Commonly observed side effects of lithium at the start of therapy are hand tremors, excessive urination, and excessive thirst. The CNS effects of the drug include hyper- tonicity, ataxia, extra pyramidal signs, vertigo, nystagmus, incontinence, impaired memory, and coma. It affects the cardiovascular system causing hypotension, bradycardia, and even cardiac arrhythmias. Lithium also affects the endocrine system, causing adverse effects such as hypothyroidism or hyperparathyroidism .
Diabetes insipidus is also associated with lithium use. On the gastrointestinal tract, it interferes with digestion to cause anorexia, gastritis, bloating, and even weight gain.
Dermatological signs can also be seen with lithium use; these can include pruritus, alopecia and other signs.
Stimulants are commonly associated with elevated blood pressure levels, headaches, insomnia, weight loss, and decreased appetite. Amphetamine use can lead to vasoconstriction, blood shot eyes, dilated pupils, restlessness or agitation, dizziness, numbness, aphasia, twitching, acne, pallor, bradycardia, tachycardia, hypotension, and hypertension. It is known to cause erectile dysfunction, aggression, irritability, paranoia, and obsessive behavior. With prolonged use amphetamine psychosis can also occur. At excessively high doses, death may also occur.
The side effects of methylphenidate are generally well tolerated by patients. Like amphetamines, it also carries an abuse potential. When administered intranasally in doses as high as 200 mg, the stimulation is comparable to amphetamines and crack cocaine. IV use has found doses varying from 40 mg to as high as 1000 mg (93). Acute toxicity for both amphetamine and methylphenidate produce similar signs and symptoms.
The FAERS Database
In order to improve the clinical safety of drugs approved by the FDA, it has introduced a database that allows individuals to report adverse events. The database, called FDA Adverse Event Reporting System (FAERS), is basically designed to enhance and support the post marketing safety surveillance of drugs that have already been approved by the FDA. The database is in strict compliance with the rules and regulations stated in the International Conference on Harmonization (ICH).
FAERS is especially useful in identifying new safety concerns that arise after a drug has been released into the market and also to evaluate if the manufacturers are compliant with reporting all due issues. Any concerns that are entered into the database are reviewed and assessed by the review committee so that appropriate actions can be taken to protect the public. Depending on the decision of the committee, the FDA may choose to either restrict use of the drug (e.g. issue conditions on the use of the drug), remove it from the market completely (drug recall) or at times only require the manufacturer to relay new safety or warning information (e.g. black box warning) to the public consumers (94).
Consumers may voluntarily report any encountered adverse effects to the FDA using the Medwatch website. It is mandatory for the manufacturer to report health and safety issues to the FDA voluntarily. Either way, the reports received are added into the FAERS database. The database is publicly accessible to promote consumer awareness; for example, consumers can review the reports that have been received regarding a particular adverse effect or drug.
CLASSIFICATION OF MENTAL HEALTH DISORDERS
Classifying mental health disorders is a universally challenging task. Since the majority of the disorders have overlapping symptoms, it is hard to classify them based on those symptoms alone.
There are currently two main sets of criteria used for classifying mental health disorders worldwide. The World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD) introduced the first criterion. Its latest revision, ICD-10, is an official tool used for diagnosing health conditions, including mental disorders, in the U.S. and in Europe. Its focus and purpose is providing guidelines in the clinical evaluation of morbid conditions. It is not rigid about definitions.
A second criterion is also recognized universally and was proposed by the American Psychiatric Association (APA). Known as the Diagnostic and Statistical Manual of Mental Disorders or simply DSM, it covers all mental disorders for pediatric, adolescents and adults. The DSM was first developed using data from the United States Army manual and psychiatric hospital statistics in 1952. It was revised in 1980 wherein a number of mental disorders were added. The current version in use is the DSM-IV-TR (fourth edition- text revision). A newer revision, the DSM-V, is currently under development and due to be published in May 2013. The DSM-IV includes extensive details of each mental disorder and adheres to their operational definitions. It is widely used, not just in the U.S., in clinical practice and research settings worldwide.
