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A history of psychiatry

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					                                             A history of psychiatry
                                            Frederick T. Lewis, D.O.

“In the beginning”
•   The world without psychiatry
     –   “Looky, looky, there goes kooky”
•   Traditional asylums
     –   Bethlehem, Bethlem, “BEDLAM” (1200’s)
     –   Bicetre, and Salpetriere. “madhouses”
•  Religion, philosophy, and medicine
The therapeutic movement
•   Phillipe Pinel
     –   Founder of modern psychiatry
     –   Chains to straitjackets
     –   Institutional morale
•   Benjamin Rush
     –   “Father of American psychiatry”
     –   The Pennsylvania Hospital
     –Questionable history as a reformer
Rush Chair
Romantic Psychiatry
•   Disorders of morals and passions.
•   William Battie
•   Johann Christian Heinroth
     –   Religious, and psychosocial influence
•  Never competed with early Medical or Biological psychiatry
Early Biological Psychiatry
•   19th century movement
•   Wilhelm Griesinger
     –   founder of the first biological psychiatry
•   Jean-Martin Charcot
     –   “iron laws of hysteria”
•   Emil Kraepelin
•   Eugen Bleuler

The psychoanalytic movement
•   Sigmund Freud
     –   Philosophical, psychological model
     –   Non scientific approach
     –   Asylums to office practice
     –   Psychosis to neurosis
     –   “The New Yorker Syndrome”
     –   Arrogant defense
    – Marginalization
The second biological psychiatry
•   Early drugs
•   The malarial fever cure
     –   Julius von Wagner-Jauregg
•   Prolonged sleep
•   Shock and coma
• Lobotomy
Modern biological psychiatry
•   Genetic substrates
•   Drugs that work!
•   Antipsychiatry
•   New battle over ECT
•  Community psychiatry
The age of prozac
•   The “diseasing” of America
•   Science vs. fashion in diagnosis
•   The future of psychotherapy
     –   “neurochem” vs. “neurochat”
•   Designer psychopharmacology
•   The future of a medical specialty

                                             Intro. to Psychiatry
                                                  D.S.M. IV
                                           Psychiatric assessment
                                            Psychiatric Interview
                                            D.S.M. IV / ICD-10
 History
      Hippocrates “Mania,” “ Hysteria” 5 B.C.
      DSM-I (1952)
 Nosology (Numbered categorization)
 Phenomenology (Descriptive)
 Multiaxial System
                                             Multiaxial System
   Axis 1   Clinical Syndromes
   Axis 2   Personality Disorders, M.R.
   Axis 3   Medical Conditions
   Axis 4   Stressors
   Axis 5   G.A.F. 0 - 100
                                           Biopsychosocial System
   Signs and symptoms based
   Criteria for each disorder
   Diagnosis - Has a purpose
   Treatment and outcome effected
                                                     Biological
   Genetics / Familial
      Seymour Kety, M.D. 1959 Danish twin Studies
      Schizophrenia 1959 Chrom. #6 1995
      Bipolar disorder 1977 Chrom. 18,21
      Panic disorder 1980
      Hysteria, Sociopathy, Alcoholism.
   Medical
    “The root of the evil lies in the constitution itself,in the fatal weakening of families from generation to
               generation…The root of the evil certainly lies there, and there is no cure for it.”

                                              Psychological Issues
 Development
 Object Relationships
 Educational, Employment
                                                   Social Issues
 Life stressors
                                         Future “Shrinks” Club at NSU
                                            Psychiatric Assessment
                                                 The Interview
                                                    History
   I.D., Demographics, Social history
   Chief Complaint (CC)
   H.P.I. onset, course, duration, precipitant
   R.O.S. medical and psychiatric
   Medical Hx. Meds. and surgery
   Past psych. Hx.
   Family psych. Hx.
                                                  Psych. Hx. Cont.
 Developmental Hx.
 Sexual Hx.
 Habits
                                            The Mental Status Exam
                                                 Observations
   Appearance / Grooming
   Attitude toward the examiner
   Behavior / Psychomotor activity
   Techniques:
      How would you describe how you look?
      You seem upset about being here today?
                                          Documenting Observations
   Appearance:
      Body type, posture, poise, clothing, hair, nails, healthy, sickly, ill ease, age, bizarre.
   Behavior: Qualitative and Quantitative
      Mannerisms, tics, twitches, agitation, rigidity, pacing, stereotyped behavior, retardation, echopraxia.
   Attitude: Rapport
      Cooperative, friendly, attentive, frank, seductive, hostile, playful, evasive, guarded.
                                                    Speech
 Quantity:
      Talkative, garrulous, voluble, taciturn, unspontaneous, normally responsive.
 Rate of Production:
      Rapid, slow, pressured, slurred, staccato, hesitant, mumbled.
 Quality:
      Emotional, dramatic, monotone, dysprosody.
                                                    Mood
                                   Depth, Intensity, Duration, fluctuations
Pervasive and sustained emotion that colors the persons perception of the world.
Descriptions:
   Depressed, despairing, irritable, anxious, angry, expansive, euphoric, empty, guilty, awed, futile, self-
   contemptuous, frightened, perplexed, labile.
                                                    Affect
 Patient’s present emotional responsiveness inferred from the patient’s facial expression, including the
   amount and range of expressive behavior.
 Description:
     Normal range, constricted, blunted, flat.
 Congruent vs. Incongruent
                                                   Thought
 Production
 Form
 Content
                                         Thought Form: Mental Trends
   Process by which a patient puts together ideas and associations, the form in which a person thinks.
   Range: From the logical and coherent to the illogical and incomprehensible.
                                         Descriptions of Thought Form
   L. of A. (LOA)
   F. of I. (FOI)
   Racing thoughts
   Tangentiality
   Circumstantiality
   Word Salad
   Incoherence
   Neologisms
   Clang associations
   Punning
   Thought blocking
   Vague thought
                                                Thought Content
   Refers to what the patient is actually thinking about.
   Range: Ideas, beliefs, preoccupations, obsessions. From the appropriate to the bizarre.
                                       Descriptions of Thought Content
   Delusions
   Paranoia
   Preoccupations
   Obsessions and Compulsions
   Phobias
   Suicidal or Homocidal thoughts
 Ideas of Reference or influence
                                          Delusions: Examples
   Paranoid
   Persecutory
   Somatic
   Guilt
   Erotic
   Religious
   Grandiose
   Jealousy
   Nihilistic
                                                  Perception
                                        Hallucinations and Illusions
Disturbances involving the sensory system experienced in reference to the self or the environment.
Types: Auditory, Visual, olfactory, tactile, gustatory.
Technique:
   Have you ever had a vision, or heard a voice that others did not experience?
                                                  Cognition
 Consciousness
 Orientation
 Concentration - Attention eg. serial 7’s
 Memory - Immediate, Short-term, Remote
 Visuospatial Ability
 Abstract Thought
 Intelligence / Reading, Writing, Vocab.
 Insight: Intellectual vs. Emotional
 Judgment / Impulsivity
 Reliability
                                            Diagnostic Studies
   Physical Exam
   Neurological Exam
   Laboratory Testing
   Diagnostic Imaging
   EEG
   Additional Interviews: Family, Friends.
   Psychological Testing
                                          Summary of Findings
   Diagnosis: DSM-IV Multiaxial
   Prognosis
   Psychodynamic Formulation
      Psychosocial implications
   Treatment Plan
      Inpatient vs. Outpatient
      Medication (Target symptoms)
      Psychotherapy (Individual, group, family)
      Length of treatment
      Refusal, Non-compliance, Non-adherence
                                          MOOD DISORDERS
                                              Frederick T. Lewis, D.O.
                                            Chair, Division of psychiatry
                                            Dept. of behavioral medicine
                                            Nova Southeastern University

