Psychiatric Symptoms and Management



Psychiatric Symptoms and Management





Anxiety

Anxiety is common psychological state that often occurs in response to stress and is manifested by fear, worry, or nervousness. Such symptoms can be highly biologically adaptive if there is an actual threat to the individual but become maladaptive if they occur in the absence of a real threat and significantly impact functioning. The psychological symptoms are often accompanied by physical symptoms of autonomic arousal, including heart palpitations and sweating. Patients with many medical conditions also display similar symptoms, so it is crucial to rule out organic causes of anxiety.





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PATHOPHYSIOLOGY



  • Noradrenergic (NE), γ-aminobutyric acid (GABA), serotoninergic (5-HT), and other neurotransmitter systems have been implicated


  • Brain areas thought to be involved include limbic system (amygdala), hippocampus, locus ceruleus, and cortical regions








TABLE 3-1 Differential Diagnosis of Anxiety













Nonpsychiatric Conditions (anxiety caused by a general medical condition [I])




  • Cardiac disorders: angina, arrhythmia, congestive heart failure, mitral valve prolapse, myocardial infarction



  • Drug intoxication: caffeine, cannabis, cocaine, PCP



  • Drug withdrawal: ethanol, benzodiazepines



  • Endocrine disorders: Addison’s disease, Cushing’s disease, hypoglycemia, hyperthyroidism, hypothyroidism, menopause, parathyroidism, pheochromocytoma



  • Hematologic disorders: anemia, porphyria



  • Medications: anticholinergic agents, bronchodilators, corticosteroids, dextromethorphan, diet pills (phentermine), OTC cold remedies (pseudoephedrine), SSRIs (discontinuation or treatment initiation), stimulants (methylphenidate)



  • Metabolic disorders: acidosis, electrolyte abnormalities, hyperthermia



  • Neurologic disorders: cerebrovascular disease, migraine, seizures



  • Pulmonary disorders: asthma, COPD, hyperventilation, pulmonary embolus


Psychiatric Conditions




  • Substance-induced anxiety disorder (II)



  • Generalized anxiety disorder (III)



  • Adjustment disorder with anxiety (IV)



  • Posttraumatic stress disorder (V)



  • Panic disorder (VI)



  • Social anxiety disorder (social phobia) (VII)



  • Specific phobia (VIII)


COPD, chronic obstructive pulmonary disease; OTC, over the counter; PCP, phencyclidine; SSRI, selective serotonin reuptake inhibitor.



DIFFERENTIATING FEATURES OF ORGANICALLY BASED ANXIETY



  • Onset after age 35 years


  • No personal or family history of anxiety disorder


  • No childhood history of debilitating anxiety, separation anxiety, or phobias


  • Lack of significant life events leading to or exacerbating anxiety symptoms


  • Lack of avoidance behavior


  • Poor response to anxiolytic medications









TABLE 3-2 Approach to the Evaluation of Anxiety





















History with special attention to:


History of present illness: onset, symptoms, duration of current episode, other mood or psychotic symptoms, current substance use


Psychiatric history: prior episodes (number of episodes, duration, average severity, time since last episode), other psychiatric disorders, substance use, medication trials


General Medical and Neurologic Examination


Psychiatric Mental Status Examination with special attention to:


Behavior (restless, fidgety), speech (increased rate), presence or absence of panic attacks


Laboratory Studies, Imaging, and Other Diagnostic Tools with special attention to:


If chest pain is present, persistent, and associated with other risk factors, consider EKG and further cardiac workup


EKG, electrocardiogram.



SUBSTANCE-INDUCED ANXIETY DISORDER (II)



  • Prominent generalized anxiety, panic attacks, or obsessive-compulsive disorder (OCD) in the setting of substance intoxication or withdrawal


  • Need confirmation from clinical history, laboratory results, or physical examination that either:


  • Anxiety developed during or within 1 month of substance intoxication or withdrawal


  • Substance use is etiologically related to anxiety symptoms


  • Not occurring exclusively during delirium


  • Diagnosis should only be made if anxiety exceeds symptoms usually seen in substance intoxication or withdrawal


GENERALIZED ANXIETY DISORDER (GAD) (III)



  • The person has chronic, excessive worry or anxiety that occurs most days for at least 6 months


  • It is associated with somatic symptoms, including fatigue, muscle tension, restlessness, sleep disturbance, difficulty concentrating, and irritability


  • Anxiety is hard to control and causes significant impairment


  • The person is seen as chronic “worrier” or “nervous person” by others around him or her



EPIDEMIOLOGY



  • 3%-8% prevalence rate


  • 2:1 female-to-male ratio


  • 50%-90% have comorbid psychiatric illness



ADJUSTMENT DISORDER WITH ANXIETY (IV)



  • Development of nervousness or worry occurring within 3 months of onset of psychosocial stressor


  • Remits within 6 months after termination of stressor


  • Not attributable to bereavement


POSTTRAUMATIC STRESS DISORDER (PTSD) (V)



  • Intense fear, horror, and helplessness experienced after a traumatic event


  • Trauma was such that patient directly witnessed, experienced, or was confronted with an event that involved actual or threatened death, injury, or threat to physical integrity


  • Persistent reexperiencing of the event through distressing recollections, dreams, dissociative flashbacks, physiological reactivity, and psychological distress to stimulus cues of event


