Pathophysiology of addiction
- nucleus accumbens (a crucial brain-reward region)
- dorsal striatum (a region implicated in the encoding of habits and routines),
- the amygdala
(a region involved in emotions, stress, and desires),
- the hippocampus (a region involved in memory), and
- the prefrontal cortex (a region involved in self-regulation and the attribution of salience [the assignment of relative value]).
- All these regions of the brain participate in the various stages of addiction, including conditioning and craving (see Fig. 1)
BEHAVIORAL MEDICINE
Highlights of Changes from DSM-IV-TR to DSM-5 APA
- Autism Spectrum Disorders:
(Includes Autistic Disorder, Asperger's Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder) ASD is characterized by 1) Deficits in social communication and social interaction and
2) Restricted repetitive behaviors, interests, and activities (RRBs).
Because both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present.
- Mood Disorders:
- Pathophysiology of Mood Disorders
- Limbic system is affected
- Nucleus Accumbens (Reward System: Involved in Substance Use Disorder; decreased activation by rewarding activities)
- Amygdala (Increased activity of Amygdaala by negative stimuli)
- Hippocampus (reduction in the hippocampal area) and
- Regions of prefrontal cortex (Subgenus area 25 in anterior cingulate cortex has altered activity)
- Deep Brain Stimulation of Nucleus Accumbens and Subgenus area 25 elevates mood in depressed individual
- Hypothalamus is also likely involved
- Neurovegetative symptoms are attributed to Hypothalamic involvement
- DEPRESSION: Objectively asses the severity (PHQ9 etc),
- Major Depressive Disorder (MDD or Unipolar Major Depression) : 5/9 of PHQ9, with at least one of 1 or 2 as a symptoms for at least 2 weeks with no history of Mania or Hypomania
- Subtypes
- Anxious Distress
- Atypical Features
- Catatonia
- Melancholic Features
- Mixed Features
- Peripartum Onset
- Psychotic Features
- Seasonal Pattern
- Dysthymia (Persistent Depressive Disorder) (Depressed mood + other features for > 2 yrs)
- Major Depressive Syndrome (occurs as a consequence of multiple issues including MDD, Bipolar Disorder, Schizophrenia, Premenstrual dysphoric disorder, Substance-Medication induced Depressive Disorder, Depressive disorder due to other medical conditions)
- DDx:
- ADHD,
- Bipolar,
- Schizophrenia and Schizoaffective disorder,
- Adjustment disorder with depressed mood
- Sadness
- Labs: Consider CBC, CMP, B12, Folate, TSH, hCG, HIV, RPR
- Treatment of MDD
- Usually mono therapy, but can consider combination especially in Melancholic features (Mirtazepine combined with SSRI (fluxetine or paroxetine), Bupropion, or Venlafaxine or SSRI(Citalopram, or Fluoxetine) Plus TCA (Desipramine or Nortriptyline)
- References:
PHQ-9 depression questionnaire Up-to-date
DSM-5 diagnostic criteria for a major depressive episode Up-to-date
DSM-5 diagnostic criteria for persistent depressive disorder (dysthymia) Up-to-date
Depression (In the Clinic)
Complicated Grief NEJM 2015
Complicated Grief NEJM 2015 (Supplement on Interviewing Patients)
- BIPOLAR DISORDER
- Key points:
- Associated with Anxiety disorders, and Substance Use Disorders
- Increased risk of suicidal ideation,
- Associated with premature death and is a major cause of disability in 15 - 44 age group
- Most disability occurs in depressive episodes
- Depressive episodes can precede manic episodes
- Type
- Bipolar I disorder (1 episode of Mania and Major Depression); Prevalence:
- Bipolar II disorder (1 episode of Hypomania and Major Depression);
- Diagnosis and Assessment
- Features to suggest Bipolar Depression from MDD
- Family history of Bipolar Disorder
- Age < 25 yr at onset
- Frequent episodes of shorter duration (< 6 months)
- Hypersomnia, and Hyperphagia more common than insomnia (specifically early morning awakening) and reduced appetite in depression
- Screening:
- Treatment
- Acute Mania:
- FDA approved 10 medications:
- One typical anti-psychotic agent:
- Li
- 2 anti-eplieptic agents:
- Carbamazepine, ER (FDA approved)
- Divaloprex Sodium (ER, Delayed release) (FDA approved)
- Lamotrigine (Not FDA approved)
- Six atypical anti-psychotics
- Aripiprazole : 15−30 mg/day
- Asenapine : 10 mg
twice daily sublin- gully
- Olanzapine: For acute mania, 10–20
mg/day; for mainte-
nance therapy, 5–20
mg/day
- Quietiapine, and Quietiapine ER :For acute mania or
maintenance thera-
py, 400–800 mg/day;
for depression, 300–
600 mg/day
- Risperidone,
- Oral : For acute mania,
1–6 mg/dayor
- Intramuscular: For acute mania: 25mgevery2wk
- Ziprasidone :For acute mania or
maintenance thera-
py, 80–120 mg/day
- Bipolar Depression
- FDA approved 2 treatment options
- Quetiapine
- Combination of olanzapine and Fluoxetine (6–12 mg and 25–50 mg once daily)
- Note: All FDA-approved anti-depressants are used only for unipolar depression except for Fluoxetine in combination with olanzapine
- Quetiapine and Olanzapine: Usually does not lead to switching of the polarity.
- Incidence of Switch to Mania using following Anti-depressants
- Desipramine (TCA) : 43 %
- Venlafaxine : 15 %
- Sertraline: 7 %
- Bupropion: 5 %
- References:
- Additional Reading Materials
- Schizophrenia Spectrum and other psychotic disorders:
- Primary Psychiatric Disorder
- Schizophrenia
- 3 main clinical presentations:
- Positive Symptoms: Aggresiveness, Delusion, Hallucination: Treatment is available
- Negative Symptoms: No treatment is available
- Cognitive Symptoms: No treatment is available
- Diagnosis: DSM IV vs DSM V difference is: In DSM IV 1 A criteria was enough for making a diagnosis, but in DSM V, we need 2 A criteria to make a diagnosis
- Treatment:
- Continuous treatment is better over intermittent treatment
- Intermittent treatment can lead to increase suicidal risk
- Note: Continuous treatment is also better for Bipolar, but for depression intermittent treatment may work just as well
- First Generation Anti-psychotics: Dopamine Blockage
- Anti-dopaminergic medications work better for Aggression > Mania > Psychosis in the order of presentation.
- Second Generation Anti-psychotics: In addition to Dopamine Blockage, Blocks Serotonin
- Serotonin blockage helps to increase dopamine, mostly in the meso-cortical area. This helps minimize the secondary negative, and secondary cognitive symptoms that occur due to anti-dopamine effect of the dopamine blockage
- Long Acting Injection
- 4 formulation
- LAI Resperidone
- In general: "..DONE" is better due to lack of anti-histaminergic properties
- LAI Olanzapine
- In general: "..PINE" More side effects...as it also has anti-histaminergic properties
- Hence, has impact on "affects" and "thinking"
- BLACK BOX Warning: Post-Injection Sedation-Coma Syndrome over next 3 hr
- Can occur in any patient even with previous use without side effects
- LAI Aripaprazole
- Schizoaffective Disorder
- Schizophreniform Disorder
- Schizophrenia symptoms with Duration < 6 months
- Delusional Disorder
- Non-psychotic enteties (Hypochondriasis, Undifferentiated Somatoform disorder etc) vs
- Primary Psychoses vs Secondary Psychoses (Medical Condition, Substance Withdrawal)
- Brief Psychotic Disorder
- Schizotypal (Personality) Disorder
- MDD with Psychotic Features
- Bipolar Disorder with Psychotic Features
- Substance Induced Psychoses
- Psychosis associated with other medical conditions
- Delirium
- Somatoform Disorders:
- Anxiety Disorders:
GAD
- Personality Disorder:
- Misc:
- ADHD
- Diagnosis (> or equal 17 yr) DSM-V:
- 5/9 symptoms of Inattention,
- 5/9 Symptoms of Hyperactivity and Impulsivity
- in 2 or more settings
- with age of onset <12 yr,
- duration of sx >6 month
- Specify Mild/Moderate/
- Catatonia: (Can occur in the context of Psychotic, Depressive, Bipolar or other medical disorders; 3 /12 Catatonic Symptoms needed for diagnosis)
Catatonia in DSM-5 Schizophrenia Research 2013
- Misc
- Urine Drug Testing
- V58.69 covers for Urine Drug Testing
- Let it know that UDS is for patient safety
- Chronic Opiate Use
- > 6 weeks after acute Injury
- 3rd opiates prescription
- Frequency of test
- Based on risk category
- Low Risk (every 1-2 yr)
- Moderate Risk (6-12 months)
- High Risk
- Aberrant Behavior
- Opiate Risk Tool
- Family history of substance use
- Personal history of substance use
- Age
- Psychological disease
- History of preadolescent sexual use
- High Risk
- Moderate Risk
- Low Risk
- Screening Test
- Amphetamines
- Barbiturates
- Cocaine
- Opiates
- Tramadol
- Osycodone
- Benozodiaspine
- Cannabinoids
- Note:
- Detection threshold can vary
- Confirmatory Test
- Liquid / Gas Chromatography
- Duration of drugs testing positive varies
- False positive Drug Tests
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