Abnormal Grief

Normal grief vs. Abnormal grief (depression)

-Abnormal grief does not resovle within 1 year and patient does not attempt to resume normal activities.

Affective Disorder Overview

I. Major Depressive Disorder: single episode meeting criteria for Major Depression or Recurrent Episodes. Time Course: must be two months between episodes for them to be considered separate.

II. Dysthymic Disorder: depressed mood most of the day, more days than not. >2 of poor appetite/overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration, hopelessness. Time course: at least two years with no more than two months without symptoms at any time.

III. Bipolar I: requires only one manic episode. No requirement for depression.

IV. Rapid cycling specifier: At least 4 episodes of a mood disturbance in 12 months that meets the criteria for MDE, Manic Episode, or Hypomanic Episode.

V. Bipolar II: One or more Major Depressive Episodes. At least one hypomanic episode. No manic episodes.

VI. Cyclothymia: Numerous periods of hypomanic episodes and depressive episodes that do not meet the criteria for a Major Depressive Episode. Time Course: Two years of symptoms with no more than two months at a time without symptoms.

VII. Adjustment D/O with depressed mood: Development of depressive symptoms in response to an identifiable stressor. Marked distress that is out of proportion to what would be expected after exposure to the stressor with impairment in functioning. Time Course: Occurs within 3 months of an identifiable stressor. Symptoms do not persist for more than 6 months after the termination of the stressor.

Major Depressive Episode:

-more than 5 of the symptoms below for more than 2 weeks with one symptom being depressed mood or loss of interest or pleasure:

1. Sleep problems (insomnia or hypersomnia)

2. Interest (diminished interest or pleasure)

3. Guilt (or worthlessness)

4. Energy (less energy or fatigue)

5. Concentration (decreased concentration or attention)

6. Affect (depressed mood)

7. Psychomotor retardation or agitation

8. Suicide (thoughts of suicide or death)

Manic Episode:

-a period of abnormally and persistently elevated, expansive, or irritable mood of at least 1 week.

-More than 3 of the symptoms below, More than 4 of the symptoms below if irritable

1. Distractibility

2. Irritable

3. Grandiosity (inflated self-esteem)

4. Flight of ideas (racing thoughts)

5. Activities: -goal directed, risky but pleasurable.

6. Sleep: decreased need, gory dreams

7. Talkative (more talkative or pressured speech)

Amnestic Disroders

Amenestic Disorders

-effecting just memory

-have an underlying cause (like delirium)… so fix underlying cause to fix the memory problems.

-some causes: pretty much anything that effects the brain: hypoglycemia, thiamine deficiency (Wernike’s), hypoxia, head trauma (obvious), brain tumor, stroke (CVA), Herpes simplex encephalitis, Multiple Sclerosis

Antidepressant Drug Therapy and Medications

When to use them?

Antidepressants are used to treat disorders of mood (Unipolar and Bipolar depression, organic mood disorders, schizoaffective), anxiety disorders (panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and social phobia), impulse control and eating disorders.

Which antidepressant to use?

There are several classes of antidepressants with several drugs in each class. The specific drug you use will depend on the patient’s side-effect profile and other medical problems and the efficacy of the drug for that specific patient. It can take several weeks for the antidepressant to show improvement in mood.

-Dosage can be increase or the drug can be augmented with another drug (such as Lithium) if improvement is not seen.

-Overdose risk highest in Bupropion and TCAs.

Side-effects

-include antichoinergic, antihistaminergic, hypotension, sedation, discontinuation syndrome (sudden cessation of SSRIs)

-Tricyclic Antidepressants can cause prolonged QT interval.

-MAOIs can cause hypo or hypertension and can cause a hypertensive crisis if ingested with tyramine containing foods, Serotonergic drugs, other drugs.

-discontinuation or serotonin syndrome (especially with MAOIs): initially, will be lethargic, restless, confused, sweaty, tremors, myoclonic jerks. Later on, can progress to hyperthermia, hypertonicity, renal failure, rhabdomyolysis, coma, death.

What to do? Should stop meds and give patient cyprohepatidine (Periactin).

