Category Archives: Mental Health Diagnosis

Paranoid Personality Disorder Symptoms and DSM-V Criteria




301.0 (F 60.0) Paranoid Personality Disorder: Overview

The key features of paranoid personality disorder involve suspicion of others and mistrust in their motivations. This disorder begins in early adulthood and persists for life and may affect multiple areas of functioning in their daily experience. The signs of mistrust must be manifested in at least four areas of their life including an inability to trust or rely upon friends and difficulty confiding in others because of fear that what is shared will be used against them, constant suspicion that others are trying to harm, trick or exploit them. They may have a pervasive pattern of not forgiving others and may misperceive insults and threats in normal conversation. They often believe that others are trying to assault their character. They obviously then feel a need to respond to the attack and frequently have a chronic suspicion that their spouse or partner is unfaithful to them.





Additional Aspects of Paranoid Personality Disorder:

This personality disorder occurs more often in men than women and is estimated to affect about 4.4% of the population in the United States. The sentiment and perspective of individuals with this disorder should not be confused with the feelings of oppression or disenfranchisement experienced by some minority, immigrant and refugee groups in the United States of America. Individuals who experience or have a family history of psychotic disorders such as schizophrenia or have other unique experiences such as being incarcerated are more often diagnosed with paranoid personality disorder.

Diagnosing Paranoid Personality Disorder:

As mentioned above, it is very important not to confuse the symptoms of psychotic disorders such as schizophrenia with paranoid personality disorder. This diagnosis would be given if the symptoms of paranoid personality disorder also persist before and after the psychotic symptoms of schizophrenia. It is important to understand that there is a significant overlap or comorbidity among personality disorders. Psychologists, psychiatrists and other mental health clinicians need to screen for whether another personality disorder may be even more appropriate such as schizotypal personality disorder.

301.0 (F 60.0) Paranoid Personality Disorder Diagnostic Criteria

A. Suspiciousness and pervasive mistrust of others in their motivations that are interpreted as malevolent, which began in early adulthood and is manifested in a variety of contexts as indicated by four (or more) of the following:

1. Suspects without a sufficient basis that others are harming, exploiting or deceiving them.
2. Has a preoccupation without justification about the trustworthiness or loyalty of friends, family or associates.
3. A reluctance to confide in others because of an unwarranted fear that the information will be used negatively against them.
4. Reads threatening meanings and demeaning motivations behind benign remarks or events.
5. Unforgiving of other’s insults, slights and perceived injuries and persistently bearing grudges
6. Perceives attacks on their character and reputation that is not apparent to others and reacts quickly and angrily in counterattack.
7. Has recurrent suspicions although unjustified about the fidelity of their spouse or sexual partner.

B. The symptoms do not occur exclusively during the course of schizophrenia, bipolar disorder or depressive disorder with psychotic features, or other psychotic disorders that are not attributable to the physiological effects of another medical condition.

Note: If the criteria are met before the onset of schizophrenia, add “premorbid,” such as “paranoid personality disorder (premorbid).”

Adapted from the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) American Psychiatric Association By Paul Susic Ph.D. Licensed Psychologist


Prozac Medication: The Benefits, Side Effects and Dosages




Prozac Medication: An Overview

Prozac is a medication used to treat depression, obsessive-compulsive disorder, bulimia, and frequently severe symptoms of premenstrual syndrome. Prozac is within the drug classification referred to as selective serotonin reuptake inhibitors (SSRI’s), which is believed to help maintain a elevated level of the neurotransmitter serotonin in the brain.

Serotonin is a neurotransmitter in the brain which is believed to affect moods. This neurotransmitter is usually quickly reabsorbed after its initial release from neurons in the brain. It is believed that excess serotonin between the neurons is blocked by medications such as Prozac from being taken back up into the releasing neurons resulting in increased levels of serotonin in the brain.

Prozac is most often prescribed to treat depression of the moderate to severe variety which interferes with daily functioning and most often is referred to as major depression. The symptoms of major depression include low mood and low energy, changes in sleeping habits and appetite, decreased sex drive, feelings of guilt or worthlessness, difficulty concentrating, slowed thinking, and suicidal thoughts. However, Prozac can be taken for a variety of other mental health disorders including obsessive-compulsive disorder, premenstrual dysphoric disorder as well as others. It is most often prescribed for adolescents, adults and the elderly but may occasionally be prescribed for children.

Prozac Medication for Obsessive- Compulsive Disorders:

In addition to being used for the treatment of depression, Prozac is also used to treat obsessive-compulsive disorder. Obsessions are thoughts that won’t go away, and compulsions are repetitive behaviors and actions which are done to relieve anxiety often associated with the obsessions. Prozac is used at times to also treat bulimia which is a binge eating disorder which involves deliberate vomiting and has also been used to treat other eating disorders including obesity.

Premenstrual Dysphoric Disorder:

Under the brand name Serafem which includes the active ingredients in Prozac, this depression medication is sometimes prescribed for premenstrual dysphoric disorder (PMDD), which is often referred to as premenstrual syndrome (PMS) including mood changes such as anxiety, depression, persistent anger, irritability, and mood swings. There are various physical problems associated with PMDD, including bloating, breast tenderness, headache and joint muscle pain. Symptoms usually tend to begin about 1 to 2 weeks before a woman’s premenstrual period. They are frequently severe enough to interfere with a woman’s daily activities, functioning and relationships.

