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BEIIAVIORAL MODICINE RE}1EW

Ellen D. Mandel, MPA, MS, PA-C Assistant Professor, UMDNJ Physician Assistant Pro gram

Lecture: Topic Outline .' Commonly Presenting Types

:rAnxie8Disorders
p p
PD

pMoodDisorders

e. Factitious

Disorders :'Eating Disorders p Childhood Disorders Dissociative Disorders p Cognitive Disorders

Somatoform Personalrtv l )lsoKlers

" etPsYchosis

Disorder .

.*

Substance Abuse Domestic Violence

:rsexual Abuse
:o Child Abuse

Learning Objectives
e'1.
Acquire a working knowledge of the major diagnostic criteria developed by the American Psychiatric Association criteria for common DSM-IVTR Classifications seen in PA practice.

:'2.
p 4.

Apply the Multiaxial Classification Schemesymptoms and treaknents for the

s.3. Identi& t]re central

anxiety and panic disorders.

Assess dre symptoms and treatments for dre somatoform disorders-

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Learning Objecfives
ar5. Identi& the dissociation disorders.
st 6. Differentiate factitious disorders from the somatoform disonders. z. 7. Identi& Munchausen's syndrome

8. Identi& the personality disorders by ccmmon clusters and related treatment options

z' 9- Identi$ the signs of schizophrenia and those for

good vs. poor prognosis. Determine treatmentar 10. Understand the potential side effects of antipsychotics including tardive dyskinesia.

Learning Objectives
z- I 1. Distinguish between delusions and dementia :o 12. Identi& the criteriaand common heafnents for
depressive vs. bipolar I and

rr

II disorders. 3. Identi& the risk factors for suicide.

s. 14. Know the diagnosis and treatment forADF,trD s.15. Understand the cycle ofabuse"
a. 16. Identifu the signs and symptoms ofsubsance abuse. a, I 7. Recommend appropriate therapylreferral.

THE PSYCHIATRIC DISORDERS

DSM-IV-TR

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DSM.IV-TR
Multi axi aI Cl as s irt. c atio n S c h e me zr Axis I: All diagnoses of mental illness including
substance atruse and developmental disorders. Itdoes NOT include penonality disorders or mental

retardation.

pAxis
pAxis
zrAxis

II: III: V:

Personality disorders and mental retardation

General medical conditioas

pAxis IV:

Psychosocial and environmsntal problems

The Global Assessment of Function (GAF). Rafts the overall level of'functioning on a 0-100 scale.

Psychotherapies: Freud et al
unconscious, sexual, - aggressive, primary. (v
:old:
instinctive,

PDefense
Mechanisms are used by the Ego to protect ^-^^^tr'-r --r^^r oneself and relieve anxiety by keeprng conflicts out of awareness.

p Ego: Mediator available

between

the Id.

Id and the world.

Uses defense

mechanisms to tame the

PSuperego: Moral
conscience.

Defense Mechanisms
zrlmmature r Acting Ou! Regressio4 Passive aggressivg
Blocking, Somatization, Schizoid fantasy eoNeruotic

Dissociation, Reaction formation, Repression, Rationalization, Isolation, Displacement Sublimation, Humor, Anticipetion

arMature

r Altruism,

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conflicts.

Psycho Eehavioral Cognitiv+ Gmup ealysis Treats Patientsare >zpatients Restus disorders by taughtio with similar unmnscious replacing identi,9 problemsmeet lnsight if not
altematives.
rdo*s

Fmily&
liladtal
lndividual

$oblemssten

oriented. healthy
Works best <aoe 40, stable,

maladaptive maladaptive withthempist" affectthe behaviotswith thoughtsand Alltechniques entirefamilyreplace them may be used. Dy3functioN

psychotic, *ithphobias

wll

wittr

positive

lncludes

Meets4. sx&rkfor yem.

smart.

