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An Introduction to Psychiatry Aws Khasawneh, MD.  Psychiatry - The term psychiatry, coined by Johann Christian Reil in 1808, comes from the Greek “psyche” (soul or mind) and “iatros" (healer or doctor) Psychiatry is a medical specialty which exists to study, p...

An Introduction to Psychiatry Aws Khasawneh, MD.  Psychiatry - The term psychiatry, coined by Johann Christian Reil in 1808, comes from the Greek “psyche” (soul or mind) and “iatros" (healer or doctor) Psychiatry is a medical specialty which exists to study, prevent, and treat mental disorders in humans. Psychiatric assessment typically involves a mental status examination and taking a case history, and psychological tests may be administered. Physical examinations may be conducted and occasionally neuroimages or other neurophysiological measurements taken. Diagnostic procedures vary but official criteria are listed in manuals, the most common being the ICD from the World Health Organization and the DSM from the American Psychiatric Association.  Ancient times Starting in the 5th century BC, mental disorders, especially those with psychotic traits, were considered supernatural in origin. This view existed throughout ancient Greece and Rome. Early manuals written about mental disorders were created by the Greeks. In 4th century BC, Hippocrates theorized that physiological abnormalities may be the root of mental disorders. Religious leaders and others returned to using early versions of exorcisms to treat mental disorders which often utilized cruel, harsh, and other barbarous methods.  Middle Ages The first psychiatric hospitals were built in the medieval Islamic world from the 8th century. The first was built in Baghdad in 705, followed by Fes in the early 8th century, and Cairo in 800. Unlike medieval Christian physicians who relied on demonological explanations for mental illness, medieval Muslim physicians relied mostly on clinical observations. They made significant advances to psychiatry and were the first to provide psychotherapy and moral treatment for mentally ill patients, in addition to other forms of treatment such as baths, drug medication, music therapy and occupational therapy. In the 10th century, the Persian physician Muhammad ibn Zakariya Razi (Rhazes) combined psychological methods and physiological explanations to provide treatment to mentally ill patients. His contemporary, the Arab physician Najab ud-din Muhammad, first described a number of mental illnesses such as agitated depression, neurosis, and sexual impotence (Nafkhae Malikholia), psychosis (Kutrib), and mania (Dual-Kulb).  Middle Ages In the 11th century, another Persian physician Avicenna recognized 'physiological psychology' in the treatment of illnesses involving emotions, and developed a system for associating changes in the pulse rate with inner feelings, which is seen as a precursor to the word association test developed by Carl Jung in the 19th century. Avicenna was also an early pioneer of neuropsychiatry, and first described a number of neuropsychiatric conditions such as hallucination, insomnia, mania, nightmare, melancholia, dementia, epilepsy, paralysis, stroke, vertigo and tremor.  Middle Ages Psychiatric hospitals were built in medieval Europe from the 13th century to treat mental disorders but were utilized only as custodial institutions and did not provide any type of treatment.Founded in the 13th century, Bethlem Royal Hospital in London is one of the oldest psychiatric hospitals. By 1547 the City of London acquired the hospital and continued its function until 1948.  19th century Universities often played a part in the administration of the asylums. Due to the relationship between the universities and asylums, scores of competitive psychiatrists were being molded in Germany. Germany became known as the world leader in psychiatry during the nineteenth century. The country possessed more than 20 separate universities all competing with each other for scientific advancement. However, because of Germany's individual states and the lack of national regulation of asylums, the country had no organized centralization of asylums or psychiatry.Britain, like Germany, also lacked a centralized organization for the administration of asylums. This deficit hindered the diffusion of new ideas in medicine and psychiatry.  19th century In the United States in 1834, Anna Marsh, a physician's widow, deeded the funds to build her country's first financially-stable private asylum. The Brattleboro Retreat marked the beginning of America's private psychiatric hospitals challenging state institutions for patients, funding, and influence. Although based on England's York Retreat, it would be followed by speciality institutions of every treatment philosophy. In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. By 1840, asylums as therapeutic institutions existed throughout Europe and the United States.  19th century However, the new and dominating ideas that mental illness could be "conquered" during the mid-nineteenth century all came crashing down. Psychiatrists and asylums were being pressured by an ever increasing patient population. Overcrowding was rampant in France where asylums would commonly take in double their maximum capacity. Increases in asylum populations may have been a result of the transfer of care from families and poorhouses,.  20th century The 20th century introduced a new psychiatry into the world. The different perspectives of looking at mental disorders began to be introduced. The career of Emil Kraepelin somewhat model this hiatus of psychiatry between the different disciplines.  20th century The initial ideas behind biological psychiatry, stating that these different disorders were all biological in nature, evolved into a new idea of "nerves" and psychiatry became a sort of rough neurology or neuropsychiatry. Following Sigmund Freud's death, ideas stemming from psychoanalytic theory also began to take root. The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of asylums. However the progress of psychiatry by the 1970s turned psychoanalytic theory into a marginal school of thought within the field.  20th century This period of time saw the reemergence of biological psychiatry. Psychopharmacology became an integral part of psychiatry starting with Otto Loewi's discovery of the first neurotransmitter, acetylcholine. Neuroimaging was first utilized as a tool for psychiatry in the 1980s. The discovery of chlorpromazine's effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disease, as did lithium carbonate's ability to stabilize mood highs and lows in bipolar disorder in 1948. While psychosocial issues were still seen as valid, psychotherapy was seen to be their "cure." Genetics were once again thought to play a role in mental illness. Molecular biology opened the door for specific genes contributing mental disorders to be identified. By 1995 genes contributing to schizophrenia had been identified on chromosome 6 and genes contributing to bipolar disorder on chromosomes 18 and 21  Development of biological th treatment in 20 century ECT Brain surgery Neuroleptics Benzodiazepines 13  Why Study Psychiatry ? 1- Psychiatric disorders are prevalent and often go untreated : lifetime prevalence in USA : 28% only 40% receive treatment during lifetimes in general practice : 1/6-1/4 of the patients seen have a psychiatric problem 14  Why Study Psychiatry ?… depression is diagnosed in only 50% of those with depression who present to GPs adequate treatment ensues in only about 17% of depressed patients in primary care settings half the patients who commit suicide sought treatment in a primary care setting within 1 month of dying two-thirds of patients with undiagnosed depression have six visits or more a year with GPs for somatic complaints 15  Why Study Psychiatry ?… 2- Global burden of mental disorders 3- Subject of medicine is human being, a “biopsychosocial” 4- Consideration of the psychological aspects of the doctor-patient relationship 16 Barriers to Dx & Treatment in Primary Care Settings (patient factors) May present with a somatic complaint Concurrent medical illness often obscures psychiatric symptoms Denial Stigma & shame The belief that psychiatric illness is untreatable The belief that drugs are mind-altering and/or addictive 17  Barriers to Dx & Treatment in Primary Care Settings (physician factors) A lack of time Fear of being embarrassed Uncertainty Fear that the patient will have an illness that is unresponsive to treatment Prior negative experience Lack of knowledge 18  Classification systems Classification systems include categorical, dimensional, and multiaxial types In the multiaxial type of classification, each case is rated on several separate categorical systems, each measuring a different aspect (for example; psychiatric illness, personality, intelligence) The two main classification systems in international use, ICD and DSM, will now be summarized 19  ICD-10 (World Health Organization) The tenth edition of the International Classification of Disease (ICD-10), prepared by the World Health Organization, covers the whole of medicine, and also includes a Classification of Mental and Behavioural Disorders. This is the official classification used in the UK. It is a descriptive classification Chapter 5 is entitled Mental and Behavioral Disorders 20  ICD - Mental and Behavioral Disorders F0 Organic, including symptomatic, mental disorders – F1 Mental and behavioral disorders due to psychoactive substance use – F2 Schizophrenia, schizotypal and delusional disorders – F3 Mood (affective) disorders – F4 Neurotic, stress-related and somatoform disorders – F5 Behavioral syndromes associated with physiological disturbances and physical factors – F6 Disorders of adult personality and behavior – F7 Mental retardation – F8 Disorders of psychological development – F9 Behavioral and emotional disorders with onset usually occurring in childhood and adolescence – F10 Unspecified mental disorder Copyright © Notice: The materials are copyrighted © and trademarked ™ as the property of The Curriculum Center for Family and Consumer Sciences, Texas Tech University.  