Prozac Medication: Precautions

You should always be open and honest with your doctor when your taking Prozac. Always give a complete medical history, including liver problems, kidney disease, seizures, heart problems, allergies and history of diabetes. This depression medication has been known to make individuals dizzy or drowsy, making it necessary to be cautious when engaging in activities that require alertness such as driving or using heavy machinery. Alcohol should be limited when on this medication. Caution is also advised if you have diabetes, alcohol dependence or liver disease. Also, caution should be taken when this medication is being used by the elderly as they are more sensitive to the effects of the drug. This drug should only be used if necessary if an individual is pregnant as the medication passes into the breast milk. Because of the possible risk to the infant, breast-feeding while on this medication is not recommended. Consultation with your physician about the benefits and risks of Prozac used during pregnancy and breast-feeding is imperative. Obviously, you should never share your Prozac with others.




Important Facts About This Depression Medication

It has been noted that there can be some very serious and at times even fatal reactions to occur when Prozac is taken at the same time as some other antidepressants such as the MAO inhibitors. Also, you need to be careful when taking high doses of Prozac over a prolonged period of time. If you are taking any other medications for depression or any other prescription or nonprescription drugs you need to notify your physician before beginning on Prozac.

Prozac Side Effects:

Although the Prozac side effects seem to be less than some of the earlier generation antidepressant medications such as desipramine, amitriptyline and nortriptyline, there are still side effects that you need to be aware of. Some of the more common side effects of Prozac are sweating, dry mouth, drowsiness, headache, insomnia and nausea. Some of the side effects that are less likely but at times even more severe are loss of appetite and unusual weight loss, uncontrollable movements such as tremors, decreased interest in sex, flu-like symptoms, and either unusual or severe mood changes. Even less likely but even more potentially serious Prozac side effects include trouble swallowing, vision changes, white spots and swelling on the mouth and tongue, painful and/or prolonged erection and changes in sexual ability. The most severe side effects associated with Prozac are irregular and fast heartbeat, and fainting. Allergic reactions to Prozac are relatively rare but may include itching, rash, swelling, trouble breathing and dizziness. If you notice any reactions after beginning treatment with Prozac, you need to notify your pharmacist or physician immediately. A more complete listing of Prozac side effects follows.

The Most Common Prozac Side Effects:

Abnormal vision, abnormal ejaculation, abnormal dreams, increased anxiety, reduced sex drive, dry mouth, dizziness, flushing, flulike symptoms, headache, gas, impotence, itching, insomnia, loss of appetite, nervousness, nausea, sinusitis, rash, sleepiness, sweating, sore throat, upset stomach, tremors, yawning, vomiting, weakness

Less Common Prozac Side Effects:

Agitation, abnormal taste, weight gain, sleep disorders, bleeding problems, confusion, chills, weight gain, ringing in the ears, palpitations, loss of memory, increased appetite, high blood pressure, frequent urination, ear pain, emotional instability

There have been other very rare side effects reported while taking Prozac. If you develop any unexplained or new symptoms after initiating treatment with this depression medication you need to contact your physician immediately.

Drug Interactions:

In addition to the Prozac side effects mentioned above, there are also concerns for negative food and drug interactions when taking this antidepressant medication. As mentioned previously, Prozac should never be taken at the same time as you are taking MAO inhibitors. This can cause a very serious medication interaction. Also, when Prozac is taken with other medications the effect may be increased, decreased or altered in other ways. You should always check with your doctor when Prozac is taken with the following medications:

Alprazolam (Xanax)
Carbamazepine (Tegretol)
Clozapine (Clozaril)
Diazepam (Valium)
Digitoxin (Crystodigin)
Drugs that impair brain function, such as sleep aids and narcotic painkillers
Flecainide (Tambocor)
Haloperidol (Haldol)
Lithium (Eskalith)
Other antidepressants (Elavil)
Phenytoin (Dilantin)
Pimozide (Orap)
Tryptophan
Vinblastine (Velban)
Warfarin (Coumadin)

Special Warnings if You are Pregnant or Breast-feeding:

Prozac has not been adequately studied for its effects on pregnancy. If you are pregnant or plan to become pregnant in the near future, you need to talk with your physician as soon as possible to determine whether you should continue taking this depression medication. Prozac is known to appear in breast milk, so breast-feeding is obviously discouraged when taking this drug.

Prozac Dosage:

It is most common for your Prozac dosage to be taken once or twice a day and should be taken exactly as prescribed by your physician. It needs to be taken regularly to be effective. If it is possible, you should take your Prozac dosage at the same time every day.

Some patients have found that it can take as much as four weeks to feel any significant effects and get some relief from their depression. Doctors will also commonly maintain the treatment regimen for about nine months after the first initial three-month treatment trial. Some individuals who experience obsessive-compulsive disorder may not feel the full effects for as much as five weeks.

The Recommended Prozac Dosage:

The most common starting dosage of Prozac is 20 mg daily taken in the morning. Your physician may increase your dose after several weeks if there has been no improvement in symptoms. Elderly people with kidney and liver disease, and any other individual taking other medications may have their dosage adjusted by their doctor.

When taking a dosage of Prozac over 20 mg, the doctor may ask you to take it once a day in the morning or may ask that you to take two smaller doses in the morning and also at noontime.

The usual Prozac dosage for depression ranges between 20 mg and 60 mg. For obsessive-compulsive disorder, the usual dosage of Prozac ranges from 20 mg to 60 mg per day, although at times a maximum of 80 mg may be prescribed. The usual dosage of Prozac for bulimia nervosa is 60 mg taken in the morning. As with other disorders, the doctor may start at a lower dosage and increase to this level over a period of time. The most common Prozac dosage for premenstrual dysphoric disorder is 20 mg per day.

For some individuals who have been treated successfully with the daily form of Prozac, their doctor may switch them to a long acting form sometimes referred to as Prozac weekly. Your physician may ask you to skip your daily doses for seven days and then take your first weekly capsule.