&

conpulsioni

weilwith ildhedback midentifed depressive & from pee6. and mehods anxiety ?ppliedto disrdersreducemn{ict U$fitl riltt ild chilge OCD, ating destruclive somatifom, iorces.
disordere.

ms. Works

M.

of the couple

Gain

bsigtds orlamily mit

Anxiefy Disorders: DSM-IV-TR Diagnoses

pPanic Disorder
e.Agoraphobia

:'Specifrc Phobia :rSocial Phobia

Generalized Anxiety Disorder

p 0bsessive Compulsive Disorder :r Post-traumatic Stress (Ptsd) pAcute Stress Dsorder

Panic

Attack

Discrete Periods

arHeart Cluster

r Palpitations,

Chest pain, Nause4 rumbnesg

tingling arBreathlessness Cluster

Shorhress of breati, Choking sensatiorl Dizziness, Paresthesias, Chills or hot flashes

arFear Cluster r Fearofdying, Fearofgoing crazy, Shaking,

Sweating, Derealization or depersonalization

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Panic Disorder: Characteristics

p>Females 2-4x

Pa.,,.,K A\^,K flc.\'.rJe,s Pen,*K )r*nJr,r

t) Storg genetic component with 4-8X greater with

lst degree relative.

Onset late adolescence to 30s

ar Over 65 yr- underreported

p p

Prior stressfirl event within 6 months

78olo

initial panic attack occurs w/o environmental

trigger

Panic Disorder Criteria

p
Spontaneous recurrent panic attacks wlo obvious

precipitant.

:r >1 attack is followed by concern for additional attack, fear ofattack implications and a sisnificert
change in behavior related to the attack.

Should assess for agoraphobia

ar Range of aftacks vary and often last 20-30 minutes

Panic Disorder: Masquerade

:r Think of hyperthyroidism, Bl2 deficiency,
seizures, CAD, anernia, pheochromorytoma,

hypoglycemia

pThink of

exoessive caffeine, amphebmineq withdrawal, heavy metal toxicity, other medication induced anxiety such as allergic

reaction to PCN, sulfa or atypical reaction

agonists.

beta

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TIIE PANIC CYCLE

APPRIA.ISAL'-

CATASI'ROPHIC MISINTERPRETATION ,/, \,u

/.tt-

---_--TBELINGS

\,/

B[}T}IIJ
SENSATIONS

Specific & Social Phobias: Criteria

p
The most common mental disonder in US. >5-1ff/o

of population affected.

pAn

irrational fear or situation.

tlat

leads to avoidance of a object

;t Eryosure to situation provokes anxiety p, Recognition of excessive nature of fear pNot

due to substances or other disorder

s, Durafion >6 nronths

Agoraphobia Criteria
:rAnxiety about being in places or situations

.
r r
a:

escape is

difEcult

embarrassment takes place

helpnotavailable

Avoidance of situations erMay require a companion in attendance atAnxiety not due to another mental disorder

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Generalized Anxiety Disorder (Gad)

r"rChronic ExcessivdlVorry for >6 months ) pHyper-arousal often with somatization e.Associated with restlessness, fatigue, poor concentation, irritability, muscle tension and sleep disturbance. :rlifetime prevalence *457o ar>Females 2:1, onset age 20

/'

----'\

PANIC DISOKDERS: General Tx

p Benzodiuepines p Antidepressants
o Tricyclics and SSRIs, MAOI

r (CAUTION: p

-20olo experience stimulantlike reaction

"Activafion Syndrome) o Provide Reassumnce: 2-6 weeks for effectiveness

Behavioral interventions

o Cognitive thempy

r r

Combine w/ biofeedback or relaxation Panlc control

tretment (pct)

o Assertiveness training

o Behavioral therapy

Obsessive-Compulsive Disorder
''OBSESSIONS . rrcumt, intrusive ''COMPULSIONS
thoughts, feelings or ideas
to the obsessions

0L

- ?n=^,^,\,L D;< u's

%e s)-qjrlirz- '/e
rj5r=cy"'+?. i

r'r

mnsciou repetitive behavim linked

that when perfomed relieve anxiety

p Full ,.

awareness makes OCD a "Disorder" and differs from the Obsessive-Compulsive

Personality Disorder (OCPD) Ego-syntonic versus ego-dystonic

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OCD: Characteristics
,t2-3Vo of population, males: females
er Onset: childhood or early adulthood

AE;r.. t

"Ten:retle,'g

p
zo

Suessful events exacerbate condition Common co-morbid conditions

r
lr

depressiorq panic disorder, eating disorders, tics, separalion anxiety in childhood" phobia

Rate is highsr with I st degree relative with Tourette's

Obsessive-Compulsive Disorder
:r

Obsession
o Contamiration

zt Compulsion

Doubt o Symmetry
o e- Can also have obsessive thoughts

r r

Constanthand*ashing
Checking

o cornPrilsive slow

without a linked
compulsion.

vS At-{e
Posttraumatic Stress Disorder (PTSr))

Silce:rg'

R"'-r{un

\,
?

