Mood Disorders

Mood Disorders-

Adjustment Disorder-

-Adjustment mood disorder usually comes with depression that occurs in response to an identifiable psychosocial cause (ex marital discord, job loss, academic failure, or persistent painful illness)

-The stressor can be a single event or can involve many psychosocial stressors

-Adjustment disorder describes patients suffering from significant symptoms that do not meet the criteria for a specific depressive disorder

-Diagnostic criteria for adjustment disorder is as follows:
1.  Decreased mood, tearfulness, and feeling of hopelessness that occur in response to an identifiable stressor within 3 months of the onset of the stressor

2.  Symptoms are clinically significant by at least one of the following:
-Significant distress that exceeds what would be expected given the nature of the stressor
-Impaired social or occupational functioning

3.  The syndrome does not meet criteria for another psychiatric disorder

4.  The syndrome does not represent an exacerbation of a preexisting psychiatric disorder

5.   The syndrome does not represent bereavement

6.  After the stressor has ended, the syndrome resolves within 6 months

-Patients may need counseling.  Sometimes require SSRI's.


-Bipolar Disorder-
-Bipolar disorder is a mood disorder that is characterized by episodes of mania, hypomania, and major depression

-There is subtypes of bipolar disorder such as bipolar I and bipolar II

-Bipolar I- experience manic episoders and nearly always experience major depressive and hypomania episodes

-Bipolar II-is at least one hypomanic episode, at least one depression episode, and the absence of manic episodes

-Some patients will have euthymia between episodes and other patients will not have euthymia between cycles

-Many studies have demonstrated a promo and symptoms such as irritability, anxiety, mood lability, agitation, aggressiveness, sleep disturbance, and hyperactivity may precede a diagnosable disorder

-Mania episoders involve clinically significant changes in mood, behavior, energy, sleep, and cognition

-Hypomanic episodes involve changes in mood, behavior, energy, sleep, and cognition, that are similar to mania, but are less severe

-Psychosis such as delusions and hallucinations can occur during manic, major depression, and mixed episodes

-Biopolar disorder patients will often have comorbid disorders such as anxiety disorder, substance use disorders, ADHD, Eating Disorders, intermittent explosive disorders, and personality disorders

-Suicide attempts are common with bipolar disorder

-Bipolar I is diagnosed in patients with one or more manic episodes.  Hypomania often occurs.  Bipolar I disorder may not be better accounted for by schizoaffective disorder, schizophrenia, delusional disorder, or other unspecified schizophrenia spectrum and other psychotic disorder.  The course of the illness is characterized by rapid cycling or a seasonal pattern, and whether the mood episodes are marked by psychotic features, catatonia, anxious distress, mixed features, melancholic features, atypical features, or peripartum onset.

-Bipolar II is diagnosed in patients with at least one episode of hypomania, at least one major depression episode, and no history of mania.  Bipolar II disorder may not be better accounted for by schizoaffective disorder, schizophrenia, delusional disorder, or other unspecified schizophrenia spectrum and other psychotic disorder.

-The goal of treatment of acute mania and hypomania is remission.

-Drugs commonly used in acute mania and hypomania include:  Lithium, Anticonvulsants, Antipsychotics, and Benzodiazepines.

-It is reasonable to allow up to two weeks in a treatment trial to determine if effective

-Patients that do not respond to 4-6 medication combinations for treating mania are candidates for ECT.

-Hypomania can usually be treated with monotherapy with Risperdal or Zyprexa

-Benzodiazepines are appropriate for patients that cannot tolerate lithium, anticonvulsants, or anti-psychotics

-Depressive symptoms can be treated with SSRI's but need to be started with a mood stabilizers


-Depression-
-The term depression refers a mood state which may be part of a syndrome.  Depression may refer to a constellation of symptoms and signs. It may also refer to a mental disorder that identifies a distinct clinical condition (unipolar major depression)

-During an assessment of a depression patient you should assess suicide risk, agitation, history of mania.

