Psychiatric Disorder

Front 1

Demoralization

Back 1

does not respond well to pharmacologic treatment; responds
best to encouragement and support

Front 2

Mood disorder

Back 2

dysfunction of ascending mesolimbic dopaminergic
brain); can present as sadness, reward circuit (mood regulator in
feelings of emptiness, or crankiness; no feelings of joy; can be activated by stress of demoralization

Front 3

Dysthymia

Back 3

may refer to mild (subsyndromal) major depression,
chronic major depression, or patients with depressive personality

Front 4

Symptoms of major depression:

Back 4

low mood, low vital sense, low self-attitude, loss of ability to experience pleasure, early morning awakening; disrupted sleep; change in eating habits

Front 5

Selective serotonin reuptake
inhibitor
Serotonin-norepinephrine reuptake inhibitors

Back 5

paroxetine (Paxil), sertraline, (Zoloft) fluoxetine (Prozac)
venlafaxine (Effexor) and duloxetine (Cymbalta); useful in chronic pain; easy to use; few drug interactions, well tolerated; side effects —agitation/activation; sexual ;
dysfunction; feelings of flatness; paroxetine may cause weight gain; two-thirds of patients improve

Front 6

Tricyclic antidepressants

Back 6

inexpensive; help patients sleep; can cause weight gain; can stop diarrhea; useful in chronic pain disorders;
doxepin (Sinequan) more sedating than nortriptyline (Pamelor) and desipramine (Norpramin least sedating); doxepin useful for patients with insomnia

Front 7

Atypical antidepressants:

Back 7

bupropion (eg, Wellbutrin)
Fewest sexual side effects; most activating;
trazodone — useful for insomnia and in patients refractory to other drugs; 500 to 600 mg/day required;
mirtazapine (Remeron) — highly associated with weight gain (useful for patients with AIDS wasting syndrome); useful for chronic pain disorders; match drugs with patients.

Front 8

Personality disorders

Back 8

extroverts —focus on “now” feelings and rewards; dramatic; histrionic; excitable; hypochondriacal; intrusive; personality not affected by antidepressant; diagnosis of depression often missed because of personality disorder; treatment of underlying depression can reduce intrusiveness of per sonality problem
introverts — ruminative; worried; similar to
obsessive-compulsive disorder clingy; whiny; hypochondriacal;
depression intensifies characteristics of both personality types

Front 9

Risk factors for ADHD:

Back 9

Genetics
psychosocial adversity
psychiatric comorbidity

Front 10

Genetics

Back 10

ADHD highly heritable; not function of bad parenting, bad character, or personality disorder;
likely to continue in adulthood in child with ADHD who has father with ADHD; if father had ADHD as child but “grew out of it,” so will his child;

Front 11

psychosocial adversity

Back 11

more chaotic and tumultuous environment increases likelihood of persistence of ADHD symptoms;

Front 12

psychiatric comorbidity

Back 12

comorbid oppositional defiant disorder (ODD) or anxiety disorder increases likelihood of ADHD in adulthood

Front 13

Screening for adult ADHD:

Back 13

1) were you ever diagnosed with ADHD as a child?
2) do you have a child who has been diagnosed with ADHD?
3) do you have chronic long-standing difficulty with focus, concentration, disorganization, getting
things done, follow-through, and consistency? follow up if patient answers yes to any of these

Front 14

Diagnostic criteria:

Back 14

core symptoms include inattention, hyperactivity, and impulsivity; before ascribing motivational or personality factors to symptoms, consider ADHD;
chronic disorganization, eg ( taking longer than others to accomplish tasks);
forgetfulness eg (losing or misplacing things);
poor perception of passage of time eg (always running late);
unable to sit through meeting without getting up;
easily frustrated; highly talkative; symptoms may
be mistaken for personality disorder

Front 15

Screening:

Back 15

identify compensatory mechanisms (eg, patient able to sit through meeting by doodling or look-
ing through day planner); compensation mechanisms break down when demands of environment exceed patient’s ability to compensate (eg , entering college, promotion at work);
ADHD is clinical diagnosis (no neuropsychologic test available)

Hint 15

ask questions specific to adult situation eg “do yo
have difficulty staying on task when it requires sustained effort
over extended period of time?”; ask language- and context-specific questions- eg,, “do you have difficulty focusing and concentrating on a task that requires focus for an extended period of time and which is otherwise boring?”;

Front 16

Executive function:

Back 16

involves organization, prioritizing, strategizing, and working memory
(ie, ability to hold information in head while manipulating other factors);
 occurs 35% of time in ADHD; defined by neuropsychologic testing (ADHD defined by clinical presentation);
recognize executive dysfunction as separate from ADHD to reduce risk of unnecessarily
ramping up patient’s medication to control organization (executive dysfunction does not respond to pharmacologic intervention); behavioral intervention needed

Front 17

Significance of childhood ADHD:

Back 17

no such thing as adult-onset ADHD”;
combined-type ADHD more likely to be diagnosed at 5 to 13 yr of age; disruptive behavior more common in boys and men;
inattentive-type ADHD typically not diagnosed until academic demands or ability to function in life compromised and impaired;
ADHD chronic and unchanging (may worsen and fluctuate, depending on stressors or other
acute psychiatric conditions)

Front 18

ADHD Adult Self-Report Scale (ASRS) Evaluation process:

Back 18

standardized; available online; sponsored by World Health Organization; can be used at baseline to qualify and quantify target symptoms after ADHD diagnosis made; can be used as
treatment evolves to assess movement of symptoms; complementary to clinical interview; look for symptoms that fulfill
criteria, such as chronic and persistent course since childhood,
positive family history (particularly first-degree family member with ADHD), and other psychiatric and medical conditions (eg, obstructive sleep apnea)

Front 19

Comorbid psychiatric conditions

Back 19

1 in 10 patients with major depression has ADHD; 1 in 5 patients with bipolar disorder
has ADHD; mood disorders typically start in late adolescence
and early adulthood (ADHD starts in childhood; consider onset of symptoms); ask about comorbidities (-
eg, substance abuse, generalized anxiety disorder) to prioritize treatment; social anxiety common; anxiety disorders generally start in childhood and persist;
prioritizing treatment —treat alcohol and substance abuse first, followed by severe mood disorder
and severe anxiety disorders; ADHD treated last because cognitive impairments seen in ADHD can be produced by aforementioned untreated diagnoses; stimulant medications used to
treat ADHD can worsen untreated comorbidities

Front 20

Approved medications for adults

Back 20

consider patients treated in trial studies screened for candidacy with
, eg , exclusion criteria; saw 6-point decrease on ADHD-Rating
Scale (ADHD-RS) with use of placebo; saw 12- to 14-point drop
with doses of 20, 40, and 60 mg of mixed amphetamine salts
(FDA-approved recommended dose for adults, 20 mg/day; no statistical separation between doses;-
does not indicate “people who didn’t respond to 20 mg wouldn’t respond to 40 mg, ”);
dexmethyl- phenidate extended-release study—
7-point drop on ADHD-RS seen with placebo;
statistically significant and clinically relevant
decreases in ADHD-RS points seen with doses of 20, 30, and 40
mg/day; recommended dose of Focalin XR for adults, 20 mg/day;
atomoxetine trials —used Conners’ Adult Attention-Deficit Rating
Scale; saw 3.5- to 4.0-point improvement (statistically significant and clinically relevant);
lisdexamfetamine study —saw 8-point reduction on ADHD-RS scale with placebo;
large reductions in ADHD symptoms seen with 30, 50, and 70 mg/day; according to
Amsterdam study, 45% reduction in ADHD-RS score required for
functional improvement; study on methyphenidate saw 4-point improvement; consider that methodologic differences of studies can affect outcomes of trials

Front 21

Drugs for treatment

Back 21

atomoxetine (Strattera; nonstimulant); dexmethylphenidate (Focalin XR);
lisdexamfetamine (Vyvanse; prodrug; recently approved for adults);

Front 22

Other drugs for treatment

Back 22

mixed amphetamine salts (eg, amphetamine and dextroamphetamine [Adderall]);
methylphenidate (eg Concerta); mixed amphetamine salts study — ,