Antidepressant Medications

I. SSRI: inhibit presynaptic serotonin pumps to prevent serotonin reuptake.

a. Fluoxetine (Prozac) -- has very long half-life and significant protein binding.

b. Citalopram (Celexa) – few interactions with other drugs

c. Escitalopram (Lexapro) – similar to citalopram but less side-effects

d. Paroxetine (Paxil) – used in maintenance treatment of panic disorders. Is more serotonin specific but has significant protein binding. Anticholinergic symptoms.

e. Sertraline (Zoloft) – used in maintenance treatment of panic disorders. Good for brain-injured patients (increased dopamine which is good for rehabilitation).

i. Side-effects: NOT as sedating

1. sexual side-effects

2. problems with GI tolerability

3. Protein binding, shot-half life à SSRI discontinuation symptoms if stop for 3-4 half lives.

f. Fluvoxamine (Luvox)-- used for OCD

II. SNRI: inhibit reuptake of serotonin and norepinephrine.

a. Venlafaxine (Effexor): for a tired, apathetic depressed patient. Very stimulating at first. Will prevent reuptake of dopamine at higher doses

i. Side-effects: hypertension, GI upset.

ii. Lowest protein body, little drug interactions

b. Duloxetine (Cymbalta): for major depression and diabetic neuropathic pain.

i. Side-effects: Fatigue, sexual side-effects, serotonin discontinuation, GI upset.

III. NDRI:

a. Bupropion (Wellbutrin) – Used to help in smoking cessation. Usesful for apathetic, amotivational, inattentive depressive patients.

i. Side-effects: Decreases seizure threshold, can cause electrolyte abnormalities.

IV. SARI:

a. Nefazodone (Serzone): good for anxious-depressed patients.

i. Side-effects: 3A3/4 inhibition, sedation,

b. Desyrel (Trazodone): rarely used for treating depression but can be used in low doses for treating insomnia.

i. Side-effects: priapism

V. NaSSA: (noradrenergic and selective serotonin antidepressants) – block a2 receptors presynaptically (feedback) to inhibit release of norepinephrine and serotonin.

a. Mirtazapine (Remeron) – only anti-depressant that comes in orally-dissolving tablet.

i. Side-effects: increased appetite, weight gain, sedating.

VI. TCA: inhibit reuptake of norepinephrine and serotonin; can cause prolonged QT interval and are very sedating.

a. Imipramine (Tofranil) – used for enuresis, bed-wetting

b. Amitryptiline (Elavil) – used in lower doses for pain management

c. Trimipramine (Surmontil)

d. Nortriptyline (Pamelor)

e. Desipramine (Norpramin)

f. Clomipramine (Anafranil) – most serotonin specific. Used for OCD.

g. Amoxapine (Asendin)

h. Sinequan

VII. MAOI: inhibits the enzyme that metabolizes norepinephrine, serotonin, dopamine, and tyramine. Results in increased neurotransmitters in the synapse.

a. Selegiline (Emsam)

b. Phenelzine (Nardil)

c. Tranylcypromine (Parnate)

Antipsychotic Drug Therapy

When to use them?

Antipsychotic drugs may be used for schizophrenia as well as other disorders that may have psychotic features such as depression, bipolar disorder, schizophreniform disorder, schizoaffective disorder.

What drug to use?

The drug that you choose depends on the side effects and the efficacy in an individual patient.

-Clozapine is more effective for schizophrenia that is refractory.

-Atypical antipsychotics (which act on both dopamine and serotonin receptors) may be more effective than the typical antipsychotics (act only on dopamine receptors).

How much to start medicating?

With most antipsychotic drugs, you will need to start by giving divided doses (2-4 times per day) to prevent the initial dose-related side-effects.

-Olanzapine (zyprexa) can be started with the initial dose (1 time per day).

It will take about 5 days to reach steady state-- after which the patient can start taking the medication once per day.

-Ziprasidone will still need to be given in divided doses.

You can add benzodiazepines for patients that feel agitated.

Whether to give Oral, intramuscular, or IV?

Oral: for all antipsychotics

Intramuscular long acting (depot) types: Risperidone, Haldol, Prolixin

-Haldol: start very high (20x the daily Oral dose but given in divided doses of 3-4). Give this much every day for 1 week. Maintenance dose: 200mg/30 days.

-Risperidol: start low (25 mg IM/ 2 wks)

-Prolixin: start low (25mg IM/ 2 wks)

Intramuscular short acting types:

-Ziprasidone and Olanzapine given in doses of 10 mg / 2 hours

-Thorazine give in doses of 25-50 mg

-Haldol givein in doses of 10 mg.

IV:

-Haldol

Side-effects

-Low potency drugs will cause anticholinergic side effects (dry mouth, constipation, blurry vision, urinary retention), orthostatic hypotension, and drowsiness.