Although reliable and comprehensive, some experts believe that the DSM-IV manual created a very large pool of diagnostic criteria including unnecessary psychopathologies that are associated with normal psychological responses, such as grief and withdrawal after a stressful and traumatic event. The manual has made diagnoses reliable and consistent but its overall validity remains obscure at best (193).
The DSM-IV divides the mental health disorders in to 5 axes or dimensions (95):
Axis I: All diagnostic categories except mental retardation and personality disorder
Axis II: Personality disorders and mental retardation
Other disorders: Tardive dyskinesia and child abuse
Psychotic disorders are those in which a person has difficulty staying in touch with reality. They are serious illnesses affecting the mind and the overall quality of life of patients.
Generally, psychotic patients lose their ability to think rationally, communicate effectively, and understand, respond or behave in an appropriate manner. Moreover, in severe psychosis, patients may develop symptoms like delusions and hallucinations. The good news is that modern treatment approaches to psychotic disorders has improved dramatically in the last few years. Even the most severe form of psychosis can be managed well on a combination of psychopharmacologic and psychiatric therapies. There are different types of psychotic disorders, some of which are described in detail below:
Schizophrenia is the most common type of psychotic disorder. It is a mental condition that is identified by “a breakdown of thought processes and a deficit of typical emotional responses” . In the U.S., the span of time between the first onset of symptoms and its diagnosis is about 2 years.
Patients with schizophrenia, or schizophrenics, experience a variety of symptoms that include paranoid delusions, hallucinations (usually auditory), social dysfunction, confused speech and disordered thought processing. Pediatric and adolescent patients generally perform poorly at schoolwork accompanied by a steep decline in their social functioning (e.g. isolation, loss of friends). For the diagnosis of schizophrenia to be valid, these symptoms should be present for a period of at least 6 months. Also, no single laboratory test is diagnostic of schizophrenia, and its diagnosis is largely based on the patient’s history or behavior as observed by others as well as the patient’s own narrative and reported experiences.
Schizophrenia can be caused by a number of factors. Genetics, environmental triggers, psychological and social processes, and substance abuse are considered to be important contributing factors. The mainstay of treatment for schizophrenia is antipsychotics with the atypical antipsychotics being the preferred class for their minimal adverse effects. Schizophrenics are often required to be on these medications throughout their lifetime since the possibility of symptom relapse is very likely if they are discontinued. Other useful treatment approaches are hospitalization and psychosocial interventions.
Schizoaffective disorder is characterized by abnormal mood changes accompanied by psychosis. Patients usually have a combination of symptoms of schizophrenia and a mood disorder (e.g. depression or bipolar disorder). According to the DSM-IV criteria of diagnosing schizoaffective disorder, it is very important that there is a period of at least 2 weeks of psychosis without an element of mood disorder with symptoms that are not the result of drugs being taken, substance abuse or any concomitant medical illness (95).
The symptoms of schizoaffective disorder are usually first experienced during early adulthood. Significant social and occupational dysfunctions accompanied by incoherent thoughts, hallucinations and delusions are often seen. Cognition and emotions are the most frequently disturbed aspects of the patient’s personality. Specifically, these symptoms are observed as appetite changes, changes in energy levels, lack of hygiene, illogical speech, concentration difficulties, sleeping issues, hallucinations and social isolation.
The identifiable risk factors are similar to those of schizophrenia and its mainstay treatment is the combination of antipsychotic drugs and mood stabilizers or antidepressants, depending on the patient’s individual needs.
Schizophreniform disorder is characterized by symptoms of schizophrenia that are present for majority of the time in a one-month period; however, they are not present for a full six-month period, a required criterion for a valid diagnosis of schizophrenia. The onset of symptoms in individuals with this disorder is quite rapid compared to the gradual occurrence of schizophrenic symptoms. However, the nature of the symptoms is similar in both cases.
Patients with schizophreniform disorder may experience delusions, hallucinations, social withdrawal and speech disturbances, and impaired thought processing but their level of social functioning may not decline significantly. Schizophreniform disorder is also treated with atypical antipsychotics combined with occupational therapy or individual psychotherapy. The prognosis in these cases largely depends on the nature of the disease, its severity, and duration of symptoms. It is quite common for schizophreniform disorder to develop into schizophrenia later in life. In fact, up to two-thirds of individuals diagnosed with schizophreniform disorder develop schizophrenia later on in their lives.
