Week two review session - PowerPoint Presentation

Slide1

Week two

review session

Slide2

topics

Anxiety Disorders

Mood Disorders

OCD Spectrum

Eating Disorders

PTSD

Neuroscience of PTSD

Opioids

LGBT Patients

Suicide

Slide3

Anxiety disorders

Slide4

Anxiety disorders

Types of Anxiety

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

Slide5

Anxiety disorders

Medical Causes of Anxiety

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

Slide6

Anxiety disorders

Medications that Cause Anxiety

Stimulants

Coffee, Nicotine

Tranquilizers

Antidepressants

Beta Adrenergic Agonists

Neuroleptics

Serotonergic Drugs and Interactions

Slide7

Anxiety disorders

Generalized Anxiety Disorder DSM V

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

Slide8

Anxiety disorders

Epidemiology of GAD

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

Slide9

Anxiety disorders

Course of GAD

Onset: 50% in childhood and adolescence

May appear for first time in adulthood

Chronic but fluctuating course

Symptoms worse at times of stress

Slide10

Anxiety disorders

Panic Attack

Discrete acute episode of intense fear or discomfort associated with at least 4 of the following symptomsPeaks within 10 minutesUsually abates rapidly

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

Slide11

Anxiety disorders

Panic Disorder DSM V

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

Slide12

Anxiety disorders

Epidemiology of panic disorder

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

Slide13

Anxiety disorders

Course of panic disorder

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

Slide14

Anxiety disorders

Agoraphobia

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

Slide15

Anxiety disorders

Specific (Simple) Phobia

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…

Slide16

Anxiety disorders

Specific (Simple) Phobia Subtypes

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

Slide17

Anxiety disorders

epidemiology and course of phobias

Lifetime Prevalence: 10%

One - Year Prevalence: 9%

Onset: mostly in childhood

Remission: only 20% of phobias that persist into adulthood

Familial Aggregation

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Anxiety disorders

Social Phobia (Social Anxiety Disorder)

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

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Anxiety disorders

Epidemiology and course of social anxiety disorder

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

Slide20

Anxiety disorders

Treatment

Evaluate Substance Use (counsel about cessation)

Reduce Caffeine Intake

Stop Illicit Drug Use

Decrease Smoking (if possible)

Non-Pharmacologic Treatments

Medications

Slide21

Anxiety disorders

Non Pharmacologic Treatments

Relaxation training

Hypnosis

Biofeedback

Systematic desensitization for avoidance

CBT

Exposure and response prevention

All effective therapies increase activity and mastery

Involve Significant Other

Slide22

Anxiety disorders

Benzodiazepines

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

Slide23

Anxiety disorders

Benzodiazepines

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

Slide24

Anxiety disorders

Benzodiazepine Uses

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

Slide25

Anxiety disorders

Benzodiazepine Mechanism

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

Slide26

Anxiety disorders

Benzodiazepine Problems

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

Slide27

Anxiety disorders

Benzodiazepine Discontinuation Syndromes

RelapseReturn to pre-existing anxiety or more intense anxiety ReboundExacerbation of pre-existing anxiety or more intense anxietyWithdrawal

Agitation

Confusion

Delirium

Tremor

Diaphoresis

Hypertension

Myoclonus

Hyperreflexia

Hyperpyrexia

Seizures

Slide28

Anxiety disorders

alternatives to bzd agonists for anxiety

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

Slide29

Mood Disorders

Slide30

Mood disorders

What is a mood disorder?

A dysfunctional interplay between:

Mood (emotional tone)

Thought

Behavior

Vegetative function (energy, interest, activity)

Slide31

Mood disorders

Types of Depression

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

Slide32

Mood disorders

depression Dsm v

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

Slide33

Mood disorders

criteria/screening for depression

SIG-E-CAPS

Sleep/sex

Interest

Guilt

Energy

Concentration

Appetite

Psychomotor agitation or retardation

Suicide

Slide34

Mood disorders

Depression facts

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

Slide35

Mood disorders

Depression subtypes

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

Slide36

Mood disorders

Childhood Depression

Irritability

Social dysfunction

Behavioral problems

More hypersomnia and lethargy

Psychotherapy >

M

edications

Slide37

Mood disorders

Medications & substances that may cause depression

Amantadine

Interferon

Prophylactic antidepressant sometimes given

Alcohol

Stimulants

Sedatives

Narcotics

Slide38

Mood disorders

Neurobiological Changes in depression

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

Slide39

Mood disorders

Neurobiological Changes in depression

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

Slide40

Mood disorders

Psychological etiologies

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

Slide41

Mood disorders

Depression prognosis

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%

Slide42

Mood disorders

Depression treatment

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

Slide43

Mood disorders

Tricyclic Antidepressants

Tricyclics (amitriptyline, nortriptyline)

