Psychiatry Definitive PDF

Part I 1. Classification of mental disorders Type description Mental disorder: abnormal behavior after a normal period functioning. Personality disorder: unable to behave in certain normal ways that have been present con- tinuously from early adult life. Learning disability: impairment of intellectu...

Part I 1. Classification of mental disorders Type description Mental disorder: abnormal behavior after a normal period functioning. Personality disorder: unable to behave in certain normal ways that have been present con- tinuously from early adult life. Learning disability: impairment of intellectual functioning present from early life. The ideal diagnostic system should be based on the etiology, but nowadays our current knowledge on the cause of mental disorders in not sufficient for a reliable etiological classifi- cation. This is the reason why the diagnostic system is based on common clinical features, shared natural history, common treatment response or combination of all of three. One of the most rational way to classify psychiatric disorders is “syndromal”: a syndrome is a group of symptoms and signs that often occur together and delineate a recognisable clinical condition. - Diagnoses are grouped according to the symptoms (descriptive attitude), not according to the etiopathogenesis (atheoretical principle). - Diagnosis is characterized by description of symptoms; sometimes time criteria (“for at least 1 month”) or exclusion criteria (“no organic brain damage”) are present. - Diagnostic criteria are heterogeneous (subjective feelings of the patient, somatic com- plaints, objective behavior, working disability or reaction of the social environment). The process of establishing a diagnosis is essential to: - Enable the communication about diagnosis, - Facilitate the comprehension of the underlying causes, - Facilitate the prediction of the prognosis. In psychiatric classification there are two system in use worldwide: - International classification of disease (ICD-10)—> created by the World Health Organi- zation, - Diagnostic and statistic manual of mental disorders (DSM-V)—> created by the Ameri- can Psychiatric Association. IDC-10 It is a general medical classification system. It includes 21 chapters, each identified by roman numbers and a letter. - The letter F identifies the disorder: mental and behavioral, - The first number refers to the broad diagnostic category (F0-organic mental disorder, F3- mood disorder, etc.), - The second number specifies the mental disorder (ex. F20-schizophrenia in the group F2- psychoses), - The other two numbers are additional information specific to the disorder: subtype, course, type of symptoms. International Classification of Disease (ICD-10) by WHO, usually used in clinical. Valid in the Czech Republic and the rest of the world (apart from America) since 1990s Basic groups of mental disorders according to the ICD-10 F00: F09 Organic brain disorders F10: F19 Mental disorders due to psychoactive substance abuse F20: F29 Schizophrenia and other psychoses F30: F39 Mood disorders (affective disorders) F40: F49 Neurotic disorders, anxiety disorders F50: F59 Behavioral symptoms (eating disorders, sleep disorders) F60: F69 Personality disorders !1  F70: F79 Mental retardation F80: F89 Disorders of mental development F90: F98 Disorders of behavior and emotions in the childhood F99 Mental disorder not specified Multiaxial version of ICD-10 uses 3 axes to broaden the assessment of the patient condition: - Axis I: mental disorders, personality disorders, intellectual disabilities, somatic diseases; - Axis II: disorders of functions, decrease in the ability due to the current mental disorder (impairment in self-care, working ability, family relationship, social behavior), - Axis III: external factors contributing to the disease (unemployment, divorce, legal prob- lems, lifestyle problems). Multiaxial diagnosis In addiction to the primary mental disorders—> additional axes regarding patient’s psychoso- cial problems, personality factors, medical health, degree of disability. Etiology and pathogenesis of mental disorders The exact cause of mental illness is not known, but results from a combination of biological, psychological, and environmental factors. Biological factors: - Genetics (hereditary): people who have a family member with a mental illness are more likely to develop it. Susceptibility is passed on in families through genes: usually linked to abnormalities in many genes-not just one. But still mental illness itself occurs from the interaction of multiple genes and other factors-stress, abuse, traumatic events, which in- fluence, or trigger an illness in a person who has an inherited susceptibility to it. - Prenatal damage: disruption of early fetal brain development or trauma that occurs at the time of birth: loss of oxygen to the brain. - Substance abuse: long-term substance abuse has been linked to anxiety, depression, and paranoia. - Other factors: poor nutrition and exposure to toxins (lead) may play a role. - Abnormal balance of neurotransmitters (NT) - Defects in or injury to certain areas of the brain have also been linked to some mental conditions. Psychological factors: - Severe psychological trauma suffered as a child, such as emotional, physical, or sexual abuse. - An important early loss (parents) - Neglected Environmental factors: - Death or divorce - Social or cultural expectation - Substance abuse by the person/ parents - Changing jobs or school - Feelings of inadequacy, low self-esteem, anxiety, anger, loneliness 2. Symptoms in disorder of consciousness, orientation and attentiveness I. Symptoms in disorders of consciousness Consciousness is the state of being aware of and responsive to one’s sourroundings and him/ herself. [Attention is the ability to clearly focus the consciousness on something. Clarity of con- sciousness is known as lucidity. Capacity of consciousness is the ability to focus on several !2 subjects or events round us at the same time. Idiognosia: is defined as the ability to assign my consciousness to my own personality]. In clinical practice the patient’s consciousness is usually evaluated based on his/her attention to: place, time, person, situation and it is important to consider whether his/her speech and behavior make any sense and if they are in accordance with the patient’s previous intentions and values. Consciousness is physiologically changed during sleep. Disorders: - Quantitative: increase, dicrease, - Qualitative: changes. Quantitative disorders of consciousness: Assess consciousness using the GCS (Glasgow Come Scale) in medicine. Quantitative disturbances may occur secondarily: after a suicidal attempt or within a serious somatic disorder. This type of patient is not treated at a psychiatric department but they are instead shifted to the ICU or department of anesthesiology, resuscitation and intensive care. - Lethargy/somnolence: abnormal drowsiness; state of near sleep. Patient is aroused for a short time through speech and pain stimulus. The patient is able to answer a question for a short time, but his/her thinking is slowed down. - Stupor: unnaturally deep sleep, seen often in drunk patients. After a painful stimulus the patient react by changing the body position, but he/she is not able to talk with the doctor. - Coma: state of prolonged unconsciousness, physiological reflexes gradually fade away and vital functions are reduced. Qualitative disorders of consciousness: - Delirium: confusional state; the patient is confused and disoriented and has a nonsensic- al behavior; it develops gradually, it fluctuates during its course. The symptoms usually start in the evening: during the day the patient may sleep or his/her consciousness may be temporary lucid. It may last for a few days or weeks and stops gradually over few days. Partial amnesia is present after. Causes: vascular dementia, failure of body organs, general anesthesia, head trauma, sud- den withdrawal of alcohol in a person dependent on alcohol, anticholinergic adverse ef- fect of some medications. With a delirium prognosis few factors may need to be considered: decrease in brain ox- idation, imbalance of neurotransmitters, lack of neuropeptide synthesis and insufficient acetylcholine synthesis. - Obnubilation: clouded mental state: the patient is not fully orientated. This state starts suddenly from a clear consciousness. Does not fluctuate during its course. Usually lasts for few minutes, but rarely several weeks and it ends quickly. Total amnesia occurs. Several forms: - Stupurous: patient does not move, - Delirious: extreme restlessness, - Somnambulation or sleep walking. - Ganser’s syndrome: dissociative disorder*; the patient is quiet but disorientated. The patients are seen to have no control over their actions. The patient answers to questions with no sense content. May be seen to occur in emotionally unstable patients after a sud- den and severe psychotrauma. *Seen to be a dissociative disorder: patient is asked 1+1: 3 or 1+1: engine: non-sensical answers or wrong answers. II. Symptoms in disorders of orientation: Orientation is the ability to correctly identify: actual time, local, personal and situational rela- tions and place. !3 Patient may be disorientated to place, time, person and situation and it is usually seen to be combined. We typically find disorders in orientation in: qualitative disorders of consciousness and organ- ic impairment of the brain (dementia). We ask the patient questions to check orientation: Where are you? What time is it? What is the date? What year are you in? III. Symptoms in disorders of attention (attentiveness) Attention is the ability to focus one’s consciousness to a certain object or action. While doing this important stimuli are emphasized and non-important ones are suppressed. Capacity—> range of attentiveness. Selectivity—> ability to focus on desired events or subjects. Tenacity: ability to focus on one object or event for a long time. Concentration: ability to focus attention on one object or event for a long time and supppress everything else at the same time. Vigility: ability to shift our attention from one topic to another. Lability: aimless shifting of attention. Oscillation: fluctuation of attention in intensity. Stability: not being able to change the intensity of attention. Attention may be active (at the subject’s will), passive (without an active involvement of the person’s will) or against the subjects will (pain stimulus). Assess attention: - number seven test: we ask the patient to subtract 7 to 100 and go on. - Bourdon concentration test - Others Disorders: - Aprosexia: complete inability to concentrate attention: manic disorders, - Hyposexia: decreased ability to concentrate attention: depression, - Hypersexia: increased ability to concentrate: psychostimulant agents, - Forgetfullness: inability to shift attention effectively: exhaustion, - Paraprosexia: reaction that may be premature or delayed. 