Brief psychotic disorder
Brief psychotic disorders are conditions in which patients experience short-lived episodes of psychosis following a stressful life event. The recovery in such cases is quick and no residual disease usually lingers.
Delusional disorder is a relatively uncommon psychiatric disorder wherein patients experience delusions that could potentially occur in reality (e.g. being poisoned or chased). Patients with delusional disorder do not have prominent hallucinations, thought or mood disorders and may appear to function quite normally. They also have normal social interactions and even their behavior might not be considered bizarre by an observer. In order to make a valid diagnosis, it is important to note that no prominent auditory or visual hallucinations are experienced by the patient; however, tactile and olfactory hallucinations pertaining to the delusion may be a noticeable symptom. Moreover, the DSM criteria stresses the importance of taking into consideration the patient’s cultural, religious and moral beliefs when considering this diagnosis because many cultures have widely accepted beliefs that may be considered delusions in other parts of the world .
It is also worth mentioning that the delusions in this case can be of any type. Patients may experience grandiose delusions in which the patient considers him/herself to be a very important public figure and possessing exceptional worth, power, knowledge, and, wealth. Erotomanic delusions may also be experienced which is characterized by the patient believing himself to be loved by another person, often a celebrity (97). Another type of delusional disorder is called persecutory delusions. It is the most common of its type in which patients believe they are being malevolently treated in some way. Similarly, patients may also experience jealousy delusions and question the loyalty or faithfulness of their partners. This can be a dangerous delusion that the clinician needs to observe closely in terms of the safety of the “disloyal” spouse. There is a legal obligation called the Tarasoff for the clinician to contact and warn the “suspected spouse” to a possible danger (208).
Shared psychotic disorder
Shared psychotic disorder is a rare and complex disorder in which a normal healthy person shares the delusion of a patient who has established delusions such as a patient suffering from schizophrenia. There are no known causative factors that contribute to its development, however; stress and social isolation may play some role. The disorder is often short-lived and can be treated with antipsychotics combined with family therapy and psychotherapy. Additionally, tranquilizers and anxiolytic medications may also be prescribed to treat the intense symptoms of restlessness and insomnia associated with it.
Substance-induced psychotic disorder
Substance-induced psychotic disorder is caused by either excessive use or withdrawal of certain psychoactive substances such as cocaine, amphetamines, caffeine, opioids, sedatives, hallucinogens, and alcohol. Patients may experience symptoms of hallucinations, delusions, and confused speech and thought processing. These symptoms are caused directly by exposure to the toxic substances and not due to an underlying medical condition. According to the DSM-IV-TR, substance-induced disorders include:
Patients recovering from alcohol dependency may experience protracted withdrawal symptoms a few days after the last alcohol intake. Withdrawal symptoms may mimic major depression and anxiety, making diagnosis challenging. One helpful method of differentiating it from the other two is by checking the patient’s history if the same symptoms happened before. Substance delirium caused by alcohol usually occurs after drinking copious amounts. Its symptoms include irregular mental status and disorientation. Sedative toxicity and withdrawal symptoms are similar to alcohol accompanied by physical symptoms such as tinnitus, muscle twitching, and paresthesias. Hallucinogen-induced psychosis is a debatable medical entity. The psychedelic “trips” are considered by DSM-IV as flashbacks, a distorted perception of reality.
The diagnosis of substance-induced psychosis is based on the history, onset, course and other factors. Moreover, physical examination and laboratory tests usually uncover the patient’s drug dependence, abuse, and withdrawal. The diagnoses may sometimes need to be re-evaluated repeatedly to completely rule out other conditions. Treatment includes discontinuation of the offending substance along with rehabilitation and psychiatric support.
