Psychiatry Summary.pdf

Psychiatry Table of Contents Psychiatric Symptoms and Signs........................................................................................ 1 Psychiatric Assessment...................................................................................................... 4 Psychiatric Disorders due to General Medical Conditions (GMC)....................................... 7 Substance-related and Addictive Disorders..................................................................... 13 Neurocognitive Disorders................................................................................................ 21 Sleep Disorders............................................................................................................... 27 Anxiety Disorders............................................................................................................ 36 Somatic Symptom and Related Disorders........................................................................ 41 Obsessive-Compulsive and Related Disorders.................................................................. 43 Trauma- and Stressor-related Disorders.......................................................................... 46 Depressive Disorders....................................................................................................... 49 Bipolar Disorder.............................................................................................................. 53 Mood Stabilisers............................................................................................................. 56 Antidepressants.............................................................................................................. 58 Suicide............................................................................................................................ 62 Dissociative Disorders..................................................................................................... 64 Psychotic Disorders......................................................................................................... 68 Personality Disorders...................................................................................................... 80 Aggression....................................................................................................................... 85 Child Psychiatry............................................................................................................... 89 Attention Deficit Hyperactivity Disorder............................................................... 89 Autism-Spectrum Disorder................................................................................... 91 Intellectual Disability........................................................................................... 95 Anxiety Disorders: Separation Anxiety................................................................. 98 Feeding and Eating Disorders........................................................................................ 100 Psychiatric Therapy Modalities...................................................................................... 107 Electroconvulsive Therapy (ECT)......................................................................... 107 Cognitive Behaviour Therapy (CBT).................................................................... 110 Mental Health Care Act (no.17 of 2002)......................................................................... 113 SIC Psychiatry Michelle Cremer Psychiatric Symptoms and Signs Behavioural Symptoms à Physical Sx Symptom / Sign Info Motor behaviour Person behaves according to what they think + feel à Conation Motor behaviour / activity expressing impulses, drives, Psychomotor activity wishes, instincts, cravings, motivations (Not always aware of own PMA à ↓ = Psychomotor retardation (‘just sit there’, not moving) move hair from face, etc.) ↑ = Psychomotor agitation (can’t sit still, fidgeting) Catatonia State of unresponsiveness to external stimuli (person is (different degrees/ Sx variation) awake) à Snd ≠ single Sx Often occur - Catatonic rigidity - Stiff, can’t move together - Catatonic posturing - Bizarre ‘poses’ maintained indefinitely - Waxy flexibility (Catalepsy) - Person allows themselves to be placed in postures by others à maintain posture for long periods - Catatonic stupor - Slow movements / hypoactive / rigid Major causes of - Akinesia - No movement catatonia - Depression - Catatonic excitement - Non-goal directed, disorganised movements - Medical - Catatonic mutism - Verbal unresponsiveness - Schizophrenia Signs / Sx Negativism Resistance against instruction, questioning, to be moved à motiveless (for no reason) + can progress to rigidity Stereotyped behaviour Fixed, repetitive pattern of motor behaviour Stereotypies / Mannerisms Repetitive, ingrained, habitual à spasmodic (grimacing), / Tics unconscious movement / posture (facial tics most common) Echopraxia Pathological imitation of another person’s movement Mm. incoordination (looks like drunk person trying to walk) Ataxia - Neurological / intoxication à not always psych Tremor Involuntary, rapid, rhythmical alternating movement Chorea Involuntary, rapid, random, jerky, purposeless movement Dyskinesia Difficulty performing voluntary movements Sustained contractions of opposing mm. groups (trunk / limbs) à mm. = stiff, painful / tender Dystonia - Strongest mm. group of affected area always contracts - Commonly due to Rx S/E Subjective feeling of inner restlessness + mm. tension à 2° Akathisia to antipsychotic Rx = pacing + other signs of psychomotor agitation 1 SIC Psychiatry Michelle Cremer Abnormalities of Speech Abnormality Info Pathological imitation of another person’s speech (can be Echolalia consequence of catatonia) Logorrhoea Speech quantity ↑ (individual specific) Poverty of Speech Speech quantity ↓ Poverty of Speech Content Normal quantity of speech but lacks information (vagueness) Rapid speech, ↑ quantity, difficult to interrupt (occurs Pressure of Speech together with pressure of thought) Nonspontaneous Speech Speech only in response to questions Dysprosody Loss of normal melody / rhythm / prosody of speech Frequent repetition (‘T,S’) / prolongation (‘L,N’) of sound / Stuttering syllable à impaired speech fluency Articulation problem (pronunciation ≠ language) Dysarthria - Common in stroke pts Difficulty with language output (language ≠ pronunciation) Aphasia - Expressive aphasia (Broca’s) à can understand - Receptive aphasia (Wernicke’s) à can’t understand Mood and Affect Mood Affect Pervasive, sustained emotion à experienced Objective, observed expression of mood / subjectively emotion - Euthymic mood à normal range of mood - Restricted à severe ↓ observable - Ecstatic / elevated / euphoric / elated à expression of emotion abn increased “high” mood - Blunted à very severe ↓ observable - Dysphoric / melancholic à unpleasant, expression of emotion low mood - Flat à absent / near absent observable - Depressed à psychopathologically sad, expression of emotion dysphoric, melancholic mood state - Appropriate à observable expression of - Mania à elation, hyperactivity, emotion in harmony with described mood hypersexuality, pressured speech + thought - Inappropriate à observable expression of - Irritable à easily angered emotion ≠ in harmony with described - Labile à oscillations between depression + mood elation (unstable = always changing) - Alexithymic à inability to be aware of / describe own emotions - Anhedonic à loss of interest in all pleasurable activities Anxiety and Related Symptoms Symptom Info Feeling of apprehension (fear of unknown) à caused by anticipation of Anxiety danger - Possibly based on prev experience / unrealistic idea Fear Anxiety caused by real / realistic danger Persistent, irrational, exaggerated, pathological dread of specific stimulus / Phobia situation à negative impact on daily life + behaviour Acute, episodic, intense attack of anxiety + ANS Sx (↑ HR, BP, RR, sweaty Panic attack palms) à associated with overwhelming feeling of dread Pathological persistence of irresistible thought / feeling (irrational) à can’t Obsession be eliminated from consciousness by logical effort (associated with anxiety) Pathological need to act on obsession / impulse à anxiety when resisted Compulsion - Physical behaviour related to obsession 2 SIC Psychiatry Michelle Cremer Psychosis Inability to distinguish reality from fantasy à 3 groups of psychotic Sx Disordered thought FORM Manifests as disorganised speech Indirect + delayed at reaching goal due to inclusion of Circumstantiality unnecessary, tedious detail (over-inclusiveness) Logical flow, no gaps Lack of observance to main subject of discourse Tangentiality Deviate from topic à went off on a tangent Derailment Sudden diversion in train of thought Discourse consists of sequence of unrelated / remotely related Loosening of ideas Associations Frame of reference changes for each sentence Inappropriate / Irrelevant Answer is logical but completely unrelated Answer Complete interruption of speech before thought / idea is Thought blocking completely expressed Also seen in epilepsy, auditory hallucinations Thoughts following each other rapidly à connections between Flight of Ideas thoughts are understandable Speech containing unnecessarily excessive detail Overinclusiveness Persisting response to previous stimulus even after a new stimulus Perseveration Not only verbal à can be tested by tapping hands = ask pt to repeat pattern Verbigeration Meaningless repetition of specific words / phrases Word salad Incoherent mixture of words / phrases (most severe) Neologisms Made up words à don’t form part of any language Pathological repetition of words / phrases Echolalia Sign of thought form disorder / catatonia Disordered thought CONTENT Delusions à Fixed false beliefs based on incorrect inferences about external reality + can’t be corrected by reasoning (most common) Category of delusion Info Belief of being harassed, cheated, persecuted (someone is Delusion of persecution Delusions following/watching them) Delusion of grandeur Belief of exaggerated importance, power, identity of paranoia Delusion of reference Belief of behaviour of others refers to them Delusion of poverty Belief of being bereft of all material possessions Belief that one’s self / others / world is non-existent / coming to Nihilistic delusion an end à e.g. he didn’t go to church therefor the tsunami that killed people is his fault Somatic delusion Belief surrounding part of body Belief of one’s will / thoughts / feelings controlled by external Delusion of control force Bizarre delusion Absurd, totally implausible, strange belief 3 SIC Psychiatry Michelle Cremer Disordered Perception Hallucination PS2 Psychiatry Toronto Notes 2020 False sensory perception NOT associated with real external Acronyms Illusion stimuli Categorised according to Other Misperception / misinterpretation of Acronyms sense involved REAL external sensory stimuli Auditory à usually voices Cenesthetic à sensation in organ 5-HT serotonin Schizophrenia DA unable to experience sensation dopamine MET -opticaltherapy motivational enhancement PTSD post-traumatic stress disorder -auditory Substance or medical ACh acetylcholine Visual DBT dialectical behavioural therapy Hypnagogic MSE mental status examination à non-pathological rTMS repetitive transcranial magnetic ACT assertive community treatment DZ dizygotic ADHD attention Epilepsy cause until proven (aura)disorder ECT deficit hyperactivity = while falling asleep MST electroconvulsive therapy MZ magnetic stimulation monozygotic therapy -tactile SGA stimulation second generation antipsychotics AN Olfactory anorexia nervosa EPS Hypnopompic extrapyramidal symptoms à non-NA Narcotics Anonymous SNRI serotonin and norepinephrine ASD autismEpilepsy spectrum disorder (aura) ERP exposure with response= pathological prevention NMS up while waking neuroleptic malignant syndrome reuptake inhibitors ASPD antisocial personality disorder EtOH ethanol/alcohol NOS not otherwise specified SS serotonin syndrome otherwise BN Gustatory bulimia nervosa GAD generalized anxiety disorder OCD obsessive-compulsive disorder SSRI selective serotonin reuptake inhibitor CBT cognitive Epilepsy behavioural(aura) therapy GMC general medical condition OCPD obsessive-compulsive personality TCA tricyclic antidepressant CD conduct disorder Tactile IPT interpersonal therapy disorder TD tardive dyskinesia CRA community reinforcement approach MAOi monoamine oxidase inhibitor ODD oppositional defiant disorder CT cognitive Cocaine therapy MDD major depressive disorder PD personality disorder CTO community treatment order MDE major depressive episode PDD pervasive developmental disorder Psychiatric Assessment Psychiatric Assessment History Identifying Data necessary: name, age, sex/gender, marital status, occupation/source of financial support, place/type of Screening Questions for Major Psychiatric residency Disorders adjunct: makeup of household, education, ethnicity, nationality, immigration history (if applicable), Have you been feeling down, depressed religion, current professional supports (GP, psychiatrist, case manager, therapist, etc), referral source, or hopeless? known or unknown to treatment team Do you feel anxious or worry about things? Has there been a time in your life where Reliability of Patient as a Historian you have felt euphoric, extremely indicate if, and for what content; utilize collateral source (i.e. parent, teacher, partner) if patient unable/ talkative, had a lot of energy, and a unwilling to be interviewed decreased need for sleep? Do you see or hear things that you think Chief Complaint other people cannot? Have you ever thought of harming in patient’s own words, with duration of symptoms yourself or killing yourself? History of Present Illness reason for seeking help (that day) and hopes/expectations for treatment current symptoms (onset, duration, fluctuation, progression, and course) and relevant associated symptoms (pertinent positives and negatives) potential precipitants for current problem, stressors, supports functional status: consider impact of current problems on personal care and survival, family functioning, occupational functioning, and broad social functioning safety screen: endangering self or others, dependents at home (i.e. children, pets), ability to drive safely, ability to care for self (i.e. eating, hygiene, taking medications) active medical problems Psychiatric Functional Inquiry mood: depression, mania Psychiatric Functional Inquiry anxiety: worries, panic attacks, phobias, or social anxiety history of trauma MOAPS obsessive-compulsive: obsessions, compulsions Mood psychosis: hallucinations, delusions Organic (e.g. substances and organic disease) risk assessment: suicidal ideation, plan, intent, and history of attempts (see Suicide, PS5) Anxiety organic: illness, dementia Psychosis Safety Past Psychiatric History all previous psychiatric diagnoses, psychiatric contacts, treatments (pharmacological and non- pharmacological), and hospitalizations include past suicide attempts, severity, necessity for medical intervention Substance Use History smoking, EtOH/drug use or withdrawal past treatments, periods of sobriety Past Medical/Surgical History all medical, surgical, neurological (i.e. head trauma, seizures), and psychosomatic illnesses current medications, doses, adherence, allergies Family Psychiatric/Medical History any past or current psychiatric illnesses and