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Psychiatric Disorders and Their Treatment Part 3 Continuing Education Psychiatric disorders and their treatment: Selected psychiatric disorders This final article in a three-part series discusses various factors that influence treatment decisions. Learning Objectives Identify the factors that influence treatment decisions Describe the major types of anxiety disorders Describe the major types of mood disorders Describe the major types of psychotic disorders Explain Alzheimer’s disease (an organic mental disorder) and intermittent explosive disorder (an impulse control disorder) It then describes several categories of psychiatric disorders, including anxiety disorders, mood disorders, psychotic disorders, organic mental disorders and impulse control disorders. Finally, examples of each disorder are discussed. Leonard J. Marcus, MD, associate professor of clinical psychiatric medicine, Department of Psychiatric Medicine, University of Virginia, Charlottesville, VA; Ronald F. Pfeiffer, MD, professor and vice chair, College of Medicine/Department of Neurology, University of Tennessee Health Science Center, Memphis, TN; and Richard T. Scheife, PharmD, FCCP, associate clinical professor of neurology, Tufts University School of Medicine, New England Medical Center, editor-in-chief, Pharmacotherapy, Boston, MA, served as consultants for this article for the Certified Medical Representatives Institute Inc. P sychiatric disorders are often unpredictable and can produce symptoms that inhibit patient cooperation and compliance with a treatment approach. Clinicians must decide which therapy setting and psychotherapeutic techniques will best meet a patient’s needs. A particular challenge in the mental-health field is a lack of evidence-based medicine that would establish clear differences between drugs and other treatment strategies for major psychiatric illnesses. Clinicians often switch patients from one antidepressant to another and explore drug combinations, sometimes taking months to find a regimen that works for an individual patient. When using pharmacotherapy, clinicians select the drug(s) and dosages with which to initiate treatment. In doing so, they consider the safety margin, potential for drug interactions, and the potential for dependence and abuse. Monitoring the results of pharmacotherapy, including drug effects and adverse effects, is essential. Based on what they see, clinicians may change the drugs, alter the dosages or modify the length of treatment. The overall success of treatment often depends significantly on patient compliance. Certain drugs are considered controlled substances due to their ability to affect behavior and their potential for abuse. The use of these drugs is subject to control and restrictions. Currently, federal drug-enforcement agencies monitor prescriptions for controlled substances in hospitals and pharmacies. It is important to be alert to the status of these drugs, to the code of regulations that governs their prescription and use, and to the different categories of RECEIVE CREDIT AND RECOGNITION Continuing Education in Pharmaceutical Representative aims to provide reps with information to help them meet the needs of the people they serve and to contribute to reps’ personal and professional development. Every third issue includes a self-assessment quiz covering the previous three Continuing Education articles. The quiz for this article will appear in this issue. Reps who correctly complete the quiz and return it to the CMR Institute with a nominal handling fee will receive a completion-recognition form showing that they have successfully completed the three-part educational series and earned .25 CEU (2.5 contact hours). The CMR Institute also will send a letter of recognition to reps’ managers upon completion of a quarterly series. A Certificate of Achievement will be awarded to any representative who successfully completes four quizzes or has obtained 1.0 CEU. Note: The Continuing Education quizzes are not part of CMR Institute’s certification program and do not count as credits toward the CMR® designation. 32 About the CMR Institute: The Certified Medical Representatives Institute is an independent non-profit educational organization established in 1966 to provide a source of professional development and certification for pharmaceutical representatives. The Institute provides an up-to-date, approved continuing education curriculum designed to expand and enhance internal company training and development in a cost-effective manner. The curriculum concentrates on providing a general knowledge base and avoids such areas as selling skills and specific product education. © 2008 The Certified Medical Representatives Institute Inc., Roanoke, VA 24014. All rights reserved. No part of this article may be reproduced by any method or in any form without written permission from the CMR Institute. Reprints of this article are available from the CMR Institute. Request Continuing Education article PD-3. responsibility. Healthcare representatives must maintain accurate inventory records of these substances. There are currently five classes of controlled substances. Note that “C” refers to “Control.” CI: Substances with no known medical use and high potential for abuse. Examples include heroin and LSD. CII: Nonrefillable drugs with high potential for abuse but clearer medical application; they require a prescription with a physician’s signature each time. Examples include methadone, morphine, amphetamine and pentobarbital. CIII and CIV: Refillable drugs with low-tomoderate abuse potential and clear medical application. Examples include benzodiazepines, acetaminophen and codeine tablets. CV: Least-controlled substances; drugs with low abuse potential and clear medical application. Examples include codeine-containing cough medicines and lomotil. Following are discussions of several categories of psychiatric disorders. Anxiety disorders