DLA Notes on FUNGAL INFECTIONS-ARTHROPOD BITES-SARCOIDOSIS-ACNE 2

DLA Notes on SKIN LESIONS 43

DLA Notes on VIRAL SKIN INFECTIONS 52
Lecture 42_ALLERGIC SKIN CONDITIONS 86
Lecture 43_PSORIASIS_ROSACEA_SKIN CANCERS 130
DLA Notes on DEMENTIA TYPES 171
Lecture 44_GERIATRIC DISORDERS 174
DLA Notes on Eating Disorders 223
DLA Notes on Neurodevelopmental Disorders 243
DLA Notes on Sexual Disorders 263
DLA Notes on Somatic Symptom Related Disorders 297
DLA Notes on Substance Related Disorders 318
Lecture 45-Introduction_Depression_Bipolar 344
Lecture 46-Anxiety_OCRD_Trauma 395
 DLA in Dermatology
Topic: Fungal skin lesions,
Arthropod-bite skin lesions,
Sarcoidosis & Acne

1
 Learning Objectives

Distinguish the dermatological disorders listed in the

next slide with reference to:
• Risk factors
• Etiology and pathogenic mechanism
• Altered morphology
• Signs and symptoms and basis for the signs and
symptoms
• Prognosis, complications, mortality/survival
• Investigations and their interpretation.

2
2
List of Dermatological conditions to be covered in
this lecture:

• Tinea/Dematophytosis
• Tinea Versicolor Fungal Infections
• Chromoblastomycosis

• Lyme disease
• Scabies Arthropod-bite lesions

• Sarcoidosis
• Acne Vulgaris

3
FUNGAL SKIN INFECTIONS

• Dermatophytes
• Tinea versicolor
• Chromoblastomycosis

4
• Dermatophyte: Group of closely related
filamentous fungi, which may colonize keratin such
as the stratum corneum of the epidermis, hair,
nails.

• Dermatophytosis (Tinea/ringworm): Infection of

the keratin of skin, nail & hair by the dermatophyte
genera of fungi, trichophyton, microsporum,
epidermophyton

• Dermatomycosis: Organisms other than the

dermatophytes that may cause deep fungal or
systemic infections with cutaneous manifestations.
5
 Dermatophytosis (aka Tinea): Clinical types
Clinically classified based on body region involved

Tinea capitis Tinea faciale

Tinea mannum Tinea cruris

Tinea unguium
Tinea corporis Tinea pedis
(onychomycosis)6
 Tinea Corporis: Clinical Features

• Lesions appear on glabrous skin (skin normally

devoid of hair) of the torso, legs, and arms
• Pruritus is common
• Annular erythematous plaques with a raised
leading edge and scaling
• Central clearing may be visible in plaques
7
Gupta AK, et al. Dermatol Clin. 2003;21(3):395-400. 7
 Tinea Cruris: Clinical Features
• More commonly affects adult males
• Leading/Advancing scaly edge
• Central clearing
• Itchy
• Lesions extend from groin
down thighs and back on to
© DermAtlas
perineum or about the anus
– Not usually found on the scrotum or labia majora
• May be associated with tinea pedis/tinea unguium.

8
 Lab Diagnosis of Dermatophytosis
• Direct microscopic examination of Hyphae in
scrapings treated with KOH str. corneum
• Culture to identify the specific species
• Biopsy shows spongiosis, parakeratosis
& papillary dermal edema

KOH prep shows Hyphae

9
 Tinea Versicolor

• Numerous, well-marginated, finely scaly, oval-to-round

macules
• Fine, powdery scale may be readily provocable with
light scraping of the involved skin with a glass slide
10
 Tinea Versicolor (TV): Pathogenesis
• Caused by genus, Malassezia (formerly called
Pityrosporum), a dimorphic, lipophilic fungus.
• Malassezia furfur and Malassezia globosa are the most
common species that cause tinea versicolor.
• Component of normal flora in 90-100% of adults.
• Yeast (spore) and filamentous (hyphal) forms are both found
in TV
• Conversion of saprophytic yeast to parasitic mycelial form
occurs in:
– Genetically predisposed(>20% have a FH)
– Hot, humid environment
– Immunosuppression
– Malnutrition
– Cushing’s Disease. 11
Tinea Versicolor (TV): Clinical features & Diagnosis
• Infection is localized to the stratum corneum
• Well-demarcated, very fine scaly produce
scales on scraping
• Back and chest, occ. Abdomen, neck, upper
arms
• Versicolor (variation in colour):
– Red/brown macules on untanned skin
– Hypopigmented on tanned skin
• Diagnosis:
– Clinical
– Direct microscopic examination
of scrapings treated with KOH
“Spaghetti & meatballs”
appearance 12
Chromoblastomycosis

13
 Chromoblastomycosis
• Tropical/subtropical chronic skin &
subcutaneous fungal infection caused by
traumatic inoculation of the pigmented
fungi (E.g: Cladosporium).
• Distribution: Mainly Central and South
America, Africa, Caribbean islands
• Usually trivial injury with wood splinters
or thorns
• Warty nodule at site of injury can spread
to adjacent skin
• May have lymphatic and cutaneous
dissemination.

14
Chromoblastomycosis: Clinical features

• Begins as small, pink, scaly papule or warty

growth and spreads slowly
• Warty papule expands to become nodular,
tumorous or verrucous like a cauliflower
• Usually affects one leg or foot, but can also affect
hand or arm
• Extremity usually swollen.
• Complications include lymphedema leading to
elephantiasis, and rarely squamous cell
carcinoma.
15
 Chromoblastomycosis: Diagnosis
• KOH preparation:
– Pigmented hyphae
– Sclerotic cells present as round, thick-walled, cigar-
colored structures called Medlar bodies (“copper
pennies”)

• Fungal culture (Sabouraud-agar)

• Histopathology
– Granulomatous reaction with giant cells
– Fungus appears as brown, spherical cells with thick,
dark cell walls and coarsely granular, pigmented.

16
Chromoblastomycosis: Direct examination of KOH
cleared lesion scrapings

Copper pennies
(Medlar bodies)

Hyphae

17
 Histology of Chromoblastomycosis
“copper
pennies”
aka Medlar
bodies

Mixed dermal infiltrate consisting of neutrophils,

histiocytes, epithelioid cells, giant cells, lymphocytes,
eosinophils and plasma cells 18
Arthropod Bites:

1. Lyme Disease
2. Scabies

19
 Patient:
A 28-year-old man
develops an
erythematous plaque,
one week after returning
home from a camping
trip.
He also complains of
malaise, fatigue and
headache.
A tick is found in his shirt.

DDx: Tinea corporis, cellulitis, urticaria, acute contact

dermatitis, insect bite reaction, erythema migrans.
Diagnosis: Lyme disease 20
 Lyme Disease: Pathogenesis
• Spirochete - Borrelia burgdorferi
• Vector - Ixodes tick: in the western US, in the eastern US &
Great Lakes region & in Europe
• Host: White-footed mouse, wood rat, deer.
• Spirochete traverses through tick’s midgut epithelium &
make its way to the tick’s salivary glands.
• Transmitted to humans via the tick's saliva; rate of
transmission is low in the first 24 hours of attachment, but
 dramatically after 48 hours (role of prophylaxis)
• Spirochete moves throughout the erythema, causing
expansion of the rash - organisms may be found both in
the center & periphery of lesion.
• Spirochetes induce TNF- production (inflammation, fever)

21
 Erythema Migrans (Lyme Disease): Features
• Annular erythema develops at site of bite from Borrelia-
infected tick; (typically in 7-15 days; range 2-28 days)

• Multiple 2o lesions can occur from spirochetemia or

lymphatic spread

• Lyme is a multisystem disease with classic

dermatologic findings

• Disease divided into three clinical stages:

1. Early localized disease;
2. Early disseminated disease;
3. Chronic disease
22
 LAB INVESTIGATIONS: Lyme Disease

• Early disease with typical rash - clinical diagnosis.

• B. burgdorferi - positive culture from skin

specimens.

• Serology: ↑ IgM in 2-6 weeks after infections;

↑ IgG in 6 weeks-months.

23
 Patient:
24-year-old prisoner has intense itchy skin lesions in his
interdigital webs, wrists, axillae, buttocks and genitals.
Examination of the lesions reveals erythematous papules
and burrows associated with vesicles, excoriations,
eczematous dermatitis and secondary bacterial infection.

Diagnosis: Scabies

Interdigital web lesion Lesions on flexor wrist Linear burrow

24
 Scabies: Pathogenesis

• Caused by, Sarcoptes scabiei

• Entire 30-day life cycle is completed Sarcoptes scabiei

(scraped from a
in the human epidermis burrow)

• Usually less than 100 mites on infested host, may

be millions with crusted scabies

• 2-6 week incubation period before immune system

becomes sensitized and symptoms develop in
first-time infestation, 24-48 hour incubation period
in subsequent infestations.
25
 Scabies: Clinical Features & Lab Diagnosis
• Intense pruritus

• Erythematous papules +/- burrows commonly

associated with excoriations, vesicles, eczematous
dermatitis and secondary bacterial infection

• Cutaneous lesions are symmetrical, typically

involving interdigital webs, wrists, axillae, waist,
ankles, feet, buttocks, genitals and areolae
• Light microscopy of
scrapings: Look for
mites, eggs or fecal
pellets.
26
SARCOIDOSIS

27
 Patient:
A 21-year-old woman
comes to the physician
because of a 10-month
history of flesh-colored
papules in her lips and
peri-oral area.

ROS: She also has shortness of breath

Labs/Other Data: Recent CXR reveals hilar
adenopathy. Blood chemistry panel normal except
for moderately elevated serum calcium. CBC shows
lymphopenia.

Diagnosis: Sarcoidosis 28
 Sarcoidosis: Features
• Systemic granulomatous disorder of unknown origin
• Commonly involves the lungs, but may involve
essentially any organ/system
• Cutaneous manifestations in up to 1/3 of patients
– May be the first clinical sign of the disease
– Lupus Pernio: Reddish-brown to violaceous
papules & plaques on the face, lips, neck, upper
back and extremities. Apple jelly color on
diascopy.
– Erythema nodosum (EN): a non-specific
inflammatory skin finding associated with acute,
transient sarcoidosis
• Löfgren's syndrome: EN plus bilateral hilar
adenopathy plus polyarthralgia.
 Dermatologic manifestations of Sarcoidosis
Lupus Pernio:
•Nontender, firm purple nodules or papules
•Non-caseating granuloma on histopathology
•Indicates severe, chronic disease involving multiple organs.

Erythema Nodosum:
•Tender nodules mostly on the shin
•Nonspecific inflammatory lesions
•Hallmark of acute, benign and self-
limited disease.
 Sarcoidosis: Pathology

Superficial & deep dermal granulomas with sparse

lymphocytic infiltrate at the margins of granulomas
(‘naked tubercles’).
 Sarcoidosis: Lab Findings
Lymphocytopenia:
• Due to compartmentalization of T lymphocytes
• Leads to decreased delayed-type hypersensitivity
to common antigens (anergy) such as tuberculin
skin test

Elevated serum calcium:

• ↑ calcitriol synthesis by sarcoid histiocytes.

Elevated serum ACE level:

• ACE is synthesized by sarcoid histiocytes
• Reflects the granuloma load
• Used to monitor clinical course not the diagnosis.
ACNE VULGARIS
 A 16-year-old male comes
to the physician because
Patient: of a 6-month history of skin
lesions characterized by
comedones, papules,
pustules and cysts over his
face, neck, shoulders and
upper back.

DDx: Folliculitis, Acne,

Furuncle

Diagnosis: Acne

Comedo/comedone = dilated hair follicle/s filled

with skin debris
 Pathogenesis of acne
• Acne involves the blockage and/or inflammation
of pilosebaceous units
• Androgens stimulate acne.

Normal
pilosebaceous unit
 Pathogenesis & Clinical course of Acne

Pilosebaceous unit

Closed comedones • Follicular hyperkeratinization &

(“white heads”) • Excessive sebum production

Non-inflammatory Acne:
•Sebum accumulation, Comedones Androgens
•Keratin buildup &
•Follicle enlargement Propionibacterium acne

Open comedones
(“black heads”) Inflammatory Acne:
Papules,
Pustules,
Cysts & Nodules
 Pathogenesis of acne
Acne is a disorder of pilosebaceous unit

Microcomedone Visible Inflamed Nodule/cyst

Comedone papule/pustule
 Pathogenesis of Acne

• Sebum is sterile and contains Triglyceride (TG),

wax and sterol esters, squalene, & free fatty acids
(FFA)

• Sebaceous follicles are rich in microbes such as

S. epidermidis and Propionibacterium acne (gram
+ rods)

• Lipases from P. acnes split TG → FFA

• FFA are chemotactic and attract neutrophils

 Disorders associated with Acne

• Polycystic ovary syndrome (PCOS) - acne,

obesity, hirsuitism, amenorrhea & glucose
intolerance

• Congenital adrenal hyperplasia (CAH)

• Androgen secreting tumors of adrenal cortex

Endocrine work-up may be helpful:

Plasma Testosterone, LH, FSH, DHEA,
Androstendione & urinary 7-ketosteroids
Question

40
A 25-year-old man comes to the physician because of a
3-month history of an enlarging mass on his right leg. It
occurred at the site where he had removed a wood
splinter 4 months ago. The papule has enlarged like
cauliflower and his leg is now swollen. Medlar bodies
are seen on KOH scraping. Which of the following is
most likely?
A. Cutaneous warts 20%
B. Necrotizing fasciitis 20%
C. Verrucous carcinoma 20%
D. Chromoblastomycosis 20%
E. Dermatophyte fungal infection 20%
41
 DLA in Dermatology
Topic: Definitions of skin
lesions & examples

1
Definition and examples
of common skin lesions

2
 Learning Objectives

Distinguish the following skin lesions and give

examples for each:
• Macule and patch
• Papule and plaque
• Vesicle, bulla, pustule and cyst
• Wheal and dermographism
• Telangiectasia and purpura
• Erosion and ulcer.

3
3
Non-Palpable vs. Palpable Skin Lesions
Non-palpable Palpable
1. Macule ≤10 mm 3. Papule ≤ 10 mm
mm

E.g., Freckles
E.g., Nevus

2. Patch >10 mm 4. Plaque >10 mm

E.g., Vitiligo E.g., Psoriasis 4

 Blisters
(fluid filled)

5. Vesicle ≤ 10 mm 6. Bulla > 10 mm

E.g., Contact Dermatitis by E.g., Bullous Pemphigoid

Poison Ivy
7. Pustule: Blister 8. Cyst: Space, often in
filled with pus the dermis, filled with
fluid or semi-solid
material

E.g., Folliculitis

E.g., Epidermal cyst

 9. Wheal

• Transient, raised
lesion
• Edema in upper
dermis

E.g., Dermographism
10. Telangiectasia 11. Purpura
• Visibly dilated blood • Subcutaneous bleed spots
vessels • Does not blanch when
• Blanches with pressure is applied
diascopy (diascopy)

E.g., Vasculitis

8
12. Erosion 13. Ulcer
Defect involving only Defect involving dermis
the epidermis or deeper

E.g., Eroded Dermatitis E.g., Neurotrophic Ulcers

 DLA in Dermatology
Topic: Viral Skin Infections

1
 Learning Objectives

Distinguish different types of viral skin disorders

(listed in the next slide) with reference to:
• Risk factors
• Etiology and pathogenic mechanism
• Altered morphology
• Signs and symptoms and basis for the signs and
symptoms
• Prognosis, complications, mortality/survival
• Investigations and their interpretation.

2
2
VIRAL SKIN INFECTIONS

•Roseola infantum
•Measles
•German measles
•Molluscum contagiosum
•Warts
•Herpes simplex infection
•Varicella-Zoster infection

3
 Patient:

11 month-old male infant develops pink macules &

papules on his trunk & proximal extremities
following a 4-day of high fever. Mother states that
despite being febrile her son is otherwise well.
DDx: Measles, rubella, scarlet fever, roseola
infantum, toxin-mediated erythema (staph, strep),
drug rash.
Diagnosis: Roseola Infantum. 4
 Roseola Infantum: Features

• High fever (to 40–40.5°C; 104–105°F) followed by

exanthem at defervescence

• Affects primarily infants and toddlers who appear

well despite fever

• Neurologic involvement possible (seizures,

encephalitis, aseptic meningitis)

5
 Roseola Infantum: Pathogenesis
• Human herpes virus types 6 & 7 (HHV-6 & HHV-7)
- ds DNA

• Spread by oropharyngeal secretions

• Lymphotropic for CD4+ T-cells - virus replicates &

spreads

• Latency eventually established - salivary glands

are most common site of recurrence

• With neurologic disease, HHV-6 has been found in

endothelial cells of vessels in the frontal lobe.
6
 Patient:

6 year-old-boy with a 3-day history of blanching

erythematous macules and papules (“morbilliform”)
eruption which is preceded by a fever, cough, and
runny nose.
DDx: Measles, rubella, other viral exanthems, drug
rash, toxin-mediated erythema.
Diagnosis: Measles (Rubeola). 7
 Rubeola (Measles): Pathogenesis
• Paramyxovirus family; Rubivirus genus - ssRNA

• Highly contagious → spread via respiratory droplet

• Viral replication begins within the Respiratory

epithelial cells → lymphoid tissue & blood → viremia

• Virus can disseminate to the lungs, liver and

gastrointestinal tract

• Complications: Otitis, pneumonia, encephalitis,

myocarditis, and subacute sclerosing
panencephalitis (neurodegenerative disorder)
8
 Rubeola (Measles): Clinical features
• Incubation period 10-14 days

• “3 C’s” prodrome: cough, coryza, conjunctivitis

• Koplik spots (enanthem): “grains of sand” on a

red base – appear near the end of the prodrome,
1-2 days before the exanthem (rash).

• Exanthem: Cephalocaudal spread

(Face → trunk → extremities) &
lasts for 5-7 days.

• Incidence  with vaccination

9
Patient: 9-month-old male infant develops
mild upper resp. symptoms & low
grade fever followed by the
appearance of erythematous
macules & papules on his face,
trunk & extremities.

Associated findings on PE: Tender

cervical lymphadenopathy

DDx: measles, rubella, other viral

exanthems (e.g. adenovirus,
enterovirus, measles, EBV) and
toxin-mediated eruptions.
Diagnosis: Rubella 10
 Rubella (German Measles): Features
•Togaviridae family; Rubivirus genus - ssRNA

•Prodrome of mild fever and URI symptoms

•Exanthem: Cephalocaudal spread, fades with

progression in 3 days.

• Tender lymphadenopathy (occipital, post. auricular)

• Primary site of infection is nasopharynx → regional

lymph nodes → viremia

•Self-limited disease in children/adults

11
Congenital Rubella syndrome: Fetal Infection
• Fetal transplacental infection in the first trimester

• Classic triad: Sensorineural deafness, Ocular defects &

congenital heart dis (PDA & Pulm stenosis)

• Other defects: Microcephaly, hepatosplenomegaly, anemia,

Prematurity, stillbirth & blueberry muffin skin.

Blueberry muffin (reddish-blue papules

are spots of dermal hematopoiesis)

Arrows show myeloblasts 12

 Patient:

26 year-old-man
presents with a 2 mm
size, painless, pearly
yellow-pink umbilicated
papule adjacent to the
right medial canthus. It
is asymptomatic.
DDx: Basal Cell Carcinoma, Xanthoma, nevus,
sebaceous hyperplasia, Molluscum Contagiousum.