  • Persistent avoidance of stimuli associated with the traumatic event and numbing of general responsiveness (e.g., detachment or sense of estrangement)


  • Symptoms of hyperarousal are present, including:



    • Difficulty falling or staying asleep


    • Irritability or angry outbursts


    • Difficulty concentrating


    • Hypervigilance


    • Exaggerated startle response


  • Symptoms present for more than 1 month (for symptoms <1 month, consider acute stress disorder)


PANIC DISORDER (PD) (VI)



  • Recurrent, unexpected panic attacks



    • Symptoms of panic attacks: overwhelming anxiety or fear that comes on acutely (<10 min) and is accompanied by four or more of the symptoms below:



      • Chest pain


      • Palpitations


      • Derealization or depersonalization


      • Fear of dying, losing control, or losing one’s mind


      • Paresthesias


      • Dizziness or lightheadedness


      • Shortness of breath


    • Many individuals may experience limited symptom attacks (e.g., only experiencing one or two of panic symptoms)



    • Attacks come on suddenly and peak within 10 minutes


    • Accompanied by more than 1 month of more than one of following:



      • Anticipatory anxiety (so-called “fear of the fear”)


      • Corresponding change in behavior (e.g., avoidance)


      • Worrying about consequences or outcomes of panic attacks


    • May occur with or without agoraphobia



      • Agoraphobia



        • Anxiety caused by being in places or situations from which escape may be difficult or embarrassing or from which help may not be readily available in case of a panic attack


        • Typically involves clusters of situations outside the home, including being in a crowd; standing in line; being on a bridge; or traveling in a bus, train, or automobile


        • Situations are avoided or endured with marked distress or anxiety about having panic


    • The first panic attack must occur unexpectedly (e.g., uncued)


    • The person may become phobic of particular situation in which panic occurred, but anxiety is from fear of another panic attack. not the situation itself



EPIDEMIOLOGY



  • 3% of the general population


  • Female > male


  • Average age of onset: 24 years


  • Potentially increased rate of suicidal ideation and attempts


SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA) (VII)



  • Excessive anxiety or fear triggered by social situations causing marked impairment


  • Fear of being publicly scrutinized or humiliated


  • Panic attacks are a common feature


  • The patient recognizes that fear is excessive or irrational


  • The phobic stimulus is avoided or lived through with significant anxiety


  • Should specify if subtype “performance anxiety” is present



EPIDEMIOLOGY



  • 3%-15% prevalence rate


  • Onset peaks in adolescence


  • Often comorbid with depression and substance abuse


SPECIFIC PHOBIA (VIII)



  • Irrational, overwhelming fear of a specific situation or object


  • Fear is recognized as irrational


  • Avoidance of phobic stimulus is common


  • Exposure to phobic stimulus can trigger panic attacks


  • Causes marked impairment


  • Types of phobias include animals (dogs), natural environment (heights), blood injection, situational (airplanes), and other (fear of choking)



EPIDEMIOLOGY



  • 5%-10% of US population


  • Most common psychiatric disorder among women; second among men


  • Bimodal distribution of situational phobias: childhood and early adulthood


TREATMENT


Psychopharmacology Guidelines



  • Start slow: patients with anxiety are very sensitive to somatic side effects



  • Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are first-line agents for most of the disorders


  • Antidepressant doses used for depression may need to be higher


  • Older agents such as tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are effective but typically have more side effects


  • TCAs are not effective for social anxiety disorder


  • Benzodiazepine are efficacious, fast-acting, and generally well tolerated but have abuse liability


  • There is a potential concern that benzodiazepines administered in aftermath of trauma may interfere with recovery after trauma


  • Beta-blockers are sometimes used to reduce autonomic arousal in patients with panic attacks


  • Beta-blockers are helpful in reducing the performance anxiety subtype but not the generalized subtype of social phobia


Psychotherapy Guidelines



  • Anxiety disorders are effectively treated by many forms of psychotherapy, especially cognitive behavior therapy (CBT)



    • Cognitive restructuring: restructures catastrophic thinking


    • Relaxation training: anxiety management strategies



      • Slow breathing


      • Muscle relaxation


    • Behavioral exposure: repeatedly exposing the patient to fearful stimuli to extinguish the conditioned fear response


  • Supportive therapy is particularly helpful for acute management immediately after the trauma of PTSD


Dementia


DEFINITION

A chronic, progressive decline in cognitive abilities


MODIFIED DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS IV (DSM-IV)


Definition and Diagnostic Features

Cognitive deficits in areas listed in 1 and 2:



  • Problems with information recall or learning


  • One or more of the following problems with cognition:



    • Aphasia (problems with language)


    • Agnosia (difficulty recognizing objects)


    • Apraxia (difficulty executing voluntary movements without motor impairment)


    • Executive functioning problems (poor planning, abstract reasoning)


  • May also be associated with:



    • Poor judgment; disinhibition; hallucinations; delusions; anxiety, mood, or sleep disturbance



DEMENTIA DIAGNOSIS CATEGORIES AND REPRESENTATIVE EXAMPLES








TABLE 3-3 Dementia Diagnosis Categories and Representative Examples





















































Degenerative




  • Alzheimer’s dementia



  • Dementia with Lewy bodies



  • Frontotemporal dementia (e.g., Pick’s disease)



