Download Pseudo Disorders

Hoang 1
Somatoform Disorders
Somatization
Conversion
Pain
One or more sites
of pain causing
impairment
Hypochondriasis
Body Dysmorphic
Preoccupation
with fears of
disease based on
bodily sensations
Preoccupation
with imagined
appearance defect
Definition
Experience
physical
symptoms due to
mental conflict
Symptoms
affecting motor or
sensory function
Associated
Features
Seeking medical
attention for
symptoms
Symptoms do not
match anatomic
pathways
Poor insight
despite medical
evaluation
AKA hysteria &
briquet
“La belle
indifference”
Doctor shopping
At least 6 months
Age
Onset before age
30
DSM-IV Criteria
& Duration
4 pain
2 GI
1 sexual
1 pseudoneuro
Psychological
factors must be
involved
Not intentional
Not intentional
Not intentional
Comorbidity
High comorbidity
with personality
disorders
Associated with
trauma
Associated with
psychological
factors
Female:Male
More common in
women
More common in
women; rural
populations; poor
people
Frequent
inspection leading
to suicide
Serious childhood
illness
Equally common
in men & women
Not Due To GMC But Cause Functional Impairment
Factitious
Malingering
Intentional
production of
symptoms
Intentional
production of
false symptoms
Few visitors;
knowledge of
medical lingo
[psychosis]
Motivation for
primary gain but
not for secondary
gain
Aware for
secondary gain
Intentional
Intentional
“Munchausen by
proxy”
(Parent hurt child
for gain)
Hoang 2
Dissociative Disorders
D. Amnesia
D. Fugue
Definition
Inable to recall personal
information
Frequency
One or more episodes
Associated Features
Associated with traumatic
event
Associated with traumatic
event
Self limited: resolve in
days
Female:Male
Common in men &
women
Sudden, unexpected travel
away from home &
retrograde amnesia
D. Identity
Two or more distinct
personalities
Depersonalization
Derealization
Feeling detached from body
Feeling the external
world is unreal
At least two personalities
take control regularly
Reality testing is intact
Can occur with
depersonalization
Confusion about personal
identity
Inable to recall personal
information
Occur in people without
psychiatric pathology
People seem unfamiliar
or mechanical
Assume new identity
History of childhood
physical or sexual abuse
Not psychotic episode
Size and shape of world
seems altered
Common in adult females
Common in mild form
Transitions via stress
Hoang 3
Euthymia: normal range of mood states with no depression or elevated mood
Anhedonia: loss of interest in regular and pleasurable activities
Expansive mood/affect: expression of feelings without restraint; associated with grandiosity
Euphoria: Intense feelings of grandeur
Dysphoria: Unpleasant mood
Mood Episode Guidelines
Major Depressive Episode
Manic Episode
Mixed Episode
Hypomanic Episode
Duration
At least 2 weeks
At least 1 week
At least 4 days
Emotions
Feeling depressed or anhedonia
Feeling euphoric, expansive,
irritable with mania
Associated Features
Significant functional
impairment
Significant functional
impairment
Change in function from
baseline
Can’t be due to drugs or GMC
Psychotic symptoms
Not psychotic
Danger to self
Not dangerous to self
Both mania and depression at
same time
Feeling euphoric, expansive,
irritable with mania
Hoang 4
Mood Disorders
Major Depressive
Disorder
Definition
Recurrent depressive
episodes with functional
problems
Dysthymic
Chronic, low grade
depression
At least 2 weeks of
depression OR
anhedonia + symptoms
Episode Frequency
Epidemiology
Bipolar Type I
Recurrent mania &
depression
Recurrent hypomania
& major depression
Premenstrual dysphoric
disorder
At least one manic or
mixed episode
No manic or mixed
episode
Two or more years of
depression
One manic or mixed
episode needed
Chronic episodic
Never goes more than 2
months without
symptoms
Good inter-episode
recovery
More in females
More in females
Equal in female/male
15% commit suicide
Co-morbid with
personality types
Earlier onset than
MDD
Abnormal NorEpi,
serotonin, dopa, &
Acetylcholine
Psychology
Loss of parent before age
11
Low energy
Trauma during
development
Low self worth
Poor coping with
personality disorders
Poor concentration
Cyclothymic
Bipolar NOS
Chronic fluctuations
b/w minor mood
episode
Type I vs. Type II
vs. Cyclothymia
GMC is not ruled
out
Two or more years
Good inter-episode
recovery
