Family History 

Receptor Theory of the disorder and the treatment

Medications and why they are chosen

Other treatments

What are the 5 Axes of the DSM and what is included in each?

What do these axes describe?

I: This is a major psychiatric diagnosis that is believed to have a chemical basis. (bipolar disorder, OCD, etc.)

II:Believed to be environmental primarily in origin.  “But for ---this would not be.” (mental retardation, etc.)

III: These are medical illnesses and treatments of medical illnesses which may or may not impact the Axis I disorder. (hypothyroidism, syphilis, etc.)

IV: Stressors that are impacting on the Axis I (loss of a job or a spouse, arguments, financial stressors, etc.)

V:This is a number from 0 to 100 and is found on a scale called the GAF. Global Assessment of Functioning. 0-100. 2 values are chosen.  One represents the patient’s highest functioning over the past year, and the other represents the current functioning level.  This is to gauge the patients progress and hope fur further improvements.

Each axis represents some part of the psychological diagnosis.

Patient Identification

Chief Complaint

HPI

Past Psych Hx

Past Med. Hx

Development/Social Hx

Legal

Family Hx

ROS

Physical Exam

Labs

MSE

Biopsychosocial  Formulation

Assessment (Axis I – V)

Plan

What area of the brain is responsible for generating the feelings of anxiety?

What neurotransmitter acts on this area to generate these feelings?

locus coeruleus

Norepinephrine

Anxiety disorders due to medical conditions   

Hypoglycemia, hypothryroidism, pheochromocytoma

Anxiety due to drugs – caffeine, cocaine

Anxiety from withdrawal-alcohol, heroin

Generalized anxiety disorder

ongoing feelings of anxiety, not intense discrete

Major Depression

mood changes

vegetative symptoms (sleep, appetite)

a.  Imipramine

b.  Benzo’s – Xanax, Ativan

c.  SSRI’S

A 28 year old female patient is admitted to the emergency room with severe chest pain.  On taking the patients history after the patient'e event, it is revealed that the patient also felt very uneasy (wanted to stand up  and pace) and felt "butterflies" in her stomach. She also notes having a similar event the week prior, but less severe. On further questioning, you learn that 4 months ago the woman witnessed the suicide of her husband and has been going to therapy.

This is most likely:

What would be an effective treatment?

Panic disorder

Pharmacotherapy (SSRI's, tricyclics such as imipramine) and behavioral therapy

Psychodynamic Psychotherapy 

Behavioral Treatment

Exposure treatment (maybe not the best...)

Cognitive approaches such as:

-Social skills training

-Cognitive behavioral group therapy (clearly effective)

What must be on your differential if a patient seems to have OCD?

What is the neuro-biological theory of this disorder?

What therapies are availible for these patients?

Schizophrenia – auditory or visual hallucinations

Tourette’s Syndrome – vocal tics and many repetative behvaiors, Also seen in other PDD’s

Major Depression – ruminative depressed and guilty feelings, etc.

Amphetamine Intoxication – repetitive behavior, mechanical

Dysfunction of the brain serotonin systems

 upregulated Metabolic activity in the head of the caudate nucleus and orbital gyri.

Brain imagining in OCD demonstrates increased blood flow in orbitofrontal cortex bilaterally, the caudete nucleus, and anterior cingulate cortex.

Combination Treatment

Combination of ERP and SSRI’S

ECT - Not effective

Psychosurgical - For extreme cases

Support groups – Involvement is beneficial

difficulty establishing diagnosis and treatment plan

Treatment resistant cases

Suicidal risk

Anyone requesting psycho surgery

What is the psychobiological pathology of post-traumatic stress disorder?

What drug should be avoided in the treatment of these patients?

1.  Heightened autonomic nervous system arousal

2.  Dysregulation of sympathetic nervous system

3. Increased urine norepinephrine excretion

4. increased alpha2 adrenergic receptor diversity

Avoid the use of benzodiazapines

As soon as possible, provide “Critical incident stress debriefing”.  Medication is not very effective.

A brief intervention program within 2 weeks of assault, with medication, relaxation, exposure and cognitive restructuring will produce a significant decrease in PTSD by years.

“episodes” clearly defined

Depressed mood or anhedonia — at least 2 wks

At least 5 of the following

Depressed mood

Decreased interest or pleasure most of the time

Insomnia or hypersomnia

Anorexia or hyperphagia or 5% weight gain/loss in month

Psychomotor agitation or retardation

Fatigue

Decreased concentration or thinking, indecisiveness

Negative thinking — worthlessness, inappropriate guilt

Recurring thoughts of death or suicide

Not organically caused

Not uncomplicated bereavement

•        Two or more:

–       Poor appetite or overeating

–       Insomnia or hypersomnia

–       Low energy or fatigue

–       Poor concentration, indecisiveness

–       Low self-esteem

–       Hopelessness

•        Not symptom-free for 2 or more months

•        Depressed mood most of day, more days than not, for at least 2 years

What is "double depressive disorder"

What disqualifies this diagnosis?

