Mood and Axities

7/25/2019 Mood and Axities

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LAMPU KOSULWIT, M.D.

MOOD DISORDERS

ANXIETY DISORDERS


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PSYCHIATRIC DISORDERS
http://www.voicesforum.org.uk/expsych.jpghttp://www.voicesforum.org.uk/expsych.jpg


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* Mental disorder

*

Psychosis

*

Neurosis

*

Functional

* Organic

*

Primary

*

Secondary

Definition of mental disorder


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Mental disorder

:

illness with

psychological or

behavioral manifestations

associated with

significant

distress and impaired functioning

caused by a biologic,

social, psychological, genetic, physical, or chemical

disturbance

----------------------------------------------------------------

Psychotic :

loss of reality testing

with delusions andhallucination

Neurosis

:

intact reality testing

,

mainly intrapsychic

conflicts

or life events

,

major symptom = anxiety

e.g.,o

bsession, compulsion , phobia


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Functional : no known structure damage or

clear-cut biologic cause to account impairment

Organic : illness caused by a specific agent

producing structural associated with cognitiveimpairment , delirium , or dementia


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Primary : no known cause ; also calledidiopathic (similar to functional)

Secondary : known to be a symptomatic

manifestation of systemic, medical or cerebral

disordere.g., Delirium from meningitis,

encephalitis, brain abscess

Dementia from hypothyroidism or

vitamin B12 deficiency, neurosyphilis,

AIDS dementia complex


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* DSM-5

* DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 5th EDITION

* AMERICAN PSYCHIATRIC ASSOCIATION


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MOOD DISORDER


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M

oodState

s

Normal range

Hypomania

Mania

Dysthymia

Depression

Elevated

Depressed


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Mood disorders

Severe/ Acute Less severe /Chronic

Unipolar

No history ofmania,

hypoamnia

Major

depressivedisorder

Dysthymia

Bipolar Bipolar I

Bipolar II

Cyclothymia


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Prevalence


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Mood disordersUnipolar:

Major depressive disorder* Dysthymic disorderBipolar:

Bipolar I disorder*: Manic & depressive episodes Bipolar II disorder: Hypomanic + major depress Cyclothymic disorder : Hypomania+minor depress

Mood disorder due to GMC

Substance induced mood disorder

* psychotic features


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Major depressive episode

1.Depressed mood * 2. Diminished interest or pleasure

---------------------------------------------------------------3. Fatigue or loss of energy

4. Feelings of worthlessness or inappropriate guilt

5. Difficulties concentrating or indecisiveness

6. Recurrent thoughts of death

7. Weight loss or gain (>5% in a month)

8. Insomnia or hypersomnia9. Psychomotor retardation or agitation

5 or more of following symptoms for 2 weeks:

Symptoms must cause sig. distress or impairment

Exclusions: Substance, Medical, Bereavement


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Manic episode

1. Grandiosity

2. Decreased need for

sleep

3. Talkativeness

4. Flight of ideas or

racing thoughts

5. Distractibility

6.Increase in goal-directed activity orpsychomotor

agitation7.Buying sprees, sexual

indescretions, foolishinvestments.

1 week of abnormally elevated, expansive or

irritable mood with 3+ of following symptoms:

Symptoms must cause sig. distress or impairment

Exclusions: Substance, Medical condition


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HypomaniaSimilar symptoms to manic episode except:

n Minimum of 4 daysn Episode not severe enough to cause marked

impairment in social or occupational functioning

mania n n

n

n

D th i di d


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Dysthymic disorderA.