                      How Serious are the medical conditions of depression and mania?
   Will be the most common chronic disease states in treatment by the year 2010.
   Electroconvulsive Therapy is the most common medical illness for which people receive general
    anesthesia.
                                            Depression Overview
   10% to 25% of adults will suffer depression
   Rates of depression are increasing
   Risk of recurrence increases with each episode
   Distress and impairment rivals other major medical conditions
   Suicide is a major risk

                                                THE FACTS

   11 Million Americans suffered from a mood disorder in 1990.
   7.8 million were in the work force.
   15% of depressed patients suicide.
   16,000 suicides occur annually.
                                        Economics of Depression

 Depressed Patients are high utilizers of health care.
 Depression associated with increased absenteeism and reduced productivity.
 Total cost of depression to society: 43.7 Billion dollars annually.
                                              Who gets depressed ?
   Occurs twice as often in women as it does in men.
   Is seen in all age, racial, socioeconomic, and ethnic groups.
   6-8% of primary care patients have a mood disorder.
   Diagnosis is missed in up to 50% of cases.
                          2 out of 3 people with a mood disorder do not get help. Why:
   Don’t recognize the symptoms.
   Feel guilty.
   Want to avoid the stigma.
   View it as a personal weakness.
   Unable to reach out to someone.
   Are misdiagnosed!!!
                                                Under Recognized
   Patient factors:
     – Stigma
     – awareness
     – resistance, denial
   Physician factors:
     – Masked Sx
     – Co morbidity
     – Ignorance / Denial
     – Time
                                               Under Treatment
   Patient factors:
     – Compliance, Tolerance
                                                   Physician factors
                                                      – orientation
                                                       – training
                                                       – denial
                           Evidence for the under treatment of Depression
                                      Mood disorders: The syndrome
   Heterogeneous group of conditions.
   Change in mood is not diagnostic!
   Constellation of signs and symptoms.
   Specified period of time.
   Specified degree of disability.

                                                      Etiology
 Psychoanalytic Theory.
 Cognitive Theory.
 Integrated Theory.
                                                   Psychoanalytic
 Mourning and Melancholia.
 Cathexis and Decathexis.
 Psychosocial model only.

                                                      Cognitive
   Learning theory
   A. Beck, M.D.
   Negative view of life.
   Negative interpretations of experiences.
   Negative expectations of the future.
                                                   Integrated model
   Biological Substrate.
   Psychological predispositions.
   Social Factors, (loss).
   Results in Neurochemical disruption.
   Catecholamine and Indoleamine theories.
                                          Biological Evidence
   Sleep changes.
   Neuroendocrine changes.
                                                 Sleep
   Prolonged sleep latency.
   Reduced R.E.M. latency.
   Reduced stage 3 and 4 sleep.
   Early morning awakening.
                                                Neuroendocrine
   Hyperactivity of the H.P.A. axis. Increased cortisol levels, and non-suppression of cortisol with the
    D.S.T.
   Blunting of T.S.H. to T.R.H. infusion.
                                          Mood disorders: Diagnosis.
                                               Major Depression
   Depressed Mood or Anhedonia for greater than a two week period.
                                         4 of the following symptoms:
   Appetite
   Sleep
   Fatique
   Psychomotor
   Guilt
   Cognitive
   Suicidal
                                         Subtypes of major depression
   Bipolar vs. Unipolar
   Psychotic vs. Non-psychotic
   Melancholic vs. Non-melancholic
   Atypical, Catatonic, Melancholic
   Minor Depression
   Recurrent Brief Depressive Disorder
   Chronic Depression
   “Double” Depression
   Interepisode Recovery
                                   Adjustment disorder with depressed mood
   Identified stressor
   Excessive response
   “Maladaptive” Impaired functioning
   Begins within 3 mos. of stressor
   Ends within 6 mos. of end of stressor
                                              Dysthymic Disorder
   “Chronically depressed”
   > 2 yr. history in adults
   > 1 yr. history in children, adol.
   Mild in nature, No psychosis
   Never function well for > 2 mos. within a two yr. period
                                           3 symptoms from below:
   Low Self-esteem
   Hopelessness
   Anhedonia
   withdrawal
   Low energy
   Guilt
   Angry
   Motivation
   Concentration
                                             Bipolar Disorders
                                                  Mania
                                             Diagnostic criteria
   Grandiosity
   Reduced need for sleep
   Hyperverbal, Pressured speech
   Racing thoughts
   Distractable
   Psychomotor agitation
   Increased goal-directed activity
   Pleasure seeking, wanderlust
                                               Bipolar Type I
 “Classical” bipolar disorder
 History of 1 manic episode
 Major depressive episodes
                                               Bipolar Type II
 No history of mania
 Hypomania
 Major depression
                                         Cyclothymia (Bipolar III)
 “Mild” bipolar disorder
 >2 yr. history. Insidious
 Minor Depression and hypomania
                                         Atypical bipolar disorders
   Bipolar IV Disorder
   Bipolar V Disorder
   Bipolar VI Disorder
   Cycling:
     –   Normal (Classical) Cycling
     –   Rapid Cycling
     –   Ultra-rapid Cycling
     – Ultra-ultra (Ultradian) Cycling
                                     Diagnostic challenges in primary care
   Comorbid medical illness
   “Masked” depression
   Depression vs. Anxiety
   Other differential diagnosis
                                               Diagnostic tools
   Zung Scale
   Hamilton depression scale
                                                   Suicide
   Suspect in depressed patients
   Inquire directly about suicidal ideation
 Determine access to means
 Assess “Risk factors”
                                               Suicide risk factors
   Advancing age
   Alone
   Loss
   major medical illness
   low self-esteem
   psychosis
   drug/alcohol
   cognitive deficits