E,;l.:e
lt.

)nr

elResponse to a catastrophic (life threatening event) with intense fear or horrorer>1 month of increased arousal, avoidance of stimuli, persistent reJiving of event, dreams, flashbacks, poor sleep, exaggerated
startle response, anger

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Acute Stress Disorder

a,Similar to PTSD
e.Symptoms start within I month of event and resolve within I mont-h

Sexual Violence: Rape

arRape is legally defined as "carnal knowledge ofa person by force and against [her] will". arOccurs every 2 minutes and9ff/aare unreported pBetter prognosis if seek immediate care

pMust

attend to the medical and psychological aspects of care

Coping Of Rape Victims: Reaction Phases

?d

Acute Phase: lasts several weeks to months Reorgaaization Phase: longerterrn of reorganization lasting as long as several years

:. Initial Presentation:

generally overwhelmed, labile, anxious. suspicious, guilty, degraded or depressed. May depersonalize the event. calm think "shock" with risk of later symptoms z.Longer Term Problems: difficulty with relationships, jobs, regressio4 dependency.

:'If

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Parfner Violence: Phases

ar

1. Verbal abuse and hostility phase r Systematic isolation

o

Undermining self-esteem
phase

ar2. Violent
o Assault

:t3.
o

Honeymoon phase Remorseful of reform

o Promises

Domestic Violence: Screening Radar

*Routine screening of female patients
pz4sk direct questions erDocument your findings
:r,4ssess patient' s safefy

,pReview options and do referrals

Battering only takes place among minorities and in lower socioeconomic

groups.

Batterers are drunk or out

of control

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Domestic Violence: Abuser ProfiIe

pl.ow
self-esteem
z.rUse tlreats, force for control

arAlcohol or substance abuse

:vJealous of parhrer's relationships

erBlame partner for violence

e-90Vo deny problem exists

zrProduct of abusive home

Child Abuser: Characteristics

:rFear of spoiling children

p>Value

on punishment

arFalse expectations of children

e Umealistic demands of love or behavior e*Lack of empathy :eFelt misunderstood as child

erFelt unrewarded and criticized

as

child

Somafoform Disorders:

DSM-IV-TR Diagnoses
p Somatization Disorder
pConversion Disorder
eePain Disorder

zrHypochondriasis

:rBody Dysmorphic Disorder

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" Somatizafion Disorder:

Criteria
5-10Yo

zt > 2 GL >1 sexual/reproductive,

>l

neurologic,

>4 pain symptoms, onset < 30 years

:r :r

in general medical practice

zt Females 5-20X greater incidence

50p/o

with co-morbid mental disorder

frequent visits

pNO CURE: schedule

fol

reassuranc

Somatization: Common Complainfs

a'"'sickliness" urination diffrcultie s p double visionlblurred vision ermemory loss
ar

p diarrhea/vomitinglnausea
pabdominal pain
a*menstrual complaints

. Conversion Disorder
er>l newological symptom
erCannot be explained medically

p Causes sip,ificant distress/impairrnent

p"La Belle Indifference"

pCommon, 20-25% incidence in medical
setting arOnset teens, more common in females zoCo-morbid with schizophrenia" major
depression and anxiety.

