Psychiatric Disorders



Psychiatric Disorders






ANXIETY: DIAGNOSIS


























































ANXIETY/WORRY ± PANICS


Palpitation Ambulation (dizzy) Numb-Nausea


Intense fear of death-derangement-derealization


Choking-Chills-Chest pain Sweating-Shaking-Short of breath


A panic attack is a sudden, intense episode of anxiety/fear with ≥4 severe symptoms that may greatly resemble a heart attack


Panic attacks may be present in any disorder but are required in panic disorder


FEAR


DIAGNOSIS


MINIMUM CRITERIA


Almost everything


Generalized anxiety disorder


STRIFE (6 months)


3 of Sleep, Tension, Restlessness, Irritability, Focus, Energy


Children only require 1 symptom


Social scrutiny


Social phobia


Intense fear/avoidance (6 months) Of social judgment


Panic attacks


Panic disorder


Recurrent/unexpected panic (1 month)


Fear of more panic attacks


And/or avoidance of triggers


Leaving home


Agoraphobia


Intense fear/panic (6 months)


2 of public transit, open spaces, closed spaces, crowds, being alone outside


Very specific


Specific phobia


Intense fear/avoidance (6 months) Of specific object/situation


Speaking


Selective mutism


Unwilling to speak (1 month)


Able/willing to speak in other locations


Not only during first month of school


Separation


Separation anxiety disorder


Intense fear (6 months)


3 of separation, ill parent, getting lost or ill, leaving home, staying home, going to sleep, bad dreams


Children only require 1 month


Additional Anxiety Disorders


Other specified


Not quite meeting full criteria


Unspecified


Limited or conflicting information


Substance/medication induced


Due to another medical condition




ANXIETY: DIAGNOSIS









































RATING SCALES


Adults


GAD-7


Generalized Anxiety Disorder-7 Specifically for GAD but can be used for other disorders 10-14 moderate, 15-21 severe


Children


Scareda


Screen for Child Anxiety Related Disorders


25 may indicate anxiety disorder


Subscores: A positive screen may indicate disorder


Somatic symptom disorder: ≥7


Generalized anxiety disorder: ≥9


Separation anxiety disorder: ≥5


Social anxiety disorder: ≥8


School avoidance: ≥3


SPECIFIERS


Social phobia


Performance only: anxiety symptoms only prominent during public speaking or performance


Specific phobia


Animal: eg, spiders, insects, dogs


Natural: eg, heights, storms, water


Blood-injection: eg, needles, medical procedures


Situational: eg, airplanes, elevators


Other: eg, choking, clowns


DIFFERENTIAL DIAGNOSIS


Medical


CAD, CHF, COPD, PE, MVP, Cushing disease, arrhythmias, hypertensive emergency, pneumonia, asthma, thyroid dysfunction, hyperparathyroidism, hypoglycemia, menopause, insulinoma, pheochromocytoma, anemia, seizure disorder, encephalopathy, essential tremor


Mental


MDD, PTSD, OCD, SUD, somatic symptom disorder, personality disorder


Meds or substance


Bupropion, caffeine, nicotine, cocaine, amphetamines, PCP, sympathomimetics, beta-2-agonists, dopamine agonists, metoclopramide, anticholinergics, steroids, indomethacin, withdrawal (alcohol, opioids, sedatives, antidepressants)


a Validated: but not listed in AIMS/SAMHSA/AHRQ recommendations




ANXIETY: TREATMENT








































































INITIAL APPROACH


Mild


Moderate


Severe/complex


Psychotherapy


Meds and/or therapy


Medication


Secondary/co-occurring: treat medical/substance use simultaneously Psychotherapy: see psychotherapy section for details


BZDs are “anti-panic” and are best used short-term or infrequently PRN


Chronic severe anxiety/panic is best treated with psychotherapy and/or SSRI/SNRIs


In patients not on opioids or with SUDs, BZDs can be initiated while waiting for other treatment to take effect, with the agreement that they will not be used long-term or as monotherapy


MEDICATION CHOICE


Choose by class, side effects, and contraindications


WEIGHT GAIN AND SEDATION


Lowest in class


Moderate


Highest in class


MEDS BY CLASS


SIDE EFFECTS AND SAFETY


1) Buspirone


Low sex side effects but no antidepressant properties


Buspirone 10-30 BID


Mild side effects but must dose BID


2) SSRI


Best for anxiety but worst sex side effects


Fluoxetine 10-80


Least withdrawal and longest half-life


Sertraline 25-200


Best for pregnancy and breast feeding


Citaloprama 20-40 or escitalopram 10-20


Low side effects overall


Long QT >40 mg (citalopram only)


