NE
Neurology

Essential Psychiatry for Neurologists

December 21, 2011.
Jason Caplan, MD,

Educational Objectives

The goal of this program is to improve the diagnosis and treatment of psychiatric disorders. After hearing and assimilating this program, the clinician will be better able to:

1. Diagnose mood disorders such as depression and bipolar disorder.

2. Identify the signs and symptoms of psychotic disorders such as schizophrenia.

3. Differentiate among and recognize the characteristics of the different personality disorders.

Summary

Major depression: ³2 wk of depressed mood plus ³4 SIG E CAPS (mnemonic for increased or decreased Sleep, decreased Interest, Guilt, decreased Energy, or Concentration, increased or decreased Appetite, Psychomotor agitation or retardation, and thoughts of or attempts at Suicide) and without history of mania or hypomania; dysthymic disorder — depressed mood on most days for ³2 yr plus ³2 of changes in appetite, sleep, energy, lowered self-esteem, poor concentration, or hopelessness

Bipolar disorders (BPDs): BPD I requires ³1 episode of mania; BPD II requires ³1 episode of hypomania; cyclothymic disorder — rapid fluctuation between depression and hypomania; mania — ³1 wk of persistently elevated, expansive, or irritable mood with ³3 (or 4 if mood irritable only) of DIGFAST (mnemonic for Distractibility, Indiscretion, Grandiosity, Flight of ideas, increased Activity, decreased need for Sleep, and increased Talkativeness or pressured speech) and must cause marked impairment in occupational or social functioning or necessitate hospitalization; hypomania — ³4 days of elevated, expansive, or irritable mood plus ³3 (or 4 if mood irritable only) of DIGFAST; marked impairment in occupational or social functioning not required; cyclothymic disorder — ³2 yr of numerous episodes of depressive symptoms and hypomanic symptoms without full-blown major depressive or manic episodes; mood disorder due to general medical condition —medical illness physiologically causes depression, eg, depression due to hypothyroidism or pancreatic cancer; substance-induced mood disorders — eg, mania due to steroids or methamphetamines

Schizophrenia: ³2 of delusions (fixed false believes), hallucinations, disorganized speech, disorganized or catatonic behavior, and negative symptoms plus ³6 mo of continuous disturbance with ³1 mo of active symptoms and significant impairment in self-care and occupational and social functioning; brief psychotic disorder — psychotic symptoms lasting 0 to 30 days; schizophreniform disorder —symptoms lasting 1 to 6 mo

Subtypes: paranoid, disorganized (disorganized speech or behavior), catatonic, undifferentiated (mainly positive symptoms), or residual (negative symptoms predominate); catatonia — treat first-line with trial of intravenous (IV) lorazepam (2 mg); if benzodiazepines not effective, switch quickly to electroconvulsive therapy (ECT); differentiated from neuroleptic malignant syndrome (NMS) by FEVER, mnemonic for Febrile, Elevated creatine phosphokinase (CPK), Vital sign instability, Elevated white blood count, and Rigidity (catatonic patients have only rigidity)

Schizoaffective disorder: both psychotic and mood symptoms that may occur separately; 2 types, bipolar or depressive; symptoms present regardless of mood (unlike major depression or bipolar disorder with psychotic features, in which psychosis occurs only during mood disturbance)

Delusional disorders: ³1 mo of nonbizarre delusion with no impairment of function or odd behavior; subtypes — erotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified; do not respond well to medication or psychotherapy

Panic disorder: recurrent panic attacks with ³1 mo of concern about having another attack or consequences of attack and significant change in behavior; panic attack — discrete period of fear peaking in 10 min with ³4 of palpitations, diaphoresis, trembling, dyspnea, sense of choking, chest pain, nausea, dizziness, derealization or depersonalization, fear of losing control or dying, paresthesias, chills, and hot flushes; classified as with or without agoraphobia

Generalized anxiety disorder (GAD): ³6 mo of excessive anxiety on most days (not due to features of another axis 1 disorder), and ³3 of WORRY WARTS (for Wound up or irritable, Worn out or easily fatigued, Absent minded or poor concentration, Restless, Tense, or Sleepless)

Obsessive compulsive disorder (OCD): obsessions, compulsions, or both, recognized by patient as excessive and ego-dystonic, and that cause marked distress and interfere with function; not restricted to another axis 1 diagnosis, eg, trichotillomania (compulsion of pulling hair), hypochondriasis (obsession about serious illness), or paraphilia (compulsions around sexual acting out); obsessions — recurrent, persistent, intrusive, inappropriate thoughts that cause distress; patient recognizes thoughts as products of own mind; compulsions —repetitive behaviors that patient must perform in response to obsession or rigid rules

Posttraumatic stress disorder (PTSD): patient experienced, witnessed, or confronted with event that involved actual or threatened death or serious injury; response involves fear, helplessness, or horror; >1 mo of symptoms in 3 areas (re-experience, hyperarousal, and avoidance); re-experience — 1 symptom required; recurrent recollections, nightmares, flashbacks (waking re-experience), or intense distress after exposure to cues; hyperarousal — 2 symptoms required; insomnia, irritability, poor concentration, hypervigilance, or exaggerated startle response; avoidance — 3 symptoms required; avoidance of thoughts, feelings, conversations, people, or places or activities associated with event; difficulty remembering aspects of event; loss of interest in usual activities; detachment or estrangement; restricted affect; sense of foreshortened future; if symptoms present for <1 mo, diagnosis acute stress disorder

Somatoform disorders: somatization disorder — multiple physical complaints beginning before 30 yr of age with treatment sought and impaired functioning; diagnosis requires 4 pain symptoms, 2 gastrointestinal symptoms, 1 sexual symptom, and 1 pseudoneurologic symptom; conversion disorder — ³1 symptom affecting motor or sensory function; hypochondriasis — preoccupation with belief in presence of serious illness; belief persists ³6 mo after evaluation and reassurance; body dysmorphic disorder — preoccupation with imagined or minor defect in appearance; factitious disorder —intentional feigning of signs and symptoms of illness motivated by desire to have illness and receive care or sympathy; more common in women; Munchausen variant more common in men; malingering — intentional feigning of signs and symptoms of illness motivated by desire to avoid something (eg, work, military service) or obtain medications, shelter, or financial compensation; pain disorder — unexplained pain

Eating disorders: anorexia nervosa — refusal to maintain normal body weight; intense fear of gaining weight; disturbed perception of body weight or shape; often presents with amenorrhea; bulimia nervosa — recurrent episodes of binge eating and purging ³2 times per week for ³3 mo; patients usually depressed, but do not treat with bupropion (Wellbutrin, Aplenzin, or Zyban) because of risk for seizures

Paraphilias: ³6 mo of recurrent, intense sexual fantasies, urges, or behaviors focused on specific act or subject; include exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism or sadism, transvestic fetishism, voyeurism, and not otherwise specified

Personality disorders: pervasive behavior; not time limited; how patient’s world outlook framed

Cluster A: paranoid (4 symptoms required); schizoid (lack of interest in human relationships); and schizotypal (unusual beliefs with eccentric behavior)

Cluster B: borderline — 5 symptoms required, typified by history of unstable relationships, emotional lability, or suicidal or parasuicidal behavior; intense fear of abandonment (often associated with difficult childhood); treat with dialectical behavioral therapy (DBT); histrionic — patient shows superficial emotional lability and desire for attention; narcissistic — patient believes in own specialness, needs attention, arrogant, entitled, exploits others, and needs power; antisocial — patient lacks concern for anyone’s safety, rules, or social constructs; conduct disorder in child

Cluster C: avoidant — patient desires relationship but cannot participate in one because of fear of rejection; dependent —unable to live without someone’s care; obsessive compulsive — patient desires rules and orderliness; ego-syntonic rather than ego-dystonia

Readings

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose. In this lecture, Dr. Caplan presents information related to the off-label use of a product, therapy, or device.

Acknowledgements

A Comprehensive Review of Neurology by Barrow Neurological Institute, held July 14-17, 2011, in Sedona, AZ.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

NE022401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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