Psychiatry - Anxiety, Personality d/o, Cognitive d/o

• Epidemiology:
• -women 30% lifetime prevalence, men 19% lifetime prevalence.
• -More frequently in higher socioeconomic groups

• Types:
• -Panic disorder
• -Agoraphobia
• -Specific and social phobias
• -Obsessive-compulsive disorder
• -Post-traumatic stress disorder
• -Acute stress disorder
• -Generalized anxiety disorder
• -Anxiety disorder secondary to generalized medical condition
• -Substance-induced anxiety disorder

• hyperthyroidism
• vitamin B12 deficiency
• Hypoxia
• Neurological disorders (epilepsy, brain tumors, MS)
• Cardiovascular disease
• Anemia
• Pheochromocytoma
• Hypoglycemia

• Caffeine intake and withdrawal
• Amphetamines
• Alcohol and sedative withdrawal
• mercury or arsenic toxicity
• organophosphate or benzene toxicity
• Penicillin
• Sulfonamides
• Sympathomimetics
• Antidepressants

• - Attacks peak in several minutes and subsides within 25 minutes. Rarely last > 1 hour
• - Attacks may be unexpected or provoked by specific triggers

• Criteria: at least 4 of the following
• -Palpitations
• -Sweating
• -Shaking
• -Shortness of breath
• -Choking sensation
• -Chest pain
• -Nausea
• -Light-headedness
• -Depersonalization (feeling detached from oneself)
• -Fear of losing control or "going crazy"
• -Fear of dying
• -Numbness or tingling
• -Chills or hot flashes

• Palpitations
• Abdominal distress
• Numbness, nausea
• Intense fear of death
• Choking, chills, chest pain, sweating, shaking, shortness of breath

Experiencing panic attacks accompanied by persistent fear of having additional attacks

• 1. Spontaneous recurrent panic attacks with no obvious precipitant
• 2. At least one attack has been followed by minimum 1 month of:
• -persistent concern about having additional attacks
• - worry about implications of attack
• - significant change in behavior related to the attacks

with or without agoraphobia (fear of being alone in public places)

• Lifetime prevalence: 2 to 5%
• Females:males 2-3:1
• Strong genetic component
• Onset: late teens to early thirties

• Major depression (depressive symptoms found in 40 to 80% of patients)
• Substance dependence (found in 20 to 40% of patients)
• Social and specific phobias
• Obsessive-compulsive disorder

• Variable, but often chronic
• Relapses are common with discontinuation of therapy
• 10 to 20% of patients continue to have significant symptoms that interfere with daily functioning
• 50% continue to have mild symptoms
• 30 to 40% remain free of sx after treatment

• Acute initial treatment of anxiety: benzodiazepines, which should be tapered as SSRI is instituted
• Maintenance: SSRIs (especially paroxetine and sertraline), typically take 2 to 4 weeks to become effective
• - can also use clomipramine, imipramine, or other antidepressants
• - treat for at lesat 8 to 12 months
• Other: relaxation, biofeedback, cognitive therapy, insight-oriented psychotherapy, family therapy

• fear of being alone in public places, often develops 2/2 panic attacks due to apprehension about having subsequent attacks in public places where escape may be difficult
• 50 to 75% of patients have coexisting panic disorder
• Treatment: SSRIs, behavioral therapy

• phobias are the most common mental disorders in the US
• 5 to 10% of the population is afflicted
• Women:men 2:1 for specific phobias
• Women:men 1:1 for social phobia

• Obsession: recurrent and intrusive thought, feeling, or idea
• Compulsion: conscious repetitive behavior linked to an obsession that, when performed, functions to relieves anxiety caused by the obsession
• Axis I disorder; patients are generally aware of their problems, realize that their thoughts and behaviors are irrational

• 1. Obsessions or compulsions (75% of patients have both obsessions and compulsions)
• 2. Person is aware of obsessions and compulsions as unreasonable and excessive
• 3. Obsessions cause marked distress, time consuming, significantly interfere with daily function

• Lifetime population prevalence: 2 to 3%
• Onset: early adulthood
• Men:women 1:1
• OCD is associated with MDD, eating disorder, other anxiety disorders, OCPD
• Treatment: high dose SSRIs (first-line), TCAs

