Download 129 Psychiatric Disorders Mood Disorders Major depressive

Psychiatric Disorders
Mood
Disorders
Childhood
Disorders
Psychotic
Disorders
Anxiety
Disorders
Eating
Disorders
Sleep
Disorders
Somatoform
Disorders
6
Major
depressive
disorder
Oppositional
defiant
disorder
Bipolar disorder
Schizophrenia
Panic
attack
Schizophreniform
disorder
Posttraumatic
stress disorder
Anorexia
nervosa
Obstructive
sleep apnea
Somatization
disorder
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A 46-year-old male presents to his primary care physician with a complaint of trouble sleeping.
He states that he lies in bed for up to 3 hours before falling asleep but does not have problems
staying asleep. Further questioning reveals that the patient lost his job 5 months ago and his family has been relying on his wife’s part-time income. He states that he has been feeling depressed 6
for the past several months, as he has not been able to find another source of employment to
support his family. He feels it is hopeless to continue to find a job, and now spends most of his
time now on the couch watching TV. He has no interest in activities he used to enjoy. He reports
a decreased appetite but denies weight loss, problems concentrating, substance abuse, or suicidal
ideations. His only past medical history includes stage I hypertension well controlled with hydrochlorothiazide. Physical examination reveals an appropriately dressed male with a restricted affect
and linear thought process.
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Major Depressive Disorder
This patient has major depressive disorder. Although there are often several criteria for many diagnoses in psychiatry,
it is important to first commit to memory the time requirements and number of symptoms. For major depressive disorder, five symptoms must be present, one of which must be either depressed mood or anhedonia (lack of Interest),
for a minimum of 2 weeks. The rest of the nine possible symptoms are Sleep disturbance, feelings of worthlessness or
inappropriate Guilt, lack of Energy, diminished Concentration, change in Appetite or weight, Psychomotor agitation
or retardation, and Suicidal ideations. A useful mnemonic is SIG E CAPS. The vignette does not describe any history
of manic episodes that could indicate bipolar disorder. If the patient had not met at least five criteria, a diagnosis of
adjustment disorder could be considered as his symptoms were precipitated by a major life stressor that was initiated
within 3 months of the stressor and had not persisted for more than 6 months. In dysthymic disorder, a patient exhibits
a less severe form of depression on more than half of the days for a period of more than 2 years.
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A 27-year-old female medical student is brought to the emergency department by her roommate
who is concerned about her lack of sleeping. The patient has not slept in 2 days and has been frantically cleaning their apartment. The roommate also states that the patient has been acting unusually promiscuous over the past week and accumulated thousands of dollars in credit card charges 6
buying new clothes. The patient states she feels great and just has not been feeling tired. Her
past history is significant for one suicide attempt at 17 years after breaking up with a boyfriend.
She was subsequently treated with fluoxetine for 2 years but currently takes no medications. On
examination, the patient is hyperverbal with psychomotor agitation and reports that she is on the
verge of discovering the cure for cancer.
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Bipolar Disorder
This patient has bipolar I disorder. This diagnosis requires the presence of at least one manic episode, usually with
a history indicative of one or more episodes of major depressive disorder. A manic episode consists of at least 1
week of an abnormally elevated, expansive, or irritable mood or a required hospitalization with at least three symptoms. Symptoms include distractibility, insomnia or decreased need for sleep, grandiosity (inflated self-esteem),
flight of ideas (racing thoughts), psychomotor agitation or increase in goal-directed activities, pressured speech, and
risk-taking (activities involving pleasure with painful consequences, i.e., excessive spending, sexual indiscretion,
gambling). A useful mnemonic is DIG FAST. For bipolar I disorder, the mood disturbance must be sufficient enough
to cause social or occupational impairment, requires hospitalization, or has psychotic features. If this is not the case,
but at least three symptoms with mood change have been present for at least 4 days, it is considered a hypomanic
episode and the diagnosis would be bipolar II disorder. It is important to distinguish the symptoms from personality
disorders, as the personality disorders are reported under axis II diagnoses.
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An 11-year-old boy is brought to the pediatrician by his mother, who is concerned about his
behavior. She states he has become increasingly rebellious since his parents divorced 3 years ago.