  • Parkinson’s disease



  • Huntington’s disease



  • Wilson’s disease



  • Progressive supranuclear palsy


Psychiatric




  • Depression



  • Schizophrenia


Vascular




  • Vascular dementia



  • Amyloid angiopathy


Obstructive




  • Normal-pressure hydrocephalus


Traumatic




  • Chronic subdural hematoma



  • Dementia pugilistica


Neoplastic




  • Malignant brain tumor



  • Benign brain tumor



  • Metastatic disease



  • Paraneoplastic syndrome


Infectious




  • HIV dementia



  • Syphilis



  • Creutzfeldt-Jakob disease


Demyelinating




  • Multiple sclerosis


Autoimmune




  • SLE


Drugs and Medications




  • Anticholinergics



  • Antihistamines



  • Sedative-hypnotics


Substance Abuse




  • Alcohol



  • Narcotics



  • Inhalants



  • Prescription drug abuse


Toxins




  • Arsenic



  • Carbon monoxide



  • Lead



  • Mercury


HIV, human immunodeficiency virus; SLE, systemic lupus erythematosus Adapted from Falk WE: The patient with memory problems or dementia. In Stern TA, Herman JB (eds). The Massachusetts General Hospital Guide to Primary Care Psychiatry, 2nd ed. New York: McGraw Hill; 2004:198. Reproduced with permission of the McGraw-Hill Companies.



CLINICAL FEATURES OF DELIRIUM, DEPRESSION, AND ALZHEIMER’S DEMENTIA

Alzheimer’s dementia is the most common form of dementia. When evaluating a patient with known or suspected dementia, it is a priority to assess for delirium and treat the patient if necessary.









TABLE 3-4 Clinical Features of Delirium, Depression, and Alzheimer’s Dementia

Delirium

Depression

Alzheimer’s Dementia


Onset

Abrupt

Relatively discrete

Insidious


Initial symptoms

Difficulty with attention and disturbed consciousness

Dysphoric mood or lack of pleasure

Memory deficits: verbal or spatial


Timeline

Fluctuating over days to weeks

Persistent; usually lasting months

Gradually progressive over years


Family history

Not contributory

May be positive for depression

May be positive for Alzheimer’s dementia


Memory

Poor registration

Patchy or inconsistent loss

Short-term memory worse than long-term memory


Subjective language deficit

Absent

Present

Variable; usually absent


Example of language deficit

Difficulty attending to conversation to conversation or written tasks

Increased speech latency

Difficulty with naming objects


Affect

Often labile

Depressed or irritable

Can vary; may be neutral


Adapted from Falk WE: The patient with memory problems or dementia. In Stern TA, Herman JB (eds). The Massachusetts General Hospital Guide to Primary Care Psychiatry, 2nd ed. New York: McGraw Hill; 2004:198.



BEHAVIORAL TREATMENT GUIDELINES



  • Safety of the patient and others takes priority. Use physical restraints or one-on-one supervision when necessary


  • Consider behavioral interventions



    • Reorient to environment


    • Simplify communication


    • Reassure, distract, and redirect


  • Identify if delirium is also present


PHARMACOLOGIC TREATMENT TO TARGET SPECIFIC SYMPTOMS


General Guidelines



  • Minimize polypharmacy


  • Identify and avoid drugs with cognitive side effects


  • Assess for and treat comorbid medical problems, especially delirium


  • Start with low doses (one quarter to one half that for normal adults) and increase slowly while monitoring for side effects


  • Older patients may be more sensitive to medication side effects such as sedation, orthostatic hypotension, anticholinergic side effects, and extrapyramidal side effects (EPS)


  • No pharmacologic treatment exists for wandering behavior









TABLE 3-5 Approach to the Evaluation of Dementia























































History with special attention to:


Source: family members, caregivers, patient (may be less reliable)


Presenting symptoms: how difficulties first came to attention, deficits in recent memory suggests Alzheimer’s disease; behavior change suggests frontotemporal dementia


Course: gradual deterioration in Alzheimer’s disease; stepwise deterioration in vascular dementia


Associated medical symptoms: falls, incontinence, gait instability


Associated psychiatric symptoms: hallucinations, paranoia, depressed or irritable mood, personality changes


Medical history: stroke risk factors such as hypertension, diabetes


Psychiatric history: mood disorder, substance abuse


Medications: Include OTC medications; anticholinergics, psychiatric medications, narcotics may have cognitive effects


Family history: Alzheimer’s disease and frontotemporal dementia


General Medical and Neurologic Examination with special attention to:


Cardiovascular system, signs of infection, inflammation, and endocrine disorders


Cranial nerves, sensation, muscle tone and strength: assess for focal abnormalities


Reflexes: primitive reflexes (palmomental, glabellar, grasp, sucking)


Coordination and balance: gait, position sense


Other: asterixis, praxis, Luria maneuver


Psychiatric Mental Status Examination with special attention to:


Mood: depression may exacerbate or cause cognitive difficulty; irritability or elevated mood may be present in patients with mood disorders and dementia


Cognitive functioning: attention, memory, orientation, language, executive functioning


Bedside and outpatient initial testing




  • Folstein MMSE (published by Psychological Assessment Resources)



  • Montreal Cognitive Assessment (tests clock drawing, naming, word registration and recall, attention, abstraction, orientation)



  • Free test and interpretation guide available at www.mocatest.org


Laboratory Studies, Imaging, and Other Diagnostic Tools with special attention to:


First-line studies: Electrolytes, glucose, BUN or creatinine, CBC, liver function tests, thyroid function tests, lipids, B12 or folate levels, syphilis serology, urinalysis, CT scan (to rule out bleeding, NPH, stroke, tumor)


Second-line studies, if indicated: brain MRI (especially if neurologic examination is abnormal), EEG (assess for seizure, metabolic encephalopathy), lumbar puncture (assess for infection, cancer, vasculitis), HIV testing, autoimmune disorder screening tests, drug levels, heavy metal screening, ECG, CXR


Testing referral may be indicated if initial screening is abnormal and there are questions regarding diagnosis or functional ability


BUN, blood urea nitrogen; CBC, complete blood count; CT, computed tomography; CXR, chest radiography; ECG, electrocardiography; EEG, electroencephalography; HIV, human immunodeficiency virus; MMSE, Mini-Mental Status Examination; MRI, magnetic resonance imaging; NPH, normal-pressure hydrocephalus; OTC, over the counter.











TABLE 3-6 Dementia Subtypes

Alzheimer’s Disease

Vascular Dementia

Lewy Body Dementia

Frontotemporal Dementia (e.g., Pick’s Disease)

Normal-Pressure Hydrocephalus


Epidemiology

Most common dementia; age >70 years

Second most common; associated with vascular risk factors

Age >70 years; associated with Parkinson’s disease

Most common early-onset dementia; appears in 50s and 60s

Occurs after trauma, infection, or hemorrhage rather than being idiopathic


Initial symptoms

Short-term memory loss

Apathy, gait problems, memory loss

Parkinsonism (rigidity, bradykinesia), sleep disturbance, visual hallucinations

Personality changes (apathy, disinhibition)

Triad of shuffling gait, urinary incontinence, and cognitive impairment


Prominent cognitive symptoms

Progressive memory impairment, disorientation, aphasia, apraxia, agnosia

Visuospatial deficits, slowed processing, impaired memory retrieval

Episodic fluctuations in arousal or alertness

Disinhibition, aphasia if left sided; memory relatively preserved

Slowed verbal responses


Noncognitive symptoms

Depression, apathy, delusions, hostility

Depression, psychosis

VH or illusions, delusions (misidentification or Capgras), autonomic dysfunction, falls or postural instability

Stereotyped motor behaviors, compulsions, hyperorality, antisocial personality, impulsivity (gambling, sexual or verbal disinhibition)

Apathy, depression


Neuropsychological deficits

Short-term memory, attention, orientation

Visuospatial deficits, executive dysfunction

Visuospatial deficits, Executive dysfunction

Executive dysfunction, memory and visuospatial preserved

Executive dysfunction


Imaging

Generalized atrophy (parietal, temporal, hippocampal)

Subcortical white matter

Subtle parietal or occipital atrophy

Frontotemporal atrophy (frontal or temporal subvariants)

Enlarged ventricles


Neuropathology

β-Amyloid plaques, neurofibrillary tangles

Microvascular ischemic changes

α-Synuclein, Lewy bodies

Tau, ubiquitin


Treatment

Cholinesterase inhibitors; memantine for moderate to severe cases

Manage vascular risk factors; smoking, HTN, hyperlipidemia; cholinesterase inhibitors

Cholinesterase inhibitors; avoid typical neuroleptics because they induce EPS; quetiapine for psychosis

SSRIs, antipsychotics; cholinesterase inhibitors have limited benefit

Ventriculoperitoneal shunt


EPS, extrapyramidal side effects; HTN, hypertension; SSRI, selective serotonin reuptake inhibitor; VH, visual hallucinations.










TABLE 3-7 Suggested Pharmacologic and Somatic Treatments for Symptoms Occurring with Dementia




































Symptom

Treatment


Cognitive symptoms

Cognitive enhancers (e.g., donepezil, galantamine, rivastigmine, memantine): generally not helpful in the acute setting but may have long-term beneficial effects on behavior and mood


Depression

SSRIs: avoid those with greater anticholinergic side effects (e.g., paroxetine)


Other antidepressants: mirtazapine, bupropion


Stimulants: methylphenidate




  • For poor energy or motivation



  • Use with caution in patients with cardiac disease


MAOIs or ECT: for severe, treatment-refractory depression


Hallucinations, paranoia, delusions

Atypical antipsychotics


Typical antipsychotics: generally avoid agents with greater anticholinergic effect (e.g., thioridazine)


Agitation (restlessness, verbal outbursts, physical aggression

Atypical antipsychotics


Typical antipsychotics: generally avoid agents with greater verbal outbursts, anticholinergic effect (e.g., thioridazine)


Benzodiazepines: caution: risk of disinhibition, worsened cognition


Other agents: trazodone, propanol, valproic acid


ECT, electroconvulsive therapy; MAOI, monoamine oxidase inhibitor; SSRI, selective serotonin reuptake inhibitor.



Guidelines Regarding Antipsychotic Use



  • Hallucinations, paranoia, and delusions may not require treatment unless they are causing great distress to the patient or potential harm to others


  • When using atypical antipsychotics, consider the risk-benefit ratio for each patient and talk with patients and their families about the Food and Drug Administration (FDA) black box warning regarding a possible increased risk of death from medication use


  • Patients with dementia with Lewy bodies (which often co-occurs with Alzheimer’s dementia) are often very sensitive to antipsychotics. (Recall that antipsychotics may cause akathisia and agitation)



Depression

Depression is a common symptom, with up to 25% of the US population experiencing a depressive episode at some point during their lives. A recent report from the Centers for Disease Control and Prevention’s National Center for Health Statistics shows that in any 2-week period, more than one in 20 Americans are depressed. Given its prevalence and morbidity, depression deserves due attention and treatment.








TABLE 3-8 Differential Diagnosis of Depression











Nonpsychiatric Conditions

Psychiatric Conditions




  • Thyroid disorders



  • Adrenal disorders



  • Metabolic disturbances (e.g., hypercalcemia, hyponatremia)



  • Diabetes mellitus



  • Medication-induced (beta-blockers, CCBs, barbiturates, cholinergic medications, corticosteroids, estrogens)



  • Nutritional deficiencies (vitamin B12, folate, pellagra)



  • Malignancy



  • Neurologic disease (CVA, subdural hematoma, MS, tumor)


  • Major depressive episode



  • Major depressive disorder



  • Dysthymia



  • Adjustment disorder with depressed mood



  • Bipolar disorder



  • Schizoaffective disorder



  • Bereavement



  • Substance abuse (including alcohol or withdrawal from stimulants)


CCB, calcium channel blockers; CVA, cerebrovascular accident; MS, multiple sclerosis.



MAJOR DEPRESSIVE EPISODE (MDE)



  • MDE is defined by five or more of the following symptoms, one of which must be depressed mood or anhedonia. All symptoms must occur in the same 2-week period, be present a minimum of most of the day on most days, and result in clinically significant social, occupation, or interpersonal impairment


  • Depressed mood


  • Profound loss of interest or pleasure in all or almost all activities (anhedonia)


  • Profound increase (atypical feature) or decrease in appetite


  • Insomnia or hypersomnia (atypical feature)


  • Objective psychomotor hyperactivity or retardation


  • Decreased energy


  • Indecisiveness or decreased concentration


  • Worthlessness or guilt


  • Recurrent thoughts of death, recurrent suicidal ideation (SI) without a plan, SI with a plan, or suicide attempt (SA)



“SIGECAPS”

Sleep (increased or decreased) Interest (anhedonia)

Guilt (feeling worthless or hopeless)

Energy (decreased)

Concentration (decreased)

Appetite (increased or decreased)

Psychomotor retardation or agitation

Suicidal ideation









TABLE 3-9 Approach to the Evaluation of Depression





























History with special attention to:


Common chief complaints:




  • Reduced energy or fatigue (occurs in >90% of patients with MDD)



  • Impairment at work or school



  • Social isolation



  • Decreased motivation



  • Difficulties with sleep, particularly with early morning waking



  • Anxiety



  • Disturbances of sexual functioning



  • Problems with concentration or thinking and memory


Psychiatric history: history of suicidal thoughts or attempts (those with prior hospitalization for SI or SA have a greater lifetime risk of completed suicide)


Social history: screen for social isolation


General Medical and Neurologic Examination with special attention to:


Signs of intoxication or withdrawal; thyroid abnormalities (sweating, tachycardia, tremor, cold intolerance, weight gain); increased ICP (ocular abnormalities)


Psychiatric Mental Status Examination with special attention to:




  • General appearance: psychomotor retardation or agitation, decreased eye contact, inadequate hygiene



  • Mood: down, depressed (although patient may deny feeling depressed), irritable, anxious, labile



  • Affect: restricted, blunted



  • Thought process: slowed



  • Thought content: may include delusions



  • Perceptions: psychotic hallucinations



  • Speech: slowed with flattened tone or volume


Laboratory Studies, Imaging, and Other Diagnostic Tools with special attention to:


First-line studies: toxicology screen, TSH, CBC, chemistry panel 7, UA


Second-line studies, if indicated: cortisol, HIV, liver function tests, B12, head imaging


CBC, complete blood count; HIV, human immunodeficiency virus; ICP, intracranial pressure MDD, major depressive disorder; SA, suicide attempt; SI, suicidal ideation; TSH, thyroid-stimulating hormone; UA, urinalysis.



MAJOR DEPRESSIVE DISORDER (MDD)



  • Presence of at least one depressive episode


  • Rule out a history of manic, mixed, or hypomanic episodes; psychotic disorder; and delusional disorder


  • Modifiers include:



    • For active MDE: mild, moderate, severe with or without psychotic, melancholic, atypical, or postpartum features


    • If full criteria for MDE are not present: partial vs. full remission with or without psychotic, melancholic, atypical, or postpartum features


  • Two thirds of people with MDE contemplate suicide; 10% to 15% commit suicide


  • There is a 50% recurrence rate after the first episode, a 70% recurrence rate after the second episode, and a 90% recurrence after the third episode



EPIDEMIOLOGY



  • Lifetime risk: women: 20%-25%; men 7%-12%


  • No socioeconomic or racial correlation


  • Increased in single people


  • Circumstances that may increase risk: being single, living in a rural area, divorced, losing a parent before age 11 years, experiencing the death of spouse, unemployment



DYSTHYMIA



  • Defined by depressed mood most of the day for more days than not for 2 years with symptom-free periods not exceeding 2 months during the 2-year period