2

B. 2 1. 2. 3. 4. self esteem 5. 6.

C. 2 A. B. 2

D. major depressive 2 E. manic / hypomanic episodesF. schizophrenia/ delusional

disorder

G. // hypothyroidismH. Significant distress or impairment

C l h i di d


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Cyclothymic disorder

A. hypomania MDD 2

B. 2 A 2

C. major depressive / manic / mixed episodes 2

D. schizoaffective d/o,

schizophrenia, schizophreniform d/o, delusional d/o,

psychotic d/o nos

E.

hyperthyroidism

F. Significant distress or impairment


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Overview of Etiological factors

SocialSupport system

Woman & mood disorders

PsychologicalStressful life events

Behavioural factors

Cognitive factors

Psychodynamic

BiologicalNeurotransmitters

Endocrine system

Family and

genetics

Mood

Disorder


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Biological: Neurotransmitters

n Low levels of serotonin depression

n Dopamine levels:

High

Mania

Low Depression

n Low level of norepinephrine

Depression


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Low Vulnerability High Vulnerability

Stress

Vulnerability

Threshold for mood disorder

Threshold model


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Treatment :

BIO :

MEDICATIONS

ECT

PSYCHO :PSYCHOTHERAPY

SOCIAL :PSYCHOEDUCATION


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Treatment of bipolar I & II

n CBTn Interpersonal psychotherapyn Psychoeducation about disordern Chart the precipitants, nature, duration,

frequency, and seasonality of dysfunctional moodto avoid future episodes.n Medication

Lithium

Anticonvulsants (Depakote, Tegretol, Lamictal)Atypical Antipsychotics (Risperdal, Seroquel)

25

Treatment: Mania


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Treatment: Mania

Mood stabilizers:

LithiumAnticonvulsants

* valproate

* carbamazepine

* lamotrigine

* topiramate

- Atypical antipsychotics

* olanzapine (zyprexa)

* risperidone (risperdal)

* quatiapine (seroquel)

Electroconvulsive therapy (ECT)


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Antimanic drugs

n Lithium 300-900 mg/d

(therapeutic blood level o.8-1.2 mEq/l)

n Valproate 400-1200 mg/d

(50-125 g/ml)

n Carbamazepine 600-1200 mg/d

(6-12 g/ml)

Treatment: Mania


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Treatment: Mania

Electroconvulsive therapy (ECT)

- severe mania

-

Treatment of

Depression


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Treatment of Depression

Treatment: Medication


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Treatment: Medication

n Used to treat and also prevent relapse.

n Antidepressants: Effective in 50-65% of depressive cases

* Selective Serotonin reuptake inhibitors (SSRIs)* Serotonin noradrenaline reuptake

inhibitors(SNRI) : venlafaxine

* Tricyclics: Effective but can overdose

* Monoamine oxidase inhibitors (MAOs)

* ect.


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Treatment

n

2-3 anxiolytic drugs

benzodiazepines : Clonazepam ,Diazepam,Lorazepam

n 1st episode 6-9

SSRIs


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SSRIsFluoxetine(20) 1 tab PO OD pc

Diazepam 2-5mg PO hs

Sertraline (Zoloft) (50) 1 tab PO pc, , ,

Venlafaxine (Efexor-XR) (75)

1 tab PO pc , ,,


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tricyclic

Amitriptyline (25) 1 tab PO hs 75-150mg/d

Nortriptyline (25) 1 tab PO hs

75-150mg/d

n anticholinergic side effects :

, postural hypotensionn Antihistamine side effects : , , .n suicide


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n off

n depress mania

mania , hypomania

T t t d i


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Treatment : depression

Electroconvulsive therapyn - psychotic

n -

n

-

n Psychotherapy

Psychotherapy


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y pyTreatment : depression

Cognitive therapy

n Aim : correcting chronic distortions in thinkingthat lead to depression

n in particular the cognitive triad of feeling ofhopelessness, helplessness about one s self,ones future, ones past

Psychotherapy

Group therapy

Family therapy

Treatment: Which is best?


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Treatment: Which is best?

n Vegetative symptoms and severe symptoms

medication importantn Medication: quicker symptom alleviation than

psychotherapy

n Psychotherapy more effective thenmedication for prevention of relapse

n Combined treatment most effective forrelapse prevention.

