Mental Health Conditions Lecture Notes PDF

PATH 1017 Mental Health Conditions Professor Jennifer Lamarre PATH 1017 2024-2025 1  Agenda 1. Discuss the DSM-V and its relationship to mental health conditions 2. Examine the neurophysiology linked to mental health conditions 3. Apply the pa...

PATH 1017 Mental Health Conditions Professor Jennifer Lamarre PATH 1017 2024-2025 1  Agenda 1. Discuss the DSM-V and its relationship to mental health conditions 2. Examine the neurophysiology linked to mental health conditions 3. Apply the pathophysiology framework to various mental health conditions: a. Schizophrenia b. Mood disorders c. Anxiety d. Obsessive compulsive disorder e. Post-traumatic disorder f. Eating disorders PATH 1017 2024-2025 2  DSM-V American Psychiatric Society - “Diagnostic and Statistical Manual of Mental Disorders”, 5th Ed, Established common language and criteria for diagnosing nearly 300 mental health disorders Divides mental health disorders into different categories according to disorder or disability PATH 1017 2024-2025 3  Making a Diagnosis Considered a “clinical” diagnosis because based on manifestations according to the DSM criteria Many self-report rating systems exist to determine severity of symptoms No labs, scans etc. will lead to a diagnosis – Instead, used to rule out other conditions PATH 1017 2024-2025 4 NEUROPHYSIOLOGY AND THE LINK TO MENTAL HEALTH CONDITIONS PATH 1017 2024-2025 5  Let’s review neurophysiology Think about the multiple functions of the cerebrum and its functional areas. If there was any damage or dysfunction to any of these areas, what symptoms would manifest? (i.e. frontal lobe, parietal lobe etc.) PATH 1017 2024-2025 6 Key Brain Structures Affected in Mental Health Conditions Amygdala Thalamus Limbic Syste m Hypothalam Hippocampu us s PATH 1017 2024-2025 7  Notes: Amygdala- Thalamus- Hypothalamus- Hippocampus- PATH 1017 2024-2025 8  Neurotransmitters Chemicals that send and regulate signals between neurons The activity that occurs at the post-synaptic receptors are essential for neurological functions Categorized into excitatory and inhibitory based on their action Currently thought that most mental health conditions are related to neurotransmitter issues – Medications and substances can function at these receptor sites and alter the communication between neurons PATH 1017 2024-2025 9  Examples of Key Neurotransmitters in Mental Health Disorders Neurotransmitter Dysfunction Disorder Dopamine Serotonin Norepinephrine GABA PATH 1017 2024-2025 10 SCHIZOPHRENIA PATH 1017 2024-2025 11  Schizophrenia Affects less than 1% of population Affects males & females equally – Peak onset- 15-25 years males; 25-35 years old females – Increased severity and poorer response to treatment in males Pattern of frequent relapses & repeated hospitalizations Most complex and debilitating mental health condition Strong link to substance abuse PATH 1017 2024-2025 12  Etiology Can you explain each etiological Main Theories: factor? – Heredity/genetics- 60% is inherited – Neurotransmitters – Dopamine hypothesis – 6 other neurotransmitters involved – Factors thought to affect neurodevelopment: – Events during fetal development – Environmental stressors – Stress PATH 1017 2024-2025 13 Additional Space for Etiology Notes PATH 1017 2024-2025 14  Manifestations Categorized into 4 different types of manifestations: – Positive- Examples- hallucinations, delusions, paranoia – Negative- Examples- apathy, avolition, anhedonia – Cognitive Examples- impaired memory, inattention, perseveration, poverty of thought Can you describe the manifestations that fit – Depressive with each category? PATH 1017 2024-2025 15  DMS-V Criteria 1. Lasts at least 6 months of which at least 1 month includes active- phase symptoms 2. Active phase symptoms include at least 2 of the following: Hallucinations Delusions What do Disorganized speech these Disorganization or catatonic behaviour terms mean? Negative symptoms PATH 1017 2024-2025 16  Phases of Psychosis Experience positive and negative symptoms Ac Unable to perform self care ut e Re Occurs 6-18 months after acute treatment co Symptoms present but