DSM-V (American Psychiatric Association) The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) comprises the official classification system of the American Psychiatric Association, and has been influential in the UK 22  DSM History DSM-I, 1952 – 106 diagnoses DSM-II, 1968 – 185 diagnoses DSM-III, 1980 – 265 diagnoses DSM-IV, 1994 – 365 diagnoses DSM-5 2013- Does this mean that more people are developing mental disorders? It means that our understanding of mental disorders is improving and diagnosis can be more specific. Instead of one classification for bipolar, now there are bipolar 1, bipolar 2, rapid cycling, and others. This enables diagnosis and treatment to be more accurate and effective. Copyright © Notice: The materials are copyrighted © and trademarked ™ as the property of The Curriculum Center for Family and Consumer Sciences, Texas Tech University.  DSM-5 Organizational Structure Neurodevelopmental Disorders Feeding and Eating Disorders Schizophrenia Spectrum and Elimination Disorders Other Psychotic Disorders Sleep-Wake Disorders Bipolar and Related Disorders Sexual Dysfunctions Depressive Disorders Gender Dysphoria Anxiety Disorders Disruptive, Impulse Control, and Obsessive-Compulsive and Conduct Disorders Related Disorders Substance Use and Addictive Trauma- and Stressor-Related Disorders Disorders Neurocognitive Disorders Dissociative Disorders Personality Disorders Somatic Symptom Disorders Paraphilias Other Disorders Copyright © Notice: The materials are copyrighted © and trademarked ™ as the property of The Curriculum Center for Family and Consumer Sciences, Texas Tech University.  The Psychiatric Interview is the single most important skill required in psychiatry “the skill of encouraging disclosure of personal information for a specific professional purpose”1 serves a variety of functions: Collecting clinical information in an efficient manner Eliciting emotions, feelings, and attitudes Establishing a doctor-patient relationship and developing rapport Generating and testing a set of hypotheses to arrive at a preferred diagnosis, accompanied by a list of other conditions (called a differential diagnosis) which must be considered Determining areas for further investigation Developing a treatment plan  What Are the Consequences of Poor Interviewing Skills? Patient dissatisfaction (Reynolds, 1978) Poor compliance (Ley, 1982) Missed diagnoses (Goldberg, 1980) Inappropriate treatment (McCready, 1986) Formal complaints (Fletcher, 1980) Increased litigation (Carroll, 1979)  Components of Psychiatric Assessment Identifying data Chief Complaint History of Present Illness Past Psychiatric History Past Medical History Medications Allergies Family History Social History Medical Review of Systems Mental Status Exam Diagnosis (incl. comorbidities) Treatment Plan  Mental Status Examination Describes the sum total of the examiner’s observations and impressions of the psychiatric patient at the time of interview 1. General Appearance and behavior: General appearance Posture and movement psychomotor activity Attitude towards examiner 2. Speech: Rate of speech Quantity of speech Content of Speech Volume tone 3 Mood and Affect MOOD: pervasive and sustained emotion that colors the patient’s perception of the world – Depressed, despairing, irritable, anxious, angry, expansive, euphoric  AFFECT: patient’s present emotional responsiveness Appropriateness of the patient’s response to the context of the subject matter the patient is discussing Reactivity : Normal range, constricted, blunted, flat Stability: stable or labile Thought THOUGHT PROCESS (Form of thinking): a way in which a person puts together ideas and associations. Formal thought disorders: Loosening of association (derailment), flight of ideas, racing thoughts, tangentiality, circumstantiality, word salad, neologisms, clang association, blocking, relevant/irrelevant  Content of Thought: Pre occupations and/or worries? Ideas and plans of suicide? Ideas and plans of homicide? Obsessional ideas/impulses/images and compulsive rituals? Delusions/overvalued ideas? Perception: Hallucinations –auditory, visual, olfactory, gustatory, tactile Illusions Depersonalization Derealization Cognitive Functions: Level of Consciousness Orientation in time, place and person Attention and concentration Memory –short term and long term Intelligence Abstract Thinking History taking & mental state examination Prof. Dr. Tawfik Daradkeh  Set the scene Privacy & Confidentiality Try to avoid interruptions Safety- Seating arrangement Note taking  General principles Put the patient at ease Introduce yourself & anyone accompanying you & explain the role Length of interview  Interview style Keep relax & in control even in difficult situation Appropriate eye contact, appear interested Show empathy Have a systematic but flexible approach May need to interrupt  Interview techniques Open questions where possible Closed questions can be helpful Avoid leading questions eg “You have a poor appetite, don’t you?”  Interview techniques May need to explain the rationale of certain questions, eg abuse, criminal record etc. Summarise to check understanding Pick up non-verbal cues Encourage patient by leaning forward, nodding, saying “go on” “tell me more about…..”  Collateral information Always useful particularly if patient is cognitively impaired, patient is concealing information etc Often best to see patient alone first and then with informant Ascertain informants concerns as well as gather information. Interview patients in first language where possible. May need interpreter Symptomatology, cultural beliefs & treatment expectations may vary  History Presenting Complaint History of presenting complaint Family History Personal History Past Psychiatric History Past Medical History Substance Use Drug History Forensic History Personality Current Social Situation  Presenting Complaint(s) Mode of referral Where is patient being seen. Presentation status eg informal etc What is their problem, in their own words  History of presenting complaint Nature of problem Chronology of each symptom Onset & duration Severity of symptoms & Degree of functional impairment Precipitating factors Perpetuating factors Protective factors Factors worsening or improving Treatments trialled  Past psychiatric history Similar or other symptoms in the past Psychiatric diagnosis Psychiatric admission Any treatments (drugs, psychotherapy, psychosocial interventions, from primary care, counselling) ECT Outcomes of treatment, any recovery, remission etc Suicide, DSH (Deliberate self-harm) attempts  Past medical history Full medical history Endocrine, CNS, systemic illness Chronic medical conditions: diabetes, ischemic heart disease, epilepsy, asthma (use of steroids), stroke Chronology of illnesses, hospitalizations Recovery  Medications history Current medications All drugs taken for psychiatric or medical illness: dose, duration and outcome Drugs that may precipitate psychiatric disorders Side effects of psychiatric medication Allergies May need to check with the GP  Family history Family tree to include patient’s siblings and parents eg adoptees, biological etc, separation, divorce, steps Pt’s nature of relationship with the family & among family Nature of death if any one not alive Known or suspected Hx of mental illness Suicides, suicidal behaviours or Hx of DSH in relatives Hx of substance misuse  Personal history Mother’s pregnancy Neuro-developmental milestones – birth, walking, talking, sitting & socializing age Childhood separation or emotional problems Home & school environment (Bullying, school refusal, shyness, conduct disorders) Schooling and academic achievements Relationships with friends and family  Social history Profession and employment record, Current employment Financial situation in general Current and past debt problems, spending etc Marital status – single, married, divorced, widowed Children – ages if dependent, parental responsibility Housing situation, past and present-living alone Stressors Social supports Typical day  Forensic history Past and present charges, penalties, arrests and convictions (Violence/Anger, sexual offences etc) Pending court cases Unrecorded offences Relationship to symptoms & substance misuse  Pre morbid personality Life long persistent characteristics prior to illness Moral and religious beliefs Leisure activities and hobbies How would others eg relatives/friends describe them  Mental state examination More reliant on observation & skilful exploration History suggest relevant cluster of pathologies.  Appearance and behaviour Body language & appropriateness of dress Evidence of self neglect Under or over psychomotor activity – excitation or retardation Facial expression – dilated pupils, rigidity Abnormal movements or posture Rapport & eye contact Distractibility Disinhibition Preoccupation  Speech Rate, tone & volume Level of coherence Rate: slow in depression; pressured in mania. Quantity: poverty in depression & chronic schizophrenia Pattern: spontaneous, coherence, circumstantial, trivial details eg obsessional traits, perseveration  Mood Subjective description-Sad, happy, top of the world, worried, up & down. Objective Range: depression – euthymic – euphoria Inability to enjoy activities (anhedonia) Inability to describe one’s emotion (alexithymia)  Affect Your objective description of emotion Depressed, anxious, fearful, irritable, suspicious, perplexed, elated, angry Fluctuations: reactivity, lability (mania), blunting (chronic schizophrenia) Congruent with thoughts/behaviour?  Thought Thought content Pre-occupations: thoughts that recur frequently but can be put out of mind eg obsessions, phobias & rituals Obsessions- ideas, images, doubts & images Delusion....out of keeping with the patient’s social & cultural background. Primary & secondary delusions Delusional perception: eg traffic light change means chosen to be Prophet.  Thought Thought form FTD: Circumstantiality, tangentiality, Neologisms, word salad, loosening of associations, perseveration.  