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jknell
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Hallucination
sensory experience ('perception') that occurs without external stimulation
Psychotic vs nonpsychotic (does the patient think the perception is real)
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Delusion
specific false belief that is firmly held despite evidence to the contrary; not endorsed by members of the individual's culture
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Psychosis
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
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Schizophrenia
Dx, subtypes, 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
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schizophrenia
treatment (specifics)
- 1st generation: D2 blockers
- -Haloperidol
- -Risperidone
- -Olanzapine
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Schizophrenia
- 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
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schizophrenia
complications
- 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
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Schizophrenia
causes
Multiple hit disorder
genetic predisposition + one or more environmental factors
- Neurodevelopmental factors
- Dopamine hypothesis
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Schizophrenia
Treatment principles
- Early treatment --> better function, improved function
- Medical evaluation - r/o medical causes, drugs, etc.
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Schizoaffective disorder
episodes of depression or mania concurrent with symptoms such as bizarre dilusions
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Delusional disorder
- 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
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Axis 1
Axis 2
Axis 3
Axis 4
Axis 5
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
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Episodes
- major depression
- mania
- hypomania
- mixed
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Major depressive episode
(MDE)
SIGECAPS
>5 for more than two weeks ... must significantly distress or impair social, occupational or other areas of function
S - sleep problems - I - Interest
- G - Guilt or worthlessness
- E - Energy
- C - Concentration
- A - Appetite change; weight change
- P - Psychomotor slowing
- S - suicide
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Bereavement
Normal psychological process
sx should last less than 2 months
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Major depressive disorder
MDD
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
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MDD
epidemiology
course
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
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Mood disorder due to general medical condition
Mood disorder due to a substance
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)
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MDE/MDD related to medical conditions
Pts at increase risk of death post myocardial infarction
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MDD
causes
Unknown...
Genetics - 2x increased risk in people with first degree relatives with MDD
Environment/stress...
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MDD
treatment
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
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Dysthymic disorder
small font
depressed mood for most of the day, for more days than not, for at least 2 years... impairs function
Not as severe as MDD
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Manic episode
DIG FAST
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
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Hypomanic episode
- only 4 days, manic-like
- Not psychotic
- Not markedly impaired function
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Mixed episode
Pt meets criteria for MDE and mania nearly every day for at least 1 week
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Bipolar I disorder
Dx
dx: one or more manic or mixed episode (not due to primary psychotic disorder
Pts will often have one or more MDE
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Bipolar II disorder
Dx: one or more MDEs and at least one hypomanic episode
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Cyclothymic disorder
(don't diagnose)
2 years with numerous periods of hypomanic symptoms and numerous periods of depressive symptoms...significant distress/impairment of function
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Bipolar I disorder
natural history/epi
- 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
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Bipolar I disorder
Tx
- 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*
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Lithium
- 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
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Divalproex
- 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)
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Carbamazepine
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
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Maintenance therapy for pts with bipolar I disorder
Mood stabilizers... (lithium +/- anticonvulsants)
if pts has 2-3 episodes in last 2-3 years; keep them on it for several years
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