hospitalizations, suicide attempts, and substance abuse 4 Always Remember to Ask About Abuse if relevant: any past medical or genetic illness See Family Medicine, FM26 PS3 Psychiatry Toronto Notes 2020 SIC Psychiatry Psychiatric Assessment Michelle Cremer Past Personal/Developmental History (as relevant) family members: ages, occupations, personalities relationships with parents/siblings/partner/friends Mental Status Exam prenatal and perinatal history (desired vs. unwanted pregnancy, maternal and fetal health, domestic violence, maternal substance use and exposures, complications of pregnancy/delivery) ASEPTIC early childhood to age 3 (developmental milestones, activity/attention level, family stability, or Appearance and behaviour attachment figures) Speech Emotion (mood and affect) middle childhood to age 11 (school performance, peer relationships, behavioural challenges) Perception late childhood to adolescence (drugs/alcohol, legal problems, peer and family relationships) Thought content and process history of physical or sexual abuse Insight and judgment adulthood (education, employment, relationships) Cognition personality before current illness, or recent changes in personality psychosexual history (puberty, first sexual encounter, romantic relationships, gender roles, and sexual dysfunction) problems/encounters with the legal system The MSE is analogous to the physical exam. It focuses on current signs, affect, behaviour, and cognition Mental Status Exam General Appearance posture, gait, grooming, hygiene, manner of dress, body habitus, facial expression, chronological vs. Spectrum of Affect Full > Restricted > Blunted > Flat apparent age, and relaxed or in distress, alertness Attitude disposition in interview (i.e. uncooperative, suspicious, or hostile) There is poor correlation between clinical impression of suicide risk and frequency Behaviour of attempts psychomotor activity (agitation, retardation), abnormal movements or lack thereof (tremors, akathisia, tardive dyskinesia, paralysis), attention level and eye contact Speech Cognitive Assessment rate (i.e. pressured, slowed), rhythm/fluency, volume, tone, articulation, quantity, spontaneity Use MMSE to assess Orientation (time and place) Mood and Affect Memory (immediate and delayed recall) mood: subjective emotional state (in patient’s own words) Attention and concentration Language (comprehension, reading, affect: objective emotional state inferred from emotional responses to stimuli; described in terms of writing, repetition, naming) quality (euthymic, depressed, elevated, anxious, irritable) Spatial ability (intersecting pentagons) range (full, restricted, flat, blunted) Gross screen for cognitive dysfunction: stability (fixed, labile) Total score is out of 30; women) WHO: SA = worst EtOH consumption patterns worldwide (14% = EtOH abuse / dependence) Most commonly consumed 18-22 yo à responsible for MVAs Cannabis, heroin, amphetamines à most commonly used drugs Epidemiology 47% of those with substance abuse have mental health problems (unRx in 38%) 29% of those with mental health d/o have a substance use d/o 47% of those with schizophrenia and 25% of those with anxiety d/o have a substance use d/o Aetiology Almost all drugs (and activities) of abuse increase dopamine in the nucleus accumbens à contributes to their euphoric properties and with repeated use their ability to change signalling pathways in the brain’s reward system Substance use d/o arise from multifactorial interactions between genes (personality, neurobiology) and environment (low SES, substance-using peers, abuse hx, chronic stress) DSM V Criteria à Substance Use Disorder Dx based on pathological pattern of behaviours related to substance use Criterion A Criteria 1 Substance used in larger amounts / longer period than originally intended Impaired control Criteria 2 Express persistent desire to cut down / regulate substance + failure to do so Criteria 3 A lot of time spent obtaining / using / recovering from S/E of substance Criteria 4 Craving = intense desire / urge, can occur at any time, more likely in environment where drug was prev obtained / used Can’t think about anything else Used to measure Rx outcome + relapse risk Criteria 5 Recurrent use = failure to fulfil obligations (work, school, home) impairment Criteria 6 Persistent OR recurrent social / interpersonal problems caused / exacerbated Social by drug = still continues to use drug Criteria 7 NB social / occupational / recreational activities ↓given up Withdraw from family activities + hobbies à to use substance Criteria 8 Recurrent use in physically hazardous situaions Risky Criteria 9 Knows of persistent OR recurrent physical / psychological problem caused / use exacerbated by drug à still continues use à failure to abstain Criteria 10 Tolerance = require ↑↑↑ substance dose to achieve desired effect / highly logical criteria reduced effect when usual dose is used Pharmaco- Criteria 11 Withdrawal = blood / tissue concentrations ↓ in person who maintained prolonged heavy use Characteristic withdrawal Sx for substance Substance consumed to relieve Sx DSM V changes Included à gambling, cannabis + caffeine withdrawal, tobacco use disorder Substance abuse + dependence Dx ≠ used à substance use disorder Poly-substance dependence = problematic, confusing Strong desire / craving replaced recurrent legal criterion Criterion: o 2/more for Dx Severity: o Mild = 2-3 criteria o Mod = 4-5 criteria o Severe = 6/+ Specifiers: o In controlled environment o On maintenance therapy Remissions: o Early à 3 – 4 units/hr + F >2 units/hr o Toxic screen à identify used substance BAC = determines degree of intoxication o Urine § Cannabis (30d) Legal EtOH level = 0.05% § PCP (14-30d) Std drink sizes § BZD (1-9d) o Brandy / whisky = 25ml § Other (1-5d) o Wine (12-14% EtOH) = 75ml o Blood o Beer (5%) = 250ml o Hair follicles o Sweat Screening Tools EtOH Illicit drugs AUDIT (Alcohol Use Disorders Identification DAST (Drug Abuse Screening Test) à assess Test) à ?problem with EtOH dependence drug use Mild Can develop delirium on top of dementia Thinking takes longer 1. Complex attention Better with simple tasks Mistakes in prev routine tasks (≠ focus with distractions) Needs help planning tasks Effort to follow conversations 2. Executive fx Fatigue à effort to plan + make decisions à progression = rely on others Early = deterioration of recent memory 3. Learning + memory Repeat themselves Word finding difficulties + substitution of descriptive terms 4. Language Language becomes vague Dysfx can progress à mutism Easily lost 5. Perceptual motor skills Struggle with tasks that need spatial skills Driving + using tools = difficult Personality change = disinhibition, apathy, ↓ empathy 6. Social cognition Lacks insight DSM-V A. Evidence of cognitive decline in 1/> domain (complex attention, executive fx, learning, memory, perceptual-motor / social cognition) based on: Concern of individual / informant / clinician that there has been significant decline in cognitive fx Substantial impairment in cognitive performance (standardized tests / another clinical assessment) Classified according to underlying cause B. Interfere with every day activities Location of brain determines presentation C. Do not occur only during delirium o Cortex à Alzheimer’s D. Not better explained by another mental disorder o Subcortical à Huntington’s o Frontotemporal à ALS Causes Causes + Age of Onset Correctable causes Young à 2° Elderly à 1° Acute/sub-acute insult Chronic ± triggers Infection HIV Alzheimer’s disease - HIV + opportunistic infections TBI Vascular disease - TB meningitis, Neurosyphilis EtOH Parkinson’s Endocrine + metabolic Early onset disease / FTD - Recurrent hypoglycaemia familial types NPH - Chronic ↓/↑ Ca ?chronic mental illness CJD