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Pain Disorder
arPain in one or more anatomic sites arPain causes distress e'Psychological NOT Medical, FactitiousAvlatingering
arFemales, 30s and 50s peak

erPoor Prognosis Litigation Concerns

Hypochondriasis
(- t6 \*
rnnn11tr of fear]of serious medical condition.

e.Bases on misinterpretation of bodily functions/disease

e. Fear persists despite medical tratment

:d Sympto;ns may wax and wane and 5fflo imp'rove

r4{7o

of general medical pop.

p Males : females p Most common during 20-30 yrs. pNO CURE: Frcquent visits, Group therapy

erFacial Flaws, physical imperfections PAverage of 4 Flaws zrOnset is 15-20 years arMore common in the unmarried
er907o

with co-morbid depressiorg 70%o with anxietv- 30% wiLh pwchotic disorder

*Treatoaerl(-QlB5-J

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4' J)
/----

Factitious Disorder

e.Intentionally produced symptoms e"Primary gain

sense

"4\e N, r$C,

Y4::)background, poor arMedical

poor sexual adjushnent
zo 3

of identity,

-9Yo

hospital admissions

pSick role

Munchausents Syndrome
TRIAD

SIMI,ILATION OF DISEASE

,'
/ ./

ffi\
*ti + j!

..-

\\ \
r-rNc

//\
,,'
PATHOLOGICAL

LIfNG

!D:r

Dissociative Disorders

Loss of memory, identity, self, onset of amnesia, detachmen! can arise suddenly

zr Dissociative Amnesia:

>l

Important Infonnatioa
no

Inolving

Episode of Imbility to Recall a Traumatic Event.

Dissociative Fugue: Wherelwho Am I? Dissociative ldentity Disorder:

>l

Identity

Depersonalizaticn Disorder: Out of Body

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Personalify Disorders
Personality is one's set of stable, pre di ct ab I e, etn o ti onal snd

)raso"d*y'}^'\s vg
bla,-,.,.\ p,"s'

behwioral traits. l::=liiffi

gitdj#ri3$rdBi.ri:lA)fiiibr,?#t

ingrained, iflerib le patterns re lating to olhers that are maladaptive and cause significant impairment in social or o c cap ati onal ftn ct i arcing.
Ego-syntonic & Stable

Personality Disorders : Diagnosis

grDSM-IV-TR: Code cn Axis pMisdiagnosis is common

II

Lackofprecision

r Overlapofcriteria r Dimensions in nulny prs{ms

pDisorders grouped into Clusters A, B, & C

Personality Disorders: Clusters

lCLUSTER A : Schizoid, Schizotypal and Paranoid o Social Detachment W Unusual Behavim e. CLUSTER B: Antisocial, Borderline, Histrionic and
Narcissistic

e Drama
o Emotional & Impulsivity

p'CLUSTER C: Avoidanq Deperrden! aud ObsessiveCompulsive o Arxiety e Fearfirlness

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Cluster,4; Schizoid PD -qIgBNrr

r Detached r lndifferent To Criticism
Or Praise

r r Absence Of Close Friends r Neither Desires Nor Enjoys Relations

$exual Experiences Oflittle Interest lasks Performed Alone

Iakes Pleasure In FewActivities

SchizotypalPD: ME PECULIAR
'"r

i
i

i
I I i I

!-{agical ftriiti"g r Experiences Uoo*uut Perceptio*s . laranoid Ideation r Eccentric

Behavior

r Unusual Thinking r lacks Close

Friends

ldeasOfReference

r .Apxiety In Social r Bule Out Psychosis

r Qgnstructed
Affect

Paranoid PD : SUSPECT
r $pusal Infidelity Suspected r Unforgiving r $uspicious r lerceives Attacks r pnemy Or Friend r Confiding In Odrer Feared r ThreatsPerceived

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Anfisocial PD
CORRUPT
ar9onformity Lacking pObligations Ignored
pReckless Disregard For Self Or Odrers
atRemorse Lacking

pUnderhanded p Planning Insufficient (Impulsive)

avTemper

Borderline: I DESPAIRR
:rldentiVProblem
erAbandonment

Affect e"Empty Feeling

erDisordered

Terror

a'Impulsivity
aYRage

e.suicidalBehavior
erParaaoia

Or Dissociative

e'Relationship Instability

Borderline PD
e.Red Flags

r Doctor Shopprng r Legal Suits r Suicide Attempts r Several Brief Marriages r Doctor Idealization
o Excessive Interest

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Histrioni c PD : Pft.4l,St' ME
zrProvocative

:rRelationships
auAttention Center
er

Of

a.rlnfluenced Easily

Etyle Impressionistic arEmotions Shiftrng

er![ADE UP (Appearance) :vEmoti ons Exaggerated

Narcissistic PD : SPEEECIAL

aclpecial
a.PreoccupiedWith

arConceited
errlnterpersonal

Fantasies erEnvious pEntitlement

aroExcessive

Exploitation
er-A,rrogant

:ol,acks Empathy

Admiration
Required

Avoidant PD: CRINGES

z. Certain8 Needed

tt

Rej ection Preoccuption z. Intimate Relations Avoided

lt

New Relations Avoided

E Gts Out Of Activities Requiring Personal Contact

zr Embarrassment ur Self-view As Unappealing

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.Dependent PD:
:r
Reassurance

RELANCE

Required pAlone With

Dscomfort Expressing Disagreement cNurhrance Desired p Companionship Difficult

Sought

:'LifeResponsibilities
By

Others :r Exaggerated Fears Of sr Initiating No Projects Caring For Self

Obsessive-C ompulsive.' I-/TW FIRMS

e
L,ose Point Of

Activity p
eo

Friendships Excluded Reluctant To Delegate

pAbility- To Complete plnllexible PAffected

Tasks By Perfectionism
Kept

a"Msefly
pStubborn

pWorftless Objects

PERSONALITY DISORDERS: TX
*Very difficult
to treat

pPatients rarely aware of the disorder

elPharmacology of little help srGroup ttrerapy ?? Maybe

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Psychotic Disorders:

DSM-IV.TR DIAGNOSES
pSchizopbrenia

p Schizophreniform Disorder
e.rBrief Psychotic Disorder

p Schizoaffective Disorder
arDelusional Disorder
er Shared Psychotic

Disorder

PSYCHOSIS
alPsychosis is a break from realif involving delusions, perceptual disturbances and/or
disordered thinking. :rDisordered thought may be related to content (ie. ideas ofreference) orprocess Qinking of ideas and words ie tangentiality, perseveration)

DELUSTONS
pFxe4
false beliefs that cannot be altered by rational arguments or accomted for by cultural background of the individual.

:*Examples: sense of persecution, feeling that thoughts are heard by others, special powers, feelings of massive guilt involving
powers

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HALLUCINATIOI\S
usensory perceptions without an actual
external stimulus

:rAuditory pVisual
rrOlfactory
rvTactile

Schizophrenia
o 1% of population over lifetime
o hesentation: Men women - age 30
o

age 20 and

Men have more severe disease: Many negative symptoms.

o Strong genetics
o Post psychotic depression is

-50%

Schizophrenia: DSM-IV-TR
pConstellation of abnormalities in thinking, emotion and behavior

pMust

have >l of delusions, hallucinations, speech disorganization, grossly

disorganized behavior or negative symptoms for at least I month.

pnrness must be present

*@

pMust

cause significant social or job

deterioration

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Schizophrenia Types
a.

:r

Paranoid Disorganized !"rcatatonic

rr Residual

PExam Findings

disheveled

o flataffect

zrundifferentiated '#:Ll:T**u
o hdluoinations

delusions

o understandproverts

r
o

pomirxightofdisoase
ideas ofreference

Symptom Types
PPOSITM P.NEGATIVE SYMPTOMS SYMPTOMS er Lack of emotional PEmotioml tumoil expression :.Delusioas Er Lack of ;o Motor agitation commuaication :rHaltucinations
:c Lack ofreactivity :aSocial wit}drawal

Prognosis: Good Vs. Poor

pGoOD o Lale Onst
r . . .
Preipitating

PFooR

r
. .

Evert Acute Oreet cood hm$id Mood Synptoms o Fmily History of Mood disrdm r Mmied . Good Suppod r Positive Syruptms

Wtidrawal' Atitistic Negadve q'ryWtms

MmY Relaps HistqY of Assttlts

r r . r

FmilyHistoryof Psychqis
Neuological Sigm Lack
3

ofRmissim within

YeN

Psinaial

tma

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Schizophrenia: Pharmacology
pNourotransmitters
p
Dopamine