He was recently suspended for making fun of a smaller classmate and his mother often receives
calls from the teacher for talking back. He refuses to do his homework and is verbally abusive to 6
his mother. Physical examination reveals a slightly overweight boy, appropriately dressed with
normal affect, and linear thought process without psychomotor agitation.
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Oppositional Defiant Disorder
This patient is presenting with oppositional defiant disorder. This is characterized by ongoing defiant and hostile
behavior toward authority figures. This differs from conduct disorder in that there are not serious violations of social
norms, such as physical altercations, property destruction, animal cruelty, theft, or other activities that might rise to
the level of concern to law enforcement. Conduct disorder also often progresses to antisocial personality disorder after
18 years of age. Other considerations might be separation anxiety disorder following the loss of an attachment figure
in the divorce, which typically starts at around 7 to 8 years of age.
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A 36-year-old male is presented at the emergency department by the police because he was found
standing on the side of the highway. The patient claims that he felt like he was unable to move
and he does not remember how long he was standing there. He thinks that FBI agents have been
following him for the past 6 months, and he does not feel safe at home anymore. He also admits 6
to having intermittent thoughts of committing suicide. During the interview, he mentions that his
thoughts of suicide are augmented due to the voices telling him to “end it.” The patient’s past
medical history is significant only for well-controlled type 2 DM. His vital signs on admission are
heart rate is 78/min, respiratory rate is 16/min, blood pressure is 118/82 mm Hg, temperature is
36.7°C (98.1°F), and oxygen saturation is 99%. On further examination, the patient displays flat
affect, paranoia, tangential and illogical thought processes, and disorganized speech. Urine drug
screening is negative for illicit substances.
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Schizophrenia
This patient meets the DSM-IV criteria for schizophrenia, which requires more than 6 months of disturbed functioning
with at least 1 month of at least two of the following symptoms (unless delusions are bizarre or voices provide running
commentary, then only one criterion is needed): delusions, hallucinations, disorganized behavior/catatonia, disorganized speech, and negative symptoms. These symptoms arise from a decrease in dopaminergic activity. Negative
symptoms (anhedonia, flat affect, avolition) stem from the frontal cortical region, whereas positive symptoms
(delusions and hallucinations) arise from the mesolimbic system. Typical treatment consists of dopamine antagonists.
However, due to high incidence of tardive dyskinesia and extrapyramidal symptoms associated with D2 dopamine
receptor blockade in typical antipsychotics, atypical antipsychotics are usually the first-line pharmacotherapy.
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A 23-year-old male is brought to a psychiatrist by his mother. She reports he has been behaving
strangely since he graduated from college 3 months ago. He stopped socializing with his friends
and now spends the entire day in his room. Upon questioning, he is reluctant to answer simple
questions. He eventually reveals that God has been speaking to him and providing him instruc- 6
tions for creating a device, which will allow him to read other people’s thoughts. Examination
reveals an unkempt, disheveled male with restricted affect and circumstantial thought process.
Urine drug screening was negative.
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Schizophreniform Disorder
This patient has schizophreniform disorder. The length of time of continuous signs of disturbance differentiates the
disorders presenting with symptoms of schizophrenia. Brief psychotic disorder denotes less than 1 month of symptoms, usually related to stress. More than 1 but less than 6 months of disturbed behavior including occupational/social
declines or negative symptoms including 1 month of psychotic symptoms is classified as schizophreniform disorder.
Symptoms persisting for more than 6 months indicate schizophrenia. Schizophrenia criteria plus major depression,
manic episodes, or both indicates a diagnosis of schizoaffective disorder. It is important to distinguish axis I disorders
from the schizoid and schizotypal personality disorders that are part of axis II.
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A 34-year-old woman is being seen in the emergency department for chest pain that started 2 hours
ago. She states it came on quickly and lasted less than 20 minutes. The event was accompanied
by palpitations, sweating, and shortness of breath. She currently has no pain or other symptoms.
Earlier in the evening she had an argument with her boyfriend. She has had one similar episode 6
in the past, but it resolved in 10 minutes and she did not seek medical attention. She takes a PPI
for mild GERD. Her blood pressure is 128/78 mm Hg, pulse is 84/min, respiratory rate is 14/min,
and temperature is 37.5°C (99.5°F). She has a normal S1 and S2 without additional heart sounds,
murmurs, or rubs. Chest is clear to auscultation bilaterally. ECG shows a normal sinus rhythm.