3: Symptoms in disorder of perception Perception is a process of recognizing the world and oneself using the human senses. Perception is a process of transferring physical stimulation into psychological information. In mentally health people: - Eidetic image: ability to intentionally evoke a sense of perception (with substantial accur- acy), - Synesthesia: during a stimulation by a certain stimulus the subject experiences another stimulus which is not present objectively (a sensation caused by another sensation—> a sound is experienced as being seen; intoxication with hallucinogens), - False image: the image which has been experienced previously carries on even if the stimulus is not present anymore. - Pareidolia: ability to perceive images and patterns in random objects or heard sounds (creation of clear perceptions based on vague stimuli—> a passenger in a train hears “a music” instead of blows of the train wheels). - Sense illusion: incorrect perception of spatial relationships; imperfection of our senses. Quantitative disorders: - Increased perception: the capacity of perception is increased, but the accuracy is de- creased. In a manic state after psychostimulants (amphetamine, metamphetamine, co- !4  caine), in hypchondria (the patient excessively concentrates on his/her physical sensa- tions). The capacity of perception is increased but the accuracy is decreased; - Decreased perception: in exhaustion, depression. The capacity of perception is decreased; the patient perceives only a part of stimuli. Qualitative disorders: - Hallucination: false sensory perception not associated with real external stimuli, - Illusion: misperception or misinterpretation of real external sensory stimuli; illusions may occur with more of the human senses than vision, but visual illusions are the most well-known and understood: Dysmorphopsias: distortions of visual content, Kahlbaum’s hallucinations: sensation grossly distorted or incongruent with the stimulus; healthy people can also sometimes experience illusion; frightened per- son in a badly lit street. Bush=man. - Pseudohallucination: the patient knows that the hallucination is pathological, due to a mental disorder or an illicit drug; t is a hallucination that is recognized as a hallucination, as opposed to a "normal" hallucination, which would be perceived as real, - Pseudoillusion: the patient knows that the illusion is pathological. Hallucinations: - Auditory hallucinations: false perception of sounds or voices (imperative, antagonistic): Commanding hallucinations: often associated with schizophrenia; can harm him/ herself or others. The command can be simple, but sometimes it is a threat. Antagonistic voices: voices that quarrel with each other. Acoasma: simple auditory hallucination (ex. whistling), Teleological hallucinations: hallucinations of advising, criticizing or admonishing voices. - Visual hallucinations: false perception related to sight, patient may see: animals (zoopsia), large/small objects (macropsia: objects seem larger/micropsia: objects are seen as smaller), oneself (autoscopic hallucination), Pick’s vision: the patients sees the walls deforming, collapsing and people walking through them; frequent in delirium, Hemianopic hallucinations: the subject hallucinates in the blind part of his/her field of vision, ex. when the occipital bone is damaged, Photom: simple visual hallucination. Charles Bonnet’s syndrome: severe myopia or blindness in the elderly leads to dis- tinct visual hallucinations. - Gustatory hallucinations: false perception of taste (unpleasant taste in epilepsy before a seizure or in brain tumors), - Olfactory hallucinations: false perception of smell, - Tactile hallucinations: false perception of touch, - Combined: related to two or more senses at the same time—> schizophrenia and intoxic- ation with hallucinogens. Other important terms related to hallucinations: - Mood-congruent hallucination: the content of hallucination is consistent with depres- sion or mania (dead persons or a graveyard in depression, the God in mania), - Mood-incongruent hallucination: the content of hallucination is not consistent with de- pression or mania (the mother’s voice in depression, quarrelling people in mania), - Somatic hallucination: false sensation of things occurring in the body, they appear to arise from internal organs, - Negative hallucination: the patient does not perceive a stimulus which is really presetn (does not see him/herself in a mirror), - Motion hallucination: the patient perceives his/her body moving, falling or that some- body is moving patient’s limbs or body, - Verbal motor hallucination: the patient feels that someone is talking though the patient’s !5  mouth, - Graphic motor hallucination: the patient feels that someone else steers the patient’s hand while writing, - Intrapsychic hallucinations: patient feels that someone else is putting his/her thoughts into the patient’s head (thoughts insertion) or that someone else is stealing the patient’s thoughts from his/her head (thoughts withdrawal). Although hallucinations are generally regarded as the hallmark of mental disorder, healthy people might also experience them: - Hypnagogic hallucination: occurring while falling asleep (nonpathological), - Hypnopompic hallucination: occurring while awakening from sleep (nonpathological). Diagnosis with hallucinations: - Schizophrenia, - Schizoaffective psychosis, - Mood disorders (mania or depression with psychotic features), - Substance-related disorders (delirium tremens with micropsia, hallucinogenic drugs). Differential diagnosis: - Brain tumors (auditory, visual hallucinations): CT, MRI, - Epilepsy (gustatory, olfactory hallucinations): EEG. Treatment: - Neuroleptics (antipsychotic drugs): D2 receptor blockers. 4: Symptoms in disorders of thinking Thinking is the top level of our recognizing process: it is specific for humans. Whilst thinking we look for association between object and event, we try to reconstruct the past and predict the future. Speech is an external manifestation of thinking. We can distinguish between: - Disorders in speed of thinking, - Disorders in structure of thinking, - Disorders in content of thinking. I. Speed of thinking - Psychomotor retardation: the mental function is slowed down (depression), - Mutism: patient doesn’t speak but the thinking process may still be going on (dissociative disorders), - Accelerated thinking: faster thinking but it is inaccurate (mania, intoxication with psy- chostimulants), - Psychomotor acceleration: all mental functions are accelerated (mania), - Pseudoincoherence: thinking is accelerated so much that speech becomes incoherent, but the logic of thinking is preserved, thinking itself is coherent but the patient is not able to verbalize the idea (mania), - Logorrhea: the impact of accelerated thinking in speech—> the speech is accelerated. II. Structure of thinking: - Perseveration: flow of ideas is in motion but the person returns back to the same idea (dementia) or there is a persisting response to a prior stimulus even if a new stimulus has been presented, - Circumstantiality: the focus on a conversation frequently drifts to unnecessary details and remarks, but returns back to the original conversation topic in the end: organic brain dis- orders, - Tangentiality: disturbance in the associative thoughts process (incoherent thinking), in which the patient tends to digress from one to another topic that arises through associ- ation; the answer never approach to the point of a question—> NO logic in patient idea !6  (schizophrenia), - Magical thinking: is the belief that something happened because of another event, but without any rational links of causation or a hidden significance is attributed to events (physiologically in children or superstition in adults), - Illogical: the reasoning does not comply with the rules of logic: schizophrenia; patient’s logic is superficial, formal, unrelated with the content of ideas (ex. patient may ask for a bandage for his head so that the ideas cannot escape from his/her mind). - Neologism: patients create new words, which only they can understand (schizophrenia), - Obsessive: the ideas constantly reoccur in the person’s mind against their will; patients cannot resist even if they know that they are pathological (ex. OCD: did I lock the door?), - Paranoid: patients associate things in the environment to their own personality: patient sees a police car and thinks they are after them. III. Content of thinking Delusions: are false believes caused by a mental disorder, the content is not true and cannot be disproved; the patient behaves in the sense of delusion (quarrels, he/she is aggressive, etc.). these believes are firmly sustained despite what almost everybody believes and despite obvi- ous proof or evidences of the contrary. The belief is not accepted by other people, the patient’s life is damaged: job, family, social activities. Delusions can be easily detected because they are bizarre and very unrealistic; others are harder to detect because they could be true (ex. I suffer from HIV). Differs from illusion—> misperception of real external stimuli. Types of delusions: - Primary: arise “de novo”, they cannot be explained on the basis of other experiences or perceptions; also known as autochthonous delusions (schizophrenia), - Secondary: delusions whose development might be explained by other abnormalities of the mental state. Classification: - Expansive delusions: the person exaggerates his or her personal significance and abilit- ies; typical in mania and sometimes seen in delusional disorders/schizophrenia; Grandious delusions: the patient believes he/she has special power or abilities (tele- pathy), Megalomanic delusion: the patient considers him/her person as significant (director of the FBI), Grandiose identity: the patient thinks that he/she has special origins, Inventive paranoia: the patient believes he/she invented something, Religious delusions: the patient thinks he/she is a religious figure, Reformatory paranoia: the patient thinks he/she is qualified to reform and save the world, Cosmic delusion: the patient thinks he/she can communicate with extraterrestrial civilizations. - Depressive delusions: the person underestimates his/her abilities, person and signific- ance. Usually in major depression. Delusion of self-accusation: the patient thinks he/she is responsible for a misfortune in the family or in the society, Delusion of self-loathing: the patient thinks to be not able to do anything, no skills, Delusion of poverty: the patient thinks he/she will be deprived of all material posses- sions, Nihilistic delusion: the patient should ceased to exist (I’m such a bad person, I don’t deserve to exist), Somatic delusion: related to strange functioning of the body (lungs of stone, stomach of glass, eaten by warms), Dysmorphophobia: the patient thinks that some parts of his/her body are mutilated. - Paranoid delusions: the patient attributes significance to irrelevant events (they laugh at !7  his place of work which means they laugh at me): Delusion of persecution: the patient thinks he/she is persecuted, spied, poisoned, gradually killed by someone, Delusion of infidelity: false belief that the partner is unfaithful (without any evidence), Erotomania: the patient believes he/she is beloved by an important person (an actor); the patient persecutes/stalks this person, Delusion of appersonation: the patient thinks he/she is someone else, Delusion of metamorphosis: the patient thinks he/she has changed into an animal. 