Examples: chlorpromazine, thioridazine, clozapine

-High portency drugs will cause extrapyramidal side-effects (dystonia, Parkinsonian syndrome, akathasia – restlessness)

Examples: Haloperidol, Fluphenazine

-All antipsychotics, except Clozapine, will produce tardive dyskinesia and can rarely cause neuroleptic malignant syndrome (NMS). However, Clozapine (and Olanzapine) can cause weight gain as well as type II diabetes.

-Atypical antipsychotics can cause type II diabetes (Olanzapine = Clozapine > Resperidone > Quatiapine)

-Thioridazine causes cardiac conduction delay (prolonged QT interval) and also retinitis pigmentosa (if given in doses over 800 mg/day). Ziprasidone may cause some prolonged QT but is usually insignificant.

-Chlorpromazine may cause cholestatic jaundice.

Antipsychotic Drugs

Atypical Antipsychotics: block both dopamine and serotonin receptors. Can cause prolonged QT (nl max of 450 for men, 470 for women) so should get a baseline ECG.

I. Olanzapine (Zyprexa) – unlike other antipsychotics, it can be given at a starting does of once a day. Is good for mania.

a. Side-effects: May cause: wt gain, diabetes, elevated lipids

i. Sedation,

ii. EPS at higher doses

II. Clozapine (Clozaril) -- good for refractory schizophrenia. Highest efficacy but used as last resort because of agranulocytosis, wt gain, sedation

a. Side-effects: May cause: wt gain, diabetes, elevated lipids

i. Sedation, drooling

ii. Seizures if above 500 mg

iii. Agranulocytosis in 1% of patients

III. Risperidone (Risperidal) – the most typical of the atypical antipsychotics (has the highest affinity for D2 receptors).

a. Side-effects: May cause:

i. EPS if more than 6 mg, Lewy body dz.

ii. increased prolacting (leading to gynecomastia, galactorrhea, disruption of menstrual cycle)

iii. Orthostatis (so start at 1-2 mg)

iv. High stroke risk

IV. Quetiapine (Seroquil): can give a low dose (<100 mg) for nonspecific anxiety or dreams/anger. Also used for psychosis or mood d/o.

a. Side-effects: may cause:

i. Orthostatic hypotension, sedation, dizziness, weight gain

ii. Low EPS

iii. Less likely to cause hyperprolactinemia

V. Aripiprazole (Abilify) – is a partial D2 agonist (so can both increase/decrease D2 activity)

a. Side-effects:

i. Nausea

ii. Insomnia (so give in morning)

iii. Less likely to cause hyperprolactinemia

iv. Weight neutral

VI. Ziprasidone (Geodon) – has to be given multiple times throughout the day even after reaching stead state.

a. Side effects: severe cardiac side-effects

i. Highest prolongation of QT and torsades

ii. Sedation, dizziness, nausea

iii. Weight-neutral

VII. Paliperidone (Invega)

Typical Antipsychotics: block only dopamine receptors. Typical antipsychotics are more likely (than atypicals) to cause tardive dyskinesia.

Low Potency: have anticholinergic side-effects (dry mouth, blurry vision, urinary retention – give bethanechol, constipation, exacerbation of narrow-angle glaucoma), tardive-dyskinesia with prolonged use, neuroleptic malignant syndrome.

I. Chlorpromazine (thorazine)

II. Thioridazine (Mellaril)

High Potency: akathisia, acute dystonic reaction, EPS!, some anticholinergic but less than low-potency.

I. Haloperidol (Haldol)

II. Fluphenazine (Prolixin)

III. Trifluperazine

Anxiety Disorders Overview

Anxiety Disorders Overview

I. Generalized Anxiety Disorder: the most common type of anxiety disorder. Patient has too much (abnormally increased) anxiety about at least two things in his life for at least six months.

II. Panic Disorder: patients get periods of intense fear and impending doom.

III. Obsessive-Compulsive Disorder (OCD): can have either obsessions or compulsions (or both).

IV. Social Phobia (social anxiety disorder): fear of embarrassment or scrutiny by others (people that are unfamiliar)

V. Specific Phobia: an abnormal fear of something specific (object, situation).

VI. Post-Traumatic Stress Disorder (PTSD): happens after exposure to a traumatic event and is marked by nightmares, flashbacks, increased arousal, emotional numbing. Lasts at least 1 month.

