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Download Diagnosis: Major Mental Illness
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Major Mental Illnesses • Thought Disorders • Schizophrenia • Mood Disorders • Major Depressive Disorder • Bipolar Disorder (Manic-depression) Characteristics of an Illness • Affect Individuals • Across Populations • Signs and Symptoms • Course • • • • Heredity Diagnosis Causes Treatment Understanding Schizophrenia Common Symptoms of Schizophrenia • Positive Symptoms – Disturbances of thinking and perception • Negative Symptoms – Loss or decrease of normal functions Positive Symptoms of Schizophrenia • Disordered thinking – Thoughts “jump” between completely unrelated topics or may be “blocked”. • Delusions – Fixed, false beliefs (not based in reality) – Outside of cultural norms • Hallucinations – False perceptions – Usually auditory Delusions of Schizophrenia • • • • • • Persecution Control Grandiose Reference Influence Religious • • • • • • Somatic Mind reading Thought broadcasting Thought insertion Thought withdrawal Guilt, sin Hallucinations of Schizophrenia • Auditory 70% • Voices commenting • Voices conversing • Voices commanding • Visual • Somatic, tactile • Olfactory 30% 15% 5% Negative Symptoms of Schizophrenia • Affect blunted or flat – Lacking emotional expression – “Blank” face, little eye contact, few gestures • Avolition – Lacking energy, spontaneity, initiative • Alogia – Diminished amount of speech, or content • Anhedonia – Lack of interests, or lack of pleasure Diagnosis: Schizophrenia How is schizophrenia diagnosed? Schizophrenia: Diagnosis Across Time • Kraeplin - Dementia Praecox (1878) • • • • Simple Paranoid Hebephrenic Catatonic • Bleuler - “Schizophrenia” (1911) • • • • Affect Associations Ambivalence Autism • Schneider - First Rank Features (1959) Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) DSM-IV Schizophrenia • • • • Characteristic symptoms for one month Impairment in functioning Continuous signs for 6 months Not do to a “look-alike” • • • • mood disorder substance abuse general medical condition autism Types of Schizophrenia • Paranoid type • Preoccupation with delusions or frequent auditory hallucinations • Disorganized type • Disorganized speech, disorganized behavior, flat or inappropriate affect • Catatonic type • Immobility, peculiar movements, purposeless and excessive activity • Undifferentiated type • Residual type Who Gets Schizophrenia? • One of every one hundred people • 2.5 million people in the United States • • • • All ethnicities Societies throughout the world Equal among men and women More prevalent in poorer communities • “Downward drift” The Course of Schizophrenia • • • • • • • Most commonly begins between ages 15-25 Usually begins later in women One, or multiple episodes Full or partial recovery between episodes Positive symptoms lessen with age Negative symptoms increase with age Tends to stabilize later in course What Causes Schizophrenia? • Unclear • Likely a complex group of brain illnesses with multiple causes • Heredity • Biochemical theory • Brain anatomy • Brain development Causes of Schizophrenia • Heredity – Genetic component to schizophrenia (runs in families) – Adoption studies – Inherit a vulnerability to schizophrenia Lifetime Risk of Developing Schizophrenia • • • • • • General population 1% Child of one parent with schizophrenia 10-15% Child of two parents with schizophrenia 30-40% Sibling with schizophrenia 10% Fraternal twins 10% Identical twins 50% “For every complex problem there is a solution that is neat, simple and wrong.” H. L. Menken “It is better to be wrong than vague, if one is wrong in an interesting way.” Bernard Carroll Stress-Diathesis Model of Schizophrenia • Genetic Vulnerability (diathesis) • “Second hit” – Perinatal - pregnancy or birth injury – Viral / Seasonality – Other stresses - puberty, social stresses • Leads to changes in the brain Brain Differences in Schizophrenia • Chemical – Dopamine Hypothesis • Anatomy / Activity – Many sites • Developmental – Cell migration Dopamine