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Psychiatry pathology, mood disorder, other disorders, psychiatric…
Psychiatry pathology
mood disorder
bipolar disorder
high suicide risk
treatment: lithium, valproic acid, carbamazepine, lamotrigine, atypical antipsychotics
bipolar 2: hypomanic episode + depressive episode
cyclothymic disorder
milder form, >2years, fluctuating between hypomanic and mild depressive
bipolar 1: at least manic episode +/- a hypomanic or depressive episode
major depressive disorder
diagnosis (at least 5 of 9,≧2 weeks)
depressed mood; sleep disturbance; loss of interest; guilt or feeling of worthlessness; energy loss and fatigue; concentration problem; appetite or weight change; psychomotor retardation or agitation; suicidal ideation
treatment: CBT and SSRIs are first line; SNRI, mitrazapine, bupropion, electroconvulsive therapy(ECT)
changes in sleep
↓ slow-wave sleep, ↓REM latency, ↑REM early in sleep cycle, ↑ total REM sleep, repeated nighttime awakening, early-morning awakening
persistent depressive disorder (dysthymia)
: ≧2 depressive symptoms lasting ≧2 years with no more than 2 months without depressive symptom
MDD with seasonal patern
.≧2 years, ≧2 symptoms, with seasonal pattern(usually winter)
postpartum mood disturbances
maternal blue
50-80% incidence rate, resolves within 10 days
postpartum depression
treatment: CBT and SSRIs are first line
10-15% incidence rate, last >2weeks
onset during pregnancy or within 4 weeks of delivery
postpartum psychosis
thought of harming the baby or self
risk factors: bipolar or psychotic disorder, first pregnancy, family history, recent discontinuation of psychotropic medication
0.1~0.2% incidence rate
treatment: hospitalization, initiation of atypical antipsychotic, ECT
electroconvulsive therapy
induce grand mal seizure while patient anesthetized
adverse: disorientation, temporary headache, amnesia
rapid-acting method to treat resistant or refractory depression
manic episode
abnormaly and persistently elevated, expansive, irritable mood and ↑activity or energy, ≧1week
distractibility(気晴らし); impulsivity/indiscretion; grandiosity; flight of ideas; ↑goal directed activity/agitation; ↓need for sleep; talkativeness(多弁) or pressured speach
depression with atypical feature
mood reactivity, reversed vegetative symptoms, leaden paralysis, long-standing interpersonal rejection sensitivity
CBT and SSRIs are first line
grief
simple hallucinations of the deceased person(死人) are common
five stage (Kubler-Ross model): denial, anger, argaining, depression, acceptance
risk factors for suicide
family history is another risk factor
male, young adult and elderly, depression, previous attempt, ethanol or drug use, psychosis, sickness, organized plan, no spouse or other social support, stated future intent
hypomanic episode
not severe manic episode
abnormal range of mood or internal emotional state and loss of control over them
major depressive, bipolar, dysthymic(気分変調), cyclothymic disorder
other disorders
somatic symptom and related disorder
somatic symptom disorder
variety of bodily complaints; thoughts and anxiety about symptoms
conversion disorder
loss of sensory or motor function, often following acute stressor; female, adolescents, young adults
unconscious, common in women
illness anxiety disorder
excessive preoccupation with having a serious illness; minimal somatic symptoms
eating disorder
anorexia nervosa(神経性無食欲症)
↓body density, amenorrhea, lanugo(産毛), anemia, electrolyte disturbance
psychotherapy and nutritional rehabilitation are first line
intense fear of weight gain and overvaluation of body image→restriction of intake and severe weight loss
reffeeding syndrome: ↑insulin→hypophosphatemia, hypokalemia, hypomagnesemia→cardiac complication, rhabdomyolysis, seizures
binge eating diorder
regular episodes of excessive and uncontrollable eating without inappropriate compensatory behaviors
risk of diabetes
treatment:psychotherapy
most common in young female
bulimia nervosa(神経性大食症)
electrolyte disturbance, metabolic alkalosis, dorsal hand calluses(硬直) from induced vomiting
treatment: psychotherapy, nutritional rehabilitation, antidepressnats; bupropion is contraindicated due to seizure risk
binge eating with recurrent inappropriate compensatory behaviors
factious disorders
imposed on self
chronic; multiple hospital admission and willingness; women and health care workers
imposed on another
ill nes in child or elderly patient is caused or fabricated by caregiver
intentional symptoms, unconscious motivation, consciously, in order to get medical attention and sympathy
