Applied Pathophysiology: A Conceptual Approach to the Mechanisms of Disease Chapter 11: Altered Mood, Attention, and Behavior

Regulation of Mood Mood: internal psychological state; emotions Structures that regulate mood Hypothalamus: autonomic control in emotions Prefrontal cortex: judgment, decision-making Amygdala: emotionally charged memories Hippocampus: long-term memory Anterior cingulate cortex: empathy, impulse Cingulate gyrus: emotional memories

Key Brain Regions Involved in Mood Regulation

Regulation of Attention Culturally influenced process of selectively concentrating on information Both a cognitive process and a behavior Involves different areas of the brain Reflexive attention (“bottom up”; RAS control) Executive processing (“top down”; frontal lobe) Visual attention

Regulation of Attention (cont’d) Types (simple to complex) Focused Sustained Selective Alternating Divided

Regulation of Behavior How people respond and act in a given situation Frontal lobe control Personality Perception Planning Self-awareness Judgment Mood Attention Memory Motivation Sexuality Expressive language

Alterations in Brain Structure and Function Traumatic brain injury Prefrontal cortex (social responsibility, concentration, abstract thinking, problem solving, emotional response) Amygdala (fear, aggression, social intelligence) Neurotransmission impairments Neurotransmitters (apathy, inattentiveness, motor deficits, agitation, restlessness, psychosis, anxiety, depression, obsessions, compulsions)

Recognizing Alterations in Mood, Attention, and Behavior Patient history Reported observations of others Screening tools Mood Disorder Questionnaire American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) World Health Organization’s ICD-10

Categorical Traits (DSM-5)

Treatment Options Psychotherapy Pharmacotherapy Counseling Alternative/complementary therapies Individual or family support group

Application of Concepts of Altered Mood, Attention, and Behavior Generalized anxiety disorder Posttraumatic stress disorder Major depressive disorder Bipolar affective disorder Attention-deficit hyperactivity disorder Autism spectrum disorders Schizophrenia

Generalized Anxiety Disorder Pathophysiology Clinical manifestations Diagnostic criteria Treatment

Generalized Anxiety Disorder Overview Anxiety disorders A group of chronic psychiatric conditions characterized by overwhelming and irrational feelings of fear or worry Can cause physical symptoms Types Obsessive-compulsive disorders Trauma/stress-related disorders

Generalized Anxiety Disorder Overview (cont’d) Types of anxiety Panic disorder Generalized anxiety Social anxiety Phobias Separation anxiety Medication/illness-induced anxiety

Generalized Anxiety Disorder Pathophysiology Increased response in amygdala to anxiety- provoking events Central nervous system mediators Norepinephrine, serotonin, dopamine, GABA Genetic factors Environmental factors

Generalized Anxiety Disorder Clinical Manifestations Worry that is: Excessive Uncontrolled Irrational Lasting >6 months Includes at least 3: Restlessness Fatigue Difficulty concentrating Irritability Tension Sleep disturbance

Generalized Anxiety Disorder Diagnostic Criteria History and physical examination Rule out medical or substance-abuse problem Standardized rating scales

Generalized Anxiety Disorder Treatment Cognitive-behavioral therapy Pharmacotherapy Selective serotonin reuptake inhibitors (SSRIs) Benzodiazepines Relaxation techniques (abdominal breathing)

Posttraumatic Stress Disorder (PTSD) Pathophysiology Clinical manifestations Diagnostic criteria Treatment

PTSD Pathophysiology An anxiety disorder caused by extreme traumatic events Military combat Concentration camp Violent crime Rape Abuse Risk factors Prior trauma Proximity, duration, severity Anxiety/depression Alcohol/drug abuse Family history Impaired support

Brain Regions Associated with PTSD

PTSD Clinical Manifestations Adults Avoidance and suppression of thoughts/emotions Nightmares Flashbacks Children Separation anxiety Crying, screaming Trembling Regression Withdrawal Disruptive behavior Inattentiveness

PTSD Diagnostic Criteria Symptoms present for at least 1 month Impaired functioning No other underlying medical condition Experiencing or witnessing traumatic event Persistently reexperiencing event Avoiding stimuli associated with event Exaggerated or impaired response

PTSD Treatment Psychotherapy Pharmacology Trauma-focused cognitive-behavioral therapy Eye movement desensitization and reprocessing Play therapy (for children) Pharmacology Antidepressants, benzodiazepines (anxiety), glucocorticoids (neurocellular homeostasis), anticonvulsants (impulsivity), clonidine (nightmares)

Major Depressive Disorder Pathophysiology Clinical manifestations Diagnostic criteria Treatment

Major Depressive Disorder Subtypes Seasonal affective Postpartum Melancholic Catatonic Atypical

Major Depressive Disorder Pathophysiology Pervasive and persistent low mood accompanied by low self-esteem and anhedonia (loss of pleasure) Biologic, psychologic, and social factors Genetic heritability (40% women, 30% men) Neurotransmitter deficiency Norepinephrine, dopamine, serotonin

Mechanism of Action of Antidepressant Agents

Major Depressive Disorder Pathophysiology (cont’d) Social and psychological influences Isolation Social rejection Loss or lack of significant relationships Poor family functioning Unemployment Poverty Abuse Alcohol/drug abuse Poor coping skills Low self-esteem Distorted thinking Low resilience

Major Depressive Disorder Clinical Manifestations Persistent very low mood Anhedonia Feelings of worthlessness, guilt helplessness, hopelessness, and self-hatred Interruption in sleep patterns Unrelenting fatigue Changes in appetite, weight, sex drive

Major Depressive Disorder Diagnostic Criteria History Reported observations by friends and family Mental status examination Ruling out physical conditions DSM-5 diagnostic criteria Onset of 5 or more symptoms persisting over a 2-week period

Major Depressive Disorder Treatment Psychotherapy/counseling Antidepressant medications Selective serotonin reuptake inhibitors (SSRIs) Tricyclic antidepressants (TCSs) Monoamine oxidase inhibitors (MAOIs) Electroconvulsive therapy Alternate therapies

Bipolar Affective Disorder Pathophysiology Clinical manifestations Diagnostic criteria Treatment

Bipolar Affective Disorder Pathophysiology Periods of mania and depression Genetic inheritance Impaired brain functioning Psychological, environmental, social factors Childhood abuse Harsh home environment Disruptions in relationships

Bipolar Affective Disorder Clinical Manifestations Periods of mania lasting at least 1 week Elevation in mood or irritability Rapid and excessive speech Distractibility Racing thoughts Impaired judgment Impulsivity Periods of depression

Bipolar Affective Disorder Diagnostic Criteria Patient history Reported observations by friends and family Mental status examination Ruling out physical conditions DSM-5 diagnostic criteria Seven subtypes

Bipolar Affective Disorder Treatment Psychotherapy Pharmacology Mood stabilizers Lithium carbonate Sodium valproate Atypical antipsychotic drugs

Attention-Deficit Hyperactivity Disorder (ADHD) Pathophysiology Clinical manifestations Diagnostic criteria Treatment

ADHD Pathophysiology Neurodevelopmental disorder of cognitive functions, causing attention deficit, hyperactivity, and impulsiveness Genetic inheritance (75%) Environmental factors (brain infection/trauma) Changes in brain structure and function

ADHD Clinical Manifestations Inattention Hyperactivity Restlessness Impulsivity Disruptive behavior Difficulties in school oar work Difficulties in social situations

ADHD Diagnostic Criteria Patient history Reported observations by friends and family Mental status examination Ruling out physical conditions DSM-5 diagnostic criteria Three subtypes

ADHD Treatment Psychotherapy Pharmacology Physical exercise Cognitive-behavioral therapy Behavioral therapy Pharmacology Stimulants Physical exercise

Autism Spectrum Disorders Pathophysiology Clinical manifestations Diagnostic criteria Treatment

Autism Spectrum Disorders Pathophysiology Neurodevelopmental disorder with onset in early childhood Environmental and genetic factors Changes in brain structure and function

Autism Spectrum Disorders Clinical Manifestations Impaired social interaction Impaired verbal and nonverbal communication Repetitive pattern of movement, interests or behaviors Poor muscle tone, incoordination, or toe walking Developmental regression

Autism Spectrum Disorders Diagnostic Criteria Clinical manifestations Screening tools DSM-5 criteria

Autism Spectrum Disorders Treatment Therapies Speech Occupational Physical Cognitive-behavioral Language training

Schizophrenia Pathophysiology Clinical manifestations Diagnostic criteria Treatment

Schizophrenia Pathophysiology A psychotic mental health disorder that affects how patients perceive the world Complex interplay among: Genetics (family history) Perinatal risks Socioenvironmental triggers Changes in brain structure and function

Familial Nature of Schizophrenia

Schizophrenia Clinical Manifestations Hallucinations Hearing voices Delusions Disorganized thoughts and speech Social withdrawal Poor hygiene Poor judgment Loss of motivation Paranoia Impairments of Memory Attention Cognitive processing

Schizophrenia Diagnostic Criteria Patient history Reported observations by friends and family Comprehensive clinical assessment Ruling out physical conditions At least 2 indicators (delusions, hallucinations, or disorganized speech) for at least 1 month, with significant impact on school, work, or home for at least 6 months

Schizophrenia Treatment Pharmacology Antipsychotics Psychological and social support