Schizophrenia
Ø
Cause:
o
Decreased glucose uptake in frontal lobes (PET scan)
o
Decrease size of hippocampus, amygdala
o
High dopaminergic activity – high Homovanilllic acid levels
o
High serotonin activity
o
High nor-epinephrine activity
o
Loss of GABA neurons
Ø
Characteristics:
o
1 %
o
15- 25 in men. 25-35 women. M=F
o
Chronic
o
Poor grooming
o
Psychotic phase – loss of touch with reality
o
Prodromal phase – in touch with reality
o
Memory normal
o
Orientation normal
o
Affect abnormal
Ø
Criteria
o
Symptoms for 6 months
o
At least 1 period of psychosis in the 6 months
o
Impairment of occupational or social functioning in the 6 months
Ø
Prodromal symptoms
o
Avoids social activities
o
Quiet
o
Irritable
o
Physical complaints
o
New interest in religion or philosophy
Ø
Psychotic symptoms
o
Disorders of Perception –
§
Auditory Hallucinations
o
Disorders of Thought Content –
§
Delusions
§
Ideas of reference
§
Loss of ego boundaries
o
Disorders of Thought Processes –
§
Thought blocking
§
Impaired abstract ability
§
Neologisms
o
Disorders of Form of Thought –
§
Word salad
§
Loose associations
§
Echolalia
§
Echopraxia
§
Tangentiality
§
Preservation
Ø
Residual Symptoms:
o
Flat affect
o
Eccentric behavior
o
Social withdrawal
Ø
Positive symptoms:
o
Hallucinations
o
Delusions
o
Agitation
o
Talkative
o
Respond well to traditional meds
Ø
Negative symptoms:
o
Flat affect
o
Thought blocking
o
Cognitive disturbances
o
Poor grooming
o
Social withdrawal
o
Respond to clozapine, risperidone, olanzepine
Ø
Subtypes:
o
Paranoid
§
Delusions of persecution (will harm him)
§
Older people
§
Best prognosis
o
Residual
§
One episode of schizophrenia previously
§
Only residual symptoms
§
No psychotic symptoms
o
Disorganized
§
Disinhibition
§
Poor grooming
§
Inappropriate emotional response
§
Young (<25)
o
Catatonic
§
Waxy flexibility
§
Mute
§
Extreme excitability or stupor
§
Echolalia, echopraxia
§
Rare
o
Undifferentiated
Tx:
Ø
Traditional antipsychotics (D2 blockers):
o
Chlorpromazine
o
Haldol
Ø
Atypical antipsychotics:
o
Clozapine (D4 blockers) –
§
less extrapyramidal, tardive dyskinesia, neuroliptic malignant
syndrome
§
high risk of agranulocytosis, seizures
o
Risperidone, olanzapine, Quetiapine (5HT blockers)
Ø
Non compliant pt:
o
Depot haldol or fluphenazine
Ø
Prognosis
o
Better if
§
Old
§
Female
§
Married
§
Social relationships
§
Mood symptoms (depression or mania)
§
Employed
§
Positive symptoms
§
Few relapses
§
Rapid onset
SIDE EFFECTS OF ANTIPSYCHOTICS:
Ø
Peripheral anticholinergic side effects:
o
Dry mouth, blurred vision, urinary retention
Ø
Central anticholinergic side effects:
o
Agitation, confusion - give physostigmine
Ø
Acute Dystonia:
o
Muscle spasms
o
Give diphenhydramine (benadryl), or amantadine, or benztropine
Ø
Akathesia
o
Subjective feeling of motor restlessness
o
Give diphenhydramine (benadryl), or amantadine, or benztropine
Ø
Pseudoparkinsonism
o
Give diphenhydramine (benadryl), or amantadine, or benztropine
Ø
Tardive Dyskinesia
o
Writhing movements of tongue, head, mouth
o
F>M
o
After 6 months of meds
o
Remit in 50%
o
May be permanent
o
With traditional antipsychotics
o
Start clozapine instead
o
Tx
§
Discontinue
§
Bezodiazepines, propranlol, choline chloride
Ø
Neuroleptic Malignant Syndrome:
o
With traditional antipsychotics
o
Fever
o
Sweating (autonomic dysfunction)
o
Confusion
o
High BP (autonomic dysfunction)
o
Muscle rigidity
o
Arrythmias
o
High CPK
o
M>F
o
Early in tx
o
20% mortality
o
Complications:
§
MI
§
Aspiration PNA
§
ARF
§
rhabdomyolysis
o
Tx:
§
Discontinue
§
Cooling blankets
§
IV fluids
§
Dantrolene or Bromocriptine
§
Nitroprusside for HTN (also adds in cooling)
BACK TO THE TOP
Mood Disorders
1.