  • While the patient is depressed, two of the following must be present:



    • Increased or decreased appetite


    • Insomnia or hypersomnia


    • Fatigue or low energy


    • Low self-esteem


    • Indecisiveness or decreased concentration


    • Hopelessness


ADJUSTMENT DISORDER WITH DEPRESSED MOOD



  • Depression resulting in significant clinical impairment but not meeting the criteria for major depression


  • Occurs within 3 months of a stressful life event and does not persist longer than 6 months after termination of the stressor


BEREAVEMENT



  • Depressive symptoms occurring within 2 months of the death of a loved one are considered normal grief


  • Certain symptoms after the death may be associated with MDD:



    • Guilt (not including guilt regarding actions taken or not taken by survivor at the time of death)


    • Thoughts of death (not including patient feeling he or she would be better off dead or should have died with the deceased person)


    • Morbid preoccupation with worthlessness


    • Marked psychomotor retardation


    • Substantial, prolonged functional impairment


    • Hallucinations (not including transient seeing or hearing of the deceased person)


TREATMENT OF DEPRESSION



  • There is a 40% remission rate with an adequate single trial with an antidepressant; the majority of the rest of patients show some improvement, but 15% to 30% of patients do not improve after a single adequate trial


  • The most common reasons for failure are inadequate dosing and inadequate duration


  • Suggested pharmacotherapy guidelines:



    • No single antidepressant is universally accepted as more effective than another


    • Therapy should be chosen based on side effects, drug interactions, dosing schedule, discontinuation symptoms, cost of treatment, and history of effective response (including history of response in a first-degree relative)



  • Before declaring treatment failure, ensure maximum titration and minimum of 4 to 6 weeks of treatment after achieving the maximum dose (full response is gauged at 8-12 weeks)


  • Duration of treatment for depression maintenance:



    • Single episode: treat for a minimum of 6 months after resolution of symptoms or for the length of previous depressive episode, whichever is longer


    • Multiple episodes: indefinite maintenance


  • Addressing inadequate treatment response (treatment failure or partial response, defined as a 20% to 25% reduction in depressive symptoms):



    • Ensure proper dosing and duration of medication


    • Consider the accuracy of the diagnosis


    • If there is no response, switch the class of medication


    • If there is a less than desired response: augmentation with lithium or thyroid hormone (T3)








TABLE 3-10 Suggested Treatment by Depressive Subtype
































Subtype

Treatment


Atypical depression (predominantly depressed mood, hyperphagia, and hypersomnia)

MAOI, SSRI, bupropion, augmentation with D2 or D3 antagonist (pramipexole or ropinirole)


Melancholic (predominant anhedonia, early morning waking, excessive guilt, reduced appetite or weight loss, psychomotor retardation and agitation)

SNRI, TCA


Irritability or anger attacks

SSRI


Seasonal affective type (recurring depression during winter months, with decreased activity, lethargy, increased eating, increased sleep, social isolation, decreased sex drive)

Light therapy: 10 K lux for 30 minutes in the morning and the evening


Depression with psychosis

Increased risk of SI, antidepressant alone: 30%-50% response vs. 70%-80% with addition of antipsychotic; ECT if addition of antipsychotic fails or rapid treatment is necessary


Multiple treatment failures, severe symptoms, or concurrent pregnancy

ECT


Depression with concurrent panic disorder

TCA or SSRI


Depression with concurrent substance abuse

Abstinence (may treat depression as well)


ECT, electroconvulsive therapy; MAOI, monoamine oxidase inhibitor; SI, suicidal ideation; SNRI, serotonin and norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant.




Disordered Eating Behaviors

Both underweight and overweight patients should be evaluated for eating disorders. Given the high morbidity and mortality associated with eating disorders, it is extremely important to identify and treat these patients expediently.








TABLE 3-11 Differential Diagnosis of Disordered Eating Behaviors















Nonpsychiatric Conditions


Weight loss: thyroid disease, malignancy, infectious diseases (including HIV), GI absorptive diseases (i.e., celiac disease), other causes of amenorrhea (including pregnancy, PCOS, pituitary disease or Sheehan’s syndrome, ovarian failure or menopause), epileptic-equivalent seizures, malignancies, diabetes mellitus, HIV


Weight gain: Cushing’s syndrome, steroids, medication side effects, lifestyle (overeating, lack of exercise), Klein-Levin syndrome (hypersomnia or hyperphagia), Kluver-Bucy syndrome (hyperorality or hypersexuality)


Psychiatric




  • Anorexia nervosa (AN)



  • Bulimia nervosa (BN)



  • Eating disorder NOS



  • Binge eating disorder



  • Major depression (frequently associated with decreased appetite and weight changes)



  • Somatization disorder (GI symptoms such as nausea and vomiting; menstrual difficulties)



  • Schizophrenia



  • Body dysmorphic disorder


GI, gastrointestinal; HIV, human immunodeficiency virus; NOS, not otherwise specified; PCOS, polycystic ovary syndrome.



