Affective/Psychiatric Disorders

What are affective/mood disorders?

• characterized by imbalances of thought, mood, and/or behaviors

• interferes with ability to function

What are hallucinations?

• sensory perceptions with a compelling sense of reality

  • also olfactory or tactile

• NO external stimulus

• often coincides with other psychiatric disorders

• visual: thalamic lateral geniculate nuclei processing → visual association cortex

• auditory: thalamic medial geniculate nuclei processing → auditory association cortex

What are the 2 types of visual hallucinations?

• release hallucinations

• ictal hallucinations

  • visual ictal hallucinations

What are release hallucinations?

• blocked normal sensory input/memory

• stored images are experienced

What are ictal hallucinations?

• mediated by abnormal neuronal discharges

  • visual ictal hallucinations: brief, geometric (epilepsy aura)

    • very complex when associated with other disorders

What are auditory hallucinations?

• misperceptions of sound

• common in some types of schizophrenia, hearing impairment, right hemisphere damage (temporal lobe)

• ethanol withdrawal states

• psychiatric disorder-induced

  • voices occuring non-localized

  • comments on behavior → thoughts echo

  • rarely described as supportive: critical and negative in tone

What are delusions?

false belief and the persistent, “unshakeable” acceptance of false belief

What is the major difference between hallucinations and delusions?

• hallucinations: PERCEPTION abnormalities

• delusions: THOUGHT abnormalities

How are delusions formed?

• formed from:

  • individual’s background

  • experiences

  • education

  • culture/religions

What are the types of delusions commonly observed in psychiatric disorders?

• delusions of persecution (personal threats)

• delusions of influence

• delusions of ill health

• delusions of grandeur (believing oneself is a great person)

• delusions of poverty

• delusions of possession (believing one’s body is possessed by a great power)

Describe the main actions, regions of localization, and proposed psychiatric disorders that Acetylcholine mediates.

• action:

  • excitatory/inhibitory

  • learning and memory

• brain region:

  • basal ganglia

  • motor cortex

• psychiatric disorder

  • neurocognitive disorders (NCD)

Describe the main actions, regions of localization, and proposed psychiatric disorders that Dopamine mediates.

• action:

  • involuntary motor movement

  • mood states

  • reward systems

  • judgement

• brain region:

  • substantia nigra

  • ventral segmental area of midbrain

• psychiatric disorder:

  • schizophrenia

  • mood disorders

  • anxiety disorders

  • substance use disorders

  • NCDs

Describe the main actions, regions of localization, and proposed psychiatric disorders that NE and E mediate.

• action:

  • learning and memory

  • reward systems

• brain region:

  • sympathetic NS

• psychiatric disorders:

  • mood disorders

  • anxiety disorders

too much dopamine can cause hallucinations and is involved in psychosis.

true

Describe the main actions, regions of localization, and proposed psychiatric disorders that serotonin mediates.

• action:

  • appetite, sleep, mood

  • hallucinations

  • pain perception

• brain region:

  • raphe nucleus in brain stem

• psychiatric disorder:

  • schizophrenia

  • mood disorders

  • anxiety disorders

  • NCDs

Describe the main actions, regions of localization, and proposed psychiatric disorders that GABA, glutamate, aspartate, and glycine mediate.

• action:

  • inhibits/excites neruons

• brain region:

  • throughout brain

• psychiatric disorder:

  • schizophrenia

  • mood disorders

  • anxiety disorders

  • substance use disorders

  • NCDs

Describe the main actions, regions of localization, and proposed psychiatric disorders that corticotropin-releasing hormone mediates.

• action:

  • activates fear behaviors

  • increases motor activity

• brain region:

  • hypothalamic-pituitary adrenal axis

• psychiatric disorder:

  • mood disorder

Describe the main actions, regions of localization, and proposed psychiatric disorders that cortisol mediates.

• action:

  • mobilizes energy

  • increases arousal

• brain region:

  • hypothalamus

• psychiatric disorder:

  • mood disorders

How is schizophrenia chracterized?

• delusions

• hallucinations or false perceptions

• psychosis resulting in a break w/ reality

• disjointed behaviors and speech

• limited emotions

• impaired ability to reason and problem solve, along with social dysfunction

• equal in males and females

What is the criteria for schizophrenia?

requires two or more psychotic manifestations that last 6 months before diagnosis

What are the proposed risk factors for schizophrenia?

• childhood trauma

• malnutrition

• long term cannabis use/chronic amphetamine use

• Vitamin D deficiency

• older fathers

• latent, persistent retrovirus infection

• psychosocial determinants

• close relative with schizophrenia

Why are close relatives with schizophrenia considered a risk factor?

1st degree relatives of a person with schizophrenia have a 10-fold greater prevalence of illness than population at large

What are the positive (psychotic symptoms) of schizophrenia?

• incomprehensible speech

• hallucinations

• delusions

• grossly disorganized

What are negative symptoms of schizophrenia?

these are severe and persistent, treatment is difficult

• absence of normal social and interpersonal behavior

• alogia → speaking very little

• avolition → lack of goal-oriented motivation

• apathy → lack of emotional expression

• affective flattening and inappropriate effect

• anhedonia (pleasure no longer pleasurable)

• disorganization symptom cluster

What is catatonic excitement?

hyperactive, purposeless activity with abnormal movements such as grimacing/posturing

What is echopraxia?

imitation of another person’s movement

What is regressed behavior?

going back to behavior of another time

What is sterotypy?

repetitive, idiosyncratic movements

What is hypervigilance?

enhanced state of sensory stimulation

What is waxy flexibility?

posture held in odd fixed position for extended periods of time

• opposite of catatonic excitement

What are the 3 divisions of schizophrenia?

• paranoid schizophrenia

• disorganized schizophrenia

• catatonic schizophrenia

What is paranoid schizophrenia?

• sudden onset

• persecutory and/or grandiose delusions

• auditory hallucinations

• rigid, intense, controlled interactions

• less negative symptoms

What is disorganized schizophrenia?

• personality disintegration

• negative symptom predominance

• withdrawn and inept, aimless behavior, personal grooming neglected

• daily activities neglected

What is catatonic schizophrenia?

• rare

• intense psychomotor disturbance

  • catatonic excitement/retardation

• extreme negativism

• grimacing, posturing, echolalia

What is the neuropathophysiology of scizophrenia?

• dysregulation of dopaminergic and serotonergic system

• decreased glutamatergic activity → dysfunction of NMDA receptors

• GABA deficits:

  • lower production found in dorsolateral prefrontal cortex and may be a consequence of mRNA dysfunction

• excessive loss of cortical gray matter

  • abnormal cortical thinning

  • reduced # of synaptic structures on neurons

  • reduced dendritic spine density of pyramidal neurons in prefrontal cortex

  • arrested migration of hippocampal neurons

  • enlargement of lateral and 3rd ventricles

    • reduction in frontal, temporal, amygdala

    • diminished neuronal content in thalamus

What is Major Depressive Disorder (MDD)?

• experience of loss of interest in previously enjoyed activities

  • resistance to engage in activities

How is MDD characterized?

• recurring thoughts of suicide

• lack of appetite

• inability to concentrate

• difficulty/inability to make decisions

• feelings of worthlessness

• lack of energy

• decreased motor skills

• substance abuse

• range of sleep disturbances from insomnia → oversleep

What is the criteria for diagnosis of MDD?

• presence of symptoms most of the day to nearly everyday for a minimum of 2 weeks

• symptoms interferes with activities such as work or functioning

What is persistent depressive disorder (dysthymia)?

• chronic but mild state of depression lasting at least 2 years

• moving from major to less severe depression often feeling sad

• stress plays a role

  • cause is idiopathic

At least 2 of what factors must be present for persistent depressive disorder?

• altered sleep pattern (too much/not enough)

• fatigue

• altered eating patterns (lack of appetite/overeating)

• inability to concentrate

• poor self esteem

• feelings of hopelessness

What is premenstrual dysphoric disorder (PMDD)?

• must not merely represent an exacerbation of symptoms of another psychiatric disorder

• hormonal fluctuation a few days-2 weeks before menstruation

  • exhaustion

  • anger

  • feeling of insecurity/loss of control

  • lack of desire for relationships

  • prevents women from participating in everyday lives

• stops with menopause → idiopathic

What is disruptive mood dysregulation disorder (DMDD)?

• relatively new in children and adolescents

• characterized by extreme moodiness in which child (6-18 yrs) displays:

  • anger (everyday)

  • temper outburst (at least 3 times a week)

  • irritability (everyday)

  • difficulty interacting with others

• diagnosed if presence of symptoms is gradual over 12 or more months → idiopathic

What is bipolar disorder?

• median age of onset → 25 yrs

  • women have higher frequency of occurrence

• experiences high (euphoria) to low (depression) mood swings

• often goes undiagnosed for 10 yrs after onset of symptoms

How do you distinguish Bipolar Disorder from major depression?

components of MDD must be met IN ADDITION to cardinal symptom of bipolar disorder mania

What are the 4 types of bipolar disorder?

1. Bipolar I

2. Bipolar II

3. Cyclothymia

4. rapid cycling

What is Bipolar I disorder?

