PS

Psychiatry
Jacqui Hollif, Melinda White and Karen-Role Wllsoo, chapter editors Christophel' Kitamura and Michelle Lam, associate editors Janine Hutson, EBM editor Dr. Jodi Lofchy and Dr. John Teshima, staff editors
The Psychiatric Assessment . . . . . . . . . . . . . . . 2 History Mental Status Exam Summary of Axes Psychotic Disorders . . . . . . . . . . . . . . . . . . . . . . 4 Differential Diagnosis of Psychosis Schizophrenia Schizophreniform Disorder Brief Psychotic Disorder Schizoaffective Disorder Delusional Disorder Shared Psychotic Disorder (Folie a Deux) Mood Disorders ......................... 7 Mood Episodes Depressive Disorders Postpartum Mood Disorders Premenstrual Dysphoric Disorder (PMDD) Bipolar Disorders Anxiety Disorders ...................... 12 Panic Disorder Generalized Anxiety Disorder (GAD) Phobic Disorders Obsessive-Compulsive Disorder (OCD) Post-Traumatic Stress Disorder (PTSD) Adjustment Disorder .................... 16 Cognitive Disorders. . . . . . . . . . . . . . . . . . . . . 17 Delirium Dementia Substance-Related Disorders ............. 20 Alcohol Opioids Cocaine Cannabis Amphetamines Hallucinogens "Club Drugsn Suicide ............................... 24 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Somatoform Disorders .................. 26 Conversion Disorder Somatization Disorder Pain Disorder Hypochondriasis Body Dysmorphic Disorder Dissociative Disorders ................... 27 Sleep Disorders ........................ 28 Nocturnal Myoclonus Narcolepsy Sexuality and Gender ................... 28 Sexual Orientation Paraphilias Gender Identity Disorder Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . 29 Anorexia Nervosa Bulimia Nervosa Personality Disorders ................... 31 Child Psychiatry ........................ 33 The Child Psychiatric Interview Developmental Concepts Mood Disorders Anxiety Disorders Childhood Schizophrenia Pervasive Developmental Disorders (PDD) Attention Deficit Hyperactivity Disorder (ADHD) Oppositional Defiant Disorder (ODD) Conduct Disorder (CD) Psychodynamic Therapies ............... 39 Defense Mechanisms Varieties of Psychodynamic Therapy Behaviour Therapy Cognitive Therapy Cognitive Behaviour Therapy Other Therapies Pharmacotherapy....................... 41 Antipsyc hotics Antidepressants Mood Stabilizers Anxiolytics Electroconvulsive Therapy Experimental Therapies Canadian Legal Issues ................... 51 Common Forms Consent Community Treatment Order (CTO) Duty to Inform/Warn

Diagnostic Criteria reprinted with pennission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. 2000 American Psychiatric Association.

Toronto Notes 2011

Psychiatry PSI

PS2 Psychiatry

Psychiatric Aasessment

Toronto Notes 2011

Psychiatric Assessment
.....

,,

History
Identifying Data
name, sex, age, ethnicity, marital status, religion, occupation, education, living situation, referral source

Scrlninl a...tiDM for Major Psychiatric Disorders Have you been feeling down, depresaed or hopeless? Do you feel anxious or WOrTY about things? Has lhn bean time in your lila wara you hllv8 hilt euphoric, extremely lllllrativl and had a lot of ll1llliY and a decreued need for sleep? Do you saa or haor things 1hat you think other people camat? Hllva you awr thought of harmi'lg yourself or committing suicide?

Reliability of Patient as a Historian may need collateral source (e.g. parent, teacher) if patient unable/unwilling to co-operate Chief Complaint
in patient's own words duration, previous history of disorder or treatment

History of Present Illness

reason for seeking help (that day), current symptoms (onset, duration and course), stressors, supports, functional status, relevant associated symptoms (pertinent positives and negatives) safety screen: Is the patient endangering self or others? Dependents at home (e.g. children, pets), ability to drive safely, ability to care for self (e.g. eating, hygiene, taking medications)

Psychiatric Functional Inquiry

I'IJ!:I!I.tric Fmctlcmallnquiry

MDAPS Mood Orvanic {e.g. substances!

Anxiety Plychasil

mood: depressed, manic anxiety: worries, obsessions, compulsions, panic attacks, phobias psychosis: hallucinations, delusions, thought form disorders suicide/homicide: ideation, plan, intent, history of attempts organic: EtOH/drug use or withdrawal, illness, dementia

Safety

Past Psychiatric History

all previous psychiatric diagnoses, psychiatric contacts, treatments (pharmacological and non-pharmacological) and hospitalizations also include past suicide attempts, substance use/abuse, and legal problems

Past Medical/Surgical History

all medical, surgical, neurological (e.g. head trauma, seizures), and psychosomatic illnesses medications, allergies

Family Psychiatric/Medical History

family members: ages, occupations, personalities, medical or genetic illnesses and treatments, relationships with parents/siblings family psychiatric history: any past or current psychiatric illnesses and hospitalizations, suicide, depression, substance abuse, history of "nervous breakdown/bad nerves; forensic history, any past treatment by psychiatrist or other therapist

Past Personal History

prenatal and perinatal history (desired vs. unwanted pregnancy, maternal and fetal health, domestic violence, maternal substance use, complications of pregnancy/delivery) early childhood to age 3 (developmental milestones, activity/attention level family stability, attachment figures) middle: childhood to age 11 (school performance, peer relationships, fire-setting, stealing, incontinence) late childhood to adolescence (drug/alcohol, legal problems, peer and family relationships) adulthood (education, occupations, relationships) psychosexual history (paraphilias, gender roles, sexual abuse, sexual dysfunction) personality before current illness, recent changes in personality

\,
The MSE ia analogous 11:11he phyaicll IXIIm. It on cwrmt aigns, aympllliTII, llflect, behaviour and

Mental Status Exam (MSE)

General Appearance and Behaviour
dress, grooming, posture, gait, physical characteristics, body habitus, apparent vs. chronological age, fada1 expression (e.g. sad, suspicious) psychomotor activity (agitation, retardation), abnonnal movements or lack thereof (tremors, akathisia, tardive dyskinesia, paralysis), attention level and eye contact, attitude toward examiner (ability to interact, level of co-operation)

It'

Mentallmtu Exam
ASEPTlC Appearance and behaviour
Speech Emotion (mood and llffectl

Perception
Thauglrt content and prace.s Insight end judgment

Speech
rate (e.g. pressured, slowed), rhythm/fluency, volume, tone, articulation, quantity, spontaneity

Cavnition

Toronto Notes 2011

Psychiatric Al8e81JD.ent

Psychiatry PS3

Mood and Affect

mood- subjective emotional state; in patient's own words affect - objective emotional state; inferred from emotional responses to stimuli, described in terms of: quality (euthymic, depressed, elevated, anxious) range (full, restricted, flat, blunted) stability (fixed, labile) mood congruence (inferred by reader by comparing mood and affect descriptions) appropriateness to thought content

il'' Spectnam of Ah:t

FIJI > llestrictad > Blunted > Flat

Thought Process
coherence - coherent, incoherent logic -logical, illogical
stream

l''

goal-directed circumstantial - speech that is indirect and delayed in reaching its goal; eventually comes back to the point tangential- speech is oblique or irrelevant; does not come back to the original point loosening of associations - illogical shifting between topics flight ofideas - quickly skipping from one idea to another where the ideas are marginally connected, associated with mania word salad - jumble of words lacking meaning or logical coherence perseveration - repetition of the same verbal or motor response to stimuli echolalia - repetition of phrases or words spoken by someone else thought blocking - sudden cessation of flow ofthought and speech clang associations - speech based on sound such as rhyming or punning neologism - use of novel words or of existing words in a novel fashion

Thlrti is poor carrlllllion bmvnn clinical impmsion of suicide risk and frequency of

"'' I
Delusions

blli.r 111111 Dlhll$11n trying tu CIUI8 harm Delusions of raftranca - interpreting

publicly known events/celebrities as having rlnct l8flnnc8 Ill the palilnt

EratDIIIllnia- belief that another is in lovuwith you Grandiose- belief of an inflated sense of selfworth or power Religious - blli.r of r1coiving

Thought Content
suicidal ideation/homicidal ideation

low- fleeting thoughts, no formulated plan, no intent intermediate - more frequent ideation, well formulated plan, no active intent high - persistent ideation and profound hopelessness/anger, well formulated plan, active intent, believes suicide/homicide is the only helpful option available pre-occupations, ruminations - reflections/thoughts at length, not fixed or false obsession - recurrent and persistent thought, impulse or image which is intrusive or inappropriate cannot be stopped by logic or reason causes marked anxiety and distress common themes- contamination, orderliness, sexual, pathological doubt/worry/guilt magical thinking - belief that thinking something will make it happen; normal in kids ideas of reference - similar to delusion of reference but the reality ofthe belief is questioned overvalued ideas- unusual/odd beliefs that are not of delusional proportions first rank symptoms of schizophrenia - thought insertion/withdrawal/broadcasting delusion- a fixed false belief that is out of keeping with a person's cultural or religious background and is firmly held despite incontrovertible proof to the contrary progression of increasing pathology, decreasing insight: ideas/themes < preoccupations < ruminations < obsessions < magical thinking < ideas of reference < overvalued ideas < first rank symptoms < delusions

insti\Jctiontlpowers from a higher beilg; of bainq a higher baing Sommic -belief 111111 one has a physical disordtir/d.nct Nihilistic- belief that 1hings do not
exist; a sensa that averytlling is

unreal

....._' I

Coanillvo All-nt
Use Folstein Mini Mental S1ata Exam
(MMSE} tu anen: Oriantation (timll and plaCII} Memory (immediatll and delayed

racall}
Attention and Concentration Language (comprehension, llllding. writilg, repetition, n1111ing} Spatial ability (intefl8cting

Perception
hallucination - sensory perception in the absence of external stimuli that is similar in quality to a true perception, auditory (most common), visual, gustatory, olfactory, tactile illusion - misperception of a real external stimulus depersonalization - change in self-awareness such that the person feels unreal, detached from his or her body, and/or unable to feel emotion derealization- feeling that the world/outer environment is unreal

pantagons}

GniH &ereen for cognitive dY5function: Tot11hcore is out of 30; <24 abnormal mild, 10-19 moderlllll. <10
UVIrl

Cognition
level of consciousness orientation - time, place, person memory - immediate, recent, remote global evaluation of intellect (below average, average, above average) intellectual functions - attention, concentration, calculation, abstraction (proverb interpretation, similarities test),language, communication

l '' Assllllllng llght IIIII Judgment

Insight Do you tllink !hat you lvMI a mental ililess? 'Wtr/ .,. you taking this mediation? 'Wtr/ are you in the hospital? Judgment

Insight
patient's ability to realize that he or she has a physical or mental illness and to understand its implications

Can be observed from collected history and plllillll's IIPJI1811111CI and actions.
Is he/she dressed appropriately fur the waathlll1 Is he/she acting IIPJiroprilllely in the given situlllion? Is h..,sh taking can at ur and/or

Judgment
ability to understand relationships between facts and draw conclusions that determine one's actions

dependents?

PS4 Psychiatry

'The Psychiatric: Asaasment/Psychotic Disorders

Toronto Notes 2011

.....