No longer first line for depression

Most potentially lethal antidepressant

1 week supply can be lethal

Slide44

Mood disorders

SSRIs

First line

Block reuptake of serotonin

All have similar efficacy and side effects

Sexual dysfunction

GI upset

Paroxetine (Paxil) worst side effects and withdrawal

Slide45

Mood disorders

Trazodone

5HT2 Antagonist

Sedation common

Used as a sleeping aid

***Risk of priapism (prolonged, painful erection)

Requires medical intervention

Slide46

Mood disorders

Bupropion (Wellbutrin)

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

Slide47

Mood disorders

Venlafaxine (Effexor)

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

Slide48

Mood disorders

Mirtazepine (remeron)

Useful for patients with

Weight loss (

causes weight gain

)

Nausea

Sleep disorder (

sedating

)

Cancer patients

Carcinoid syndrome: elevated serotonin causes nausea, depression

Slide49

Mood disorders

Monoamine oxidase inhibitors (maoi)

Useful for refractory, bipolar and atypical depression

Must NOT be combined with other antidepressants

Serotonin

S

yndrome

High Body Temperature, Agitation, Increased Reflexes, Tremor, Sweating, Dilated Pupils, and Diarrhea.

Slide50

Mood disorders

Electroconvulsive therapy (ECT)

Most effective treatment

Fewest side effets

Memory impairment, usually temporary

Turns on neuroprotective genes

Useful for depression and mania

Slide51

Mood disorders

Bipolar disorder

Bipolar I

Mania

Intermittent hypomania

Bipolar II

Hypomania only

Family members have hypomania but not mania

Slide52

Mood disorders

Mood disorders

Mania

t

Depressive Episode

Cyclothymic D/O

Bipolar II

Bipolar I

Depression

Rapid Cycling Bipolar

Hypomania

Mania

Mood

Slide53

Mood disorders

Bipolar disorder Symptoms

Intense irritability

Mood swings

Thrill seeking

Psychotic symptoms

Early onset depression

Highly recurrent depression

Atypical depressive symptoms

Slide54

Mood disorders

Mania

Elevated, expansive or irritable mood

At least one week or any duration if hospitalized

At least 3 symptoms (4 if mood irritable)

Grandiosity

Decreased need for sleep

Increased speech/pressured speech

Flight of ideas/racing thoughts

Distractibility

Increased activity/agitation

Excessive involvement in behavior with potentially painful consequences

Slide55

Mood disorders

hypoMania

Abnormal mood lasting at least 4 days

Same symptoms as manic episode

Change in functioning

Not severe enough to cause marked impairment or require hospitalization

Lack of Psychotic Symptoms

If psychosis is present



mania

Slide56

Mood disorders

Medical conditions to keep in mind with mood disorders

Thyroid

D

ysfunction

Adrenal

D

ysfunction

Diabetes

Pancreatic

C

ancer

(

classically presents with depression

)

Head Injuries

Infectious

Autoimmune

Slide57

Mood disorders

Bipolar treatment

Mood

S

tabilizers

Lithium

,

Carbamazepine (Tegretol)

,

Divalproex (Depakote)

Antipsychotics

All can be used to treat mania

Psychotherapy improves compliance and coping skills (+medications)

Interpersonal therapy

Social rhythms therapy

Family focused therapy

Antidepressants

risky in bipolar

 m

ay induce mania

Slide58

Mood disorders

Lithium

Dosing :

Once

D

aily

Narrow

T

herapeutic

I

ndex

Blood levels must be monitored

Uses:

Mood Stabilization

May be Neuroprotective

Reduces SI and Suicide Rates

Side Effects:

Weight

G

ain (

*weight gain can cause compliance issues

)

T

hyroid or

K

idney damage

(possible)

Slide59

Mood disorders

Carbamazepine (Tegretol)

Dosing: Multiple/Day

Uses:

Mood Stabilizer

Depression and Rapid Mood Swings Improved

PTSD

Lithium Intolerance

Side Effects:

Weight

G

ain is

LESS

of a concern

Induces own

M

etabolism (and

that of

other drugs

like BC pills

)

Bone

M

arrow

S

uppression (do not combine with clozapine)

Slide60

Mood disorders

Divalproex (Depakote)

Dose: Once in PM

Uses:

Mood Stabilizer

Anxiolytic

Aggression

Side Effects:

Sedating

Weight gain

PCOS and ovarian cysts

Slide61

OCD Spectrum

Slide62

OCD

OCD DSM V Criteria

Presence of obsessions, compulsions or both:

The obsessions and/or compulsions:

Are time consuming (take more than 1 hour a day)

Cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance or another medical problem

The disturbance is not better explained by the symptoms of another mental disorder

Slide63

OCD

Obsessions

Recurrent and persistent thoughts, urges or images

that are experienced at some time during the disturbance, as

intrusive and unwanted

Most individuals experience marked

anxiety or distress

Individual

attempts to ignore or suppress such thoughts

,

urges or images, or to neutralize them with some other thought or action (i.e. by performing a compulsion)

Slide64

OCD

Obsessions

Contamination Obsessions

Harm obsessions

Perfectionism/Ordering/Arranging/Counting/Need for Symmetry

Excessive Doubting/Need to Know Obsessions with Checking/Reassurance-seeking

Superstitious Thinking

Sexual obsessions

Slide65

OCD

compulsions

Repetitive behaviors

Hand washing, ordering, checking

Mental Acts

Praying, counting, repeating words silently

Individual feels driven to perform these acts in

response to an obsession

or according to

rules that must be applied rigidly

Slide66

OCD

compulsions

Behavior or mental acts are aimed to prevent or reduce anxiety or distress

, or prevent some dreaded situation

Acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive

Slide67

OCD

obsessions and compulsions

Slide68

OCD

insight

With

good or fair insight

: the individual recognizes that OCD beliefs are

definitely or probably not true

or that they may or may not be true.

With

poor insight

: the individual thinks OCD beliefs are

probably true

.

With

absent insight/delusional beliefs

: the individual is completely

convinced that OCD beliefs are true

Slide69

OCD

Pathophysiology

Suspected to be related to:

Disorder Serotonin neurotransmission

Dopaminergic neurotransmission

Glutamate levels

Increased blood flow and metabolic activity in the orbitofrontal cortex, limbic structures, caudate, and thalamus.

Structures associated with emotional regulation and inhibition or impulses and judgement

Slide70

OCD

epidemiology

Lifetime Prevalence: 2.5%

In US about 3 million people have OCD

1 in 200 adults

Age of Onset

Males: 6-15 years

Females: 20-29 years

Twins

Monozygotic: 80-87% concordance for OCD

Dizygotic: 47-50% concordance for OCD

Slide71

OCD

Course of OCD

Onset

Generally in adolescence (although some childhood onset)

Childhood Onset OCD: high comorbidity for Tourette Disorder and ADHD

Generally gradual, though can be acute

Symptoms exacerbate during times of stress, during depressions, pregnancy

Course:

Chronic waxing and waning course

Quality of Life Struggles

(self esteem, strained relationship, decrease functioning, SI/SA)

Slide72

OCD

Treatment

First Line: CBT alone or CBT + medication CBT Triangle ERP (Exposure and Ritual Prevention) Medications (used when patient can’t tolerate CBT alone)SSRI (higher doses compared to Depression)Clomipramine (TCA)

Slide73

OCD

Treatment

Approved SSRIs for OCD

Sertraline (Zoloft)*

Fluoxetine (Prozac)*

Fluvoxamine (Luvox) and Luvox CR

Clomipramine (Anafranil)

Paroxetine (Paxil)*

Other Meds OFF Label

Citalopram (Celexa)

Escitalopram (Lexapro)

Venlafaxine (Effexor)

Duloxetine (Cymbalta)

Adjunctive Therapies

Antipsychotic Medications

Glutamate Modulators

Benzodiazepines

Slide74

OCD

experimental treatments

Gamma Knife

Fewer short term side effects

More long term side effects: due to radiation, edema, destruction of brain tissue is irreversible

