Bipolar And Related Disorders

DEPRESSIVE DISORDERS; BIPOLAR AND RELATED DISORDERS - 18% Diagnoses Overview Signs/Symptoms Major depressive disorder ●​ A mood disorder in which a person experiences two or more weeks of significantly depressed moods ●​ Shares a common genetic heritability with GAD ●​ Feelings of worthlessness, and diminished interest or pleasure in most activities. ●​ Rule out thyroid pathology!!! Persistent depressive disorder (dysthymia) ●​ Depressive Symptoms for > 2 years ●​ In children and adolescents, mood can be irritable and duration must be at least 1 year ●​ The individual has never been without the depressive symptoms for more than 2 months at a time. ●​ Never been a manic episode or a hypomanic episode Bipolar I disorder Major depressive disorder ●​ Manic episode with or without major depressive episodes ●​ MORE mania than depression ●​ Manic episodes alternating with depression; psychosis during manic episodes ●​ Pressured speech ●​ Lack of sleep without being tired ●​ Impulsive ●​ Increase in goal directed behavior ●​ Grandiosity ●​ Distractibility Treatment ●​ SSRIs are the first line treatment ●​ Full medication effect is complete in 4–6 weeks ●​ Psychotherapy ●​ Persistent Depression that is resistant to treatment: ECT ●​ ECT is also indicated in urgen clinical scenarios ○​ Severe suicidality ○​ Severe psychosis ○​ Catatonia ○​ Malnutrition + food refusal ●​ Lithium is considered a first-line medication ○​ Lithium use can affect thyroid function, potentially causing hypothyroidism, ●​ Acute mania – Lithium, valproate, SGAs (olanzapine, aripiprazole) carbamazepine ●​ Mania maintenance - SGAs, Gabapentin, lamotrigine (Lamictal) Bipolar II disorder Persistent depressive disorder (dysthymia) ●​ At least one hypomanic episode and at least one major depressive episode ●​ MORE depressed than manic ●​ Therehas never been a manic episode, only hypomanic ●​ Does not cause marked impairment, no psychotic symptoms ●​ Impulsivity ●​ Lithium is considered a first-line medication ●​ CBT Cyclothymic disorder ●​ A chronic mood disorder characterized by episodes of depression and hypomania for at least 2 years. ●​ Less intense but often longer lasting of bipolar ●​ Criteria for a major depressive, manic, or hypomanic episode have never been met. ●​ Lithium ●​ Anticonvulsant medications ○​ Valproate ○​ Carbamazepine ●​ Psychotherapy Major Depressive Disorder with Psychotic Features ●​ Episode of major depression lasting at least 2 weeks with the following symptoms: sleep changes, loss of interest, guilt, lack of energy, lack of concentration, lack of appetite, psychomotor changes, and suicidal ideation. ●​ Symptoms plus psychotic features of delusions or hallucinations, either auditory or visual. ●​ Antidepressant plus an antipsychotic ○​ Sertraline + Olanzapine Suicide Risk factors ●​ Age ○​ Adolescent and >70 ●​ Male sex ●​ Poor physical health ○​ Chronic back pain ●​ History of mental illness ●​ Feeling hopelessness, helplessness ●​ Isolation ●​ Unemployment or stressful work situation ●​ Poor financial situation ●​ Previous suicide attempt ●​ Family history of suicide or suicide attempt ●​ LGBTQ ANXIETY DISORDERS; TRAUMA- AND STRESS-RELATED DISORDERS - 18% Diagnoses Generalized anxiety disorder Overview ●​ Persistent and excessive worry pertaining to multiple events or domains that continues for 6 months or more ●​ Shares a common genetic heritability with MDD Signs/Symptoms ●​ ●​ ●​ ●​ Difficult to control the worry Restlessness Sleep disturbances Muscle tension Treatment ●​ SSRIs ○​ Paroxetine ○​ Escitalopram ●​ SNRIs ○​ Venlafaxine ●​ Buspirone: Can be used as an adjunct to SSRIs ●​ Benzodiazepines: Used in the interim until SSRI response is seen. ​ **RULE OUT TSH DXs** +EKG for serious causes (acute) Panic disorder ●​ Recurrent unexpected panic attacks. ●​ An occurrence of three panic attacks in three weeks ●​ The amygdala plays a role in the pathogenesis ●​ Symptoms develop abruptly and reach a peak within 10 minutes. ●​ Sweating ●​ Chest pain ●​ “Fear of terror” ●​ “impending doom” ●​ Paresthesias ●​ Concern of having ANOTHER panic attack ●​ SSRIs ○​ Fluoxetine ○​ Sertraline ○​ Paroxetine ○​ Citalopram ●​ Benzodiazepines for acute attacks ●​ CBT Social Phobia ●​ Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. ●​ Examples include: ○​ Social interactions ○​ Being observed ○​ Performing in front of others ●​ The social situations are avoided or endured with intense fear or anxiety. ●​ SSRIs, SNRIs ●​ Performance Type ○​ Benzodiazepines ○​ Propranolol Specific phobias ●​ Marked and persistent (> 6 months) fear that is excessive or unreasonable ●​ Cued by presence or anticipation of specific object or situation ●​ Types: animal/insect, environment, blood/infections, situational (closed spaces), other ●​ The phobic object or situation almost always provokes immediate fear or anxiety. ●​ The phobic object or situation is actively avoided or endured with intense fear or anxiety. ●​ Treat with exposure therapy (first line) ●​ SSRI + CBT ●​ Short acting benzodiazepines such as alprazolam (i.e prior to flying) ●​ Treat agoraphobia just as GAD with SSRIs and CBT Post-traumatic stress disorder ●​ The patient has experienced a traumatic event which causes an acute stress reaction. ●​ Once the symptoms persist past 1 months it is now considered post-traumatic stress disorder (PTSD) ○​ (acute stress disorder is <1 month) Adjustment Disorder ●​ Emotional or behavioral responses to a stressful event that develop within 3 months after the onset of a stressor ●​ Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). ●​ Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). ●​ Dissociative reactions (e.g., flashbacks) ●​ Persistent avoidance of stimuli associated with the traumatic event(s ●​ Reaction must be in excess of ●​ SSRIs are considered first-line along with cognitive behavioral therapy (CBT) ●​ Prazosin for nightmares what would be expected given the nature of the event. SUBSTANCE-RELATED DISORDERS -14% Diagnoses Overview Signs/Symptoms Treatment Alcohol-related disorders ●​ Intoxication ○​ Lethargy ○​ Difficulty sitting upright ○​ Impaired judgment ○​ Nystagmus ○​ Slurred speech ●​ Alcohol misuse ○​ Can be hereditary ○​ Unsuccessful efforts to cut down or control alcohol use. ○​ Craving, or a strong desire or urge to use alcohol. ○​ Lab tests ■​ Elevated mean corpuscular volume ■​ Elevated TGs ■​ Elevated serum uric acid ■​ Elevated LFTs ●​ Tolerance, as defined by either of the following: ○​ A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. ○​ A diminished effect with continued use of the same amount of alcohol. ●​ Withdrawal, as manifested by either of the following: ○​ The characteristic withdrawal syndrome for alcohol ○​ Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms. ●​ First Line ○​ Oral Naltrexone decreases desire ○​ Acamprosate - changes brain chemistry in a way that reduces anxiety, irritability, and restlessness associated with early sobriety ●​ Topiramate - reduces drinking at least as well as naltrexone and acamprosate ●​ Disulfiram (Antabuse) - inhibits acetaldehyde dehydrogenase, aversive conditioning ●​ Gabapentin - decreases desire Intoxication ●​ Mild - Supportive ●​ Wernicke encephalopathy ⇒ Thiamine ●​ Alcohol related ketoacidosis ○​ Normal saline and glucose **Monitor CBC and Liver enzymes** Sedative-, hypnotic-, or anxiolytic-related disorders Cannabis-related disorders ●​ “Popping xanax”- utilizing benzodiazepines ●​ Intoxication ○​ Respiratory depression ○​ Hypotension ○​ Amnesia ○​ Stupor.somnolence ○​ Coma ○​ Death ●​ Withdrawal ○​ Rebound anxiety ○​ Seizures ○​ Tremor Intoxication ●​ Hyperemesis Syndrome: ○​ Vomiting due to ingesting excessive amounts of cannabis ○​ Improved with a hot shower ●​ Recent consumption of cannabis ○​ Behavioral or psychological changes ■​ Red eyes ■​ Increased appetite ■​ Dry mouth ■​ Fast heart rate ■​ Altered time perception ■​ Laughing at inappropriate times ●​ Flumazenil ○​ GABA antagonist ●​ Long acting benzo ○​ Clonazepam ●​ Naloxone for concomitant overdose with opioids ○​ Give first if respiratory depression ●​ Supportive ●​ Benzodiazepines ●​ Urine drug screen ○​ Up to 6 weeks ●​ Saliva drug screen ○​ 1 Day ●​ Withdrawal ○​ Mild - Physical Exercise ○​ Mod/Severe - Dronabinol Withdrawal