Summary of Axes
Multiaxial Assessment Ami differential diagnosis ofDSM-IV clinical disorders Amll personality disorders, developmental disability Amlll general medical conditions that are potentially relevant to the understanding or management of the mental disorder AmiV psychosocial and environmental issues AmV global assessment of functioning (GAF, 0 to 100) incorporating effects of axes I to IV Formulation a diagram outlining current issues and interrelations between an individual's biological, psychological, and social factors for each category: predisposing, precipitating, perpetuating, and protecting factors Approach to Management 1. biological (e.g. pharmacotherapy) 2. psychological (e.g. CBT) 3. social (e.g. support group)

Axil V: Glollll AHMtment of Funetioning 91-100 SupllrillrfulctionD,j ifuwida 1111111

llfiii:IMilll

81-90 Abient Dlll'ilirlll fjii1JJtmns 11-80 I "'llffums 1111 p-.t.lley 11re 1nnli. nd 8lqJ8Cfed 1o psychoalc:ill sllmors 61-70 tu oannv blctioninu
51-80 41-50 31-40

21-30 Beh!Muis irAienced IPfdeUionl/ i1lbilatior. serious impUmant il

11-20

Seriuui II','IT1p1Dmi Ill SoliE irpirmrmt in lllitytesliJW

CIIIIIIUiic:llion, impliiMnt iiiMTil

or--llyfllill1ollllilllin milinll hygiene 111110" irnpmenl in

CIIIIIIUiic:llion l'lnillllnt danger hllting sel ar otlm ar pmistEnt inlblily 1o lllliDin ninimll JMQOflli hygipor serious wicilaiiCI Ndeqlllll mmtion

CIIIIIIUiil:lliorV!udgmeol SoliE dlnger at IMtirv ul Cl olin

1-10

rJ--"

Psychotic Disorders
Definition characterized by a significant impairment in reality testing delusions or hallucinations (with/without insight into their pathological nature) behaviour so disorganized that it is reasonable to infer that reality testing is disturbed

Differential Diagnosis of Psychosis

It'

Dilano!U of "',.:ha!U

GASPP
AlfiCiiv. disonlllll Substllnce induced Psychotic diSOrdllt$ Perso1111ity disorders

General medical condition

primary psychotic disorders: schizophrenia, schizophrenifonn, briefpsychotic, schizoaffective, delusional disorder mood disorders: depression with psychotic features, bipolar disorder (manic episode with psychotic features) personality disorders: schizotypal, schizoid, borderline, paranoid, obsessive-compulsive general medical conditions: tumour, head trauma, dementia, delirium, metabolic substance-induced psychosis: intoxication or withdrawal

Schizophrenia

\,
Mlnagement of Aclltl Plyohosil end
Mlnia

Reprinted with pennission from the Diagnostic and Statistical Manual of Menllll Disorders, Text Revision, Fourth American Psychiatric Associllian.

DSMIVTR Diagnostic Criteria for Schizophrenia

(Copyright

Ens1U8111fwty of sllf, patiiiTI: and

other patienll

Have an exit strategy

llec1811&8 slimtJlation
IM mlllicati0111 (benzadiampine + antipsychotic} often naedad as patient may refuse oral meds Phy$ical1'811nlii'Q may be n8C8Aary Do not un entidep11111811b1 or
atimullllllli Assume 1 non-thf'lllllllning stance

A. characteristic symptoms (active phase): <!:2 of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated) delusions hallucinations disorganized speech (e.g. frequent derailment or incoherence) grossly disorganized or catatonic behaviour negative symptoms, e.g. affective flattening, alogia (inability to speak), or avolition (inability to initiate and persist in goal-directed activities) Note: only 1 "N symptom is required if delusions are bizarre or hallucinations consist of a voice keeping a running commentary on the person's behaviour or thoughts, or 2 or more voices conversing with each other B. sociaVoccupational dysfunction: <:1 major areas of functioning (work, interpersonal relations, self-care) markedly below the level achieved prior to the onset of symptoms C. continuous signs of disturbance for :?!6 monthJ, including <!: 1 month of active phase symptoms; may include prodromal or residual phases D. schizoaffective and mood disorders excluded E. the disturbance is not due to the direct physiological effects of a substance or a general medical condition (GMC) F. if history of pervasive developmental disorder, additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least 1 month

Toronto Notes 2011

Psychotic Diaorders

Psychiatry PSS

Subtypes
paranoid preoccupation with one or more delusions (typically persecutory or grandiose) or frequent auditory hallucinations relative preservation of cognitive functioning and affect; onset tends to be later in life; believed to have the best prognosis catatonic at least two of: motor immobility (catalepsy or stupor); excessive motor activity (purposeless, not influenced by external stimuli); extreme negativism (resistance to instructions/attempts to be moved) or mutism; peculiar voluntary movement (posturing, stereotyped movements, prominent mannerisms); echolalia (repeating words/phrases of another's speech) or echopraxia (imitative repetition of another's movements, gestures or posture) disorganized disorganized speech and behaviour; flat or inappropriate affect poor premorbid personality. early and insidious onset. and continuous course without significant remissions undifferentiated symptoms of criteria A met, but does not fall into the 3 previous subtypes residual absence of prominent delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behaviour continuing evidence of disturbance indicated by the presence of negative symptoms or two or more symptoms in criteria A present in attenuated form

r-t,

Sutl.-ted Criteria hlr Prodromal Synnm.s Attenuated positive symptom syndrome: Ahnonnal unusual thought
content, suspiciousness, PlfCipiUal lllldfor

organilation of communication; onset or worsening in past year

Brief intermittent psychlrtic syndrome: Frankly psychotic, unusual

thought cont.nt suspiciousn-. grandiosity, perceptual abnonnalitias, arnVor organization of onset in past three months Gl!llltic risk plus functional deterioration: Fim:-degree relative with hisby of any psycllotic disorder or schizotypal personality disorder in patient; subsblttilll functional dacli111 inpastynr

Adlplad ,_ Sadoli, B. J.llld Sldoli, V. A. KllpEI111d Sldock's Crlllf/llhelrM Tllllrboak of l'!yc/lillly. 8th Edition. lippincott Wililms &

Wbs,2005.

Epidemiology
prevalence: 0.5%-1%; M:F = 1:1 mean age of onset: females -27; males -21

llllllilliiii._IDI!lltianrl...._.. l'lydlalil (DUPI 1111 il Fftt......

Etiology
multifactorial: disorder is a result of interaction between both biological and environmental factors genetic- 50% concordance in monozygotic (MZ) twins; 40% if both parents have schizophrenia; 10% of dizygotic (DZ) twins, siblings, children affected neurochemistry- "dopamine hypothesis theory: excess activity in the mesolimbic dopamine pathway may mediate the positive symptoms of psychosis (ie. delusions, hallucinations, disorganized speech and behaviour, and agitation) neuroanatomy - decreased frontal lobe function, asymmetric temporal!limbic function, decreased basal ganglia function; subtle changes in thalamus, cortex, corpus callosum, and ventricles; cytoarchitectural abnormalities neuroendocrinology - abnormal growth hormone, prolactin, cortisol, and adrenocorticotropic hormone neuropsychology- global defects seen in attention, language, and memory suggest lack of connectivity of neural networks indirect evidence of geographical variance, winter season of birth, and prenatal viral exposure

To milw tt. aaocidion betwaln DlJ' and symplllm IMrily Ill firlt1nlltmant conllct. and lllJ' llld 1JIIIInlnlllllll:Dmn. lludy Cllndllilli:l: Crml rMw ll1d ..... analysis ai43Ridils Ytitb 4171 !lllilrD. Pri:iplll: Pllieds Mil noHilicWe p$dlotic dilonlm Ill or ciDu 1D irst 1nlllm8rt. blulll: Sharllr 00P was IISSGCillld with weater raspom 1D lrtpsychatic1rldmant, liS nand by gWIII PI'I'Cha!lllholo!w. poeitiw l\'ll1llllnlS. l'IIQilivl syn'lllllrl. and funclianll DiamaL AI tt.liml aflllltma ilililtion, longlr OOP MS ocidad with U.11Po'riy af nllgltiw iYf!1plum5 lU notwilh U.IMrily al poeiliYa l'jfllpiDrns, alollll blc:tioR. Canlbial: 00P rillY be apotlntillly ndllbli praaliGIIic ladur.

,_..IC

IIIII:

Pathophysiology
neurodegenerative theory natural history may be rapid or gradual decline in function and ability to communicate glutamate system may mediate progressive degeneration by excitotoxic mechanism which leads to production of free radicals neurodevelopmental theory: abnormal development of the brain from prenatal life neurons fail to migrate correctly, make inappropriate connections, and break down in later life inappropriate apoptosis during neurodevelopment resulting in faulty connections between neurons

SuppartMt Evidnc: fur DupiiiiiM

llypothnls Dopamine (DA) agonim exacerbate
schimphl"'nill Antipsycllotic drugs act by blocking post-synaptic DA receptors Potency of milll'f antipsychotic drugs cor1'811rtn with 02 blockade of pottsynaptic receptors Antipsycilotic drugiii'IIIIIOCillted

Management of Schizophrenia
biological acute treatment and maintenance with antipsychotics anticonvulsants anxiolytics management of side effects psychosocial psychotherapy (individual, family, group): supportive, cognitive behavioural therapy (CB'O assertive community treatment (ACT) social skills training, employment programs, disability benefits housing (group home, boarding home, transitional home)

with an inci"'8Se in the nwnber of D2 lll1d D4 post-synaptic

PS6 Psychiatry

Psychotic Disorders

Toronto Notes 2011

-"{.,
Good Prognollic: Fc:ton Acum onsll Precipitating factors
Good cognitive functioning Good premorbid functioning No family history Presence of alfeclive 5ymp1Dms Absence of structural brain
abnonnalilie5

Prognosis
the majority of individuals display some type of prodromal phase course is variable: some individuals have exacerbations and remissions and others remain chronically ill; accurate prediction ofthe long term outcome is not possible early in the illness, negative symptoms may be prominent; positive symptoms appear and typically diminish with treatment; negative symptoms may become more prominent and more disabling over time, 1/3 improve, 1/3 remain the same, 1/3 worsen

Good response ID drugs Good suppon ayst1111

Schizophreniform Disorder
diagno1is: criteria A, D and E of schizophrenia are met; an episode of the disorder lasts at least 1 month but less than 6 months. If the symptoms have extended past 6 months the diagnosis becomes schizophrenia treatment: similar to acute schizophrenia prognosis: better than schizophrenia; begins and ends more abruptly; good pre- and postmorbid function

Brief Psychotic Disorder

diagnosis: acute psychosis (presence of 1 or more positive symptoms in criteria A 1-4 of schizophrenia) lasting from 1 day to 1 month, with eventual full return to premorbid level of functioning can occur after a stressful event or postpartum (see Postpartum Mood Disorders, PSlO) treatment: secure envirorunent, antipsychotics, anxiolytics prognosis: good, self-limiting, should return to pre-morbid function in about 1 month

Schizoaffactive Disorder
DSM-IV-TR Diagnostic Criteria for Schizoaffective Disorder
Reprinted with permission from the lli1gnoatic and Statistical Manu1l Df Manllll Disorders, Taxt Revision, Fourth American l'syi:himic AsiOCillion.

[Copyright 200DI.

A. uninterrupted period of illness during which there is either a major depressive episode (MDE), manic episode, or a mixed episode concurrent with symptoms meeting criteria A for schizophrenia B. in the same period, delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms C. symptoms that meet criteria for a mood episode are present for a substantial portion of total duration of active and residual periods of the illness D. the disturbance is not due to the direct physiological effects of a substance or GMC treatment: antipsychotics, mood stabilizers, antidepressants prognosis: between that of schizophrenia and of mood disorder

....

.,

Delusional Disorder
DSM-IV-TR Diagnostic Criteria for Delusional Disorder
Reprinted with permission from the Diagnostic and Statistical Manual Df Menllll Disonlen, Text Revision, Fourth American l'syi:himic AsiOCillion

[Copyright 200D).

followed, poisoned, loved at a distancal.