If you miss your dose of Prozac you should take it as soon as you remember. If a significant time has passed however, you should skip that dosage and resume your normal dosage schedule.

Over dosage of Prozac:

Prozac like all medications, needs to be taken as recommended. Dosages more than the recommended amount can be dangerous and even fatal. Also, combining Prozac with certain other medications or drugs may cause symptoms of over dosage. If you suspect an overdose, you need to contact your doctor or go to an emergency room immediately.

The most common symptoms of Prozac over dosage include rapid heartbeat, nausea, seizures, vomiting and sleepiness. Some of the less common symptoms of Prozac over dosage include stupor, sweating, rigid muscles, low blood pressure, mania, coma, delirium, fainting, high fever and irregular heartbeat.

By Paul Susic Ph.D. Licensed Psychologist


Help Wanted: Psychologists in Metropolitan St. Louis Missouri





Part-time and Full-time Psychologists Wanted in the St. Louis Metropolitan Area:

An excellent opportunity and exceptional pay for doctoral level psychologists in St. Louis city, St. Louis county, St. Charles County and the surrounding metropolitan area is now available. Senior Care Psychological Consulting is looking for psychologists to provide services in office, long-term care facilities and homes. Hours are very flexible including part-time and full-time opportunities to provide counseling, assessment and/or psychological testing services to geriatric patients and individuals with long-term chronic medical and mental health concerns. Experienced individuals are preferred but we will train individuals with the right personality and aptitude.

Compensation:

Senior Care Psychological Consulting provides excellent compensation, paid twice monthly without your having to wait on billing cycles or having to assume the risk of nonpayment. The average hourly rates are between $70-$114 per hour. This is a wonderful opportunity for a doctoral level psychologist who is interested in learning or continuing their experience in working with geriatrics and individuals with long-term medical and mental health disability. If you’re interested you may contact Paul Susic Ph.D. Licensed Psychologist at (636) 300-9922 or you may email me at seniorcarepsych@yahoo.com for more information or to express your interest. Senior Care Psychological Consulting is an equal opportunity employer.

Paul Susic Ph.D. Licensed Psychologist
Clinical Director
Senior Care Psychological Consulting





Senior Care Psychological Consulting:

Senior Care Psychological Consulting in St. Charles, Missouri





The Only Strictly Doctoral Psychology Practice in St. Louis, Missouri

Senior Care Psychological Consulting is the premier provider of doctoral level geropsychology services for the metropolitan St. Louis, Missouri area. Senior Care Psychological Consulting is a specialty geriatric psychology practice providing psychological assessment, mental health counseling services, psychological testing, neuropsychological evaluation and disability evaluation to the elderly and chronic mentally ill in an office-based practice in St. Charles, Missouri. We also provide in- home services as well as providing services in nursing homes and other long term care facilities throughout the metropolitan St. Louis, Missouri area.




Paul Susic Ph.D. Licensed Psychologist and Senior Care Psychological Consulting

Senior Care Psychological was founded by Paul Susic Ph.D Licensed Psychologist who has been providing mental health services to the senior community for well over two decades. Paul developed one of the first exclusively geriatric psychiatric Partial Hospital programs in the St. Louis area, which he managed for approximately five years as the Program Manager at the former Incarnate Word Hospital. He also created and developed a whole continuum of outpatient mental health services which he also managed at Incarnate Word Hospital. He later was promoted to Director of the Department of Psychiatry of Incarnate Word Hospital, which he left in December, 1999 to begin a full-time geropsychology practice.

Paul Susic and Senior Care Psychological Counseling have continued their commitment to providing high-quality psychological assessment and mental health counseling services to the senior community. Senior Care specializes in providing psychological counseling and assessment services, psychological testing and neuropsychological evaluation in- home, in nursing homes and long-term care facilities throughout the metropolitan St. Louis area and also in an office based practice in St. Charles, Missouri. All services are provided under the direction of Dr.Susic who is the Clinical Director. Mental health assessments, testing as well as assessments for cognitive (memory) functioning and need for long-term placement are also available at senior care.

Please feel free to call and ask for Paul Susic Ph.D. Licensed Psychologist, and he will be pleased to assist you in any way possible. He may be reached at his office at (636) 300-9922 for local calls, or or he may also be reached by e-mail at seniorcarepsych@yahoo.com

Senior Care Psychological Consulting 500 Huber Park Ct. Suite 205, Weldon Spring, MO 63304

Information and webpage by Paul Susic Ph.D. Licensed Psychologist




Senior Care Psychological Consulting:

Bipolar I Disorder: Most Recent Episode Manic Diagnosis




Bipolar I Disorder: Most Recent Episode Manic Diagnosis: Most Essential Features

In order to have a bipolar I disorder diagnosis, it is absolutely essential to have at least one episode of mania. This manic episode will need to last at least a week, almost every day with symptoms present most of the time. During this period of mania, you will experience a high level of energy along with an elevated, irritable or expansive mood. Many individuals also experience an increased level of goal-directed behaviors. These behaviors need to be much more pronounced than normal, usual behaviors. If the mood is only irritable you may experience the following symptoms: the need for sleep; pressured speech or abnormally talkative; flight of ideas and racing thoughts; inflated sense of self-esteem or grandiosity; difficulty concentrating and easily distracted; major increase in psychomotor agitation or goal-directed activity associated with work, social, sexually related and possibly a significant increase in behaviors that could be riskier and result in severe negative consequences.

Additionally, individuals experiencing bipolar I disorder frequently also have histories of major depressive and hypomanic episodes, but it is not essential. Although many people believe that bipolar I disorder involves rapid mood swings, frequently that does not occur. Changes from mania to depression or hypomania could go on for weeks, months or longer. They may resolve to be followed by additional episodes at a later point in time.


