section name header

Information ⬇

[Section Outline]

Mood Disorders (Major Affective Disorders) !!navigator!!

Mood disorders are characterized by a disturbance in the regulation of mood, behavior, and affect; subdivided into (1) depressive disorders, (2) bipolar disorders (depression plus manic or hypomanic episodes), and (3) depression in association with medical illness or alcohol and substance abuse (see Chaps. 202 Alcohol Use Disorder, 203 Narcotic Abuse, and 204 Cocaine and Other Commonly Used Drugs).

Major Depression

CLINICAL FEATURES- Affects 15% of the general population at some point in life; 6-8% of all outpatients in primary care settings satisfy diagnostic criteria. Diagnosis is made when five (or more) of the following symptoms have been present for 2 weeks (at least one of the symptoms must be #1 or #2 below):
  1. Depressed mood
  2. Loss of interest or pleasure
  3. Change in appetite or weight
  4. Insomnia or hypersomnia
  5. Psychomotor agitation or retardation
  6. Fatigue or loss of energy
  7. Feelings of worthlessness or inappropriate guilt
  8. Decreased ability to concentrate and make decisions
  9. Recurrent thoughts of death or suicide

A small number of pts with major depression will have psychotic symptoms (hallucinations and delusions) with their depressed mood. Negative life events can precipitate depression, but genetic factors influence the sensitivity to these events.

Onset of a first depressive episode is typically in early adulthood, although major depression can occur at any age. Untreated episodes generally resolve spontaneously in a few months to a year; however, a sizable number of pts suffer from chronic, unremitting depression, or from a partial treatment response. Half of all pts experiencing a first depressive episode will go on to a recurrent course. Untreated or partially treated episodes put the pt at risk for future problems with mood disorders. Within an individual, the nature of episodes may be similar over time. A family history of mood disorder is common and tends to predict a recurrent course. Major depression can also be the initial presentation of bipolar disorder (manic depressive illness).

SUICIDE- Approximately 4-5% of all depressed pts will commit suicide, and most will have sought help from a physician within 1 month of their death. Physicians must always inquire about suicide when evaluating a pt with depression.
DEPRESSION WITH MEDICAL ILLNESS- Virtually every class of medication can potentially induce or worsen depression. Antihypertensive drugs, anticholesterolemic agents, and antiarrhythmic agents are common triggers of depressive symptoms. Among the antihypertensive agents, β-adrenergic blockers and, to a lesser extent, calcium channel blockers are most likely to cause depressed mood. Iatrogenic depression should also be considered in pts receiving glucocorticoids, antimicrobials, systemic analgesics, antiparkinsonian medications, and anticonvulsants.

Between 20% and 30% of cardiac pts manifest a depressive disorder. Tricyclic antidepressants (TCAs) are contraindicated in pts with bundle branch block, and TCA-induced tachycardia is an additional concern in pts with congestive heart failure. Selective serotonin reuptake inhibitors (SSRIs) appear not to induce ECG changes or adverse cardiac events, and thus, are reasonable first-line drugs for pts at risk for TCA-related complications. SSRIs may interfere with hepatic metabolism of warfain, however, causing increased anticoagulation.

In cancer, the prevalence of depression is 25%, but it occurs in 40-50% of pts with cancers of the pancreas or oropharynx. Extreme cachexia from cancer may be misinterpreted as depression. Antidepressant medications in cancer pts improve quality of life as well as mood.

Diabetes mellitus is another consideration; the severity of the mood state correlates with the level of hyperglycemia and the presence of diabetic complications. Monoamine oxidase inhibitors (MAOIs) can induce hypoglycemia and weight gain. TCAs can produce hyperglycemia and carbohydrate craving. SSRIs, like MAOIs, may reduce fasting plasma glucose, but they are easier to use and may also improve dietary and medication compliance.

Depression may also occur with hypothyroidism or hyperthyroidism, in neurologic disorders, in HIV-positive individuals, and in chronic hepatitis C infection. Some chronic disorders of uncertain etiology, such as chronic fatigue syndrome and fibromyalgia, are strongly associated with depression.