Deep Brain Stimulation

More short term side effects: bleeding and infection

Fewer long term side effects: reversible, non destructive

Ongoing management

Slide75

OCD

Compulsive hoarding

The acquisition of, and failure to discard, possession that appear to be useless or of limited value

Living spaces sufficiently cluttered so as to preclude activities for which those spaces were originally designed

Significant distress or impairment in functioning is caused by the hoarding

Patients may be preoccupied with:

Needing to do things perfectly/ avoid mistakes

Difficulties making decisions

Difficulties with organization

Shame over their clutter

Avoiding tasks (such as cleaning) that they find overwhelming

Slide76

OCD

Compulsive hoarding Treatment

CBT

Medication Management as in OCD

In Home Visits

MORE treatment resistant that OCD

Slide77

OCD

Body dysmorphic disorder

Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others

At some point during the course of the disorder, the individual has performed repetitive behaviors or mental acts in response to appearance concerns

The preoccupation causes clinical significant distress or impairment in social occupational, or other important areas of functioning

The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder

Specify with muscle dysmorphia

Specify insight

Slide78

OCD

Body dysmorphic disorder

Compulsions

Mirror checking or avoidance

Comparing one’s appearance to others

Excessive grooming rituals

combing, styling, plucking, picking, shaving, applying ++ makeup or skin/hair products

Camouflaging

wearing hats, wigs, scarves over the face, masks, band-aids, heavy makeup]

Reassurance-seeking (“Do I look ok?”)

Touching/checking body parts/areas

Excessive tanning

Seeking cosmetic surgery/procedures

they are almost never satisfied with the results

Excessive spending/shopping for cosmetic products

Slide79

Suicide

Slide80

suicide

CDC definition: death from injury, poisoning, or suffocation where there is evidence (either explicit or implicit) that the injury was self-inflicted and that the decedent intended to kill himself/ herselfA problem solving strategy to end intolerable, inescapable and/or interminable emotional or physical painAn extreme form of emotional avoidanceGain control over unwanted feelings, thoughts, memories, physical sensations

Suicide

Slide81

suicide

Myth: People that talk about suicide will not commit suicide.Truth: 1/3 visit physicians in the week priorMyth: Suicide happens in a single diseaseTruth: Suicide happens in mood disorders, schizophrenia, some personality disorders, and medical illness90% of people who die by suicide have a treatable psychiatric conditionMyth: There are specific factors that foretell suicidal behavior in an individual and there is a correct intervention that will prevent suicideTruth: Very little research supports these beliefs

Suicide myths & truths

Slide82

suicide

Myth: Suicide is related to the moon, weather, etc. Truths:Most suicides occur between 7am & 4pm In hospitals, between 5am & 7amShift changesThere is no correlation with holidaysSuicides peak in May-JuneDecrease in seasonality due to modernization

Suicide myths & truths

Slide83

suicide

Females attempt suicide more oftenMales complete suicide more often and by more violent/lethal means

Suicide male vs female

Slide84

suicide

Cutting, Burning, ScratchingUsually there is not intent to kill oneselfActs are usually an expression of anger towards self or othersExamine the context within which such behavior occursDisinhibited sexual behaviorDangerous situations without regard for safetyCan prevent suicide (albeit in unhealthy ways)Provides “relief” from distressing emotional experiences through physical sensation

Parasuicidal behavior

Slide85

suicide

Decreased serotonin levels may result in:Increased risk taking/impulsivityIncreased alcohol consumption Increased aggressivenessOrbitalfrontal cortex: role in impulsive and aggressive behaviorsImpairment in serotonergic neuronsMore that are mis-formed/misconnected (faulty wiring)

Biology

Slide86

suicide

50% of suicides are committed with firearms Suffocation/hanging, poisoning, cutting, drowningPoisoning most common method of choice for femalesMen use firearms more oftenWorldwide, hanging is most common83% of gun-related deaths in homes with guns are suicidesFirearms are used more in suicides than homicidesFirearm are the fastest growing method of suicide

Suicide methods

Slide87

suicide

We are good at identifying risk factors in groups of peopleWe are NOT good at predicting if one individual will take actionRisk factors:GREATEST RISK FACTOR IS A PREVIOUS SUICIDE ATTEMPTDepressionBipolar disorderSchizophreniaBorderline and antisocial personality disordersAlcohol & Substance abuse