Hypothesis of Schizophrenia • Describes what is wrong in the brain but not how it got that way • Dopamine system is hyperactive • Too much dopamine • Problem with the dopamine receptors • Clues - amphetamines, Cocaine, L-DOPA Neuroanatomy of Schizophrenia • No single change is seen in all people with schizophrenia • Enlarged ventricles • Underactive frontal lobe – planning, judgement, abstraction, expressing feelings • Overactive temporal lobe – preceptions and emotions Attention / Arousal Model of Schizophrenia • Stimulus flooding – Lack of an effective filter – Too much information from the environment – Leads to withdrawal from social contact • Stimulus overload – Leads to frustration, poor concentration, nervousness Examples of Stimulus Overload • “Everything seems to grip my attention although I am not particularly interested in anything. I am speaking to you just now, but I can hear noises going on next door and in the corridor. I find it difficult to shut these out, and it makes it more difficult for me to concentrate on what I am saying to you.” • “My concentration is very poor. I jump from one thing to another. If I am talking to someone they only need to cross their legs or scratch their heads and I am distracted and forget what I was saying. I think I could concentrate better with my eyes shut.” Schizophrenia • IS – – – – – Biological disease of the brain Disabling and emotionally devastating Relatively common Misunderstood and stigmatized Treatable • IS NOT – Caused by bad parenting – A personal weakness – Split personality Understanding Mood Disorders Major Depression Bipolar Disorder Mood Disorders • • • • • Signs and Symptoms Diagnosis The Biology Other Causes The Course of Illness Major Depression: Signs and Symptoms • • • • Emotional Thought Somatic (body) Behavioral Major Depression: Emotional Symptoms • • • • Sad, irritable or empty mood Diurnal variation Diminished capacity for enjoyment Diminished interests Major Depression: Thought (Cognitive) Symptoms • • • • Difficulty concentrating Indecisiveness Memory problems Depressed content of thought – – – – Worthlessness Guilt Hopelessness Death and Suicide Major Depression: Somatic Symptoms (Body Functions) • • • • • Sleep disturbances Appetite disturbances, weight changes Fatigue, low energy Upset stomach, constipation Physical pain Major Depression: Behavioral Signs and Symptoms • Social withdrawal • Increased dependency • Poor frustration tolerance • Suicide attempts • Substance abuse • • • • • • Slow motion Slow speech Poor eye contact Tearfulness Agitation Poor self-care Major Depression: Types of Episodes • Melancholia – – – – – No pleasure or “reactivity” Weight loss Early morning awakening Worse in the morning Excessive Guilt • Atypical – – – – – Mood brightens to positive events Weight gain Over-sleeping Heavy feeling in arms and legs Interpersonal rejection sensitivity “Masked Depression” • • • • • • May not complain of feeling depressed Anxious, agitated Fatigue, insomnia Chronic pain, unrelieved by pain killers Confused, disoriented, poor memory Alcohol or drugs obscure symptoms Major Depression: DSM-IV • Depressed mood, or loss of interest/ pleasure • Other symptoms (total of 5) • • • • • • • Increase or decrease in appetite/weight Insomnia or hypersomnia Agitation or slowing Fatigue or loss of energy Worthlessness or guilt Poor concentration or indecisiveness Recurrent thoughts of death or suicide Major Depression: DSM-IV (continued) • Two week duration • Impaired functioning in life roles • Rule out “look alikes” – Secondary depression Secondary Depression • Other treatable illnesses cause depression – Examples • • • • • Endocrine problems (thyroid disease, diabetes) Infections (mononucleosis, influenza) Anemia Poor nutrition Neurologic illnesses (strokes, Parkinson’s disease, multiple sclerosis • Tumors (lung, pancreas, brain) Secondary Depression (continued) • Alcohol • Drugs • Medications • Examples - steroids, high blood pressure medications, sleeping pills, oral contraceptives • Toxins Major Depression: The Causes • Limbic System • Neurochemical • Serotonin • Norepinephrine • Others • Heredity • Identical twins - 40% • Environmental stresses Major Depression: The Course • Can occur at any age – Usual onset similar to schizophrenia, or later – 10% have first episode after age 60 • More common in women (2:1) • Lifetime prevalence 17% • Recurrent in 50-60% – Later episodes: longer, deeper, more frequent, less of a trigger • May be seasonal Major Depression Severity • Mild to severe • May include psychosis, poor self care, suicide • Abraham Lincoln describing his own depression: • “I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on earth. Whether I shall ever be better, I cannot tell. I awfully forebode I shall not. To remain as I am is impossible. I must die or be better, it appears to me.” Bipolar Disorder • • • • • Signs and Symptoms of Mania Diagnosis Other Causes The Biology The Course of Illness Mania: Signs and Symptoms • Persistently elevated, expansive or irritable mood lasting at least one week • Associated symptoms • • • • • • • Inflated self -esteem or grandiosity Decreased need for sleep More talkative Racing thoughts or flight of ideas Distractibility Agitation or increase in activities Excessive involvement in pleasurable activities with a high risk for painful consequences – Spending sprees, sexual indiscretions, foolish investments Manic Episode: DSM-IV • Elevated, expansive, or irritable mood for one week • Three associated symptoms • Significant impairment in life roles • Not do to a “look-alike” • Medical condition • Medication • Substance abuse Hypomania • Episode similar to mania, but less severe • No impairment in functioning • May actually be more productive, creative • Bipolar II Disorder Bipolar Disorder: The Course • • • • • • • • 1% of general population Equal in men and women Age of onset similar to schizophrenia Episodes can come on very fast (1-7 days) Later episodes longer, more severe, more frequent Substance abuse common Heredity plays a greater role than in depression Family members also at higher risk for major depression • High suicide risk Mood Disorders • ARE – Biological disease of the brain – Disabling and emotionally devastating for many – Common – Misunderstood and stigmatized – Treatable • ARE NOT – The fault of the family – A personal weakness Characteristics of an Illness • Affect Individuals • Across Populations • Signs and Symptoms • Course • Heredity • Diagnosis • Causes • Treatment Treatment of Schizophrenia and Other Psychotic Disorders Long Acting Antipsychotics • Haldol Decanoate (Haloperidol) • Prolixin Decanoate (Fluphenazine) Clozapine • Pros – Gold standard for refractory schizophrenia – Effective for positive symptoms – Does not produce EPS or TD – May improve cognition – Effective for mood symptoms Clozapine • Cons – Agranulocytosis, blood draws, monitoring – Seizure risk – Other side effects – Titration – Acquisition cost Risperidone • Pros – Effective for positive symptoms – Less EPS than with conventional agents – May help cognitive and mood symptoms • Cons – Dose dependent EPS – Dose dependent prolactin elevation Olanzapine • Pros – Effective for positive symptoms – Low EPS and TD liability – FDA indication for mania – May improve cognition • Cons – Weight gain – Acquisition cost Quetiapine • Pros – Effective for positive symptoms – Very low EPS liability – Limited data for mood symptoms, cognition • Cons – Titration, split dosing, sx break through – Sedation, weight gain Psychosocial Treatments • • • • • Patient and family psychoeducation Vocational training Social Skills training Clubhouse model Schizophrenics Anonymous Update on the Pharmacologic Treatment of Psychosis Timothy Florence, MD Clinical Instructor University of Michigan Department of Psychiatry Psychosis • Defined by impaired reality testing • Characterized by: – thought content: delusions – perception: hallucinations – thought stream: grossly disorganized – behavior: grossly disorganized Typical Psychoses • Schizophrenia • Psychotic mood disorders – Bipolar disorder – Major depressive disorder with psychotic features • Substance-induced