Neurologic Psychiatric Essay

Some and disenfranchise others)Studying individuals with the diagnosis (if the terminology changes older studies may not be as useful since the selection of research subjects may not match the newer designations)Making social policy (much social policy is determined by the impact of illnesses in terms of numbers affected age of those affected and other similar factors)Providing guidance for treatment (both pharmacological and nonpharmacological)In fact drugs marketed in this country are under the auspices of the Food and Drug Administration (FDA)Every drug on the market has certain “indications” (what the drug can be used for)If the terminology changes this could invalidate the accepted use of many medications (and may prevent payment for medications and/or services)Example of changes causing controversy:The DSM-5 will not list Asperger’s Syndrome as a separate diagnosis – it only has Autism Spectrum Disorder as a diagnosis for autism Asperger’s and pervasive developmental disorderMany with prior diagnoses of Asperger’s are concerned that they may not receive services or have the same level of group identityNeurologic Psychiatric or both?Current concepts of psychiatric illnesses are moving towards an appreciation of their neurobiological causesThe segregation of illnesses into one category or another is becoming outdated for many of the illnesses included in the DSMThus the term that is often used is “neuropsychological” or “neuropsychiatric” disorderChanges in DSM-5 for 2013: (the Ashford Library has the full resource – see instructions on how to access cite and reference in the course)The removal of the exception for bereavement (grief) in the DSM-5 allows for an immediate diagnosis of depression; this recognizes bereavement as a stressor that can trigger a depressive episode (i.e. depression can be diagnosed without a waiting period for “grieving”).Disruptive mood dysregulation disorder is added as a pediatric diagnosis for children with “persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year” – although some feel this is too broad and will inappropriately label some children the rationale is to reduce the incorrect diagnosis of bipolar disorder.The term “gender identity disorder” will be replaced by “gender dysphoria” (emotional distress about their gender identity).Hoarding will be a separate condition from obsessive compulsive disorder.Excoriation (skin-picking) will be added.Posttraumatic stress disorder will have expanded domains and more symptoms included as descriptors.Substance abuse and substance dependence are combined into one term “substance use disorder” (note this has been in general use already by addiction specialists).Dyslexia remains in the category of learning disorders.Pedophilia has a name change to “pedophilic disorder.”Some disorders that were proposed for inclusion will not be in the manual or will be recommended for further study – including attenuated psychosis syndrome Internet use gaming disorder nonsuicidal self-injury suicidal behavioral disorder hypersexual disorder (sex addiction) anxious depression parental alienation syndrome and sensory processing disorder.The old “axis” organization will be replaced by a simple chapter scheme with chapters arranged so that related disorders will be close to each other.More on Drug Therapy in General:What are “endogenous” chemicals such as neurotransmitters and hormones?Our bodies are made up of structures that are created from chemicals that are in the most part synthesized (manufactured) by our own cells. The blue print for this synthesis is our genetic code and is inherited from our parents. Chemicals that we synthesize ourselves are called endogenous (“endo” means “inside”) and include neurotransmitters that allow the nervous system cells to communicate with other body cells as well as the endocrine system that manufactures hormones. Hormones are chemicals that are manufactured by glands and released into the bloodstream thus traveling around the entire body and having the potential to affect all our organs.Drugs are “exogenous” chemicals:Chemicals that are administered from the outside i.e. drugs are exogenous (“exo” means “outside”). Drugs change the biologic functioning of a cell via specific chemical actions; sometimes these actions are poorly understood. Generally the “class” of a drug is defined by this physiologic action of the drug and is usually called the “mechanism of action” (MOA) of the drug. In most cases the reason a drug can exert this action is that the body is already producing endogenous chemicals to exert similar effects. Other than newer “engineered” (designer) drugs the origin of most pharmaceuticals is in nature as botanicals; chemical research aims to modify the parent drug to preserve the drug effect and eliminate unwanted side effects. Thus one hears of “generations” of drugs – this means that an initial parent drug has been chemically modified several times to produce similar drugs that retain parent drug function and yet have gained desired