psychiatric presentation

1. Presented by
 RASYIDAH
 SHARIFAH NAHIDHAH
 SITI HAJAR

2.  Mood : prevailing internal emotional state
 Affect: external display of feelings
 Mood disorders are a category of illnesses
that describe a serious change in mood.
http://www.mentalhealthamerica.net

3.  Classification of mood disorders:
• Major Depressive Disorder
• Dysthymic Disorder
Depressive
(unipolar)
• Bipolar I
• Bipolar II
• Cyclothymic disorder
Bipolar
• Substance induced mood
disorder
• Mood disorder due to general
medical condition
Etiologic

4.  Among 5 most common disorder.
 Lifetime prevalence 5-20%.
 Female to male ratio is 2:1
 The incidence rate is greatest
between ages 20-40.
 Major cause of disability and
suicide.
American Medical
Association
researchers found
that 27% of
MEDICAL
STUDENTS had
depression or
symptoms of it,
and 11%
REPORTED
SUICIDAL
thoughts during
medical school!

5. ETIOLOGY:
1. Biological Factors
 More common in monozygotic twins.
 Unipolar depressions in a parent
 Abnormalities in Amine Neurotransmitters
 Neuroendocrine abnormalities in hypothalamic pituitary
adrenal (HPA) axis.
2. Psychological Factors
 Major life events
 Interpersonal relations, absent or unsatisfactory significant
special bonds have negative effect on self regards
 Rapid hormonal changes
 Distorted thinking
 Lose hopefulness

6. Criteria For Major Depressive Episode : 5 Or More
Of The Following For At Least 2 Weeks
DEPRESSED MOOD1
ANHEDONIA
2

7. GUILT SLEEP DISTURBANCE
3 4

8. APPETITE
ENERGY
5
6

9. CONCENTRATION
SUICIDALITY
PSYCHOMOTOR
7
8
9

10. Mood Sleep Interest
Guilt Energy Concentration
Appetite Psychomotor Suicidality
Criteria For Major Depressive Episode : 5 Or More
Of The Following For At Least 2 Weeks

11. 1. Other psychiatric disordes, sleep disorders and neurological
disorders.
2. Endocrine disorders: Addison’s disease, Cushing’s disease,
Hyper/hypothyroidism, Perimenstrual syndromes,etc.
3. Metabolic disorders: Hypoglycemia, Hypercalcemia, Porphyria.
4. Hematological disorders: anemia
5. Inflammatory conditions: SLE
6. Infections: Syphilis, Lyme disease, HIV encephalopathy
7. Medication related: Anti hypertensives, Steroids, etc
8. Substance misuse: Alcohol, benzodiazepine, opiates, marijuana,
etc.

12.  There are NO specific tests.
Investigations focus on exclusion of treatable causes
or other secondary problems.
 Standard tests:
1. Complete blood
picture
2. ESR
3 .B12/folate
4. Liver function test
5. Thyroid function test
6. Glucose level
7. Calcium level

13.  Focused investigations :only if indicated by history
and/or physical signs:
1. Urine or blood toxicology
2. Breathe or blood alcohol
3. Arterial blood gas( ABG)
4. Thyroid antibodies
5. Antinuclear antibody
6. Syphilis serology
-----ETC

14.  Hospitalization
If there is:
 Serious risk of suicide
 Serious risk of harm to
others
 Significant self -neglect
 Severe depressive
symptoms
 Severe psychotic symptoms
 Lack of breakdown of social
supports
 Initiation of ECT
 Treatment resistant depression
 A need to address comorbid
conditions

15. First line of treatment: Anti-depressant
 effective in 65-75% of patients.
 The decision of choosing anti-depressant depends on:
 Patient factor: age, sex, comorbid illness, previous response to
antidepressants.
 Symptomatology: sleep problem(sedative agents), lack or
energy/hypersomnia (adrenergic stimulatory agents), OCD
symptoms (clomipramine), risk of suicide (avoid TCA)
 Eg. Tricyclic anti-depressant and Monoamineoxidase inhibitors.

16. TRICYCLIC ANTIDEPRESSANTS (TCA)
 Action: reuptake inhibition of norepinephrine(NE) and serotonin (5-HT), increasing both in
synaptic cleft
 Examples : Imioramine (Tofranil) , Clomipramide (Anafranil) , Amitryptptiline (Tryptizol)
 TCA are cheap drugs but have many side effects.
Selective Serotonin Reuptake Inhibitors
(SSRI)
 Action: more selective inhibitory effect on reuptake of serotonin.
 Lesser side effects than TCA
 Examples: 1. Fluoxetine (Prozac)
2 Sertaline (Lustral)
3. Paroxetine (Seroxat)
4. Fluvoxamine (Faverin)

17. Second line of treatment:
 When the first line
treatment fail.
 Unacceptable side effects
from 1st line drug.
 Change of antidepressant
to different class or the
same class with different
side effect.
Electro convulsive therapy
May be use when there
are severe biological
features (significant
weight loss/ reduced
appetite) or marked
psychomotor retardation.

18.  Mild, chronic depression for at least 2 years.
 Common psychiatric comorbidities: major depression
(up to 75%), “ Double Depression” anxiety disorders
(up to 50%), personality disorders (20–40% )
somatoform disorders (2.8%–45.2%), substance abuse
(up to 50%)
 Difficult to diagnose due to soft mood symptoms,
distracting comorbidities and lack of patient
recognition.
 Treatment includes psychotherapy mainly

19. DEFINITION
- known as manic-depressive illness
- a brain disorder
- causes unusual shifts in mood, energy,
activity levels, and the ability to carry
out day-to-day tasks

20. BIPOLAR I
-manic episodes that last at least 7
days
BIPOLAR II
-a pattern of depressive episodes
and hypomanic episodes
CYCLOTHYMIC DISORDER
-numerous periods of hypomanic
symptoms, periods of depressive
symptoms lasting for at least 2
years
OTHER SPECIFIED OR NON-
SPECIFIED BIPOLAR AND
RELATED DISORDER
-bipolar disorder symptoms that do
not match the three categories
listed above

21. MANIC EPISODE:
 Feel very “up,” “high,” or elated
 A lot of energy
 Increased activity levels
 Trouble sleeping
 Talk really fast about a lot of different things
 Be agitated, irritable, or “touchy”
 Feel like their thoughts are going very fast
 Think they can do a lot of things at once
 Do risky things, like spend a lot of money or have reckless sex

22. DEPRESSIVE EPISODE:
 Feel very sad, down, empty, or hopeless
 decreased activity levels
 trouble sleeping, they may sleep too little or too much
 Feel like they can’t enjoy anything
 Feel worried and empty
 trouble concentrating
 Forget things a lot
 Eat too much or too little
 Feel tired or “slowed down”
 Think about death or suicide

23.  The lifetime prevalence is 0.4-1.6%
 Male : female is equal.
 The 1st episode of mania usually occurs in the early 20
 Most likely associated with comorbid suctance abuse or
dependence.
 Manic episodes often begin abruptly over hours to days and
escalate in 1 to 2 weeks
 10-20% of hospital 1st admissions for depression later develop
a bipolar disorder.
 15-20% of bipolar patients commit suicide.

24.  A distinct period of elevated, expansive or irritable mood at least 1
week
 3 of the following, if mood is only irritable:
-Self-esteem: highly inflated, grandiosity.
-Sleep: decreased need for sleep, rested after only a few
hours.
-Thoughts: racing thoughts and flight of ideas.
-Attention: easy distractibility.
-Activity: increased goal directed activity.
-Hedonism: high excess involvement in pleasurable activity
(sex, travel)

25.  Substance induce mood disorder and mood disorder 2ry
to medical condition are the essential differential
diagnosis:
-Endocrine disorders
-Neurological conditions
-Systemic disorders
-Drugs
-Recreational drugs

26. 1. Brain Structure and Functioning
2. Genetics
3. Family History
4. Substance abuse
5. Negative life events

27. 1. Hospitalization.
2. Pharmacotherapy
-Mood stabilizers
-Antipsychotics
3. Electroconvulsive Therapy (ECT)
The patient is continue treatment for 4-6 months after resolution
of the symptoms then preventive treatment considered.

28. 5. Prevention of relapses
- Prophylaxis
- Therapeutic alliance
- Family education
6. Psychotherapy
Some psychotherapy treatments used to treat bipolar disorder
include:
• Cognitive behavioral therapy (CBT)
• Family-focused therapy
• Interpersonal and social rhythm therapy
• Psychoeducation

29. THANK YOU