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Major Mental Illnesses Thought Disorders Schizophrenia Mood Disorders Major Depressive Disorder Bipolar Disorder (Manic-depression)

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Presentation on theme: "Major Mental Illnesses Thought Disorders Schizophrenia Mood Disorders Major Depressive Disorder Bipolar Disorder (Manic-depression)"— Presentation transcript:

1 Major Mental Illnesses Thought Disorders Schizophrenia Mood Disorders Major Depressive Disorder Bipolar Disorder (Manic-depression)

2 Characteristics of an Illness Affect Individuals Across Populations Signs and Symptoms Course Heredity Diagnosis Causes Treatment

3 Understanding Schizophrenia

4 Common Symptoms of Schizophrenia Positive Symptoms –Disturbances of thinking and perception Negative Symptoms –Loss or decrease of normal functions

5 Positive Symptoms of Schizophrenia Disordered thinking –Thoughts jump between completely unrelated topics or may be blocked. Delusions –Fixed, false beliefs (not based in reality) –Outside of cultural norms Hallucinations –False perceptions –Usually auditory

6 Delusions of Schizophrenia Persecution Control Grandiose Reference Influence Religious Somatic Mind reading Thought broadcasting Thought insertion Thought withdrawal Guilt, sin

7 Hallucinations of Schizophrenia Auditory 70% Voices commenting Voices conversing Voices commanding Visual 30% Somatic, tactile 15% Olfactory 5%

8 Negative Symptoms of Schizophrenia Affect blunted or flat –Lacking emotional expression –Blank face, little eye contact, few gestures Avolition –Lacking energy, spontaneity, initiative Alogia –Diminished amount of speech, or content Anhedonia –Lack of interests, or lack of pleasure

9 Diagnosis: Schizophrenia How is schizophrenia diagnosed?

10 Schizophrenia: Diagnosis Across Time Kraeplin - Dementia Praecox (1878) Simple Paranoid Hebephrenic Catatonic Bleuler - Schizophrenia (1911) Affect Associations Ambivalence Autism Schneider - First Rank Features (1959)

11 Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV)

12 DSM-IV Schizophrenia Characteristic symptoms for one month Impairment in functioning Continuous signs for 6 months Not do to a look-alike mood disorder substance abuse general medical condition autism

13 Types of Schizophrenia Paranoid type Preoccupation with delusions or frequent auditory hallucinations Disorganized type Disorganized speech, disorganized behavior, flat or inappropriate affect Catatonic type Immobility, peculiar movements, purposeless and excessive activity Undifferentiated type Residual type

14 Who Gets Schizophrenia? One of every one hundred people 2.5 million people in the United States All ethnicities Societies throughout the world Equal among men and women More prevalent in poorer communities Downward drift

15 The Course of Schizophrenia Most commonly begins between ages Usually begins later in women One, or multiple episodes Full or partial recovery between episodes Positive symptoms lessen with age Negative symptoms increase with age Tends to stabilize later in course

16 What Causes Schizophrenia? Unclear Likely a complex group of brain illnesses with multiple causes Heredity Biochemical theory Brain anatomy Brain development

17 Causes of Schizophrenia Heredity –Genetic component to schizophrenia (runs in families) –Adoption studies –Inherit a vulnerability to schizophrenia

18 Lifetime Risk of Developing Schizophrenia General population 1% Child of one parent with schizophrenia 10-15% Child of two parents with schizophrenia 30-40% Sibling with schizophrenia 10% Fraternal twins 10% Identical twins 50%

19 For every complex problem there is a solution that is neat, simple and wrong. H. L. Menken

20 It is better to be wrong than vague, if one is wrong in an interesting way. Bernard Carroll

21 Stress-Diathesis Model of Schizophrenia Genetic Vulnerability (diathesis) Second hit –Perinatal - pregnancy or birth injury –Viral / Seasonality –Other stresses - puberty, social stresses Leads to changes in the brain

22 Brain Differences in Schizophrenia Chemical –Dopamine Hypothesis Anatomy / Activity –Many sites Developmental –Cell migration

23 Dopamine Hypothesis of Schizophrenia Describes what is wrong in the brain but not how it got that way Dopamine system is hyperactive Too much dopamine Problem with the dopamine receptors Clues - amphetamines, Cocaine, L-DOPA

24 Neuroanatomy of Schizophrenia No single change is seen in all people with schizophrenia Enlarged ventricles Underactive frontal lobe –planning, judgement, abstraction, expressing feelings Overactive temporal lobe –preceptions and emotions

25 Attention / Arousal Model of Schizophrenia Stimulus flooding –Lack of an effective filter –Too much information from the environment –Leads to withdrawal from social contact Stimulus overload –Leads to frustration, poor concentration, nervousness

26 Examples of Stimulus Overload Everything seems to grip my attention although I am not particularly interested in anything. I am speaking to you just now, but I can hear noises going on next door and in the corridor. I find it difficult to shut these out, and it makes it more difficult for me to concentrate on what I am saying to you. My concentration is very poor. I jump from one thing to another. If I am talking to someone they only need to cross their legs or scratch their heads and I am distracted and forget what I was saying. I think I could concentrate better with my eyes shut.

27 Schizophrenia IS –Biological disease of the brain –Disabling and emotionally devastating –Relatively common –Misunderstood and stigmatized –Treatable IS NOT –Caused by bad parenting –A personal weakness –Split personality

28 Understanding Mood Disorders Major Depression Bipolar Disorder

29 Mood Disorders Signs and Symptoms Diagnosis The Biology Other Causes The Course of Illness

30 Major Depression: Signs and Symptoms Emotional Thought Somatic (body) Behavioral

31 Major Depression: Emotional Symptoms Sad, irritable or empty mood Diurnal variation Diminished capacity for enjoyment Diminished interests

32 Major Depression: Thought (Cognitive) Symptoms Difficulty concentrating Indecisiveness Memory problems Depressed content of thought –Worthlessness –Guilt –Hopelessness –Death and Suicide

33 Major Depression: Somatic Symptoms (Body Functions) Sleep disturbances Appetite disturbances, weight changes Fatigue, low energy Upset stomach, constipation Physical pain

34 Major Depression: Behavioral Signs and Symptoms Social withdrawal Increased dependency Poor frustration tolerance Suicide attempts Substance abuse Slow motion Slow speech Poor eye contact Tearfulness Agitation Poor self-care

35 Major Depression: Types of Episodes Melancholia –No pleasure or reactivity –Weight loss –Early morning awakening –Worse in the morning –Excessive Guilt Atypical –Mood brightens to positive events –Weight gain –Over-sleeping –Heavy feeling in arms and legs –Interpersonal rejection sensitivity

36 Masked Depression May not complain of feeling depressed Anxious, agitated Fatigue, insomnia Chronic pain, unrelieved by pain killers Confused, disoriented, poor memory Alcohol or drugs obscure symptoms

37 Major Depression: DSM-IV Depressed mood, or loss of interest/ pleasure Other symptoms (total of 5) Increase or decrease in appetite/weight Insomnia or hypersomnia Agitation or slowing Fatigue or loss of energy Worthlessness or guilt Poor concentration or indecisiveness Recurrent thoughts of death or suicide

38 Major Depression: DSM-IV (continued) Two week duration Impaired functioning in life roles Rule out look alikes –Secondary depression

39 Secondary Depression Other treatable illnesses cause depression –Examples Endocrine problems (thyroid disease, diabetes) Infections (mononucleosis, influenza) Anemia Poor nutrition Neurologic illnesses (strokes, Parkinsons disease, multiple sclerosis Tumors (lung, pancreas, brain)

40 Secondary Depression (continued) Alcohol Drugs Medications Examples - steroids, high blood pressure medications, sleeping pills, oral contraceptives Toxins

41 Major Depression: The Causes Limbic System Neurochemical Serotonin Norepinephrine Others Heredity Identical twins - 40% Environmental stresses

42 Major Depression: The Course Can occur at any age –Usual onset similar to schizophrenia, or later –10% have first episode after age 60 More common in women (2:1) Lifetime prevalence 17% Recurrent in 50-60% –Later episodes: longer, deeper, more frequent, less of a trigger May be seasonal

43 Major Depression Severity Mild to severe May include psychosis, poor self care, suicide Abraham Lincoln describing his own depression: I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on earth. Whether I shall ever be better, I cannot tell. I awfully forebode I shall not. To remain as I am is impossible. I must die or be better, it appears to me.

44 Bipolar Disorder Signs and Symptoms of Mania Diagnosis Other Causes The Biology The Course of Illness

45 Mania: Signs and Symptoms Persistently elevated, expansive or irritable mood lasting at least one week Associated symptoms Inflated self -esteem or grandiosity Decreased need for sleep More talkative Racing thoughts or flight of ideas Distractibility Agitation or increase in activities Excessive involvement in pleasurable activities with a high risk for painful consequences –Spending sprees, sexual indiscretions, foolish investments

46 Manic Episode: DSM-IV Elevated, expansive, or irritable mood for one week Three associated symptoms Significant impairment in life roles Not do to a look-alike Medical condition Medication Substance abuse

47 Hypomania Episode similar to mania, but less severe No impairment in functioning May actually be more productive, creative Bipolar II Disorder

48 Bipolar Disorder: The Course 1% of general population Equal in men and women Age of onset similar to schizophrenia Episodes can come on very fast (1-7 days) Later episodes longer, more severe, more frequent Substance abuse common Heredity plays a greater role than in depression Family members also at higher risk for major depression High suicide risk

49 Mood Disorders ARE –Biological disease of the brain –Disabling and emotionally devastating for many –Common –Misunderstood and stigmatized –Treatable ARE NOT –The fault of the family –A personal weakness

50 Characteristics of an Illness Affect Individuals Across Populations Signs and Symptoms Course Heredity Diagnosis Causes TreatmentTreatment

51 Treatment of Schizophrenia and Other Psychotic Disorders

52 Long Acting Antipsychotics Haldol Decanoate (Haloperidol)Haldol Decanoate (Haloperidol) Prolixin Decanoate (Fluphenazine)Prolixin Decanoate (Fluphenazine)

53 Clozapine ProsPros –Gold standard for refractory schizophrenia –Effective for positive symptoms –Does not produce EPS or TD –May improve cognition –Effective for mood symptoms

54 Clozapine ConsCons –Agranulocytosis, blood draws, monitoring –Seizure risk –Other side effects –Titration –Acquisition cost

55 Risperidone ProsPros –Effective for positive symptoms –Less EPS than with conventional agents –May help cognitive and mood symptoms ConsCons –Dose dependent EPS –Dose dependent prolactin elevation

56 Olanzapine ProsPros –Effective for positive symptoms –Low EPS and TD liability –FDA indication for mania –May improve cognition ConsCons –Weight gain –Acquisition cost

57 Quetiapine ProsPros –Effective for positive symptoms –Very low EPS liability –Limited data for mood symptoms, cognition ConsCons –Titration, split dosing, sx break through –Sedation, weight gain

58 Psychosocial Treatments Patient and family psychoeducationPatient and family psychoeducation Vocational trainingVocational training Social Skills trainingSocial Skills training Clubhouse modelClubhouse model Schizophrenics AnonymousSchizophrenics Anonymous

59 Update on the Pharmacologic Treatment of Psychosis Timothy Florence, MD Clinical Instructor University of Michigan Department of Psychiatry

60 Psychosis Defined by impaired reality testingDefined by impaired reality testing Characterized by:Characterized by: –thought content: delusions –perception: hallucinations –thought stream: grossly disorganized –behavior: grossly disorganized

61 Typical Psychoses SchizophreniaSchizophrenia Psychotic mood disordersPsychotic mood disorders –Bipolar disorder –Major depressive disorder with psychotic features Substance-induced psychotic disorderSubstance-induced psychotic disorder Psychotic disorder due to medical conditionsPsychotic disorder due to medical conditions

62 Mental Health: A Report of the Surgeon General David Satcher, MD, PhD

63 Surgeon Generals Report: Key Messages Mental illnesses are real illnesses and are biologically basedMental illnesses are real illnesses and are biologically based Effective treatments are availableEffective treatments are available

64 Surgeon Generals Report: Action Steps Overcome STIGMA by disseminating accurate informationOvercome STIGMA by disseminating accurate information Improve PUBLIC AWARENESS of effective treatmentsImprove PUBLIC AWARENESS of effective treatments Improve access to treatmentImprove access to treatment Individualize treatmentIndividualize treatment Ensure delivery of state-of-the-art treatmentsEnsure delivery of state-of-the-art treatments Reduce financial barriersReduce financial barriers Continue to build the science baseContinue to build the science base Ensure adequate supply of service providersEnsure adequate supply of service providers

65 Characteristics of an Illness Affect IndividualsAffect Individuals Across PopulationsAcross Populations Signs and SymptomsSigns and Symptoms CourseCourse

66 Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV)

67 DSM-IV Schizophrenia Characteristic symptomsCharacteristic symptoms –Delusions –Hallucinations –Disorganized speech –Disorganzied or catatonic behavior –Negative symptoms

68 Negative Symptoms of Schizophrenia Affect blunted or flatAffect blunted or flat –Lacking emotional expression –Blank face, little eye contact, few gestures AvolitionAvolition –Lacking energy, spontaneity, initiative AlogiaAlogia –Diminished amount of speech, or content AnhedoniaAnhedonia –Lack of interests, or lack of pleasure

69 Negative Symptoms Caused by:Caused by: –Inherent deficit (deficit syndrome) –Positive symptoms –Depression –Medications –Environmental deprivation

70 DSM-IV Schizophrenia Characteristic symptoms for one monthCharacteristic symptoms for one month Impairment in functioningImpairment in functioning Continuous signs for 6 monthsContinuous signs for 6 months Not do to a look-alikeNot do to a look-alike mood disordermood disorder substance abusesubstance abuse general medical conditiongeneral medical condition autismautism

71 Positive Symptoms of Schizophrenia Disordered thinkingDisordered thinking –Thoughts jump between completely unrelated topics or may be blocked. DelusionsDelusions –Fixed, false beliefs (not based in reality) –Outside of cultural norms HallucinationsHallucinations –False perceptions –Usually auditory

72 Who Is At Risk For Schizophrenia? Prevalence - 1%Prevalence - 1% All ethnicitiesAll ethnicities Societies throughout the worldSocieties throughout the world Equal among men and womenEqual among men and women More prevalent in poorer communitiesMore prevalent in poorer communities Social driftSocial drift

73 Who Is At Risk? Predisposing factors:Predisposing factors: –Season –Perinatal pregnancypregnancy birth injurybirth injury –Nutrition –Heredity Precipitating factors:Precipitating factors: –Environment –Stress –Substance Abuse

74 The Course of Schizophrenia Extremely variableExtremely variable Often chronicOften chronic OnsetOnset –Males: –Females: Functional decline earlyFunctional decline early Differential diagnosis of first episode challengingDifferential diagnosis of first episode challenging Recurrent episodesRecurrent episodes –More difficult to treat –Longer to remission

75 Dimensions of Functional Impairment OccupationalOccupational SocialSocial InstrumentalInstrumental Self-careSelf-care Independent livingIndependent living

76 Predictors of Functional Status Premorbid functioningPremorbid functioning Cognitive symptomsCognitive symptoms Negative symptomsNegative symptoms

77 Severity of Functional Deficits in Schizophrenia 10% will work full-time10% will work full-time 33% will work part-time33% will work part-time Less than 10% of males will have a childLess than 10% of males will have a child Self-care deficits are reflected in high rates of medical comorbiditySelf-care deficits are reflected in high rates of medical comorbidity

78 Cognition and Outcome: Reasons for the Correlation Cognitive deficits often make learning new skills difficultCognitive deficits often make learning new skills difficult Job success requires the ability to learn and remember the demands of the positionJob success requires the ability to learn and remember the demands of the position Deficits in organization make persons unable to perform the job responsibilitiesDeficits in organization make persons unable to perform the job responsibilities Deficits in concentration make performance unreliableDeficits in concentration make performance unreliable

79 Schizophrenia PORT Treatment Recommendations Choice of antipsychotic medication should be made based on:Choice of antipsychotic medication should be made based on: –Patient acceptability –Prior individual drug response –Individual side effect profile –Long-term treatment planning

80 What Is Schizophrenia? HeterogeneousHeterogeneous Likely a complex group of brain illnesses with multiple causesLikely a complex group of brain illnesses with multiple causes Genetic predisposition or vulnerability thresholdGenetic predisposition or vulnerability threshold Series of consequences resulting from brain dysfunctionSeries of consequences resulting from brain dysfunction Requires a second hitRequires a second hit

81 Lifetime Risk of Developing Schizophrenia General population 1%General population 1% Child of one parent with schizophrenia 10-15%Child of one parent with schizophrenia 10-15% Child of two parents with schizophrenia 30-40%Child of two parents with schizophrenia 30-40% Sibling with schizophrenia 10%Sibling with schizophrenia 10% Fraternal twins 10%Fraternal twins 10% Identical twins (adoption studies) 50%Identical twins (adoption studies) 50%

82 Neuroanatomy of Schizophrenia No single change is seen in all people with schizophreniaNo single change is seen in all people with schizophrenia Enlarged ventriclesEnlarged ventricles Underactive frontal lobeUnderactive frontal lobe –planning, judgement, abstraction, expressing feelings Overactive temporal lobeOveractive temporal lobe –preceptions and emotions

83 Schizophrenia ISIS –Biological disease of the brain –Disabling and emotionally devastating –Relatively common –Misunderstood and stigmatized –Treatable IS NOTIS NOT –Caused by bad parenting –A personal weakness –Split personality

84 Mania: Signs and Symptoms Persistently elevated, expansive or irritable mood lasting at least one weekPersistently elevated, expansive or irritable mood lasting at least one week Associated symptomsAssociated symptoms Inflated self -esteem or grandiosityInflated self -esteem or grandiosity Decreased need for sleepDecreased need for sleep More talkativeMore talkative Racing thoughts or flight of ideasRacing thoughts or flight of ideas DistractibilityDistractibility Agitation or increase in activitiesAgitation or increase in activities Excessive involvement in pleasurable activities with a high risk for painful consequencesExcessive involvement in pleasurable activities with a high risk for painful consequences –Spending sprees, sexual indiscretions, foolish investments

85 Manic Episode: DSM-IV Elevated, expansive, or irritable mood for one weekElevated, expansive, or irritable mood for one week Three associated symptomsThree associated symptoms Significant impairment in life rolesSignificant impairment in life roles Not do to a look-alikeNot do to a look-alike Medical conditionMedical condition MedicationMedication Substance abuseSubstance abuse

86 Bipolar Disorder: The Course 1% of general population1% of general population Equal in men and womenEqual in men and women Age of onset similar to schizophreniaAge of onset similar to schizophrenia Episodes can come on very fast (1-7 days)Episodes can come on very fast (1-7 days) Later episodes longer, more severe, more frequentLater episodes longer, more severe, more frequent Substance abuse commonSubstance abuse common Heredity plays a greater role than in depressionHeredity plays a greater role than in depression Family members also at higher risk for major depressionFamily members also at higher risk for major depression High suicide riskHigh suicide risk

87 The Use of Atypical Antipsychotics for Psychosis and Mood Stabilization Timothy Florence, M.D. Clinical Instructor Department of Psychiatry University of Michigan