Major depressive disorder
2.
Bipolar I disorder
3.
Biploar II disorder
4.
Dysthymic disorder
5.
Cyclothymic disorder
MAJOR DEPRESSIVE
DISORDER:
Ø
Incidence 5-12% men, 10-20% women
Ø
Onset: 40yr
Ø
Duration: at least 2 wks of mood
change + other symptoms as below
Ø
Features:
Ø
Better at night
Ø
SIG: EM CAPS
Ø
Sleep (early morning wakening,
insomnia)
Ø
Interest
Ø
Guilt
Ø
Energy
Ø
Mood (sad, depressed)
Ø
Concentration
Ø
Appetite (decrease)
Ø
Psychomotor activity (inc or
decrease)
Ø
Suicidal ideation (65%) _ 15% commit
Ø
5 out of 9 (including E & M)
Ø
Psychotic symptoms can occur
Ø
Somatic symptoms can occur (pain
abdomen)
Ø
Seasonal affective disorder:
associated with winter and short days (respond well to returning to hot weather
and sun areas)
Ø
Treatment:
Ø
SSRI (drug of choice) – good for
overweight, safe in overdose
Ø
Tricyclic – weight gain
Ø
MAOIs – hypertensive crisis (avoid
cheese, beans, wine, beer, liver, smoked fish)
Ø
All take 3-6 wks
Ø
All equivalent efficacy
Ø
Li or T3 can be used to augment
efficacy of antidepressants
Ø
Psychotic features treated with
antipsychotics
Ø
Stimulants (methylphenidate) to
improve mood in terminally ill or refractory. Rapid action.
Ø
ECT:
Ø
Indications: MDD, acute mania,
schizophrenia (acute, catatonic)
Ø
Side effects: retrograde amnesia
Ø
# of Treatment: 8 treatments over
2-3wks
Ø
contra: high ICP
Ø
maintenance: output ECT monthly or
antidepressants
Ø
Reasons for hospitalization:
Ø
Suicide risk
Ø
Inability to care for self
Ø
Poor social support
Ø
Alcohol use
BIPOLAR DISORDER:
Ø
I
o
1%
o
M=F
o
Mania & major depression
Ø
II
o
0.5%
o
F>M
o
Hypomania & major depression
Ø
Onset < 30y
Ø
Manic symptoms at least 1 wk
Ø
Interval b/w manic episodes 6-9
months
Ø
Untreated manic episode last 3months
Ø
Treatment
o
Lithium for mania
o
Carbamezipine and valproic acid
(esp. for rapid cycling bipolar)
DYSTHYMIC DISORDER:
At least 2y r of mood
change (no other symptoms as in MDD)
Ø
Mild to moderate depression most of
the time
Ø
Not episodic (i.e. present always)
Ø
Never really happy
Ø
No life stressor
Ø
Treatment:
o
Cognitive therapy
o
Anti depressants (SSRI)
CYCLOTHYMIC DISORDERS:
Ø
Episodes of hypomaia and mild + mild
to mod depression
Ø
Treatment as for bipolar
BACK TO THE TOP
Somatoform
Disorders
SOMATOFORM DISORDERS:
Ø
Patient truly believes
Ø
Classification
o
Somatization disorder
§
Multiple somatic complaints over many yrs
§
4 pain symptoms
§
2 GI symptoms
§
1 Sexual symptom
§
1 Neurologic symptom
o
Conversion disorder
§
Sudden loss of a motor function or a sensory loss
§
Pt. appears unconcerned
o
Hypochondriasis
§
At least 6 months of health concern
§
No reassurance works
§
Each time a new complaint
§
See many doctors
o
Body Dysmorphic disorder
o
Pain disorder
o
Undifferentiated Somatoform disorder
Ø
50% anxiety or depression
Ø
Gain
o
Primary gain
§
Unconsciously express feeling so that he doesn’t have to deal with
the feeling
o
Secondary gain
§
To get attention or avoid responsibility
Ø
Treatment
o
Form good pt-doctor relationship
o
Decrease sec gain
o
Meds for anxiety or depression
FACTITIOUS DISORDER (MUNCHAUSEN SYNDROME):
Ø
Pt. knows he is not sick
Ø
To obtain medical attention
Ø
Not for any other gain
Ø
Often has a medical experience
Ø
FACTITIOUS DISORDER BY PROXY (a form of child abuse)
MALINGERING:
Ø
Pt. knows he is not sick
Ø
Financial gain or excuse from work
Ø
Avoid medical treatment
Ø
Symptoms improve when he obtains the gain
BACK TO THE TOP
Impulse Control Disorders
Ø
Unable to resist
Ø
Relief after behavior
Kleptomania
SSRI
Aversive treatment
Associated with Bulimia
Pyromania
SSRI
Intermittent explosive disorder (losses self control
without adequate cause)
SSRI
Pathological Gambling
Gambler Anonymous
Associated with ADHD
Trichotillomania
SSRI
Pimozide
BACK TO THE TOP
Eating
Disorders
OBESITY:
Ø
20% above ideal weight
Ø
in US 25%
Ø
F>M
Ø
Low socioeconomic
Ø
Treatment:
o
Phentermine
o
Gastric bypass
ANOREXIA NERVOSA & BULIMIA NERVOSA:
Ø
Appetite normal
Ø
Behavior to avoid gain
Ø
Disturbance of body image
Ø
Menstrual abnormalities
Ø
F>M
Ø
Late adolescence (AN has 2 peaks, 14 and 18yrs)
Ø
High academic achievers
Ø
High socioeconomic
Ø
Industrialized societies
Ø
Often after stressful event
ANOREXIA NERVOSA
Ø
Wt loss 15% or more
Ø
3 or more missed periods
Ø
metabolic acidosis
Ø
high cholesterol
Ø
mild anemia
Ø
leucopoenia
Ø
lanugo hair
Ø
melanosis coli
Ø
Treatment
o
Restore nutritional status
§
Wt >20% below normal – admit
o
Amitryptyline
o
Cyproheptadine
o
SSRI
o
Family therapy
Ø
Prognosis
o
10% die from starvation or suicide
o
usually chronic
BULIMIA NERVOSA
Ø
relatively normal weight
Ø
esophageal varices
Ø
enamel erosion
Ø
swelling of parotids
Ø
scars on dorsum of hand
Ø
electrolyte imbalance
Ø
menstrual irregularities
Ø
Treatment
o
Tricyclics
o
SSRI
o
MAOI
BACK TO THE TOP
Dissociative Disorders
Sudden loss of memory,
identity, or feeling of detachment
DISSOCIATIVE AMNESIA:
Ø
Inable to recall important facts about self
Ø
After acute stress
Ø
Resolves in min to yrs
Ø
TX:
o
Hypnosis
o
Na Amobarbital interview
DISSOCIATIVE FUGUE:
Ø
sudden inability to remember personal information (new identity)
Ø
associated with moving
Ø
pt unaware of new identity
Ø
Resolves in min to yrs
Ø
TX:
o
Hypnosis
o
Na Amobarbital interview
DISSOCIATIVE IDENTITY DISORDER (multiple personality
disorder):
Ø
At least 2 separate personalities
DEPERSONALIZATION DISORDER:
Ø
Feeling of detachment from self, environment or situation
BACK TO THE TOP
Cognitive
Disorders:
(cognition: perception of something as real and not
emotion)
1-
Delirium
2-
Dementia
3-
Amnestic disorders
Ø
Deficit in memory, orientation, judgment, mental function
Ø
Mood change, anxiety, irritable, paranoid
DELIRIUM:
Ø
Characteristics
o
Decrease consciousness
o
Fluctuating symptoms with lucid intervals
o
Loss of orientation (1st time, than place, than person)
o
Rapid onset
o
Confused
o
Anxiety
o
Sleep disturbances
o
Sun downing (worse at night)
o
Visual hallucinations
o
Paranoid
Ø
Elderly, children
Ø
ICU
Ø
Abnormal EEG (very fast or slow waves)
Ø
Causes:
o
Meningitis, head injury
o
Any systemic illness
o
Alcohol
o
Withdrawal ( benzo, alcohol, barbiturates)
Ø
Treatment:
o
Use restraint only as last resort
o
Constant observation esp by someone familiar to pt
o
Frequent reassurance, touch and verbal orientation
o
Haldol (0.5 – 1mg IV, IM, or PO)
o
Risperidone
o
Olanzapine
DEMENTIA:
Ø
characteristics:
- Consciousness normal
- Slow onset
- Steady (not fluctuating)
- Hallucinations uncommon
- No diurnal variability
- Depression
1.
ALZHEIMER DISEASE:
Ø
Consciousness normal
Ø
Severe memory loss (1st)
a.
Recent memory worse than remote
Ø
Language problems (2nd)
Ø
Spatial ability – copying diagram (3rd)
Ø
Personality changes (paranoid, angry)
Ø
Mood changes (depression)
Ø
Progressively deteriorates
Ø
DD:
a.
Normal ageing
b.
Pseudodementia of depression
Ø
Diagnosis: (for all dementias)
a.
MMSE
b.
Labs
&n