EPIDEMIOLOGY AND DEFINITIONS OF EATING DISORDERS


Anorexia Nervosa (AN)



  • Significantly low weight (≥15% below expected body weight) in combination with resistance to weight gain, often motivated by excessive concern with thinness or control overeating


  • Low weight is maintained by dietary restriction but is frequently accompanied by purging and exercise (see Bulimia nervosa)


  • Lifetime prevalence: 0.9% in women; 0.3% in men


Bulimia Nervosa (BN)



  • Characterized by regular episodes of binge eating followed by a variety of purging, exercise, and dietary behaviors to prevent weight gain


  • Lifetime prevalence: 1.0%-1.5% in women









TABLE 3-12 Approach to the Evaluation of Disordered Eating





































History with special attention to:


History of present illness: evaluate motivation for change, past response to therapy, nutritional compromise impacting psychosocial treatment, requirements for level of care


Psychiatric history: high comorbidity with affective disorders, anxiety disorder, OCD, personality disorders


Medical history: menstrual dysfunction (amenorrhea, irregular menstruation), GI dysfunction (slowed motility, nausea, bloating)


Family history: more prevalent among patients with a first-degree relative with an eating disorder or alcoholism


Social history: risk factors include a history of dieting and participating in sports in which leanness is emphasized (ballet, running, wrestling) or in which scoring is subjective (skating, gymnastics)


Review of systems: evaluate for hair loss, dry skin, headache, concentration, sleep issues, cold intolerance, fatigue, weakness, fainting, dizziness, irregular heart beat, dyspepsia, diarrhea, constipation, menses, muscle cramps, nocturia


General Medical and Neurologic Examination with special attention to:


Evidence of undernutrition, low weight, and purging, including growth delay, dental enamel erosion, enlarged parotid glands, cognitive changes, weight, height, vital signs (including orthostatics)


Calculate BMI or percentage of expected body weight based on weight, height, gender, and stage of development




  • Ensure that weight is taken before hydration (“dry weight”)



  • Rough guideline: 100 lb for 5′ and 5 lb for each additional inch for women; 106 lb for 5′ and 6 lb for each additional inch for men


Psychiatric Mental Status Examination with special attention to:


Mental status changes that could be attributed to significant medical compromise such as electrolyte disturbance


Laboratory Studies, Imaging, and Other Diagnostic Tools with special attention to:


First-line studies: ECG (QTc prolongation), endocrine laboratory studies (↓LH, ↓FSH, ↑cortisol, ↑GH), electrolytes (hypokalemia, metabolic alkalosis), blood glucose, CBC, renal function, TSH


Second-line studies, if indicated: bone densitometry (osteopenia, osteoporosis)


BMI, body mass index; CBC, complete blood count; ECG, electrocardiography; FSH, follicle-stimulating hormone; GH, growth hormone; GI, gastrointestinal; LH, luteinizing hormone; OCD, obsessive-compulsive disorder; TSH, thyroid-stimulating hormone.



Eating Disorder Not Otherwise Specified (NOS)



  • Aberrant eating patterns and weight management habits not meeting criteria for AN or BN


  • The most common presentation of eating disorders


  • Occurs in 3% to 5% of women age 15 to 30 years



Binge Eating Disorder (BED)



  • Episodic binge eating without purging, exercise, and dietary behaviors to prevent weight gain


  • Eating not linked to cues (social, hunger, satiety) that conventionally drive eating


  • Episodes may be associated with distress and other negative affect


  • At least three of the following must be present:



    • Eating more rapidly than normal


    • Eating until feeling uncomfortably full


    • Eating large amounts of food when not feeling hungry


    • Eating alone because of embarrassment of how much one is eating


    • Feeling disgusted with oneself, depressed, or guilty of overeating


  • Lifetime prevalence: 3.5% in women; 2% in men


TREATMENT


Medical



  • Evaluate the patient’s medical and nutritional compromise


  • Treat the medical sequelae of undernutrition, purging behaviors, and obesity


  • Watch for refeeding syndrome caused by low phosphorous (gastric bloating, congestive heart failure (CHF), edema; can lead to respiratory failure, coma, seizures, or death)


  • Surveillance for and treatment of common and life-threatening complications, such as medical sequela of BN (tooth enamel decay, esophagitis, blistered knuckles) or emergencies such as arrhythmias or hematemesis


  • Management of obesity-related complications in patients with BED (diabetes, sleep apnea, dyslipidemia, cardiovascular disease)


Nutritional



  • Determine energy and micronutrient deficits and protocol for nutritional rehabilitation


  • The patient may safely gain 0.5 to 2.0 lb per week as an outpatient or up to 3 to 4 lb as an inpatient


  • Provide vitamin supplementation


Psychiatric and Psychosocial



  • Section 12 criteria for admission to inpatient psychiatric facility after medical stabilization: the patient must demonstrate him- or herself to be unable to care for him- or herself, as evidenced by weight below 75% of ideal body weight, electrolyte disturbance (K <3.2), electrocardiographic changes, abnormal vital signs (i.e., bradycardia, low blood pressure, significant orthostatic changes, hypothermia), or indications of suicidality


  • Patients under 20% of expected weight for their height should be enrolled in inpatient programs



  • Treatment initially supports nutritional goals and medical and psychiatric stabilization



    • Family therapy is the treatment of choice for adolescents with AN


    • CBT and interpersonal therapy (IPT) have been demonstrated effective for BN


Pharmacologic


GENERAL GUIDELINES



  • Treat common comorbid psychiatric conditions, such as depression and anxiety


  • Medications that modify appetite: mirtazapine: increase appetite; topiramate: decrease appetite; Meridia: appetite suppressant