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Bipolar I Disorder: Most Recent Episode Manic-Special Considerations:

Bipolar I most recent episode manic have some special concerns in that it can be an extremely dangerous mood at times. Some research has found that as many as 25% to 50% of individuals who have a diagnosis of bipolar I disorder eventually attempt suicide.

Individuals experiencing a manic episode often become involved in very risky behavior. Some of these experiences can even be life-threatening. Clinicians working with patients having bipolar I mood episodes need to be very aware of the risks involved in that they need to make it a part of their work with clients to make risk assessments and have crisis planning.

The healthcare costs associated with bipolar I disorder are very high. Some research has found that bipolar I disorder results in three times higher cost than among other individuals because of the increased level of hospitalization, visits to doctors and the expense of medications.

Bipolar I Disorder: Most Recent Episode Manic-Psychological Treatment and Medications

Bipolar I disorder requires lifelong management of symptoms. Fortunately, there are effective treatments that can help you or your loved ones to have a relatively normal life. Medications are available to stabilize mood and psychosocial treatments are available. Research has found that some of the more effective treatments include the combination of medications along with psychological interventions. Some of the more effective psychological interventions for the treatment of bipolar I disorder include cognitive behavioral therapy, psychoeducation, family-focused therapy, and interpersonal social rhythm therapy.

The specific criteria for bipolar I disorder most recent episode manic follow:

Basic Bipolar I Disorder Diagnosis Criteria

A. Criteria have been met for at least one manic episode.
B. The occurrence of the manic and major depressive episode or episodes is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other schizophrenia spectrum and other psychotic disorders.

Manic Episode;

A. A distinct period of abnormal and persistent, elevated, expansive or irritable mood, and abnormal and persistent increased goal directed activity or energy. This must last for at least a week and be present most of the day, nearly every day.

B. During this period of mood disturbance with increased energy or activity, three (or more) of the following symptoms (except for if the mood is only irritable) and are to a significant degree and must be a noticeable change from your usual behavior.

1. Inflated self-esteem or sense of grandiosity.
2. A decreased need for sleep such as feeling rested after only three hours of sleep.
3. More talkative than usual or a sense of pressure when talking.
4. Racing thoughts and flight of ideas.
5. Easily distracted.
6. Increase in goal-directed activity socially, at work or school, or sexually, or psychomotor agitation.
7. Excessive involvement in negative or high-risk situations such as engaging in unrestrained buying sprees, uninhibited sexual indiscretions, or foolish business investments.

C. The disturbance must be severe enough to cause significant impairment in social or occupational functioning, or to result in hospitalization to prevent harm to yourself or others, or if there are psychotic features present.

D. The episode cannot be attributed to the physiological effects of a substance such as a specific drug of abuse, a medication or other treatment or another medical condition.
Note: A full manic episode that emerged during antidepressant treatment or electroconvulsive therapy. Manic symptoms significantly at a level beyond the actual physiological effect of that treatment may be sufficient evidence for a manic episode and therefore of a bipolar one diagnosis.

Note: Criteria A-D above constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.

Coding for Specific Bipolar I Diagnoses:

The diagnostic code for bipolar I diagnosis are 296. _ _ (F31. _ _). The specific diagnosis and the related coding is based upon the current or most recent episode only. Mental health clinicians also need to consider and specify the severity, whether psychotic features are present, whether the client is in partial or full remission.

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from the Diagnostic And Statistical Manual of Mental Disorders Fifth Edition DSM-5



See Related Posts:

Treatment for Depression: Psychotherapy and Psychological Treatments





Treatment for Depression: An Introduction

Treatments for depression have come a long way in the last couple of decades with many advancements in psychotherapy and psychological treatments that have been empirically supported by research. Research into cognitive behavioral therapy, behavior therapy and interpersonal therapy have now been conclusively found to be effective. Evidence has also been found to support the use of cognitive therapy and reminiscence therapy among senior adults. A review of each of the main specific therapeutic modalities follows below.

Treatment for Depression: Cognitive Behavioral Therapy

Cognitive behavioral therapy was originally developed by Aaron Beck M.D. in the late 1960’s. It has easily become the most popular treatment modality for depression, anxiety disorders and a multitude of other mental health conditions. Cognitive behavioral therapy focuses on the connection between thoughts, moods and behaviors and utilizes primarily the thoughts as the main intervention point to modify moods and ultimately behaviors. It recognizes the negative bias that many people develop that results in biased information processing and dysfunctional beliefs that lead to and maintain depression. The main goal is to identify and change the dysfunctional or maladaptive thinking which is believed to then consequently change the individual’s affect and behaviors.




Cognitive behavioral therapy is traditionally provided within a structured format that facilitates learning experiences, monitoring thoughts, development of more adaptive coping skills and Socratic questioning of maladaptive thinking. A full course of cognitive behavioral therapy may involve 14 to 16 sessions along with booster sessions whenever necessary. There has been significant evidence over the last several decades recognizing the effectiveness of cognitive behavioral therapy in treating depression. Various outcome studies have found it to be at least as effective as pharmacotherapy and may be more effective than depression medications alone in assisting with preventing relapse of depressive symptoms. A more recent field of cognitive behavioral therapy has also had an increased interest and attention in that it has integrated the concept of mindfulness as well into the traditional cognitive behavioral model, in an attempt to reduce the incidence of relapse.

Behavior Therapy Treatment of Depression:

Behavior therapy focuses on the use of reinforcement and extinction of behaviors that are found to be either positive or negative. Behavior therapies focus on increasing the quality as well as the frequency of pleasant experiences which are then expected to result in improvements in an individual’s mood. A structured treatment program that was developed utilizing this theoretical perspective is the Coping With Depression course. This course uses the format of a psychoeducational group which usually consists of 12 sessions over approximately eight weeks, and then uses skills training to improve social skills. The objective is then to increase activities that are pleasant as well as to teach individuals how to relax. Some recent evidence has found that the use of this Coping With Depression course is at least as effective as antidepressant medications in treating depression in the short-term and possibly even over the long-term.

