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Definition of Mental Disorder (DSM-5)syndrome characterized by significant disturbance in an individual's COGNITION, EMOTION REGULATION, or BEHAVIOR that reflects a dysfunction in psychological, biological, or developmental processes underlying mental functioning. Associated with SIGNIFICANT DISTRESS OR DISABILITY IN SOCIAL, OCCUPATION, OR OTHER IMPORTANT ACTIVITIES
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Components of MSE (Mental Examination Exam):1) General appearance and behavior2) Mood and affectivity3) Speech characteristics4) Thoughts5) Perception6) Sensorium and Cognition7) Judgement and Insight
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General Description:Part of MSElook for:1) Appearance2) Behavior3) Psychomotor activity4) Attitude
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Mood and Affectivity:Part of MSElook for:1) Mood 2) affect3) appropriateness (to situation, does face match what is being said?)4) Range5) Mobility6) Reactivity
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Speech/Thought:Part of MSElook for:1) speech characteristics2) Thought process (ex: formal thought disorder)3) Though content (ex: delousions)4) Depressive cognitions, anxiety, phobias, obsessions, SI
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Formal Thought Disorder:What the person says does not make sense compared to the normal thought process which is logical and goal oriented. EX:Loosening of associations (no connection between sentences)Tangentiality (goes on tangent)Derailment (shift in speak)Word Salad / incoherence (speak gibberish)Circumstantiability (gives tedious details about everything)
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Perception:Part of MSE1) Hallucinations2) Illusions
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Sensorium and cognition:Part of MSElook for:1) level of consciousness2) Attention and concentration3) Orientation and memory4) language, reading, writing5) Visuospatial ability6) Abstraction7) General Fund of information
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Judgement and Insight:Part of MSE:Test judgement / social judgement / clinical judgement Grades of insight (what is person's understanding of known illness)
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Affectan immediate expression of emotion (ex: it is the weather, where as mood is the climate)
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Disturbances of Affect:1) Blunted - reduction in expression2) Flat - absent expression3) Inappropriate - discordance between expression and content of speech4) Labile - abnormal variability with rapid shifts
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Mood:emotional experience over a more prolonged period of time (ex: mood is climate where as affect is weather)
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Formal Thought Disorder:Involves:IncoherenceLoose associationsTangentialityDerailmentCircumstantialityFlight of ideas
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Delusion:A firm and fixed false belief that is held with firm conviction in spite of evidence of the contrary and not in keeping with the person's religious and/or cultural beliefs
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Types of Delusions:1) Bizarre2) Jealousy3) Erotomanic4) Grandiose5) Persecutory (most common)6) Somatic (feelings on body parts)7) Thought insertion (think others put thoughts in their head)8) Thought broadcast (think others know about my thoughts)
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Hallucinations:Perception in the absence of external stimulus
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Types of Hallucinations:1) Auditory (most common)2) Visual (inorganic brain disease)3) Tactile4) Olfactory (inorganic brain disease)5) Gustatory
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AnxietyApprehensive anticipation of future danger or misfortune accompanied by a feeling of worry, distress and/or somatic symptoms of tension
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Panic:Discrete periods of sudden onset of fear or terror, often associated with FEELINGS OF IMPENDING DOOM
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Obsessions:Recurrent, persistent, thoughts, urges or images that are experienced as INTRUSIVE AND UNWANTED, and it causes ANXIETY
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Compulsions:Repetitive behaviors or mental acts that the individual feels driven to perform in response to obsession.These are done to reduce anxiety produced by obsessions.
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Depersonalization and Derealization"As if" phenomenonFeeling detachedFeeling like an outside observer
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Phobiapersistent fear of a specific object, activity or situation THAT IS OUT OF PROPORTION TO THE ACTUAL DANGER posed by the specific object, activity or situation and a compelling desire to avoid it. Impacts the person life
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Neurocognitive Disorders (3 broadly defined syndromes)1) Delirium2) Major Neurocognitive Disorders3) Mild Neurocognitive Disorders
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DeliriumCharacterized by disturbance in ATTENTION (reduced ability to direct, focus, sustain and shift attention) and AWARENESS (reduced orientation to the environment) that develops over a short period of timeAcute onset, fluctuating course, impairment of attention is associated with global impairment of cognitive functions (memory deficits, disorientation, language and perception)
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Types of Deliriumsubstance withdrawal deliriummedication-induced deliriumdue to another medical conditiondue to multiple etiologiesif acute: hours to daysif persistent: weeks to months (not common)
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medical conditions commonly associated with deliriumCNS disorderMetabolic disorderCardiopulmonary disorder (oxygenation deficit to brain)Sepsis/ infectionsystemic illness
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Delirium Types (3)1)Hyperactive- hyperactive level of psychomotor activity may be accompanied by mood lability, agitation, and/or refusal to cooperate with medical care2)Hypoactive - Most common; hypoactive level of psychomotor activity that may be accompanied by SLUGGISHNESS AND LETHARGY that approaches to stupor. 3) Mixed level of activity - individual has normal level of psychomotor activity even though attention and awareness are disturbed. Activity levels may also rapidly fluctuate.
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Clinical Features of Delirium:DISTURBANCE IN ATTENTION OR AWARENESSacute onset, fluctuating symptomsConfusion, disorientation, illusions/hallucinations, emotional disturbance (apathy, anxiety, fear), emotional disturbance may manifest calling out, screaming, shouting, disturbed sleep awake cycle
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Major Cognitive Disorders:Evidence of significant cognitive decline from previous level of performance in one or more of the 6 cognitive domains, based on history and neuropsychological testing:1) complex attention (sustained, divided and selective attention + processing speed)2) Executive function (planning, decision making, inhibition, mental flexibility)3) Learning and Memory (immediate, recent, remote, new learning, declarative, implicit)4) Language5) Perceptual motor (visual perception, visuo-constructual, praxis, diagnosis)6) Social cognition (behavior i out of norm, difficulty recognizing emotions)COGNITIVE DEFICITS MUST INTERFERE WITH EVERYDAY ACTIVITIES!!and not due to delirium and not explained by another medical disorder
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Subtypes of Major Neurocognitive Disorders:Alzheimer's, Vascular Disease, FTLD, TBI, Lewy Body disease, Parkinson's, HIV infection, Substance Use, Huntington's Disease, Prion Disease
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Difference between Major and Mild Neurocognitive Disorders?Major Neurocognitive Disorders impair activities of daily living (ADLs) and instrumental activities of Daily Living
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Clinical features of Neurocognitive Disorders:Disturbance in the SIX domainsInsidious onsetgradual progressionPatients are adept at minimizing their symptomsCollateral history is importantALWAYS assess ADLs and IADLs
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Dementia work up:CT headTSHRPRB12, Folate levels
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Levels of Consciousness:Alertness- awake and fully aware of stimuliLethargy - not fully alert, drifts to sleep when not actively stimulatedObtundation - difficult to arouse and when aroused patient is confusedStupor - patient responds only to vigorous stimulationComa - completely unarousableAssess with Glasgow Coma Scale
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Attentionability to attend to a specific stimulus w/o being distracted by extraneous stimuli
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Concentrationability to sustain attention over a sustained period of time
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Evaluation of attention and concentrationDigit repetitionRandom letter test serial subtractionspell "world" backwardsAnatomical localization: ascending reticular activating system
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Assessment of Cognitive Functions:1) Level of consciousness2) Attention3) Language4) Memory5) Constructional ability6) higher cognitive function (fund of information, calculation, proverb interpretation)
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Dysarthriadisorder of articulation
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Dysprosodyloss of speech melody (ex: monotone)
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Aphasiaimpaired production / comprehension of spoken language
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Alexialoss of reading ability in a previously literate person
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Agraphiaacquired disturbance of writing
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Evaluation of languagehandednessspontaneous speechcomprehensionrepetition (no ifs ands or buts)namingreadingwriting
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Paraphasiaword or syllable substitution
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Global AphasiaError in comprehension and production of speech
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Conduction aphasiadisproportionate deficit in repetition; lesion in arcuate fasciculus and left parietal region
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Transcortical aphasiaintact repetition; disruption of language functions
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Anomic aphasiainability to name
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Memoryprocess that allows an individual to store information for later recall3 stages: registration, encoding, recall
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3 types of memory1) Immediate, short term2) Recent3) Remote
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Evaluation of memoryDigit repetition (immediate memory)New learning ability (short term)recent memory (orientation)Remote memory (historical facts about patient experiences)
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Localization of Immediate memory:any condition in which there is impaired attention (ex: encephalopathy)
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Localization of recent memorymamillary bodies, medial temporal lobe, hippocampus, dorsal medial thalamic nuclei
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Localization of remote memoryAssociation cortex
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Constructional abilityability to draw or construct two or three dimensional figures or shapesconstructional tasks are extremely sensitive in detecting organic brain disease
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Assessment of constructional abilitycopying geometric shapesdrawing on command3D block construction
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Constructional ability localization:Parietal lobeRight Parietal Lobe lesions produce higher incidence and greater severity of defect than left parietal lobe lesions
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Other higher cognitive functionsFund of informationCalculation (parietal)Proverb interpretation (frontal)Social judgement (frontal)
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Apraxiaacquired disorder of learned, skilled, sequential movements that cannot be accounted for by elementary disturbances of strength, coordination or lack of comprehension or attention.INABILITY TO CARRY OUT MOTOR COMMANDS IN THE ABSENCE OF ANY GROSS MOTOR DEFICIT
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Gerstmann's Syndrome1) Finger agnosia2) Right-Left disorientation3) Dysgraphia4) DyscalculiaParietal lobe lesions- dominant or bilateralANGULAR GYRUS
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Most common types of dementia (3)ADVascularLewy Body
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Eating Disorderscharacterized by a persistent disturbance of eating or eating related behavior that results in altered consumption or absorption of food and significantly impairs physical health or psychosocial functioning (patients judge how they look)
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Feeding disorders (3):PicaRumination DisorderAvoidant/Restrictive Food intake Disorder
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Eating Disorders (3)Anorexia NervosaBulimia NervosaBinge Eating Disorder
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Picapersistent eating of nonnutritive, non food substances for over a period of 1 monthEx: paper, soap, cloth, chalk, hair, stringInappropriate to developmental levelNot culturally supportedOften associated with Intellectual Disability
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Rumination DisorderRepeated regurgitation of food over a period of at least 1 month (bringing up their food without effort)Regurgitated food is swallowed or spit outNot due to medical conditionNOT OCCURRING EXCLUSIVELY during Anorexia, Bulimia, or BED
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Avoidant/Restrictive Food Intake DisorderAvoiding food due to lack of interest in eating / avoiding food based on sensory characteristics (color, taste, texture)Weight loss / nutritional deficiency / dependence of enteral supplementsDoes not occur exclusively during AN or BNTHERE IS NO BODY IMAGE DISTURBANCEOften associated with Intellectual Disability, Autistic Spectrum Disorder, and phobias about choking
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Anorexia NervosaRestriction of energy intake leading to SIGNIFICANTLY LOW BODY WEIGHTIntense fear of gaining weight or becoming fat, even though underweightDisturbance in the way in which the body is shaped (patient always checks their weight)Two subtypes
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Anorexia Nervosa Types:1) Restrictive - worst prognosis2) Binge-eating / purging type - binge and then try laxatives or purgingDistribution is 50-50 and there is crossoverSeverity of illness is based on BMI
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Anorexia Nervosa EpidemiologyHigh risk group is adolescent girls and young women10-20 X more common in women, more frequent in professions that require thinnessmore frequent in caucasians
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Anorexia Clinical Triad1) self-induced starvation to a significant degree2) relentless drive for thinness or a morbid fear of fatness3) presence of medical signs and symptoms resulting from starvation
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Anorexia Clinical featurespts control what they eatdrastic reduction in food intakerefuse to eat with families or in public spacesPreoccupation with food - cooking, collecting recipesPeculiar behaviors - hiding food, carrying candy in pocketsRitualistic behaviorsbinging followed by self-induced vomiting, diuretic and laxative abuse
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Anorexia Medical Complications form reduced eating:HypothyroidismHypothermiaLoss of cardiac muscle, PVC, bradycardiaConstipation, abdominal painamenorrhea, low LH and FSHLanugo (thin hair in back of neck), dry skinOsteoporosis (IRREVERSIBLE)Abnormal tasteMild cognitive impairment
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Anorexia Medical Complications form purging:Electrolye abnormalities (low K, hypochlormemic alkalosis, low Mg)Salivary gland and pancreatic inflammation, increase in amylase (swelling of parotid glands)Erosion of dental enamelSeizures
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Anorexia course and prognosiscourse is variableRestrictive type has poor prognosisamong highest mortality rates of all mental illnessesMortality rates are high
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Anorexia Rx:Nutritional Rehab (weight gain 2-3 lbs per week)Psychotherapy (CBT, family therapy, self help groups)Pharmacotherapy (Cyproheptadine and other antihistamines, limited role of antidepressants like mirtazepine, TCA, fluozetine
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Bulimia NervosaBulimia- means binge eatingdistinguishing feature from AN is that ATTEMPTS TO RESTRICT FOOD ARE PUNCTUATED BY BINGES COMPENSATED BY PURGING AND/OR LAXATIVE ABUSEThere is loss of control over eating and is followed by guilt
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Bulima Nervosa DSM-5Recurrent episodes of binge eating: 2 hr period of excessive food intake and loss of control while eating. Recurrent inappropriate compensatory behaviorAbove occurs once a week for at least 3 mosself evaluation influenced by body shapedoes not occur exclusively during episodes of anorexiaSeverity is defined in terms of episodes of compensatory behavior per week
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BN Clinical Features:more prevalent than ANonset in adolescence or young adult hoodmost patients are within normal weight range or slightly overweightmenstrual irregularitiesmedical complications due to purging or laxative abusecross over between AN and BNPATIENTS REGARD BEHAVIOR AS MORE EGO DYSTONIC
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BN Etiologyless heritability than ANincreased childhood and parental obesityearly menarcheparental alcoholismincreased Hx of childhood abuse
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BN medical complicationsMostly secondary to purging or laxative abuseElectrolyte imbalancearrhythmiasdental erosions
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BN co-morbiditydepressionsubstance abuseimpulse control disordersBipolar affective disorderDissociative disorders
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BN Rx:1) CBT is effective2) antidepressants have anti-bulimic effect
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Binge Eating Disorder (BED)recurrent episodes of binge eating (eating food that is definitely larger than what most people would eat over a discrete period of time plus a sense of lack of control)most common eating disordereating more rapidly / eating til uncomfortably full / eating when not hungry / eating alone or embarrassment / guiltAT LEAST ONCE A WEEK FOR 3 mos; NO COMPENSATORY BEHAVIOR
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BED Co-morbidities:Anxiety disordersdepressionsubstance abuseDisorder is more prevalent among those seeking weight loss treatmentCross over not commonMedical complications related to obesity
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CBT for eating disorders:for Bulima Nervosa and Binge Eating Disorder
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Family based treatment for eating disorder:Good for adolescent anorexia nervosa