  INTRODUCTION TO THE PSYCHIATRIC EVALUATION OF CHILDREN AND ADOLESCENTS
INTRODUCTION TO PSYCHOPHARMACOLOGY OF CHILDREN AND ADOLESCENTS

                                                 ASSESMENT:

 History taking is paramount in Psychiatry. We don’t have a lot of meaningful diagnostic testing we
    can rely on. It is the quality of the history that is taken that truly determines the difference between a
    good diagnostician and clinician.

 The fundamentals of Child Psychiatry is the understanding of children’s normal development and the
    world in which children function and live:
     – The world of their school.
     – The world of their family.
     – The world of their friends and peers.


                                       CHILD PSYCHOPATHOLOGY:
 Four Classes of Disorders:
     – Disorders of Behaviors
     – Disorders of Mood, the “Affective” Disorders (i.e.. Depression, Anxiety, OCD, PTSD, Bipolar
        Disorders)
     – Disorders of Thought or Psychosis
     – Developmental Disorders
            I.e.. Reading disabilities, Mathematical disabilities, Mental retardation, Pervasive
             developmental disorders (autism))

                                       SOURCES OF INFORMATION:

   Essential Informants:
     – Parents or primary caretakers
     – The child
     – The school
   Additional sources of information:
     – Old records
     – Previous Psychiatric or Psychological evaluation
     – Psychological testing, IQ and Developmental evaluations
     – Juvenile delinquency or HRS reports


* Each of the above may entail a separate interview.

                                      ACCURACY OF INFORMATION:
 Parents and other adults report externalizing symptoms accurately about 80% of the time, children about
    20% are poor reporters.
 Children are accurate reporters of internalizing symptoms (i.e.. anxiety or depression) in about 70%,
    parents about 30%.
                                          PARENTAL INTERVIEW:

   Rapport:
     – Clarify who is concerned and why, and who made the referral (i.e.. the parent, school, juvenile
       justice system).
     – What is the parental attitude and expectation of the referral.
     – Details of chief complaint/history of current illness:
          Duration o f signs and sympto ms. How long?
          Frequency and intensity
          Precipitants, if any
          Circumstances in which the problem occurred
          Conseq uences of behavior
     – How do these symptoms affect the child’s functioning
          Ho me
          School
          P eer s
          Psychological cognitive and emotional develop ment


                                             CHILD INTERVIEW:

 Aim of the interview:
     – Establish rapport
 Child interview techniques:
     – Developmental mental status requires flexible techniques appropriate to the child’s age:
            Interactive play techniques (i.e. play house, puppets)
            Projective techniques
            Direct discussion

                                     DIFFERENTIAL DIAGNOSIS:
   Behavioral Disorders:
     – ADHD
     – Impulsive Control Disorder
     – Intermittent Explosive Disorder
     – Oppositional Deficit Disorder
     – Conduct Disorder
   Anxiety Disorder/ Affective Disorder
     – Separation Anxiety Disorder
     – Generalized Anxiety Disorder
     – Post-traumatic Stress Disorder
     – Obsessive Compulsive Disorder
     – Panic Disorder
   Depressive Disorder
     – Major Depression

     – Dysthymia

     – Major Depression with Psychotic Features

     – Bipolar Disorder



                                   DIFFERENTIAL DIAGNOSIS: (con’td)
 Psychotic Disorder:
     – Psychosis NOS
     – Brief Reactive Psychosis
     – Childhood Schizophrenia
 Developmental Disorders:
     –  Mental Retardation
     –  Developmental Reading Disorder
     –  Developmental Mathematical Disorder
     –  Receptive Expressive Language Disorder
     –  Pervasive Developmental Disorder
                                       TREATMENT PLANNING:
   Psychopharmacology as the sole treatment is rarely satisfactory.
   Biopsychosocial treatment is the standard of care for children.
   Interventions for therapy:
     – Behaviorally based
     – Family therapy
     – School interventions
     – Individual/ group therapy
     – Play therapy
   Further testing:
     – Psychological testing
     – Neurological referral
     – Lab work up
     – Imaging studies, EEG


                                       PSYCHOPHARMACOLOGY:
 Stimulants:
     –   For most patients stimulants are the first line of treatment for children with ADHD.
     –   They are effective 70-80% of the time. They are effective in reducing ADHD symptoms 25-50%.
           Common Myth:
              – They cause drug abuse and sedation.
           Proposed mechanism of action:
              – Neurotransmitters:
                    Dopamine ( the most activity)

                    Norepinephrine

                    Serotonin



                                         ALPHA-2 ANTAGONISTS:
 Clonidine
 Tenex
     –   Mechanism of Action:
           Blocks norepinephrine
     –   Side Effects:
           Sedation
           Low BP
           Dry mouth
           Dizziness
     –   Dosage:
           Clonidine: 0.05mg - 0.4mg.
           Tenex: 0.5mg. - 4.0mg.