Lethality assessment

Slide88

suicide

Mixed statesDepressive maniasAgitated depressionsCan dangerously increase suicide risk by providing energy and impulsivity to negative thoughts and perceptionsExpression of suicide or death in the context of hopelessness or negative feelingsImpulsive and aggressive behavior or historyIncreased substance useRecent stressorsFamily crisis

Lethality assessment

Slide89

suicide

Ideation (thinking about) or made an attempt? Circumstances? Why thinking about/attempted suicide?Planned or impulsive? Did the patient tell someone what they did?Notes? Planning Possessions? PlanningIf attempt, how serious?Guns in the home? If so, they must be removed/relocated Collateral information

Lethality assessment

Slide90

suicide

Suicidal thoughts are a moment in time. Help people get past that moment. Hospitalize a suicidal patientStart appropriate meds (SSRI, mood stabilizers) May need to use antipsychotic medications in patients with psychosisConsider psychotherapy in combination with SSRIs, if not already in treatment When starting SSRIsClose follow up with patients is essential!Patients may have increased suicidalityOften, a patient’s avolitional symptoms begin to resolve before the patient’s mood symptoms and suicidal ideation —> more motivated, might act on thoughts

Treatment

Slide91

suicide

Safety contracts: no evidence they workSafety plansScreen for depression, mania, etc.Ask about suicideLook for other self-injurous behavior (cutting)Ask about drugs and alcoholAsk about stressors (family life, relationships, school, job, etc.)Ask about guns, remove guns, safety mechanisms on guns

Prevention

Slide92

Eating disorders

Slide93

Eating disorders

eating disorders

Severe disturbances in eating behavior resulting in physical, emotional, or functional impairments or suffering

Types of Eating Disorders

Associated with weight loss

Associated with weight gain

Associated with no change in weight

Slide94

Eating disorders

Anorexia Nervosa

Persistent energy intake

restriction

relative to requirements leading to significantly low body weight (

calorie counting, portion control

)

Intense

fear of gaining weight

or of becoming fat, or persistent behavior that interferes with weight gain (

excessive exercise

)

Fear usually not alleviated by weight loss

Disturbance in self-perceived weight or shape

Persistently

does not recognize the seriousness

of the current low body weight

Self-esteem of individuals is highly dependent on their perceptions of body shape and weight

Slide95

Eating disorders

Anorexia Nervosa severity

Low BMI

is a hallmark

Mild: BMI ≥ 17

Moderate: BMI 16–16.99

Severe: BMI 15–15.99

Extreme: BMI < 15

Increased Severity also reflected by:

Clinical symptoms

Degree of functional disability

Need for supervision

Slide96

Eating disorders

Anorexia Nervosa Types

Restricting Type

Weight loss is accomplished primarily through

dieting, fasting, and/or excessive exercise

Not engaged in recurrent episodes of binge eating or purging behavior

Purging Type

Recurrent episodes of

purging behavior to accomplish weight loss

or avoid absorbing calories (excessive and low BMI)

Binge-Eating Type

With compensatory behavior to “undo” binges

More likely to be impulsive and to abuse drugs or alcohol

Slide97

Eating disorders

Physical Signs of Anorexia Nervosa

Appear emaciated

Hypothermia

Report cold insensitivity

Bradycardia

Hypotension

Constipation

Dependent edema

Lanugo

Hormonal abnormalities: decreased growth hormone levels, plasma cortisol, gonadotropin levels —> delayed sexual development, thyroid hormones, amenorrhea

Slide98

Eating disorders

Bulimia Nervosa

Recurrent episodes of binge eating

Inappropriate

compensatory behaviors to prevent weight gain

Self-induced vomiting

Misuse of laxatives, diuretics, or other medications

Fasting

Excessive exercise

Self evaluation that is excessively influenced by body shape and weight

Typically of normal weight or overweight

Slide99

Eating disorders

Bulimia Nervosa physical signs

Induced vomiting:

Parotitis

Enamel erosion

Dorsal

Hand calluses

Electrolyte disturbances (hypokalemia, hypochloremia, hyponatremia),

Metabolic alkalosis

Potentially fatal outcomes:

Esophageal tears

Gastric

Rupture

Cardiac arrhythmias

Slide100

Eating disorders

Binge Eating

In a discrete period of time, eating an amount of food that is larger than what most individuals would eat in a similar period of time under similar circumstances

