Antipsychotic Availability Notes (other than pill/capsule)
Paliperidone long acting injectable Good for hepatically (Invega) (Sustenna) impaired; Extended Release
Quetiapine Extended release Sedating (Seroquel)
Risperidone Liquid Increases (Risperdal) Dissolvable Prolactin IM Long acting injectable (Consta) Ziprasidone Liquid Monitor EKG (Geodon) IM
Supportive Psychotherapy Club House ACT services NAMI Vocational Rehab Nicotine counseling
1 (or more ) delusions Duration: 1 month or longer Criterion A for Schizophrenia has never been met. Functioning is not markedly impaired Behavior is not obviously odd or bizarre
Features: Differential Diagnosis
Prevalence: Obsessive-compulsive and ◦ lifetime 0.2 % related disorders ◦ Most frequent is persecutory Delirium • Males > females for Jealous major neurocognitive d/o type psychotic disorder due to • Function is generally better another medical condition than in schizophrenia substance-medication- • Familiar relationship with induced psychotic disorder schizophrenia and Schizophrenia & schizotypal Schizophreniform Depressive and bipolar d/o Schizoaffective Disorder
Delusion types
Erotomanic Grandiose Jealous Persecutory Somatic Mixed Unspecified
• Substance Abuse • Dependence • Withdrawal
◦ Alcohol Divided into 2 ◦ Caffeine groups: ◦ Cannabis ◦ Hallucinogens (with separate ◦ Substance use categories for phencyclidine and other disorders hallucinogens) ◦ Substance-induced ◦ Inhalants disorders ◦ Opioids ◦ Sedatives, hypnotics, and anxiolytics ◦ Stimulants (amphetamine-type substances, cocaine, and other stimulants) ◦ Tobacco ◦ Other or unknown substances
Continue using the substance despite significant substance-related problems Repeated relapses and intense drug craving Taken in larger amounts or over a longerior period than was originally intended Express persistent desire to cut down Spend a great deal of time obtaining the substance, using the substance, or recovering from its effects Tolerance Withdrawal
Reversible Disturbances in: After ingestion Not attributable to ◦ Perception another medical condition or another ◦ Wakefulness mental disorder ◦ Attention ◦ Thinking Can occur in individuals without a ◦ Judgment substance use ◦ Psychomotor behavior disorder ◦ Interpersonal behavior Does not apply to tobacco
Cessation of or reduction in heavy and prolonged substance use Clinically significant distress or impairment Not due to another medical condition or another mental disorder Not always associated with a substance use disorder Most have an urge to re-adminster the substance to reduce the symptoms
Psycho Bipolar Depressive Anxiety OCD Sleep tic D/O D/o D/o D/o D/o Alcohol I/W I/W I/W I/W I/W Caffeine I I/W Cannabis I I I/W Hallucinogens I I I I Inhalants I I I Opioids I/W W I/W Sedative, I/W I/W I/W W I/W hypnotics, or anxiolytics Stimulants I I/W I/W I/W I/W I/W Tobacco W Sexual Delirium Neurology Substance Sub- Substance Dys- D/o Use D/o stance Withdrawal function Intoxi- cation Alcohol I/W I/W I/W I/W I/W Caffeine I I/W Cannabis I I I/W Hallucinogens I I I I
Inhalants I I I Opioids I/W W I/W Sedative, I/W I/W I/W W I/W Hypnotics, or anxiolytics
Stimulants I I/W I/W I/W I/W I/W Tobacco W Evaluation Treatment
Suboxone Evaluation by Vivitrol LCAS/Psychiatrist Antabuse CAGE SAIOP Treat underlying disorder SBIRT (e.g. antidepressants for LFTS depression) UDS Opiate withdrawal – clonidine, Loperamide, Hepatitis panel Flexaril, Ibuprofen STD’s Alcohol withdrawal – Lorazepam; CIWA Physical exam – pupils protocols; GI evaluations
Enduring pattern Applied to children/adolescents if present for at least 1 year CLUSTERS A, B, C Gender Differences: ◦ Antisocial M > F ◦ Borderline: F > M Differential Diagnosis: Psychotic disorders, Anxiety/depressive Disorders, PTSD, Substance use, medical condition
Paranoid: other’s motives Treatment: are interpreted as
malevolent ◦ Group therapy Schizoid: pattern of detachment, restricted ◦ Psychotherapy range of emotional expression ◦ low dose antipsychotics Shizotypal: cognitive or perceptual distortions, and ◦ SSRI’s for mood eccentricities of behavior symptoms Antisocial: disregard for and violation of the rights for others ◦ Males > females Histrionic: excessive ◦ Treatment: therapy, emotionality and valproate, atypical attention seeking antipsychotics ◦ Therapy ◦ Antidepressants Borderline: instability in interpersonal Narcissistic: grandiosity, relationships, self-image, need for admiration, and affects, and marked lack of empathy impulsivity ◦ Males > females ◦ Females > males ◦ Treatment: psychotherapy ◦ Treatment: Antipsychotics, ◦ Consider SSRI’s/Lithium Lithium, SSRI’s ◦ Dialectical Behavior therapy
