Download Conscious symptom production and unconscious motivation

Update on Depression, Anxiety and
Psychosomatic Pain Disorders
Marcia
Kaplan, M.D
Volunteer
Faculty, Cincinnati
Professor of
Psychoanalytic institute
Psychiatry UC
Dept. of
Psychiatry
Unofficial
psychiatrist
UC Dept. of
Neurology
Dr. Kaplan has no conflicts to report.
In the past 12 months, Dr. Privitera has received:
research funding from NIH, American Epilepsy
Society, UCB, and Johnson & Johnson
consulting fees from Johnson & Johnson, Glaxo
Smith Kline, UCB
honoraria for speaking from Johnson & Johnson,
Glaxo Smith Kline, Pfizer and UCB
Disclosures
DSM-V Diagnostic Criteria for
Major Depression
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Depressed mood / anhedonia, plus
– Sleep disturbance
– Difficulty concentrating
– Significant appetite/weight change
– Psychomotor agitation/retardation
– Pervasive loss of energy/fatigue
– Feeling worthless; excessive or inappropriate guilt
– Recurrent thoughts of death/suicide
Symptoms present for 2 weeks
Always or
often
Sometime
s
Rarely
Never
Everything is a
struggle
4
3
2
1
Nothing I do is right
4
3
2
1
Feel guilty
4
3
2
1
I’d be better off
dead
4
3
2
1
Frustrated
4
3
2
1
Difficulty finding
pleasure
4
3
2
1
Score >15 indicates depression
Differential Diagnosis of Depression
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Single episode vs. chronic, recurrent, severe
Bipolar Depression
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Early onset
Prominent sleep problems lifelong
Family history of mood problems and alcohol abuse
Unusual response to antidepressants
Dysthymia
Grief
External life events
DSM-V Anxiety Disorders
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Separation anxiety disorder
Generalized anxiety disorder
Panic disorder
Agoraphobia
Social anxiety disorder
Obsessive Compulsive Disorders
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Obsessive-compulsive disorder
Body Dysmorphic disorder
Hoarding disorder
Trichotillomania
Excoriation - Skin picking
Trauma and Stressor related disorders
Post-traumatic stress disorder
 Acute stress disorder
 Adjustment disorder
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DSM-V Somatoform Disorders
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Somatic Symptom Disorder = somatization
•Includes “with predominant pain” = former pain
disorder
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Conversion Disorder
Illness anxiety disorder = hypochondriasis
Psychological factors affecting other medical
conditions
How Much History Do You Need?
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eliciting a history of childhood (or adult) neglect/abuse helps
establish a rationale for psychiatric referral
psychiatric consultation for patients with somatic symptom
disorder reduces subsequent health care expenditures
without changing patients’ satisfaction with their health status
Smith et al, New Eng J Med 1986
How Can Psychiatric Consultation
Help Patients with Chronic Pain?
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acknowledgement of the patient’s suffering, loss, and
limitations
establishment of accurate picture of patient’s daily
routine, important relationships, sources of financial and
emotional support
referral to appropriate type of psychotherapy
improve medication management
address patient’s need for attention from primary care
physician, “run interference” with health professionals
involved in patient’s care
Conscious or Unconscious?
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Unconscious symptom
production and motivation:
somatization disorder
conversion disorder
hypochondriasis
•
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Conscious symptom
production and
unconscious motivation:
factitious disorder
Conscious symptom
production and
motivation:
malingering
Look for Co-Morbidities
•
Important to consider with every patient, since
these factors complicate dx and tx
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alcohol abuse/dependence
narcotic abuse/dependence
post-traumatic stress disorder
•“survivor triad”:
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insomnia, nightmares, GI distress
Depressive disorders
Anxiety disorders
Medication Treatment
•
First line: SSRIs
• fluoxetine
• sertraline
• paroxetine
• citalopram, escitalopram
Medication Treatment
•
Escitalopram/citalopram
• Dose range 10 – 40 mg qd (20-80 for
citalopram)
• start with 5 - 10 mg in anxious pts
• Most selective for 5-HT1 presynaptic
receptor
• minimal agitation, insomnia
• CYP 450 inhibition minimal
Medication Treatment
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SNRIs:
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Venlafaxine: qd - Effexor XR, Venlafaxine ER. Pristiq;
venlafaxine IR t.i.d.