                                    TRICYCLIC ANTIDEPRESSANTS:
 Imipramine
 Desipramine
 Nortryptoline
     –   Mechanism of Action:
           Primarily inhibits re-uptake of Norepinephrine with some serotonergic activity.
     –   Efficacy:
           ADHD
               – 60% of patients respond, but not as robustly as stimulants
              – Wear off effect?
            Depression
            Anxiety Disorder
            Aggression?
              – Results are variable depending on whether the aggression is related to the
                irritability of Depression
                                 TRYCYCLIC ANTIDEPRESSANTS: (cont’d)

    –   Side Effects:
          Anticholinergic:
              – Dry mouth
              – Dry eyes
              – Constipation
          cardiac:
              – Heart block
              – Arrhythmias
                   Regular EKG monitoring required

          Lethal in overdose
    –   Advantages:
          Linear Kinetics
          Blood level mo nitoring


                                       BUPROPION: (Wellbutrin)

 Mechanism of Action:
    – Norepinephrine re-uptake inhibitor
    – Dopamine activity?
 Side Effects:
   – GI
   – Headache
   – Constipation
   – Insomnia
   – Seizures
        4 in 1000 patients
        Contraindicated in seizure disorder
                                          ATOMOXETINE:

 In the future, this will be the first FDA approved non-stimulant for ADHD.
    – Norepinephrine re-uptake inhibitor
                         SELECTIVE SEROTONIN REUPTAKE INHIBITORS:
 Mechanism of Action:
    –   Blocks reuptake of serotonin
 Features:
    – Anti-ruminating qualities
    – Anti-anxiety qualities
   – Anti-aggression properties
   – Advantages of different ½ lives may be utilized:
        Fluoxetine       36 hours
        Sertraline       24 hours
        Paroxetine       24 hours
        Fluvoxamine 12-16 hours
        Celexa           24 hours
   *Kinetics is non-linear
   SELECTIVE SEROTONIN REUPTAKE INHIBITORS: (cont’d)
 Side Effects:
   – Nausea/vomiting
    –Dyspepsia
    –Headache
   – Behavioral toxicity
   – Social Disinhibition
   – Insomnia
 Serotonin withdrawal:
   – ½ life related
   – Dizziness
   – Arthalgias
   – Nausea/vomiting
   – Anxiety agitation
                                       MOOD STABILIZING AGENTS:
 Lithium
 Depakote
 Tegretol
 Trileptal
 Topomax
 Neurontin
 Gabatril
 First line of treatment in Bipolar Disorder
 Further Efficacy:
   – Helpful in the management of severe aggression and affection lability
   – Antidepressant properties with Lithium and Tegretol
 All three require blood monitoring
                                  MOOD STABILIZING AGENTS: (cont’d)
 Lithium:
   – Mechanism of Action:

          Serotonin activity

          Stabilizing Ca+ cha nnel

   – Side Effects:

          T remors

          Polydipsia

          Sedation

          Polyuria/enuresis

          Ac ne

          Weight gain

   – Highly toxic in overdose

          Renal failure, co ma, death

   – Narrow therapeutic window

          0 .4 – 1 .4

   – Toxicity can be problematic

   – Lab work up:

          T hyroid func tion test in about 10%

          Lytes, BUN, Creatinine

          CBC/Diff, Platelets

                                  MOOD STABILIZING AGENTS: (con’td)
 Depakote: (Valproic Acid)
   • Probably the most prescribed mood stabilizing agent.
         • Mechanism of Action:
              • Gabinergic system
         • Side Effects:
              • Mild sedation
              • Increased LFT’s rare
              • Weight gain
              • Liver necrosis and death before age 3
              • Thrombocytopenia
        •Therapeutic level: 50 -100 (>75, preferred)
        •Lab work up:
            • LFT’s
            • CBC/Diff
            • platelets
                              MOOD STABILIZING AGENTS: (cont’d)
 Tegretol: (Carbamezapine)
   * More sedating than Depakote.

    – Mechanism of Action:
         Mechanism unknown
         Believed to be serotonergic
         Reduces polysynaptic responses
   – Side Effects:
         Sedation
         Little or no weight gain
         Rash
         Aplastic Anemia
         Stevens-Johnson Syndrome
   – Therapeutic blood levels: 4 – 12 ( levels > 8 appear more therapeutic)
                                MOOD STABILIZING AGENTS: (cont’d)
 Trileptal:
   * Less sedating than Tegretol
   – Mechanism of Action:
         Blocks voltage sensitive Na+ channels
         Modulates high voltage Ca+ channels
MOOD STABILIZING AGENTS: (cont’d)
 Topomax:
   – Mechanism of Action:
         State dependent Na+ channel action
         Enhances GABA
         Antagonizes the glutamate reception
   – Side Effects:
         10% memory cognitive problems
         Weight loss 1/3
MOOD STABILIZING AGENTS: (cont’d)
 Neurontin:
   – Mechanism of Action:
         Structurally related to GABA, but does not bind to GABA sight
   – Side Effects:
         Mild sedation
   – Uses:
         Good anti-anxiety effects
                                MOOD STABILIZING AGENTS: (cont’d)
 Gabatril:
   * GABA reuptake inhibitor
   * Wide dosage range
   – Side Effects:
         Sedation
   – Uses:
         Clinical uses in children remains to be elucidated
ANTIPSYCHOTIC AGENTS:
                                  ANTIPSYCHOTIC AGENTS: (cont’d)
 Atypicals: (cont’d)
   – Efficacy:
         Severe aggression
        Psychosis
         
        Tics and Tourette’s Disorder
         
                               ANTIPSYCHOTIC AGENTS: (cont’d)
 Conventionals:
   – Haldol
       Higher side effect profile for EPS
       More sedation
   – Thorazine
       Tardive Dyskinesia 1/5 at 5 years