Content: persecution, infidelity, grandiose, hypochondriacal, love, guilt, nihilistic, poverty, reference, infestation. Derealisation & depersonalization Thought insertion, withdrawal, broadcast Voices- echo, running commentary & 3rd PAH Passivity affect, action & impulse  Perceptions Illusions Hallucinations Auditory (2nd, 3rd) visual gustatory, olfactory (organic, TLE), tactile (cocaine addiction, drug withdrawals) Pseudo-hallucinations Hypnopompic/hypnogogic hallucinations Functional/Reflex hallucinations Extracampine  Cognition Orientation to time, place & person Test short term and long term memory Determine subjective and objective concentration levels Carry out a MMSE Separate poor concentration from memory problems  Insight Awareness of abnormal state of mind Insight rests on a continuum from being partially insightful to having insight Ask the patient if they think they are ill Mentally or physically Ask the patient if they are willing to accept help Ask the patient if they will take treatment  Multiaxial System Axis I: Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention Axis II: Personality Disorders and Mental Retardation Axis III: General Medical Conditions Axis IV: Psychosocial and Environmental Problems Axis V: Global Assessment of Functioning  Useful Reading Lecture notes- Psychiatry Shorter Oxford Textbook of Psychiatry (ed) Gelder, Harrison & Cowen Fish’s Clinical Psychopathology, Casey & Kelly Sims’ Symptoms in the Mind, Femi Oyebode Psychiatric Inteviewing and Assessment, Poole & Higgo Phenomenology Dr. Mahmoud Bashtawi Definition The study of events, either psychological or physical. In psychiatry, it involves the observation and categorization of abnormal psychic events, the internal experiences of the patient and his consequent behavior. or what you call it Psychopathology ;the signs and symptoms of psychiatry. Psychopathology The study of phenomena of mental illness : abnormal thoughts, feelings, perceptions and cognitions. Descriptive psychopathology aims to describe such phenomena. Psychodynamic psychopathology aims to describe and explain causes of abnormal mental phenomena using psychoanalytic theories. Classification of signs and symptoms in Psychiatry Disorders of Perception Disorders of Thinking Disorders of Mood Disorders of Cognition Perception the awareness of objects and interpretation of sensory information;i.e. awareness of what is presented through the sense organs. Imagery: A sensory experience over which the subject has voluntary control and experiences as taking place within the mind. Disorders of Perception illusion Hallucination Depersonalization Derealization Illusions Illusions misperceptions of external stimuli conditions more likely to occur: reduced level of sensory stimulation (e.g. at dusk) reduced level of consciousness (e.g. delirious pts.) when attention is not focussed on the sensory modality (e.g. in darkness) when there is a strong affective state (e.g. stressed and anxiety) Hallucinations sensory perception without an objective stimulus but with a similar quality to a true percept. can be of all sensory modalities: visual , auditory , somatic ,gustatory and olfactory Auditory hallucinations Voices Single or multiple Male or female Known or unknown person person 1st person: “thought echo” - hearing own thoughts spoken aloud. 2nd person: calling patient by ‘you’ 3rd person: calling patient by ‘he’ or ‘she’ Voices Commanding, running commentary or arguing with each other Timing: day , night or all the time. continuous or intermittent. Theme: friendly or derogatory Hallucinations Visual Hallucinations: commonly associated with organicity. Olfactory and gustatory hallucinations often experienced together often unpleasant in nature common in temporal lobe epilepsy Somatic (tactile and deep) tactile (haptic): touched, insect crawling under the skin e.g. formication in cocaine abuse deep sensation: e.g. viscera being pulled out, sexual stimulation, electric shock Hallucinations Extracampine hallucinations: perceiving a sensation from beyond the limits of the sense organ e.g. visions from outside visual field, hearing voices from far away Reflex hallucinations: stimulus in one sensory modality causing a hallucination in a different sensory modality e.g. music causing visual hallucination (LSD abuse) Hypnogogic and hypnopompic hallucinations occurs at the point of falling to or waking from sleep usually brief and elementary Disorders of Perception Depersonalization: a feeling that his body parts are abnormal, unreal e.g. my brain or my head becomes big until it fills the room Derealization: a feeling that the external environment is abnormal, unreal Patient describe things in his surrounding that are artificial and lifeless both can occur in tiredness, TLE, depression etc. Thought disorders (TD) Qutaibah Essam  Introduction Formal Thought Disorders (FTD) Serious problems with thinking, feeling & behavior What is thinking? goal of directed flow of ideas initiated by a task leading to oriented conclusion Components? 1. Flow/Stream 2. Form of thought 3. Content 4. Possession  Disorders of Flow 1- Pressure of thought  Disorders of Flow 2- Poverty of thoughts  Disorders of Flow 3- Thought blocking  Formal Thought disorders 1- loosening of association / derailment  Formal Thought disorders 2- Flight of ideas  Formal Thought disorders 3- Perseveration  Formal Thought disorders 4- Word Salad  Formal Thought disorders 5- Cirumstantialities Normal Speech Cirumstantialities  Formal Thought disorders 6- Tangentiality Normal Speech Tangentiality  Formal Thought disorders 7- Echolalia  Formal Thought disorders 8- Neologism  Content of thought Disorders 1- Obsessions Recurrent & persistent thoughts/images/impulses Subjective struggle Recognized as his own Regarded as untrue & senseless  Content of thought Disorders 2- Compulsions Repetitive, purposeful behaviors Performed in stereotyped way Subjective sense to be done Urge to resist Examples:  Content of thought Disorders 3- Overvalued Ideas Emotion Some degree of ambivalence & doubt  Content of thought Disorders 4- Preoccupation Prevent pt. from performing day to day activities  Content of thought Disorders 5- Delusions False fixed unshakeable belief Inappropriate to person’s education & social background  Classification of delusions According to special feature 1- Systematized Chronic Presence of nucleus Well knitted, Interconnected, layered & well encapsulated 2- Non-systematized 3- Shared Folie a deux (2 including pt) Folie a mass (>2P)  Classification of delusions According to theme 1- Persecutory (paranoid) Others want to harm him 2- Delusion of reference personal significance for pt 3- Grandiose (expansive) Beliefs of exaggerated self-importance  Classification of delusions According to theme 4- Religious 5- De Clerambault’s syndrome Being loved by a man, who is inaccessible higher status, never spoken before, unable to reveal his love for her 6- Delusion of Jealousy Common in men Unfaithfulness of spouse (infidelity)  Classification of delusions According to theme 7- Delusion of Guilt & worthlessness minor past faults 🡪 deserve to punished 8- Nihilistic Delusion Cotard’s syndrome 9- Hypochondriacal Delusions Belief of ill health despite contrary medical evidence  Thought Possession Disorders 1- Thought insertion  Thought Possession Disorders 2- Thought withdrawal  Thought Possession Disorders 3- Thought broadcasting Emotion Affect: a feeling-tone that accompanies an idea; observed expression of emotion; may be inconsistent with patient's description of emotion Appropriate affect - Inappropriate affect: - Restricted or constricted affect: reduction in intensity of feeling tone less severe than blunted affect but clearly reduced - Blunted affect: a disturbance in affect manifested by a severe reduction in the intensity of externalized feeling tone Flat affect: absence or near absence of any signs of affective expression; voice monotonous, face immobile Labile affect: rapid and abrupt changes in emotional feeling tone, unrelated to external stimuli Emotion B. Mood: a pervasive and sustained emotion, subjectively experienced and reported by the patient and observed by others; examples 1. Euthymic mood: normal range of mood, implying absence of depressed or elevated mood 2. Euphoria: intense feeling of well being 3. Elation: intense feeling of well being with exaggerated motor activity 5. Expansive mood: expression of one's feelings without restraint, frequently with an overestimation of one's significance or importance Mood 6. Ecstasy: felling of intense rapture 7. Dysphoric mood: an unpleasant mood 8. Anhedonia: loss of interest in and withdrawal from all regular and pleasurable activities, often associated with depression Other emotions Anxiety: feeling of apprehension caused by anticipation of danger, which may be internal or external 2 Fear: anxiety caused by consciously recognized and realistic danger 3 Agitation: severe anxiety associated with motor restlessness 4 Panic: acute, episodic, intense attack of anxiety associated with overwhelming feelings of dread and autonomic discharge 5 Ambivalence: coexistence of two opposing impulses toward the same thing in the same person at the same time Motor behavior Echopraxia: pathological imitation of movements of one person by another Catatonia: motor anomalies (stupor or excitement) in some disorders Catalepsy: general term for an immobile position that is constantly maintained Catatonic excitement: agitated, purposeless motor activity, uninfluenced by external stimuli Catatonic stupor: markedly slowed motor activity, often to a point of immobility and seeming unawareness of surroundings Catatonic symptoms catatonic stupor = markedly slowed motor activity, often to a point of immobility catatonic excitement = agitated, purposeless motor activity catatonic posturing = voluntary assumption of an inappropriate or bizarre posture echopraxia = pathological imitation of movements stereotypy = repetitive fixed pattern of physical action mannerism = habitual involuntary movement command automatism = automatic following of suggestions  Schizophrenia spectrum and other psychotic disorders Table of contents Schizoprenia spectrum 01 Terminology Psychosis, delusion and 03 disorders Schizophreniform, brief perceptual disturbances psychotic and schizoaffective disorders 02 Schizophrenia Definition, diagnosis, 04 Antipsychotics Classification and side epidemiology, pathophysiology effects  01 Terminology  Psychosis Psychosis is a general term used to describe a distorted perception of reality. It is characterized by delusions, perceptual disturbances(hallucinations, illusion) , and disorganized thought or speech or behavior Psychosis can be a symptom of schizophrenia, mania, depression, and dementia, it can be substance or medication-induced. Perceptual disturbances HALLUCINATION: SENSORY PERCEPTION WITHOUT AN EXTERNAL STIMULUS. A. AUDITORY: MOSTLY SEEN IN SCHIZOPHRENIA. B. VISUAL: WITH DRUG INTOXICATION OR WITHDRAWAL. C. OLFACTORY: WITH EPILEPSY D. TACTILE: SECONDARY TO SUBSTANCE ABUSE &WITHDRAWAL. Perceptual disturbances ILLUSION: MISINTERPRETING AN EXISTING STIMULUS E.X: HEARING VOICES REGARDLESS OF THE ENVIRONMENT WOULD BE A HALLUCINATION, WHEREAS HEARING VOICES IN THE SOUND OF RUNNING WATER (OR OTHER AUDITORY SOURCE) WOULD BE AN ILLUSION.  