Psychiatry

a. Mood Disorders:

1. Major depressive disorder: 

DSM V criteria:

1. 1 of either: (1) depressed mood, or (2) loss of interest (>2 weeks), plus;
2. ≥5 of the following:

• Depressed mood most of the days
• Markedly diminished interest or pleasure
• Change in weight or appetite (typically ↓)
• Change in sleep (typically ↓, terminal or early morning insomnia)
• Psychomotor retardation or agitation
• Loss of energy or fatigue
• Worthlessness or guilt
• Impaired concentration or indecisiveness
• Thoughts of death or suicide ideation\attempt

3. Marked social or occupational impairment
4. Not due to drugs or medical conditions

 

2. Dysthymic disorder: 

DSM V criteria:

1. Chronic low mood (>2 years) + no remission periods (>2 months), plus;
2. ≥2 of the following:

• Low energy or fatigue
• Low self esteem
• Hopelessness
• ↓\↑ appetite
• ↓\↑ sleep
• Impaired concentration or indecisiveness

3. Marked social or occupational impairment
4. Not due to drugs or medical conditions

 

3. Bipolar disorder:

DSM V criteria for manic episode:

1. Abnormally + persistently elevated or irritable mood (>1 week)
2. ≥3 (≥4 if primarily irritable) or more of: “DIG FAST”

• Distractibility
• Increased risk-taking
• Grandiosity
• Fast\racing thoughts
• Activity increased
• Sleep decreased
• Talkativeness

3. Marked social or occupational impairment
4. Not due to drugs or medical conditions

 

4. Hypomania:

• Shorter (4 days) and less severe than mania (no hallucinations\delusions or marked impairment)
• Mania could present with hallucinations or delusions if severe

 

⊗ Bipolar I: 1 or more manic episode (w\ or w\out depression)

⊗ Bipolar II: 1 or more major depressive episode + at least 1 hypomanic episode

⊗ Cyclothymia: 2 years of episodes of hypomania and dysthymia (no mania or major depression)

⊗ Mixed mania: simultaneous mania + depression

⊗ Rapid cycling: > 4 of alternating episodes (mania, depression) per year, separated by intervals of 2-3 days

 

Treatment:

• Mood stabilizers: lithium, lamotrigine, valproate
• Atypical antipsychotics: risperidone, olanzapine, quetiapine, …
• All atypical antipsychotics are FDA approved, except clozapine (causes agranulocytosis)
• Monitor for metabolic syndrome: high blood sugar and cholesterol
• Bipolar depression: lamotrigine
• Caution w\ antidepressants as they might induce a manic episode

 

---

b. Anxiety Disorders:       

Normal anxiety	Pathological anxiety
–    Proportional to external stimulus –    Mild and not prolonged –    Doesn’t impair function –    Attention is focused on the external threat rather than on the person’s feelings	–    Out of proportion to the external stimulus –    Excessive and prolonged –    Impairs function –    Attention is focused on the person’s response to threat; palpitations, sweating, tremor

 

1. Generalized anxiety disorder:

1. Excessive worry more days than not about several events and they find it difficult to control the worry (>6 months), plus
2. ≥ 3 of the following:

• Restless or feeling on edge
• Easily fatigues
• Difficulty concentrating
• Irritability
• Muscle tension
• Sleep disturbance (intermittent, wake unrefreshed, difficulty falling asleep)

3. Marked social or occupational impairment
4. Not due to drugs or medical conditions

• » Epidemiology: 4-7%, median onset 30 yo, female > male (2:1)
• » Treatment: CBT, meds (buspirone, benzo, antidepressants)

 

2. Social anxiety disorder:

1. Marked fear of social performance situations in which the person is exposed to the possible scrutiny of others and fears s\he will act in a way that will be humiliating (>6 months)
2. Avoidance + out of proportion anxiety
3. Marked social or occupational impairment
4. Not due to drugs or medical conditions

• » Epidemiology: 7%, teens onset, females > males
• » Pathogenesis: hyperactivity of amygdala
• » Treatment: CBT, social skills training, meds: SSRI (citalopram), SNRI, MAOIs, benzo, gabapentin

 

3. Specific phobia: 

1. Marked or persistent fear (>6 months) that is excessive or unreasonable (out of proportion to the actual danger) cued by the presence or anticipation of a specific object or a situation
2. Avoidance + out of proportion anxiety
3. Marked social or occupational impairment
4. Not due to drugs or medical conditions

• » Epidemiology: 15%, early onset, females > males (2:1)
• » Etiology: personality (anxious, dependent), learning, contextual conditioning
• » Treatment: systematic desensitization, medications (benzo) for short term

 

4. Agoraphobia: 

1. Marked fear or anxiety for (> 6 months) about ≥ 2 of the following situations:

• Using public transportation
• Being in open or enclosed spaces
• Standing in line or being in a crowd
• Being outside of the home alone

2. Avoidance + out of proportion anxiety
3. Marked social or occupational impairment
4. Not due to drugs or medical conditions