Never symptom-free
more than 2 months
Rarely require
hospitalization
Many hypomanic
and minor depressive
episodes
Melancholia: anhedonia
with decreased sleep
Postpartum psychosis
= bipolar
Atypical depression:
excessive sleep
Seasonal affective
disorder
Psychotic depression:
hallucinations
Rapid cyclers = 4 or
more episodes per year
Postpartum depression
Bipolar Type II
Not enough information
One ore more MDD
episode
Etiology
Subtypes
Depression NOS
Hoang 5
Anxiety: apprehensive anticipation of danger (unpleasant & somatic symptoms)
Phobia: persistent, excessive, or irrational fear of specific things or situation
Fear response: 1. cognitive appraisal
2. physiologic danger
3. behaviors
Panic attack: period (10 minutes or less) of intense fear with four or more of the symptoms (ie. Choking, chest pain, sweating, numbness)
Anxiety Disorders
Panic Disorder
Social Phobia
OCD
Generalized Anxiety
Disorder
PTSD
Definition
Recurrent unexpected
panic attacks
Fear of embarrassing
situations or places
Recurrent unwanted &
distressing thoughts or
behaviors
Excessive worry about
real life problems
Reexperiencing,
hyperarousal, emotion
numb
Symptoms
Anticipation, worry, and
change in behavior
Distress & interfere with
daily function (egodystonic)
3 or more anxiety
symptoms (restless,
tension, fatigue)
** Response involve
fear, helplessness, &
horror **
Associated Features
With or without
agoraphobia (open
places)
Exposure to situation
provoke anxiety
Not pleasurable but reduce
anxiety
Seek help for somatic
concerns
[psychosis]
Good insight into excessive
nature
Insight present [psychosis]
2nd most common
disorder
Co-morbidity with alcohol
and depression
Chronic & disabling
Co-morbidity with other
psychiatric disorders
Higher in women & strong
genetics
Equally in men & women
Higher in women
2:1
Female : Male
Onset
3x more in women
Half is childhood onset
Higher in veterans
Last more than 1 month
Hoang 6
Psychotic Disorders
Schizophrenia
Schizophreniform
Brief Psychotic
Delusional
Shared Psychotic
Duration
At least 6 months
1-6 months
1 day - 1 month
At least 1 month
Develop delusions with
relationship partner
AKA
Pre-senile dementia
Symptoms
Social/occupational
dysfunction
Good prognostic features:
Eventual return to
premorbid functioning
Non-bizarre delusions
Mood symptoms for
substantial part of illness
Preceded by psychosocial
stressor
Delusions/Hallucinations
persist at least 2 weeks in
absence of mood
symptoms
Disorganized speech/
thought/ behavior
Psychic ambivalence
Female
Co-morbid mood disorder
Late & acute onset
Insight preserved
No family history of
pyschosis
Schizoaffective
Loosening of associations
DSMIV Criteria
At least 1 month of
Bizarre Delusions
OR
Hallucinations
(auditory then visual)
Epidemiology
Episodic with gradual
decline
Sudden onset of at least 1
positive characteristic
symptom
No impairment of function
or bizarre behaviors
Delusions of both are
similar in content
Major mood episode while
experiencing characteristic
symptoms of
schizophrenia
Onset at 40
50% attempt suicide
Prevalence
1%
Distribution
Equal in men/women
0.03%
Less than 1%
Erotomanic type
Grandiose type
Jealous type
Persecutory type
Somatic type
Depressive type: only
major depressive episodes
Earlier onset in men
Common in lower status:
“downward drift”
Abnormalities & Subtypes
Decreased brain volume &
increased lateral ventricles
Smaller prefrontal cortex
with loss of asymmetry
between left & right brain
CD PUR subtypes
“Shh” therapy works
Bipolar type: manic or
mixed episodes
Hoang 7
Psychosis: gross impairment in reality testing or ego boundaries
Schizophrenic disorders: delusions, hallucinations, disorganized speech & behavior
Psychosis due to GMC: delusions & hallucinations without insight
Personality Disorders
B
A
Dramatic, impulsive, attention, seeking/getting
Odd, eccentric, guarded, reserve
Paranoid
Paranoid
Schizotypal
Affect
personality
Schizoid
Unemotional
& loners
Paranoid
Magical
delusion
thinking
Paranoid
[psychosis]
Rational
schizophrenic
[psychosis]
i.e. Pheebe
C
i.e. Human
cat & Spock
Antisocial
Borderline
Histrionic
Narcissistic
Danger to
others
Danger to
self
Excessive
attention
seekers
No effort
for
attention
Id driven
by wants
Primitive
behavior
Center of
universe
Lack of
respect &
guilt
Fear or
rejection
Sense of
entitlement
i.e.