Paroxetine 10-60 HS or ER 12.5-62.5 HS


Good for anxiety but worst withdrawal


ER form may have less withdrawal


Pregnancy


3) SNRI and related


Good for pain but often worst nausea


Venlafaxine ER 37.5-225 or desvenlafaxine 25-100


May help hot flashes but bad withdrawal


Duloxetine 20-120


Bad withdrawal and ± formulary


4) Psych referral


For psychotherapy or additional meds


Common side effects: stimulation/sedation, stomach upset, headache, dry mouth, sexual


a Off-label: evidence-based but no FDA indication




ANXIETY: TREATMENT





















































INSTRUCTIONS


Increase


Add


Cross


Try


Treat


At 1 week then Q2-4 until remission or intolerable


Augmentation for partial effect at 75%-100% max dose


To next if no effect at 50% max dose for 4 weeks


2 meds per class (if possible) before moving to next


For 6 months for 1 episode, 12 for 2, lifelong for ≥3


Reduce dosing by 50% if <18, >65, or severe liver or kidney disease


AUGMENTATION


All


▼ substance use and ▲ treatment of sleep and pain


Add meditation, exercise, and/or psychotherapy


Persistent anxiety


1) Buspirone 10-30 BID


2) Clonazepam 0.5-2 daily or div BID (short-term)


PRN anxiety


1) Lorazepam 0.5-3 div TID (short-term) or safer alternative hydroxyzinea 25-100 TID (if SUD/opiates)


Performance anxiety: propranolola 10-40 (1 hour prior)


PSYCHOTHERAPY & RESOURCES


Mindfulness (including relaxation techniques) and CBT (including behavioral activation and problem-solving treatment)


The Anxiety and Worry Workbook—Clark/Beck


The Anxiety and Phobia Workbook—Bourne


When Panic Attacks—Burns


The Anxiety Workbook for Teens—Schab


On Edge: A Journey Through Anxiety—Petersen


Adaa.org—Anxiety and Depression Association of America


CONTRAINDICATIONS & MONITORING


Citalopram


Clonazepam


Lorazepam


Paroxetine


Propranolol


Long QT >40 mg


Pregnancy, SUD, sedative/opiate use


Pregnancy, SUD, sedative/opiate use


Pregnancy


Bradycardia, asthma, heart failure


See safety and monitoring in appendix for additional information


a Off-label: evidence-based but no FDA indication




OCD: DIAGNOSIS
















































OBSESSION AND/OR COMPULSION


Obsessions are intense, unwanted ideas, urges, or images


Compulsions are rituals performed to either undo or prevent obsessions or some other impending disaster


Obsessive-compulsive personality disorder is distinct in that the patient feels that the rigid rules are necessary, pervasive, and a part of who they are (may be difficult to distinguish from OCD with absent insight/delusional beliefs)


SYMPTOMS


DIAGNOSIS


MINIMUM CRITERIA


Washing, checking, symmetry, etc


Obsessive-compulsive disorder


Obsessions and/or compulsions 1 hour or more a day


Physical flaws


Body dysmorphic disorder


Focus on perceived flaws


Includes repetitive behaviors hiding, comparing, repairing flaws


Collecting


Hoarding disorder


Distress in discarding objects


Due to perceived need to save them


Often leading to accumulation


May include animals


Skin picking


Excoriation disorder


Frequent skin picking


With difficulty stopping


Can be during stress (focused) or when distracted (automatic)


Hair pulling


Trichotillomania


Frequent hair pulling


With difficulty stopping


Can be during stress (focused) or when distracted (automatic)


Additional Obsessive-Compulsive and Related Disorders


Other specified


Not quite meeting full criteria


Unspecified


Limited or conflicting information


Substance/medication induced


Due to another medical condition




OCD: DIAGNOSIS













































RATING SCALES


Obsessive-Compulsive Disorder


Y-BOCSa


Yale-Brown Obsessive Compulsive Scale-II


Symptom checklist: generates a symptoms list


Severity rating scale: quantifies symptoms over time


16 moderate, 24 severe, 32 extreme


CY-BOCSa


Children’s Yale-Brown Obsessive Compulsive Scale


Symptom checklist: generates a symptoms list


Includes self- and clinician-rated versions


Severity rating scale: quantifies symptoms over time


Includes child-, parent-, and clinician-rated versions 16 moderate, 24 severe, 32 extreme


SPECIFIERS


OCD


Tic-related: current or past history of tic


BDD


With muscle dysmorphia: focused on muscle size


Hoarding


With excessive acquisition: due to difficultly discarding


All


With good or fair insight: aware that beliefs are not true


With poor insight: feel that beliefs are probably true


With absent insight/delusional beliefs: beliefs are true


DIFFERENTIAL DIAGNOSIS


Medical


TBI, stroke, hypothyroidism, meningitis, encephalitis, dementia, genetic disorder


Mental


MDD, PTSD, social phobia, specific phobia, agoraphobia, paraphilia, substance use, panic disorder, tic disorder, illness anxiety disorder, delusional disorder, bipolar disorder, personality disorders, autism spectrum disorders, impulse control disorders, eating disorders


Meds or substance


PCP, stimulants, sympathomimetics, dopamine agonsists, steroids, hallucinogens, withdrawal (alcohol, opioids, sedatives)


a Validated: but not listed in AIMS/SAMHSA/AHRQ recommendations




OCD: TREATMENT

















































































INITIAL APPROACH


Mild


Moderate


Severe/complex


Psychotherapy


Meds and/or therapy


Medication


Secondary/co-occurring: treat medical/substance use simultaneously


Psychotherapy: see psychotherapy section for details


Response to meds: OCD>OCD-related >> OCPD


MEDICATION CHOICE


Choose by class, side effects, and contraindications


WEIGHT GAIN AND SEDATION


Lowest in class


Moderate


Highest in class


MEDS BY CLASS


SIDE EFFECTS AND SAFETY


1) SSRI


Best for anxiety but worst sex side effects


Fluoxetine 10-80


Least withdrawal and longest half-life


Sertraline 25-200


Best for pregnancy and lactation


Citaloprama 10-40 or escitaloprama 5-20


Low side effects overall


Long QT >40 mg (citalopram only)


Paroxetine 10-60 HS or ER 12.5-62.5 HS


Good for anxiety but worst withdrawal


ER form may have less withdrawal


Pregnancy


2) Fluvoxamine (SSRI)


Best for OCD but multiple interactions


Fluvoxamine 25-200 BID or ER 50-400 HS


Must dose BID (IR form)


ER form is single dose but ± formulary


3) Clomipramine (TCA)


Best for OCD but sedating/constipating


Clomipramine 25-250 HS


Pregnancy, MI


4) SNRI & related


Good for pain but often worst nausea


Venlafaxine ERa 37.5-225 or desvenlafaxinea 25-100


May help hot flashes but bad withdrawal


Duloxetinea 20-120


Bad withdrawal and ± formulary


Mirtazapinea 7.5-45 HS


Least nausea and good for sleep/anxiety


Most sedation and weight gain


5) Psych referral


For psychotherapy or additional meds


Common side effects: stimulation/sedation, stomach upset, headache, dry mouth, sexual


a Off-label: evidence-based but no FDA indication




OCD: TREATMENT

















































INSTRUCTIONS


Increase


Add


Cross


Try


Treat


At 1 week then Q2-4 until remission or intolerable


Augmentation for partial effect at 75%-100% max dose


To next if no effect at 50% max dose for 4 weeks


2 meds per class (if possible) before moving to next


For 1-2 years then attempt 10% taper monthly


Reduce dosing by 50% if <18, >65, or severe liver or kidney disease


AUGMENTATION


All


▼ substance use and ▲ treatment of sleep and pain


Add meditation, exercise, and/or psychotherapy


OC disorders


1) Try up to 150% standard max dose of primary agent


2) Risperidonea 0.5-3 HS


3) Add/use clomipramine 25-250 HS


Tic or Tourette syndrome


1) Clonidinea 0.05-0.2 BID or ERa 0.05-0.4 HS


2) Or less sedating guanfacinea 0.5-2 BID or ERa 1-4


3) Tetrabenazinea 12.5-25 BID or SGAa


PSYCHOTHERAPY & RESOURCES


CBT: OCD, BDD, hoarding, trichotillomania, and excoriation


Exposure and response prevention: OCD and hoarding


Habit reversal treatment: trichotillomania and excoriation


Getting Over OCD—Abramowitz


Buried in Treasures—Tolin/Frost/Steketee


Overcoming BDD—Neziroglu/Khemlani-Patel/Santos


Trichotillomania—Woods/Twohig


Skin Picking—Pasternak


The Man Who Couldn’t Stop—Adam


Iocdf.org—International OCD foundation


CONTRAINDICATIONS & MONITORING


Citalopram


Clomipramine


Paroxetine


Tetrabenazine


Long QT (>40 mg)


Pregnancy, MI


Pregnancy


Long QT, liver failure, arrhythmia


Initial monitoring: TCA=EKG (>40 or cardiac disease); SGA=HA1c, lipids, EKG (if cardiac risk factors)


See safety and monitoring in appendix for additional information


a Off-label: evidence-based but no FDA indication




PTSD: DIAGNOSIS















































TRAUMA


Trauma exposure


Re-experiencing


Arousal increase


Unpleasant Mood


Avoidance


To actual or threatened serious injury or death Nightmares, flashbacks, or intrusive memories With ▲ startle, vigilance, irritability, or insomnia Including depression, detachment, or amnesia Of stimuli associated with trauma memory