Lack of control over eating

during the episode

Typically

ashamed

of their eating problems and attempt to

conceal

their symptoms

Continues until the individual is uncomfortably, or even painfully, full

At least 1 week for 3 months

The binge eating is

not associated with

the recurrent use of inappropriate

compensatory behavior

Occurs in normal overweight and obese individuals

Slide101

Eating disorders

Binge Eating Triggers

Triggers include:

Negative emotions

Interpersonal stressors

Dietary restraint

Negative feelings related to body weight, body shape, and food

Boredom

Slide102

Eating disorders

Treatment

May require hospitalization

Medical Stabilization

PHP (supervision and home)

CBT

Individual Counseling

Family Therapy

Group Therapy

Behavioral Contracts

Slide103

Eating disorders

Treatment

Medications

SSRI: Fluoxetine (Prozac) FDA approved for Bulimia Nervosa with Depression/Anxiety

Antipsychotic Medications: assist with cognitive distortions

Warnings

TCA and MAO-I (cardiac effects)

Buproprion (Wellbutrin): increased risk of seizures = contraindicated given electrolyte abnormalities already present

Slide104

PTSD

Slide105

PTSD

PTSD

Sexual violence, serious injury, threatened/ actual physical assault, torture, accidental trauma, natural/ man-made disasters, terrorism

Witnessed events, such as observing physical or sexual abuse of another person, domestic violence, war or disaster, etc.

Indirect exposure, such as learning about traumatic experiences of close relatives or friends

Slide106

PTSD

Epidemiology of PTSD

More prevalent among females than males

Highest rates are found among survivors of rape, military combat/captivity, ethnically/politically motivated internment and genocide

50-90% of the population may be exposed to traumatic events during their lifetimes; most do NOT develop PTSD

Slide107

PTSD

ACUte stress disorder DSM v

Exposure to actual or threatened death, serious injury, or sexual violation in at least 1 of the following ways:

Directly experiencing the traumatic event

Witnessing the event as it occurred to others

Learning that the event occurred to a close family member or friend

Experiencing repeated or extreme exposure to aversive details of the traumatic events

Slide108

PTSD

ACUte stress disorder DSM v

B. Presence of 9 or more of the following symptoms

Intrusion Symptoms

Recurrent, involuntary and intrusive distressing memories of the traumatic event

Recurrent distressing dreams

Dissociative reactions (e.g. flashbacks)

Intense or prolonged psychological distress or marked physiological reactions in response to cues

Negative Mood

Persistent inability to experience positive emotions

Dissociative Symptoms

An altered sense of the reality of one’s surroundings or oneself (e.g. being in a daze, time slowing)

Inability to remember an important aspect of the traumatic event

Arousal Symptoms

.Sleep disturbance 11.Irritable behavior and angry outbursts

Hypervigilance

Problems with concentration

Exaggerated startle response

Slide109

PTSD

ACUte stress disorder DSM v

C. Duration is 3 days to 1 month after trauma exposure

D. Causes

clinically significant distress or impairment

in social/occupational functioning

Slide110

PTSD

Risk Factors for developing PTSD

Temperament-childhood emotional problems by age 6 years

Environmental-lower SES, lower education, childhood exposure to prior trauma, childhood adversity, lower IQ, family psych history

Genetic/physiological-female gender, younger age

Environmental-severity (dose) of trauma, perceived life threat, personal injury, interpersonal violence, dissociation

Temperamental-negative appraisals, inappropriate coping strategies, development of acute stress disorder

Environmental-subsequent exposure to repeated upsetting reminders, subsequent adverse life events, financial or other trauma- related losses

Slide111

PTSD

PTSD DSM V

Exposure to actual or threatened death, serious injury, or sexual violation in at least 1 of the following ways:

Directly experiencing the traumatic event

Witnessing the event as it occurred to others

Learning that the event occurred to a close family member of friend

Experiencing repeated or extreme exposure to aversive details of the traumatic events

Intrusion Symptoms (1 or more)

Recurrent, involuntary and intrusive distressing memories of the traumatic event

Recurrent distressing dreams related to the traumatic event

Dissociative reactions (flashbacks)

Intense or prolonged psychological distress at exposure to internal or external cues of the traumatic event

Marked physiological reactions to internal or external cues

Slide112

PTSD

PTSD DSM V

C. Avoidance Symptoms (1 or both)

Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely related to the traumatic event

Avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts or feelings about the traumatic events

D. Negative cognition and mood symptoms (2 or more)

Inability to remember an important aspect of the traumatic event

Persistent and exaggerated negative beliefs or expectations

Persistent, distorted cognitions about the cause/consequences of the traumatic event (self-blame)

Persistent negative emotional state (fear, horror, anger, guilt, shame, etc.)