Anxiety represents both a physical and a psychological reaction to real or imagined danger. Physiologic arousal and increased alertness help the body prepare for action. However, anxiety becomes pathological when there is no real danger and it impairs normal functioning. Four major types of anxiety disorders are: Generalized anxiety disorder (GAD) GAD is characterized by chronic and persistent free-floating anxiety. Patients who suffer from this disorder experience excessive or inappropriate anxiety given their real-life situations. They are overly concerned about at least two life circumstances (such as health or finances) for most days during a period of at least six months or longer. Panic disorder This disorder is characterized by unexpected, discrete attacks of intense anxiety, fear or discomfort. During these attacks, the autonomic nervous system responds as if the patient is in life-threatening danger. Panic attacks usually last for a few minutes, but they can persist for up to an hour or longer. Attacks can be triggered by exposure to specific stimuli, such as a crowded room, or they may be brought on by excitement, intense emotion, physical exertion or certain other situations. Phobias Phobias are characterized by the debilitating, pathological fear of a specific stimulus object, event or situation that is exaggerated beyond any real threat of danger. Two major types of phobias are as follows: Social phobia, characterized by gradual onset, occurs when patients avoid public scrutiny for fear they will behave inappropriately or lose control in a public setting, causing them humiliation or embarrassment. Simple phobia, the most common type of phobia, is characterized by a persistent, irrational fear and avoidance of a single object or situation, such as snakes, storms, high places or air travel. Obsessive-compulsive disorder (OCD). Patients with this disorder suffer from recurrent obsessions or compulsions that produce marked anxiety. An obsession is a senseless, usually negative thought that intrudes into the consciousness; an example is the thought of killing a loved one. A compulsion is an intentional, repetitive and purposeful act performed in response to an obsession. The exact cause of obsessive-compulsive disorder is unknown; however, evidence suggests involvement of the serotonergic system. Anxiety is a reaction to real or imagined danger. It becomes pathological when there is no danger and it impairs functioning Anxiety in the context of these disorders can be further characterized as: Free-floating anxiety, which is a feeling of general apprehensiveness, unrelated to anything specific. Situational anxiety, which occurs in response to a specific object, event or situation. Separation anxiety, which is an exaggerated response to leaving a certain person or secure place (such as a parent, home, neighborhood or city, etc.). Mood disorders Mood disorders are characterized by a prolonged emotion – usually depression or elation – that impacts overall mental health. Key mood disorders include major depression, bipolar disorder, dysthymia and cyclothymia. Major depression is a common psychiatric symptom, syndrome (condition) and disorder. As a disorder, it is defined as a depressed mood and loss of interest in nearly all activities for the greater part of every day for at least a two-week period, plus at least four additional symptoms of depression. The mood change is so severe that it affects the patient’s ability to function on the job and in personal relationships. If untreated, major depression (often called unipolar depression) may persist throughout life. Although it may occur as a single episode, it is most often recurrent. Bipolar disorder involves alternating episodes of mania and major depression. The manic-depressive cycle is often recurrent, and its chronicity causes patients to experience levels of dysfunction severe enough to affect their work and personal lives. Bipolar patients are often predisposed to both June 2008 | www.pharmrep.com Pharmaceutical Representative 33 alcohol and drug abuse, as well as several types of personality disorders. They typically have a history of mood swings with periods of intense goaloriented activity, followed suddenly by periods of erratic or no activity. In addition to genetic factors, biological factors related to biochemical and endocrine imbalances may be important in the development of this disorder. Dysthymia is a chronic, mild depression that affects patients over most days for a minimum period of two years. Its symptoms are similar to those of major depression, although much less severe, and the disorder interferes less with normal functioning. An imbalance of the neurotransmitters norepinephrine and serotonin may contribute to the development of dysthymia. Like major depression, there is also evidence of a genetic predisposition. Stresses such as the loss of a loved one or financial problems can also precipitate dysthymia. Cyclothymia is essentially a mild form of bipolar disorder. Cyclothymia is characterized by episodes of hypomania (a mild degree of mania) in which patients feel an elevated mood. In cyclothymia, the highs are not as high nor the lows as low as they are in full-blown bipolar disorder; the duration of the mood elevations and depressions are also much shorter. If cyclothymia is left untreated, many patients eventually develop bipolar disorder. Psychotic disorders In general, psychosis is a state of severe mental dysfunction that impairs the ability to maintain contact with reality and meet the ordinary demands of life. It is characterized by the presence of delusions, hallucinations, incoherence, lack of substantive thought, markedly illogical thinking, or bizarre, grossly disorganized or catatonic behavior. Important psychotic disorders include schizophrenia, major depression with psychotic features, mania with psychotic features and psychosis resulting from organic brain damage. Schizophrenia is a psychosis involving