PTypicatneuroleptics

hypothesis (Mmtly D, Blocken) o watch for Tardive o too much of it DYekineeia(TD) pserotcnin 'Hmr* r toomuchofir 'haloPqidol rrNorepinophrine -dAtypical neuroleptics r too much ofit "cAtsA aminobutyric acid) . not snough
mcrcence

(gamma- Y*i,T:l-t::if' or ' l-ower

,.sc
Sch iz

K &^Le

ophrenia : /ha rm acology

:" Monitor for :r Monitor foc ./ r TardiveDyskinesia:a o dystoni4 pseudoparkinsorisnq writhingoffare,tongueand akathisia head o mticholinergic ' Mqe ctmon ir older fern16 md 5oolo Do Not R@B slmptoms such as dry wth c*fiotr of,Meds moutlr, comtipatiuq Neuroleptic Maligrat uinary retendoq '

brunivision ffiH:l*,lff#|

,n;..rRz r^.J -Q,fr- $,r.,,n

lVlood I)isorders: I Affective Disorders

er

A mood is

ofone'sinternal emotional state. Either external or internal

description

zo

stimuli can trigger Labels include sad, angry, mad,

happy, rrDstress can occur irritable. depending on severity or

tolerance.

moods.

Patients with mood disorders experience an abnormal range of moods and lose some measure of control over them.

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Mood Disorders: Affective Disorders

.f

-uajorDepressive Disorder (MDD)

:t

Medical Causes: o CVA, endocrinopathies,

Parkinson's, Mono, Carcinoid syndrome, cancers, SLE

I :'Bipolar II l" Dys*rymic

a" Bipolar

Disorder

pDrug

Causes

cY olothtmic Di sorder

r ETO{ BP meds, steroids,

levodopa, sedatives, anticonvulsants,

withdnwal.

Major Depressive Episode:

p >5 of the following symptoms for >2 wks. p Must ilclude depressed mood or anhedonia
pDepressed Mcod Or
a' Loss Of Pleasure/Intorest (anhedonia)

Appetite change,fWt. Iass

Sleep

o
o

Dsttnbalce

Psychcmotor Dist{rbance Fatigue

. r
o

WorfilessnesVGuilt
Dealh/Suicide Idalion

o Concentatiur Problers

Major Depression:
SIG:Energy CAPsuIes
PSleepDsorder

Interest

Deficit

?' Guilt

PEneryyDeficit

p Concentraiion Deficit
er3$petite Disorder

P Psychomotor
z. Seicidality

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Major Depressive Disorder

arAt least one major depressive episode

pNo history of rnania

ii'ft

:tlifetime prevalence
;rOnset ^40 years
aryFemales:Males 2:1

5t%

e,Elderly 25-5A%

Maj or Depressive Disorder:

Pharmacology
s. Thought to be caused by inadequate serotonin aad its main ?t Trcatment

z. Hospitalize if suicidal

metabotite, 5hydro:'yindolacetic
acid

*uMeds o SSRI, TCA, pOccasionally

IV{AOI

(5-HIAA)

pPossibly relatedto
abnormal regulation
beta-adrenergic receptors

of :.

o stimulmts, T3 o anti-psychotics, lithiurn,

o ECT Therapy!!
!

Clinical Tips
erSome Patients Do Not Have Subjective Sense

Of Being Depressed zvCommon Somatic Complaints

r pain, gastrointestinal
hopelessness

complaints, neurological

complaintq general fatigue, lethargy

:r Suicide Signs: extreme withdrawal,

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Suicide Risk Factors Summary

Age sD Ethnicity :-Religion e-Living Alone :rBereaVement
:o Objectl-oss

p Health Status
z'Impulsivity

pRigid Thinking
P Shessful Events

r
'

Upsurge

MltltiPle

srUnemployment

:'Hospitalization

Suicide Risk Factors Summary

p Direct Verbal

ll.rrrnrr'r-

,^J

ltr"of

Warnings pr PIa:r o Specffic o kdralitY

o Available
pa^*

zr Indirect Statements & Signs

Depre ssion

el{opelessness

plnloxicafion
at Special Clinical PoPulalions

Attemnts . selflfrienk PGender (mtfr'1 r Rektivm

Dysthymic Disorder

r Appetite: Up Or Down r Concentration Deficit r Hopelessness r Bnergy Deficit r \ilorthlessness r $leep Disorder: Morc Or Less

