Академический Документы
Профессиональный Документы
Культура Документы
Submitted by:
17-M-14
34-M-14
44-M-14
65-M-14
70-M-14
PSYCHOSIS
Psychosis is a symptom, not an illness. A mental
or physical illness, substance abuse, or extreme
stress or trauma can cause it.
You may have depression, anxiety, and sleep
problems, too. It could be a struggle just to get
through your day.
You might also feel paranoid, experience
hallucinations, have trouble expressing ideas, or
slack off in your personal hygiene.
causes
Doctors do not know exactly what causes
psychosis.
In some people who have a biological
vulnerability to developing psychosis, it may be
triggered by too little sleep, some prescription
medications, and abuse of alcohol or drugs like
marijuana and LSD.
Traumatic events, like the death of a loved one or
sexual assault, can lead to psychosis in people
who are vulnerable to it
So can traumatic brain injuries, brain tumors,
strokes, Parkinson’s disease, and Alzheimer’s
disease.
Psychiatric disorders
Anxiety disorders
Bipolar disorders
Major depressive disorder
Schizophrenia
Sleep-wake disorders
Substance related disorders
ANXIETY DISORDERS
Types of Anxiety disorders
Generalized anxiety disorder (GAD)
Panic disorder
Social anxiety disorder (SAD)
Post traumatic stress disorder
(PTSD)
CLINICAL PRESENTATION
Generalized anxiety disorder (GAD)
Women are twice as likely as men to have GAD. The illness has a gradual
onset at an average age of 21 years.
Panic disorder
Recurrent unexpected panic attacks. At least one attack has been followed by
at least one month of one: 1) persistent worry about additional panic attacks
or 2) change in behavior related to the attacks.
Symptoms reach a peak within 10 minutes and usually last no more than 20 or
30 minutes.
Social anxiety disorder (SAD)
SAD is a chronic disorder with an intense fear or anxiety about one or more
social situations in which there is scrutiny by others which may result in negative
evaluation and rejection.
The fear or avoidance lasts for at least 6 months and causes significant
impairment in functioning.
Post traumatic stress disorder (PTSD)
In adults and children older than 6, there is exposure to actual or threatened
death, serious injury, or sexual violence, either directly, or by witnessing the
event(s) happening to others, learning about the event(s) happening to someone
close, or experiencing repeated or extreme exposure to details of the event(s).
Symptoms (Table 66–4) must be present longer than 1 month.
Diagnosis
Treatment
Generalized anxiety disorder (GAD)
Goals of Treatment: The goals are to reduce severity, duration, and frequency of symptoms and
improve functioning. The long-term goal is minimal or no anxiety symptoms, no functional
impairment, prevention of recurrence, and improved quality of life.
Nonpharmacologic modalities include psychotherapy, short-term counseling, stress management,
cognitive therapy, meditation, supportive therapy, and exercise. Ideally, patients with GAD should
have psychological therapy, alone or in combination with anti anxiety drugs.
Panic disorder
Goals of Treatment: The goals are complete resolution
of panic attacks, marked reduction in anticipatory
anxiety, elimination of phobic avoidance, and
resumption of normal activities.
General Approach
Educate patient to avoid caffeine, nicotine, alcohol,
drugs of abuse, and stimulants.
If pharmacotherapy is used, antidepressants, especially
the SSRIs, are preferred in elderly patients and youth.
The benzodiazepines are second line in these patients
because of potential problems with disinhibition.
Usually patients are treated for 12 to 24 months
before discontinuation is attempted over 4 to 6
months.
FIGURE 66–1. Algorithm for the
pharmacotherapy of panic disorder.
Social anxiety disorder
Goals of Treatment: The goals are to reduce the
physiologic symptoms and phobic avoidance, increase
participation in desired social activities, and improve
quality of life.
Patients with SAD often respond more slowly and
less completely than patients with other anxiety
disorders.
After improvement, at least 1 year of maintenance
treatment is recommended. Long term treatment may
be needed for patients with unresolved symptoms,
comorbidity, an early onset of disease, or a prior
history of relapse.
FIGURE 66–2. Algorithm for the pharmacotherapy of generalized social anxiety
disorder.
Post traumatic stress disorder (PTSD)
Goals of Treatment: The goals are to decrease core symptoms, disability,
and comorbidity and improve quality of life.
Bipolar disorder
Introduction
Bipolar I disorder: at least one manic episode,
which may have been preceded by and may be
followed by hypomanic or major depressive
episodes.
Bipolar II disorder: at least one hypomanic
episode and a current or past major depressive
episode.
PATHOPHYSIOLOGY
Medical conditions, medications, and treatments
that may induce mania are shown in Table 67–1.