VII. Acute Stress Disorder: similar to PTSD but is an acute reaction after exposure to a traumatic event (occurs within 1 month of the traumatic event and lasts between 2 days and 4 weeks)

Attention Deficit Hypersensitivity Disorder

So, both boys and girls can have ADHD and it is believed that the prevalence is about equal. But, it appears that boys are diagnosed more often. The reason for that may because the type of ADHD in boys is the hyperactive type while the ADHD in girls is that of inattention (teachers will not complain about a quiet girl not paying attention but will complain about a boy who is stirring up trouble and is loud).

Symptoms::
-hyperactive/impulsive type:
-inatentive type.

Famous people diagnosed with ADHD

There are a number of famous people diagnosed with adhd. Here is a list of some of these individuals:

Actors with ADHD:
-Jim Carey
-Whoopie Goldber
-Mariette Hartley
-Robin Williams

They all appear to be very hyperactive-- but I supposed its worked well for their careers.

Artists with ADHD:
Pablo Picasso
Van Gogh

Politicians with ADHD:
John F. Kennedy
Abraham Lincoln
Winston Churchill
Nelson Rockafeller

Child Psychiatry

Attention deficit hyperactivity disorder (ADHD)

Attention Deficit Hyperactivity Disorder (ADHD)

-3 subcategories: inattentive, hyperactive-impulsive, combined

-6 symptoms involving inattentiveness/hyperactivity for at least 6 months before age 7.

-Treatment:

Medicatons: CNS stimulants – methylphenidate (Ritalin) is the first line

Dextroamphetamine (dexedrine)

Pemoline (Cylert)

SSRIs/TCAas for adjuvant therapy

Disruptive Behaviour Diosrders: Conduct Disorder & Oppositional Defiant disorder

Conduct Disorders

Conduct disorder: violation of rights of others and of rules/norms

-most commond child psych diagnosis

-3 acts in the following 4 catgories;

1) aggressive towards others (people or animal)

2) destruction of property

3) deceitfulness

4) violation of rules

-up to 40% risk of developing antisocial personality disorder (gotta be over 18 years old)

Treatment: firm rules that are consistently enforced.

SSRIs for impulsivity, irritiability, mood lability

Lithium for aggression.

Oppositional Defiant Disorder (ODD)

-6 months of negative/hostile/defiant behaviour with 4 of the following:

1) loss of temper

2) arguments with adults (how dare he!)

3) defying the adults rules (hahahaha.. man this is all racist against kids!)

4) easily annoyed

5) annoying others (my brother?)

6) anger and resentment (poor kid)

7) spiteful (devil child!)

8) blaming others for misbehaviour

-begins by age 8

Learning Disorders in Children

Learning disorders: in reading (boys), mathematics (girls?), written expression, NOS.

-rule out hearing or seeing problems beforehand

Mental Retardation

Mental retardation : IQ below 70. 50-70 is mild mental retardation (most common)

Causes of mental retardation:

-Genetic: Down’s syndrome (most common), Fragile X syndrome (2^nd most common)

-Prenatal: TORCH (toxoplasmosis, other: syphillis/AIDS/alcohol/drugs, Rubella/german measles, Cytomegalovirus/CMV, Herpes simplex)

-Perinatal: anoxia, prematurity, birth trauma

-Postnatal: hypothryoidism, malnutrition, toxin exposure, trauma

Cognitive Disorder: Delirium and Dementia

Cognitive Disorders: Delirium and Dementia

Delirium is an alteration in consciousness with reduced focus or attention that occurs for a short period of time. It can be caused by a medical condition, drug use, or withdrawal.

Clinical Features of Delirium:

Hallucinations (especially visual), illusions, psychomotor agitation, infection and medication toxicity (especially in the elderly). Up to 15% of hospitalized patients may have delirium.

Differential Diagnosis of Delirium:

-Dementia (but demented patients are alert and do not have alteration in consciousness)

-Psychotic Disorder and Mood Disorders with Psychotic Features (but disorders with psychotic features do not develop as abruptly and there is no medical or drug-related cause).

-Malingering (but these “patients” will not have any evidence to prove that they have a medical problem or that they took a drug or are having withdrawal from it)

Treatment of Delirium:

-Haldol (Haloperidol): can be given via IV. Good for treating agitation, confusion, and problems with perception.

-Quetiapine (Seroquel): orally given in small doses. Should monitor heart rate and blood pressure.