delusions, hallucinations, abnormal thoughts, changes in affect and bizarre behavior. Patients with this disabling illness will have trouble at work and in relationships, and they are likely to have problems with basic self-care and personal hygiene. Both environmental and genetic factors are thought to play a role in the development of this disorder. There are distinct types of schizophrenia, including: Paranoid schizophrenia, which is characterized by feelings of persecution. Catatonic schizophrenia, in which patients show marked psychomotor disturbance, usually alternating between extremes of stupor and excitement. Disorganized schizophrenia, which is characterized by bizarre thinking and speech, an inappropriate Clinical decision making Disorder characteristics Patient characteristics The Patient Psychotherapy options Inpatient Type of therapy Group or individual sessions Pharmacotherapy considerations Outpatient Type of therapy Group or individual sessions Prescription Drug Dosage Monitoring Drug interactions Margin of safety Dependence, abuse potential 34 Pharmaceutical Representative www.pharmrep.com | June 2008 Length Drug effects Compliance Adverse effects affect, and regressive (childlike) behaviors and mannerisms. Major depression with psychotic features is also referred to as psychotic depression. It is characterized by both a severely depressed mood and a paranoid psychosis, but without the other signs and symptoms of schizophrenia. Persecutory delusions (e.g., worried that their hospital food is poisoned) are an important characteristic of this disorder. Mania with psychotic features is characterized by manic episodes that include psychotic symptoms, most commonly arising in bipolar disorder. As in the case of bipolar disorder, patients often resist treatment because they fail to recognize a problem with their behavior during the manic phase of their disease. Psychosis resulting from organic brain damage may be secondary to injury or psychoactive substance abuse. Patients generally suffer impaired cognitive and/or psychomotor activity, often leading to difficulties in interpersonal relationships and occupational performance. Somatic and persecutory delusions are more common than hallucinations in this disorder. Other disorders Other types of psychological disorders include organic mental disorders and impulse control disorders. Organic mental disorders are psychological or behavioral abnormalities produced by brain damage that may or may not be reversible. One well-known example is Alzheimer’s disease. Alzheimer’s disease is a degenerative disorder of the cerebral cortex and subcortical structures of the brain. It produces a progressive loss of intellectual function – including memory, abstract thinking, judgment and decision-making abilities – as well as increasingly abnormal behavior. Alzheimer’s disease is considered to be a progressive, irreversible process and is associated with brain cell death. Although the exact cause of Alzheimer’s disease is unknown, there may be a familial predisposition to the disease. Studies show that Down’s syndrome (a type of mental retardation with distinct physical traits) predisposes a person to develop Alzheimer’s disease. Recent research links the gene apolipoprotein E (apoE) with familial cases of Alzheimer’s disease. The gene directs the synthesis of a cholesterol-transporting blood protein. It is present in about 25% of the population and is found in 80% of late-onset familial cases of Alzheimer’s disease. Biochemical and medical factors also may be important in Alzheimer’s disease, such as slow-acting infectious agents (called prions), an auto-immune or viral component, past head trauma, arteriosclerotic changes and cholinergic abnormalities. In Article Summary • Clinicians face particular challenges when deciding which therapy setting and psychotherapeutic techniques will best meet a patient’s needs • Anxiety becomes pathological when there is no real danger and it impairs normal functioning – Four major types of anxiety disorders are generalized anxiety disorder, panic disorder, phobias and obsessive-compulsive disorder • Mood disorders are characterized by a prolonged emotion – usually depression or elation – that impacts overall mental health – Major types of mood disorders include major depression, bipolar disorder, dysthymia and cyclothymia • Psychosis is a state of severe mental dysfunction that impairs the ability to maintain contact with reality and meet the ordinary demands of life – Important psychotic disorders include schizophrenia, major depression with psychotic features, mania with psychotic features and psychosis resulting from organic brain damage • Other types of psychological disorders include organic mental disorders and impulse control disorders many cases, extracellular deposits of amyloid (a fibrous protein) have been found in the cerebrovascular tissue of patients. Where the amyloid originates is unclear, but it is probably from nervous tissue or blood vessels. Impulse control disorders are those in which the patient cannot resist the impulse to perform a harmful act. Intermittent explosive disorder falls into this category. Intermittent explosive disorder is characterized by a number of episodes of uncontrolled outbursts of rage in which patients assault other people or destroy property. The attacks are disproportionate reactions to any provoking circumstances. Interestingly, the patient is not abnormally aggressive between outbursts and often shows genuine regret or selfreproach after an episode. Although the exact cause of intermittent explosive disorder is unknown, one theory is that personality or environmental factors are important; the disorder may result from a combination of personality characteristics and a lack of internal behavioral controls. Some theorize that it is caused by neurologic abnormalities. The next series of articles will focus on disease management. June 2008 | www.pharmrep.com Pharmaceutical Representative 35