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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.
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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
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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
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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
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