PSYCHOLOGICAL DISORDERS

WTD3: Chapter 25WTD3: Chapter 25

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Disease burden by selected illness Disease burden by selected illness categories in established market categories in established market economies, 1990economies, 1990

PercentPercentAll cardiovascular conditionsAll cardiovascular conditions 18.618.6

All mental illness**All mental illness** 15.415.4

All malignant disease (cancer)All malignant disease (cancer) 15.015.0

All respiratory conditionsAll respiratory conditions 4.84.8

All alcohol useAll alcohol use 4.74.7

All infectious diseaseAll infectious disease 2.82.8

All drug useAll drug use 1.51.5

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0

10

20

30

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MajorDepression

Dysthymia PanicDisorder

SocialPhobia

GeneralizedAnxietyDisorder

Any AnxietyDisorder

Prevalence Of Depressive AndPrevalence Of Depressive AndAnxiety DisordersAnxiety Disorders

Prevalence Of Depressive AndPrevalence Of Depressive AndAnxiety DisordersAnxiety Disorders

Lifetime Prevalen

ce(%)

National Comorbidity Survey

National Comorbidity Survey

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FACT SHEETS26.2 percent of Americans ages 18 and older 26.2 percent of Americans ages 18 and older — about one in four adults are diagnosed with a — about one in four adults are diagnosed with a mental disorder annually (57.7 million people )mental disorder annually (57.7 million people )Only 6% (one in 17) suffer from a serious Only 6% (one in 17) suffer from a serious mental illnessmental illnessA leading cause for disability in age group 15-A leading cause for disability in age group 15-444445% of people diagnosed have more than 2 45% of people diagnosed have more than 2 mental disorders diagnosedmental disorders diagnosedHigher in older people (14/100,000)Higher in older people (14/100,000)

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Suicide

eighth leading cause of death for males and eighth leading cause of death for males and the sixteenth leading cause of death for females in 2004 the sixteenth leading cause of death for females in 2004

Suicide by: Males (%)

Females (%)

FirearmsFirearms 5757 3232

SuffocationSuffocation 2323 2020

PoisoningPoisoning 1313 3838

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SuicideCall this toll-free number, available 24 hours Call this toll-free number, available 24 hours a a day, every day: 1-800-273-TALK (8255). day, every day: 1-800-273-TALK (8255). Most suicide attempts are expressions of Most suicide attempts are expressions of extreme distress, not harmless bids for extreme distress, not harmless bids for attention. attention. A person who appears suicidal should not be A person who appears suicidal should not be left alone and needs immediate mental-left alone and needs immediate mental- health health treatment. treatment.

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Risk factors for Suicide

depression and other mental disorders, or depression and other mental disorders, or a substance-abuse disorder (More than 90 a substance-abuse disorder (More than 90 percent of people who die by suicide have percent of people who die by suicide have these these risk factors.) risk factors.) prior suicide attempt prior suicide attempt family history of suicide family history of suicide family violence, including physical or sexual family violence, including physical or sexual abuse abuse firearms in the home, (the method used in more firearms in the home, (the method used in more

than half of suicides )than half of suicides )incarceration incarceration exposure to the suicidal behavior of others, such exposure to the suicidal behavior of others, such

as family members, peers, or media figures.as family members, peers, or media figures.

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?Chemical Basis for suicideDecreased levels of serotonin have been Decreased levels of serotonin have been

found in:found in: people with depressionpeople with depressionimpulsive disordersimpulsive disordersa history of suicide attempts, and a history of suicide attempts, and in the brains of suicide victims in the brains of suicide victims

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? Genetic basis

Two genes are involvedTwo genes are involvedBoth genes code for components of the Both genes code for components of the brain’s glutamate chemical messenger system, brain’s glutamate chemical messenger system, involved in the antidepressant response.involved in the antidepressant response.6 percent started to have suicidal thoughts 6 percent started to have suicidal thoughts while taking an antidepressant. while taking an antidepressant. This rate soared to 36 percent among the few This rate soared to 36 percent among the few patients with patients with bothboth of the suspect gene of the suspect gene versions; versions; 59 percent of the patients who had suicidal 59 percent of the patients who had suicidal thoughts had at least thoughts had at least oneone of the versions. of the versions.

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?TherapyCognitive behavioral therapy (useful in Cognitive behavioral therapy (useful in bipolar)bipolar)Drug rehabDrug rehabClozapine helps in schizophrenicsClozapine helps in schizophrenics

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ANXIETY DISORDERS Generalized Anxiety Disorder Generalized Anxiety Disorder Obsessive-Compulsive Disorder (OCD) Obsessive-Compulsive Disorder (OCD) Panic Disorder Panic Disorder Post-Traumatic Stress Disorder (PTSD) Post-Traumatic Stress Disorder (PTSD) Social Phobia (or Social Anxiety Disorder)Social Phobia (or Social Anxiety Disorder) 18% (40 MILLION FFECTED PER YEAR)18% (40 MILLION FFECTED PER YEAR)

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Panic Disorder

““For me, a panic attack is almost a violent For me, a panic attack is almost a violent experience. I feel disconnected from reality. experience. I feel disconnected from reality.

I feel like I’m losing control in a very extreme way. I feel like I’m losing control in a very extreme way.

My heart pounds really hard, I feel like I can’t get My heart pounds really hard, I feel like I can’t get my breath, and there’s an overwhelming my breath, and there’s an overwhelming

feeling that things are crashing in on me.”feeling that things are crashing in on me.”

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Panic Disorder: “Terror Attacks”

a pounding heart, sweatiness, weakness, a pounding heart, sweatiness, weakness, faintness, or dizziness faintness, or dizziness may flush or feel chilled; their hands may tingle may flush or feel chilled; their hands may tingle or feel numb; and they may experience nausea, or feel numb; and they may experience nausea, chest pain, or chest pain, or smothering sensations. smothering sensations. a sense of unreality, a fear of impending doom, or a sense of unreality, a fear of impending doom, or a fear of losing control. a fear of losing control.

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Panic Disorder6 million American adults affected 6 million American adults affected Twice as common in women as menTwice as common in women as menPanic attacks often begin in late Panic attacks often begin in late

adolescence or early adulthood adolescence or early adulthood ?inherited?inherited?Claustrophba/ ?Agarophobia ?Claustrophba/ ?Agarophobia

both can occurboth can occurMay be associated with other May be associated with other

mental disordersmental disorders

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OCD

““I would wash my hair three times as I would wash my hair three times as opposed to once because three was a opposed to once because three was a

good good luck number and one wasn’t. It took luck number and one wasn’t. It took me me longer to read because I’d count the longer to read because I’d count the lines in lines in a paragraph. When I set my a paragraph. When I set my alarm at night, alarm at night, I had to set it to a I had to set it to a number that wouldn’t number that wouldn’t add up to a ‘bad’ add up to a ‘bad’ number.” number.”

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OCD

Persistent, upsetting thoughts Persistent, upsetting thoughts (obsessions) (obsessions) Patients use rituals (compulsions) to Patients use rituals (compulsions) to control the anxiety these thoughts control the anxiety these thoughts produce. produce. Most of the time, the rituals end up Most of the time, the rituals end up controlling them. controlling them.