Anxiety Disorders
                                         Categories of anxiety
   Normal “stress” of daily life
   Anxiety secondary to Medical illness
   Symptoms of another psychiatric disorder
   True anxiety disorders
                                            Anxiety: The Problem!!
   Most commonly reported psychiatric condition. (Lifetime prevalence 25%)
   Presents with somatic complaints greater than 80% of the time
   FP’s Dx. MDD or an AD 77% of patients with psychological complaints, but only in 22% with somatic
    complaints
   40% of “high utilizers” lifetime hx. GAD
                                                     Facts
   E.C.A. Studies “The most common mental disorder.”
   Primary care physicians see at least one patient a day suffering from an anxiety disorder.
   More common than diabetes or asthma.
   Unrecognized up to 50% of the time.
                                               Generalizations
   Mental disorders that almost always present somatically.
   Characteristic signs and symptoms.
   All disorders share a biological basis.
   There exists clear diagnostic and treatment guidelines.
                                                Classifications
   Adjustment disorder with anxiety
   Adjustment disorder with mixed anxiety and depression.
   Generalized anxiety disorder
   Panic disorder (Agorophobia)
   Post-traumatic stress disorder
   Social phobia
   Specific phobia
                                                   Biology
   The gamma-aminobutyric acid or inhibitory neurotransmitter system.
   GABA - Benzodiazpine receptor complex
                                   Neurobiology of Depression vs. Anxiety
                                  Noradrenergic Hypothesis of Panic Disorder
                                  Noradrenergic Hypothesis of Panic Disorder
                                    Comorbid and confounding conditions
   Anxiety and depression
   Anxiety and Substance abuse
   Anxiety and physical symptoms
 Somatoform disorders
 Personality traits and personality disorders
                                                   GAD
                                                  Group I
   Adjustment disorder with anxiety
   Adjustment disorder with mixed anxiety and depression
   Generalized anxiety disorder
   Panic disorder
                                                    Group II
   Obsessive - Compulsive disorder
   Post-traumatic stress disorder
   Social phobia
   Specific phobia
                                             Adjustment disorders
   Maladaptive reaction to identifiable stressor
   Greater than normal reaction to stressor
   Begins within 3 months of stress
   Duration: Less than 6 months
   Continous symptoms
                                      Treatment of adjustment disorders
   Counseling / Therapy
   Relaxation training
   Coping strategies
   Pharmacologic approaches
                                         Generalized anxiety disorder
   Excessive worry about 2 or more issues
   Duration: > 6 months
   Not secondary to another disorder
                                               3 of 6 symptoms:
   Muscle tension
   Restless, or on edge
   Low energy, fatique
   Impaired concentration
   Impaired sleep
   Irritability
                                              Treatment of GAD
   Counseling or psychotherapy
   Behavioral therapy
   Exercise
   Pharmacologic approaches
                                             Social Phobia (SAD)
   Fear of social or performance situations
   Provokes fear or anxiety
   Patient recognizes as unreasonable
   “Avoid” or “Endure”
   Interferes with functioning
   Not due to another illness
 20 - 25% before beginning of alcoholism
                                               Specific phobia
   Unreasonable fear of specific object or event. (Water, animals, blood)
   Stimulus results in anxiety, panic
   Patient recognizes as unreasonable
   “Avoid” or “Endure”
   Interferes with routine functioning
                                                Panic disorder
   Discrete attacks of anxiety with physical symptoms (Herald attack)
   Unexpected, spontaneous (78%)
   No organic factor
   Fear of additional attacks
   Worry about implications of attack
   Change in behavior related to attack
   Unexpected vs. “Situational” Attacks
                                               Panic symptoms
   Palpitations
   Sweating
   Shaking
   S.O.B.
   Choking
   Chest pain
   Nausea, vomiting
                                            Panic symptoms cont.
   Dizzy, lightheaded, faint
   Derealization, depersonalization
   Fear of losing control, going crazy
   Fear of dying
   Paresthesias
   Chills, or hot flashes
                                           Panic disorder subtypes
   Panic disorder without agoraphobia
   Panic disorder with agoraphobia
   Agoraphobia without panic disorder
                                                 Agoraphobia
   Anxiety about being in places or situations in which escape may be difficult
   Anxiety about being in places or situations in which help may not be available
   Avoid or endure
                                          Agoraphobia fear clusters
   TRAVEL (planes, bus, subway)
   DRIVING (alone, bridges, tunnels)
   SAFETY (proximity of help)
   PUBLIC PLACES (stores, malls, crowds)
                                         Treatment of panic disorders
   Behavior therapy
   Psychotherapy
   Pharmacologic approaches
                                      Obsessive - Compulsive disorder
 Previously thought to be rare
 Lifetime prevalence rates of 2 - 3%
 Comorbid disorders include: Depression, anxiety disorders, eating disorders, schiz., Tourette’s
    syndrome
   35% of first-degree relatives are also afflicted with OCD
   Post-strep. Type, PPOCD.
                                                    Obsessions
   Recurrent, unpleasant, thoughts or images that are viewed as distressing
   NOT worry about real life problems
   Attempts to suppress or neutralize with other thoughts or actions
   Recognizes as a product of their own mind
                                              Common obsessions
   Contamination / illness
   Doubt
   Violent thoughts
   Fear of harming self or others
   Sexual images
   Symmetry
   Somatic
   Religious
                                                   Compulsions
   Repetitive behavior or mental act one feels driven to perform in response to obsessions
   Act is aimed at reducing stress or preventing a dreadful event
   Is recognized as unreasonable and excessive by the patient
                                             Common compulsions
   “The big three” Checking, counting, and washing
   Hoarding / collecting
   Ordering / arranging
   Repeating
                                               Treatment of OCD
   Behavior therapy
   Psychotherapy
   Pharmacologic approaches
   E.C.T.
   Psychosurgical approaches

                                      Posttraumatic stress disorder
 Long, controversial history
 DSM- III in 1980
 Studies show direct relationship between level of stress and risk of PTSD
 Risk factors: Male, hispanic, comorbidity, family hx., (females with trauma)
 Increased risk of suicide and impulsivity
                                                  PTSD
 Lifetime prevalence in men of 5.0% and 10.4% in women.
 Risk increases with the duration and severity of the stress
 Genetic vulnerability plays a role
 Stress severe enough anyone may develop
 Up to 52% of patients meet criteria for substance abuse
 Abstinence from alcohol exacerbates PTSD