  • Monitor for potential weight gain as a medication side effect (i.e., with atypical antipsychotics)


ANTIDEPRESSANTS



  • There are no FDA-approved medications for the treatment of AN


  • Fluoxetine is FDA approved for treatment of BN (higher dosing, 60-80 mg)


  • Antidepressant use should not be initiated until weight gain has been achieved because side effects can be more severe in malnourished patients


  • Bupropion is contraindicated in patients with BN because of an increased risk of seizures


ANTIPSYCHOTICS



  • Some data suggest that atypical antipsychotics may have benefits for some AN patients, but this use is off label and has no established efficacy


  • Use with caution because of the risk for idiopathic and hypokalemiarelated QT prolongation


OTHER



  • Antiepileptics have shown some effectiveness anecdotally in patients with BED


  • Zinc (50-100 mg) has been shown to more rapidly improve weight restoration in patients with AN


Dissociation

Dissociation is a process by which mental contents (cognitions, emotions, sensations, behaviors) become segregated from one another. This process exists along a continuum from normative to pathological (Steinberg, 2000).

During exposure to traumatic stress, dissociation may serve an adaptive function by buffering the impact of overwhelming experience. However, with repeated exposures, dissociation may become conditioned as a
primary defense and occur chronically in response to reminders of the original traumatic event or even to relatively minor stressors of everyday living (Howell, 2005).


TYPES OF DISSOCIATIVE EXPERIENCES


Normative



  • Daydreaming


  • Becoming absorbed in a movie or a book


  • Meditation


  • “Highway hypnosis” (e.g., being briefly lost in a trance while driving)


  • Fantasy


  • Formal or self-induced hypnotic state


Pathological



  • Numbing: feeling detached from one’s emotions


  • Flashback: intrusive immersion in sensory components of a past traumatic experience


  • Depersonalization: feeling detached from one’s self or looking at one’s self as an outsider would


  • Derealization: feeling detached from one’s environment or a sense that the environment is unreal or foreign


  • Amnesia: inability to account for a specific and significant block of time that has passed


  • Identity confusion: feeling uncertain, puzzled, or conflicted about who one is


  • Identity alteration: shifting of one’s role or identity, accompanied by changes in behavior








TABLE 3-13 Differential Diagnosis of Dissociative Experiences

















Nonpsychiatric Conditions


Depersonalization: hypoglycemia, hypothyroidism, migraine, temporal lobe epilepsy or lesion, nondominant parietal lobe lesion, SLE, hypnogogic or hypnopompic phenomena


Derealization: temporal lobe epilepsy or lesion, hypnogogic or -pompic phenomena


Amnesia: Cerebral anoxia, cerebral tumor, head trauma, herpes encephalitis, hippocampal infarction, transient global amnesia, Wernicke-Korsakoff syndrome


Psychiatric Conditions




  • Acute stress disorder



  • PTSD



  • Dissociative amnesia



  • Dissociative fugue



  • Depersonalization disorder



  • Dissociative identity disorder



  • Dissociative disorder NOS


NOS, not otherwise specified; PTSD, posttraumatic stress disorder; SLE, systemic lupus erythematosus.










TABLE 3-14 Approach to the Evaluation of Dissociation





















History with special attention to:


Screening questions for dissociative disorders (Lowenstein, 1991):




  • Absorption: “Do you ever become preoccupied with daydreams inside your head for hours at a time?”



  • Numbing: “Do you ever feel detached from your feelings or emotions?”



  • Flashbacks: “Do you ever experience a frightening event from the past with such intensity that you lose track of where you are in the present? Do you hear it, see it, and smell it?”



  • Depersonalization: “Do you ever feel as if your body is unreal or you are outside your body observing yourself?”



  • Derealization: “Do you ever feel as if your surroundings are foggy or unreal?”



  • Amnesia: “Do you have gaps in the continuity of your memory for childhood?” and “Do you have blank spells or lose time?”



  • Identity alteration: “Do you hear voices inside your head talking with each other and to you?” and “Do you feel like there is more than one person or part inside of you?”


Social history: screen for trauma


General Medical and Neurologic examination


Psychiatric Mental Status Examination


Laboratory Studies, Imaging, and Other Diagnostic Tools with special attention to:


Use the nonpsychiatric differential above and use laboratory, neuroimaging, EEG, and sleep study testing as indicated


EEG, electroencephalography.



Acute Stress Disorder (ASD)



  • Requires experience of a traumatic event, occurrence of three to five dissociative symptoms, one reexperiencing symptoms, and marked avoidance and arousal at the time of or shortly after the event


  • Occurs within 1 month of the traumatic event and persists for at least 2 days


  • Recognizes dissociative symptoms as frequent sequelae to traumatic exposure


Posttraumatic Stress Disorder (PTSD)



  • See page 56 for more information


  • Requires experience of a traumatic stressor, occurrence of one reexperiencing symptom, three avoidance symptoms, and two arousal symptoms for duration of more than 1 month after the event


  • Does not require dissociative symptoms for diagnosis; however, several dissociative symptoms fall under PTSD diagnostic criteria, including flashbacks, numbing, detachment, restricted affect or absence of emotional responsiveness, and amnesia



Dissociative Amnesia

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Jun 12, 2016 | Posted by in PSYCHIATRY | Comments Off on Psychiatric Symptoms and Management

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