psychotic disorder • Psychotic disorder due to medical conditions Mental Health: A Report of the Surgeon General David Satcher, MD, PhD www.surgeongeneral.gov/library/mentalhealth/index.html Surgeon General’s Report: Key Messages • Mental illnesses are real illnesses and are biologically based • Effective treatments are available Surgeon General’s Report: Action Steps • Overcome STIGMA by disseminating accurate information • Improve PUBLIC AWARENESS of effective treatments • Improve access to treatment • Individualize treatment • Ensure delivery of state-of-the-art treatments • Reduce financial barriers • Continue to build the science base • Ensure adequate supply of service providers Characteristics of an Illness • Affect Individuals • Across Populations • Signs and Symptoms • Course Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) DSM-IV Schizophrenia • Characteristic symptoms – Delusions – Hallucinations – Disorganized speech – Disorganzied or catatonic behavior – Negative symptoms Negative Symptoms of Schizophrenia • Affect blunted or flat – Lacking emotional expression – “Blank” face, little eye contact, few gestures • Avolition – Lacking energy, spontaneity, initiative • Alogia – Diminished amount of speech, or content • Anhedonia – Lack of interests, or lack of pleasure Negative Symptoms • Caused by: – Inherent deficit (deficit syndrome) – Positive symptoms – Depression – Medications – Environmental deprivation DSM-IV Schizophrenia • • • • Characteristic symptoms for one month Impairment in functioning Continuous signs for 6 months Not do to a “look-alike” • • • • mood disorder substance abuse general medical condition autism Positive Symptoms of Schizophrenia • Disordered thinking – Thoughts “jump” between completely unrelated topics or may be “blocked”. • Delusions – Fixed, false beliefs (not based in reality) – Outside of cultural norms • Hallucinations – False perceptions – Usually auditory Who Is At Risk For Schizophrenia? • • • • • Prevalence - 1% All ethnicities Societies throughout the world Equal among men and women More prevalent in poorer communities • “Social drift” Who Is At Risk? • Predisposing factors: – Season – Perinatal • pregnancy • birth injury – Nutrition – Heredity • Precipitating factors: – Environment – Stress – Substance Abuse The Course of Schizophrenia • Extremely variable • Often chronic • Onset – Males: 15-25 – Females: 25-35 • Functional decline early • Differential diagnosis of first episode challenging • Recurrent episodes – More difficult to treat – Longer to remission Dimensions of Functional Impairment • • • • • Occupational Social Instrumental Self-care Independent living Predictors of Functional Status • Premorbid functioning • Cognitive symptoms • Negative symptoms Severity of Functional Deficits in Schizophrenia • • • • 10% will work full-time 33% will work part-time Less than 10% of males will have a child Self-care deficits are reflected in high rates of medical comorbidity Cognition and Outcome: Reasons for the Correlation • Cognitive deficits often make learning new skills difficult • Job success requires the ability to learn and remember the demands of the position • Deficits in organization make persons unable to perform the job responsibilities • Deficits in concentration make performance unreliable Schizophrenia PORT Treatment Recommendations • Choice of antipsychotic medication should be made based on: – – – – Patient acceptability Prior individual drug response Individual side effect profile Long-term treatment planning What Is Schizophrenia? • Heterogeneous • Likely a complex group of brain illnesses with multiple causes • Genetic predisposition or vulnerability threshold • Series of consequences resulting from brain dysfunction • Requires a second “hit” Lifetime Risk of Developing Schizophrenia • • • • • • General population 1% Child of one parent with schizophrenia 10-15% Child of two parents with schizophrenia 30-40% Sibling with schizophrenia 10% Fraternal twins 10% Identical twins (adoption studies) 50% Neuroanatomy of Schizophrenia • No single