5. Symptoms in disorders of emotions Emotions are the expression of our attitude to ourselves and the surrounding world. Emotions are associated with physical manifestation: facial expression, pantomimics (gesture), tone of voice, vegetative changes, hormonal changes. Definition: emotion is a complex feeling state with psychic, somatic and behavioral compon- ents that is related to affect and mood. Affect: intensive, short-term emotion associated with vegetative signs, somatic symptoms and behavioral symptoms. A person's affect is their immediate emotional state which the person can recognize subjectively and which can also be recognized objectively by others. It usually swift, intensive, short, fierce, with somatic symptoms (ruddy face, deep breathing) and behavioral symptoms (gesticulation, restlessness). Mood: long-lasting, less intensive emotion, usually not with somatic or behavioral symp- toms and usually have no point of origin. Classification of emotions: - Lower emotions: are feelings connected to: perception (pleasant feeling of touching some material), body sensations (pain, hunger), feelings connected to drives (sexual urge), individual feeling (happiness, sadness). - Higher emotions (human beings): social feelings (love, empathy), esthetic feelings (beauty), ethic feeling (sense of justice), intellectual feeling. Euthymic mood: normal range of mood in healthy persons. Disorder of emotions include: - Disorders of affect, - Disorders of mood, - Qualitative disturbances of emotions. Disorder of affect - Increased affective irritability: readiness for frequent and strong affects, e.g. in an emo- tionally unstable personality. - Uncontrolled affect: the subject is carried away by his/her emotions and the result is usu- ally violence; no disorder of consciousness is present, - Pathological affect: strong affect in a predisposed personality that usually manifests with aggressiveness, associated with an acute strong psychotrauma + personality disorder + indisposition (exhaustion)—> disturbance of consciousness (delirium) with confused or violent behavior (homicide), followed by a complete amnesia; the patient is not respons- ible of his/her behavior from a legal point of view, because it is associated to a qualitative !8  disorder of consciousness. - Anxious raptus: an enormous feeling of anxiety, that may result in an extreme and violent aggression and destructive activity against oneself or other people or objects (major de- pression), - Inhibition of affect: reaction to a traumatic events, after which the patient behaves calmly, automatically, without emotions. - Affective stupor: the patient is unable to move and speak for a short time, usually after a terrible experience; consciousness is preserved. - Inappropriate affect: disharmony between the emotional expression and the idea, thought or speech accompanying it (e.g. Inappropriate face expression, inappropriate tonality), - Blunted (flat) affect: a severe reduction in the intensity of emotional expression (mono- tonous voice, immobile face). Non-managed affect: intensive, fierce, violent, no delirium and amnesia are present Subdued affect: affective reaction during the demanding situation is subdued, intense reac- tion is postponed. Disorders of mood Occur when the duration of mood is inadequately long, it may last for few weeks, months or years without fluctuating in mood intensity (physiologically—> few hours). The external cause is missing and it influences the patient’s life. There are two types: - Expansive mood: the mood is pathologically increased = expression of one’s positive feelings without limitations or restraint; it can be associated with an overestimation of one’s significance or importance + movements and speech are quick. It manifests with: Euphoria: the patient is extremely and inadequately happy but calm, Manic mood: the patient is extremely and inadequately happy, restless and hyper- active, Ecstatic mood: increased mood in a turbulent way (strong religious, sexual, sporting experience), Moria or frivolity: indifference, lack of foresight, tactlessness, Explosive mood: tendency for hot-headedness (=easily angered). Resonant mood: the patient is hyperactive and self-confident (like in expansive mood) but hostile and irritable (like in depression). - Depressive mood: psychopathological feeling of sadness, movements and speech are slow, a suicidal behavior may occur. It manifests with: Anxiety mood: a general fear with no clear content, Helplessness: inability to find a solution, Apathetic mood: low activity, low interests in anything, indifference, unconcern, Dysphoric mood: irritation + harshness + susceptibility to inadequate emotional reactions, Anhedonic mood: loss of interests in regular pleasurable activities (=inability to experience pleasure). Qualitative disturbances of emotions (cannot measure them) - Labile mood (mood swings): oscillations between euphoria and depression or anxiety (vascular dementia)—> incontinence of emotions: extremely labile emotions; - Ambivalence: coexistence of two opposing impulses towards the same object in the same person in the same time (schizophrenia), - Disorders of high emotions: heartlessmess, egoism (antisocial personality disorders), - Phobia: fear of some objects or situations (agoraphobia, claustrophobia, mysophobia, acrophobia); the patient is not able to suppress this fear even if s/he knows it is pathologi- cal; - Alexithymia: inability to identify, describe and understand emotions, mood is rather de- scribed by physical symptoms. - Flat emotions: lack of interests, apathy (schizophrenia, depression, organic brain disor- ders), !9 - Emotional oversensitiveness: strong emotional reactions to a weak stimulus, - Increased tenacity of emotions: prolonged persistent emotions (personality disorders). - Catathymia: mental processes are under the control of emotions, - Moral insanity: absence of emotions, inability to love, extreme egoism, antisocial behav- ior. Other important terms related to emotions: - Grief (mourning): deep but physiological sadness associated to a real loss, - Fear: caused by a recognized and realistic danger, - Panic: acute, episodic, intense attack of anxiety. Physiological disturbances associated with mood disorders: - Anorexia: loss of appetite, - Insomnia: initial (difficulty in falling asleep), middle (difficulty in sleeping through the night) and terminal (early morning awakening), - Diminished libido: decreased sexual interest (in depression), - Constipation: difficulty in defecating (in depression). Examination of emotions: - Asking the patient, - Observing the patient (nonverbal manifestations of emotions), - Personal history, - Objective personal history (suicidal behavior), - Psychological testing. 6. Symptoms in disorder of personality Personality is the integration of human mental functions. It is influenced by: biological back- ground, psychosocial influences and social (family, friends, job, school). Idiognosis: the ability to recognize your own personality and divide it from external envir- onment. Premorbid personality: indicates the patient’s personality before the mental illness. - Degradation: total decrease of the level of personality (chronic alcoholism), - Deterioration: a decrease of intellect, typically in dementia, - Depravation: a decline of personality in a social sphere (alcoholism), - Disintegration: when parts of the personality fail to cooperate (schizophrenia), - Break-up personality: disintegration and simultaneous damage in individual parts of personality, - Split personalities: two or more personalities are simultaneously present within the pa- tient and the patient is aware of this (histrionic personality disorder), - Multiple personalities: two or more personalities are successively present in the patient, who is able to experience the present personality but suffers from a memory loss of the other personalities which are not present in that moment. - Metamorphosis: patient may think he or she is another person or even an animal, - Depersonalization: the patient perceives him/herself as strange, - Derealization: a previously well experienced situation is perceived by the patient as strange, - Agnosia: inability to process sensory information or recognize objects, person, shapes (organic brain disorders), - Aphasia: disturbance of comprehension and expression (organic brain dysfunction). 7. Disorders in memory and intellect I. Symptoms in disorders of memory Memory is the ability to accept, retain, and recall past experiences and events. !10 Types of memory: - Mechanical: simple memory of events and how they followed each other, - Logical: based on relations and causal associations among events, - Visual and auditory: based on sensual perception. Levels of memory: - Immediate, - Recent, - Recent past, - Remote. Quantitative disorders of memory (able to measure them on a scale) - Amnesia: partial or total, retrograde and anterograde and temporary or permanent, loss of memory (after trauma, dementia). - Hypomnesia: memory is weakened, - Hypermnesia: memory is increased in a pathological way: memory related to symptoms in a particular disease in hypochondriacs. Qualitative disorders of memory (harder to measure) - Pseudologia phantastica: fabled lies—> the patients tells incredible stories as if they have truly experienced them, but they are not able to distinguish between real events or imagination; - Confabulation: is an unconscious filling of gaps in memory; serious problem with en- coding new information. Missing information is unknowingly substituted by fabrications. Patients forget about the made up information and keeps on adding new made up inform- ation to the story. - Memory illusion: non-experienced event (they may have read it in a book), - Cryptomnesia: patient does not remember that his or her idea comes from someone else’s idea. - Ecmnesia: the time localization of a memory is damaged, - Paramnesia: one memory can be divided into two memories situated in different time periods or two memories from different time periods can be united, - Deja-vu, -entendu, -eprouve: inappropriate illusions of familiarity with what the patient is seeing, hearing, experiencing, - Jamais-vu, -entendu, -eprouve: the patient feels that he/she has never seen, heard, ex- perienced something, even if it is not true. II. Symptoms in disorders of intellect Intellect is the rational ability to adapt to changing environment. To survive it is needed to explore the surroundings, interpret the information and use it. Measured by IQ (intelligence quotient). - IQ in children: mental age divided by physical age x 100, - IQ in adults: the result of the IQ test of the patient is divided by the given result of the population. Average IQ given in the range of 91-110. Above average: 111-140. Below average: 70-90. Disorders: - Intellectual disability: intellect has not developed sufficiently; the development usually starts within the first 2 years of a child’s life, so if the damage occurs before this then there is a chance of disability. - Dementia: intellect has developed but the damage came later on. - Pseudodementia: clinical features of dementia but not caused by an organic condition (usually depression). - Dyscalculia: loss of ability to do calculations, - Dysgraphia: loss of ability to write, loss of words structure, - Alexia: loss of a previously possessed reading faculty, not explained by defective visual !11  acuity. 8. Symptoms in disorders of decision-making (volition) and behavior I. Symptoms in disorders of volition Will: ability to choose a goal and try to achieve it. We reach our goals intentionally and not by chance. - Abulia: absence of will to do anything (major depression or chronic schizophrenia), - Hypobulia: pathological decrease of will (e.g. depression and dementia), - Hyperbulia: pathological increase of will (typical in mania). II. Symptoms in disorders of behavior Voluntary behavior: knowingly and intentionally pursues a chosen goal, it is the result of will. Subconscious calculated behavior: the aim is pursued instinctively and not consciously. Impulsive behavior: strong urge to take action, aim is not chosen willingly and there is no decision making involved either. Performed immediately, no disorders of consciousness and the subject are able to remember his or her impulsive behavior: - Kleptomania: impulsive stealing of useless things, - Poriomania: impulsive wandering, - Oniomania: compulsive buying, - Pyromania: impulsive fire setting, - Erotomania: impulsive seeking for sexual adventures, - Trichotillomania: impulsive pulling out of one’s hair, - Pathological gambling. Compulsion: urging behavior in obsessions associated with rituals to alleviate the inner ten- sion. Clinical practice: patient may be seen to wash their hands over and over again or check a document repeatedly. Typical in OCD. Quantitative disorders of behavior (measured on a scale) - Stupor: no movement but still conscious, - Hypokinesia: slow movements: Parkinson’s, - Restlessness: seen in mania, - Agitation: emotional state of excitement: patient is unable to sit in one place: seen in mania, - Raptus: abrupt and serious explosions of movement, danger to their surroundings. Qualitative disorders of behavior (cannot be measured on a scale) - Catalepsy: muscle rigidity, fixity of bizarre posture, loss of sensation and consciousness, - Catatonic stupor: marked slow motor activity until a point of immobility, - Psychological pillow: head of a lying patient remains erect in the air for many hours after the pillow is removed, - Active negativism: the patient does the opposite of what the doctor tells to do, - Passive negativism: patients does not listen to orders of the doctor, - Movement stereotypy: purposeless repetition of some movements, - Verbigeration: purposeless repetition of some words or sentences, - Command automatism: abnormal mechanical responsiveness to commands, - Echomatism: mimicking the surroundings—> echomimia (mimic), echopraxia (move- ments), echolalia (speech), - Mannerism: involuntary bizarre movements which are inappropriate/artificial/ceremoni- al (caricature of the original movement), - Paramimic: involuntary inadequate making faces, smacking kiss, - Catatonic raptus: sudden aggression out of control. 