Markedly diminished interest or participation in significant activities

Feelings of detachment or estrangement from others

Persistent inability to experience positive emotions

Slide113

PTSD

PTSD DSM V

E. Arousal / Reactivity Symptoms (2 or more)

Irritable behavior and angry outbursts

Reckless or self-destructive behavior

Hypervigilance

Exaggerated startle response

Problems with concentration

Sleep disturbance

F. Duration of the disturbance is greater than 1 month Inability to remember an important aspect of the traumatic event

G. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning

H. The disturbance is not attributable to substance abuse or other medical condition

Specify with or with our Dissociative Symptoms (depersonalization or derealization)

Slide114

PTSD

PTSD Consequences

Longer duration of PTSD symptoms in females

Substance abuse

Aggression/violence

Suicidal ideation, attempts

Work problems (absenteeism, reduced occupational success)

Marital problems

Homelessness

Slide115

PTSD

Neuroscience of ptsd

Overactive amygdala

Hyperarousal, stuck emotional memory (negative emotions)

Inadequate regulation

by ventral/medial prefrontal cortex

Cannot suppress attention/response to trauma-related stimuli

Inadequate hippocampal response

Memories are fragmented and flooding of negative emotions without appropriate context

Reduced volume (atrophy) in PTSD

Potentially cause by glucocorticoid “stress hormones”

Cingulate Cortex

Smaller volume —> more severe PTSD

Slide116

PTSD

PTSD circuitry

PTSD changes functional connectivity in brain pathways

Increased blood flow in right limbic (incl. amygdala)

Decreased

blood

flow in left inferior frontal cortex (Broca’s area)

HypERactive

amygdala

HypOactive

prefrontal cortex

Exaggerated right amygdala response to fearful faces, not to happy faces

Blood flow decreased in medial frontal gyrus with blood flow increase in amygdala

Slide117

PTSD

cortical function in ptsd

Frontal lobes allow us to appreciate context of a stimulus

, and to modify our behavioral response accordingly

If we lose this ability, behavior becomes more instinctual in nature

The hypofrontal findings in PTSD subjects likely relate to learned response to trauma cues

The loss of frontal tone leads to the amygdala’s release from inhibition, perpetuating the fear circuits

Slide118

PTSD

Neurochemistry of PTSD

Norepinephrine hyperactivity

Dopamine sensitization

SSRIs alleviate symptoms

May affect amygdala to decrease fear

HPA axis

Changes in plasma cortisol

Increase response of glucocorticoid receptors

Noradrenergic hyperactivity relates to PTSD hyperarousal and re-experiencing

Dysregulation of HPA feedback to amygdala and locus ceruleus causes more noradrenergic hyperactivity

GC, CRH, endogenous opioids are involved in maintaining noradrenergic hyperactivity

Slide119

PTSD

Increased sympathetic outflow in PTSD

Changes in BP, HR

Exaggerated startle response

Increased plasma norepinephrine

Increased CSF norepinephrine

Increased urine norepinephrine

Slide120

PTSD

Sleep disturbance in PTSD

Sleep disturbances common

Decreased sleep time

Increased REM (not restorative sleep)

Increased awakenings

Prazosin, central alpha-1 blocker, alleviates nightmares

Slide121

PTSD

PTSD treatment

CBT

Psychoeducation

EMDR

Debriefing

Psychopharmacology

SSRIs (first line for men and women)

Adrenergic Inhibitors (Prazosin)

Benzodiazepines

Anticonvulsants

Antipsychotics

Slide122

PTSD

Propranolol

Propranolol, central beta blocker, prevents arousal-related memory consolidation

Secondary prevention of PTSD in aftermath of acute trauma

Slide123

Opioids

Slide124

OPIOIDS

Types of opioids

Naturally Occurring

Morphine and Codeine

Semi-Synthetic

Hydromorphone (Dilaudid)

Diacetylmorphine (Heroin)

Oxycodone (Percodan)

Synthetics:

Methadone

Meperidine (Demerol)

