Mood and Anxiety Disorders: Understanding Dissociative and Personality Disorders, Exams of Nursing

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Patho Week 9 Transcript Mood, Dissociative and Personality Disorders – Psychological Disorders (PSY 00:01 Now, let's get into the second broad bean of psychological disorder that I would say is probably the most common would be mood disorders. 00:10 So these are -- disorders characterized by a persistent pattern of abnormal mood and there's -- well, referring to you is affect and mood. 00:21 So affect refers to an individual's visible emotion in the moment and mood is sustain internal emotion that reflects his or her view of life. 00:29 So when we look at things like depression, now, would follow under mood disorder, this is sort of a long term impact on their view on life and the emotion they're going to portray. 00:41 So somebody who is depressed isn't going to be smiling all the time and super happy and smelling the roses, emotionally speaking the visible emotion that you see would be a little bit more down -- would be a little bit more on the negative side and their internal mood would be that they feel like, "What's the point of living, I'm so unhappy, I don’t find happiness in the things that I should be finding happiness in." The DSM-5 separates mood disorders into two categories. There are depressive and related disorders, and bipolar and related disorders. 01:15 Let's start by discussing the depressive disorders. First, there is major depressive disorder, this one is often called unipolar or a major depression. 01:24 For diagnosis five or more of the following conditions must have been present nearly every day during the same two week period and one of them must be depressed mode or lost of interest or pleasure. 01:37 The conditions are: depressed mood most of the day; markedly diminished interest or pleasure in all or almost all activities for most of the day. 01:47 Significant so more than 5% weight gain or loss or decreased or increase appetite. 01:53 Insomnia, often sleep-maintenance insomnia or hypersomnia; psychomotor agitation or retardation observed by other, not self-reported. Fatigue or loss of energy. 02:06 Feelings of worthlessness or excessive or inappropriate guilt. 02:11 Diminished ability to think or concentrate or indecisiveness. 02:15 Recurrent thoughts of death or suicide. A suicide attempt or a specific plan for committing suicide. 02:23 The next form is persistent depressive disorder. 02:26 It is characterized by depressive symptoms that persist for two or more years without remission. 02:33 PDD consolidates disorders, formally termed chronic major depressive disorder and dysthymic disorder. 02:41 For diagnosis, patients must have had a depress mode for most of the day for two or more years plus two or more of the following conditions: poor appetite or over eating; insomnia or hypersomnia; low energy or fatigue; low self- esteem; poor concentration or difficulty in making decisions; feelings of hopelessness. 03:05 Now, let's talk about premenstrual dysphoric disorder. It involves mood and anxiety symptoms that are clearly related to the menstrual cycle with onset during the pre-menstrual phase had the symptom free interval after menstruation. 03:20 People with dissociative disorders use dissociation as a defense mechanism pathologically and involuntarily. 06:52 Dissociative disorders are sometimes triggered by psychological trauma, but may be preceded only by stress, psychoactive substances or no identifiable trigger at all. 07:03 This disorder is formerly known as multiple personality disorder. There are symptoms of disruption of identity that may be reported as well as observed. 07:12 Next, there is depersonalization/derealization disorder, this disorder occurs when you persistently or repeatedly have the feeling that you're observing yourself from outside your body or you have a sense that things around you aren’t real or both. 07:30 Feelings of depersonalization and derealization can be very disturbing and may feel like you're living in a dream. 07:38 The diagnosis of depersonalization/derealization disorder is clinical based on criteria in the DSM-5. 07:46 Patients have persistent or recurrent episodes of depersonalization/derealization or both. 07:52 Patients know that their unreal experiences are not real. They have an intact sense of reality. 07:59 Symptoms cause significant distress or significantly impair social or occupational functioning. 08:05 Now, let's talk about dissociative amnesia. The information you lost in this type of amnesia would normally be part of conscious awareness and would be described as autobiographic memory. 08:18 Although the forgotten information may be inaccessible to consciousness, it sometimes continues to influence behavior. 08:26 For example, a woman who is attacked in an elevator, refuses to ride in elevators even though she cannot recall the attack. 08:34 In a change from the DSM-4 to the DSM-5, dissociative fugue is now subsumed under dissociative amnesia. 08:43 Lastly, let's talk about personality disorders. There are ten types of them which are grouped into three clusters, A, B and C. 08:53 In cluster A, we find paranoid personality disorder. It is characterized by excessive distressed and suspicion. 09:01 People with paranoid personalities rarely confide in others and tend to misinterpret harmless comments and behavior as malicious. 09:10 PPD usually begins by early adulthood, and is manifested by an overall sense of distrust and unjustified suspicion that causes persistent misinterpretation of others intentions as being malicious. 09:24 People with the paranoid personality disorder are usually unable to acknowledge their own negative feelings towards others but do not generally lose touch with reality. 09:34 The next type in cluster A is schizoid personality disorder. People with Schizoid personality disorder, rarely feel there is anything wrong with them. Symptoms include: an indifference to social relationships and a limited range of emotional expression. It manifests itself by early adulthood, through social and emotional detachment that prevent people from having close relationships. 10:01 People with it are able to function in everyday life, but will not develop meaningful relationships with others, they are typically solitary or loners and may be prone to excessive day dreaming, as well as forming attachments to animals. 10:15 The last disorder in this cluster is schizotypal personality disorder. 10:20 It is a psychiatric condition marked by disturb thoughts and behavior, unusual beliefs in fears and difficulty with forming and maintaining relationships. 10:32 Speech may include digressions, odd use of words or display magical thinking such as a belief in clairvoyance and bizarre fantasies. 10:41 Patients usually experience distorted thinking behaves strangely and avoid intimacy, they typically have few if any close friends and feel nervous around strangers. 10:52 Although they may marry and maintain jobs. This disorder appears more frequently in males, surfaces by early adulthood and can exacerbate anxiety and depression. 11:04 Next, let's have a closer look on cluster B disorders, there we find antisocial personality disorder, it is characterized by a pattern of disregard for and violation of the rights of others. 11:17 The diagnosis of APD disorder is not given to individuals under the age of 18 but is given only if there is a history of some symptoms of conduct disorder before age 15. 11:30 People with this illness may seem charming on the surface, but they are likely to be irritable and aggressive as well as irresponsible. 11:39 They may have numerous somatic complaints and perhaps attempts suicide. 11:43 Due to their manipulative tendencies, it is difficult to tell whether they are lying or telling the truth. 11:50 Another disorder is the borderline personality disorder, here you find an instability and impulse control or mood or image of self and others. 12:00 People with obsessive compulsive personality disorder have overarching concerns with things being perfect. 15:47 So their concern with orderliness, perfectionism and control over ones environment, they obsessed about themselves and their room and their desk, everything needs to be perfect and to the point again where it supersedes and becomes the primary goal of their daily functioning. Anxiety – Psychological Disorders ( Transcript Change transcripts language English Change transcripts language 00:01 So, let’s start going through each now. 00:03 Anxiety, so what is anxiety? So this is an emotional state, so it’s more emotionally driven of unpleasant physical and mental arousal. 00:10 And so what happens with individuals with anxiety is that you have these intense, frequent, irrational and uncontrollable episodes, and so their thoughts and behaviors get a little bit out of control. 00:22 And when you speak to individuals who have anxiety, they say, “My mind is racing a mile a minute and I really can’t control where I’m going,” and the thoughts don’t necessarily make sense, they become slightly irrational. 00:34 So for example, somebody who is suffering from anxiety might say, “I have an appointment at 10 o’clock but it’s 9:10 right now and I haven’t put on my pants yet but my pants are still on the dryer, and that reminds me I need to get a new lint remover for the dryer and the stores are going to be closing in 20 minutes, and the car needs gas, and how am I going to make it to the store?” So you can see it’s snowballing out of control and their thoughts are going frantic. 01:02 It’s not that they’re not connected, but it’s slightly irrational, as opposed to somebody who is maybe not suffering from anxiety might say, “I have an appointment in 20 minutes. 01:10 I should probably get a move on and get in the car and get going,” end of story, full stop. 01:16 So you can see how one is going quite frantic and one is a little bit more controlled, and that’s the biggest description that they say is I have a lack of control of my thoughts. 01:27 Let's have a view on the different types of anxiety disorders. 01:31 First, there is separation anxiety disorder, the individual with this disorder is fearful or anxious about separation from attachment figures to a degree that is developmentally inappropriate. 01:41 There is persistent fear or anxiety about harm coming to attachment figures and events that could lead to loss of or separation from attachment figures and reluctance to go away from attachment figures as well as nightmares and physical symptoms of distress. 01:54 Although, the symptoms often develop in childhood, they can be express throughout adulthood as well. 01:58 Another type of anxiety disorders is selective mutism. 02:01 This is characterized by a consistent failure to speak in social situations in which there is an expectation to speak. 02:07 For example in school, even though the individual speaks another situations, the failure to speak has significant consequences on achievement and academic or occupational settings or otherwise interferes with normal, social communication. 02:18 Next we have specific phobia, individuals with specific phobia are fearful or anxious about or avoidant of certain objects or situations. 02:27 A specific cognitive ideation is not featured in this disorder as it is in other anxiety disorders. 02:32 The fear anxiety or avoidance is almost always immediately induced by the phobic situation to the degree that it is persistent and out of proportion to the actual risk post. 02:42 There are various types of specific phobias for example, with animals, natural environment, blood injection injuries, just to name a few. 02:51 Then there is social anxiety disorder. 02:53 In this case, the individual is fearful or anxious about or avoidant of social interactions and situations that involve the possibility of being scrutinize. 03:01 This include social interactions such as meeting unfamiliar people, situations in which the individual may be observed eating or drinking. 03:08 In situations in which the individual performs in front of others. 03:11 The cognitive ideation is being negatively evaluated by others by being embarrassed, humilities or rejected or offending others. 03:18 Next on the list is panic disorder. 03:20 The individual with this form of anxiety disorder experiences recurrent unexpected panic attacks and is persistently concerned or worried about 00:50 Let’s get a little bit more history. 00:52 She worked with a therapist already and she's tried relaxation therapy, but she now presents with – and she is desiring medical treatment. 01:00 She has never taken any chronic medications for anxiety in the past. 01:04 So, right away, let's think about what we want to do for treatment. 01:07 What will be the best choice for initial pharmacotherapy for this patient. 01:11 Is it, A, a benzodiazepine; B, tricyclic antidepressant; C, an SSRI; or D, bupropion? The answer to me is C. 01:21 SSRIs have a strong track record of efficacy in patients with generalized anxiety disorder and they are generally better tolerated than some of the other agents listed there and don't have the risk for misuse and addiction that benzodiazepines have. 01:38 So, we’ll go over therapy, but that's after we get through our usual discussion of epidemiology, symptomatology and diagnosis first. 01:47 So, anxiety is very, very prevalent. 01:50 So, the lifetime prevalence of an anxiety disorder, you can see it's well higher among women versus men. 01:56 Women have up to a 7, 7.5% risk whereas men have an average risk of 4% overall for generalized anxiety and panic disorder. 02:07 So, what are the risk factors for anxiety disorders? As I just mentioned, female sex is one. 02:13 It is hereditary. 02:13 Family history is important. 02:16 Comorbid mental health disorders. 02:17 And so, this could be – the most common one being depression, but also bipolar disorder, post-traumatic stress disorder can also be associated with significant anxiety and anxiety disorders. 02:30 And then, other physical diagnoses. 02:32 Pain is one that's frequently related to anxiety disorders. 02:36 Gastrointestinal disorders, particularly irritable bowel syndrome is one I think is commonly reflected in anxiety disorders as well. 02:46 And then a history of abuse. 02:47 So, that could be physical abuse or sexual abuse associated with a higher risk of anxiety as well. 02:54 What about the diagnostic criteria for generalized anxiety disorder. 02:58 First of all, the symptoms should be present for at least six months. 03:01 This is a chronic disorder. 03:03 They include anxiety and then they have to have at least three of the following symptoms – restlessness, fatigability, difficulty concentrating, irritability, muscle tension or sleep disturbance. 03:16 So, anxiety present for at least six months with three of those other symptoms, which shows when you’re talking about fatigability, difficulty concentrating, sleep disturbance, all those are related to function too and they really can have a significant impact on one's life. 03:32 Panic disorder, I actually think the criteria here are a little bit more lenient. 03:37 So, the definition of panic is a severe anxiety that peaks within minutes. 03:42 So, it really feels – we call them panic attacks because it feels like an attack. 03:47 It comes on. 03:48 Sometimes it's cued by certain things, maybe being in an enclosed space or some other memory that's triggered that produces panic. 03:56 A lot of times, it arises out of nowhere. 03:59 And then it goes away spontaneously within minutes as well. 04:05 Now, it has to be associated with at least four other symptoms. 04:08 And I’m just going to highlight a few of them because these describe some of the symptoms that are common in panic disorder. 04:13 Palpitations being one. 04:14 Feeling lightheaded. 04:16 Getting chest pain. 04:18 Feeling nauseous. 04:19 Sweating. 04:20 Getting tremulous, shaky. 04:22 But there are seven more. When it comes to pharmacotherapy, first-line therapy really is a serotonin reuptake inhibitor. 06:53 There is evidence of fair efficacy and the drugs are generally safe and well tolerated. 06:58 Tricyclic antidepressants can also be used for panic disorder, but there's a problem with tolerability due to anticholinergic side effects. 07:06 Buspirone is another option, but it’s just less effective. 07:08 So, it’s a second line agent. 07:11 And benzodiazepines, I don't recommend them generally for most patients for long-term use because of the potential for misuse and abuse, but they can be helpful for short-term situations. 07:22 And where I use benzodiazepines is particularly for patients with severe psychosocial stressors. 07:27 So, they just lost a loved one or they just went through an eviction this week. 07:35 Benzodiazepines may take the edge off that anxiety for another five or seven days, but usually that's the limitation I had put on it, is a week of treatment or so. 07:46 In terms of the clinical course, patients can feel heartened that, while it usually comes on while they’re in early adulthood, there are a number that remit spontaneously. 07:58 Whereas most developed, more chronic disease, 40% recover fully within 12 years. 08:04 Even among those who recover, though, there is a risk for dysthymic disorders and depression. 08:10 That may be as high as 50%. 08:12 So, that’s something to watch even among patients who have experienced a regression of their anxiety. 08:20 And when you diagnose a patient with both depression and anxiety at the same time, that predicts a longer clinical course. 08:28 Unfortunately, also greater functional impairment. 08:32 So, what we learned today was that anxiety disorders are very, very common. 08:37 And not to go overboard with your laboratory diagnosis. 08:42 Definitely pay attention to psychosocial stressors. 08:44 SSRIs in terms of pharmacotherapy are a great option, but don't forget about the basics, limiting caffeine and increasing exercise very important. 08:53 And also, consider talk therapy. 08:55 That can really work well for some patients and is a nice adjunctive treatment for patients with anxiety disorders. 09:02 Thank you very much. Depression 00:00 Now we're going to talk about depression, one of the most common mood disorders that's extremely important to know about for your exam. So what is depression? Well, it's an episode of dysphoria that's associated with more than a low mood, but also associated with a loss of interest in activities. The epidemiology for depression includes a lifetime prevalence of 12%. The onset can be at any age, however, young adults and elderly are at particular risk. The prevalence in 18 to 29-year-old individuals is actually threefold higher than in other groups. Females will experience nearly threefold higher rates of depression than man and there is actually no ethnic or socioeconomic difference. However, a very important note to keep in mind is that while depression can occur across ethnicities, many minorities are actually more likely to be misdiagnosed and instead of being accurately diagnosed with depression or mood disorder, they may be labeled as having schizophrenia, an important note to consider. About 2/3 of all depressed patients will contemplate suicide and 10-15% actually died by suicide. Only half of the patients with major depressive disorder will ever receive treatment. So most people go completely unnoticed. Do you know who described depression as anger turned inwards? That was Sigmund Freud. He actually wrote about this concept in his 1917 paper called Mourning and Melancholia. Here he described depression as introjected rage over object loss. Let me give you a clinical case example. Consider a 40-year-old woman. She has been struggling with feeling unloved at home, dissatisfied in her career and taken advantage of by her extended family. She has had longstanding troubles with her sleep, appetite, sense of self-worth, energy and she has lost interest in all of her hobbies. 