gender dysphoria
transsexualism: desire to live as opposite sex
transvestism: paraphilia(性的倒錯), wearing clothes of the opposite sex
cross-gender identification
narcolepsy
hypnagogic or hypnopompic hallucinations; nocturnal and narcoleptic sleep; cataplexy(脱力発作)
treatment: good sleep hygiene, daytime stimulants, nighttime sodium oxybate
excessive daytime sleepness; sleep attacks; ↓hypocretin production in lateral hypothalamus
malingering(仮病)
to have a disorder in order to attain a specific 2° gain
symptoms are intentional, motivation is intentional, consciously
sexual dysfunction
drug side effect, medical disorder, psychological or performance anxiety
sexual desire disorder, sexual arousal disorder, orgasmic disorder, sexual pain disorder
enuresis(夜尿症)
treatment: behavioral modification and positive reinforcement
urinary incontinence ≧2 times/week for ≧3months in person >5years old
substance abuse
substance use disorder (2 or more, in 1 year)
tolerance; withdrawal; substance taken in larger amount, or longer time; desire or attempt to cut down; energy spent obtaining, using, or recovering from substance; social, occupational, or recreational activites reduced; use despite knowing substance cause problems; craving; recurrent use in physically dangerous situation; failure to fulfill major obligations; social or interpersonal conflicts
stage
precontemplation→contemplation→preparation/determination→action/willpower→maintenance→relapse→
sleep terror disorder
inconsolable period of terror with screaming in the middle of night; during non-REM sleep; in children
psychiatric emergency
serotonin syndrome
↑activity, autonomic stimulation, agitation
treatment: cyproheptadine
caused by psychiatric or non psychiatric drug that ↑ 5-HT
carcinoid syndrome
diarrhea, flushing, wheezing, right heart disease
treatment: octretide
caused by carcinoid tumor
hypertensive crisis
hypertension
treatment: phentolamine
caused by tyramine rich foods + MAO inhibitor
neuroleptic malignant syndrome
myoglobinuria, fever, encephalopathy, vital unstable, ↑enzyme, rigidity of muscle
treatment: dantrolene, dopamine agonist
antipsychotics + genetic predisposition
malignant hyperthermia
fever, severe muscle contraction
treatment: dantrolene
inhaled anesthetics, succinylcholine + genetic predisposition
delirium tremens
altered mental status, autonomic hyperactivity, anxiety, seizure, tremor, psychomotor agitation, insomnia, nausea
treatment: benzodiazepine
cause: alcohol withdrawal
acute dystonia
muscle spasm, stiffness, oculogyric crisis(注視発作)
treatment: benztropine
cause: typical antipsychotics, anticonvulsants(抗けいれん薬), metoclopramide
lithium toxicity
nausea, vomiting, slurred(不明瞭な) speech, hyperreflexia, seizure, ataxia, nephrogenic DI
treatment: discontinue lithium, hydrate, hemodialysis
change in lithium dosage, concurrent use of thiazides, ACE inhibitor, NSAIDs
tricyclic antidepressant toxicity
respiratory depression, hyperpyrexia, prolonged QT interval, convulsion, coma, cardiotoxicity
supportive treatment
TCA overdose
schizophrenia
schizophreniform disorder
.≧2 symptoms, lasting 1-6 months
brief psychotic disorder
.≧1 positive symptom lasting < 1month, usually stress related
schizoaffective disorder
schizophrenia + major mood disorder, patient must have >2 weeks of psychotic symptom without mood disorder
lifetime prevalence=1.5%, male>female, ↑risk for suicide
chronic mental disorder with periods of psychosis, disturbed behavior and thought, and decline in functioning lasting more than 6 months
associated with ↑dopaminergic activity, ↓dendritic branching
delusion, hallucination(often auditory), disorganized speech, disorganized or catatonic(緊張性) behavior, negative symptom
treatment: atypical antipsychotics
anxiety disorder
panic disorder
↑ risk of suicide
treatment: CBT, SSRI, venlafaxine are first line
symptoms(peak in 10 minutes)
palpitation(動悸), paresthesias, depersonalization or derealization, abdominal distress or nausea, intense fear of dying, intense fear, light-headness, chest pain, chill, choking(息苦しさ), sweating, shaking, shortness of breath
persistent concern of additional attack, or worrying about consequence of attack, or behavioral change related to attack
recurrent unexpected panic attacks not associated with a known trigger
specific phobia(恐怖症)
treat with systematic desensitization
social anxiety disorder
treatment: CBT, SSRI, venlafaxine
exaggerated fear of embarrassment in social situation
severe, persistent fear or anxiety
agoraphobia(広場恐怖症)
associated with panic disorder
treatment: CBT, SSRIs