-Lorazepam (Ativan): good for treating agitation. Safe for patients with renal or hepatic problems.

Dementia involves multiple cognitive deficits including memory and one or more of aphasia, apraxia, agnosia, and problems with executive functioning. In addition, there is social and occupational impairment. About 3% of people over 65 and 20% over 80 have dementia.

Clinical Features of Dementia:

-early: losing belongings and getting lost

-later on: problems doing daily living activities.

-Impaired judgement

-paranoid delusion and visual hallucinations

-can have delirium along with dementia because patients are more susceptible to medications and disease

Causes of Dementia:

I. Alzheimer’s

a. Most common type of dementia. Patients have a gradual onset and continue to decline in cognitive function.

b. Can have both Early and Late onset types.

c. 8-10 years life expectancy.

II. Vascular

a. Focal neurological signs/symptoms (show up as infarcts on MRI)

b. Changes can be abrupt instead of gradual.

III. Medical Conditions

a. AIDS

b. Head Trauma: the dementia does not progress.

c. Parkinson’s

d. Huntington’s: language and knowledge is not impaired while memory and executive function are impaired.

e. Pick’s Disease: disinhibition, apathy, language problems

i. Affect frontal and temporal lobes

f. Creutzfeldt-Jakob Disease: caused by prion,

i. Dementia, myoclonic movements, EEG activity.

g. Lewy body Dementia: visual hallucinations, syncope, losing consciousness.

IV. Substance Induced: lasts longer than the intoxication of the substance

V. Multiple Causes

Differential Diagnosis for dementia:

-Delirium

-Amnestic Disorder

-Major Depressive Disorder

Treatment of Dementia

-Alzheimer’s Disease: Donepezil (Aricept), Galantamine (Reminyl) and Rivastigmine (Exelon); also, Memantine (Namenda) and Vitamin E.

-for Agitation/Aggression: Atypical antipsychotics, Haloperidol, Divalproex, Buspirone, Trazodone, Lorazepam.

Complete Psychiatric Assessment and Evaluation

Psychiatric Assessment and Evaluation

Location:

Patient Information: Name: Age:

Gender:

Marital Status: Race: Referral Source:

Chief Complaint

HPI

             Date of Onset:
             Duration:
             Course of Symptoms:
             Psychological Stressors:

*get feel for patient’s issue and adapt ROS (checklist for that specific issue).

Past Psychiatric History:

Diagnosis:

Trauma:

Chemical Dependencies:

Violence (self/others):

Treatment:

Med/Surgical History:

Psychosocial History:

Childhood:

Relationship to Children:

Living Situation:

Employment/income:

Legal issues:

Education:

Substance abuse (illicit drugs, tobacco, alcohol)

Medications:

Allergies:

ROS (checklist)

Mental Status Exam:

I. General Description

a. Appearance (well groomed, )

b. Behavior and psychomotor activity (appropriate,)

c. Attitude (cooperative, aggressive, )
II. Mood and affectivity

a. Mood (neutral, euphoric, depressed, anxious, irritable)

b. Affect (full, flat, blunted, inappropriate)

c. Appropriateness

III. Speech

IV. Perception

V. Thought

a. Content – hallucinations, delusions, illusions, derealization, depersonalization, suicidal/homicidal ideation.

b. Process (handout) -- pressured speech, poverty of speech, circumstantiality, tangentiality,

VI. Sensorium and Cognition

a. Consciousness

b. Orientation and memory

c. Concentration and attention

d. Reading and writing

e. Visuospatial ability

f. Abstract thought

g. Info and intelligence

VII. Impulsivity

VIII. Judgment, Insight, Reliability

Multiaxial Assessment Diagnosis

Axis I – clinical disorders

Axis II – personality/mental disorders

Axis III – general medical conditions

Axis IV – Psychosocial + environmental problems

Axis V – Global Assessment of Function

Treatment Plan:

General Medical Screening (labs):

Delirium information

Delerium

-acute

-rapid onset

-waxing and waning levels of consciousness

-can be the result of numerous underlying causes (fix underlying problem to resolve delirium).

-Possible causes: FEUD : fluids/nutrition, environment, underlying cause/infection, drug withdrawl.

-more complete list of possible causes: I’M DELIRIUS: Impaired delivery, Metabolic, Drugs, Endocrinopathy, Liver Disease, Infrastructure (cortical neuron disease), Renal failure, Infection, Oxygen, Urinary tract infection, Sensory deprivation.