Hannibal
[psychosis]
Compulsive, fearful, timid
Avoidant
i.e. mouse
librarian
Dependent
i.e. human
dogs
Obsessivecompulsive
Personality
Disorder
Hoang 8
Sexual Dysfunctions
Dysfunctions
Sexual Desire
Sexual Arousal
Orgasmic
Sexual Pain
Disorders
Symptoms
Hypoactive sexual Desire
Sexual aversion
Dislikes & avoids all genital contact with partner
Female sexual arousal
Patient can’t lubricate enough to complete sexual activity
Male erectile
Patient can’t keep or get erection to complete sexual activity
Female orgasmic
Normal sexual excitement phase, but orgasm is delayed or absent persistently
Male orgasmic
Normal sexual excitement phase, but orgasm is delayed or absent persistently
Premature ejaculation
Minimal sexual stimulation cause early ejaculation
Female dyspareunia
Genital pain with sexual intercourse not due to inadequate lubrication or vaginismus
Female vaginismus
Repeated spasms of vaginal muscles interfering with sex
Substance-induced
Symptoms develop within 1 month of drug use OR medications cause symptoms
Due to GMC
PE or lab findings show direct physiological effects of GMC AND not due to mental disorder
*All cause marked distress or interpersonal problems
** All not caused by GMC or substance abuse
Hoang 9
Paraphilias: recurrent, intense sexual urges or behaviors involving unusual situations
Cause significant distress or impairment
At least 6 months
Paraphilias
Exhibitionism
Fetishism
Frotteurism
Pedophilia
Masochism
Sadism
Transvestic
Fetishism
Voyeurism
Duration
At least 6
months
At least 6
months
At least 6
months
At least 6 months
At least 6
months
At least 6
months
At least 6
months
At least 6
months
Symptoms
Exposure of
genitals at
unsuspecting
stranger
Involves use of
nonliving
objects
Touching &
rubbing against
non-consenting
person
Sex with
prepubescent child
(13 or younger)
Real act of
being
humiliated,
beaten, bound,
or made to
suffer
Real acts of
psychological
or physical
suffering of
victim
Heterosexual
male crossdressing
Observing an
unsuspecting
person who is
naked,
disrobing, or
having sex
Criteria
Cause distress &
impairment
Cause distress &
impairment
Cause distress &
impairment
Cause distress
& impairment
Cause distress
& impairment
Cause distress &
impairment
Cause distress
& impairment
Act on nonconsenting
person
Gender
dysphoria
(discomfort with
gender identity)
& frequent in
males
Not limited to
female
clothing or
devices
Person is at least
16 years old & 5
years older than
victim
Exclusive or
nonexclusive
Gender identity disorder NOS
Intersex conditions & gender dysphoria
Transient cross-dressing
Preoccupation with castration or penectomy without desire to acquire sex characteristics of other sex
Hoang 10
Atypical Antipsychotics
Block Serotonin more than Dopamine receptors
Drug
Clozapine
Treatment
Treat TD & refractory cases
Side Effects
Anticholinergic
Sedation
Hypersalivation
Orthostasis
Weight gain
Risperidone
EPS
Risk of stroke
Olanzapine
Somnolence
Increased appetite & weight
Quetiapine
Cataracts in beagle dogs
Ziprasidone
Aripiprazole
Cautions
Seizures
Agranulocytosis
Cardiac conduction problems
Newest
Well tolerated
Thought – mood – anxiety – psychosis – personality – agitation disorders
Traditional antipsychotics
Dopamine blockade D2
Anticholinergic = Anti-SLUDGE
Anti-Histamine – Cardiotoxicity – Orthostasis – Pigmentary changes – Photosensitivity – Sexual dysfunction – Lower seizure threshold
Antipsychotics
Haloperidol
Fluphenazine
Thiothixene
Perphenazine
Clorpromazine
Thioridazine
Hoang 11
Antidepressants Classes
TCA
MAOI
SSRI
Mechanism
Block reuptake of serotonin &
norepinephrine
Block catabolism of serotonin, NE,
dopamine, & monoamines
Block serotonin reuptake
Side effects
-1 blockade (sexual dysfunction)