-Unipolar Major Depression (Major Depression Disorder) is characterized by a history of one or more major depressive episodes with no history of mania or hypomania

-A major depressive episode is characterized by 5 or more of the symptoms occurring for at least two consecutive weeks; and at least one symptom either depressed mood or loss of interest or pleasure

1.  Depressed mood for most of the day, nearly every day
2.  Loss of interest or pleasure in most of all activities, nearly every day
3.  Insomnia or hypersomnia nearly every day
4.  Significant weight loss or weight gain (5 percent with a month)
5.  Psychomotor retardation or agitation that is observable by others
6.  Fatigue or low energy nearly every day
7.  Decreased concentration
8.  Thoughts of worthlessness or excessive guilt
9.  Recurrent thought of death or suicide ideation, or a suicide attempt

-There are subtypes of of depressive episodes they include:  anxious distress, atypical features, catatonia, melancholic features, mixed features, peripartum onset, seasonal onset, and psychotic features

-Most minor depressive episodes are treated by primary care clinicians

-For patients with minor depression who are moderately to severely ill psychotherapy should be considered first line therapy

-Moderate to severe episodes of minor depression that are not responsive to psychotherapy should have an antidepressant such as an SSRI introduced to regimen


-Patients should be referred when patients whom the diagnosis of depression or comorbidities are uncertain, depression that endangers the life of the patient or others, severe psychotic or catatonic depression, and depression that occurs within the context of bipolar disorder


-Dysthymia (Persistent Depressive Disorder)-DSM 5 Criteria
1.  Depressed for  most of the day, for most days than not for at least two years.  Children and adolescents must be at least 1 year

2.  The presence of a 2 or more of the following:
-Poor appetite or overeating
-Insomnia or hyperinsomnia
-Low energy or fatigue
-Low self esteem
-Poor concentration or difficulty making decisions
-Feelings of hopelessness

3. During the period of time the individual has not been without the symptoms for at least two months.

4.  Criteria for major depression disorder may be continuous present for two years

5.  There has never been any mania or hypomania

6.  The disturbance is not better explained my a persistent schizoaffective disorder, schizophrenia, delusional disorder, or unspecified schizophrenia spectrum and other psychotic disorder

7.  Symptoms are not attributable to substance abuse or other medical condition (hypothyroidism)

8.  These symptoms cause a significant distress or impairment in social, occupational, or other areas of functioning


-Dysthymia is best treated with SSRI's or SNRI's and atypical antidepressants, serotonin modulators, tricyclic antidepressants

-Dysthymia really should have some combination of psychotherapy and antidepressants

Eating Disorders

Eating Disorders-

Anorexia Nervosa-

-Anorexia nervosa is a disorder that the patient has an abnormally low body weight, intense fear of gaining weight, and distorted perception of body weight and shape.

-The term anorexia is not correct because the patient maintains their appetite

-Associated features of anorexia nervosa include:  relentless pursuit of thinness, fear of certain foods, obsessional preoccupation with food, preference for low calorie foods, overuse of condiments, concerns about eating in public, social withdrawal, exercise related rituals, restlessness or hyperactivity, resistance to treatment and weight gain, feeling of ineffectiveness, poor sleep, dysphoria, low libido, inflexible thinking, need to control their environment, and perfectionism

-Anorexia occurs more in females than males

-Medical complications of anorexia include:  emaciation, hypothermia, bradycardia, hypotension, hypoactive bowel sounds, amenorrhea, xerosis, brittle hair, and hair loss

-Common laboratory findings with anorexia include:   leukopenia, elevated BUN, hypercholesterolemia, low estrogen levels, low T3, and low testosterone in males, and low bone mineral density

-Common comorbid conditions include with anorexia nervosa include:  anxiety disorders, obsessive compulsive disorders, body dysmorphic disorders, post traumatic stress disorder, mood disorders, substance abuse disorders, disruptive impulse control and conduct disorders

-According to the DSM 5 Anorexia Nervosa must have all of the following:
1.  Restriction of energy intake that leads to low body weight, given the patients age, sex, developmental trajectory, and physical health

2.  Intense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain, despite being underweight

3.  Distorted perception of body weight and shape, undue influence, of weight and shape on self worth or denial of medical seriousness of one's low body weight.

-The treatment of anorexia nervosa involves nutritional rehabilitation and psychotherapy.