-want to avoid using benzodiazepines as they can worsen delirium

Delirium

-acute

-rapid onset

-waxing and waning levels of consciousness

-can be the result of numerous underlying causes (fix underlying problem to resolve delirium).

-Possible causes: FEUD : fluids/nutrition, environment, underlying cause/infection, drug withdrawl.

-more complete list of possible causes: I’M DELIRIUS: Impaired delivery, Metabolic, Drugs, Endocrinopathy, Liver Disease, Infrastructure (cortical neuron disease), Renal failure, Infection, Oxygen, Urinary tract infection, Sensory deprivation.

-want to avoid using benzodiazepines as they can worsen delirium

Dementia vs. Pseudodementia in Elderly

Dementia in elderly vs. Pseudodementia in elderly

*Dementia: slow onset, patient focuses on past success, increased confusion at night, guesses at answers (confabulation), unaware of promblems

*Pseudodementia: depression in elderly. Acute onset, patietn focuses on failures, not confused at night, often avoids answering questions (“don’t know”), is aware of problems.

*Treatement for pseudomenetia: SSRIs, ECT, Mirtazapine (sedating so good for insomnia too), Methylphenidate (for those with psychomotor retardation.. but don’t give after noon to avoid insomonia).

Disorder Mood

Disorders of the Mood are very common occurrence. When thinking of Disorder Mood or Mood disorder, we can split it up into 2 main types: Depressive and Bipolar.

Disorder Mood of Bipolar disorder type include: Bipolar I, Rapidy cycling, Bipolar II, and Cyclothemia.
Bipolar I: requires only one manic episode. No requirement for depression.
Rapid cycling specifier: At least 4 episodes of a mood disturbance in 12 months that meets the criteria for MDE, Manic Episode, or Hypomanic Episode.
Bipolar II: One or more Major Depressive Episodes. At least one hypomanic episode. No manic episodes.
Cyclothymia: Numerous periods of hypomanic episodes and depressive episodes that do not meet the criteria for a Major Depressive Episode. Time Course: Two years of symptoms with no more than two months at a time without symptoms.
Adjustment D/O with depressed mood: Development of depressive symptoms in response to an identifiable stressor. Marked distress that is out of proportion to what would be expected after exposure to the stressor with impairment in functioning. Time Course: Occurs within 3 months of an identifiable stressor. Symptoms do not persist for more than 6 months after the termination of the stressor.

Disorder Mood of depressive type, include: major depressive disorder, dysthymic disorder, adjustment disorder with depressed mood.
Major Depressive Disorder: single episode meeting criteria for Major Depression or Recurrent Episodes. Time Course: must be two months between episodes for them to be considered separate.
Dysthymic Disorder: depressed mood most of the day, more days than not. >2 of poor appetite/overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration, hopelessness. Time course: at least two years with no more than two months without symptoms at any time.

General Psychiatry Progress Reports interviewing outline at the VA TRP

before seeing patient:
-quick overview of past MH note -major medical problems the patient has
-psychiatry related medications he is on (do any of them need refills, possible interactions) ——–

The interview:
-about me
-tell me a bit about yourself and what brings you to the VA.
…..
-last time here?
-how have things been since last time
— what is better/worse -sleep -diet , -exercise -mood -energy
…..
-illicit drug use/tobacco/alcohol
-employed
-social situation: who do you live w/, how are things at home, how are things w/ wife/children, what do you like to,
-suicidal/homicidal ideation
-irritated? anxious? angry? -groups attended?
……
-what specific things would you like to talk about?

Introduction to Psychotherapy

In psychotherapy, the psychotherapist attempts to increase the insight and the range of behavioral responses to increase functional ability and decrease symptoms.

Some of the key vocabulary:
Transferance: this is something that a patient feels towards the therapist because of past experiences. The theory of transferance implies that we are the sum of relationships and that all interactions are influenced by these relationships.
example: a patient is afraid to go into surgery because he fears that the surgeon (like his father) is not sympathetic towards pain.
so, we use transferance in psychotherapy to understand past relationships in the context of present ones.
Countertransferance: the doctor can also have his own issues... so countertransferance says that the therapist may have feelings towards the patient because of the experiences that the therpaist had.
example: therapist who is bored with the patients complaints because it unconsciously is similar to the constant trivial complaining that she might hear from a relative.