Psychotic disorder due to a medical condition
The essential features of this psychiatric illness are hallucinations, delusions and/or other psychiatric symptoms that are caused directly by the underlying medical condition. The patient’s history, physical examination results, and laboratory findings must also corroborate the signs and symptoms. According to the DSM-IV TR criteria, it is also essential to rule out disturbances that are not caused by an accompanying medical disorder and do not exclusively occur during the course of delirium. One example is temporal lobe epilepsy in which patients experience olfactory hallucinations. Other neurological conditions that may cause psychotic symptoms include brain tumors, cerebrovascular diseases, Huntington’s disease, multiple sclerosis, migraines, CNS infections, and systemic lupus erythematosus with CNS involvement. Additionally, electrolyte imbalance, severely impaired blood glucose levels, and decreased blood gases such as carbon and oxygen may also cause psychotic symptoms. Although it is important to treat the underlying condition, this may not always result in remission of the psychotic symptoms. In most cases, the symptoms may persist for a very long time even after the underlying disease has been treated or brought under control.
Paraphrenia is a psychiatric condition that occurs most frequently in the elderly population. The DSM-IV and ICD 10 do not consider paraphrenia to be a separate entity from schizoaffective disorders, delusional disorders and psychosis. The characteristic feature of this condition is a preoccupation with one or more semi-systematized delusions. Patients often experience distress and agitation with no intellectual deterioration and apparent social dysfunction (98).
A personality disorder is a psychiatric condition in which the patient has perception difficulties and exhibit deviant behavior from the norms expected of the surrounding culture and social environment. Patients with this condition often have staunch beliefs and an unhealthy way of thinking and behaving regardless of the circumstances. If left untreated, it can very well lead to significant problems related to work, social interactions and school performances. Patients with a personality disorder experience a number of symptoms including frequent mood swings, unhealthy relationships, isolated behaviors, anger management issues and, distrust in others.
Personality disorders are broadly grouped into three main categories, depending on the degree of similarity between the symptoms. Each category is discussed below.
Cluster A personality disorders
This is a group of personality disorders characterized by odd, eccentric thinking and behavior which include paranoid personality disorder, schizoid personality disorder and schizotypal personality disorder, all of which are discussed in detail below (99).
Patients with paranoid personality disorder have difficulty trusting others, are suspicious of the people around them, and under the impression that they are trying to harm them. They exhibit hostility towards others and are most likely emotionally detached. They tend to hold grudges and are unforgiving. However, they are often extremely sensitive and may not be able to take any form of criticism. These patients often find themselves to be under condemnation/disapproval by other people and may take benign conversations as attacks on their personality and react violently.
Patients with schizoid personality disorder show a general lack of interest in social relationships and also exhibit a lack of emotional expression, appearing dull or indifferent to the people around them. It is not as debilitating as schizophrenia and the patient does not completely lose touch with reality. Hallucinations and delirium in such patients is a rare or almost nonexistent finding.
Patients with schizotypal personality disorder exhibit strange beliefs and superstitions, attire, thinking patterns and behavior. They are uncomfortable with personal relationships. They are emotionally detached and may appear as indifferent to the people and happenings around them. Another characteristic feature of this disorder is the concept of ‘magical thinking’; these patients believe they have the ability to influence other people by their thoughts alone and vice versa. For example, while listening to a public speech, they may believe that a hidden message is being conveyed to them and exhibit fixation at uncovering it (99).
Cluster B category of the personality disorders are characterized by overt expression of emotions and dramatic behavior and thinking patterns. The common disorders included in this category are antisocial personality disorder, borderline personality disorder, histrionic personality disorder and also narcissistic personality disorder.
Antisocial personality disorder is characterized by aggressive behavior patterns, recurrent violations of law and order, disrespect for other people, an indifference towards the safety of other people, along with persistent lying and stealing habits (100).
On the other hand, patients with borderline personality disorders have unstable moods with grim fears of being left alone. These patients tend to have intense relationships that are unstable and involve a continuous change in the feelings experienced towards the other people. They may also exhibit unpredictable impulsive behavior such as excessive spending, gambling, and promiscuity. Additionally, they have suicidal tendencies and exhibit risky behavior. In severe cases, patients may also experience episodes of psychosis and its symptoms such as hallucinations. Also, major depressive episodes can occur in such patients, which can markedly increase the risk of suicide.
Patients with histrionic personality disorder show extreme emotional liability and attention seeking behavior. They may also show excessive concern with physical appearances. They experience feelings of discomfort when they do not receive adequate attention in a social arena and may sometimes dress provocatively or act flirtatiously in order to fulfill their attention-seeking needs. They stand out from the crowd easily with overtly dramatic actions. Furthermore, they take criticism poorly and require constant approval from their peers (100).
Lastly, patients with narcissistic personality disorder experience extreme self-admiration and are focused mainly on their own self. They believe in their own superiority to others and seek constant praise for their efforts and actions. They also tend to fantasize excessively about their success and attractiveness. They may also fail to acknowledge others people’s feelings and focus only in seeking the attention of others. They also believe they are special and cannot be understood by the general people. Generally, they demonstrate aggressiveness and arrogance, considering others to be envious of them (101).
Cluster C personality disorders are characterized by anxious and fearful thinking patterns. Included in this classification are obsessive-compulsive personality disorder, dependent personality disorder and avoidant personality disorder (102).
Patients with avoidant personality disorder have timid personalities, are socially isolated and demonstrate extreme shyness in social gatherings. They are overly sensitive towards criticism as well.
Similarly, those with dependent personality disorders exhibit extreme dependence on other people. They have submissive personalities and are unable to take any form of abuse. They also tend to jump into relationships right after the previous one has ended in order to fulfill their need to be taken care of by other people.
Obsessive-compulsive personality disorders differ from obsessive-compulsive disorder (OCD), which is a type of anxiety disorder and not a personality disorder. Patients with obsessive-compulsive personality disorders have inflexible personalities and they feel an intense need to maintain law and order. They tend to be preoccupied with rules and regulations and cannot tolerate indiscipline. They need to take charge of and control situations, and expect perfection in most aspects of life. These patients also see themselves to be more reliable, productive and proficient than others (102).
Emotional and behavioral disorders fall under the category of “emotional disturbances” and are characterized by improper behavior, learning difficulties, prolonged unhappiness or depressive moods, difficulty in maintaining personal healthy relationships and a tendency to develop physical symptoms or fears that are associated with school or other personal factors. In children with emotional/behavioral disorders, these symptoms are present for long periods of time and influence a child’s educational performance in the long run.
There are many factors that contribute towards children developing behavioral disorders. These factors can be biological i.e. malnutrition, brain damage, physical illness and inborn behavioral characteristics. Sometimes these behavioral disorders develop when children are raised in strained circumstances at home; for example, when they see their parents going through a divorce, suffer from abuse and neglect, or observe inappropriate parental behavior such as usage of bad language, and a frivolous attitude towards education and school performances (103).
There are different screening modalities that help identify children with behavioral disorders at an early age. The screening methods include use of intelligence and achievement tests, behavior ratings when compared to other children of the same age group, intrapersonal assessments tools and also direct behavior observation.
There are several different types of behavioral disorders; each one is briefly described below (103).
Conduct disorder is more frequently seen among boys than girls. Children with conduct disorders are excessively aggressive and may be unnecessarily inclined towards lying and stealing. They also have difficulty managing confrontational situations diplomatically and exhibit defiance. Moreover, they are antisocial, destructive, violent and impertinent. They also show resistance to discipline methods normally used by parents and teachers.
Oppositional defiant disorder is a condition in which children continuously defy and challenge authority figures. They show resentment and throw tantrums accompanied by physical displays of aggression.
Another behavior disorder commonly found among school age children is aggression. It is usually learnt from parents, friends, siblings and even television. It can become permanent if not dealt with early.
Socialized aggression disorder is similar to the one described above. Children and young adults with socialized aggression disorder are hostile, defiant, disobedient and both physically and verbally aggressive. They are usually active participants/members of delinquent gangs and may have juvenile criminal records.
Anxiety and withdrawal disorder is characterized by fears related to a future event. Patients with this disorder may also exhibit extreme irrational fears (phobias).