• Having experienced or witnessed a traumatic event
• Persistent reexperience of the event (dreams, flashbacks, etc.)
• Avoid stimuli associated with the trauma
• Numbing of responsiveness (constricted affect, feeling detachment)
• Persistent symptoms of increased arousal (difficulty sleeping, outbursts of anger, startle response)
• Symptoms must be present for >1month

• 1/2 patients remain symptom free after 3 months of treatment
• Treatment: TCAs, SSRIs, MAOIs, Anticonvulsants (flashbacks and nightmares)
• Other: psychotherapy, relaxation, support groups

• people experience major traumatic event but have anxiety symptoms for only a short duration
• - Event occurred <1 month ago
• - Symptoms last <1 month

• persistent, excessive anxiety and hyperarousal for at least 6 months
• Worry about general daily events
• Anxiety is difficult to control

• Excessive anxiety and worry about daily events and activities for at least 6 months
• Difficult to control the worry
• Must be associated with 3 of the following: Restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance

• Lifetime prevalence: 45%
• Women:Men is 2:1
• Onset: before age 20 (usually)
• 50-90% of pts with GAD have coexisting mental disorder (esp. major depression, social or specific phobia, panic disorder)
• Prognosis: chronic, fluctuating sx in 50% of patients

• Most effective: psychotherapy and pharmacotherapy
• Buspirone
• Benzodiazepines (clonazepam or diazepam) -- should taper off asap due to risk of tolerance and dependence 
• SSRIs
• Venlafaxine (extended release)

• (Not anxiety disorders)
• Maladaptive behavioral or emotional symptoms develop aafter a stressful life event
• Sx begin within 3 months after the events, end within 6 months
• Cause significant impairment in daily function or interpersonal relationships
• *Symptoms are not those of bereavement
• Stressful ivent is not life threatening

Ego-syntonic: patients lack insight about their problems

• 1. Pattern of behavior/inner experience that deviates from the person's culture, manifests in two or more of the following ways:
• Cognition
• Affect
• Personal Relations
• Impulse control

• 2. The pattern:
• - Is pervasive and inflexible in a broad range of situations
• - Is stable and as an onset no later than adolescence or early adulthood
• - leads to significant distress in functioning
• - Not accounted for by another mental/medical illness or substance use

• Weird, Wild, Worried
• Cluster A: schizoid, schizotypal, paranoid
• Cluster B: antisocial, borderline, histrionic, narcissistic
• Cluster C: avoidant, dependent, obsessive-compulsive
• Personality disorder NOS: passive-aggressive personality disorder

• Pervasive distruss and suspiciousness of others, interpret motives as malevolent
• At least 4 of the following:
• 1. Suspicion that others are exploiting or deceiving him or her
• 2. Preoccupation with doubts of loyalty or trustworthiness of acquaintances
• 3. Reluctance to confide in others
• 4. Interpretation of benign remarks as threatening or demeaning
• 5. Persistence of grudges
• 6. Perception of attacks on his or her character that are not apparent to others; quick to counterattack
• 7. Recurrence of suspicions regarding fidelity of spouse or lover

PPD do not have any fixed delusions and are not frankly psychotic

• social withdrawal, often perceived as eccentric and reclusive; no desire for close relationships
• 4 or more of the following:
• 1. Neither enjoying nor desiring close relationships
• 2. Generally choosing solitary activities
• 3. Little interest in sexual activities
• 4. Taking pleasure in few activites
• 5. Few close friends or confidants
• 6. Indifference to praise or criticism
• 7. Emotional coldness, detachment, or flattened affect

• Schizoid PD do not have any fixed delusions
• Schizoid PD do not have the same eccentric behavior or magical thinking seen in patients with schizotypal PD

• pervasive pattern of eccentric behavior and peculiar thought patterns
• Five or more of the following:
• 1. Ideas of reference
• 2. Odd beliefs or magical thinking, inconsistent with cultural norms
• 3. Unusual perceptual experiences
• 4. Suspiciousness
• 5. Inappropriate or restricted affect
• 6. Odd or eccentric appearance or behavior
• 7. Few close friends or confidants
• 8. Odd thinking or speech
• 9. Excessive social anxiety

• Pts refuse to conform to social norms and lack remorse for their actions; impulsive, deceitful, often violate the law
• Must be at least 18 years old with history of conduct disorder, 3 or more of the following:
• 1. Failure to conform to social norms by committing unlawful acts
• 2. Deceitfulness/repeated lying/manipulating others for personal gain
• 3. Impulsivity/failure to plan ahead
• 4. Irritability and aggressiveness/repeated fights or assaults
• 5. Recklessness and disregard for safety of self or others
• 6. Irresponsibility/failure to sustain work or honor financial obligations
• 7. Lack of remorse for actions

