|INFORMATION ON SOME COMMONLY TREATED CONDITIONS
Major depression, or "clinical depression," is a mood disorder characterized by the presence of five or more of the following
symptoms during a period of at least 2 weeks and resulting in significant distress of problems with functioning:
-depressed mood much or most of the time
-markedly diminished interest in usual activities
-change in appetite and/or weight
-insomnia or excessive sleeping
-marked agitation/restlessness or slowing of thoughts and movement observable by others
-feelings or worthlessness or excessive guilt
-impaired concentration or unusual indecisiveness
-recurrent thoughts of death or suicide
Untreated depression may last from a few months to over a year (and sometimes many years).
Treatment of depression may include psychotherapy, antidepressant medications, or both. More severe cases of depression
tend to require medication treatment, whereas patients with mild-to-moderate depression may improve significantly with
Bipolar disorder is a mood disorder characterized by the occurrence of manic (or "hypomanic," or mild manic) episodes and
Manic episodes typically last at least a week, and are defined by the presence of at least 3 of the following symptoms:
-diminished need for sleep, such that one feels normal or better than normal energy after only a few hours of sleep
-flight of ideas, observed by others as a tendency to have one's thoughts jump rapidly from one topic to another
-increased activity (work, cleaning/organizing)
-Uncharacteristic irresponsible behaviors (shopping sprees, casual sexual encounters, impulsive financial decisions)
In severe cases, patients may experience auditory or visual hallucinations or experience delusions.
Hypomanic periods appear similar in symptom type, but may last only 4 days, and are of lesser severity.
Mood stabilizing medications (lithium, lamotrigine, etc.) are the mainstay of bipolar disorder treatment. Cognitive-behavioral
psychotherapy, focusing on recognizing and modifying thoughts and behaviors leading to mood episodes, may also play a key
role in controlling bipolar disorder.
Obsessive-Compulsive Disorder (OCD)
Patients with OCD have recurrent obsessional thoughts about some potential negative situation or outcome (getting sick
because of contact with germs; inadvertently harming someone) experience significant anxiety as a consequence. In order to
alleviate this anxiety, they often engage in compulsive behaviors to reassure themselves that this adverse event will not
happen (or has not happened already). For instance, patients with an irrational fear of germs may compulsively wash their
hands whenever they touch any surface (doorknob, another person's hand) that they fear could transmit illness. While many
people may have occasional OCD symptoms, diagnosis of OCD requires that the symptoms are sufficiently severe as to cause
significant distress or functional impairment (problems with school/work/relationships).
The staple of OCD treatment is a form of cognitive-behavioral therapy called exposure and response prevention, or ERP.The
basic theory of ERP is that OCD is essentially a disorder of the brain's fear response system; obsessions are irrational fears.
When patients engage in compulsions to neutralize the fears, they reinforce the dysfunctional fear circuits in the brain. In
ERP, patients effectively re-wire the fear centers of the brainwork with the therapist by systematically confronting the fearful
obsessional thoughts (this is the "exposure" part of ERP) without engaging in the reassuring compulsive behaviors (this is the
"response prevention"). This process essentially rewires the brain such that the obsessional thoughts no longer produce
marked distress and thus no longer necessitate the compulsive behaviors.
For some patients with more severe OCD, medication therapy using antidepressants medications (usually SSRIs, which
increase serotonin activity), anti-anxiety medications, or other options may be needed.
Panic disorder is an anxiety disorder characterized by recurrent unexpected (in the sense that it seems there is no clear
trigger such as a fearful thought or situation) panic attacks. The symptoms defining a panic attack are the result of the
activation of the body's fear response, sometimes called the "fight or flight" reaction. Symptoms of a panic attack include
pounding heart, sweating, trembling, shortness of breath, chest pain or discomfort, nausea or abdominal discomfort,
light-headedness, feeling cold or hot, tingling or numbness, depersonalization (feeling disconnected from one's self), fear of
going losing control or going crazy, fear of having a stroke/heart attack or dying. While over 70% of the population will
experience a panic attack at some point in their lives, in most cases, people can identify the cause of the panic, and therefore
do not fear them.
In patients with panic disorder, however, panic attacks seem to occur without clear triggers. Thus, panic disorder patients
fear that panic attacks can occur at nearly any time without warning. Panic disorder can thus be considered a disorder of the
fear system such that patients experience fear of the experience of anxiety itself. Since panic attacks are frightening and
potentially embarrassing, patients with panic disorder make changes in their behavior in order to avoid experiencing panic (not
driving in certain places; avoiding crowds and closed spaces like elevators or planes). These changes can significantly impact
one's ability to function both at work and in one's personal life.
Treatment of panic disorder consists of cognitive-behavioral therapy (CBT) and possibly medications. Through a structured
CBT protocol, patients work with therapists to modify the fear circuitry of the brain. Medications such as antidepressants and
anti-anxiety medications may have a role in treating panic disorder, but the best long-term results are seen in patients who
complete the appropriate CBT treatment protocol.
Social Anxiety Disorder
Patients with social anxiety disorder experience marked anxiety about situations where they anticipate negative scrutiny by
others. Situations may include eating in a restaurant, walking in public, interacting with a sales clerk, or meeting with one or
more persons in private. The anxiety associated with these situations causes significant distress and/or problems with work or
Social anxiety disorder, like other disorders characterized by excessive anxiety, is thought to reflect a disturbance of the
brain's fear system. Essentially, the fear center is over-active, signaling danger in interpersonal situations where such danger
does not exist or exaggerating the amount of risk.
Cognitive-behavioral therapy (CBT) seeks to modify the over-active fear circuits by cognitive exercises to examine and
replace dysfunctional beliefs about feared situations. The behavioral element of CBT entails systematic graduated exposure to
the feared situations, resulting in re-setting of the fear circuitry.
Medications may facilitate the work of CBT, which can be quite challenging. Commonly used medications include
antidepressants (particularly those modulating serotonin), beta-blocker drugs (to mute the effect of adrenaline), and
Generalized Anxiety Disorder (GAD)
GAD is characterized by a tendency to experience excessive worry and anxiety most days for at least 6 months. Patients
report great difficulty in controlling the worry, which may involve job, finances, safety/health of family and even minor
chores/errands. In order to be diagnosed with GAD, patients must also experience 3 or more of the following: physical
symptoms such as increased muscle tension, insomnia, restlessness, or fatigue; cognitive/emotional symptoms such as
irritability or impaired concentration.
Treatments include antidepressant medications and cognitive-behavioral therapy.
Attention Deficit Hyperactivity Disorder (ADHD)
ADHD is a disorder characterized by impaired concentration, hyperactivity and impulsivity; patients may have primarily
inattention problems, primarily hyperactivity symptoms, or both. In order to be diagnosable, the symptoms must be of sufficient
severity to cause significant distress or impair functioning at work/school or in relationships.
Treatment usually consists of drugs that modulate levels of the brain chemicals norepinephrine and dopamine. There is also
evidence that cognitive-behavioral therapy (CBT) may be useful in ADHD.
Hoarding is characterized by persistent difficulty discarding objects, regardless of their value, resulting in significant
accumulation of clutter. The resulting clutter results in significant distress and may strain relationships. The accumulation of
items may also create a health hazard (fire risk; difficulty escaping in event of emergency; pest infestation).
While certain antidepressant medications may help, the most important component of treatment is cognitive-behavioral
therapy (CBT). Through CBT, patients learn to challenge the dysfunctional thoughts and behaviors that give rise to the
hoarding problem. They also work with the therapist in systematically de-cluttering their living space. Ideally, CBT for hoarding
involves therapy sessions in the patient's home.
While occasional, transient sleep disturbances are common, a diagnosis of insomnia is reserved for individuals who
experience persisting problems with insomnia. A diagnosis of insomnia is considered if a person experiences problems with
falling or staying asleep at least 3 days per week for at least 3 months. Insomnia may occur as part of a stress reaction or
episode of depression, but it may also be an independent problem without other associated symptoms. In either case, many
patients with significant insomnia develop anxiety about sleeplessness. Such anxiety about sleep, together with behaviors
undertaken to combat the insomnia, may exacerbate the problem and contribute to its persistence.
Treatment may consist of cognitive-behavioral therapy (CBT) alone, medications alone, or combined CBT and medications.
CBT targets the anxiety about sleep through a combination of education about sleep biology; relaxation strategies; sleep
restriction; modifying behaviors affecting night-time sleep (napping; watching t.v. in bed).
Patients with schizophrenia experience "psychotic" episodes, lasting from a few days to several weeks or months. "Psychotic"
symptoms include hallucinations (usually auditory), delusions (fixed false beliefs such as being convinced that there is an
elaborate conspiracy to cause one harm); or markedly disturbed thought process such that the logical coherence between
thoughts is lacking. When psychotic episodes have resolved, patients tend to manifest "negative symptoms," which reflect
deficits in normal functioning (diminished emotional responsiveness; lack of initiative/interest).
Treatment of schizophrenia centers around medication treatment with antipsychotic medications. Because these drugs have
significant potential adverse effects, careful monitoring for side effects is a critical part of appropriate treatment. There is also
evidence that cognitive-behavioral approaches may be beneficial in improving functioning, quality of life and symptom control.
The term "dementia" (replaced in current psychiatric diagnostic manual DSM-5 by "major neurocognitive disorder") refers to
a deterioration in at least two of the following domains of cognitive function: attention, memory, executive (planning, insight),
social cognition, language. The decline in function results in significant impairment in one's ability to live independently. The
most common cause of dementia is Alzheimer's disease. Other types of dementia include vascular dementia, which results
from damage to brain cells due to disturbances in blood flow (from one or more large strokes or cumulative damage from small
"silent" strokes); dementia due to Parkinson's or Lewy body disease; frontotemporal dementia.
Sometimes other conditions may mimic dementia. For example, in some cases of severe depression in older adults, patients
may manifest profound cognitive impairments of the sort seen in dementia, in a condition referred to as "pseudodementia."
Furthermore, certain medical conditions such as thyroid disease, vitamin B12 and folic acid deficiencies, and normal pressure
hydrocephalus (NPH) can result in cognitive abnormalities as seen in dementia. Finally, acute medical or physiological
disturbances such as bladder infections or other illnesses and medications may give rise to mental changes resembling
Accordingly, when symptoms of dementia are observed, a detailed clinical evaluation by a geriatric psychiatrist or neurologist
is recommended. Assessment will likely include review of laboratory tests, brain scans as well as clinical history.
If a diagnosis of dementia is made, treatment depends on the presumed type of dementia. At present, there are
FDA-approved treatments only for Alzheimer's and Parkinson's disease-related dementias, namely the cholinesterase inhibitor
medications (Aricept, Exelon, Reminyl) and Namenda. The utility of these medications in other dementias is less clear.
Overall, these drugs seem to have some mild benefit in improving attention and memory, but their impact tends to be modest
Since mood (anxiety, depression), behavioral disturbances (combativeness with caregivers), insomnia and psychotic
symptoms (e.g., paranoia, hallucinations) are common as dementia progresses, other types of medication therapy such as
antidepressants, sleep enhancers, and antipsychotics may be needed. These medications may have adverse effects, so
careful review of risks/benefits and monitoring for side effects are crucial.