less severe ve ry Symptoms in remission St Residual symptoms may persist in mild form abl Able to live independently e PATH 1017 2024-2025 17  What is the treatment for Schizophrenia? Multidisciplinary approach including: – Psychotherapy – Medication: Antipsychotics- act as dopamine antagonists to reduce psychotic symptoms (i.e. risperidone) Antidepressants – Skills training – Support and safety PATH 1017 2024-2025 18  Prognosis Highly variable Medication and social supports are key Early intervention associated with better recovery – 25-30% experience complete remission after one or more psychotic episodes For many, course is chronic and debilitating with relapses – 30-40% are homeless PATH 1017 2024-2025 19 MOOD DISORDERS PATH 1017 2024-2025 20  Mood Disorders Also called “affective disorders” Involves dysregulation of mood (depressed or elevated) – Affects physiology, cognition and behaviour – May have serious impact on individual, family, career etc. Affects the 6% of general population total person, not just mood – Females 1.7-2.7X greater than males – Average age of onset: Depression- mid 20s to 30s (likely earlier) Bipolar- mid to late 20s Prevalence greatest between 35-64 years PATH 1017 2024-2025 21  Mood Disorders Etiology Direct cause unknown Theories: – Neurobiological Genetics Altered neurotransmission – Neurotransmitters- serotonin, norepinephrine – Kindling theory Neuroendocrine (HPA axis) dysfunction PATH 1017 2024-2025 22  Etiology (cont’d) Kindling Theory/Phenomenon: – Stress initially alters neurotransmission resulting in first episode of depression – This sensitizes brain to future stress and magnifies responses – Creates new “hardwiring” of brain PATH 1017 2024-2025 23  Neuroendocrine (HPA Axis) Dysfunction Dysfunction of the hypothalamic-pituitary- adrenal axis (HPA axis) – Controls physiologic responses to stress – Becomes hyperactive in depression Overtime, elevated cortisol damages hippocampus and is thought to lead to chronic depression PATH 1017 2024-2025 24  Types of Mood Disorders Persistent depressive disorder (unipolar): – Major depressive episode (single or recurrent) Bipolar disorders: – Manic episodes PATH 1017 2024-2025 25  Major Depression May be a first episode or recurrence Symptoms must be a result of the depression and not due: – Effects of a substance – Medical condition – Loss of a loved with within the previous 2 months Symptoms are emotional, cognitive, behavioural or social Can be triggered by a major life event or stressor PATH 1017 2024-2025 26  Major Depression DSM-V Criteria 5 or more of the following present during the same 2- week period and represent a change from previous functioning. At least one symptom must be 1) or 2): 1. Depressed mood 2. Markedly diminished interest or pleasure in activities 3. Significant weight loss without dieting or weight gain or an increase or decrease in appetite 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness or excessive or inappropriate guilt 8. Diminished ability to think or concentrate or indecisiveness 9. Recurrent thoughts of death, suicidal ideation or suicide attempt PATH 1017 2024-2025 27  Bipolar Disorder Occurs on spectrum Occurs when pt experiences episodes of depression and episodes of mania overtime – mania, hypomania and depressive Mania and depression must not be due to: – Substances, electroconvulsive therapy, light therapy PATH 1017 2024-2025 28  Manic Episodes DSM-V Criteria: Abnormally and persistently elevated, expansive or irritable mood and changes in activity and energy level for at least 1 week And at least 3 of the following must be present: – Inflated self-esteem or grandiosity – Decreased need for sleep – More than usual talkativeness or pressure to keep talking – Flight of ideas or subjective experience of thoughts racing – Distractibility – Increase in goal-directed activity or psychomotor irritation – Excessive involvement in pleasurable activities that have painful consequences PATH 1017 2024-2025 29 Manic vs depressive manifestations PATH 1017 2024-2025 30  Treatment Counselling (individual and group) Psychotherapy, cognitive-behavioural therapy Medication Biological