Delusion Delusions are fixed, false beliefs that remain despite evidence to the contrary, and cannot be accounted for by the cultural background of an individual. They’re categorized as: 1. Bizarre: False belief that is impossible. 2. Non-bizarre: False belief that is plausible but not true. Why are delusions not part of perceptual disturbances? Referential Delusion*** Believing that public communication such as TV shows, newspapers, or song lyrics contain special messages exclusively for them  Persecutory or Paranoid Delusion*** Believing oneself to be pursued, stalked, framed, or tricked by others  Delusion of Control*** Belief that one’s thoughts can be heard by others or belief that outside thoughts are being placed in one’s head Delusions of Grandeur Belief that one has special powers beyond those of a normal person.  Delusions of Guilt Belief that one is guilty or responsible for something.  Somatic Delusion Belief that one has a certain illness or health condition.  Erotomanic Delusion Holding false beliefs about love or a relationship, such as being convinced that a celebrity is in love with them.  Religious Delusion Thinking that they have a unique connection to a deity or religious figure or that they are possessed by a demon  Test your knowledge Q1. What delusions are Q2. Systematized or non commonly seen in systematized? schizophrenia?  02 Schizophrenia  Schizophrenia SCHIZO = SPLIT PHRENIA = MIND SO SCHIZOPHRENIA REFERS TO THE SPITTING OF MIND NOT SPLIT OF PERSONALITY AS SOME MIGHT THINK PSYCHIATRIC DISORDER CHARACTERIZED BY ABNORMALITIES IN THINKING, EMOTION AND BEHAVIOR. NO PATHOGNOMONIC SYMPTOM OR PRESENTATION. USUALLY CHRONIC, WITH SIGNIFICANT CONSEQUENCES ON THE PATIENT.  Symptoms of Schizophrenia ✓ Hallucinations The 5 A’s ✓ ✓ Impairments in ✓ Delusions ✓ Anhedonia attention ✓ In executive ✓ bizarre behavior ✓ Affect (flat) ✓ disorganized speech Alogia (poverty of function ✓ In working memory ✓ catatonia ✓ speech) Avolition (apathy) ✓ Attention (poor) Phases of Schizophrenia (prodrome, active psychotic, residual) >6 >1 Diagnosis of Schizophrenia( DSM-5) Two or more of the following must be present for at least 1 month: 1. Delusions. 2. Hallucinations. 3. Disorganized speech. 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms. In addition to: significant social, occupational, or functional (self-care) deterioration. Duration of illness for at least 6 months (including prodromal or residual periods in which the above full criteria may not be met). Exclude other causes of psychosis  21,000,000 Approximately 1% of the population 5-10% Of Schizophrenics commit violent crime(murder) in the UK 14x More likely to be victims of violent crime than the average person  Age of presentation Late 20s Early-mid 20s  Genetic predisposition Avus orcus Avia orcus Herald Lillian Orcus Fiona Fergus Felicia Farkle 22-YEAR-OLD MALE COLLEGE STUDENT HAS BEEN STAYING IN HIS ROOM MOST OF THE TIME AND AVOIDING HIS SOCIAL ACTIVITIES. HIS FRIENDS HAVE NOTICED THAT OVER THE PAST 9 MONTHS, “HE HAS BEEN VERY RELIGIOUS” AND OFTEN TALKS ABOUT THE MEANING OF LIFE. HE REVEALS TO YOU THAT HE IS “JESUS” AND HIS PURPOSE OF EXISTENCE IS TO SAVE THE HUMAN RACE.  Types of Schizophrenia Catatonic Paranoid Disorganized Undifferentiated Residual Types of Schizophrenia Paranoid type (highest functioning type, older age of onset.) Criteria: Preoccupation with one or more delusions or frequent auditory hallucinations. No predominance of disorganized speech, disorganized or catatonic behavior, or inappropriate affect. Disorganized type (poor functioning type, early onset.) Criteria: Disorganized speech Disorganized behavior Flat or inappropriate affect Types of Schizophrenia Catatonic type (rare.) Two of the following criteria: Motor immobility Excessive purposeless motor activity Extreme negativism or mutism Peculiar voluntary movements or posturing Echolalia (repeats words or phrases) or echopraxia (practices behaviour) Undifferentiated type characteristic of more than one subtype or none of the subtypes Residual type prominent negative symptoms (such as flattened affect or social withdrawal) with only minimal evidence of positive symptoms (such as hallucinations or delusions)  Dopamine hypothesis of psychosis The exact cause of schizophrenia is unknown, it appears to be partly related to increased dopamine activity in certain neuronal tracts. Evidence supporting: Cocaine and amphetamines increase dopamine activity and can lead to Evidence against: schizophrenic-like symptoms. Dopamine-inhibiting drugs modify Most antipsychotics successful in treating dopamine within minutes, associated schizophrenia are dopamine receptor improvement takes several days. antagonists. (Dopamine indirectly responsible?) Other neurotransmitter abnormalities Elevated serotonin Some of the second-generation (atypical) antipsychotics (e.g., risperidone and clozapine) antagonize serotonin and weakly antagonize dopamine. Elevated norepinephrine Long-term use of antipsychotics has been shown to decreased activity of noradrenergic neurons. Decrease in gamma-aminobutyric acid (GABA): There is a decreased expression of the enzyme necessary to create GABA in the hippocampus of schizophrenic patients. Genetics Schizophrenia has a large genetic component. If one identical twin has schizophrenia, the risk of the other identical twin having schizophrenia is 50%. A biological child of a schizophrenic person has a higher chance of developing schizophrenia, even if adopted. Prognosis Better Prognosis Worse Prognosis Later onset Early onset Good social support Poor social support Positive symptoms Negative symptoms Mood symptoms Family history +ve Acute onset Gradual onset Female sex Male sex Few relapses Many relapses Good premorbid Poor premorbid functioning functioning (social isolation, etc.)  Schizophreniform Disorder Diagnosis: Same criteria as Schizophrenia. One difference, in schizophreniform disorder the symptoms have lasted between 1 and 6 months, whereas in schizophrenia the symptoms must be present for more than 6 months. Prognosis: 1/3 recover. 2/3 Schizoaffective/Schizophrenia. Treatment: Hospitalization, antipsychotics, supportive psychotherapy.  Brief psychotic disorder Diagnosis: Criteria same for schizophrenia. Symptoms last from 1 day to 1 month. Prognosis: 50-80% recovery. 20-50% schizophrenia/mood disorder. Treatment: Hospitalization (brief), psychotherapy, antipsychotics +/- benzodiazepines.  Schizoaffective disorder Clinical Diagnosis can be challenging: Schizophrenia + mood disorder. (Recurring abnormal mood and psychotic components) - Mood component: Elevated, depressed, Or mixed. - Period of at least two weeks of psychosis without mood disorder - Have mood symptoms present for substantial portion of psychotic illness. - Symptoms not due to other conditions or drugs. Prognosis: Better than schizophrenia, worse than mood disorder. Treatment: Hospitalization, psychotherapy, medical (antipsychotics, mood stabilizers, antidepressants, ECT).  Comparing Time Courses and Prognoses of Psychotic Disorders Time Course: < 1 month—brief psychotic disorder 1–6 months—schizophreniform disorder 6 months—schizophrenia Prognosis from Best to Worst Mood disorder Brief psychotic disorder Schizoaffective disorder Schizophreniform disorder Schizophrenia  Shared psychotic disorder Diagnosis: Patient shares delusional symptoms of a person they are in a close relationship with. Family members for example. Prognosis: 20-40% recover upon removal from inducing person. Treatment: first step separate patient from inducing person. Psychotherapy. Antipsychotics if symptoms persist after 1-2 weeks of seperation. Antipsychotic drugs (neuroleptics) Typical Atypical neuroleptics neuroleptics Chlorpromazine, thioridazine, Risperidone, clozapine, olanzapine, trifluoperazine, haloperidol. quetiapine, aripiprazole, These are dopamine (mostly D2) ziprosidone. antagonists. These antagonize serotonin receptors (5- They are classically better at HT2) as well as dopamine treating positive symptoms than receptors. negative. Atypical neuroleptics are classically They have important side effects better at treating negative symptoms and sequelae such as extrapyramidal than traditional neuroleptics. symptoms, neuroleptic malignant They have a much lower incidence of syndrome, and tardive dyskinesia extrapyramidal side effects.  Side effects of antipsychotic medications Extrapyramidal symptoms: dystonia(spasms) of face, neck, and tongue; parkinsonism(resting tremor, rigidity, bradykinesia); akathisia (sense of restlessness and need to move) Anticholinergic symptoms: Dry mouth, constipation, blurred vision. Tardive dyskinesia: Darting/writhing movements of face, tongue and head. Neuroleptic malignant syndrome: Confusion, high fever, elevated blood pressure, tachycardia, “lead pipe” rigidity, sweating, and greatly elevated creatine phosphokinase (CPK) levels.  Thanks! CREDITS: This presentation template was created by Slidesgo, and includes icons by Flaticon, and infographics & images by Freepik  Mood Disorders The doctor’s comments are added below in the notes section  A mood is a description of one’s internal emotional state. Both external and internal stimuli can trigger moods, which may be labelled as sad, happy, angry, irritable, and so on. It is normal to have a wide range of moods and to have a sense of control over one’s moods. Patients with mood disorders (also called affective disorders) experience an abnormal range of moods and lose some level of control over them. Distress may be Mood: caused by the severity of their moods and the resulting impairment in social and occupational functioning. Always investigate medical or substance-induced causes of mood episodes before making a primary psychiatric diagnosis. (hyperthyroidism/ temporal lobe seizures may cause manic episodes. Cerebrovascular diseases/ Parkinson's disease/ hypothyroidism..etc may cause depressive episodes). Antidepressants, sympathomimetics, dopamine, corticosteroids and any more may cause substance/medication-induced bipolar disorder.  