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psychiatry

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psychiatry Powered By Docstoc
					psychiatry
•   Major Depressive Disorder:
•   Lifetime prevalence 5 -20 %
•   Female-to-male ratio 2:1
•   Incidence increases between ages 20 and
    40
•   Symptoms of depression: SIG E CAPS
•   Sleep – increased or decreased
•   Interest- anhedonia
•   Guilt or worthlessness
•   Energy – decreased energy or fatigue
•   Concentration-difficult or disturbed
•   Appetite- increased or decreased
•   Psychomotor retardation or agitation
•   Suicidal ideations
• Differential diagnosis :
• Psychiatric : cocaine withdrawal, bereavement ,
  schizoaffective disorder, dysthymia, dementia,
  bipolar disorder and adjustment disorder .
• Organic :hypothyroidism, MS, Parkinson’s
  disease, Addison’s disease,anemia ( pernicious
  anemia), infectious mononucleosis
  ,malignancies (pancreatic cancer)
• Drugs :oral contraceptive, steroids and some
  beta blockers
• Treatment :
• Psychotherapy and pharmacotherapy
• SSRIs are the first line treatment ,
  including: fluoxetine( prozac ), paroxetine(
  paxil) fluvoxamine( luvox) and citalopram
  (celexa)
• Side effect : sexual dysfunction
• Key points :
• 1- Major depression is unipolar mood
  disorder
• 2- It is often recurrent
• 3- Major depression has a 15% suicide
  rate
• 4- Combined psychotherapy and
  pharmacotherapy are the best treatment
•   Dysthymic disorder
•   Mild ,chronic form of major depression
•   Lifetime prevalence 6 %
•   Lasting 2 years
• Symptoms:
• Increased or decreased appetite
• Increased of decreased sleep
• Decreased energy of fatigue
• Decreased self-esteem
• Difficulty concentrating or disturbed
  concentration
• hopelessness
• Treatment
• Same as MDD except psychotherapy may
  play a larger role and the course of
  treatment may be more protracted
•   Bipolar disorders:
•   Bipolar I disorder
•   Bipolar II disorder
•   cyclothymia
•   Bipolar I disorder :
•   Biphasic mood disorder
•   It is cyclic
•   Suicide rate of 10- 15 %
•   Lifetime prevalence 0.4-1.6%
•   Male-to-female ratio equal
•   Strong genetic component
•   Recurrent rate 90%
•   Signs & Symptoms : DIG FAST
•   Distractibility
•   Insomnia
•   Grandiosity
•   Flight of ideas
•   Activity and psychomotor agitation
•   Speech pressured
•   Thoughtlessness –seeks pleasure without
    regard for consequence
• Management
• Acute mania : benzodiazepines and
  antipschotics
• Mood stabilizers :lithium and valproic acid
• Lithium
• Mainstay of treatment for bipolar disorder
  and mania
• Side effects :hypothyroidism and
  nephrogenic diabetes insipidus,
  teratogenesis
• Low index therapeutic : 0.6 to 1.5
• Signs of toxicity
• Coarse tremor ,dysarthria ,ataxia, seizure
  and coma
• Treatment may require dialysis
• NSAIDs, ACEIs and diuretics increased
  plasma lithium level
•   Valproic Acid
•   Mixed mania
•   Rapid cycling
•   High index therapeutic
•   Well tolerated
•   Side effects
•   GI distress
•   Sedation
•   Hepatoxicity
•   Pancreatitis
•   thrombocytopenia
•   Bipolar II disorder
•   Similar to type I but milder form
•   Lifetime prevalence about 0.5 %
•   More common in women
•   Treatment similar as type I but less
    aggressive
• Cyclothymic disorder
• Recurrent
• Oscillates between hypomania and
  dysthymia
• Lifetime prevalence 0.4 – 1 %
• Ratio women-to-men equal
• Psychotherapy ,mood stabilizer and anti-
  depressants are used
•   SCHIZOPHRENIA
•   Affects 1% of the population
•   Ratio men-to- women equal
•   Onset in men between 15- 25
•   Onset in women between 25-35
•   Etiology
•   Unknown
•   Inheritable component
•   Dopamine hypothesis
•   Positive symptoms
•   Hallucinations
•   Delusions
•   Bizarre behavior
•   Negative symptoms
•   Flat affect
•   Alogia
•   Avolition, asociality
•   Poverty of thought
•   Subtypes of schizophrenia
•   Paranoid
•   Catatonic
•   Disorganized
•   Undifferentiated
•   Residual
• Differential diagnosis
• Psychiatic( schizo-affective,
  schizophreniform, mood disorder with
  psychotic features, dementia, delirium
• Organic :early wilson’ disease, tumors,
  neurosyphilis, endocrine abnormalities
• Drugs : substance abuse( amphetamine,
  cocaine or PCP
• Management
• Anti-psychotic
• Psychosocial intervention
•   ANTIPSCHOTIC MEDICATIONS
•   Typical antipsychotic
•   Block dopamine receptors
•   Commonly used haloperidol
• Side effects :
• 1- Extrapyramidal symptoms:
• Acute dystonia occurs first few days of
  therapy.
• Characterized by muscle spasms
• Involving musculature of the head and
  neck
• Treatment
• IM/iv benztropine or diphenhydramine
• Discontinuation of the antipsychotic
•   Akathisia
•   Occurs within first month of therapy
•   Sensation of inner restlessnes
•   Treatment :propanolol, lorazepam
• Parkinsonism :
• Resting tremor, cogwheel rigidity,
  bradykinesia , masklike facies
• Treatment : anticholinergic , amantadine
•   Tardive dyskinesia
•   Develops with long-term neuroleptic use
•   Involuntary abnormal lip smacking
•   Tongue protusion
•   Writhing movements of the limbs or trunk
•   Treatment
•   Withdraw neuroleptic
•   Switch to clozapine
•   TD is often irreversible
• Neuroleptic malignant syndrome
• Potentially life threatening complication of
  antipsychotic drug use
• Fever, rigidity, clouding of consciousness
• Mutism, dysphagia, agitation,coma
• Lab : increased creatine kinase and LFT’
•   Treatment
•   Discontinue neuroleptic drug
•   Supportive measures
•   Dantrolene, bromocriptine
• Anxiety Disorders
• Panic Disorder and AGORAPHOBIA
• Recurrent unexpected panic attacks with
  or w/o agoraphobia
• Agoraphobia : disabling condition fear
  places in which escape might be difficult
•   Signs &Symptoms
•   Palpitation
•   Sweating
•   Trembling
•   SOB, feeling of choking
•   Chest pain or discomfort
•   Fear of dying
• Differential diagnosis
• Psychiatric : GAD, social phobia, PTSD
• Drugs : substance-induced
  anxiety(caffeine ,cocaine or
  amphetamines)
• Organic : pheochromocytoma ,arrhythmia,
  PE, hypoxia, angina, and hyperthyroidism
• Treatment
• SSRIs
• Cognitive behavior therapy
•   POST-TRAUMATIC DISORDER
•   Occurs after trauma exposure
•   Intrusive thoughts
•   Flashbacks
•   Nightmares
•   Numbing of responsiveness
•   insomnia
• Differential diagnosis
• Acute stress disorder similar to PTSD
• Occurs within 1 month and last 2 days to 1
  month
• Treatment
• SSRIs and mood stabilizers
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