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Glossary of Psychiatry Module

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Schizophrenia
Disorder that lasts at least 6 months and includes at least 1 month of active-phase, typically psychotic symptoms
Social and/or occupational dysfunction must be present
Schizophreniform disorder
Symptomatic presentation that is equivalent to schizophrenia except the entire course of illness lasts 1-6 months and there need not be decline in function
Schizoaffective disorder
Chronic illness characterized by concurrent symptoms of schizophrenia as well as major mood disorder
Period of at least 2 weeks when delusions or hallucinations are present w/o prominent mood symptoms
Mood symptoms present for a substantial portion of the total duration of the illness
Negative symptoms usually less severe than in schizophrenia
Delusional disorder
One or more bizarre delusions that persist for a month or more
Cannot diagnose if patient has ever been diagnosed with schizophrenia
Hallucinations are not prominent
Psychosocial functioning is not impaired except by the direct impact of the delusion
Types of delusions are few and strikingly repetitive regardless of cause
Types - erotomanic, grandiose, jealous, persecutory, somatic
Brief psychotic disorder
symptoms last more than one day and remit by 1 month
Psychotic disorder due to a general medical condition
Psychotic symptoms are judged to be a direct physiological consequence of a medical condition
Substance-induced psychotic disorder
Psychotic symptoms are judged to be a direct physiological consequence of drug abuse, a medication, or toxin exposure
Schizophrenia and other psychotic disorders
Illnesses characterized by gross impairment in reality testing and the creation of a new reality
Direct evidence of psychotic behavior is the presence of either delusions or hallucinations
Mood disorders
Disturbance of pervasive and sustained emotion (mood) that color psychic life and are accompanied by elation (mania) or depression
Major depressive disorder
At least 2 weeks of depressed mood or loss of interest accompanied by other symptoms of depression
Dysthymic disorder
At least 2 years of depressed mood accompanied by additional depressive symptoms that do not meet criteria for MDD
Bipolar I disorder
One or more manic or mixed by MDD
Bipolar II disorder
One or more MDD episodes accompanied by at least one hypomanic episode
Cyclothymic disorder
At least 2 years of numerous periods of hypomanic symptoms and numerous periods of depressive symptoms
Mood disorder due to a medical condition/substance abuse
JUST KNOW AS A POSSIBILITY
Anxiety disorders
Disorders characterized by apprehension, tension, and unease and are often accompanied by avoidant behavior
Panic disorder with agoraphobia
Recurrent panic attacks with avoidance of place or situations from which escape might be difficult in the event of a panic attack

Can also have PD w/o agoraphobia
Specific phobia
Anxiety provoked by exposure to feared object or situation often leading to avoidance
Social phobia
Anxiety provoked by social or performance situations often leading to avoidance
OCD
Recuurent intrusive thoughts (obesessions) which cause marked anxiety and distress and/or compulsions (acts) which serve to neutralize anxiety
PTSD
Duration is >1 month
Acute - <3 months
Chronic >3 months
Associated with sexual abuse, physical assault, torture, accidental trauma, disasters, illness diagnosis
Generalized anxiety disorder
Excessive worry about everyday events
Global feeling of anxiety
>6 months duration
Restlessness
Fatigued
Difficulty concentrating
Muscle tension
Insomnia
Substance related disorders
Alcohol dependence
Alcohol abuse
Alcohol intoxication syndromes
Alcohol withdrawal syndromes
Substance intoxication syndromes
Substance withdrawal syndromes
Anorexia nervosa
Refusal to maintain minimally normal body weight
Bulemia nervosa
Binge eating followed by inappropriate compensatory behaviors
Somatoform disorders
Physical symptoms that suggest physical disorders for which there are no organic findings; symptoms are linked to psychological factors
Somatization disorder
Polysymptomatic disorder beginning before age 30 that persists for years
Conversion disorder
Symptoms of deficits affecting voluntary motor or sensory function; psychological factors are associated with symptoms
Hypochondriasis
Fear or idea of having a serious illness
Body dysmorphic disorder
Preoccupation with imagined or exaggerated defect in physical appearance
Pervasive developmental disorders
Pervasive and severe impairments in several areas of development
Attention deficit/hyperactivity disorder
Persistent pattern of inattention and/or hyperactivity-impulsivity
Separation anxiety disorders
Excessive anxiety concerning separation from home or from those to whom the person is attached
Mood
Sustained emotion which markedly colors behavior, affect, and thought
May not be obvious to a person when it is normal, but is certainly obvious when it is abnormal
Affect
What the person is feeling at the moment and is assessed through observation and inquiry; reported affect may be incongruent with the observations
Normal affect
Full affective play in response to internal and external stimuli
Restrict/blunt affect
Diminished to minimal emotional responsiveness that is inappropriate to situation
Flat affect
Significant lack of responsiveness, accompanied by an expressionless voice and face