                                    Eponyms of PTSD in U.S. Wars
   Civil War: “Irritable heart”
   World War I: “Effort Syndrome”
   World War II: “Combat Stress Reaction”
   Vietnam War: “PTSD”
   Gulf War: “Gulf War Syndrome”
   Symptoms: Fatigue, SOB, Fainting, Palpitations, Insomnia, Pain, Cognition
                                         Examples of traumatic events
   War
   Accidents
   disasters
   Physical assault (trauma)
   Witnessing injury or death of another
   Receiving very bad news
                                            PTSD Clinical Features
   Reexperiencing the event in the form of nightmares / intrusive memories coupled with psych. And
    physical reactivity
   Avoidance of cues that serve as reminders of the traumatic event
   Numbing of responsiveness, detachment
   Sense of a foreshortened future
   Increased autonomic arousal; insomnia, vigilance, concentration, and startle
                                               Criteria for PTSD
   Overwhelming stressor
   Reexperiencing the event (thoughts, dreams, flashbacks, psych.and physical reactivity)
   Avoidance (thoughts, people, situations, amnesia, detachment, affect, short future)
   Increased arousal (sleep, anger, vigilance, concentration, startle response)
   Symptoms lasting > 1 month.
   Acute, Chronic, and Delayed onset Types
   Acute Stress Disorder
                                              Treatment of PTSD
   Psychotherapy
   Desensitization
   Hypnotherapy
   Pharmacologic approaches
                                              Psychotic disorders
                          Overlap of Mood Disorders and           Psychotic Disorders
                                        The Mood Disorder Spectrum
                                                  “Psychosis”
   Any and all breaks with reality, regardless of the etiology
   Organic vs. “functional”
   Occur in medical, neurological, substance - induced, and psychiatric conditions
   Schizophrenia as prototypical
                                             Med., Neuro., Drugs
   Psychotic disorder due to general med. condition. eg. renal failure
   Dementia and delirium. (medications)
 Substance - induced psychotic disorder. (pcp, Amphetamine)
                                                Mood disorders
 Bipolar disorder (mania)
 Major depression with psychotic features
                                             Personality disorders
   Schizotypal
   Schizoid
   Paranoid
   Borderline
                                              Psychotic disorders
   Schizophrenia
   Schizophreniform disorder
   Schizoaffective disorder
   Delusional disorder
   Brief psychotic disorder
                                          Atypical Psychotic Disorders
 Autoscopic Psychosis
     – “Phantoms”
 Capgras Syndrome
     – “Imposters”
 Cotard’s Syndrome
     – Nihilistic delusional disorder
 Shared Psychotic Disorder
     – “Folie a deux”
                                    Culture-Bound Psychotic Syndromes
 Amok
     – Malaysia; sudden rampage in males
 Koro
     – Asia; penis withdrawing into abdomen
 Piblokto
     – Eskimos; attacks of hysteria in women
 Wihtigo
     – Indians; fear of becoming a cannabal
 Empacho
     – Cubans; inability to digest food
                                               Differential Tree
   Medical, neurological, drugs
   Mood disorder
   Personality disorder
   Psychotic disorder
                                                Schizophrenia
   Brain disorder characterized by disordered thought, emotion, and behavior
   Constellation of symptoms, no pathognomonic symptom
   Heterogenious disorder, no consistent etiology, pathophysiology, or tx. response
                                                    Facts
 Transcultural, described as early as the 12th century B.C.
 Lifetime prevalance of 1-2%
 Huge impact on the GNP. Tx. cost of 7 billion annually
                                                 History
   Emil Kraeplin (1907)
   “Dementia Praecox”
   Disorder of Hallucinations, delusions, and withdrawal, ending in dementia
   “Brain disease” involving cortical neurons
                                                History cont.
   Eugen Bleuler (1911) “Schizophrenia”
   Brain disorder caused by neurological or metabolic defect
   Formulated a cross sectional approach to the diagnosis. “The four A’s”
                                               The four “A’s”
   Affect
   Association
   Autism
   Ambivalance
                                                   Etiology
   Good evidence for a genetic substrate. Monozygotics 4X as Dizygotics
   Gene on the 5th chromosome
   Stress diathesis model. Heredity interacts with environment. Biopsychosocial
                                           Symptoms of psychosis
   Disorders of thought form
   Disorders of thought content
   Disorders of thought production
   Disorders of perception (hallucinations)
   Disorders of emotion and behavior
                                          Formal thought disorders
   Loose associations, derailment
   Tangentiality
   Circumstantiality
   Incoherence, word salad
                                             Disorders of content
                                                  Delusions
   Paranoid, reference, control
   Broadcasting, insertion, deletion
   Jealousy (unfaithful)
   Guilt (confession)
   Grandiose
   Religious
   Somatic
                                            Disorder of perception
                                                hallucinations
   Auditory
   Visual
   Tactile
   Olfactory
 Gustatory
                                      Disorders of emotion and behavior
   Bizarre behaviors. (inappropriate, disinhibited, stereotyped)
   Catatonic behavior. (waxy flexibility, mutism, negativism)
   Affect. (paucity, blunting, flat)
                                               Cerea flexibilitas
                                             Symptom dichotomy
   “Positive” symptoms (added to the premorbid state: delusions, hallucinations, bizarre behaviors)
   “Negative” symptoms (absence of functioning: affect flattening, alogia, avolition, anhedonia,
    attention)
                                                   Prognosis
   Acute onset
   Late onset
   Married
   Premorbid function
   Mood disorder
   Fam. Hx. Mood dis.
   Good support
   Positive Symptoms
   Early onset
   Insidious onset
   Single
   Poor premorbid
   Fam. Hx. Schizo.
   Poor support
   Negative Symptoms
                                                  Dx. Criteria
   Psychotic symptoms (2 for > 1 mo.)      Hallucinations, delusions, form, behavior, negative symptoms
   Impairment in social or occupational functioning
   Duration of the illness > 6 mo.
                                                Schiz. subtypes
   Catatonic (motor abnormalities)
   Disorganized (thought disorganization)
   Paranoid (paranoid delusions)
   Undifferentiated (wastebasket)
                                             Course of the illness
   Prodromal phase (change in functioning prior to onset of psychosis, dx. retrospectively)
   Residual phase (negative symptoms only)
   Continous vs. episodic
   Complete vs. incomplete remissions
                                          Schizophreniform disorder
   Criteria the same as for schizophrenia
   Duration of illness < 6 mo.
   Good vs. poor prognosis (onset, affect, functioning)
                                           Schizoaffective disorder
   Patient exhibits mood disorder symptoms along with schizophrenia
   Schizophrenic symptoms persist when the patient is not depressed or manic
   Psychotic symptoms present only when depressed or manic, dx. mood disorder
                                           Brief psychotic disorder
 Sudden onset of psychosis (stressor, postpartum)
 Duration of hours to 1 month
 Returns to premorbid level of functioning
                                              Delusional disorder
  Prominent single delusion
  No other psychotic symptoms present
  Duration of > 1 mo.
  Subtypes: Erotomanic, Grandiose, Jealous, Persecutory, Somatic, Mixed
                                             Final thoughts
 Less than 30% of schiz. return to work
 Onset of schiz. after age 45 is very rare
The best management of schiz. is combination of neuroleptics and psychosocial interventions

                                             Personality disorders
                                           Frederick T. Lewis, D.O.