change is seen in all people with schizophrenia • Enlarged ventricles • Underactive frontal lobe – planning, judgement, abstraction, expressing feelings • Overactive temporal lobe – preceptions and emotions Schizophrenia • IS – – – – – Biological disease of the brain Disabling and emotionally devastating Relatively common Misunderstood and stigmatized Treatable • IS NOT – Caused by bad parenting – A personal weakness – Split personality Mania: Signs and Symptoms • Persistently elevated, expansive or irritable mood lasting at least one week • Associated symptoms • • • • • • • Inflated self -esteem or grandiosity Decreased need for sleep More talkative Racing thoughts or flight of ideas Distractibility Agitation or increase in activities Excessive involvement in pleasurable activities with a high risk for painful consequences – Spending sprees, sexual indiscretions, foolish investments Manic Episode: DSM-IV • Elevated, expansive, or irritable mood for one week • Three associated symptoms • Significant impairment in life roles • Not do to a “look-alike” • Medical condition • Medication • Substance abuse Bipolar Disorder: The Course • • • • • • • • 1% of general population Equal in men and women Age of onset similar to schizophrenia Episodes can come on very fast (1-7 days) Later episodes longer, more severe, more frequent Substance abuse common Heredity plays a greater role than in depression Family members also at higher risk for major depression • High suicide risk The Use of Atypical Antipsychotics for Psychosis and Mood Stabilization Timothy Florence, M.D. Clinical Instructor Department of Psychiatry University of Michigan Theoretical Mood Stabilizing Mechanisms • Dopamine-Serotonin Interaction – 5-HT inhibits DA release – 5-HT antagonism enhances DA release • GABA Hypothesis – Inhibitory neurotransmitter system – May mediate Valproate and Carbamazepine effects Dopamine-Serotonin Hypothesis • DA Antagonism – Mesolimbic • Improves mania – Mesocortical • Worsens depression – Nigrostriatal • Worsens depression • 5-HT Antagonism – Mesolimbic • Worsens mania – Mesocortical • Improves depression – Nigrostriatal • Improves depression GABA Hypothesis • No change in GABA receptors with conventional neuroleptics • GABA receptor down-regulation with chronic Clozapine and Olanzapine treatment • Mood stabilizing effects may be related to effects on GABA neuro-transmission Bipolar Disorder Mortality • At least 25% attempt suicide • Suicide rate: 11-19% • Suicidal ideation in mixed mania: 50% Bipolar Disorder Morbidity • Recurrent illness for 90% of patients • Fuctional recovery often lags behind symptomatic recovery • Recurrent episodes may lead to progressive deterioration • Number of episodes may affect subsequent treatment response and prognosis • 6th leading cause of disability worldwide Mood Stabilizing Agents • FDA Approved – Lithium – Valproate • Other Anticonvulsants – Carbamazepine – Lamotrigine – Gabapentin – Topiramate • Benzodiazepines • Conventional Neuroleptics • Atypical Antipsychotics – Clozapine – Risperidone – Olanzapine Novel Antipsychotic Agents • Clozapine • Open - label studies • Risperidone • One study compared to Haloperidol and Lithium • Olanzapine • Two double-blind placebo controlled studies Clozapine for Bipolar Disorder • Fifteen open trials in treatment-refractory illness suggest antipsychotic and mood stabilizing properties • Pooled response rate = 70% • May be used in conjunction with other mood stabilizers • Exception - Carbamazepine Risperidone in Acute Mania • Four week, double-blind, randomized study • No placebo control • Comparable and significant reductions in manic symptoms with Risperidone, Haloperidol, Lithium Dopamine Rebound Syndrome • • • • • • • Euphoria / Dysphoria Hypomania / Mania Decrease in negative symptoms Agitation Psychosis Dyskinesias Withdrawal tardive dyskinesia Cholinergic Rebound Syndrome • Insomnia • Jitteriness • Restlessness / Anxiety • Somatic distress • Gastrointestinal symptoms • • • • • • Sweating Drooling Increased urination Movement disorders Hypomania / Mania Delirium