Download Diagnosis: Major Mental Illness

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
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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
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Persecution
Control
Grandiose
Reference
Influence
Religious
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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)
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Simple
Paranoid
Hebephrenic
Catatonic
• Bleuler - “Schizophrenia” (1911)
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Affect
Associations
Ambivalence
Autism
• Schneider - First Rank Features (1959)
Diagnostic and Statistical Manual
of Mental Disorders, fourth
edition (DSM-IV)
DSM-IV Schizophrenia
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Characteristic symptoms for one month
Impairment in functioning
Continuous signs for 6 months
Not do to a “look-alike”
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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
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All ethnicities
Societies throughout the world
Equal among men and women
More prevalent in poorer communities
• “Downward drift”
The Course of Schizophrenia
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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
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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
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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
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Signs and Symptoms
Diagnosis
The Biology
Other Causes
The Course of Illness
Major Depression: Signs and
Symptoms
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Emotional
Thought
Somatic (body)
Behavioral
Major Depression: Emotional
Symptoms
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Sad, irritable or empty mood
Diurnal variation
Diminished capacity for enjoyment
Diminished interests
Major Depression: Thought
(Cognitive) Symptoms
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Difficulty concentrating
Indecisiveness
Memory problems
Depressed content of thought
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Worthlessness
Guilt
Hopelessness
Death and Suicide
Major Depression: Somatic
Symptoms (Body Functions)
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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
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Slow motion
Slow speech
Poor eye contact
Tearfulness
Agitation
Poor self-care
Major Depression:
Types of Episodes
• Melancholia
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No pleasure or “reactivity”
Weight loss
Early morning awakening
Worse in the morning
Excessive Guilt
• Atypical
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Mood brightens to positive events
Weight gain
Over-sleeping
Heavy feeling in arms and legs
Interpersonal rejection sensitivity
“Masked Depression”
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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)
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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
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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
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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
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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
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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
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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?
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•
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•
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
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Occupational
Social
Instrumental
Self-care
Independent living
Predictors of Functional Status
• Premorbid functioning
• Cognitive symptoms
• Negative symptoms
Severity of Functional Deficits
in Schizophrenia
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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:
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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
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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
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Sweating
Drooling
Increased urination
Movement disorders
Hypomania / Mania
Delirium