INFORMATION ABOUT PSYCHIATRIC DISORDERS

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Depression

Major depression, or "clinical depression," is a mood disorder characterized by the presence of five or more of the followingsymptoms during a period of at least 2 weeks and resulting in significant distress and/or problems with functioning:

-depressed mood much or most of the time

-markedly diminished interest in usual activities

-change in appetite and/or weight -insomnia or excessive sleeping

-marked agitation/restlessness or slowing of thoughts and movement observable by others

-diminished energy

-feelings or worthlessness or excessive guilt

-impaired concentration or unusual indecisiveness

-recurrent thoughts of death or suicide

 

Untreated depression may last from a few months to over a year (and sometimes many years). Treatment of depression may include psychotherapy, antidepressant medications, or both. More severe cases of depression tend to require medication treatment, whereas patients with mild-to-moderate depression may improve significantly with psychotherapy. The best evidence-based psychotherapy is cognitive behavioral therapy (CBT).

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Bipolar Disorder

​​Patients with bipolar disorder experience manic (or "hypomanic," or milder manic) episodes and depressive episodes. Manic episodes typically last at least a week, and are defined by the presence of at least 3 of the following symptoms:

-euphoric and/or irritable mood

-inflated self-esteem

-diminished need for sleep, such that one feels normal or better than normal energy after only a few hours of sleep

-increased talkativeness

-distractibility

-flight of ideas, observed by others as a tendency to have one's thoughts jump rapidly from one topic to another

-increased activity (work, cleaning/organizing)

-uncharacteristic irresponsible behaviors (shopping sprees, casual sexual encounters, impulsive financial decisions)

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In severe cases, patients may experience auditory or visual hallucinations or experience delusions.

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Hypomanic periods appear similar in symptom type, but may last only 4 days, and are of lesser severity.

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These "elevated mood" periods are the defining feature of bipolar disorder, rather than "mood swings." They may occur several times a year or only once every few or several years. Rapid cycling refers to the occurrence of 4 or more mood episodes per year.

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Mood stabilizing medications (lithium, lamotrigine, valproic acid, quetiapine, etc.) are the mainstay of bipolar disorder treatment. These are medications that have been found to reduce the frequency of manic and depressive episodes. Cognitive-behavioral psychotherapy, focusing on recognizing and modifying thoughts and behaviors leading to occurrence and maintenance of mood episodes, can greatly improve bipolar disorder symptoms.

 

 

Obsessive-Compulsive Disorder (OCD)

Patients with OCD have recurrent irrational obsessional thoughts about some potential harm or situation (e.g., getting sick because of contact with germs; inadvertently harming someone). Because of the irrational fear thought, they experience significant anxiety. In order to relieve this anxiety, they engage in compulsive behaviors to prevent the feared adverse event, or they may check to make sure that the harm has not happened already. For instance, patients with an irrational fear of germs may compulsively wash their hands whenever they touch any surface (doorknob, another person's hand) that they fear could transmit illness. These compulsive behaviors may consume a great deal of time and energy. Alternatively, patients with OCD may avoid situations where they fear harm to themselves or others could occur. Unfortunately, all of these behavioral responses reinforce and validate the fear. 

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While many people have occasional OCD symptoms, diagnosis of OCD requires that the symptoms are sufficiently severe as to cause significant distress or functional impairment (problems with school/work/relationships). The staple of OCD treatment is a form of cognitive-behavioral therapy called exposure and response prevention, or ERP. The basic theory of ERP is that OCD is essentially a disorder of the brain's fear response system; obsessions are irrational fears. When patients engage in compulsions to neutralize the fears, they reinforce and validate the dysfunctional fear circuits in the brain. In ERP, patients effectively re-wire the fear centers of the brain. This rewiring occurs as patients are encouraged to systematically confront the fearful obsessional thoughts (this is the "exposure" part of ERP) while resisting the urge to engage in the reassuring compulsive behaviors (this is the "response prevention"). This process rewires the brain's fear circuits such that the obsessional thoughts no longer produce marked distress and thus no longer necessitate the compulsive behaviors. For some patients with more severe OCD, medication therapy using antidepressants medications (usually SSRIs, which increase serotonin activity), anti-anxiety medications, or other options may be needed. In many cases, patients with OCD realize that their fears are irrational, but in cases where such insight is lacking, antipsychotic medications (e.g., aripiprazole, quetiapine) may be necessary.

 

 

Panic Disorder

Panic disorder is an anxiety disorder characterized by recurrent unexpected panic attacks, or spikes of anxiety. Patients with this disorder feel that the panic attacks happen for no reason, unrelated to specific fears. The symptoms of a panic attack result from activation of the body's fear response, sometimes called the "fight or flight" reaction.

 

Symptoms of a panic attack include pounding heart, sweating, trembling, shortness of breath, chest pain or discomfort, nausea or abdominal discomfort, light-headedness, feeling cold or hot, tingling or numbness, depersonalization/derealization (feeling disconnected from oneself, as though looking at self from outside), fear of going losing control or going crazy, fear of having a stroke/heart attack or dying. While over 70% of the population will experience a panic attack at some point in their lives, in most cases, people can identify the cause of the panic (a specific worry or fear thought), and therefore do not fear them.

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For patients with panic disorder, however, their panic attacks seem to occur without clear triggers. Thus, patients fear that panic attacks can occur at any time without warning. Panic disorder is thus a disorder of the brain's natural fear system wherein the person fears the experience of anxiety itself. Since panic attacks are frightening and potentially embarrassing, patients with panic disorder change their behavior in order to avoid having panic (e.g., not driving in certain places; avoiding crowds and closed spaces like elevators or planes; avoiding places where escape is difficult like hair salons or movie theaters). These changes can significantly impact functioning at work and in one's personal life. Treatment of panic disorder consists of cognitive-behavioral therapy (CBT) and possibly medications. Through a structured CBT protocol, patients work to modify the fear circuitry of the brain. Medications such as antidepressants (especially SSRIs such as lexapro and zoloft) can improve panic disorder symptoms, but patients who complete a course of CBT treatment experience the best long-term results.

 

 

Social Anxiety Disorder

Patients with social anxiety disorder experience marked anxiety about situations where they anticipate negative scrutiny by others. Situations may include eating in a restaurant, walking in public, interacting with a store clerk, or social events. The anxiety associated with these situations causes significant distress and/or problems with work or relationships. Social anxiety disorder, like other disorders characterized by excessive anxiety, occurs because brain's fear system is overactive and perceives danger in routine social situations activating the fight-or-flight response. Because of this excessive anxiety, patients with social anxiety become avoidant, thus limiting functioning in their school, work and social lives. Cognitive-behavioral therapy (CBT) helps to re-wire the fear circuits. he behavioral element of CBT entails systematic graduated exposure to the feared situations and desensitization to the associated anxiety, resulting in re-setting of the fear circuitry. Medications may facilitate the work of CBT. Commonly used medications include antidepressants (particularly SSRIs) and beta-blocker drugs (to mute the effect of adrenaline). 

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Generalized Anxiety Disorder (GAD)

Patients with GAD are chronic worriers. Diagnosis requires experience of excessive worry and anxiety most days for at least 6 months. Patients report great difficulty in controlling the worry, which may involve job, finances, safety/health of family and even minor chores/errands. In order to be diagnosed with GAD, patients must also experience 3 or more of the following:

-physical symptoms such as increased muscle tension, insomnia, restlessness, or fatigue

-cognitive/emotional symptoms such asirritability or impaired concentration.

Treatments include antidepressant medications and cognitive-behavioral therapy (CBT).

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Attention Deficit Hyperactivity Disorder (ADHD)

ADHD is a disorder, which begins in childhood, characterized by impaired attention, hyperactivity and impulsivity. Patients may have primarily inattention problems, primarily hyperactivity symptoms, or both. In order to be diagnosable, the symptoms must be of sufficient severity to cause significant distress or impair functioning at work/school or in relationships. If symptoms seem to worsen in adulthood, it is likely that associated mood or anxiety symptoms or a sleep disorder are contributing to the symptoms. Psychoactive substances such as cannabis may also impact the brain circuits related to ADHD. A comprehensive diagnostic assessment should be conducted to elucidate the cause of ADHD symptoms. Treatment usually consists of drugs that modulate levels of the brain chemicals norepinephrine and dopamine (e.g., atomoxetine, guanfacine, clonidine, methylphenidate, dextroamphetamine). Cognitive-behavioral therapy (CBT) may also be helpful in ADHD.