• BPD pts have unstable moods, behaviors, interpersonal relationships
• At least 5 of the following:
• 1. Desperate efforts to avoid real or imagined abandonment
• 2. Unstable, intense interpersonal relationships
• 3. Unstable self-image
• 4. Impulsivity in at least two potentially harmful ways
• 5. Recurrent suicidal threats or attempts or self-mutilation
• 6. Unstable mood/affect
• 7. General feeling of emptiness
• 8. Difficulty controlling anger
• 9. Transient, stress-related paranoid ideation or dissociative symptoms

• Attention-seeking behavior and excessive emotionality; dramatic, flamboyant, extroverted
• At least 5 of the following:
• 1. Uncomfortable when not the center of attention
• 2. Inappropriately seductive or provocative behavior
• 3. Uses physical appearance to draw attention to self
• 4. Has speech that is impressionistic and lacking in detail
• 5. Theatrical and exaggerated expression of emotion
• 6. Easily influenced by others or situations
• 7. Perceives relationships as more intimate than they actually are

• Sense of superiority, need for admiration, lack of empathy; "Special"
• At least 5 of the following:
• 1. Exaggerated sense of self-importance
• 2. Preoccupied with fantasies of unlimited money, success, brilliance
• 3. Believes that he or she is "special" or unique
• 4. Needs excessive admiration
• 5. Has sense of entitlement
• 6. Takes advantage of others for self-gain
• 7. Lacks empathy
• 8. Envious of others or believes others are envious of him or her
• 9. Arrogant or haughty

• social inhibition and an intense fear of rejection. Patients desire companionship, but are shy and easily injured
• At least 4 of the following:
• 1. Avoids occupation that involves interpersonal contact due to a fear of criticism and rejection
• 2. Unwilling to interact unless certain of being linked
• 3. Cautious of intrapersonal relationships
• 4. Preoccupied with being criticized or rejected in social situations
• 5. Inhibited in new social situations because of feelings of inadequacy
• 6. Believes he or she is socially inept and inferior
• 7. Reluctant to engage in new activities for fear of embarrassment

• Poor self-confidence and fear separation
• At least 5 of the following:
• 1. Need reassurance from others regarding everyday decisions
• 2. Need others to assume responsibility for most areas of life
• 3. Cannot express disagreement b/c of fear of loss of approval
• 4. Difficulty initiating projects
• 5. Goes to lengths to obtain support from others
• 6. Feels helpless when alone
• 7. Urgently seeks another relationship when one ends
• 8. Preoccupied with fears of being left to take care of self

• pattern of perfectionism, inflexibility, and orderliness
• At least 4 of the following:
• 1. Preoccupation with details, rules, lists, organization such that the major point of the activity is lost
• 2. Perfectionism that is detrimental to completion of task
• 3. Excessive devotion to work
• 4. Excessive conscientiousness and scrupulousness about morals and ethics
• 5. Will not delegate tasks
• 6. Unable to discard worthless objects
• 7. Miserly
• 8. Rigid and stubborn

• Cognitive d/o affect memory, orientation, attention, and judgement
• Dementia
• Delirium
• Amnestic disorders

• Dementia is an impairment of memory and other cognitive function without alteration in the level of consciousness
• Most progressive and irreversible
• Memory, cognition, language skills, behavior, personality

• Incident increases with age
• 20% of people > age 80 have severe form of dementia
• Delusions and hallucinations occur in approximately 30% of demented patients
• Depression and anxiety seen in 40 to 50% of patients

• waxing/waning of consciousness
• high mortality if untreated
• 1. Quiet: patient may seem depressed or exhibit symptoms similar to failure to thrive
• 2. Agitated: obvious pulling out lines; may hallucinate

• Delirium vs Dementia
• Clouding of consciousness vs loss of memory/intellectual ability
• Acute onset vs Insidious onset
• Lasts 3 days to 2 weeks vs months to years
• Orientation impaired
• Immediate/recent memory impaired vs remote and recent memory impaired
• Usually reversible vs 15% reversible
• EEG changes vs No EEG changes