TREATMENT

Major Depression

  • Pts with suicidal ideation require treatment by a psychiatrist and may require hospitalization.
  • Most other pts with an uncomplicated unipolar major depression (a major depression that is not part of a cyclical mood disorder, such as a bipolar disorder) can be successfully treated by a nonpsychiatric physician.
  • Vigorous intervention and successful treatment appear to decrease the risk of future relapse.
  • Pts who do not respond fully to standard treatment should be referred to a psychiatrist.
  • Antidepressant medications are the mainstay of treatment, although combined treatment with psychotherapy improves outcome. Symptoms are ameliorated after 6-8 weeks at a therapeutic dose in 60-70% of pts.
  • A guideline for the medical management of depression is shown in Fig. 199-1. A Guideline for the Medical Management of Major Depressive Disorder.
  • Once remission is achieved, antidepressants should be continued for 6-9 months. Pts must be monitored carefully after termination of treatment since relapse is common.
  • Pts with two or more episodes of depression should be considered for indefinite maintenance treatment.
  • Electroconvulsive therapy is generally reserved for treatment-resistant depression unresponsive to medication or for pts in whom the use of antidepressants is medically contraindicated.
  • Transcranial magnetic stimulation (TMS) is approved for treatment-resistant depression.
  • Vagus nerve stimulation (VNS) has been approved for treatment-resistant depression as well, but its degree of efficacy is controversial.
  • Other emerging approaches for refractory depression include low intensity transcranial current stimulation (tCS), intravenous or intranasal forms of ketamine, and deep brain stimulation of the internal capsule and cingulate region.

Bipolar Disorder (Manic Depressive Illness)

CLINICAL FEATURES- A cyclical mood disorder in which episodes of major depression are interspersed with episodes of mania or hypomania; 1.5% of the population is affected. Most pts initially present with a manic episode in adolescence or young adulthood. Antidepressant therapy may provoke a manic episode; pts with a major depressive episode and a prior history of “highs” (mania or hypomania-which can be pleasant/euphoric or irritable/impulsive) and/or a family history of bipolar disorder should not be treated with antidepressants, but instead referred promptly to a psychiatrist.

With mania, an elevated, expansive mood, irritability, angry outbursts, and impulsivity are characteristic. Specific symptoms include (1) unusual talkativeness, (2) flight of ideas and racing thoughts, (3) inflated self-esteem that can become delusional, (4) decreased need for sleep (often the first feature of an incipient manic episode), (5) increase in goal-directed activity or psychomotor agitation, (6) distractibility, and (7) excessive involvement in risky activities (buying sprees, sexual indiscretions). Pts with full-blown mania can become psychotic. Hypomania is characterized by attenuated manic symptoms and is greatly underdiagnosed, as are “mixed episodes,” where both depressive and manic or hypomanic symptoms coexist simultaneously.

Untreated, a manic or depressive episode typically lasts for several weeks but can last for 8-12 months. Variants of bipolar disorder include rapid and ultrarapid cycling (manic and depressed episodes occurring at cycles of weeks, days, or hours). In many pts, especially females, antidepressants trigger rapid cycling and worsen the course of illness. Bipolar disorder has a strong genetic component; the concordance rate for monozygotic twins approaches 80%.

TREATMENT

Bipolar Disorder

  • Bipolar disorder is a serious, chronic illness that requires lifelong monitoring by a psychiatrist.
  • Acutely manic pts often require hospitalization to reduce environmental stimulation and to protect themselves and others from the consequences of their reckless behavior.
  • The recurrent nature of bipolar disorder necessitates maintenance treatment.
  • Mood stabilizers (lithium, valproic acid, second-generation antipsychotic drugs, carbamazepine) are effective for the resolution of acute episodes and for prophylaxis of future episodes.

Schizophrenia and Other Psychotic Disorders !!navigator!!

Schizophrenia

CLINICAL FEATURES- Characterized by perturbations of language, perception, thinking, social activity, affect, and volition. Occurs in 0.85% of the population worldwide; lifetime prevalence is ∼1-1.5%. Pts usually present in late adolescence, often after an insidious premorbid course of subtle psychosocial difficulties. Core psychotic features last ≥6 months and include positive symptoms (such as conceptual disorganization, delusions, or hallucinations) and negative symptoms (loss of function, anhedonia, decreased emotional expression, impaired concentration, and diminished social engagement). Negative symptoms predominate in one-third and are associated with a poor long-term outcome and poor response to treatment.

Prognosis depends not on symptom severity but on the response to antipsychotic medication. A permanent remission without recurrence does occasionally occur. About 10% of schizophrenic pts commit suicide. Comorbid substance abuse is common.