•        Met criteria for Dysthymic Disorder then in future meets the criteria for Major Depressive Disorder superimposed.

•        Patients with partial remission of MD, are disqualified from the diagnosis of Dysthymic Disorder

What criteria must be met for major depressive disorder with atypical features?

What is this disorder typically associated with?

•        Mood reactivity

–       Mood crashes or brightens in response to events

•        Two of the following:

–       Increased weight or appetite

–       Hypersomnia

–       Leaden paralysis (heavy, leaden feelings in arms or legs)

–       Chronic rejection sensitivity

•        Often associated with anxiety

-also often seen in seasonal affective disorder, in premenstrual dysphoric disorder and in bipolar depression

The differential diagnosis of depression includes substance abuse, schizophrenia, anemia, hyper- and hypothyroidism, cancer, medications, chronic illnesses, trauma, and CNS disease.

The majority of these condition feature depressive symptoms such as mood changes, apathy, and loss of energy.

Usually these conditions can be ruled out by  medical history,blood and urine screens, or imaging studies.

•        Non-psychotic – any antidepressant

•        Atypical – better response to MAOI and SSRI

•        Bipolar – antidepressant and mood stabilizer

•        Elevated, irritable, or expansive mood for one week

•        Three of following (if irritable need 4):

1. Grandiosity
2. Decreased need for sleep
3. Hyperverbal or pressured speech
4. Flight of ideas or racing thoughts
5. Distractibilty
6. Psychomotor agitation or increase in goal-directed activity
7. Excessive involvement in pleasurable, but risky activities

•        Distinct period of elevated, expansive or irritable mood lasting at least 4 days and clearly different from normal.

•        During the period of mood disturbance, 3 or more of the following symptoms have persisted (4 if the mood is irritable)

1.Inflated self esteem

2.Decreased need for sleep

3.More talkative than usual

4.Subjective racing thoughts, flight of ideas

5.Distractibility

6.Increase in goal directed activity

7. Excess involvement in pleasurable activity

It does not cause significant impairment or warrant hospitalization.

At least:

1 hypomanic episode

1 major depressive episode

Never manic or mixed episodes! Can cause distress or impairment.

•        Bipolar’s verson of Dysthymic Disorder

•        Many hypomanic and depressive periods (not meeting threshold for Depressive Episode)

•        At least 2 years (1 in children)

•        No major depressive, manic or mixed episodes (first 2 years)

•        At least 4 episodes per year

•        Initial onset or later onset

•        More common in women

•        More thyroid abnormalities

•        Role of antidepressants

•        May not persist

•        Lithium Carbonate (also useful in adjunctive depression treatment) never in pregnancy

•        Depakote (valproic acid) do not use in pregnancy

•        Tegretol (carbamazepine)

•        Trileptal (oxycarbazepine)

•        Topamax (topiramate)

•        Lamictal (lamotrigine)

•        ECT

•        Also use atypical antipsychotics

•        EFA (controversial)

•        Neurontin (gabapentin) is NOT a mood stabilizer only used in pain & anxiety

•        Valproic Acid (Depakote)- FDA approved to treat mania; used for prophylaxis too

•        Lamaotrigine (Lamictal) –FDA approved for prophylaxis; also helpful for bipolar depression

•        Carbamezapine (Tegretol)

•        Gabapentin (Neurontin) NOT INDICATED

•        Newer – topiramate (Topamax), Carbamezapine (Tegretol), Oxycarbamezapine (Trileptal)

•        tiagabine(Gabitril)

Associations (inappropriate)

Autism

Affect disturbances

Ambivalence

What is schizophreniform disorder in relation to schizophrenia?

What about schizoaffective disorder?

a mental disorder diagnosed when symptoms of schizophrenia are present for a significant portion of the time within a one-month period, but signs of disruption are not present for the full six months required for the diagnosis of schizophrenia.

Schizoaffective disorder is a psychiatric diagnosis that describes a mental disorde rcharacterized by recurring episodes of elevated or depressed mood (bipolar disorder criteria), or of simultaneously elevated and depressed mood, that alternate with, or occur together with, distortions in perception

Positive: Add to someone's experience of reality above which is normal (such as having hallucinations).

Negative: The opposite; these are symptoms which take away from reality in a person's view (such as blunted emotional responses).