9. Symptoms in disorders of instincts !12 Instincts are inborn, biologically determined, life-long. They serve to fulfill the basic biolo- gical needs. Instincts are significant source of a human behavior but they work indirectly. They are modified by the social environment: ex. instinct of aggressiveness may be trans- formed into a competitive behavior at work. I. Disorders of self preservation instinct: - Suicide: deliberate and intentional termination of one’s life (depression and schizo- phrenia patients). - Tentamen suicidii (attempted suicide): serious suicide attempt. - Parasuicide: suicide attempt in which the actual aim is not death; patient thinks that he or she really means the attempt but in reality the aim is to get the attention of other people to what they are doing. Patients maybe seen to overdose, slit their wrists, - Self-killing: accidental termination of one’s own life within a behavior where the aim was not death (ex. patient mistakes a window for a door and falls out). - Rational suicide: patient chooses death to avoid a more serious suffering, - Self-sacrifice: the patient voluntary sacrifices him/herself for a social group, - Extended suicide: the patient kills him/herself after his/her family, with the aim to end their suffering as well. - Group suicide or mass suicide: two or more people kill themselves, - Self-mutilation: self-harm or self-injury. II. Disorders of self-alimentation instinct Problems associated with nutrition when people fail to take care of self-nutrition. - Anorexia: absence of appetite, refusing to eat, - Bulimia: binge eating, - Polyphagia: excessive hunger or increases appetite. May be seen to occur in personality disorders. - Coprophagia: consumption of feces, may be in paraphilia’s. III. Disorders of sexual instinct Sexual dysfunctions, gender identity disorder and sexual paraphilias. IV. Disorders of parental instinct - Overprotectiveness, - Deficiency of parental instinct: absence of an emotional relationship to the child, fre- quently resulting in child abuse and neglect. Typical in antisocial personality disorder. V. Disorders of social instinct - Exaggerated familiarity: increase socialization, - Reclusiveness: tendency to isolate oneself from the society. 12. Suicidal behavior Definition: suicide is the conscious and intentional taking of one’s own life. Death is the cri- terion of success, which is also the aim of the act. The reason for suicide is usually based on reality (rational suicide) or psychopathology (de- pression, schizophrenia, substance dependence, personality disorder, post-traumatic stress disorder). People who are likely to commit suicide will show signs such as: - Threatening to hurt or kill him or herself, or talking about wanting to hurt of kill them- selves, - Looking for ways to kill themselves by accessing firearms, pills, - Talking or writing about death, dying or suicide when these actions are out of the ordin- ary. Subtypes of suicidal behavior: !13 - Anxiety-agitated, - Impulsive-aggressive, - Anhedonia: inability to find excitement from activities which we usually found enjoyable, - hopelessness type At the molecular/neurobiological level suicidal behavior is associated to decreased levels of serotonin in the brain, because of fewer brain serotonin transporter sites or smaller serotonin neurons. + Increased levels of norepinephrine and thyrosine hydroxilase. Assessment of suicidal risk-SAD PERSONS S: Sex (M) A: Age D: Depression P: previous suicidal attempts E: ethanol abuse R: rational thinking loss S: social supports lacking O: organized plan N: no hobbies S: sickness Risk factors for suicide: - Young adults: recently discharged from the hospital, with loss of all social support and chronic or painful illness. - High age: acts of deliberate self-harm or suicidal behavior, decrease in socioeconomic level, somatic exhaustion. Man: stressful life event, chronic social problems, serious life stress Protective factors are seen to be: female gender, family commitments, pregnancy, good so- cioeconomic situation, good overall support, treatment of somatic disorder. Dynamics of suicidal development Suicidal development has a certain sequence: from the stage of consideration through a stage of ambivalence up to the stage of decision-making. I. Consideration: at the beginning: the thoughts have no content. Person fights against these thoughts. The suicide appears as a possibility to solve the problems. II. Ambivalence: the suicidal tendency occurs, the patient may refer to crisis centers and hot- lines to seek for help; the patient has ambivalent attitudes: struggle between self-destruct- ive and self-preserving tendencies. III.Decision: if the self-destructive tendency prevails, this patient ends up with the decision to commin suicide; after the decision the clinical state of the subject may seem to be im- proved: no more intrusive and contradictory ideas. At the beginning of suicidal development we can observe the Ringel’s pre-suicidal syndrome: - Narrowing a person’s personal space (constriction): narrowing interpersonal relation- ships leading to social isolation, mental withdrawal, pessimistic perception of reality, domination of fear, depression, anxiety, helplessness. - Blocking of aggression to other people or its reversal against oneself: The person be- lieves that he or she does not possess the qualities that he/she is meant to have, - Urgent suicidal fantasies: relieve the subject, obsessive ideas and wished to be dead oc- cur. !14 Person may either pick violent or non-violent methods of committing suicide. Management It’s important to assess the risk using several scales such as self-rating scale that contains 4 items representing the different dimension of suicidality: - Lifetime suicidal ideation/suicidal attempts, - Frequency of suicidal ideation in the past years, - Threat of suicidal attempts, - Self-reported probability to commit suicide in the future. Assess the reason of the suicidal patient. Patient’s history + current problems (suicide attempt in the past and suicide in the family). Assess of a possible presence of a mental disorder. If serious the patient needs hospitalization, but we are allowed to restrain a patient against their will if we believe they lack judgement: court must be informed within 24 hours of hos- pitalization. When: - After a failed suicide attempt if psychotic symptoms, major depression, plan for another suicide, violet attempt, regretting the rescues, - Suicidal thoughts are manifested, - Firm decision to commit suicide. If not serious—> outpatient care helped by a psychiatrist or a general practitioner. Treatment Combine psychotherapy and pharmacotherapy. Medication should be administered in the evening: use its sedative effect when we try to improve the patients sleep. - Psychosis + anxiety or restlessness: antipsychotic with a sedative effect (sulpiride, olan- zapine), - Depression: antidepressants + antipsychotics, benzodiazepines (anxiolytics). - Bipolar affective disorders: lithium, - Severe anxiety: benzodiazepine temporary followed by antidepressants, - Personality disorders: temporary benzodiazepine. Prevention Suicide is a serious problem therefore it needs careful attention. We can spot three types of suicide: - Primary: individually orientated, - Secondary: in the patients in crisis life situations, - Tertiary: post suicide in those who survived. Can be prevented with: crisis intervention + counselling, hotlines, psychiatric outpatients. Suicide in seniors: - Late-onset depression, - Loss of loved partner, - Sever disease in a terminal stage leading to a self-insufficiency, - Severe chronic pain, - Loneliness and social isolation, - Dependence on others, - Abuse of alcohol or other addictive substances. 10. Major syndromes in psychiatry Correct assessment of a syndrome in psychiatry is very important because pharmacotherapy is based on syndromes rather than a nosological entity. !15 For example the treatment of depression is anti-depressants regardless of whether the depres- sion occurred due to a brain disorder, alcoholism, schizophrenia or major depression. 1. Delirious syndrome: disorientated and confused state within delirium e.g. vascular de- mentia. 2. Obnubilatory syndrome: altered consciousness within obnubilation, 3. Ganser’s syndrome: psychologically induced obnubilatory syndrome. Belongs to disso- ciate disorder, answers are seen to be paralogical which means that formally appropriate but content is nonsense. 4. Neurasthenic syndrome: irritability, inner mental tension, restlessness, lack of concen- tration. 5. Oneroid syndrome: mild alteration of consciousness + the patient experiences fantastic and dream-like visions. 6. Hallucinatory syndrome: Hallucinations prevail, mostly auditory ones e.g. in schizo- phrenia. 7. Obsessive syndrome: urging thoughts come back over and over against the patients will, typical in OCD. 8. Autistic syndrome: being absorbed in one’s world of pathological imaginations and fantasies: schizophrenia. 9. Paranoid syndrome: pathological suspiciousness is the dominant symptom, frequently in schizophrenia. 10. Manic syndrome: triad of pathologically elevated mood, tachypsychism (condition which alters the perception of time) and accelerated psychomotor pace; seen in mania. 11. Depressive syndrome: triad: depressive mood, bradypsychism (slowing of mental func- tions) and slowed psychomotor pace: seen in major depression. 12. Anxious syndrome: anxiety without any concrete reason prevails. Typical in anxiety dis- orders. 13. Amnestic syndrome: memory is impaired: after head trauma. 14. Korsakoff syndrome: Encoding of new information into memory is damaged: seen in alcoholism. 15. Organic brain syndrome: non-specific syndrome, the result of organic damage to the brain. Damage should be long tern. Changes in personality, intellect and memory are de- creased. 16. Hypocondriac syndrome: anxious self-monitoring, fear of some diseases. 17. Phobic syndrome: the patient’s fear has a clear content. 18. Abulia syndrome: decrease in will (depression). 19. Apathy syndrome: emotional dumbness (dementia). 20. Hypokinetic syndrome: lack of movement (dementia). 21. Hyperkinetic syndrome: increased movements (mania). 