                                                    Personality
   Is a characteristic pattern of behaviors as well as responses to life events and stressors
   Critical to the doctor - patient relationship, occur in 10% of pop.
   Physician self understanding
                                                Traits vs. Disorders
   “Normal” vs. pathologic
   Disorder is chronic, insidious disturbance of behavior
   Formed by adolescence
   Inflexible and maladaptive, shading all aspects of the individual, (mood, cognition)
   Ego syntonic vs. ego dystonic
                                                   Classification
   DSM - IV Axis II importance of comorbid
   Diagnostic clusters
   Axis II traits vs. disorder
                                                     Diagnosis
   Often most difficult dx. in psychiatry
   Trait vs. state Change in functioning or personality style
   Stressors, situations, culture
   Differs quantitatively, not qualitatively from normality
                                                    Assessment
   Clinical interview
   Self - report inventories, MMPI , MCMI
   Semistructured interviews, SCID
   Psychological testing
                                                      Etiology
   Biopsychosocial model
   Biological evidence: Brain trauma, EEG abnormalities, Sleep, DST, SPEM, twins
                                                    Treatments
   Psychodynamic psychotherapy
   Supportive psychotherapy
   Interpersonal psychotherapy
   Behavioral therapy
 Cognitive therapy
 Pharmacological therapy
                                               Medications
   Neuroleptics
   Anticonvulsants
   Lithium carbonate
   Antidepressants
                                                Cluster A
                                                 “odd”
 Schizotypal
 Schizoid
 Paranoid
                                                 Cluster B
                                                “dramatic”
  Histrionic
  Narcissistic
  Antisocial
  Borderline
Cluster C
“anxious”
 Avoidant
 Dependent
 Obsessive - compulsive
                                                Schizotypal
   Disorder of behavior, thought, speech, and perception. Subtle schizophrenia
   Odd, peculiar, eccentric, “magical”
   Isolation, withdraw
   Tx. Neuroleptics, therapy.
                                                  Schizoid
   Social isolation, “loners”
   No disorder of thought
   Indifference, ambivalence
   Emotional, affective blunting
   Tx. Therapy
                                                  Paranoid
   Suspicious, mistrustful, rigid,
   Hypervigilance
   Not psychotic
   Angry, hostile, anxious, cynical
   “Chip on their shoulder”
   Tx. Supportive therapy
                                                 Histrionic
   Attention seeking, dramatic, seductive
   Manipulative, “Pseudostupidity”
   Low self esteem, vain, fragile self image
   Rejection sensitivity
 Tx. Therapy
                                                 Narcissistic
   Egocentric, grandiose, exploitive, arrogant
   Fame, fortune, achievement
   No consideration for others, but very sensitive to criticism by others
   Full of shame and self doubt
   Tx. Psychoanalytic therapy

                                                  Antisocial
   Sociopath, psychopath
   Lack guilt, social responsibility
   Lack morals, empathy
   Veneer of charm, seductiveness
   Tx. Behavioral, legal system
                                                  Borderline
   Intensity of interpersonal style
   All or none thinking
   Affective instability
   Chronic anger, lack of trust of others
   Self destructive behavior
   “Splitting” behavior
   Tx. Medication, therapy
                                                  Dependent
   Excessive reliance on others
   Desire for relationships, (Controlling)
   Low self esteem
   Difficult to dx. in the medically ill
   Tx. therapy
                                                   Avoidant
   Shy, introverted, and withdrawn
   Anxious, and socially awkward
   Insecure, low self esteem
   Desires relationships, schizoid is indifferent
   Tx. Therapy, Medication
                                             Obsessive - compulsive
   Rigid, perfectionistic, disciplined
   Controlling, obsessive worry, torment
   Aggressive
   “Hoarders”
   Scatology
   Tx. Medication, therapy
                                               Passive - aggressive
   Not personality disorder in DSM - IV
   Passive and indirect resistance to authority
   Core of anger
   Complaining, whining, procrastination,and undermining
   Tx. Therapy
                                                     Summary
   Pure form vs. mixed form
   Axis I and II comorbidity
   Be aware of your own feelings
   Ego syntonic vs. dystonic
   Increased risk for suicide
   Meds may be useful
                                            Psychosexual Disorders
                                                Eating Disorders
                                            Frederick T. Lewis, D.O.
                                                   NSUCOM
                                                     cartoon
                                            Psychosexual Disorders
•   Sexual Dysfunction
     –   Inhibition in sexual interest
     –   Disturbance in sexual response cycle
•   Paraphilias
     –   No impairment in sexual function
     –   Arousal involving abnormal objects
•   Gender Identity
                                                Phase / Disorders
•   Phase I (Desire)
•   Phase II (Arousal)
•   Phase III (Plateau)
•   Phase IV (Orgasm)
•   Phase V (Resolution)
•   DSM IV: Disorders of desire, arousal, orgasm, pain.
                                           Disorders of Desire
•   Hypoactive Sexual Desire Disorder
     –   Global lack of readiness to participate in sexual activity. (Low libido)
     –   Does not imply inability to function sexually.
     –   Ego dystonic to syntonic
•   Sexual Aversion Disorder
     –   Avoidance of sexual activity with partner
     –   Poor body image, avoiding nudity
     –   Normal masturbation fantasy