88 Theoretical Mood Stabilizing Mechanisms Dopamine-Serotonin InteractionDopamine-Serotonin Interaction –5-HT inhibits DA release –5-HT antagonism enhances DA release GABA HypothesisGABA Hypothesis –Inhibitory neurotransmitter system –May mediate Valproate and Carbamazepine effects

89 Dopamine-Serotonin Hypothesis DA AntagonismDA Antagonism –Mesolimbic Improves maniaImproves mania –Mesocortical Worsens depressionWorsens depression –Nigrostriatal Worsens depressionWorsens depression 5-HT Antagonism5-HT Antagonism –Mesolimbic Worsens maniaWorsens mania –Mesocortical Improves depressionImproves depression –Nigrostriatal Improves depressionImproves depression

90 GABA Hypothesis No change in GABA receptors with conventional neurolepticsNo change in GABA receptors with conventional neuroleptics GABA receptor down-regulation with chronic Clozapine and Olanzapine treatmentGABA receptor down-regulation with chronic Clozapine and Olanzapine treatment Mood stabilizing effects may be related to effects on GABA neuro-transmissionMood stabilizing effects may be related to effects on GABA neuro-transmission

91 Bipolar Disorder Mortality At least 25% attempt suicideAt least 25% attempt suicide Suicide rate: 11-19%Suicide rate: 11-19% Suicidal ideation in mixed mania: 50%Suicidal ideation in mixed mania: 50%

92 Bipolar Disorder Morbidity Recurrent illness for 90% of patientsRecurrent illness for 90% of patients Fuctional recovery often lags behind symptomatic recoveryFuctional recovery often lags behind symptomatic recovery Recurrent episodes may lead to progressive deteriorationRecurrent episodes may lead to progressive deterioration Number of episodes may affect subsequent treatment response and prognosisNumber of episodes may affect subsequent treatment response and prognosis 6th leading cause of disability worldwide6th leading cause of disability worldwide

93 Mood Stabilizing Agents FDA Approved –Lithium –Valproate Other Anticonvulsants –Carbamazepine –Lamotrigine –Gabapentin –Topiramate Benzodiazepines Conventional Neuroleptics Atypical Antipsychotics –Clozapine –Risperidone –Olanzapine

94 Novel Antipsychotic Agents Clozapine Open - label studies Risperidone One study compared to Haloperidol and Lithium Olanzapine Two double-blind placebo controlled studies

95 Clozapine for Bipolar Disorder Fifteen open trials in treatment-refractory illness suggest antipsychotic and mood stabilizing propertiesFifteen open trials in treatment-refractory illness suggest antipsychotic and mood stabilizing properties Pooled response rate = 70%Pooled response rate = 70% May be used in conjunction with other mood stabilizersMay be used in conjunction with other mood stabilizers Exception - CarbamazepineException - Carbamazepine

96 Risperidone in Acute Mania Four week, double-blind, randomized studyFour week, double-blind, randomized study No placebo controlNo placebo control Comparable and significant reductions in manic symptoms with Risperidone, Haloperidol, LithiumComparable and significant reductions in manic symptoms with Risperidone, Haloperidol, Lithium

97 Dopamine Rebound Syndrome Euphoria / DysphoriaEuphoria / Dysphoria Hypomania / ManiaHypomania / Mania Decrease in negative symptomsDecrease in negative symptoms AgitationAgitation PsychosisPsychosis DyskinesiasDyskinesias Withdrawal tardive dyskinesiaWithdrawal tardive dyskinesia

98 Cholinergic Rebound Syndrome InsomniaInsomnia JitterinessJitteriness Restlessness / AnxietyRestlessness / Anxiety Somatic distressSomatic distress Gastrointestinal symptomsGastrointestinal symptoms SweatingSweating DroolingDrooling Increased urinationIncreased urination Movement disordersMovement disorders Hypomania / ManiaHypomania / Mania DeliriumDelirium


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