N333: Mental Health Disorders

Anxiety Disorders

Group of mental health conditions characterized by excessive fear and anxiety, as well as related behavioral disturbances

• These disorders involve an emotional response (fear or anxiety) that is disproportionate to the actual threat and causes significant distress or impairment in daily functioning

• Includes:

  • Generalized Anxiety Disorder (GAD)

  • Panic Disorder

  • Social Anxiety Disorder

  • Specific Phobia

  • Agoraphobia

  • Separation Anxiety Disorder

Generalized Anxiety Disorder (GAD)

Persistent and excessive worry about various life situations for at least 6 months, causing significant distress or impairment in social, occupational, or other important areas of functioning

• Symptoms: Excessive worry, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances (e.g., trouble falling asleep or staying asleep)

• Treatment:

  • First-line - Cognitive Behavioral Therapy (CBT): Helps address dysfunctional thinking patterns, teaches relaxation techniques, and coping strategies

  • Medications:

    • SSRIs (e.g., Fluoxetine, Sertraline)

    • SNRIs (e.g., Venlafaxine)

    • Hydroxyzine: An antihistamine with anxiolytic effects, used for short-term anxiety relief

    • Buspirone: A non-benzodiazepine anxiolytic, especially useful for short-term anxiety management, with lower risk of dependency

    • Benzodiazepines: (e.g., Lorazepam) for short-term relief (use cautiously due to risk of dependence)

Insomnia (Sleep Disorder)

Difficulty falling or staying asleep, or waking up too early, occurring at least 3 nights per week for at least 3 months, causing significant distress or impairment in daily functioning

• Symptoms: Difficulty falling or staying asleep, or waking up too early, leading to unrefreshing sleep

• Treatment:

  • Cognitive Behavioral Therapy for Insomnia (CBT-I): Helps improve sleep hygiene and addresses negative thoughts related to sleep

  • Medications:

    • Non-benzodiazepine sedative-hypnotics: (e.g., Zolpidem) for short-term use

    • Melatonin agonists: (e.g., Ramelteon) for sleep onset insomnia

    • Sedating antidepressants: Mirtazapine (for comorbid depression and insomnia) and Trazodone, Doxepin (for sedative effects)

    • Antihistamines: (e.g., Diphenhydramine) for short-term relief

    • Benzodiazepines: (e.g., Lorazepam, Temazepam) for short-term use, avoided due to dependence risk

Narcolepsy (Sleep Disorder)

Sleep disorder characterized by excessive daytime sleepiness and sudden, uncontrollable sleep attacks occurring at least 3 times per week over a period of 3 months

• Symptoms:

  • Excessive daytime sleepiness, sleep attacks

  • Cataplexy (muscle weakness triggered by strong emotions)

  • Sleep paralysis and vivid hallucinations

• Treatment:

  • First-line therapy: Stimulants (e.g., Modafinil) to improve wakefulness during the day

  • Supportive therapy: Scheduled naps, maintaining a regular sleep schedule

Mood Disorders

Mental health conditions marked by persistent disturbances in emotional state, including depression (low mood) and mania/hypomania (elevated mood), that significantly impacts daily functioning

• Includes:

  • Major Depressive Disorder (MDD)

  • Bipolar Disorder

  • Cycothymic Disorder

  • Persistent Depressive Disorder (PDD)

  • Disruptive Mood Dysregulation Disorder

  • Premenstrual Dysphoric Disorder (PMDD)

Major Depressive Disorder (MDD)

Mental health condition characterized by a persistent low mood and loss of interest or pleasure in daily activities (anhedonia) lasting for at least 2 weeks

• Symptoms:

  • Depressed mood most of the day, anhedonia, significant weight changes, insomnia or hypersomnia, fatigue, feelings of worthlessness, thoughts of death or suicide

  • Symptoms must be present for at least 2 weeks and cause significant distress or impairment in daily functioning

• Treatment:

  • Cognitive Behavioral Therapy (CBT) and other forms of psychotherapy

  • Medications:

    • SSRIs (e.g., Fluoxentine, setraline)

    • SNRIs (e.g., Venlafaxine, duloxetine)

    • TCAs (e.g., Imipramine, amitriptyline)

    • MAOIs (e.g., Phenelzine, tranylcypromine)

  • Other Treatments:

    • Electroconvulsive Therapy (ECT): For severe, treatment-resistant depression

    • Transcranial Magnetic Stimulation (TMS): For patients who do not respond to medications or therapy

    • Ketamine therapy: An emerging treatment option for resistant depression

    • Exercise: Regular physical activity has shown to reduce depressive symptoms

Serotonin Syndrome

A potentially life-threatening condition caused by excessive serotonin activity in the central nervous system, usually due to drug interactions or overdose, particularly with SSRIs, SNRIs, MAOIs, or triptans

• Symptoms:

  • Cognitive: Agitation, confusion, delirium, hallucinations

  • Autonomic: Hyperthermia, tachycardia, hypertension, diaphoresis (sweating), nausea, vomiting

  • Neuromuscular: Hyperreflexia, clonus (especially in lower extremities), tremors, muscle rigidity

• Treatment:

  • Immediate discontinuation of serotonergic drugs

  • Supportive care: Hydration, cooling measures, and sedation (e.g., benzodiazepines)

  • Serotonin antagonists: Such as cyproheptadine may be used in severe cases

  • Monitoring: Hospitalization for severe cases to monitor vital signs and manage complications

  • Prevention: Caution use of serotonergic drugs, avoid polypharmacy, and monitor for early signs of serotonin excess

Bipolar Disorder (Mood Disorders)

A mood disorder characterized by episodes of mania or hypomania, often alternating with periods of depression, The specific criteria differ based on the type of bipolar disorder

• Symptoms:

  • Alternating episodes of depression (low mood, fatigue, hopelessness, difficulty concentrating) and mania (elevated mood, increased energy, impulsivity, decreased need for sleep, racing thoughts, and risky behaviors)

  • Hypomania is a severe form of mania seen in Bipolar II, while Bipolar I involves more severe manic episodes, often requiring hospitalization

• Treatment:

  • Mood Stabilizers: Lithium, valproic acid, carbamazepine

  • Antipsychotics: Risperidone, aripiprazole, olanzapine

  • Antidepressants: Used with caution to prevent triggering mania

  • Psychotherapy: CBT and psychoeducation to manage symptoms and prevent relapse

Psychotic Disorders

Characterized by a disconnection from reality, often manifesting as hallucinations, delusions, or disorganized thinking

• These disorders can significantly impair a person’s ability to function and often require treatment involving antipsychotic medications and psychotherapy

• Include:

  • Schizophrenia

  • Schizoaffective Disorder

  • Delusional Disorder

  • Brief Psychotic Disorder

  • Substance-Induced Psychotic Disorder

  • Psychotic Disorder Due to a Medical Condition

Schizophrenia

Chronic and severe mental disorder characterized by distorted thinking, perceptions, emotions, and behavior. Symptoms must persist for at least 6 months, with at least 1 month of positive symptoms

• Positive Symptoms:

  • Delusions: False beliefs (e.g., paranoia, grandiosity)

  • Hallucinations: False sensory perceptions (e.g., auditory, visual)

  • Disorganized Speech/Behavior: Incoherent speech, erratic behavior

• Negative Symptoms:

  • Flat Affect: Reduced emotional expression

  • Avolition: Lack of motivation, neglect of personal hygiene

  • Anhedonia: Inability to experience pleasure

  • Social Withdrawal: Isolation and difficulty with relationships

• Cognitive:

  • Impaired Memory: Difficulty with recall and learning

  • Poor Executive Function: Difficulty planning, organizing, problem-solving

  • Attention Deficits: Difficulty concentrating

• Treatment:

  • First-line - Antipsychotic Medications:

    • Typical Antipsychotics (1st Gen): Used if atypical medications are ineffective, but with higher risk of movement side effects (e.g., Haloperidol, Chlorpromazine)