Labile affect
Feelings that change rapidly
Inappropriate affect
Feelings that are incongruent with the content being discussed
Sexual dysfunction
Sexual desire disorders
Sexual arousal disorders
Orgasmic disorders
Pain disorder
Form
How is thinking organized
Circumstantial
Individual is unable to report with attention to useful detail before reaching the point or answering a question
Tangential
Individual digresses into unnecessary detail to such a degree that he or she does not answer the question, but answers another question
Loosening of associations
Links between thoughts are destroyed and bizarre; illogical and chaotic thinking results
"Derailment"
Flight of ideas
A succession of thoughts with rapid shifting from one idea to another
The point of conversation or the answer to a question is never reached
Blocking
Sudden interpretation of a train of speech before the idea has been completed
Clanging
The sound of a word, rather than its meaning, gives the direction to subsequent associations
Neologism
Creation of new words coined by a person and not understandable to others
Perseveration
Persistent repetition of words, ideas, or subjects, so that once a person begins to speak about aa particular subject, it continually recurs
Obsessive thoughts
Recurrent, persistent thoughts are experienced as intrusive and inappropriate
Phobic preoccupation
Fears which are often experienced as excessive, but nonetheless lead to avoidance behavior
Ex: fear of germs, fear of contamination
Odd or bizarre thinking
Ideas of references, extremely superstitious or superstitions that fall short of delusional intensity
Delusion
Thought, idea, or belief with three characteristics
-Not true
-Cannot be reasoned with
-Out of harmony with the individual's educational or cultural background and surroundings; not shared by individual's cultural/religious group
Systematized delusion
If certain premises are granted, one can derive a whole set of delusions that appear to have a coherent and connected organization
Unsystematized delusion
Beliefs appear bizarre, contradictory, and fragmented
Schneiderian symptoms
Delusions of thought insertion, thought withdrawal, thought broadcasting, alien control
Distinction between self and non-self is lost, person is a "puppet"
Hallucination
Sensory misinterpretation which occurs without any external stimulus and is classified in terms of sensory spheres involved
Visual and auditory most common
Schneiderian symptoms of hallucination
Two or more voices having conversations about the self
Illusion
Sensory misinterpretation which occurs with external stimuli
Depersonalization
Alteration in perception or experience of the self so that one feels detached, as if one was an outside observer
Derealization
Alteration in perception or experience of the outside world so that it seems strange or unreal
Axis I
Clinical syndromes
Axis II
Personality disorders
Mental retardation
Axis III
General medical conditions
Axis IV
Psychosocial and environmental problems
Problems with primary support group
Problems related to the social environment
Educational problems
Occupational problems
Axis V
Global assessment of functioning (GAF)
70 - mild symptoms
60 - moderate symptoms
50 - serious symptoms
40 - behavior considerably influenced by hallucinations and delusions, or inability to function in almost all areas
Mental status examination
Description - appearance, non-verbal behavior, characteristics of talk, relatedness to interviewer
Mood and affect
Thought - form and content
Perception
Cognitive function - LOC, attention, orientation, memory, general intellectual evaulation
Insight into the presence or nature of illness
Schizophrenia category A symptoms
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms
Only 1 criterion A symptom is required if...
Delusions are bizarre or
Hallucinations consist of a voice keeping a running commentary on the person's behaviors or thoughts
Two or more voices conversing with each other
Schizophrenia diagnosis (B-F)
Social/occupational dysfunction
Continuous for at least 6 months including prodrome and residual
Schizoaffective/mood disorder exclusion
Substance/GMC exclusion
Relationship to pervasive developmental disorder
Paranoid schizophrenia
Preoccupation with one or more delusions ro frequent auditory hallucinations
No disorganized speech, disorganized or catatonic behavior, flat or inappropriate affect
Disorganized schizophrenia
All of the following are prominent:
Disorganized speech
Disorganized behavior
Flat or inappropriate affect
Catatonic schizophrenia
At least 2 of the following:
Motoric immobility as evidenced by catalepsy
Excessive motor activity
Extreme negativism
Peculiarities of voluntary movement
Echolalia or echopraxia
Undifferentiated schizophrenia
Criterion A met, but criteria for other subtypes not met
Bleulerian criteria
Four A's
Affect
Association (loose)
Autism (preference for fantasy over reality)
Ambivalence
Schneiderian criteria
Delusions
Somatic hallucinations
Commenting auditory hallucinations
Hearing one's thoughts spoken aloud
Thought broadcasting
Positive symptoms - functions distorted
Hallucinations
Delusions
Disorganized speech
Bizarre behavior
Negative symptoms - functions diminished
5 A's

Alogia - loss of fluency
Affective blunting
Avolition - loss of drive
Anhedonia - problems with pleasure
Attention impairment
Dopamine hypothesis (Schz.)
