Mood and Anxiety Disorders + OCD

Mood, anxiety and OCD

OCD diagnosis

A. Presence of obsessions, compulsions, or both: 5

• Obsessions are defined by (1) and (2):

• 1. Recurrent and persistent thoughts, urges, or impulses -- intrusive

and unwanted, most individuals cause marked anxiety or distress.

• 2.The individual attempts to ignore or suppress such thoughts,

urges, or images, or to neutralize them with some other thought or

action

• Compulsions are defined by (1) and (2):

• 1. Repetitive behaviors or mental acts that the individual feels driven

to perform in response to an obsession or according to rules that

must be applied rigidly

• 2.The behaviors or mental acts are aimed at preventing or reducing

anxiety or distress, or preventing some dreaded event or situation

B. The obsessions or compulsions are time-consuming (e.g., take more

than 1 hour per day) or cause clinically significant distress or

impairment in social, occupational, or other important areas of

functioning

What is obsession

Regular, intrusive thought that cause anxiety/distress

What is compulsion

Drive to perform rituals to alleviate obsession

Contamination dimension obsession and compulsion

Obsession: concern about dirt and germ

Compulsion: washing/showering/cleaning

Harm dimension obsession and compulsion

Obsession: concern about getting hurt

Compulsion: checking

Unacceptability dimension obsession and compulsion

Obsession: intrusive aggressive, sexual or religious thought

Compulsion: mental ritual/praying

Symmetry dimension obsession and compulsion

Obsession: concern about symmetry

Compulsion: ordering, straighening, repeating, counting

Hoarding dimension obsession and compulsion

Obsession: concern about hoarding

Compulsion: hoarding behavior

OCD with good insight

Knows OCD belief is not true or may or may not be true

OCD with poor insight

Think that OCD belief are probably true

OCD with absent/delusional belief

Thinks OCD beliefs are definitely true

OCD and related disorders

OCD, body dysmorphic disorder, trichotillomania (hair pulling), hoarding, excoriation (skin picking), Tourette, hypochondriasis, olfactory reference

OCD coexist with what other conditions

ADHD, tic disorders, stereotypic movement disorder

CSTC circuits relation to OCD early phase

Dorsal, ventral cognitive and ventral reward CSTC + frontolimbic more active

CSTC circuits relation to OCD late phase

Sensorimotor, dorsal and ventral cognitive CSTC involvement → causes compulsions

Molecular mechanism of OCD

Dopamine → causes stereotypic behavior; decreased D2 in striatum

Glutaminergic neuron relate to CSTC

S&S anxiety

Fear, nervousness, worry/derealization, muscular tension, dizziness, insomnia

How does anxiety differ from normal flight/fight

Normal flight/fight occurs in REAL threat causing fear; anxiety is caused by ANTICIPATION OF FUTURE threat

Circuits related to anxiety

vHPC (ventral hippocampus), mPFC (medial prefrontal cortex) BNST (bed nucleus of the stria terminalis) → Interpret stimuli as threatening or not → In anxiety there is increased perception of things as threatening

Generalized anxiety disorder diag

A. Chronic, persistent worry for at least 6 mo

B. Individual finds it difficult to control worry

C. Anxiety and worry associated with >=3 of the following

• Restlessness

• easily fatigued

• cannot concentrate

• irritability

• muscle tension

• sleep disturbance

D. Causes significant distress

• Not caused by disease or drug

• Not explainable by other disorder

• Excessive worry involve multiple domain and are out of proportion

What are panic attacks

Fear + onset of cognitive (racing thought, believing you are going insane etc) and somatic (choking, tachycardia, jelly legs etc) symptoms

Panic disorder diag

A. Recurrent unexpected panic attacks → abrupt surge of intense fear or intense discomfort that reaches a peak within 10 minutes, which > 4 of the following symptoms occur:

• Palpitations, pounding heart, or accelerated heart rate

• Sweating

• Trembling or shaking

• Sensations of shortness of breath

• Feelings of choking

• Chest pain or discomfort

• Nausea or abdominal distress

• Feeling dizzy, unsteady, light-headed, or faint

• Chills or heat sensations

• Paresthesias (numbness or tingling sensations)

• Derealization or depersonalization

• Fear of losing control or "going crazy."

• Fear of dying

B. At least 1 of the attacks or both has been followed by >1 month:

• Persistent concern or worry about additional panic attacks or their consequences

• Significant maladaptive change in behavior related to the attacks

What is agoraphobia

Intense fear of 2 of the following:

• Using public transport

• Being in open spaces

• Being in enclosed spaces

• Standing in line/being in a crowd

• Being outside of their home alone

Phobia diagnosis

A. Marked fear/anxiety abt smth

B. Phobic object always elicit fear

C. Phobic object is actively avoided

D. Fear is out of proportion to the danger

E. Fear is persistent ≥6 mo

F. Fear causes distress

Social anxiety diagnosis

A. Persistent fear of > 1 social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others -- fears that he or she will act in a way that will be embarrassing and humiliating

B. Exposure to the feared situation almost always provokes anxiety, which may take the form of a situationally bound

C. The person recognizes that this fear is unreasonable or excessive.

D. The feared situations are avoided or else are endured with intense anxiety and distress.

E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

F. The fear, anxiety, or avoidance is persistent, typically lasting >6 months

Adjustment disorder diagnosis

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s)

B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:

• Marked distress that is out of proportion to the severity or intensity of the stressor

• Significant impairment in social, occupational, or other important areas of functioning

C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder

D. The symptoms do not represent normal bereavement

PTSD diag (A-C)

A. Exposure to threatened death/violence

• Direct exposure

• Witness trauma

• Learning it happened to relative or friend

• Indirect exposure though profession

B. Persistent re-experience

• Unwanted memories

• Nightmares

• Flashback

• Emotional distress and physical reactivity after exposure to reminder

C. Avoidance of trauma related stimuli

PTSD diag (D-H)

D. Negative thoughts or feelings

• Inability to recall trauma

• Overly negative thought of self

• Self blame for the event

• Negative affect

• Anhedonia

• Isolated feeling

• Cannot experience positive affect

E. Trauma related arousal/reactivity

• Irritability

• Risky behavior

• Hypervigilance

• Cannot sleep/concentrate

F. Last >1 mo

G. Cause distress/impairment

H. NOT due to medication

PTSD specifications

Dissociative → Depersonalization and derealization; delayed → full criteria not met until 6 mo after trauma

Major depressive disorder diagnostic criteria

5/9 required and MUST include depressed mood and/or anhedonia

Present most of the day, nearly every day for 2 week:

• Depressed mood

• Anhedonia

• Sleep disorder, insomnia

• Appetite change

• Fatigue/energy loss

• Psychomotor retardation noticed by others

• Feeling of worthlessness

• Trouble concentrating

• Suicide ideation

Cause significant distress

MDD insomnia most common type

Late insomnia (waking up too early and can’t go back to sleep), hypersomnia atypical

Specifiers for depressive disorders

Anxious distress that may/may not be mixed with depression, melancholy = anhedonia, delusion/hallucination, catatonia

Medical conditions that are bidirectional with MDD

Atherosclerotic coronary artery disease (CAD), heart disease (coronary artery disease and congestive heart failure), diabetes mellitus (DM)

Disruptive mood dysregulation disorder (DMDD) diagnostic criteria for 6-17 y/o

A. Severe recurrent (<=3 times/wk) temper outbursts that are out of proportion to situation

B. Mood between outburst is irritable or angry

C. Symptoms present for >=12 mo, symptom free for no more than 3 mo

D. Present in 2/3 setting: school, home, peer

E. NOT diagnosed <6 and >18

F. Onset BEFORE 10 y/o

What is persistent depressive disorder (dysthymia)

Depressed mood with 2 other depression symptom for the previous 2 years, respond to antidepressant

What is PMDD

Premenstrual → Tracked for 2 cycles, occur before menses onset and improve after onset and are minimal/absent post menses

PMDD symptoms

• Labile affect

• Anger/irritability

• Depressed mood

• Anxiety/tension

• Anhedonia

• Cannot concentrate

• Lethargy

• Change in appetite

• Sleep problem

• Feeling overwhelmed

• Physical symptom

What is adjustment disorder with depressed mood

Disorder following attributable stressors; marked symptoms within 3 mo of stressor onset; do NOT persist for >6 mo after stressor terminates

What is the difference between grief and MDD

Grief can fluctuate with more support and acceptance and ability to function

What is bipolar I disorder

Mania episode with/without 1 episode of MDD

What is bipolar II disorder

1 episode of hypomania with 1 episode of MDD

What is cyclothymic disorder

Does not meet criteria of MDD and mania

What symptom fully excludes MDD and confirms BPD

MANIA → 1 episode of mania means BPD NOT MDD

Criteria for mania

Sustained euphoria or dysphoria (irritable) for at least 1 week and at least 3 of the following

• Grandiosity

• Little need for sleep

• Feeling pressured to speak/talking loudly

• Easily distracted

• Significantly increased activity/motor agitation

• Engaging in risky behavior

• Racing thought

Cause siginificant distress

Hypomania = 4 consecutive day of mania symptom

Mood disorder treatment

Antidepressant, psychotherapy, ECT, TMS or ketamine; ECT only for severe