Interpersonal Therapy for Depression:

An interpersonal therapy model for depression was developed by Klarman, Wiseman and Associates in the 1980’s. The basis for Interpersonal therapy is the Interpersonal model of depression which considers depression to be the result of or to be exacerbated by interpersonal difficulties between people. As a result, interpersonal therapy focuses on remediating these interpersonal problems. Interventions may focus on role transitions, or disputes, interpersonal deficits and skills and even grief issues which have been denied, delayed or may be inadequately completed.

Interpersonal therapy is also provided within a structured format and utilizes a progression through three phases: (1) the diagnosis and identification of specific areas of interpersonal difficulties as well as an explanation of the course of therapy; (2) focus on resolution of the specific problematic areas or difficulties and (3) termination of therapy. This type of therapy has been utilized in a modified format among several specific populations such as adolescents and the elderly and has been used for other mental health disorders as well. Interpersonal therapy has been demonstrated to be effective for both the acute and maintenance phases of depression.

Learned Helplessness Treatment Model for Depression:

Significant research has also recognized the importance of the learned helplessness model for the development and maintenance of depression. Learned helplessness is based upon a model by Martin Seligman Ph.D. in the early 1960’s in which he recognized that there was a connection between an individual’s sense of control over their environment and depression. He found that an individual’s inability to have a sense of control over adverse circumstances in their environment resulted in a sense of helplessness and ultimately depression. He believed this perspective and consequent depressed mood was basically a learned experience. This model recognizes the need for increasing an individual’s sense of control over their environment, reducing feelings of helplessness, hopelessness and depression.

Treatment for Depression: Conclusion

Research and my (Paul Susic Ph.D. Licensed Psychologist) clinical experience has found over the last several decades that optimal treatment for depression may include both psychotherapy and/or psychological treatments along with medications for the most effective treatment of major depressive disorder. Although medications frequently are prescribed as a front-line treatment for depression, this physiological focus is often not ideal. Medications alone have been found to have higher relapse risks of additional episodes than psychotherapy alone. In most cases it seems that the most effective approach may be to attempt to remediate the depression with psychotherapy and then add medication as necessary rather than trying medication and then adding psychotherapy as an adjunct treatment.

By Paul Susic Ph.D. Licensed Psychologist





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Bipolar Disorder Medication: Treatments of Choice?




Bipolar Disorder Medication Treatments: Overview

Bipolar disorder medication has been the treatment of choice for several decades now to control the severe and sometimes disabling symptoms of bipolar disorder. Doctors have been prescribing lithium and other mood stabilizers as well as anticonvulsant medications and atypical antipsychotics as the primary treatment for bipolar disorder along with the use of antidepressants and antianxiety medications, to help manage acute episodes as well as for the longer term management and to assist in managing future episodes.

Bipolar disorder medication treatments still rely upon the use of mood stabilizers such as lithium for the acute treatment of both manic and depressive episodes. Lithium has been used now for many decades to manage these moods and to prevent cycling into the other mood state. Doctors also have been known to use the anticonvulsants, antipsychotic medications, antidepressants, antianxiety and even sleep medications to manage the intense manic and depressive episodes as well as some of the associated problems, such as when the bipolar patient has a high level of anxiety or difficulty sleeping.

Mood stabilizers such as Lithium are used to prevent and treat the manic highs and the depressive lows. These medications are used to manage the symptoms so they do not interfere with school, work and with personal relationships. The main mood stabilizing medications are:

Divalproex sodium (Depakote)
Carbamazepine (Tegretol)
Lithium
Lamotrigine (Lamictal)
Valproic acid (Depakene)




Some of these medications are also chategorized as anticonvulsants such as valproic acid, lamotrigine and carbamazepine.

Other medications used to treat bipolar disorder include the atypical antipsychotic medications. These include
Aripiprazole (Abilify)
Risperidone (Risperdal)
Quetiapine fumarate (Seroquel)
Olanzapine (Zyprexa)
Ziprasidone (Geodon)
Loxapine (Loxitand or loxapine inhaler (Adasuve)
Asenapine (Saphris)
Cariprazine (Vraylar)
Lurasidone (Latuda)

If an individual is experiencing insomnia or sleep difficulties in relation to their bipolar symptoms, they may receive prescriptions for antianxiety medications such as benzodiazepines. Some of the more common benzodiazepines include:

Alprazolam (Xanax)
Lorazepam (Ativan)
Diazepam (Valium)
Clonazepam (Klonopin)

Or frequently some of the newer sleep medication such as zaleplon (Sonata) and eszopiclone (Lunesta} will be prescribed as they are believed to cause fewer problems with thinking and memory then the antianxiety medicines, benzodiazepines.

Frequently, the doctor will prescribe the mood stabilizing medication lithium initially, but may also start a medication to also assist with the bipolar depression such as:

Fluoxetine (Prozac) which is combined with olanzapine (Zyprexa) to form a medication referred to as Symbyax
Quetiapine fumarate (Seroquel)
Lurasidone (Latuda) which may be taken either alone or with valproic acid or lithium.

Bipolar disorder medication treatments and depression:

Due to the predominance of depressive symptoms in bipolar disorder, antidepressants are often combined with mood stabilizers. However, there are significant concerns that the use of antidepressants can trigger manic episodes. These concerns have usually been related to the older antidepressants referred to as tricyclics rather than some of the newer serotonin reuptake inhibitors such as Paxil, Prozac and Zoloft. This risk was identified in a study by Gijsman, Geddes, Rendell, Nolen and Goodwin in 2004 in which it was found that there was a significant risk of the emergence of a manic conversion from depression among patients with a mood or anxiety disorder treated with tricyclic antidepressants, rather than when patients were treated with the SSRI’s. Also, even higher conversion rates from depression to manic episodes were found among younger antidepressant users.

Benzodiazepines and bipolar disorder:

Benzodiazepines have been used at times to reduce agitation and comorbid anxiety as an adjunctive medication treatment for bipolar disorder. However, the actual efficacy of these medicines has not been adequately studied at the present time when used in addition to the mood stabilizing medications.

Normal course of medication treatment for bipolar disorder:

Although mood stabilizers, antidepressants and other adjunctive medications have been used for the treatment of bipolar disorder for many years, the normal course of bipolar disorder continues to be one of relapse of episodes of mania/ hypomania and depression. Studies (Gitlin, Swenson, Heller, and Hammond, 1995) have found one-year relapse rates as high as 40% even while being treated with mood stabilizers. Medication compliance continues to be a major issue with patients with bipolar disorder, with one study (Keck et al., 1998) finding inadequate medication use among approximately one half to two thirds of the patients within one year of initial treatment. Discontinuing the use of medications and the related relapse of bipolar symptoms with these patients is very problematic, especially when these medications have been stopped abruptly. Psychological treatments have been successfully utilized to promote medication compliance and to improve the symptom course of bipolar disorder patients. Overall, psychosocial interventions and psychotherapy have been found to improve the management of long-term bipolar symptoms and assist in relapse prevention.

References:

Gijsman, H.M., Geddes, J.R., Rendell, J.M., Nolen W.A. and Goodwin, G.M. (2004). Antidepressants for bipolar depression: a systematic review of randomized, controlled trials. American Journal of Psychiatry, 161, 1537-1547.

Gitlin, M.J., Swenson, J., Heller, T.L. and Hammen, C. (1995). Relapse and impairment in bipolar disorder. American Journal of Psychiatry, 152, 1635-1640.

Keck, P.E., McElroy, S.L., Strakowski, S.M., West, S.A., Sax, K.W., Hawkins et al (1998). Twelve-month outcome of patients with bipolar disorder following hospitalization for a manic or mixed episode. American Journal of Psychiatry, 155, 646-652.

By Paul Susic Ph.D. Licensed Psychologist


Bipolar Disorder: What is it exactly?




Bipolar Disorder an Overview:

Dipolar disorder, formerly called manic depression is a chronic and very disabling condition. Bipolar disorder is a disorder of instability in mood, behaviors and lifestyle. The main feature of bipolar disorder is a manic episode followed by either another episode of mania at a later point in time, depression or hypomania. In most cases, one or more of these patterns occur repeatedly and chronically over an individual’s lifetime. The overall diagnosis of bipolar disorder is usually bipolar I or bipolar II disorder, with a reference to the most recent episode of “manic, hypomanic or depressed”. Specific symptoms and diagnosis can be found on this website by referring to the bipolar disorder diagnostic pages.

Individuals diagnosed with bipolar disorder may have very different symptom patterns. Some episodic symptom patterns seem to have some balance between episodes of mania, depression and hypomania, while others seem to have predominately one symptom pattern. Some researchers have found that among individuals with bipolar I disorder depressive episodes seem to predominate, with over 3.5 times as many weeks of depression relative to weeks experiencing manic episodes or hypomania. Most bipolar individuals will receive a diagnosis of bipolar disorder I most- recent episode depressed at some point in their mental health history. Individuals with bipolar II disorder, have 38 times more depressive symptoms than hypomanic symptoms.




People diagnosed with bipolar disorder experience tremendous levels of functional impairment in their lives even while maintained on medication. These deficits in functioning are very comprehensive including work-related, academic and interpersonal functioning. Some studies have found that even while maintained on medicine that deficits in functioning continue for as much is five years after the depressive or manic episodes have remitted. Some researchers (Dion, Tohen, and Anthony, 1998) have concluded that 30% of these individuals were unable to work at all and only 21% were able to work at their previous level of functioning following a manic, depressive or hypomanic episode. Similar findings were also found for individuals already on medication for bipolar disorder. Only a small percentage of manic patients seem able to work consistently following hospitalization. Bipolar disorder is also found to be associated with very high levels of marital and family distress, dysfunction and divorce.

Bipolar Disorder: Some Basic Information

Bipolar disorder has been estimated to affect about 1% to 2% of the general population. These estimates may be even higher levels when considering the entire bipolar spectrum including cyclothymia.
The initial onset of bipolar disorder seems to be in the late teens to early twenties. People with early onset disorder seem to have a higher level of additional comorbid symptoms, including conditions such as substance abuse and anxiety disorders. Also, early onset patients seem to have a more chronic course, with more episodes of depression and to have a higher likelihood of suicidal behaviors.

Men and women both seem to have about the same likelihood of developing bipolar disorder. However, more women than men seem to have the rapid cycling pattern, which is defined as four or more cycles in a year, as well as being diagnosed with bipolar II disorder more often.

People with bipolar disorder seem to experience comorbidity with several other mental health conditions and disorders. The most common comorbid conditions experienced by individuals with bipolar disorder include panic disorder, social anxiety disorder, posttraumatic stress disorder, obsessive-compulsive disorder and generalized anxiety disorder. High rates of substance use disorders have been identified in clinical populations as well, with some clinicians believing that the rates may be as high as six times the general population.