Diagnosis: Molluscum contagiosum

13
 Molluscum Contagiosum (MC): Features
• Caused by a virus, member of the poxvirus family
• Common, benign, self-limited process in children.
• In adults, usually is a STD
• Increasing frequency in immunocompromised
hosts (mostly in HIV-infected)
• Transmission via skin-to-skin
contact and sometimes fomites
• Painless umbilicated papules
on face, neck, axillae, arms,
hands or anywhere except
palms and soles. 14
Pathology: Molluscum

Crateriform, lobular epidermal Intracytoplasmic

hyperplasia basophilic inclusions
(Molluscum bodies) 15
Patient:
31-year-old man presents with verrucous
(fungating) papules & plaques in his right hand
fingers, penis & peri-anal region.

DDX: Verruca vulgaris (warts), actinic keratoses,

seborrheic keratosis, cutaneous horn & squamous
cell carcinoma.
Diagnosis: Verruca vulgaris (warts) 16
 Warts: Pathogenesis
• Human papilloma virus (HPV), a non-enveloped ds DNA
virus - resistant to heat and desiccation

• Transmitted via direct contact with infected individuals or

contaminated surfaces

• Micro abrasions or epidermal defects enable inoculation

• Contagion determined by:

– Lesion location
– Viral load
– Degree and nature of contact
– Immunologic status of exposed individual

• Lifecycle completed in fully differentiated squamous

epithelia. 17
Human Papilloma Virus: Types & Oncogenicity

• HPV Types: Many types (1-35)

-Type2 - common warts;
-Type 6 & 11 - Anogenital warts with low risk
for cancer;
-Type 16 & 18 - Anogenital warts with high-
risk for squamous cell Ca of anogenital region in
both sex and ca cervix in female.

• Oncogenic potential: Viral proteins E6 & E7 (of

type 16 & 18) are important in the induction of
cancer by inhibiting p53/pRb pathways.

18
 Cutaneous warts (Verruca vulgaris): Clinical features

• Trauma-prone areas
• Auto-inoculation secondary to
scratching may result in linear
array
• May be associated with nail
matrix destruction
• Butcher’s warts: Verrucous papules
or cauliflower like lesions, usually
multiple, on dorsal, palmar or
periungual hands and fingers of
meat cutters (but not from the
meat!)
• Plantar and palmar warts: Often
painful; Punctate black dots
(“seeds”) are characteristic,
representing thrombosed
capillaries. 19
 Genitomucosal Lesions by HPV: Clinical Features

• AKA, Anogenital warts (condyloma

acuminata, genital or venereal warts)
• Commonest STD
• Mostly by HPV types, 6, 11, 16 & 18.
• Papules/nodules involving perineum,
genitalia, inguinal fold, mons pubis, anus
• Discrete 1-3 mm sessile papules to
large, exophytic, (cauliflower-like)
masses or plaques
• Skin-colored, brown or whitish
• Internal extension into vagina, urethra,
perirectal epithelium possible
20
 Warts: Histopathology

• Acanthotic epidermis with

“church spire” papillomatosis,
hyperkeratosis and vertical
tiers of parakeratosis.
• Elongated ridges point radially
toward center from the
periphery.

• Koilocytes a type of dysplastic

squamous cell appear as large,
pale-staining keratinocytes w/
eccentric nuclei surrounded by
perinuclear halo

21
 Patient-A and Patient-B: Present with tender,
grouped vesicles on an erythematous base of 3-4 days’
duration. They are otherwise well.

Patient A: Lesion in Patient B: Lesions near

angle of mouth gluteal cleft

DDx: Acute contact dermatitis, bullous impetigo, Herpes

simplex, Herpes zoster.

Diagnosis: Herpes simplex

22
 Herpes Simplex: Pathogenesis
• Caused by HSV type 1 & 2, Enveloped, ds-DNA virus

• Primary/acute infection: Virus replicates at inoculation site

(mucocutaneous surface) causing primary lesions
• Latent infection: Virus from primary travels retrograde
along sensory nerves to ganglia to establish latent
infection
• Reactivation results in mucocutaneous lesions.

• HSV-1: Main cause of orolabial infection.

-50% of primary outbreaks of genital herpes.
• HSV-2: Almost entirely genital; oral infection is rare
-Accounts for >90% of recurrent genital herpes
(HSV-2 recurs more frequently than HSV-1)
Sacks SL. The Truth About Herpes. 4th ed. 1997
Mindel A. Lancet 1998;351(suppl III):16-18
23
Thompson C. Int J STD AIDS 2000;11(8):501-502
Benedetti J, et al. Ann Intern Med 1994;121(11):847-854
 Orolabial Herpes simplex: Clinical features
Primary: High fever followed by
vesicular lesions on the oral mucosa,
tongue, and lips. Lesions later rupture
and coalesce, leaving ulcerated
plaques.
Recurrent: A prodrome of pain,
burning, and tingling followed by the
Primary
vesicles that become pustular and
ulcerate (cold sores).

Herpetic Whitlow
Recurrent 24
 Genital Herpes: Clinical Features
Primary infection (HSV 1 & 2):
• Extensive painful vesiculoulcerative
genital lesions, including exocervix.
• Systemic symptoms (fever, myalgia).
• Tender regional lymphadenopathy
• May develop complications such as
aseptic meningitis, and extragenital
lesions.
• Resolve in 16-22 days.
Recurrent Infection (Mostly HSV2):
• Lesions are preceded by a prodrome of
tenderness, pain, and burning at the site
of eruption.
• More severe in women than men.
• Resolve in 8-10 days.
Aoki FY. Genital herpes simplex virus (HSV) infections. Canadian Guidelines on STIs. 2006
Reproduced with the permission of Francisco Diaz-Mitoma, MD, PhD, FRCPC and Stephen L. Sacks, MD, FRCPC
 Herpes Simplex: Laboratory Diagnosis

Tzanck smear:
-Multinucleated giant cells diagnostic (HSV/VZV)
-Rapid diagnosis
-Low sensitivity

• Viral culture: gold standard

• PCR: Multinucleated giant cells =
• -Up to 4-fold more sensitive fused infected
keratinocytes.
– -Does not require live virus
• Serology:
• -Type-specific
• -Distinguish between primary and recurrent infection
• -Can take up to 4 months for antibodies to appear
26
Aoki FY. Genital herpes simplex virus (HSV) infections. Canadian Guidelines on STIs. 2006
 Varicella-Zoster Virus (VZV) Infection:
Pathogenesis

• Infects many cell types

– Skin cells
– T-cells
– Neurons of the dorsal root ganglia
• Only 1 serotype (HHV-3)
• Humans: only known reservoir

27
 Varicella-Zoster Virus (VZV) Infection
Primary Infection: Recurrent Infection:
Varicella or Chickenpox Herpes Zoster or Shingles

• Usually, pediatric, • Occurs only in people who

self-limited and have had chickenpox
benign disease • Increased risk with age
and immunosuppression
28
 Varicella (Chickenpox): Features
• Prodrome: mild fever, malaise, myalgia.
• Eruption: pruritic, erythematous
macules and papules on head & neck,
spread distally.
– Lesions evolve over 12 to 14 h into
vesicles with clear serous fluid
surrounded by narrow red halos:
“dew drops on a rose petal”
– Evolve into pustules and crusts
– Few to several hundred lesions at
varying stages
– Heal within 7 to 10 days.
• Oropharynx commonly involved
• Infective until all lesions are crusted.
29
 Varicella-Zoster Virus Establishes Latency
VZV moves along the
Dorsal root
sensory nerve to the
ganglion
Spinal cord dorsal root ganglion

Primary
Skin
Lesions
VZV establishes
latency in the
dorsal root ganglion

• Viral latency is established during primary infection

(varicella).
• Transport of virus up sensory nerve from infected
dermal sites.
• Dormant in dorsal root ganglion.
 Herpes Zoster: Clinical Features & Lab
• Pain & itching before eruptions
• Pain may mimic pleurisy, MI, biliary
or renal colic, appendicitis
• Dermatomal, unilateral eruptions
– Thoracic and lumbar 50-70%
– Ophthalmic ~15%
• Painful erythematous macules,
papules and vesicles on
erythematous base, then crusting
• Heals within 4 weeks
• LAB: Tzanck, DIF, PCR if in doubt
 Complications of Varicella Vs Zoster
Varicella
• Bacterial superinfection
with or without scarring
• CNS complications:
Reye’s syndrome &
encephalitis
• Pneumonia (10-30%
mortality if untreated)
• Glomerulonephritis,
• Myocarditis,
• Pancreatitis,
• Orchitis,
• Hepatitis.
• Third trimester infections:
fetal anomaly.
Zoster
• Bacterial superinfection with
consequent scarring
• Post-herpetic neuralgia (PHN)
• Ophthalmic zoster: keratitis,
uveitis, iridocyclitis,
panophthalmitis, glaucoma.
• Ramsay-Hunt syndrome:
Ipsilateral facial nerve
paralysis with loss of taste in
the anterior 2/3 tongue.
• Other: Meningoencephalitis,
motor paralysis, pneumonitis
hepatitis.
32
Question

33
A 75-year-old woman came to the ER with a 1-day
history of blisters on the left side of her chest. She came
to the ER with severe left sided chest pain 3 days ago
and tests were done and ruled out a myocardial
infarction. Physical examination shows multiple small
vesicles on the left side of her back, extending onto her
chest and left breast. The vesicles stop abruptly at the
midline. Which of the following is the most likely
diagnosis?

A. Erythema nodosum 20%

B. Herpes zoster 20%
C. Varicella 20%
D. Bullous pemphigoid 20%
E. Herpes simplex 20%
Pathophysiology Lecture 42
Topic: Dermatology
Allergic Skin Conditions

Dr. S. Upadhya

1
 Learning Objectives

Distinguish the dermatological disorders listed in the

next slide with reference to:
• Risk factors
• Etiology and pathogenic mechanism
• Altered morphology
• Signs and symptoms and basis for the signs and
symptoms
• Prognosis, complications, mortality/survival
• Investigations and their interpretation.

2
2
List of Dermatological conditions to be covered in
this lecture:

• Allergic contact dermatitis

• Atopic dermatitis
• Leukocytoclastic vasculitis
• Urticaria
• Erythema Multiforme
• Bullous pemphigoid
• Pemphigus

3
Patient:
A 20-year-old woman has a 2-day history of pruritic facial
plaques which are localized to her right face & neck. She
likes to work in her garden.
Past medical history (PMH): unremarkable

PE: Erythematous, linear plaque.

The linearity of the lesions is highly
suggestive of an “outside job”

Differential diagnosis (DDx):

•“Itch-scratch”
•allergic contact dermatitis
•atopic dermatitis
•seborrheic dermatitis

Diagnosis: Allergic Contact Dermatitis (ACD) 4

 Allergic Contact Dermatitis (ACD)
• ACD accounts for 20% and irritant contact dermatitis
accounts for 80% of contact dermatitis

• Nickel, poison Ivy, poison Oak, rubber hand gloves are

among the most common causes

• Usually localized to the site of contact

• Often linear or geometric & well demarcated

• Type IV hypersensitivity – delayed type

• The gold standard for diagnosing ACD is Patch

testing (especially useful when physical & history
are not sufficiently specific to identify the causative
allergen)
5
 Pathogenesis of Allergic Contact Dermatitis

CLA: Cutaneous
Lymphocyte-associated
Antigen 6
 ACD: Clinical
Stages

Acute: Sub-acute: Chronic:

vesicles/blisters Erosions, scales Thickening &
and crust Lichenification
7
 Patient:

14-year-old Caucasian girl presents with

a chronic itchy skin eruption since age 1.
Her itching is worse when she sweats.
PMH: Seasonal rhinitis
FH: Brother has atopic dermatitis
PE: Erythematous, scaly, dry and
crusted (eczematous) patches and
plaques.
Diagnosis: Atopic Dermatitis (AD)

8
 Atopic Dermatitis (AD)
• A chronic, pruritic inflammatory skin disease of
unknown origin
• Usually starts in early infancy, remits
spontaneously or continue in adults
• Susceptibility to AD is inherited - 80% in
identical twins and 20% in fraternal twins
• Patients often have asthma and allergic
rhinitis/hay fever in addition, termed atopic triad.
• Characterized by pruritus, eczematous lesions,
xerosis (dry skin), and lichenification (thickening
of the skin and an increase in skin markings)
• Chronic and relapsing course.
9
 Pathogenesis of Atopic Dermatitis

• Genetic
– 60% of adults with AD have children with AD
– 80% of children have AD if both parents are
affected
• Immune dysfunction resulting in IgE sensitization
(extrinsic)
• Decreased Barrier Function (intrinsic)
– Mutations of Filaggrin gene

Acute AD is Type I hypersensitivity and chronic is

Type IV
10
 Pathogenesis of AD (continued): Damaged Skin
Barrier Leads to Sensitization

Langerhans cells

Intact epithelial barrier prevents

allergens from reaching antigen
presenting cells (APCs) Damaged epithelial barrier allows
allergens to penetrate, leading to
allergic manifestations 11
Atopic Dermatitis (AD): Clinical
Acute presentation:
Erythematous, scaly, dry
and crusted (eczematous)
patches and plaques.

Chronic presentation:
Prominent xerosis and
Lichenification

12
EVALUATION of patients with ACD & AD :

• History and physical

• Biopsy can confirm dermatitis but findings are

similar in both

• Patch testing should be used when causative

agent unclear

13
 ACD: Pathology

Acute: Spongiosis,
vesiculation,
eosinophils

Chronic: Psoriasiform
epidermal hyperplasia
14
 Atopic Dermatitis: Pathology
(Similar to ACD)

Chronic: Epidermal
Acute: Spongiosis
hyperplasia

15
 A 59-year-old man comes with a 3-
day history of purpuric papules &
Patient: plaques on the bilateral lower
extremities.

ROS: No joint aches, abdominal pain

& hematuria

PMH: Recent sore throat (ASLO+)

treated 2 weeks ago.

PE: Purpuric lesions that do not

blanch under diascopy.

DDx: Erythema multiforme, urticaria,

petechiae, vasculitis
Diagnosis: Vasculitis 16
 Cutaneous Leukocytoclastic Vasculitis (LCV)
• AKA hypersensitivity vasculitis involving small vessels
(primarily post capillary venules)
• Unknown etiology in 50% of cases;
• Due to immune complex formation by circulating antigens
such as medications, infections, autoimmunity and
neoplasms
• Typically presents 7-10 days after exposure to inciting antigen
• Palpable purpura, urticarial lesions, hemorrhagic macules or
vesicles
• Lesions mostly in lower extremities, dependent areas or
pressure points
• Extracutaneous symptoms like GI, Renal, Joint or Neuro
symptoms should raise suspicion of systemic vasculitis as in
SLE, PAN.
17
 Pathogenesis of LCV

Circulating immune complexes locally deposited; complexes

activate complement (C5a) that attract neutrophils.
PMNs & monocytes adhere to blood vessels, degranulate 
release lysosomal protease enzymes & toxic oxygen
metabolites  tissue damage / vascular injury.

Represents type III hypersensitivity reaction 18

 Pathology: Leukocytoclastic vasculitis

• Presence of vascular and perivascular infiltration of

polymorphonuclear leukocytes (green arrow) with formation
of nuclear debris (leukocytoclasis)
• Extravasation of erythrocytes (blue arrow), and fibrinoid
necrosis of the vessel walls
• Magnified view of nuclear debris shown on the left image.
19
 Patient:
A 60-year-old man comes to the
emergency department with a 3-hour
history of generalized, annular and
edematous plaques, as well as mild
abdominal pain. He also has peri-
orbital swelling and mild swelling of his
tongue.

PMH: Type 2 DM for which he takes

Metformin; No known allergies.
DDx: Urticaria, vasculitis,
erythema migrans, erythema
multiforme, granuloma annulare.

Diagnosis: Urticaria (Hives)

20
 Urticaria: Features
• Characterized by blanching, raised, palpable
wheals surrounded by flare (red halo)
• Lesions are transient & migratory, last <12-24h
• Dermographism common (urticarial lesions
resulting from light scratching)
• Associated with pruritus or stinging
• Systemic associations: palpitations, nausea,
malaise, dizziness, syncope, wheezing, vomiting,
diarrhea, fever, chills, abdominal pain, arthralgia,
myalgia, headache
• Women more than men
• Types: Acute (recur up to 6 weeks) or Chronic
(>6 wk)
21
 Urticaria: Etiology

• Food additives (benzoates, sulphites,

tartrazine), and Drugs (ACE inhibitors,
antibiotics, Opiates, ASA, NSAIDs,
radiocontrast materials)
• Physical factors: Heat, cold, light
• Systemic diseases (next slide)
• Infections: Viral (upper resp & hepatitis),
helminths
• Mast cell disorders
• Idiopathic

22
 Systemic Diseases associated with Urticaria

• Collagen Vascular:
• SLE, RA, Sjögren’s, vasculitis
• Malignancies:
• Ca colon, lung, rectum
• Lymphoma
• Endocrine:
• Hyperthyroidism, pregnancy, menopause

23
Urticaria: Clinical Features

Wheals: Classic central

pallor & erythematous flare.
Angioedema: Swelling is
deeper than wheals and may
affect mucosal surfaces.
Note swelling of the lips &
periorbital region .

Dermographism 24
 Pathogenesis of Urticaria
Type 1 hypersensitivity reaction (IgE mediated)

IgE-independent
urticaria also can
result from exposure
to substances that
Histamine, directly cause mast
Bradykinin, cell degranulation
Leukotriene, (Eg., Opiates and
Prostaglandin
NSAIDs)

25
Patient:
A 20-year-old man comes with a 2-day history of targetoid
plaques on his palms. There are similar lesions also on the
forearms, neck, and trunk; lesions are non-blanching.
Conjunctivae are moderately injected; oropharynx is normal.
There is a crusted erosion on the glans penis.

He feels generally well but also notes that he experienced

an episode of recurrent genital herpes one week ago.

PMH: Recurrent HSV infection

DDx: Urticaria, drug-eruption,

vasculitis, tinea corporis, erythema
multiforme.

Diagnosis: Erythema Multiforme (EM) 26

 Erythema Multiforme (EM)

• Acute, self-limited, skin & mucosal directed

immune reaction
• Often precipitated by an infection (HSV,
mycoplasma pneumoniae)
• Characterized by epithelial injury mediated by
skin-homing CD8+ cytotoxic T lymphocytes.
Cytotoxic T cell attack is focused on the basal
cells of cutaneous and mucosal epithelia,
presumably due to recognition of still unknown
antigens
• The “target” or “iris” lesion is fairly distinctive
therefore usually a clinical diagnosis. May see
bullous lesions as well.
27
 Factors Precipitating EM
Infection Viral HSV-1, HSV-2, VZV, Adenovirus,
(90%) EBV, CMV, Hepatitis virus,
Coxsackie virus & HIV
Bacterial Mycoplasma pneumoniae,
Chlamydia psittaci, Salmonella,
Mycobacterium tuberculosis
Fungal Histoplasma capsulatum,
Dermatophytes
Drugs (<10%) NSAIDs, Sulfonamides, Anti-
epileptics, Antibiotics
Systemic disease Inflammatory bowel disease,
(rare) lupus erythematosus, Behcet’s
disease
28
 Clinical spectrum of EM

• Mild case are referred to as EM minor

(skin + 1 mucosal surface)
• Severe cases as EM major or Stevens-
Johnson Syndrome (skin + more than 1
mucosal surfaces)
• The most extensive and aggressive form
of SJS is called Toxic Epidermal
Necrolysis (TEN)
• Clinical, prognostic and etiologic evidence
highlight the distinction of EM from the
SJS and TEN ‘spectrum’
29
Clinical Features Of SJS/TEN

20-30% mortality

In addition to skin,
multiple mucous
membranes such as
gastrointestinal,
respiratory, ocular
and genitourinary
are involved.