-Patients should also be monitor for complications of their anorexia nervosa

-Types of psychotherapy involved include:  cognitive behavior therapy, specialist supportive clinical management, motivational interviewing, and family therapy

-Medications are not the indicated for the initial treatment of anorexia.  Adjunctive medical therapy is indicated for the acutely ill patients who do not respond to initial treatment with nutritional rehabilitation and psychotherapy


-Bulimia Nervosa-
-Bulimia nervosa is episodes of binge eating which patients use inappropriate compensatory methods to prevent weight gain, including self induced vomiting, misuse of laxatives, diuretics, and enemas.  Can also use excessive exercise, fasting and strict diets

-Common physical signs of bulimia nervosa include:  tachycardia, hypotension, xerosis, parotid gland swelling, and erosion of dental enamel

-Many medical complication of bulimia nervosa and affects many systems:  gastrointestinal, cardiac, endocrine, dental, skin, and renal and electrolytes

-Core features of bulimia nervosa include: binge eating, inappropriate compensatory behavior, excessive concern about body weight and shape

-Patients with bulimia nervosa can have comorbid disorders:  anxiety disorders, depression disorders, post traumatic stress disorder, and substance use disorders

-Common personality disorders associated with Bulimia Nervosa include:  borderline, avoidant, dependent, paranoid, histrionic, and obsessive compulsive disorder

-DSM 5 Criteria for Bulimia Nervosa includes the each of the following:
1.  Episodes of binge eating
2.  Inappropriate compensatory behavior to prevent weight gain
3.  The patients self evaluation is unduly influenced by the body shape and weight
4.  The disturbance does not occur exclusively during episodes of anorexia nervosa

-The treatment of Bulimia Nervosa includes nutritional rehabilitation, psychotherapy, and pharmacology.

-First line medication for Bulimia is the SSRI, Prozac
-Second line medication consider celexa, luvox, or zoloft


-Obesity-
-Obesity is defined by a BMI over 30 kg/m2

-Severe obesity is considered a BMI over 40 kg/m2

-The initial management of individuals who would benefit from weight loss is lifestyle intervention, a combination of diet, exercise, and behavior modification

-Some patients may require pharmacologic therapy or bariatric surgery

-Pharmacologic therapy can include:  orilstat, locaserin, combination phentermine or topamax

-For patients with a BMI greater than 30 kg/m2 or a BMI 27-29.9 kg/m2 with comorbidities who have failed to achieve weight loss goals though diet and exercise alone, pharmacologic therapy should be added to lifestyle intervention

-For patients with a BMI greater than 40 kg/m2 who have failed diet and exercise, bariatric surgery is recommended

Autistic Disoder

Autistic Disorder-
Autistic Disorder-

-Autism Spectrum Disorder (ASD) is a biologically based neurodevelopmental disorder characterized by impairments of two major domains:  (1) deficits in social communication and social interaction, (2) Restrictive repetitive patterns of behavior, interests, and activities

-ASD encompasses disorders known as autistic disorder (classic autism, infantile autism),  childhood disintegrative disorder, pervasive developmental disorder NOS, and Asperger's Syndrome

-The pathogenesis of autism is not completely understood.  It appears to have a genetic etiology that alters brain development

-Environmental factors such as toxic exposures, teratogens, and perinatal insults account for a few cases

-Advanced parenteral age (maternal and paternal) have been associated with increased risk of having a child with autism

-No data has been reproduced that shows a correlation with autism with vaccines

-Any of the following specialists may need to be involved with autistic children:  developmental pediatrician, psychologist or neuropsychologist, geneticist or genetics counselor, speech language pathologist, occupational therapist, audiologist, and social worker

-Therapies for ASD may be provided in an early childhood intervention program, school based special education program, or by therapists in private practice

-Treatment of autism disorder focuses on behavior and educational interventions that target the core symptoms of ASD

-Medications are often used to treat the target symptoms of ASD as follows: hyperactivity, inattention, impulsivity, aggression, outburst, self-injury, anxiety, obsessive compulsive behaviors, rigidity, repetitive behaviors, depressive symptoms, and sleep dysfunction

Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder-
Attention Deficit Hyperactivity Disorder (ADHD)-
-ADHD is characterized by inattention, impulsiveness, restlessness, executive dysfunction, and emotional dysregulation

-Symptoms of ADHD of hyperactivity or impulsivity are less recognizable in adults

-The pathogenesis of ADHD in adults is not known

-The two major scales for diagnosing ADHD are the Conners' Adult ADHD rating scale and Adult ADHD self report scale

-The DSM 5 criteria for diagnosis of ADHD are below:
A.  A persistent pattern of inattention and/or hyperactivity and impulsivity that interferes with functioning and development as characterized by (1) or (2)

1.  Inattention-Six or more of the following symptoms have persisted for at least six months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities

-Fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities
-Has difficulty sustaining attention in tasks or play activities
-Doses not seem to listen when spoken to directly
-Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
-Has difficulty organizing tasks and activities
-Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
-Loses things necessary for tasks or activities
-Is easily distracted by extraneous stimuli
-Is forgetful in daily activities

2.  Hyperactivity and Impulsivity-  Six or more more of the following symptoms have persisted for at least 6 months that is inconsistent with developmental level and negatively impacts directly on social and academic/occupational activities.

-Often fidgets with or taps hands or feet or squirms in seat
-Often leaves seat in situations when remaining seated is expected
-Often runs or climbed in situations where it is inappropriate
-Often unable to play or engage in leisure activities quietly
-If often "on the go" acting as if driven by a motor
-Often talks excessively
-Often blurts out an answer before a question has been completed
-Often has difficulty waiting turn
-Often interrupts or intrudes on others

B.  Several inattentive or hyperactive symptoms were present prior to age 12.

C.  Several inattentive or hyperactive symptoms are present in two or more settings

D.  There is clear evidence that the symptoms interfere with, or reduce the quality of social, academic, or occupational functioning

E.  These symptoms dod not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another psychiatric disorder

-Differential diagnosis includes:  depression, mania, anxiety disorders, and substance abuse disorders

-Up to one third of children with ADHD will have one or more coexisting condition (learning disabilities, oppositional defiant disorder, conduct disorder, anxiety disorder, mood disorders, tics, and sleep disorders)

-Children 4-18 can typically be managed by their primary care provider without a comorbid problem

-Specialities that have to sometimes be involved include:  developmental behavior pediatrician, child neurologist,  psychopharmacologist, child psychiatrist, and clinical child psychologist.

-Treatment modalities include:  behavior interventions, pharmacotherapy, combinations therapy, school based interventions, social skills training, and psychotherapy interventions

-Medications with or without behavior/psychologic interventions are first line therapy for school aged patients

-Trial of medications for school aged children or adolescent, a stimulant is considered first line.  Concerta is choice

-Straterra can be considered an alternative to stimulants

-Dosing for ADHD has 3 stages:  titrations, maintenance and termination

-Also need to look at does the child need it during summer or on weekends

Anxiety Disorders

Anxiety Disorders-

-Generalized Anxiety Disorder-

-Generalized Anxiety Disorder (GAD) is a disorder that presents with excessive worrying that is hard to control, that causes impairment or significant distress, and occurs on most days for at least six months

-Other symptoms of GAD include apprehension, increased fatigue, irritability, and muscle tension

-Treatment modalities for GAD include:  cognitive behavior therapy and SSRI's.

-GAD is associated with increased rates of substance of abuse, post traumatic stress disorder, and obsessive compulsive disorder

-Genetic factors appear to predispose patients to the development of GAD

-Most patients with GAD present with symptoms other than worrying.  Many complain of poor sleep, fatigue, difficulty relaxing, and motor tension.

-GAD is considered to be a potential chronic illness but may vary in severity over time

-The generalized anxiety disorder 7 inter scale (GAD-7) is used to screen for GAD in primary care

-DSM 5 Criteria for Generalized Anxiety Disorder (GAD) requires the presence of:
1.  Excessive worry and anxiety occurring on most days for at least 6 months about a number of events and activities.
2.  The patient finds it difficult to control the worry.
3.  The anxiety and worry are associated with 3 of the following symptoms:
-Restlessness or feeling on edge
-Being easily fatigued
-Difficulty concentrating
-Irritability
-Muscle Tension
-Sleep Disturbance

4.  The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social or occupation areas of functioning
5.  The disturbance is not attributable to the physiological effects of drugs or alcohol
6.  The disturbance is not better explained by another mental disorder.

-Differential diagnosis include depression, hypochondrias, panic disorder, and adjustment disorder

-First line medications are SSRI's and SNRI's in treatment of GAD

-The following SSRI's have been shown to be efficacious:  Paxil, Zoloft, Celexa, and Lexapro

-SNRI's such as Effexor and Cymbalta have been shown to be effective.

-Second line medications are tricyclic antidepressants, benzodiazepines, and some anti-convulsants

-Other alternative medications have include certain anti-psychotic medications and Atarax


-Panic Disorder-
-Panic Disorder and panic attacks are discrete episodes of intense worry that begins rapidly and lasts several minutes to an hour.

-Patients with panic attacks usually present with somatic symptoms such as chest pain and/or shortness of breath.

-With Panic Disorder, patients experience recurrent unexpected panic attacks, and one month or more of either worrying about future attacks, or a significant maladaptive change in behavior related to the attacks

-Somatic features of panic attacks can include chest pain, tachycardia, headaches, dizziness, faintness, pseudo seizures, and epigastric abdominal pain

-Panic disorder has been shown to have a high prevalence among patients with bipolar disorder and alcohol abuse

-Panic Attack is defined by the DSM 5 as an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during the time 4 or more of the following symptoms occur:
1.  Palpitations or accelerated heart rate
2.  Sweating
3.  Trembling or shaking
4.  Sensation of shortness of breath or smothering
5.  Feeling of choking
6.  Chest pain or discomfort
7.  Nausea or abdominal distress
8.  Feeling dizzy, unsteady, lightheaded or faint
9.  Chills or heat sensations
10. Paresthesias
11.  Derealization or depersonalization
12.  The fear of losing control
13.  Fear of dying


-Panic Disorder is defined by the DSM 5 as
1.  Recurrent unexpected panic attacks
2.  At least one of the attacks has been followed by a month or more of one or both of the following:
-Persistent worry about panic attacks or the consequences
-A significant maladaptive change in behavior related to the attacks
3.  The disturbance is not related to the physiologic effects of a substance (medication or illicit drugs)
 or other medical condition such as hyperthyroidism or cardiopulmonary problems.
4.  The disturbance is not better explained by another mental disorder

-Differential diagnosis of panic disorder includes:  somatic symptom disorder, illness anxiety disorder, other mental disorders, stimulant use, and general medical conditions

-Several classes of medications have been shown to be effective in panic disorder including:  SSRI's, SNRI's tricyclic antidepressants, monoamine oxidase inhibitors, and benzodiazepines.

-SSRI's are generally preferred because of their side effect profile and advance reactions with overdosing.

-Benzodiazepines have abuse potential and have physiologic dependence.  Should be use on as needed basis initially until stable or SSRI.

-Psychotherapy may also be helpful


-Phobias-
-A phobia is a anxiety disorder characterized by clinically significant fear of a situation or object that leads to an avoidance of a behavior.

-There are 5 main specifiers of specific phobias according to DSM % that are based on the nature of the phobic stimulus

1.  Animals (Spiders, Insects, and Dogs)
2.  Natural Environment (Height, Storms, Water)
3.  Blood Injection-Injury (Needles or invasive medical procedures)
4.  Situational (Airplanes, Elevators and Closed Spaces)
5.  Others (Situations that lead to choking or vomiting, loud sounds, or costume characters)

-Common comorbidities are other anxiety disorders and mood disorders with alcohol dependence

-The development of a specific photophobia is influence by a complex interaction of biologic, psychological and social/environmental disorders

-Differential diagnosis of phobias include agoraphobia, panic disorder, social anxiety disorder, post traumatic stress disorder, separation anxiety disorder, illness anxiety disorder, and eating disorders

-The DSM 5 Criteria for Specific Phobia are below:

1.  Marked fear about an specific object or situation
2.  The phobic object or situation always provokes immediate fear or anxiety
3.  The phobic object or situation is actively avoided or endured with an intense fear or anxiety
4.  The pear of the anxiety is out of proportion to the actual danger posed by specific object
5.  The fear, anxiety or avoidance is typically lasting for 6 months or more
6.  The fear caters clinically significant distress or impairment in social, occupational, or other areas of functioning
7.  The disturbance is not better explained by the symptoms of another mental disorder including fear and anxiety and avoidance of social situations

-First line treatment for specific therapy is cognitive behavior therapy that includes exposure treatment

-Pharmacotherapy such as benzodiazepines and SSRI's have a limited role of specific phobia but can be used as an adjunct


-Post Traumatic Stress Disorder-
-Post Traumatic Stress Disorder (PTSD) is a complex of somatic, cognitive, affective, and behavior effect of psychological trauma.

-PTSD is characterized by intrusive thoughts, nightmares, and flashbacks of past traumatic events, avoidance of reminders of trauma, hyper-vigilance, and sleep disturbance

-Many different traumas result in PTSD.  Common traumas area as follows:  military combat, violent personal assault, natural and man made disasters, severe car accidents, rape, incest, childhood sexual abuse, diagnosis of life threatening illness, severe physical injury, and hospitalization in an intensive care unit

-Most patients who experience trauma react to some degree when experience reminders of trauma.  Most patients compensate for such intense arousal by attempting to avoid experiences to elicit symptoms.

-DSM-5 Criteria for PTSD over the age of six are as follows:
1.  Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
-Directly experiencing the traumatic event
-Witness in person of the event as it occurred to others
-Learning that the traumatic event occurred to close family member or friend.  Must be violent and accidental.

2.  Presence of one of the following intrusion symptoms associated with the traumatic event beginning after the traumatic event occurred
-Recurrent, involuntary, and intrusive distressing memories of the traumatic event
-Recurrent distressing dreams in which the content and/or affect the dream are related to the traumatic event
-Dissociative reactions in which the individual feels or acts as if the traumatic event were recurring
-Intense or prolonged psychosocial distress at exposure to internal or external cures that symbolize or resemble an aspect of the traumatic event
-Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic events

3.  Persistent avoidance of stimuli associated with traumatic event, beginning after the traumatic event occurred, by one or both of the following:
-Avoidance of or efforts to avoid distressing memories, thoughts, or feeling about or closely associated with the traumatic event
-Avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about closely associated with the traumatic event

4.  Negative alterations in cognition and mood associated with the traumatic event beginning or worsening after the traumatic event occurred as evidenced by at least 2 of the following:
-Inability to remember an important aspect of the traumatic event
-Persistent and exaggerated negative beliefs or expectations about oneself, others or the world
-Persistent, distorted cognitions about the cause or consequences of the traumatic events that lead the individual to blame himself/herself or others
-Persistent negative emotional state
-Markedly diminished interest or participations in significant activities
-Feeling of detachment or estrangement from others
-Persistent inability to experience positive emotions

5.  Marked alterations in arousal and reactivity associated with traumatic event, beginning or worsening after the traumatic event occurred as evidence by two or more of the following:
-Irritable behavior and angry outbursts typically expressed as verbal or physical aggression toward people or objects
-Reckless or self destructive behavior
-Hyper-vigilance
-Exaggerated startle response
-Problems with concentration
-Sleep disturbance

6.  Duration of the disturbance is more than 1 month

7.  The disturbance causes clinically significant distress or impairment in social, occupational, or other areas of functioning

8.  The disturbance is not attributable to physiologic effects of a substance or another medical condition

-Treatment of PTSD includes psychotherapy and pharmacotherapy.  They often are combined and refractory to treatment.

-SSRI's are first line medications for PTSD

-TCA's, MAOi's atypical antidepressants, and atypical antipsychotics do not help PTSD

-Alpha adrenergic receptor blockers have been shown to reduce nightmares and improve sleep

-Benzodiazepines are used to treat the symptoms of anxiety and increased arousal

-Medications should be continued for at least 6 months to 12 months