interventions Support for physiological processes (i.e. nutrition, sleep) Safety (i.e. suicide prevention) PATH 1017 2024-2025 31  Medication Antidepressants – Selective serotonin reuptake inhibitors (SSRIs)- (i.e. celexa) – Tricyclic antidepressants- i.e. elavil – MOAIs (monoamine oxidase inhibitor agents) – Newest- selective serotonin norepinephrine reuptake inhibitors (SNRIs)- i.e. effexor Mood Stabilizers – Lithium Anticonvulsants used for mood stabilization-( i.e. carbamazepine) PATH 1017 2024-2025 32  Biological Interventions: Electroconvulsive therapy (ECT) Transcranial magnetic stimulation Vagal nerve stimulation Deep brain stimuli Phototherapy PATH 1017 2024-2025 33  Prognosis Varies widely – Depression: 1/5 fully recover 2/3 have a recurrence – Bipolar disorder: high rates of relapse and recurrence Increased risk of suicide PATH 1017 2024-2025 34 ANXIETY DISORDERS PATH 1017 2024-2025 35  Anxiety Feeling of uneasiness Often related to perceived threat conflict or danger State of tension, dread, impending doom Threatens to overwhelm individual A warning sign of danger to motivate person to act – May trigger the fight or flight response People have a variety of defence mechanisms to control or manage anxiety PATH 1017 2024-2025 36  Anxiety May start in childhood/adolescence and persist into adulthood – Women > men Exists on a continuum Mild anxiety can lead to increased productivity, creativity As it increases: – Perceptual fields narrow – Energy becomes available for problem solving – Disorganization increases High rate of coexisting depression and other disorders PATH 1017 2024-2025 37  Anxiety conditions Generalize Panic d Anxiety Disorders Disorder Phobias PATH 1017 2024-2025 38  Anxiety Etiology Hypothalamus-pituitary (HPA) axis is activated by stress and promotes “fight or flight” response Increased activity in amygdala & hippocampus Neurotransmitters – – Genetics: – Altered serotonin transporter gene (shortened) increases sensitivity to stress Heredity Anxiety can also be learned or develop from social situations PATH 1017 2024-2025 39 Additional Space for Etiology Notes PATH 1017 2024-2025 40  Generalized Anxiety Disorder (GAD)- DSM-V Excessive anxiety and worry about a number of different issues/events that a the person cannot control and 3 of the following symptoms present for at least 6 months: – Restlessness or feeling on edge – Easily fatigued – Difficulties with concentration – Irritability – Muscle tension – Sleep disturbance AND Interferes with normal social or occupational functioning PATH 1017 2024-2025 41  Panic Disorders Onset in adolescents to mid 30s Panic attacks are sudden spontaneous episodes accompanied by symptoms such as palpitations, dizziness, dyspnea, feeling of doom May occur in a variety of mental health disorders (i.e. PTSD) PATH 1017 2024-2025 42  Panic Attacks- DSM-V Criteria A distinct period of intense fear or discomfort in which 4 or more symptoms develop abruptly and reach a peak within 10 minutes: 1. Palpitations, pounding 9. De-realization (feelings heart, accelerated of unreality) or heartbeat depersonalization 2. Sweating (detached from 3. Trembling or shaking oneself) 4. Sensation of SOB or smothering 10.Fear of losing control 5. Feeling of choking or going crazy 6. Chest pain or discomfort 11.Fear of dying 7. Nausea or abdominal 12.Paresthesias discomfort 8. Feeling dizzy, light-headed 13.Chills or hot flashes or faint PATH 1017 2024-2025 43  Panic Disorder –DSM-V Criteria Two criteria must be met: – Recent and unexpected panic attacks – At least one of the attacks has been followed by: Persistent concern about having additional attacks Worry about the implications/consequences of the attacks Significant change in behaviour related to the attacks PATH 1017 2024-2025 44  Phobias Panic attacks that occur in response to particular situations or learns to avoid the situation that cause the panic attack Phobias last 6 months or more Women>Men Peak onset: Childhood, early adulthood Types: – Specific phobias – Social phobias PATH 1017 2024-2025 45  Anxiety Disorders- Treatment Reassure and offer assistance Anxiety-reduction strategies