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Save my name, email, and website in this browser for the next time I comment. Synopsis of psychiatry, 8th ed. Psychotherapy PART 2. Individual psychotherapy: Varies according to the time frame used psychotherapy can be either brief or protracted. It can be supportive, directive, and reality-oriented versus expressive, exploratory, and oriented toward a discussion of unconscious material.
Supportive psychotherapy 1. Insight-oriented psychotherapy 1. Indicated in the treatment of anxiety, somatoform and dissociative disorders, personality disorders, neuroses, and trauma. It should be noted that although psychotherapy may be indicated for all these disorders, the degree of patient insight and motivation for undergoing treatment are critical to its success. Behavior modification: Includes a group of loosely related therapies that work according to the principles of learning.
A short list of examples of these therapies follows. Systematic desensitization: Exposing the patient to increasingly anxiety-provoking stimuli and at the same time teaching him or her to relax. This therapy is used in the treatment of phobias and in preventing compulsions. Substitution: Replacing an undesirable behavior smoking with a desirable one chewing gum. Hypnosis works in selected patients in the management of pain, the resolution of conversion disorders, and relaxation training.
Cognitive-behavioral therapy A. Focuses on the cognitive responses that are the primary targets for intervention.
Used in changing maladaptive behavior occurring as a result of cognitive responses. The most common use for this form of therapy is in the treatment of major depression, where the self-defeating attitudes that are so common are identified, challenged, and replaced with more realistic thoughts. Social therapies: These therapies use the principles of supportive and individual or marital therapy, but occur in groups of similar patients, a family, or a couple. PART 2. Tables through summarize the characteristics of these agents.
Many of these medications affect neurotransmitters Figure The main neurotransmitters are monoamines norepinephrine, dopamine, serotonin, acetylcholine, histamine , amino acids gamma-aminobutyric acid , and glutamic acid. Antidepressants: Antidepressants can be placed in three main categories.
Tricyclics and heterocyclics, which once represented the first line of treatment. These drugs work by increasing the level of monoamines in the synapse by reducing the reuptake of norepinephrine and serotonin. Although they are quite effective, they are dangerous in overdose, causing fatal cardiac arrhythmias Table Selective serotonin reuptake inhibitors SSRIs are the most commonly used antidepressants today.
Major side effects include gastrointestinal and sexual dysfunction Table Monoamine oxidase inhibitors MAOIs are not commonly used because a tyramine-free diet no wine or cheese must be followed or a hypertensive crisis may result. These agents may be more helpful in depression with atypical features overeating, oversleeping, irritability Table Miscellaneous medications Table Mood stabilizers: These medications are used to treat mania and include agents such as lithium, valproic acid, and carbamazepine.
Neurotransmitters in the neuronal synapse. Selective serotonin reuptake inhibitors block the reuptake of serotonin by the presynaptic neuron top , allowing more serotonin to be available at the postsynaptic receptor. Monoamine oxidase inhibitors block the ability of this enzyme to inactivate monoamines such as norepinephrine in the synaptic cleft bottom , allowing more neurotransmitter to bind to the postsynaptic receptor.
It is characterized by confusion, muscle rigidity, high temperature, muscle twitching, shivering, and loss of consciousness, and it may be fatal. Lithium and valproic acid are both teratogenic and must be used with caution in women of childbearing age Table Antipsychotic agents A. First-generation antipsychotics typical antipsychotics 1. These medications work by blocking central dopamine receptors.
They are most effective in reducing the positive symptoms of schizophrenia, including hallucinations and delusions. Side effects Table include the following. Central nervous system effects: i. Extrapyramidal symptoms EPS : Parkinsonian syndrome, acute dystonias, akathisia ii. Tardive dyskinesias: Late onset of choreiform and athetoid movements of the trunk, extremities, or mouth iii.
Sedation iv. Neuroleptic malignant syndrome NMS : Can occur at any time with an antipsychotic agent; typically movement disorder muscle rigidity, dystonia, agitation and autonomic symptoms high fever, sweating, tachycardia, hypertension. Treatment includes medication with dantrolene and bromocriptine. Anticholinergic effects c. Cardiovascular effects i. Alpha-adrenergic blockade, which causes orthostatic hypotension ii. Cardiac rhythm disturbances, especially prolongation of the QT interval.
Endocrine effects: Decreasing the amount of dopamine in the pituitary gland leads to increased prolactin levels, which may cause gynecomastia and galactorrhea as well as sexual dysfunction.
Weight gain. Second-generation antipsychotics atypical antipsychotics : These medications are more commonly used than first-generation antipsychotics because they are less likely to produce EPS, tardive dyskinesia, and NMS.
However, many have significant side effects Table of their own that limit their use eg, clozapine can cause fatal agranulocytosis. They are effective in anxiety and sleep disorders and in anxiety and agitation in other disorders such as acute psychosis. They are generally safe in overdose if used alone. They are metabolized mainly in the liver. Their side effects include sedation, behavioral disinhibition especially in the young or the elderly , psychomotor impairment, cognitive impairment, confusion, and ataxia.
They are addictive, and after prolonged use, withdrawal may cause seizures and death. Table lists commonly used benzodiazepines. Drugs used to treat the side effects of other psychotropic medications 1. Anticholinergic agents used to treat dystonias caused by the use of antipsychotic medication include benztropine, biperiden, diphenhydramine, and trihexyphenidyl.
Medications used to treat akathisias restlessness caused by the use of antipsychotic medication include propranolol and benzodiazepines. Medications used to treat parkinsonian side effects caused by the use of antipsychotic medication include amantadine and levodopa.
Which of the following medications is most likely responsible? What is the next step? He has no medical problems, states that he feels fine, and says that last night he even had a nice meal with wine. Which of the following medications is he most likely taking? She takes imipramine each evening for depression. Which of the following is the most likely cause of her symptoms? He enjoys drinking beer on the weekends.
Which of the following side effects is most likely to occur? Alcohol potentiation Alcohol withdrawal Sexual dysfunction Diabetes insipidus 40 [2. He comes to the emergency department several days later with muscle spasms, confusion, fever, tachycardia, and hypertension.
Which of the following is the most likely cause? Which of the following medications should be avoided? Bipolar disorder B. Major depression C. Panic disorder D. Schizophrenia E. Social phobia [2. Haloperidol Risperidone Clozapine Thioridazine Fluphenazine [2. On hospital day 2, she experiences auditory and visual hallucinations, has tremors, and is agitated. Which of the following would be the best therapy? Which of the following is the most likely etiology? Advanced maternal age Mood-stabilizing medication Folate excess Ethnicity [2.
He is rushed to the emergency room where resuscitation is attempted but fails. Which of the following is most likely to be noted during the attempted resuscitation or the autopsy? Massive coronary artery occlusion Aortic valve stenosis Electrocardiographic conduction abnormalities Cardiac tamponade Massive pulmonary embolism Match the following therapies A through F to the clinical scenarios listed questions [2. Answers [2. High doses of thioridazine are associated with irreversible pigmentation of the retina, leading initially to symptoms of night vision difficulty and ultimately to blindness.
This priapism is most likely caused by trazodone. One treatment is epinephrine injected into the corpus of the penis. This patient probably experienced a hypertensive crisis induced by an interaction between the wine and phenelzine, a MAOI. Sexual dysfunction is a very common side effect of SSRI medications.
Because both agents increase serotonin levels, 5 weeks should elapse between discontinuation of one medication and initiation of the other. The danger is very serious serotonin syndrome, which has features similar to those of NMS. Seizure disorders and eating disorders are contraindications for bupropion because of its possible lowering of the seizure threshold and its anorectic effects. This patient has symptoms of diabetes insipidus, a side effect of lithium used in the treatment of bipolar disease.
This individual has neutropenic fever as a result of agranulocytosis, a side effect of the atypical antipsychotic agent clozapine.
This woman is probably experiencing either alcohol or benzodiazepine withdrawal; in either case, benzodiazepines would be the treatment. This woman was likely taking valproic acid, a mood stabilizer used in treating bipolar disorder, which increases the risk for teratogenicity eg, a neural tube defect. A tricyclic antidepressant overdose may lead to increased QT intervals and ultimately to cardiac dysrhythmias. Dialysis is used to treat lithium toxicity when it is severe and lifethreatening, such as causing seizures or coma.
Akithisia restlessness can be treated with propranolol. A benzodiazepam overdose can be treated with flumazenil, which is a benzodiazepam antagonist. The parkinsonian-like symptoms of neuroleptic agents are treated with amantadine or levodopa. An exception to this rule is amoxapine. Selective serotonin reuptake inhibitors are the most commonly used medications for depression but should not be used in conjunction with MAOIs. One medication should be discontinued for at least 5 weeks before the other is initiated to avoid serotonin syndrome.
Serotonin syndrome is similar to NMS and is characterized by confusion, muscle rigidity, high temperature, muscle twitching, shivering, and loss of consciousness. It may be fatal. The most common side effects of SSRIs are gastrointestinal and sexual dysfunction. Individuals taking MAOIs should avoid cheese, wine, liver, and aged foods tyramine or an acute hypertensive crisis may ensue.
Trazodone can lead to priapism; thus, a prolonged painful erection that is trazodone-induced is considered an emergency and is treated with an intracorporeal injection of epinephrine or drainage of blood from the penis. Bupropion is used for smoking cessation but must be avoided in patients with eating disorders or seizures. Lithium is cleared through the kidneys and must be used with caution in older patients and in those with renal insufficiency. Lithium and valproic acid are both teratogenic and must be used with caution in women of childbearing age.
Antipsychotic agents produce many adverse effects, including EPS, sedation, and orthostatic hypotension. Neuroleptic malignant syndrome can be caused at any time by an antipsychotic agent.
It typically includes movement disorder muscle rigidity, dystonia, agitation and autonomic symptoms high fever, sweating, tachycardia, hypertension. Clozapine can cause fatal agranulocytosis, and thus leukocyte count monitoring is mandatory.
Benzodiazepine withdrawal resembles alcohol withdrawal and can be fatal. He was diagnosed with major depression for the first time 20 years ago. During a second episode, which occurred 15 years ago, he was treated with imipramine, and once again his symptoms remitted after 4 to 6 weeks.
He denies illicit drug use or any recent traumatic events. The man states that although he is sure he is experiencing another major depression, he would like to avoid imipramine this time because although it worked in the past, it produced unacceptable side effects such as dry mouth, dry eyes, and constipation. Previously he was successfully treated with a tricyclic antidepressant TCA , although this class of medication often produces anticholinergic side effects such as dry mouth, dry eyes, and constipation, which this patient complains about.
The question becomes what medication should be used to treat recurrent major depression when tricyclics are not an option. Common side effects: Gastrointestinal symptoms—stomach pain, nausea, and diarrhea—occur in early stages of the treatment.
Minor sleep disturbances—either sedation or insomnia—can occur. Other common side effects include tremor, dizziness, increased perspiration, and male and female sexual dysfunction most commonly delayed ejaculation in men and decreased libido in women.
Analysis Objectives 1. Understand the treatment of uncomplicated major depression without psychotic features. Be able to counsel a patient in regard to the common side effects of SSRIs. Considerations Although the patient has been successfully treated with a TCA imipramine two times in the past, these medications are no longer considered first-line treatments because of their common side effects and their potential lethality.
If taken all at once, a weekly dosage of one these medications can produce lethal cardiac arrhythmias. For a patient such as this one, who has a successful history of being treated with imipramine on two prior occasions, one might consider using this medication again. However, the patient specifically requests another type of medication because of his previous discomfort with the side effects. SSRIs, the current first-line treatment approach for patients with major depression, are thus the logical choice; they have fewer side effects and are safer.