11. Laboratory and auxiliary examination methods in psychiatry These examinations are not specific for any psychiatric disorder, they help to specify the dia- gnosis and choose a proper treatment procedure. I. Genetics - Huntington’s: gene mutation, - Alzheimer’s disease: risk allele 4 on chromosome 19: not always 100%, - Mental retardation: in utero or in new-borns, - Polymorphisms of the genes for liver enzymes metabolizing psychotropics drugs. II. EEG-electroencephalography Non-invasive + cheap method that detects brain’s electrical cortical activity. Standard EEG takes 20 mins. EEG curve is changing during the assessment: basic parts of an EEG are called graphoele- ments. Every graphoelement has its: frequency, amplitude, shape, distribution, occurrence, symmetry, synchrony, rhythmicity, periodicity, persistence and reactivity. !16 According to their frequency several basic types of EEG are defined: - α—> posterior quadrants of hemispheres, - β—> central + frontal parts, - θ—> frontal + temporal - δ The EEG record in the majority of non-organic mental disorders is almost normal! EEG in psychiatry is used: - Mostly to exclude major organic changes/disorders in the brain, - Qualitative disturbances of consciousness: delirium—> δ or θ activities are mostly found, - The first episode of schizophrenia—> θ and δ activities are increased, α decreased (espe- cially in the temporal area of the left brain hemisphere), - Mood disorders: the EEG pattern is normal, - Treatment-resistant + seizure-like disorders of behavior (obsessions, violence, panic), - TCA’s: instability of EEG frequency and amplitude, - BZD’s: increase β activity with so called “β spindles”. But also for: - Tabes dorsalis (demyelination by advanced syphilis infection): EEG anomalies are rare, mild and non-specific, - Progressive paralysis: 60-70% of patients have medium: severe EEG changes, - Creutzfeldt-Jacob: a. Slow activity and physiological activity takes turns b. Synchronic polyphasic complexes of high voltage and slow flat activity c. EEG curve is completely shallow - Chronic alcoholism leading to systemic portal encephalopathy: θ waves dominate, - Chronic alcoholism with thiamine deficiency: δ or θ waves may dominate, - Hyperthyroidism: quickens the basic EEG activity, β waves may appear as well, - Hypothyroidism: Slowing down of α activity and decrease of the EEG voltage are found. - Multiple sclerosis: EEG changes are more obvious in acute episodes rather than in re- mission: frontotemporal theta activity, slowing down of the basic activity, desynchroniza- tion and diffuse sharp waves. - Brain tumours do not produce electrical activity by themselves: may see epileptic seizures may occur in patients with epileptic EEG changes as well as subjects without them. - Cortical dementia: 80% of patients are seen to have EEG anomalies. Patients suffering from Alzheimers dementia: reduction of alpha waves and delta and theta waves may be present. - Anxiety disorders: EEG is usually physiological: neurasthenia the alpha activity may be slow, and the beta activity may have a low voltage. Evoked EEG potentials: EEG changes induced by external stimuli. Video EEG: combination of classical EEG + simultaneous video-recording of the patient’s behavior (ex. dissociative seizure). Polysomnography: diagnostic for sleep apnea syndrome, narcolepsy, hypersomnia, insomnia and includes: - EEG, - electromyogram, - electrooculogram, - breathing movements: thorax and abdomen, - nasal/oral airflow, - blood saturation. III. Endocrinology - Thyroid hormones: Hypofunction: depression, mental retardation, dementia, hypoactive delirium. Hyperfunction: psychosis, hyperactive delirium and mania. !17 - Cortisol: in schizophrenia and depression the cortisol levels remain high even after dexa- methasone has been administered (it is increased all the time!). Decreased cortisol levels: PTSD, chronic fatigue syndrome, chronic pain. - Prolactin: mostly examined in patients treated with antipsychotics—> hyperprolact- inemia: gynecomastia, galactorrhea, decreased libido, impotence, weight increase, osteo- porosis. - Phaloplethysmography and Vulvoplethysmography: used mostly in diagnosis of sexu- al paraphilias. IV. Blood biochemistry - Ions, - Liver enzymes, - Nitrogen agents To exclude somatic diseases. V. Blood count Some medicaments may induce leukopenia or agranulocytosis: Clozapine induces agranulo- cytosis—> monitoring for the first 18 months of treatment is required and even up to 2 months after the patient comes off the drug. VI. Blood alcohol level Needed in first time examinations. Patient needs to be sober before a psychiatric examination. Breath test is usually done: quick and cheap. VII. Blood and Urine To monitor the levels of illicit drugs in the system. - Cannabinoids: still found in urine up to 2 weeks after one-time use and up to a month in every day use. - Opiates, cocaine, amphetamines: 2-3 days after use. - BZD’s seen urine after the interval for up to 2 weeks. A toxicological examination of urine: - May uncover possible drug abuse even after a time interval, - Check ups for abstinence in patients dependent on illicit drugs. For acute intoxication a toxicological examination in the blood is also performed. VIII. Blood levels of psychotropics and their metabolites It is performed routinely for mood stabilizers because of: - Their narrow therapeutic window, - Linear association between dose of the medicament and its efficacy. This examination could be also useful to establish patient’s compliance and the pharmacokin- etic profile. IX. Chemical examination of urine Only to exclude pathological processes in the urinary excretory system which may induce mental symptoms: urinary tract infections—> delirium (in geriatric patients). X. Ultrasonography Applied in toddlers before their fontanelles close. In adult patients: examine liver function in alcoholism. But also: - Carotid arteries: vascular dementia, - Deep vein thrombosis: side effect of some antidepressants and antipsychotics. XI. ECG Vascular dementia. XII. Examination of the back of the eyes !18 Papilledema: increased intracranial pressure may induce—> quantitative or qualitative dis- orders of consciousness. It is routinely performed before the electroconvulsivant treatment (ECT) because increased ICP is an absolute controindication. XIII. Neurological examination Assess: consciousness, orientation, overall appearance, movement, gait, muscular strength, reflexes. XIV. CSF examination It can be applied in early stager of Alzheimer disease: - Amyloid b protein: decreased, - Total and phosphorilated tau protein: increased. XV. Brain imaging - MRI: more detailed images and no radiation; some findings are specific for schizo- phrenia, - PET: detect changes in metabolism: neurotransmitters (functional), - SPECT: to find defects in blood supply—> differentiates between Alzheimer’s disease and frontotemporal or vascular dementia. - CT: detecting brain changes like atrophy, ischemia, tumour, haemorrhage, - fMRI: detects small changes in blood flow and metabolism in the brain. XVI. Rating and self-rating scales - Beck Anxiety Inventory (BAI), - Beck Depression Inventory (BDI), - CAGE questionnaire (alcohol abuse), - South Oask Gambling Screen (SOGS), - Suicide Behaviors Questionnaire-Revised (SBQ-R). XVII. Clinical psychological assessment Performance tests: - IQ tests, - Tests of specific abilities and mental function (memory, attention), Personality tests: - Projective tests, - Objective tests, - Questionnaires and inventories 13. Ethical issues in psychiatry Ethic is a discipline dealing with principles based on morality, customs and traditions. They are rules not laws. However some ethical norms are legal norms as well: ethical issues like violation of medical confidentiality, omission of an examination which was medically indicated, medical negligence. Ethical principles: 1. Respect for an individual especially regarding patients autonomy—> each person can decide his fate and is responsible for his/her decisions. 2. Beneficence: pursuit of patients wellbeing and trying not to harm the patient. 3. Justice The ethical issues in psychiatry derives from the assumption that the psychiatric patients most of the times is not able to make decision for him/herself and he/she might refuse an assistance from a doctor or a hospitalization. !19 Paternalism and autonomy Ethical conduct is based on a paternalistic model of health care. The model resembles the re- lation between a father and his child. The medical doctor protects the interest of a patient as a father protects a child and is ethically justified to make decisions for a patient. Medical doctor decides for the patient in his best interest and assumes ‘fatherly’ responsibilit- ies. The physician is allowed to inform the patient on important issues, which he believes will be beneficial to him/her: so does not get told everything. In medicine just like in parenting it is important to know exactly what the patient needs and what will help them within their treatment. Limitations of autonomy and independent decision-making Patients with mental disorders may be uncritical of their illness, may threaten other people or themselves, often there is a lack of insight. Need to avoid situations in which their behavior can get worse. Patients may not recognize that they need treatment. Commonly within psychiatry patients are hospitalized without their consent and if this oc- curs the court should be informed within 24 hours. In psychiatry many patients are hospitalized without their consent—> it leads to many con- flicts resulting in accusing the psychiatrist to abuse of their independency and dignity. Two ethical sides of psychiatry: - Protect the patient and people around him from the adverse effects of mental illness, - to prevent the limitation and abuse of patients rights on the other. Should find a way to comply with both as good doctors! 14. Legal issues in psychiatry, stigma Stigma of mental illness and the principles of justice Aim to protect people with a mental illness who face prejudice and its consequences. Stigma of mental illness. Stigma influences the conduct of healthcare professionals and the patient’s life in his/her family and society Example: patient suffering from AIDS is expected to be a homosexual, or an addict. A patient with dyskinesia: dull. Patients with tuberculosis were thought to be promiscuous and irresponsible in the past. Patients with psychoses can be stigmatized as unpredictable, unreliable and dangerous. Stigma has a negative impact on healthcare professionals who either consciously or uncon- sciously falls under the pressure of the stereotypical image of a mentally ill patient: fear, dis- trust or avoidance. Stigma has an adverse effect on a risk of relapse of the disease. 14. Legal issues in psychiatry, sigma in psychiatry I. Legal issues More complicated in psychiatry. Mentally ill people are more vulnerable in comparison with patients with somatic diseases and find it harder to protect their own rights. Mentally ill people may be neglected, abused or discriminated against. The Act of Healthcare Services Law defines: Who is able to provide health care Conditions of care Quality of care Problems of patients and how to deal with them Rights of the patient Controlling situations and punishments !20 Act on specific health care services Comprises: - Involuntary treatment of the mentally ill as a protective measure, - Voluntary therapeutic castration of paraphiliac patients, - Sex reassignment surgery in transsexuals, - Psychosurgery, - Genetic examination. Rights of a patient: - Only have services approved by him or her in writing, - Professional health care service, - Privacy, respect, dignity and consideration of health care professionals, - Choose the physician or hospital, - Know the name of the professionals taking care, - Refuse medical/nurse students being present, - Get a second opinion, - Presence of a close person, - Be informed about treatment that isn’t covered by health insurance, - Have appropriate services for disabled people. Patients obligations: - Provide his identity to medical staff, - Truthfully inform staff about mental state, other services, medications or any drugs, - Undergo a toxicology screening Which circumstances can we refuse to treat the patient? - Excessive workload so not good quality of care, - Not enough staff or do not have the right equipment, - Against the patients religious or moral beliefs. Obligations of health care providers: - Organize and implement an individual treatment plan, - Inform the patient’s other health care providers about all the necessary issues to his/her clinical state and treatment, - Treat the patient if it is ordered by a court of law, - Inform the patient about the cost of the treatment if not covered by insurance, - Inform the patient about his/her clinical state. Violation of the obligation is seen to be a criminal act with a sentence of around 8 years. Right concerning information about the patient: the patient can determine who may be in- formed about his or her condition so even close family members do not have to be told. The exception is when the patient has to be taken home to be cared for. Who can look at the patient’s records: Close members of family, people the patient has alloc- ated after their death. Medical professionals. When is hospitalization without patient consent allowed? When court has ordered it, If it is necessary: contagious diseases, If they are seen to