Duloxetine: Cymbalta
Milnacipran (Savella) now marketed for fibromyalgia
5HT2A/ SRI: nefazodone, trazodone
Alpha 2 antagonist, HT-3 SRI, antihistaminic:
mirtazapine
NDRI: bupropion
NRI: desipramine, nortriptyline, protriptyline,
Medication Treatment
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Venlafaxine
• SRI at low doses, NRI at higher doses
• Dose range 37.5 to 375
• BP elevation at doses >150 mg
• Insomnia,
• Sexual inhibition
• Sweating, decreases hot flashes
Discontinuation syndrome
CYP 450 minimal inhibition
Medication Treatment
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Bupropion – SR or XL
NRI, DRI
Dose range 100 – 450 mg, qd or bid dosing
Activating, not anxiolytic
Less risk of sexual inhibition or weight gain
Smoking cessation utility
Elevated risk of seizures in female binge eaters
CYP 450 minimal inhibition
Medication Treatment
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Mirtazapine
Alpha 2, 5HT2A, HT3, H1 antagonism
Dose range 15 – 90 mg
Anxiolytic, sedation, weight gain
No sexual inhibition
CYP 450 minimal inhibition
Tricyclics and MAOIs
•
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First antidepressants with effectiveness well established,
probably through enhancement of 5-HT and NT
transmission
many side effects: histaminic, alpha-adrenergic, and
cholinergic blockade;
drug and food interactions for MAOIs
•
Medication Management
of Chronic Pain
Antidepressants:
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TCAs
SNRIs – venlafaxine, duloxetine
antiepileptic drugs:
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Gabapentin
Pregabalin
Valproate
Carbamazepine
Problematic (but sometimes useful) in
Medication Management of Chronic Pain
• Second generation antipsychotics
• Check blood sugar, weight and cholesterol, TGs at outset
• Benzodiazepines
• Use for back-up, not foundation of treatment
• Opiates
• Obvious problems with addiction, unintended mood
effects
Treatment Algorithm
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Rule out thyroid abnormality
Baseline liver functions
Ask about alcohol and drug use
Pregnant, or trying to be?
Family history of affective illness?
Treatment Algorithm
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Begin with SSRI at usual starting dose (or
half for severe anxiety, hx of side effects)
Monitor progress at 4 weeks (have pt. call if
problems)
If some improvement, optimize dose
If no improvement, switch medication
Treatment Algorithm
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If escitalopram 5 mg -> 10 mg for at least 3
weeks fails…
• Mirtazapine
• for severe anxiety, insomnia, anorexia
• 15 mg q PM, increase as tolerated
• Venlafaxine
• For depressed mood, poor concentration and
motivation, not good for agitation
• 37.5 mg in AM with food, increase as tolerated –
ideal at 150 mg
Treatment Algorithm
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Bupropion
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best for hypersomnia, psychomotor slowing, low
motivation, concerns about weight gain and sexual
inhibition
Not ideal for agitated or anxious patients
 IR form 75 mg in AM, increase as tolerated
 SR form 100 mg in AM, increase as tolerated
 XL form 150 mg in AM, increase as tolerated
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Treatment Algorithm
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Second generation antipsychotics for
augmentation
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Aripiprazole (Abilify) for poor concentration,
impaired motivation
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Quetiapine (Seroquel) for insomnia,
agitation, anxiety
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half of 2 mg pill in AM, increase as tolerated
25 mg in evening, increase as tolerated
Olanzapine (Zyprexa) for resistant
depression, anxiety
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2.5 mg in evening, increase as tolerated
Assessing Response
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Immediate improvement: placebo
response
Some improvement by 2 weekscontinue
No better in 4 weeks: raise dose or
change Rx
Response ok, remission better
When to Refer
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Refractory depression
Actively suicidal or homicidal
Severe anxiety, agitation
New onset mania, psychosis or
personality change
Significant work, relationship problems