Psychiatric disorders

sensory experience ('perception') that occurs without external stimulation

Psychotic vs nonpsychotic (does the patient think the perception is real)

specific false belief that is firmly held despite evidence to the contrary; not endorsed by members of the individual's culture

Loss of reality testing

• NOT likely to be primary disorder if...
• 1. Onset at >45 years of age
• 2. No family hx
• 3. No psychiatric premorbid behaviors
• 4. Risk factors for causative neurologic disorders
• 5. Neurological signs and symptoms
• 6. Rapid onset or resolution, fluctuations
• 7. Resistance or unusual response to treatment

• Sustained psychosis, long term functional deterioration
• Dx: 2 or more of the Pos sx for 1 month
• 6 months of one or more of the negative sx

Positive sx: Delusions, hallucinations, disorganized speech, disorganized or catatonic behavior

• Negative sx: (4 A's)
• Affect - flattening or blunting
• Alogia - decrease in spontaneous speech
• Avolition - loss of goal-directed behavior
• (Anhedonia) - inability to experience pleasure

Subtypes: Paranoid (most common), disorganized, catatonic, undifferentiated, residual

• Tx:
• - 1st generation antipsychotics; D2 blockers; motor side effects
• -2nd generation antipsychotics; D2 and 5-HT blockers; metabolic syndrome

• 1st generation: D2 blockers
• -Haloperidol
• -Risperidone
• -Olanzapine

• Premorbid phase (odd or eccentric behavior)
• Prodromal phase (before onset of psychosis) mid to late teens; can have suspiciousness, misinterpretations, odd/eccentric, unusual beliefs, social withdrawal, anxiety/depression, poor sleep, decreased hygiene...
• Acute (active) phase
• Recuperative (recovery) - improvement of some of the symptoms of the acute phase
• Residual phase - nonpsychotic residua of the disease
• Chronic illness phase

• suicide - 30% attempt; 5-10% successfully commit suicide
• Depression - half have significant depression
• Homelessness
• Violence - 4X increased
• Substance dependence seen in 40% of schizophrenics
• Medical problems - insulin tolerance, osteoporosis, poor nutition, increased pain tolerance, polydipsia
• Early death - 10 years shorter than average

Multiple hit disorder

genetic predisposition + one or more environmental factors

• Neurodevelopmental factors
• Dopamine hypothesis

• Early treatment --> better function, improved function
• Medical evaluation - r/o medical causes, drugs, etc.

episodes of depression or mania concurrent with symptoms such as bizarre dilusions

• rare. middle to late adult life
• delusions do not often respond to antipsychotics

• 1. Systematized - delusions fit into a scheme that makes logical sense to the patient
• 2. Non-bizarre - delusions are technically possible
• 3. Encapsulated - pt behaves normally, other than the delusions

Axis 1 - major psychiatric disorders and syndromes, including substance use disorders

Axis 2 - personality disorders and mental retardation

Axis 3 - general medical conditions

Axis 4 - psychosocial and environmental problems and stressors

Axis 5 - global assessment of function

• major depression
• mania
• hypomania
• mixed

>5 for more than two weeks ... must significantly distress or impair social, occupational or other areas of function

• Depression +
• S - sleep problems
• I - Interest
• G - Guilt or worthlessness
• E - Energy
• C - Concentration
• A - Appetite change; weight change
• P - Psychomotor slowing
• S - suicide

Normal psychological process

sx should last less than 2 months

dx: major depressive episode not due to

-schizophrenia, psychotic disorder, other mood disorder

May be single or recurrent

• MDD does NOT increase risk for drug/alcohol abuse

Lifetime prevalence: 15%

Mean age of onset: 26 yrs (rare before puberty); Many 30+

episodes last (average) 4 to 9 months

Pts will have 2 to 3 episodes during their lifetime

*earlier onset tends to have more severe disease

Females >> Males (2:1)

10% of severely depressed patients (successfully) commit suicide

Both: significant distress or impairment of function as a direct consequence of...

- physiological consequence of general medical condition

-consequence of substance intoxication or withdrawal (within 1 month)

Pts at increase risk of death post myocardial infarction

Unknown...

Genetics - 2x increased risk in people with first degree relatives with MDD

Environment/stress...

goal: restore wellness

1. Cognitive behavioral therapy (CBT): address pt's views of self, world, and future

2. Interpersonal therapy

• 3. Antidepressant drugs
• - Tricyclic antidepressants (TCA)
• - SSRI; not any faster or better, but fewer side effects

Side effects: anticholinergic, drowsiness, nervousness, insomnia...

Pharmaceuticals either 1) increase NE, 2) increase 5-HT, 3) both, or 4) increase DA

• Marked improvement in 70% of patients
• *drugs should be continued for 4 to 9 months after the resolution of the depression

• 4. Electroconvulsive therapy (ECT)
• - most effective treatment for MDD: works within days
• -primarily used for pts that are unresponsive to Rx

depressed mood for most of the day, for more days than not, for at least 2 years... impairs function

Not as severe as MDD

distinct period of elevated, expansive or irritable mood lasting at least 1 week during which patient has >3 of the following...

• D- Distractible
• I - Impulsive - pleasurable activities w/ high risk for painful consequences
• G - Grandiosity
• F - Flight of ideas
• A - Activity (increase in goal-directed activity)
• S - Sleep decreased (need decreased)
• T - Talkative

• only 4 days, manic-like
• Not psychotic
• Not markedly impaired function

Pt meets criteria for MDE and mania nearly every day for at least 1 week

dx: one or more manic or mixed episode (not due to primary psychotic disorder

Pts will often have one or more MDE

Dx: one or more MDEs and at least one hypomanic episode

(don't diagnose)

2 years with numerous periods of hypomanic symptoms and numerous periods of depressive symptoms...significant distress/impairment of function

• 1 % of the population (lifetime prevalence)
• 4x risk in first degree relatives; 70% heritability

Onset: 15 to 30 years (younger than MDD)

Male ~ Female

Frequent episodes: 4/life

Bipolar DOES increase risk for alcohol/drugs

• Mood stabilizers: for the treatment of manic episodes
• - lithium
• - divalproex
• - carbamazepine

*concern for treating depressive episodes aggressively for fear that pt will go into manic state*

• Mechanism: unknown (mood stabilizer)
• Indication: Bipolar (manic episodes)
• onset: takes 5 to 7 days

Excretion: renal; follow plasma levels

AEs: cognitive impairment, tremor, diarrhea, hypothyroidism, elevated PTH and hypercalcemia, weight gain, edema, increase thirst, polyuria, nephrogenic diabetes insipidus, acne

• Mechanism (as a mood stabilizer): unknown
• - antiepileptic drug: blocks voltage gated sodium channels

AEs: cognitive effects, tremor, nausea, diarrhea, weight gain, hair loss, hepatotoxicity, pancreatitis, teratogenicity (neural tube defects)

mechanism: unknown; also an anticonvulsant

75% protein bound; metabolized in liver

AEs: sedation, rash, hepatotoxicity, hyponatremia, common leucopenia (but rare aplastic anemia), increased metabolism of oral contraceptives, teratogenicity

Mood stabilizers... (lithium +/- anticonvulsants)

if pts has 2-3 episodes in last 2-3 years; keep them on it for several years