified (Capgras syndrome), mixed.
Autoscopic psychosis (visual hallucination of a transparent phantom of one’s
own body). Capgras syndrome (delusion of doubles) familiar persons have been replaced by identical imposters who behave exactly like the original person. Lycanthropy is the delusion that the person is a werewolf or other animal. Cotard syndrome is the false perception of having lost everything, including money, status, strength, health, and internal organs. Folie á deux is a shared psychotic disorder in which one person develops psychotic symptoms similar to the ones a long-term partner has been experiencing.
Ddx:
- Schizophrenia: Other psychotic symptoms present (eg, hallucinations, disorganization, negative symptoms); greater functional impairment
- Personality disorders: Pervasive pattern of suspiciousness (paranoid), grandiosity (narcissistic), or odd beliefs (schizotypal), but no clear delusions.
Tx:
- Antipsychotics
- Cognitive-behavioral therapy
Oppositional defiant disorder (ODD)
Dx:
Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness for ≥6 months
- Argues with adults, defies authority figures, refuses to follow rules
- Deliberately annoys others
- Blames others for own mistakes or misbehavior
- Easily annoyed, angry, resentful, or vindictive
- Not due to another mental disorder
The oppositional behaviors must be excessive compared to normative, age-appropriate behaviors and observed during interactions with individuals other than siblings.
Tx:
- Parent management training
- Psychotherapy (anger management, social skills training)
- No pharmacotherapy for ODD but assess for comorbid ADHD & treat if present
Management programs in which parents are trained to reward prosocial behavior and use brief, non-aversive consequences for misbehavior.
Individual or group psychotherapy focusing on anger management and problem-solving and social skills is also beneficial.
Children with ODD should be assessed for attention-deficit hyperactivity disorder (ADHD), a common comorbid condition. Treating ADHD can help to reduce behaviors that frequently put them in conflict with parents and other adults.
Conduct Disorder
Characterized by more severe and aggressive behaviors (eg, physical aggression or cruelty toward people or animals, destruction of property, stealing, lying). However, ODD can precede the development of conduct disorder and increases the risk of adult antisocial behavior, impulse control problems, substance abuse, anxiety, and depression.
Infants with “difficult” temperaments, as opposed to “easy” temperaments, have been shown to be at risk in the early school years for conduct problems. This correlation, although somewhat weaker, is also present through adolescence.
Clinical features
- Rare impulse control disorder with typical onset in adolescence
- Repetitive failure to resist impulses to steal
- Stolen objects have little value
- Increasing tension prior to theft; pleasure or relief when committing theft
- Stolen objects given away, discarded, or returned; guilt & remorse are common
Ddx:
- Shoplifting: Theft for personal gain; much more common
- Antisocial personality disorder: General pattern of antisocial behavior
- Bipolar disorder, manic episode: Impulsivity, impaired judgment
- Psychotic disorders: Stealing in response to delusions, hallucinations
PERSONALITY
“Persistent; egosyntonic”
❓When anyone reflects on their life, they can identify patterns- characteristic thoughts, moods, and actions- that began when they were a young person and and have subsequently occured in many person and social situations. Thinking about your own life, can you identify patterns like that which have caused you significant problems with your friends or family, at work or in another setting❓ Can recognize patterns in the way youprecieve yourself and other people, the ways you respond emotionally to exciting or difficult circumstances, the way you interact, or your ability to control your impulses and urges❓
Diagnosis of personality disorders requires evidence of lifelong patterns of interpersonal problems. They are not typically diagnosed before the age of 18.
A personality disorder is an inflexible and maladaptive pattern of behavior, causing impairment in social or occupational functioning or subjective distress.
A personality trait is defined as an enduring pattern of perceiving, relating to, and thinking about the environment and oneself that is exhibited in a wide range of important social and personal contexts.
🛡 Defense Mechanisms are normal features of human behavior that enable individuals to navigate social relationships in a way that preserves self-esteem, limits anxiety, and creates a feeling of control. They can be pathological if they become fixed or interfere with self-development.
Displacement s the transfer of feelings or impulses toward an object or person who is deemed to be safer (ie, less likely to take offense or retaliate; more socially acceptable)
Projection involves misattributing one’s own [distressful] thoughts and feelings to another person. [eg. accusing someone else of feeling the way you do]
Transference occurs when the patient’s feelings from the past about his parents (or other important persons) are experienced in the present relationship with the therapist.
Negative transference is the development of a nonproductive relationship between patient and physician, often based on the patient’s negative perception of authority figures from the past.
Countertransference occurs when the physician unconsciously re-experiences feelings about other important persons with the patient. By analyzing his or her countertransference toward the patient, the therapist may acquire useful insight into the patient’s dynamics and his or her own. Consequently, even negative countertransference feelings can be helpful tools in the psychotherapy process.
Reaction formation, an individual transforms unacceptable emotions, desires, or impulses into their extreme opposites. [eg. transformed into over-solicitous behavior that may seem more socially acceptable]. Individuals are usually not aware that they are exhibiting this defense mechanism despite it being readily apparent to others.