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OCD 2.2 million American adults affected2.2 million American adults affected M:F starts in early childhood-adulthoodM:F starts in early childhood-adulthood ?familial?familial Drugs/ ‘Desensitize’ the behaviorDrugs/ ‘Desensitize’ the behavior

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Post-Traumatic Stress Disorder (PTSD)

““Then I started having flashbacks. Then I started having flashbacks. They They kind of came over me like a splash kind of came over me like a splash of of water. I would be terrified. Suddenly water. I would be terrified. Suddenly I I was reliving the event. Every instant was reliving the event. Every instant was was startling. I wasn’t aware of startling. I wasn’t aware of anything anything around me, I was in a bubble, around me, I was in a bubble, just kind of just kind of floating. And it was floating. And it was scary. Having a scary. Having a flashback can wring flashback can wring you out.”you out.” 7.7 million American adults affected7.7 million American adults affected F>MF>M

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PTSD featuresstartle easily, startle easily, become emotionally numb (especially in become emotionally numb (especially in relation to people with whom they used to be relation to people with whom they used to be close), close), lose interest in things they used to enjoy,lose interest in things they used to enjoy, have trouble feeling affectionate, have trouble feeling affectionate, be irritable, be irritable, become more aggressive, or even become become more aggressive, or even become

violent. violent.

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PTSD outcomes

Usually begin within 3 months. Usually begin within 3 months. Must last more than a month to be Must last more than a month to be

considered PTSD. considered PTSD. The course of the illness varies-The course of the illness varies-Recover within 6 months, Recover within 6 months, While others have symptoms that last While others have symptoms that last

much longermuch longerBecomes chronic. Becomes chronic.

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Social Phobia (Social Anxiety Disorder)

““When I would walk into a room full of When I would walk into a room full of people, I’d turn red and it would feel people, I’d turn red and it would feel like like everybody’s eyes were on me. I everybody’s eyes were on me. I was was embarrassed to stand off in a embarrassed to stand off in a corner by corner by myself, but I couldn’t think of anything to myself, but I couldn’t think of anything to say to anybody. It was humiliating. I felt say to anybody. It was humiliating. I felt so so clumsy, I couldn’t wait to get out.”clumsy, I couldn’t wait to get out.”15 million American adults affected15 million American adults affectedM:FM:FChildhood-early adolescence onsetChildhood-early adolescence onset

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SADIntense, persistent, and chronic fear of Intense, persistent, and chronic fear of being watched and judged by others being watched and judged by others and of and of

doing things that will embarrass them. doing things that will embarrass them. Blushing, profuse sweating, trembling, Blushing, profuse sweating, trembling, nausea, nausea, and difficulty talking. and difficulty talking.

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Specific Phobias : 19 million affected F>M

Fear of flying- ‘It was an awful feeling Fear of flying- ‘It was an awful feeling when when that airplane door closed and I that airplane door closed and I felt felt trapped. My heart would pound, trapped. My heart would pound, and I would and I would sweat bullets. When the sweat bullets. When the airplane would airplane would start to ascend, it just start to ascend, it just reinforced the feeling reinforced the feeling that I couldn’t that I couldn’t get out. When I think about get out. When I think about flying, I flying, I picture myself losing control, picture myself losing control, freaking freaking out, and climbing the walls, …’out, and climbing the walls, …’Others-closed-in places, heights, Others-closed-in places, heights, escalators, escalators, tunnels, highway driving, tunnels, highway driving, water, flying, water, flying, dogs, and injuries dogs, and injuries involving blood. involving blood.

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Generalized Anxiety Disorder (GAD)

““I’d have terrible sleeping problems. There I’d have terrible sleeping problems. There were times I’d wake up wired in the were times I’d wake up wired in the middle middle

of the night. I had trouble concentrating, of the night. I had trouble concentrating, even reading the newspaper or a novel. even reading the newspaper or a novel. Sometimes I’d feel a little lightheaded. My Sometimes I’d feel a little lightheaded. My heart would race or pound. And that would heart would race or pound. And that would make me worry more. I was always make me worry more. I was always imagining things were worse than they imagining things were worse than they really really were: when I got a stomachache, I’d were: when I got a stomachache, I’d think it think it was an ulcer.”was an ulcer.”6.8 million affected F>M6.8 million affected F>M

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GADUnprovoked exaggerated worry and Unprovoked exaggerated worry and tension tension Overly concerned about health issues, Overly concerned about health issues, money, family problems, or difficulties at money, family problems, or difficulties at

workworkWorries excessively about a variety of Worries excessively about a variety of everyday problems for at least 6 months everyday problems for at least 6 months Can’t relax, startle easily, and have Can’t relax, startle easily, and have difficulty concentrating, have insomniadifficulty concentrating, have insomnia

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GAD: Associated Physical symptoms

fatigue, fatigue, headaches, headaches, muscle tension/aches, muscle tension/aches, difficulty swallowing, difficulty swallowing, trembling, twitching, irritability, sweating,trembling, twitching, irritability, sweating,nausea, lightheadedness, nausea, lightheadedness, having to go to the bathroom frequently, having to go to the bathroom frequently, feeling out of breath, and feeling out of breath, and hot flashes hot flashes

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ANXIETY DISORDERS Therapy Guidelines

Psychotherapy and / or medicationsPsychotherapy and / or medicationsIdentify and treat drug abuse Identify and treat drug abuse Treat with- antidepressants, anti-anxiety Treat with- antidepressants, anti-anxiety drugs, and beta-blockers drugs, and beta-blockers 4 to 6 weeks before symptoms start to fade 4 to 6 weeks before symptoms start to fade

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SSRIsFluoxetine (Prozac®), Fluoxetine (Prozac®), sertraline (Zoloft®), sertraline (Zoloft®), escitalopram (Lexapro®), escitalopram (Lexapro®), paroxetine (Paxil®), and paroxetine (Paxil®), and citalopram (Celexa®) citalopram (Celexa®) for panic disorder, OCD, PTSD, and social for panic disorder, OCD, PTSD, and social

phobia, OCDphobia, OCDvenlafaxine (Effexor®), for GADvenlafaxine (Effexor®), for GAD

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“serotonin syndrome,”

confusion, hallucinations, increased confusion, hallucinations, increased sweating, muscle stiffness, seizures, sweating, muscle stiffness, seizures, changes in blood pressure or heart changes in blood pressure or heart rhythm rhythm

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Tricyclics: anxiety disorders other than OCD

cause dizziness, drowsiness, dry mouth, cause dizziness, drowsiness, dry mouth, and weight gain, and weight gain, imipramine (Tofranil®), which is imipramine (Tofranil®), which is prescribed prescribed for panic disorder and GAD, for panic disorder and GAD, and and clomipramine (Anafranil®), which is clomipramine (Anafranil®), which is the the only tricyclic antidepressant useful for only tricyclic antidepressant useful for treating OCD. treating OCD.