Hallucinogen-related disorders Stimulant-related disorders ●​ Phencyclidine ●​ Known as angel dust Intoxication ●​ Cocaine, methylphenidate, amphetamines ●​ MOA- Dopamine receptor agonist ●​ Stopped use of cannabis that was used heavily for a long time ○​ Decrease appetite ○​ Weight loss ○​ Restlessness ○​ Anger, anxiety, sleep difficulty ○​ Sweats, fevers, chills ●​ Hallucinations ●​ Behavioral changes secondary to phencyclidine ingestion ○​ Nystagmus ○​ HTN or inc. HR ○​ Hyperthermia ○​ Sweating ○​ Decreased response to pain ○​ Ataxia, dysarthria, muscle rigidity ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ Pupillary dilation!!!! Hypertension Sweating/Clammy skin Nausea/vomiting Weight loss Psychomotor agitation, violent behavior Cardiac arrhythmias Respiratory depression Confusion, seizures, dystonia, dyskinesias, or coma Sympathomimetic Toxidrome ●​ Benzodiazepines ○​ Monitor and treat seizure activity ●​ Activated charcoal may be used within 1 hour ●​ Benzodiazepines for agitation ○​ S/S from excess SNS stimulation ●​ Cocaine induced aortic dissection ○​ Risk increases with HX of HTN ○​ Sharp non-migrating chest pain Withdrawal Inhalant-related disorders ●​ MC: Ages 12-17 ●​ Negative impacts on the heart such as myocarditis ●​ Ventricular tachydysrhythmias ●​ Sudden cardiac arrest ●​ Common substances include: Toluene, butane, propane, fluorocarbons, chlorinated hydrocarbons and acetone ●​ Paint thinner Tobacco-related disorders ●​ Daily tobacco use for several weeks ●​ ●​ ●​ ●​ Fatigue Nightmare Increased appetite Psychomotor agitation ●​ Behavioral or psychological changes secondary to the inhalant ingestion ○​ Frequent epistaxis ○​ Chronic headaches ○​ Vision changes ○​ Dizziness ○​ Nystagmus ○​ Incoordination, Off balance gait ○​ Slurred speech ○​ Lethargy, decreased reflexes, psychomotor retardation, tremor, muscle weakness, blurry vision, ○​ Decreased consciousness, euphoria ●​ Modafinil ●​ Bupropion ●​ Supportive ●​ Antipsychotics for agitation ●​ Counseling - first line ●​ Nicotine replacements MDMA Opioid-related disorders ●​ Abrupt stopping or reduction in tobacco consumption with ≥ 4 of the following: ○​ Irritability ○​ Anxiety ○​ poor concentration ○​ increased appetite ○​ Restlessness ○​ depressed mood ○​ inability to sleep ●​ Varenicline ○​ Nausea SE ●​ Bupropion ○​ Less effective than above ○​ CI with seizures ●​ AKA Ecstasy ●​ ●​ ●​ ●​ Intoxication/Addiction/Withdrawal ⇒ Cocaine ●​ ●​ ●​ ●​ ●​ ●​ “At a rave..” Hyperthermia Agitation and hyperactivity Dehydration Hyponatremia DIAPHORETIC SKIN ●​ Pupillary constriction (miosis) ●​ Respiratory depression/HYPOVENTILATION ●​ Euphoria ●​ Confusion ●​ Constipation ●​ Needle puncture sites in arms (track marks) IV fluids Cooling Benzos Supportive care ●​ Addiction Treatment ○​ Opioid partial Agonist: Good for pain relief and opioid use disorder. Produces less euphoria. Can be prescribed. ⇒ Buprenorphine and naloxone ○​ Long acting opioid agonist: Only administered by a clinic, some euphoric effect. ○​ Long acting opioid antagonist: Naltrexone, blocks euphoric effect, does not address pain. Cannot be started unless patient is inactive with using ○​ Short acting opioid antagonist: Naloxone, used to reverse an overdose ●​ Intoxication/Overdose ○​ 1 - Ensure ventilation and oxygenation ○​ 2- Naloxone ○​ 3- Supportive Withdrawal Anticholinergic Intoxication ●​ Yawning ●​ Diaphoresis, mydriasis, rhinorrhea ●​ Fever, insomnia ●​ - First line inpatient: Buprenorphine naloxone, induces withdrawal symptoms if opioids are in the system - Maintenance: Methadone ●​ - Supportive ●​ ”Drank a whole bottle of some random pill in their medicine cabinet” ○​ Ex. Diphenhydramine ●​ Urinary retention ●​ Tachycardia ●​ Agitation ●​ Flushed skin ●​ Non Reactive Mydriasis - Dilation ●​ DRY SKIN ●​ Benzos ○​ Diazepam ●​ Activated charcoal ●​ Antidote - Physostigmine ●​ Secure airway ●​ Fluids SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS - 12% Diagnoses Overview Positive Symptoms Signs/Symptoms Treatment Negative Symptoms ●​ ●​ ●​ ●​ Psychotic symptoms Hallucinations Delusions Disorganized speech and behavior Positive symptoms respond better to