TEN: Severe
mucocutaneous
exfoliation
30
 Clinical Features & Course of EM

• Abrupt, most lesions present within 24 hours

• Pruritus or burning may accompany the lesions
• Each lesion present >7 days, episode ~2 weeks
• No sequelae expected, except ocular sequelae
in EM major without adequate eye care
• Recurrence is common in HSV-related EM

31
 Differences Between Urticaria and EM

Urticaria EM

Central zone is normal skin Central damaged skin

(or white/yellow) (dusky, bullous, crusted)
Lesions are transient Lesions are fixed (usually >7
(usually <24 hours) days)
New lesions daily All lesions appear within 72
hours
Associated with No edema
swelling/angioedema

32
 EM: Pathology

Keratinocyte necrosis, spongiosis, superficial dermal

edema and perivascular mononuclear infiltrate.

33
Autoimmune Bullous Skin lesions

• Bullous Pemphigoid
• Pemphigus Vulgaris
• Pemphigus Foliaceus

34
Patient:
• A 63-year-old man comes with multiple blisters on
his trunk and extremities. He feels well except for
local pruritus. He is otherwise healthy and takes
no routine medications. He has no occupational or
recreation exposures.
• Physical exam: patient appears non-toxic, non-
distressed & afebrile. There are scattered 1-3 cm
intact bullae admixed with erosions on the trunk
and extremities. There are no oral or genital
lesions.
• DDx: Pemphigus, pemphigoid, EM/SJS, ACD,
HSV/VZV, bullous impetigo, bullous drug eruption.
• Diagnosis: Bullous Pemphigoid 35
 Bullous Pemphigoid (BP): Features
▪ Autoimmune subepidermal blistering disease of elderly

▪ Associated with circulating auto-antibodies directed against

hemidesmosomal antigens (BPAg1 and BPAg2)

 Type 2 hypersensitivity reaction

▪ Intensely pruritic eruption with widespread tense bullae

formation; No mucosal involvement; in early stages urticarial
lesions are present

▪ May be drug-induced: Furosemide, penicillamine, abx (e.g.

amoxicillin, ciprofloxacin), potassium iodide, gold, captopril

▪ Chronic disease lasts for 3-6 years with spontaneous

exacerbations & remissions 36
 Pathology: BP

H&E: subepidermal bullae with eosinophils

37
 Pemphigus: Features
▪ A group of auto-immune blistering disease of the
skin & mucous membranes
▪ Lesions are intraepidermal due to loss of cell-cell
adhesion of keratinocytes (Flaccid bullae)
▪ Auto-antibodies directed against desmosomal
antigens (Dsg-1 & Dsg-3) on the keratinocytes
 Type 2 hypersensitivity reaction
 Types: Pemphigus vulgaris (PV) and Pemphigus
foliaceus (PF)
▪ Drug-induced (penicillamine & captopril) and
paraneoplastic variants exist (most commonly
non-Hodgkin lymphoma & CLL)
 Rare association with myasthenia gravis 38
Patient with Pemphigous Vulgaris (PV) : Flaccid-
bullae & mucocutaneous erosions

Oral involvement in >90%

39
 PF
PV
Location of 
bullae: 
Pemphigus 
Stratum
Stratum Vulgaris vs  Corneum
Corneum Dsg1
Foliaceus
Granular
Granular
Layer
Layer
Spinous
Spinous
Layer
Layer
Dsg3
Basal
Basal
Layer
Layer
Basement
Basement
Membrane
Membrane 40
 Pemphigus Foliaceus vs Vulgaris
P Foliaceus P Vulgaris

Antigen Desmoglein 1 Desmoglein 3

Blister Location Subcorneal Suprabasilar

in Epidermis
Nature of skin Bullae are 50% present
lesions difficult to find as
they transform
into erosions
Mucosal (oral) No >90%
lesions
Prognosis Survive Die without
treatment 41
 Pemphigus Lab diagnosis: Histology and
Immunofluorescence microscopy

Direct Immunofluorescence:
Intercellular IgG & C3 in
epidermis

Histo: Intra-epidermal blister

with acantholysis 42
Clicker Question

43
A 32-year-old man was hiking in New York State
and 3 days later broke out in an itchy blistering
eruption. Physical examination reveals linear
papules and vesicles on his arms, hands and legs
and to a lesser extent on his trunk. Which of the
following is most likely?
A. He has an irritant contact dermatitis 0%
B. He likely has an allergic contact 0%
dermatitis to ragweed
C. He likely has a type IV reaction to 0%
poison ivy.
D. He likely has developed pemphigus 0%
E. The eruption is expected to clear in 5-7 0%
days.
44
 Pathophysiology Lecture 43
Topic: Chronic inflammatory &
Neoplasms of skin

Dr. S. Upadhya

1
 Learning Objectives

Distinguish the dermatological disorders listed in the

next slide with reference to:
• Risk factors
• Etiology and pathogenic mechanism
• Altered morphology
• Signs and symptoms and basis for the signs and
symptoms
• Prognosis, complications, mortality/survival
• Investigations and their interpretation.

2
2
List of Dermatological conditions to be covered in
this lecture:

• Psoriasis
• Rosacea
• Actinic keratosis
• Squamous cell carcinoma
• Basal cell carcinoma
• Melanoma

3
PSORIASIS

4
 Patient:
A 52-year-old man presents with a
2-year history of silvery white, scaly
erythematous plaques on his
buttock, knees & elbows. He also
notes the more recent development
of pitting in his nails.
FH: His father had a similar rash
SH: Increased alcohol use

DDx: Eczema, Psoriasis, Cutaneous T cell lymphoma,

Subcutaneous lupus erythematosus (SCLE), Tinea
corporis.
Diagnosis: Psoriasis.

5
 Psoriasis: Triggering factors
• Medications (interferon, lithium, beta-
blockers, antimalarials, rapid
corticosteroid tapers)
• Trauma (Koebner phenomenon)
• Infections: strep, HIV
• Stress
• Alcohol
• Smoking
• Positive family history (35-90%)

6
 Pathogenesis of Psoriasis
• T cell-mediated inflammatory disease
• Presumed to be autoimmune, although the
antigens are not well described

T cell activation and recruitment in the dermis

and epidermis
↓

Release of cytokines such as IL-17, IL-23 &

TNF-α ↓

Inflammation, keratinocyte hyperplasia,

neovascularization & vasodilatation
↓

Plaque formation 7
Plaque Psoriasis: Clinical Features
• Red, scaly, usually well
demarcated plaques with
silvery scales

Scalp
Ears

Elbows
Umbilicus
Gluteal cleft
Nails
Genitals
Knees

Koebner phenomenon
Psoriasis in a scratch Toenails
 Nail Psoriasis

• In 30-50% of patients
• Often associated with
Pitting
arthritis
• Pits most common
• Onycholysis
• Oil drop changes
• Splinter hemorrhages
• Nail plate thickening and
Oil drop sign & crumbling
distal onycholysis
 Psoriatic Arthritis • In 10-30% of patients
• Onsets 10 years after skin
• Single or multiple inflamed
joints
• Small joints of hands and
feet
• May have flexion
deformities
• Enthesitis (tendons &
Distal interphalangeal ligaments close to joints)
Psoriatic Arthritis • Associated with severe nail
changes.
10
 Psoriasis: Pathology

• Acanthosis
• Hypogranulosis
• Parakeratosis
• Elongated rete
ridges

(collection of neutrophils in stratum corneum)

Auspitz sign: Removal of the scale leaves a bleeding spot

(dilated dermal blood vessels & a perivascular infiltrate of
lymphocytes & neutrophils). 11
 Plaque Psoriasis or Eczematous Lesions?

Atopic eczema Plaque psoriasis

• Are the the edges of the lesions well demarcated?

• When the patches/plaques are scratched, are scales silvery?
• Is there a leading edge?
• Are there cracks in the surface with oozing/weeping?
12
Photo on left: courtesy of Dr. Dimitris Rigopoulos, Greece; photo on right: © Danderm; www.danderm-pdv.is.kkh.dk 12
ROSACEA
 Rosacea
•Persistent erythema of the face lasting for at least 3
months.
•Associated with flushing, papules, pustules, and
telangiectasias on the convex surfaces.
•Secondary characteristics are burning and stinging,
edema, plaques, a dry appearance, ocular
manifestations, and phymatous changes.
•Women:Men=2:1, but Men more prone to
rhinophyma.
•Common in Celtic descents & rare in Africans &
Asians
•Onset usually after 30 & Peak: 4th to 7th decade.
 Rosacea Triggers
•Food:
•Hot food, Spicy food, Tomatoes, Chocolate
•Alcohol
•Hot and cold temperatures
•Wind
•Exercise
•Stress
•Drugs:
•Corticosteroids
•Amiodarone.
 Pathogenesis of Rosacea

Increased
activation of Increased
nitric oxide & recruitment of
TRIGGER lymphocytes &
pro-inflammatory
cytokines* neutrophils

Neutrophil
mediated
INFLAMMATION enzymes†
degrade dermal
structures
16
*Tumor necrosis factor-alpha (TNF-α), Interleukins (IL-1 and IL-6).
†Matrix metalloproteinases (MMPs), reactive oxygen species (ROS), nitric

oxide (NO).
 Pathogenesis of Rosacea: Cathelicidin, LL-
37 expression is increased in rosacea

Normal Rosacea
Cathelicidin precursor Cathelicidin precursor
Normal
SCE-mediated  SCE activity
processing

Cathelicidin, LL-37  Cathelicidin, LL-37

Chemotactic Angiogenic
Bactericidal  pro-inflammatory activities
(chemotactic and angiogenic)

Effective innate immunity Chronic inflammation

SCTE=stratum corneum enzyme (a serine protease)

Bevins CL, et al. Nat Med. 2007;13:904‐906. 17
 Rosacea: Skin changes
•Symmetric over convexities of central face
•Primary features:
•Flushing:
•Usually lasts > 10 minutes
•Sparing of periocular skin
•Often assoc. with burning, stinging
•Persistent Erythema
•Telangiectasia
•Papules, pustules (follicular and
non-follicular)
……..NO COMEDONES
 Rosacea: Skin & Eye

•Secondary features:
•Burning or stinging
•Rhinophyma
•Ocular:
•50% of patients; Later than skin
•Strong correlation with flushing
•Dry, gritty eyes, itching, burning, tearing, blurry vision,
photophobia, blepharitis, conjunctival hyperemia,
conjunctivitis, keratitis, superficial punctate keratopathy,
keratoconjunctivitis sicca, corneal vascularization
ulceration and perforation, iritis, chalazion.
Actinic Keratosis
&
Skin Cancer
 Actinic Keratosis: Clinical Features

• UV light–induced lesion of the skin

• Red to reddish-brown & has fine
sandpaper texture
• Rough, scaly macules, papules, or
plaques of any size
• Common locations (sun exposed):
Face, lower lip, ear, scalp, neck,
extensor forearm, dorsum of hand
& shin.
• AK is a premalignant lesion:
Invasive Squamous cell Ca
develops in ~ 10%
 Actinic Keratosis: Histopathology

Basal cell layer atypia (dysplasia) with epithelial

buds associated with marked hyperkeratosis,
parakeratosis, and dermal solar elastosis.
 Tumor Progression and Cancerization

• Different stages at multiple sites throughout

the sun-exposed skin
• DNA analysis of the cells within actinic
keratoses shows characteristic UV-induced
mutations in key genes, including TP53
 Skin Cancer Basics
 Skin cancer is #1 cancer in the US; 1 in 5
Americans will develop a skin cancer
 >90% of skin cancers are caused by sun exposure

 The most common skin cancers are basal cell

carcinoma & squamous cell carcinoma (SCC)

 Actinic Keratosis is a precursor to SCC

 Melanoma accounts for 5% of all skin cancers but

80% of skin cancers deaths are the result of

malignant melanoma (MM)
 Incidence of MM rising at faster rate than other

cancers (3-8% per year)

 Skin histology and nature of tumor cell in skin
cancers

SCC

BCC
Melanoma
 Skin Cancer: Risks

• UV exposure
• Fair skin that burns
• Red/blonde hair
• Lots of freckles
• Lots of moles
• Family history of skin cancer
• Immunosuppression
 Skin Cancer: Pathogenesis

•UV radiation induces immunosuppression (by altering Ag

presentation & producing immunosuppressive cytokines) 
compromises tumor rejection
•PTCH gene mutation causing disruption of the Hedgehog–
Patched signaling pathway is closely linked to development
of BCC
•P53 gene mutation in both BCC & SCC
• CDKN2A (Cyclin-dependent kinase inhibitor 2A) mutation
plays a significant role in the development of melanoma

AK/SCC = P53 mutations; less frequently CDKN2A

BCC = PTCH & P53 mutation
Melanoma = CDKN2A & BRAF or RAS mutation
Squamous Cell Carcinoma (SCC): Features

• Well defined, red, scaling plaques

• May arise from prior actinic keratoses
• Invasive SCC is nodular, scaly lesion
that may undergo ulceration
• Lymphatic metastasis is related to the
thickness of the lesion and degree of
invasion into the dermis
• SCCs arising at internal sites
(oropharynx, lung, esophagus, anus)
are generally invasive & aggressive.
SCC: Histopathology

Atypical cells at all levels

of the epidermis, with
nuclear crowding and
disorganization
Advanced SCC has
anaplastic cells with foci of
necrosis and dyskeratosis
Basal Cell Carcinoma (BCC):
Features
• Waxy papules with central
depression
• Pearly appearance
• Rolled (raised) border
• Erosion or ulceration mostly central
and pigmented
• May show dilated subepidermal
blood vessels (telangiectasia)
• Some BCC contain melanin
pigment and can have an
appearance similar to melanoma
• Slow growing: 0.5 cm in 1-2 years
• Metastasis is extremely rare.
BCC: Histopathology

Nests of basaloid cells

are seen budding from
the undersurface of the Nodular aggregates of
epidermis basal cells in the dermis
 Melanoma versus Benign Nevus

Benign nevus has one pattern,

one color throughout

ABCDEs differentiate melanomas:

 Asymmetry
 Border irregularity
 Color variations
 Diameter (mole <6 mm in dia usually benign)
 Evolution over time
Four major clinicopathologic subtypes
of cutaneous melanoma are:
• Superficial spreading melanoma
• Nodular melanoma
• Lentigo maligna melanoma
• Acral lentiginous melanoma

Criteria: 
• Anatomic site/s
• Degree of sun damage
• Histologic growth pattern – junctional, 
pagetoid and buckshot scatter
33
Superficial Spreading Melanoma
(SSM)
 Most common type (70%)
 Common in fair-skinned
 4th to 6th decade of life
 Common sites:
 Trunk (Male)

 Legs (Female)
 Brown-black macule with color variation and
irregular border – has all ABCDE features
 Long radial growth phase followed by vertical
growth (a/w palpable nodule)
 1/3 in preexisting nevi
 Type most associated with repeated sunburns
Nodular melanoma:
• Second common type (10-15%)
• Sites: anywhere in both sexes; trunk in males
• Rapidly grows over weeks to months
• Dark brown-to-black papule or dome-shaped
nodule
• May be amelanotic (not pigmented); thus, any
rapidly growing flesh-colored lesion
• Ulcerates or bleeds with minor trauma
• Tends to lack ABCDE features

35
Lentigo maligna melanoma (LMM):
• Elderly population (>65)
• Commonly on the head, neck, and arms (chronically
sun-damaged skin)
• Arise from an in situ precursor lesion called lentigo
maligna (macular pigmentation) that is present for >10-
15 years
• Raised blue-black nodules within the in situ lesion.
• Histologically characterized by a predominantly
junctional confluent proliferation of melanocytes and
extension along adnexal structures.

36
Acral lentiginous melanoma:
• Least common in white persons
• Most common in dark-skinned individuals (African
American, Asian, and Hispanic persons)
• Sites: on the palms, the soles, or beneath the nail
plate (subungual variant)
• Hutchinson sign (pigments spreading to the proximal
or lateral nail folds) is a hallmark of subungual
melanoma (middle image)
• More rapid progression to vertical phase than SSM or
LMM

37
 Melanoma: Histology

Note: Melanoma cells migrate singularly upward towards

the skin surface (pagetoid spread), and form “nests”, which
may also show an expansion that could result in nests
bridging together (circled).
 Melanoma: Prognostic Factors

Factor Comment
Tumor thickness (Breslow’s ≤1 mm: low risk; >1 mm high risk
vertical thickness)
Ulceration Worse
Age Higher age with worse
Anatomic site Head, neck & trunk with poor
prognosis than extremities
Number of lymph nodes Macroscopic (palpable) nodal
involved metastases with poorer prognosis than
microscopic (non-palpable) metastases
Site of distant metastases Visceral metastases with poorer
prognosis than non-visceral (skin,
subcutaneous or lymph node)
Clicker Question
A 67-year-old man comes to the physician because of a
red and scaly skin lesions on his face and ears. The
patient is a fair-skinned, sun-sensitive person and works
in a boatyard. Physical examination shows 4-6 mm sized
reddish-brown papules that have a texture of sandpaper.
Biopsy of the lesion shows epidermal hyperkeratosis and
parakeratosis with atypical keratinocytes in the basal
layer. This patient is at great risk to develop which of the
following?
A. Basal cell carcinoma 20%
B. Melanoma 20%
C. Merkel cell carcinoma 20%
D. Squamous cell carcinoma 20%
E. Cutaneous T cell lymphoma
20%
 DEMENTIA: TYPES AND FEATURES

Definition: Evidence from the history and clinical assessment that indicates significant
cognitive impairment in at least one of the following cognitive domains:
 Learning and memory
 Language
 Executive function
 Complex attention
 Perceptual-motor function
 Social cognition.

Patients with dementia may have difficulty with one or more of the following:
 Retaining new information (e.g., trouble remembering events)
 Handling complex tasks (e.g., balancing a checkbook)
 Reasoning (e.g., unable to cope with unexpected events)
 Spatial ability and orientation (e.g., getting lost in familiar places)
 Language (e.g., word finding)
 Behavior

The major types of dementia:

1. Alzheimer disease (AD) – first most common cause of dementia

2. Dementia with Lewy bodies (DLB) – second most common
3. Frontotemporal dementia (FTD)
4. Vascular (multi-infarct) dementia (VaD)
5. Parkinson disease with dementia (PDD)
6. Others: Dementia with progressive supranuclear palsy (PSP) and Huntington
disease.

Alzheimer dementia (AD):

Memory impairment is the most common initial symptom of AD. Memory for recent
events, served by the hippocampus, entorhinal cortex, and related structures in the
medial temporal lobe, is prominently impaired in early stage. Later, the patient will have
deficit in other cognitive domains such as executive dysfunction (apraxia), visuospatial
impairment and deficit in language (aphasia).
Memory is usually tested by asking patients to learn and recall a series of words or
objects immediately and then at a delay of 5 to 10 minutes. Impaired ability to recall
objects with selective cues (hints) or recognize items as previously studied on a
recognition memory test represents a more severe deficit. Questions about orientation
and recent current events are also useful memory tests.

