Week two review session

1. Week two review session

2. Anxiety Disorders Mood Disorders OCD Spectrum Eating Disorders PTSD Neuroscience of PTSD Opioids LGBT Patients Suicide topics

3. Anxiety disorders

4. Anxiety disorders Generalized anxiety disorder Panic disorder Agoraphobia without history of panic disorder Specific phobia Social phobia (social anxiety disorder) Separation anxiety disorder (usually in children) Selective mutism (children) Anxiety disorder due to a general medical condition Substance induced anxiety disorder Types of Anxiety

5. Anxiety disorders Endocrine or Metabolic • Hyper/Hypothyroidism, Pheochromocytoma, Hypoglycemia, Hypocalcemia, Cushing’s Syndrome Respiratory • Hypoxemia and Pulmonary Embolus Cardiac • Arrhythmias, CHF, Coronary Insufficiency Neurological • Dementia, Delirium, Neoplasm, Encephalitis, Partial Complex Seizures, Vestibular Dysfunction Medical Causes of Anxiety

6. Anxiety disorders Stimulants • Coffee, Nicotine Tranquilizers Antidepressants Beta Adrenergic Agonists Neuroleptics Serotonergic Drugs and Interactions Medications that Cause Anxiety

7. Anxiety disorders Excessive worry about multiple everyday events lasting more than 6 months (more days than not) Difficult to control the worry Associated with 3 or more of the following symptoms • Restlessness or feeling on edge • Easily fatigued • Difficulty concentrating • Muscle tension • Insomnia, restless sleep • Irritability Anxiety or worry can cause significant distress or impairment in social, occupational, or other areas Not associated with other substance or other medical problem Generalized Anxiety Disorder DSM V

8. Anxiety disorders One - Year Prevalence: 2.7-3.1% Lifetime Prevalence: 4.1 - 6.6% 90% have Comorbid Psychiatric Conditions • Other Anxiety Disorders • Depression • Substance Abuse Familial Trait Epidemiology of GAD

9. Anxiety disorders Onset: 50% in childhood and adolescence May appear for first time in adulthood Chronic but fluctuating course Symptoms worse at times of stress Course of GAD

10. Anxiety disorders Discrete acute episode of intense fear or discomfort associated with at least 4 of the following symptoms Peaks within 10 minutes Usually abates rapidly Panic Attack • Palpitations, Tachycardia • Sweating • Tremor • SOB (or sense of smothering) • Feeling of Choking • Chest Pain • Nausea or Abdominal Distress • Dizziness, Unsteadiness, Lightheadedness, Faintness • Derealization or Depersonalization • Fear of Losing Control (going crazy) • Fear of Dying • Paresthesia • Chills or Hot Flashes

11. Anxiety disorders Recurrent, unexpected panic attacks (no specific precipitant, no content of anxiety) • Associated with same symptoms of panic attacks (listed on previous slide) At least one of the attacks has been followed by one month (or more) of one of both of the following: • Persistent concern or worry about additional panic attacks or their consequences • A significant maladaptive change in behavior related to the attacks (avoidance) Not associated with other substance or other medical problem Not better explained by another mental health disorder Panic Disorder DSM V

12. Anxiety disorders Lifetime Prevalence: 1.5-3.5% One - Year Prevalence: 1 - 2% 1/3 - 1/2 in the community have agoraphobia • Data from sampled population in community and is actually higher in clinical samples Epidemiology of panic disorder

13. Anxiety disorders Onset: late adolescence to mid-30s Course Varies • Chronic Symptoms • Episodic recurrences with years of remission in between Agoraphobia may or may not remit with remission of panic attacks Prognosis after 6-10 years • 30% are well • 40-50% are improved although still symptomatic • 20-30% are unchanged or worse Course of panic disorder

14. Anxiety disorders Anxiety about being in situations from which • Escape might be difficult or embarrassing • Help might not be available Agoraphobic Situations • Outside the home • Crowds or Lines • Bridges or Tunnels • Bus, Train or Car Avoidance of situations or anxiety while in those situations May occur with or without panic disorder Agoraphobia

15. Anxiety disorders Marked, persistent, unreasonable fear of circumscribed objects or situations Phobic object is avoided or anxiety is experienced when it is confronted If a question or scenario is drawing attention to an object or situation causing anxiety, it’s likely a phobia Different subtypes… Specific (Simple) Phobia