Table lists the criteria for major depression, recurrent. Depressed mood 2. Anhedonia 3. Significant weight change or change in appetite 4. Insomnia or hypersomnia 5.
Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness or excessive guilt 8. Decreased ability to concentrate or indecisiveness 9. These agents are used as antidepressants and in treating eating disorders, panic, obsessive-compulsive disorder, and borderline personality disorder.
Venlafaxine: A phenylethylamine antidepressant structurally different from other antidepressant agents, which acts as a nonselective inhibitor of the reuptake of norepinephrine, serotonin, and dopamine.
Clinical Approach Major depression is a common problem. In the United States, about one in seven individuals will suffer from this disorder at some time in their life. Women are affected twice as often as men, with a mean age of occurrence at 40 years, and half of affected individuals are between the ages of 20 and 50 years.
Those without close personal relationships are at greater risk. A common hypothesis concerning the etiology of major depressive disorder involves the alteration of biogenic amines, particularly norepinephrine and serotonin.
Genetics plays a role, as evidenced by family studies. The course of major depression is chronicity and a propensity for relapse. Good prognostic signs include a short hospital stay, the absence of psychotic symptoms, stable family functioning, and close social relationships.
Given the frequency with which depression is a presenting complaint in the primary care setting, a mnemonic is helpful in remembering the criteria for an episode of major depression. Each letter stands for a criteria except for depressed mood used in diagnosing an episode of major depression: S—sleep changes I— decreased interest G— excessive guilt E— decreased energy C— decreased concentration A—appetite changes P—psychomotor agitation or retardation S—suicidal ideation.
Differential Diagnosis It is important to rule out other disorders that could be causing a depressed state, including medical diseases eg, hypothyroidism or multiple sclerosis , medications eg, antihypertensives , or substances eg, alcohol use or cocaine withdrawal. Obtaining a thorough history, performing a physical examination, and ordering appropriate laboratory studies are crucial in the assessment of any new onset of depression.
Many psychiatric illnesses are characterized by depressive symptoms, including psychotic disorders, anxiety disorders, and personality disorders. A critical distinction to make, especially in recurrent episodes of depression, is between major depressive disorder, recurrent, and bipolar disorder, depressed. This distinction is essential not only for making the correct diagnosis but also for proper treatment. Standard therapies for major depression may be less effective and actually worsen bipolar illnesses.
It is necessary to obtain any current or past history of episodes of mania, as well as any family history of bipolar disorder. Assessment of Suicide Risk One of the most important determinations a clinician must make in the case of a depressed individual is the risk of suicide.
The best approach is to ask the patient directly using questions such as, Are you or have you ever been suicidal? Do you want to die? A patient with a specific suicide plan is of special concern. Also, the psychiatrist should be alert to warning signs such as an individual becoming uncustomarily quiet and less agitated after a previous expression of suicidal intent or making a will and giving away personal property.
The results of a careful mental status examination, risk factors, prior suicidal attempts, and suicidal thoughts and intent must be all considered. Many experience what is known as postpartum blues, in which there is sadness, strong feelings of dependency, frequent crying spells, and dysphoria.
These feelings, which do not constitute major depression and therefore should not be treated as such, seem to be attributable to a combination of the rapid hormonal shifts occurring during the postpartum period, the stress of childbearing, and the sudden responsibility of caring for another human being. Postpartum blues usually lasts for only several days to a week. In rare cases, postpartum depression exceeds in both severity and length that observed in postpartum blues and is characterized by suicidality and severely depressed feelings.
Women with postpartum depression need to be treated as one would treat a patient with major depression, taking care to educate them as to the risks of breast-feeding an infant when the antidepressant appears in the milk. Left untreated, postpartum depression can worsen to a point where the patient becomes psychotic, in which case antipsychotic medication and hospitalization may be necessary as well. Save my name, email, and website in this browser for the next time I comment.
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