TREATMENT

Schizophrenia

  • Hospitalization is required for acutely psychotic pts who may be dangerous to themselves or others.
  • Conventional antipsychotic medications are effective against hallucinations, delusions, and thought disorder.
  • Newer generation antipsychotic medications-risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, iloperidone, asenapine, lurasidone, and clozapine-are helpful in pts unresponsive to conventional neuroleptics and may also be more useful for negative and cognitive symptoms.
  • Drug treatment by itself is insufficient, and educational efforts directed toward families and relevant community resources are necessary to maintain stability and optimize outcomes.

Anxiety Disorders !!navigator!!

Characterized by severe, persistent anxiety or sense of dread or foreboding. Most prevalent group of psychiatric illnesses seen in the community; present in 15-20% of medical clinic pts.

Panic Disorder

Occurs in 2-3% of the population; familial aggregation may occur. Onset in late adolescence or early adulthood. Initial presentation is almost always to a nonpsychiatric physician, frequently in the ER, as a possible heart attack or serious respiratory problem. The disorder is often initially unrecognized or misdiagnosed. Three-quarters of pts with panic disorder will also satisfy criteria for major depression at some point.

CLINICAL FEATURES- Characterized by panic attacks, which are sudden, unexpected, overwhelming paroxysms of terror and apprehension with multiple associated somatic symptoms. Attacks usually reach a peak within 10 min, then slowly resolve spontaneously, occurring in an unexpected fashion. Diagnostic criteria for panic disorder include recurrent panic attacks and at least 1 month of concern or worry about the attacks or a change in behavior related to them. Panic attacks are accompanied by palpitations, sweating, trembling, dyspnea, chest pain, dizziness, and a fear of impending doom or death.

When the disorder goes unrecognized and untreated, pts often experience significant morbidity: they become afraid of leaving home and may develop anticipatory anxiety, agoraphobia, and other spreading phobias; many turn to self-medication with alcohol or benzodiazepines.

Panic disorder must be differentiated from cardiovascular and respiratory disorders. Other conditions that may mimic or worsen panic attacks include hyperthyroidism, pheochromocytoma, hypoglycemia, drug ingestions (amphetamines, cocaine, caffeine, sympathomimetic nasal decongestants), and drug withdrawal (alcohol, barbiturates, opiates, minor tranquilizers).

TREATMENT

Panic Disorder

  • The cornerstone of drug therapy is antidepressant medication.
  • SSRIs benefit the majority of pts and do not have the adverse effects of the TCAs.
  • Benzodiazepines are often used in the short term while waiting for antidepressants to take effect although there is no good evidence that they work more quickly.
  • Early psychotherapeutic intervention and education aimed at symptom control enhance the effectiveness of drug treatment.
  • Psychotherapy (identifying and aborting panic attacks through relaxation and breathing techniques) can be effective.

Generalized Anxiety Disorder (Gad)

Characterized by persistent, chronic anxiety; occurs in 5-6% of the population.

CLINICAL FEATURES- Pts experience persistent, excessive, and/or unrealistic worry associated with muscle tension, impaired concentration, autonomic arousal, feeling “on edge” or restless, and insomnia. Pts worry excessively over minor matters, with life-disrupting effects; unlike panic disorder, complaints of shortness of breath, palpitations, and tachycardia are relatively rare. Secondary depression is common, as is social phobia and comorbid substance abuse.
TREATMENT

Generalized Anxiety Disorder

  • A combination of pharmacologic and psychotherapeutic interventions is most effective; complete symptom relief is rare.
  • Benzodiazepines are the initial agents of choice when generalized anxiety is severe and acute enough to warrant drug therapy; physicians must be alert to psychological and physical dependence on benzodiazepines.
  • A subgroup of pts respond to buspirone, a nonbenzodiazepine anxiolytic.
  • Some SSRIs also are effective at doses comparable to their efficacy in major depression.
  • Anticonvulsants with GABAergic properties (gabapentin, oxcarbazepine, tiagabine, pregabalin, divalproex) may also be effective against anxiety.

Obsessive-Compulsive Disorder (Ocd)

A severe disorder present in 2-3% of the population and characterized by recurrent obsessions (persistent intrusive thoughts) and compulsions (repetitive behaviors) that impair everyday functioning. Pts are often ashamed of their symptoms; physicians must ask specific questions to screen for this disorder including asking about recurrent thoughts and behaviors.

CLINICAL FEATURES- Common obsessive thoughts and compulsive behaviors include fears of germs or contamination, handwashing, counting behaviors, and having to check and recheck such actions as whether a door is locked.