Mood episodes are distinct periods of time in which some abnormal mood is present. They include depression, mania, and hypomania. Mood disorders are defined by their patterns of mood episodes. They include major depressive disorder (MDD), bipolar I disorder, Mood Disorders vs bipolar II disorder, persistent depressive disorder, and cyclothymic disorder. Some may Mood Episodes: have psychotic features (delusions or hallucinations). Mood disorders often have chronic courses that are marked by relapses with relatively normal functioning between episodes.  Manic Episode: “A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal- directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).” Hypomanic Episode: “A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Terms Depressive Episode: is a period characterized by the symptoms of major depressive disorder. Sufferers primarily have a depressed mood for two weeks or more, and a loss of interest or pleasure in everyday activities, accompanied by other symptoms such as feelings of emptiness, hopelessness, anxiety, worthlessness, guilt and irritability, changes in appetite, problems concentrating, remembering details or making decisions, and thoughts of suicide. Insomnia or hypersomnia, aches, pains, or digestive problems that are resistant to treatment may also be present.  Mania is a more severe form that lasts for a week or more and has a severe negative impact on your ability to do your usual day-to-day activities – often disrupting or stopping these completely. Severe mania is very serious, and often needs to be treated in hospital. During manic episodes, around 50% of patients with bipolar 1 disorder will exhibit mood-congruent psychotic features. Individuals who have mood- congruent psychosis will have hallucinations and delusions that are consistent with their current mood. Terms Hypomania lasts for a few days, and can feel more manageable than mania. It can still have a disruptive effect on your life and people may notice a change in your mood and behaviour. But you will usually be able to continue with your daily activities without these being too badly affected. Hypomanic episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic Bipolar Disorder The doctor’s comments are added below in the notes section  American Psychological Association defines bipolar disorder as: “ A serious mental illness in which common emotions become intensely and often unpredictably magnified. Individuals with bipolar disorder can quickly swing from extremes of happiness, energy and clarity to sadness, fatigue and confusion. These shifts can be so devastating that individuals may choose suicide.” Bipolar disorder In DSM-5, Bipolar and related disorders are separated from the depressive disorders and placed between the chapters on schizophrenia spectrum and other psychotic disorders and depressive disorders. A connection between the two diagnostic classes in terms of symptomatology, family history, and genetics.  Anxious distress: Defined by feeling keyed up/tense, restless, difficulty concentrating, fears of something bad happening, and feelings of loss of control. Mixed features: Depressive symptoms present during the majority of days during mania/hypomania: dysphoria/depressed mood, anhedonia, psychomotor retardation, fatigue/loss of energy, feelings of worthlessness or inappropriate guilt, thoughts of death or suicidal ideation. Specifiers for Bipolar Rapid cycling: At least four mood episodes (manic, hypomanic, depressed) within 12 months. Disorders Melancholic features (during depressed episode): Characterized by anhedonia, early morning awakenings, depression worse in the morning, psychomotor disturbance, excessive guilt, and anorexia. Atypical features (during depressed episode): Characterized by hypersomnia, hyperphagia, reactive mood, leaden paralysis, and hypersensitivity to interpersonal rejection.  Psychotic features: Characterized by the presence of delusions and/or hallucinations. Specifiers Catatonia: Catalepsy, purposeless motor activity, extreme negativism or mutism, bizarre postures, and echolalia. Especially responsive to ECT. for Bipolar Peripartum onset: Onset of manic or hypomanic symptoms occurs during pregnancy or Disorders 4 weeks following delivery. Seasonal pattern: Temporal relationship between onset of mania/hypomania and particular time of the year.  Bipolar I disorder involves episodes of mania and episodes of depression; however, episodes of depression are not required Bipolar I disorder for the diagnosis. It is also known as manic-depression or bipolar depression.  The only requirement for this diagnosis is the occurrence of a manic episode (5% of patients experience only manic episodes). Diagnosis and Between manic episodes, there may be DSM-5 interspersed euthymia, depressive episodes, or hypomanic episodes, but Criteria: none of these are required for the diagnosis  At least one lifetime manic episode is required for the diagnosis of bipolar I disorder. Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. Criteria Depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. The occurrence of the manic and depressive episode(s) is not better explained by another psychotic disorder.  During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behaviour: (DIG FAST) 1. Distractibility, (attention too easily drawn to unimportant or irrelevant external stimuli) as reported or observed 2. Irritability or euphoria (one of them must be present in a manic episode) 3. Grandiosity or inflated self-esteem 4. Flight of ideas or subjective experience that thoughts are racing Manic 5. Activities: Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity). Excessive involvement in Episode pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). 6. Sleep deficit, insomnia or decreased need for sleep (e.g., feels rested after only 3 hours of diagnosis sleep) 7. Talkativeness: more talkative than usual or pressure to keep talking Causes marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. The episode is not attributable to the physiological effects of a substance or a general medical condition. Epidemiology Lifetime prevalence: 1–2%. Women and men are equally affected. No ethnic differences seen; however, high-income countries have twice the rate of low- income countries (1.4% versus 0.7%). Onset usually before age 30, mean age of first mood episode is 18. Frequently misdiagnosed and thereby inappropriately or inadequately treated Etiology Biological, environmental, psychosocial, and genetic factors are all important. Bipolar I has the highest genetic link of all major psychiatric disorders First-degree relatives of patients with bipolar disorder are 10 times more likely to develop the illness. Concordance rates for monozygotic twins are 40–70%, and rates for dizygotic twins range from 5% to 25%. Course & prognosis Untreated manic episodes generally last several months. The course is usually chronic with relapses; as the disease progresses, episodes may occur more frequently. Ninety percent of individuals after one manic episode will have a repeat mood episode within 5 years. Bipolar disorder has a poorer prognosis than major depressive disorder. Maintenance treatment with mood stabilizing medications between episodes helps to ↓ the risk of relapse. 25 to 50% of people with bipolar disorder attempt suicide, and 10–15% die by suicide. Differential diagnosis Major depressive disorder Generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or other anxiety disorders. Attention-deficit/hyperactivity disorder Personality disorders Disorders with prominent irritability Treatment Treatment for bipolar disorder includes mood stabilizers such as lithium, valproic acid, and carbamazepine (for rapid cyclers), and second-generation antipsychotics. Lithium remains the gold standard, particularly due to demonstrated reduction in suicide risk.  Alternatively thought of as BIPOLAR II recurrent depressive episodes with hypomania. DISORDER  A. Criteria have been met for at least one hypomania episode and at least one major depressive episode B. There has never been a manic episode. C. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, Diagnosis delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. and DSM-5 D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or Criteria impairment in social, occupational, or other important areas of functioning. Remember: If there has been a full manic episode, even in the past, or if the patient ever has a history of psychosis, then the diagnosis is bipolar I, not bipolar II disorder.  Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.) 2. Markedly diminished interest or pleasure in almost all activities Major 3. Significant weight loss when not dieting or weight gain 4. Insomnia or hypersomnia nearly every day. Depressive 5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down). Episode 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day 9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, a suicide attempt, or a specific plan for committing suicide. Epidemiology: Prevalence is unclear, with some studies greater and others less than bipolar I. May be slightly more common in women. Onset usually before age 30. No ethnic differences seen. Frequently misdiagnosed as unipolar depression and thereby inappropriately treated. Etiology: same as bipolar I disorder. Course and Prognosis: tends to be chronic, requiring long-term treatment. Likely better prognosis than bipolar I. Treatment: fewer studies focus on the treatment for bipolar II. Currently, treatment is the same as bipolar I disorder.  