ID, Ego, Superego:
so, we heard these words so many times already...
ID -- what you want (drives, aggression, libido)
Ego --your logical and abstract thinking, verbal reasoning, and defense mechanism.
Superego-- cant have what you want -- moral conscience, internalize; is present in people by the age of 5 yrs.

Defense Mechanisms -- so the ego (which includes defense mechanisms) is the mediator of the conflict between your desires (Id) and your moral conscience (superego).

Types of psychotherapy:
-pscyhoanalysis
-------
-psychodynamic psychotherapy
-brief psychotherapy
-------
-cognitive psychotherapy
-behavioral psychoterapy
-------for anyone but particularly low functioning patients:
-supportive psychothrapy
-group psychotherapy

Mood vs. Affect

Mood — a sustained emotional attitude. The patient will usually tell you what their mood is.
examples: neutral, euphoric, depressed, anxious, irritable

Affect — is how you perceive the patient’s emotional state (by their nonverbal behavior, how they talk, etc.)
examples: full, flat, blunted, inappropriate

Personality Disorders Overview

General Characteristics of Personality Disorders:

-the patient’s way of interacting with environment, people and with themselves is pretty consistent over time and is not caused by stresses, drugs, other medical/mental issues.

-starts early around time of adolescence or early adulthood

-when they become inflexible and thus unable to adapt to environment, the disorder becomes apparent. The patient never realizes that he/she has a personality disorder.

Types of Personality Disorders:

I. Cluster A Personality Disorders: patients prefer social isolation and have an increased incidence of schizophrenia (may have milder variants of it and have increased susceptibility to develop schizophrenia).

a. Paranoid Personality Disorder: extreme distrust of others, bearing grudges, hypervigilant, etc.

b. Schizoid Personality Disorder: social detachment with restricted affect

c. Schizotypal Personality Disorder: problems with perception, odd behavior or thinking, difficulty in holding close relationships.

II. Cluster B Personality Disorders: patients have dramatic, disruptive, or irrational behavior

a. Antisocial Personality Disorder: patient violates other people’s rights, is deceitful, irresponsible, and lacking remorse.

b. Borderline Personality Disorder: instability of affect, self-image, relationships, and impulsivity.

c. Histrionic Personality Disorder: emotionality and attention seeking

d. Narcissistic Personality Disorder: grandiosity, lack of concern and empathy for others, likes to be admired.

III. Cluster C Personality Disorders: the “worried” type. Very anxious people.

a. Avoidant Personality Disorder: avoiding situations of contact with other people, worried about being rejected, scrutinized, or embarrassed.

b. Dependant Personality Disorder: need to be cared for, submissive and clinging behavior.

c. Obsessive-Compulsive Personality Disorder: too concerned about order, control, and perfectionism to a point that it is so inflexible that it can paralyze decision making and make it difficult to complete tasks.

Pyschotic Disorders Overview -- disorders of thought process and content

I. Schizophrenia: Two or more of: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative sx (only one if delusions are bizarre or the hallucinations have a voice with running commentary or two voices in conversation). Social/Occupational dysfunction. Time course: at least 6 months and at least 1 month of symptoms or less if treated.

a. Paranoid – preoccupation with one or more delusions or frequent auditory hallucinations

b. Disorganized – prominent disorganized speech and behavior; flat or inappropriate affect.

c. Catatonic – at least two types of motoric immobility (catalepsy or stupor), excessive activity, extreme negativism, peculiar movements, echolalia, echopraxia.

d. Undifferentiated – not any of the above

e. Residual – Absence of prominent symptoms but continuing evidence of a disturbance.

II. Schizophreniform: Similar to schizophrenia above. Time course: at least 1 month but less than 6 months.

III. Schizoaffective: Mood disorder with symptoms of schizophrenia. During the same period of illness thee have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. Time course: two weeks without mood symptoms.

IV. Delusional: Non-bizarre delusions (real life situations), does not meet criteria for schizophrenia, no marked impairment of behavior (several different types). Time course: at least 1 month duration.

V. Brief Psychotic Disorder: Delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, with or without stressor. Time course: at least one day but less than one month with full return to functioning.

Sleep Disorders Overview

Primary Insomnia: patient cannot fall asleep or stay asleep.

Primary Hypersomnia: patient has excessive sleep without any medical conditions and is sleepy during the daytime.

Narcolepsy: sleepiness during the daytime in which the patient can have sleep attacks (quickly falling into sleep). Is associated with REM sleep during the day, hallucinations, cataplexy, sleep paralysis.