Undoing involves symbolically nullifying an unacceptable or guilt-provoking thought, idea, or feeling by confession or atonement (commonly seen in obsessive-compulsive disorder).
- *Rationalization**, explanations are given to justify unacceptable feelings and behaviors (eg, the patient explaining that his outburst over the garbage was due to concern about unhygienic conditions).
- *Suppression** is a mature defense mechanism that involves consciously putting aside unwanted feelings (eg, this patient making the conscious decision to put aside his anger and be cordial to his wife).
Sublimation is a mature defense mechanism that involves channeling an unacceptable impulse into an acceptable form of behavior (eg, intense hostility and anger are redirected by choosing boxing as a sport, journaling, helping families with the disease).
Regression, is very common when new siblings enter the household. Regression is characterized by returning to an earlier stage of development (enuresis). This defense mechanism is also common when people are tired, ill, or uncomfortable.
Splitting is a defense mechanism commonly seen in borderline personality disorder in which an individual is unable to integrate mixed feelings (eg, seeing others as alternately “all bad” and “all good”).
Altruism is a mature defense mechanism in which a person manages unpleasant emotions through service to others (eg, organizing a support group for caregivers). This service provides gratification, in contrast to reaction formation in which pleasure is lacking.
Intellectualization a defense mechanism that allows him to avoid anxiety by focusing on the nonemotional aspects; .interferes with ability to deal with feelings and grieve.
Illusion a perceptual misinterpretation of a real stimulus.
Identification with the aggressor is the adoption of characteristics or behavior of the victim’s aggressor as one’s own.
Denial is the avoidance of awareness of some painful aspect of reality by negating sensory data.
Isolation of affect, a neurotic defense, refers to the splitting off of the affective component (usually unpleasant or unacceptable) from an idea or thought.
CLUSTER 🅰 (“WEIRD”)
Accusatory, Aloof, and Awkward (“eccentric or odd behavior with inability to develop social relationships”)
“Odd/eccentric”
- Paranoid: suspicious, distrustful, hypervigilant
- Schizoid: prefers to be a loner; detached, unemotional
- Schizotypal: unusual thoughts, perceptions & behavior
Paranoid Personality Disorder
Characterized by mistrust, coldness and distance in most relationships; those relationships in which attachment has occurred are controlling and jealous. These individuals tend to have very hostile reactions to other people’s trivial, innocent, or even positive acts. Their reaction to others may then perpetuate their problems, since other people may be driven away by the paranoid person’s reactions. They have a mistrust of others and read hidden meaning into comments or events.
- Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
- Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
- Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against her or him
- Reads hidden demeaning or threatening meanings into benign remarks or events
- Persistently bears grudges
- Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily to counterattack
- Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
Although Paranoid personality disorder involves paranoid interpretations of benign comments and events, it can be differentiated from psychotic disorders by the lack of specific, well-developed delusions.
Schizoid personality disorder
Individuals with this disorder typically have few friends by choice 🙂 and show little interest in intimacy or sexual experiences. They tend to be emotionally detached, with flat affect and apparent indifference to praise or criticism. Individuals with schizoid personality disorder are often considered loners who tend toward introverted behaviors.
- Lack of desire for close relationships and preference for solitary activities.
- While every bit as isolated as those with avoidant personality disorder, like it that
way.
Schizotypal personality disorder
Individuals with schizotypal disorder are typically socially awkward, have few friends, and experience difficulty sustaining close relationships due to social anxiety that does not diminish with familiarity. Odd dress and peculiar speech are common. Schizotypal personality disorder can be differentiated from other personality disorders by the predominance of eccentric behaviors and odd beliefs.
- Magical thinking (eg, superstition, clairvoyance), suspiciousness, and paranoid ideation can occur but are NOT of delusional proportions. Perceptual distortions can also occur, but there are NO frank hallucinations.
- Eccentric behaviors, odd beliefs, interpersonal deficits (reduced capacity for close relationships).
- General paranoia and idiosyncratic thinking about positive and negative energy, but no fixed delusions.
CLUSTER 🅱 (“Wild”) Bad to the Bone
“Dramatic/erratic”
- Antisocial: disregard & violation of the rights of others
- Borderline: chaotic relationships, abandonment fears, labile mood, impulsivity, inner emptiness, self-harm
- Histrionic: superficial, theatrical, attention-seeking
- Narcissistic: grandiosity, lack of empathy
Have a genetic association with mood disorders and substance use disorder.
Borderline Personality Disorder
These patients frequently present with acute depression and suicidal threats or behavior in the setting of feeling rejected or abandoned. Their relationships involve extremes of idealization and devaluation (splitting). Chronic feelings of emptiness, difficulty being alone, intense episodic dysphoria, and inappropriate anger are also typical. The mood shifts in BPD occur in response to situational stressors, lasting usually a few hours and rarely more than a few days.