Alternating periods of hypomania CYCLOTHYMIC and periods with mild-to- moderate depressive symptoms. DISORDER  A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time. Diagnosis and C. Criteria for a major depressive, manic, or hypomanic episode have never been met. DSM-5 D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia Criteria spectrum and other psychotic disorder. E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Epidemiology Lifetime prevalence: 2 situations due to concern of difficulty escaping or obtaining help in case of panic or other humiliating symptoms: outside of the home alone , open spaces (e.g., bridges) , enclosed places (e.g., stores) , public transportation (e.g., trains) , crowds/lines.  The triggering situations cause fear/anxiety out of proportion to the potential danger posed, leading to endurance of intense anxiety, avoidance, or requiring a companion. This holds true even if the patient suffers from a medical condition such as inflammatory bowel disease (IBS) which may lead to embarrassing public scenarios.  Symptoms cause significant social or occupational dysfunction  Symptoms last ≥ 6 months  Symptoms not better explained by another mental disorder  Strong genetic factor: Heritability about 60%  Psychosocial factor: Onset frequently follows a traumatic event  >50% of patients experience a panic attack prior to developing agoraphobia  Onset is usually before age 35  Course is persistent and chronic, with rare full remission  Comorbid diagnoses include other anxiety disorders, depressive disorders, and substance use disorders  Similar approach as panic disorder: CBT and SSRIs (for panic symptoms)  Patients with GAD suffer from severe worry or anxiety that is out of proportion to situational factors.  Must last most days for at least 6 months  Described as “worriers” or “nervous”  Symptoms include:  Muscle tension  Restlessness  Insomnia  Difficulty concentrating  Easy fatigability  Irritability  Persistent anxiety (rather than discrete panic attacks)  Excessive anxiety and worry that occurs more days than not for > 6 months  Difficult to control the worry  > 3 symptoms  Anxiety caused significant distress or impairment in function  Not attributed to another organic cause  5-9% prevalence in community samples  2:1 female/male ratio  Median age of onset of GAD: 30 years old  Chronic but fluctuating course of illness (worsened during stressful periods)  1/3 of risk for developing GAD is genetic  Rates of full remission are low  Cognitive Behavioral Therapy  Other Psychotherapies  Pharmacotherapy  Antidepressants  Benzodiazepines  Buspirone  Failure to speak in specific situations for at least 1 month, despite the intact ability to comprehend and use language.  typically starts during childhood.  majority suffer from anxiety, particularly social anxiety as the mutism manifests in social settings.  patients may remain completely silent or whisper and may use nonverbal means of communication (writing / hand gestures)  Consistent failure to speak in select social situations (e.g., school) despite speech ability in other scenarios.  Mutism is not due to a language difficulty or a communication disorder.  Symptoms cause significant impairment in academic, occupational, or social functioning.  Symptoms last >1 month (extending beyond 1st month of school)  Typically emerges by 1 year of age and peaks by 18 months. When the anxiety due to separation becomes extreme or developmentally inappropriate, it is considered pathologic.  May be preceded by a stressful life event. Excessive and developmentally inappropriate fear/anxiety regarding separation from attachment figures, with at least three of the following:  Separation from attachment figures leads to extreme distress.  Excessive worry about loss of or harm to attachment figures.  Excessive worry about experiencing an event that leads to separation from attachment figures.  Reluctance to leave home, or attend school or work.  Reluctance to be alone.  Reluctance to sleep alone or away from home.  Complaints of physical symptoms when separated from major attachment figures.  Nightmares of separation and refusal to sleep without proximity to attachment figure.  Lasts for ≥ 4 weeks in children/adolescents and ≥ 6 months in adults.  Symptoms cause significant social, academic, or occupational dysfunction.  Symptoms not due to another mental disorder.  Patients with PTSD have experienced a trauma and develop disabling symptoms in response to the event.  Symptoms usually begin within 3 months of the trauma  Syndrome can occur at any age  The person experienced, witnessed or learned of an event that involved actual or threatened death, serious injury, or threat of harm to self or others  The person’s response involved intense fear, helplessness or horror  Sexual abuse  Being diagnosed with a  Rape life threatening illness  Physical abuse  Sudden unexpected  Severe motor vehicle death of family/friend accidents  Witnessing violence  Robbery/mugging (including domestic  Terrorist attack violence)  Combat veteran  Learning one’s child has  Natural disasters life threatening illness  Symptoms must be > one month duration and include:  Re-experiencing symptoms  Active avoidance of triggering stimuli  Emotional numbing  Hyperarousal symptoms  There are recurrent, intrusive thoughts of the event (can’t not think about it)  Dreams (nightmares) about the event  Acting or feeling the event is recurring, or sense of living the event (flashbacks)  Psychological or Physiological Distress upon exposure to reminders or cues of the event.  Avoid thoughts, feelings, places or people that arouse memories of the event  Being unable to recall important parts of the event  Decrease interest in activities  Feeling detached or estranged from others  Decreased range of affect  Sense of foreshortened future  Patient experiences at least two of the following:  Insomnia (falling or staying asleep)  Irritability or outbursts of anger  Decreased concentration  Hypervigilance  Increased/exaggerated startle response  Prevalence is 1% in the general population, and can be as high as 25% in those who have experienced trauma  In combat veterans, prevalence is 20%  Very high prevalence in women who are victims of sexual trauma  PTSD usually begins within 3 months after the trauma.  Symptoms of PTSD may have delayed expression.  50% of patients with PTSD have complete recovery within 3 months.  Symptoms tend to diminish with older age.  80% of patients with PTSD have another mental disorder (e.g., MDD, bipolar disorder, anxiety disorder, substance use disorder).  Psychotherapies  Exposure-based cognitive behavioral therapy  Psychotherapy aimed at survivor anger, guilt and helplessness (victimization)  Pharmacological treatment targets the reduction of prominent symptoms  SSRI’s or SNRI’s are first line therapy  Prazosin, α1-receptor antagonist, targets nightmares and hypervigilance  May augment with atypical (second-generation) antipsychotics in severe cases. ACUTE STRESS DISORDER ADJUSTMENT DISORDER  Major traumatic event  Development of emotional or behavioral symptoms within 3  Similar symptoms as PTSD months in response to an  Shorter duration. identifiable stressful life event.  The onset of symptoms occurs  The symptoms are not those of normal bereavement. within 1 month of the  Resolve within 6 months after  Trauma and symptoms last for stressor has terminated less than 1 month.  Does not meet criteria for another mental disorder.  5–20% of patients in outpatient mental health clinics  May occur at any age.  A phobia is defined as an irrational fear that leads to avoidance of the feared object or situation.  A specific phobia is a strong, exaggerated fear of a specific object or situation.  A social phobia (also called social anxiety disorder) is a fear of social situations in which embarrassment can occur.  Fear of being exposed to public scrutiny  Fear of behaving in a way which will be humiliating or embarrassing  Symptomatic resemblance to panic disorder with anticipatory anxiety (person may be anxious/worrying far in advance of the event)  Extensive phobic avoidance  Distinction: anxiety only occurs when the patient is subject to the scrutiny of others (public speaking, oral exam, eating in the cafeteria)  Phobic stimulus is avoided or endured with intense anxiety  Fear and avoidant behaviors interfere with person’s normal routine or cause marked distress  Speaking in public  Eating in public  Using public restrooms  Marked and persistent fear that is excessive and unreasonable of a specific object or situation  Exposure to the phobic stimulus will provoke an anxiety response  Fear of animals  Fear of heights  Fear of blood or needles  Fear of illness or injury  Fear of death  Fear of flying  Phobias are the most common psychiatric disorder in women and second most common in men (substance-related is first)  Lifetime prevalence of specific phobia: >10%  The diagnosis of specific phobia is more common than social phobia.  Onset can be as early as 5 years old for phobias such as seeing blood, and as old as 35 for situational fears (such as a fear of heights). The average age of onset for social phobias is mid-teens. (mean age 10 / median age 13)  Women are two times as likely to have specific phobia as men; social phobia occurs equally in men and women.  Substance-related disorders are found more commonly in phobic patients, especially alcohol-related disorders. Up to one third of phobic patients also have associated major depression  The cause of phobias is most likely multifactorial, with the following components playing important parts:  Genetic: Fear of seeing blood often runs in families and may be associated with an inherited, exaggerated vasovagal response. First-degree relatives of patients with social phobia are three times more likely to develop the disorder.  Behavioral: Phobias may develop through association with traumatic events. For example, people who were in a car accident may develop a specific phobia for driving.  Neurochemical: An overproduction of adrenergic neurotransmitters may contribute to anxiety symptoms. This has led to the successful treatment of some phobias. (Most notably, performance anxiety is often successfully treated with beta blockers).  