a. Mood Disorders:
1. Major depressive disorder:
DSM V criteria:
- 1 of either: (1) depressed mood, or (2) loss of interest (>2 weeks), plus;
- ≥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
- Marked social or occupational impairment
- Not due to drugs or medical conditions
2. Dysthymic disorder:
DSM V criteria:
- Chronic low mood (>2 years) + no remission periods (>2 months), plus;
- ≥2 of the following:
- Low energy or fatigue
- Low self esteem
- Hopelessness
- ↓\↑ appetite
- ↓\↑ sleep
- Impaired concentration or indecisiveness
- Marked social or occupational impairment
- Not due to drugs or medical conditions
3. Bipolar disorder:
DSM V criteria for manic episode:
- Abnormally + persistently elevated or irritable mood (>1 week)
- ≥3 (≥4 if primarily irritable) or more of: “DIG FAST”
- Distractibility
- Increased risk-taking
- Grandiosity
- Fast\racing thoughts
- Activity increased
- Sleep decreased
- Talkativeness
- Marked social or occupational impairment
- 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:
- Excessive worry more days than not about several events and they find it difficult to control the worry (>6 months), plus
- ≥ 3 of the following:
- Restless or feeling on edge
- Easily fatigues
- Difficulty concentrating
- Irritability
- Muscle tension
- Sleep disturbance (intermittent, wake unrefreshed, difficulty falling asleep)
- Marked social or occupational impairment
- 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:
- 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)
- Avoidance + out of proportion anxiety
- Marked social or occupational impairment
- 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:
- 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
- Avoidance + out of proportion anxiety
- Marked social or occupational impairment
- 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:
- 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
- Avoidance + out of proportion anxiety
- Marked social or occupational impairment
- 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:
- Recurrent unexpected panic attacks about which there is persistent concern or anticipatory anxiety (>1 month), plus
- ≥ 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
- Marked social or occupational impairment
- 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:
- 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:
- Exposure: direct experience, witnessed, learning that it happened to a close person, repeated or extreme details of trauma
- Marked social or occupational impairment (>1 month)
- 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:
- (>6 months) of disturbance + (>1 month) of active psychotic features, ≥2 out of:
- Delusions
- Hallucinations
- Disorganized speech
- Catatonic features or disorganized behavior
- Negative features
- Marked social or occupational impairment
- 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)
- Preoccupied w\ fear of a serious disease (>6 months), but not to a degree of a delusion (fixed belief)
- Hx of seeing many doctors, misinterpretation of bodily sensations despite reassurance
- 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:
- Complaints of isolated neurological symptoms w\ no physical cause, preceded by stressors
- Not intentionally produced
- Cannot be explained by medical condition or effects of a substance
- 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:
- Intentionally production of symptoms to assume sick role, conscious fabrication for attention
- Can be by proxy
8. Malingering:
- 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)