Avoidant: social inhibition, feelings of inadequacy, and hypersensitivity to Obsessive- negative evaluation ◦ Treatment: compulsive: psychotherapy; social preoccupation with skills; B-blockers; SSRI’s ( sertraline, excitalopram, orderliness, paroxetime);Benzos prn perfectionism, and Dependent: submissive control. and clinging behavior ◦ Treatment: first-line: related to an excessive need to be taken care of psychotherapy; SSRI’s; ◦ Treatment: Second-line: psychotherapy; Family (Clomipramine) therapy; SSRI’s if anxiety
Somatic Symptom Disorder Illness Anxiety Disorder Conversion Disorder (functional neurological symptoms disorder) Psychological factors affecting other medical conditions Factitious disorder Other Specified somatic symptoms and related disorder Unspecified somatic symptom and related disorder Very distressing Result in significant disruption of functioning Excessive and disproportionate thoughts typically at least for 6 months The DSM-IV disorders of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder have been removed Does not require a specific number of complaints from among four symptom groups. Does not require that the somatic symptoms are medically unexplained.
A. One or more somatic symptoms that are distressing B. Excessive thoughts, feelings, or behaviors manifested by 1 of: 1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms 2. Persistently high level of anxiety about health or symptoms 3. Excessive time and energy devoted to these symptoms C. the state of being symptomatic is persistent (typically more than 6 months)
A. Preoccupation with having or acquiring a serious illness. B.Somatic symptoms are not present or, if present, are only mild in intensity C. High level of anxiety about health.. D. Individual performs excessive health-related behaviors E. Present 6 months, but specific illness that is feared may change over that period of time F. Not better explained by another mental disorder
A. 1 or more symptoms of altered voluntary motor or sensory function. B. Clinical findings provide evidence of incompatibility between symptom and recognized condition. C. not better explained D. Causes clinically significant distress 1. Temporal association between the psychological factors and the development or exacerbation of or delayed recovery from the medical condition 2. Interfere with the treatment of the medical condition (e.g., poor adherence) 3. Health risks for the individual
Moved into Somatic Key criteria: Symptom and Related Disorders from its own chapter ◦ Present self as ill, impaired, or injured No motivation included in DSM 5 criteria ◦ evident even in the absence of obvious external rewards Divided into: ◦ Imposed on Self ◦ Imposed on another (previously by proxy)
Factitious Disorder Conversion Disorder
• Early Recognition • Psychotherapy • Non-threatening • Hypnosis confrontation • Short-term anxiolytics • Relaxation therapy • SSRI’s to reduce • Regular visits impulsive • Referral to mental tendencies or health care provider anxiety • Minimize unnecessary • Regular visits medications
Obesity Anorexia Nervosa Bulimia Nervosa
1/3 of U.S. adults Obesity-related conditions: heart disease, stroke, type 2 diabetes, cancer Higher medical costs Higher in minorities Higher among middle age adults
distorted body image Prevalence: females 0.4% excessive dieting Development: adolescence pathological fear of becoming fat. Risk/Prognostic: ◦ anxiety Restricting type: The person restricts their food intake on their own and ◦ displace obsession traits does not engage in binge-eating or purging behavior. Comorbidity: Bipolar, Depressive, and anxiety Binge eating/purging type: The disorders person self-induces vomiting or misuses laxatives, diuretics, or enemas. Suicide risk: 12 per 100,000 Treatment: ◦ Inpatient
◦ Partial hospitalization DSM changes: ◦ Outpatient ◦ Word “refusal” not included in terms ◦ CBT of weight maintenance ◦ Nutritionist ◦ amenorrhea deleted ◦ Medications: SSRI’s (Prozac), Zyprexa, benzos, bowel regimen ◦ avoid Wellbutrin, TCA’s