The diagnostic criteria for specific phobias is as follows:  1- Persistent, excessive fear elicited by a specific situation or object which is out of proportion to any actual danger/threat.  2- Exposure to the situation triggers an immediate fear response.  3- Situation or object is avoided when possible or tolerated with intense anxiety  4- Symptoms cause significant social or occupational dysfunction  5- Duration ≥ 6 months  6- Symptoms not solely due to another mental disorder, substance (medication or drug), or another medical condition  The diagnosis of social phobia has the same criteria as above except that the feared situation is related to social settings in which the patient might be embarrassed or humiliated in front of other people.  Specific Phobia  Pharmacological treatment has not been found effective. Systemic desensitization (with or without hypnosis) and supportive psychotherapy are often useful. If necessary, a short course of benzodiazepines or beta blockers may be used during desensitization to help control autonomic symptoms.  Systemic desensitization: Gradually expose patient to feared object or situation while teaching relaxation and breathing techniques.  Social Phobia  Paroxetine (Paxil), an SSRI, is FDA approved for the treatment of social anxiety disorder. Beta blockers are frequently used to control symptoms of performance anxiety. Cognitive and behavioral therapies are useful adjuncts.  Obsessions: recurrent, intrusive, unwanted thoughts, feelings or ideas (i.e. fear of contamination).  Compulsions: a conscious repetitive behavior linked to an obsession that, when performed, functions to relieves anxiety caused by the obsession (i.e. compulsive handwashing).  OCD is an Axis I disorder in which patients have recurrent intrusive thoughts (obsessions) that increase their anxiety level. They usually relieve this anxiety with recurrent standardized behaviors (compulsions).  OCD can cause significant impairment of daily functioning, as behaviors are often time consuming and interfere with routines, work, and interpersonal relationships.  Person recognizes the obsession as a “product of his/her own mind”, rather than imposed from the outside, and that they are unreasonable or excessive.  The symptoms cause significant distress in their lives, and patients wish they could get rid of them.The obsessions are “ego-dystonic” (not enjoyable for the ego), as opposed to “ego-syntonic” (the ego likes it).  1- Experiencing obsessions and/or compulsions that are time-consuming (e.g., >1 hour/daily) or cause significant distress or dysfunction.  Obsessions: Recurrent, intrusive, anxiety-provoking thoughts, images, or urges that the patient attempts to suppress, ignore, or neutralize by some other thought or action (i.e., by performing a compulsion).  Compulsions: Repetitive behaviors or mental acts the patient feels driven to perform in response to an obsession or a rule aimed at stress reduction or disaster prevention. The behaviors are not realistically linked with what they are to prevent or are excessive  2- Not caused by the direct effects of a substance, another mental illness, or another medical condition.  1. Obsessions about contamination followed by excessive washing or compulsive avoidance of the feared contaminant  2. Obsessions of doubt (forgetting to turn off the stove, lock the door, etc.) followed by repeated checking to avoid potential danger  3. Obsessions about symmetry followed by compulsively slow performance of a task (such as eating, showering, etc.)  4. Intrusive thoughts with no compulsion. Thoughts are often sexual or violent.  Lifetime population prevalence: 2 to 3%  Onset is usually in early adulthood, and men are equally likely to be affected as women.  OCD is associated with major depressive disorder, eating disorders, other anxiety disorders, and obsessive–compulsive personality disorder.  The rate of OCD is higher in patients with first- degree relatives who have Tourette’s disorder  Neurochemical: OCD is associated with abnormal regulation of serotonin.  Genetic: Rates of OCD are higher in first-degree relatives and monozygotic twins than in the general population.  Psychosocial: The onset of OCD is triggered by a stressful life event in approximately 60% of patients  Pharmacologic SSRIs are the first line of treatment, but higher-than-normal doses may be required to be effective. Tricyclic antidepressants (TCAs) (clomipramine) are also effective.  Behavioral Treatment Behavioral therapy is considered as effective as pharmacotherapy in the treatment of OCD; best outcomes are often achieved when both are used simultaneously. The technique, called exposure and response prevention (ERP), involves prolonged exposure to the ritual-eliciting stimulus and prevention of the relieving compulsion (e.g., the patient must touch the dirty floor without washing his or her hands). Relaxation techniques are employed to help the patient manage the anxiety that occurs when the compulsion is prevented.  Last Resort In severe, treatment-resistant cases, electroconvulsive therapy (ECT) or surgery (cingulotomy) may be effective.  The course is variable but usually chronic, with only about 30% of patients showing significant improvement with treatment, forty to 50% of patients have moderate improvement, and 20 to 40% remain significantly impaired or experience worsening of symptoms.  Obsessive-Compulsive Disorder is different from obsessive compulsive personality disorder (OCPD) Don’t get this mixed up with OCD!  This is a personality disorder (therefore Axis II) in which the person is excessively preoccupied with details, lists, and organization. He or she is overconscientious and inflexible and perceives no problem (symptoms are ego-syntonic, and patients lack insight).  Prominent symptoms of anxiety that are judged to be the direct physiological consequence of a drug or abuse, a medication or toxin exposure  Panic Attacks  Agoraphobia without a history of panic disorder  Panic Disorder without agoraphobia  Panic Disorder with agoraphobia Characterized by at least 6 months of persistent  and excessive anxiety and worry  Characterized by the re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma  Symptoms present for at least one month  If event just occurred and/or symptoms present for less than one month, a diagnosis of Acute Stress Disorder is given  Clinically significant anxiety provoked by exposure to certain types of social or performance situations, often leading to avoidance behavior  Clinically significant anxiety provoked by  exposure to a specific feared object or situation, often leading to avoidance behavior  Characterized by obsessions that cause marked anxiety or distress and/or compulsions that serve to neutralize anxiety  Substance Induced Anxiety Disorder  Anxiety Disorder not otherwise specified THANK YOU Management of Anxiety Disorders Done by: Rizq M. Haddad Anxiety and Anxiety disorders Anxiety: subjective experience of fear and it’s physical manifestations. It is important for clinicians to be able to distinguish normal from pathological anxiety. Anxiety disorders are caused by a combination of genetic, environmental, biological and psychosocial factors. Associated with neurotransmitter imbalances, including increase activity of norepinephrine and decrease activity of GABA and Serotonin. Anxiety and Anxiety disorders Panic Disorder (PD) with/without Agoraphobia Phobic Disorder (social, specific) Obsessive- Compulsive Disorder (OCD) Post-traumatic Stress Disorder (PTSD) Acute Stress Disorder Generalized Anxiety Disorder (GAD) Anxiety disorder secondary to general medical condition Substance-induced anxiety disorder Management of Anxiety Pharmacotherapy Psychotherapy Pharmacotherapy Anti-depressants: Selective Serotonin Reuptake Inhibitors (SSRI) Tricyclic Antidepressatns (TCA) Monoamine Oxidase Inhibitors ( MAOI) Atypical anti-depressants Anxiolytics: Benzodiazepines Buspirone Beta blockers Anti-convulsants Psychotherapies Supportive psychotherapy Cognitive behavioral therapy Systematic desensitization Exposure and response prevention Management of Panic Disorder Pharmacotherapy ▫ The long-term treatment is SSRIs, especially paroxetine and sertaline  Typically take 2-4 weeks to become effective and higher doses are required than for depression)  Always start SSRIs at low dose and increase slowly because It can have side effects that may initially worsen anxiety. ▫ Benzodiazepines  Effective immediately but are best used temporarily because of their risk of causing tolerance and dependency. ▫ Other Antidepressants (clomipramine, imipramine) may be used ▫ Treatment should continue for at least 8-12 months, as relapse is common after discontinuation of therapy. Management of Panic Disorder Psychotherapy ▫ Relaxation training ▫ Biofeedback ▫ Cognitive therapy ▫ Insight-Oriented psychotherapy For Agoraphobia when the coexisting panic disorder is treated usually it resolves. Management of Specific Phobia Pharmacotherapy ▫ Has not been found effective. ▫ A short course of benzodiazepines or beta blockers may be used during desensitization to help control autonomic symptoms. Psychotherapy ▫ Behavior therapy  is most effective ▫ Systemic desensitization  Graded exposure and flooding Management of Social Phobia Pharmacotherapy ▫ SSRIs  Paroxetine is FDA approved for the treatment of social anxiety disorder. ▫ Beta blockers  Used to control symprtoms of performance anxiety. Psychotherapy ▫ Cognitive therapy ▫ Behavioral therapy Management of OCD Pharmacotherapy ▫ SSRIs  The first line of treatment.  Higher than normal doses may be required to be effective. ▫ Tricyclic antidepressants Psychotherapy ▫ Behavioral therapy  As effective as pharmacotherapy.  