Dementia with Lewy bodies (DLB):

Dementia in these patients is characterized by early impairments in attention and
executive and visuospatial function, with memory affected later in the course of the
disease. Early symptoms include driving difficulty (e.g., getting lost, misjudging
distances, or failing to see stop signs or other cars) and impaired job performance.

1
In addition to dementia, distinctive clinical features include: visual hallucinations,
parkinsonism, cognitive fluctuations, dysautonomia, sleep disorders, and sensitivity to
antipsychotic agents.
Neuropathology: Lewy bodies are round, eosinophilic, intracytoplasmic inclusions that
are easily observed in the pigmented neurons of the substantia nigra. Lewy bodies are
easy to visualize on microscopic examination using the hematoxylin and eosin stain as
pink inclusions surrounded by white halos. In dementia with Lewy bodies (DLB), cortical
Lewy bodies may be found in the deep cortical layers throughout the brain, especially in
the anterior frontal and temporal lobes, the cingulate gyrus, and the insula, substantia
nigra and locus ceruleus. Alpha-synuclein is a normal synaptic protein that may have a
role in vesicle production. An aggregated and insoluble form of alpha-synuclein is a
major component of Lewy bodies.

Frontotemporal dementia (FTD):

FTD is characterized by prominent changes in social behavior and personality or
aphasia. This dementia is accompanied by degeneration of the frontal, orbital frontal
and/or anterior temporal lobes. FTD is an early-onset dementia, with an average age
of symptom onset in the sixth decade.
Early behavioral changes of include the following:
●Disinhibition or socially inappropriate behaviors such as touching or kissing strangers,
public urination, and flatulence without concern are common. Patients may make
offensive remarks or invade others’ personal space. Patients with FTD may exhibit
utilization behaviors, such as playing with objects in their surroundings or taking others’
personal items.
●Apathy and loss of empathy –Patients may participate less in conversations and grow
passive. Apathy is mistaken frequently for depression, and patients are often referred
for psychiatric treatment early in the disease course.
●Hyperorality – Patients may eat beyond satiety or put excessive amounts of food in
their mouths that cannot be chewed properly. They may attempt to consume inedible
objects.
●Compulsive behaviors – Patients with FTD can develop a rigid personality, rigid food
preferences, and inflexibility to changes in routine.

Vascular (multi-infarct) dementia (VaD):

VaD is a heterogeneous syndrome rather than a distinct disorder, in which the
underlying cause is cerebrovascular disease in some form and its ultimate manifestation
is dementia. There is cognitive dysfunction with motor and sensory neurological
dysfunction. This is associated with risk factors such as age, smoking, hypertension,
hyperlipidemia, diabetes, vasculitis and transient ischemic episodes. Patients with VaD
experience an abrupt onset and stepwise deterioration of neurological signs/symptoms.
Clinical features:
Cortical syndrome: In primarily cortical VaD, cognitive features are specific to the areas
affected as follows:
●Medial frontal: executive dysfunction, abulia, or apathy.
●Left parietal: aphasia, apraxia, or agnosia.

2
●Right parietal: hemineglect (anosognosia, asomatognosia), confusion, agitation,
visuospatial and constructional difficulty.
●Medial temporal: anterograde amnesia.
Cortical branch occlusions are often caused by systemic embolism from the heart or
large arteries and may present with clinical stroke. However, when the superior division
of the middle cerebral artery is not involved, hemiparesis may not be an obvious signal
to its sudden appearance. Onset may appear more insidious as a result, and it is not
uncommon for the patient to improve again before the next event.
Subcortical syndrome: Both lacunar infarctions and chronic ischemia may affect the
deep cerebral nuclei and white matter pathways. These often disrupt frontal lobe and
other cortico-cortico circuits, producing deficits attributable to remote brain areas.
Characteristic features that suggest subcortical involvement include:
●Focal motor signs-UMN type motor deficits with or without facial involvement.
●Gait disturbances such as apraxic gait or Parkinsonian gait.
●History of unsteadiness and frequent, unprovoked falls
●Early urinary frequency, urgency, and other urinary symptoms not explained by
urologic disease
●Pseudobulbar palsy.

Parkinson disease with dementia (PDD):

Patients with PDD have core motor features of Parkinson disease that include
Bradykinesia and akinesia, Rigidity, Resting tremor and Postural instability.
PDD is characterized by executive dysfunction and impaired visuospatial function, with
less prominent memory deficits and relatively preserved language function. Executive
dysfunction is present early in the disease course and is manifested by deficiencies in
set shifting, attention, and planning of movements. Face recognition (visuospatial
function) is also impaired early in the course of PDD. Features such as aphasia and
severe memory loss are absent in these patients (These features are common in
Alzheimer patient).

3
 PATHOPHYSIOLOGY Lecture 44

Topic: COMMON GERIATRIC PROBLEMS

Dr. S. Upadhya
1
 Learning Objectives: Geriatrics

Compare and contrast common geriatric problems

listed in the next slide with reference to:
• Prevalence and risk factors
• Pathogenic mechanism
• Altered morphology, physiology
• Signs and symptoms and basis for signs and
symptoms
• Differential diagnosis
• Nutritional factors involved in the problems
• Prognosis, complications, mortality/survival
• Investigations (screening and confirmatory; list
principles involved and results expected).
2
The common geriatric problems to
be covered include:

• Delirium/Acute confusional state

• Neurocognitive disorder/Dementia
• Falls & Gait disorders
• Immobility
• Weight loss & Malnutrition
• Urinary incontinence
• Pressure (decubitus) Ulcers

3
Three old men are sitting on the porch of a retirement
home.
The first says: "Fellas, I got real problems. I'm 75 years
old. Every morning at seven o'clock I get up and I try to
urinate. All day long I try to urinate. They give me all
kinds of medicine but nothing helps."
The second old man says: "You think you have
problems. I'm 80 years old. Every morning at 8:00 I get
up and try to move my bowels. I try all day long. They
give me all kinds of stuff but nothing helps."
Finally the third old man speaks up: "Fellas, I'm 90
years old. Every morning at 7:00 sharp I urinate. Every
morning at 8:00 I move my bowels. Every morning at
9:00 sharp I wake up."

4
5
SPECIAL CONSIDERATIONS WITH GERIATRIC
PATIENTS

Multiple factors promote or deter “wellness” in

the elderly (physical, cognitive, psychological and
social/supportive factors)
Atypical ways of presentation of the common
illnesses in the elderly
Age-related changes in body systems are
common
There are limitations in various investigative
procedures for the elderly (Eg: Mini mental state
exam)
6
 Atypical presentations in elderly patient
Diagnosis Presenting Symptoms and Signs
Myocardial infarction Altered mental status
Fatigue
Functional decline
Infection Altered mental status
Functional decline
Hypothermia
Depression Cognitive impairment
Failure to thrive
Functional decline
Electrolyte disturbance Altered mental status
Falls
Fatigue
Personality changes
Fecal impaction Altered mental status
Chest pain
7
Urinary incontinence
Organ System Age-Related Decline in Function
Special senses Presbyopia & lens opacification
Decreased hearing (presbycusis)
Cardiovascular Decreased conductivity
Decreased ventricular filling
Increased systolic blood pressure
Impaired baroreceptor function
Respiratory Decreased lung elasticity
Decreased mucus clearance
Decreased arterial Po2
Gastrointestinal ↓ Esophageal & colonic motility
Renal ↓ Glomerular filtration rate
Immune Decreased cell-mediated immunity
↑ Suppressor T cells; ↓Helper T cells;
↓ Memory cells & ↑ autoimmunity
8
 Functional Impairments
About 25% of elderly patients over 65 have either
impairment in IADLs or ADLs
About 50% of elderly patients over 85 have ADLs
Instrumental Activities of Daily Living (IADL):
•Transportation
•Shopping
•Cooking
Ability to have an
•Use of telephone
Independent household
•Managing money
•Managing medications
•House cleaning and laundry
Basic Activities of Daily Living (ADL):
Bathing, Dressing, Eating,
Moving from bed to chair, Toileting. 9
Components of Comprehensive Geriatric
Assessment (CGA)
Functional Get up and go test
assessment
Sensory Vision and hearing tests
assessment
Cognitive Mini-mental state examination
assessment (MMSE)
Psychological Depression and anxiety evaluations
assessment
Medication Pharmacodynamics of medications
assessment
Social & Legal Investigate human support/financial
assessment support/caregiver’s burnout
 Cellular Basis of Aging

•Cellular functions progressively decline with age

•It is the cumulative effect of :
-Intrinsic cellular aging and
-Extrinsic stressors of cellular environment

•Theories of aging:
-Limited cell cycles & shortening of telomeres
(Hayflick limit).
-Cellular wear and tear by free radicals.
-Epigenetic state of the chromosomes and
microRNAs.
-Impaired Autophagy.
11
Geriatric syndromes: Clinical problems of Aging

Source: Clinical Problems of Aging, Harrison's Principles of Internal Medicine, 19e

Common geriatric problems :

Delirium/Acute confusional state

13
 DELIRIUM (ACUTE CONFUSIONAL STATE)
• Def: A transient, usually reversible mental
dysfunction and manifests with a wide range of
neuropsychiatric abnormalities.

• Features include confusion, disruptions in

thinking and behavior, changes in perception,
attention, mood and activity level.

• Etiology: It is the consequence of a medical

condition (E.g., infection, hypoxemia or metabolic
derangement).

• To be differentiated from dementia or depression.

14
 DELIRIUM (ACUTE CONFUSIONAL STATE)
• Mechanism: Reversible impairment of cerebral
oxidative metabolism and multiple
neurotransmitter abnormalities.

• Risk factors for delirium:

Dementia, Male sex, Severe illness, Use of
restraints & Alcoholism.

• Diagnosis is clinical (patient’s history).

• Workup to find the cause:

CBC, Electrolytes, BUN, LFT, Urinalysis, ECG,
Head CT, Lumbar puncture, Chest X-ray. 15
Common geriatric problems :

Dementia (neurocognitive
disorder)

16
 DEMENTIA (NEUROCOGNITIVE DISORDER)
Definition:
Group of neurological disorders that show progressive
impairment in one or more cognitive function of the brain.
Criteria to diagnose:
Evidence from the history and clinical assessment that
indicates cognitive impairment in at least one of the
following cognitive domains:
• Learning and memory
• Language
• Executive function
• Complex attention
• Perceptual-motor function
• Social cognition & Visuospatial
17
 Visuospatial skills

Jigsaw puzzle Flips

Clock-reading Geometric-drawing
18
Major types of dementia:

1. Alzheimer disease (AD) – first most

common dementia
2. Dementia with Lewy bodies (DLB) –
second most common
3. Frontotemporal dementia (FTD)
4. Vascular (multi-infarct) dementia (VaD)
5. Parkinson disease with dementia (PDD)
6. Others: Dementia with progressive
supranuclear palsy (PSP) and Huntington
disease.
19
Causes of Dementia in elderly patients:
• Alzheimer disease - Most common (60-
80%)
• Vascular dementia - Next common and
relatively high in African-origin, hypertensive and
diabetic.

Less common causes:

• Alcoholism
•Thyroid disease
• Subdural hematoma
• Vitamin B12 deficiency
20
Patient:
A 84-year-old retired school teacher is brought to the
neurologist by his son because of a progressive
loss of memory. The patient is not able to recognize
his family members. Recently, he lost his way to home
from park during the routine evening walk. The past
history is not remarkable for any systemic illnesses.
PE: CVS, RS, abdomen, urinary are unremarkable except
for osteoarthritis of his knees. Sensory and motor system
examinations are normal. There is no involuntary
movements or ataxia. Examination of higher functions of
brain indicates apraxia and agnosia. Mini-mental state
examination (MMSE) yields a total score of 17 (normal:27-
30).
MRI of brain shows evidences of hydrocephalus with
ventricular enlargement
21
A score of <24
is significant &
is suggestive of
Dementia or
Delirium.

22
The most likely diagnosis in patient is:

Alzheimer disease (AD)

The diagnosis is done by exclusion of other

conditions
Points favorable to AD are:
-Elderly age
-Loss of memory
-Agnosia, apraxia, visuospacial inability
-Absence of systemic or brain disorders
-No disturbance in consciousness
-Low score in Mini-mental state exam
-MRI showing evidences of cortical atrophy
23
 Pathophysiology of Alzheimer disease (AD)

A neurodegenerative disorder characterized by

cognitive and behavioral impairment.

Biochemical basis of AD:

a) Plaques in the brain interstitium cotaining
beta-amyloid peptides (BAP).
b) Neurofibrillary tangles (NFT) in the neurons
composed of hyperphosphorylated tau proteins.
c) Deficiency of cholinergic neurons originating
from Nucleus Basalis of Meynert (NBM).
d) Oxidative damage selectively within the brain
regions regulating cognitive functions.
24
Beta amyloid peptides (BAP) in brain interstitium

Normal APP Defective APP Beta amyloid clump

•BAP plaques are dense, insoluble deposits which

are fragments of amyloid precursor proteins (APP), a
transmembrane neuronal protein.
•Defective APPs are enzymatically broken down and
clumped together to form BAPs.
•The plaques primarily accumulate in hippocampus
and the association cortices. 25
 Neurofibrillary tangles (NFT) in neurons:

•Microtubule tau proteins get hyperphosphorylated and

aggregate within the neuronal cells as NFT.
•NFTs break down axonal transport in the neurons.

Normal tau proteins

Hyperphosphorylated tau 26
Morphological changes in brain:
Note the presence of neurofibrillary tangles and
beta-amyloid plaques in the Alzheimer's Disease
27
 Pathophysiology of AD (continued)
Genetic basis of Alzheimer:
•Autosomal dominant AD (<5%): Early onset,
among first-degree relative.
•Familial clustering in 15-25% late onset AD.
•Mutation in APP gene on chromosome 21.
•Down syndrome patient develops AD at an early
age of 40.
•Mutation in Presenilin-1 (PS1) gene on
chromosome 14.
•Mutation in Presenilin-2 (PS2) gene on
chromosome 1.
• APOE gene on chromosome 19 is linked to an
increased risk for AD. 28
Areas of brain affected in Alzheimer's disease

(Prefrontal,
Orbitofrontal (Tempero-Parieto-
cortex) (Temporal, Occipital cortex)
cortex, Hippocampus)

29
Clinical Features of Alzheimer’s disease:

Stage 1:
•Memory loss
•Language impairment
•Disorientation for date and time
Stage 2:
•Apraxia – inability to perform motor task despite
intact motor system functioning
•Agnosia – inability to recognize objects
•Poor planning and judgement
•Inability to carry out ADLs
•Restlessness and agitation
Stage 3:
•Emaciation, indifference to food
•Inability to communicate (mutism)
•Bladder and bowel incontinence. 30
 MRI is the most useful means of measuring
disease progression

The most common findings in MRI: cortical atrophy, dilated

ventricles, and accentuated cortical sulci.
Extensive hippocampal atrophy has occurred on the right
side in the above image (see arrow). 31
 Alzheimer’s brain – Macroscopic changes

Note Amyloid plaques and thinned out gyri in Alzheimer's brain

32
 Major macroscopic changes in Alzheimer’s brain

Cortical areas involved in

thinking, planning and
memory shrivels.
Shrinkage is severe in the
hippocampus, an area that
plays a key role in formation
of new memories.
 Brain ventricles enlarge &
sulci deepen which gives an
appearance of hydrocephalus
Hydrocephalus ex vacuo without rise in CSF pressure.
33
Common geriatric problems:

Immobility

34
 IMMOBILITY

Common causes of immobility:

•Weakness due to – Disuse of muscles,
malnutrition, anemia, myopathy
•Stiffness due to – Osteoarthritis, Parkinson’s
disease, Rhe.arthritis
•Pain from bones, joints, bursa, muscles, podiatric
disorders
•Imbalance and Fear of falling due to –
Neurological disorders, postural hypotension or
comorbid illness.
35
Hazards of immobilization in old age:

•Deconditioning of CVS – fluid shift, ↓CO, ↑HR

•Skeletal muscles – loss of strength & velocity
•Pressure sores
•Thrombophlebitis and pulmonary embolism

These changes develop within a few days;

But the recovery takes weeks to months

Measures to minimize consequences:

Shifting position in every 2 hours for bed sore
Upright position for CVS deconditioning
Motion exercises in bed for muscles
36
Optimum nutrition
Common geriatric problems:

Urinary Incontinence

37
 URINARY INCONTINENCE

Causes of geriatric incontinence:

•Transient – problems mostly outside the bladder &
potentially reversible.
• Established – problem mostly around the bladder.

Transient causes Established causes

• Delirium
• Infection
• Atrophic urethritis/vaginitis
• Pharmaceuticals
• Psychological factors
• Excessive urine output
• Restricted mobility
• Stool impaction
 Urge incontinence
(Detrusor overactivity)
 Stress incontinence
(Urethral incompetence)
 Overflow incontinence
(Detrusor underactivity)
 Mixed incontinence
38
Types of Urinary incontinence

39
Urge incontinence: Overactive bladder contracts
involuntarily. A bladder can become overactive because of
infection or irritation of the nerves that normally control the
bladder (neurologic conditions).
Stress incontinence: Due to poor bladder support by the
pelvic muscles or to a weak or damaged sphincter. Urine
leaks when the person strains or stresses the abdomen,
such as coughing, sneezing, laughing, or even walking.

Overflow incontinence: Occurs when bladder weakness or

a blocked urethra prevents normal emptying. An enlarged
prostate can result in such blockage. Bladder weakness in
both men and women can occur with decreased nerve
function.
Mixed incontinence: A combination of both stress and urge
incontinence. 40
Common geriatric problems :

Pressure (decubitus) Ulcers

41
 PRESSURE ULCERS

 Most of pressure ulcers develop during a hospital

stay for an acute illness

 Risk factors for pressure ulcer:

42
COMMON SITES OF PRESSURE SORES

Supine

Prone

Lateral

43
National Pressure Ulcer Advisory Panel (NPUAP)
Stages of Pressure Ulcer
Stage I : Pressure-related changes of intact skin compared to
the adjacent or opposite areas such as: Color (redness in
lightly pigmented skin; red, blue, or purple hues in darkly
pigmented skin); Temperature (increased warmth or coolness);
Consistency (firm or boggy feel); Sensation (pain, itching).
Stage II: Partial-thickness skin loss involving the epidermis
and/or dermis. Ulcer is superficial and manifests as an
abrasion, blister, or shallow crater.

Stage 2 44
Stage 1
 Stages of Pressure Ulcer (continued)
Stage III: Full-thickness skin loss involving damage or necrosis
of subcutaneous tissue, which may extend down to, but not
through, underlying fascia. Ulcer is a deep crater with or
without undermining of adjacent tissue.
Stage IV: Full-thickness skin loss with extensive tissue
destruction and/or necrosis, or damage to muscle, bone, or
supporting structures (such as tendons or the joint capsule).

Stage 3 Stage 4
45
 PRESSURE ULCERS: Evaluation

Evaluation of pressure ulcers should include:

• Person’s risk factors

• Wound stage
• Wound size
• Wound depth
• Presence or absence of exudate & its type
• Evidence of wound healing (granulation
tissue)
• Presence of surrounding infections, sinus
tracking or cellulitis
46
Clicker Time!

