EOR: BH

cluster of physical, behavioral and mood changes with cyclical occurrence during the luteal phase of the menstrual cycle

premenstrual syndrome (PMS)

severe premenstrual syndrome with functional impairment where anger, irritability and internal tension are prominent

premenstrual dysphoric disorder (PMDD)

physical clinical manifestations of PMDD

MC → abdominal bloating & fatigue

breast swelling pain/tenderness

weight gain

HA

change in bowel habits

muscle/joint pain

emotional clinical manifestations of PMDD

irritability (MC), anger, internal tension, anxiety, feeling on edge

hostility, mood swings, sudden depressed mood

increased sensitivity to rejection

libido changes, feeling overwhelmed

behavioral clinical manifestations of PMDD

food cravings, changes in appetite, poor concentration, noise sensitivity, loss of motor senses, decreased interest in usual activities, easy fatiguability, dec energy, sleep changes

diagnosis of PMDD

sxs occur 1-2 wks before menses (luteal phase), relieved w/in 2-3 of menses onset + at least 7 sxs-free days during follicular phase

when are sxs most severe for PMDD?

2 days prior to onset of menses

PMDD treatment

life mods → exercise, dec stress, caffeine, alc, cig & salt intake

OTC → NSAIDs, vit B6 & E

FIRST LINE → SSRIs

OCPs → alt to SSRIs or if trying to conceive

risk factors for suicide

previous attempt → strongest single predictive factor

access to firearms

gender → F attempt more, M more successful

age → inc w age

race → whites > blacks

underlying psych disorder

substance abuse

marital status → alone > never married > widowed > divorced > married no kids > married + kids

+FHx

h/o impulsivity

chronic illness

highly skilled workers → physicians, etc.

single strongest predictive factor for suicide

previous attempt

who has the highest risk for suicide in the US?

elderly white men

what is considered a "protective factor" for suicide risk?

marriage

sudden, abrupt, discrete episode of intense fear, anxiety or discomfort that usually peaks within 10 minutes and resolves within 1 hour

panic attack → pts may feel anxious hrs after attack ends

diagnosis of panic attack

≥ 4 sxs of sympathetic system overdrive:

dizziness

trembling

choking feeling

paresthesias

sweating

SOB

chest pain-discomfort

cills/hot flashes

fear of losing control

fear of dying

palpitations/↑ HR

nausea/abd distress

depersonalization or derealization

hallmark of panic attacks

sense of impending doom or dread

being detached from oneself

depersonalization

feelings of unreality

derealization

1st line management of acute panic attack

benzos

diagnostic criteria for panic disorder

- Recurrent unexpected panic attacks (3 in 3 wks)

- ≥ 1 sx for 1 month → attacks followed by persistent concern about future attacks, persistent worry about the implication of attacks (losing control), significant maladaptive behavior related to attacks

most effective treatment for panic disorder

CBT + SSRIs

**SSRIs are long term tx, benzos are short term

what can be used as initial therapy in mild panic disorder?

psychotherapy alone

intense fear or anxiety about being in places or situations from which escape or obtaining help may be difficult if panic-like sxs occur

agoraphobia → sxs last at least 6 months

management for agoraphobia

same as panic disorder → CBT +/- SSRIs

what is common in the majority of cases of generalized anxiety disorder (GAD)?

comorbidity with major depression or other anxiety disorders

diagnostic criteria for GAD

- excessive anxiety & worry occurring more days than not for at least 6 months about various events/activities; NOT episodic, situational or focal

- uncontrollable/difficult to control the worry

- anxiety & worry assoc w ≥ 3: restlessness/on edge, easily fatigued, difficulty concentrating/mind going blank, irritability, muscle tension, sleep disturbance

- sxs cause clinically significant distress or impairment

**sxs/disturbance not attributable to substance use/abuse, medical d/o (hyperthyroid) or other mental d/o

first line pharm management for GAD

SSRIs & SNRIs

most effective management for GAD

psychotherapy (CBT) + pharm (SSRIs/SNRIs)

if a pt with GAD has partial response to SSRI/SNRIs, what med can be used as an alternative?

buspirone (Buspar)

what class of meds can be used to help control the autonomic sxs (palpitations, diaphoresis, tachycardia) of panic attacks/performance anxiety?

BBs

MOA → partial serotonin (5HT-1A) receptor agonist & dopamine receptor antagonist

buspirone

selective anxiolytic indicated for GAD with minimal CNS depressant effects (little sedation), does not potentiate CNS depression of alcohol & does not have anticonvulsant or muscle relaxant properties

buspirone

ADRs of buspirone

HA, dizziness, GI sxs, restless leg syndrome, extrapyramidal sxs (EPS)

MC type of phobia

social anxiety disorder

diagnostic criteria for social anxiety disorder

1. disabling, persistent (≥ 6 months) intense excessive fear of social or performance situation in which the person is exposed to scrutiny of others

2. individual fears they will act in a way or show anxiety sxs that will be negatively evaluated/embarrassing

3. social situations almost always provoke fear/anxiety → expected attacks

4. social situations are avoided or endured with intense fear/anxiety

social anxiety disorder may coexist with what personality disorder?

avoidant

mainstay of treatment for social anxiety disorder

psychotherapy

treatment of choice for specific phobias

exposure & desensitization therapy

repeated physical complaints seen in separation anxiety disorder

HA, N/V, stomachache

Screening forms for MDD

PHQ-2 & 9

risk factors for MDD

- +FHx

- lack of interpersonal relationships

- recent difficult life events

- early childhood trauma (abuse/neglect)

- postpartum status

- divorced/separated/widowed

- low socioeconomic status

Pathophys:

- alteration in monoamine neurotransmitters → serotonin, NE & dopamine

- Hypothalamic-pituitary axis overactivity

major depressive disorder (MDD)

Diagnostic criteria for MDD

≥ 5 sxs for ≥ 2 weeks:

Sleep → insomnia or hypersomnia

Interest → loss; anhedonia

Guilt → feelings of worthlessness

Energy → loss or fatigue

Concentration → decreased

Appetite → weight loss/gain

Psychomotor agitation/retardation → restlessness or slowness

Suicide ideation

SIGECAPS is used for

MDD

Loss of pleasure or interest in previously enjoyable activities is called?

anhedonia

What are the 2 "core symptoms" that must be present to diagnose MDD?

Depressed mood or anhedonia

Treatment of choice for pts < 18 y/o with MDD?

Psychotherapy → CBT or interpersonal therapy

1st line pharm therapy for MDD?

SSRIs/SNRIs

what class of meds is used in MDD pts with an associated pain disorder?

SNRIs

next step for for MDD resistant to tx with SSRIs/SNRIs (+/- therapy)

TCAs, MAOIs, mirtazepine, electroconvulsant therapy (ECT)

what is the most effective management for treatment-resistant MDD?

ECT → safe to do in pregnancy & elderly

when treating MDD, you should give a drug _______ weeks at maximum dose before switching

6 wks

what are lifestyle modifications used for tx of MDD?

exercise, diet changes, dec alc, stop smoking, no drug use, regular schedule

depressed mood more days than not for ≥ 2 years and have never been without sxs ≥ 2 months at a time

persistent depressive disorder (aka dysthymia)

symptoms of persistent depressive disorder (dysthymia)

≥ 2 sxs:

- poor appetite or overeating

- insomnia or hypersomnia

- low energy/fatigue

- low self-esteem

- poor concentration or indecisiveness

- feelings of hopelessness

chronic severe, persistent irritability occurring in childhood & adolescence is a core feature of what disorder?

disruptive mood dysregulation disorder (DMDD)

in disruptive mood dysregulation disorder (DMDD), symptoms begin before what age?

10 → not diagnosed before 6 or after 18

occurs ≥ 3x/wk for ≥ 12 months (no ≥ 3 months w/o sxs):

- present in 2 settings

- recurrent temper outbursts manifested verbally &/or behaviorally that are out of proportion to the situation & inconsistent w/ developmental level

- mood between outburst is persistently irritable or angry & observable by others

DMDD

1st line management for DMDD

psychotherapy (parent management training)

**pharm only used for sx control & comorbidities (ex: stimulants, SSRIs, mood stabilizers)

what disorder is previously known as complex bereavement disorder?

prolonged grief disorder

difference between manic and hypomanic episode

manic → 3+ sxs of DIGFAST for > 1 wk + significant impairment

hypomanic → 3+ sxs of DIGFAST > 4 days but no impairment or psychotic features

1+ MANIC episode +/- major depressive episode

bipolar I

1+ major depressive episode + 1+ HYPOMANIC episode

bipolar II

biggest risk factor for bipolar disorder

family history → 1st degree relative w BPD inc likelihood by 10x

what classes of meds are "contraindicated"/not recommended for bipolar disorder as it may activate mania?

antidepressants (SSRIs/SNRIs) monotherapy → not as effective as lithium & antipsychs/anticonvulsants

≥ 2 consecutive years of prolonged, milder hypomanic and depressive symptoms and not sx free for ≥ 2 months

cyclothymic disorder → hypomania & depression sxs do not meet criteria for major depressive or full hypomanic episodes

**pt complains of "mood swings"

MOA of lithium

inhibits 5HT/NE reuptake & 2nd messenger systems

what bipolar med should be avoided in kidney failure (CrCl < 30)?

lithium

what workup should be done before starting lithium?

Scr, electrolytes, TSH, weight, UPT, CBC, EKG

ADRs of lithium

hypothyroidism

tremor

weight gain

GI → N/V/D, dysgeusia

nephrogenic DI

cardiac → bradycardia, abnormal T waves

polyuria/polydipsia

what drugs lead to increased lithium levels?