Positive symptoms are due to overactivity of DA pathways
Neurodevelopmental hypothesis (Schz.)
Primary event(s) resulting in Schizophrenia are the result of changes in utero or in the perinatal period that disrupt the developmental aspects of brain structure and function such as myelination or synaptic pruning
-Obstetric
-Environmental
Males with schizophrenia
Earlier onset (3-4 years)
Poorer premorbid function
Poorer outcome
Minor physical anomalies
Greater structural brain anomalies
Females with schizophrenia
Greater temporal and spatial variations in rate of occurrence
Greater susceptibility to second trimester influenza
Greater susceptibility to first trimester dietary insufficiency
Difference may be related to protective effects of estrogen via DA blocking effect at D2 receptors
DRSC theory of schizophrenia
Early in development, synaptogenesis creates connections randomly, with subsequent selective elimination of weaker connections based upon experience and endogenous factors
In schizophrenia, reduced synaptic density in PFC and other areas of association cortex
Schizophrenia treatment
Pharmacotherapy
Individual psychotherapy
Family evaluation and therapy
Conventional antipsychotics
Primarily D2 blockers
More effective against (+) symptoms
High incidence of serious side effects
Conventional antipsychotic side effects
Tardive dyskinesia
Parkinsonian like symptoms
Dystonia
Akathisia
Neuroleptic malignant syndrome
Uninhibited prolactin secretion
Atypical antipsychotics
Blocks D2 and 5-HT2A receptors
Serotonin inhibits DA release
Less likely to cause EPS
More likely to improve negative symptoms
All require monitoring for metabolic syndrome
Atypical antipsychotic side effects
WASH HOH
Weight gain
Anticholinergic
Sedation
Hyperglycemia

Hyperlipidemia
Orthostatic hypotension
Hypercholesterolemia
Positive prognostic signs in schizophrenia
Supportive family
FH of an affective disorder
Premorbid history of good social relationships, school performance
Poor prognostic signs
Insidious onset
FH of schizophrenia
Presence of negative symptoms
DSM diagnosis of psychosis
Delusions, hallucinations, disorganized speech, disorganized or catatonic behavior
Risk factors for delusional disorder
Increased age
Sensory impairment
Family history
Social isolation
Recent immigration
Shared psychotic disorder
Delusion that arises in someone who is involved in a close relationship with someone who already has a psychotic disorder with prominent delusions
Secondary case is usually passive, gullible, lower self esteem
May resolve with separation
Psychosis in mood disorders
Hallucinations or delusions
See in severe depression and mania
Usually mood congruent (delusions of persecution/guilt in depression; grandeur in mania)
About 15% of MDD will develop psychosis, more common in mania
Psychosis in personality disorders
Personality disorders are enduring, pervasive patterns of behavior that deviate from the cultural norm
May see transient psychotic symptoms (lasting minutes to hours)
Usually paranoid delusions
Psychosis in delirium
Disturbance in consciousness with change in cognition
Occurs over hours or days, fluctuates
Perceptual disturbances, including hallucinations, are common
May have delusional conviction of reality of hallucination
Essential to determine cause
Psychosis in PTSD
Symptoms develop following extreme traumatic stressor
Include reexperiencing the event, avoidance, numbing or responses, and increased arousal (anxiety, sleep problems, anger)
May have hallucinations (usually auditory) and paranoid ideation in severe cases
Psychosis in post-partum mood disorder
May see with major depression, bipolar disorder, or brief psychotic disorder
Usually delusions about infant or command hallucinations to harm infant
Often accompanied by disorganized thoughts or behavior
Occurs in 1:500-1:1000 deliveries, much more common if history of prior disorder
Psychiatric emergency
Substance induced psychotic disorder
Need to R/O drug use in any new onset psychosis
Many illicit drugs can cause psychosis
Many legal drugs can cause psychosis in OD
Drug interactions can lead to high blood levels of drugs which may lead to psychosis
Prominent hallucinations or delusions that are the direct physiological effect of a substance