treatment and lower morbidity Delusions ●​ ●​ ●​ ●​ ●​ ●​ ●​ Loss of interests Loss in drive Decrease in emotional range Amotivation Avolition Lacing in speech Flat affect Negative symptoms are most associated with poor treatment and functional outcomes, increased morbidity Erroneous belief that usually involve a misinterpretation of perceptions or experiences Medical Psychosis ⇒ Most often causes disorientation Delusional disorder ●​ Otherwise normally functioning person with a belief in something that does not exist. ●​ Beliefs lasting > 1-month ●​ Comorbid with MDD ●​ One or more non-bizarre delusions of thinking ●​ Expressing beliefs that occur in real life, such as being poisoned, being stalked ●​ Being loved or deceived ●​ Having an illness ●​ Functioning is otherwise unimpaired ●​ “Chronic scabies..” ●​ More specific than paranoid personality disorder Brief Psychotic Disorder ●​ Presence of delusions, hallucinations, disorganized speech, catatonic behavior for at least 1 day and LESS than 1 month ●​ ●​ ●​ ●​ ●​ Symptoms began suddenly Emotional turmoil OVerwhelming confusion Impairment Delusions ●​ Psychotherapy ●​ Pharmacologic - atypical antipsychotic agents Dissociative Identity Disorder ●​ Sexual abuse and physical abuse, particularly in early childhood, are strongly associated ●​ Multiple identities that are not aware of the others ●​ Episodes of amnesia + recurrent gaps in memory Dissociative Amnesia ●​ Loss of memory of a traumatic event ●​ Dissociative Fugue: Sudden unexpected travel or wandering in a dissociated state Schizophrenia ●​ Major psychosis for greater than 6 months + difficulty functioning ●​ Genetic risk identified but NO specific genes ●​ Advanced paternal age Schizoaffective disorder ●​ A mental health condition including schizophrenia and mood disorder symptoms. ●​ Symptoms may occur at the same time or at different times. ●​ Psychotherapy is the mainstay of the treatment of DID ●​ Delusions ●​ Hallucinations ●​ Disorganized speech/thought processes ●​ Unable to stay on topic (loose associations) ●​ Unable to provide answers related to questions (tangential response) ●​ Symptoms impair daily functioning ●​ Disorganized behavior ●​ Unpredictable agitation, inappropriate sexual behavior, child-like silliness, catatonic motor behavior, lacking self-care/hygiene ●​ Atypical Antipsychotics: (risperidone, olanzapine, aripiprazole, ziprasidone, quetiapine, asenapine, and paliperidone) for negative symptoms & fewer side effects ●​ Clozapine is an atypical antipsychotic that is not considered first-line because of the propensity to cause agranulocytosis. ○​ Must enroll in Risk Evaluation and Mitigation Stage Program ●​ Typical neuroleptics - dopamine antagonists (haloperidol, chlorpromazine, thioridazine, loxapine, fluphenazine) best for positive symptoms ●​ Patients meet the criteria for a ●​ Psychotherapy ●​ Pharmacologic - atypical antipsychotic agents, anticonvulsants, and Selective Serotonin Reuptake Inhibitors (SSRI) diagnosis of schizophrenia AND also have a mood disorder ●​ Symptoms that meet the criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness. MDD with Psychotic Features ●​ Psychotic features can ONLY occur during the mood episode ●​ Hallucinations are not as common Schizophreniform disorder ●​ Major psychosis for > 1 month but < 6 months ●​ Does NOT require a significant decline in social or occupational functioning ●​ Symptoms but differs primarily in duration and impact on social/occupational functioning. ●​ Delusions ●​ Disorganized speech ●​ Flat affect ●​ Psychotherapy ●​ Medications: atypical antipsychotics as the usual drug of choice. ○​ Patients who do not respond to the initial atypical antipsychotic may benefit from being switched to another atypical antipsychotic, the addition of a mood stabilizer such as lithium or an anticonvulsant, or being switched to a typical antipsychotic. Cyclothymic Disorder ●​ Mood disorder characterized by episodes of depression and hypomanic symptoms that do not meet the criteria of MDD or bipolar disorder ●​ No history of mania ●​ Psychotherapy ●​ Mood stabilizers ○​ Valproic acid ○​ Lamotrigin ○​ Lithium