Overview of Psychosocial Disorders

1. Overview of Psychosocial Disorders Lynn K. Wittwer, MD, MPD

2. Psychosocial Disorders Multiaxial Diagnostic system Axis I disorders Axis II disorders Assessment and Stabilization of Behavioral Disorders Psychotropic Medications

3. Multiaxial Diagnostic System DSM-IV Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Nomenclature established in 1994. by the American Psychiatric Association Dx based on multi axial system Each axis refers to different domain of information

4. Multiaxial Diagnostic System Axis I Mental Disorders Axis II Personality Disorders Mental Retardation Axis III General Medical Conditions Axis IV Psychosocial stressors and adaptive functioning

5. Axis I Disorders Dementia Disturbance of cognitive functioning Memory, judgment, abstract thinking Language Often slow onset, impairment may mask underlying medical illness May have reversible causes Metabolic Polypharmacy Depression

6. Axis I Disorders Delirium Global impairment in cognitive functioning Decreased consciousness Course is acute Severity fluctuates over period of time Visual hallucinations common Differ from psychotic hallucinations due to strong emotional response. Psychotics are indifferent

7. Axis I Disorders Substance induced disorders Intoxication Maladaptive behavior, judgment impairment Perceptual abnormality Loss of attention, emotional control Psychomotor issues Features of intoxication differ based on substance Withdrawal Syndromes Cessation or reduction in use of a substance of abuse

8. Axis I Disorders Disorders due to general medical condition Determination that psychiatric symptoms may be caused by underlying medical condition i.e. �Major depression due to hypothyroidism�.

9. Axis I Disorders Schizophrenia and Psychotic Disorders Defined by presence of psychotic sx Delusions- fixed false beliefs not amenable to facts Persecution � being followed, harassed, conspired against Grandiose � special powers or abilities Bizarre � absurd thought Hallucinations- false sensory perceptions Schizophrenia Most common form of psychosis Serious illness, accounts for 25% of all hospitalized patients.

10. Axis I Disorders Schizophrenia (cont.) Evidence suggests an organic/genetic cause The following present at least one month: Deterioration in function �Active phase� sx Delusions, hallucinations Disorganized speech or behavior Catatonic behavior Absence of mood syndrome

11. Axis I Disorders Schizophrenia (cont.) Manifestation Usually late adolescence, early adulthood Prodromal phase � gradual deterioration of function Active phase Characteristics Disorganized thinking/behavior Disheveled Poor judgment Poor associations Loss of logical connection between one thought and the next Inattention, anhedonia Blunting of emotion

12. Axis I Disorders Schizophrenia (cont.) Treatment Antipsychotics � effective for hallucinations delusions Not usually effective for other negative symptoms Schizophreniform disorder Pt. meets criteria for schizophrenia but symptoms present less than 6 months

13. Axis I Disorders Other Psychotic Disorders Brief psychotic disorder Acute psychosis after traumatic event Combat Death of a loved one Natural disaster Marriage

14. Axis I Disorders Other Psychotic Disorders Delusional Disorder Characterized by non bizarre delusions Differs from schizophrenia in that ADL�s are not impaired. Onset is usually middle to late adulthood Persecution � conspired against, harassed, etc. Jealousy � spouse or SO is cheating Somatic � infected w/ parasites, emit foul odor

15. Axis I Disorders Mood Disorders Major Depression Pervasive dysphoric mood or loss of interest lasting at least two weeks. Anhedonic, guilt, hopelessness, suicidal thoughts, self reproach. Vegetative symptoms include Fatigue, loss of appetite, sleeplessness Inability to concentrate, and psychomotor agitation Often associated with underlying medical disorder and/or substance abuse Primary mood disorder responds well to antidepressants

16. Axis I Disorders Mood Disorders (cont.) Bipolar disorder Manic-depressive Characterized by mania � elation or irritability Sx include Decreased need for sleep, racing thoughts Rapid, pressured speech Grandiose ideas, may believe themselves to be famous, rich, sexy, have special powers, etc. Manic phase usually followed by depressed state

17. Axis I Disorders Mood Disorders (cont.) Dysthymic disorder More chronic, less severe form of depression Characterized by life-long gloomy, pessimistic outlook Women more often affected Vegetative sx not as severe as depression

18. Axis I Disorders Anxiety Disorders Panic disorder Recurrent, acute attacks of severe anxiety Attack is characterized by autonomic signs of catecholamine release. Presenting complaints may mimic many medical conditions Generalized anxiety disorder Free floating anxiety w/o actual anxiety attack Persistent worry, irritability, insomnia, muscle tension Symptoms are chronic

19. Axis I Disorders Anxiety Disorders Phobic disorders Inherent fear, avoidance of exposure or anticipated exposure to specific situation or stimulus. Social phobia, etc.

20. Axis I Disorders Anxiety Disorders Other Anxiety Disorders Post-traumatic stress � Anxiety to a severe psychosocial stressor Symptoms include intrusive memories of the event. Nightmares, survivor guilt. Substance abuse frequent complication Obsessive-compulsive � intrusive thoughts or images that cannot be eliminated from the mind Obsessive thoughts include contamination, perversion, etc. Compulsive behavior includes handwashing, repetitive checking, counting, etc.

21. Axis I Disorders Somatoform Disorders C/o or symptoms for which medical dx cannot be established Somatization � medically unrelated sx in multiple organ systems Hypochondriasis � preoccupied by fear of medical illness Pain disorder � pain is the sole complaint and physical ailment unsupported.

23. Axis II Disorders Personality Disorders Defined as lifelong pattern of behavior, not related to illness, causing considerable distress or impairment in social/occupational functioning.