Chest X-ray is normal and a urine drug screening is negative.
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Panic Attack
This patient has had a panic attack. Panic attacks can present with a variety of symptoms including palpitations,
sweating, trembling, sensation of shortness of breath or smothering, feeling of choking, chest pain or discomfort, nausea or abdominal distress, derealization or depersonalization, fear of losing control, fear of dying, paresthesias, and
chills or hot flushes. The attack must be a period of intense fear or discomfort with four or more symptoms developing abruptly and reaching a peak within 10 minutes. This should be considered in a young, healthy patient with
chest pain and otherwise normal findings, particularly when accompanied by a precipitating event. In this case, the
patient’s attack may have been triggered by the argument. Panic disorder is characterized by recurrent unexpected
panic attacks or persistent concern of having a panic attack or its consequences. This may or may not be accompanied
by agoraphobia, a fear of being in public places. Panic attacks on exposure to specific situations are characterized as
a specific phobia. It is important to rule out cocaine-induced myocardial ischemia, which can be seen on ECG and
urine drug panel.
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A 42-year-old woman is being seen by her primary care physician for an annual visit. Her only
complaint is daytime fatigue that has been affecting her performance at work. She denies any
fever, weight changes, temperature intolerance, weakness, or lightheadedness. Inquiry into sleep
patterns reveals that she awakens in fear each night due to recurring dreams of being followed, 6
often with palpitations and profuse sweating. After further questioning, she tearfully admits that
she was sexually assaulted in a parking garage 3 months ago. Further discussion reveals that the
patient has debilitating panic attacks whenever she sees a parking garage and now avoids going
out in public whenever possible.
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Posttraumatic Stress Disorder
This patient has posttraumatic stress disorder (PTSD). PTSD is characterized by the exposure to a traumatic event
that the person persistently re-experiences. This may be through intrusive thoughts of recollection, recurrent dreams,
flashbacks, or intense responses to external cues. Patients will also have increased arousal and avoidance of stimuli
associated with the event. The level of disturbance in PTSD will cause impairment of social, occupational, or other
important area of functioning. In addition, like any other diagnosis in psychiatry, the condition must not be due to
the effect of a substance (e.g., illicit drug, medication), medical condition, or exacerbation of a preexisting axis I
(psychiatric) or axis II (personality) disorder. PTSD can present with symptoms similar to generalized anxiety
disorder, so a complete history is essential. It is important to note that in patients with PTSD who have a military
background, there is a high incidence of concurrent substance abuse. Therefore, it is important to screen for alcohol
and drug use, and generally, BZDs are not recommended in this population.
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A 16-year-old female is brought to the gynecologist by her mother for amenorrhea. Her first
menses was at 12 years of age, and she developed regular monthly cycles until about a year ago.
Her last menses was 6 months ago. The patient states that she is not sexually active. Physical
examination reveals a slender female, Tanner Stage V. She is 65 inches (165 cm) tall and weighs 6
104 lb (47.2 kg) with a BMI of 17.1 kg/m2. Pelvic examination is unremarkable. Skin examination
shows soft, fine hair on her extremities and a small abrasion of the skin over the right third and
fourth metacarpophalangeal joints. When asked about the abrasion, the patient states she scratched
her hand during gymnastics practice.
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Anorexia Nervosa
This patient has anorexia nervosa. To meet the DSM-IV criteria, a patient must be less than 85% of ideal body
weight, but maintain a distorted impression of their body weight or shape, with an intense fear of gaining weight and
3 months of amenorrhea. Since calculating 85% of total body weight can be time consuming in the clinical setting,
a BMI of less than 17.5 kg/m2 is typically used as the standard indicating an anorexic weight range. Amenorrhea
in anorexia nervosa is a result of low levels of luteinizing hormone (LH) and suppression of physiologic hormone
fluctuations. Lanugo (thin body hair) is one of many complications that can develop from anorexia, which can also
include osteoporosis, cachexia, cardiac arrhythmias, and even sudden death. This patient’s skin abrasion is suggestive
of self-induced vomiting. Anorexics may achieve and maintain their low weight through a number of methods including binging, purging (vomiting, laxative abuse, diuretics, etc.), excessive exercise, and starvation. Complications of
purging can include electrolyte abnormalities (particularly hypokalemia), salivary gland enlargement, dental caries,
and seizures. Patients with bulimia nervosa also binge and purge; however, they have a normal or high BMI, without
such distortion in body perception. Patients may also have an isolated distorted perception of a specific part of their
body, which is known as body dysmorphic disorder.