Onset is usually in early adulthood (childhood onset is not rare); more common in males and first-born children. Comorbid conditions are common, the most frequent being depression, other anxiety disorders, eating disorders, and tics. The course of OCD is usually episodic with periods of incomplete remission; some cases may show a steady deterioration in psychosocial functioning.

TREATMENT

Obsessive-Compulsive Disorder

  • Clomipramine and the SSRIs (fluoxetine, fluvoxamine, sertraline) are effective, but only 50-60% of pts show adequate improvement with pharmacotherapy alone.
  • A combination of drug therapy and cognitive-behavioral psychotherapy is most effective for the majority of pts.

Posttraumatic Stress Disorder (Ptsd)

Occurs in some individuals exposed to a severe life-threatening trauma. If the reaction occurs shortly after the event, it is termed acute stress disorder, but if the reaction is delayed and subject to recurrence, PTSD is diagnosed. Predisposing factors include a past psychiatric history and personality characteristics of extroversion and high neuroticism.

CLINICAL FEATURES- Individuals experience associated symptoms of detachment and loss of emotional responsivity. The pt may feel depersonalized and unable to recall specific events of the trauma, although it is reexperienced through intrusions in thought, dreams, or flashbacks. Comorbid substance abuse and other mood and anxiety disorders are common. This disorder is extremely debilitating; most pts require referral to a psychiatrist for ongoing care.
TREATMENT

Posttraumatic Stress Disorder

  • SSRIs, venlafaxine, nefazodone, and topiramate all are somewhat effective.
  • Hydrocortisone, intranasal oxytocin, and opiates such as morphine given during the acute stress period may prevent the development of PTSD.
  • Adjunctive naltrexone can be effective when comorbid alcoholism is present.
  • Low dose trazodone and mirtazapine are frequently used at night to help with insomnia.
  • Psychotherapeutic strategies help the pt overcome avoidance behaviors and master fear of recurrence of the trauma.

Phobic Disorders

CLINICAL FEATURES- Recurring, irrational fears of specific objects, activities, or situations, with subsequent avoidance behavior of the phobic stimulus. Diagnosis is made only when the avoidance behavior interferes with social or occupational functioning. Affects ∼10% of the population. Common phobias include fear of closed places (claustrophobia), fear of blood, and fear of flying. Social phobia is distinguished by a specific fear of social or performance situations in which the individual is exposed to unfamiliar individuals or to possible examination and evaluation by others (e.g., having to converse at a party, use of public restrooms, meeting strangers).
TREATMENT

Phobic Disorders

  • Agoraphobia is treated as for panic disorder.
  • Beta blockers (e.g., propranolol, 20-40 mg PO 2 h before the event) are particularly effective in the treatment of “performance anxiety” (but not general social phobia).
  • SSRIs and MAOIs are very helpful in treating social phobias.
  • Social and simple phobias respond well to behaviorally focused psychotherapy.

Somatic Symptom Disorder

CLINICAL FEATURES- Pts with multiple somatic complaints that cannot be explained by a known medical condition or by the effects of substances; seen commonly in primary care practice (prevalence of 5-7%). Pts may present with multiple physical complaints referable to different organ systems; pts with somatic symptom disorder can be impulsive and demanding. In conversion disorder, the symptoms involve voluntary motor or sensory function. In factitious illnesses, the pt consciously and voluntarily produces physical symptoms; the sick role is gratifying. Munchausen's syndrome refers to individuals with dramatic, chronic, or severe factitious illness. A variety of signs, symptoms, and diseases have been simulated in factitious illnesses; most common are chronic diarrhea, fever of unknown origin, intestinal bleeding, hematuria, seizures, and hypoglycemia. In malingering, the fabrication of illness derives from a desire for an external reward (narcotics, disability).
TREATMENT

Somatic Symptom Disorder

  • Pts with somatic symptom disorder are usually subjected to multiple diagnostic tests and exploratory surgeries in an attempt to find their “real” illness. This approach is doomed to failure.
  • Successful treatment is achieved through behavior modification, in which access to the physician is adjusted to provide a consistent, sustained, and predictable level of support that is not contingent on the pt's level of presenting symptoms or distress.
  • Visits are brief, supportive, and structured and are not associated with a need for diagnostic or treatment action.
  • Pts may benefit from antidepressant treatment.
  • Consultation with a psychiatrist is essential.

Outline ⬆

Section 15. Psychiatry and Substance Abuse