Case Study Jessica


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Case Study Jessican Jessica is a 28 year-old married female. She has a very demanding, high

stress job as a second year medical resident in a large hospital.

n Jessica has always been a high achiever. She graduated with top honors inboth college and medical school. She has very high standards for herself andcan be very self-critical when she fails to meet them.

n Lately, she has struggled with significant feelings of worthlessness and shamedue to her inability to perform as well as she always has in the past.

n For the past few weeks Jessica has felt unusually fatigued and found itincreasingly difficult to concentrate at work.

n Her coworkers have noticed that she is often irritable and withdrawn, which isquite different from her typically cheerful and friendly disposition.

n She has called in sick on several occasions, which is completely unlike her.

n On those days she stays in bed all day, watching TV or sleeping.

Case Study Jessica


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Case Study Jessican At home, Jessicas husband has noticed changes as well.n

Shes shown little interest in sex and has had difficulties fallingasleep at night.n Hes overheard her having frequent tearful phone conversations

with her closest friend.

n When he tries to get her to open up about whats botheringher, she pushes him away with an abrupteverythings fine.

n Although she hasnt ever considered suicide, Jessica has foundherself increasingly dissatisfied with her life.

n Shes been having frequent thoughts of wishing she was dead.

She gets frustrated with herself because she feels like she hasevery reason to be happy, but the sense of that situation is badand is not likely to improve.

J i


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Jessica

n n

n

Case study 2


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29 8 .

3

y


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Anxiety disorder


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Anxiety disorder

Anxiety disorders are common

psychiatric disorders

Anxiety disorder


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Many patients : experience

physical symptoms related to anxiety

visit to primary care physicians

high prevalence rates of these anxiety disorders

often are underrecognized and

undertreated clinical problems

anxiety disorders


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anxiety disorders

DSM-V anxiety disorders

1. Panic Attack (Specifier)

2. Panic disorder

3. Agoraphobia

4. Generalized anxiety disorder(GAD)

5. Social Anxiety Disorder (Social Phobia)

6. Specific phobia


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Anxiety disorders

Lifetime prevalence : 1.5%-29%

(depending on subtype or severity)

Major depressive disorder comorbidity (50%)

Anxiety can precede or be coincident with depressiononset

Anxiety disorder


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Race:

* no difference in rates of panic disorder

Sex:

female : male = 3 : 2

Anxiety disorder


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Age :

* Most : begin in childhood

adolescence

early adulthood

Sex:

female : male = 3 : 2

Anxiety disorder


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New-onset anxiety symptoms in older adults

should search for

- unrecognized general medical condition

- substance abuse disorder

- major depression with secondary anxiety

symptoms

Normal anxiety Anxiety disorder


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Normal anxiety Anxiety disorder

1.

2.

3.

Anxiety disorder


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Pathophysiology :

caused by an

interaction of bio-psycho-social factors

including

- genetic vulnerability

- situations : stress, or traumatic experience

Anxiety disorder


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Pathophysiology :

In CNSmajor mediators - norepinephrine and

- serotonin

other neurotransmitters and peptides, such as

- corticotropin-releasing factor

Peripherally, the ANS

esp. sympathetic nervous system, mediates many of the symptoms


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Panic disorder

Panic disorder


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is characterized by recurrent panic attacks

periods ofintense fear of abrupt onset

peaking in intensity within minutes


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Four of the following must be present for a panic attack:1. Palpitations, pounding heart, or accelerated heart rate

2. Sweating3. Shaking

4. Sensation of shortness of breath or dyspnea 5. Feeling of choking

6. Chest pain or discomfort

7. Nausea or abdominal distress

8. Feeling dizzy, unsteady, lightheaded, or faint9. Derealization or depersonalization

10. Fear of losing control or going crazy

11. Fear of dying12. Paresthesias (numbness or tingling sensation)

13. Chills or hot flashes


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# Panic attackmental disorder#code#

PTSD SUNBSTANCE USEDISORDERS

# cardiac,

respiratory , vestibular, gastrointestinal)