Distinguish from primary psychosis because always associated with intoxication or withdrawal
Consider in any person >35 with new onset psychosis
Alcohol induced psyhosis
Can see with intoxication or withdrawal
Hallucinations are usually auditory unless delirium is present
Usually associated with prolonged, heavy ingestion of alcohol
Psychosis clears spontaneously, but will recur if drinking recurs
Delirium tremens
Delirium superimposed on withdrawal symptoms
Often severe confusion
Tactile and visual hallucinations are common
May have seizures
Cocaine induced psychosis
Common as part of intoxication syndrome
Usually paranoia and hallucinations (tactile or visual)
Do not see with cocaine withdrawal
Cocaine abuse often co-exists with a primary psychotic illness
Crack
Often have visual/auditory misperceptions and then visual/auditory/tactile hallucinations
Paranoia can be extreme
Amphetamine psychosis
Psychosis usually associated with high doses and long duration of use but may see after even low dose if susceptible
May not resolve for days after drug cessation and may be followed by amnesia
Will become sensitized aften an episode of psychosis so even small dose may cause recurrence
MDMA (Ecstasy)
Synthetic derivative of amphetamine
Selective serotonin neurotoxin - may be long lasting effects on the serotonin system
Psychiatric symptoms - panic, dysphoria, paranoia
After heavy use, may get longer lasting paranoia
Increased vulnerability to other disorders
Cannibis
High doses can induce brief psychotic symptoms
Usually persecutory delusions of auditory/visual hallucinations
More common in people with underlying primary psychiatric diagnosis
"Hemp insanity" more common in places with highly potent drug available
Probably exacerbates schizophrenia, but not causative
Hallucinogens
Hallucinogen persisting perception disorder (flashbacks) - may include visual hallucinations though usually recognized as not real
Post-hallucinogen psychotic disorder is rare and usually do not see negative symptoms as seen in schizophrenia
PCP
Perceptual disturbances (lights, change in sounds, illusions) but reality testing remains intact
Occasionally see psychotic disorder, may last for up to 6 weeks after other symptoms of intoxication are gone
Single low dose of PCP can rekindle symptoms in someone with schizophrenia
Inhalants
Use most prevalent in teens
May see hallucinations and delusions during intoxication
If in excess of what is normally seen with intoxication, diagnose substance induced psychotic disorder
Controversy over whether inhalants can produce persisting psychotic state
Opioids
May see prominent hallucinations or delusions with opioid intoxication or withdrawal
Prescription opiates often abused in combination with other drugs
Purer form of heroin available - can be snorted
Medication induced psychosis
May occur as side effect of therapeutic dosing or as a result of overdose
Highest risk are elderly, renal, and liver disease
"4Anti-SCAM"
Psychosis due to GMC
"STILT MVR"
Seizures (aura, TL)
Trauma (subdural hematoma)
Infection
-HIV
-Sepsis
-Encephalitis
Liver failure
Tumor (TL)
Metabolic disease
-Thyroid
-Adrenal
-Vitamin def.
Vascular disease
Renal failure
Uremia
Fatigue
Decreased cognitive function
Confusion
May get delirium and psychosis
Hepatic encephalopathy
Impairment in consciousness
Often delirium with hallucinations (visual)
Acute intermittent porphyria
50% have psychiatric symptoms
-Lability
-Psychosis
-Delirium
Confabulation
Filling in gaps in memory with imaginary events
Usually momentary, may misplace true memory in time
Often trying to please interviewer or hide memory loss
May appear delusional but short lived, transient and varying
See in amnesia, dementia, Korsakoff's (Wernicke's)
Pseudodementia
See commonly in elderly
Severe psychomotor retardation
Events do not register so appears to have poor memory
May actually have true cognitive failure secondary to depression
Also common to see depression as early response to dementia
Main actions of typical antipsychotics
D2 receptor antagonists
M1 muscarinic antagonists
Alpha-adrenergic antagonists
H1 histaminic antagonists
Mesolimbic DA pathway
Blockade of postsynaptic DA2 receptors reduces the (+) symptoms of schizophrenia
No difference in efficacy among conventional agents
Mesocortical DA pathway
DA blockade causes DA def.