Diagnostic Markers:
Leukopenia Elevated BUN Hypercholesterolemia Elevated LFT’s Hypomagnesmia Hypozincemia Hypophophatemia Hyperamulasemia Metabolic alkalosis Serum T4 levels low range T3 decreased Low estrogen and testosterone Sinus Bradycardia Prolonged QYC Low bone mineral denisty EEG – diffuse abnormalities Emaciation
Binge eating followed by Associated features: inappropriate behaviors ◦ Usually normal weight ◦ Menstrual irregularity to avoid weight gain Prevalence females 1 to Lack of control 5% ◦ Peaks in older DSM-5 criteria reduced adolescence and the frequency of binge to adulthood ◦ Crude mortality rate is once a week for 3 months nearly 2% per decade ◦ Risk/Prognostic features: childhood obesity early pubertal maturation
◦ Treatment: ◦ CBT ◦ Nutritionist ◦ Medications: SSRI’s (Prozac), Zyprexa, benzos, bowel regimen ◦ Avoid Wellbutrin
Duration: 6 months Symptoms: 6 (5 if age 17 and older) ◦ fails to give close attention to details/makes careless ◦ trouble holding attention on tasks or play activities ◦ does not seem to listen when spoken to directly ◦ does not follow through on instructions ◦ trouble organizing tasks and activities ◦ avoids, dislikes, or is reluctant to do tasks that require mental effort ◦ loses things necessary for tasks and activities ◦ easily distracted ◦ forgetful in daily activities.
Duration: 6 months Symptoms: 6 (5 for age 17 and older) ◦ fidgets with or taps hands or feet, or squirms in seat. ◦ leaves seat ◦ runs about or climbs in situations where it is not appropriate ◦ unable to play or take part in leisure activities quietly ◦ "on the go" acting as if "driven by a motor” ◦ talks excessively ◦ blurts out an answer ◦ trouble waiting his/her turn ◦ interrupts or intrudes on
For children 6 symptoms from either (or both) the inattention group and the hyperactivity and impulsivity criteria 5 symptoms for older adolescents and adults (over age 17 years) Symptoms present prior to age 12, compared to 7 in DSM-IV. No exclusion criteria for people with autism spectrum disorder impairment in reciprocal social communication and social interaction Restricted, repetitive patterns of behavior, interests, or activities Present from early childhood May have language impairments Motor deficits Self-injury
Prevalence: US 1%, diagnosed 4 times as much in males Differential Diagnosis: Development: recognized 12- 24 mo • Rett syndrome May develop plateaus or • Selective Mutism regression • Language disorders and May involve language delays social pragmatic Not a degenerative disorder communication disorder • Intellectual disability Risk/Prognostic factors: without autism presence/absence of spectrum, stereotypic associated intellectual disability, language movement disorder impairment, additional mental • ADHD health disorders • Schizophrenia ◦ Epilepsy ◦ Environmental – advanced paternal age, low birth weight, Comorbidity: fetal exposure to valproate • intellectual impairment • structural language d/o
SOURCE: https://www.youtube.com/watch?v=cGgz9LDnWbo Time 0:32 to 0:45 https://www.youtube.com/watch?v=a7X0UsZecA U SOURCE: https://www.youtube.com/watch?v=YYokWJYbn_Q 0:23 to 0:44 ADOS CARS Research TEACCH evaluation Autism Speaks SSRI’s for anxiety (Fluoxetine) Consider alpha-agnoist for ADHD/impulsive behaviors before a stimulant Irritability associated with Autism (Risperidone and Aripiprazole)
Child/elder abuse Conduct disorder Domestic violence Grief reaction Suicide
Definition: Child Neglect- nonaccidental physical Abandonment injury to a child ◦ Lack of supervision ◦ Failure to attend to necessary emotional or Ranges from minor psychological needs bruises to severe ◦ Failure to provide fractures or death necessary education, medical care, nourishment, shelter/and Duty to report or clothing
Prevalence: Sexual • Child Psychological abuse 25% women, Abuse: -nonaccidental verbal or 12% men symbolic acts by parent or caregiver ◦ Berating, disparaging, humiliating
Affects 10% of Suspect if: population 65 years of ◦ Bruises age ◦ Burns
◦ soiled clothes Forms: -Physical ◦ weight/nutrition issues -Sexual ◦ injuries from restraints -Psychological Be aware of: -Financial ◦ conflicting accounts ◦ previous h/o abuse by caregiver -Neglect ◦ caregiver unwilling to comply -Violation of basic with treatment plans rights ◦ caregiver won’t let patient respond