DISRUPTIVE, IMPULSE-CONTROL AND CONDUCT DISORDERS; NEURODEVELOPMENTAL DISORDERS - 10% Diagnoses Attention-deficit/hyperactivity disorder Overview ●​ Hyperactivity, impulsivity, or inattentiveness manifesting prior to age 12 years. Signs/Symptoms Treatment ●​ > 6 symptoms of inattention, hyperactivity-impulsivity, developmentally inappropriate Preschool Children/Mild Symptoms (3-5) ●​ Parent-child behavioral therapy School-aged Children/Mod-Severe (6+) ●​ ADHD is one of the most heritable psychiatric disorders ●​ males are 2-5 x more likely to have ADD and duration of symptoms > 6 months ●​ Symptoms must occur in more than one setting (example school and home) ●​ Hyperactivity and impulsivity ●​ 1st line meds – caution: wt. loss & ↓ growth with stimulants! ●​ Methylphenidate ○​ Ritalin ○​ ConcertaDaytrana) ●​ Dexmethylphenidate (Focalin) ●​ Amphetamine/dextroamphetami ne (Adderall, Dexedrine) ●​ Atomoxetine (Strattera) selective norepinephrine reuptake inhibitor (non-stimulant) 2nd line/adjuncts ■​ Antidepressants (guanfacine, clonidine (alpha agonist), imipramine, bupropion, venlafaxine) Behavior modification (structure, routine & appropriate goals), family, educational mgmt. Conduct disorder ●​ A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated ●​ It is often seen as the precursor to antisocial personality disorder ●​ A child is referred to your office for unusual animal cruelty and bullying at school ●​ Often bullies, threatens, or intimidates others. ●​ Often initiates physical fights. ●​ Has broken into someone else’s house, building, or car. ●​ The most effective treatment for an individual with conduct disorder is one that seeks to integrate individual, school, and family settings. Oppositional defiant disorder ●​ A pattern of angry/irritable mood, argumentative/defiant behavior, vindictiveness lasting at least 6 months ●​ A child is found to back talk and resist following instruction from parents or authorities ●​ Frequent temper tantrums ●​ Arguments with adults and authority figures. ●​ Does not conform to rules and regulation ●​ Unlike children with conduct disorder (CD), children with oppositional defiant disorder are not aggressive towards people or animals, do not destroy property, and do not show a pattern of theft or deceit. Autism spectrum disorder ●​ A child has normal cognitive development, poor relationships and does not spontaneously seek activities with others ●​ Individuals diagnosed with autism spectrum disorder present a developmental delay in socialization, language, and cognition ●​ Social communication and social interaction deficit in many contexts ●​ Restricted and repetitive patterns of behavior, interests, or activities ●​ Modified Checklist for Autism in Toddlers (MCHAT) ○​ Score of 3-7 ⇒ Administer second stage Psychotherapy: is aimed at helping the child learn to express and control anger in more appropriate ways. ■​ Cognitive-behavioral therapy aims to reshape the child's thinking (cognition) to improve problem-solving skills, anger management, moral reasoning skills, and impulse control. ■​ Family therapy may be used to help improve family interactions and communication among family members. Peer group therapy might also be helpful Pharmacotherapy to control ODD include mood stabilizers, antipsychotics, and stimulants. ●​ ●​ Refer – Autism specialists, speech & language pathologist ●​ Audiology evaluation, +/- EEG ●​ Behavioral therapy ●​ Medications: ○​ Second generation antipsychotics(risperidone , aripiprazole) for aggression/hyperactivity, mood lability; can also use haloperidol, carbamazepine ○​ SSRIs for stereotyped/repetitive behavio PERSONALITY DISORDERS; OBSESSIVE-COMPULSIVE AND RELATED DISORDERS - 8% Cluster A ●​ Paranoid ●​ Schizoid ●​ Schizotypal Diagnoses Cluster B ●​ ●​ ●​ ●​ Cluster C Antisocial Borderline Histrionic Narcissistic Overview ●​ Avoidant ●​ Dependent ●​ Obsessive-Compulsive Signs/Symptoms Treatment Antisocial personality disorder ●​ A disregard for and violation of the rights of others with a lack of remorse which commonly results in criminality ●​ males > females ●​ Conduct disorder if < 18 years ●​ Blatant disregard for the rights of