SOC 204 Goldberg Ch 10
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Goldberg Chapter 10 Psychotherapeutic Drugs
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SOC 204 Goldberg Ch 10
- 2. WHAT PERCENTAGE OF PEOPLE WITH A MENTAL ILLNESS SEEK PROFESSIONAL HELP FOR THEIR ILLNESS? A. 90% B. 55% C. 40% D. 10% 16% 20% 44% 20% 90% 55% 40% 10%
- 3. MENTAL DISORDERS Medical Model APA Diagnostic and Statistical Manual of Mental Disorders (DSM5)
- 4. DSM-V CRITERIA B. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). Source: DSM-V, American Psychiatric Association
- 5. EARLY TREATMENT OF MENTAL DISORDERS Syphilitic Infection Early drug therapy Insulin-shock therapy Electroconvulsive therapy Sedatives
- 6. ALTHOUGH THE EFFECTIVENESS OF ANTI-DEPRESSANT MEDICATIONS IS ONLY SLIGHTLY HIGHER THAN PLACEBOS, MOST PATIENTS BELIEVED THEY ARE HELPED BY THESE MEDICATIONS. A. True B. False True 0% False 100%
- 7. ANXIETY DISORDERS Generalized Anxiety Disorder Panic disorder Phobias Other related disorders Obsessive Compulsive Disorder Post-traumatic Stress Disorder
- 8. ANXIETY VIDEOS Panic Attack: http://digital.films.com/PortalViewVideo.aspx?xtid=6788 OCD: http://digital.films.com/PortalViewVideo.aspx?xtid=41357
- 9. MEDICATIONS FOR ANXIETY Long-acting benzodiazepines
- 10. MOOD DISORDERS Major Depression Manic Episodes Bipolar Disorder
- 11. MOOD DISORDER VIDEOS Manic episode: http://youtu.be/p9hbXPVaOuk Depressive episode: http://digital.films.com/PortalViewVideo.aspx?xtid=41085#
- 12. BEFORE GIVING ANTIDEPRESSANTS TO CHILDREN: A. The medications were tested for effectiveness B. The medications were tested for safety C. The medications were not tested on children 8% 35% 58% The medications were te... The medications were te... The medications were no...
- 13. MEDICATIONS FOR MOOD DISORDERS Antidepressants Monoamine Oxidase Inhibitors Tricyclic Antidepressants Selective Serotonin Reuptake Inhibitors Electroconvulsive therapy (not medication) Mood stabilizers
- 14. SCHIZOPHRENIA Psychosis Diagnostic Criteria • Delusions • Hallucinations • Disorganized Speech • Disorganized Behavior • Negative Symptoms
- 15. THE NUMBER OF CHILDREN TAKING ANTIPSYCHOTIC DRUGS HAS INCREASED IN THE US. IN EUROPE: A. Rates have slightly increased as well B. Rates have remained the same C. Rates have decreased D. Rates have increased at an alarming rate, doubling the numbers 78% 7% 7% 7% Rates have remained the... Rates have slightly incre... Rates have decreased Rates have increased at a...
- 16. SCHIZOPHRENIA VIDEOS Schizophrenia: http://digital.films.com/PortalViewVideo.aspx?xtid=11024# Schizophrenia: http://digital.films.com/PortalViewVideo.aspx?xtid=42758 YouTube: https://www.youtube.com/watch?v=bWaFqw8XnpA
- 17. MEDICATIONS FOR SCHIZOPHRENIA Antipsychotics Tranquilizers, neuroleptics, antipsychotics Conventional (Before 1990s), Atypical (past 10 years) More effective than placebo Relapse when discontinued SIDE EFFECTS • Tardive dyskenesia • Pseudoparkinsonism
- 18. DUAL DIAGNOSIS • Two or more co-existing mental illnesses • Common = substance abuse and a mental illness • Major psychiatric disorders increase an individual’s risk for substance abuse
- 19. PSYCHOTHERAPEUTIC DRUG ABUSE • 7 million Americans • Unintentional poisoning deaths increased by 84% (1999-2004)
- 20. CONSEQUENCES Number of people in mental hospitals declined Outpatient community mental health programs were set up Changes for psychiatrists Civil rights issues re: hospitalization May stop taking medication upon release Unmedicated patients may not be able to care for themselves More mentally ill persons are jailed each year than are admitted to state hospitals 1/3 of all homeless people have some form of mental illness
Editor's Notes
- Model: symptoms diagnosis determination of cause treatment cure Criticisms of model: Usually the only symptoms of mental disorders are behavioral Behaviors are varied and can have many causes Model guides much of current thinking Psychoactive drugs are used to control symptoms of mental illness Researchers seek to identify chemical imbalances associated with specific mental disorders APA Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) provides criteria for classifying mental disorders Includes hundreds of specific diagnostic categories Widely used classification system The National Alliance on Mental Illness defines mental illnesses as: “medical conditions that disrupt a person’s thinking, feeling, mood, ability to relate to others and daily functioning” Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, posttraumatic stress disorder (PTSD), and borderline personality disorder One definition of a mental disorder is “an abnormal state of mind (whether of a continuous or an intermittent nature), characterized by delusions, or by disorders of mood or perception or volition or cognition” Medical model The premise that a pathogen is responsible for a person’s illness or disease Pathogen Any organism that produces disease The application of the medical model to emotional problems gives rise to some concern – behaviors deemed inappropriate might not be the result of any given disease Ethnic and racial minorities often face cultural and social stressors that pose greater risk factors for mental illness People of lowest socioeconomic status are more likely than those of higher strata to suffer from a mental illness American adolescents are experiencing major depressive episodes and dysthymia at an increasing rate Other groups affected by depression include postpartum women and the elderly
- Criteria for Major Depressive Episode: DSM-5 A. Five (or more) of the following symptoms have been present during the same 2- week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. • Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). • Significant weight loss when not dieting or weight gain (e.g., a change of more than 5 percent of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. • Insomnia or hypersomnia nearly every day. • Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). • Fatigue or loss of energy nearly every day. • Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). • Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). Source: DSM-V, American Psychiatric Association
- Syphilitic infection and malaria therapy In the early twentieth century, many psychotic patients were suffering from syphilitic infection of the nervous system (general paresis) Fever associated with malaria was thought to improve the condition Antibiotics were developed that cured syphilis Early drug therapy Narcosis therapy: depressants used to induce sleep Intravenous thiopental sodium (“truth serum”) used during psychotherapy to help patients express themselves Insulin-shock therapy Electroconvulsive therapy: it was incorrectly believed that inducing convulsions with drugs or electric shocks would cure schizophrenia Sedatives used in severely disturbed patients Called tranquilizers, neuroleptics, or antipsychotics Reduce psychotic symptoms without causing sedation Following introduction of drug therapy, restraints and treatments like convulsive therapy were reduced or discontinued among hospitalized patients Before 1950, mentally ill people were subjected to bloodletting, given sneezing powder, were flogged and starved, and had hot irons applied to their bodies Psychoanalysis grew in popularity starting with Freud – today, it seldom is used to treat mental problems Depression was treated with drugs such as amphetamines; other types of mental illnesses were treated with antihistamines, barbiturates and other depressants Electroconvulsive therapy (ECT), first developed in 1938, was used to treat depression and psychosis Electrical activity in the brain is temporarily interrupted and a seizure within the brain is triggered Many patients experienced adverse cognitive effects Despite concerns, ECT is still a treatment option 10-15% of the general population receive drugs for emotional problems each year 43% of people with mental disorders reside in the US and Europe 1 in 3 Americans suffer from a mental disorder Antidepressants are the medication most frequently used by people aged 18–44
- Anxiety disorders—characterized by excessive worry, fears, or avoidance Panic disorder Specific phobia Social phobia Social anxiety Generalized anxiety disorder Other, related disorders Obsessive-compulsive disorder Posttraumatic stress disorder Neurosis Long-term disorder featuring the symptoms of anxiety and/or exaggerated behavior dedicated to avoiding anxious feelings Includes obsessive-compulsive behaviors, psychosomatic ailments, phobias, and panic attacks Anxiety typically is treated with antianxiety drugs DSM-5 Disorders Anxiety Disorders Separation Anxiety Disorder Selective Mutism Specific Phobia Social Anxiety Disorder (Social Phobia) Panic Disorder Panic Attack (Specifier) Agoraphobia Generalized Anxiety Disorder Substance/Medication-Induced Anxiety Disorder Anxiety Disorder Due to Another Medical Condition Other Specified Anxiety Disorder Unspecified Anxiety Disorder Obsessive-Compulsive and Related Disorders Obsessive-Compulsive Disorder Body Dysmorphic Disorder Hoarding Disorder Trichotillomania (Hair-Pulling Disorder) Excoriation (Skin-Picking) Disorder Substance/Medication-Induced Obsessive-Compulsive and Related Disorder Obsessive-Compulsive and Related Disorder Due to Another Medical Condition Other Specified Obsessive-Compulsive and Related Disorder Unspecified Obsessive-Compulsive and Related Disorder Trauma- and Stressor-Related Disorders Reactive Attachment Disorder Disinhibited Social Engagement Disorder Posttraumatic Stress Disorder Acute Stress Disorder Adjustment Disorders Other Specified Trauma- and Stressor-Related Disorder Unspecified Trauma- and Stressor-Related Disorder Depressive Disorders Disruptive Mood Dysregulation Disorder Major Depressive Disorder, Single and Recurrent Episodes Persistent Depressive Disorder (Dysthymia) Premenstrual Dysphoric Disorder Substance/Medication-Induced Depressive Disorder Depressive Disorder Due to Another Medical Condition Other Specified Depressive Disorder Unspecified Depressive Disorder Somatic Symptom and Related Disorders Illness Anxiety Disorder (additional disorders not listed) People with generalized anxiety disorder (GAD) experience constant, chronic, and unsubstantiated worry, often about health, family, money, or work. This worrying goes on every day, possibly all day. It disrupts social activities and interferes with work, school, or family. Physical symptoms of GAD include the following: muscle tension fatigue restlessness difficulty sleeping irritability Edginess A panic attack is the abrupt onset of intense fear or discomfort that reaches a peak within minutes and includes at least four of the following symptoms: Palpitations, and/or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or being smothered Feeling of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint De-realization (feelings of unreality) or depersonalization (being detached from oneself) Fear of losing control or going insane Sense of impending death Paresthesias (numbness or tingling sensations) Chills or hot flashes Specific Symptoms of Panic Disorder: A person with panic disorder experiences recurrent either expected or unexpected Panic Attacks and at least one of the attacks has been followed by one month (or more) of one or more of the following: Persistent concern about about the implications of the attack, such as its consequences (e.g., losing control, having a heart attack, “going crazy”) or fears of having additional attacks A significant change in behavior related to the attacks (e.g., avoid exercise or unfamiliar situations) The Panic Attacks may not be due to the direct physiological effects of use or abuse of a substance (alcohol, drugs, medications) or a general medical condition (e.g., hyperthyroidism). Though panic attacks can occur in other mental disorders (most often anxiety-related disorders), the panic attacks in Panic Disorder itself cannot occur exclusive to symptoms in another disorder. In other words, attacks in Panic Disorder cannot be better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations),Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination),Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives). Panic disorder is associated with high levels of social, occupational, and physical disability; considerable economic costs; and the highest number of medical visits among the anxiety disorders, although the effects are strongest with the presence of agoraphobia. Though Agoraphobia may also be present, it isn’t required in order to diagnose panic disorder. The Diagnostic and Statistical Manual of the American Psychiatric Association (APA) currently defines social anxiety disorder as follows: The Current DSM-5 Definition: A. A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating. B. Exposure to the feared situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally pre-disposed Panic Attack. C. The person recognizes that this fear is unreasonable or excessive. D. The feared situations are avoided or else are endured with intense anxiety and distress. E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. F. The fear, anxiety, or avoidance is persistent, typically lasting 6 or more months. G. The fear or avoidance is not due to direct physiological effects of a substance (e.g., drugs, medications) or a general medical condition not better accounted for by another mental disorder... Copyright 2013, The American Psychiatric Association Under DSM-5, several changes have been made to prevent the over diagnosis of specific phobias based on the overestimation of danger or occasional fears. A person no longer has to demonstrate excessive or unreasonable anxiety for a diagnosis of specific phobia. Instead, the anxiety must be “out of proportion” to the threat considering the environment and situation. Specific Phobia Symptoms A person who has a specific phobia disorder experiences significant and persistent fear when in the presence of, or anticipating the presence of, the object of fear, which may be an object, place or situation. The DSM-5 criteria for a specific phobia are: Marked and out of proportion fear within an environmental or situational context to the presence or anticipation of a specific object or situation Exposure to the phobic stimulus provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack. The person recognizes that the fear is out of proportion. The phobic situation(s) is avoided or else is endured with intense anxiety or distress. The avoidance, anxious anticipation or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. The new DSM-5 criteria states that the symptoms for all ages must have a duration of at least 6 months. The anxiety, panic attack, or phobic avoidance associated with the specific object or situation is not better accounted for by another mental disorder. Impact of Specific Phobia on Daily Life One sign that a fear is a phobia is when it limits family, social and professional lives, as per the DSM-5 requirements. A person who has a specific phobia may turn down a job opportunity because it involves flying, or a meeting that is on a high floor. A fear that limits professional and social opportunities, and has a negative effect on performance, confidence and relationships could be a phobia. Whether specific phobias are learned or inherited is still being researched. Twin studies suggest that genetic factors can play a role in the development of a phobia. Brain imaging shows hyperactivation of the amygdala and other areas of the brain in those with phobias. A person can have one phobia that significantly impacts his/her quality of life. Those with multiple types of phobias with an early onset are the most likely to experience significant impacts on quality of life. They are also more likely to develop other mental disorders. Females are more likely to have multiples type of phobias (Burnstein et al., 2012). Phobias can lead to other medical and mental disorders if not treated early. Individuals with a phobia of vomiting, for example, have developed eating disorders. Individuals who have phobias score lower on the quality of life scale. Therapy has produced improvements in QOL. Subjects with injection phobia treated with behavioral therapy have achieved normal quality of life levels (Agdal, Raadal, Öst, & Skaret, 2012). Specific Phobia Therapy Neuroscientists have identified abnormal hyperactivation in threat processing in those who have anxiety disorders. Cognitive behavioral therapy (CBT) has been shown to be successful in downregulating the threat response. In response to subliminal threats, however, the same study produced hyperactivation rather than downregulation in parts of the brain (Lipka, Hoffman, Miltner, & Straube, 2013). CBT for phobias can be of short duration. Soldiers following a two-day intensive CBT session for specific phobia to wearing a protective mask experienced decreases in cortisol secretion and overcame their phobia (Brand, Annen, Holsboer-Trachsler, & Blaser, 2011). CBT is increasingly being delivered through multimedia. Children have been offered 6-week CBT over the internet with their parents. Virtual reality exposure therapy (VRET), a form of desensitization therapy, provides a way of facing one’s fears in a safe but realistic environment. Among the features produced in a virtual environment in one study – involvement, realness, presence, spacial presence – involvement produced a treatment response (Price, Mehta, Tone, & Anderson, 2011). An increasingly popular approach is to use VRET with behavioral or cognitive behavioral therapy. Other types of therapies used to treat specific phobia include medication, anxiety management, exposure therapy and meditation. OBSESSIVE COMPULSIVE DISORDER Obsessions: persistent ideas, thoughts, impulses, or images that are experienced as inappropriate or intrusive and that cause anxiety and distress. The content of the obsession is often perceived as alien and not under the person's control. Compulsions: repetitive behaviours or mental acts that are carried out to reduce or prevent anxiety or distress and are perceived to prevent a dreaded event or situation. Diagnostic criteriaObsessional symptoms or compulsive acts or both must be present on most days for at least 2 successive weeks and be a source of distress or interference with activities. Eitherobsessions orcompulsions (or both) are present on most days for a period of at least 2 weeks. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day) or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships. 2.Obsessional symptoms should have the following characteristics: they must be recognised as the individual's own thoughts or impulses. there must be at least one thought or act that is still resisted unsuccessfully, even though others may be present which the sufferer no longer resists. the thought of carrying out the act must not in itself be pleasurable (simple relief of tension or anxiety is not regarded as pleasure in this sense). the thoughts, images, or impulses must be unpleasantly repetitive. 2.Obsessions (thoughts, ideas, or images) andcompulsions (acts) share the following features, all of which must be present: they are acknowledged as originating in the mind of the patient, and are not imposed by outside persons or influences. they are repetitive and unpleasant, and at least one obsession or compulsion that is acknowledged as excessive or unreasonable must be present. the patient tries to resist them (but resistance to very long-standingobsessions orcompulsionsmay be minimal). At least one obsession or compulsion that is unsuccessfully resisted must be present. experiencing the obsessive thought or carrying out the compulsive act is not in itself pleasurable. (This should be distinguished from the temporary relief of tensions or anxiety.) 2.If another Axis I disorder is present, the content of the obsessions or compulsionsis not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of a Major Depressive Disorder. 3.The obsessions orcompulsions cause distress or interfere with the patient's social or individual functioning, usually by wasting time. 3.The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. PTSD In DSM-5, published in May, 2013, PTSD is classified as a trauma- and stress-related disorder.[1] Criterion A: (applicable to adults, adolescents and children over 6. There is a separate Posttraumatic stress disorder for children 6 years and younger.) Exposure to real or threatened death, injury, or sexual violence. Several items in Criterion B (intrusion symptoms) are rewritten to add or augment certain distinctions now considered important. Special consideration is given to developmentally appropriate criteria for use with children and adolescents. This is especially evident in the restated Criterion B—intrusion symptoms. Development of age-specific criteria for diagnosis of PTSD is ongoing at this time. Criterion C (avoidance and numbing) has been split into "C" and "D": Criterion C (new version) now focuses solely on avoidance of behaviors or physical or temporal reminders of the traumatic experience(s). What were formerly two symptoms are now three, due to slight changes in descriptions. New Criterion D focuses on negative alterations in cognition and mood associated with the traumatic event(s) and contains two new symptoms, one expanded symptom, and four largely unchanged symptoms specified in the previous criteria. Criterion E (formerly "D"), which focuses on increased arousal and reactivity, contains one modestly revised, one entirely new, and four unchanged symptoms. Criterion F (formerly "E") still requires duration of symptoms to have been at least one month. Criterion G (formerly "F") stipulates symptom impact ("disturbance") in the same way as before. Criterion H stipulated the disturbance is not due to the effects of a substance or another medical condition. Specify whether:With dissociative symptoms: (not due to effects of a substance or another medical condition)In addition, meets the criteria of Depersonalization In addition, meets the criteria of Derealization Specify if:With delayed expression Full criteria not met until more than 6 months after the event
- Mood disorders— characterized by depressed or manic symptoms Major depression Manic episodes Bipolar disorder Symptoms don’t always fit neatly into diagnostic categories Mood disorders Forms of mental illness that affect the person’s emotions Can be depression or mania Depression Dejection characterized by withdrawal or lack of response to stimulation Mania Characterized by inappropriate elation, an irrepressible mood, and extreme cheerfulness Bipolar affective disorder A mental condition characterized by alternating moods of depression and mania Formerly called manic-depression Unipolar depression Mental disorder marked by alternating periods of depression and normalcy Depression can cause substance abuse, but substance abuse also can lead to depression Clinical depression is a real illness that can be treated effectively Some individuals with substance abuse problems are misdiagnosed with bipolar illness A frequent problem among people with bipolar disorder is noncompliance with medications Women experience twice the rate of depression as men, regardless of race or ethnic background Criteria for Manic Episode: DSM-5 A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: • inflated self-esteem or grandiosity • decreased need for sleep (e.g., feels rested after only 3 hours of sleep) • more talkative than usual or pressure to keep talking • flight of ideas or subjective experience that thoughts are racing • distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) • increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation • excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder. Source: DSM-V, American Psychiatric Association Criteria for Major Depressive Episode: DSM-5 A. Five (or more) of the following symptoms have been present during the same 2- week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. • Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). • Significant weight loss when not dieting or weight gain (e.g., a change of more than 5 percent of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. • Insomnia or hypersomnia nearly every day. • Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). • Fatigue or loss of energy nearly every day. • Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). • Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). Source: DSM-V, American Psychiatric Association
- Monoamine oxidase (MAO) inhibitors Examples: phenelzine, tranylcypromine Tricyclic antidepressants Examples: amitriptyline, doxepin, nortriptyline Selective serotonin reuptake inhibitors (SSRIs) Examples: fluoxetine, sertraline, venlafaxine Monoamine Oxidase Inhibitors Discovered when a drug for tuberculosis was found to also elevate mood Work by increasing the availability of serotonin, norepinephrine, and dopamine Limited use due to side effects and toxicity Users must avoid certain foods and drugs to prevent severe side effects TRICYCLICS Discovered when researchers were working to create a better phenothiazine antipsychotic and found a drug that improved mood May work by reducing the uptake (and thereby increasing the availability) of norepinephrine, dopamine, and serotonin Not effective in all patients, but they reduce the severity and duration of depressive episodes SSRI SSRIs may work by reducing the uptake (and thereby increasing the availability) of serotonin Safer than tricyclic antidepressants, less likely to lead to overdose deaths Only a little more effective than placebo Strong warning from FDA about an increased risk of suicidal tendencies in children and adolescents MECHANISMS OF ACTION Appear to work by increasing the availability of norepinephrine or serotonin A lag period before improvement in mood is seen We don’t yet have the complete picture of how antidepressants work ECT Most effective treatment for relieving severe depression Works very rapidly, more quickly than antidepressant drugs Best treatment choice in cases with a risk of suicide Can be used in conjunction with drugs MOOD STABILIZERS Lithium: Approved for U.S. sale in 1970 Early studies found it to be effective in manic patients Acceptance slow in United States Previous history of poisonings Low perception of seriousness of mania U.S. drug approval and sale process Can be safe or toxic; blood levels must be monitored High rate of patient noncompliance Lithium Normalizes mood in bipolar patients, preventing both mania and depressed mood swings Little effect in treating unipolar depression Other mood stabilizers are anticonvulsant drugs (valproic acid, carbamazepine, lamotrigine) Depression is treated with five major classes of drugs: Monoamine oxidase inhibitors (MAOIs) Tricyclic antidepressants Selective serotonin reuptake inhibitors (SSRIs) Serotonin and norepinephrine reuptake inhibitors (SNRIs) Atypical antidepressants that do not fall into one of the above categories Monoamine oxidase (MAO) is an enzyme on the outer membranes of mitochondria – inactivates the neurotransmitters serotonin, dopamine, and norepinephrine MAOIs block the action of monoamine oxidase Four principal MAOIs in the US: Tranylcypromine (Parnate) Phenelize (Nardil) Isocarboxazid (Marplan) Selegiline (Emsam) Work well for neurotic conditions such as acute anxiety, obsessive-compulsive behavior, phobias, panic attacks Toxic effects occur when MAOIs interact with foods containing tyramine – release of catecholamines produces sympathomimetic effects MAOIs interact dangerously with certain medications, especially dextromethorphan, Demerol, and other antidepressants that affect serotonin such as Prozac Tricyclic Amitriptyline (Elavil) is used for depression accompanied by agitation Imipramine (Tofranil) is given for depression involving psychomotor retardation, as well as for agoraphobia, panic attacks, and obsessive-compulsive behavior Clomipramine (Anafranil) also has been used to treat obsessive-compulsive behaviors Antidepressant action takes 3-4 weeks Tricyclics are also effective in moderating pain, and can be beneficial in treatment of the eating disorder bulimia Common side effects are distorted vision, tachycardia, dry mouth, constipation, sleepiness, and urinary retention With alcohol, risk of a deadly reaction increases – overdose causes coma, cardiac difficulties, and respiratory problems If patients cease taking tricyclics abruptly, they demonstrate withdrawal symptoms Even at low dosage, tricyclics can be toxic – excessive levels can be fatal Another side effect is development of type 2 diabetes, especially when taken with the newer antidepressants Side Effects Tachycardia Dry mouth Confusion Hypotension Disorientation Impotence Glaucoma Distorted vision Sleepiness Constipation Urinary retention Tremors Rashes Jaundice Respiratory problems Coma Death Selective serotonin reuptake inhibitors (SSRIs) Antidepressant medications that increase the concentration of serotonin in the brain Reduce aggressive and violent behavior Adverse effects include sexual dysfunction, increase in weight, and altered sleep patterns Not much more effective than placebos Prozac (fluoxetine) Fewer serious side effects Also used for bulimia, obesity, anxiety, and OCD Implicated in a number of suicides Zoloft (sertraline) Especially effective with elderly patients Prescribed for patients with acute coronary syndrome Also used to treat OCD Paxil (paroxetine) Increased risk of suicides in children When taken during pregnancy, increases risk of cardiac malformations and neonatal complications New version: PaxilCR Lexapro (escitalopram) Also used for OCD, panic disorder, social anxiety disorder, PTSD, premenstrual dysphoric disorder, menstrual mood swing and irritability, and compulsive gambling ATYPICAL Nefazodone (Serzone) No longer available in the US Reported as causing severe liver failure Trazodone Mood elevator Side effects may include confusion, concentration difficulties, headaches, and nervousness Mirtazapine May cause mood changes, unusual thought processes, seizures, lowered libido, and changes in menstrual cycle Bupropion (Wellbutrin) Inhibits uptake of dopamine and norepinephrine. Also used for smoking cessation and seasonal affective disorder Side effects are usually mild Serotonin and norepinephrine reuptake inhibitors (SNRIs) Work by decreasing the reabsorption of both serotonin and norepinephrine in the brain Side effects may include pain in the eyes, vision blurring, or blindness May cause a variety of other side effects, from diarrhea and agitation to irregular heartbeats and convulsion Venlafaxine (Effexor XR) Side effects similar to SSRIs Overdose can be dangerous or fatal Desvenlafaxine (Pristiq) Similar to venlafaxine and causes similar side effects Duloxetine (Cymbalta) May help relieve physical pain in addition to depression Side effects include nausea, dry mouth, constipation Heavy drinkers or those with certain liver or kidney problems should not take duloxetine Lithium A positively charged ion, similar to sodium Used to treat symptoms associated with mania Side effects include tremors, excessive thirst, frequent urination, fluid retention, and weight gain Inability to excrete lithium can lead to toxic levels in the body Chlorpromazine Alternative antimanic with fewer toxic effects Lithium is effective for acute mania and for preventing mania and depression from recurring Maximal benefit is achieved in one to two weeks Effective for people who have unipolar depression and do not respond to tricyclic antidepressant drugs The therapeutic window is small – three to four times the therapeutic level can cause grave consequences SIDE EFFECTS Nausea Excessive perspiration Water retention Vomiting Confusion Drowsiness Tinnitus Kidney dysfunction Respiratory depression Polydipsia Hand tremors Polyuria Diarrhea Weight gain Muscular weakness Distorted vision Coma Death
- Schizophrenia—chronic psychosis characterized by delusions, hallucinations, disorganized speech and behavior, and lack of emotional response; causes significant interference with social and/or occupational functioning Psychosis—a serious mental disorder involving loss of contact with reality Psychosis Severe mental condition marked by loss of contact with reality Organic psychoses Have physical causes such as excessive drug use, brain infections, metabolic or endocrine disorders, brain tumors, and neurological diseases Functional psychoses Have no known or apparent cause (e.g. schizophrenia) According to the DSM-5, (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) Schizophrenia is a disorder in which a person will experience gross deficits in reality testing, manifested with at least two or more the following symptoms, which must be present for at least one month (unless treatment produces symptom remission): At least one symptom collectively referred to as positive symptoms: must be in categories 1, 2, or 3, 1.Delusions- strange beliefs and ideas which are resistant to rational/logical dispute or contradiction from others. 2.Hallucinations- typically auditory, or less frequently, visual. 3. Disorganized Speech- incoherence, irrational content. 4. Disorganized or Catatonic behavior- repetitive, senseless movements, or adopting a pose which may be maintained for hours. The individual may be resistant to efforts to move them into a different posture, or will assume a new posture they are placed in. 5. Negative symptoms- flat affect, amotivation, anergia, failure to maintain hygiene (American Psychiatric Association, 2013). 1. Marked reduction in level of functioning in one or more areas, such as occupational, social, or personal care or hygiene . If symptom onset occurs during childhood or adolescence, there is inability to reach age-typical functioning in academic, social or interpersonal areas. 2. Symptoms must persist at least six months, during which at least one month of symptoms (unless treatment produces symptom remission) meet the criteria for positive symptoms and may include periods of prodromal or residual symptoms. During prodromal or residual periods, the signs of the disturbance may be manifested by negative symptoms or by two or more positive symptoms present in a less prominent form (e.g.,unusual beliefs or perceptions). 3.Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out. 4 The psychotic episode cannot be attributed to substance use (ethanol withdrawal, cocaine abuse) or a medical condition. 5. If autism spectrum disorder or a communication disorder of childhood onset has been previously diagnosed, the diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other symptoms of schizophrenia, are present for at least one month, excluding successful treatment (American Psychiatric Association, 2013). If symptoms have persisted for one year, and if there are no contradictory diagnostic criteria, the clinician may include specifiers: 1. First episode, currently in acute episode: First apparent onset of the disorder as defined by the above diagnostic criteria. 2. First episode, currently in partial remission: First apparent onset of the disorder with a period of improvement in which the symptoms are only partially present. 3. First episode, currently in full remission: Absence of apparent symptoms after a first episode. 4. Multiple episodes, currently in acute episode: 5. Two or more episodes, current one acute. 6. Multiple episodes, currently in partial remission 7. Multiple episodes, currently in full remission 8. Continuous: maintenance of symptoms fulfilling the diagnostic symptom criteria for the majority of time. 8. Unspecified- With catatonia 9. Current severity: Severity can be rated by a quantitative assessment of positive and negative symptoms on a Five point Likert scale for the previous seven days- e.g.- zero- absent to Four, present and severe. (American Psychiatric Association, 2013).