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IIInsomnia

While occasional, transient sleep disturbances are common, a diagnosis of insomnia is reserved for individuals who experience persisting problems with falling or staying asleep. A diagnosis of insomnia is considered if a person experiences problems with falling or staying asleep at least 3 days per week for at least 3 months. Insomnia may be a symptoms of anxiety or depression, but it may also be an independent problem without other associated symptoms. In either case, many patients with significant insomnia develop anxiety about sleeplessness. Such anxiety about sleep, together with behaviors undertaken to combat the insomnia, may exacerbate the problem and contribute to its persistence. Treatment may consist of cognitive-behavioral therapy (CBT) alone, medications alone, or combined CBT and medications. CBT targets the worry thoughts about not sleeping and behaviors through a combination of education about sleep biology; relaxation strategies; sleep restriction; modifying behaviors affecting night-time sleep (napping; watching t.v. in bed). 

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Schizophrenia

Patients with schizophrenia experience "psychotic" episodes, lasting from a few days to several weeks or months. "Psychotic" symptoms include hallucinations (usually auditory), delusions (fixed false beliefs such as being convinced that there is an elaborate conspiracy to cause one harm); or markedly disturbed thought process such that the logical coherence between thoughts is lacking. When psychotic episodes have resolved, patients display "negative symptoms," such as diminished emotional responsiveness; lack of initiative/interest. Antipsychotic medications constitute the primary treatment for schizophrenia. Because these drugs have significant potential adverse effects, careful monitoring for side effects is a critical part of appropriate treatment. Some psychotherapy approaches, specifically cognitive-behavioral therapy (CBT) and skills training may be beneficial in improving functioning, quality of life and symptom control.

 

 

Dementia/Neurocognitive disorders

The term "dementia" (replaced in current psychiatric diagnostic manual DSM-5 by "major neurocognitive disorder") refers to a deterioration in at least two of the following domains of cognitive function: attention, memory, executive (planning, insight), social cognition, language. The decline in function results in significant impairment in one's ability to live independently. The most common cause of dementia is Alzheimer's disease. Other types of dementia include vascular dementia, which results from damage to brain cells due to disturbances in blood flow (from one or more large strokes or cumulative damage from small"silent" strokes); dementia due to Parkinson's or Lewy body disease; frontotemporal dementia.

 

Sometimes other conditions may mimic dementia. For example, in some cases of severe depression in older adults, patients may manifest profound cognitive impairments of the sort seen in dementia, in a condition referred to as "pseudodementia."Furthermore, certain medical conditions such as thyroid disease, vitamin B12 and folic acid deficiencies, and normal pressure hydrocephalus (NPH) can result in cognitive abnormalities as seen in dementia. Finally, acute medical or physiological disturbances such as bladder infections or other illnesses and medications may give rise to mental status changes resembling dementia. Accordingly, when symptoms of dementia are observed, a detailed clinical evaluation by a geriatric psychiatrist is important. Assessment will likely include review of laboratory tests, brain scans, and review of clinical history. In suspected Alzheimer's, analysis of cerebrospinal fluid or amyloid brain scans can provide more definitive evidence supporting the diagnosis. In the near future, special blood tests may become available to assist in diagnosis of Alzheimer's. 

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Treatment depends on the presumed type of dementia. At present, there are FDA-approved treatments only for Alzheimer's and Parkinson's disease-related dementias. The cholinesterase inhibitor medications (Aricept, Exelon, Reminyl) can be helpful for mild Alzheimer's and Parkinson's though only Exelon is approved for the latter. Namenda is approved for moderate to severe Alzheimer's. The utility of these medications in other dementias is less clear. Overall, these drugs seem to have some mild benefit in improving attention and memory, but their impact tends to be modest overall. More recently, the FDA has approved intravenous antibody treatments for early Alzheimer's, but long-term studies are lacking and they carry risk of brain bleeds.

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Since mood (anxiety, depression), behavioral disturbances (combativeness with caregivers), insomnia and psychotic symptoms (e.g., paranoia, hallucinations) are common as dementia progresses, other types of medication therapy such as antidepressants, sleep enhancers, and antipsychotics may be needed. These medications may have adverse effects, so careful review of risks/benefits and monitoring for side effects is crucial.