16. Anxiety disorders Animal Type: • Animals, Insects • Childhood Onset Natural Environment Type: • Storms, Heights, Water • Childhood Onset Situational Type: • Tunnels, Bridges, Elevators, Flying, Enclosed Spaces • Onset in Childhood or Mid-20s Blood - Injection - Injury Type: • Seeing Blood, Injury, Getting Injection or Procedure • Familial • Vasovagal Response Other • Space Phobia (fear of falling down if not near wall or other support) • Fear of Loud Noises • Fear of Costumed Characters • Fear of Chocking or Vomiting Specific (Simple) Phobia Subtypes

17. Anxiety disorders Lifetime Prevalence: 10% One - Year Prevalence: 9% Onset: mostly in childhood Remission: only 20% of phobias that persist into adulthood Familial Aggregation epidemiology and course of phobias

18. Anxiety disorders Anxiety about humiliating oneself in social or performance situations Social situation may provoke panic attacks Social or performance situation is avoided or endured with dread Generalized social anxiety disorder: anxiety about most social situations • Anxiety about both performance and social interactions • Performance anxiety more common than generalized social anxiety Presentations • Difficulty answering questions in class • Poor exam performance • Discomfort presenting (rounds) • Avoidance of parties • Substance use Social Phobia (Social Anxiety Disorder)

19. Anxiety disorders Lifetime Prevalence: 3-13% 20% have fears of public speaking • Only 2% are impaired by it Increased risk in First Degree Relatives Course • Onset: Adolescence • History: Childhood inhibition or shyness • Chronic symptoms if untreated • High comorbidity with substance abuse Epidemiology and course of social anxiety disorder

20. Anxiety disorders Evaluate Substance Use (counsel about cessation) • Reduce Caffeine Intake • Stop Illicit Drug Use • Decrease Smoking (if possible) Non-Pharmacologic Treatments Medications Treatment

21. Anxiety disorders Relaxation training Hypnosis Biofeedback Systematic desensitization for avoidance CBT Exposure and response prevention All effective therapies increase activity and mastery Involve Significant Other Non Pharmacologic Treatments

22. Anxiety disorders Lorazepam (Ativan) • Short Half Life Clonazepam (Klonopin) • Long Half Life Diazepam (Valium) • Long Half Life Alprazolam (Xanax) • High Potency • Short Half Life Midazolam (Versed) • Short Half Life Benzodiazepines

23. Anxiety disorders Long Half Life • Less frequent dosing • More accumulation with divided dose • Slower onset of withdrawal • Longer, more attenuated withdrawal Short Half Life • Dosed more frequently • Less accumulation • Faster onset of withdrawal • Shorter, more intense withdrawal Benzodiazepines

24. Anxiety disorders Acute Anxiety Initial Treatment of Anxious Depression • Reduction in anxiety in patients treated with antidepressants Treatment of Chronic Anxiety • Only when patients do not respond well to other treatments Patients who do not drive trucks, operate heave equipment or pilot airplanes Benzodiazepine Uses

25. Anxiety disorders Excitatory neurons have receptor complex that contains an ion channel for Cl ions • GABA Receptor • GABA binds and causes change in shape of the Cl channel (open = more Cl ions into the neuron) • BZD Receptor • BZD binds and increases the affinity of the GABA receptor for GABA (works better = more effect) Adding negative charges makes it harder to depolarize the neuron, thereby slowing the neuron down Inverse Agonist Benzodiazepine Mechanism

26. Anxiety disorders Sedation Psychomotor impairment Inter-dose withdrawal with short acting BZDs, especially alprazolam Interactions with other CNS depressants, especially alcohol Discontinuation syndromes BZDs can reinforce passive approach to illness and desire for immediate relief from a pill Dependance Drug-seeking behavior Benzodiazepine Problems

27. Relapse Return to pre-existing anxiety or more intense anxiety Rebound Exacerbation of pre-existing anxiety or more intense anxiety Withdrawal Anxiety disorders Benzodiazepine Discontinuation Syndromes • Agitation • Confusion • Delirium • Tremor • Diaphoresis • Hypertension • Myoclonus • Hyperreflexia • Hyperpyrexia • Seizures

28. Anxiety disorders SSRIs Buspirone (BuSpar) • Not sedating • No withdrawal or impairment • Side effects: nausea, headache, dizziness Gabapentin (Neurontin) Pregabalin (Lyrica) Divalproex/Valrpoate (Depakote) Beta Blockers • Propranolol for performance anxiety alternatives to bzd agonists for anxiety

29. Mood Disorders

30. Mood disorders A dysfunctional interplay between: • Mood (emotional tone) • Thought • Behavior • Vegetative function (energy, interest, activity) What is a mood disorder?

31. Mood disorders Unipolar Depression • One “low” mood episode • Multiple “low” mood episodes • Baseline when not “low” • Tends to be chronic and recurrent Bipolar Depression • Depressive episode(s) that has/have been preceded or followed by a manic episode or multiple manic episodes Types of Depression

32. Mood disorders Depressed mood or anhedonia (loss of pleasure) At least 5 of the following symptoms for at least 2 weeks: • Depressed mood most of the time • Anhedonia • Significant weight change • Insomnia or hypersomnia • Agitation/retardation • Fatigue or loss of energy • Feelings of worthlessness or guilt • Problems concentrating or indecisiveness • Recurrent thoughts of death or suicide depression Dsm v

33. Mood disorders SIG-E-CAPS • Sleep/sex • Interest • Guilt • Energy • Concentration • Appetite • Psychomotor agitation or retardation • Suicide criteria/screening for depression

34. Mood disorders More common in females Emotionally and physically debilitating Familial: depressed parents tend to have depressed children Best predictors: • Family history of depression • Childhood loss of a parent Depression facts

35. Mood disorders Major Depressive Episode Major Depressive Disorder Atypical Depression • Opposite vegetative symptoms to usual depression. • Sleep and eat too much, lethargic • Feel better in morning and worse as day goes on • More likely to be bipolar depression (guides treatment) Psychotic Depression • Depression + psychotic symptoms • More severe, recurrent, more likely to be bipolar • Antidepressant + antipsychotic > antidepressant alone Depression subtypes

36. Mood disorders Irritability Social dysfunction Behavioral problems More hypersomnia and lethargy Psychotherapy > Medications Childhood Depression

37. Mood disorders Amantadine Interferon • Prophylactic antidepressant sometimes given Alcohol Stimulants Sedatives Narcotics Medications & substances that may cause depression

38. Mood disorders Loss of hippocampal volume • Regulates stress response • Regulates memory: harder to remember adaptive responses to stressors Too much cortisol dissolves brain • Neuronal atrophy Parts of the brain controlling emotional regulation are revved up Neurobiological Changes in depression

39. Mood disorders Neurotransmitters: • Norepinephrine HIGH • ***Review books state norepi is LOW • Serotonin LOW • Dopamine LOW Car spinning wheels in the snow analogy • Visually not going anywhere • Inner workings revved up and overactive Neurobiological Changes in depression

40. Mood disorders Loss Helplessness/hopelessness Anger, not being able to express anger Relationship struggles Unresolved grief Polar ways of thinking (all-or-nothing) • Negative schemata • Negative cognitions Psychological etiologies

41. Mood disorders The longer one is depressed, the longer they tend to stay depressed Recurrence when treatment started: • At onset: 10%-15% • After 6 months of depression: 30%-40% • After 1 year: 50% • After 2 years: 95% Depression prognosis

42. Mood disorders Medications & Psychotherapy ***Suicide Risk*** Psychotherapy is equally efficacious as medications in mild-moderate unipolar depression Medications more efficacious for severe, psychotic and bipolar depression Combination of medications and psychotherapy required for complicated depression Depression treatment

43. Mood disorders Tricyclics (amitriptyline, nortriptyline) • No longer first line for depression • Most potentially lethal antidepressant • 1 week supply can be lethal Tricyclic Antidepressants

44. Mood disorders First line Block reuptake of serotonin All have similar efficacy and side effects Sexual dysfunction GI upset Paroxetine (Paxil) worst side effects and withdrawal SSRIs

45. Mood disorders 5HT2 Antagonist Sedation common • Used as a sleeping aid ***Risk of priapism (prolonged, painful erection) • Requires medical intervention Trazodone

46. Mood disorders Dopamine and norepinephrine reuptake inhibitor NO sexual or cardiac side effects Risk of seizure: lowers seizure threshold Do NOT use in eating disorders (seizures/electrolyte disturbances) Can help quit smoking Bupropion (Wellbutrin)

47. Mood disorders SNRI • Serotonin uptake inhibition at low doses • Norepinephrine uptake inhibition at moderate doses • Dopamine uptake inhibition at high doses May cause hypertension at higher doses Venlafaxine (Effexor)

48. Mood disorders Useful for patients with • Weight loss (causes weight gain) • Nausea • Sleep disorder (sedating) • Cancer patients • Carcinoid syndrome: elevated serotonin causes nausea, depression Mirtazepine (remeron)

49. Mood disorders Useful for refractory, bipolar and atypical depression Must NOT be combined with other antidepressants • Serotonin Syndrome • High Body Temperature, Agitation, Increased Reflexes, Tremor, Sweating, Dilated Pupils, and Diarrhea. Monoamine oxidase inhibitors (maoi)

50. Mood disorders Most effective treatment Fewest side effets • Memory impairment, usually temporary Turns on neuroprotective genes Useful for depression and mania Electroconvulsive therapy (ECT)