Non-bil81111 dlllusions involve situllions that could occur in nllllife {1.g. being

A. non-bizarre delusions for at least 1 month B. criterion A for schizophrenia has never been met (though patient may have tactile or olfactory hallucinations if they are related to the delusional theme) C. functioning not markedly impaired; behaviour not obviously odd or bizarre D. if mood episodes occur concurrently with delusions, total duration has been brief relative to duration of the delusional periods E. the disturbance is not due to the direct physiological effects of a substance or GMC subtypes: erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified treatment: psychotherapy, antipsychotics, antidepressants prognosis: chronic, unremitting course but high level of functioning

Shared Psychotic Disorder (Folie

a Deux)

diagnosis: delusion that develops in an individual who is in a close relationship with another person who already has a psychotic disorder with prominent delusions; the delusion is similar in content to that of the other person treatment: separation of the two people results in the disappearance of the delusion in the healthier member; antipsychotics may play a role prognosis: good

Toronto Notes 2011

Psychotic Diaorden/Mood Disorders

Psychiatry PS7

Table 1. Differentiating Psychotic Disorders

Disonlar
Brief psychotic disorder
Schizophrenifurrn disorder Schizophrvnia Schizoaffective disorder Deklsional disorder 2" to substance intoxication/withdrawal 2" to mood disorder
Psychotic Symptoms
syrrlms Df critaion A

DUI'IIian

Mood &,mplams
If present, 2 If present, 2 If pr85Bnt, 2
Pr868nt
.... ' !

<!month
1-6 months

Criterion A Criterion A
weeks (with no mood symptoms)

>6 months >I month >1morrlh

During intoxication or !::1 month after withdrawal Unspecified

Non-bizarre delusions, hallucinations

A

If present, 2
Variable

Dumion of n .., DifrenlllliiQI!Ihl fallawing 3 Plychalic Disorders Brief psyc:hotic disorder < 1 month Schizophrenifonn disorder Hi months Schizophrenia >6 months

DelusionfA!allucinations (mood congruent)

,.

Mood Disorders
Definitions
mood disorders are defined by the presence of mood episodes mood episodes represent a combination of symptoms comprising a predominant mood state that is abnormal in quality or duration, e.g. major depressive, manic, mixed, hypomanic types of mood disorders include depressive (major depressive disorder, dy5thymia) bipolar (bipolar UII disorder, cyclothymia) secondary to GMC, substances, medications

Table 2. Secondary Causes of Mood Disorders

V
N

Vascular Infectious Neoplastic Degenerative lntoxicatian/Drugf/ Deficiencies

Cardiomyopathy, CHF, ML rNA Encephalilil/m111ingitis, hapatitis. pnawnonia, TB, syphilis

Pancreatic cancer, carcinoid, r,toeochrornocytoma

Huntington's disease, multiple sclerosis, tuberous sclerosis, degenerative (VIIscular, Alzheimer's dementia) Antihypertensives, antiparkinsonian, hormones, steroids, antituberculous, interferon, antineoplastic medications, vitllrnin deficiencies (Wernicke's encephalopathy, beriberi, pellagra, pernicious anemia)

c
A
T
E

Congenital Autoimmune Traumatic EndocrinWMetabolic Hypothyroidism, hyperthyroidism, SIADH, porphyria, Wilson's disease, diabetes

SLE. polyarteritis nodosa

Medical Workup of Mood Disorder

routine screening physical examination complete blood count thyroid function test electrolytes urinalysis, urine drug screen additional screening: neurological consultation chestx-ray electrocardiogram CTscan

Mood Episodes
DSM-IV-TR Criteria for Major Depressive Episode
ReprintEd with permission from the Diagnostic and StatistiCIII Mlnual ol Mental Disorders. Text Revision, Fourth Edition, (Copyright 2000). l'lychillric Aaociati011. A. of the following symptoms have been present during the same 2-weck period and represent It' c:rtt.ill far

(:.5)

a change from previous functioning; at least one of the symptoms is either 1) depressed mood. or 2) loss of interut or pleasure (anhedonia) Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations depressed mood most ofthe day, nearly every day, as indicated by either subjective report or observation made by others markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

MSIGECAPS Mood- depressed Sleep - incruued/ducr&nlld

lnta181l - decr&nlld Guilt En1111Y- decl8ued Concentnrtion - decreased Apputitu - increued/ducr111118d

Psychomotor - aaitatiorVretardltion
Suicidal ideation

PS8 Psychiatry
1

Mood Diaorders

Toronto Notes 2011

significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day insomnia or hypersomnia nearly every day psydtomotor agitation or retardation nearly every day fatigue or loss of energy nearly every day feelings ofworthlessness or excessive or inappropriate guilt (which may he delusional) nearly every day (not merely self-reproach or guilt about being sick) diminished ability to think or concentrate, or indecisiveness, nearly every day recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide B. the symptoms do not meet criteria for a Mixed Episode (see below) C. the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning D. the symptoms are not due to the direct physiological effects of a substance or a GMC E. the symptoms are not better accounted for by bereavement (i.e. after the loss of a loved one); the symptoms persist for longer than 2 months; symptoms are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation
DSMIYTR Criteria for Manic Episode
Reprinted with pennission from the Diagnostic and Sbti$1ical Manual of Mental Disorders. Text Revision, Fourtll Edition. [Copyright 20001. American Psychiatric Assoc:illlian. It'

Critari1 for Mui1 {:dl GSTPAID Grendiasity Sleep (decreased need)

Talkative

Pleasurable activities, Painful

consequences

Activity
ldells (flight of) Distnlctibll

A. a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting :1:!:1 week (or any duration if hospitalization is necessary) B. during the period of mood disturbance, ?!3 of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree: inflated self-esteem or grandiosity decreased need for sleep (e.g. feels rested after only 3 hours of sleep) more talkative than usual or pressure to keep talking flight of ideas or subjective experience that thoughts are racing distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. the symptoms do not meet criteria for a Mixed Episode (see below) D. the mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features E. the symptoms are not due to the direct physiological effects of a substance (e.g. drug of abuse, medication, or other treatment) or a general medical condition (e.g. hyperthyroidism). Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g. medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder
Mixed Episode criterion met for both manic episode and major depressive episode (MDE) nearly every day for 1 week criteria D and E of manic episodes are met Hypomanic Episode criterion A of a manic episode is met, but duration is 0::4 days criterion B and E of manic episodes are met episode associated with an uncharacteristic decline in functioning that is observable by others change in function is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization absence of psychotic features

\,
An example of a mixlld episode would be manic behaviour, 111cing 1houglrts with or nihilistic conl&nt.

Depressive Disorders
MAJOR DEPRESSIVE DISORDER DSM-IV-TR Diagnostic: Criteria for Major Depressive Disorder (MOD). Single Episode (vs. Recurrent)
Reprinted with pennission from the Diagnostic and Sbti$1ical Manual of Mental Disorders, Text Revision. Fourtll American Psychiatric Assoc:illlian.

[Copyright 20001.

A. presence of a single Major Depressive Episode (vs. Recurrent, which requires presence of two or more Major Depressive Episodes; to be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a MDE)

Toronto Notes 2011

Mood Disorders

Psyc:hiatry PS9

B. the Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder not otherwise specified C. there has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode Note: This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance- or treatment-induced or are due to the direct physiological effects of a general medical condition

Features/Specifiers
psychotic - with hallucinations or delusions chronic -lasting 2 years or more catatonic - at least two of: motor immobility; excessive motor activity; extreme negativism or mutism; peculiarities ofvoluntary movement; echolalia or echopraxia melancholic - quality ofmood is distinctly depressed, mood is worse in the morning, early morning awakening, marked weight loss, excessive guilt, psychomotor retardation atypical- increased sleep, weight gain, leaden paralysis, rejection hypersensitivity postpartum (see Postpartum Mood Disorders, PS10) seasonal- pattern of onset at the same time each year (most often in the fall or winter)

.Antidlpnua l1lr Dlpnaillll illhllcll

Epidemiology
prevalence: male 5-12%, female 10-25% (M:F = 1:2) mean age of onset: -30 years

C<ntre lllllfllse rl Sj<rllllllli: llll1iiM 2010;

a..

Etiology
biological genetic: 65-75% MZ twins; 14-19% DZ twins neurotransmitter dysfunction at level of synapse (decreased activity of serotonin, norepinephrine, dopamine) secondary to general medical condition psychosocial psychodynamic (e.g. low self-esteem) cognitive (e.g. negative thinking) environmental factors (e.g. job loss, diet, bereavement, history of abuse) co-morbid psychiatric diagnoses (e.g. anxiety, substance abuse, mental retardation, dementia, eating disorder)

n.s lylllmllic nMaw ll'ld mall.ny8s af 51 RCTs 13803 pllien!sl complied llllli-deprmlrQ 1D pllcabo in pllilllll with a pbyliclll dilllld111 (eg. Cani:lt Mllwha hM t.l UgriiJIId acllpm-' (ilcluding Mljor DlpmsiaD. Ad;.trnart
llld Dtthnial.

lnue3

TeAs, patilfl!J willa pl1ylicll ill-.

Risk Factors
sex: female > male age: onset between 25-50 years of age family history: depression, alcohol abuse, sociopathy childhood experiences: loss of parent before age 11, negative home environment (abuse, neglect) personality: insecure, dependent, obsessional recent stressors: illness, financial, legal postpartum <6 months lack of intimate, confiding relationships or social isolation accounts for about 50% of acute psychiatric admissions in the elderly affects about 15% of community residents >65 years old high suicide risk due to social isolation, chronic medical illness suicide peak: males aged 80-90; females aged 50-65 often present with somatic complaints (e.g. changes in weight, sleep, energy) or anxiety symptoms refer to Table 4 to compare with delirium and dementia

II. Jalrl'lw.t '-llli Dlpnaillll C<ntre lllllfllse rl Sj<slltw ZOOS; 11M3 llludr. Syslelllllil: miew aflrillls11111 wele [II IIIMiomilld, doublt-bhled 121 wilh pllilllll with StJohn's wart wilh plica 111111ndlrd lllliiiiJnulllllld 141 incblld clinicll ooblamn. Minis: 5419 pllilnls willl mljrr dapnlllion. OIIIDanK 1. l!ftc1iwnast: lrnlmlnt 111P01111 - . 1 by adepl8Uion sc:Q 2. SQI.y: the pnii)Oitian afpalilnll who npped aut duiiD ldvlllelli'ltM.U. StJolm'swartvs. St Jolin's wort 'liS. smndlrd . . . . 21 Dis. 5481 pllilntl, IWb 18 comparisons with pllcellollld 17 willl llllidepmlanls. StJohn's wort il111011lffilctive 111111 placebo(leSPIIIIIe!UIItio l.87,1!1% (RRR=1.02. MCij.leslliMI1e eflecllwitl

Depression in the Elderly

dlpllldlf1t 011 the CGUOO'y af orijn.

Treatment
biological: antidepressants (see PS45), lithium, antipsychotic&, anxiolytics, electroconvulsive therapy (ECT), light therapy psychological individual therapy: psychodynamic, interpersonal, cognitive behavioural therapy family therapy group therapy social: vocational rehabilitation, social skills training experimental: deep brain stimulation, transcranial magnetic stimulation, vagal nerve stimulation

Clilllilllh'lpr vs. Mlllclbl il1111 Tllllbllll:riMIUnlltDS...Dipraleila AldrGen 2005; 62:4(1t.C16 llludr.lllndanilld control trill. Minis: 240 aulpl1ienls willlllllllllnle IDIIMlf'll MDD, IQ8d 18-70. 16 weeks at piiOXeline willl111 witlout IUQmmliOII wilb llbium Cllbmw1a or dlsipmninllrjdraci*Jridl (n=1201 VIISJI cognitiw (n=&UI. Response up 1D Blab was c:onllolled bypil plcello ln&OI lllil o.p.ian lllding sCill Mil ulld 1D llll1minl. IIIII* At BW81kl, 501(MCI41-5"l rl

o ....