The General Course of Bipolar Disorder:

The general course of bipolar disorder is to have repeated manic, depressive and hypomanic episodes that significantly impair an individual’s work and school experiences as well as their personal relationships. Also, these disruptions in functioning may increase the intensity and frequency of the symptoms and episodes. Over the long-term, about three fourths of the individuals who have met the diagnostic criteria for bipolar disorder will have a relapse within a period of 4 to 5 years, with about half having a relapse the following year. As previously mentioned, the residual impairment in functioning seems to continue even in between symptom episodes.

A number of factors seem to be associated with the increased frequency or likelihood of a mood episode. Stressful life and family experiences seem to delay recovery and increase the rate of relapse. It is believed that stressful family experiences and negative interaction patterns are associated with greater relapse rates.

The high level of comorbidity is also associated with a more difficult course. There appears to be significant evidence to support the fact that anxiety and substance use disorders are particularly significant to the appearance, maintenance and relapse of bipolar symptoms and episodes. Clinical experience also seems to confirm that the comorbid existence of anxiety in addition to bipolar disorder is linked to a reduced likelihood of recovery from a mood episode, reduced ability to function in everyday life, greater likelihood of suicide attempts and a reduced ability to respond to some medications. Comorbid substance abuse disorders often cause an individual to experience poor recovery, increase the level of noncompliance with an individual’s medication routine, and increase the frequency of hospitalization. Some individuals may also experience psychotic episodes during depressive episodes resulting in significantly impaired functioning and relapse.

Suicide is also a great concern among individuals with bipolar disorder. Researchers (Brown, Beck, Steer, and Grisham, 2000) have evaluated the course of over 7000 psychiatric outpatients in Pennsylvania diagnosed according to the DSM-IV criteria and found that among the various mental health diagnosis, bipolar disorder patients have the highest level of completed suicides, followed by major depressive disorder and personality disorders. When compared to what are determined to be relatively average psychiatric patients, patients with bipolar disorder seem to have about a 400% higher risk of suicide followed by major depressive disorder which seems to have about 300% higher risk for suicide.

Bipolar Disorder Treatments:

Optimum treatment for bipolar related disorders includes psychotherapy and mood stabilizing medications. Some the primary psychological treatments include psychoeducation, cognitive behavior therapy, family-focused therapy, and interpersonal social rhythm therapy. Lithium and other mood stabilizing medications have had a high rate of success in stabilizing bipolar symptoms and episodes. Individuals who are noncompliant with their medications continue to have very high rates of relapse however.

References:

Brown, G.K., Beck, A.T., Steer, R.A. & Grisham, J.R. (2000) Risk factors for suicide in psychiatric outpatients: A 20-year prospective study. Journal of Consulting and Clinical Psychology, 68, 371-377.
Dion, G.L.,Tohen, M., and Anthony, W.A., (1998). Symptoms and functioning of patients with bipolar disorder six months after hospitalization. Hospital Community Psychiatry, 39, 652-657.

By Paul Susic Ph.D. Licensed Psychologist



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Social Anxiety Disorder (Social Phobia) Symptoms, Diagnosis and Treatment




Social Anxiety Disorder Symptoms:

Social Anxiety Disorder, previously referred to as social phobia is one of the more common anxiety disorders. It is usually experienced when you must perform in front of others or feel like you are being scrutinized by other people. The overall feeling is one of fear of possible embarrassment or humiliation. While many people find some way to endure the high level of anxiety they experience, others may avoid these feared experiences altogether. Usually you fear that you are going to be judged by others as being nervous, weak or stupid when you say or do something. In most cases people believe that their anxiety is excessive, and their fear is way out of proportion to the situation. Children however, do not recognize that their fear is excessive.

Studies have found that the most common social anxiety disorder or phobia is the fear of public speaking. It is believed to affect 3 out of 4 people or 75% of the population. It also accounts for approximately 19% and is easily the largest majority of those suffering from some form of phobia. This anxiety speech disorder is known to commonly affect speakers, people whose jobs require them to make public presentations, and even students speaking before the class. This form of social anxiety disorder is just as prevalent among men as among women. Overall, the most common social anxiety disorders include the following:

• fear of signing documents and writing in public
• fear of crowds
• fear of using restrooms in public
• fear of eating, spilling food or choking in public
• fear of being watched by others at work
• fear of taking examinations

Social Anxiety Disorder Diagnosis:

Social Anxiety Disorder is often distinguished by whether it is generalized or specific. The DSM-V has a performance only specifier which is given if you only experience this severe level of anxiety performing such as when public speaking. In these cases you may not feel otherwise impaired in your occupational, social or academic situations where public speaking is a requirement. You may not be afraid or avoid other social experiences. Also, if you experience panic attacks in conjunction with Social Anxiety Disorder, the specifier with panic attacks should be added to the diagnosis. If you experience anxiety in a more generalized sense in any social group situation where you fear being watched or evaluated, you may be experiencing a more generalized form of Social Anxiety Disorder. In most cases, the actual Social Anxiety Disorder diagnosis will not be given unless it interferes with your work, social activities or important personal relationships in very significant ways, usually causing a high level of personal distress. Like agoraphobia, Social Anxiety Disorder may be accompanied by panic that is related to the feelings of being embarrassed or humiliated, when trapped in a circumstance that provokes a high level of anxiety and distress. In these situations, the anxiety would rise only in circumstances related to the specific type of social situation feared.




Social Anxiety Disorder treatment:

There are several treatments that have been used to cope with Social Anxiety Disorder. One of the common sense recommendations by lay persons and some clinicians is to “take a deep breath”. Deep breathing from the abdomen and relaxation techniques can be practiced on a regular basis to relieve the physical symptoms of anxiety.