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Dysthymic Disorder: Tx
ifetime pr ev alenc e 6Yo e.2-3X higher in women
zr L

rrOnset .' age 25 in 50% of patients

arTreatrnent

r Cognitive or insight oriented ther4y are best r SSRI, TCA, MAOI if used with therapy as
above

Manic Episode
pElation, Expansive
Week
a. Three Or More
1

? Jr.y. n.{ f[o'lu^\

Of

Following

r Grandiosity
o Decreased Sleep o Talkative o FlightOfldoas o Disaadibility o > Goal Directed Activity o > Pleasurable Activitic

Hypomanic Episode
>4 Days Of Eletio4 lrritability, Or Expansiveness Talkativeness Pleasurable Activities Episode Not Severe Enougfi To Cause Marked

nce}. L\ A,^\t

{ ? "1,'t,

?o pl(

\,

Social Or Occupdional Impairment/ No Psychotic

Features

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Bipolar
p
Episodes of r

Bipolar

II

interspersed*r{:g$ 30 present n' If unheated will cycle -3months and often relapses
onset
before age

depression :r r^

History of >1 depressiveepisode

E Lifetime prevdenE-lgi, ;4eSnenC( with Qry**i"-t rrywomen= Men p Lifetimo prevalence * sr

o'Se/o

:o Genetics

rvMore common in
women

z'Onset-before ags30

:r Much

less debilitating

Bipolar I & II: Pharm*cologr

zrlithium, anti-convulsants suoh
carbamazepine or valproic
as

acid

pPsychotherapy ?IECT works well in the treatnrent of Manic phase.

tuly

Mixed Episode: {Dysphoric Mania)

pManic Episode And Depressive Episode (Every
Day For

I Weeki

:.0>Females

:t >Lithium Non-responders
e.Initabiliry :- Emotional Instability p>Self-injury
p>Dangemusness

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Cyclothymic Disorder
erAlternating periods of hypomania and
periods with rnild to moderate depressive symptoms.

@ffiffi;;5\wi
----Z

thour >2month brea k

m symptoms

Cyclothymic Disorder
:rL ifetime prevalence < I %o ,r'May co-exist with borderline PD
arOnset

age 15 to 25

pFemales

Males

:rTreatrnent

r r

Chronic course with 33Yo eventually being diagnosed with Bipolar Disorder. May use Antimanic agents as needed.

Adjustment Disorder With

Depressed Mood
p Not Classified Under Mood Disorders ri.,l.ffi:i'ffiii#..{',r;
e, Depressed
so

Mood Following Identifrsble

Psychosocial Stressor Excessive Response Sadnesq Isolation, Sleeplea! Concentration Treatmont supportive psychotherapy, groups, treat insomnia, arxiety, depression as needed.

p Remit Within 6 Months

;,
zr

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Eating Disorders
etAnorexia Nervosa

pBulimia Nervosa

Vs. Bulimia

"ANOREXIA o Weightloss, r hfino'rWeight Introvtrt64 Itidc In Changes, Extrovsrtea WeighbfoodConhol, Shang Sexually Food = Control Active, Or$ Of Cmtrol Wift Food . Restrictive vs. Binge/Purge r Purgirywmiting, o l&20X mcre common laxatives, diuetics in women e Nm-Purging: excessive . 4olo in |,ems uercis/fasting . onset -lG3o yea$

pBUIJMIA

Anorexia Nervosa
pWeight Fears
o Weight Below 85%o r FearOfGaining Weight

r Body Image Distorted r Amenorrhea

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Bulimia Nervosa
stBulimics

r Bingeing r Out-of-control Feelings While Eating r Concern With Body Shape . Purging

Childhood Disorders
zryAttention Deficit Hyperactivity Disorder

r Inattentive r Combined

Type

e Hyperactive Impulsive

pConduct Disorder
P Oppositional Defi ant Disorder
ar

Separation Anxiety Disorder

Attention Deficit Hyperactivity .Disorder (ADHD)

et> 6 symptoms involving inattentiveness, hyperactivity or both for >6 months plnattention: problems listening,
concentrating, payirg atteation to detail, easily distracted, often forgetfl.rl

