Psychiatric illnesses

Insomnia is a related psychiatric illness having potentially serious consequences. In any given year up to one-third of the general population may experience insomnia and consequently considerable impact on quaUty of life. Potentially serious psychosocial, health, and socioeconomic consequences may foUow. Many sedative—hypnotics additionally have a firmly estabUshed position within the field of anesthesiology as premedication, inducing agents, and/or for maintenance in intensive care medicine. 

Schizophrenia is perhaps the most debiUtating psychiatric illness in modem medicine, affecting about 1% of the general population. Many of those affected require institutionalization (180). Unfortunately, the compounds available to treat this disorder are not hiUy effective in treating the spectmm of symptoms in all patients. Adverse effects are also a problem (181). In addition, available antipsychotic (neuroleptic) dmgs (Table 5) can at most only provide symptomatic rehef. 

Future Outlook for Pharmacologic Treatment of Abuse and Dependence. The importance of the psychosocial dimension ia predisposiag iadividuals toward substance use disorders and subsequentiy maintaining the disorder caimot be overestimated. Additionally, genetic influences have been found to exert an important influence on HabiUty for dmg abuse. A high comorbidity of psychiatric illnesses with substance use disorders further compHcates therapeutic iaterventions ia such patients (236). 

Medications that have been used as treatment for anxiety and depression in the postwithdrawal state include antidepressants, benzodia2epines and other anxiolytics, antipsychotics, and lithium. In general, the indications for use of these medications in alcoholic patients are similar to those for use in nonalcoholic patients with psychiatric illness. However, following careful differential diagnosis, the choice of medications should take into account the increased potential for adverse effects when the medications are prescribed to alcoholic patients. For example, adverse effects can result from pharmacodynamic interactions with medical disorders commonly present in alcoholic patients, as well as from pharmacokinetic interactions with medications prescribed to treat these disorders (Sullivan and O Connor 2004). 

Uni 1ke other drugs of abuse, the diagnosis of PCP intoxication is often difficult because of the wide spectrum of clinical findings that occurs with this drug. PCP toxicity sometimes can be mistaken for delirium tremens, acute psychiatric illness, sedative/ hypnotic overdosage, amphetamine intoxication, or sedative/ hypnotic withdrawal syndromes. 

Sociocultural, illness, and biological factors affect individual attitudes towards psychotropic medications. Health beliefs or explanatory models, particularly causal attributions regarding the illness and the treatment options afforded within such models, exert a profound influence on patients attitudes and behavior regarding medications (Smith, Lin Mendoza, 1993). Such effects can be subtle and can occur during the course of treatment even if there has been initial successful negotiation about the nature of the illness and treatment. In psychiatric illness little research has been leveled at the personal meaning that patients bring to treatment practices such as electro-convulsive therapy (ECT), oral medications, and depot injections, or to the transition between different administrative routes and types of medications. 

Sociocultural Stigma of psychiatric illness and treatments Attitudes of family and their support network Preference of traditional medicines Sociocultural values and influences... 

At the very least that medication is deemed necessary confirms having a condition that is highly stigmatized in many societies, and perhaps more in non-Western (Ng, 1997), and may lead patients to question their self-identity and capabilities in their personal and social roles (Carder, Vuckovic Green, 2003). Insight into the nature of psychiatric illness in turn affects patients attitude to medications (David, 1990) and compliance (Ziguras, Klimidis, Lambert etal, 2001). 

Co-morbid medical or psychiatric illness Impaired cognitive function... 

Prescribing of psychotropic drugs, such as antipsychotics, antidepressants, anxiolytics and mood stabilizers, is common in psychiatric inpatients for acute and maintenance treatment of psychiatric illness. 

Nomikos, G.G., Schilstrom, B., Hilderbrand, B.E., Panagis, G., Grenhoff, J., Svensson, T.H. Role of alpha7 nicotinic receptors in nicotine dependence and implications for psychiatric illness. Behav. Brain Res. 113 97, 2000. 

Psychosis, or psychotic disorder A major psychiatric illness including schizophrenia... 

Agid O, Shapira B, Zislin J, Ritsner M, Hanin B, Murad H et al. Environment and vulnerability to major psychiatric illness a case control study of early parental loss in major depression, bipolar... 

The development of mild forms of anxiety and neuroveg-etative and/or cognitive responses to stress may represent an adaptive evolutionary step against environmentally (external) or self-triggered (internal) threats, but maladaptive reactions have also emerged in human evolution. Thus, anxiety disorders are maladaptive conditions in which disproportionate responses to stress, or even self-evoked responses, are displayed. Anxiety disorders are one of the most frequent psychiatric illnesses, and have a lifetime prevalence of 15- 20% [1, 89]. The most common presentations are generalized anxiety disorder, with a lifetime prevalence rate of close to 5% [1, 89] social anxiety disorder, with very variable lifetime prevalence rates ranging from 2 to 14% [90] panic disorder, with rates from 2 to 4% [1,89] and post-traumatic stress disorder (PTSD), with a prevalence rate close to 8%. Specific phobias, acute stress and obsessive-compulsive behavior are other clinical presentations of anxiety disorders. 

Breeze, J. L., Hesdorffer, D. C., Hong, X. et al. Clinical significance of brain white matter hyperintensities in young adults with psychiatric illness. Harv. Rev. Psychiat. 11 269-283, 2003. 

Anxiety symptoms may be present in several major psychiatric illnesses (e.g., mood disorders, schizophrenia, organic mental syndromes, and substance withdrawal). 

Several studies of ERPs and brain function have produced mixed results due to methodological confounds. When subjects are screened for medical and psychiatric illness, and age effects were controlled, THC does not alter brain stem and auditory or visual P300 responses (Patrick et al. 1997). Despite daily cannabis use in subjects, the only finding consisted of an elevated auditory P50 amplitude. 

When is medication indicated in the treatment of psychiatric illness There is no short answer to this question. At one end of the continuum, patients with schizophrenia and other psychotic disorders, bipolar disorder, and severe major depressive disorder should always be considered candidates for pharmacotherapy, and neglecting to use medication, or at least discuss the use of medication with these patients, fails to adhere to the current standard of mental health care. Less severe depressive disorders, many anxiety disorders, and binge eating disorders can respond to psychotherapy and/or pharmacotherapy, and different therapies can target distinct symptom complexes in these situations. Finally, at the opposite end of the spectrum, adjustment disorders, specific phobias, or grief reactions should generally be treated with psychotherapy alone. 

Before we introduce you to the many psychiatric illnesses and the medications used to treat these illnesses, you first need a general understanding of just how these medications work. In this chapter, we will introduce you to these concepts. 

First, you will learn about the human nervous system and how it works when it is healthy. This will include an introduction to the structure (anatomy) of the nervous system and the function (physiology) of the nervous system. Next, we ll describe the things that can go wrong. We ll look at how the system breaks down and malfunctions. Then we ll show you how these breakdowns can result in psychiatric illness. Finally, we ll introduce you to the medications used to treat psychiatric illness. You will learn where these medications work and our best guess of how they work. The presumed mechanism of action of many medications is just that, presumed. In contrast to antibiotics, in which we know quite a lot about the ways that they kill bacteria or stop them from reproducing and how these mechanisms ultimately effect a cure for an infectious disease, less is known about how psychotropic medicines work. Oh, we pretty well understand what psychotropic medicines do when they reach the nerve cell. For example, most of the antidepressants used today block the reuptake of serotonin at the nerve cell, but we re still not sure why blocking serotonin reuptake gradually improves mood in someone with depression. This will lead to a tour, if you will, of what happens to a medication from the time the pill is swallowed, until it exerts its therapeutic effect. 

The challenge that arises at this juncture is integrating all of the above information with what we know about the pathophysiology (i.e., cause) of the psychiatric illness and the characteristics of the individual patient to devise a rational approach to... 

The course of BPAD can be quite variable. Although BPAD has not traditionally been thought of as a chronic disorder similar to schizophrenia but rather an episodic one, most clinicians have noted a gradually worsening course with more frequent episodes as the illness progresses. This is one psychiatric illness in which treatment not only alleviates the current symptoms but might also improve the long-term course. 

An episode of bipolar depression is virtually indistinguishable from that of unipolar depression. The key is to gather a careful history of the patient s premorbid functioning, earlier episodes of illness, and family psychiatric illness. This information should be gathered from the patient, as well as family members and friends. Previous episodes of full-blown mania seldom go unreported however, prior hypo-manic episodes are often unrecognized not only by the patient but by friends and family as well. One should inquire about periods of decreased need for sleep (as... 

The symptoms of a panic attack are so frightening that an unusually large number of those with panic disorder (in comparison to other psychiatric illnesses) seek treatment on their own accord. However, easily half of those who seek treatment do so in general medical settings such as hospital emergency rooms and the offices of primary care physicians. Easily mistaken for severe and even life-threatening medical conditions such as asthma attacks and heart attacks, panic disorder results in disproportionately higher health care utilization than other anxiety disorders. 

The differential diagnosis of panic disorder includes other psychiatric illnesses, medical illnesses, and substances that can cause panic attacks. Also included are medical illnesses that cause symptoms resembling panic attacks. It should be mentioned that these other conditions, which are described below, and panic disorder are not necessarily mutually exclusive. In fact, there is a high rate of comorbidity between panic disorder, other anxiety disorders, and mood disorders. Because panic disorder is frequently accompanied by agoraphobia, the differential diagnosis also includes illnesses that are associated with symptoms resembling the avoidance of the agoraphobic patient. 

Believed historically to be a relatively rare disorder, large-scale epidemiological research undertaken during the last 20 years indicates that OCD is in fact quite common. The lifetime prevalence of OCD is 2-3%, making it more common, in fact, than bipolar disorder, schizophrenia, and most psychiatric illnesses other than depression and the substance use disorders. 

In DSM-IV parlance, psychiatric illnesses that result from substance use are called substance-related disorders. Within this broad spectrum are two distinct categories substance use disorders and snbstance-induced disorders. The substance use disorders consist of abusive patterns of nse that produce a myriad of problems in relationships, employment, medical or physical well-being, and legal matters. There is no predefined amount or frequency of substance use that defines these disorders instead, they are diagnosed when the consequences of substance use include an adverse impact on other areas of life. As noted earlier, in some instances, substance nse disorders lead to physical dependence that is manifested by tolerance and the potential for withdrawal symptoms. When anyone talks about addiction, it is typically snbstance nse disorders to which they refer. 

The good news is that treatment can have a profound impact on the clinical course of substance dependence. Most patients who have been treated are eventually able to stop their pattern of compulsive misuse. Some abstain altogether while others are able to manage long periods of sobriety with only brief episodes of substance use. Those who are able to maintain periods of sustained abstinence from substance abuse and dependence also find improvement in job performance and social functioning. Those who do the best had little comorbid psychiatric illness, were able to... 

It is also important to know about comorbid psychiatric disorders. If these are overlooked, treating the substance use disorder becomes significantly more difficult. Recognizing this, most treatment centers have developed dual diagnosis programs to treat those patients who have another major psychiatric illness in addition to a substance use disorder. It may be virtually impossible to discern at first, but the other psychiatric illnesses might either contribute to or be a result of substance use. The social toll of alcoholism alone can trigger a severe clinical depression. However,... 

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