Cognitive-behavioural therapy – i.e. desensitization/exposure therapy Medications – – Long-term: SSRI, NSSRIs – Short-term- Benzodiazepines PATH 1017 2024-2025 46  Anxiety Disorders- Prognosis Depends on type of disorder, treatment and pt – GAD usually has earlier onset and tends to be chronic – Panic disorder- chronic course – 30% well after treatment – 40-50% improved but still symptomatic – 30% are the same or slightly worse – Phobias: Usually responds well to desensitization therapy those that persist into adulthood typically do not end PATH 1017 2024-2025 47 OBSESSIVE COMPULSIVE DISORDER (OCD) PATH 1017 2024-2025 48  Obsessive Compulsive Disorder - OCD Women=men, onset 20-30s 2.5% experience during lifetime Linked with eating disorders, substance abuse, depression Etiology theories: – Trauma to basal ganglia or cortical connections – Genetic predisposition triggered by infection or environmental stressors PATH 1017 2024-2025 49  Obsessive Compulsive Disorder DSM-V Criteria: 1- Presence of either obsessions and/or compulsions Example: fear of germs and repeated handwashing 2- Obsessions & compulsions are time consuming, cause distress and impair social and occupational functioning What is the difference between obsessions and compulsions? Example? PATH 1017 2024-2025 50 OCD Treatment & Prognosis Treatments: – Anxiety-reduction strategies – Therapy: cognitive, behavioural Exposure with response prevention therapy – Medications- SSRIs OCD- prognosis similar to other anxiety disorders – 2/3 show improvement with treatment 15% gradually deteriorate to the point of impaired social/occupational functioning – 1/3 fully recover PATH 1017 2024-2025 51 PTSD PATH 1017 2024-2025 52  Post-Traumatic Stress Disorder (PTSD) Develop at any age, any point post-event Rates varies widely – Who is affected? Causal factor is an identifiable traumatic event (typically severe) What other conditions is it linked to? Influenced by availability of support PATH 1017 2024-2025 53  PTSD DSM-V Criteria- A) Summary History of exposure to a traumatic event that meets specific stipulations Symptoms from each of four symptom clusters: – B) Intrusion, – C) Avoidance – D) Negative alterations in cognitions and mood – E) Alterations in arousal and reactivity F) Duration of symptoms G) Changes in functioning H) Not attributable to a substance or co-occurring medical condition. PATH 1017 2024-2025 54  PTSD DSM Criteria Criteria A: Event: History of exposure to a traumatic event that meets specific stipulations: – 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 friend – Experiencing repeated or extreme exposure to aversive details of the traumatic event(s); this does not apply to exposure through media such as television, movies, or pictures PATH 1017 2024-2025 55  PTSD DSM Criteria Criteria B: Intrusion: The persistent re-experiencing of the event in 1 of several ways: – Thoughts or perception – Images – Dreams – Illusions or hallucinations – Dissociative flashback episodes – Intense psychological distress or reactivity to cues that symbolize some aspect of the event PATH 1017 2024-2025 56  PTSD DSM Criteria Criteria C: Avoidance: Avoidance of stimuli that are associated with the trauma and numbing of general responsiveness Presence of 1 or both of the following criteria: – Avoidance of thoughts, feelings, or conversations associated with the event – Avoidance of people, places, or activities that may trigger recollections of the event PATH 1017 2024-2025 57  PTSD DSM Criteria Criteria D: Negative Alteration in Mood or Cognition: 2 or more of the following symptoms: – Inability to remember an important aspect of the event(s) – Persistent and exaggerated negative beliefs about oneself, others, or the world – Persistent, distorted cognitions about the cause or consequences of the event(s) – Persistent negative emotional state – Markedly diminished interest or participation in significant activities – Feelings of detachment or estrangement from others – Persistent inability to experience positive emotions PATH 1017 2024-2025 58  PTSD DSM Criteria Criteria E: Alterations in arousal and reactivity: -2 or more of the following