Nutritional = fx dementia - Vit B1, B6, B12, niacin (pellagra) Heavy metals, toxins, SOL = brain tumours, subdural medications haematoma Auto-immune / vasculitis = SLE Hypoxia (common) = parasuicide, HF, status epilepticus Substances Other à N pressure hydrocephalus (cog impairment + ataxic gait) 23 SIC Psychiatry Michelle Cremer 1. Alzheimer’s Terminal illness + gradual deterioration (50-70% of all NCD) à rare 50% reduction in quantitatively measured by the Apnea/Hypopnea Index (AHI) = # of apneic and hypopneic events per ventilation for >10 sec) hour of sleep Hyperpnea: excessive increase in rate or sleep apnea generally accepted to be present if AHI ≥5 depth of breathing AHI: Mild OSA 5-15 events/h, Moderate 15-30 events/h, Severe >30 events/h Classification obstructive (OSA) caused by transient, episodic obstruction of the upper airway absent or reduced airflow despite persistent respiratory effort central (CSA) (see Neurology, N47) can be hypercapneic CSA caused by transient, episodic decreases in CNS drive to breathe or nonhypercapnic where the drive to breathe is increased no airflow because no respiratory effort Cheyne-Stokes Respiration: a form of CSA in which central apneas alternate with hyperpneas to produce a crescendo-decrescendo pattern of tidal volume; seen in severe LV dysfunction, brain injury, and other settings (see Figure 2) mixed (MSA) features of both CSA and OSA loss of hypoxic and hypercapnic drives to breathe secondary to “resuscitative breathing”: overcompensatory hyperventilation upon awakening from OSA induced hypoxia Risk Factors for OSA: obesity, upper airway abnormality, neuromuscular disease, hypothyroidism, alcohol/sedative use, nasal congestion, sleep deprivation, enlarged tonsils, crowded oropharynx, short/wide neck for CSA: LV failure, brainstem lesions, stroke, brain tumours, encephalitis, encephalopathy, obesity (hypoventilation), neuromuscular disease, myxedema, high altitude, narcotics Signs and Symptoms obtain history from spouse/partner Continuous Positive Airways Pressure for secondary to repeated arousals and fragmentation of sleep: nocturnal gasping/choking, daytime Obstructive Sleep Apnea somnolence, personality and cognitive changes, snoring Cochrane DB Syst Rev 2006;CD001106 secondary to hypoxemia and hypercapnia: morning headache, polycythemia, pulmonary/systemic Study: Pooled analysis of 36 RCTs (n=1718) HTN, cor pulmonale/CHF, nocturnal angina, arrhythmias comparing nocturnal CPAP with an inactive a typical presentation for OSA is a middle-aged obese male who snores control or oral appliances in adults with OSA. Conclusions: The use of CPAP showed significant improvements in objective and Investigations subjective measures including cognitive sleep study (polysomnography) function, sleepiness, measures of quality of evaluates sleep stages, (EEG, EOG, EMG), airflow, ribcage movement, arousals, ECG, SaO2, limb life, and a lower average systolic and diastolic movements, snoring, body position, video recording blood pressure. People who responded equally indications well to CPAP and oral appliances expressed a strong preference for oral appliances; however, excessive daytime sleepiness participants on oral appliances were more likely unexplained pulmonary HTN or polycythemia to withdraw from therapy. daytime hypercapnia titration of optimal nasal CPAP or BiPAP assessment of objective response to other interventions (e.g. oral appliances for sleep apnea, positional therapy) Treatment modifiable factors: weight loss, decreased alcohol/sedatives, nasal decongestion, treatment of underlying medical conditions OSA or MSA: nasal CPAP, postural therapy (e.g. no supine sleeping), dental appliance CPAP has been shown to reduce CSA or hypoventilation syndromes: nasal BiPAP/CPAP, respiratory stimulants (e.g. acetazolamide, cardiovascular risk and cardiovascular theophylline, progesterone), adaptive servoventilation (e.g. progesterone) in select cases related deaths in patients with obstructive sleep apnea tracheostomy rarely required and should be used as last resort for OSA Complications depression, weight gain, decreased quality of life, workplace and vehicular accidents, cardiac complications (e.g. HTN), reduced work/social function associated with higher potential risk of CVS complications (e.g. heart attacks, strokes, arrhythmias, heart failure) 34 SIC Psychiatry Michelle Cremer 35 SIC Psychiatry Michelle Cremer Anxiety Disorders Group of mental d/o where there is excessive anxiety that causes clinically significant distress (subjective), or excessive anxiety that causes impairment of general functioning Anxiety becomes pathological when: § Fear is greatly out of proportion to risk or severity of threat § Response continues beyond existence of threat or becomes generalised to other or similar or dissimilar situations § Social or occupational fx impaired § Often comorbid with substance use and depression Manifestations of anxiety d/t activation of sympathetic nervous system: § Physiology: amygdala, NT involvement = 5-HT, cholecystokinin, epinephrine, norepinephrine, DA § Psychology: thoughts about given situation or stimulus contribute to feeling of fear and perception of threat § Behaviour: anxiety can lead to avoidance which can result in disruption of daily functioning Classification of DSM-V Anxiety Disorders of Adulthood 1) Generalised anxiety disorder (GAD) 2) Specific phobia § Animal § Natural environment § Blood-injection injury § Situational § Other 3) Social anxiety disorder 4) Agoraphobia 5) Panic disorder 6) Substance or medication-induced 7) Anxiety disorder due to another medical condition 8) Other specified anxiety § Limited symptom attacks § GAD not occurring more days than not § Khyâl cap (wind attacks) disorder § Ataque de nervous (attack of nerves) 9) Unspecified anxiety disorder 36 SIC Psychiatry Michelle Cremer Generalised Anxiety Disorder DSM-V CRITERIA FOR GENERALISED ANXIETY DISORDER A. excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6mo, about a number of events or activities (i.e. work or school performance) B. difficult to control the worry C. anxiety and worry are associated with 3 (or more) of the following Sx (with at least some Sx having been present for more days than not for the past 6mo) 1. restlessness or feeling keyed up or on edge 2. being easily fatigued 3. difficulty concentrating or mind going blank 4. irritability 5. muscle tension 6. sleep disturbance (difficulty falling or staying asleep, restless, unsatisfying) D. the anxiety, worry, or physical Sx cause clinically significant distress or impairment in social, occupational, or other important areas of functioning E. the disturbance is not attributable to the physiological effects of a substance or another medical condition F. the disturbance is not better explained by another mental disorder **other physiological Sx: epigastric pain, dry mouth, tension headaches Work-up for GAD History (onset usually during adolescence) MSE Physical examination (rule out medical condition) Special investigations: TFT, FBC, LFT, UKE Treatment Considerations: 1) Decide on dx or working dx 2) Decide on collat. information and special investigations 3) Do risk assessment 4) Decide on how and where to treat 5) Decide who to involve 6) Decide whom to refer to and F/U plan Lifestyle: avoid caffeine, alcohol, good sleep hygiene Psychosocial: (1st line for mild GAD) CBT (cognitive restructuring), relaxation, mindfulness, exposure Biological: SSRIs (1st line) Benzodiazepines Other Citalopram 20-40mg/d Lorazepam 0.5-2mg tds Venlafaxine 150-300mg/d Fluoxetine 20-60mg/d Oxazepam 10-20mg tds Buspirone 20-60mg/d Escitalopram 10-20mg/d (anxiolytic à atypical AP for Advantages: quick response Sertraline 50-200mg/d refractory GAD) Disadvantages: habit forming, Fluvoxamine 