irrational fear/anxiety while facing or anticipating ≧2 specific situations
generalized anxiety disorder
restlessness, irritability, sleep disturbance, fatigue, muscle tension, difficulty concentrating
treatment: CBT, SSRIs, SNRIs are first line
anxiety lasting ≧6 months unrelated to a specific person, situation, event
adjustment disorder
emotional symptoms that occur within 3 months of an identifiable psychosocial stressor lasting <6 months once stressor end
.>6months→GAD
obsessive-compulsive disorder
behavior inconsistent with belief and attitude, associated with Tourette syndrome
treatment: SSRI, CBT, venlafaxine, clomipramine
recurring intrusive thought, feelings, or sensations
body dysmorphic syndrome
preoccupation with minor or imaging defect in appearance→distress and impaired functioning
patient seek cosmetic treatment
post-traumatic disorder(PTSD)
treatment: CBT, SSRIs, and venlafaxine
acute stress disorder
last between 3 days and 1 month, treat with CBT
.>1month
experiencing a potentially life-threatening situation→persistent hyperarousal, avoidance of associated stimuli, intrusive re-experiencing of event, changes in cognition or mood
treatment
CBT, SSRIs, SNRIs
childhood
childhood and early-onset disorder
separation anxiety disorder
treatment: CBT, play therapy, family thearapy
overwhelming fear of separation from home or attachment, >4weeks, may lead to factitious physical complaints to avoid school
conduct disorder
after age 18, antisocial personality disorder
treatment: psychotherapy
repetitive and pervasive behavior violating the basic right of others or societal norms
autism spectrum disorder(ASD)
poor social interactions, social communication deficits, repetitive/ritualized behaviors, restricted interests
may be accompanied by intellectual disability; rarely accompanied by unusual abilities
more common in boys
disruptive mood dysregulation disorder(重篤気分調節症)
treatment: stimulants, antipsychotics, CBT
severe and recurrent temper outbursts out of proportion to situation
attention deficit hyperactivity disorder(ADHD)
treatment: stimulants, cognitive behavioral therapy
at least 6 months of limited attention span and/or poor impulse control, onset before age 12, often persists into adulthood
oppositional defiant disorder(反抗挑戦性障害)
treatment: psychotherapy
enduring pattern of hostile, defiant behavior toward authority figures in the absense of serious violations of social norms
Tourette syndrome
associated with OCD, ADHD
treatment: psychoeducation, behavioral therapy, antipsychotics, etc
sudden, rapid, recurrent, nonrhythmic, stereotyped motor and vocal tics, >1 year
infant deprivation effects(愛情剥奪効果)
longterm deprivation of affection result in: failure to thrive; poor language and socialization skill; lack of basic trust; reactive attachment disorder; disinhibited social engagement
deprivation for >6months can lead to irreversible change
child abuse
physical abuse
fracture, bruises, burns, subdural hematomas, retinal hemorrhage, avoid eye contact
red flags: history inconsistent with degree or type of injury, delayed mediacal care, caregiver story change with retelling
usually from biological mother
sexual abuse
usually from male
peak is 9-12 years old
genital, anal, oral trauma, STIs, UTIS
child neglect
failure to provide a child with adequate food, shelter, supervision, education, affection
poor hygine, malnutrition, withdrawal, impaired social and emotional development, failure to thrive
vulnerable child syndrome
parents perceive the child as especially susceptible to illness or injury
can result in missed school or overuse of medical service
psychoactive drug intoxication and withdrawal
depressants
opioid
intoxication
euphoria(陶酔), respiratory and CNS depression,↓gag reflex, pupillary constriction, seizure
treatment: naloxone
withdrawal
sweating, dilated pupils, piloerection, fever, rhinorrhea(鼻漏), lacrimation, yawing, nausea, stomach cramps, diarrhea
treatment: support, methadone, buprenorphine
barbiturate
intoxication
respiratory depression; treat with management
withdrawal
delirium, cardiovascular collapse
alcohol
intoxication
emotional lability, slurred speech, ataxia, coma, blackout
withdrawal
[tremors, insomnia, GI upset, diaphoresis(多汗), mild agitation]→[seizure]→[hallucinosis]→[delirium tremens]
benzodiazepine
intoxication
ataxia, minor respiratory depression; treat with flumazenil
withdrawal
sleep disturbance, depression, rebound anxiety, seizure
stimulants
cocaine
intoxication
impaired judgement, pupillary dilation, hallucination, etc; chronic use lead to perforated nasal septum
treatment: α-blockers, benzodiazepine