24. Assessment/Management Psychiatric assessment Prehospital Decision making Is the patient stable or unstable? Underlying serious medical condition? Is psychiatric consultation necessary? Should the patient be forcibly detained for emergency evaluation?

25. Assessment/Management Psychiatric assessment (cont.) Physical Restraint Required for violent behavior Necessary if patient states they are potentially violent Necessary during medical condition causing disturbed behavior, i.e. Hypoglycemia, meningitis, etc.

26. Assessment/Management Initial Evaluation of Behavioral Disorder History Medical & psych Medication/drugs, alcohol Onset of behavior/mood change Rapid onset indicative of medical condition

27. Assessment/Management Mental Status Examination Objective is to differentiate functional (psychiatric) from organic causes. Abnormal mental status exam suggests organic cause. Level of consciousness Spontaneous speech Language comprehension Communication ability Appearance

28. Assessment/Management Physical Exam Objective is to identify disorders that may impact behavior disorder. Abnormal vital signs Fever Hypothermia Etc.

29. Diagnosis that cause Emergency Behavioral Syndromes in the Elderly Delirium Medications (esp. anticholinergic agents), physical illness (esp. infections and metabolic diseases), and drug withdrawal states Dementia Alzheimer�s and multi-infarct dementia. Treatable causes include drugs, depression, endocrine disorders, subdural hematomas, ETOH dependency Medications Psychotropic drugs, digitalis, cimetidine, and anticonvulsants Physical Illnesses Renal and hepatic failure, COPD, electrolyte imbalance and CV disease Depression Bipolar disorder, major depression, psychotic depression ETOH intoxication/dependency

30. Assessment/Management Chemical Restraint Can be considered once as much information as possible has been gathered and patient continues to resist physical restraint. Droperidol (Inapsine) 0.75-2.5mg IV 1.25-5.0 mg IM

31. Psychotropic Medications Antipsychotic (Neuroleptics) MOA � block dopaminergic receptors in the CNS Symptom specific for acute psychotic episodes Side Effects Acute dystonias Akathisia Anticholinergic effects Cardiovascular side effects Evidence of torsades w/ high dose Butyrophenones Neuroleptic Malignant Syndrome Rigidity, fever, autonomic instability

33. Psychotropic Medications Atypical Agents Clozapine Indicated for schizophrenia not responsive to standard agents Pt�s suffering severe EPS Tardive dyskinesia Side effects Agranulocytosis Strongly sedating Hypotension Can cause seizures Respiratory depression/arrest

34. Psychotropic Medications Atypical Agents (cont.) Risperidone Serotonin/dopamine antagonist Low risk of EPS Side effects Sedation, insomnia, constipation, weight gain Hypotension, QT prolongation Overdose sx reflect increased side effects

35. Psychotropic Medications Atypical Agents (cont.) Olanzapine Zyprexa � little or no EPS. Side effects include substantial weight gain Quetiapine Seroquel Side effects include sedation, orthostatic hypotension, and dizziness

36. Psychotropic Medications Anxiolytics - Benzodiazepines Indications Severe emotional distress Acute panic reactions Anxiety/agitation during psychosocial crisis Non-psychiatric uses Seizure control Muscle relaxation Treating withdrawal

37. Psychotropic Medications Anxiolytics (cont.) Side effects Drowsiness, decreased mentation Sedation, ataxia Decreased respiratory effort Effects can be reversed with Flumazenil (Romazicon)

38. Psychotropic Medications Heterocyclic Antidepressants Indicated for major depression Also effective for Dysthymic disorder Panic disorder Agoraphobia Obsessive compulsive Enuresis School phobia

39. Psychotropic Medications Heterocyclic Antidepressants (cont.) Side effects � common even w/ therapeutic doses Anticholinergic Cardiotoxic T wave changes Prolonged QT AV block Ventricular dysrhythmias Orthostatic hypotension

40. Psychotropic Medications Monoamine Oxidase Inhibitors Increase nor epi and serotonin in the CNS Used for atypical major depression Hyperphagia Hypersomnolence Emotional lability Rejection hypersensitivity Side effects May precipitate a manic episode Potentiate sympathomimetics, oral hypoglycemics and anticholinergics May precipitate hypertensive crisis

41. Psychotropic Medications Selective Serotonin Reuptake Inhibitors (SSRI�s) Indicated for depression Prozac, Paxil, Luvox, Zoloft Side effects Relatively rare Serotonin syndrome may occur CNS and GI irritability

42. Psychotropic Medications Combination antidepressants Venlafaxine (Effexor) Combination tricyclic/SSRI Side effects Hypertension Discontinuation syndrome Bupropion (Wellbutrin) Lowest incidence for sexual side effects Inhibits reuptake of nor epi and dopamine

43. Psychotropic Medications Combination antidepressants Nefazodone (Serzone) Blocks serotonin receptors Typically used for post depression insomnia Side effects rare Mirtazapine (Remeron) Increases release of nor epi and serotonin Less side effects that SSRI�s

44. Psychotropic Medications Mood Stabilizers Lithium Indicated for acute mania and maintenance therapy in bipolar disorder Also effective for other �explosive� disorders and self mutilation Side effects/toxicity Neurologic symptoms progressive Hypotension, dysrhythmias, cardiovascular collapse Treatment is supportive with forced diuresis

45. Psychotropic Medications Mood Stabilizers Lithium Indicated for acute mania and maintenance therapy in bipolar disorder Also effective for other �explosive� disorders and self mutilation Side effects/toxicity Neurologic symptoms progressive Hypotension, dysrhythmias, cardiovascular collapse Treatment is supportive with forced diuresis