Results in negative symptoms and cognitive slowing
DA def. may be primary or secondary
Nigrostriatal DA pathway
Pathway extends from SN to BG
Part of extrapyramidal NS
Reciprocal relationship between DA and ACh in BG
DA blocks ACh release suppressing ACh activity
DA receptor blockade results in ACh over activity
Anti-cholinergic drugs help treat these movement disorders
EPS
Drug induced Parkinsonism
-Shuffling gait
-Muscular rigidity
-Tremor
-Bradykinesia
Benztropine
Trihexyphenidyl
Amantadine

Akithisia - subjective sense of inner restlessness
Propanolol or benzos

Dystonia - painful, involuntary muscle spasms, usually in head or neck muscles
Diphenhydramine or cogentin
Elevated prolactin
Galactorrhea
Amenorrhea
Sexual dysfunction
Weight gain
Anti-cholinergic side effects
"CDC BUD"
Constipation
Drowsiness
Confusion

Blurred vision
Urinary retention
Dry mouth
Anti-Adrenergic side effects
"DOD"
Drowsiness
Orthostatic hypotension
Dizziness
Anti-histamine side effects
"DW"
Drowsiness
Weight gain
Typical antipsychotics
Classified based upon potency and affinity for post-synaptic D2 receptors
Increased affinity leads to increased EPS
Phenothiazines
-Chlorpromazine
-Thioridazine
Strong anti-cholinergic SE
Weak DA effect --> decreased EPS
Chlorpromazine -> blocks alpha receptors -> OH and sexual dysfunction
Thioridazine -> pigmented retinopathy
Thioxanthines
IM injection
Strong anti-cholinergic effects
Weak DA antagonist
Useful for low compliance patients - lasts for 30 days
Butyrophenones
-Haloperidol
Most potent DA antagonists
Less anti-cholinergic SE
High potency typicals
Haloperidol
Fluphenazine
Trifluoperzine
Greater association with EPS due to increased affinity
Neuroleptic malignant syndrome
Muscle rigidity, fever, ANS instability, decreased level of consciousness, elevated CPK
Stop anti-psychotic
Administer DA agonist and dantrolene
Olanzapine
Side effects - "WASH HO" weight gain, sedation, OH, anti-cholinergic SE, hyperglycemia, hyperlipidemia
Risperidone
Greater propensity to cause EPS - dose related
More likely to lead to hyperprolactinemia
SE - "Women's SHOE" weight gain, sedation, OH, EPS, hyperprolactinemia
Quetiapine
Significant blockade at H1 receptors -> sedation, weight gain
Ziprasidone
Split doses
QTc prolongation
Less likely to cause weight gain
Clozapine
Slow titration needed -> SE
Common SE - "SWIM" sedation, weight gain, increased salivation, metabolic syndrome
Serious side effects - "CAS" Cardiopulmonary arrest, agranulocytosis, seizures
Useful in treatment refractory patients with reduced risk of suicide and improves TD
Aripiprazole
Antagonist at 5-HT2A, but partial agonist at D2 receptors
PA - block a receptor if over stimulated and stimulate same receptor when needed
SE - akathisia
Metabolic syndrome
Weight gain
Dyslipidemia
Glucose intolerance
Greatest risk - clozapine, olanzapine
Typical course of antipsychotic response
First few days - agitation, psychomotor excitement
T -> H -> D
Thought disorder, hallucinations, delusions
Evaluate response in 3-5 weeks
Medical illnesses that may present as psychosis
Head trauma
Infections
Neoplasms
Vascular diseases
Autoimmune diseases
Metabolic derangements
Endocrine dysfunction
Dementia
Delirium
Liver and renal failure
Features of depression
Depressed mood
Anxiety
Irritability
Absence of emotion
Negative perception of self, present and future
Altered physiology
Anticipation
Children of prodrome have disease earlier and more severely
Assortive mating
Non-random mating associations
Atypical depressive symptoms
Hypersomnia
Increased appetite
Lethargy
Mood reactivity
Atypical depression
More frequently bipolar
Associated with mood reactivity, sensitivity to rejection, personality problems
More likely to respond to SSRI or MAOI
Psychotic depression
More severe
More recurrent
Greater familial presence
Less likely to respond to antidepressants
More likely to have bipolar outcome
Seasonal affective disorder
Depression begins in fall or winter
Normal mood or hypomania in spring and summer