PTSD can follow a single trauma or prolonged/repeated exposures


Complex/childhood trauma may present less like PTSD and more like a collection of other pathologies including MDD, bipolar, anxiety, substance use, or personality disorder


Not all trauma leads to clinical difficulties or a psychiatric diagnosis Trauma symptoms will often decrease over time, but may remain latent or reoccur


SYMPTOMS


DIAGNOSIS


MINIMUM CRITERIA


Minor acute


Adjustment disorder


1-4 symptoms Distress that is out of proportion Or significant impairment in function Usually from 3-6 months from trigger


Major acute


Acute stress disorder


All 5 symptoms (≤30 days)


Major chronic


Posttraumatic stress disorder


All 5 symptoms (>30 days)


Usually within 6 months of trauma


Inhibited child


Reactive attachment disorder


Inhibited behavior toward adults Due to persistent neglect or abuse Social and emotional negativity


Disinhibited child


Disinhibited social engagement disorder


Disinhibited behavior toward adults Due to persistent neglect or abuse


Not due to ADHD


Additional Trauma- and Stressor-Related Disorders


Other specified


Not quite meeting full criteria


Unspecified


Limited or conflicting information




PTSD: DIAGNOSIS

















































RATING SCALES


Posttraumatic Stress Disorder


PC-PTSD


Primary Care PTSD Screen Used for screening and diagnosis only ≥3


NSESSa


National Stressful Events Survey PTSD Short Scale


Used to follow symptom severity over time


0-36 (with higher scores indicating greater severity)


SPECIFIERS


Adjustment Disorder


Type


With anxiety: anxiety/nervousness/worry prominent


With depressed mood: low mood/tearfulness prominent


With disturbance of conduct: acting out prominent


With mixed anxiety and depressed mood: both


With mixed disturbance of emotions and conduct: all


Timing


Acute: <6 months of symptoms


Persistent (chronic): ≥6 months of symptoms


PTSD


Type


With dissociative symptoms: feel unreal/outside body


Timing


With delayed expression: no symptoms until 6 months after trauma


DIFFERENTIAL DIAGNOSIS


Medical


Traumatic or anoxic brain injury, postconcussive syndrome


Mental


MDD, OCD, anxiety, psychosis, substance use, dissociative disorders, personality disorders


Meds or substance


Bupropion, caffeine, nicotine, cocaine, amphetamines, PCP, sympathomimetics, withdrawal (alcohol, opioids, sedatives, antidepressants)


a Validated: but not listed in AIMS/SAMHSA/AHRQ recommendations




PTSD: TREATMENT




















































































INITIAL APPROACH


Mild


Moderate


Severe/complex


Psychotherapy


Meds and/or therapy


Medication


Secondary/co-occurring: treat medical/substance use simultaneously


Psychotherapy: see psychotherapy section for details


Adjustment & Acute Stress Disorder


Treat severe target symptoms for 30 days before attempting taper


Insomnia only


PRN panic attacks


24-hour anxiety


Zolpidem 5-10 HS


Lorazepam 0.5-1 up to TID


Clonazepam 0.25-1 up to BID


Posttraumatic Stress Disorder


A) Start alpha blocker if combat-related or re-experiencing dominant


B) Start SSRI if mood and avoidance dominant (or co-occurring MDD)


Titrate A or B to 75%-100% of max dose then augment with other (A/B)


If all symptoms severe, start both types of medication initially (A + B)


WEIGHT GAIN AND SEDATION


Lowest in class


Moderate


Highest in class


A1) Alpha blocker


Best for re-experiencing but common ▼ BP


Re-experiencing and hyperarousal


Prazosina 1-15 HS (or 1-7 BID if AM ≥ PM)


If ▼ BP/dizzy


Doxazosina 1-15 HS


A2) SGA


Less ▼ BP but ▲ lipids/weight gain


Risperidonea 0.5-4 HS


Quetiapinea 25-400 HS


Olanzapinea 5-20 HS


B1) SSRI


Best for anxiety but worst sex side effects


Fluoxetinea 10-80


Sertraline 25-200


Paroxetine 10-60 HS or ER 12.5-62.5 HS


B2) SNRI & related


Good for pain but often worst nausea


Venlafaxine ERa 37.5-225


Mirtazapinea 7.5-45 HS


3) Psych referral


For psychotherapy or additional meds


Common side effects: stimulation/sedation, stomach upset, headache, dry mouth, sexual (SSRI/SNRI); ▼ BP/dizziness (prazosin/doxazosin); fatigue, dry mouth, stomach upset, increased appetite/weight gain, feeling foggy-headed, muscle restlessness/stiffness (SGA)


a Off-label: evidence-based but no FDA indication

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May 8, 2019 | Posted by in PSYCHOLOGY | Comments Off on Psychiatric Disorders
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