CLINICAL PRESENTATION
Different types of episodes may occur
sequentially with or without a period of normal mood
(euthymia) between.
Major Depressive Episode
Delusions, hallucinations, and suicide attempts are
more common in bipolar depression than in unipolar
depression.
Manic Episode
Acute mania usually begins abruptly, and symptoms increase
over several days. Bizarre behavior, hallucinations, and
paranoid or grandiose delusions may occur. There is marked
impairment in functioning.
Manic episodes may be precipitated by stressors, sleep
deprivation, antidepressants, central nervous system (CNS)
stimulants, or bright light.
HYPOMANIC EPISODE
There is no marked impairment in social
or occupational functioning, no delusions,
and no hallucinations. Some patients may
be more productive than usual, but 5% to
15% of patients may rapidly switch to a
manic episode.
Goals of treatment:
Treatment
General approach
NONPHARMACOLOGIC
THERAPY
Nonpharmacologic approaches include:
1) psychotherapy (eg, individual, group, and family),
interpersonal therapy, and/or cognitive behavioral therapy,
2) stress reduction techniques, relaxation therapy, massage, and
yoga,
3) sleep (regular bedtime and awake schedule; avoid alcohol or
caffeine intake prior to bedtime),
4) nutrition (regular intake of protein-rich foods or drinks and
essential fatty acids; supplemental vitamins and minerals), and
5) exercise (regular aerobic and weight training at least three
times a week).
PHARMACOLOGIC THERAPY
MAJOR DEPRESSIVE DISORDER
Major Depressive disorder
The essential feature of major depressive disorder is a clinical course
characterized by one or more major depressive episodes without a
history of manic or hypomanic episodes.
CLINICAL PRESENTATION
Emotional symptoms: diminished ability to experience pleasure, loss
of interest in usual activities, sadness, pessimism, crying,
hopelessness, anxiety (present in ~90% of depressed outpatients),
guilt, and psychotic features (eg, auditory hallucinations and
delusions).
Physical symptoms: fatigue, pain (especially headache), sleep
disturbance, decreased or increased appetite, loss of sexual interest,
and gastrointestinal (GI) and cardiovascular complaints (especially
palpitations).
Intellectual or cognitive symptoms: decreased ability to concentrate
or slowed thinking, poor memory for recent events, confusion, and
indecisiveness.
Psychomotor disturbances: psychomotor retardation (slowed physical
movements, thought processes, and speech) or psychomotor agitation.
DIAGNOSIS
Major depressive disorder is characterized by one or more major
depressive episodes , as defined by the Diagnostic and Statistical
Manual of Mental Disorders, 5th ed.
Five or more of the following must have been present nearly every
day during the same 2-week period and cause significant distress
or impairment:
Depressed mood;
Diminished interest in almost all activities;
Weight loss or gain;
Insomnia or hypersomnia;
Psychomotor agitation or retardation;
Fatigue or loss of energy;
Feelings of worthlessness or excessive guilt;
Diminished concentration or indecisiveness;
Recurrent thoughts of death, suicidal ideation without a specific plan,
suicide attempt, or a plan for committing suicide.
Continue..
The depressive episode must not be attributable to
physiological effects of a substance or medical
condition. Lastly, there must not be a history of
manic-like or hypomanic-like episodes unless they
were induced by a substance or medical condition.
Diagnosis requires a medication review, physical
examination, mental status examination, a complete
blood count with differential, thyroid function tests,
and electrolyte determinations.
Many chronic illnesses and substance abuse and
dependence disorders are associated with
depression. Medications associated with depression
include many antihypertensives, oral contraceptives,
isotretinoin, interferon-β1a, and many others.
TREATMENT
Goals of Treatment: The goals are to reduce
symptoms of depression, minimize adverse effects,
ensure adherence to the prescribed regimen,
facilitate return to premorbid functioning, and
prevent further depressive episodes.
NONPHARMACOLOGIC TREATMENT:
Psychotherapy may be first-line therapy for mild to
moderately severe major depressive episode. The
efficacy of psychotherapy and antidepressants is
considered to be additive.
Psychotherapy alone is not recommended for acute
treatment of severe and/or psychotic major
depressive disorder.
Continue..
Electroconvulsive therapy (ECT) is a safe and effective
treatment for major depressive disorder. It is considered
when a rapid response is needed, risks of other
treatments outweigh potential benefits, there is history
of a poor response to drugs, and the patient prefers
ECT. A rapid therapeutic response (10–14 days) has
been reported.
Repetitive transcranial magnetic stimulation has
demonstrated efficacy and does not require anesthesia
as does ECT.
PHARMACOLOGIC THERAPY
General Approach: