CHAPTER 11: PSYCHIATRIC DISORDER
Points to be covered in this topic
➤ INTRODUCTION
➤ DEPRESSION
➤ ANXIETY
➤ PSYCHOSIS
➤ Definition
➤ Etiopathogenesis
➤ Clinical Manifestation
➤ Diagnosis and Investigation
➤ Management
11.1 INTRODUCTION
• A mental condition, often known as a mental
illness or psychiatric disorder, is a pattern of
behavior or thought that causes considerable distress
or impairs personal functioning.
• A clinically significant disturbance in an individual's cognition, emotional
regulation, or behavior is also indicative of a mental condition.
Examples of psychiatric disorders are -
(a) Major depressive illness (Depression), which is characterised by chronic poor
moods and a loss of energy and enthusiasm, is an example of a mental disorder.
(b) Generalised anxiety disorder (Anxiety), characterised by excessive, persistent,
and unreasonable worry about everyday matters.
(c) Psychosis is characterised by a separation from reality (hallucinations or
delusions may occur).
(d) Post-traumatic stress disorder, which is characterised by intense, troubling
thoughts and feelings about a traumatic experience long after it has occurred.
(e) Bipolar disorder, which is distinguished by excessive mood, energy, and activity
levels.
11.2 DEPRESSION
11.2.1 Introduction of Depression
• Depression, commonly known as major depressive disorder (MDD) or clinical
depression, is a chronic, episodic, and relapsing mood illness characterised largely
by a melancholy or sad mood and anhedonia that lasts at least two weeks.
• Anhedonia is the inability to enjoy typically joyful activities. Major depressive
disorder can cause a great deal of distress and disability. It is the most common
reason for suicide. Females are about twice as likely as guys to suffer from major
depressive disorder.
• There are several sub types of major depressive disorder that are distinguished by
additional symptoms or occurrence in certain settings, such as-
(a) Atypical depression, which is distinguished by weight gain and increased
appetite.
(b) Psychotic depression accompanied by other psychotic symptoms such as
hallucinations and delusions.
(c) Peripartum depression, which develops during or soon after childbirth.
11.2.2 Etiopathogenesis of Depression
• Depression has a complicated etiology. It takes into account both biological and
psychological aspects. Most cases are thought to be caused by low levels of
monoamine neurotransmitters (serotonin, noradrenaline, and dopamine).
• Traumatic and stressful experiences, as well as comorbidities such as
neurodegenerative and chronic inflammatory disorders, all play essential roles in
the development of depression.
• Depression complications include self-harm and suicidal behavior.
11.2.3 Clinical Manifestations of Depression
• Depression symptoms can range from mild to severe and include a sad mood, a
feeling of deep sadness (melancholia), anhedonia, low energy, worthlessness, guilt,
psychomotor retardation or agitation, change in appetite and/or sleep, increase in
purposeless physical activity (e.g., hand-wringing or pacing), slowed movements
and speech, suicidal thoughts, and other signs.
11.2.4 Depression Diagnosis and Investigation
• First and foremost, rule out medical reasons of depression as well as drug-induced
depression.
• To make a depression diagnosis, use the DSM-5 criteria. The Diagnostic and
Statistical Manual of Mental Disorders, 5th Edition is abbreviated as DSM-5.
11.2.5 Management of Depression
Goals of Therapy
• Resolution of all signs and symptoms of depression (i.e. remission) and
restoration of functioning are the goals of therapy.
• Reduction of future depression episodes (i.e., relapse or recurrence).
• Prevention of new episodes of sadness and suicide.
• Treatment of remaining symptoms (such as fatigue, cognitive impairment,
anhedonia, and anxiety).
• Restored occupational, psychological, and interpersonal function.
There are three treatment options:
I. Psychotherapy alone
II. Pharmacotherapy alone
III. Psychotherapy combined with pharmaceutical therapy
The following considerations influence treatment mode selection:
1. Symptom severity (mild, moderate, or severe).
2. Other diseases (comorbidities) or psychological stresses present.
3. Patient preference.
4. Prior treatment history.
[Link] Non-Pharmacological Depression Treatment
➤ Psychotherapy - Psychotherapy is the first-line treatment option for mild to
moderate depression. It is also the preferred treatment for pregnant patients or those
who wish to become pregnant. In individuals with moderate to severe depression, it
is used in conjunction with antidepressants.
Types of psychotherapy include
(a) Cognitive-behavioral therapy (CBT)
(b) Interpersonal therapy
(c) Psychodynamic psychotherapy
(d) Family and couples therapy
(a) Cognitive-Behavioral Therapy (CBT): CBT assists the patient in recognizing
negative or unhelpful thought and behavior patterns. It encourages self-control over
thought habits.
(b) Interpersonal Therapy (IPT): Interpersonal therapy attempts to resolve
interpersonal problems (e.g., social isolation, extended mourning), reduce stress in
family and work situations, improve communication skills, and promote
symptomatic healing.
(c) Psychodynamic Psychotherapy: Psychodynamic psychotherapy tries to promote
personality development by identifying main conflicts, ego distortions, acting as a
role model, and allowing emotional release of hostility.
(d) Family and Couples Therapy: It is suggested for patients who are experiencing
marital or family conflict.
➤ Individualized psychotherapy should be provided depending on treatment
goals, comorbidities, symptom severity, patient preference, and availability.
Other Non-Pharmacologic Therapies
• Sleep Deprivation Therapy / Wake Therapy: This therapy is used to treat
individuals who are depressed but are not taking antidepressants. It is used in
conjunction with other Chrono-therapeutic methods to treat more severe and
refractory kinds of depression.
• Exercise: Regular exercise, particularly Yoga, may help to alleviate discomfort.
• Electroconvulsive Therapy (ECT): Also known as "electroshock therapy," this is
the preferred treatment for severe major depressive disorder that has not responded
to pharmaceutical treatment and/or psychotherapy. Among antidepressant
treatments, it has the highest effectiveness rate.
• Neurostimulation Therapy: This therapy may be beneficial in patients with
psychotic symptoms or catatonia who require immediate attention (e.g., patient
refusing food and nutritionally compromised, suicidal patient). Catatonia is a
behavioral disorder characterised by the inability to move normally.
• Repetitive Transcranial Magnetic Stimulation (rTMS): This therapy is approved
for patients with serious depressive disorder who have not responded to at least one
antidepressant trial treatment. It employs pulsed magnetic fields to create electrical
stimulation of superficial cortical neurons.
• Light Therapy: It is a well-established treatment for serious depression with a
seasonal component that employs strong light. It hastens the antidepressant effect.
[Link] Pharmacological Management of Depression
Principles of Pharmacological Therapy:
1. The goal of depression medication is to relieve current symptoms (i.e.,
remission) and to avoid future episodes of depression (i.e., relapse or
recurrence).
2. Antidepressant drugs will be chosen based on their side effect profile, the
patient's or family member's prior response history, the existence of
comorbidities, the danger of mortality from overdose from concurrent
prescriptions, and the patient's desire and cost.
3. Patients should be advised that while side effects may appear quickly,
symptom recovery may take 2 to 4 weeks or longer. If side effects develop,
either reduce the drug's dose or switch to another antidepressant that does not
cause the same side effects.
4. Always begin with the lowest possible medicine dose and gradually advance
to the full therapeutic amount.
5. Patients who do not improve after 2–4 weeks of treatment should have their
antidepressant dose raised.
6. Initial treatment period: 6 to 12 weeks
7. If the patient is in remission, antidepressants should be continued for at least
4–9 months (continuation phase).
8. If the patient has had three previous major depressive episodes or severe
bouts (e.g., suicide attempt or psychosis) or has risk factors for recurrence, or
persistent MDD, antidepressants should be used for at least 1–3 years
(maintenance phase).
9. Medication withdrawal should take 6–8 weeks.
10. SSRIs are the first-line treatment for depression, whereas SNRIs are the
second-line treatment.
Antidepressant classification:
1. Serotonin reuptake inhibitors (SSRIs), such as Fluoxetine, Paroxetine,
Sertraline, Citalopram, Escitalopram, and Fluvoxamine
2. Serotonin-Norepinephrine reuptake inhibitors (SNRIs), such as Venlafaxine,
Duloxetine, Desvenlafaxine, Levomilnacipran, Milnacipran
3. Atypical antidepressants, such as bupropion, mirtazapine, and trazodone
4. Monoamine oxidase inhibitors (MAOIs): Tranylcypromine, Phenelzine,
Selegiline, Isocarboxazid, and Moclobemide
5. TCAs (tricyclic antidepressants): (a) Secondary amines (mostly
norepinephrine reuptake inhibitors), such as Nortriptyline, Desipramine,
Protriptyline, and Amoxapine
(b) Tertiary amines (norepinephrine + serotonin reuptake inhibitors +
anticholinergic properties): Amitriptyline, clomipramine, doxepin,
imipramine, and Trimipramine
6. St. John's Wort herbal supplement in Reuptake Inhibitors (SSRIs).
11.3 ANXIETY
11.3.1 Introduction to Anxiety
• Anxiety is a stressful, unsettling emotional condition characterised by
apprehension and uneasiness. Anxiety becomes a condition when symptoms
become severe, disabling, and have a negative impact on quality of life.
• Anxiety disorders are typically chronic and encompass a wide range of conditions
marked by excessive and persistent dread, anxiety, worry, and/or avoidance
behaviour. (Avoidance behaviour is any activity a person does to escape from
painful thoughts, feelings and events).
• These diseases are not caused by substance misuse, physical conditions (such as
Pheochromocytoma or hyperthyroidism), or other psychological disorders.
Anxiety disorders are among the most frequent mental disorders which include
(a) Generalised anxiety disorder (GAD): This is characterised by excessive,
unreasonable concern and tension for at least 6 months.
(b) Panic disorder: This condition is distinguished by recurring, unexpected panic
attacks.
(c) Social anxiety disorder (SAD): This disorder is caused by a fear of being
embarrassed or acting humiliatingly in public.
(d) Specific phobia: Fear of one or more specific situations or items (Phobic
stimuli) that has lasted at least 6 months.
✓ For example, Hematophobia (Fear of blood), acrophobia (Fear of heights),
Entomophobia (Fear of insects), claustrophobia (fear of enclosed spaces),
agoraphobia (Fear of public places), Enochlophobia (Fear of crowds), and so on.
(a) PTSD (Posttraumatic stress disorder): It is a psychological disorder that
develops in certain people after they have encountered or witnessed a (Traumatic)
horrific incident. Recurring, upsetting memories of the trauma and recurring,
disturbing dreams about the event may be symptoms.
(b) Obsessive-compulsive disorder (OCD): This disorder is characterised by
irrational thoughts and anxieties (Obsessions), which lead to obsessive,
(a) repetitive behaviour aimed at reducing anxiety.
✓ For example, checking locks, gas knobs, counting money and others.
11.3.2 Etiopathogenesis of Anxiety
• Anxiety disorders are caused by a variety of factors. Genetic, developmental,
environmental, neurobiological, cognitive, and psychological factors may all be
involved.
• Several neurotransmitter systems, including serotonin (5-HT), gamma-
aminobutyric acid (GABA), norepinephrine (NE), corticotrophin-releasing factor
(CRF), and cholecystokinin, may exhibit aberrant activity.
• Stress, smoking, and psychological trauma, particularly throughout childhood, can
all be environmental and developmental variables.
• Anxiety Disorder Complications: Any of the anxiety disorders can lead to
'Depression,' rendering a person suicidal.
Complications of Anxiety Disorders: Any of the anxiety disorders can lead to
'Depression', making person suicidal.
11.3.3 Clinical Manifestations of Anxiety
Psychiatric symptoms:
• Avoidance of circumstances that cause anxiety
• Panic, fear, and apprehension
• Irritability
• Concentration issues
• Nightmares
• Recurring thoughts or flashbacks to catastrophic events
• Obsessive, uncontrollable thoughts
• Having a strong desire to leave the current circumstance
Physical symptoms
• Rapid heartbeat or palpitations
• Sweating
• Dry mouth
• Trembling or shaking
• Shortness of breath or hyperventilation
• Muscle tension or aches
• Insomnia or difficulty sleeping
• Feeling dizzy or lightheaded
• Fatigue or feeling tired
Cognitive Symptoms
• Racing thoughts (a pattern of rapid, repetitive, and often uncontrollable flow of
thoughts in the mind)
• Persistent negative thoughts
• Overthinking
• Inability to be still and calm
• Unrealistic or irrational fears
11.3.4 Diagnosis and Investigation of Anxiety
• The history and mental state assessment are used to make the diagnosis.
• The DSM-5 criteria should be used for diagnosing anxiety.
11.3.5 Management of Anxiety
Principles of Therapy of Anxiety
Consider the following factors before deciding medications for anxiety disorders:
• Age of patient
• Patient's previous experience of treatment with individual drugs
• Risks for accidental overdose and deliberate self-harm
• Tolerability
• Patient's preference
• Cost of therapy
➤ Therapy typically consists of a combination of pharmacotherapy (especially
SSRIs) and psychotherapy (especially cognitive-behavioral therapy (CBT)).
➤ Selective serotonin reuptake inhibitors are recommended as 1st-line
pharmacotherapy for anxiety disorders.
(I) Generalized anxiety disorder (GAD)
The goal of treating generalized anxiety disorder is remission with minimal or no
anxiety symptoms and no functional impairment.
• Treatment includes: Psychotherapy, pharmacotherapy, or both
• Psychotherapy: CBT
• Pharmacotherapy: Antidepressants SSRIs/SNRI for at least 12 months
• It takes at least two to four weeks for antidepressants to start having an antianxiety
impact. While benzodiazepines can be taken in the interim
• while SSRIs are taking effect, long-term usage of benzodiazepines is not advised
due to the increased risk of benzodiazepine dependence.
(II) Panic disorder
Acute panic attack
• Reassurance and breathing exercise
• Short-acting benzodiazepine (e.g. alprazolam).
Long-term management
• SSRIs, SNRIs (venlafaxine), TCAs, and benzodiazepines can be used as CBT
antidepressants before the antidepressants start working.
• It takes 8 to 12 weeks for antidepressants to fully produce their therapeutic effects.
(III) Social anxiety disorder (SAD)
Treatment includes:
• CBT
• SSRIs and SNRIs (such as Venlafaxine) are first-line medications.
• Pharmacotherapy in the second line: Clonazepam
• Before performing in front of an audience or giving a speech in public, beta
blockers (like Propranolol) OR Benzodiazepines (like Clonazepam) should be taken
30 to 60 minutes beforehand.
(IV) Specific phobia
• CBT (desensitization therapy); Benzodiazepine or SSRIs
(V) Posttraumatic stress disorder
Treatment includes:
• Trauma-focused cognitive behavioral therapy (TFCBT)
• First-line pharmacotherapy: SSRIs
• Symptomatic treatment: Propranolol
(VI) Obsessive-compulsive disorder
Treatment
• Mild OCD: CBT
• Severe OCD: CBT plus an SSRI (e.g., fluoxetine, fluvoxamine, sertraline, or
paroxetine).
[Link] Non-Pharmacological Management of Anxiety
Lifestyle Changes
• Stress reduction
• Reduction of alcohol and caffeine consumption
• Avoidance of nicotine and drug use
• Regular exercise
• Sleep hygiene
• Cognitive-Behavioral Therapy (CBT): Benzodiazepine or SSRIs.
[Link] Pharmacological Management of Anxiety
• Selective Serotonin Reuptake Inhibitors (SSRIs): Described previously
• Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)
• Benzodiazepines: Diazepam, Lorazepam, Alprazolam, Clonazepam
11.4 PSYCHOSIS
11.4.1 Introduction to Psychosis
• A collection of symptoms known as psychosis cause
a person to become detached from reality.
• This could entail believing falsehoods and perceiving
imaginary or nonexistent objects. Among its symptoms
could be one or more of the following cognitive
disorders.
Types of Psychosis
1. Primary psychosis: It may be caused by a psychiatric disorder e.g.,
schizophrenia, brief psychotic disorder, schizoaffective disorder, delusional
disorder, etc.
2. Secondary psychosis: It may be the result of substance use, an underlying
medical condition, or a mood disorder e.g. Alcohol misuse, cannabis, brain
tumour, etc.
• Acute psychosis is a psychiatric emergency.
• Psychosis is the characteristic feature of schizophrenia spectrum.
➤ Schizophrenia
• The devastating mental condition known as schizophrenia is typified by negative
symptoms such as anhedonia, loss of normal emotions, abilities, motivation, and
behaviour, as well as positive symptoms such as delusions, deviant behaviours,
hallucinations, and cognitive problems.
11.4.2 Etiopathogenesis of Psychosis
Etiology
• There is strong evidence that the onset of psychotic diseases is influenced by
genetic risk factors.
• Epigenetic or environmental factors (drug addiction, stress, immigration,
infection, postpartum period, or other medical causes) are correlated with the onset
of psychotic episodes.
• First-episode psychosis is associated with a decrease in temporal grey matter.
Pathophysiology
• Neurotransmitters - dopamine, glutamate, GABA, and acetylcholine are involved
in psychosis.
• Psychotic disorders' positive symptoms are thought to be caused by an
overabundance of dopamine in the mesolimbic tract. Psychosis is also associated
with a reduction in the activity of the N-methyl-D-aspartate (NMDA) glutamate
receptor.
Complications of Psychosis
• There is always a chance that oneself or others could be in danger during a
psychotic episode.
• Suicide risk may be higher in those with psychotic disorders than in the general
population.
11.4.3 Clinical Manifestations of Psychosis
A psychotic episode or condition can manifest as one or more of the five symptoms
listed below: Delusions, Hallucinations, Disordered behaviour, disordered thinking,
and Unpleasant symptoms
1. Delusions: A person is said to be suffering from a delusion if they firmly believe
something that is untrue. An individual might think, for instance, that someone or
some group is plotting to harm or murder them; they might think they have the
ability to raise the dead.
2. Hallucinations: In the absence of an outside stimulation, hallucinations are
sensory impressions. When someone experiences hallucinations, they may see,
hear, taste, smell, or feel things that are not real. For instance, sensing bodily
sensations like a crawling sensation on the skin, hearing voices when no one has
spoken, etc.
3. Disorganized thoughts: Patients with disorganised thoughts typically
communicate through their speech and overall communication styles. For example,
someone may start off discussing one topic and then change it entirely before
finishing their sentence; someone is unable to respond to a question directly without
going into undue or excessive detail.
4. Disorganized behavior: Unpredictable and/or inappropriate emotional reactions
that are out of step with the circumstances constitute disorganised behaviour. It
could manifest as strong emotional reactions, aimless behaviour, catatonic
behaviour, or infantile foolishness. Staying motionless, making abrupt or
unexpected motions, not speaking, and other weird behaviours are examples of
catatonic behaviour.
5. Negative symptoms: One of the negative signs is a reduction or absence of
regular functioning. For instance, a patient may exhibit anhedonia, speech
difficulties, psychomotor slowness, lack of energy, interest, or focus, as well as
incoherence or emotional blunting.
11.4.4 Diagnosis and Investigation of Psychosis
Diagnosis of psychosis may include
(a) A detailed patient's history, clinical presentation and mental status exam (MSE).
(b) A urine toxicology screen along with standard medical tests to rule out the non-
psychiatric cause of psychosis.
11.4.5 Management of Psychosis
• A schizophrenic patient's family and cares are crucial to their care. Treating
psychotic symptoms requires both creating a secure and therapeutic environment
for the patient and engaging with them in a composed, compassionate way.
• Depending on the cause of the psychosis, a patient's course of treatment can vary
significantly.
• Patients with psychotic symptoms may benefit greatly from cognitive behavioral
therapy in addition to antipsychotic medication.
• A patient who is severely psychotic, agitated, and maybe hostile and who poses a
risk of hurting themselves or others has to be admitted to the hospital and given
medical attention.
[Link] Non-Pharmacological Management of Psychosis
• Provide a safe and therapeutic environment to the patient.
• Interacting with the patient in and calm, empathetic manner.
• Cognitive behavioral therapy (CBT)
• Consider rehabilitation
[Link] Pharmacological Management of Psychosis
• Typically, antipsychotic medications are advised as the initial line of treatment for
schizophrenia and psychosis. They function by obstructing the neurotransmitter
dopamine's effects.
[Link] Classification of Antipsychotic Agents
Antipsychotic medication can be divided into two classes
1. Typical/First generation include chlorpromazine, haloperidol, Perphenazine,
Molindone, Fluphenazine and Loxapine
2. Atypicals / Second generation include Amisulpride, Clozapine, Olanzapine,
Quetiapine, Risperidone, Aripiprazole, Brexpiprazole, Cariprazine,
Lurasidone, Paliperidone and Ziprasidone.
On the basis of affinity for dopamine D₂ receptors and the average therapeutic
dose, typical/first generation antipsychotic agents are further classified as:
(i) High-potency (Haloperidol and Fluphenazine) with more EPS and less
histaminic (Sedation), alpha adrenergic (Orthostasis), and anticholinergic (Dry
mouth) side effects. (EPS- Extrapyramidal side effects)
(ii) Low-potency (Chlorpromazine): associated with less EPS but more H1, alpha 1,
and muscarinic side effects.
Antipsychotic Agents and Their Doses
• Pricing, ease of use, effectiveness, safety, and simplicity all play a role in the
selection of an antipsychotic medication.
• In general, atypical antipsychotics are favoured over first-generation/typical
antipsychotics.
• Antipsychotics should be started at a low dose and increased as necessary.
• Benzodiazepines are a useful treatment for psychosis's catatonic symptoms.
• Only two antipsychotics—clozapine and olanzapine—have been demonstrated to
reduce suicidality in individuals with psychosis.
• For patients who are severely psychotic, an injectable combination of a standard
antipsychotic and a benzodiazepine is most beneficial.
• Significant adverse effects from antipsychotics include tardive dyskinesia,
extrapyramidal symptoms (EPS), metabolic syndrome, cardiac abnormalities,
anticholinergic effects, and sexual side effects.
• Atypical antipsychotics have adverse effects on metabolism and lead to weight
gain.