ACE/ARBs

diuretics

NSAIDs

dec salt intake

what drugs lead to decreased lithium levels?

caffeine

inc salt intake

theophylline

signs of lithium toxicity

tremor, diarrhea, vomiting, ataxia, and restlessness

which bipolar med blocks Na channels & increases GABA

used in pts w renal impairment 1st line

valproic acid

ADRs of valproic acid

alopecia, tremor, GI

SJS/TEN/DRESS

hyperammonemia

increases levels of lamotrigine

BWW for valproic acid

hepatotoxicity, pancreatitis, fetal risk (neural tube defects)

which bipolar med inhibits glutamate release, blocks Na channels & is ineffective for acute mania?

lamotrigine

ADRs of lamotrigine

common → nausea, dizziness, sedation

rare → aseptic meningitis, blood dyscrasias (agranulocytosis, pancytopenia)

decreases levels of valproic acid

BBW for lamotrigine

SJS/TEN/DRESS

bipolar med used in pregnant patients

haloperidol

disorder characterized by a pattern of markedly disturbed & developmentally inappropriate behaviors in which a child rarely turns to an attachment figure for comfort, support, protection & nurturance

reactive attachment disorder

- child rarely seeks & responds to comfort when distressed

- minimal social/emotional responsiveness to others

- limited positive affect

- episodes of unexplained irritability, sadness or fearfulness during nonthreatening interactions w/ adult caregivers

reactive attachment disorder

risk factors for reactive attachment disorder

insufficient care → lack of comfort from adult caregivers, repeated changes of primary caregivers (foster care - can't form stable connection), rearing in unusual settings (high child to caregiver ratio)

pattern of behavior that involves culturally inappropriate, overly familiar behavior w/ relative strangers; violates social boundaries of culture

disinhibited social engagement disorder

- reduced/absent resistance in approaching/interacting w unfamiliar adults

- overly familiar verbal/physical behavior (inconsistent w age-appropriate boundaries)

- diminished/absent checking back w adult caregiver after venturing away

- willingness to go off w unfamiliar adults w minimal/no hesitation

disinhibited social engagement disorder

PTSD vs acute stress disorder timeline

PTSD → trauma occurred at any time; sxs > 1 month

acute stress → trauma occurred < 1 month ago; sxs < 1 month

when does PTSD sxs usually present?

within 3 months following trauma

what comorbidities are seen with PTSD?

MDD, bipolar, anxiety, substance use disorder

trauma/stress disorders (PTSR and ASD) are more common in males or females?

females → greater risk of exposure to traumatic events

who is at the highest risk of indirect/secondary trauma (not directly exposed to trauma themselves) resulting in PTSD?

healthcare workers

exposure symptoms of PTSD

directly experienced trauma

witnessed trauma in person

learning trauma that occurred to family/friend

repeated/extreme exposure to aversive details of trauma

intrusion symptoms of PTSD

recurrent memories, dreams, flashbacks, internal/external cues that results in psych/physiological distress

avoidance symptoms of PTSD

avoiding memories, thoughts or feelings of the trauma

avoiding external reminders (people, places, conversations, situations) related to the trauma

symptoms of negative alterations in cognition/mood seen in PTSD

- memory loss

- persistent negative beliefs/expectations of oneself/others

- distorted cognitions about cause/outcome of trauma leading to blaming oneself/others

- persistent negative emotional state → fear, horror, anger, guilt, shame

- diminished interest/participation in significant activities

- feelings of detachment/estrangement

- inability to experience positive emotions

symptoms of alterations in arousal/reactivity seen in PTSD

- irritable/angry outbursts

- reckless/self-destructive

- hyper-vigilance → heightened awareness of potential threats

- exaggerated startled response

- concentration problems

- sleep disturbance

first lime pharm tx for PTSD

SSRIs & SNRIs → sertraline and paroxetine (both SSRIs) are the only FDA approved meds

what can be used to treat insomnia related to PTSD?

trazodone

non-pharm therapy for PTSD

CBT → helps decrease sxs of re-experiencing & hyperarousal

EMDR (eye movement desensitization and reprocessing) → helps the brain process the traumatic memory

what medication is used to target nightmares and hypervigilance in PTSD?

prazosin (alpha 1 inhibitor) → blocks the brain's response to norepinephrine

criteria for PTSD

1+ month of:

- exposure to trauma

- memories/flashbacks of trauma

- avoidance of thoughts/feelings and external reminders of trauma

- 2 negative alterations in cognition/mood

- 2 alterations in arousal/reactivity

criteria for acute stress disorder

exposure to a trauma < 1 month ago + any 9 sxs:

- intrusion → memories, dreams, flashbacks, psych/physical distress/reactions

- negative mood → inability to express positive emotions

- dissociative → depersonalization/derealization, memory loss

- avoidance → memories/thoughts/feelings, external reminders

- arousal → sleep disturbance, irritable/angry outburst, hyper vigilance, concentration probs, exaggerated startle response