Mental Disorders - Part 1.pdf

1 DEPRESSIVE & BIPOLAR DISORDERS Presented by: Dr. A. Rechea 2 Learning Objectives Brief review of psychiatric evaluation Review the epidemiology, symptomatology, etiology and neurobiology, differential diagnosis, DSM-V criteria for diagnosis of the psychiatric disorders listed below: Depressive dis...

1 DEPRESSIVE & BIPOLAR DISORDERS Presented by: Dr. A. Rechea 2 Learning Objectives Brief review of psychiatric evaluation Review the epidemiology, symptomatology, etiology and neurobiology, differential diagnosis, DSM-V criteria for diagnosis of the psychiatric disorders listed below: Depressive disorders: Major Depressive Disorder, Persistent Depressive Disorder (Dysthymia) and Premenstrual Dysphoric Disorder (PMDD) Bipolar and related disorders: Bipolar I disorder, Bipolar II disorder and Cyclothymic disorder. 3 Examination: Mental Status Examination (MSE) Actions Appearance Behavior Feelings Mood Affect Thoughts Speech Thought process Thought content Perception Cognition Observation Direct questions 4 MSE: emotional state Mood Affect This is the emotion that a patient feels This is the emotion that you can see expressed on a patient's face. It can over a longer period. Think of it as the change frequently, much like the weather climate of their emotional world. can change in a day. How the patient says they're feeling. What you understand from their words and behaviors. Remains relatively constant. Look for smiles, frowns, and other expressions. Notice if these expressions change quickly. Assess if their reactions are in line with the situation. 5 Mental Disorder What Are They? Mental health disorders are conditions where a person experiences changes or difficulties in their thinking, emotional control, or behavior. Why Do They Happen? These changes are often due to issues in how our bodies and minds develop and function. How Do They Affect Lives? They can lead to challenges in everyday life, such as in relationships, work, or other important areas. Key Point for Nurses: As a nurse, you might see patients struggling with these issues. It's important to recognize these signs and understand how they can impact a patient's life and care needs. Mood Disorders 6 Depressive Disorders DSM 5 Major Depressive Disorder Persistent Depressive Disorder (Dysthymia) Substance/Medication Induced Depressive Disorder Depressive Disorder due to Another Medical Condition Premenstrual Dysphoric Disorder Disruptive Mood Dysregulation Disorder 7 8 Depressed mood Anhedonia ▪ Depressed ❖Loss of interest or ▪ Sad pleasure in life ❖Not caring anymore ❖No enjoyment in previously pleasurable activities ❖Social withdrawal or neglect of pleasurable avocations ❖Reduced sexual interest or desire ▪ Hopeless ▪ Discouraged ▪ Down in the dumps ▪ May deny ▪ Inferred from facial expression & demeanor ▪ May focus on somatic complaints (bodily aches & pains) ▪ Irritability Symptoms of MDD: “SAD-A-FACES” 1. 2. 3. 4. 5. S-sleep disturbance (insomnia/hypersomnia) A- appetite (decrease or increase) & weight (loss or gain) change D-depressed mood A-anhedonia ( interest/pleasure in activities)* F-fatigue or loss of energy 6. A-agitation or retardation (psychomotor) Observe for signs of restlessness (agitation) or unusually slow movements (retardation), which can be more objectively measured. 7. C- concentration or thinking diminished or indecisiveness 8. E- esteem (worthlessness or guilt) - Listen for expressions of feeling worthless or excessive guilt, which can impact self-esteem. 9. S – suicidality (thoughts of death, suicidal ideation, plan or attempt) ▪ Somatic complaints ▪ Loss of sex drive ▪ Delusions or hallucinations (if mood congruent) 9 Major depressive disorder (MDD): Diagnosis ❑Core symptoms: Depressed mood Anhedonia (loss of interest or pleasure) ❑Plus, four additional symptoms: 5/9 symptoms ❑Duration: Most of the day, nearly every day for at least 2 weeks ❑No hx/o: mania, hypomania ❑Causes: Distress or dysfunction ❑Onset: Any age, Peak in 20’s ❑Female to male ratio: 2:1 ❑Course: Episodic – Single or recurrent ❑Rule out: Substance/Medication-Induced depressive disorder Depressive disorder due to another medical condition ❑Genetic & Physiological Risk Factors-Familial: first-degree relatives, 2-4x> general population MDD: Suicide Risk ▪ 60% of depressed patients have suicidal ideation. ▪ 15% of depressed patients die by suicide Risk factors: Past history of suicide attempts or threats ✓Following hospital discharge- for several months ✓Being single or living alone ✓Male sex ✓Prominent hopelessness ✓Presence of borderline personality disorder ✓Presence of anxiety SAD PERSONS 11 MDD: subtypes (specifiers) MDD With: ▪ Anxious distress - excessive worry, nervousness, or restlessness in patients ▪ Atypical features - unusual symptoms such as mood reactivity (mood lifts in response to positive events) or increased appetite and sleep ▪ Psychotic features - delusions or hallucinations that can either align with their mood (mood-congruent) or not (mood-incongruent)) ▪ Peripartum onset ▪ Seasonal pattern (emotional distress seems to appear at a certain time of the year, commonly in winter months) MDD with Peripartum onset (Postpartum depression) ▪ Characterized by ▪ depressed affect, anxiety, and poor concentration….. ▪ duration: > 2 weeks ▪ Onset: during pregnancy or after delivery NOTE: DSM-5, MDD with peripartum onset either starts during pregnancy or within 4 weeks after delivery Postpartum blues Characterized by Rapidly fluctuating mood, tearfulness, fatigue, irritability, and anxiety duration: < 2 weeks Onset after delivery (usually 4-5 days after) 14 MDD vs Persistent depressive disorder (Dysthymia) MDD Dysthymia Core symptoms Depressed mood Anhedonia (loss of interest or pleasure) Depressed mood Severity of symptoms 5/9 symptoms Above + 2 or more (milder symptoms 1,2,5,7,8 ) Duration Most of the day, nearly every day for at least 2 weeks Most of the day, more days than not for at least 2 years ( 1 year for children & adolescents) Common elements No history of mania, hypomania Distress or dysfunction 15 Premenstrual Dysphoric Disorder (PMDD) One (or more of): [mood & anxiety symptoms] Marked Depressed mood, hopelessness, or self-deprecating thoughts Affective lability (rapid changes in emotion, such as sudden tears or laughter) Irritability or anger or interpersonal conflicts Plus one (or more of) for a total of 5 with above: [behavioral/physical] Decreased interest in usual activities Hypersomnia or insomnia Change in appetite; overeating; or specific food cravings Physical symptoms: breast tenderness or swelling, joint or muscle pains, bloating, or weight gain Premenstrual Dysphoric Disorder 16 Diagnostic Criteria At least 5 symptoms (Anxiety, Mood, & behavioral/physical) Final week before the onset of menses Improve after onset of menses Minimal or absent postmenses Majority of menstrual cycles Distress or interference with work, school, social activities or relationships Confirmed by prospective daily ratings during at least 2 symptomatic cycles - Keep a daily record of symptoms; done for at least two cycles where symptoms are present. This helps confirm the pattern and consistency of symptoms 17 Bipolar & Related Disorders DSM-5 Substance/Medication-Induced Bipolar & Related Disorder Bipolar & Related Disorder Due to Another Medical Condition Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder 18 Bipolar Disorder What are the core symptoms of Mania or Hypomania? Elevated, expansive or irritable mood Abnormally increased activity or energy Bipolar disorder: symptoms (“DIG FAST”) 1. D- Distractibility - most common, most subjective 2. I – Indiscretions/Impulsivity/Impaired judgment excessive involvement in pleasurable activities that have a high 19 potential for painful consequences sexual indiscretions, reckless driving, spending sprees & sudden traveling 3. G - Grandiosity (an exaggerated sense of one's importance, power, or knowledge). In some cases, these beliefs can be delusional- not grounded in reality. 