Responds to artificial bright light
More frequently bipolar than non-seasonal depression
Medical illnesses that commonly cause depression
"HI NAME"
Hematologic
Infectious
Neurologic
Autoimmune
Malignancy
Endocrine
Substances that commonly cause depression
"NASS-T"
Narcotics
Alcohol
Stimulants
Sedatives
Tranquilizers
Physiology of depression
Increased CRF
Increased cortisol
Due to decreased negative feedback ability of cortisol on the hypothalamus in MDD
(-) response to DST
Response reverses with treatment
Sleep in MDD
More awakenings
Decreased REM latency
Increased REM density
Decreased slow wave sleep
Imaging in MDD
Reduced frontal lobe volume
Loss of hippocampal volume
May be due to neurotoxicity of cortisol and excitatory amino acids
Neurotransmitters in MDD
NE - increased
5-HT - decresed
DA - decreased
ACh - increased
GABA - decreased
Glutamate - increased
Pathophysiology of MDD
More likely due to intracellular changes
-p53
-GSK-3beta
-Increased 5-HT inactivation
-Downregulation of Bcl-2
-BDNF - increased by AD's
Mind-body interactions in MDD
The same psychological event is more liekly to produce depression in people with vulnerable stress response systems
Risk of chronicity in MDD
Onset - 10-15%
>6 months - 30-40%
>1 year - 50%
>2 years - 95%
Tricyclic antidepressants
-REVIEW INDICATIONS - pg 24
Tertiary amines - block reuptake of both NE and 5-HT
Secondary amines - inhibit NE reuptake
Side effects - anticholinergic, postural hypotension, heart block, weight gain, sudden death after AMI
Risk of suicide OD
-LD50 = 1 week supply
Amitriptyline - migraines, chronic pain
Nortriptyline - refractory MDD, migraines
Imipramine - Enuresis
Desipramine - refractory MDD
Clomipramine - OCD
SSRI
Fluoxetine - long acting
Sertraline
Paroxetine - more weight gain; anti-cholinergic
Fluvoxamine
Citalopram
Escitalopram - S-enantiomer of citalopram
Side effects - sexual dysfunction, aggravation or improvement of migraine headaches, diarrhea, abdominal cramps, weight loss/gain, sedation/activation, withdrawal with paroxetine, anti-DA effect
Serotonin-dopamine interaction
5-HT3R - increases DA - nausea
5-HT2R - decreases DA - Parkinsonian symptoms
Consequences of anti-DA effect of SSRI
Emotional blunting
Decreased motivation and activity
Memory loss
Akathisia
EPS
Tardive dyskinesia (rare)
Trazodone
5-HT2 antagonist
1/2 life - 5-8 hours
Sedation common
May reduce SSRI sexual dysfunction
Risk of priapism
Nefazodone
SRI and 5-HT2 antagonist
Does not suppress REM sleep
Short half life - divided dose
Anxiogenic metabolite
Hepatotoxicity
Buproprion
DA and NE reuptake inhibitor
No sexual or cardiac side effects
First choice for PD patients with depression
Risk of seizures at high doses
May be helpful for ADD ad dementia
Venlafaxine
Multiple NT uptake inhibitor
-5-HT at low doses
-NE at moderate doses
-DA at high doses
Useful for severe and refractory depression
Higher rate of remission than SSRI
Reduces hot flashed associated with menopause
XR form most common
Side effects - sedation, sexual dysfunction, HTN at higher doses, withdrawal syndromes
Mirtazepine
5-HT2, 5-HT3, alpha 2 antagonist
Useful for patients with weight loss, nausea, sleep disorder
Side effects - weight gain, sedation
Useful in cancer especially Carcinoid
Duloxetine
NE and serotonin reuptake inhibitor
Useful for severe depression
Side effects - nausea, sexual dysfunction, others, HTN unlikely
Electroconvulsive therapy
Most effective antidepressant therapy
Usual course - 6-9 treatments
CI - recent AMI, space occupying lesion
rTMS
Induction of localized electrical current by magnetic field
No anesthetic or sedation needed
Effective as ECT in some studies, not in others
Artificial bright light
Effective as AD for SAD
Minimum intensity of light 2500 lux
Duration - 30 min - 2 hours
Works within 3 days - 2 weeks
Effect lost 3 days after treatment cessation
Can induce hypomania
Prescribing antidepressants
Start with low dose
If no response at all in 2-4 weeks change AD
Wait up to 6-8 weeks for full effect