- Called tranquilizers, neuroleptics, or antipsychotics Reduce psychotic symptoms without causing sedation Following introduction of drug therapy, restraints and treatments like convulsive therapy were reduced or discontinued among hospitalized patients Treatment with phenothiazines found to be more effective than a placebo Patients relapse when therapy is discontinued Two groups of antipsychotics Conventional (introduced before mid-1990s) Atypical (introduced in the past 10 years) Antipsychotics produce pseudoparkinsonism, indicating a link to dopamine receptors Time delay in drug effects indicates that the mechanism of action is probably more complex Atypical antipsychotics block both D2 dopamine and 5HT2A serotonin receptors Produce less pseudoparkinsonism Safe in that they are not addictive and are difficult to use to commit suicide Side effects Some allergic reactions (jaundice, skin rashes) Photosensitivity (easily sunburned) Agranulocytosis (low white blood cell count) Movement disorders (tremors, muscle rigidity, shuffling walk, masklike face) Tardive dyskinesia LONG TERM Even patients experiencing success tend to stop taking the drug Short-term efficacy exists, but long-term appears to be considerably lower No clear evidence that atypical antipsychotics work better than conventional When used in children there is a high risk of weight gain and metabolic changes Elderly patients with dementia have a significant increase in death risk from cardiovascular and other problems. Antipsychotic drugs (major tranquilizers or neuroleptics) used particularly for schizoprenia Antipsychotic drugs, are pharmacologically different from minor tranquilizers and other sedative-hypnotic drugs Chlorpromazine – an anesthetic used to ameliorate anxiety and shock during surgery – was marketed for mental disorders in 1955 under the trade name Thorazine Well-known antipsychotic drugs: Haloperidol (Haldol) Trifluoperazine (Stelazine) Fluphenazine (Prolixin) Olanzipine (Zyprexa) Quetiapine (Seroquel) Promazine (Sparine) Thioridazine (Mellaril) Schizophrenic patients have to take antipsychotic drugs for four to six weeks for maximum effectiveness One problem is that they are absorbed erratically Some patients receive injections of antipsychotic drugs so the drug can be released slowly into the bloodstream These drugs build up in fatty areas of brain and lungs, and cross the placenta to affect the fetus CHILDREN/ANTIPSYCHOTICS Antipsychotic drugs are prescribed more often to children in the US than to children in other developed countries Adverse effects in children (particularly females): Excessive weight gain Type 2 diabetes Neurological symptoms Digestive problems Cardiovascular conditions EFFECTIVENESS Schizophrenics receiving antipsychotic drugs almost always show improvement, but a small percentage gets worse Improvement is most rapid during the first several weeks of treatment Although many people taking antipsychotic drugs relapse, it appears that these drugs reduce violent behavior SIDE EFFECTS Antipsychotic drugs produce undesirable motor problems (extrapyramidal symptoms) Inappropriate motor movements (acute dyskinesias) sometimes appear within a year after treatment: Parkinsonism Dystonia Akathesia Tardive dyskinesia Motor disorders such as involuntary repetitive facial movements, lip smacking, involuntary movement of trunk and limbs, and twitching Less severe side effects: Difficulty urinating, constipation, dry mouth Altered skin pigmentation, jaundice, and extreme sensitivity to sunlight Changes in heart rate
- Dual diagnosis (co-occurring disorders) describes a person with two or more existing mental illnesses, each of which can be diagnosed independent of the others Common co-occurring disorders include substance abuse/addiction or alcoholism and a mental illness such as depression, anxiety, or a personality disorder Major psychiatric disorders increases an individual’s risk for substance abuse
- About 7 million Americans over age 12 report recent use of psychotherapeutic drugs for nonmedical purposes Unintentional poisoning deaths involving psychotherapeutic drugs, such as sedative-hypnotics and antidepressants, increased by 84% from 1999 to 2004 In many cases, individuals had been abusing multiple drugs of different classes, compounding the toxicity
- Number of people in mental hospitals declined dramatically following the introduction of drugs that control the symptoms of schizophrenia to a great degree Outpatient community mental health programs were set up to treat patients closer to home in a more natural environment at less expense Changes for psychiatrists Less time spent doing psychotherapy Priority and emphasis on establishing an appropriate drug regimen Civil rights issues relating to hospitalization Indefinite commitment to a hospital is unconstitutional Periodic review of a patient’s status helps determine if patient presents a danger to self or others Problems Patients may have well-controlled symptoms while on medication in a hospital but may stop taking medication upon release Unmedicated patients, although not overtly dangerous, may still be too ill to care for themselves From hospital to jail or the street More mentally ill persons are jailed each year than are admitted to state mental hospitals About one-third of all homeless people have some form of serious mental illness