4. can be delusional) 5. F - Flight of ideas or racing thoughts 6. A - Activity increase: social, work, school 7. S – Sleep : decreased need for sleep 8. T – Talkativeness: pressured speech or more talkative than usual + Mood: elevated, expansive or irritable 20 Bipolar & Related Disorders Subtype Manic episode Hypomanic episode MDE Bipolar I Yes (At least one) Yes/No Yes/No Bipolar II Never Yes (At least one) Yes (At least one) Cyclothymic disorder No Hypomanic symptoms but do not meet criteria Depressive symptoms but do not meet criteria Determine if the patient has had at least one manic or hypomanic episode at any point in their lifetime. Single episode is nearly diagnostic of bipolar disorder (I or II). 21 Cyclothymic disorder At least 2 years (1 year in children & adolescents) Numerous periods with hypomanic symptoms (not full episode) Numerous periods with depressive symptoms (not full episode) Symptoms present at least half the time Not without symptoms for >2 months at a time Never met criteria for a major depressive, manic or hypomanic episode Distress or dysfunction 22 Bipolar & related disorders: Lifetime suicide risk Bipolar & related disorders: Genetic & Physiological Risk Factors Bipolar 15X > general population Account for 25% of completed suicides Bipolar I = 36.3% suicide attempt rate Bipolar II =32.4% suicide attempt rate Lethality: bipolar II > I ▪ Relatives with bipolar I & II (average 10x) ▪ Family history: strongest & most consistent risk factor ▪ Share a genetic origin with schizophrenia 23 Causes of Depressed/Low Mood A general medical disorder Using a substance or medication Identifiable psychosocial stressor Bereavement, with grief that is unusually prolonged, intense, and disabling? Occur in conjunction with other symptoms of a depressive disorder, e.g., fatigue, changes in sleep, guilt, appetite. SAD-A-FACES Repeatedly occur during the week before the onset of menses and remit with the onset of menses or a few days thereafter? Is there a current or past history of manic/hypomanic symptoms? Depressive disorder due to another medical condition Substance or medicationinduced depressive disorder Adjustment Disorder Complicated grief MDD, Dysthymia Premenstrual dysphoric disorder Bipolar disorder 24 LEARNING OBJECTIVES. Review the epidemiology, symptomatology, etiology and neurobiology, differential diagnosis, DSM-V criteria for diagnosis of the psychiatric disorders listed below: Somatic symptom and related disorders: Somatic symptom disorder, Illness anxiety disorder, Conversion disorder (functional neurological symptom disorder) and Factitious disorder. Substance-related disorders: Substance use disorders and Substance/medication DSM V CRITERIA FOR SOMATIC SYMPTOM DISORDER Psychiatry A. One or more somatic symptoms that are distressing or result in significant disruption of daily life Diagnostic criteria (according to DSM-5) A.≥ 1 somatic symptom (e.g., heartburn, fatigue, headache, abdominal pain) that causes significant distress or impairment B.The patient exhibits excessive thoughts, feelings, or behaviors related to the somatic symptoms or health, manifested by ≥ 1 of the following: A.Disproportionate and constant thinking about the severity of symptoms B.Constant anxiety about symptoms or general health C.Excessive amounts of time and energy attending to symptoms or health concerns C.Duration: ≥ 6 months DSM V CRITERIA FOR ILLNESS ANXIETY DISORDER Affected individuals present with a persistent preoccupation with having or developing a serious Psychiatry illness despite recurrent medical examinations that find otherwise. Somatic symptoms are usually absent or mild, but patients spend large amounts of time and energy obsessing over their health and over the possibility of developing a disease. Motivation is unconscious; symptoms are not intentionally produced (opposite of factitious disorders) Epidemiology ♀ = ♂ Age of onset: usually early adulthood Strongly associated with comorbid anxiety or depressive disorders Diagnostic criteria (according to DSM-5) A. Preoccupation with having or acquiring an illness B. Somatic symptoms absent or mild C. Significant anxiety over health D. Excessive health-related behaviors (e.g., constantly checking for minor signs of illness) or maladaptive avoidance behaviors (e.g., avoiding doctor appointments and hospitals) Duration: ≥ 6 months Not better explained by another mental disorder DSM V CRITERIA FOR FACTITIOUS DISORDER DSM V CRITERIA FOR FACTITIOUS DISORDER IMPOSED ON OTHERS Factitious Disorder (Previously known as Münchhausen syndrome ) Previously known as Münchhausen syndrome by proxy Individuals intentionally falsify physical signs and symptoms, even through selfharm (e.g., injecting insulin), to assume the role of a patient. Type of child or elder abuse Epidemiology♀ > ♂ Associated with a history of significant exposure to health care (e.g., profession in health care, significant childhood illness, important relationship with a medical professional) and personality disorders (e.g., narcissistic, borderline, ) Assoiciated with a willingness to undergo invasive or risky treatments Patients intentionally produce symptoms in someone else (usually their child or aging parent). ♀ = ♂ Associated with a history of maternal abuse and personality disorders (e.g., narcissistic or borderline personality disorder) The deceptive behavior is evident even in the absence of obvious external rewards. Diagnostic Criteria Factitious Disorder Imposed on Self A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. B. The individual presents himself or herself to others as ill, impaired, or injured. C. The deceptive behavior is evident even in the absence of obvious external rewards. D. The behavior is not better explained by another mental disorder, such DSM V CRITERIA FOR CONVERSION DISORDER (FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER) Psychiatry A. One or more symptoms of altered voluntary motor or sensory function. B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. C. The symptom or deficit is not better explained by another medical or mental disorder. D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. Specify symptom type: With weakness or paralysis With abnormal movement (e.g., tremor, dystonic movement, myoclonus, gait disorder) With swallowing symptoms With speech symptom (e.g., dysphonia, slurred speech) With attacks or seizures Our patient With anesthesia or sensory loss With special sensory symptom (e.g., visual, olfactory, or hearing disturbance) With mixed symptoms Specify if: Acute episode: Symptoms present for less than 6 months. Persistent: Symptoms occurring for 6 months or more. Specify if: With psychological stressor (specify stressor) Without psychological stressor SOMATIC SYMPTOM AND RELATED DISORDERS AT A GLANCE Psychiatry FEATURE/ DISORDER SOMATIC SYMPTOM DISORDER Present Medical symptom Medical Present/ Absent explanation of symptom Anxiety Present related to the symptom 75% of previously diagnosed hypochondriacs ILLNESS ANXIETY DISORDER Absent/Mild CONVERSION FACTITIOUS DISORDER DISORDER Faked Absent Present (neurological) Absent Present Absent Absent 25% of previously diagnosed hypochondriacs Absent Malingering is an important differential diagnosis for factitious disorder Disorder Symptom production Factitious disorder Conscious Malingering Conscious Motivation External rewards Unconscious Even in their absence Conscious Present (Secondary gain) What are substance related disorders? Psychiatry All drugs that are taken in excess → direct activation of the brain reward system → involved in the reinforcement of behaviors and the production of memories Produce such an intense activation of the reward system that normal activities may be neglected Initial use- conscious and voluntary Continued use is due to the effects of the drug on brain functioning Cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems Sedatives Stimulants Alcohol Cocaine Barbiturates Amphetamine Benzodiazepines Ecstasy Minor: caffeine, nicotine Hallucinogens and related substances Opioids LSD, Cannabis- causes distortions Dissociative anesthetics like Ketamine and Phenylcyclidinecause depersonalization Heroin Morphine Codeine Methadone Oxycodone Fentanyl The substance-related disorders are divided into two groups: Psychiatry 1. Substance use disorders 2. Substance-induced disorders The following conditions may be classified as substanceinduced: ❖ Intoxication ❖ Withdrawal ❖ Other substance/medication-induced mental disorders 32 Substance use disorders-12 month period, 2 of 11 manifestations ❑Impaired Control (4): ▪ ▪ ▪ ▪ Psychiatry Using more substance or for longer than intended. Unsuccessful attempts to cut down. Significant time lost in obtaining, using, or recovering from the substance. Strong craving or urge to use the substance. ❑Social Impairment (3): Failing to meet responsibilities at work, school, or home. Ongoing social or interpersonal issues. Giving up or reducing social and work activities. ❑Risky Use (2): o Using substances in dangerous situations. o Continued use despite knowing it's worsening physical or psychological problems. ❑Pharmacological Indicators (2): ❖ Tolerance: Needing more of the substance to feel the same effect. ❖ Withdrawal: Experiencing withdrawal symptoms when not using, or using to avoid withdrawal symptoms. 33 INTOXICATION Psychiatry A. B. C. D. Recent ingestion of, consumption of or exposure to a substance Clinically significant problematic behavioral or psychological changes related to A Intoxication Specific signs or symptoms per substance Rule out another medical condition, another mental disorder, including intoxication with another substance Neutral Sedatives Stimulants Hallucinogens and related substances Opioids Respiratory depression Slurring of speech Lateral nystagmus Sedation Disinhibition Nausea Vomiting Agitation Fever PCP: muscle rigidity, fever, dissociation LSD and Cannabis: delirium Respiratory depression Apnea Sedation Coma Miosis Hypotension Constipation Agitation Insomnia Paranoia Cardiac arrhythmias Hypertension Mydriasis Vasospasm (mimics symptoms of Schizophrenia, or manic episodes of Bipolar disorder) WITHDRAWAL Psychiatry 1. Cessation of or reduction in heavy or prolonged use (or daily use) 1. After antagonist administration for opioids 2. Symptoms and signs develop after 3. Distress/impairment 4. Rule out another medical condition, another mental disorder including intoxication or withdrawal from another substance Withdrawal Intoxication Neutral Sedatives Stimulants Hallucinogens and related substances Opioids Delirium Seizures Hypertension Tachycardia Diaphoresis Tremors Depression Sedation Lethargy Cannabis- irritability, insomnia, distractibility, inattention, anxiety Autonomic hyperactivity Mydriasis Pain Diarrhea (mimics major depressive disorder with atypical features) ALCOHOL WITHDRAWAL Generally, begin within 6 to 24 hours of the last drink or a sudden reduction in chronic alcohol drinking Syndromes Onset, peak & duration Symptoms & signs Uncomplicated (“Shakes”) Begins in 12-18 hours Peaks at 24-48 hours Subsides in 5-7 days Anxiety, tremors, nausea, vomiting, increased HR & BP Seizures Occurs in 7-38 hours Peaks at 24-48 hours Single burst of 1-6 generalized seizures Status epilepticus is rare Hallucinosis Begins in 48 hours Lasts about 1 week Chronic in some Vivid & unpleasant hallucination (usually visual & commonly involve seeing insects or animals in the room), can also be auditory, or tactile Clear sensorium; vital signs are usually normal Delirium tremens Begins in 2-3 days Peaks 4-5 days later Lasts 3 days typically Can persist for weeks Confusion, disorientation, perceptual & sleep cycle disturbances, agitation, autonomic hyperarousal (fever, severe tachycardia, hypertension, and drenching sweats) 37 Eating DISORDERS 38 Eating Disorders Essential Feature Anorexia Nervosa Persistent energy intake restriction (leads to low body weight) Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain Disturbance in self-perceived weight or shape Bulimia Nervosa Recurrent episodes of binge eating Recurrent inappropriate compensatory behaviors (at least once a week for 3 months) to prevent weight gain Self evaluation unduly influenced by body shape & weight Binge-eating Disorder Recurrent episodes of binge eating At least once a week for 3 months 39 ANOREXIA NERVOSA Anorexia Nervosa Moderate: 16-16.99 Mild: ≥17 Severe: 15-15.99 Severity: BMI (kg/m2) Extreme: