23. Psychiatry



One of the most powerful diagnostic tools is patient’s own story of illness (history of present illness, HPI). To obtain accurate and good HPI, a physician must use open- ended questions, e.g., “What brings you in here today?” “What is bothering you today?,” and “Tell me more.”


Do not ask many close-ended questions, such as “Do you have headache?” “Are you here for chest pain?” With close-ended question (always of interviewer’s choice), we are bound to fall into self-created cognitive traps, such as confirmation bias, availability heuristics, fast-default-mode thinking, patient-history distortions, and so on. (To learn about common cognitive traps in clinical thought process, I would recommend reading the book “How Doctors Think” by Jerome Groopman.)671



23.1 Autism Spectrum Disorders (Autism, Asperger syndrome, and Childhood Disintegrative Disorder)


Background: A group of neurodevelopmental disorders, possibly of genetic etiology, seen more commonly in patients with other genetic conditions, such as fragile-X syndrome. The incidence is significantly higher in boys than in girls.


Common features:




  • Problems with social communication and interaction, e.g., problems with nonverbal social cues, avoidance of socializing, not making eye contact, or hugging.



  • Focused interest and repetitive pattern of activities and behavior: e.g., fixated on a toy, piano-playing, or words (repetitive use of words, phrases, grunts, or mumbles), or fixation on routines (repeats same behavior in a preset pattern).


Differentiating features:




















Autism

Delay in language development and cognitive deficits


Asperger syndrome


  • Like in autism, patients with Asperger exhibit repetitive behaviors, and have issues with communication and understanding social cues.



  • Important difference is that there is, generally, no language or cognitive impairment. Also, patients with Asperger are a bit more communicative and social.


Childhood disintegrative disorder

Unlike Asperger and autism, these patients develop normally up until at least 2 years of age, but later start developing autistic symptoms with loss of previously acquired skills.a


aMajor differential diagnosis is Rett syndrome, which can have early normal-appearing development followed by loss of developmental milestones and social capabilities. Rett syndrome is due to genetic mutation and occurs only in females. There is also a dramatic decrease in head size and development of profound mental retardation.


Management: If physician suspects or parents raise concerns during routine visit, NSIM is to schedule a follow-up visit for thorough evaluation using checklist tool for screening of autism spectrum disorders. Early intervention with remedial education and behavioral therapy is recommended. In some cases, selective serotonin reuptake inhibitor (SSRIs) or stimulants are necessary, but these are not first-line therapies.



23.2 Attention Deficit Disorder aka Attention Deficit Hyperactivity Disorder (ADD/ADHD)


Background: Genetic catecholamine balance has been implicated in pathogenesis. It is more common in boys.


Clinical features: It is characterized by a lack of attention and/or hyperactivity. Symptoms of hyperactivity might not be present if predominantly inattentive type, or vice versa.



















Inattentive features

Hyperactive features



  • Difficulty concentrating on tasks or activities



  • Difficulty with organization



  • Often appears to not listen to peers or adults



  • Lacks attention to detail



  • Avoids tasks that he or she dislikes or perceives as difficult



  • Easily distractible



  • Forgetful

• Frequent fidgeting or squirming




  • Frequently leaving seat in classroom or at dinner table



  • Impulsivity in classroom, including interruptive behaviors



  • Difficulty waiting



  • Excessive running in inappropriate settings



  • Difficulty playing or maintaining play


To make the diagnosis the symptoms must be present for at least 6 months, onset before age of 12, and occur in more than one setting (e.g., school and home).


Common coexisting problems include oppositional defiant disorder, conduct disorder, emotional problems, and substance abuse.


Treatment options include the following:




  • Stimulants: Methylphenidate, Atomoxetine, Dextroamphetamine, etc.



  • Behavioral interventions which are designed to change behavior (positive reinforcement, time-out, etc.)



  • Psychotherapy may be useful for adolescents but is not helpful in children. Examples include analyzing thought patterns and cognitive behavioral therapy (CBT).


Prognosis: Generally improves with age.



23.3 Tourette Syndrome


Background: Disorder of frequent sudden unexpected involuntary movements or vocalizations, which are referred to as tics. Tics can manifest as either motor or vocal, and patients must have both. Onset should be before the age of 21.


Clinical features:




  • Motor tics usually involve the face, head, and neck.



  • Vocal tics can be sudden screaming, coughing, or coprolalia (shouting profanities).



  • Common coexisting problems include ADHD, obsessive compulsive disorder (OCD), etc.



  • Palilalia (immediate repetition of one’s own verbalizations) is common in Tourette syndrome.


Treatment: Drug of choice for bothersome tics is tetrabenazine,



1Tetrabenazine works by inhibiting reuptake of monoamines, thereby depleting neurotransmitters, such as dopamine, serotonin, norepinephrine.

and other options are atypical antipsychotics. In focal motor or vocal tics, botulinum injections can be tried. Behavioral therapy can be effective, too.



MRS

MAD ADHD


For treatment of both Tourette’s and ADHD, alpha agonists (guanfacine, clonidine) can also be used.



23.4 Mood Disorders



23.4.1 Major Depressive Episode


Diagnostic criteria: Presence of at least 5 of the following symptoms for at least 2 weeks, along with functional impairment. Depressed mood or Interest/pleasure loss should be present as one of the symptoms.





















































Symptoms

Additional info

S


Sleep loss or gain

Too much or too less sleep


P a


Psychomotor retardation or agitation


  • Motor retardation = movements are slow (patient slowly enters the room with stooped posture)



  • Agitation = restlessness


A


Appetite loss or gain

Significant increase or decrease in weight


C


Concentration loss or cognitive-function loss

Decrease in ability to concentrate or decrease in cognitive capabilities (pseudodementia)


E


Energy loss, or Easy fatigability

Lack of energy is the most common presenting symptom


D


Depressed mood

I


Interest loss or pleasure loss (anhedonia)

G


Guilt or feeling of worthlessness

S


Suicidal thoughts, ideations, or preoccupation

Depression is a major risk factor for suicide.

aPsychosis might be present, if depression is very severe. Mood-congruent hallucinations and delusions can develop. For example, patient can hear a voice saying, “you’re worthless and you are better off dead.”


Management:




  • First step is




  • Review medications that can lead to depression (e.g., propranolol) and inquire regarding history of manic or hypomanic episodes. (!)



  • Screen for suicide risk.



    2Expression of thoughts or intent of suicide


    Patient immediately loses the right of autonomy and confidentiality (harm to self).


    NSIM: hospitalization (even if patient or parents refuse it).





  • First-line therapy:


Psychotherapy (includes cognitive behavioral therapy OR interpersonal therapy)


+ pharmacotherapy (antidepressants).



23.4.2 Antidepressants






































Drug class

Examples

Indications

Side effects

Selective serotonin reuptake inhibitors (SSRIs)


Citalopram Escitalopram Fluoxetine Fluvoxamine Sertraline


Paroxetine

First-line agent for depressive and anxiety disorders


  • Erectile or sexual dysfunction



  • May cause insomnia or anxiety



  • Sertraline may cause diarrhea (But generally, these are relatively safe)


Serotoninnorepinephrine reuptake inhibitors (SNRIs)


Cymbalta Venlafaxine


Duloxetine


  • Second-line agent for depressive and anxiety disorders.



  • Also useful in patients with neuropathic pain.


Atypicals: second-line agents


Bupropion

Used for smoking cessation


  • Increases seizure threshold, so avoid in patients with eating disorders and increased risk of seizures.



  • No weight gain and no sexual dysfunction


Trazodone

Sedating, hence can be useful in insomnia


  • Priapism



  • Sedation


Mirtazapine

Useful in patients with insomnia, anxiety, or weight loss

• Weight gain (improves appetite)



MRS

SPACE DIGS


– I or D needs to be present to ID depression.



Caution

(!) In patients with major depression, we should always ask about prior history of manic or hypomanic episodes, so we do not miss the diagnosis of bipolar disorder. Initiation of lone SSRI, in this case, may precipitate manic or hypomanic episode.


























Drug class

Examples

Indications

Side effects

Tricyclic antidepressants (TCAs)


Amitriptyline


Imipramine


Clomipramine

Mostly used for resistant depression


  • Due to blocking effect on α1- receptors, it can cause sedation, hypotension, or orthostatic hypotension.



  • Also blocks M-receptors and cause urinary retention, dry mouth, etc.


TCAs have the highest risk for overdose-related toxicity.


Monoamine oxidase inhibitors


Selegiline


Phenelzine


Isocarboxazid


Tranylcypromine

Resistant depression

Drug–drug interaction Watch out for serotonin syndrome when taken with SSRIs Watch out for acute hypertensive crisis when taken with foods high in tyramine (wine, cheese, etc.)


Follow-up after initiating pharmacological treatment:




  • Antidepressants may take at least 4 weeks to work.



    3If patient comes in after 1 week reporting that there is no change in his symptoms, NSIM is to reassess after few more weeks.




  • First episode of major depressive disorder: continue medication for 4-9 months.



  • Second episode or very severe episode: continue for 1-3 years or indefinitely.



Electroconvulsive therapy (ECT)

Indications:




  • Primary indication is very severe depression with immediate threat (e.g., refusal to eat or drink, immediate risk of suicide, severe psychosis).



  • Severe persistent refractory depressive episode with failure of medical therapy.



  • Severe depression with psychosis in pregnancy (benefits of ECT in this case outweigh the risk to fetus).


Contraindications: Recent heart attack or stroke, high-risk cardiovascular disease, unstable brain aneurysm, and intracranial space-occupying lesion.


Common side effects: Amnesia (retrograde and anterograde), muscle aches, etc.



23.4.3 Grief versus Depression after Death of a Close Family Member

































Grief (bereavement)

Depression

Common presentation


Loss of appetite, sleep and/or memory, and sadness


Duration


<1 year

>1 year


Hallucinations


Can occur but are specific to the event and the person who died (e.g., hearing the loved one talking)

Nonspecific (e.g., hearing a voice saying that you are worthless)


Expresses “thoughts of dying”


Involves joining the deceased

Related to hopelessness (to everything)


Social and occupational function


Can usually function

Cannot function



Clinical Case Scenarios

1. Patient with hx of depression on pharmacotherapy presents with progressively worsening headache of few days duration. His BP is 190/120 mmHg. He reported going to a party and drinking red wine prior to the onset of symptoms. What is the likely mechanism?



23.4.4 Bipolar Disorder


Background: Bipolar disorders are characterized by coexistence of depressive and manic moods, which are not attributed to substance abuse or medical condition.


Diagnosis of manic episode: Requires persistent mood disturbance (elevated, expansive, or irritable) and increased energy or activity for at least 1 week resulting in functional impairment +


presence of at least 3 of the following:





























D


Distractibility (attention too easily drawn to unimportant things)


I


Irresponsibility (increased buying, gambling, foolish investments, and sexual indiscretions)


G


Grandiosity (inflated self-esteem)


F


Flight of ideas


A


Activity increased (goal-directed or purposeless)


S


Sleep requirement is decreased


T


Talkative


Two types:


























Bipolar I

Bipolar II

Criteria and definition


Criteria: mania ± depressive disorder

Criteria: Hypomania + major depressive episode


Definition of hypomania: Irritable or elevated mood and increased energy/activity but does not fulfill the diagnostic criteria of mania.


Psychosis


May or may not be present


Absent


Major depressive episode required for diagnosis


NO

YES


Treatment of bipolar disorder:





Lithium

Pharmacology: Acts on multiple levels by decreasing dopamine/NMDA (N-methyl-D- aspartate) transmission and increasing GABAergic transmission.


Contraindications: Creatinine elevation and dehydration.


Side effects:




  • Dose-dependent toxicity: Diarrhea, tremors, confusion, and/or ataxia.



    4If patient has these symptoms, NSIDx is to check lithium levels and serum electrolytes (creatinine). After that, decrease the dose even if lithium levels are within normal limits, as these are dose-dependent side effects.




  • Potential renal complications are nephrogenic diabetes insipidus, chronic kidney disease (due to chronic instertitial nephritis), distal (type I) renal tubular acidosis, etc.



  • Thyroid dysfunction (commonly hypo- but hyperthyroidism can also occur).



  • Hyperparathyroidism and hypercalcemia



MRS

ME DIG FAST 3 graves in 1 week.


ME are the essential symptoms.


M = mood elevation or irritability.


E = energy increased.


Major differential diagnosis is drug abuse (especially adrenergic drugs, e.g., cocaine): during drug usage patients can have features like mania/hypomania, and while not using drugs patients can have rebound depression.



MRS

VAL are mood stabilizers:




  • Valproate



  • Antipsychotic (second generation)



  • Lithium



Caution

(!) Initiation of lone SSRI may precipitate manic or hypomanic episode.


Monitoring lithium treatment: Routine lithium levels, thyroid function tests, and BMP (basic metabolic panel).



23.4.5 Pregnancy and Bipolar Disorder


























Situation

Management

New diagnosis of bipolar disorder and patient is planning to conceive

Start lamotrigine


New pregnancy in a patient with bipolar disorder on these medications

Valproate or carbamazepine

Switch to other meds (risk of fetal anomalies is higher than the risk of adverse effects of switching therapy)


• Lamotrigine is preferred; other drugs are quetiapine and risperidone.


Lithium

Continue lithium


• Risks associated with switching therapy are higher than risk of Ebstein anomaly.


New-generation antipsychotics

No change



23.4.6 Milder Mood Disorders

















Dysthymic disorder aka persistent depressive disorder

Cyclothymic disorder

Criteria: The following must be present for at least 2 years




  • Depressive symptoms that do not fulfill the criteria of major depressive disorder



  • Symptoms in dysthymic disorder are often milder than in major depressive disorder.

• Mood swings that alternate between baseline mild depression and period of mild hypomanic symptoms.



23.5 Schizophrenia and Other Psychotic Disorders



23.5.1 Psychosis


Definition of psychosis: Presence of delusions + hallucinations + disorganized thoughts or behavior.




  • Delusions = Fixed, false beliefs that have no logical base (e.g., believing that your neighbor is out there scheming to kill you.)



  • Hallucinations = Hearing voices, seeing or smelling things that are not there.




