be a danger to themselves or other people: aggressiveness/suicidal be- havior, If their state require hospitalization but they cannot give consent: coma/delirium states. It must be reported to the court of law within 24 hours and within 7 days the court decides if the hospitalization is legal. If the hospitalization continues the court requires the opinion of a forensic psychiatrist within 3 months. Which information must be reported? !21 - If a child is neglected, abused, - If the patient is performing a serious crime, - If the patient has escaped from the hospital, - If the patient is no longer able to have a driver license. Assessing the patient’s legal capacity Can they handle their own money and possessions? Can they get married? Can they look after their children? Invalidity of subject’s legal actions Commonly happens that the subject performs some legal act and it is immediately opposed due to the person having a serious mental disorder at the time of the crime. II. Stigma in psychiatry The stigma of mental disease indicates the characteristics that distinguish mentally challenged people from others in society. Stigma can lead to discrimination and isolation of mentally ill people. A wrong image is cre- ated—> as a result the mentally ill patient is seen as mentally weak, unable, unreliable, un- controllable, silly and aggressive/dangerous. Stigma leads to discriminations. Auto stereotypes (self-stigma) are described in psychiatric patients which means that patients have negative perceptions and assessments of themselves. Stigmatization is psychiatry is important in serious mental disorders, it can have a powerful and devastating effect on the quality of life of these people, especially in schizophrenia. Leads to discrimination, social isolation, unemployment and low self-esteem. Stigma relates not only to the mentally ill person but also to their social surrounding. Some families fail to even acknowledge that someone in the house has a problem which means that they are less willing to support them and are less inclined to seek professional help. Destigmatization has become the primary goal of psychiatry, increasing the public’s general knowledge on mental health, especially schizophrenia. Direct contact of mentally ill people with the public is seen to facilitate acceptance. Psychiatrist can prevent stigmatization of mental disorders using the following principles: - Psychiatric diagnosis should not be determined unless we have data to support the facts, - Inappropriate and abusive terms should not be used, - Respect the patient’s diagnosis. 15. Transcultural Psychiatry Branch of psychiatry, which deals with the cultural background of mental disorders. It stresses the importance of taking into consideration the diversity of human society and cul- tural background. It studies the prevalence of mental disorders in different parts of the world. Culture-bound syndromes Are defined as combination of psychological and somatic symptoms that are considered to be a recognizable disease only within a specific society or culture. There are no objective bio- chemical/structural alteration of body organs or functions. Within a certain culture a disorder is recognized as a disease and it is treated with local rem- edies: folk medicine, healers, shamans and natural ways. Culture specific syndromes !22 - Death by electric fan: Korea - Amok: Malaysia: obsession with an evil spirit is noted - Nervous strain syndrome: Nigeria: brain fatigue - Dhat syndrome: Men in india complain of premature ejaculation, difficulty in erection - Sudden blacking out: in the Caribbean people under stress suddenly experience a partial loss of consciousness. - Ghost sickness: Navajo Indians believe certain symptoms are caused by spirits of the dead - Evil eye: That others in society can give someone the ‘evil eye’ and this leads to long term problems within the person in terms of life or health Ethinic minorities In Czech republic we have the minority of the members of the Romany (gypsy) ethnicity. The thinking and behavior of the gypsy members is different to the Czech community. Abnormal- ities occur in the Romany society, they try and adjust to it through their own strength. Com- mon habit of the Romany people is to exaggerate. Meet the criteria for histrionic personality traits. Sometimes psychiatrists unnecessarily diagnose a culturally normal behavior of these people as psychotic state, when the symptoms are just anxiety and somatic troubles. Romany patients instead of having a fear for his or her health, they say that the sick around them pull their health down with them. Post modern religious and sects Society is characterized by a growing social diversity. In postmodern societies, we find an increasing number of different religions. One-third of Europeans recently believe in reincarn- ation. Many people believe in spiritual beings of many different kinds, practical magical rituals recognize Satan or worship various Avatars. Transcultural psychiatry allows psychiatrists to understand that every situation has its social and historical context. Without knowing this it is not possible to help the patient. We cannot just base the patient on anatomical and physiological factors, because this is seen to be uneth- ical, plus the treatment would be inefficient as well. It is important to distinguish between cultural differences and pathological phenomena. 16. Research in psychiatry - Epidemiological research: it is related to incidence and prevalence of mental disorders. Presented as the ratio of new cases of a proper diagnosis to the total number of individu- als in a given population. It is used to plan and organize adequately a mental health ser- vice. - Genetic research: it plays a fundamental role in looking for the cause of mental dis- orders. Range: 0.2 (adjustment disorder): 0.8 (schizophrenia) if the score is 0 then this means that no genes play a role. - Gene-environment interplay, - Research conducted on animals: mostly rats: see how they apply drugs to themselves. - Genetic manipulation and physical or chemical damage of the animal’s brain is em- ployed. Induce psychotic symptoms onto the animals by hallucinogens, amphetamines or ketamine, - Pharmacological studies: aimed at assessing the efficacy and safety and tolerability of potential new drugs. - Placebo/ double blind tests. !23  Part II 1. Alzheimer’s disease and dementia in Alzheimer’s disease Alzheimer’s disease (AD) is the most common cause of dementia (50-70%). Frequently oc- curs together with cerebrovascular disease. It is a degenerative disease of the brain with prominent cognitive and behavioral impairment that is sufficiently severe to interfere with the social and occupational life. Most important risk factor is seen to be increasing age. At the age of 60-65 years about 1% of population suffer from dementia. Course of Alzheimer’s disease remains hidden or latent for a long time, clinical symptoms occur later when the damage to the brain tissue is already severe. The prevalence depends on age: - Early onset: before 65 years of age, prevalence 1%, - Late onset: after 65 years, the prevalence increase to 25-33% among 85 years—> because the world population is gradually aging, so the prevalence is rising. Risk factors: Age Familial occurrence of AD Genetic predisposition: allele 4 of the apolipoprotein E gene, APP gene, Down’s syn- drome, Head injury Low level of education Vascular hypertension DM obesity smoking Protective factors: Genetic predisposition: allele 2 of the apolipoprotein E gene, High level of education Long term use of anti-inflammatory drugs HRT-hormone replacement therapy Healthy lifestyle Types: Sporadic AD= 95% of cases, without any familiar history. Familiar AD= 5% of cases, usually early onset. 3 genes are implicated: APP (amyloid pre- cursor protein), PSEN 1 and 2 (presenilin genes). Pathophysiology In all neurodegenerative types of dementia, the pathological change of brain proteins leads to shrinking and apoptosis of neurons and brain atrophy. Pathological production and accumulation of ‘beta amyloid’ in the brain interstitium are con- sidered. 1. Amyloid precursor protein is cleaved in a pathological way by beta and gamma secretase in AD, 2. Accumulation of the beta amyloid into plaques, which are extracellular and effects com- munication between nerves (sterile inflammation), 3. Neurofibrillary tangles are seen to be intracellular and made up of abnormally phos- phorylated tau protein: neurons that have these tangles are seen to be dying because the intracellular transportation is severely affected. !24 Beta amyloid may also deposit in the walls of blood vessels, which results in amyloid an- giopathy: may result in small brain cortex infarction. It affects especially the central acetyl cholinergic system: medial temporal lobe (hippocam- pus) and parietal lobe. Brain atrophy (medial temporal lobe) is caused by shrinking of neurons and decrease in number of neurons. Clinical symptoms - Mental functions are affected: disorientation, personality changes, depression, hypobulia, hallucinations, - A: Activities: disturbance of daily activities, loss of self care, - B: behavioral: shouting, aggressiveness, wandering, depression, hallucinations, - C: Cognitive disorders: decline in memory—> short term memory is affected first, after which it is long term memory, amnesia, aphasia, apraxia, failure of judgment. Early—> recent memory, naming difficulties, disorientation for date/time, problems with daily activities, irritability/mood change. Middle—> getting lost in familiar areas, disorientation date/place, problems with dressing, comprehension difficulties, agitation, aggression, anxiety, depression. Late—> incontinence, impaired remote memory, primitive reflexes/extrapiramidal signs. Course and prognosis The start of the disease is slow and hardly detectable, dementia worsens gradually. It is complicated by falls and injury. It is irreversible. Terminal comorbidity may lead to death: pneumonia, embolism, heart attack etc. Death usually occurs 5-15 years after the beginning. Cachexia may occur. Examination - Diagnostic process is mostly based on a detailed patient history, - Mental state examination: consciousness, symptoms of depression or psychosis, - Cognitive testing: Mini-mental state examination—> questions focused on orientation, calculation, short-term memory, attention, understanding and use of language + clock drawing test + cognitive function (design, executive skills, visual motor coordination), - Physical examination, - Blood biochemistry, full blood count, and urine, - EEG to exclude: delirium, Creutzfeldt-Jacob disease, - Imaging: CT, MRI, PET and SPECT: atrophy of the brain; to exclude other causes of de- mentia (hemorrhage, tumor, brain infarction), - CSF: beta amyloid is low (deposition in brain), tau protein is high. Full diagnosis cannot be assessed until we do a brain autopsy. Primary prevention of AD—> healthy lifestyle: eat healthy, exercise, intellectual stimulation, avoid stress, avoid head trauma. Treatment Educate the family about how to deal with a patient who has AD, adjust their environment, and stimulate their memory to work more. Support to the caregivers is necessary. Pharmacotherapy: - Cognitive enhancers: acetylcholinesterase inhibitors—> Donepezil, Rivastigmine, Galan- tamine, - Modulator of glutammatergic NMDA receptors: Memantine, Treatment of the behavioral and psychological symptoms of dementia: - SSRI’s for depression, - antipsychotics for delusions/hallucinations/restlessness/aggressiveness: Tiaprid, Melper- on, Quetiapine. !25 2. Organic mental disorders apart from Alzheimer’s disease and dementia in Alzheimer’s disease Organic mental disorders are common in old age, but they may occur anytime during one’s life because of trauma or inflammations. Most common manifestation is cognitive impairment—> leading symptoms. The most frequent organic mental disorder is dementia: acquired, progressive impairment of cognition that interferes with social functioning, leading to a global cognitive deficit. Memory impairment is usually the first