• one or more manic eps → mood is elevated, expansive, irritable

  • alternating major depressive episodes (MDEs)

• risky behavior

• manic episodes

  • EXTREME: increased talkativeness, racing thoughts/ideas, grandiosity, distractibility, delusions, overactivity

• eps begins suddenly and last from few days to few months

• depressive symptoms more severe and less responsive to conventional therapies

What is Bipolar II disorder?

• MDE and at least one hypomanic or less severe manic episode

  • hypomania: milder form of mania

• hypomania symptoms present for at least 4 days

What is cyclothymia?

• similar to Type I but less severe symptoms

• hypomania and nonpsychotic depression must be present for at least 2 years in adults

  • 1 year for children and adolescents

• exclusion disorder → do NOT meet criteria for MDE or manic episode

What is rapid cycling?

• 4 or more manic episodes for at least 2 weeks in a year

• remission is replaced with clinical manifestations of PRONOUNCED depressive symptoms

What is the pathophysiology of bipolar disorder?

• prefrontal cortex abnormalities:

  • gray matter reduction

  • decrease in activity

  • extensive connection with limbic system (= mood dysregulation)

Explain the mechanism of lithium as the ‘gold standard’ of treatment for bipolar disorder.

• Inositol phosphate (InsP) → underlying relationship with MANIA of bipolar disorder

  • IP3 → 2nd messenger for innositol phosphate

• lithium:

  • targets IP3

  • blocks formation and transport of inositol

• valproate and carbamazepine also prescribed as tx

What are anxiety disorders characterized by?

• intense fearfulness occurring WITHOUT precipitating potentially dangerous event

• accompanied by:

  • subjective manifestations

  • objective manifestations

• most prevalent

  • females 60% more likely than males

What are subjective manifestations?

• heightened awareness

• deep fear of impending disaster/death

What are objective manifestations?

• HPA axis-mediated activation (NE/E) of sympathetic cascade

  • increased HR, BP

  • dry mouth

  • “fight or flight”

  • palpitations

  • restlessness

  • sweating

What is generalized anxiety disorder (GAD) characterized by?

• excessive anxiety/worry with difficulty controlling it

• frequently diagnosed in ages 45-59

What are the criteria for GAD?

• chronic and excessive worry and anxiety that interfere with daily activities/relationships for majority of days or at least 6 months

• apprehension

• anxiety

• tension

• autonomic hyperactivity

• results:

  • fatigue

  • inability to concentrate

  • sleep disturbances

• 50% of all people with GAD experience depression

What is panic disorder?

• unexpected surges of recurrent fear/intense discomfort accompanied by physical/behavioral symptoms

• almost always manifests OBJECTIVELY

What characterized panic disorder?

• feelings of being out of control

• fear of death

• physical manifestations (objective)

  • sweat

  • chills

  • tingling

  • numbness

  • chest/stomach pain

  • dyspnea

  • nausea

• chest pain and SOB

  • also complaint of myocardial infarction

• lasts 15-30 mins up to 1 hour

What is the neuropathophysiology of anxiety disorder?

• serotonergic under-activation

  • SSRI/SNRI or 5 HT1a agonists: 1st line treatments

• adrenergic over-activation

• sympathetic NS and corticosteroid activation involved in the stress response

• panic disorder thought to be related to hyperactive amygdala, limbic, and cortical prefrontal cortex

  • regulated by glutamatergic activity

What are major mediators of anxiety?

• GABA

• NE

• serotonin

• DA

• benzodiazepines: 2nd line and rescue treatments

What is wernicke-korsakoff syndrome?

• affective-like disorder resulting from chronic alcohol use

  • ethanol induced brain lesions/damage precipitate symptomology

What are the major brain lesions/pathologies mediating symptoms of Wernicke-Korsakoff Syndrome?

• cortical atrophy

  • progressive degeneration of whole cortex

• hydrocephalus ex vacuo

  • enlargement of CSF spaces

• cerebellar vermicular atrophy

  • progressive degeneration of cerebellar midline (vermis → line in middle of cerebellum)

What is Wernicke’s Disease?

• reversible

• due to thiamine (vitaminB1) deficiency = glucose production interference

  • deficiency common in alcoholics

    • ethanol increases thiamine excretion but decreases expression of thiamine transporters in kidney

• symptoms:

  • acute weakness + paralysis of ocular musculature

  • nystagmus

  • ataxia (unsteady gait)

  • confusion

  • peripheral neuropathy

  • alcohol withdrawal signs: delirium, hallucinations

What is Korsakoff Psychosis?

• irreversible

• severe memory impairment

• learning impairment

• confabulations

  • imaginary experience recitation to fill in memory gaps

  • distinct feature

• polyneuritis