criteria: – Irritable behaviour and angry outbursts – Reckless or self-destructive behaviour – Hypervigilance – Exaggerated startle response – Concentration problems – Sleep disturbance PATH 1017 2024-2025 59  PTSD DSM Criteria Criteria F: Duration The duration of symptoms is more than 1 month Criteria G: Changes in Functioning The disturbance causes clinically significant distress or impairment in functioning Criteria H: Exclusions The disturbance is not attributable to the physiological effects of a substance or other medical condition PATH 1017 2024-2025 60  PTSD Treatment Maintain personal safety Anxiety-reduction strategies Cognitive-behavioural therapy Medications- SSRIs Counselling & ongoing social supports PATH 1017 2024-2025 61  PTSD -Prognosis Prognosis depends on individual and supports – 30% recover fully – 40% have mild symptoms – 20% have moderate symptoms – 10% unchanged or worsening symptoms PATH 1017 2024-2025 62 EATING DISORDERS PATH 1017 2024-2025 63  Eating Disorders Serious disturbances in eating – Restriction of intake – Excessive concern over body weight or shape – E.g. Anorexia Nervosa, Bulimia Nervosa Most common in: – Adolescent girls & young women – Industrialized countries Highest mortality rate of all mental illnesses PATH 1017 2024-2025 64  Eating Disorders Etiologic factors Can you explain – Genetic- Chromosome abnormality each etiological – Neurotransmitters- serotonin factor? – Developmental – Sociocultural Eating disorders are often accompanied by other mental health disorders PATH 1017 2024-2025 65 Additional Space for Etiology Notes PATH 1017 2024-2025 66  Diagnostics Based on DSM No definitive diagnostic test Hx and physical exam for complications PATH 1017 2024-2025 67  Anorexia Nervosa Typically begins in teen years Affects 1-2% of Canadian females 15-25 years Becomes obsessed with weight loss Severe calorie restrictions Food rituals Excessive physical exercise Perfectionist PATH 1017 2024-2025 68  Anorexia Nervosa DSM-V Criteria: 1. Refusal to maintain a minimally normal body weight for age/height 2. Intense fear of gaining weight or becoming fat 3. Disturbance in way one’s body size, weight or shape is perceived PATH 1017 2024-2025 69  Anorexia Nervosa - manifestations Malnutrition affects organs and causes complications: – Amenorrhea – Loss of secondary sex characteristics – Osteoporosis – Cold intolerance – Cardiac issues – Blood and electrolyte abnormalities – Lanugo Can you explain why these manifestations – Sudden death occur? PATH 1017 2024-2025 70  Anorexia Nervosa - Treatment Challenging to treat because pt often does not recognize that a problem exists Multidisciplinary approach to care with goals of: – Regaining weight (1-2lb/wk) – Medication to treat complications – Resolving issues with family, pain from past – Strategies to address physiological, relationship and emotional issues What happens if you re-feed the pt too quickly? PATH 1017 2024-2025 71 Anorexia Nervosa- Prognosis 50% recover 1/3 develop bulimia nervosa 10-20% die of complications PATH 1017 2024-2025 72  Bulimia Nervosa 10x more common in women than men Typically begins in teen years Affects 3-5% of Canadian women aged 15- 25 years May include purging and non-purging behaviours Associated with other mental health disorders and substance abuse Impulsive PATH 1017 2024-2025 73  Bulimia Nervosa DSM-V Criteria: 1. Recurrent binge eating 2. Inappropriate compensatory behaviours (i.e. self-induced vomiting) 3. Self-perception that is unduly influenced by body shape and weight PATH 1017 2024-2025 74  Bulimia Nervosa Complications result from: – Overeating – Self-induced vomiting – Laxative and diuretic abuse PATH 1017 2024-2025 75  Bulimia Nervosa – Manifestations & Complications Fluid & electrolyte imbalances Parotitis Dental issues – examples? Esophagitis, Mallory-Weiss Syndrome, dysphagia, esophageal strictures, GERD Aspiration pneumonia CVS Psychological PATH 1017 2024-2025 76  Bulimia Nervosa Treatment: – Psychological Typically aware and upset about their behaviours and feelings – Pharmaceutical: Tricyclic antidepressants SSRI-serotonin reuptake inhibitors PATH 1017 2024-2025 77