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MAO inhibitors

phenelzine (Nardil®), phenelzine (Nardil®), tranylcypromine (Parnate®), and tranylcypromine (Parnate®), and isocarboxazid (Marplan®) \isocarboxazid (Marplan®) \panic disorder and social phobia panic disorder and social phobia Food/Drug/Herb interactions-cannot eat a variety Food/Drug/Herb interactions-cannot eat a variety of of foods and beverages (including cheese and red foods and beverages (including cheese and red wine) wine) that contain that contain tyramine*tyramine* or take certain or take certain medications, medications, including some types of including some types of birth control birth control pills, pain pills, pain relievers (such as relievers (such as Advil®, Motrin®, or Advil®, Motrin®, or Tylenol®), cold Tylenol®), cold and and allergy medications, and allergy medications, and herbal supplementsherbal supplements* tyramine* tyramine - is similar to essential amino acid - is similar to essential amino acid TYROSINE – required for synthesis of epinephrineTYROSINE – required for synthesis of epinephrine

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High-potency benzodiazepines Clonazepam (Klonopin®) is used for Clonazepam (Klonopin®) is used for social phobia and GAD, social phobia and GAD, Lorazepam (Ativan®) is helpful for panic Lorazepam (Ativan®) is helpful for panic

disorder, and disorder, and Alprazolam (Xanax®) is useful for both Alprazolam (Xanax®) is useful for both

panic disorder and GAD.panic disorder and GAD.Note!-Some people experience Note!-Some people experience withdrawal symptoms if they stop withdrawal symptoms if they stop taking taking benzodiazepines abruptly benzodiazepines abruptly instead of instead of tapering tapering

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Beta-Blockers

Propranalol (Inderal®)Propranalol (Inderal®)Can prevent the physical symptoms Can prevent the physical symptoms that that accompany certain anxiety accompany certain anxiety disorders, disorders, particularly social phobia. particularly social phobia.

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CBT

Cognitive-behavioral therapy (CBT) is Cognitive-behavioral therapy (CBT) is very very useful in treating anxiety useful in treating anxiety disorders. disorders. CBT or behavioral therapy often lasts CBT or behavioral therapy often lasts about about 12 weeks. It may be conducted 12 weeks. It may be conducted individually individually or with a group of or with a group of people people who have who have similar problems. Group similar problems. Group therapy is therapy is particularly effective for particularly effective for

social phobia. social phobia. Psychotherapy by trained peoplePsychotherapy by trained people

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CBT

Benefits of CBT last longer than Benefits of CBT last longer than those those of medication for people of medication for people with panic with panic disorder, and the same disorder, and the same may be true may be true for OCD, PTSD, and for OCD, PTSD, and social phobia. If a social phobia. If a disorder disorder recurs at a later date, the recurs at a later date, the same same therapy can be used to treat it therapy can be used to treat it successfully a second time. successfully a second time.

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ADHD: Attention Deficit Hyperactivity Disorder

Impulsiveness:Impulsiveness: a child who acts quickly without a child who acts quickly without thinking first. thinking first.

HyperactivityHyperactivity:: a child who can't sit still, walks, a child who can't sit still, walks, runs, or climbs around when others are runs, or climbs around when others are

seated, talks when others are talking. seated, talks when others are talking. Inattention:Inattention: a child who daydreams or seems to a child who daydreams or seems to

be in another world, is sidetracked by what be in another world, is sidetracked by what is is going on around him or her during preschool going on around him or her during preschool and and early school years early school years 3 -5 percent of children have ADHD, or 3 -5 percent of children have ADHD, or approximately 2 million children approximately 2 million children

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ADHDFirst described in 1845First described in 1845Remember!-Remember!-All children are sometimes restless, All children are sometimes restless, sometimes act without thinking, sometimes act without thinking, sometimes daydream the time sometimes daydream the time away. away.

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ADHD

DSM-IV-TR classifies-DSM-IV-TR classifies- predominantly hyperactive-impulsive predominantly hyperactive-impulsive

typetype predominantly inattentive typepredominantly inattentive type combined typecombined type

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ADHD- hyperactive-impulsive

Always “on the go” or constantly in Always “on the go” or constantly in motion. They dash around touching motion. They dash around touching or or

playing with whatever is in sight, playing with whatever is in sight, or or talk incessantly talk incessantly

Squirm and fidgetSquirm and fidgetWiggle their feet, touch everything, tap Wiggle their feet, touch everything, tap

the pencilthe pencil

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ADHD- Impulsiveunable to curb their immediate unable to curb their immediate reactions reactions or think before they act or think before they act ‘‘blurt out’ inappropriate commentsblurt out’ inappropriate commentsShow emotions without restraintShow emotions without restraintCan’t wait!Can’t wait!Even as teenagers or adults, they may Even as teenagers or adults, they may impulsively choose to do things that have impulsively choose to do things that have

an immediate but small payoff rather an immediate but small payoff rather than than engage in activities that may take engage in activities that may take more more effort yet provide much greater but effort yet provide much greater but delayed delayed rewards. rewards.

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You are hyperactive –impulsive-ADHD-

Feeling restless, often fidgeting with hands Feeling restless, often fidgeting with hands or feet, or squirming while seated or feet, or squirming while seated

Running, climbing, or leaving a seat in Running, climbing, or leaving a seat in situations where sitting or quiet behavior is situations where sitting or quiet behavior is expected expected

Blurting out answers before hearing the Blurting out answers before hearing the whole question whole question

Having difficulty waiting in line or taking Having difficulty waiting in line or taking turns. turns.

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You are inattentive –-ADHD-

Difficulty in- focusing deliberate, Difficulty in- focusing deliberate, conscious conscious attention to organizing and attention to organizing and completing a completing a task or learning something task or learning something new.new.Homework is particularly hard Homework is particularly hard If finally finished, is full of errors and If finally finished, is full of errors and erasureserasuresHomework is often accompanied by Homework is often accompanied by frustration for both parent and child. frustration for both parent and child.

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signs of inattention:‘Daydreamers’

Often becoming easily distracted by Often becoming easily distracted by irrelevant sights and sounds irrelevant sights and sounds Often failing to pay attention to details Often failing to pay attention to details and and making careless mistakes making careless mistakes Rarely following instructions carefully Rarely following instructions carefully and and completely losing or forgetting completely losing or forgetting things like things like toys, or pencils, books, and toys, or pencils, books, and tools needed for tools needed for a task a task Often skipping from one uncompleted Often skipping from one uncompleted activity to another. activity to another.

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Is it really ADHD?

Because everyone shows some of these Because everyone shows some of these behaviors at times, the diagnosis requires behaviors at times, the diagnosis requires

that that such behavior be demonstrated to a such behavior be demonstrated to a degree that is degree that is inappropriate for the inappropriate for the person’s age. person’s age. Behaviors must appear early in life, before Behaviors must appear early in life, before age 7, and continue for at least 6 age 7, and continue for at least 6 months. months. Above all, the behaviors must create a real Above all, the behaviors must create a real handicap in at least two handicap in at least two areas of a areas of a person’s life person’s life

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Who can help?Specialty Can

DiagnosADHD

Can prescribe medication, if needed

Provides counseling or training

Psychiatrists yes yes yesPsychologists yes yes* yesPediatricians

or Family Physicians

yes yes no

Neurologists yes yes noClinical Social

workersyes no yes

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ADHD ‘like’ disorder caused by-

A sudden change in the child’s life—the death of A sudden change in the child’s life—the death of a a parent or grandparent; parents’ divorce; parent or grandparent; parents’ divorce; a parent’s a parent’s job loss job loss Undetected seizures, such as in petit mal or Undetected seizures, such as in petit mal or temporal lobe seizures temporal lobe seizures A middle ear infection that causes intermittent A middle ear infection that causes intermittent hearing problems hearing problems Medical disorders that may affect brain Medical disorders that may affect brain functioning functioning Underachievement caused by learning disability Underachievement caused by learning disability Anxiety or depression. Anxiety or depression.

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?Blame ADHD on environment

cigarettes and alcohol during pregnancy cigarettes and alcohol during pregnancy high levels of lead in the bodies of young high levels of lead in the bodies of young preschool children preschool children brain injurybrain injurydiet restrictions helped about 5 % ofdiet restrictions helped about 5 % ofchildren with ADHD, mostly young children with ADHD, mostly young children children who had food allergieswho had food allergies

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?Size matters

As a group, the ADHD children showed 3-As a group, the ADHD children showed 3-4 percent smaller brain volumes in all 4 percent smaller brain volumes in all regions—the frontal lobes, temporal gray regions—the frontal lobes, temporal gray matter, caudate nucleus, and cerebellum. matter, caudate nucleus, and cerebellum.

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ADHD Associated conditions20-30% have additional learning disability-20-30% have additional learning disability-difficulty in understanding certain sounds difficulty in understanding certain sounds or words and/or difficulty in or words and/or difficulty in expressing expressing oneself in words oneself in words reading or spelling disabilities, writing reading or spelling disabilities, writing disorders, and arithmetic disorders may disorders, and arithmetic disorders may appear appear reading disorder, reading disorder, dyslexiadyslexia, is quite , is quite widespread (8%)widespread (8%)

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ADHD Associated conditions

Tourette SyndromeTourette Syndrome -nervous tics -nervous tics and repetitive mannerisms, such as and repetitive mannerisms, such as eye eye

blinks, facial twitches, or blinks, facial twitches, or grimacing. grimacing. Others may clear their throats frequently, Others may clear their throats frequently, snort, sniff, or bark out words. snort, sniff, or bark out words. Oppositional Defiant Disorder Oppositional Defiant Disorder (ODD)-(ODD)- boys-defiant, stubborn, non- boys-defiant, stubborn, non-compliant, have outbursts of compliant, have outbursts of temper, or temper, or become belligerent. They argue with become belligerent. They argue with adults and refuse to obey. (30-50%)adults and refuse to obey. (30-50%)

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ADHD Outcome- 20-40%-conduct disorder (CD), a more serious 20-40%-conduct disorder (CD), a more serious

pattern of antisocial behavior conduct disorder:pattern of antisocial behavior conduct disorder: frequently lie or steal, frequently lie or steal, fight with or bully others, and are at a real risk of fight with or bully others, and are at a real risk of

getting into trouble at school or with the police. getting into trouble at school or with the police. violate the basic rights of other people, violate the basic rights of other people, are aggressive toward people and/or animals, are aggressive toward people and/or animals, destroy property, break into people’s homes, commit destroy property, break into people’s homes, commit

thefts, carry or use weapons, or engage in thefts, carry or use weapons, or engage in vandalism. vandalism.

These children or teens are at greater risk for These children or teens are at greater risk for substance use experimentation, and later substance use experimentation, and later dependence and abuse. dependence and abuse.

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ADHD Associated conditions

Anxiety and Depression Anxiety and Depression Bipolar Disorder Bipolar Disorder

(difficult to differentiate)(difficult to differentiate)

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ADHD Drug Therapy- StimulantsTrade Name Generic Name Approved

Age

AdderallAdderall amphetamineamphetamine 3 and older3 and older

ConcertaConcerta mmethylphenidateethylphenidate (long acting)(long acting) 6 and older6 and older

Cylert*Cylert* pemolinepemoline 6 and older6 and older

DexedrineDexedrine dextroamphetaminedextroamphetamine 3 and older3 and older

DextrostatDextrostat dextroamphetaminedextroamphetamine 3 and older3 and older

FocalinFocalin dexmethylphenidatedexmethylphenidate 6 and older6 and older

Metadate ERMetadate ER mmethylphenidateethylphenidate (extended release)(extended release) 6 and older 6 and older

Metadate CDMetadate CD mmethylphenidateethylphenidate (extended release)(extended release) 6 and older6 and older

RitalinRitalin methylphenidatemethylphenidate 6 and older6 and older

Ritalin SRRitalin SR mmethylphenidateethylphenidate (extended release)(extended release) 6 and older6 and older

Ritalin LARitalin LA mmethylphenidateethylphenidate (long acting)(long acting) 6 and older6 and older

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ADHD Therapy Drug – non stimulant

Strattera®, or atomoxetine, works on the Strattera®, or atomoxetine, works on the neurotransmitter norepinephrine, whereas neurotransmitter norepinephrine, whereas

the stimulants primarily work on dopamine the stimulants primarily work on dopamine Side effects of Ritalin-The most common Side effects of Ritalin-The most common side effects are decreased appetite, insomnia, side effects are decreased appetite, insomnia, increased anxiety, and/or irritability. Some increased anxiety, and/or irritability. Some children report mild children report mild stomach aches or stomach aches or headaches. headaches.

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?Duration of medication

About 80 percent of children who need About 80 percent of children who need medication for ADHD still need it as medication for ADHD still need it as teenagers. Over 50 percent need teenagers. Over 50 percent need medication as adults. medication as adults.

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AUTISM: (Pervasive Developmental Disorders)

Severe and pervasive impairment in thinking, feeling, Severe and pervasive impairment in thinking, feeling, language, and the language, and the ability to relate to others. ability to relate to others. Subtypes-Subtypes-Autistic disorder, Pervasive development disorder not otherwise specified (PDD-NOS), Asperger syndrome

Rett syndrome and childhood disintegrative disorder.

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Autism

3.4 of every 1,000 children 3-10 years old had autism 3.4 of every 1,000 children 3-10 years old had autism only 50 percent of children are diagnosed only 50 percent of children are diagnosed before before kindergartenkindergarten.. demonstrate deficits in demonstrate deficits in

1) social interaction, 2) verbal and nonverbal communication, and 3) repetitive behaviors or interests, unusual responses to sensory experiences, such as certain sounds or the way objects look

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Indicators of Autism Disorders:

Does not babble, point, or make meaningful gestures by 1 Does not babble, point, or make meaningful gestures by 1 year of age year of age Does not speak one word by 16 months Does not speak one word by 16 months

Some kids are late speakers, though. Make sure they don’t have infections, hearing problems, etc.

Does not combine two words by 2 years Does not combine two words by 2 years Does not respond to name Does not respond to name Loses language or social skills Loses language or social skills

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Other Indicators of Autism Disorders:

Poor eye contact Poor eye contact Doesn't seem to know how to play with toys Doesn't seem to know how to play with toys Excessively lines up toys or other objects Excessively lines up toys or other objects Is attached to one particular toy or object Is attached to one particular toy or object Doesn't smile Doesn't smile At times seems to be hearing impaired At times seems to be hearing impaired

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Autism:

By age 3, most children have passed predictable By age 3, most children have passed predictable milestones on the path to milestones on the path to learning language; learning language; Can be muteCan be muteMay simply scream or grab May simply scream or grab ?genetics: fragile-X syndrome/ tuberous sclerosis?genetics: fragile-X syndrome/ tuberous sclerosis

Specifically associated with autism spectrum disorders

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Autism:no single best treatment package no single best treatment package early intervention is important; another is that most early intervention is important; another is that most individuals with ASD respond well to highly structured, individuals with ASD respond well to highly structured, specialized programs specialized programs applied behavior analysis applied behavior analysis build on the child's interestsbuild on the child's interestsoffer a predictable scheduleoffer a predictable scheduleteach tasks as a series of simple stepsteach tasks as a series of simple stepsactively engage the child's attention in highly structured actively engage the child's attention in highly structured activitiesactivitiesprovide regular reinforcement of behavior. provide regular reinforcement of behavior.

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Autism: ?Diet

gluten-free, casein-free diet gluten-free, casein-free diet ? use of secretin- Anecdotal reports have shown ? use of secretin- Anecdotal reports have shown

improvement in autism symptoms, including sleep improvement in autism symptoms, including sleep patterns, eye contact, language skills, and patterns, eye contact, language skills, and alertness. alertness.

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? Causes AutismUnknownUnknownHeavy metals not proven/ mercury no Heavy metals not proven/ mercury no longer used in longer used in vaccinesvaccinesThat said, shouldn’t give multiple vaccines at once – need to give them gradually. That said, shouldn’t give multiple vaccines at once – need to give them gradually. DPT (whooping cof, diptheria, tetanus) should be given 1DPT (whooping cof, diptheria, tetanus) should be given 1stst 9 months of life. 9 months of life. 18 months, mumps, measles, rubella18 months, mumps, measles, rubellaAge 5 - Hep A, BAge 5 - Hep A, BThe catch is that daycare can expose kids to all of these before the age of 12 months! Rotavirus, The catch is that daycare can expose kids to all of these before the age of 12 months! Rotavirus, staph, strep and more can be acquired here as well. That means more antibiotics and resulting staph, strep and more can be acquired here as well. That means more antibiotics and resulting superinfections. superinfections.

Postmortem and MRI studies have shown that many Postmortem and MRI studies have shown that many major brain structures are implicated in autism. This major brain structures are implicated in autism. This includes the cerebellum, cerebral cortex, limbic system, includes the cerebellum, cerebral cortex, limbic system, corpus callosum, basal ganglia, and brain stem. corpus callosum, basal ganglia, and brain stem. Abnormal brain development beginning in the infant’s Abnormal brain development beginning in the infant’s first few months. first few months. ““Growth dysregulation hypothesis” Growth dysregulation hypothesis”

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Structures involved in Autism

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Bipolar Disorder: Manic-Depressive

2.6% (5.7million)2.6% (5.7million) ““Manic-depression distorts moods and thoughts, incites Manic-depression distorts moods and thoughts, incites

dreadful behaviors, destroys the basis of rational thought, dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. One that and too often erodes the desire and will to live. One that brings in its wake almost unendurable suffering and, not brings in its wake almost unendurable suffering and, not infrequently, suicide.” infrequently, suicide.”

Mood swingsMood swings

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Signs and symptoms of mania (or a manic episode)

Increased energy, activity, and restlessness Increased energy, activity, and restlessness Excessively “high,” overly good, euphoric mood Excessively “high,” overly good, euphoric mood Extreme irritability Extreme irritability Racing thoughts and talking very fast, jumping from one idea to Racing thoughts and talking very fast, jumping from one idea to another another Distractibility, can’t concentrate well Distractibility, can’t concentrate well Little sleep needed Little sleep needed Unrealistic beliefs in one’s abilities and powers Unrealistic beliefs in one’s abilities and powers Poor judgment Poor judgment Spending sprees Spending sprees A lasting period of behavior that is different from usual A lasting period of behavior that is different from usual Increased sexual drive Increased sexual drive Abuse of drugs, particularly cocaine, alcohol, and sleeping Abuse of drugs, particularly cocaine, alcohol, and sleeping medications medications Provocative, intrusive, or aggressive behavior Provocative, intrusive, or aggressive behavior Denial that anything is wrong Denial that anything is wrong

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DSM-IV Criteria for Manic episode

3 or more of the other symptoms most of the day, nearly 3 or more of the other symptoms most of the day, nearly every day, for 1 week or longer. every day, for 1 week or longer. If the mood is irritable, four additional symptoms must be If the mood is irritable, four additional symptoms must be present. present. Psychotic symptoms -hallucinations (hearing, seeing, or Psychotic symptoms -hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person’s usual cultural logical reasoning or explained by a person’s usual cultural concepts). concepts).

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Signs and symptoms of depression

(or a depressive episode)

Lasting sad, anxious, or empty mood Lasting sad, anxious, or empty mood Feelings of hopelessness or pessimism Feelings of hopelessness or pessimism Feelings of guilt, worthlessness, or helplessness Feelings of guilt, worthlessness, or helplessness Loss of interest or pleasure in activities once enjoyed, including Loss of interest or pleasure in activities once enjoyed, including sex sex Decreased energy, a feeling of fatigue or of being “slowed down” Decreased energy, a feeling of fatigue or of being “slowed down” Difficulty concentrating, remembering, making decisions Difficulty concentrating, remembering, making decisions Restlessness or irritability Restlessness or irritability Sleeping too much, or can’t sleep Sleeping too much, or can’t sleep Change in appetite and/or unintended weight loss or gain Change in appetite and/or unintended weight loss or gain

These are the early signs. Can happen quickly or slowly.Chronic pain or other persistent bodily symptoms that are not Chronic pain or other persistent bodily symptoms that are not caused by physical illness or injury caused by physical illness or injury Thoughts of death or suicide, or suicide attempts Thoughts of death or suicide, or suicide attempts

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Criteria for Depressive Episode

A depressive episode is diagnosed if five or A depressive episode is diagnosed if five or more of these symptoms last most of the more of these symptoms last most of the day, nearly every day, for a period of 2 day, nearly every day, for a period of 2 weeks or longer weeks or longer

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Bipolar: DSM-IV-TR classifies-Bipolar 1:recurrent episodes of mania and depression Bipolar 1:recurrent episodes of mania and depression (Classic type)(Classic type)Bipolar 2:never develop severe mania but instead Bipolar 2:never develop severe mania but instead experience milder episodes of hypomania that alternate experience milder episodes of hypomania that alternate with depression with depression Rapid-recycling type: four or more episodes of illness Rapid-recycling type: four or more episodes of illness occur within a 12-month period occur within a 12-month period

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Outcomes:

Bipolar disorder is a recurrent illness, Bipolar disorder is a recurrent illness, long-term long-term preventive treatment is strongly recommended and preventive treatment is strongly recommended and almost always indicated almost always indicated ““mood stabilizers” –mood stabilizers” –

This is the best western tx for it – keep the mood swings from occuring. Lithium Lithium

Controls mood swings, but high doses can cause convulsions, coma, death. Must measure blood levels every couple of months. This is the 2nd choice now.

Anti-convulsants- valproate (Depakote®) or Anti-convulsants- valproate (Depakote®) or carbamazepine (Tegretol®), (valproate may lead to carbamazepine (Tegretol®), (valproate may lead to adverse hormone changes in teenage girls and polycystic adverse hormone changes in teenage girls and polycystic ovary syndrome in women who began taking the ovary syndrome in women who began taking the medication before age 20)medication before age 20)

All drugs here are teratogenic…not for use with preggers.

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Depression: A Systemic Illness—The Emotional and Physical Signs

Headache Headache FatigueFatigue Disturbed sleepDisturbed sleep DizzinessDizziness Chest painChest pain Vague joint/limb painVague joint/limb pain Vague back/abdominal painVague back/abdominal pain GI complaints (nausea, GI complaints (nausea,

vomiting, constipation, vomiting, constipation, diarrhea, gas)diarrhea, gas)

Sexual dysfunction/apathySexual dysfunction/apathy Menstrual problemsMenstrual problems

Depressed moodDepressed mood

AnhedoniaAnhedonia

HopelessnessHopelessness

Low self-esteemLow self-esteem

Impaired memoryImpaired memory

Difficulty concentratingDifficulty concentrating

AnxietyAnxiety

Preoccupation with Preoccupation with negative thoughtsnegative thoughts

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Types of Depression

Major depressive disorderMajor depressive disorder More than 12 weeks

Dysthymic disorderDysthymic disorder Psychotic depressionPsychotic depression Postpartum depressionPostpartum depression

Can manifest up to 18 months after delivery!Can manifest up to 18 months after delivery!

Seasonal affective disorder (SAD)Seasonal affective disorder (SAD)

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Symptoms of DepressionPersistent sad, anxious or "empty" feelings Persistent sad, anxious or "empty" feelings Feelings of hopelessness and/or pessimism Feelings of hopelessness and/or pessimism Feelings of guilt, worthlessness and/or helplessness Feelings of guilt, worthlessness and/or helplessness Irritability, restlessness Irritability, restlessness Loss of interest in activities or hobbies once pleasurable, Loss of interest in activities or hobbies once pleasurable,

including sex including sex Fatigue and decreased energy Fatigue and decreased energy Difficulty concentrating, remembering details and making Difficulty concentrating, remembering details and making

decisions decisions Insomnia, early–morning wakefulness, or excessive Insomnia, early–morning wakefulness, or excessive sleeping sleeping Overeating, or appetite loss Overeating, or appetite loss Thoughts of suicide, suicide attempts Thoughts of suicide, suicide attempts Persistent aches or pains, headaches, cramps or digestive Persistent aches or pains, headaches, cramps or digestive

problems that do not ease even with treatment problems that do not ease even with treatment

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Co-existing conditions:

Anxiety/ PTSD/ OCD/ Panic DisorderAnxiety/ PTSD/ OCD/ Panic DisorderAlcohol/ Substance abuseAlcohol/ Substance abuseHeart Disease/ Stroke/ Cancer/ HIV/ Heart Disease/ Stroke/ Cancer/ HIV/ Diabetes/ Parkinson’sDiabetes/ Parkinson’s

All above have or can have an element of depression.

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Etiology?

Genetic/ Biochemical/ EnvironmentalGenetic/ Biochemical/ EnvironmentalFunctional MRI/PET scans show the depressed brain Functional MRI/PET scans show the depressed brain functioning differently than a non-depressed brainfunctioning differently than a non-depressed brainTraumaTraumaHead injuries can result in depressionHead injuries can result in depressionF>M (?Hormone related)F>M (?Hormone related)High estrogen for instanceHigh estrogen for instanceMen present with fatigue, irritability, loss of interest in Men present with fatigue, irritability, loss of interest in once–pleasurable activities, and sleep disturbances once–pleasurable activities, and sleep disturbances Women present with feelings of sadness, worthlessness Women present with feelings of sadness, worthlessness and/or excessive guilt. and/or excessive guilt.

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Childhood depression

Pretend sick/ Refuse to go to schoolPretend sick/ Refuse to go to school Sulk/ ‘Trouble’Sulk/ ‘Trouble’ At age 15 F:M =2:1 – At age 15 F:M =2:1 – females more likely to get females more likely to get

depressed.depressed. ‘‘Identity’ issues Identity’ issues (i.e., gender)(i.e., gender)

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Depression Therapy

Highly treatableHighly treatableCheck for medical reasons- thyroid/viral diseasesCheck for medical reasons- thyroid/viral diseasesPsychotherapy / MedicationPsychotherapy / MedicationMedication- Medication- SSRIs include fluoxetine (Prozac), citalopram (Celexa), SSRIs include fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft) sertraline (Zoloft) SNRIs –(Serotonin and norepinephrine)-venlafaxine SNRIs –(Serotonin and norepinephrine)-venlafaxine (Effexor) and duloxetine (Cymbalta). (Effexor) and duloxetine (Cymbalta). Tricyclics and MAOIsTricyclics and MAOIsFood/drug interactions, so less commonly used now. Food/drug interactions, so less commonly used now.

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Side Effects

SSRIs and SNRIs:SSRIs and SNRIs:Headache–usually temporary and will subside. Nausea–temporary and usually short–lived. Insomnia and nervousness (trouble falling asleep or waking often during the night)–may occur during the first few weeks but often subside over time or if the dose is reduced. Agitation (feeling jittery). Sexual problems– reduced sex drive, erectile dysfunction, delayed ejaculation, or inability to have an orgasm.

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Side Effects

Tricyclics- Tricyclics- Dry mouth- Constipation- Bladder problems–Sexual problems– Blurred vision–Drowsiness during the day–

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FDA ‘Black Box’ Warning

2007- all antidepressant medications extend the 2007- all antidepressant medications extend the warning to include young adults up through age 24. A warning to include young adults up through age 24. A "black box" warning is the most serious type of "black box" warning is the most serious type of warning on prescription drug labeling. warning on prescription drug labeling.

Possible side effects to look for are worsening Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. agitation, or withdrawal from normal social situations.

Black box warning happened after Columbine shootings – at least one of those kids was on some of these anti-depressants

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Talk Therapies

Short–term (10 to 20 weeks) / long termShort–term (10 to 20 weeks) / long term Cognitive Behavioral Therapy - Helps change Cognitive Behavioral Therapy - Helps change

negative thinking negative thinking IPT (Inter Personal Therapy)-Understand and work IPT (Inter Personal Therapy)-Understand and work

through troubled personal relationshipsthrough troubled personal relationships Both are useful as stand alone therapy for mild to Both are useful as stand alone therapy for mild to

moderate depressionsmoderate depressions

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? ECT- Electro Convulsive Therapy

For severe unresponsive forms of DepressionFor severe unresponsive forms of Depression ECT may cause some short-term side effects, ECT may cause some short-term side effects,

including confusion, disorientation and including confusion, disorientation and memory loss. memory loss.

Age old treatment since electricity was invented…shock therapy.

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Brodmann AreasBrodmann Areas

Done for severly intractible depressive patients – area 25 is the region where needles are inserted, wired up…See next page. Experimental – done in Dallas and at Emory at Atlanta.

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Deep Brain Stimulation for Depression For about 10 percent of people with For about 10 percent of people with

severe depression, when no other severe depression, when no other available treatments workavailable treatments work

Area in the brain -- called area 25 -- Area in the brain -- called area 25 -- that plays a critical role in depression.that plays a critical role in depression.

Deep Brain Stimulation for Treatment-Resistant Deep Brain Stimulation for Treatment-Resistant DepressionDepressionNeuron, Neuron, Helen Mayberg et. Al, Helen Mayberg et. Al, Neuron, Vol 45, 651-660, 03 March 2005Neuron, Vol 45, 651-660, 03 March 2005

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Help Line for depression

Call the doctor. Call the doctor. Call 911 or send to a hospital emergency Call 911 or send to a hospital emergency

room to get immediate help or ask a friend or room to get immediate help or ask a friend or family member to help with these things. family member to help with these things.

Call the toll-free, 24-hour hotline of the Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889) to talk to a trained counselor. 4TTY (4889) to talk to a trained counselor.

Make sure the suicidal person is not left Make sure the suicidal person is not left alone. alone.

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90

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Depression/Anxiety Disorders Comorbidity*

27% (OCD + depression5)

37%

(SAD + depression2)62%

(GAD + depression1)

56% (PD + depression3)

48%

(PTSD + depression4)

42% (simple phobia +

depression2)

GAD

PDSpecific Phobia PTSD

SAD

OCD

Depression

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Schizophrenia

Positive symptomsPositive symptoms are unusual thoughts or are unusual thoughts or perceptions, including hallucinations, delusions, perceptions, including hallucinations, delusions, thought disorder, and disorders of movement thought disorder, and disorders of movement

Negative symptomsNegative symptoms represent a loss or a decrease in represent a loss or a decrease in the ability to initiate plans, speak, express emotion, the ability to initiate plans, speak, express emotion, or find pleasure in everyday life. or find pleasure in everyday life.

Men in their late teens and early 20s and in women Men in their late teens and early 20s and in women in their mid-20s to early 30s in their mid-20s to early 30s

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Schizophrenia

1% to 1.5% 1% to 1.5% M=FM=F?genetic?genetic?>’born in’ winter and spring months ?>’born in’ winter and spring months (viral- flu in 2(viral- flu in 2ndnd trimester) trimester)?Industrialization?Industrialization?altered brain anatomy ?altered brain anatomy Hypoxia/difficult laborHypoxia/difficult labor

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Schizophrenia chemistry

DA system hyppothesis –’blocking DA receptors DA system hyppothesis –’blocking DA receptors helps the patientshelps the patients5-HT receptors blocking5-HT receptors blockingGlutamate and NMDA Glutamate and NMDA

((N-methyl- D-aspartateN-methyl- D-aspartate ) receptors hypo ) receptors hypo functionfunctionGABA receptor overactvityGABA receptor overactvityDecreased brain peptidesDecreased brain peptidesNE activity decreased NE activity decreased

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Diagnosis

Positive symptomsPositive symptoms : actively expressed and : actively expressed and easily observed –easily observed –

hallucinations, thought disorder, hallucinations, thought disorder, delusions, and bizarre behavior. delusions, and bizarre behavior. Negative symptomsNegative symptoms : decrease in : decrease in emotional range, poverty of speech, emotional range, poverty of speech, loss loss of interests, and loss of driveof interests, and loss of drive

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Diagnosis

Cognitive symptoms :Cognitive symptoms : deficits in attention, deficits in attention, memory, and executive functions memory, and executive functions

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Medical Causes of Psychosis

Medical Causes of PsychosisMedical Causes of Psychosis Temporal lobe epilepsy Temporal lobe epilepsy Brain tumor, stroke, brain trauma Brain tumor, stroke, brain trauma CNS infections (AIDS, neurosyphilis) CNS infections (AIDS, neurosyphilis) Dementia (Alzheimer's, Lewy's body, vascular) Dementia (Alzheimer's, Lewy's body, vascular) Wilson's disease Wilson's disease Huntington's disease Huntington's disease Vitamin deficiency (B12) Vitamin deficiency (B12) Endocrine disorders (Cushing's syndrome) Endocrine disorders (Cushing's syndrome) Autoimmune disorders (systemic lupus) Autoimmune disorders (systemic lupus) Metabolic disorders (porphyria) Metabolic disorders (porphyria)

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Therapy

Hospitalize during acute phaseHospitalize during acute phaseDA-receptor antagonists (called typical DA-receptor antagonists (called typical

antipsychotics) –haloperidol and antipsychotics) –haloperidol and fluphenazine fluphenazine 5-HT (serotonin)-dopamine antagonists 5-HT (serotonin)-dopamine antagonists

(called atypical antipsychotics) (called atypical antipsychotics)

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Atypical Atypical AntipsychoticAntipsychotic

Initial Initial Dose(mgDose(mg

))

Standard DoseStandard Dose(mg/day)(mg/day)

MaxMaxDoseDose AdvantagesAdvantages DisadvantagesDisadvantages

ClozapineClozapine 25-5025-50 300-600300-600 900900 Effective in Effective in refractory refractory schizophreniaschizophrenia

Lowest risk of Lowest risk of extrapyramidal extrapyramidal symptoms symptoms (EPS)(EPS)

AgranulocytosisAgranulocytosis

No liquid formNo liquid form

No injectable No injectable formform

Weight gain, Weight gain, seizuresseizures

OlanzapineOlanzapine 5-105-10 15-2015-20 2020 Well toleratedWell tolerated

Approved for Approved for acute maniaacute mania

Weight gainWeight gain

No liquid formNo liquid form

No injectable No injectable formform

QuetiapineQuetiapine 25-5025-50 400-600400-600 800800 Well toleratedWell tolerated

Lowest EPS Lowest EPS riskrisk

Slow titrationSlow titration

SedationSedation

No liquid formNo liquid form

No injectable No injectable formform

RisperidonRisperidonee

1-21-2 4-84-8 1616 Well toleratedWell tolerated

Well-defined Well-defined dose rangedose range

Dose-dependent Dose-dependent EPSEPS

No injectable No injectable formform

ZiprasidonZiprasidonee

40-8040-80 80-16080-160 160160 Well toleratedWell tolerated

No weight gainNo weight gain

Injectable form Injectable form

QT prolongationQT prolongation

Taken with foodTaken with food

Nausea, insomniaNausea, insomnia

No liquid formNo liquid form

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OUTCOMES Favorable short-term outcome –Favorable short-term outcome – Continued medication. Continued medication. Good premorbid adjustment / good health prior to Good premorbid adjustment / good health prior to

illness onset. illness onset. Being married improves prognosisBeing married improves prognosis Female sexFemale sex More acute or more obvious presentation of illness. More acute or more obvious presentation of illness. Fewer and briefer psychotic episodes. Fewer and briefer psychotic episodes. Less exposure to high levels of overly critical, Less exposure to high levels of overly critical,

demanding, or emotionally over-involved relatives demanding, or emotionally over-involved relatives (so-called "high expressed emotion" factor). (so-called "high expressed emotion" factor).

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Long term outlook

Remissions/ RelapsesRemissions/ Relapses 49-68% improvement49-68% improvement Illness tends to fade with age Illness tends to fade with age

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DELIRIUM

““Rapid onset of variable Rapid onset of variable and fluctuating and fluctuating changes in mental changes in mental status”status”

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Delirium

1.1. Physiologic consequences of a medical Physiologic consequences of a medical disturbance disturbance

2.2. Disturbance in consciousness Disturbance in consciousness

3.3. A change in cognition that cannot be A change in cognition that cannot be better accounted for by a preexisting better accounted for by a preexisting or evolving dementiaor evolving dementia

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Delirium

AKA:AKA:acute confusional state acute confusional state acute brain syndrome acute brain syndrome metabolic encephalopathy metabolic encephalopathy toxic psychosis and toxic psychosis and acute brain failure acute brain failure

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Delirum

Higher in older patientsHigher in older patientsAIDSAIDSCABGCABGPrescription DrugsPrescription DrugsFeatures- disorientation, concrete Features- disorientation, concrete thinking, and inattention thinking, and inattention

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Mechanism of DeliriumExcessive neurotransmitter releaseExcessive neurotransmitter releaseAbnormal signal conductionAbnormal signal conduction

Overactivity of muscarinic cholinergic neurons in Overactivity of muscarinic cholinergic neurons in the reticular-activating system, cortex, and the reticular-activating system, cortex, and hippocampus hippocampus Hypoxia leads to increased DA releaseHypoxia leads to increased DA release

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TherapyHaloperidol {HaldolHaloperidol {Haldol®}®}(preferred)(preferred)BZs –useful in quick reliefBZs –useful in quick reliefDelirium is associated with significant Delirium is associated with significant morbidity and mortality (30%)morbidity and mortality (30%)

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Eating Disorders: Anorexia Nervosa

Refusal to maintain body weight (85% +) Refusal to maintain body weight (85% +) Intense fear of gaining weight or becoming Intense fear of gaining weight or becoming fat, even though underweight.fat, even though underweight.Undue influence of body weight or shape on Undue influence of body weight or shape on self-valuation, or denial of the seriousness self-valuation, or denial of the seriousness of the current low body weight.of the current low body weight.In postmenarchal females, amenorrhea ie, In postmenarchal females, amenorrhea ie, the absence of at least three consecutive the absence of at least three consecutive cycles. cycles.

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Anorexia TypesRestricting Type: Restricting Type: Not regularly engaged Not regularly engaged in binge-in binge- eating or eating or purging behavior (ie, purging behavior (ie, self-induced self-induced vomiting or the misuse vomiting or the misuse of of laxatives, diuretics, laxatives, diuretics, or enemas) or enemas)

Binge-Eating/ Binge-Eating/ Purging Type: Purging Type: Regularly engaged Regularly engaged in binge-eating in binge-eating or or purging behaviorpurging behavior

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Bulimia Nervosa

Recurrent episodes of binge eating Recurrent episodes of binge eating (1) Eating, in a discrete period of time (eg, within (1) Eating, in a discrete period of time (eg, within any any 2-hour period) 2-hour period) (2) A sense of lack of control over eating during the (2) A sense of lack of control over eating during the episode episode Recurrent inappropriate compensatory behavior in Recurrent inappropriate compensatory behavior in order to prevent weight gainorder to prevent weight gainThe binge eating and inappropriate compensatory The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a behaviors both occur, on average, at least twice a week week for 3 months. for 3 months. Self-evaluation is unduly influenced by body shape Self-evaluation is unduly influenced by body shape and weight. and weight. Does not occur exclusively during episodes of Does not occur exclusively during episodes of anorexia anorexia nervosa.nervosa.

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Pathophysiology

UnknownUnknown ? Ednorphins- denial of hunger? Ednorphins- denial of hunger Decreased 5HT/NE turnover in the bodyDecreased 5HT/NE turnover in the body ?genetic (5%)?genetic (5%) FH: substance abuse/ alcoholics/ obesity/ FH: substance abuse/ alcoholics/ obesity/

mood disordersmood disorders

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Psychosocial Factors

>Hostility>Hostility >Chaos>Chaos >Isolation>Isolation <care and empathy<care and empathy >Societal pressures>Societal pressures High achieversHigh achievers Impaired impulse regulationImpaired impulse regulation

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PSYCHIATRIC COMORBIDITY

Major depressive disorder or dysthymia Major depressive disorder or dysthymia (50% to 75%)(50% to 75%)

Bipolar disorder (4% to 13%)Bipolar disorder (4% to 13%)OCD (25% with AN)OCD (25% with AN)Sexual abuse (20% to 50%)Sexual abuse (20% to 50%)Substance abuse (12 to 18% with AN Substance abuse (12 to 18% with AN especially binge/purge subtype) and especially binge/purge subtype) and (30% to 37% with BN)(30% to 37% with BN)

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Therapy

Rehab / Psychotherapy/ MedicationRehab / Psychotherapy/ Medication Hospitalize Hospitalize if:if:

wt <75% of expected wt.wt <75% of expected wt. Electrolytes/ Otrho. Htn/ HR <40/ Electrolytes/ Otrho. Htn/ HR <40/

tachycardia/ hypothermia / suicidaltachycardia/ hypothermia / suicidal

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Therapy

Psychosocial Treatments –Psychosocial Treatments – dynamic expressive-supportive therapy and dynamic expressive-supportive therapy and

cognitive behavioral techniques cognitive behavioral techniques Antidepressants: SSRIs Antidepressants: SSRIs Rule of 3- 1/3 recover fully/ 1/3 partial/ 1/3 Rule of 3- 1/3 recover fully/ 1/3 partial/ 1/3

no responseno response

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Prognosis

AN: long time follow up- 60 monthsAN: long time follow up- 60 monthsMortality (20%)- cardiac arrest/ suicideMortality (20%)- cardiac arrest/ suicide

Good factors-admission of hunger, Good factors-admission of hunger, lessening of denial and improved self-lessening of denial and improved self- esteem esteem

Bad factors- initial lower minimum Bad factors- initial lower minimum weight, weight, vomiting/laxative abuse, failure vomiting/laxative abuse, failure to respond to to respond to previous treatment, previous treatment, disturbed family disturbed family relationships and parental relationships and parental conflictsconflicts. .

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BN: Prognosis Short term success- 70%Short term success- 70% Relapse rates- 30-50% at 6 monthsRelapse rates- 30-50% at 6 months Better than ANBetter than AN Poor Factors- Poor Factors- hospitalizationhospitalization higher frequency of vomitinghigher frequency of vomiting poor social and occupational functioningpoor social and occupational functioning poor motivation for recoverypoor motivation for recovery severity of purging and severity of purging and presence of medical complications,presence of medical complications, high levels of impulsivityhigh levels of impulsivity longer duration of illness longer duration of illness presence of obesity and substance abuse presence of obesity and substance abuse

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Alcohol Dependence

10-15% of general population10-15% of general population Cage – cut down, annoyed by others, guilt, Cage – cut down, annoyed by others, guilt,

eye openereye opener1 – 50% sensitivity2 – >75%

MOA – varied, mostly GABA agonistMOA – varied, mostly GABA agonist

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Alcohol Dependence

Genetics – 50% Environment – 50%Genetics – 50% Environment – 50% Father to son 4-5 times Father to son 4-5 times Mother to daughter 4-5 timesMother to daughter 4-5 times +FH – natural “tolerance”+FH – natural “tolerance”

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Alcohol Levels

Body can metabolize about 1 drink per Body can metabolize about 1 drink per hourhour

Eliminates about .015-.02/hourEliminates about .015-.02/hour 0.1 – euphoria0.1 – euphoria 0.2 – confusion0.2 – confusion 0.3 – stupor0.3 – stupor 0.4 – coma0.4 – coma 0.5 - death0.5 - death

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Alcohol Cont.

50% of all MVA related fatalities50% of all MVA related fatalities Legal limit 0.08 – 0.10 (or 80 – 100)Legal limit 0.08 – 0.10 (or 80 – 100) 12oz beer = 5oz wine = 1.5oz of liquor (80 12oz beer = 5oz wine = 1.5oz of liquor (80

proof)proof) 22ndnd highest risk factor for suicide attempts highest risk factor for suicide attempts

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Treatments

DetoxificationDetoxification Alcoholics Anonymous/12 StepAlcoholics Anonymous/12 Step Residential/PHPResidential/PHP Intensive OutpatientIntensive Outpatient Half-Way HousesHalf-Way Houses

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Treatment Cont.

Antabuse – blocks aldehyde dehydrogenaseAntabuse – blocks aldehyde dehydrogenase NaltrexoneNaltrexone AcamprosateAcamprosate Ondansetron – 5HT3 antagonistOndansetron – 5HT3 antagonist Questionably SSRI’sQuestionably SSRI’s

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Clinical Effects of Amphetamines:

CNS: CNS: Increased alertness longer-lasting than cocainedecreased fatigue/appetiteIrritability, weakness“amphetamine psychosis”Arrhythmias, circulatory collapse

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Psychotomimetic Drugs

"Faster, faster, until the thrill of speed overcomes the fear of death."Hunter S. Thompson

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