others ●​ Aggressive, irritable ●​ Classic triad: set fires, torture animals, bedwetting ●​ Lack of remorse ●​ Psychotherapy ●​ Avoid medications with abuse potential Avoidant personality disorder ●​ Characterized by patients low self-esteem and desire for relationship are stopped due to fear of rejection ●​ Hypersensitive to critisim and failure ●​ Unable to hold a job and relationships ●​ Psychotherapy ●​ Beta blockers ●​ SSRIs Body dysmorphic disorder ●​ Preoccupation with an imagined defect in physical appearances/exaggerated distortion of a minor flaw ●​ Common concerns: face/hair/skin/breasts/genitalia ●​ High comorbidity with depressive and anxiety disorders ●​ Defects are not visible to others ●​ Repetitive behaviors - mirror checking, excessive grooming ●​ SSRIs - First Line ●​ Clomipramine (TCA) ●​ CB ●​ Comparing appearance to others Borderline personality disorder ●​ Borderline personality disorder presents with emotional instability, unstable relationships, and self-harming behavior ●​ Females > Males ●​ Black and white perception ●​ Intense and unstable relationships, moods and perception of self ●​ Impaired impulse control ●​ Suicide attempts ●​ Self harm ●​ Splitting is a major defense mechanism ○​ Relationships are either all good ("my boyfriend is a perfect angel") or all bad ("my boyfriend is evil and I hate him") ●​ Dialectal behavioral therapy ●​ Engange in conversation, discuss symptoms, validate her distress Dependent personality disorder ●​ Submissive and clingy with an excessive need to be taken care of resulting from a low self-esteem ●​ Difficulty making decisions without reassurance from others ●​ Need others to assume responsibility for major area in his/her life ●​ Psychotherapy Histrionic personality disorder ●​ Attention seeking dramatic seductive behaviors ●​ Needs to be the center of attention ●​ Dramatic ●​ Dresses for attention ●​ Very shallow ●​ Seductive and flirtatious ●​ A large concern with appearance ●​ Psychotherapy Narcissistic personality disorder ●​ Concerned what others think of them and need admiration ■​ Need for admiration, grandiose thoughts, concerned about what others think yet lack empathy ■​ Sense of entitlement ■​ Lacks empathy ■​ Reacts to criticism with rage ●​ Psychotherapy ●​ Avoid medications with abuse potential Obsessive-compulsive disorder ●​ Focus on obsessions repetition of compulsive behaviorsFocus on obsessions repetition of compulsive behaviors ●​ Obsessions: Recurring, intrusive thoughts that cause severe distress and impairment ●​ Compulsions: Performance of repetitive actions (rituals) in an attempt to neutralize the obsessions ○​ e.g., hand washing, checking - the primary goal is to not lose control ○​ The disorder is ego-dystonic: behavior inconsistent with one's own beliefs and attitudes - separates OCD from obsessive-compulsive personality disorder ●​ First Line - CBT ○​ Exposure and response prevention ●​ SSRIs - Higher doses ●​ Clomipramine - First line TCA ●​ Augment with antipsychtoics Obsessive-compulsive personality disorder ●​ Patients tend to be preoccupied with order, perfectionism, and control ●​ The patient is not aware of their behavior causing issues. ●​ Controlling and rigid ●​ Seeks to follow rules and maintain order ●​ Inability to throw out worthless objects ●​ Perfectionism ●​ Usually occupationally high functioning ●​ Psychotherapy Paranoid personality disorder ●​ Paranoid personality disorder is characterized by persistent feelings of suspiciousness and mistrust of other people ●​ Excessive distrust and suspicion ●​ Broad pattern of paranoia ●​ Higher incidence in families with schizophrenia ●​ Read hidden meanings into benign remarks or events ●​ NO delusions or hallucinations ●​ Psychotherapy ●​ Anxiolytics Schizoid personality disorder ●​ Patients tend to have emotional aloofness, indifferent to praise or criticism, without bizarre or idiosyncratic thinking ●​ Exhibit voluntary social withdrawal ●​ Content with social isolation (vs avoidant) ●​ Limited emotional expression ●​ No association with schizophrenia ●​ Prefers to be alone ●​ Psychotherapy Schizotypal personality disorder ●​ Odd eccentric