Social Anxiety Disorder Psychological Treatments:

Cognitive Behavior Therapy:

Cognitive Behavior Therapy has been effectively used for Social Anxiety Disorder. With this type of therapy, fearful thoughts are identified, challenged and often replaced by more realistic and adaptive thoughts. For example, a thought such as “I am going to be so nervous that I make a fool of myself” may be replaced by a thought such as “I will be nervous at first, but most people will not be bothered by that”.

Exposure Techniques for Social Anxiety Disorder:

One of the more effective long-term treatments for Social Anxiety Disorder is the use of exposure. Exposure can be imaginal or real-life exposure to the actual circumstances that are feared. The exposure is usually gradual or incremental in facing circumstances you are phobic or fearful of. If you experience an extremely high level of social anxiety about public speaking, you may give a very short talk to one or several friends, and then gradually increase it to a longer period of time with more observers. You would incrementally build up both the length of time and individuals observing to reduce the level of anxiety over a period of time.

While treatment for Social Anxiety Disorder is often done on a one-on-one basis, many mental health clinicians recommend group therapy as the ideal treatment format. This seems to more directly reflect the stimuli that would provoke the actual phobic reaction or Social Anxiety Disorder.

Social Skills and Assertiveness Training:

Sometimes learning basic social skills and learning to assert oneself can be very helpful in overcoming social phobias and Social Anxiety Disorder. Learning to smile, make eye contact, and maintaining conversations can be very helpful to developing a sense of mastery and coping with social situations, reducing the underlying level of anxiety. Also, learning to assert oneself can also be very helpful in learning how to tell others what you want or don’t want, without feeling like you must just go along with others demands.

Medications for Social Anxiety Disorder:

Medications are often given for Social Anxiety Disorder. The most common medications are the antidepressants, SSRI medications such as Paxil, Zoloft, Luvox and Serzone, and anxiety medications such as the benzodiazepines, which include Xanax or Klonopin. These medications are usually used as an adjunct to the cognitive behavior and exposure-based therapies mentioned above. Occasionally, MAO inhibitors such as Nardil and Parnate have been recommended to treat social phobias or social anxiety disorders.

Summary of Social Anxiety Disorder:

Many people suffer from Social Anxiety Disorder sometimes referred to as social phobia. The actual diagnosed disorder was changed in the new DSM-V which is used to diagnose mental health disorders by clinicians. You don’t have to suffer from Social Anxiety Disorder forever as both medications and psychological treatments are now available to relieve suffering.

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from The Anxiety and Phobia Workbook by Edmund J. Bourne Ph.D.



Bipolar and Related Disorders and DSM-5 Diagnostic Codes




Bipolar and Related disorders:

The bipolar in bipolar disorder refers to the fluctuation between depression and mania sometimes in a very dramatic, severe way. Earlier in the 19th century, mental health professionals used the terms manic depression and affective psychosis to describe bipolar disorder. In the first edition of the DSM (Diagnostic And Statistical Manual of Mental Disorders), bipolar disorder was referred to as manic depressive illness and was later renamed bipolar disorder in the DSM-III because of the stigma attached to mania and an attempt to describe and focus on the polarity between the two different symptom patterns of depression and mania.

The diagnosis of bipolar disorder has increased significantly especially among adolescents since the DSM-III. A report by CNN concluded that as many as 4.4% of individuals in the United States may receive some type of diagnosis along the bipolar spectrum in their lifetime. Unfortunately, individuals with bipolar disorder have the highest suicide rate among all of the mental health disorder diagnoses, with the rate of anywhere from 10 to 20 times higher than the general population in the United States.


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Specific Bipolar and Related Disorders and DSM-5 Diagnostic Codes:

The following specifiers apply to bipolar related disorders were indicated: specify: with anxious distress (specify current severity: mild, moderate, moderate-severe, severe); with mixed features; with rapid cycling; with melancholic features; with atypical features; with mood-incongruent psychotic features; with mood-incongruent psychotic features; with catatonia (use additional code 293.89 [F06. 1]); with peripartum onset; with seasonal pattern

Bipolar I Disorder:

Current or Most Recent Episode Manic:
296.41 (F31.11) Mild
296.42 (F31.12) Moderate
296.43 (F31.13) Severe
296.44 (F31.2) With psychotic features
296.45 (31.73) In partial remission
296.46 (F31.74) In full remission
296.40 (F31.9) Unspecified
296.40 (F31.0) Current or most recent episode hypomanic
296.45 (F31.73) In partial remission
296.46 (F31.74) In full remission
296.40 (F31.9) Unspecified

Current or Most Recent Episode Depressed:
296.51 (F31.31) Mild
296.52 (F31.32) Moderate
296.53 (F31.4) Severe
296.54 (F31.5) With psychotic features
296.55 (F31.75) In partial remission
296.56 (F31.76) In full remission
296.50 (F31.9) Unspecified

296.7 (F31.9) Current or most recent episode unspecified

296.89 (F31.81) Bipolar II Disorder

Specify current or most recent episode: Hypomanic, Depressed

Specify courses if full criteria for a mood episode are not currently met: In partial remission, In full remission
Specify severity if full criteria for a mood episode are not currently met: Mild, Moderate, Severe

301.13 (F34.0) Cyclothymic Disorder

Specify if: With anxious distress
Substance/Medication – Induced Bipolar and Related Disorder
Note: See the criteria set a corresponding recording procedures for substance-specific codes and ICD-nine-CM and ICD-10-CM coding.

293. 83 Bipolar Related Disorder Due to Another Medical Condition
specify if:
(F06.33) With manic features
(F06. 33) With manic-or hypomanic-like episode
(F06. 34) With mixed features

296.89 (F31.89) Other Specified Bipolar Related Disorder

296.80 (F31.9) Unspecified Bipolar and Related Disorder