47
An 81-year-old man is brought with a 2-year
history of progressive cognitive impairment in the
form of memory loss, personality changes and
errors in judgment. His past and medical history is
unremarkable. MMSE test score is 14. Which of
the following changes in his brain is most likely?
A. Depletion of dopamine neurotransmitter 20%
B. Hyperphosphorylation of neuronal tau 20%
proteins
C. Deposition of amyloid-A in brain 20%
D. Degeneration of caudate nucleus 20%
E. Aggregates of intraneuronal alpha 20%
synuclein
48
A 91-year-old man is brought to the ER with a
history of multiple episodes of fall from the couch.
Patient’s care-giver states that the patient has
been having severe impairment in the basic
activities of daily living for the past 8 months.
Which of the following cerebral hemorrhages is
most likely in this patient? 20% 20% 20% 20% 20%

A. Subarachnoid hemorrhage
B. Intracerebral hemorrhage
C. Epidural bleed
D. Subdural bleed
E. Lacunar hemorrhage
A. B. C. D. E.
49
 1

DLA NOTES ON
EATING DISORDERS
 2

EATING DISORDERS
DSM-5 Onset
Anorexia Nervosa Adolescence or young adulthood
Bulimia Nervosa
Binge-eating Disorder
 3

Eating Disorders
Essential Feature
Anorexia Nervosa Persistent energy intake restriction (leads to low body
weight)
Intense fear of gaining weight or of becoming fat,
or persistent behavior that interferes with weight gain
Disturbance in self-perceived weight or shape
Bulimia Nervosa Recurrent episodes of binge eating
Recurrent inappropriate compensatory behaviors to
prevent weight gain
Self evaluation unduly influenced by body shape &
weight
Binge-eating Disorder Recurrent episodes of binge eating
 4

DISORDERS
Frequency/Duration of symptoms
Anorexia Nervosa Not specific
Bulimia Nervosa At least once a week for 3 months
Binge-eating
Disorder
 5

ANOREXIA NERVOSA

Dieting, fasting,
Restricting type
excessive exercise

Anorexia Nervosa
Self-induced
Binge- vomiting, misuse of
eating/purging type laxatives, diuretics
or enemas
 6

Anorexia Nervosa

Moderate: Severe:
16-16.99 15-15.99

Extreme:
Mild: ≥17
Severity: <15
BMI
(kg/m2)
 7

Anorexia Nervosa: associated features

• Significant & potentially life threatening medical
conditions
• Physiological disturbances: amenorrhea, vital sign
abnormalities, loss of bone mineral density
• Abnormal laboratory findings
• Depressive symptoms & signs: depressed mood, social
withdrawal, irritability, insomnia, diminished interest in sex
• Obsessive-compulsive features related & unrelated to
food
• Preoccupied with thoughts of food, collect recipes or hoard food
 8

Anorexia Nervosa: associated features

• Concerns about eating in public, feelings of
ineffectiveness, a strong desire to control one’s
environment, inflexible thinking, limited social spontaneity,
& overly restrained emotional expression
• Binge-eating/purging type: higher rates of impulsivity,
alcohol & other drug use
• Excessive physical activity
• Misuse medications, by manipulating dosage, in order to
achieve weight loss or avoid weight gain (insulin)
 9

Bulimia Nervosa: associated features

• Normal weight or overweight
• BMI≥18.5 and <30 in adults
• Uncommon among obese
• Between binges:
• Restrict total caloric consumption, select low-calorie (“diet”) foods
• Avoid foods perceived as fattening or likely to trigger a binge
• Menstrual irregularity or amenorrhea often occurs
• Fluid & electrolyte disturbance from purging behaviors
sometimes sufficient to cause serious medical problems
 10

Bulimia Nervosa: associated features

• Rare complications: esophageal tears, gastric rupture,
& cardiac arrhythmias
• Serious cardiac & skeletal myopathies from repeated
use of ipecac
• GI symptoms including rectal prolapse
• Chronic dependence on laxatives to stimulate bowel
movements
 11

Binge-eating Disorder (BED)

• Recurrent episodes of binge eating
• Eating, in a discreet period, an amount of food that is definitely larger
than what most individuals would eat in a similar period under similar
circumstances
• Sense of lack of control over eating during the episode
• Episodes are associated with 3 or more of:
• Eating much rapidly than normal
• Eating until feeling uncomfortably full
• Eating large amounts of food when not feeling physically hungry
• Eating alone because of feeling embarrassed by how much one is eating
• Feeling disgusted with oneself, depressed, or very guilty afterwards
• Marked distress
• At least once a week for 3 months
• No ICBs
 12

Comorbidity
Disorder/symptoms Anorexia Bulimia Binge eating
Nervosa Nervosa disorder
Depressive X X X
Bipolar X X X
Anxiety X X X
OCD X(restricting)
Substance use X (alcohol, others) X (alcohol, X (lesser)
(binge-eating, stimulants)
purging) At least 30%
Personality Borderline (most
frequent)
 13

DISORDERS: Prevalence
Prevalence
Anorexia Nervosa Young females: 0.4% (12-month)
F:M ratio is 10:1
Bulimia Nervosa Young females: 1-1.5% (12-month)
F:M ratio is 10:1
Binge-eating US adults (>18): F is 1.6% and M is 0.8%
Disorder F:M ratio is 2:1
 14

DISORDERS: Course
Course
Anorexia Nervosa Highly variable
Some recover fully after a single episode
Some fluctuating pattern of weight gain followed by
relapse
Others chronic over many years
Crude mortality rate (CMR): approximately 5% per
decade
Death from medical complications or suicide
Bulimia Nervosa Chronic or intermittent with periods of remission
alternating with recurrences of binge eating
CMR: 2% per decade
Cross-over to Anorexia Nervosa or BED
Binge-eating Disorder Higher remission rates than AN or BN, relatively
persistent
Cross-over is uncommon
 15

Genetic & Physiological Risk factors

Genetic & Physiological
Anorexia First-degree relatives; increased risk of
Nervosa bipolar & depressive disorders
Monozygotic>dizygotic
Brain abnormalities on functional MRI
or PET scan
Bulimia Nervosa Familial transmission
Genetic vulnerabilities
Childhood obesity & early pubertal
maturation
Binge-eating Run in families
Disorder
 16

Environmental Risk Factors

Environmental Risk Factors
Anorexia Cultures & settings where thinness is
Nervosa valued
Occupations & avocations that
encourage thinness (modeling, elite
athletics)
Bulimia Nervosa Internalization of a thin body ideal
Childhood sexual or physical abuse
Binge-eating None
Disorder
 17

Other risks
Suicide Risk; Others
Anorexia Elevated suicide risk (12 per 100, 000
Nervosa per year)
Social isolation and/or failure to fulfill
academic or career potential
Bulimia Nervosa Elevated suicide risk; limited social life
Binge-eating Weight gain & obesity
Disorder
 18

CLICKER QUESTION
 19

• A 24-year-old woman comes to see you

because of weekly episodes over the past 3
months of eating large quantities of food
followed by self-induced vomiting.
• She is very concerned about gaining weight
since she is a professional model.
• Her body weight is normal.
 20

What is the likely diagnosis?

A. Anorexia nervosa
B. Binge eating disorder
C. Bulimia nervosa
D. Major depression
E. Obsessive-compulsive disorder
 1

DLA NOTES ON
NEURODEVELOPMENTAL
DISORDERS
 2

Neurodevelopmental Disorders
I. Autism Spectrum Disorder
Rett’s
disorder
Childhood
Asperger’s
disintegrative
disorder
disorder

Autism
Autistic
disorder
Spectrum NOS
Disorder
 3

Autism Spectrum Disorder

A. Persistent deficits in social communication
and social interaction across multiple
contexts
• Social-emotional reciprocity
• Nonverbal communication for social interaction
• Developing, maintaining, & understanding
relationships
 4

Autism Spectrum Disorder

B. Restricted, repetitive patterns of behavior,
interests, or activities (2 of the following):
• Stereotyped or repetitive motor movement, use of
objects or speech
• Insistence on sameness, inflexible adherence to
routines, or ritualized patterns of verbal or nonverbal
behavior
• Highly restricted, fixated interests that are abnormal in
intensity or focus
• Hyper- or hyporeactivity to sensory input or unusual
interest in sensory aspects of the environment
 5

II. Attention Deficit Hyperactivity Disorder

• Symptoms: inattention and hyperactivity-impulsivity
• 6 inattention
• 6 hyperactivity-impulsivity
• 6 months duration
• 5 inattention or hyperactivity-impulsivity symptoms
• in older adolescents & adults (17 and older)
• 2 or more settings – home, school, or work; with friends or
relatives; in other activities
 6

Inattention
1. Forgetful in daily activities
2. Difficulty organizing tasks & activities
3. Loses things necessary for tasks or activities
4. Difficulty sustaining attention in tasks or play activities
5. Fails to give close attention to details or makes careless
mistakes
6. Does not follow through on instructions & fails to finish
schoolwork, chores or duties in the workplace
7. Easily distracted by extraneous stimuli
8. Does not seem to listen when spoken to directly
9. Avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort
 7

Hyperactivity-Impulsivity
1. Fidgets with or taps hands or feet or squirms in seat
2. Leaves seat in situations when remaining seated is expected
3. Runs about or climbs where it is inappropriate (feeling
restless in adolescents or adults)
4. “On the go”as if“driven by a motor”
5. Unable to play or engage in leisure activities quietly
6. Talks excessively
7. Blurts out an answer before a question has been completed
8. Difficulty waiting his or her turn
9. Interrupts or intrudes on others
 8

ADHD: specifiers
• Combined presentation
• Predominantly inattentive presentation
• Predominantly hyperactive-impulsive presentation

• Mild: few symptoms, minor impairments

• Moderate: symptom & impairments are in between
• Severe: many or severe symptoms, marked impairment
• In partial remission
 9

Comorbidity
Disorders ASD ADHD
Depressive disorders X MDD
Bipolar disorders
Anxiety disorders X X
OCD X
Personality disorders X
Substance use disorder X
Neurocognitive disorders
Oppositional defiant /conduct disorder/intermittent explosive X
Impulse-control disorders
Avoidant-restrictive food intake disorder X
Self-injurious, aggressive & disruptive behaviors
Epilepsy, sleep problems, & constipation X
 10

Prevalence
DSM-5 Prevalence
1 Autism Spectrum Disorder Approximately 1%

2 Attention-Deficit/Hyperactivity Children: about 5%

Disorder Adults: about 2.5%
 11

Sex
DSM-5 Male to female ratio
1 Autism Spectrum Disorder Males > females (4x)

2 Attention-Deficit/Hyperactivity Male > female

Disorder 2:1 in children &
1.6:1 in adults
Females: inattentive features
 12

ASD: risk factors

Genetic &
Environmental
physiological
• Heritability: 37- • Advanced
90% based on paternal age
twin concordance • Low birth weight
rates • Fetal exposure to
• Genetic mutation: valproate
15% of cases (not
fully penetrant)
• Polygenic
 13

Autism Spectrum Disorder

• Children with ASD
have too many
neurons early on then
lose neurons as they
age
• UC Davis MIND Institute study
published in Proceedings of the
National Academy of Sciences
(March 20, 2018)

Danger detector; regulate anxiety & social interactions

 14

ADHD: risk factors

Genetic &
Temperamental Environmental
physiological
• Heritability: • Reduced • Very low birth
substantial behavioral weight (<1,500
• Elevated in first- inhibition, effortful grams): 2-3x risk
degree biological control, or • Smoking during
relatives constraint pregnancy
• Elevated rates of • Negative • Reactions to food
minor physical emotionality • Child abuse,
anomalies • Elevated novelty- neglect, multiple
• Subtle motor seeking foster placements
delays & other • Neurotoxin
neurological soft exposure,
signs infections, or
alcohol exposure in
utero
 15

Onset: when recognized

ASD: ADHD

• Severe: <12 • Prior to age

months 12
• Typical: 12-24
months
• Subtle: > 24
months
 16

Course: ASD

Early childhood Adolescence:

& early school
• most improve
years: • small proportion
• marked symptoms deteriorate

Later childhood: Adulthood:

• developmental gains • Small portion live &
in some areas work independently
• Superior language
& intellectual ability
• Compensation
strategies & coping
mechanisms mask
difficulties in public
 17

Course: ADHD
Adolescence
& adulthood:
• Less motoric
Elementary hyperactivity
school: • Restlessness,
Toddler: inattention, poor
• Inattention planning &
• Excessive more prominent impulsivity
motor activity & impairing persists

Preschool: Early
• Hyperactivity adolescence:
• Stable
• Some with
antisocial
behaviors
 18

CLICKER QUESTION
 19

• An 8-year-old boy comes to the clinic for his annual physical, and
his mother expresses concern about his trouble in school.
• For the past year, she has noticed his struggle in completing
schoolwork and staying focused.
• He often fidgets, even when asked to stay seated.
• At school, he blurts out answers before being called on, often
interrupts others, and demonstrates a difficulty in waiting for his
turn when it comes to group activities.
• The patient had a medically uneventful birth and childhood, with
unremarkable deviations from developmental milestones.
 20

Which of
the • A. Autism Spectrum Disorder
• B. Anxiety Disorder
following is • C. Social Anxiety Disorder
• D. Separation Anxiety Disorder
the most • E. Attention Deficit Hyperactivity
likely Disorder

diagnosis?
 1

DLA NOTES ON:

SEXUAL DISORDERS
 2

Sexual Disorders

Sexual
Disorders

I. Sexual II.Gender III. Paraphilic

Dysfunctions Dysphoria Disorders
 3

Sexuality
• A person’s “sexuality” is contributed to
by multiple aspects of his or her self
image and how he or she is viewed by the
outside world
 4

Human Sexuality
Terms Definition
Sexual identity Biological sex (chromosomes, gonads, internal &
external genitalia, hormones, secondary sexual
characteristics)
Gender identity Self-awareness of “maleness” or “femaleness”
Influenced by prenatal & postnatal factors
Gender role Behaviors engaged in that“identify” him or her as “male”
or “female”
“masculine” or “feminine”acts
Sexual orientation Object of one’s sexual drives: homosexual, heterosexual
or bisexual
Sexual behavior Result of sexual impulses & desire
 5

Evaluation
1. General:
• Knowledge of stages of normal sexual response
2. Medical History
3. Sexual History
4. Examination
 6

Four-step model
(Masters and Johnson 1966, 1970)
Stage Men Women
Excitement [arousal] Penile erection Vaginal lubrication
HR & BP ↑ HR & BP ↑
Plateau [maximum Further sexual pleasure
arousal] ↑ muscle tension, HR, and blood flow to the
genitals
Orgasm [muscular ] Ejaculation Muscular contractions
[0.8 second interval]

Resolution Leads to return to baseline

Refractory period Increases with age None

 7

Changes associated with aging

Males

Slower to Decreased
achieve erection levels of
Need more estrogen
direct stimulation Less vaginal
to achieve an lubrication
erection Narrowing of the

Females
vagina
 8

Changes associated with physical &

psychological status
◼Medications
◼Diseases
◼Injuries
◼Psychological conditions

Can affect the sexual response in any of the phases and

lead to different syndromes
 9

Drugs & Medicines

Causing Sexual Dysfunction
Cardiovascular Methydopa: low libido, impotence, anorgasmia
Thiazide diuretics: low libido, impotence, decreased lubrication
Clonidine: impotence, anorgasmia
Propranolol: low libido
Digoxin: gynecomastia, low libido, impotence
Clofibrate: low libido, impotence

Hormones Estrogen: low libido in men

Progesterone: low libido, impotence
Gastrointestinal Cimetidine: low libido, impotence
Methanteline bromide: impotence

Opiates Orgasmic dysfunction

Anticonvulsants Low libido; Impotence; Priapism
Psychotropic Sedatives ; Anxiolytics; Antipsychotics; Antidepressants;
Lithium
 10

Medical & Surgical Conditions

System Condition Dysfunction

Endocrine Hypothyroidism Low libido

Adrenal dysfunction Impotence
Hypogonadism Decreased vaginal lubrication
Diabetes mellitus
Vascular Hypertension Impotence
Atherosclerosis [Ejaculation & libido intact]
Stroke
Venous insufficiency
Sickle cell
Neurologic Spinal cord damage Sexual disorder-early sign
Diabetic neuropathy Low libido (or high libido)
Herniated lumbar disc
Alcoholic neuropathy
Multiple sclerosis
Temporal lobe epilepsy
 11

Medical & Surgical Conditions

Condition Dysfunction
Local genital disease: male Priapism, Low libido
Peyronie’s disease Impotence
Urethritis
Prostatitis
Hydrocoele
Local genital disease: Imperforate hymen Vaginismus
female Vaginitis Dyspareunia
Pelvic inflammatory disease Low libido
Endometriosis Decreased arousal

Systemic debilitating Renal Low libido

disease Pulmonary Impotence
Hepatic Decreased arousal
Malignancies (advanced)
Infections
 12

Medical & Surgical Conditions

Condition Dysfunction
Surgical-postoperative Prostatectomy Impotence
states: male (radical perineal) [No loss of libido]
Abdominal- perineal Ejaculatory impairment
bowel resection

Surgical-postoperative Episiotomy Dyspareunia

states: female Vaginal repair of Vaginismus
prolapse Decreased lubrication
Oophorectomy
Surgical-postoperative Amputation (leg) Mechanical difficulties in
states: both Colostomy sex
Ileostomy Low self-image
Fear of odor
 13

Psychological Causes

Predisposing: Precipitating: Maintaining:

• Lack of • Childbirth • Interpersonal

information or • Infidelity issues
experience • Dysfunction in • Family stress
• Unrealistic the partner • Work stress
expectations • Financial
• Negative family problems
attitudes to sex • Depression
• Sexual trauma: • Performance
rape, incest anxiety
• Gender identity
conflicts
 14

Routine screening questions-avoid why

questions
✓Is there anything you would like to change about
your sex life?
✓Have there been any changes in your sex life?
✓Are you satisfied with your present sex life?
✓Are you sexually active?*
✓With men, women or both?
✓Do you practice safe sex?*
 15

Interview techniques
❑Be sensitive & nonjudgmental
❑Move from general to specific topics
❑Sexual issues integrated into ROS, discussion of new
medication or when chief complaint is gynecological or
urological, or when discussing interpersonal
relationships
❑Covert presentations - headache, insomnia, low back or
generalized pelvic pain that have no apparent medical
basis
❑Vary questions - age, social class/occupation, nature of
continuing relationship with you
❑Fit patient’s needs & your time
❑If a sexual problem is uncovered take a detailed history.
 16

Physical Examination
• Thorough
• Special attention to:
• Endocrine
• Vascular
• Neurological
• Urological
• Gynecological
 17

Laboratory examination
◼Depends on the nature of the problem & index of
suspicion (organic vs. psychological)
◼Screening for unrecognized systemic disease - CBC,
urinalysis, creatinine level, lipid profile, thyroid function
studies & FBS
◼Low libido & ED - testosterone, prolactin, LH & FSH
◼Dryness - estrogen level , vaginal smear
◼Dyspareunia - ESR, cervical culture, PAP smear
◼Erectile function - nocturnal penile tumescence (NPT)
studies, ultrasonography & angiography
 18

Referral to Specialists
• Urology
• Gynecology
• Endocrinology
• Neurology
• Psychiatry
 19

Sexual Disorders

Sexual
Disorders

I. Sexual II.Gender III. Paraphilic

Dysfunctions Dysphoria Disorders
 20

Sexual dysfunctions
(as listed in DSM-5)
Disorders (in alphabetical order)
1 Delayed Ejaculation
2 Erectile Disorder
3 Female Orgasmic Disorder
4 Female Sexual Interest/Arousal Disorder
5 Genito-Pelvic Pain/Penetration Disorder
6 Male Hypoactive Sexual Desire Disorder
7 Premature (Early) Ejaculation
8 S/M-induced Sexual Dysfunction

Sexual dysfunctions: genetic &
physiological risk factors
Disorders
Female Sexual
Interest/Arousal Disorder
Female Orgasmic Disorder
Male Hypoactive Sexual
Desire Disorder
Erectile Disorder
Premature (Early) Ejaculation
Delayed Ejaculation
Genito-Pelvic Pain/Penetration
Disorder
21
Genetic & physiological
Some medical conditions (DM, thyroid dysfunction)
Medical conditions (MS, pelvic nerve damage & spinal cord injury,
vulvovaginal atrophy), medications (SSRIs)
Endocrine disorders (hyperprolactinemia), age, low testosterone
levels
Acquired: age, diabetes & decreased desire(medications (SSRIs),
Antipsychotics, Lithium
Dopamine or serotonin transporter gene polymorphism
Thyroid disease, prostatitis & drug withdrawal
Age-related loss of fast conducting peripheral sensory nerves &
Age-related decreased sex steroid secretion (in >50)
History of vaginal infections
Pain during tampon insertion or inability to insert tampons before any
sexual contact

Sexual dysfunctions: temperamental risk
factors
Disorders
Female Sexual
Interest/Arousal Disorder
Female Orgasmic Disorder
Male Hypoactive Sexual
Desire Disorder
Erectile Disorder
Premature (Early) Ejaculation
Delayed Ejaculation
Genito-Pelvic Pain/Penetration
Disorder
22
Temperamental
Negative cognitions & attitudes about sexuality
Past history of mental disorders
Differences in sexual excitation & inhibition
Psychological factors: anxiety, concerns about pregnancy
Mood & anxiety symptoms
Feelings about himself, perception of partner’s sexual desire toward
him, feelings of being emotionally connected, & contextual variables
may affect sexual desire negatively (& positvely)
Neurotic traits (college students), submissive traits (40 & above)
Alexithymia (deficits in cognitive processing of emotion)
No
No
No
 23

Sexual Disorders

Sexual
Disorders

I. Sexual II.Gender III. Paraphilic

Dysfunctions Dysphoria Disorders
 24

II. Gender Dysphoria

• Marked incongruence between experienced/expressed

gender and assigned gender
• Children: At least 6 out of 8 listed criteria (one must be
criterion 1, namely strong desire to be of the opposite
gender )
• Adolescents & Adults: At least 2 out of 6 criteria
• Duration: at least 6 months
• Distress or impairment
 25

Gender Dysphoria
• Differential:
• Nonconformity to gender roles
• Transvestic disorder
• Body dysmorphic disorder
• Schizophrenia & other psychotic disorders
• Comorbidity:
• Children: anxiety, disruptive & impulse-control, &
depressive disorders, autism spectrum disorder
• Adolescents: anxiety & depressive disorders, autism
spectrum disorder
• Adults: anxiety & depressive disorders
 26

Gender Dysphoria
• Prevalence: natal males 0.0005% to 0.014%, natal females
0.002% to 0.003% (modest underestimates)
• Onset
• Usually between age 2-4 for those without disorder of
sex development
• Starting at birth for those with disorder of sex
development: medical attention
• Sex ratio:
• Natal boys to girls 2:1 to 4.5:1;
• Adolescents close to equal
• Adults favors natal males 1:1 to 6.1:1 (except Japan &
Poland)
 27

Sexual Disorders

Sexual
Disorders

Sexual Gender Paraphilic

Dysfunctions Dysphoria Disorders
 28

Paraphilic Disorders
Diagnostic Criteria
➢Criteria A: qualitative nature of the paraphilia
➢Criteria B: negative consequences of the paraphilia
(distress, impairment, harm to others)
➢Diagnosis of paraphilic disorders if they meet both A & B
 29

Paraphilic Disorders: Criteria A

Disorders Over a period of 6 months, recurrent & intense sexual
arousal from:
… as manifested by fantasies, urges or behaviors
Voyeuristic disorder Observing an unsuspecting person who is naked, in the
process of disrobing, or engaging in sexual activity
Exhibitionistic disorder Exposure of one’s genitals to an unsuspecting person
Frotteuristic disorder Touching or rubbing against a nonconsenting person
Sexual masochism Act of being humiliated, beaten, bound or otherwise made to
disorder suffer
Sexual sadism disorder The physical or psychological suffering of another person
Pedophilic disorder Involving sexual activity with a prepubescent child or
children (<13)
Fetishistic disorder Either the use of nonliving objects or a highly specific focus
on nongenital body part(s)
Transvestic disorder Cross-dressing
 30

Paraphilic Disorders: Criteria B

Disorders Criteria B
Voyeuristic disorder The individual has acted on these sexual urges with a
nonconsenting person, or
Exhibitionistic disorder
The sexual urges or fantasies cause clinically significant
Frotteuristic disorder distress or impairment in social, occupational, or other
important areas of functioning
Sexual masochism The fantasies or sexual urges cause clinically significant
disorder distress or impairment in social, occupational, or other
important areas of functioning
Sexual sadism disorder Same as 1-3 above
Pedophilic disorder The individual has acted on these sexual urges or
the sexual urges or fantasies cause marked distress or
interpersonal difficulty
Fetishistic disorder The fantasies, sexual urges or behaviors cause clinically
significant distress or impairment in social, occupational, or
Transvestic disorder
other important areas of functioning
 31

Paraphilic Disorders
Disorders Onset, course
Voyeuristic disorder Males: adolescence (at least 18); vary with age
Exhibitionistic disorder Males: adolescence, vary with age
Frotteuristic disorder Males: late adolescence or adulthood, vary with
age
Sexual masochism Mean: 19.3 years, vary with age
disorder
Sexual sadism disorder Mean: 19.4 in males; females young adults;
fluctuates
Pedophilic disorder Males: puberty ( diagnosed at minimum of age
16); fluctuate, increase or decrease with age
Fetishistic disorder Prior to adolescence; continuous, fluctuates in
intensity & frequency
Transvestic disorder May begin in childhood, elicits less sexual
excitement as individual grows older
 32

CLICKER QUESTION
 33

• ID: 42-year-old man comes to his primary care provider's office

• CC: difficulties initiating sexual intercourse with his wife.
• HPI:
• Married for 5 years and able to initiate intercourse just fine.
• Past year, financial difficulties due to job loss at a construction
company.
• Frequent arguments over financial matters.
• Past 6 months, noticed difficulties sustaining an erection and lack of
interest in sexual activities.
• Past medical history: insignificant for any previous conditions
• Medications: none
• Review of systems: insignificant.
• Laboratory tests: basic metabolic panel, hemoglobin A1c, and
thyroid function tests indicates no abnormal values.
 34

Which of the following is the most

likely diagnosis?
A. Diabetes mellitus 0%
B. Hypoactive Sexual Desire Disorder 0%
C. Schizoid Personality Disorder 0%
D. Hypothyroidism 0%
E. Major Depressive Disorder 0%
 1

DLA NOTES ON
SOMATIC SYMPTOM RELATED
DISORDERS
 2

SOMATIC SYMPTOM AND RELATED

DISORDERS: DSM5 list
Somatic symptom disorder
Illness anxiety disorder
Conversion disorder (functional neurological symptom disorder)
Psychological factors affecting medical conditions
Factitious disorder
 3

Somatic Symptom Disorder

A. One or more distressing or disruptive somatic
symptoms
B. Excessive thoughts, feelings or behaviors related to the
somatic symptoms or associated health concerns (at
least one)
1 Disproportionate & persistent thoughts about the seriousness of
one’s symptoms
2 Persistently high level of anxiety about health or symptoms
3 Excessive time & energy devoted to these symptoms or health
concerns
C. Although any one somatic symptom may not be
continuously present, the state of being symptomatic is
persistent (typically >6 months)
 4

Somatic Symptom Disorder: specifiers

• With predominant pain

• Persistent : severe symptoms, marked impairment, long

duration (>6 months)
• Mild: 1 from criterion B
• Moderate: 2 or more from criterion B
• Severe: moderate + multiple somatic complaints or one very
severe somatic symptom
 5

Illness Anxiety Disorder

A. Preoccupation with having or acquiring a serious
illness
• Excessive or disproportionate to medical condition or risk for
developing a medical condition
B. Somatic symptoms are not present or are only mild in
intensity
C. High level of anxiety about health; easily alarmed about
personal health status
D. Excessive health-related behaviors (checks body for
signs of illness) or maladaptive avoidance (doctors &
hospitals)
E. Illness preoccupation present for at least 6 months;
specific illness feared may change over time
 6

Illness Anxiety Disorder: specifiers

• Care-seeking type
• Elevated rates of medical utilization
Consult multiple physicians for the same problem & obtain repeatedly
negative test results
Generally dissatisfied with their medical care & find it unhelpful,
Feeling that they are not being taken seriously by physicians
▪ Physicians sometimes are dismissive or respond with frustration or hostility
▪ Result in failure to diagnose a medical condition present

• Care-avoidant type
• Too anxious to seek medical attention
 7

Conversion disorder
A. Altered voluntary motor or sensory
function symptom (1 or more)
B. Clinical evidence of incompatibility
between the symptom & recognized
neurological or medical conditions
C. Rule out: another medical or mental
disorder
D. Distress or impairment or warrants
medical evaluation
 8

Conversion disorder: symptoms

• Motor:
• weakness or paralysis, abnormal movements (tremor or dystonic
movements), gait abnormalities, abnormal limb posturing
• Sensory:
• altered, reduced or absent skin sensation, vision or hearing
• Psychogenic or non-epileptic seizures
• Unresponsiveness resembling syncope or coma
• Reduced or absent speech volume (dysphonia/aphonia),
altered articulation (dysarthria)
• Sensation of lump in the throat (globus)
• Diplopia
 9

Conversion disorder: associated

features
• Onset may be associated with stress or trauma, either
psychological or physical in nature
• Etiological relevance: close temporal relationship
• Dissociative symptoms: depersonalization, derealization,
dissociative amnesia
• La belle indifference: lack of concern about the nature &
implications of the symptom
• Not specific
 10

Psychological Factors Affecting Other Medical

Conditions (PFAOMC)
A. A medical symptom or condition (other than a mental
disorder) is present
B. Psychological or behavioral factors adversely affect
the medical condition
1. Influence the course as shown by a close temporal association
between factors & the development or exacerbation of, or
delayed recovery from, the medical condition
2. Interfere with the treatment (poor adherence)
3. Influence the underlying pathophysiology, precipitating or
exacerbating symptoms or necessitating medical attention
C. Rule outs: another mental disorder (panic disorder,
MDD, PTSD)
 11

Psychological Factors Affecting Other Medical

Conditions (PFAOMC)
• Psychological distress
• Patterns of interpersonal interaction
• Coping styles
• Maladaptive health behaviors (denial, poor
adherence to medical recommendations)
 12

Factitious Disorder
• Falsification of physical or psychological signs or
symptoms, or induction of injury or disease, associated
with identified deception
• Presents as ill, impaired, or injured
• Imposed on self: himself/herself
• Imposed on another (by proxy): another individual (victim)
• Evident even in the absence of obvious external
rewards
• Rule outs: another mental disorder (delusional disorder or
another psychotic disorder)

Somatic Symptom & Related Disorders -
Summary
Disorders
1. Somatic symptom disorder
2. Illness anxiety disorder
3. Conversion disorder (functional
neurological symptom disorder)
4. Psychological factors affecting
medical conditions
5. Factitious disorder
13
Essential feature
Somatic symptoms plus abnormal thoughts,
feelings & behaviors
High level of anxiety about health
Neurological symptoms incompatible with
neurological pathophysiology
Psychological or behavioral factors adversely
affect a medical condition by increasing risk
for suffering, death, or disability
Falsification of illness or injury with deception
but no obvious external rewards
 14

Factitious Disorder: differential diagnosis

• Malingering:
• Intentional reporting of symptoms for personal gain or external
benefits (secondary gain)
• Money, time off work, release from responsibilities
• Medical condition or mental disorder not associated with
intentional symptom falsification
 15

Onset, course
Disorders Onset, course
1. Somatic Children
symptom disorder Most common: recurrent abdominal pain,
headache, fatigue & nausea
Single prominent symptom: more common
Parents’ response important: determine level
of associated distress
Adults
Somatic symptoms & concurrent medical
illness are common
May be underdiagnosed & considered part of
normal aging or “understandable”
Concurrent depressive disorder common in
those with numerous somatic symptoms
 16

Onset, course
Disorders Onset, course
2. Illness anxiety Onset: early & middle adulthood
disorder Increases with age
In older: focus on memory loss
Chronic & relapsing condition
3. Conversion Onset: throughout life
disorder • Non-epileptic attacks: peaks in 3rd
decade
• Motor symptoms: peaks in the 4th
decade
Transient or persistent
Prognosis: better in children than in
adolescents or adults
 17

Onset, course
Disorders Onset, course
4. Psychological Onset: across the lifespan
factors affecting
medical conditions
5. Factitious disorder Onset: early adulthood, often after
hospitalization for a medical condition or a
mental disorder
• Imposed on another: begin after
hospitalization of child or other
dependent
Course: usually intermittent episodes
Recurrent episodes may become lifelong
 18

Environmental risk factors

• Few years of education
Somatic Symptom
• Low socioeconomic status
Disorder
• Recent stressful life events

• Predisposing: childhood abuse or

serious childhood illness
Illness Anxiety
• Precipitating: major life stress or a
Disorder serious but ultimately benign health
threat

• Childhood abuse or neglect

Conversion
Disorder • Stressful life events: often, not
always present
 19

CLICKER QUESTION
 20

Case
• A 27-year-old female attorney presents to her family physician with
complaints of having a “lump in the throat”.
• Physical exam reveals no abnormalities.
• Thyroid functions are normal.
• On follow-up she still has a “lump in the throat” and the cross covering
physician notes in her old chart a history of numerous mysterious
problems over the years.
• She has a history of pain in the legs, abdomen, chest, and buttocks,
none of which have been found to have a demonstrable etiology.
• She also has a history of nausea and bloating without a detectable
cause.
• Lastly, she has a history of sexual indifference.
 21

What is her likely diagnosis?

A. Conversion disorder
B. Somatic symptom disorder
C. Body dysmorphic disorder
D. Illness anxiety disorder
E. Malingering
 1

DLA NOTES ON:

SUBSTANCE-RELATED
DISORDERS
 2

Substance-Related Disorders
1. Alcohol
2. Caffeine
3. Cannabis
4. Hallucinogens (PCP, others-ecstasy, MDMA)
5. Inhalants
6. Opioids
7. Sedatives, hypnotics & anxiolytics (S/H/A)
8. Stimulants (amphetamines, cocaine, others)
9. Tobacco
10. Gambling Disorder
 3

Substance-related disorders
DSM-5
Substance Use Disorder

Substance/Medication-Induced Disorders
• Intoxication
• Withdrawal
• Other
 4

Substance use disorders-12 month period

2 of 11 manifestations
Impaired control (4)

• Larger amounts or longer period than intended

• Persistent desire or unsuccessful efforts to cut down or control use
• Great deal of time spent in activities necessary to obtain, use or
recover from its effects
• Craving, or a strong desire or urge to use*

Social impairment

Risky use

Pharmacological
 5

Substance use disorders

Impaired control

Social impairment (3)

• Failure to fulfill major role obligations at work, school or home

• Persistent or recurrent social or interpersonal problems
• Social, occupational, or recreational activities given up or
reduced

Risky use

Pharmacological
 6

Substance use disorders

Impaired control

Social impairment

Risky use (2)

• Use in physically hazardous situations

• Persistent or recurrent physical or psychological problem
likely caused or exacerbated by the substance

Pharmacological
 7

Substance use disorders

Impaired control

Social impairment

Risky use

Pharmacological (2)

• Tolerance: increased amounts to achieve intoxication or

desired effect or markedly diminished effect with same amount
• Withdrawal: characteristic syndrome or substance taken to
relieve or avoid withdrawal symptoms
 8

DSM-5 Disorders
Use disorder
Alcohol X
Caffeine No
Cannabis X
Hallucinogens X
Inhalants X
Opioids X

Sedatives/Hypnotics/Anxiolytics X
(S/H/A)
Stimulants X
Tobacco X
Other (or unknown X
 9

Intoxication
A. Recent ingestion of, consumption of or exposure to a
substance
B. Clinically significant problematic behavioral or
psychological changes related to A
C. Specific signs or symptoms per substance
D. Rule out another medical condition, another mental
disorder, including intoxication with another substance
 10

Intoxication
Intoxication
Alcohol X
Caffeine X
Cannabis X
Hallucinogens X
Inhalants X
Opioids X
S/H/A X
Stimulants X
Tobacco No
 11

Mechanisms
Drug Mechanisms
Alcohol & Facilitation of GABA binding to its receptors
Sedatives, hypnotics,
anxiolytics
Caffeine Nonselective adenosine receptor antagonist &
phosphodiesterase inhibitor
Cannabis Cannabinoid receptors
Hallucinogens
• Phencyclidine NMDA antagonist
• LSD Serotonin receptor agonism
• Ecstasy/MDMA Catecholamine & serotonin release
Inhalants Cell membrane disruption
Opioids Opioid receptor agonism
Stimulants Catecholamines (E, NE, DA) release and/or blockage of their
reuptake
 12

Intoxication
Drug Manifestations
Alcohol & Respiratory depression, slurring of speech, lateral nystagmus,
Sedatives, hypnotics, sedation, disinhibition, nausea/vomiting
anxiolytics
Caffeine CNS overstimulation
Cannabis Delirium uncommonly, (not associated with coma or death,
sedation, confusion), psychotic like symptoms in adolescents
Hallucinogens:
• Phencyclidine Agitation, fever, muscle rigidity
• LSD Agitation, delirium
• Ecstasy/MDMA Same as stimulants plus dehydration
Inhalants Cardiac arrhythmias, encephalopathy
Opioids Respiratory depression/apnea, sedation/coma, miosis,
hypotension, constipation,
Stimulants Agitation
Cardiac arrhythmias, hypertension, mydriasis, vasospasm
 13

Withdrawal
• Cessation of or reduction in heavy or prolonged use (or
daily use)
• After antagonist administration for opioids
• Symptoms and signs develop after
• Distress/impairment
• Rule out another medical condition, another mental
disorder including intoxication or withdrawal from another
substance
 14

Alcohol Withdrawal
Syndromes Onset, peak & duration Symptoms & signs

Uncomplicated Begins in 12-18 hours Anxiety, tremors, nausea,

(“Shakes”) Peaks at 24-48 hours vomiting, increased HR & BP
Subsides in 5-7 days
Seizures Occurs in 7-38 hours Single burst of 1-6 generalized
Peaks at 24-48 hours seizures
Status epilepticus is rare
Hallucinosis Begins in 48 hours Vivid & unpleasant auditory, visual
Lasts about 1 week or tactile hallucinations
Chronic in some Clear sensorium
Delirium Begins in 2-3 days Confusion, disorientation,
Peaks 4-5 days later perceptual & sleep cycle
Lasts 3 days typically disturbances, agitation, mild fever,
Can persist for weeks autonomic hyperarousal
 15

Withdrawal
Drug Manifestations
Alcohol & Alcohol withdrawal delirium, seizures, hypertension,
Sedatives, hypnotics, tachycardia, diaphoresis, tremors
anxiolytics (Higher risk with chronic heavy use & sudden cessation)
Caffeine “Crash”
Cannabis Irritability, insomnia, distractability, inattention, anxiety
Hallucinogens:
• Phencyclidine -------
• LSD -------
• Ecstasy/MDMA Uncommon, similar to stimulants
Inhalants Anhedonia, irritability, lethargy
Opioids Autonomic hyperactivity, mydriasis, pain, diarrhea,
(Higher risk with chronic heavy use & sudden cessation)
Stimulants Depression, sedation, lethargy
 16

Substance/Medication-Induced Mental
Disorders
• Clinically significant symptomatic presentation of a
relevant mental disorder
• Evidence from history, PE, or lab findings of
• Disorder during or within 1 month of intoxication or
withdrawal or taking medication
• Substance capable of producing mental disorder
• Not independent mental disorder
• Rule out delirium
• Distress/impairment
 17

Substance/Medication-Induced Mental
Disorders (DSM-5)
• Psychotic disorders
• Bipolar & related disorders
• Depressive disorders
• Anxiety disorders
• Obsessive-compulsive & related disorders
• Sleep disorders
• Sexual dysfunctions
• Delirium
• Neurocognitive disorders
 18

S/M-Induced Disorders
Psychotic Bipolar Depressive
Alcohol I/W I/W I/W
Caffeine No No No
Cannabis I No No
Hallucinogens I I I
Inhalants I No I
Opioids No No I/W
S/H/A I/W I/W I/W
Stimulants I I/W I/W
Tobacco No No No
Other (or I/W I/W I/W
unknown
 19

S/M-Induced Disorders
Anxiety O-C & Sleep Sexual
related dysfunctions
Alcohol I/W No I/W I/W
Caffeine I No I/W No
Cannabis I No I/W No
Hallucinogens I No No No
Inhalants I No No No
Opioids W No I/W I/W
S/H/A W No I/W I/W
Stimulants I/W I/W I/W I/W
Tobacco No No W No
Other (or I/W I/W I/W I/W
unknown
 20

S/M-Induced Disorders
Delirium Neurocognitive Other
Alcohol I/W I/W/Persisting
Caffeine No No
Cannabis I No
Hallucinogen I No Persisting perception
disorder (flashbacks)
Inhalants I I/Persisting
Opioids I/W No
S/H/A I/W I/W/Persisting
Stimulants I No
Tobacco No No
Other (or I/W I/W/Persisting
unknown
 21

Monitoring the Future 2017

• https://www.youtube.com/watch?v=yJwd-4xgdgE
 22

Course
Use Disorder Course

Alcohol Variable, remission & relapse

Caffeine N/A
Cannabis Preteens, adolescents & young adults: excessive use with peers,
conduct problems, to using alone or throughout the day
Adults: daily use
Hallucinogens: PCP ?
Hallucinogens: Other Low incidence, low persistence & high rates of recovery
Inhalants Usually remits in early adulthood
Opioids Continues over many years, 20-30% with long-term abstinence
S/H/A Escalating use
Stimulants: amphetamine Episodic or daily use
Binges terminating when supplies are depleted or exhaustion ensues
Stimulants: cocaine Smoking & IV use associated with rapid progression to disorder
Tobacco Daily use, 80% attempt to quit, 60% relapse within 1 week, <5%
abstinent for life
Other (or unknown) ?
 23

Drugs of abuse
◼ Directly activate the reward pathways
(dopamine) involved in the reinforcement of
behaviors and the production of memories
• Produce feelings of pleasure (“high”)
• May lead to neglect of normal activities
• Through different pharmacological mechanisms
 24

Biology of Substance Use Disorder

• Effects on the brain:
• Immediate: increase neurotransmitters that signal
pleasure
• Most important: dopamine (DA)
• Neurons in the ventral tegmental area (VTA)
• Project through medial forebrain bundle
• Release DA towards the nucleus accumbens & frontal cortex
• Other neurotransmitters involved: serotonin & glutamate
• Glutamate: maintenance of addictive behavior

• Long-term: induces changes in neurotransmitter receptors

• Role in development of physical & psychological dependence
• Compulsion to continue using
• Increased dose to repeat positive effect (tolerance)
 25

CLICKER QUESTION
 26

Which of the following signs/symptoms is most

likely in a patient with alcohol withdrawal
(delirium tremens)?

A. Depression
B. Status epilepticus
C. Hypotension
D. Hyperthermia
E. Bradycardia 0% 0% 0% 0% 0%

A. B. C. D. E.
 1

LECTURE 45:
INTRODUCTION,
DEPRESSIVE
& BIPOLAR DISORDERS
Presented by: Dr. A. Rechea

Prepared by:
Richard A. Young, MD
Associate Professor, SGU &
Clinical Assistant Professor, Icahn SOM at Mt Sinai, NY.
 2

The Psychiatric Evaluation Outline

Therapeutic relationship

• Rapport (therapeutic alliance)

• Safety

Comprehensive Evaluation

• History
• Mental Status Examination
• Assessment: diagnosis, differential diagnosis &
Case Formulation
• Treatment Plan
 3

History
Component Information
Identifying Data Name, age, marital status, race, ethnicity, gender, occupation,
referral source, source of information, reliability
Chief Complaint Reason for evaluation, patient or others report
HPI Symptoms, stressors, distress, impairment, recent treatment
Past
Psychiatric Onset, past episodes & treatment, past dangerousness
Medical Medications, illnesses, allergies or reactions to medications,
surgeries
Substance use Substances used, amount, frequency, pattern, route,
consequences. perceived benefits, tolerance, withdrawal,
associated psychiatric symptoms, treatments
Family Medical, psychiatric, substance use, suicide, violence, criminal;
work, genogram, nature of relationships
Social Development, socioeconomic, interpersonal relationships, legal,
beliefs
 4

Examination: Mental Status Examination

(MSE)
• Appearance
• Behavior
Actions
Observation
• Mood
• Affect
Feelings

• Speech

Thoughts
• Thought process
• Thought content
• Perception
Direct
• Cognition
questions
 5

MSE: emotional state

Mood Affect
• Expressed • Observed
• Patient report • Facial expressions
• Sustained • How quickly it
changes
• Moment to moment
• Appropriateness
 6

DSM
• Diagnostic & Statistical Manual of
Mental Disorders
• American Psychiatric Association
• History:
• DSM I: 1952, 132 pages (106
diagnoses)
• DSM II: 1968, 134 pages
• DSM III: 1980, 494 pages
• DSM III-R: 1987
• DSM IV: 1994
• DSM-IV-TR: 2000, 943 + 37 =980
pages (365 diagnoses)
• DSM 5: 2013, 947+44=991 pages
(350 diagnoses)
 7

Mental Disorder
• Syndrome characterized by clinically significant
disturbance in an individual’s
• cognition,
• emotion regulation,
• or behavior
• that reflects a dysfunction in the biological,
psychological, or developmental processes underlying
mental functioning
• usually associated with significant distress or disability
in social, occupational, or other important activities
 8

DEPRESSIVE DISORDERS
 9

Depressed mood
• Depressed
• Sad
• Hopeless
• Discouraged
• Down in the dumps
• May deny
• Inferred from facial expression & demeanor
• May focus on somatic complaints (bodily aches & pains)
• Irritability
 10

Anhedonia
• Loss of interest or pleasure in life
• Not caring anymore
• No enjoyment in previously pleasurable activities
• Social withdrawal or neglect of pleasurable avocations
• Reduced sexual interest or desire
 11

Depressive Disorders
DSM 5
Major Depressive Disorder
Persistent Depressive Disorder (Dysthymia)
Substance/Medication Induced Depressive Disorder
Depressive Disorder due to Another Medical Condition
Premenstrual Dysphoric Disorder
Disruptive Mood Dysregulation Disorder
 12

MDD & Dysthymia

MDD Dysthymia
Core Depressed mood Depressed mood
symptoms Anhedonia (loss of interest
or pleasure)
Severity of 5/9 symptoms (see next 2 or more (plus above)
symptoms slide)
Duration Most of the day, nearly Most of the day, more days
every day for than not for
at least 2 weeks at least 2 years
( 1 year for children &
adolescents)

Common No h/o mania, hypomania

elements Distress or dysfunction
 13

Symptoms of MDD: “SAD-A-FACES”

1. S-sleep disturbance (insomnia/hypersomnia)
2. A- appetite (decrease or increase) & weight (loss or gain)
change
3. D-depressed mood*
4. A-anhedonia ( interest/pleasure in activities)*
5. F-fatigue or loss of energy
6. A-agitation or retardation (psychomotor) [objective]
7. C- concentration or thinking diminished or indecisiveness*
8. E- esteem (worthlessness or guilt)
9. S – suicidality (thoughts of death, suicidal ideation, plan or
attempt)
 14

Persistent Depressive Disorder (Dysthymia)

symptoms
• Depressed mood plus
• 2 or more of:
1. A –appetite change: poor appetite or overeating
2. C -concentration deficit: poor concentration or indecisiveness
3. H - hopelessness
4. E - energy deficit: low energy or fatigue
5. W – worthlessness: low self-esteem
6. S – sleep change: insomnia or hypersomnia
• Never symptom free for less than 2 months & persists for at least 2 years
 15

Onset

MDD Dysthymia

• Any age • Specify:

• Increases with • Early (before 21)
puberty • Late (21 or
• Peak in 20’s older)
• Median: 32 • Childhood,
adolescence or
young adulthood
 16

Female to male ratio: MDD & Dysthymia

PREVALENCE Lifetime Point

WOMEN 10-25% 5-9%

MEN 5-12% 2-3%

F-to-M ratio is 2:1 (Bipolar: 3:2)

 17

Course

Chronic (Dysthymia)
Episodic (MDD)
Increased comorbidities
Single
Double depression
Recurrent
Less likely to resolve
compared to MDD • 2 month interval
between episodes
 18

Comorbidity

Dysthymia (<MDD)
Early onset with increased
MDD
comorbidity
Substance-related disorders
Substance use disorders
Panic Disorder, GAD, phobia, OCD
Anxiety disorders
Personality Disorder: borderline
Personality disorders: cluster B & C
Anorexia Nervosa, Bulimia Nervosa
Medical conditions (diabetes,
morbid obesity, cardiovascular
disease)
 19

Substance/Medication-Induced
Depressive Disorder
Depressed mood or anhedonia Intoxication Withdrawal
Alcohol X X
PCP X
Other hallucinogens X
Inhalants X
Opioids X X
Sedative, hypnotic, or anxiolytic X X
Amphetamine (or other stimulant) X X
Cocaine X X
Medications: steroids, L-dopa, antibiotics, X X
dermatological agents, chemotherapeutic
drugs, immunological agents
 20

Depressive disorder due to another

medical condition
• Neurologic: Stroke, Huntington’s disease, Parkinson’s disease, TBI, MS
• Endocrine & metabolic: Cushing’s disease & hypothyroidism
• Inflammatory
• Infectious
• Cardiac
• Neoplastic

• Anything that can either affect the brain directly or indirectly can lead
to depression
 21

Premenstrual Dysphoric Disorder (PMDD)
• One (or more of): [mood & anxiety symptoms] Marked
• Depressed mood, hopelessness, or self-deprecating thoughts
• Affective lability
• Irritability or anger or interpersonal conflicts
• Anxiety, tension, and/or feelings of being keyed up or on edge
• Plus one (or more of) for a total of 5 with above: [behavioral/physical]
• Decreased interest in usual activities
• Hypersomnia or insomnia
• Change in appetite; overeating; or specific food cravings
• Lethargy, easy fatigability, or marked lack of energy
• Subjective difficulty in concentration
• A sense of being overwhelmed or out of control
• Physical symptoms: breast tenderness or swelling, joint or muscle pains, bloating, or
weight gain
 22

Premenstrual Dysphoric Disorder
• At least 5 symptoms
• Final week before onset of menses
• Improve after onset of menses
• Minimal or absent postmenses
• Majority of menstrual cycles
• Distress or interference with work, school, social activities or relationships
• Confirmed by prospective daily ratings during at least 2
symptomatic cycles
 23

PMDD
• Associated features:
• Risk for suicide
• Prevalence:
• 12-month: 1.8-5.8%
• Onset & Course:
• Onset: after menarche
• Approaching menopause: symptoms worsen (anecdotal)
• After menopause: symptoms cease
• Oral contraceptives: fewer premenstrual complaints
 24

Grief versus Major Depressive Episode
GRIEF MDE
Mood Emptiness & loss Depressed mood or anhedonia

Positive emotions and Pervasive unhappiness & misery

± humor (anhedonia)
Thought content Thoughts and memories of Self-critical or pessimistic
deceased preoccupations
Death & dying Possibly “joining” deceased Ending one’s life /suicidal
(not Suicidal) (worthlessness, undeserving of
life, unable to cope with pain of
depression)
Self esteem Preserved self-esteem Worthlessness & self-loathing
Course Decrease in intensity over Persistent
days to weeks
Occur in waves (pangs )
 25

Genetic & Physiological Risk Factors

MDD Dysthymia

• Familial (first • First-degree

degree relatives): relatives
2-4x> GP
• Higher for early-
onset & recurrent
forms
• Heritability: 40%
 26

Neurobiology:
• Catecholamine or serotonin hypothesis
• Neuroimaging:
• Prefrontal cortex, anterior cingulate cortex, amygdala,
hippocampus
• Subgenual prefrontal cortex (SGPFC)
• Increased blood flow, decreased volume on functional and
structural brain imaging
• Neurophysiology: abnormal sleep EEG
• Decreased delta (slow wave) sleep, decreased REM latency &
increased REM density (more dreams and nightmares)
• Neuroendocrine: HPA dysregulation ?
 27

Temperamental Risk Factors

MDD Dysthymia

• Neuroticism (negative • Poorer long-term

affectivity): outcome with:
• onset in response to • neuroticism
stressful life events (negative affectivity),
Causing: greater
symptom severity,
poorer global
functioning,
presence of anxiety
or conduct disorders
 28

Environmental Risk Factors

MDD Dysthymia

• Adverse childhood • Parental loss or

experiences separation
• Sensitive to
rejection & stress
• Stressful life events
as precipitants
• Inducing a
biological reaction
(cortisol)
 29

Causative Factors in Depression

1. Neurotransmitters (serotonin, norepinephrine)
2. Neurotrophins & other growth factors (BDNF)
3. Inflamation (cytokines)
4. Connectivities (patterns of linkages in the brain
– anatomical and functional)
5. Oxytocin (attachment processes)
6. Stress, trauma
 30

Suicide Risk
• Exist at all times during episodes
• Risk factors:
• Past history of suicide attempt or threats
• Following hospital discharge- for several months
• Being single or living alone
• Male sex
• Prominent hopelessness
• Presence of borderline personality disorder
• Presence of anxiety
 31

CLICKER QUESTION
 32

ID: A 42-year-old woman is brought

to the physician by her husband
CC/HPI: persistent sadness,
apathy, and tearfulness for the past
2 months.
Past History: SLE x 10 years
poorly controlled with corticosteroid
therapy.
PE: 1-cm erythematous lesions
over the upper extremities and
neck and a malar butterfly rash.
MSE: appears depressed; says that
she would be better off dead.
 33

Which of the following is the most appropriate

next step in managing this patient?

A. Ask the patient about her

20 20 20 20 20
suicidal thoughts % % % % %
B. Reassure the patient that she
will get well
C. Recommend psychiatric
hospitalization
D. Begin antidepressant
medication
E. Increase the dose of A. B. C. D. E.
corticosteroid
 34

BIPOLAR & RELATED

DISORDER
 35

What are the core symptoms of mania or

hypomania?

• Elevated, expansive or irritable mood

• Abnormally increased activity or
energy
 36

Bipolar & Related Disorders

DSM-5
Substance/Medication-Induced Bipolar & Related Disorder
Bipolar & Related Disorder Due to Another Medical Condition
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
 37

Differential Diagnosis of mania or

hypomania
• Malingering or Factitious Disorder
• Substance/medication-induced bipolar & related disorder
Secondary • Bipolar & related disorder due to AMC
causes
• MDD
• GAD, panic disorder, PTSD
• Schizophrenia spectrum & other related psychotic disorders
• Substance use disorders
• Personality disorders
Other mental
disorders
 38

Substance/Medication-Induced Bipolar &

Related Disorder
Intoxication Withdrawal
Alcohol X X
PCP X
Other hallucinogens X
Sedative, hypnotic, or anxiolytic X X
Amphetamine (or other stimulant) X X
Cocaine X
Other (dexamethasone) X X
 39

Bipolar & Related Disorder due to AMC

• Best known:
• Cushing’s disease
• Multiple sclerosis (MS)
• Stroke
• Traumatic brain injury (TBI)
 40

Bipolar & Related Disorders

Subtype Manic episode Hypomanic MDE
episode
Bipolar I Yes (At least Yes/No Yes/No
one)
Bipolar II Never Yes (At least one) Yes (At least one)
Cyclothymic No Hypomanic Depressive
disorder symptoms but do symptoms but do not
not meet criteria meet criteria

Determine if the patient has had at least one manic or hypomanic episode
at any point in their lifetime. Single episode is nearly diagnostic of bipolar
disorder (I or II).
 41

Symptoms: “DIGFAST”
1. D- Distractibility - most common, most subjective
2. I – Indiscretions/Impulsivity/Impaired judgment
• excessive involvement in pleasurable activities that have a high
potential for painful consequences
• sexual indiscretions, reckless driving, spending sprees & sudden
traveling
3. G - Grandiosity (can be delusional)
4. F - Flight of ideas or racing thoughts
5. A - Activity increase: social, work, school
6. S – Sleep : decreased need for sleep
7. T – Talkativeness: pressured speech or more talkative than usual

• + Mood: elevated, expansive or irritable

 42

Cyclothymic disorder
• At least 2 years (1 year in children & adolescents)
• Numerous periods with hypomanic symptoms (not full episode)
• Numerous periods with depressive symptoms (not full episode)
• Symptoms present at least half the time
• Not without symptoms for >2 months at a time
• Never met criteria for a major depressive, manic or
hypomanic episode
• Distress or dysfunction
• Specify: with anxious distress
 43

Onset
Bipolar I Bipolar II Cyclothymic
Disorder
Mean: 18 mid-20’s Adolescence or
early adult
Throughout the May be preceded Insidious
life cycle by anxiety,
substance use, or
eating disorders
 44

Course
Bipolar I Bipolar II Cyclothymic
Disorder
• Single manic episode • Begins with a MDE • Persistent
to recurrent mood • Recognized when
episodes in >90% hypomanic episode occurs
• Manic episode before (12% of individuals with
MDE in about 60% MDD)
• More lifetime episodes
• MDEs more enduring &
disabling
• Develop bipolar I disorder: • Develop bipolar I
5-15% or II disorder: 15-
50%
 45

Comorbidities
• Anxiety disorders (predates): 75% in bipolar I & II
• Substance use disorder (>50% in bipolar I, 37% in II)
• Alcohol use disorder: > risk for suicide attempt
• Medical conditions (metabolic syndrome, migraine)
• Eating disorders (binge eating>bulimia or anorexia): bipolar
II
• Sleep disorders (cyclothymic)
• ADHD, any disruptive, impulse-control or conduct disorder (bipolar I,
cyclothymic)
 46

Bipolar Disorder Risk Factors

Biological Dimensional/Prodromal Environmental

• Family history • Subthreshold hypomanic • Substance misuse
• Neurodevelopmental symptoms • Stressful life events/sexual
• Temperament • Anxiety/depression abuse
symptoms • Antidepressants
• Mood lability • Smoking
• Sleep problems • Children with high academic
attainment
 47

Genetic & Physiological Risk Factors

Bipolar I Bipolar II Cyclothymia

• Relatives with • Relatives with • Relatives with

bipolar I & II bipolar II MDD, bipolar I
(average 10x) disorder & II disorder
• Family history: • Also substance-
strongest & related
most disorders
consistent risk
factor
• Share a
genetic origin
with
schizophrenia
 48

Lifetime suicide risk

• Bipolar
• 15X > general population
• Account for 25% of completed suicides
• Bipolar I = 36.3% suicide attempt rate
• Bipolar II =32.4% suicide attempt rate
• Lethality: bipolar II > I
 49

CLICKER QUESTION
 50

A 40-year-old actress revealed publicly that she suffers from bipolar

disorder type 1.
She has been suffering from this disorder for over 10 years.