• » Epidemiology: 2%, mean onset is 17 yo, females > males (2:1)
• » Associated w\ panic attacks\disorder, depression, substance use

 

5. Panic disorder: 

1. Recurrent unexpected panic attacks about which there is persistent concern or anticipatory anxiety (>1 month), plus
2. ≥ 1 of the following:

• Persistent worrying about having more additional attacks
• Worry about the implications of the attacks
• Significant change in behavior because of the attacks

3. Marked social or occupational impairment
4. Not due to drugs or medical conditions

• » Epidemiology: 3%, teen\early 20’s onset, female > male (2-3:1)
• » Associated w\ major depression and substance dependence
• » Treatment: educate, reassure, eliminate stimulants, CBT, meds (SSRI, venlafaxine, TCA, benzo, valproate, gabapentin)

 

5.5 Panic attack:

1. Discrete period of intense fear in which symptoms develop and peak w\in 10 mins, 4 out of:

• Palpitations, sweating, shaking, SOB, feeling of chocking, chest pain, nausea, chills, paresthesia’s, dizziness\fainting, derealization\depersonalization, fear of losing control\going crazy\dying

 

6. Obsessive compulsive disorder:

• Obsessions and\or compulsions cause marked distress, take >1 hr\d, cause marked impairment
  • Obsessions: recurrent and persistent thoughts, impulses, or images that are intrusive and unwanted -> marked anxiety or distress + resistance to the person’s attempts at ignoring or suppressing them
  • Compulsion: repeated compelling acts done in response to obsessions

• » Epidemiology: 2-3%, mean onset 19 yo (w\ males having earlier onset), females = males (1:1)
• » Associated w\ anxiety disorders (>70%), MDD (60%), tic disorder (30%), schizophrenia\affective (12%)
• » Pathogenesis: increased activity in the right caudate
• » Treatment: CBT, serotonergic antidepressant, adjunctive antipsychotics or psychosurgery

 

7. Post traumatic stress disorder: 

1. Exposure: direct experience, witnessed, learning that it happened to a close person, repeated or extreme details of trauma
2. Marked social or occupational impairment (>1 month)
3. Not due to drugs or medical conditions

≥1 of intrusive symptoms after trauma:	≥1 of avoidance symptoms:	≥2 of negative alterations in cognition and mood:	≥2 of alterations in arousal and reactivity:
–    Recurrent involuntary and intrusive memories of events –    Recurrent trauma-related nightmares –    Dissociative reactions –    Intense physiologic distress at cue exposure	–    Avoidance of distressing memories, thoughts, or feelings of the events –    Avoidance of external reminders (people, places)	–   Inability to remember an important aspect of the events –   Blame self or others –   Marked diminished interest \ felling detached	–    Irritable, angry outbursts –    Reckless, self-destructive –    Hypervigilance, exaggerate startle response –    Problems w\ concentration, sleep disturbance

• » Specifiers:
  • w\ dissociative Sx (derealization \ depersonalization)
  • w\ delayed expressions (>6 months after the event)
• » Epidemiology: 7-9%, more in young women
• » Pathogenesis:
  • Increased activity of amygdala
  • Decreased activity of medial prefrontal cortex (including orbitofrontal and ant cingulate cortex -> regulate affect)
• » Treatment: CBT, group therapy, meds (antidepressants, mood stabilizers, B blockers, clonidine, prazosin)

 

---

c. Psychotic Disorders:

1. Schizophrenia: 

DSM V criteria:

1. (>6 months) of disturbance + (>1 month) of active psychotic features, ≥2 out of:

• Delusions
• Hallucinations
• Disorganized speech
• Catatonic features or disorganized behavior
• Negative features

2. Marked social or occupational impairment
3. Not due to drugs or medical conditions

• Negative sx: flat affect, alogia, avolition, anhedonia
• Positive sx: delusions, hallucinations, behavioral dyscontrol, thought disorder
• » Epidemiology: 1%, early onset, male > female
• » Genetics: MZ (47%), DZ (12%), one parent (12%), both parents (40%)
• » Etiology: genetic association, stress diathesis model, dopamine hypothesis
• » Anatomical abnormalities: small total brain volume, cortical atrophy, smaller hippocampus, lateral ventricles enlargement, wide third ventricle
• » PET\SPECT: normal global cerebral flow, hypo frontality, no activation of dorsolateral prefrontal cortex (problem solving, adaptation, coping w\ changes)
• Good prog: late + acute onset, precipitating factor, good baseline, married, good support, positive sx, Hx of mood disorders
• Poor prog: early + gradual onset, no precipitating factors, poor baseline, single\divorced\widowed, neuro signs or sx, prenatal trauma, Hx of schizo, no remission in 3 years, many relapses

 

Delusions	paranoid\persecutory, ideas of reference, external locus of control, thought broadcasting, thought insertion or withdrawal, jealousy, guilt, grandiosity, religious, somatic
Hallucinations	auditory, visual, olfactory, somatic\tactile, gustatory
Thought disorder	neologisms, tangentiality, derailment, loosening of associations (word salad), preservation
Behavior disorder	bizarre dress, catatonia, poor impulse control, anger, agitation
Mood & affect	inappropriate, blunted, flat, isolation

 

 2. Schizophreniform disorder: 

• Same as schizophrenia, but (between 1–6 months)

 

3. Brief psychotic disorder:

• Same as schizophrenia, but (<1 month), w\ sudden onset
• Example: postpartum psychosis -> develop during or w\in 4 wks post-delivery, resolve w\in 2-3 months
• Different from postpartum blues: very common, considered normal, lasts for a few days

 

4. Delusional disorders:

• Delusions are systematized and non-bizarre
• No other feature of schizophrenia
• Less functional impairment

 

---

d. Somatoform Disorders: 

SOMATIZATION: DSM IV

SOMATIC SYMPTOM DISORDER: DSM V

1.      Starts before the age of 30 years, (>6 months): –       4 pain symptoms –       2 GI symptoms –       1 sexual symptom –       1 pseudo-neurological symptom 2.      Not intentionally produced 3.      Cannot be explained by medical condition or effects of a substance

1.      ≥1 somatic symptoms -> distressing \ impairs function, (>6 months) 2.      Excessive thoughts, feeling, or behaviors related to the somatic symptoms, manifested as ≥1 of: –       Disproportionate and persistent thoughts –       Persistently high level of anxiety about health or sx –       Excessive time and energy devoted 3.      Not intentionally produced 4.      Cannot be explained by medical condition or effects of a substance   – Specifiers: w\ predominate pain, persistent, mild (only 1 sx in criteria B), moderate (≥2 sx in criteria B), severe (≥2 sx in criteria B + multiple somatic sx)

 

• Clues: vague \ bizarre symptoms, started before 30 yo, associated w\ stress and exacerbation
• Theories of somatization:
  • Neurobiological: defective processing of sensory \ emotional information
  • Psychodynamic: symptoms occur as expression of underlying emotional conflict
  • Behavioral: reinforced behavior, “illness-maintenance system”
  • Sociocultural: culture doesn’t allow and stigmatize expression of emotions -> conveyed as physical symptoms which are generally accepted
• One of the main contributing factors for somatization is secondary gain (attention, sick leaves,..), which are the first things that need to be addressed and removed when treating somatization
• Management:
  • doctor-patient relationship, stick to one doctor
  • monthly brief regular visits, listen, partial PE, increase awareness and possibility of psychological factors involved
  • CBT, relaxation, group therapy, family therapy

 

1. Hypochondriasis (DSM IV) = Illness anxiety disorder (DSM V) 

1. Preoccupied w\ fear of a serious disease (>6 months), but not to a degree of a delusion (fixed belief)
2. Hx of seeing many doctors, misinterpretation of bodily sensations despite reassurance
3. Marked social or occupational impairment

• » Course: episodic, associated w\ stress, care-seeking vs care-avoidant type
• » Management: r\out actual disease, focus on anxiety not physical sx, provide client w\ correct information (where w\ somatizers, you don’t need to; because they actually suffer from symptoms, and they’re not worried about a specific disease like hypochondriacs)

 

2. Conversion disorder:

1. Complaints of isolated neurological symptoms w\ no physical cause, preceded by stressors
2. Not intentionally produced
3. Cannot be explained by medical condition or effects of a substance
4. Marked social or occupational impairment

• Absent significant investigation findings, females > males (2-10:1)
• Patients may exhibit “la belle indifference”
• Primary gain: keeping internal conflicts outside their awareness
• Secondary gain: advantage & benefits of being sick
• Course: resolve w\in days (>90%), 75% no another episode, 25% another episode, 25-50% physical process will ultimately be identified

 

3. Body dysmorphic disorder:

• Preoccupation w\ imagined defect in appearance
• Fixation or avoidance of mirrors
• Lifelong chronic course (wax & wane)
• Onset 15-30 years, females > males
• Many seek out plastic surgeries -> almost invariably unsuccessful
• Similar to OCD in terms of treatment (SSRI)

 

4. Pain disorder:

• Only symptom of pain, ≥ 1 anatomical site
• Not relieved by analgesia
• Constant in intensity
• Affected by psychological stressors

 

5. Undifferentiated somatoform disorder:

• Unexplained physical complaint for (>6 months) -> loss of appetite, fatigue, weakness

 

6. Somatoform disorder not otherwise specified:

• Unexplained physical complaint for (<6 months) -> loss of appetite, fatigue, weakness
• Hypochondriasis (<6 months)
• Pseudocyesis “الحمل التسذب”

 

7. Factitious:

1. Intentionally production of symptoms to assume sick role, conscious fabrication for attention
2. Can be by proxy

 

8. Malingering:

1. Intentionally production of symptoms for secondary gain (escape work, compensation, obtain drugs)

 

---

Download the PDF version: here

---

 References:

• Dr Fahad Allohidan, Dr Waleed Alsuhibani, Dr Fares Alharbi’s lectures
• Basic psychiatry (book)