Goal of treatment is full remission
Best predictors of risk of depression
Childhood loss of a parent
FM of depression
Bipolar disorder
Mania or hypomania
>99% have depressive episodes
Activation alternates or mixed with depression
Pathophysiolgy probably involves altered second messenger signalling and gene expression
Ongoing treatment is usually necessary
20-50% of cases of depression
Anticipation present
Linkage studies
Highest rate of substance abuse of all psychiatric illness
Mania
Psychosis
Gross impairment
Hypomania
Symptoms last days
No impaired functioning or psychosis
No hospitalization
Cyclothymia
Mild mood swings
Hyperthymia
Elevated activity
Reduced sleep
Optimistic
Bipolar I vs. II
Bipolar I - mania
Bipolar II - hypomana, family members have hypomania, but not mania
Medical causes of mania and mood swings
"A SCRATCH"
Adrenal steroids
Stimulants
Cushing's disease
RT sided cerebrovascular disease
Antidepressants
Thyroid disease
Cocaine
Hypercalcemia
Evolution of bipolar mood disorders
Pseudounipolar depression -> recurrent depression -> mania/hypomania -> rapid/ultradian/cycling/chronicity/psychosis
Mood stabilizers
Antimanic action
Prevent recurrences of mania and depression
Better against mania than depression
Lithium
Advantages - once a day, AD properties, neuroprotective
Disadvantages - narrow TI, measure blood levels, long term side effects
"WHite CHAIR"
Hypothyroidism
Weight gain
Cognitive dysfunction
Hyperparathyroidism
Acne
Interference with insulin signaling
Renal damage
Carbamazepine
Advantages - better tolerated than lithium, no weight gain, may improve depression, may be useful for PTSD
Disadvantages - induces metabolism of drugs (oral contraceptives), side effects
"SNOBS"
Sedation
Neurotoxicity
Occasional hypothyoidism
Bone marrow suppression (rare) - agranulocytosis
SIADH
Divalproex
Advantages - sleep improvement, anxiolytic, anti-agressive
Disadvantages - not an AD, side effects - weight gain, sedation, hair loss, cognitive impairment, polycystic ovaries, pancreatitis
Lamotrigine
Anticonvulsant
Antidepressant properties
Prevents recurrences of depression but not mania
Side effects - "CRIS"
CNS side effects
Rash
Induction of mania
Sedation
Atypicals for bipolar
All antipsychotics have antimanic properties
Clozapine is most reliable mood stablizer in refractory bipolar disorder
AD risky in bipolar disorder
Transient improvement
Increased rate of recurrence of depression
Induction of hypomania
Psychotherapy in bipolar disorders
Effective therapies
-IP
-Social rhythms
-Family focused
Treatment of bipolar disorder
Mood stabilizer -> antipsychotc -> add anti-depressant -> stop anti-depressant
Panic anxiety
Intense, unprovoked fearfulness
Usually associated with ANS arousal
Last just a few minutes
Symptoms of hyperarousal
W/ or w/o agoraphobia
Can resemble cardiac problem
Medical causes of anxiety
Endocrine
Metabolic
Respiratory
Cardiac
Neurological
Medications that cause anxiety
Stimulants
Tranquilizers - interdose withdrawal
Antidepressants
Beta agonists
Neuroloeptics
Serotonergic drugs
Substances that cause anxiety
Caffeine
Stimulants
Nicotine
Alcohol
MSG
CNS depressant withdrawal
Aspartame
Psychiatric disorders associated with anxiety
Depression
Bipolar disorder
PTSD
OCD
Schizophrenia
Personality disorders
Etiology of anxiety disorders
Indentification with anxious patient
Conditioned fear
Hyperactive arousal systems
-NE - locus coeruleus
-Glutaminergic
Deficient braking system
-Serotonin
-GABA
Panic disorder - abnormal CO2 response
Agoraphobia
Anxiety about being in situations from which escape might be difficult or embarrassing and help might not be available
Specific (simple) phobia
Marked, persistent, unreasonable fear of circumscribed objects or situations
-Animal
-Natural
-Situational
-Blood injection - familial
Social phobia (social anixety disorder)
Anxiety about hummilating oneself in social or performance situations
Benzodiazepine use in anxiety
Acute anxiety - especially cardiac pt.