Auditory


Auditory hallucinations are more often associated with psychiatric disorders, e.g., “I hear people talking about me.”


Visual


These are more often associated with delirium, dementia, substance abuse, etc.


Tactile


Very common in alcohol withdrawal syndrome, e.g., formication (sensation of insects crawling over one’s skin).


Olfactory


Commonly associated with neurological disorders such as epilepsy, brain tumors, or encephalitis.




  • Disorganized thoughts














































In the following example, clinician has asked the patient a question regarding topic 1


How the patient proceeds to answers this question:


Type of disorganized thought

What happens?

Beginning of conversation

Middle of conversation

End of conversation

Circumstantial


Deviates from the first topic but eventually comes back to the first topic (circumstantial = circular)

Topic 1

Topic 2

Topic 1


Tangential


Does not come back to the original topic being discussed

Topic 1

Topic 2

Topic 2


Loose association


Jumps from one topic to another to another in a serially tangential fashion

Topic 1

Topic 2

Topic 3


Flight of ideas


Talkative and loosely associated thoughts with no connections (not even tangential)


• Most severe

Topic 1, 2, 3

Topic 4, 5, 6

And goes on 7, 8, 9, 10, 11, 12


Other examples of disorganized thoughts:
























Neologisms

Creation of new words with made-up meanings

Word salad

An incoherent collection of words, which may include neologisms.


Clang associations

Word associations based on the phonetics rather than the meaning of the word (e.g., “my spy die on a sky”)


Echolalia

Immediate and uncontrolled repetition of verbalizations made by another person


Preservation

Persistent repetition of words or ideas




  • For example, “I love this place, place, place, place, place, place, place, place.”



  • For example, answering “Yes” to all questions.




  • Disorganized behavior




















Echopraxia

Mimicking other person’s actions

Catatonia can be of two types

Nonresponsive

No response to external stimuli in a seemingly awake person; the person can be in a weird fixed position for a long period of time and have waxy flexibility


Hyperexcited

Excessive excited movement with no purpose


Symptoms of psychosis can be divided into the following two categories















Positive symptoms

Negative symptoms



  • Hallucinations



  • Delusions



  • Disorganized thoughts, speech, and behavior



  • Excited or erratic mood


  • Flat affect



  • Decreased interest



  • Decrease in memory and attention



  • Impaired executive functions such as planning or organizing



  • Depressed mood



  • Inability to socialize or pick up nonverbal cues



23.5.2 Psychosis in Various Conditions


































Presentation

Likely diagnosis (given in bold)

Psychosis alone for

< 1 month

Brief psychotic disordera


> 1 month but < 6 months

Schizophreniform disorder b


> 6 months

Schizophrenia b


Psychosis for 2 or more weeks + major mood disorder




  • Psychosis is independent of depressive or manic phase.



  • Either major depressive episode or bipolar disorder criteria should be fulfilled.

Schizoaffective disorder


For example, history of severe depression and psychosis. Later depressive symptoms improve, but patient still has psychosis (“hearing voices saying that the government is spying on you”).


Mood-congruent psychosis synchronous with depressive or manic phase (i.e., psychosis symptoms are only observed during major depressive or manic episode).

Major depressive disorder or manic disorder with psychotic features


e.g., major depressive episode along with auditory hallucinations saying, “you are completely worthless.” After major depressive episode resolves patient no longer has the hallucinations.

aDifferential diagnosis of brief psychotic disorder is acute confusional states due to medical condition. These patients can have acute hallucinations, delusions, and/or agitation:




  • Sedative (alcohol or benzodiazepine) withdrawal: Can present with hallucinations alone (alcoholic hallucinosis) or with delusions. Patients commonly have high BP, heart rate, and/or diaphoresis.



  • Delirium: Any acute illness in old people can precipitate delirium.



  • Other causes: Drug abuse (e.g., amphetamines—look for tachycardia, high BP, insomnia), Parkinson medications, steroids (steroid psychosis), systemic lupus erythematosus, encephalitis, etc.


bDifferential diagnosis is delusional disorder (delusions alone for ≥1 month with no hallucinations. Patients are normal functioning and have no disorganized thoughts/behavior, so it does not complete the criteria for psychosis).



5At times, delusions can be shared by a group of individuals and is known as shared delusional disorder.

Only gold members can continue reading. Log In or Register to continue

Related posts:

10. Neurology Eating disorders The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) Nicolas Cherbuin andAnthony Francis Jorm Family Psychiatric History Default ThumbnailThe Psychoses of Epilepsy Psychopharmacology

Stay updated, free articles. Join our Telegram channel
Tags: ,
Dec 11, 2021 | Posted by in PSYCHIATRY | Comments Off on 23. Psychiatry

Full access? Get Clinical Tree

 Get Clinical Tree app for offline access