Children with anxiety disorders often exhibit physical symptoms of nausea, pains and aches, crying episodes, sleep disorders and nightmares. They usually have low self-esteem and are shy and fearful in social gatherings. If left unchecked and untreated, children may develop obsessive-compulsive behaviors in an attempt to overcome the anxiety.
Mood disorders are characterized by mood disturbances triggered by underlying causes. These disorders are often also called affective disorders. They are classified into the following categories:
This category includes major depressive disorder (MDD), also known as clinical depression and unipolar depression (in the absence of mania). Major depressive disorders are characterized by at least a 2-week period of lack of interest in social activities, continuous low moods, irritable and depressed state of mind, altered eating and sleeping habits and suicidal tendency. Due to the latter, these patients need prompt medical attention and treatment. MDD has several subcategories under it; namely, atypical depression, melancholic depression, psychotic major depression, catatonic depression, postpartum depression and seasonal affective disorders (104).
Excessive weight gain, increased appetite, and also impaired social relations characterize atypical depression. Melancholic depression is characterized by the loss of pleasure in all activities, excessive weight loss, early morning wakening, and psychomotor retardation. Patients with psychotic major depression experience depressive episodes accompanied by psychotic symptoms such as delusions and/or hallucinations. Catatonic depression is rare and characterized by severe depression accompanied by bizarre, purposeless movements or other motor symptoms. Patients are often mute and immobile. It can result from neuroleptic malignant syndrome. Postpartum depression and seasonal affective disorders are also forms of depression that occur after the birth of a baby and depressive episodes that are related to seasons (commonly winter), respectively.
Bipolar disorder is characterized by periods of depression alternating with mania (persistently high moods). Bipolar I disorder is predominantly manic or mixed episodes without significant depression. Bipolar II disorder, on the other hand, consists of alternating recurrent episodes of mania and depression. Cyclothymia is another form of bipolar disorder in which patients have hypomanic episodes alternating with dysthymic episodes (with no full blown depressive episode).
Dysthymic disorder is a chronic form of depression, lasting for 2 years and more. There is no 2-month period in which the following symptoms are not observed; overeating or loss of appetite, excessive sleep or insomnia, fatigue and lack of energy, difficulty concentrating and also constant feelings of hopelessness. For a diagnosis of dysthymic disorder to be valid, it is important to rule out substance abuse, other underlying medical condition or any other identifiable cause. Furthermore, it is important for patients diagnosed with dysthymia to have not had an episode of major depressive disorder within this 2-year period, and no episodes of mania, hypomania or mixed episode.
Substance-induced mood disorder
Substance-induced mood disorder is defined as manic, hypomanic or depressive symptoms caused by either usage or withdrawal of a specific substance or drug. The DSM-IV TR diagnoses substance abuse disorder on the basis of persistent mood disturbances characterized by either depressed mood or lack of interest in all activities. Also, there should be clear evidence that these disturbances have been proven either from patient history, clinical data or through laboratory findings as a direct cause of substance use/intoxication/withdrawal within a 1-month period. It is also important that the mood disorder does not occur during delirium and that the disturbance is not better accounted for by a mood disorder that is not caused by substance abuse.
One of the common causes of substance-induced disorder is alcohol. Major depressive disorder is linked to long-term alcohol intake. Previously, it was believed that people suffering from depression can benefit from alcohol use to nullify their pain or curb their depression, but current research literature rejects this idea, suggesting instead that chronic use of alcohol directly causes major depressive disorder, especially in heavy drinkers. Furthermore, chronic alcohol use is associated with higher suicide rates.
In most cases, extensive history can help differentiate between preexisting depression and depression that may have resulted directly from chronic alcohol use. Similarly, chronic intake of benzodiazepines may also cause depression in certain predisposed individuals. Moreover, benzodiazepine withdrawal also causes rebound depression. Illicit drug use of substances like amphetamine, methamphetamine and cocaine, are associated with mania, hypomania, and depression.
Mood disorders caused by an underlying medical condition
This category includes mood disturbances that are direct results of underlying medical conditions. Neurological disturbances such as dementia and related states, metabolic disturbances including electrolyte balance, endocrine diseases, cardiovascular diseases, pulmonary diseases, and autoimmune diseases are known to cause mood disturbances.