*Hyperactivityl Impulsivity : blurting out,

rntemrpting, fidgeting leaving seat, talking excessively

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ADHD
er3-5Yo prevalence

in school age kids

8ry3-5x greater in males

plncreased incidence of mood disorders,

personaiity disorders and conduct disorder

?'Many remit in adulthood, 2AYo carry over

zrTreatment: CNS stimulants such as methylphenidate, dexedrine, pemoline

e'Adjunctive: SSRI, TCA

arTherapy with family, groups (social skills)

\
Oppositional Defiant Disorder

H..,*,\./"Jh*afy
* r.1.,,,^,.ik b..:,-'rrltzt
_"

@hostileand defiantbehavior during which >4 are

present:

l,+r

r frequent

loss of temper, arguments with adultg

defuing adult rules, deliberately annoying people, easily annoye{ anger aad resentment spiteful and extornal blarne-

* s;'j'

Ja^r.r o-. h,ra^*A

--

r Prevalence 16-220/o, start -age 8 r Treatment thelapy, parenting skillgproblem

solving

Conduct Disorder
rry

\-\urr

a,",n"

-,ixlz/r}

fn+

A pattem of behavior fhat involves violation ofthe basic rights ofothers or of social norms and rules.
acts of aggression toward people or animals, destruction of property, doceitfulness, serious violation of rules-

p>3

z. Prevalence Gl67o in boys and 2-9%o in

girls
tD up to 40% dovelop

antisocial PD

tt

Treatment Structure, Rules, therapy, problem solving skills-

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Separation Anxiety tr)isorder

:ryFear of leaving one's parents or other major attiachment frgrres.

erMay refuse to go to school or sleep alone

ErPrevalence
40%

of school

age

kids

a.Boys: girls
arParent(s) often affected with arxiety disorder

arTreatnent with family. *l- antidepressants

Substance Abuse: One of the following for ) One vear

F

AB03i ur )rrr-\rn* ,
I

I
L
Y

Dangerou* Behaviors

erAbuse Leads Dependence

to

Ixgal
Problerns

Substance Dependence: 3 of the following

within

12 months
z.Tolerance

fnc,n: O a PKy r,z,\ nerrj.

pWithdrawal
e dwelopmmtaf

substance specific sJ.ndrom due to cessation of substanoe that hm been havy or

needforincreased mounts of lhe

substance to achieve the desired effect or diminished efiects with

prclonged

loweramounk ofdre
substance

Persistent desire, unable to cut baclq significant time spent getting and recovering from use and decreased time

in other activities

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Screening: Cage Test

:r
I

"Have you t'elt you ought

drinkine oiother substanci

* z.

usel-

t6Edown

on your

"Ha-ue peopl@noyed you try criticizirg your drinkirg or substance use?"_

"Halve you felt bad o@lty about your drinking or othor substanco use?" p4. "Have you ever needed an fGlpener in the

ar:.

morning to steady your nerves or get rid

ofa

hangover?" (2 yesresponses)

Cognitive Disorders
erDementia

- *\r,.
State Exam

erDelirium

a'Mini Mental

(M\dSE)

Assesses

ptient's current state of cognitive

ch"rf

^'r-J'kftv.r

ff\r:'r'rb Sard,tlT"

r Perfect score : 30 r dysfunction: "95

functioning.

Cq^-eL.,iCh

- Elr b,,+4p.$v:,2 r:.s

Cognitive Disorder: Ilementia

:tlmpairrnent of memory and other cognitive
f,mctions without alteration in level
consciousness.

Qrr.,- ,{ ?\ .rr- ig-i-q #:*

&lzh e,nnr-<! D,rop.drza

of

erOften progressive and irreversible st>age 80 has 20% prevalence

erMay co-exist with depression" anxiety,

personality change, delusions and hallucinations.

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Delirium
pAn
acute disorder of cognition related to impairment of cerebral metabolisrn.

arMedical Cause Of Copitive hnpairment

Flucfuating Coune

o Rapid Onset

r Attention Inpalrmen! r Agitation

Thiaking Disturbance

aoTreatment: Underlyrng Causes and provide

additional symptomatic relief

Thanks for your

Good Luck on your Boards