improvements. Prescribing decisions are often made using the concept of the “drug of choice” (DOC) meaning that this is preferred “first-line” (first choice) therapy for a particular clinical condition due to its efficacy and safety profile when used alone (monotherapy). What a drug “does” to the body is pharmacodynamics; what the body “does” to the drug is pharmacokinetics. Thus pharmacodynamics is what most people think of when discussing a drug’s therapeutic or adverse effects including dose-response effects efficacy and toxicity. What about Stress?What is Stress?Stress is an unpleasant experience even if it is temporary. Many experts define stress as any environmental stimulus that causes specific physiological (biological) changes in the body. This stimulus is called the stressor.Body systems involved in the stress response:Two body systems are involved – the nervous (neurological) system and the endocrine (hormonal) system.The nervous system includes the brain spinal cord and nerves in the periphery of the body – since these nerves go to every organ and location in the body it is called a “distributed” system. Nerve cells manufacture chemicals called neurotransmitters that allow the cells to communicate with one another and also with other types of cells in the body. Although most of the time these neurotransmitters are released close to their place of action sometimes they are released directly into the bloodstream such as when epinephrine (adrenalin) and norepinephrine (a related chemical) are released into the bloodstream during stress. This means that all the body’s cells and organs will be affectedThe endocrine system includes a collection of glands that manufacture chemicals called hormones. These are released directly into the bloodstream potentially affecting all the cells and organs of the body. An example is insulin being released from our pancreas into our bloodstream in response to a meal.More on the stress response:Stress is unpleasant even when it is transient. Triggering the stress response means that both the nervous system and endocrine system are activated causing many changes throughout the body. Why would we have such an unpleasant response? The stress response really a threat response and is designed to get your body ready for EITHER “flight” (running way from a threat) or “fight”(fighting the threat) in order to survive. Thus our heart beats faster to send more blood to our muscles our pupils dilate to let in more light our muscles have more contractile strength we perspire so that we can cool our body during intense physical exertion and our blood sugar rises to provide our muscles and brain with increased energy. Is Stress Common?A significant minority of Americans are subject to regular stress. Most individuals cite concerns about money work and the economy as major sources of stress. What are Some of the Health Consequences of Stress?While the threat (stress) response might be a great idea if faced with a real physical threat this response can be detrimental of recurrent emotional/psychological stresses or for chronic stresses. Over time prolonged and repeated stress can cause high blood pressure and/or accelerate atherosclerosis – changes in our arteries that predispose to life-threatening conditions such as heart attack and stroke. Other issues may be an increase in body mass index (BMI) with overweight and obesity the result – both of these are associated with many health risks. In addition there are adverse effects on sleep cognition (thinking) and increased risk of other related psychological problems (e.g. anxiety depression). More on Post-traumatic Stress Disorder (PTSD):lifetime prevalence is 10 – 14% can occur at any agesymptoms usually begin within 3 months of the trauma50% of the general population is exposed to a traumatic event in their lifetime either directly or “vicariously”Obviously a large issue in management of military personnel and veterans (may affect up to 13% of returning war veterans)From DSM-5 Section on “Trauma- and Stressor-Related Disorders”:American Psychiatric Association (2013). Section II: Trauma- and Stressor-Related Disorders. Diagnostic and statistical manual of mental health disorders: DSM-5 (5th ed.). Washington DC: American Psychiatric Publishing. DOI: 10.1176/appi.books.9780890425596.991543“Trauma- and stressor-related disorders include disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion. These include reactive attachment disorder disinhibited social engagement disorder posttraumatic stress disorder (PTSD) acute stress disorder and adjustment disorders. Placement of this chapter reflects the close relationship between these diagnoses and disorders in the surrounding chapters on anxiety disorders obsessive-compulsive and related disorders and dissociative disorders.”DSM-5 Diagnostic criteria:“1. Exposure to actual or threatened death serious injury or sexual violence in one (or more) of the following ways:Directly experiencing the traumatic event(s).Witnessing in person the event(s) as it occurred to others.Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend the event(s) must have been violent or accidental.Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g. first responders collecting human remains; police officers repeatedly exposed to details of child abuse).Note: Criterion does not apply to exposure through electronic media television movies or pictures unless this exposure is work related.2. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s) beginning after the traumatic event(s) occurred:Recurrent involuntary and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children there may be frightening dreams without recognizable content.Dissociative reactions (e.g. flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children trauma-specific reenactment may occur in play.Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).3. Persistent avoidance of stimuli associated with the traumatic event(s) beginning after the traumatic event(s) occurred as evidenced by one or both of the following:Avoidance of or efforts to avoid distressing memories thoughts or feelings about or closely associated with the traumatic event(s).Avoidance of or efforts to avoid external reminders (people places conversations activities objects situations) that arouse distressing memories thoughts or feelings about or closely associated with the traumatic event(s).4. Negative alterations in cognitions and mood associated with the traumatic event(s) beginning or worsening after the traumatic event(s) occurred as evidenced by two (or more) of the following:Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury alcohol or drugs).Persistent and exaggerated negative beliefs or expectations about oneself others or the worldPersistent distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.Persistent negative emotional state (e.g. fear horror anger guilt or shame).Markedly diminished interest or participation in significant activities.Feelings of detachment or estrangement from others.Persistent inability to experience positive emotions (e.g. inability to experience happiness satisfaction or loving feelings).5. Marked alterations in arousal and reactivity associated with the traumatic event(s) beginning or worsening after the traumatic event(s) occurred as evidenced by two (or more) of the following:Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.Reckless or self-destructive behavior.Hypervigilance.Exaggerated startle response.Problems with concentration.Sleep disturbance (e.g. difficulty falling or staying asleep or restless sleep).6. Duration of the disturbance is more than 1 month.7. The disturbance causes clinically significant distress or impairment in social occupational or other important areas of functioning.8. The disturbance is not attributable to the physiological effects of a substance (e.g. medication alcohol) or another medical condition.” (American Psychiatric Association 2013 Section II: Trauma- and Stressor-related Disorders)Reference: American Psychiatric Association. (2013). Section II: Trauma- and stressor-related disorders. In American Psychiatric Association (Ed.) Diagnostic and statistical manual of mental health disorders: DSM-5 (5th ed.). doi:10.1176/appi.books.9780890425596.991543Clinical Presentation of PTSD:after an extremely distressing event (combat sexual abuse or rape natural disasters)May involve the patient or be “vicarious” (e.g viewing the event hearing about the event)Jurors in trials for violent crime have suffered PTSD symptoms having just heard the crime evidence being presented in courtThe response is intense fear & helplessness and/or horrorPatient “relives” the event with emotional numbness and:intrusive recurrent recollections of the eventrecurrent distressing dreams of the eventflashbacks/hallucinations (reliving the event like a video loop that won’t stop)intense distress if exposed to symbols or activities or representations of the event (anniversary pictures)Treatments for PTSD:Psychological (“Talk”) therapy:Cognitive Behavioral Therapy (CBT) individual or group has been shown effectiveThis condition mimics an intense grief reaction thus grief counseling may be of benefit to enable mourning for lossPharmacologic (Drug) Treatment:SSRIs antidepressants – some are FDA approved for this indication e.g. sertraline (Zoloft) paroxetine (Paxil)SNRIs antidepressants – some are FDA approved for this indication e.g. venlafaxine-XR (Effexor-XR)Benzodiazepione tranquilizers (sedatives) are NOT used – there are too many long-term treatment issues (dependence tolerance)Sometimes other drugs are added to antidepressants to augment (add to) their effect; these additional drugs are often atypical antipsychotics (e.g. risperidone) but these do not work well aloneFor nightmares the antihypertensive drug prazosin (Minipress)seems to work (dosing issues and side effects may limit its use)What About Prevention of PTSD Using Drugs?Some experts are now using off-label propranolol (beta-blocker) immediately after the event in order to prevent the onset of PTSD (theory is that sympathetic catecholamines in the brain are needed to “impress” the brain with the event and if these are blocked the PTSD cannot happen); but recent evidence is not convincing of benefitRecent evidence that use of morphine to manage traumatic pain can prevent PTSD associated with trauma; aggressive management of pain is part of PTSD managementMore on Cognitive Behavioral Therapy (CBT):Also called “Rational Emotive Behavior Therapy” – pioneered by Ellis & BeckA collaborative form of psychotherapy with mental health & primary-care providers (also can be performed with computer programs)Patient has 10-15 visits usually lasting 45 min – 1 hour eachEvidence-based success in treating depression anxiety syndromes chronic pain school trauma recidivism crisis intervention (including suicide) chronic fatigueWhat is it all about? The patient:changes negative patterns of thinking and behaviorlearns to look at the positive aspects of situationshas more awareness of one’s surroundings and the psychological effects createdPrinciples:your FEELINGS are due to your THOUGHTSif your thoughts are changed then your feelings will followlearn to recognize cues to bad feelings and trace them to irrational thoughts – replace the irrational thoughts with rational thoughtsrecognize that we have control over our thoughts and our feelings – do not allow “automatic” thoughts to control our mind or our feelingsBasic science – why does it work?PET scans looking at metabolic activity of CNS show changes in areas of the brain such as the frontal cortex cingulate and hippocampussame types of changes are seen with SSRI therapyBasic Techniques used in CBT:problem-solving techniques – looking at situations differentlybehavior modification techniques – relaxation deep breathingrecognition of situations and triggers for bad feelingsrecognition of irrational (biased) thoughts and correction of sameGoals in managing pain using CBT:help patients understand that their thoughts and behaviors can affect the pain experience emphasize individual control of pain using cognitive methodstrain patients in effective coping skillsapply and maintain learned coping skillsOther forms of CBT:A newer form of CBT includes “mindfulness” activitiesThus this form is often called Mindfulness Based CBT or MBCBTThis has proven helpful in managing difficult-to-treat insomnia anxiety depression and other disordersAdditional Resources (web links videos and articles):American psychiatric association practice guidelines. (n.d.). Retrieved from http://psychiatryonline.org/guidelines.aspxFull list of Clinical Practice Guideline (including PTSD) from the American Psychiatric Association.American Psychiatric Association. (2013). Section II: Trauma- and stressor-related disorders. In American Psychiatric Association (Ed.) Diagnostic and statistical manual of mental health disorders: DSM-5 (5th ed.). doi:10.1176/appi.books.9780890425596.991543Full text available in the Ashford Library.NCBI Bookshelf. (http://www.ncbi.nlm.nih.gov/books/)Many free booksThe Management of Post-Traumatic Stress Working Group. (2010). VA/DoD clinical practice guideline: Management of post-traumatic stress. Retrieved from http://www.healthquality.va.gov/PTSD-FULL-2010c.pd…The National Institute of Mental Health.(2016 January). Mental health medicines. Retrieved from http://www.nimh.nih.gov/health/publications/mental…Course Text:Sarafino E. P. & Smith T. W. (2014). Health psychology: Biopsychosocial interactions (8th ed.). New York NY: John Wiley & Sons Inc.Required ResourcesREQUIRED TEXTSarafino E.P. & Smith T.W. (2016). Health psychology: Biopsychosocial interactions (9th ed.). Retrieved from https://vitalsource.comChapter 3: Stress – Its Meaning Impact and SourcesChapter 4: Stress Biopsychosocial Factors and IllnessChapter 5: Coping With and Reducing StressARTICLESCenters for Disease Control. (2017) Coping with stress after a traumatic event [PDF]. Retrieved from https://www.cdc.gov/violenceprevention/pdf/Copingw…This publication provides an overview of the normal response to stress. It includes information regarding when referral to a mental health specialist should be considered.Centers for Disease Control. (2016) Understanding school violence [PDF]. Retrieved from https://www.cdc.gov/violenceprevention/pdf/School_…This publication provides information about facts relating to school violence. The fact sheet also includes recommendations for prevention.National Institute of Mental Health. (2015) Helping children and adolescents cope with violence and disasters for parents of children exposed to violence or disaster: What parents can do [PDF]. Retrieved from https://www.nimh.nih.gov/health/publications/helpi…This publication provides an overview of the parental response to a child’s exposure to a violent event. Additional information about Post Traumatic Stress Disorder (PTSD) is included.National Institute of Mental Health. (2014) Helping children and adolescents cope with violence and disasters: Police fire and other first responders: What rescue workers can do [PDF] Retrieved from http://ipsi.uprrp.edu/opp/pdf/materiales/helping_r…This publication provides an overview of the response of rescue workers helping children exposed to a violent event. Some general information on post-traumatic stress disorder is also provided.National Institute of Mental Health. (2016) Post-traumatic stress disorder. Retrieved from http://www.nimh.nih.gov/health/topics/post-traumat…This website has information for the general public regarding identification risk factors and management of post-traumatic stress disorder (PTSD). Other information includes causes and living with PTSD.National Institute of Mental Health. (2019) Preventing Youth Violence [PDF]. Retrieved from https://www.cdc.gov/violenceprevention/pdf/yv-fact…This publication provides facts related to youth violence including epidemiologic information and risk factors for involved youth. In addition recommendations for prevention are included.BOOKAmerican Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington D.C.: American Psychiatric Publishing.This is the manual of psychiatric diagnostic criteria used by mental health professionals. For this week you will be utilizing Section II: Trauma- and Stressor-Related Disorders. This section in the manual deals with multiple conditions that involve exposure to trauma or are associated with precipitating stressors. Information about various such disorders is provided regarding the diagnostic criteria epidemiology and differential diagnosis across the lifespan. One of the diagnoses listed is that of post-traumatic stress disorder (PTSD) and we will focus on that disorder in the assignment for this week.To access the DSM-5 from the Ashford University Library:Log into the Ashford LibraryClick on “Find Articles & More”Click on “Databases by Subject”Click on “Psychology”Click on “DSM-5 Library”Click on “DSM-5™”Click on “Section II”Click on “Trauma- and Sarafino E.P. & Smith T.W. (2016). Health psychology: Biopsychosocial interactions (9th ed.). Retrieved from https://vitalsource.comChapter 3: Stress – Its Meaning Impact and SourcesChapter 4: Stress Biopsychosocial Factors and IllnessChapter 5: Coping With and Reducing Stress Chapter 3: Stress – Its Meaning Impact and SourcesChapter 4: Stress Biopsychosocial Factors and IllnessChapter 5: Coping With and Reducing Stress Centers for Disease Control. (2017) Coping with stress after a traumatic event [PDF]. Retrieved from https://www.cdc.gov/violenceprevention/pdf/Copingw…This publication provides an overview of the normal response to stress. It includes information regarding when referral to a mental health specialist should be considered.Centers for Disease Control. (2016) Understanding school violence [PDF]. Retrieved from https://www.cdc.gov/violenceprevention/pdf/School_…This publication provides information about facts relating to school violence. The fact sheet also includes recommendations for prevention.National Institute of Mental Health. (2015) Helping children and adolescents cope with violence and disasters for parents of children exposed to violence or disaster: What parents can do [PDF]. Retrieved from https://www.nimh.nih.gov/health/publications/helpi…This publication provides an overview of the parental response to a child’s exposure to a violent event. Additional information about Post Traumatic Stress Disorder (PTSD) is included.National Institute of Mental Health. (2014) Helping children and adolescents cope with violence and disasters: Police fire and other first responders: What rescue workers can do [PDF] Retrieved from http://ipsi.uprrp.edu/opp/pdf/materiales/helping_r…This publication provides an overview of the response of rescue workers helping children exposed to a violent event. Some general information on post-traumatic stress disorder is also provided.National Institute of Mental Health. (2016) Post-traumatic stress disorder. Retrieved from http://www.nimh.nih.gov/health/topics/post-traumat…This website has information for the general public regarding identification risk factors and management of post-traumatic stress disorder (PTSD). Other information includes causes and living with PTSD.National Institute of Mental Health. (2019) Preventing Youth Violence [PDF]. Retrieved from https://www.cdc.gov/violenceprevention/pdf/yv-fact… American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington D.C.: American Psychiatric Publishing.This is the manual of psychiatric diagnostic criteria used by mental health professionals. For this week you will be utilizing Section II: Trauma- and Stressor-Related Disorders. This section in the manual deals with multiple conditions that involve exposure to trauma or are associated with precipitating stressors. Information about various such disorders is provided regarding the diagnostic criteria epidemiology and differential diagnosis across the lifespan. One of the diagnoses listed is that of post-traumatic stress disorder (PTSD) and we will focus on that disorder in the assignment for this week.

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