    • Atypical Antipsychotics (2nd Gen): Preferred for positive and negative symptoms with fever side effects (e.g., Risperidone, Apriprazole)

  • Supportive Therapy:

    • Cognitive Behavioral Therapy (CBT): Helps manage symptoms and reduce anxiety

    • Social Skills Training: Improves communication and social integration

    • Family Therapy: Educates and supports families in managing the condition

    • Community Support Programs: Vocational training and housing assistance to improve independent living

First-Generation (Typical) Antipsychotics

Older class of antipsychotic medications primarily used to treat positive symptoms of schizophrenia (e.g., hallucinations, delusions)

• Work by blocking dopamine D2 receptors in the brain, reducing dopamine activity

• More likely to cause extrapyramidal symptoms (EPS), such as tremors, rigidity, tardive dyskinesia (TD), and neuroleptic malignant syndrome (NMS)

• Examples:

  • Chlorpromazine

  • Haloperidol

  • Fluphenazine

  • Thioridazine

  • Perphenazine

  • Trifluoperazine

  • Loxapine

  • Mesoridazine

Second-Generation (Atypical) Antipsychotics

Newer class of antipsychotics used to treat both positive and negative symptoms of schizophrenia (e.g., social withdrawal, lack of emotion)

• Block dopamine D2 receptors but also affect serotonin receptors, lower risk of EPS compared to first-generation drugs

• Less likely to cause tardive dyskinesia and other movement disorders

• Can have side effects like weight gain and metabolic syndrome

• Examples:

  • Risperidone

  • Olanzapine

  • Quetiapine

  • Aripiprazole

  • Clozapine

  • Ziprasidone

Adverse Effects of Antipsychotics

• Weight Gain: Leads to increased risk of metabolic syndrome (e.g., diabetes, hypertension)

• Sedation: Particularly in first-generation antipsychotics

• Anticholinergic Effects: Dry mouth, blurred vision, constipation, urinary retention

• Cardiovascular Effects: Orthostatic hypotension, QT prolongation, and increased risk of arrhythmias

• Hyperprolactinemia: Elevated prolactin levels can lead to menstrual disturbances, galactorrhea, and sexual dysfunction

• Extrapyramidal Symptoms (EPS)

• Tardive Dyskinesia (TD)

• Neuroleptic Malignant Syndrome (NMS)

Extrapyramidal Symptoms (EPS)

Drug-induced movement disorders from antipsychotics (mainly first-generation)

• Symptoms:

  • Parkinsonism: Tremors, rigidity, slow movements

  • Dystonia: Muscle contractions, twisting movements (e.g., head and neck)

  • Akathisia: Restlessness, inability to stay still (burning sensation)

• Treatment:

  • Anticholinergics (e.g., benztropine, diphenhydramine)

  • Beta-blockers (e.g., propranolol)

  • Switch to atypical antipsychotics

Tardive Dyskinesia (TD)

Long-term side effect of antipsychotic use, causing irreversible involuntary movements

• Symptoms: Lip smacking, tongue thrusting, chewing movements

• Treatment:

  • Discontinue or reduce antipsychotic use, switch to atypical antipsychotics

  • Use VMAT2 inhibitors (tetrabenazine)

Neuroleptic Malignant Syndrome (NMS)

A rare, life-threatening condition caused by antipsychotic medications, typically first-generation antipsychotics. It is a medical emergency requiring immediate intervention

• Symptoms:

  • Hyperthermia: High fever

  • Muscle rigidity: Lead-pipe rigidity

  • Autonomic dysregulation: Tachycardia, labile blood pressure, diaphoresis

  • Altered mental status: Confusion, delirium, coma

• Treatment:

  • Immediate discontinuation of the antipsychotic medication

  • Supportive care: IV fluids, cooling measures, and monitoring vital signs

  • Medications: Dantrolene (muscle relaxant), bromocriptine (dopamine agonist) or amantadine

  • Intensive care may be required for severe cases