100-300mg/d cognitive S/E (concentration, Paroxetine 20-60mg/d memory), withdrawal = rebound anxiety and depression **use if quick results needed and then taper (unlikely) **improvement time with Rx in GAD = 6-8wks (may need higher doses than used for depression) 37 SIC Psychiatry Michelle Cremer Stress Sum of all physiological and psychological responses to an event or situation that requires adjustment Stressor: event or situation that requires adjustment Normal anxiety or fear Abnormal anxiety or fear 1) Constructive, no effect on functioning 1) Destructive, has effect on functioning 2) Proportional subjective distress 2) Excessive subjective distress 3) Proportional duration 3) Excessive duration 4) Proportional physical phenomena 4) Excessive physical phenomena Panic Disorder DSM-V CRITERIA FOR PANIC DISORDER A. recurrent unexpected panic attacks – a panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: § palpitations, pounding heart, or accelerated heart rate § sweating § trembling or shaking § sensations of shortness of breath or smothering § feelings of choking § chest pain or discomfort § nausea or abdominal distress § feeling dizzy, unsteady, light-headed, or faint § chills or heat sensations 2+ § paresthesias (numbness or tingling sensations d/t Ca shift) § derealization (feelings of unreality) or depersonalization (being detached from oneself) § fear of losing control or “going crazy” § fear of dying B. 1mo (or more) of “anxiety about panic attacks” - at least one of the attacks has been followed by one or both of the following: § persistent concern or worry about additional panic attacks or their consequences § a significant maladaptive change in behaviour related to the attacks C. the disturbance is not attributable to the physiological effects of a substance or another medical condition D. the disturbance is not better explained by another mental disorder Unprovoked or unexpected panic attack Provoked or suspected panic attack § substances § danger § medications § phobias § medical conditions § obsessions and compulsions § panic disorder **Limited Sx attack: looks just like a panic attack but with 6mo) fear that is excessive or unreasonable, cued by presence or anticipation of a specific object or situation animal or insect environment (heights, storms) blood, injection or injury situational (airplane, closed spaces) other (loud noises, clowns) à Mx: CBT SOCIAL PHOBIA (SOCIAL ANXIETY DISORDER) Marked and persistent (>6mo) fear of social or performance situations in which one is exposed to unfamiliar people or to possible scrutiny by others; fearing he/she will act in a way that may be humiliating or embarrassing Only phobic d/o that responds to Rx: SSRIs, venlafaxine, B-blockers (atenolol, propranolol) AGORAPHOBIA A. marked fear or anxiety about two (or more) of the following five situations: § using public transportation § being in open spaces § being in enclosed places § standing in line or being in a crowd § being outside of the home alone B. the individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms C. the agoraphobic situations almost always provoke fear or anxiety D. the agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety 39 SIC Psychiatry Michelle Cremer E. the fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context F. the fear, anxiety, or avoidance is persistent, typically lasting ≥6 mo G. the fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning H. if another medical condition is present, the fear, anxiety, or avoidance is clearly excessive I. the fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder and are not related exclusively to obsessions, perceived defects or flaws in physical appearance, reminders of traumatic events, or fear of separation Note: agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned à Mx: CBT Substance or Medication-induced Anxiety Disorder A. panic attacks or anxiety is the predominant clinical picture B. symptoms developed soon after substance intoxication or withdrawal, or medication exposure C. substance or medication is a known culprit D. not due to another anxiety disorder E. not during delirium Specifiers: § with onset during intoxication § with onset during withdrawal § with onset after medication exposure Anxiety Disorders due to Another Medical Condition A. panic attacks or anxiety is the predominant clinical picture B. evidence that the anxiety symptoms are the direct effect from another medical condition C. clinically significant distress or functional impairment D. not due to another mental condition E. not during delirium Other Specified Anxiety **Limited Symptom attacks Unspecified Anxiety Disorder § chooses not to specify why criteria are not met § insufficient information Stopping Treatment in Anxiety Disorders Treatment is usually lifelong Discontinuation can be considered when: o 1yr of complete remission (Sx free) o Full fx restoration o Pt has sense of well-being o It’s the right time in the pt’s life (no new stressors) o Slowly, over months o Reinstitute Rx if relapse 40 SIC Psychiatry Michelle Cremer Somatic Symptom and Related Disorders General Characteristics Physical signs and Sx lacking objective medical support in the presence of psychological factors – judged to be important in the initiation, exacerbation, or maintenance of the disturbance Cause significant distress or impairment in functioning Sx are produced subconsciously, not the result of malingering or factitious d/o Primary gain: somatic Sx represents symbolic resolution of a subconscious psychological conflict; serves to reduce anxiety and conflict with no external incentive Secondary gain: the sick role, external benefits obtained or unpleasant duties avoided Classification of DSM-V Somatic Symptom and Related Disorders 1) Somatic Symptom Disorder 2) Illness anxiety disorder 3) Conversion disorder (functional neurological symptom disorder) 4) Psychological factors affecting other medical conditions 5) Factitious disorder 6) Other specified somatic symptom and related disorders: Brief somatic symptom disorder Brief illness anxiety disorder Illness anxiety disorder without excessive health-related behaviours Pseudocyesis (phantom pregnancy) 7) Unspecified somatic symptom and related disorder Somatic Symptom Disorder Pts have physical Sx and believe them to be representative of serious illness Persistent belief despite negative medical investigations, may develop different Sx over time Complications: anxiety, depression, unnecessary medications or surgery DSM-V CRITERIA FOR SOMATIC SYMPTOM DISORDER A. one or more somatic symptoms that are distressing or result in significant disruption of daily life B. excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following: disproportionate and persistent thoughts about the seriousness of one’s Sx persistently high level of anxiety about health or symptoms excessive time and energy devoted to these symptoms or health concerns C. although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically >6mo) Specifiers: somatic symptom disorder with predominant pain persistent (continuous, disabling, severe) 41 SIC Psychiatry Michelle Cremer Differential Diagnosis Medical Conditions Mental Disorders True disease Other somatic Sx and related d/o Conditions with vague presentations: Anxiety d/o: GAD, panic d/o o Neurological: MS, Myasthenia gravis Mood d/o: MDD, persistent depressive d/o, o Autoimmune: SLE dysthymia o Metabolic: intermittent porphyria, Obsessive-compulsive and related d/o: OCD, porphyria veriegata, hyperparathyroidism, body dysmorphic d/o haemosiderosis Psychotic d/o: SCZ, schizoaffective d/o, o Infections: Syphilis, HIV delusional d/o, somatic type o Miscellaneous: IBD Management Form a good dr-pt relationship Seek and treat comorbid mental d/o and other medical diseases Minimise unnecessary interventions Aim at information that improves QoL Use medication judiciously o Amitriptyline 25-50mg or SSRI o Avoid habit-forming drugs – benzos, opioids o Placebo only used where a pt knows they might receive a placebo Illness Anxiety Disorder Preoccupation with fear or having, or the idea that one has a serious disease – causes significant impairment High level of anxiety about health, easily alarmed about personal health Engages in maladaptive behaviour – excessive physical checking or total healthcare avoidance Somatic Sx are mild or not present If there is a physical condition, or risk for it, the preoccupation is clearly obsessive Duration ≥6mo Specifiers: Care-seeking type Care-avoidant type Conversion Disorder (Functional Neurological Symptom Disorder) ≥1 symptoms or deficits affecting voluntary motor or sensory fx that mimic a neurological or GMC (i.e. impaired coordination, local paralysis, double vision, seizures, or convulsions) Does not need to be preceded by a psychological event as per previous DSM criteria, however this is still worth exploring as many patients will present after such an event or related to a medical diagnosis in a first-degree relative Spontaneous remission in 95% acute cases Specifiers: with Weakness or paralysis à do EMG Abn movements Swallowing Sx Speech Sx Attacks or seizures Anaesthesia or sensory loss Special Sx categories Mixed Sx Acute or chronic With or without a psychological stressor 42 SIC Psychiatry Michelle Cremer Psychological Factors Affecting Other Medical Conditions Medical Sx that is adversely affected by psychological factors in their being a known additional health risk, influencing underlying pathophysiology, adversely affecting the course or adherence to treatment Behaviour changes that adversely affect medical condition Factitious Disorder Imposed on self: o Deception about physical or psychological Sx or signs, having the person presenting himself as ill, impaired, injured or without any clear external rewards Imposed on another à Munchausen snd o Deception about physical or psychological Sx or signs, having the person presenting another person as ill, impaired or injured, without any clear external rewards Specifiers: Single episodes Recurrent episodes Obsessive-Compulsive and Related Disorders Classification of DSM-V Obsessive-Compulsive and Related Disorders 1) Obsessive-compulsive disorder 2) Body dysmorphic disorder 3) Hoarding disorder 4) Trichotillomania 5) Excoriation disorder 6) Substance/medication-induced obsessive-compulsive and related disorder 7) Obsessive-compulsive and related disorder due to another medical condition 8) Other specified obsessive-compulsive and related disorder: Body dysmorphic-like disorder with actual flaws Body dysmorphic-like disorder without repetitive behaviours Body-focussed repetitive behaviour disorder Obsessional jealousy Shubo-kyofu Koro Jikoshu-kyofu 9) Unspecified obsessive-compulsive and related disorder 43 SIC Psychiatry Michelle Cremer Obsessive-Compulsive Disorder (OCD) DSM-V CRITERIA FOR OBSESSIVE-COMPULSIVE DISORDER A. presence of obsessions, compulsions, or both § obsessions are defined by (1) and (2) 1. recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and cause marked anxiety or distress in most individuals 2. the individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e. by performing a compulsion; see below) § compulsions are defined by (1) and (2) 1. repetitive behaviours (i.e. hand washing, ordering, checking) or mental acts (i.e. praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly 2. behaviours mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviours or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive B. the obsessions or compulsions are time-consuming (i.e. take >1 h/d) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning C. the obsessive-compulsive symptoms are not attributable to the physiological effects of a substance or another medical condition D. the disturbance is not better explained by the symptoms of another mental disorder Specifiers With good or fair insight With poor insight With absent insight or delusional beliefs Tic-related Related Behaviours Avoidance Time consuming compulsions Injury and damage Risk Factors Genetic: neurological dysfx, Fhx Environmental: adverse childhood experience (abuse, behavioural inhibition), exposure to traumatic events, GAS infection Management Risk assessment: risk of inadvertent injury to themselves Psychoeducation: about the d/o, pharmacological Rx + s/e, psychosocial Rx + its challenges Biological: SSRI/SNRI (12-16wk trials, higher dosage than used in depression), clomipramine, tranylcypromine (MAOI), adjunctive antipsychotics (Risperidone) Psychosocial: CBT (exposure with response prevention – ERP), behaviour therapy 44 SIC Psychiatry Michelle Cremer Body Dysmorphic Disorder Preoccupation with ≥1 perceived flaws in physical appearance not observed by others Repetitive behaviours (i.e. mirror checking, excessive grooming, skin picking, or reassurance seeking) or mental acts (i.e. comparing self to others) related to appearance ± muscle dysmorphia Causes clinically significant distress or functional impairment Rule out eating disorder Specifiers: o With good or fair insight o With poor insight o With absent insight or delusional beliefs Management Risk assessment: unnecessary surgery, comorbid mental conditions Psychoeducation: about the d/o, pharmacological Rx + s/e, psychosocial Rx + its challenges, about surgery mostly being unnecessary, living an active life Biological: SSRIs – fluoxetine (chronic) Psychosocial: CBT, behaviour therapy, social worker Hoarding Disorder Persistent difficulty discarding possessions regardless of actual value Feels the need to save items, discarding creates distress Results in possessions cluttering or compromising active living areas (may be uncluttered with 3rd party intervention, i.e. family member, cleaners, authorities) Causes clinically significant distress or functional impairment Rule out: o Brain injury or neurocognitive d/o o Cerebrovascular disease o Prader-Willi syndrome o OCD o MDD (low energy) o ID or Autistic d/o (restricted interests) o Psychotic d/o (delusions) Trichotillomania Recurrent pulling out own hair à hair loss Repeated attempts to stop or decrease hair pulling Causes clinically significant distress or functional impairment Rule out dermatological condition and body dysmorphic d/o Excoriation (Skin-Picking) Disorder Recurrent skin picking à lesions Repeated attempts to stop or decrease skin picking Causes clinically significant distress or functional impairment Rule out scabies, substance use, psychotic d/o (delusions, tactile hallucinations), body dysmorphic d/o, stereotypic movement d/o, non-suicidal self-injury 45 SIC Psychiatry Michelle Cremer Trauma- and Stressor-related Disorders Classification of DSM-V Trauma- and Stressor-Related Disorders 1) Posttraumatic stress disorder 2) Acute stress disorder 3) Adjustment disorder 4) Other specified trauma- and stressor-related disorder 5) Unspecified trauma- and stressor-related disorder **Stressor: any situation or event that requires an individual to make an adjustment ***Stress response: sum total of all adjustments (physiological, behavioural, psychological) Post-Traumatic Stress Disorder (PTSD) DSM-V CRITERIA FOR POST-TRAUMATIC STRESS DISORDER A. exposure to actual or threatened death, serious injury, or sexual violence in ≥1 of the following ways: § directly experiencing the traumatic event(s) § witnessing, in person, the event(s) as it occurred to others § learning that the traumatic event(s) occurred to a close family member or close friend; in cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental § experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (i.e. first responders collecting human remains, police officers repeatedly exposed to details of child abuse) B. presence of ≥1 of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: (RIMIND) § Recurrent, involuntary, and Intrusive distressing memories of the traumatic event(s) § Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) § Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) § recurrent distressing Nightmares in which the content and/or affect of the dream are related to the traumatic event(s) § Dissociative reactions (i.e. flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring C. persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: § avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) § avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) 46 SIC Psychiatry Michelle Cremer D. negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by ≥2 of the following: § inability to remember an important aspect of the traumatic event(s) § persistent and exaggerated negative beliefs or expectations about oneself, others, or the world § persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others § persistent negative emotional state (i.e. fear, horror, anger, guilt, or shame) § markedly diminished interest or participation in significant activities § feelings of detachment or estrangement from others § persistent inability to experience positive emotions E. marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by ≥2 of the following: § irritable behaviour and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects § reckless or self-destructive behaviour § hypervigilance § exaggerated startle response § problems with concentration § sleep disturbance (i.e. difficulty falling or staying asleep or restless sleep) F. duration of the disturbance (criteria B, C, D, and E) is more than 1mo G. the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning H. the disturbance is not attributable to the physiological effects of a substance or another medical condition Specifiers: § With dissociative symptoms (not attributable to physiologic effects of a substance or a medical condition) § Depersonalization: persistent or recurrent experiences of feeling detached from, or as if one were an outside observer of one’s mental processes or body § Derealisation: persistent or recurrent experiences of unreality of surroundings § With delayed expression: the full diagnostic criteria are not met until 6mo after the event Management § Psychological o Trauma therapy, CBT § Ensure safety, mobilise support, emotional regulation techniques o EMDR (Eye Movement Desensitisation and Reprocessing) – reprocessing memories of distressing events by recounting them while using a form of dual attention stimulation (eye movements, bilat. sound or tactile stimulation) § Biological o First line: fluoxetine, sertraline, venlafaxine o Prazosin (disturbing dreams and nightmares) o Benzos (acute anxiety) o Adjunctive atypical antipsychotics (risperidone, olanzapine) Complications § Substance abuse § Relationship difficulties § Depression § Impaired social and occupational functioning § Personality disorders 47 SIC Psychiatry Michelle Cremer Adjustment Disorder Difficulty coping with a stressful life event or situation à develop acute, often transient, emotional or behavioural Sx that resemble less severe versions of other psychiatric conditions DSM-V CRITERIA FOR ADJUSTMENT DISORDER A. the development of emotional or behavioural symptoms in response to an identifiable stressor(s) occurring within 3mo of the onset of the stressor(s) B. these symptoms or behaviours are clinically significant as evidenced by either of the following: § marked distress that is in excess of what would be expected from exposure to the stressor § significant impairment in social or occupational functioning C. the stress-related disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a pre-existing mental disorder D. the symptoms do not represent normal bereavement E. once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6mo Specifiers: § with depressed mood § with anxiety § with mixed anxiety/depression § with conduct disturbance § with mixed disturbance of conduct/emotions § unspecified Classification § Single or multiple § Recurrent or continuous § Developmental events è Adjustment-like disorder with delayed onset of Sx (>3mo after stressor) è Adjustment-like disorder with prolonged duration (>6mo) without prolonged duration of stressor Management § Brief psychotherapy § Biological: benzos for significant anxiety Sx 48 SIC Psychiatry Michelle Cremer Depressive Disorders 1. Major Depressive Disorder Prevalence = 10% (↑ in elderly) à 2nd most NB contributor to disability 15% attempt suicide Recurrent pattern of 2mo intervals of remission Affects HPA axis, immune system à multiple organ systems unRx à long-term physical consequences = CHD, asthma, DM, RA (co-morbid conditions) DSM-V Criteria A. 5/> Sx during same 2wks + change from prev functioning Depressed mood (most of the day, nearly every day) Loss of interest / pleasure Weight loss + appetite changes Insomnia / hypersomnia Psychomotor agitation / retardation Fatigue Worthlessness / guilt Concentration difficulties / indecisive Thoughts of death / suicidal ideation B. Sx cause significant distress / impairment in NB areas of fx C. Not caused by substances / AMC D. MDD not better explained by another psychiatric condition E. No hx of manic / hypomanic episodes Specifiers Anxious distress à tense, restless, excessive worry, fearful Melancholic features (worse in morning) à despondent, despair, psychomotor changes Atypical features à mood reactivity, weight gain, hypersomnia, leaden paralysis, rejection sensitivity Psychotic features (mood congruent / incongruent) Catatonia Peripartum onset (2yrs (adult) / >1 (child) NO suicidal thoughts + psychomotor changes DSM-V Criteria A. Depressed mood most of the day >2yrs (children = irritable >1yr) B. 2/> SIGECAPS C. Never without Sx >2mo D-H. Exclusions + distress / impairment No manic episodes Not caused by substances / AMC / other mental disorder Differential Diagnosis Sadness Adjustment d/o / bereavement Substance induced mood d/o Mood d/o due to AMC à epilepsy, RA, SLE, MS, PD, thyroid d/o, HIV Bipolar d/o / schizoaffective d/o ADHD Treatment *same antidepressant Rx Mild à psychotherapy Mod – Severe à medication ± psychotherapy (OPD / primary care) Complicated / Severe / resistant / co-morbidities à refer + admission Multi-disciplinary approach à social work, psychology, OT o Address psychosocial issues Pharmacotherapy + psychotherapy = better outcome Aim = complete remission (40% with 1st / 2nd line Rx) 1. Psychoeducation Nature of disorder Identify sx + signs Rx options Response to Rx + course of d/o Dosages + S/E Avoidance of EtOH + substances Relapse prevention Support groups + family support 2. Pharmacotherapy *As for MDD 3. Other therapies CBT Interpersonal psychotherapy Psychodynamic psychotherapy ECT TMS DBS 51 SIC Psychiatry Michelle Cremer 3. Premenstrual Dysphoric Disorder Mood Sx occur at specific time in menstrual cycle (after ovulation + remits within days of menses) 3-8% (12mo prevalence in 2-6%) “heightened PMS” DSM-V Criteria A. 5/> Sx in wk before menses onset, improve within few days + minimal / absent in wk post menses (ajority of menstrual cycles) B. 1/> Sx Affective lability Irritability / anger / ↑ interpersonal conflict Depressed mood, hopelessness, self-deprecating thoughts Anxiety, tension, feeling on edge C. 1/> Sx additionally (reach total of 5 Sx with B) ↓ interest in usual activities Subjective difficulty concentrating Lethargy, easily fatigued Marked appetite changes (overeating / specific food changes) Hypersomnia / insomnia Overwhelmed / out of control Physical Sx à breast tenderness / swelling, joint / mm. pain, weight gain / bloating D. Significant distress / interference with work / school / usual activities or relationships with others E. Not Sx exacerbation of another psychiatric d/o (MDD, panic d/o, PDD, personality d/o) F. Criterion A confirmed with prospective dly rating during >2 Sx cycles G. Not attributable to physiological effects of substance / AMC Clinical Features Physical Behavioural Mood Swelling Sleep disturbance Irritability Breast tenderness Appetite change Mood lability Aches Poor concentration Anxiety / tension Headaches ↓ interest Depression / dysphoria Bloating / weight change Social withdrawal Feeling overwhelmed / out Joint / mm pain of control Differential Dx Premenstrual snd or dysmenorrhoea Bipolar d/o MDD or PDD Hormonal Rx Management Pharmacotherapy SSRI: fluoxetine, sertraline, venlafaxine, citalopram, paroxetine, clomipramine BZD: Alprazolam Ovulation suppressor: GnRH analogues, danazol, TD estradiol patches, OCP Other: o Bromocriptine = mastalgia o Spironolactone = water retention o Ca supplementation o Tryptophan (ovulation à menses) NO evidence for diet mods, salt / caffeine / EtOh restriction, exercise, stress Mx NOT effective = lithium, progesterone, danazol in luteal phase, evening primrose oil 52 SIC Psychiatry Michelle Cremer 4. Substance- / Medication-Induced Depression EtOH ↑↑ MDD risk x2 Pharmacological agents used: Analgesics Anti-HPT Antibacterials Chemo drugs Steroids Sedatives 5. Depressive Disorder due to AMC Causes: Mechanism of AMC o Endocrine à hypothyroidism / Cushing’s o CNS à Parkinson’s, CVI, TBI, epilepsy, MS, HIV o Malignancy à lymphoma, pancreas ca - Endocrinopathies of HPA axis o Nutritional deficiency à B12, folate - CNS à epilepsy, CVA, trauma Rxn to Dx = ca / HIV - Infectious à HIV, syphilis Rx of AMC - Malignancy o Corticosteroids - DM - Metabolic abn o Anticonvulsants o Hyper-/hypocalcaemia o ARVs o Hyponatraemia o Antimalarials - Nutritional deficiency + anaemia o Anti-HPT o B12, folate, pellagra Combination of above Bipolar Disorder Mood abn = core feature Episodes and Sx Depressive Episodes Manic Episodes Hypomanic Episodes 1st episode + majority Alone = dx of bipolar ≥5 Sx during 2wks Abn, persistently elevated, Abn, persistently elevated, expansive / irritable mood ≥1 expansive / irritable mood ≥4d *SIGECAPS wk / hospitalisation à clearly different from normal (non-depressed) mood DIG FAST Manic Sx (lesser degree) Distractibility Slight changes in mood + Involvement in fx = uncharacteristic + Share inappropriate pleasurable activity ↑↑ observable by others info in social situations Grandiosity NO psychotic Sx = expressive emotion Flight of ideas NO hospitalisation Activity ↑ (PMA) Sleep need ↓ Talkative (pressured speech) - Males à manic - Females à depressive + mixed (manic + depressive features every day = 1wk) - Age of onset à 30yo 53 SIC Psychiatry Michelle Cremer Subtypes 1. Bipolar 1 d/o = hx of prev manic episode (can present with manic, hypomanic, major depressive, mixed features) 2. Bipolar 2 d/o = hypomanic + major depressive episode (NEVER full-blown manic ep) 3. Cyclothymic d/o = hypomanic + depressive Sx à ≠ meet criteria for hypomanic / major depressive episode 4. Substance- / medication-induced bipolar + related d/o = associated with intoxication + withdrawal Manic à stimulants = caffeine, cocaine Depression (CNS suppression) à EtOH, BZD, sleeping tablets, cocaine withdrawal 5. Bipolar + related d/o due to GMC = pathophysiology of GMC Hyperthyroidism, phaeochromocytoma 6. Other specified bipolar + related d/o = clinical bipolar picture but ≠ meet criteria for other subtype Short duration Recurrent hypomanic episodes (≠ major depressive ep) Major depressive + hypomania (≠ meet criteria) ?Primary bipolar / due to MMS 7. Unspecified bipolar + related d/o = clinical bipolar picture + insufficient info to make specific dx Specifiers Current / most recent episode: Severity = mild / mod / severe Depressed / manic / hypomanic mood with: o Anxious distress o Atypical features (leaden paralysis, easily offended, weight gain, hypersomnia) o Peripartum onset o Psychotic features (mood congruent / incongruent) o Melancholic features (dark, dismay, despair, ≠ appetite, weight loss) o Mixed features (mania + depression at same time) o Catatonia Lifetime pattern: Rapid cycling à ≥4 episodes /yr Seasonal pattern = winter Partial remission à improved but not all Sx gone / all Sx gone but not long enough Full remission à symptomless >2mo 54 SIC Psychiatry Michelle Cremer Management à In-pt vs Out-pt = based on risk assessment Hospitalisation Out-pt Mx Suicide / homicide risk 1. Maintenance phase Relapse + no access to food / shelter due 2. Frequent evaluation = hypomanic + mild- to absence of support system mod depressive episodes Rapidly progressive Sx Psychosis Manic, major depressive, mixed episodes (Involuntary / voluntary admission) Psychotherapy Indications = maintenance + hypomanic / mild-mod depressive episodes à NOT manic, major depressive, mixed / psychotic episodes CBT Most common causes of relapse: Interpersonal + family therapy 1. Stressful life event Psychoeducation 2. Substances OT 3. Non-adherence Pharmacotherapy à stage specific Mood stabilisers à mainstay of Rx Depressive Manic Hypomanic 1. MS: Lamotrigine > Lithium 1. MS: Lithium, Valproate 1. MS: Lithium, Valproate 2. AP: Olanzapine, Aripiprazole 2. AP: Olanzapine, Haloperidol 2. AP: Olanzapine, Haloperidol (NO haloperidol = psychosis) 3. BZD: Clonazepam 2mg po TDS 3. BZD: Clonazepam 3. ECT (can cause seizures) 4. ECT 4. NO AD (if using AD = stop) 4. AD = LAST resort à always 5. NO AD add at least 1 MS If 2 MS used: Acute: Emergency sedation (IM à 1 = Rx depression Lorazepam, Haloperidol, à 2 = prevent manic episode Ziprasidone) Acute: Quetiapine > Lamotrigine Mixed Maintenance 1. MS: Valproate, Lamotrigine 1. MS: Lithium, Valproate, 2. AP: Olanzapine Lamotrigine 2. AP: Carbamazipine (not routinely used) ***Valproate ≠ Rx / prevent depression à Lamotrigine 55 SIC Indications Categories Psychiatry BipolarPharmacology maintenance phase Classic = lithium C Holtzhausen & L Classen Hypo/manic episodes Anticonvulsants = valproate, carbamazepine, Depressive episodes lamotrigine M d S abi i e Mixed episodes Atypical antipsychotics = olanzapine, aripiprazole Indications Side Effects Monitoring Bipolar maintenance 1. LITHIUM TOXICITY = medical emergency STOP lithium UKE + CC = kindey fx (1st month 6 Manic prevention + push IV fluids (polyuria increases excretion + dilutes mo) mixed features + concentration) FBC = leukocytosis rapid cycling rx o Cardiovascular changes + renal dysfunction TSH = thyroid fx (1st mo 6 mo) bipolar depression rx o Seizures, impaired LOC, coma B-HCG = pregnancy (periodically) o Tremor, dysarthria, ataxia ECG = dysrhythmia/ heart block Lithium o Myoclonus + muscular Fasciculations (1st mo periodically) o N/V/D 500mg po mane Lithium levels (4 days after increase slowly adjust 2. SEROTONIN SYNDROME (+ SSRI + MAOI) 3. Teratogenesis Eb ei a malie starting/ changing dose 3-6 mo) according to trough 4. Weight gain & fluid retention Normal: 0.6-1.2mmol/L lithium level (draw before next dose) 5. Renal effects (renal excretion) o Polyuria + polydipsia Psychiatry Lots of pee: polyuria, polydipsia o Hypokalaemia Impaired LOC, coma Narrow therapeutic index o Nonspecific interstitial fibrosis > 10 yr usage = ineffective rx/ lethal Tremor, Tongue = dysarthria 6. Thyroid effects = hypo > hyperthyroidism Heart: ECG changes Classic mood stabiliser lithium toxicity 7. Cardiac effects (secondary to hypokalaemia) Increased N/V/D o T-wave flattening/ inversion Unbalanced: ataxia, electrolytes o Sinus dysrhythmia Myoclonus, Mm. fasciculations Mood Stabilisers

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