Initial treatment of anxious depression
Treatment of chronic anxiety in patients who do not do well with other treatments
Pharmacology of benzos
Changes conformation of GABA receptor such that it increases GABA binding (lower Km)
Leads to increased Cl- --> hyperpolarization
Inverse agonist
Acts on a receptor but has the reverse action as the typical agonist
Benzo receptor subtype effects
Type 1 - A
Type 2 - SCAMP
Type 3 - WD
Potency
High potency - smaller dose, more receptor occupancy, more intense withdrawal
Low potency - higher dose, less intense withdrawal
Lipid solubility
High - drug gets into brain fast, perferable if rapid onset is needed, increased risk of dependence (buzz feeling)
Low - get into and leave brain slowly, slow onset of action, effect lasts longer after a single dose, lower abuse potential
Half life
Long - less frequent dosing, more accumulation, slower onset of withdrawal
Short - dosed more frequently, less accumulation, faster onset of withdrawal
Benzo metabolic pathways
Complex - diazepam, chlordiazepoxide, flurazepam
Simple - midazolam, alprazolam, lorazepam, oxazepam
Bezodiazepine side effects
Sedation
Psychomotor impairment
Interdose withdrawal
Interactions - EtOH
Benzo withdrawal features
Agitation
Confusion
Delirium
Tremor
Myoclonus
Hyperreflexia
Hyperpyrexia
Seizures
BZD-1 receptor selective agents
Quazepam
Zolpidem
Zalepon

Less sedation, impairment, withdrawal
Partial agonist
Not quite as good at activation as natural ligand
High natural ligand + PA --> decreased effect
Low natural ligand + PA --> increased effect
Nonselective parital BZD receptor agonists
Zopiclone
Eszopiclone

Weaker acute effect than benzos, less dependence and withdrawal
Alternatives to BZD agonists for anxiety
AD - excpet buproprion
-SSRI
Buspirone
Gabapentin
Pregabalin
Divalproex/valproate
Beta blockers
Buspirone
5-HT1A PA
Not sedating, no withdrawal or impairment of driving
Common side effects - nausea, HA, dizziness
Beta blockers for anxiety
Most useful for autonomic arousal
Propanolol for performance anxiety - sedation and sexual dysfunction
Treatment choices for anxiety
Acute - benzo
Chronic - AD
Substance abuse - buspirone
Prominent ANS - beta blocker
Pulmonary patient - buspirone, AD
Behavioral treatments should always be considered
Identification
Taking over and making one's own attitudes and behaviors of significant others
Repression
Removing threatening or unacceptable memories, impulses, and thoughts from awareness. The repressed material is not subject to voluntary recall
Denial
Protecting one's self from unpleasant reality by refusing to perceive it
Displacement
Emotions, ideas, or wishes are transferred from their original object and directed to a more acceptable substitute
Reaction formation
Directing overt behavior and attitude in precisely the opposite direction of one's underlying, unacceptable impulses
Projection
Attribute to others one's own unacceptable impulses, thoughts, and desires
Rationalization
Thinking up logical, socially approved reasons for our past, present, or proposed behavior
Isolation
Separating emotional components from a thought, resulting in repression of either emotion or the idea
Splitting
Perception of one's self and others as "all good" or "all bad" rather than experiencing self or others ambivalently
Suppression
A deliberate conscious effort to control and conceal unacceptable thoughts, feelings, or acts
Sublimation
Diverting basic drives or impulses into socially appropriate channels
Humor
Seeing the comic side of situations
Altruism
Taking a negative experience and turning it into a socially positive one
Risk factors for PTSD
Gender
Prior trauma
Prior mood and/or anxiety disorder
Education
PTSD etiology
Significance facilitates remembrance
Stress hormones (E, CRH, ACTH, AVP, cortisol)
Amygdala - BLA
Hippocampus - volume reduction
PTSD treatment
CBT may speed recovery when given 2-3 weeks after exposure
SSRI - 1st line
TCA - only amit. and imip.
Benzos - addictive potential
Anticonvulsants
Antipsychotics
Adrenergic modulators - alpha 2 agonists promising, beta blockers immediately post-event
EMDR
Form of psychotherapy including exposure based therapy, eye movement, and recall and verbalization of traumatic memories
Psychiatry in primary care
BRIEFLY REVIEW
Indications for referral
Failure to respond to 1 or 2 med trials or 2 trials in 2 months
Hospitalization may be necessary
Patient is actively suicidal
Patient is psychotic
Patient is bipolar
Pediatric or pregnant
SSRI - serotonin syndrome
From therapeutic does, OD, or drug interaction
Clonus
Hyperthermia
Hypertonicity
AMS
Dysautonomia
Hyperreflexia
Management - symptomatic, benzos, 5-HT2A antagonist
Health consequences of heavy drinking
GI, breast cancer
Liver disease
Trauma
Suicide
FAS
Health risk level of alcohol consumption
3 drinks per day (males)
2 drinks per day (females)
5 drinks per occasion
Alcohol abuse
Continued risky use despite problems over time
Alcohol dependence
Abuse + compulsive use + life centered +/- tolerance/withdrawal over time
Course persists over decades
Alcoholism
Abuse or dependence
Risk factors for alcoholism
Anxiety
Depression
PTSD
Childhood abuse - up to 50%
Risk taking behavior
Altered DA/transporters
Type 1 alcoholism
Milieu limited
Onset >25
Gradual course
Either parent alcoholic
Son or daughter
Environmental and genetic risk
Reward dependent; risk avoidant
Anxious, depressed, needy
Type 2 alcoholism
Male limited
Onset <20
Rapid course
Father alcoholic
Son
High genetic risk
Impulsive, risk takers, alterations in frontal lobe/executive center
Conduct, ADHD
Non-familial alcoholism
Either gender
Onset >25
Gradual
No FH
Either gender
Environmental, acquired
Various behaviors

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