Panic disorder

Four of the following must be present for a panic attack:


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1. Palpitations, poundingheart, or accelerated heartrate

2. Sweating

3. Shaking

4. Shortnessof breath or dyspnea

5. Sensationof choking 6. Chest pain or discomfort

7. Nauseaor abdominaldistress

8. Feeling dizzy, unsteady, lightheaded, or faint

9. Derealization or depersonalization

10.Fearof losingcontrol or going crazy

11.Fear of dying

12. Paresthesias

13. Chills or hotflashes

1 month 1 1. Persistent concern or worry about panic attacks or their

consequences (losing control, havig a heart attack, going crazy)

2. A significant maladaptive change in behavior related to attack( panic attacks

)

Agoraphobia


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A. marked fear or anxiety about 2(or more) of the following 5situations:

1.using public transportation (e.g. buses, trains, ships, planes). 2.being in open spaces (e.g. marketplaces, bridges).

3.being in enclosed places (e.g.,shops,theaters,cinemas).

4.Standing in line or being in a crowd.

5.Being outside of the home alone.B. Avoid these situations because of thoughts that escape might bedifficult or help might be available in the event of developing panic-likesymptoms or other incapacitating or embarrassing symptoms ( )

C. A D. A

Agoraphobia


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E. out of proportion to the actual danger

F. 6 G. clinically significant

distress or impairmnet in social , occupational, or otherimportant areas of functioning

H. specific phobia, OCD, PTSD


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Generalized anxiety disorder

Generalized anxiety disorder


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is characterized by

unrealistic excessive anxiety and worry

** free floating anxiety **

Worrying is difficult to control

DSM V : GADA ()


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A. () 6 ( )

B. C. 6 3 ( 6)1. 2. 3. 4.5. 6. ( )

D.

E. / F. ( )

Mood disorder,Psychotic disorder Pervasive developmental disorder

Generalized anxiety disorder screening


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mnemonic


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Social anxiety disorder


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Social phobia

Marked and persistent fear or anxiety aboutone or more social situation 6

impairment in social, occupational, or other

important areas of functioning

Specific Phobias


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Specific Phobias


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Specific Phobias

Marked persistent fear of situation or object

6

Examples : heights, animals or seeing blood, flying,

receiving an injection

Exposure causes intense anxiety and avoidance causinginterference

Anxiety disorder


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MEDICATION

Antidepressant : drugs of choice

- SSRIs

- TCA

- SNRI

Benzodiazepines

Pharmacotherapy : anxiety disorder


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Antidepressant : SSRIs

antianxiety

DZP, CLORAZEPATE, ALPRAZOLAM(prn panic)

Propanolol(10) 1*3 or 1* prn

Anxiety disorder


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MEDICATION

Antidepressant : drugs of choice

- SSRIs : fluoxetine, sertraline,

fluvoxamine, paroxetine, escitalopram

- TCA : clomipramine

- SNRI : venlafexine

Anxiety disorder


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* All SSRIs :

- equal in the treatment of anxiety disorders;

BUT select it by side effect and drug

interaction consideration.

Case Study : Kristen

Kristen is a 38 year old divorced mother of two teenagers


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Kristen is a 38 year-old divorced mother of two teenagers.

She has had a successful, well-paying career for the past several years in upper-level management.

Shes found herself worrying constantly about losing her job and being unable toprovide for her children. This worry has been troubling her for the past 8months. Despite her best efforts, she hasnt been able to shake the negativethoughts.

Ever since the worry started, Kristen has found herself feeling restless, tired, andtense. She often paces in her office when shes there alone.

Shes had several embarrassing moments in meetings where she has lost track ofwhat she was trying to say.

When she goes to bed at night, its as if her brain wont shut off.

She finds herself mentally rehearsing all the worse-case scenarios regardinglosing her job, including ending up homeless.

Kristen


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Kristen


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Mood and Axities