behavior and discomfort with social relationships ●​ Eccentric behavior, magical thoughts, odd beliefs, and perceptual distortion ●​ These patients are able to function in society, through ●​ Psychotherapy ●​ Short course of low dose antipsychotics if needed struggle to maintain social relationships ●​ Patients may develop schizophrenia SOMATIC SYMPTOM AND RELATED DISORDERS; NONADHERENCE TO MEDICAL TREATMENT - 8% Diagnoses Overview Signs/Symptoms Treatment Factitious disorder ●​ Patient consciously reports false symptoms, or induces symptoms, with the goal of playing the "sick role ●​ A condition in which a person, without a motive for reward, acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms, purely to attain a patient's role. ●​ Can be imposed on another often a child (By proxy ○​ Most common: Biological mothers ●​ Conjoint confrontation by the PCP and the psychiatrist ●​ In factitious disorder imposed on another (e.g., in a child) ○​ Children must be removed by child protective services Illness Anxiety Disorder ●​ Obsession with the idea of having a serious but undiagnosed medical condition ●​ Patient's are worried about having or developing a serious illness ●​ This preoccupation is present for at least 6 months ●​ Is not better explained by another mental disorder (e.g., obsessive-compulsive disorder and somatic symptom disorder) ●​ Minimal physical symptoms and greater focus on a possible disease ●​ Group/insight-oriented therapy ●​ Regular appts with a provider for reassurance ●​ Medications: (SSRIs) if concurrent/underlying anxiety or major depressive disorder Somatic symptom disorder ●​ Physical symptoms from various systems ●​ Somatic symptoms lead to a significant amount of disruption in the patient's life. ●​ Excessive thoughts, feelings, and behaviors in relation to their somatic symptoms or their health concerns. ●​ The somatic symptom must be persistent for ≥ 6 months ●​ Have a single clinician as the designated primary caretaker ○​ Schedule monthly visits and psychotherapy ○​ Avoid unnecessary diagnostic testing unless indicated ●​ Group therapy and social support Functional Neurological symptom disorder ●​ Conversion disorder ●​ Symptoms occur suddenly following a psychosocial stressor ●​ Usually non painful ●​ Often a paralysis ●​ Education about the condition ●​ Psychotherapy Narcolepsy ●​ Narcolepsy is a chronic ●​ The main clinical ●​ Amphetamines ●​ Methylphenidate ●​ Modafinil hypersomnia disorder that is characterized by unstable sleep-wake transitions. manifestation is excessive daytime sleepiness ●​ Irresistible urge to sleep ●​ Sudden onset of sleep ●​ Transient atonia and weakness of the muscles in response to emotional stimuli REM Sleep behavior disorder ●​ REM sleep behavior disorder is a parasomnia in which patients act out their dreams while in the REM stage of sleep. ●​ Abnormal vocalizations ●​ Abnormal motor movements ●​ Can lead to violence and injury to self or others ●​ Patients cna remember the content of their dreams but does not remember their actions ●​ Melatonin - First line Nightmares ●​ Medications such as Donepezi can cause nightmares ●​ Treat underlying cause ●​ D/C offending agents ●​ Prazosin FEEDING OR EATING DISORDERS - 8% Diagnoses Overview Signs/Symptoms Treatment Anorexia nervosa ●​ Patient who refuses to eat due to fear of being overweight ●​ Intense fear of becoming fat, even though underweight. ●​ Frequent weight checks + denial ●​ BMI < 17 ●​ Associated body image disturbance ●​ Binging/purging ○​ Laxatives/diuretics abuse ○​ Excessive exercise ○​ Self induced vomiting ●​ Restricting ○​ Eat very little ○​ Exercise to excess ●​ Restore nutritional state ●​ Hospitalization - if weight is < 75% expected body weight ●​ Psychotherapy - behavioral therapy ●​ Pharmacologic - SSRIs; ○​ Fluoxetine is first line treatment ○​ Have added benefit of causing weight gain ○​ Have not been proven to be effective in anorexia nervosa ○​ Have some efficacy in bulimia nervosa Bulimia nervosa ●​ Patient who has episodes of mass eating followed by self-induced vomiting or intense exercise ●​ Frequent binge eating with or without purging ●​ Purging commonly performed by ○​ self-induced vomiting ○​ May abuse laxatives/diuretics ○​ May exercise excessively ●​ Restore the nutritional state. ●​ Fluoxetine 60 mg PO once/day is recommended ○​ SSRIs used alone often reduce the frequency of binge eating and vomiting. ●​ Second-line medications: TCAs, MAOIs ●​ Patients are disturbed by their behavior ●​ Binging and compensatory behaviors occur at least once a week for 3 months. ●​ BMI > 17 ●​ On the exam look for these classic physical findings: ○​ scars on knuckles ○​ swollen parotid glands ○​ dental erosions ○​ metabolic alkalosis ○​ low urine chloride ○​ volume depletion ○​ normal weight! ○​ hypokalemia! ●​ Behavioral/family/group therapy ●​ CBT Binge Eating Disorder ●​ Recurrent episodes of eating large amounts of food, with the absence of compensatory behaviors ●​ Occurs weekly for at least 3 months Avoidant/Restrictive Food intake Disorder ●​ Severe restriction of food intake and avoidance of certain foods ●​ ●​ ●​ ●​ Nutritional Deficiencies Weight Loss Often begins early in childhood NO concerns of body image or weight ●​ Nutrition counseling ●​ CBT ●​ Exposure therapy PARAPHILIC DISORDERS; SEXUAL DYSFUNCTIONS - 4% Diagnoses Overview Signs/Symptoms Treatment Exhibitionistic disorder ●​ Recurrent and intense sexual arousal from the exposure of one's genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviors. ●​ The individual has acted on these sexual urges with a non-consenting person ●​ Sexual urges or fantasies cause clinically significant distress or impairment in social and occupational functioning ●​ If patients have committed a sexual offense, treat with psychotherapy and SSRIs first ●​ Antiandrogen drugs may be considered Female sexual interest/arousal disorder ●​ Lack of, or significantly reduced, sexual interest/arousa for a minimum duration of approximately 6 months ●​ Absent/reduced interest in sexual activity ●​ Absent/reduced sexual/erotic thoughts or fantasies ●​ No/reduced initiation of sexual activity, and typically unreceptive to a partner's at­tempts to initiate ●​ Education about sexual anatomy and function ●​ Effective sexual stimuli may include nonphysical, physical nongenital, and non-penetrative genital stimulation ●​ CBT ●​ Hormonal therapy - testosterone, etc Fetishistic disorder ●​ Sexual arousal is obtained by specific objects ●​ Recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body part ●​ Psychotherapy Male hypoactive sexual desire disorder ●​ The judgment of deficiency is made by the clinician, taking into account factors that affect sexual functioning, such as age and general and socio­cultural contexts of the individual's life ●​ Pedophilic disorder ●​ Repeated and intense sexual urges or fantasies about ●​ The individual has acted on these sexual urges Persistently or recurrently deficient (or absent) sexual/erotic thoughts, fantasies and desire for sexual activity for a minimum duration of approximately 6 months ●​ Testosterone therapy ●​ Sex therapy ●​ Cognitive behavioral therapy First line watching, touching, or engaging in sexual acts with children (generally 13 years or younger), Over a period of at least 6 months ●​ Or the sexual urges or fantasies cause marked distress or interpersonal difficulty ●​ In the US, the treatment of choice for pedophilia is IM medroxyprogesterone acetate ●​ GnRH agonist - Leuprolide ○​ Reduces pituitary production of LH and FSH and thus reduces testosterone production Sexual masochism disorder ●​ Sexual gratification in response to undergoing humiliation, bondage, or suffering ●​ The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in functioning ●​ Psychotherapy ●​ SSRIs ●​ Antiandrogens Voyeuristic disorder ●​ Sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity. ●​ The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress ●​ Psychoanalytic therapy ●​ Group therapy Gender Dysphoria ●​ Sense of incongruence between an individual's experience or expressed gender and their assigned sex at birth. ●​ Significant distress ●​ Wearing clothing and adopting behaviors that align with their gender ●​ Desire to undergo medical treatments to align appearance with identity