Diagnostic Criteria:
Pervasive pattern of unstable relationships, self-image & affects & marked impulsivity, with ≥5 of the following features:
- Frantic efforts to avoid abandonment
- Unstable & intense interpersonal relationships
- Markedly & persistently unstable self-image ❓Poorly developed sense of who you are❓
- Impulsivity in ≥2 areas that are potentially self-damaging
- Recurrent 🔪suicidal behaviors or threats of self-mutilation (eg, cutting)
- Mood (affective) instability (marked mood reactivity)
- Chronic feelings of emptiness
- Inappropriate & intense anger
- Transient stress-related paranoia or dissociation
Tx:
- Primary treatment is psychotherapy (several types effective; best evidence for dialectical behavior therapy)
- Adjunctive pharmacotherapy to target mood instability & transient psychosis (second-generation antipsychotics, mood stabilizers)
- Antidepressants if comorbid mood or anxiety disorder
Pattern of recurrent suicidal behavior, mood instability, unstable relationships, inappropriate anger, impulsivity, abandonment fears, and stress-related paranoia and dissociation are characteristic of borderline personality disorder. In addition to suicidal threats, gestures, and attempts, these patients often engage in nonsuicidal self-injury (eg, cutting, burning).
A history of childhood trauma (physical and sexual abuse, neglect) is common in patients with borderline personality disorder. Insecure attachment to the primary caregiver may underlie the unstable relationships and fears of abandonment that are commonly seen in the disorder. Dissociative symptoms (eg, this patient’s experience of detachment from her body [depersonalization]) are common in patients who have been traumatized.
📺 Projective Identification consists of three steps: (1) an aspect of the self is projected onto someone else, (2) the projector tries to coerce the other person to identify with what has been projected, and (3) the recipient of the projection and the projector feel a sense of oneness or union.
Splitting is commonly seen in borderline personality disorder and can contribute to the
🚔 Antisocial personality disorder
Clinical features:
- Violates rights of others, social norms, laws 🚔
- Impulsive, irritable, aggressive (fights, assaults)
- Consistently irresponsible, lies, is deceitful
- ❓ Accomplishments that arent your own.
- Lack of remorse
- Age ≥18
- Evidence of conduct disorder before age 15
Management
- Psychotherapy for milder forms (monitor for manipulation of therapeutic relationship)
- Treat comorbid psychiatric disorders (eg, substance use, depression)
ASPD is a lifelong disorder characterized by a pervasive pattern of disregard for and violation of the rights of others, beginning in childhood or early adolescence (when it is diagnosed as conduct disorder) and continuing into adulthood (age ≥18 required for diagnosis). This patient’s history of truancy and fighting from the 7th grade onward is evidence of conduct disorder before age 15, a clinical feature of ASPD.
Individuals with ASPD tend to be aggressive and impulsive and may repeatedly get into fights or physically assault others. Additional typical behaviors include illegal activities (eg, drug use, theft), lying, manipulation of others for personal gain, and failure to sustain consistent employment. This patient’s arrogant self-appraisal and irresponsible behavior (eg, blames his boss and teachers; fails to accept responsibility for his own behavior; quits job without realistic plans for getting another) are characteristic of ASPD.
Histrionic personality
Very dramatic, childlike presentations, often coupled with 💋 sexual overtones. There is an excessive need for approval and, often, inappropriately seductive behavior to get attention.
Five or more of the following:
- Uncomfortable in situations in which he or she is not the center of attention
- Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
- Displays rapidly shifting and shallow expression of emotions
- Consistently uses physical appearance to draw attention to self
- Has a style of speech that is excessively impressionistic and lacking in detail
- Show self-dramatization, theatricality and exaggerated expression of emotion
- Is suggestible
- Considers relationships to be more intimate than they actually are
🤴🏾 Narcissistic personality disorder
Characterized by grandiose self-images, fantasies of glory, exploitative behavior, a sense of 🤴🏾 entitlement, and a lack of empathy and concern for others. Patients with this disorder demand constant attention and have fragile self-esteem. There is genuine surprise and associated anger when they do not obtain their goals. It is more commonly diagnosed in men. 5 or more of the following:
- Has a grandiose sense of self-importance
- Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
- Believes that he or she is special and unique and can only be understood by, or should associate with, other special or high-status people
- Requires excessive admiration
- Has a sense of entitlement
- Is interpersonally exploitative
- Lacks empathy
- Is often envious of other or believes that others are envious of him or her
Tx: Treatment of narcissistic personality disorder is extremely difficult and requires a tactful
therapist who can make confrontations, but do it gently. Forming an alliance with these patients can be very difficult.
CLUSTER c (“Worried”) -
Share a genetic association with anxiety disorders.
Cowardly, compulsive, and clingy (“fearful or anxious behavior”)
“Anxious/fearful”
- Avoidant: avoidance due to fears of criticism & rejection
- Dependent: submissive, clingy, needs to be taken care of
- Obsessive-compulsive: rigid, controlling, perfectionistic
Avoidant personality disorder
- Characterized by social avoidance, hypersensitivity, and feelings of inferiority.
- Desire relationships but avoid them due to fears of rejection or being embarrassed.
- Desire social acceptance
