Lesson 7.4: Mood, Anxiety, and Psychotic Disorders

Introduction

In this lesson, students will delve into the complexities of mood, anxiety, and psychotic disorders. As part of understanding the nervous system and behavioral health, it is essential to identify and manage these prevalent conditions through effective strategies. The objectives of this lesson are to equip students with the knowledge to diagnose various psychiatric disorders, understand their management including both pharmacological and non-pharmacological options, and develop an ability to monitor treatment responses.

Learning Objectives

• Accurately diagnose and manage depression, bipolar disorder, anxiety disorders, and psychosis.
• Understand pharmacologic and nonpharmacologic treatment options and monitoring strategies.
• Utilize clinical criteria to identify common psychiatric disorders.
• Select and evaluate evidence-based psychiatric treatment.
• Grasp the fundamental concepts and terminology related to mood, anxiety, and psychotic disorders.

Mood Disorders

What are Mood Disorders?

Mood disorders encompass a group of conditions characterized primarily by a disturbance in a person's mood. The main types of mood disorders include Depression and Bipolar Disorder. Each type presents unique symptoms and requires specific approaches to treatment.

Depression

Major Depressive Disorder (MDD)

Major depressive disorder is characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities once enjoyed.

Diagnostic Criteria

According to the DSM-5, to be diagnosed with MDD, an individual must experience at least five of the following symptoms for at least two weeks:

1. Depressed mood most of the day
2. Markedly diminished interest or pleasure in all or most activities
3. Significant weight loss when not dieting, weight gain, or decrease/increase in appetite
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive guilt
8. Diminished ability to think or concentrate
9. Recurrent thoughts of death or suicide

Pharmacologic Treatment

First-line treatment options include:

• Selective Serotonin Reuptake Inhibitors (SSRIs) such as Fluoxetine, Sertraline, and Escitalopram. These medications increase serotonin levels in the brain, improving mood and emotional balance.
• Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs), for example, Venlafaxine and Duloxetine, which affect both serotonin and norepinephrine.

Example Treatment Plan:

A 35-year-old female patient presents with persistent sadness, change in appetite, and insomnia. After thorough evaluation, she meets the criteria for MDD. A treatment plan may include starting with Sertraline at a dose of 50 mg daily, with follow-up in four weeks to assess efficacy and side effects. If insufficient response, dosages may be adjusted or additional therapies may be considered.

Non-pharmacologic Treatment

• Cognitive Behavioral Therapy (CBT) has shown effectiveness in managing MDD. CBT focuses on changing negative thought patterns and behaviors.
• Mindfulness and lifestyle changes, including physical activity and nutrition, can also support recovery.

Bipolar Disorder

Bipolar disorder is marked by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression).

Diagnostic Criteria

For diagnosis of Bipolar I, the individual must experience at least one manic episode. This is characterized by:

• An abnormally and persistently elevated mood lasting at least one week
• Increased goal-directed activity or energy
• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual or pressure to keep talking
• Flight of ideas or sensation that thoughts are racing
• Easily distracted
• Involvement in activities with a high potential for painful consequences

Treatment Considerations

Medication is crucial in managing bipolar disorder. Mood stabilizers such as Lithium are commonly used. In cases of acute mania or depression, atypical antipsychotics may be administered.

Example Treatment Plan:

For a 28-year-old male experiencing severe manic symptoms, treatment may begin with Lithium. Target therapeutic ranges for Lithium are between $0.6-1.2 \, mEq/L$. Dosage would be carefully monitored with blood tests due to its narrow therapeutic index.

Anxiety Disorders

Overview

Anxiety disorders include a range of conditions that lead to excessive fear or anxiety. Common disorders are Generalized Anxiety Disorder (GAD), Panic Disorder, and Social Anxiety Disorder.

Generalized Anxiety Disorder (GAD)

GAD is characterized by excessive anxiety and worry about various aspects of life that are difficult to control.

Diagnostic Criteria

According to DSM-5, symptoms must involve excessive anxiety occurring most days for at least six months, and include:

• Restlessness
• Being easily fatigued
• Difficulty concentrating or mind going blank
• Irritability
• Muscle tension
• Sleep disturbance

Treatment

Pharmacological treatments may involve SSRIs or SNRIs, while Cognitive Behavioral Therapy (CBT) is effective for long-term management.

Example Treatment Plan:

In the case of a patient presenting with chronic anxiety symptoms, treatment may involve starting on Escitalopram 10 mg daily, coupled with weekly CBT sessions.

Psychotic Disorders

Definition and Features

Psychotic disorders are characterized by delusions, hallucinations, disorganized thinking, and impaired functioning. Schizophrenia is a primary example.

Schizophrenia

Schizophrenia typically manifests in late adolescence or early adulthood and involves significant impairment in social and occupational functioning.

Diagnostic Criteria

Symptoms include:

• Delusions: Strongly held false beliefs
• Hallucinations: Sensory experiences without external stimuli
• Disorganized behavior or speech
• Negative symptoms: Affect flattening, anhedonia, or lack of motivation

Treatment

Antipsychotic medications are the cornerstone of treatment. Long-acting injectables can also be utilized for patients at risk of non-compliance.

Example Treatment Plan:

A 22-year-old presents with prominent hallucinations. Treatment may start with Risperidone, a second-generation antipsychotic, with dosage adjusted based on therapeutic response and side effects monitored closely.

Conclusion

Understanding mood, anxiety, and psychotic disorders is a fundamental aspect of psychiatric practice. students should now be equipped with the tools needed to diagnose and manage these common yet complex disorders. Knowledge of both pharmacological and nonpharmacological treatment modalities will empower students to provide optimal care for patients experiencing these conditions.

Study Notes

• Mood disorders include major depressive disorder and bipolar disorder.
• Diagnostic criteria for mood disorders are based on DSM-5 guidelines.
• Pharmacological treatments may be SSRIs, SNRIs, mood stabilizers, or antipsychotics depending on the disorder.
• Non-pharmacologic treatments like CBT and lifestyle changes are beneficial in conjunction with medications.
• Anxiety disorders are characterized by excessive worry and fear across various scenarios.
• Psychotic disorders involve delusions and hallucinations, requiring careful diagnosis and consistent medication.