                                              Disorders of Arousal
•   Female Sexual Arousal Disorder
•   Male Erectile Disorder
     –   Inability to achieve or maintain sufficient physiologic or emotional arousal during sex
•   Females: Lubrication-swelling response
•   Males: Failure to attain or maintain an adequate erection
                                                Orgasm Disorders
•   Female Orgasmic Disorder
     –   Delay or absence in orgasm following normal sexual excitement. (Clitoral vs. Coital)
•   Male Orgasmic Disorder
     –   Delay or absence in orgasm following normal sexual excitement.
•   Premature Ejaculation
     –   Minimal sexual stimulation, before the person wishes it
                                            Sexual Pain Disorders
•   Dyspareunia
     –   Recurrent, persistent genital pain, before, during, or after sexual intercourse
     –   Not caused by medical condition or drugs
•   Vaginismus
     –   Recurrent or persistent spasm of the musculature of the outer third of the vagina that interferes with
         intercourse
     –   Not caused by physical disorder

                                                 Etiology of ED
•   Psychogenic: Depression, Anxiety
•   Neurogenic: Trauma, DM, MS
•   Endocrine: Testosterone, Prolactin
•   Vascular: Smoking, HTN, PVD
•   Drugs: Psychotropics
                                             Etiology of Dysfunction
•   Biogenic
     –   Drugs, Diseases
•   Psychogenic
     –   Normal sexual history
     – PLISSIT
        • Permission
        • Limited information
        • Specific suggestions
        • Intensive therapy (Referral)
                                   Psychogenic Erectile Dysfunction
                                         Medical Conditions
                                         Associated with ED
Depression          70%
Diabetes Mellitus    50%
Heart Disease       40%
Hypertension        15%
                                         Hyperprolactinemia
• Breast enlargement
•   Weight gain
•   Galactorria
•   Amenorrhea, reduced fertility
•   Osteoporosis
•   Sexual dysfunction
•   Risk of breast cancer
•   Accelerated puberty
•   Polydipsia?
                                             Pharmacology of Sex
•   Libido / Desire: DA, Prolactin
•   Arousal / erection: NO, Ach
•   Orgasm / Ejaculation: 5HT2a, NA
                                                    Viagra
•   Works in 80% of men with ED regardless of the etiology
•   Mild ED responds best
•   Psychogenic ED responds well
•   Data suggest SSRI induced ED may respond in men and women
•   Never use with nitrates
                                            Pharmacology of weight
•   5HT2c
•   H1
•   D2
•   B3
•   Neuropeptides (Leptin)

                                            Paraphilias (Deviations)
•   Recurrent, intense sexual urges and fantasies involving objects, children, abuse, or nonconsenting
    persons.
•   Many are illegal, resulting in damage to victims.
•   Report all known or suspected child abuse.
•   Little data on prevalence.
                                                 Exhibitionism
•   Urge to expose one’s genitals to strangers
•   Sexual arousing fantasies about exposure
•   May or may not have acted on the fantasy
•   May or may not be distressed by fantasy
•   Predominately males
                                                   Fetishism
•   Recurrent sexual urges and fantasies involving nonliving objects
•   May masturbate while in presence of the object. May be distressed by the fantasy
•   Eg. Shoes, underwear
•   Transvestic fetishism: Cross-dressing
                                                  Frotteurism
•   Recurrent sexual urges involving rubbing or touching a nonconsenting person
•   Act is sexual exciting not the aggression
•   May have acted on the fantasy or be distressed by them
                                                 Pedophilia
•   Recurrent sexual urges involving sex with a prepubescent child
•   May have acted or is distressed by the urges
•   Child generally under 13
•   Patient generally over 16 or 5 yr older than the victim
                                              Sexual Masochism
•   Recurrent sexual urges and fantasies that involve the act of suffering, beating, or being bound
•   May have acted or have been distressed
•   Alone or with a partner
•   Autoerotic asphyxiation / hypoxiphilia
                                                 Sexual Sadism
•   Recurrent sexual urges and fantasies that involve acts of inflicting suffering and humiliation
•   May have acted or have been distressed
•   Consenting and nonconsenting partners
•   Escalation in behavior
                                                   Voyeurism
•   Recurrent sexual urges and fantasies involving the observation of unsuspecting persons who are either
    naked, disrobing, or engaged in sex
•   May have acted or be distressed
•   Not pornography
•   Behavior frequently seen in rapists

                                                Eating Disorders
•   Preoccupation with weight and desire to be thin.
•   90-95% females
•   Upper, upper-middle class caucasians
•   4-8% of women in select populations
                                                Eating Disorders
                                                   Etiologies
•   Biological Theories
     –   Variation of mood disorders
     –   Subtypes of OCD
     –   “Autointoxication”
     –   50% monozygotic concordance
•   Psychosocial Theories
     –   Societal trends toward beauty and fashion
     –   Incidence in homosexual males
                                                Anorexia Nervosa
•   Weight 15% below normal
•   Reduced caloric intake
•   Eating rituals, and behaviors
•   Exercise abuse
•   50% MDD, 25% OCD
•   Intense fear of gaining wt.
•   3 missed menstrual cycles
•   Physical stigmata of starvation
•   20% die in 20 yrs of onset

                                               Anorexia subtypes
•   Restricting type
     –   Controls food intake, socially avoidant, OC
•   Binge eating / purging type
     –   Binge eating and self induced vomiting, may use laxatives, diuretics, or exercise.
     –   Commonly depressed, self destructive, PD
                                             Bulemia Nervosa
•   Weight preoccupied females (Normal Wt.)
•   Engage in binge and purge episodes at least twice per week
•   5,000 – 10,000 calories per binge episode
•   Cycles may occur several times per day
•   Very secretive
•   Comorbidities: Depression, anxiety, CD, PD
                                            Bulemia subtypes
•   Purging type
     –   Abuse laxatives, diuretics and self induced vomiting to control weight
•   Nonpurging type
     –   Use excessive exercise or fasting to control weight
•   “Bulem-arexic”
                                             Medical Complications
                                                  Starvation
•   Cachexia: Low T3, cold intolerance
•   Low FSH, LH, amenorrhea
•   Lanugo
•   Leukopenia
•   Osteoporosis
•   Cardiac abnormalities
                                             Medical Complications
                                                   Purging
•   Hypokalemia, alkalosis
•   Salivary gland inflammation (Squirrel)
•   Esophageal / gastric erosion
•   Increase serum amylase
•   Dental erosion
•   Seizures

                              Treatment
•   Treatment team approach
     –   Medical
     –   Dietary
     –   Psychopharmacology
     –   Psychotherapies

				
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