Breathing-Related Sleep Disorder (Sleep Apnea): sleep disruption at night that results in day-time sleepiness.

Circadian Rhythm Sleep Disorder: patient’s sleeping schedule does not correspond to his preferred sleeping schedule.

Dyssomnias Not otherwise Specified: includes Nocturnal Myoclonus (periodic leg movements) and restless leg syndrome.

Sleep problems in elderly

Sleep problem in elderly:

-REM sleep amount is the same but distributed throughout the sleep into shorter cycles

-Non-REM: more of stage 1 and stage 2 and less of the deep sleep (stage 3 and stage 4).

Treatment: stop alcohol, regular daily schecule,

Medications: hydroxyzine (Vistaril), zolpidem (Ambien)

Somatoform and Factitious Disorders Overview

Somatization Disorder: lots of pains that cause impairment or cause the patient to seek treatment.

Conversion Disorder: Usually happening after a stressful event, the patient is unable to use voluntary muscles or has sensory problems.

Hypochondriasis: fear of having a serious disease because of a misinterpretation of medical symptoms (even though the patient is assured by a physician/exams that the disease is not present).

Body Dysmorphic Disorder: being worried about an untrue defect in appearance to the point that it causes functional impairment.

Factitious Disorder: patient intentionally pretends to have medical problem (physical or psychological) in order to gain something (money).

Substance Abuse Disorders

First, some vocabulary on Substance Abuse:

Substance Intoxication: a reversible syndrome in which behavioral and psychological changes occurring after ingestion of an intoxicating substance.

Substance abuse: patient is using a substance that is causing work, law, or social problems but the patient is not yet dependent on the substance.

Substance Dependence: patient shows signs of tolerance and withdrawal and may realize the substance is bad for him but that this may not be enough to help him stop usage.

Substance Withdrawal: distress or impairment resulting after stopping the use of a substance.

Substance-Induced Disorders: includes dementia, delirium, persisting amnesia, psychotic disorder, sexual dysfunction, anxiety, etc. caused by using an intoxicating substance.

Evaluating for Substance Abuse: Physicians must determine how much of the drug the patient is using, how frequently, and how the drug is affecting the patient’s life.

Physical Examination: different drugs may have varying effects on the patient’s body.

Laboratory Evaluation: Drugs may show up in the blood or urine and the use of drugs increases the risk for certain diseases.

Substance Related Disorders –

I. Alcohol, sedatives, anxiolytics, and hypnotics will cause problems with gait, coordination, speech, memory, and even coma.

a. Amnesia and disinhibition

b. Addictive. With sedatives, this is dangerous because once a person becomes tolerant, they want more of the drug to get the same high. If they take too much of the drug, they risk depressing their respiratory centers in the brain stem to a point where respiration is stopped.

II. Opioids: euphoria à dysphoria à sedation

a. Can overdose and die or go into coma. Can get diseases from shooting it up via IV.

b. Heroin is the most addictive (most withdrawal symptoms)

i. Need to open up their airway, give naloxone. Methadone or Clonidine for withdrawal symptoms.

III. Cocaine: euphoria, hyper, anxiety (paranoid)

a. Chronic use results in paranoid ideation and depression.

b. Medical issues: nasal problems, heart problems (arrhythmias), brain infarcts, cocaine induced seizures.

c. Withdrawal: excessive sleep, depression, tiredness will last for up to 5 days.

d. Clonidine, amantidine, carbamazepine, TCAs (desipramine) for treating withdrawal symptoms.

IV. Nicotine: cant get intoxicated on it but do have a number of withdrawal symptoms like anxiety, irritability, problems concentrating, eating more.

a. Can give nicotine gum, patches, nasal sprays, inhalers, or Bupropion to treat withdrawal symptoms.

V. Phencyclidine (PCP): involuntary eye movements, increased bp or fast heart rate, resistance to pain.

a. Patient may be paranoid or have hallucinations

b. Can detect PCP in the blood (within 5 days of use)

c. Benzodiazepines (lorazepam) and Haloperidol for treating withdrawal symptoms.

VI. Amphetamine/Methamphetamine (Speed, Crystal, Crank): feeling high (happy/euphoric), energetic, irritable

a. Withdrawal symptoms include dreams, excessive sleep or little sleep, tiredness and anxiety.

b. Treat withdrawal with Benzos (calm the patient).

Substance-Related Disorders Overview

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