Histamine blockade
Acetylcholine blockade
Hypertensive crisis
Serotonin syndrome
Anxiety & akathisia
Insomnia vs. sedation
GI upset
Anorexia
Sexual dysfunction
Overdose
Delirium
Cardiotoxicity
Lower seizure threshold
Drugs
Desipramine
Amitriptyline
Nortriptyline
Imipramine
Onset
Block serotonin & norepinephrine
reuptake
Risk of suicide
Serotonin syndrome
Approved for depression:
Phenelzine
Tranylcypromine
3-4 Weeks
MAOIs
Effective for depression & anxiety
Monoamine hypothesis = depression caused by low serotonin & norepinephrine
Serotonin syndrome
Mental status change
Autonomic instability
Neuromuscular abnormalities
SNRI
Citalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
S-Citalopram
Venlafaxine
Mirtazapine
Duloxetine
Hoang 12
SSRIs
First-line for depression & anxiety
Safe overdose & better tolerated
Serotonergic agents
Trazadone
Priapism
Nefazadone
Uncommon sexual dysfunction
Acute hepatoxicitiy
Dangerous drug interactions
Buproprion
Increase Dopamine, Norepinephrine, little on serotonin
Effective with atypical depression
FDA for smoking cessation
No sexual dysfunction
Seizure risk & agitation
Venlafaxine
Blood pressure elevations
Mirtazapine
Sometimes block serotonin receptors = prevent SSRI side effects
Histamine blockade = weight gain & sedation
Low sexual side effects
Duloxetine
Increase serotonin & NE like TCAs
Hoang 13
Mood Stabilizers
Lithium
Type
Valproic Acid
Carbamazepine
Anticonvulsant
Anticonvulsant
Anticonvulsant
Increase GABA
Decrease sodium influx
Modulate GABA-B receptors
Block sodium channels (& calcium)
Increase glutamate
Trigeminal neuralgia
Bipolar
Epilepsy
Alcohol & benzodiazepine withdraw
FDA for bipolar depression
Sedation
Cognitive dulling
GI upset
Clumsiness
Life-threatening rash
Double vision
Dizziness
Ataxia
Mechanism
Increase Dopamine, Ne,
serotonin, Ach, & GABA
Onset
1-3 weeks
Indications
Classic Bipolar (mania)
Unipolar depression
Personality disorders
PTSD
Bipolar (mania)
Epilepsy
Personality disorder
PTSD & GAD
Alcohol abuse
Migraine prophylaxis
Uses
Augment antidepressants
Augment antipsychotics
Reduce suicidal behaviors
Favorable side effect than Li
Effective in atypical bipolar
Wider therapeutic index
Side Effects
Tremor
Acne
Weight gain & sedation
Cognitive dulling
Diarrhea
Diabetes insipidus
Lower seizure threshold
Granulocytosis
Renal complications
Weight gain & sedation
Tremor
Alopecia
Diarrhea
Ataxia
Pregnancy = Ebstein’s anomaly
In breast milk
Pregnancy = Neural tube defects
In breast milk
Pregnancy = craniofacial, neural
tube, fingernail, & development
ECG prolongation
Hypothyroidism
Leukocytosis
Increase liver function
Agranulocytosis
Fatal hepatoxicity & pancreatitis
Autoinduction of P450 system
Cardiac conduction delay
Leukopenia
Cautions
Lamotrigine
SIADH
Rash
Hepatic failure & pancreatitis
Hoang 14
Benzodiazepines = increased GABA-A
Alprazolam = addictive (Xanax)
Clonazepam
Diazepam = addictive (Valium)
Lorazepam
Triazolam
Midazolam
Chlordiazepoxide
Anxiolytic at low doses
Sedative at high doses
Hoang 15
Mental Retardation
IQ less than 70
Delays in self care & communication
Pervasive Developmental Disorders
Autistic Disorder
Impaired reciprocal social interaction
Mental retardation & seizures
Impaired verbal & nonverbal communication
Restricted activities
Treatment
Alpha-2 Agonists
Clonidine
Risperidone
Asperger’s Disorder
High functioning autisms
Retts Disorder
Normal growth for first months
Decelerated head growth b/w 4-8 months
Females only
Incoordination
Childhood Disintegrative Disorder
Normal development for first years
Loss in (2 or more) language – social skills – bladder control – play – motor skills
Before age 10
PDD NOS
Impairment in development but not met for specific PDD