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A 57-year-old male presents to his primary care physician for follow-up on his hypertension. In
addition, he notes that he is always tired and frequently falls asleep at work. He reports that he
usually goes to bed around 10:30 PM and wakes up at 7:00 AM and does not have problems falling
asleep or staying asleep. However, he is still very tired when his alarm clock wakes him up. He 6
takes lisinopril and hydrochlorothiazide for hypertension. His blood pressure is 158/86 mm Hg,
pulse is 74/min, respiratory rate is 14/min, and temperature is 36.9°C (98.4°F). The patient’s BMI
is 35 kg/m2. Physical examination shows an obese male with a mildly erythematous oropharynx,
and presence of an S4 heart sound in addition to S1 and S2.
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Obstructive Sleep Apnea
This patient has obstructive sleep apnea (OSA), which is characterized by functional obstruction of the upper airway
for brief periods while the patient sleeps. These pauses (periods of apnea) last at least 10 seconds and often longer,
leading to a decrease in arterial oxygen saturation and transient arousal from sleep. Patients are usually not aware
of these disturbances while they are sleeping, but will often awake from a sufficient period of sleep without feeling
refreshed and have unexplained excessive daytime sleepiness. Typically, a partner will also note that they snore
loudly. OSA is generally found in individuals with obesity and is frequently associated with hypertension. Narcolepsy is much less common, but also presents with excessive daytime sleepiness and intrusion of aspects of rapid eye
movement (REM) sleep into daytime wakefulness. The most common symptoms are sleep attacks, in which a patient
cannot avoid falling asleep, typically leading to irresistible 10- to 20-minute periods of sleep. These can occur at very
inconvenient times, such as while driving, and may include cataplexy, a sudden loss of muscle tone, that may lead to
collapse from paralysis of all skeletal muscles. Other conditions that can lead to daytime sleepiness include shift work
(disruption of circadian rhythms), restless leg syndrome, jet lag, and insufficient sleep.
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A 33-year-old female presents to the emergency department with acute epigastric pain. She
describes the pain as sharp, constant, and unbearable. It is not associated with eating and gets
worse with moving. Review of systems is also positive for headache, nausea, dizziness, dysphagia, shortness of breath, neck pain, easy bruising, and increased urinary frequency. She is afebrile, 6
and other vital signs are normal. Examination reveals a soft, nondistended abdomen with normoactive bowel sounds that is tender to percussion and palpation in all areas. There is no guarding
or rebound tenderness. A review of her records shows that she was recently admitted and received
a colonoscopy for intractable diarrhea. She has also had several visits over the past few years for
gastroenteritis, unexplained knee pain, and a urinary tract infection. In addition, she underwent
exploratory laparoscopy for menometrorrhagia and underwent diagnostic evaluation for possible
multiple sclerosis.
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Somatization Disorder
This patient has somatization disorder, a very specific diagnosis out of the five somatoform disorders. It entails a history of multiple physical complaints beginning before the age of 30 years and occurring over a period of years with
either treatment or significant impairment in social or occupational functioning. The complaints must include four
pain symptoms (related to at least four different sites or functions), two GI symptoms other than pain (e.g., nausea,
vomiting, diarrhea), one sexual or reproductive symptom other than pain (e.g., sexual dysfunction, irregular menses),
and one pseudoneurological symptom other than pain (e.g., impaired coordination, weakness, double vision), none
of which can be explained by physical or laboratory examination. In this disorder, the symptoms are the result of
unconscious psychological factors and are not intentionally produced, such as in factitious disorder, where the patient
motivation is to assume the sick role, or in malingering, where external incentives such as financial gain are present.
Related disorders include pain disorder, in which pain at one or more anatomical sites is the predominant focus, and
conversion disorder, manifested by one or more neurologic symptoms affecting voluntary motor or sensory function.
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