• Most common dementia (80% of all dementias)
• 5% of all people > 65
• 15 to 25% of all people >85
• Women>men
• Average life expectancy: 8 years after diagnosis
• 40% have family history of Alzheimer's

• Gradual progressive decline of cognitive function, especially memory and language.
• Personality changes and mood swings are very common
• Memory impairment plus at least 1 of the following:
• Aphasia: disorder of language affecting speech and understanding
• Apraxia: inability to perform purposeful movements
• Agnosia: inability to interpret sensations correctly (visual, inability to recognize a previously known object)
• Diminished executive function

• decreased levels of acetylcholine (locus ceruleus)
• decreased levels of norepinephrine (basal nucleus of Meynert)
• Pathology: diffuse atrophy, enlarged ventricles
• Neurofibrillary tangles derived from Tau proteins

• No cure or effective treatment
• NMDA receptor antagonists: memantine
• Cholinesterase inhibitors help slow progression:
• -Tacrine (Cognex)
• -Donepezil (Aricept)
• -Rivastigmine (Exelon)

• Microvascular disease in the brain ⇒ multiple small infarcts
• IDENTICAL to Alzheimer's: memory impairment plus at least one of the following
• 1. Aphasia
• 2. Apraxia
• 3. Agnosia
• 4. Diminished executive function

• Vascular dementia:
• -focal neurological symptoms
• -onset is more abrupt
• -preservation of personality
• -Can reduce risk by modifying risk factors (smoking, hypertension, diabetes)

• RARE cause of slowly progressing dementia
• Hallmarks: aphasia, apraxia, agnosia
• Pathology: atrophy of frontotemporal lobes; Pick bodies

intraneuronal inclusion bodies (necessary for diagnosis of FTD)

• Autosomal dominant genetic disorder
• progressively disabling cognitive, physical, and psychological functioning
• death after approx. 15 years

• Onset: 35 to 50 years
• Progressive dementia
• Choreiform movements
• Muscular hypertonicity
• depression and psychosis very common

• Pathology: trinucleotide repeat of short arm of chrom 4; basal ganglia
• MRI: caudate atrophy
• genetic testing is diagnostic
• Treatment: none!

• prominent neuronal loss in substantia nigra (provides dopamine to basal ganglia) causing physical and cognitive impairment
• Approx 30% of patients with PD develop dementia

• Bradykinesia
• Cogwheel rigidity
• Resting tremor - "pill-rolling" tremor most common
• Masklike facial expression
• Shuffling gait
• Dysarthria (abnormal speech)

• Idiopathic (most common)
• Traumatic (Muhammad Ali)
• Drug- or toxin-induced
• Encephalitic
• Ramilial (rare)

• Levodopa: degraded by dopamine by dopadecarboxylase
• Carbidopa: peripheral dopadecarboxylase inhibitor prevents levodopa from being converted to dopamine
• Amantadine: mechanism unknown
• Anticholinergics: help relieve tremor
• Dopamine agonists (bromocriptine, etc.)
• Monoamine oxidase (MAO)-B inhibitors (selegiline): inhibit break-down of dopamine

• Rapidly progressive, degenerative disease of the CNS caused by prion
• Clinical manifestations: rapidly progressive dementia 6 to 12 months after onset of sx
• 90% have myoclonus
• Extrapyramidal signs, ataxia, lower motor neuron signs are also common

• Kuru
• Gerstmann-Straussler syndrome
• Fatal familial insomnia
• Bovine spongiform encephalopathy ("mad cow disease")

• NPH is a reversible cause of dementia
• Enlarged ventricles with increased CSF pressure
• Clinical triad: gait disturbance, urinary incontinence, dementia
• Wet, wabbling, weird (dementia)
• Treatment: relieve increase pressure with shunt

• rapid onset of symptoms
• periods of altered levels of consciousness
• potential reversal of symptoms
• Fluctuating course with lucid intervals
• Patients are often anxious, incoherent, unable to sleep normally

• CNS injury or disease
• Systemic illness
• Drug abuse/withdrawal
• Hypoxia
• Fever
• Sensory deprivation
• Medications (anticholinergics, steroids, antipsychotics, antihypertensives, insulin)
• Postop
• Electrolyte imballances

• impairment of memory without other cognitive problems
• Always occur 2/2 an underlying medical condition
• Etiology: hypoglycemia, systemic illness, hypoxia, head trauma, brain tumor, CVA, seizures, multiple sclerosis, herpes simplex encephalitis, substance use