Fentanyl (Sublimaze)

Slide125

OPIOIDS

MECHANISM

Bind to the Opioid Receptor

Found in the CNS and PNS

Receptor Types

Mu1: euphoria and analgesia (addictive)

Mu2: respiratory depression (deadly)

Slide126

OPIOIDS

OPIOIDS AND MU RECEPTOR

Full Agonists (Common in Abuse)

Heroin, Methadone, Oxycodone

Partial Agonist (Less Common in Abuse)

Buprenorphine

Antagonist (Occupies WITHOUT Activating)

Naloxone and Naltrexone

Slide127

OPIOIDS

Tolerance

Develops QUICKLY

Following detox… tolerance is reduced (potentially fatal if same doses are taken)

Suspected changes in NUMBER and SENSITIVITY of receptors

Many side effects DECREASE with increased use of drug

Addiction changes the brain

Slide128

OPIOIDS

Effects

Euphoria

Analgesia

Pupillary constriction

Apathy

Drowsiness

Respiratory Depression

Constipation, Nausea

Slide129

OPIOIDS

intoxication DSMV

Recent Use of Opioids

Clinically significant problematic behavior or psychological changes

Pupillary Constriction (or Dilation in severe OD) and one of the following

Drowsiness or Coma

Slurred Speech

Impairment in Attention or Memory

Symptoms NOT due to a general medical condition or other mental disorder

Slide130

OPIOIDS

Withdrawal DSMV

Either of the following…

Cessation of or reduction in opioid use that has been heavy or prolonged (weeks)

Administration of an opioid antagonist after a period of opioid use

Three or more of the following developing within minutes to days after either of the above (A)

Dysphoric Mood

Nausea and Vomitting

Muscle Aches

Lacrimation or Rhinorrhea

Pupillary Dilation, Sweating, and Piloerection

Diarrhea

Yawning

Fever

Insomnia

Symptoms in B cause distress or impairment in social, occupational, or other areas.

Symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Slide131

OPIOIDS

Withdrawal

General rule:

Short duration of action = Short, intense withdrawal

Long duration of action = Prolonged withdrawal.

Treatment:

IV Naloxone if patient in respiratory distress.

Methadone, if objective symptoms are present

Patient Criteria

>16 yo

1 year history of dependence

Medically compromised patients

Pregnant women

Slide132

OPIOIDS

Methadone maintenance

Full Agonist

Long half life (24-36 hours)

Regularly scheduled

Produces steady state

Steady state reached over weeks, 3-7 days on same dose.

Alertness without craving

Slide133

OPIOIDS

buprenorphine

Mu Partial Agonist

Forms

• Suboxone: buprenorphine + naloxone (inactivates if injected)

• Subutex: buprenorphine only. Give in controlled settings

Wait until withdrawal starts

Dosing

2-4mg first day, then increase over 3 days

Average = 16-20mg

Slide134

LGBT patients

Slide135

LBGT Patients

Definitions

Gender Identity – An individual’s internal sense of being male, female or something else.

Gender identity is internal and not necessarily visible to others

Transgender – A term for people whose gender identity, expression or behavior is different from those typically associated with their assigned sex at birth.

Genderqueer – A term used by some individuals who identify as neither entirely male nor entirely female.

Gender Non Conforming – a term for individuals whose gender expression is different from societal expectations related to gender.

FTM – a person who transitions from “female-to-male” meaning a person who was assigned female at birth but identifies as male. Also known as a transgender man.

MTF – a person who transitions from “male to female” meaning a person who was assigned male at birth but identifies as female. Also known as a transgender female.

Cis gender – Individual who experiences their own gender as the same as which they were assigned at birth (people who are not transgender).

Slide136

LBGT Patients

Gender Dysphoria DSM v

A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following:

a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics

A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender.

A strong desire for the primary and/or secondary sex characteristics of the other gender

A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).

A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)

A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

Associated with clinically significant distress or impairment in social, occupational or other important areas of functioning.

Slide137

LBGT Patients

Suicide and LGBT

41% of respondents reported attempting suicide at least once

Those who were bullied harassed, assaulted or expelled reported significantly higher levels of attempted suicide attempts (51% of respondents)

54% of respondents reported attempting suicide who make less than $10,000 a year.

61% who reported attempting suicide, were victims of violence.

64% of those who attempted suicide were victims of sexual assault