caffeine
intoxication
restlessness, ↑siuresis, muscle twitching
withdrawal
headache, difficulty concentrating, flu-like symptoms
amphetamine
intoxication
euphoria, grandiosity, pupillary dilation, weakfulness, attention, hypertension, tachycardia, anorexia, paranoia, fever, cardiac arrest, seizure
treatment: benzodiazepine
nicotine
intoxication
restlessness
withdrawal
irritability, anxiety, restlessness, difficulty concentrating; treat with nicotine patch, gum, lozenges
hallucinogens
lysergic acid diethylamide(LSD)
intoxication
perceptual distortion, depersonalization, anxiety, paranoia, psychosis, flashback
marijuana(マリファナ)
intoxication
euphoria, paranoid delusion, psychosis; ↑appetite, dry mouth, conjunctival injection, hallucination
withdrawal
irritability, anxiety depression, insomnia, restlessness, ↓appetite
phencyclidine
intoxication
violence, agitation, nystagmus, tachycardia, hypertension, delirium, seizure
MDMA
intoxication
hallucinogenic effect, life threatening effect(hypertension, tachycardia, hyperthermia, hyponatremia, serotonin syndrome
withdrawal
depression, fatigue, appetite, difficulty concentrating, anxiety
alcoholism
treatment: disulfiram, acamprosate, naltrexone, supportive care
alcoholic cirrhosis, hepatitis, pancreatitis, peripheral neuropathy, testicular atrophy
Wernicke-Korsakoff syndrome
confusion, ophthalmoplegia, ataxia
by vitamin B1 deficiency
amnesias
retrograde amnesia
before CNS insult
Korsackoff syndrome
amnesia caused by vitamin B1 deficiency and associated destruction of mammillary bodies, seen in alcoholics, confabulations are characteristic
anterograde amnesia
after CNS insult
dissociative disorders
depersonalization/derealization disorder
feelings of detachment or estrangement(乖離) from body, thought, perception, action, environment; intact reality testing
dissociative identity disorder
2 or more distinct identities
associated with sexual abuse, PTSD, depression, substance abuse, borderline personality, somatoform condition
multiple personality disorder, common in women
may be accompanied by dissociative fungue(解離性遁走)
dissociative amnesia
inability to recall important personal information, usually subsequent to severe trauma or stress
psychosis
delusions(妄想)
unique, false, fixed, idiosyncratic belief
include erotomanic(俺のこと好きじゃね？), grandiose(大げさ), jealous, persecutory(被害妄想), somatic, mixed, unspecified
hallucination
visual, auditory, olfactory, gustatory(味覚), tactile(触覚), hypnagogic(催眠), hypnopompic(覚醒時)
perception in the absence of external stimuli
disorganized thought
speech may be incoherent, tangential(脱線), derailed
orientation
causes
alcohol, drug, fluid/electrolyte imbalance, head trauma, hypoglycemia, infection, nutrirional deficiency, hypoxia
patient ability to know who, where, when
delirium
waxing and waning level of consciousness, disorganized thinking, hallucination, illusion, misperception, disturbance in sleep-wake cycle, cognitive dysfunction, agitation
usually 2° to other illness, can be caused by medication
personality
personality disorders
cluster B
antisocial
disregard for and violation of rights of others with lack of remorse(良心の呵責), criminality, impulsivity
borderline
unstable mood and interpersonal relationships, impulsivity, self-mutation, suicidality, sense of emptiness
dramatic, emotional, or erratic
histrionic
excessive emotionally and excitability, attention seeking, sexually provocative, overly concerned with appearance
narcissistic
grandiosity(気取った), senseof entitlement, lack of empathy and requires excessive admiration
cluster C
avoidant
hypersensitive to rejection, socially inhibited, timid, feeling of inadequacy, desire relationship with others
obsessive-compulsive
preoccupation of order, perfectionism, and control
anxious or fearful
dependent
excessive need for support, low self confidence
cluster A
paranoid(妄想型)
pervasive distrust and suspiciousness of others and a profoundly cynical view of the world
schizoid
voluntary social withdrawal, limited emotional expression, content with social isolation
odd or eccentric: inability to develop meaningful social relationship
schizotypal
eccentric appearance, odd belief or magical thinking, interpersonal awkwardness
personality
personality trait
an enduring, repetitive pattern of perceiving, relating to, and thinking about the environment and oneself
personality disorder
inflexible, maladaptive, and rigidly pervasive pattern of behavior causing subjective distress and impaired functioning
not aware of problem
delusional disorder
fixed, persistent, false belief system lasting > 1month