symptoms (short term first), then other symptoms fol- low: dysphasia, agnosia (inability to process sensory information), apraxia (loss of the ability to execute learned purposed movements), impaired executive functions, personality disinteg- ration. The prevalence of dementia increases with aging. The transient phase between normal per- formance and dementia is called: mild cognitive impairment—> mild degree of deteriora- tion of daily activities, self-care and general functioning. People in this phase have a high risk to develop dementia, but it can be also a stationary condition. Classification of dementia: - Primary—> neurodegenerative type: Dementia in Alzheimer’s disease (most common, 60%), Lewy body dementia (10%), Frontotemporal lobar degeneration (8%), Dementia in Parkinson’s disease (7%), Dementia in Huntington disease, Dementia in Creutzfeldt-Jacob disease.. - Secondary: Ischemic-vascular dementia (15%), Post-traumatic dementia, Epilepsy, Infectious disease in the brain: syphilis, herpes, AIDS, Intoxication: alcohol, barbiturates, poisoning by CO, Brain tumors, Metabolic disease, Vitamin deficiency. I. Lewy body dementia Second most frequent neurodegenerative disease after AD and frequently combined with AD. Causes: related to Parkinson’s disease which is seen to be the accumulation of the pathologic- al protein alpha-synuclein in the bodies of neurons. In Parkinson the localization is different (—> substantia nigra). Lewy bodies: spherical bodies inside the neurons formed by neurofilament proteins aggreg- ated with ubiquitin and alfa-synuclein—> the core is formed by synuclein and the surface by ubiquitin. Affects the brain stem (substantia nigra) and other parts of the brain (cortex); mostly accumulate in the cortex—> causing a progressive dementia (paralimbical and neocor- tical parts of the brain). Clinically - Progressive dementia, - Oscillation of quality of consciousness and cognitive function, - Parkinsonism: hypomimia, muscle rigidity, tremor, - Neuropsychiatric symptoms: hallucinations, - Increased sensitivity to adverse side effects of antipsychotics (extrapiramidal s.). !26 Diagnosis - Detailed history of disease + recognize clinical symptoms, - CT, MRI - SPECT: shows typical impairment of dopamine. Treatment - Acetylcholinesterase inhibitors, - Avoid treatment with typical antipsychotics—> parkinsonism; use quetiapine or cloza- pine. Course and prognosis Similar to AD but when treating hallucination we should avoid anti-psychotics because of their Parkinson like side effects so in this case we can give clozapine and quetiapine. II. Dementia in Parkinson’s disease Progressive neurodegenerative illness caused by loss of dopaminergic neurons in the substan- tia nigra. Age of onset 50-60. Clinical symptoms Typical symptoms: resting tremor, rigidity, bradykinesia, postural instability. Dementia is usually mild-moderate and only 20-40% of patients suffer from dementia. Other features: - Attention and concentration are impaired, - patients can be apathetic, - diminished volition, - presence of delusions, - decline of executive functions—> inability to schedule activities, solve problems. Histopathology Alfa-synuclein is the predominant pathological protein. To differentiate between PD and Lewy body dementia is useful to use the “one year rule”: if dementia arises within the first year of Parkinsonism then diffuse Lewy body dementia is more probable as a diagnosis. Diagnosis Is based on a detailed history of the disease, neurological and psychiatric examination. The diagnosis can be specified by SPECT. Treatment - Antipsychotics: for hallucinations + delusions; quetiapine, clozapine, - antidepressants: SSRIs, - acetylcholinesterase inhibitors: for dementia. III. Frontotemporal lobar degeneration Group of diseases characterized by impairment of frontal and temporal lobes function. It is also called Pick disease. It is the most common cause of dementia in patients younger than 65 years. Clinical symptoms - Change of personality is typical, - Impairment in social behavior, - Inappropriate activities, - Vulgarization, - Loss of hygienic habits, - Speech disorders. !27 The three most important types are classified according the localization and symptoms: - Frontal parts of both brain frontal lobes: behavioral variant (behavioral symptoms and personality changes); frontal type of dementia; - Frontal parts of the temporal lobes bilateral or at the dominant side: semantic demen- tia—> fluent anomic aphasia with loss of speech comprehension and knowledge; - Dominant frontal and temporal brain lobes: primary progressive aphasia—> non-fluent speech, mispronouncing of words, but comprehension of speech is preserved. Diagnosis - Detailed history, - Neuropsychological examination: look for symptoms, - Imaging: CT, MRI, PET, SPECT—> localize the atrophy and local decrease of metabol- ism. Treatment Is symptomatic: behavioral—> antidepressants (SSRIs). IV. Dementia in Huntington’s disease Autosominal dominant disorder, due to a mutation in the two copies of the gene called “Hunt- ington”—> expansion of CAG triplet leading to abnormal protein forming, which gradually damages the brain cells by still unknown mechanisms. Clinical symptoms - Disease affects muscle coordination primary, - and leads to mental decline and behavioral symptoms, - Late stages: bradypsychism, apathy. Clinical manifestations manifest between 30-60 years: patients usually have children before these manifestations. Diagnosis Genetic testing Course and prognosis No cure, disease is lethal, full time care is required in the late stages of the disease. Symptomatic pharmacotherapy for depression and psychosis. V. Dementia in Creutzfeldt Jakob disease Rare, most common human prion disease. Usually affects people between 45-75 years. There are 4 types: - classical/sporadic, - familial, - vCJD (caused by consumption of food with prions), - iatrogenic (caused by contamination of body tissue from an infected person) Cause Prion: misfolded protein that replicate themselves by converting their properly folded coun- terparts in their host to the same misfolded structure they possess. Leads to rapid neurodegeneration which creates holes in the brain—> sponge-like structure. Clinically Rapidly-progressive dementia with memory loss, personality changes, hallucination + anxi- ety, depression, delusion, OCD, psychosis. Neurological symptoms: speech impairment, jerky movements, balances and coordination dysfunction, changes in gait and rigidity !28 Diagnosis - EEG: typical triphasic spikes. - MRI: high signal intensity within the caudate nucleus and the putamen, - CSF: 14.3.3 protein. Course and prognosis Very fatal, most patients die within 6 months often due to pneumonia or impaired coughing reflex. Treatment Symptomatic VI. Secondary types of dementia Vascular dementia Most frequent secondary dementia. Dementia due to: - Microangiopathy, - Critically located brain infarction, - Multiple brain infarctions, - Hypoperfusion, - Brain haemorrhage, - Other vascular lesions Clinically Acute onset and fluctuating course. Basic symptoms are similar to other types of dementia: multiple memory and intellectual dis- turbances, a decrease in other cognitive functions, a decrease in social activities and working performance. Diagnosis See AD. Treatment Treat first the cause of the cerebrovascular disorder: hypertension, ischemic heart disease, arrhythmia, dyslipidemia, DM, obesity. Other organic mental disorders are seen to be caused by brain or somatic disorders. Organic hallucinosis: this disease is seen to be caused by brain tumours, brain infection or injury; Complex hallucinations frequently associated with delusions are the most common. 3. Alcohol induced clinical states Epidemiology: - A lifetime prevalence of substance abuse or dependence in the U.S: 14% - Men are affected more than women, - Affected subgroups: unemployed, minorities, medical professionals, - In Czech Republic: About 200 000: 300 000 alcoholics. Substance abuse: - The substance use interferes with the person’s life: at least one specific symptom is present, substance dependence is more serious than substance abuse, - It affects the biological reward center: causes dopamine release, !29 - Safe level of alcohol is 21 units/week for men and 14 units/week for women. - Dangerous levels which can make harm is 50 units/week for men and 35 units/week for women. Etiology - Genetic factors - Personality - Social environment + triggering situation I. Acute alcohol intoxication The effects of alcohol vary broadly among individuals, depending on: - Gender, - Body composition, - Level of tiredness, - Food intake. Low alcohol dose ingestion has stimulatory effects: excitation, increased mood, increased talkativeness, increased self-inhibition, increased aggressiveness. High alcohol intake dose intake: sedation, tiredness, somnolence, sleep. If too high may lead to alcohol poisoning: loss of consciousness or death because of respiratory depression and suffocation by vomiting. Symptoms are in relation with blood levels: - < 1g/kg: drunkness—> impairment of attention and visual-motor coordination + prolon- gation of reaction time, - Inebriation - > 3 g/kg: alcohol poisoning. After acute alcoholic intoxication patients experience hangover, characterized by: dysphoria, anxiety, nausea/vomiting, weakness, sweating, absence of hunger. Due to accumulation of acetaldeide and dehydration. II. Alcohol dependence syndrome Group of behavioral, cognitive and psychopathological phenomena after repeated and long- term systematic use: - Craving: strong desire/sense of compulsion to take the substance, - Impaired capacity to control the substance intake, - Physiological withdrawal state, - Tolerance to the effects of substance, - Alternative source of pleasure or interests are abandoned, - Persistence of substance intake despite clear evidence of its harmful effects. Alcohol withdrawal Sudden discontinuation of alcohol consumption when alcohol has been used repeatedly and systematically for years. - Uncomplicated: autonomic hyperactivity—> sweating, increased pulse rate, hand tremor, insomnia, nausea, vomiting, transient visual or auditory hallucinations, psychomotor agit- ation, anxiety, grand mal seizures. - Complicated: delirium tremens (rapid onset of confusion). Can last 3-4 days. It is treated with: Diazepam and Clomethiazol. Delirium tremens Usually it develops 24-48 hours after the last use of alcohol and gets worse in the evening/ night. Prodromal syndrome: - insomnia and nervousness, - epileptic grand mal seizure. The patient is disorientated, has fragmented and disorganized thinking, hallucinates. Tremor occurs in hands and then the whole body + excessive sweating. It leads to central hyperther- !30 mia and cardiac insufficiency. First choice of treatment: Clomethiazol (hypnotic) or large doses of Diazepam. Medical complications of alcohol use: - Neuropathy, cardiomyopathy - Infectious diseases, traumas - Nutritional diseases, GI disorders - Liver disease, cancer etc. etc. III. Psychotic and psychiatric complications - Alcoholic hallucinations: antagonist voices that generates anxiety, agitation, aggressive- ness, - Alcoholic paranoid psychosis: delusional jealousy, paranoid-persecutory delusions, - Organic alcoholic psychosis due to thiamine deficiency: alcohol interferes with thiamine absorption from GI tract, leading to: Korsakoff syndrome: memory impairment with anterograde and retrograde amnesia; various confabulations (false memories), Wernicke encephalopathy: ophtalmoplegia (ocular disturbance) + ataxia (unsteady gait) + changes in mental state (apathy, attention impairment, confusion). If the onset is acute—> medical emergency, - Alcoholic dementia: develops over several years of alcohol abuse; slow progress to: cog- nitive impairment, memory decline, disturbances of orientation, judgement, learning, af- fect; degradation of personality: insufficient self-care, homelessness. - Alcoholic depression: high risk of alcohol drinking relapse and suicide, - Sexual dysfunction: normal is to develop erectile dysfunction or delayed ejaculation. IV. Alcohol