Best results when used with pharmacotherapy simultaneously. ▫ Exposure and Response Prevention (ERP)  Involves exposure to the ritual-eliciting stimulus and prevention of the relieving compulsion. (e.g., the patient must touch the dirty floor without washing his or her hands). ▫ Relaxation techniques Last resort ▫ Electroconvulsive therapy (ECT) ▫ Surgery (cingulotomy) Management of PTSD & ASD Pharmacotherapy ▫ Antidepressants  SSRIs, TCA, MAOIs ▫ Anticonvulsants  For flashbacks and nightmares. Psychotherapy ▫ cognitive-behavioral, support, psychodynamic therapy ▫ Relaxation training ▫ Support group, family therapy ▫ Eye Movement Desensitivation and Reprocessing (EMDR) Addictive medications (benzoidazepines) should be avoided in the treatment of PTSD because of the high tare of substance abuse in these patients. Management of GAD Pharmacotherapy ▫ Antidepressants  SSRIs, Buspirose,Venlafaxine ▫ Benzodiazepines Psychotherapy ▫ Cognitive-behavioral therapy The most effective treatment approach is a combination of psychotherapy and pharmacotherapy Anti-depressants Selective Serotonin Reuptake Inhibitors (SSRI) Tricyclic Antidepressatns (TCA) Monoamine Oxidase Inhibitors ( MAOI) Selective Serotonin Reuptake Inhibitors (SSRI) MOA: ▫ SSRIs inhibits presynaptic serotonin pumps that take up serotonin, which will increase acailability in synaptic cleft. The most commonly prescribed anti-depressant due to: ▫ Low incidence of side effects, most of which resolve with time. ▫ No food restrictions. ▫ Safer in overdose. Selective Serotonin Reuptake Inhibitors (SSRI) Fluoxetine: ▫ Longest half life with active metabolites; therefore, no need to taper. ▫ Safe in pregnancy, approved for use in children. ▫ Can elevate levels of neuroleptics, leading to increase side effects. Sertaline: ▫ Highest risk for GI disturbances. ▫ Very few drug interactions. Proxetine: ▫ High protein bound, leading to several drug interactions. ▫ More anticholinergic effects like sedation, constipation, weight gain. ▫ Short half-life leading to withdrawal phenomena if not taken consistently Selective Serotonin Reuptake Inhibitors (SSRI) Fluvoxamine: ▫ Approved only for use in OCD. ▫ Nausea and vomiting more common. ▫ Lots of drug interactions. Citalopram: ▫ Fewest drug interactions. ▫ Possibly fewer sexual side effects. Escitalopram: ▫ Levo-enantiomer of citalopram; similar efficacy, fewer side effects. ▫ More expensive that citalopram. Selective Serotonin Reuptake Inhibitors (SSRI) Indications : Depression in children above 6 years (fluoxetine) and adults Premenstrual dysphoric disorder (sertraline) Impulse control disorder Hypochondriasis and body dysmorphic disorder (fluoxetine) Premature ejaculation (fluoxetine/sertraline) Autism and ADHD/obesity/eating disorder/migraine/IBS In anxiety disorders: ▫ Panic disorder  paroxetine and sertraline ▫ OCD  all are effective. But if a child has OCD our first choice will be sertraline then fluvoxamine and finally citalopram. ▫ Agoraphobia, social anxiety, Posttraumatic stress disorder (PTSD),Acute stress disorder  paroxetine Selective Serotonin Reuptake Inhibitors (SSRI) Less side effects than TCA & MAOI due to serotonin selectivity. (don’t work on histamine, adrenergic or muscarinic receprtos) Side Effects and management: ▫ Sexual dysfunction (25-30%):  decrease interest, anorgasmia, delayed ejaculation. These typically do not resolve in a few weeks.  Treated by augmenting the regimen with buproprion, changing to non- SSRI or by adding another medications like sildenafil for men. ▫ GI disturbances:  mostly nausea and diarrhea  giving food can help. ▫ Insomnia:  also vivid dreams,  often resolves over time ▫ Headache. Selective Serotonin Reuptake Inhibitors (SSRI) Side Effects and management: ▫ Anorexia, weight loss. ▫ Restlessness  An akathisia-like state has been reported at initiation and termination of SSRIs.  Benzodiazepine or B-blocker or anticholinergic ▫ Seizure  Rate of 0.2%  Slighty lower than TCAs. Selective Serotonin Reuptake Inhibitors (SSRI) Serotonin syndrome Caused by taking 2 drugs, both of which increase serotonin  too much serotonin in the brain; like when used with MAOI Symptoms: nausea, diarrhea, palpitations, chills, rigor, restlessness, confusion and lethargy, Hyperreflexia. Drugs that increase the serotonin maybe found over the counter cold remedies, possibly  serotonin syndrome. Selective Serotonin Reuptake Inhibitors (SSRI) Management of Serotonin Syndrome ▫ stop the drug ▫ ABC ▫ Gastric lavage if overdose ▫ IV fluid and NaHCO3 ▫ Benzodiazepines (calm the pt, muscle relaxant and prevent seizure) ▫ B-blocker ▫ Mirtazapine ▫ ECT Selective Serotonin Reuptake Inhibitors (SSRI) SSRIs increase suicidal thinking and behavior, this is most documented in children and adolescents but may be accurate for adults as well. You should give a patient an adequate trial of antidepressants, usually between 1 and 2 months at full dose, before considering changing medication. Tricyclic Antidepressants (TCA) MOA: ▫ Inhibits the reuptake of norepinephrine and serotonin, which leads to increase availability of monoamines in the synapse. Because of the long half lives, most are dosed once daily. They are rarely used as first-line agents because they have a higher incidence of side effects, require greater monitoring of dosing, and can be lethal in overdose. Tricyclic Antidepressants (TCA) Tertiary amines: (highly anticholinergic, more sedating, greater lethality in overdose) ▫ Amitriptyline  Useful in chronic pain, migraines, and insomnia. ▫ Imipramine  Has intramuscular form  Useful in enuresis and panic disorders ▫ Clomipramine  Most serotonin specificm useful in treatment of OCD. ▫ Doxepin  Useful in treating chronic pain  Emerging use as a sleep aid in low doses Tricyclic Antidepressants (TCA) Secondary amines: (metabolites of tertiary amines) ▫ Nortriptyline  Least likely to cause othostatic hypotension  Useful therapeutic blood levels  Useful in treating chronic pain ▫ Desipramine  More activating; least sedating  Least anticholinergic Tricyclic Antidepressants (TCA) Indications: ▫ Depression ▫ Anxiety disorders OCD clomipramine PTSD imipramine and doxepin ▫ Pain syndrome ▫ Nocturnal enuresis ▫ Eating disorder ▫ Attention Deficit Hyperactive Disorder ▫ Insomnia ▫ Compulsive behaviors in children Tricyclic Antidepressants (TCA) Side Effects:  Anti-histaminic properties (sedation)  Anti-adrenergic properties (arrhythmias, tachycardia, postural hypotension)  Anticholinergic effects ( dry mouth, constipation, urinary retention, blurred vision)  Weight gain  Major complications 3Cs (Convulsion, Coma, Cardiotoxicity)  Lethal in overdose  Seizures (0.3%) Monoamine Oxidase Inhibitors MOA ▫ Prevent the inactivation of biogenic amines such as norepinephrine, serotonin, dopamine and tyramine. Examples of MAOIs ▫ Phenelzine, tranylcypromine, isocarboxazid. Uses ▫ Depression, panic disorder, posttraumatic stress disorder, acute stress disorder. Monoamine Oxidase Inhibitors Side Effects: ▫ Serotonin syndrome if taken with SSRI ▫ Hypertensive crisis when taken with tyramine- rich foods or sympathomimetics. ▫ Postural hypotension, drowsiness, weight gain ▫ Sexual dysfunction, dry mouth, sleep dysfunction Anxiolytics Benzodiazepines Buspirone Beta blockers Benzodiazepines MOA ▫ Works by potentiating the effects of gammaamino-butyric acid GABA. First-line anxiolytics. Many patients become dependent and addicted. Choice of BDZs is based on time to onset of action, duration of action, and method of metabolism. Benzodiazepines should not be used as sole treatment for chronic anxiety. Benzodiazepines Long acting (half-life >20 hours) ▫ Diazepam  Rapid onset.  Used during detoxification from alcohol or sedative- hypnotic-anxiolyticx and for seizure. ▫ Clonazepam  Treatment of anxiety, including panic attacks.  Avoid with renal dysfunction; longer half-life allows for once daily dosing. Diazepam Contraindications: Cautions: - Respiratory disease - Respiratory depression - Muscle weakness - Unstable Myasthenia Gravis - Myasthenia Gravis - History of drugs and alcohol abuse - Pulmonary insufficiency - Marked personality disorder - Acute porphyria - Sleep apnea syndrome Benzodiazepines Intermediate acting (half-life 6-20 hours) ▫ Alprazolam  Treatment of anxiety; including panic attacks  Short onset of action leads to euphoria, high abuse potential. ▫ Lorazepam  Treatment of panic attacks, alcohol and sedative-hypnotic- anxiolytic detoxification, agitation ▫ Oxazepam  alcohol and sedative-hypnotic-anxiolytic detoxification  Not metabolized by the liver. ▫ Temazepam  Decreasingly used for treatment of insomnia due to dependence.  Not metabolized by the liver. Benzodiazepines Short acting (half-life < 6 hours) ▫ Triazolam  Treatment of insomnia.  Primarily used in medical and surgical settings. ▫ Midazolam  Primarily used in medical and surgical settings. Benzodiazepines Side effects: ▫ Drowsiness ▫ Impairment of intellectual function* ▫ Reduced motor coordination (careful in elderly) ▫ Anterograde amnesia ▫ Withdrawal can be life threatening and causes seizure ▫ Toxicity with alcohol: Respiratory depression Benzodiazepines Special cases ▫ Hepatic Impairment  benzodiazepines can precipitate Coma if used in hepatic impairment , so use benzodiazepines that are not metabolized by the liver: Lorazepam, Oxazepam, Temazepam. ( L.O.T ) ▫ Renal impairment  patients with renal impairment have increased cerebral sensitivity to these drugs. ▫ Pregnancy  There is a risk of neonatal withdrawal symptoms when these drugs are used during pregnancy.  So avoid regular use and use only if there is a clear indication such as seizure control  high doses administrated during late pregnancy or labor may cause neonatal hypothermia , hypotonia , and respiratory depression.  Teratogenic - especially in the 1st trimester- Cleft palate. ▫ Breast-feeding  should be avoided if possible during breast-feeding. Buspirone The anxiolytic action is at 5HT-1A receptor (partial agonist) It has a slower onset of action than BDZs (takes 1-2 weeks for effect). Not considered as effective as other options, and so it is often used in combination with another agent (SSRI), for treatment of anxiety. It idoes not potentiate the CNS depression of alcohol (useful in alcoholics), and has a low potential for abuse/addiction. Buspirone Side effects: ▫ Nausea ▫ Dizziness ▫ Headache ▫ Nervousness ▫ Excitement Rarely …… dry mouth , tachycardia , chest pain , drowsiness , confusion , seizure , fatigue and sweating Buspirone Special cases ▫ Hepatic Impairment  Reduce dose in mild and moderate disease  Avoid it in severe disease ▫ Renal impairment  Reduce dose in mild and moderate cases  Avoid it if eGFR less than 20 ml/min/1.73 m2 ▫ Pregnancy and breastfeeding  avoid this drug. B-blockers (propranolol) Useful for treating the autonomic effects of panic attacks or performance anxiety, such as palpitations, sweating a