02:23 When she learns that her husband has been secretly taking money from her personal account, this woman becomes enraged and furious at her husband. But then, she takes her own life. 02:36 A perfect example of anger turned inwards. The cause of depression is not exactly known, but we do believe that biological, genetic, environmental, and psychosocial factors play a role. 02:52 Let's consider this chart here. There's a lot of information. This all describes the pathogenesis of depression. So what is decreased in patients with depression? Well, we know that drugs that increase the availability of serotonin, noradrenaline, and dopamine will actually alleviate symptoms of depression. And therefore we think that all of these neurotransmitters are reduced in people who have depression. Let's talk a little bit about the monoamine hypothesis. 03:24 01:48 Females are affected more than males. 01:52 Note that more males are affected with OCD, however, in childhood than women. 01:58 In fact, males will specifically have an onset of age before 10 years old when they acquire OCD. 02:06 The main age of onset, however, for most people with the disorder including women are the mid-20s. 02:13 And 25% of cases will occur before 14 years old. 02:19 There’s a strong link between suicidal thoughts and behaviors and OCD, very important to note because in the psychiatry exam and in clinical practice, you want to pay close attention to suicide risk all the time. 02:34 There’s also a strong link between mental illness with in close relative especially those diagnosed with OCD. 02:42 So let’s think of this example a little bit more. 02:45 Let’s say you’ve actually started treating Jane and you’ve come to learn that she often she restricts here food intake to 10 bites at meals in an effort to stop her intrusive thoughts about having a disease. 03:00 She often feels fatigued without energy and has trouble getting out of bed and she reports to you that she has a very low mood. 03:08 What other psychiatric disorders is Jane at risk for having as a comorbidity to OCD? Well, here’s some of the differential diagnoses for OCD. 03:23 Personality disorders, obsessive compulsive personality, anxiety disorders. 03:30 This could include panic, social anxiety, generalized anxiety disorder and specific phobias. 03:37 Schizophrenia, mood disorders including depression and bipolar disorder, also somatoform disorders. 03:46 Things like body dysmorphic disorder, eating disorders and impulsivity disorders, which include tic disorder, Tourette’s, trichotillomania, and excoriation. 03:58 Note that OCD increases the likelihood of other mental illnesses in general. 04:04 Up to 29% of individuals seeking treatment have been found to have a history of a tic disorder. 04:12 So what are the different factors that lead to OCD? Let’s go through them one by one. 04:17 There are genetics. 04:19 So is there a correlation between genetic factors and OCD? Absolutely. 04:24 We tend to think there’s both familial and sporadic types of a link. 04:30 Twin and family studies show a correlation to a genetic contribution. 04:36 And how about the environment? What bacteria affects the development of OCD? The answer is group A streptococcus. 04:45 And what parts of a woman’s cycle affects the development of OCD? The premenstrual and postpartum periods. 04:56 Does trauma affect the development of OCD? It does. 05:01 Actually, exposure to traumatic events or stress can exacerbate OCD or lead to its manifestation. 05:10 And which medical trauma affects the development of OCD? Well, that would be neurological lesions, things like an ischemic stroke or traumatic brain injury. 05:22 Neurobiological factors are also important. 05:26 Do you know which circuit in the brain is linked to the neuroanatomical abnormalities seen in OCD? Well, structural imaging shows a link to neuroanatomical abnormalities in the cortico-striato-thalamo-cortical circuits, the CSTC circuits. 05:47 PET Scanning and functional MRIs have found abnormal activity in different nodes of the CSTC circuits. 05:57 Here’s a question for you, do individuals experience obsessions as voluntary and pleasurable? The answer is no, they do not. 06:07 In fact, it’s extremely distressing to a patient with OCD and it really interferes with their day to day functioning. Differentiating Dementia 0:00