dependence Pharmacological dependence: caused by changes of receptors and other cellular mechanism affected by the substance. The substance vary in the degree to which they cause pharmacolo- gical dependence. Psychological dependence Operates partly through conditioning. Some of the symptoms experienced as a substance is withdrawn become conditioned responses that reappear when withdrawal takes place again. Cognitive factors play an important role, as patients expect an unpleasant effect of withdraw- al. Subtypes of alcohol dependence - Alfa and beta: alcohol abuse; - Gamma (angiosacksen): addiction—> period of abstinence, inability to control the amount of alcohol, - Delta (french): inability to abstain, ability to control the amount of alcohol, withdrawal symptoms. Stages: 1. Drinking because of psychotropic effects: drinking frequency, tolerance and dose slowly rise; 2. Gradually needs higher and higher doses to get the same psychotropic effects; people close to the patient perceive his/her drinking like frequent and excessive; the individual tries to hide the drinking; alcohol blackouts begin to appear; 3. Tolerance rises, not control of the amount of alcohol assumed, system of rationalization—> the patient tries to apologize; alcohol-centric behavior—> no other interests; developing of feeling of guilt; slowly deterioration of nutrition and health care. 4. Withdrawal state after abstinence, eye-opener in the morning, continuous drinking for sev- eral days, without any interruption, organ damage slowly develops, personality degrades, suicide. Paradoxically the tolerance decreases. !31 Treatment - Detoxication: elimination of the substance from the body—> anti-alcoholic stations (drunk tanks), departments of internal medicine, intensive care units, - Disulfiram: intoxication with acetaldehyde after alcohol intake: hangover feeling; it is an inhibitor of acetaldehyde dehydrogenase: if the patient uses alcohol + disulfiram—-> ser- ious adverse effects (palpitation, reddening of skin, hypotension, nausea, vomiting)—> maintain abstinence. Treatment of craving in alcoholism - Medication is administered for several years - Acamprosate: the chemical structure is similar to GABA, reduces craving after the pa- tient abstains. - Naltrexone: opioid substance, diminishes euphoria after alcohol; blocks the effects of endorphins—> reduces dopamine. - Nalmefene: blocks opioid receptors in the brain, reduces alcohol-induced euphoria, indic- ated in severe alcoholism, helps to reduce the amount of alcohol used by the patient. - Self-help organizations: Alcoholics Anonymous AA: helping other people we help ourselves. Long Term Effects: There is evidence to suggest that regular consumption of alcohol may have either beneficial or harmful effects on brain functioning and on cognitive competence depending on the quant- ities involved: - Consumption of 1 to 9 standard drinks per week may improve cognitive functioning and reduce the risk of dementia, whilst drinking more than 21 units per week may increase the risk of dementia. - Chronic alcohol dependence is associated with extensive brain damage and cognitive deficits leading in extreme cases to alcoholic dementia, a loss of intellectual functioning combined with amnesia. Alcohol-induced brain damage appears to be partially reversible with abstinence. Alcohol can also lead to three types of harm; - Physical - Neuropsychiatric - social Alcohol and abnormal fetal development: - facial abnormalities - low weight - low intelligence - over-activity 4. Substance dependence apart from alcohol induced clinical states I. Opioids Opioids are natural, semi-synthetic drugs with an affinity to specific receptors in the brain. Can be: - Natural: Opium, morphine, codeine, - synthetic: heroin, hydrocodine or dihydrocoideine. Opiates can be used in a variety of ways: smoking, ingestion, injections. - Strong agonists: morphine, pethidine, fentanyl, heroin, - Medium agonists: Codeine, ethylmorphine, - Antagonists: naloxone-antidote! In medicine opiates are used to relieves pain, but also produce euphoric, sedative and antitus- sic properties. !32 Receptors: - Mu-receptors: analgesia, respiratory depression, euphoria, miosis (pin-point pupils) and increase in smooth muscle tone. - Kappa: receptors: sedation, spinal anesthesia, dysphoria, hypotension. - Delta-receptors: analgesia, miosis and hypotension. Acute intoxication - Low dose: euphoria, sedation, reduction in activity, facial flushing, - IV application: flushing, - Signs of an overdose: bradycardia, miosis, slow breathing, respiratory depression, lung edema, involuntary muscle contraction. Opioid addiction Warning signs: decreased appetite, anorexia, preference for sweet food, weight loss, constipa- tion, loss of interest in other activities, loss of libido. The addiction develops very fast and is usually severe—> strong craving, fast development of tolerance, sharp increase in doses. With heroin, begins 6 hours after the last dose, reach peak after 36-48 hours and then de- clines. Produce great stress—> drive for seeking supplies. The symptoms include: - Intense craving for the drug - Restlessness and insomnia - Muscle and joint pain - Running nose and eyes - Sweating - Abdominal cramps Consequences: - Psychiatric: delirium, anxiety, disorders in sexual and sleep functions, depression with a risk of suicide, degradation of the patient’s personality, - Somatic: no organ damage, but consequences of parental application (non-sterile method) —> pneumonia, endocarditis (affection of heart valves), abscess in the site of application. - Pregnancy: opioids are considered to be teratogenic + risk of neonatal withdrawal state. Treatment - Intoxication: antagonist—> Naloxone; in patients with opiate dependence it induces withdrawal state, - Detoxification: elimination of withdrawal state—> gradual tapering of the dose + combi- nation with opioid receptors antagonists (clonidine) + Naltrexone. II. Cannabinoids Cannabis can be consumed in 2 forms: Marijuana (dried vegetative part) or cannabis resin (hashish). THC is the most prominent psychoactive compound. It binds cannabinoid receptors in brain and PNS. Acute intoxication Impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, conjunctiva injection, increased appetite, dry mouth, tachycardia. Effects vary with dose, user’s expectation and the social setting. Some patients develop acute psychosis while consuming large amount of cannabis, quickly recover when the drug is stopped. Addiction Long-term usage—> low activity, cognitive disorder. !33 Apathic-hypobulic syndrome: decrease in activity + interests + curiosity. Withdrawal symptoms are mild: irritability, sleep disorders, sweating, decreased appetite. In many cases medications are not necessary. Complications - Memory deficit, induction of schizophrenia - Psychiatric consequences: Paranoid state, - Somatic: decrease of immune function with a high risk of bronchial and pulmonary can- cer. Bronchitis, pneumonia or asthma. III. Medicaments with addictive potential Anxiolytic and hypnotic drugs: BZD, barbiturates, Z-drugs -Most frequently used: benzodiazepines (positive allosteric modulation of GABA receptors). Most serious health problems are presented by barbiturates—> agonists of GABAa receptors. BZD and Barbiturates are taken by mouth and I.V. Younger dependent people: some dissolve capsule and inject I.V (complications: phlebitis, ulcers, abscesses and gangrene). Intoxication (resembles those of alcohol) - Slurred speech - Incoherence - Drowsiness - Depression of mood Diagnosis - Nystagmus (useful sign): barbiturates - Urine test - Blood test Tolerance Develops when the drugs are prescribed continuously for a long period, exact period is uncer- tain (approximately 6-8 weeks): less quickly than opioids. Tolerance due to psychological effects is greater than tolerance to their depressant effect on respiration: increase risk of unintentional overdose. Withdrawal - Similar to alcohol (anxiety, restlessness, insomnia, nausea, may progress to hallucina- tions, vomiting, hypotension, fever, major seizures), - Longer acting drugs withdrawal syndrome is delayed for several days. - If not treated: can cause death. - Withdrawal symptoms are less pronounced with long-acting (e.g diazepam) than with short-acting benzodiazepines (e.g: lorazepam) Treatment - Intoxication: gastric lavage, forced diuresis, flumazenil. - Detoxification: reduce the dose very slowly because of the risk of epileptic seizures or delirium. - Prevention: drugs with low risk of addiction (Buspirone) and non-pharmacological mea- sures. IV. Stimulant drugs: Amphetamines, cocaine and MDMA (ecstasy) Cocaine Obtained from the coca plant, it may be consumed as a white powder or crack (purification of cocaine with baking soda). Administered by sniffing, smoking or IV. Pharmacology: !34 - Euphoric effects by blockade of dopamine, noradrenaline and serotonin re-uptake—> ac- tivation of reward system of the brain, - After long-term regular use changes is the brain dopamine system may develop—> in- creased dopaminergic activation and withdrawal state. Amphetamine and MDMA (ecstasy) Effects similar to manic syndrome: increase in psychomotor activity, talkativeness, high-self confidence, risky behavior, high sexual activity. Tolerance slowly rises, it is faster in IV users. After continous use of the drugs the euphoric effect is less and less noticeable, while anxiety, tension, tiredness and dysphoria are more pronounced. Acute intoxication (mania-like symptoms) - Stimulatory and anesthetic effects, - Euphoria, - Reduction in feelings of tiredness and hunger, - Increased attention, - Temporary increase in cognitive abilities, - Increased self-confidence, - Vegetative and somatic symptoms: tachycardia, hypertension, mydriasis, weight loss, chest pain; circulatory collapse. Formication: Feeling of insects crawling under the skin. Withdrawal: - Anxiety, - Tremor, - Dysphoria, - Lethargy, - Fatigue, depression, - Craving, - Muscle pain, - Hyposomnia. Complications in prolonged use: - Psychiatric consequences: Mood disorders: hypomanic/manic states during intoxication, depression and axiety after discontinuation, Psychotic disorder: paranoid, Delirium, Disturbance of perception and thinking: resemble the paranoid form of schizophrenia with persecutory delusions, auditory and visual hallucinations and sometimes ag- gressiveness behavior. - Somatic consequences: Sniffing—> chronic inflammation of nasal mucosa—> nosebleed, ulceration, nasal septum perforation, IV complications, Arrhythmia, Stroke, Epileptic seizures, Multi-organ failure, Others. Condition subsides within a week or two of stopping of the drug, but occasionally persists for months. In some prolonged case diagnose: schizophrenia or depression. Caffeine !35 Stimulatory effect: monoamine and acetylcholine release and inhibition of cAMP phosphodi- esterase—> rise of cAMP. Acute intoxication: 50-100 mg; accelerates thinking, enhances creation of associations, facil- itates verbal communication and activity, reduce tiredness and sleepiness. High dose: euphoric effect. Symptoms of addiction: rise in tolerance, craving, inability to reduce daily dose. Withdrawal symptoms: irritability, insomnia, sleepiness, headache, nausea. Psychiatric consequences of caffeine abuse: depression, anxiety disorders, eating disorders, schizophrenia. Somatic consequences: high blood pressure, increased heart rate, arrhythmia. Nicotine Can be assumed by smoking, chewing or sniffing. Lethal dose 50-60 mg. Dopamine rises in the reward circuits—> development of addiction (usually more that 20 cigarettes/day). Acute intoxication: shortens reaction time, increases concentration, mental performances and euphoria. Increases heart rate, blood pressure, respiratory rate, salivation. Overdosage: arrhythmia, involuntary muscle contraction and abdominal colic. Withdrawal state: 2-3 hours after the last cigarette and lasts 2-3 weeks. Somatic consequences: cardiovascular disease, cancer (lungs, latynx, oesophagus), lung dis- ease (emphysema, edema, fibrosis), migraine, risk in pregnancy (abortion,