In her recent interview about her condition, she talks about the
episodes of major depression and how she copes with it.
 51

Which of the following features is unique to bipolar

disorder type I and distinguishes it from bipolar disorder
type II?

A. Agitation 0%
B. Episode of high energy lasting four 0%
consecutive days
C. Loss of activities that were once 0%
enjoyed
D. Loss of libido 0%
E. Mood elevation that impairs work ability 0%
 1

LECTURE 46:
ANXIETY DISORDERS,
OC & RD,
TRAUMA & STRESSOR-RELATED
DISORDERS

Presented by: Dr. A. Rechea

Prepared by:
Richard A. Young, MD
Associate Professor, SGU &
Clinical Assistant Professor, Icahn SOM at Mt Sinai, NY.
 2

ANXIETY DISORDERS
 3

Fear & Anxiety

FEAR ANXIETY
Definition Emotional response to a Anticipation of future
real or perceived threat
imminent threat
Associated Autonomic arousal Muscle tension and
with necessary for fight or vigilance in preparation
flight, thoughts of for future danger and
immediate danger, and cautious or avoidant
escape behaviors behaviors
In both Sometimes the level of fear or anxiety is reduced by
pervasive avoidance behaviors.
 4

Physical: Emotional:
Autonomic arousal Uneasiness or
(palpitations, SOB, edginess to terror or
muscle tension, panic
dizziness, upset
stomach, chest
tightness, sweating,
trembling)

Cognitive: Behavior:
worry, apprehension, Avoidance, escape
obsessions, & and safety-seeking
thoughts about
emotional, bodily or
social threat
 5

Substance/Medication-Induced Anxiety
Disorder
• Intoxication
• caffeine, cocaine, sympathomimetics, theophylline,
corticosteroids, thyroid hormones
• Withdrawal
• alcohol, narcotics, sedative-hypnotics
 6

Anxiety disorder due to another medical

condition
• Potential causes of anxiety:
• Condition (known medical condition)
• Complications
• Treatment
• Clues:
1. Onset after age 35
2. No psychological symptoms in the context of severe physical symptoms
3. No avoidance behavior
4. No significant life events generating or exacerbating symptoms
5. No childhood history of anxiety, phobias or separation anxiety
6. No personal & family history of an anxiety disorder
7. Poor response to antipanic agents
 7

Medical conditions associated with

anxiety
Cerebral
Metabolic Endocrine Neurological
Hypoxia

Cardiovascular Acidosis
(arrhythmias, Hyperadrenalism, Vestibular
angina, CHF, pheochromocytoma dysfunction
anemia)

Hyperthermia

Respiratory (COPD, Hyperthyroidism,

Seizures (TLE)
PE) Electrolyte hyperparathyroidism
abnormalities
(hypercalcemia)
 8

Other Psychiatric Disorders: with anxiety

• Psychotic disorders:
• Persecutory fears may mimic anxiety or phobias
• Depressive disorders:
• >half of all anxious patients experience
significant depression
• Cluster C personality disorders (avoidant,
obsessive-compulsive, dependent)
• Adjustment disorder with anxiety
 9

DSM-5: ANXIETY DISORDERS

• Separation Anxiety
• Selective Mutism
• Specific Phobia: Animal, natural environment,
blood-injection, injury, situational
• Social Anxiety
• Panic Disorder
• Agoraphobia
• Generalized Anxiety Disorder
 10

Separation Anxiety Disorder

• Developmentally inappropriate & excessive fear or anxiety concerning
separation from major attachment figures*
1. Recurrent or excessive distress when anticipating or experiencing
separation from attachment figures
2. Persistent or excessive worry about losing attachment figures
3. Worry about experiencing an untoward event that causes separation
4. Persistent reluctance or fear of being alone without attachment figure
5. Persistent reluctance or refusal to go out for fear of separation
6. Persistent reluctance or refusal to sleep away from home or without
being near attachment figure
7. Complaints of physical symptoms when separation occurs or is
anticipated
8. Repeated nightmares involving theme of separation

• *MAIN DIAGNOSTIC FEATURE

 11

Selective Mutism
• Failure to speak in social situations where speaking is
expected despite speaking in other situation
• Do not initiate speech or reciprocally respond when
spoken to by others
• MAIN DIAGNOSTIC FEATURE
• Not due to lack of knowledge or, comfort with, the
spoken language required in the social situation
• Interferes with educational or occupational achievement
or social communication
 12

Phobias: main diagnostic features

Social Phobia (1+)
• Social situations/
exposure to
scrutiny
Specific Phobia Agoraphobia (2+)
• Public transportation
• Object or • Open spaces
situation • Enclosed spaces
• Line or crowd
• Outside of the home alone

Marked
fear or
anxiety
 13

Phobias: common criteria

Avoided or endured
Object or situation
with intense fear or Out of proportion to
provokes
anxiety the actual threat or
immediate fear or
• (in agoraphobia, require danger
anxiety a companion)

Persistent fear,
Distress or
anxiety or
dysfunction
avoidance
 14

Specific Phobia
• Specifiers:
• Animal (spiders, insects, dogs)
• Natural environment (heights, storms, water)
• Blood-injection-injury (needles, invasive medical
procedures)
• Situational (airplanes, elevators, enclosed spaces)
• Other: choking, vomiting, loud sounds
 15

Social Anxiety Disorder

(Social Phobia)
• Fears negative evaluation (actions or anxiety
symptoms)
• humiliated, embarrassed, rejected, offend others
• Specifier:
• Performance only:
• Public speaking or performance
 16

Agoraphobia
 Fears it will be difficult to escape or get help
with panic-like or other incapacitating or
embarrassing symptoms, & avoids
 Excessive
 17

Panic Disorder
• Recurrent unexpected panic attacks
• Main diagnostic feature
• & followed for at least 1 month by one or both of:
• Concern or worry about additional attacks or their
consequences [anticipatory anxiety}
• Maladaptive change in behavior related to the attacks
[avoidance or companion]
 18

Panic attack : At least 4/13 symptoms

listed below

Psychological Autonomic Cardiopulmonary

• fear of losing control or going • sweating • palpitations or pounding heart
crazy • chills or heat sensations or accelerated heart rate
• fear of dying • chest pain or discomfort,
• derealization or • shortness of breath or
depersonalization smothering

Neurological
• trembling or shaking
• feeling dizzy or unsteady or
light-headed or faint
• paresthesias
GI
• feelings of choking
• nausea or abdominal distress
 19

Panic attack
• Two types:
• Expected: obvious (trigger)
• Unexpected: not obvious
• Nocturnal
• Limited-symptom attacks:
• < 4 physical and/or cognitive symptoms
 20

Generalized Anxiety Disorder

• Anxiety :
• Excessive anxiety & worry regarding a number of events or
activities
• MAIN DIAGNOSTIC FEATURE
• No control: difficult to control the worry
• Duration: Occurs more days than not for at least 6 months
• 3+/6 symptoms:
• Irritability
• Difficulty concentrating
• Restlessness
• Easy fatigability
• Sleep disturbance
• Tension (muscle)
• [Only 1 required in children]
• Distress or dysfunction
 21

Anxiety Disorders: Duration of symptoms

for diagnosis
Disorder Duration
Separation Anxiety 4 weeks in children & adolescents
6 months or more in adults
Selective Mutism At least 1 month
Specific Phobia 6 months or more
Social Anxiety Disorder (Social
Phobia)
Agoraphobia

Panic Disorder Panic attack followed by 1 month or more

of anticipatory anxiety or change in
behavior
GAD 6 months or more
 22

Anxiety Disorders: Course

Disorder Course
Separation Anxiety Exacerbation & remission
Majority: free of symptoms later
May persist through adulthood
Selective Mutism Variable persistence
Specific Phobia Childhood & adolescence: wax & wane
Adulthood: unlikely to remit
Social Anxiety Disorder Remission within 1 year: 30%
(Social Phobia) Remission within a few years: 50%
Persistent: 60%
Agoraphobia Persistent & chronic, complicated
Complete remission: 10%
Panic Disorder Complicated by comorbidities
GAD Chronic, wax & wane
 23

Environmental Risk Factors

• Parental loss &

Childhood separation
• Physical &
events sexual abuse
• Reduced warmth

• Specific
Anxiety Phobia
• Social Phobia
Disorders • Panic Disorder
• GAD
 24

CLICKER QUESTION
 25

An otherwise healthy 27-year-old man is referred to a cardiologist because

of three episodes of severe palpitations, dull chest discomfort, and a choking
sensation.

The episodes occur suddenly and are associated with nausea, faintness,
trembling, sweating, and tingling in the extremities; he feels as if he is dying.

Within a few hours of each episode, physical examination and laboratory

tests show no abnormalities.

He does not abuse drugs or alcohol and has no history of interpersonal

problems.
 26

Which of the following is the most likely

diagnosis?

A. Separation anxiety disorder

B. Generalized anxiety
disorder
C. Social anxiety disorder
D. Panic disorder
0% 0% 0% 0% 0%
E. Agoraphobia
A. B. C. D. E.
 27

OBSESSIVE-COMPULSIVE & RELATED

DISORDERS
 28

OCRD: Essential features

Disorders –DSM 5 Feature

Obsessive-Compulsive Disorders Obsessions & Compulsions

(OCD)
Body Dysmorphic Disorder Perceived defects or flaws in
physical appearance
Substance/Medication-Induced OCD & All of the above features
Related Disorders
OCD & Related Disorders Due to All of the above features
Another Medical Condition
 29

OCD

Obsessions: thought, Compulsions : behaviors

urges, or images or mental acts
• Recurrent & persistent, • Repetitive, performed in
intrusive & unwanted, response to an
& cause marked anxiety obsession or according
& distress to rigid rules
• Attempts to ignore, • Aimed at preventing or
suppress or neutralize reducing anxiety or
with other thought or distress, or prevent
action dreaded event or
situation; not realistic,
clearly excessive
 30

OCRD: Comorbidities
• Common comorbidites
• MDD
• Anxiety Disorders
 31

Obsessive-Compulsive & Related Disorders

Disorders Genetic & Physiological Risk Factors

OCD 2x in first-degree relatives & 10x if OCD
began in childhood or adolescence
Monozygotic (0.57) > dizygotic (0.22)
Orbitofrontal cortex, anterior cingulate
cortex & striatum dysfunction
BDD Elevated in relatives of individuals with
OCD
 32

Obsessive-Compulsive & Related Disorders

Disorders Environmental Risk Factors

OCD Childhood physical & sexual abuse
Other stressful or traumatic events
Infectious agents
Post-infectious autoimmune syndrome
BDD Childhood neglect & abuse
Persistent childhood teasing (60%)
Parents with excessive emphasis on
aesthetic appearance
 33

Trauma & Stressor-Related Disorders:

 34

DISORDERS
DSM-5
1 Posttraumatic Stress Disorder (PTSD)
2 Acute Stress Disorder
3 Adjustment Disorders
 35

PTSD & Acute Stress Disorder:

Onset & Course (after traumatic event)
Acute Stress Disorder PTSD

• Onset: after 3 days • Onset: usually within 3

months
• Delayed: after 6
• Duration: 3 days to 1 months
month • Duration: >1 month
• Course:
• Transient & remit in 1 • Course:
month • Complete recovery in 3
months (50%)
Symptomatic for >1
year & >50 years
 36

PTSD & Acute Stress Disorder

T-R-A-M-A PTSD* Acute Stress
Disorder
Traumatic event (TE) X X
Re-experiencing/intrusion 1 or more 9 or more from 5
categories:
Avoidance 1 or more 1. intrusion
2. avoidance
Negative cognitions & mood 2 or more 3. negative mood
4. dissociation &
Arousal 2 or more 5. arousal
 37

Traumatic event (TE)

PTSD Acute Stress Disorder
Actual or threatened death, serious injury, or sexual violence:

1. Direct experience
2. Witness to trauma
• For <6, especially primary caregivers
• except electronic media, television, movies, or pictures
3. Learned about a close family member or friend (violent or
accidental)
• For <6, parent or caregiving figure
4. Repeated or extreme exposure to aversive details
• First responders, police officers
• Not for <6
 38

Re-experiencing/intrusion symptoms

PTSD (1 or more) Acute Stress Disorder

1. Recurrent, involuntary, & intrusive distressing memories of the TE (s),
In children: repetitive play reenactment
2. Recurrent distressing dreams with content and/or affect related to the
TE (s)
In children: frightening dreams without recognizable content
3. Dissociative reactions (flashbacks): feels or acts as if the TE (s) were
recurring
In children: trauma-specific reenactment
4. Intense or prolonged psychological distress*
5. Marked physiological reactions*
*to internal or external cues that symbolize or resemble an aspect
(reminders) of the TE (s)
 39

Avoidance symptoms

PTSD Acute Stress Disorder

Avoidance of or efforts to avoid
1. Distressing memories, thoughts, or feelings about or
closely associated with the TE (s) {internal}
2. External reminders (people, places, conversations,
activities, objects or situations) that lead to number 1
 40

Negative alterations in cognitions & mood

PTSD Acute Stress Disorder

Dissociation
• An altered sense of the reality of
one’s surroundings or oneself
(seeing oneself from another’s
perspective, being in a daze,
time slowing)

• Inability to remember an important aspect of the TE (s)

• Dissociative amnesia
• No head injury, alcohol or drugs
 41

Negative alterations in cognitions & mood

PTSD Acute Stress Disorder

Cognitions
• Persistent and exaggerated negative
beliefs or expectations about
oneself, others or the world
• Persistent, distorted cognitions
about the cause or consequences of
the TE (s) that lead to blame (self or
others)
 42

Negative alterations in cognitions & mood

PTSD Acute Stress Disorder

Mood (Persistent)
No positive emotions (happiness, satisfaction, love)
Negative emotions (fear, horror,
anger, guilt, shame)
Anhedonia
Detachment or estrangement from
others
 43

Marked alterations in arousal & reactivity

PTSD Acute Stress Disorder

1. Concentration problems
2. Hypervigilance
3. Exaggerated startle response
4. Sleep disturbance
5. Irritable behavior and angry outbursts (with little or no
provocation): verbal or physical aggression towards people or
objects
In children: extreme temper tantrums
6. Reckless or self-destructive
behavior (not listed for <6)
 44

Differential Diagnosis
PTSD Acute Stress Disorder
Acute stress disorder PTSD
Adjustment disorders Adjustment disorders
Dissociative disorders Dissociative disorders
Anxiety disorders Panic disorder
OCD OCD
MDD
Psychotic disorder Psychotic disorders
TBI TBI
Personality disorders
Conversion disorder
 45

Environmental Risk Factors

Acute Stress Prior trauma
Disorder Exposure to traumatic event
Pretraumatic Prior trauma (specially during childhood)
(PTSD) Family psychiatric history
Childhood adversity
Lower SES, education & intelligence
Minority racial/ethnic status
Cultural characteristics (fatalistic, self-blaming)
Peritraumatic Severity of the trauma
(PTSD) Perceived life threat
Personal injury
Interpersonal violence
For military: being a perpetrator, witnessing atrocities, or killing the
enemy
Dissociation during the trauma that persists afterwards
Posttraumatic Subsequent exposure to upsetting reminders
(PTSD) Subsequent adverse life events
Financial or other trauma-related losses
Protective factor: social support
 46

Neurotransmitters & hormones

Epinephrine • Prepares the body for fight or flight

• Orienting to new stimuli, selective attention &

Norepinephrine autonomic arousal
(NE) • Locus coeruleus projects throughout the
brain & into the periphery

Serotonin • Regulating stress response

 47

Neurotransmitters & hormones

• Modulates the stress response by containing monoamines (NE
& serotonin) & restoring homeostasis by providing negative
Cortisol feedback
• Mobilizes short-term energy
• May have adverse catabolic effects when chronically elevated

Corticotropin • Increases the turnover of NE (during stress)

releasing factor • NE increases the concentrations of CRF in the locus
coeruleus
(CRF)

Neuropeptide Y &
neurosteroids • Co-released with NE
allopregnanolone • Promote adaptation to stress and confer resilience

& pregnanolone
 48

PTSD Model
Overactive

Amygdala & Anterior

related cingulate cortex
structures • Emotion regulation
(paralimbic Hippocampus
regions)
• “Cool” or

Underactive
• “Hot” or emotional “cognitive” memory
memory system system
 49

Adjustment Disorders
Prevalence Common, vary widely
Outpatient mental health: 5-20%
Consultation-liaison: up to 50%

Onset Within 3 months of onset of a stressor

Acute stressor: immediate onset
Course Once the stressor or its consequences have
terminated, the symptoms do not persist for
> an additional 6 months

Persistent form: persistent stressor or

consequences
 50

Adjustment Disorders
Environmental Risk Factors
Disadvantaged individuals may be at increased
risk due to high rate of stressors
 51

CLICKER QUESTIONS
 52

• A 32 year old divorced woman has a four year history of worrying about
whether she locked the front door of her house when she leaves to work or
shop.
• Soon after she drives down the street, she worries that the front door is still
open, so she returns home to check.
• When she finds the door locked, this reassures her momentarily.
• This occurs five to eight times each morning, often making her late for work.
• To try to overcome this problem, she leaves home early, and has a detailed
system of making notes in her car to confirm that she locked the door.
• She realizes that her checking is absurd, but she cannot stop it.
• Her mental status is normal except for these concerns.
• There is no evidence of a general medical or traditional neurologic condition
that could explain her behaviors.
 53

Which of the following is the most

likely diagnosis in this patient?
A. Generalized Anxiety Disorder 0%
B. Panic disorder 0%
C. Posttraumatic Stress disorder 0%
D. Obsessive compulsive disorder
0%
E. Specific phobia
0%
 54

A 30-year-old man sustains flash burns secondary

to a gas line explosion.

3 months after the explosion, he begins

experiencing recurring thoughts the
accident and disturbing dreams of the explosion.

He finds that he is unable to cook on his gas stove

and startles easily in response to noises.
 55

What is the most likely diagnosis?

A. Posttraumatic Stress disorder 20%

B. Acute stress disorder 20%
C. Specific phobia 20%
D. Adjustment disorder with 20%
anxious mood
E. Panic disorder 20%