Violate rules/social norms At least 3 of the 15 criteria in past 12 months 1 present in past 6 months Aggression to People and Animals Destruction of Property Deceitfulness or Theft Serious Violations of Rules 1 year Prevalence: 2 to 10% Risk/prognostic factors: lower than average intelligence ◦ parental rejection ◦ Neglect Development: middle ◦ harsh discipline ◦ abuse, childhood to adolescence ◦ lack of supervision ◦ frequent changes of caregivers
Greater in children of biological parents with severe alcohol use disorder, depressive/bipolar disorders, schizophrenia, ADHD
Comorbidity: ◦ ADHD ◦ ODD
Treatment: ◦ Multimodal approach ◦ Stimulants ◦ Valproic acid/atypical antipsychotics for aggression ◦ SSRI’s for mood lablity/irritability
DSM 5 changes: Specify if with limited prosocial emotions
◦ Persistent yearning/longing Prevalence: 2.4 -4.8% for the deceased ◦ Intense sorrow and frequent crying Females > Males ◦ Preoccupation with the presence of severe grief decease/manner of death ◦ Marked difficulty accepting reactions that persist at death least 12 months after ◦ Distressing memories of the death of the bereaved deceased ◦ Anger over loss ◦ Maladaptive appraisals Treatment: about oneself in relation to ◦ social contact and deceased reassurance ◦ Excessive avoidance ◦ Treat true depressive sxs ◦ Distrustful of others SSRI ◦ Feel isolated ◦ Treat sleep disturbance ◦ Believe life has no meaning ◦ Benzodiazepines short- ◦ Diminished sense of identity term prn ◦ Difficulty engaging in activities
Always ask about ideation, plan, means Document risk factors, protective factors, discussion of resources Majority of completed suicides in America involve firearms 3rd leading cause of death ages 15-24 Increased risk with chronic medical illness (including chronic pain) is associated with increased risk of suicide. Women more likely to attempt suicide Men are approximately 4 times more likely to die Biggest risk factor is a prior history of suicidal behaviors or attempts. Resources: www.suicidology.org Phone: 1 (800) 273-TALK (8255) - crisis line
Dysthymia child Personality Disorder Conduct D/O Adjustment D/O Persistent Complex Bereavement Bulimia Nervosa Hypomania MDD
0 d 4d 1 wk 2 wk 4 wk 3 mo 6 mo 1 yr 2 yr
Mania Acute Stress Specific Phobia Dysthymia Panic Disorder Social Anxiety adult Brief Psychotic D/O Schizophrenia Delusional D/O Somatic Sxs Related D/O PTSD ADHD A 24 yo female reports decreased interest in hanging out with friends and difficulty getting out of her bed. Her appetite has decreased and she struggles to stay focused at work. Her symptoms worsened after her boyfriend left 8 months ago. She is sad, has contemplated suicide, and has been cutting on her arm. Which diagnosis is most appropriate?
A. Adjustment Disorder B. Major Depressive Disorder C. Persistent Depressive Disorder (Dysthymic Disorder) D. Borderline Personality Disorder A 40 year old male rarely leaves his home and reports difficulty interacting with others. He is scanning the room while talking and endorses command auditory hallucinations and past visual hallucinations of aliens. He describes anxiety about his medication being poisoned. He admits to problems being compliant with meds and in the past experienced side effects while on Haldol. What would be the next appropriate treatment?
A. SSRI B. Older generation antipsychotic C. Atypical antipsychotic D. Clozaril A 13 yo male is failing the 8th grade. His teachers describe his as fidgety and impulsive. He sometimes skips school and has been known throw desks when he is angry. He has multiple suspensions for fighting, bringing a weapon to school, and stealing. What is the most appropriate diagnosis?
A. Antisocial Personality Disorder B. ADHD C. Autism Spectrum Disorder D. Conduct Disorder DSM 5 http://www.nimh.nih.gov/health/publications/bipolar -disorder-in-adults/index.shtml http://www.clevelandclinicmeded.com/medicalpubs/ diseasemanagement/psychiatry-psychology/bipolar- disorder/ http://www.safehorizon.org/page/domestic- violence-statistics--facts-52.html http://www.nami.org/Template.cfm?Section=By_Illne ss&Template=/ContentManagement/ContentDisplay. cfm&ContentID=23041 http://wikybrew.com/issues-related-eating- disorders/ http://www.thecarlatreport.com