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Personality:enduring pattern of perceiving, relating, and thinking about the environment and oneself that is seen in a wide range of social and personal situationsIt is: stable, predictable, flexible and adaptable
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Personality Disorder:ENDURING PATTERN OF INNER experiences and behavior that deviate from cultural standards. Manifested as: Cognition, affect, interpersonal functioning, impulse controlPattern is rigidly pervasiveOnset in adolescence and the behavior pattern is stable and of long durationSignificant distress and / or impairment in social, occupational functioning
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Personality Disorder Clusters (3)A: ODD (paranoid, schizoid, schizotypical)B: SAD (antisocial, borderline, histrionic, narcissistic)C: Anxious (avoidant, dependent, obsessive-compulsive)
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Paranoid personality Disorder:Person has no psychotic delusions but is suspicious and bears grudgesFeatures: Suspects that he is being exploited or deceived, doubts loyalty or trustworthiness of friends, reluctant to confide, reads hidden meaning, bears grudges, perceives attack on his reputation and is quick to react and counterattack, argumentative, difficult to get along, suspicious about spouses fidelity. Life-long disorder may go on to have schizophrenic breakdownMore common in males, minorities, immigrants, and deaf, patients with schizophreniaDifferential: Schizophrenia, Delusional DisorderTx: Psychotherapy is 1st choice; pharmacotherapy has limited role (antianxiety and neuroleptics)
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Schizoid Personality DisorderPerson NEITHER DESIRES NOR ENJOYS CLOSE RELATIONSHIPS, always chooses SOLITARY ACTIVITIES, no interest in having a sexual relationship, NO CLOSE FRIENDS, indifferent to praise or criticism, emotional detachment, less likely to be involved in activitiesMore common in males, onset in early childhood, Lifelong courseDifferential: Paranoid PD, Schizotypical PD, SchizophreniaRx: Psychotherapy 1st choice, Neuroleptics, Benzos, SSRI's
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Schizotypal Personality Disorder:Person has a pattern of social interpersonal beliefs with reduced capacity for close relationships AND cognitive and perceptual distortions:Ideas of reference, odd beliefs (UFO's, black magic), Unusual perceptual experiences, odd thinking, suspicious, Inappropriate or constricted affect, Behavior or appearance that is odd (wear all black in hot weather), BRIEF PSYCHOTIC EPISODESmore likely in relatives of schizophrenia, 10% risk of suicide, schizophrenic breakdownDifferential: Schizophrenia, Paranoid PD, Borderline PDRx: Pharmacotherapy (1st choice, neuroleptics), Psychotherapy is difficult
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Antisocial Personality Disorder:In cluster B; person has pervasive pattern of DISREGARD FOR RIGHTS OF OTHERS, inability to conform to social norms, multiple and continuous criminal acts, impulsivity or failure to plan ahead, physical fights or aggressiveness, lack of remorse. HISTORY OF CONDUCT DISORDER IN CHILDHOOD IS NEEDED.common in males (FH is 5x more likely), wide spectrum of people and professions, mellow with age, graduate to other psychiatric disorders (depression, substance abuse, somatic symptom disorders)Diffirential: Substance abuse disorders, mania, ADHD, mental retardationRx: Treat co-morbid psychiatric disorders, self help groups, psychotherapy, antiepileptic, B-blockers for aggression
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Borderline Personality DisorderCluster B; person has a pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by EARLY ADULTHOOD and present in a variety of contexts. IMPAIRED CAPACITY TO FORM STABLE INTERPERSONAL RELATIONSHIPSaffective instability (rapid mood swings), impulsivity, identity disturbance (chronic boredom or emptiness), recurrent manipulative suicidal and parasuicidal behaviors (cutting behavior), idealization/devaluation (splitting- let me tell you something i've never told anyone before), fear of abandonment, brief psychotic episodes under stress
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Borderline Personality Disorder EpidemiologyMore common in women, genetic factors, adverse childhood events reported, severity of abuse related to severity of symptomsNeurobiological findings in: anterior cingulate cortex, prefrontal cortex, hippocampus, amygdala
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BPD Rx:Psychotherapy: Dialectical Behavior Thearpy (DBT)Pharmacotherapy: symptom focused- neuroleptics (though disturbances), SSRI's (dysphoria), Valproate (mood swings)
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Dialectical Behavior Therapybased largely in behaviorist theory with some cognitive therapy elements; weekly individual and group session and available telephone consultations4 essential parts: DBT skills training group, DBT individual therapy, DBT phone coaching, therapy for DBT therapist consultation team and providers