Prognosis one year after diagnosis of a MDE without treatment, 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full MDE, 2096 continue to have some symptoms
that no longer meet criteria for a MDE, 40% have no mood disorder

1D 25\ (MCI16-3KI r1 pllilllll 1111 pi pllllllba. There was no slgnliclnt dillete111Z lllldil:llion Uld CST. Al16 Wl8b, 4ft of prianls 1111 mediCIIioa llld af prierO on CBT achM
Sulllllly:lhn illiD cilmacl in lllti:IIC'f bltw8en CBT VI. piiCIIIBiile il1hu 1n111mt1rt rl modmtiiO-dlprlssioll.

...

ri!DeniJ 1111 C8T llld reii)OIIded

PS10 Psychiatry DYSTHYMIA

Mood Diaorders

Toronto Notes 2011

DSM-IV-TR Diagnostic Criteria for Dysthymic Disorder

Reprintlld with penmission from the Diagnostic and Statistical Manual of Menbd Disorden, Taxt Revision, Fourtlt American l'syi:hilltric Assoc:illlion.

[Copyright 2000).

A. depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year B. presence, while depressed, of the following poor appetite or overeating insomnia or hypersomnia low energy or fatigue low self-esteem poor concentration or difficulty making decisions feelings ofhopelessness C. during the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 months at a time D. no MDE has been present during the first 2 years of the disturbance ( 1 year for children and adolescents); ie. the disturbance is not better accounted for by chronic MDD, or MDD in partial remission E. there has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder F. the disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder G. the symptoms are not due to the direct physiological effects of a substance or a GMC H. the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Epidemiology
point prevalence: 3%; life prevalence: 6%; M:F = 1:2-3

Treatment
psychological principle treatment for dysthymia individual, group, and family therapy biological antidepressant therapy (SSRis/SNRis) as an outpatient

Postpartum Mood Disorders

Postpartum alues transient period of mild depression, mood instability, anxiety, decreased concentration,
increased concern over own health and health of baby - considered to be normal emotional changes related to the puerperium occurs in 50-80% of mothers; begins 2-4 days postpartum, usually lasts 48 hours, can last up to

10days
does not require psychotropic medication patient at increased risk of developing postpartum depression

lhlt newlloms llpOIId 1D SSRIII!Id att.llllidlpt-m during lbe !bird trirnesl!! ci pn:giiiiiCY may be lldw!sely lllluc1ad, bei:IUI8 ri raporll ri cm;bticlllllll

Helllh

.......

IINIIhe-daAMI ri,.....M-. lh:llriSS.IIIIO...AIIIidlp:

II

Postpartum Depression (PPD}

diagno1is: MDE, onset within 4 weeks postpartum clinical presentation typically lasts 2 to 6 months; residual symptoms can last up to 1 year may present with psychosis- rare (0.2%), usually associated with mania, but can be MDE severe symptoms include extreme disinterest in baby, suicidal and infanticidal ideation epidemiology: occurs in 10% of mothers, risk of recurrence 50%

IUpport and 1ubllfvediv. AlhisGr( ljlpiied ID: bupropian (UIId fordlprassili ..

risk fad:on
previous history of a mood disorder (postpartum or otherwise) psychosocial factors: stressful life events, unemployment, marital conflict, lack of social support, unwanted pregnancy, colicky or sick infant

Clllllianl. cillllopnrn, butine, r-..rine,

mirllza!lila.lJ1111181iw, Wllliaellld wailfuine. I:GncUilnr. Plrisil:ians lnd Pltients shoUd caqfully benlllil$11111 both 1be ndher lnd unbam blbyMien 1Niting dlpwiign in IJIIUI!lnhwt,.. Cniderllplllitg in 1hl1linlllinMiar. \'o\mwi shdl doelt:n . . . $lOpping 1hel8 n.clicetin.

treatment
psychotherapy short-term safety of maternal SSRis for breastfeeding infants established; long-term effects unknown supportive. non-directive counselling by trained home visitors if depression severe, consider ECT prognosis: impact on child development - increased risk of cognitive delay, insecure attachment, behavioural disorders; treatment of mother improves outcome for child at 8 months through increased mother-child interaction

Toronto Notes 2011

Mood Disorders

Psychiatry PSll

Premenstrual Dysphoric Disorder (PMDD)

DSM-IV-TR Diagnostic Criteria for Premenstrual Dysphoric Disorder

-----

Reprinllld with parmiaion from Ills Dillgnostic and Statistical Mlnual ol Msnllll Disordsrs,. Text Revilion, Fourth Edition, (Copyright 2000]. American Psychilllric Association.

A. in most menstrual cycles during the past year, five (or more) of the following symptoms were present for most of the time during the last week of the luteal phase, began to remit within a few days after the onset of the follicular phase, and were absent in the week post-menses, with at least one of the symptoms being one ofthe first four listed 1. markedly depressed mood. feelings of hopelessness, or self-deprecating thoughts 2. marked anxiety, tension, feeling of being "keyed up" or "on edge 3. marked affective lability 4. persistent and marked anger, irritability, or increased interpersonal conflicts 5. decreased interest in usual activities 6. difficulty concentrating 7. lethargy, easily fatigued, lack of energy 8. change in appetite - overeating or specific food cravings 9. hypersomnia or insomnia 10. a sense ofbeing overwhelmed or out of control 11. physical symptoms - breast tenderness or swelling, headaches, joint or muscle pain, sensation ofbloating or weight gain B. the disturbance markedly interferes with work, school, social activities or relationships with others C. the disturbance is not merely an exacerbation of the symptoms of another disorder such as Major Depressive Disorder, Panic Disorder, Dysthymic Disorder or Personality Disorder D. Criteria A, B and C must be confirmed by prospective daily recordings and/or ratings during at least two consecutive symptomatic cycles

Treatment
1st line: SSRis highly effective in treating PMDD fluoxetine and sertraline most studied can be used intermittently in luteal phase x 14 days 2ndline clomipramine alpraxolam ocanax-) for anxiety symptoms 3rdline OCP containing progesterone drospirenone (e.g. Yasmin) GnRH agonists (e.g.leuprolide) if GnRH agonist completely relieves symptoms, may consider definitive surgery (ie. total abdominal hysterectomy+ bilateral salpingo-oophorectomy)

Bipolar Disorders
BIPOLAR I I BIPOLAR II DISORDER Definition
Bipolar I Disorder disorder in which at least one manic or :m.iied episode has occurred commonly accompanied by at least 1 MDE but not required for diagnosis Bipolar II Disorder disorder in which there is at least 1 MDE and at least 1 hypomanic episode no put or mixed episode

Epidemiology prevalence: 0.6-0.9%; M:F = 1:1

age of onset: teens to 20's

Risk Factors
slight increase in upper socioeconomic groups

60-65% of bipolar patients have family history of major mood disorders

Classification
classification of bipolar disorder involves describing the current or most recent mood episode as either manic, hypomanic, mixed or depressed the current or most recent episode can be further classified as without psychotic features, with psychotic features, with catatonic features, with postpartum onset, with seasonal pattern, with rapid cycling {at least 4 episodes of a mood disturbance in the previous 12 months that meet criteria for a Major Depressive, Manic, Mixed, or Hypomanic Episode)

PS12 Psychiatry

Mood Disorders/Anxiety Discmlers

Toronto Notes 2011

-a.. JCill'sycbitlty. 2006 Ftb; 67(21"277-86

SlUr. Rnlbnized, blnded ciricll trill.

a.np, ...... lllnr. r-s !.alt-

A ........_Co.lllllrill"eo.-

Treatment
biological: mood stabilizers, anticonvu.lsants, antipsychotics, antidepressants, ECT (Note: Treatment of bipolar depression must be done extremely cautiously; as a switch from depression to mania can result Monotherapy with antidepressants should be avoided) psychological: supportive and psychodynamic psychotherapy, cognitive or behavioural therapy social: vocational rehabilitation, leave of absence from school/work, drug and EtOH cessation, substitute decision maker for finances, sleep hygiene, social skills training, education for family members

Pllilnll: 52 pitilllll witb DSM-IV bipollt 11112 clisardir. lhllrnnllan: l'ltilla llacl1ld 1D uha& llri 1rill 1heApy ten wilh emGtive 111clliquQ crv.tmeat uu1. Both llftiUII' lUnd maad lllbililtn. lillin Oulana: ilylflmonll lltitudlf, psycholocie1fulctioninQ. hopellanta, ser-CIIItn'A. medicl1ion ld1aalce.l'lltiem by nflrl blindld 1D

Will-

CYCLOTHYMIA Diagnosis
presence of numerous periods of hypomanic and depressive symptoms (not meeting criteria for MDE) for yean; never without symptoms for >2 months no MDE, manic or mixed episodes; no evidence of psychosis symptoms are not due to the direct physiological effects of a substance or GMC symptoms cause clinically significant distress or impairment in social, occupational, or other important areas offunctioning

. . . . ,. &ll'lll'llhl. cr pllianiJ fewer deptessive lnd ' dyllln:tionllllliludal. Thlnl Will non-tignificlnt
1D gruiW timltD depfllliR II.... M1211ri 1o11orw"' cr paants bid 111w1r Young

indl,......

M11nilllaling IICUIIIInd irciiMd behMual A118 rronlh5, cr pllierQ 1ea

-nyafiRia. cr 111 pruvile benefits in 111e 12mantlls u:caedilg llllq)latillll rllllllllpy.

Treatment
similar to Bipolar I anticonvu.lsants psychotherapy

Anxiety Disorders
Definition
anxiety is a universal human characteristic involving tension, apprehension, or even terror,

which serves as an adaptive mechanism to warn about an external threat by activating the sympathetic nervous system (fight or flight) manifestations of anxiety can be described along a continuum of physiology, psychology, and behaviour physiology- main brain structure involved is the amygdala; neurotransmitters involved include serotonin, cholecystokinin, epinephrine, norepinephrine, dopamine psychology- one's perception of a given situation is distorted which causes one to believe it is threatening in some way behaviour - once feeling threatened, one responds by escaping or facing the situation, thereby causing a disruption in daily functioning anxiety becomes pathological when fear is greatly out of proportion to risk/severity of threat response continues beyond existence of threat or becomes generalized to other similar or dissimilar situations social or occupational functioning is impaired

Differential Diagnosis
Tabla 3. Differential Diagnosis of Anxiety Disorders
Canlavncular Relpiratol'f
Endocrina Post-MI,IIIhythmia, cqestive hellt failure, pulmoniiV ermolus, mitral Vlllve prolapse Asthma. COPD, pn1111monia. hyp11V8ntilation

Hyperttryroicism, pheoclv'omocytoma, hypoglycemia, hyperadrenalism, hyperpanrthyroidism

Vitamin B 12 deficiency, porphyria

Metabolic

Neurulogic
Substance-Induced

wstibular dysfunction, encaphalilis

cocaine, thyroid preparations, OTC for coldtldecongestants), disorder5 (OCPD), somilloform disardB!i

Intoxication {caffeine,

withdlliWIII {benzodiazupines, alcohol) Psychotic di5DrdB!i, mood di5DrdB!i,

Other Psychiatric Disardm

Medical Workup of Anxiety Disorder

routine screening: physical examination, CBC, thyroid function test, electrolytes, urinalysis, urine drug screening additional screening: neurological consultation, chest x-ray; electrocardiogram (ECG), CT scan

Toronto Notes 2011

Anxiety Disorders

Psychiatry PS13

Panic Disorder
DSM-IV-TR Diagnostic Criteria for Panic Disorder without Agoraphobia
Reprinllld with parmiaion from Ills Dillgnostic and Statistical Mlnual ol Msnllll Disordsrs,. Text Revilion, Fourth Edition, (Copyright 2000]. American Psychilllric Association.

A. both (1) and (2) (1) recurrent unexpected panic attacks: a discrete period of intense fear or discomfort, in which <!:4 of the following symptoms develop abruptly and reach a peak within 10 minutes palpitations, pounding heart, or accelerated heart rate sweating trembling or shaking sensations of shortness of breath or smothering feeling of choking chest pain or discomfort nausea or abdominal distress feeling dizzy, unsteady, lightheaded, or faint derealization (feelings of unreality) or depersonalization (being detached from oneself) fear oflosing control or going crazy fear of dying paresthesias (numbness or tingling sensations}, chills or hot flushes (2) at least one of the attacks has been followed by 1 month (or more) of<!:l of the following persistent concern about having additional attacks worry about the implications of the attack or its consequences (e.g. losing control, having a heart attack, "going crazy") a significant change in behavior related to the attacks B. absence of agoraphobia C. the panic attacks are not due to the direct physiological effects of a substance or GMC D. the panic attacks are not better accounted for by another mental disorder, such as Social Phobia, Specific Phobia, Obsessive-Compulsive Disorder, Post-Trawnatic Stress Disorder, Separation Anxiety Disorder

Situational trigger ____. Panic attack

Increased anxiety 111d venellllimtion

til othar

+-

Mentally 1166oc:illlad with

siluation

Figure 1. Panic Attack

It'

Critarill for Panic Diu"* (:.:41

nUDENI'S FEAR ._ 3 C'

Swuting

Trambling Unsteadiness, di12iness Derealization Exc111ivll htrt m., palpitations

NaU581

Tinglilg ShorlniSS of braath

Fur of dying, losing control, going crazy

3 C's: Chait pail, Chilli, Choking

Epidemiology prevalence: 1.5-596 (one ofthe top five most common reasons to see a family doctor); M:F = 1:2-3 onset average late 20's, familial pattern Treatment psychological supportive psychotherapy, relaxation techniques (visualization, box-breathing), cognitive behavioural therapy (correct distorted thinking, desensitization/exposure therapy) biological SSRis: fluoxetine, citalopram, paroxetine, fl.uvoxamine, sertraline SNRI: venlafaxine with SSRI/SNRis start low, go slow, aim high to prevent non-compliance due to physical side effects, explain symptoms to expect prior to initiation other antidepressants (TCAs: clomipramine, imipramine, mirtazapine, MAOis) consider avoiding bupropion due to stimulating effects benzodiazepines (short term, low dose, regular schedule, long half-life, no pm) Prognosis 6-10 years post-treatment: 3096 well, 40-5096 improved, 20-3096 no change or worse clinical course: chronic, but episodic with psychosocial stressors Panic Disorder with Agoraphobia agoraphobia anxiety about being in places or situations from which escape might be difficult (or embarrassing) or where help may not be available in the event of having an unexpected panic attack fears commonly involve situations: being out alone, being in a crowd, standing in a line, or travelling on a bus situations are avoided, endured with anxiety or panic, or require companion treatment: as per panic disorder

Generalized Anxiety Disorder (GAD)

DSM-IV-TR Diagnostic Criteria for Generalized Anxiety Disorder
Reprinled with permission from tile Dillgnostic and Statistical Manual ol Menllll Disorders. Text Revision. Fourth Edition. (Copyright 2000]. American Psychilllric Association.

A. excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance) B. the person finds it difficult to control the worry

PS14 Psychiatry

Anxiety Disorders

Toronto Notes 2011

It'

cnt.ria hr GAD {:.?:31

Blank mind Easily flrtigued Sleep di&lurbn:u Keyed up
lrrilllbility

IE SKIM

Musc'-llnsion

C. the anxiety and worry are associated with of the following 6 symptoms (with at least some symptoms present for more days than not for the past 6 months) Note: Only one item is required in children 1. restlessness or feeling keyed up or on edge 2. being easily fatigued 3. difficulty concentrating or mind going blank 4. irritability 5. muscle tension 6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) D. the focus of the anxiety and worry is not confined to features of an Axis I disorder, such as panic disorder, social phobia, etc. E. the anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning F. the disturbance is not due to the direct physiological effects of a substance or a GMC and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder
Epidemiology 1-year prevalence: 3-8%; M:F = 1:2 if considering only those receiving inpatient treatment, ratio is 1:1 most commonly presents in early adulthood Treatment lifestyle: caffeine and EtOH avoidance, sleep hygiene psychological: psychotherapy, relaxation, mindfulness, and CBT biological benzodiazepines (short term, low dose, regular schedule, long half-life, no prn) buspirone (tid dosing) others: SSRis/SNRI, TCAs, beta-blockers avoid bupropion due to stimulating effects combinations of above Prognosis chronically anxious adults become less so with age depends on pre-morbid personality functioning, stability of relationships, work, and severity of environmental stress difficult to treat

Phobic Disorders
Specific Phobia definition: marked and persistent fear that is excessive or unreasonable, cued by presence or anticipation of a specific object or situation lifetime prevalence 12-16%; M:F ratio variable types: animal/insect, environment (heights, storms), blood/injection/injury, situational (airplane, closed spaces), other (loud noise, clowns) Social Phobia (Social Anxiety Disorder) definition: marked and persistent fear of social or perfonnance situations in which person is exposed to unfamiliar people or to possible scrutiny by others; person fears he/she will act in a way that may be humiliating or embarrassing (e.g. public speaking, initiating or maintaining conversation, dating, eating in public) lifetime prevalence may be as high as 13-16%; M<F Diagnostic Criteria for Phobic Disorders exposure to stimulus almost invariably provokes an immediate anxiety response; may present as a panic attack person recognizes fear as excessive or unreasonable situations are avoided or endured with anxiety/distress significant interference with daily routine, occupational/social functioning, and/or marked distress if person is <18 years, duration is at least 6 months Treatment psychological exposure therapy/desensitization, insight-oriented psychotherapy behavioural therapy is more efficacious than medication biological beta-blockers or benzodiazepines in acute situations (e.g. public speaking) SSRis, MAOis; clomipramine Prognosis chronic

Toronto Notes 2011

Anxiety Disorders

Psychiatry PSIS

Obsessive-Compulsive Disorder (OCD)

DSM-IV-TR Diagnostic Criteria for Obsessive Compulsive Disorder
Reprinbld with permission from the Diagnostic and Statistical Mlrlual ol Mentlll Disorders. Text Revision. Fourth Edition. (Copyright 2000]. Ameriam l'!iychilllric Asaociati011.

A. either obsessions or compulsions obaeasions as defined by (1), (2), (3), and (4) (1) recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress (2) the thoughts, impulses, or images are not simply excessive worries about real-life problems (3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action (4) the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion) compulsions as defined by (1) and (2) (1) repetitive behaviours or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly (2) the behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive B. at some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable (ego-dystonic) Note: This does not apply to children C. the obsessions or compulsions cause marked distress, are time consuming (take hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships D. if another Axis I disorder is present, the content ofthe obsessions or compulsions is not restricted to it (e.g. preoccupation with food in the presence of an Eating Disorder) E. the disturbance is not due to the direct physiological effects of a substance or a GMC
Epidemiology lifetime prevalence rates 2-3%; M=F rate ofOCD in first-degree relatives is higher than in the general population Treatment CBT: desensitization, flooding, thought stopping, implosion therapy, aversive conditioning pharmacotherapy clomipramine, SSRis (higher doses and longer treatment needed than for treatment of depression, i.e. up to 8-12 weeks) atypical and typical antipsychotics - risperidone, haloperidol Prognosis tends to be refractory and chronic

Post-Traumatic Stress Disorder (PTSD)

DSM-IV-TR Diagnostic Criteria for Post-Traumatic Stress Disorder
Reprintlld with permission from the Diagnostic and Statistical Mlrlual of Mentlll Disorders. Text Revision, Fourth Edition, (Copyright 2000]. American Psychiatric Asaociati011.

A. the person has been exposed to a traumatic event in which both of the following were present (I) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behaviour B. the traumatic event is persiatently re-experienced in one (or more) of the following wa}'5: (1) recurrent and intrusive distressing recollections of the event. including images, thoughts, or perceptions Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed (2) recurrent distressing dreams ofthe event Note: In children, there may be frightening dreams without recognizable content (3) acting or feeling as ifthe traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated) Note: In young children, trauma-specific reenactment may occur (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect ofthe traumatic event (5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect ofthe traumatic event

PS16 Psychiatry

Anxiety Disorders/Adjuatment Disorder

Toronto Notes 2011

It'

cnt.ria hr .._st-Trau!Miic ttr.. Disorder

TIIAUMA

T111umatic event
11&-experienca lha avant

Avoidence of llimuli nsociated with lhatnJuma

Unabl1 to function

More 1han 1 Month Arousal increased

C. persistent avoidance of stimuli associated with the trauma and numbing of general (not present before the trawna), as indicated by of the following: ( 1) efforts to avoid thoughts, feelings, or conversations associated with the trauma (2) efforts to avoid activities, places, or people that arouse recollections of the trauma (3) inability to recall an important aspect of the trawna (4) markedly diminished interest or participation in significant activities (5) feeling of detachment or estrangement from others (6) restricted range of affect (e.g_ unable to have loving feelings) (7) sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal life span) D. persistent symptoma of increased arousal (not present before the trauma), as indicated by of the following: ( 1) diffi.culty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hypervigilance (5) exaggerated startle response E. duration of the disturbance (symptoms in Criteria B, C, and D) is month F. the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Epidemiology prevalence in general population: 7% men's trauma is most commonly combat experience; women's trawna is usually ph)15ical or sexual assault Treatment CBT: S}'5tematic desensitization, relaxation techniques, thought stopping biological

SSRis
benzodiazepines (for acute anxiety) first-line adjunct- atypical antipsychotics (quetiapine, olanzapine, risperidone) Eye Movement Desensitization and Reprocessing (EMDR): an experimental method of reprocessing memories of distressing events by recounting them while using a form of dual attention stimulation such as eye movements, bilateral sound, or bilateral tactile stimulation

Complications substance abuse, relationship diffi.culties, depression, impaired social and occupational functioning, Axis II disorders

Adjustment Disorder
DSM-IV-TR Diagnostic Criteria for Adjustment Disorder
Reprinted with parmi11ion from the lliagnOIIic and Statistical Manual of Manbll Disardan, Text Ravi1ion, Fourth American Psychiatric AaiOCiatian.

(Copyright

A. the development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s) B. these symptoms or behaviours are clinically significant as evidenced by either of the following (1) marked distress that is in excess ofwhat would be expected from exposure to the stressor (2) significant impairment in social or occupational (academic) functioning C. the stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a pre-existing Axis I or Axis II disorder D. the symptoms do not represent bereavement E. once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional6 months specifyif acute: if the disturbance lasts less than 6 months chronic: if the disturbance lasts for 6 months or longer adjustment disorders are coded based on the subtype, which is selected according to the predominant symptoms

Classification types of stressors single (e.g. termination of romantic relationship) multiple (e.g. marked business difficulties and marital problems) recurrent (e.g. seasonal business crises) continuous (e.g_ living in a crime-ridden neighbourhood) developmental events (e.g. going to school, leaving parental home, getting married, becoming a parent, failing to attain occupational goals, retirement) Note: the specific stressor is specified on Axis IV

Toronto Notes 2011

Adjustment Disorder/Cognitive Disorders

Psychiatry PS17

subtypes, adjustment disorder with: depressed mood anxiety mixed anxiety and depressed mood disturbance of conduct mixed disturbance of emotions and conduct unspecified

Epidemiology
M=F

Treatment
brief psychotherapy (group, individual), crisis intervention biological benzodiazepines may be used for those with anxiety symptoms (short-term, low-dose, regular schedule, long half-life, no pm) SSRis for both depressed and anxiety symptoms

Cognitive Disorders
Delirium
see N10

DSM-IV-TR Diagnostic Criteria for Delirium due to a GMC

Reprinlad with pannission from lila Diagnostic and Statistical Manual of Mantll Discrdars. Text Revision, Fourth Edition, (Copyright 211110). American l'lychilllric Association.

A. disturbance of consciousness (i.e. reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention B. a change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia C. the disturbance develops over a short period of time {usually hours to days) and tends to fluctuate during the course of the day D. there is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a GMC

Clinical Presentation and Assessment

common symptoms wandering attention distractibility disorientation (time, place, rarely person) misinterpretations, illusions, hallucinations speech/language disturbances (dysarthria, dysnomia, dysgraphia) affective symptoms (anxiety, fear, depression, irritability, anger, euphoria. apathy) shifts in psychomotor activity (groping/picking at clothes, attempts to get out of bed when unsafe, sudden movements, sluggishness, lethargy) Folstein Mini Mental Status exam is helpful to assess baseline of altered mental state - i.e. score will improve as symptoms resolve

Risk Factors
hospitalization (incidence 10-40%) nursing home residents (incidence 60%) childhood (e.g. febrile illness, anticholinergic use) old age (especially males) severe illness (e.g. cancer, AIDS) pre-existing cognitive impairment or brain pathology recent anesthesia substance abuse

PS18 Psychiatry Etiology

It' D..irium

Cognitive Disorders

Toronto Notes 2011

I WATCH DEATH
lnfectiou.

Wi1hdrawal from drugs Al:ut rnmbolic disonlw

T111uma
CNS pathology Hypoxia
Deficiencies in vitamins

Endocrinopathies
Al:ute VQCular irl$1111$ Toxins

Heavy metals

Infectious (encephalitis, meningitis, UTI, pneumonia) Withdrawal (alcohol, barbiturates, benzodiazepines) Acute metabolic disorder (electrolyte imbalance, hepatic or renal failure) Trauma (head injury, postoperative) CNS pathology (stroke, hemorrhage, tumour, seizure disorder, Parkinson's) Hypoxia (anemia, cardiac failure, pulmonary embolus) Deficiencies (vitamin B12> folic acid, thiamine) Endocrinopathies (thyroid, glucose, parathyroid, adrenal) Acute vascular (shock, vasculitis, hypertensive encephalopathy) Toxins: substance use, alcohol or alcohol withdrawal, sedatives or sedative withdrawal, narcotics (especially morphine), anesthetics, anticholinergics, anticonvulsants, dopaminergic agents, steroids, insulin, glyburide, antibiotics (especially quinolones), NSAIDs Heavy metals (arsenic, lead, mercury)

Investigations
standard: CBC and differential, electrolytes, calcium, phosphate, magnesium, glucose, ESR, LFTs Cr, BUN, TSH, vitamin B12, folate, albumin, urine C&S, R&M as indicated: ECG, CXR, Cf head, toxicology/heavy metal screen, VDRL, HIY, LP, EEG (typically abnormal: generalized slowing or fast activity), blood cultures indications for radiological investigations: focal neurological deficit, acute change in status, anticoagulant use, acute incontinence, gait abnormality, history of cancer

Management
intrinsic identify and treat underlying cause immediately stop all non-essential medications maintain nutrition, hydration, electrolyte balance and monitor vitals extrinsic environment should be quiet and well-lit optimize hearing and vision room near nursing station for closer observation; constant care if patient jumping out of bed, pulling out lines family member present for reassurance and re-orientation calendar, clock for orientation cues biological haloperidol or risperidone (low dose) lorazepam physical restraints if patient becomes violent

Prognosis
up to 50% I year mortality rate after episode of delirium

Dementia
see NeuroloKY. Nll

....

.,

DSM-IV-TR Diagnostic Criteria for Dementia (Alzheimer's Type)

Reprinted with permi11i011 from the Diagnostic 111d American Psychimic Assoc:iation

Manual of

Disorden,

Taxt Revision, Fourtll

[Copyright 2000).

MDIII: Common

Alzheimer's dementia Vascular dementia Llwy-Body demlntill

r,_ of Dim..._

Fronto-tEmporal dementia

A. the development of multiple cognitive deficits manifested by both 1. memory impairment (impaired ability to learn new information or to recall previously learned information) 2. 1 of the following cognitive disturbances: aphasia (language disturbance) apraxia (impaired ability to carry out motor activities despite intact motor function) agnosia (failure to recognize or identify objects despite intact sensory function) disturbance in executive functioning (i.e. planning, organizing, sequencing, abstracting) B. the cognitive deficits in Criteria AI and A2 each cause: significant impainnent in social or occupational functioning and represent a significant decline from a previous level of functioning C. the course is characterized by gradual onset and continuing cognitive decline D. the cognitive deficits in Criteria AI and A2 are not due to any of the following: 1. other central nervous system conditions that cause progressive deficits in memory and cognition 2. systemic conditions that are known to cause dementia 3. substance-induced conditions E. the deficits do not occur exclusively during the course of a delirium F. the disturbance is not better accounted for by another Axis I disorder

Toronto Notes 2011

Cognitive Disorders

Psychiatry PS19

Epidemiology
prevalence increases with age: 10% in patients over 65 years of age; 25% in patients over 85 years of age prevalence is increased in people with Down syndrome and head trauma Alzheimer's dementia comprises >50% of cases; vascular causes comprise approximately 15% of cases (other causes of dementia- see NeuroloiD'. N12) 10% of dementia cases are potentially curable (mainly vascular etiology) average duration of illness from onset of symptoms to death is 8-10 years

Subtypes
with or without behavioural disturbance (e.g. wandering, agitation) early onset age of onset <65 years late onset: age of onset >65 years

Investigations (rule out reversible causes) standard: see Delirium, PS18 as indicated: VDRL, HIY, SPECT, CT head in dementia indications for CT head, (see Delirium section) plus: age <60, rapid onset (unexplained decline in cognition or function over 1-2 months), dementia of relatively short duration (<2 years),
recent significant head trauma, unexplained neurological symptoms (new onset of severe headache/seizures)

Management
treat medical problems and prevent others provide orientation cues (e.g. clock, calendar) provide education and support for patient and family (day programs, respite care, support groups, home care) consider long-term care plan (nursing home) and power of attorney/living will inform Ministry of Transportation about patient's inability to drive safely consider pharmacological therapy cholinesterase inhibitors [e.g. donepezil (Aricept)] for mild to severe disease glutamatergic NMDA receptor antagonist (e.g. memantine) for moderate to severe disease low-dose neuroleptics (haloperidol, risperidone) and antidepressants if behavioural or emotional symptoms prominent - start low and go slow reassess pharmacological therapy every 3 months
Tabla 4. ComJIIrison of Dementia, Delirium and Psaudodamantia of Depression

Dementia DnHI:
Dundion Nabnl HisiDry Graduallslep.wise decline

Deliri..u Al:ute (hours - days)

Pseudadellantil of Depression
Subacute Variable Racunant Usually ravarsibla Normal Difficulty concentrating

J.Wo12005; 294{151:1!134-1943 ...,_ To -lba Mlara far increll8d lllllfllity from llypicllllllipl,cholic 6ug trelltmlnl fur del.lliont, nd llgitltioa in dementil. SbidrCbncllrillicl: MIIHllllylil ri1511CTs witl511 0plltients. Pllllci[IIID: l'lllilnts willl Alllllim di-e or demllltiL . . . lld OI:QIIIUd 111018 r:tt.n - ; pidients llndomimd1D d11411 (118115\1 vs. 40 (2.3\). Thl oddi lllil by 1111111-ll'lllylis- 1.54; 1M cridlact i!UMI[CII, 1.111-2.23; P=O.ozj. SelllitM.y lllllly$85 not !IIGW swid&nQI far lifllwllill rilb for indivicllll drugs Dl diiQIIOiil. c..:tun.: Alypi:al mugsny be atOCilllll with ...... illalald risk of dellh COQBred to pldo. This risk should be considnt Mhin lile rl medical need for 1lle d!ugs.llb:y evidence, 1111diCII cunuxtlidily, lind lba efliclcy llld Slfety of llla'MMc.

,...............

lllug

Months -years
Progressiva Usualy imMIIllbla

Days-weeks
Auctuating. ravarsbla High morbidity/mortality in very old Auctuating (over 24 hours) Decreased (Wllldering. easy distraction) lmpairad (usuallytll lima and place), fluctuates

Lenl of CaniiCiaUIDIR Normal

Attanlion Not aflected Intact initialy Di&inhibition, impairment in ADIJIADL personality change. loss of social graces Normal Fragmented sleep at night Labile but not usually anxious

DrientlliDI
Bellniour

ntact
&Bif.rnmv&uic:ide

58'18111 agitation'ralirirtion
Fluctuates between extremes Reversed sleep wake cycle Anxious, irritable, fluctuating

l'lychomotor
Sleep Walle Cycle

Slowing

Early momilg awakening

Depressed, stable Fluctuating Recent Not affected

Mood and Affut

Cognition

Decreased executive functioning, Auctuating preceded by mood paucity of thought changes Recent. eventually remote Agnosia. aphasia. decreased comll'l!hension, repetition, speech (echolalia, palilaliaf

MemorvLoss
LlngiJIIIII

Marked recent
Dysnomia. speech rarmling. im!levanl, incoherent, subject chalges Nightmarish and poorly formed Visual cDITIIIDn Frightenirizarre Al:ute ilnass. dl\lljtuxicity

Delusions Hallucinatian

Nihilistic, somatic Less common. predominates

Variable

llullity of Hllluc:illltion1 Vacuouflbland

SeN-deprecatory RIO systemic illness. mads

Medii:IISbdul

Variable

PS20 Psychiatry

Substance-Related Disorders

Toronto Notes 2011

Substance-Related Disorders
Types of Substance Disorders 47% of those with substance abuse have mental health problems 29% of those with a mental health disorder have a substance use disorder 47% of those with schizophrenia, 25% of those with an anxiety disorder A. Substance-use disorders 1. substance abuae: maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 1 ofthe following occurring within a 12 month period recurrent use resulting in failure to fulfill major role obligation recurrent use in situations in which it is physically hazardous (e.g. driving) recurrent substance-related legal problems continued use despite interference with social or interpersonal function 2. substance dependence: maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by occurring at any time in the same 12 month period tolerance (need for increased amount to achieve intoxication or diminished effect with same amount of substance) withdrawal/use to avoid withdrawal taken in larger amount or over longer period than intended persistent desire or unsuccessful efforts to cut down excessive time to procure, use substance, or recover from its effects important interests/activities given up or reduced continued use despite physical/psychological problem caused/exacerbated by substance B. Substance-induced disorders 1. substance intoxication: reversible physiological and behavioural changes due to recent exposure to psychoactive substance 2. substance withdrawal: substance-specific syndrome that develops following cessation of or reduction in dosage of regularly used substances

It'

Subltii-Depllldence
11113 Cs Compulsive use Lou ofC11111101
Conslqiiii!CIS of USI

Alcohol
see Family Medicine, FM10 and Emerl:'ency Medicine, ER48
History validated screening questionnaire C ever felt the need to Cut down on drinking? A ever felt Annoyed at criticism ofyour drinking? G ever feel Guilty about your drinking? E ever need a drink first thing in morning (Eye opener)? for men, a score is a positive screen; for women, a score 1 is a positive screen if positive CAGE, then assess further to distinguish between problem drinking and alcohol dependence General Assessment When was your last drink? Do you have to drink more to get the same effect? Do you get shaky or nauseous when you stop drinking? Have you ever had a withdrawal seizure? How much time and effort do you put into obtaining alcohol? Has your drinking affected your ability to work, go to school, or have relationships? Have you suffered any legal consequences? Has your drinking caused any medical problems? Table 5. Differentiating Moderate Drinking from a Drinking Problem

Table Wme (12'llo)- 5 oz. or 142 ml Fortified Wine 3 oz. or 85 ml Rlgular Baer {5'11.)- 12 oz. or 341 ml

A "Stllndard Drink" Spirit (40'llo)-1.5 oz. or 43 mL

OR

1 pint beer = 1.5 SO

1 bottle wine = 5 SD 1 "mick8y" = 8 SD "26-ar" = 17 SD "40 oz. - 27 SD

Mllb sur. to ask about olhar alcohols: mouthwash, rubbing alcohol, methanol, ethylene Qlvcol,llf1Bisnave (may be used as a cheaper alternative}

\,
Alcohol abuse Cllll only be diagnosed in tna absence of alcohol depllldance. Thl criteria for abuse and dapendsnce are outlined under substance-usa disorders.

Modeme Dmking Drinking within lha rac:orrmanded guidelines (U.S. Department Dl 111d Human Services) Men: 2or lest/day Wom111: 1or lass/day Elderly: 1or I.Vd&y

Drinking Problem
Drinking abovelha rac011111andad !J!idelinas, associated with: Drinking to llllllca dapniSiion or anxiety Loss Dl irterest in food Lying/hiding dmking habits Drinking alone Injuring ar others while intoxicated Was drunk mare !han three or lour times over the last yell' Increasing Withdrawal symptoms: feeling irritable, rasanlful, u11'81sonabla whan not dririing ExperiiiiCing medical, social, or financial problems caused by drinking

Toronto Notes 2011

Substance-Related Disonlen

Psychiatry PS21

Alcohol Intoxication
legal limit for impaired driving is 10.6 mmol!L (50 mgtdL) reached by 2-3 drinkslh for men and 1-2 drinks/h for women coma can occur with 60+ mmol!L (non-tolerant drinkers) and 90-120 mmol!L (tolerant drinkers)

Alcohol Withdrawal
occurs within 12 to 48 hours after prolonged heavy drinking and can be life-threatening alcohol withdrawal can be described as having 4 stages, however not all stages may be experienced stage 1 (onset 6-12 hours after last drink): tremor, sweating, agitation, anorexia, cramps, diarrhea, sleep disturbance stage 2 (onset 1-7 days): visual, auditory, olfactory or tactile hallucinations stage 3 (onset 12-72 hours and up to 7 days): seizures, usually tonic-clonic nonfocal and brief stage 4 (onset 3-5 days): delirium tremens, confusion, delusions, hallucinations, agitation, tremors, autonomic hyperactivity (fever, tachycardia, hypertension) course: in young almost completely reversible; elderly often left with cognitive deficits mortality rate 20% if untreated

......

Dltirium (alcohol withdr.wal delirilm) AuiDnomic hyparactivity (diaphorasis, 1achycardie, incrnsad raspinrtion) Hlllldtramor

Insomnia l'$ychomotor agitation Anxilly Nau11111 or vomiting Tonic-clonic nizLI'IIS VisualftaclilrlauditD!y hallucinations l'llrsiCU!ory delusions

Management of Alcohol Withdrawal

monitor using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) scoring

system
areas of assessment include nausea and vomiting paroxysmal sweats tactile disturbances visual disturbances anxiety tremor auditory disturbances headache, fullness in head agitation orientation and clouding of sensorium all categories are scored from 0-7 (except: orientation/sensorium 0-4), maximum score of 67 mild<10 moderate 10-20 severe >20 basic treatment protocol using CIWA-A scale diazepam 20 mg PO q1-2h prn until CIWA-A <10 points; tapering dose not required observe 1-2 h after last dose and re-assess on CIWA-A scale thiamine 100 mg 1M then 100 mg PO OD for 3 days supportive care (hydration and nutrition) if history of withdrawal seizures diazepam 20 mgPO q1h for minimum of three doses regardless of subsequent CIWA scores if history of seizure disorder or multiple withdrawal seizures despite diazepam, use anti-seizure medication (e.g. Dilantin) if oral diazepam not tolerated diazepam 2-5 mg IV/min- maximum 10-20 mg q1h; or lorazepam SL if >65 years old or severe liver disease, severe asthma, or respiratory failure, use short acting benzodiazepine lorazepam PO/SL/IM 1-4 mg q1-2h ifhallucinations are present haloperidol2-5 mg IM/PO q1-4h- max 5 doses/day or atypical antipsychotics (olanzapine, risperidone) diazepam 20 mg x 3 doses as seizure prophylaxis (haloperidol lowers seizure threshold) admit to hospital if still in withdrawal after >80 mg of diazepam delirium tremens, recurrent arrhythmias, or multiple seizures medically ill or unsafe to discharge home

Wernlcke-Korsakoff Syndrome
alcohol-induced amnestic disorders due to thiamine deficiency necrotic lesions - mammillary bodies, thalamus, brainstem Wernicke's encephalopathy (acute and reversible}: triad of nystagmus (CN VI palsy}, ataxia and confusion Korsakoff's syndrome (chronic and only 20% reversible with treatment): anterograde amnesia and confabulations; cannot occur during an acute delirium or dementia and must persist beyond usual duration of intoxication/withdrawal management Wernicke's: thiamine 100 mg PO OD x 1-2 weeks Korsakoff's: thiamine 100 mg PO bid/tid x 3-12 months

PS22 Psychiatry

Substance-Related Disorders

Toronto Notes 2011

-"{.,
EtOH lhtallolism EtOH
Alcohol Dehydrogenase

Treatment of Alcohol Dependence

Non-pharmacological behaviour modification: hypnosis, relaxation training. aversion therapy, assertiveness training, operant conditioning supportive services: half-way houses, detoxification centres, Alcoholics Anonymous psychotherapy, motivational interviewing medications important as adjunctive treatment: SSRis, ondansetron, topiramate

Aclllaldahyda
1 Acetaldehyde Dehydrog811111e

Pbarmacological
naltrexone: opioid antagonist, shown to be successful in reducing the "high associated with alcohol, moderately effective in reducing cravings, frequency or intensity of alcohol binges disulfiram (Antabuse): blocks oxidation of alcohol (blocks acetaldehyde dehydrogenase); with alcohol consumption, acetaldehyde accumulates to cause a toxic reaction (vomiting, tachycardia, death); ifpatient relapses, must wait 48 hours before restarting Antabuse

Acetic Acid

..... ,

Opilid Antqonilll: Nahrexone n. Naloxone

Nallraxona (R8Via4t) Usad for opioid and ElOH dependence Long hlllf lila (hours) Naloxone {Narcan4t): Used for life-threatening CNS/mpiniiDry diPfnsion in opioid

Opioids
types of opioids: heroin, morphine, oxycodone, Tylenol #3 (codeine) major risks associated with the use of contaminated needles; increased risk of hepatitis B and C, bacterial endocarditis, HIV

overdoIii Shorthalflifa(<1 h) Very fast acting (mils) High llflinity for opioid I'IICIIpiDr Induces opioid withdnlwal symptoms

Acute Intoxication
direct effect on receptors in CNS resulting in decreased pain perception, sedation, decreased sex drive, nausea/vomiting, decreased GI motility (constipation and anorexia}, and respiratory depression

..... ,
Sy.lem

Toxic Reaction
typical syndrome includes shallow respirations, miosis, bradycardia, hypothermia, decreased level of consciousness treatment ABC's IV glucose naloxone hydrochloride (Narcan): 0,4 mg up to 2 mg IV for diagnosis treatment: intubation and mechanical ventilation, naloxone drip, until patient alert without naloxone (up to 48+ hours with long-acting opioids) caution with longer half-life; may need to observe for toxic reaction for at least 24 hours

Comnan Pres..a.tioM llf Dnll u..

Findmp

G-ral

Weight lou (npecially cocaine, heroin) lnjectud conjunctiva (cannabis) Pinpoint pupils (opioids) T111ck milks (injection drugs)
TI'IILml

MSK

Withdrawal
symptoms: depression, insomnia, drug-craving, rnyalgias, nausea, chills, autonomic instability (lacrimation, rhinorrhea, piloerection) onset: 6-12 h, duration: 5-10 days complications: loss of tolerance (overdose on relapse), miscarriage, premature labour management: long-acting oral opioids (methadone, buprenorphine), alpha-adrenergic agents (clonidine)

Gl

Vi111l hlpatitis (injection drugs) Unaxplained alevations in All (injection drup)

lhhlviaul'll

Missed appointmants
Non-compliance Drug-sulking (especially benZDdiazepines, opioids)

Treatment of Chronic Abuse

psychosocial treatment (e_g_ Narcotics Anonymous); usually emphasize total abstinence long-term treatment may include withdrawal maintenance treatment methadone relieves drug cravings and withdrawal symptoms without inducing sedation or euphoria naltrexone or naloxone (opioid antagonists) may also be used to extinguish drug-seeking behaviour

l'sychaloglcel Insomnia Fatigue

Deprunion Flat affect

(benzodilll6Pif181, barbitu1'1118S) Pnnoia (cocaine) Psychosis {cocaine, cannabis, halklcilogens)

Cocaine
street names: blow, C, coke, crack. flake, freebase, rock. snow alkaloid extracted from leaves of the coca plant; blocks presynaptic uptake of dopamine (causing euphoria), norepinephrine and epinephrine (causing vasospasm, hypertension) self-administered by inhalation or intravenous route

Socill

Marital discord

Family violllnce Worlr/school absantelism and poor perfonmance

Intoxication
elation, euphoria, pressured speech, restlessness, sympathetic stimulation (e.g. tachycardia, mydriasis, sweating) prolonged use may result in paranoia and psychosis

Overdose
medical emergency: hypertension, tachycardia, tonic-clonic seizures, dyspnea, and ventricular arrhythmias treatment with IV diazepam to control seizures and propanolol or labetalol to manage hypertension and arrhythmias

Toronto Notes 2011

Substance-Related Disonlen

Psychiatry PS23

Withdrawal initial"crash" (1-48 hours): increased sleep, increased appetite

withdrawal (1-10 weeks): dysphoric mood plus fatigue, irritability, vivid, unpleasant dreams, insomnia or hypersomnia, psychomotor agitation or retardation complications: relapse, suicide (significant increase in suicide during withdrawal period) management: supportive management

Treatment of Chronic Abuse optimal treatment not established psychotherapy, group therapy, and behaviour modification useful in maintaining abstinence studies of dopamine agonists to block cravings show inconsistent results Complications cardiovascular: arrhythmias, Ml, CVA, ruptured AAA neurologic: seizures psychiatric: psychosis, paranoia, delirium, suicidal ideation

Cannabis
marijuana, hashish (hash) and hash oil come from cannabis sativa street names: weed, herb, chronic, jay, bud, blunt, bomb, doobie, hydro, sinsemilla, hash, joint, pot, grass, reefer, Mary Jane (MJ), ganja, homegrown, dope, spliff marijuana is the most often used illicit drug psychoactive substance: delta-9-tetrahydrocannabinol (A9-THC) smoking is the most common mode of self-administration intoxication characterized by tachycardia, conjunctival vascular engorgement, dry mouth, increased appetite, increased sense of well-being, euphoria/laughter, muscle relaxation, impaired performance on psychomotor tasks including driving high doses can cause depersonalization, paranoia, and anxiety may trigger psychosis and schizophrenia in predisposed individuals chronic use associated with tolerance and an apathetic, amotivational state cessation does not produce significant withdrawal phenomenon treatment of dependence includes behavioural and psychological interventions to maintain an abstinent state

.....

,..,

Medical Uus llf Mrll-1111

Anorexi&-CIIIchexia (AIDS, clllCer)

Spasticity, muscle spasms (multiple sclerosis, spinll cord injury)

Lavodop&-inducad dyskinssill (Parkinson's Dise115e) Con1rolling lies end obsassive-

compulsive behaviour (Tourvttl's

syndroma) Reducing irtr&-ocular prnsurw (glaucoma)

c-. U..llllllilll"' Jllrdldic Mdivl

lllldalllllllb O.....:A S,..ldc llllilw 111tt.a!2007;370:31J.328 To IIVilw U.ll'idlncl far Clllllbis u 1111 ocammce Dllffiictive ll1illlll

,_.II:

Amphetamines
types of amphetamines: amphetamine, methamphetamine, dextroamphetamine street names: speed, bennies, glass, crystal, crank, pep pills and uppers class of drugs structurally related to catecholamine neurotransmitters, includes methamphetamine (see Club Drugs, PS24) intoxication characterized by euphoria, improved concentration, sympathetic and behavioural hyperactivity at high doses can cause coma chronic use can produce a paranoid psychosis diagnostically similar to schizophrenia with agitation, paranoia, delusions and hallucinations withdrawal symptoms include dysphoria, fatigue, and restlessness antipsychotics useful in treatment of stimulant psychosis

canlrallllldi ...tid willlin JanPhl daiQnL buill: Thllll-111 incl8ll8d ria It III1V Plld!CIIi:: outcon il indMdLIIII wbo hid -used Clllllllis (pooled a4IAd cQ!s ndio =1.41, 9S.. Cl 1.2ll-1.65). Findingswm CDI'IIilllntwithaa. mpDI'Ie Ellect wilb pder risk in peapil who

'-llh aullxnnn. S1udy l:hnc:tRiil:c Amell-lllllysis of35 bngiludiniiQici*.IJic:aa-

2.14). fildings far diJIRSSion.

balh cu. IPI'ithaiic llld llflcliw Clltomll)l IUbllmill t:aOnling lllicl- prw.rt.

Cancblnl: The linllngs .. aJasisllatwMh the vil.w tlllt c11111bis ilgeases risk of

Hallucinogens
types ofhallucinogens: LSD, mescaline, psilocybin, PCP, cannabis, ecstasy, salvia (see Club Drugs, PS24) LSD is a highly potent drug; intoxication characterized by tachycardia, hypertension, mydriasis, tremor, hyperpyrexia, and a variety of perceptual and mood changes high doses can cause depersonalization, paranoia, and anxiety no specific withdrawal syndrome characterized treatment of agitation and psychosis: support, reassurance, diminished stimulation; benzodiazepines or high potency antipsychotics seldom required

eh:ts,llllhqh evidence ii less Allnlllor af1ICIM 04Jb:om8L ClmiiiJis Ullllld tt. dellebpmsd It psychosis 11e stronu-lv associllll!d. il difi:uk10 dltanrila cually and il poail*l 1hlt lhi111111Cialian raulil from Clllllulding fll:tm 111 biaL The lllllkn did concllda 1hlt

indiiJIIIImltlllnlilllt illlllican

U.. is dcild l'lidanca1D Willi '101111Q p8IJIIII 1hlt using Cllllllbis c:ould increase thei' rist It dMbping a psvchatic ir.llllr in ln.

PS24 Psychiatry

Substance-Related Disorders/Suidde

Toronto Notes 2011

Table &. The Mechanism and Effects of Common "Club Drugs"

Drug Mechlniun

ElfKt

Adv1ne EffedJ

D1111geroa Effeclll

Rauta
MDMA
("'Ecstasy",

T,"E1

Actll on saroiDnargic Ernmced sensorium; Sweating. Hyparth111111ia, Tablllt and dopaminergic feelings of well-being. tachycardia arrhythmias, DIC, pathways, properties empathy fatigue. muscle rhabdomyolysis. Df a hallucinogen spasms (especially renal failure, seizures, and an amphetamine jaw clenching), death, lq.tann ataxia to serotonergic sysl!m [in animal models)
Bipbasic dopamine response (inhibition then release) and releasas substance EL.Phoric effects, Sweating. incnesed aggression, tachycardia, impaired jldgement fatigue. muscle spasms [especially jaw clenching), ataxia CNS depression will! EIOH Severe withdrawal from abrupt cessation of high doses: tremor, seizures, psychosis Salt dissolved in water

Gamma Hvdraxybutyrata IGHB, "G", "li...id Ecltaly"J

....

,.Jr-----------------, ,

Flunitruepilm (Rahypnal, .Rooli "Rape", "Tbe fllfllel Pill1

J'

Potent benzodiazepine, Sedation. rapid oral absorption psychomDIDr impainnent. amnestic effects, saxual

Salt or powder Dissolved inwtar Tastes sally

GHB

Daliii... Drvp
{Rohypnol)

Knlmine ("Special K",

"Kit-at"l

Kmmiu

NMDA recepiDr antagonist, rapid-acting genaral anesthetic used in pediatrics

Amphetamine stimulant, inlllces norepinephrine, dopamill8 and serotonin release

"Dissociative" state, profound amnesie/ nlgesia; hallucinations and sympathomimetic effects Rush begins in minutes, ellects last 6-8 hours, incnesad decreased appetite, general sense li well-being, tolerance occurs quickly, users often bilge and crash

Psychological distress, accidm due to of experience and lack Df bodily control Short term use: high agitation, rage, violent behaviour, occesi01181y hypertbennia and convulsions

In overdose, decreased LOC,

Tablet taken orally, crushed 111d respiratory dissolwd or depression, catetonill snorted

....

,.Jr-----------------, ,

Mtlllampbetamine ("spllll", "nlllth", "chalk", "ice", c.,ml")

with crystal ma1h use.

Formication -tactile hllluciflllion 1hllt insects Dr snakes re cnMiinv over or under 1ha skin. Espflcially IISSDCi818d

Long t111111 use: addiction, anxiety, confusion, insomnia, p111111oia. auditory and tactile hallucinations (esp. formication), delusions, mood disturbance, suicidal and homicidal thoughts, stroke, may be contaminated with lead, and W uselli may present with acute lead poisoning

Smoked, snorted, injected, orally ingested,

per rectum,
per vagina

P..ncyclidine I"PCP". "angel dust")

Nat understood, usad by V8ls to immobilize lqe animals

Amnestic, euphoric, HorimntaVverticel Prolonged agitated Orally, smoked, hallucilliltory state nystagmus, psychosis (tntat will! or IV myodonus, ataxia. with haloperidol); and autonomic high risk for suicide; common viol111ce1Dw8rds {treat will! diazepam others 1111 High dose cen ceusecoma

Suicide

Suiddlllillk Factors

SAD PERSONS Sax {rrmle) Age >60 yam old

DaprliSiion Previous lltlllmpts

Epidemiology attempted:completed = 20:1 M:F = 3:1 for completed; 1:4 for attempts Risk Factors epidemiologic factors age: increases after age 14; second most common cause of death for ages 15-24; highest rates in persons >65 years sex: male race/ethnic background: white or native Canadians on reserves marital status: widowed/divorced living situation: alone; no children < 18 years old in the household other: stressful life events; access to firearms

Ethanol abuse
lhlti01111l thinking lass {delusions, hallucinations, hopelessness] Suicide in family Orvanized plan No SPCJII'& (no support aystems) Swious illnus, intractllbl1 pain

Toronto Notes 2011

Suicide

Psychiatry PS25

psychiatric disorders mood disorders (15% lifetime risk in depression; higher in bipolar) anxiety disorders (especially panic disorder) schizophrenia ( 10-15% risk) substance abuse (especially alcohol- 15% lifetime risk) eating disorders (5% lifetime risk) adjustment disorder conduct disorder personality disorders (borderline, antisocial) past history prior suicide attempt family history of suicide attempt/completion

r-t,

md S..k:ide Risk Onca anlid1pmsant 1llllapy is initiar.d,

patienta shOilld be followed frequently as then is a "suicide window" in which the patient mil'( still be depressed, but now hllsmough lllllliY to CIIT'f out
suicide. Avoid tricyclic antidepressllllts {TCAsl because of high lllthality in overdose!

Clinical Presentation symptoms associated with suicide hopelessness anhedonia

insomnia severe anxiety impaired concentration psychomotor agitation panic attacks

Approach Every Patient: "Have you had any thoughts of wanting to hurtl1dll }'Oll1'8elf?" ideation - "Do you have thoughts about ending your life, committing suicide?" passive - would rather not be alive but does not admit to idea that involves act of initiation e.g. 'Td rather not wake up," "' wouldn't mind if a car hit me" active e.g. "' think about killing myself" plan - "Do you have a plan as to how you would end your life?" intent - "You talk about wanting to die, but are you planning to do "What has stopped you from ending your life?" past attempts - highest risk if previous attempt in past year ask about lethality, outcome, medical intervention
Assessment of Suicidal Ideation onset and frequency of thoughts - "When did this start? How often do you have these thoughts?" control over suicidal ideation - "Can you stop the thoughts or call someone for help?" lethality- "Do you want to end your life? Or get a 'release' from your emotional pain?" access to means - "How will you get a gun?" "Which bridge do you think you would go to?" time and place- "Have you picked a date and place? Is it in an isolated location?" provocative factors- "What makes you feel worse (e.g. being alone)?" protective factors- "What keeps you alive (e.g. friends, family, pets, faith, therapist)?" final arrangements - "Have you written a suicide note? Made a will? Given away your belongings?" practiced suicide or aborted attempts - "Have you put the gun to your head? Held the medications in your hand? Stood at the bridge?" ambivalence- "There must be a part of you that wants to live- you came here for help" Assessment of Suicide Attempt setting - isolated vs. others present, chance of discovery planned vs. impulsive attempt, triggers/stressors intoxication medical attention - brought in by another person vs. brought in by self to ER time lag from suicide attempt to ER arrival expectation of lethality, dying reaction to survival- guilt/remorse vs. disappointment/self-blame Management depends on the level of risk identified higher risk patients with a plan, access to lethal means, recent social stressors, and symptoms suggestive of a psychiatric disorder should be hospitalized immediately do not leave patient alone; remove potentially dangerous objects from room ifpatient refuses to be hospitalized, complete form for involuntary admission lower risk patients who are not actively suicidal, with no plan or access to lethal means discuss protective factors and supports in their life, remind them of what they live for, promote survival skills that helped them through previous suicide attempts

.....

.Jr-----------------,

Asking pati8rrts about suicide will not give them the idaa or the incentive to
commit suicide.

Thl best pradictor of comphttlld suicide is a history ol llttempted

suicide.

The most common psychiatric

disOR!tn IIIIDt:iallld with compllllad suicide .,. mood disonla1111111d alcohol abuse.

PS26 Psychiatry

SuiddeJSomatoform. Disorders

Toronto Notes 2011

make a safety plan - an agreement that they will not harm themselves, avoid alcohol, drugs, and situations that may trigger suicidal thoughts, follow-up with you at a designated time, and contact a health care worker, call a crisis line or go to an emergency department if they feel unsafe or if their suicidal feelings return or intensify depression: hospitalize if severe or if psychotic features are present; otherwise outpatient treatment with good supports and SSRis/SNRis alcohol-related: usually resolves with abstinence for a few days; if not, suspect depression personality disorders: crisis intervention/confrontation, may or may not hospitalize schizophrenia/psychosis: hospitalization parasuicide/self-mutilation: long-term psychotherapy with brief crisis intervention when necessary proper documentation of the clinical encounter and rationale for management is essential

Somatoform Disorders
General Characteristics
physical signs and symptoms lacking a known medical basis in the presence of psychological factors that are judged to be important in the initiation, exacerbation, or maintenance of the disturbance cause significant distress or impairment in functioning symptoms are produced unconsciously symptoms are not the result of malingering or factitious disorder which are under conscious control primary gain: somatic symptom represents a symbolic resolution of an unconscious psychological conflict; serves to reduce anxiety and conflict; no external incentive secondary gain: the sick role; external benefits obtained or unpleasant duties avoided (e.g. work)

il'' Malingering - irtenlionl produc:tion of

falsa or grossly IIXIIIIQIIIDd physical or JIIYChologiclll JYmplllma, molivatad by extemal reward (e.g. avoiding woR. obtaining financial compensation or obtaining drugsI

FICiitiolls disGr4er- inhlntionll production or feigning of physical or psyd!ological signs or sympiDms in order to assume the sick role where external incentives (e.g. economic gainl are abaent

Management of Somatoform Disorders

brief frequent visits limit number of physicians involved in care focus on psychosocial not physical symptoms minimize medical investigations; co-ordinate necessary investigations biofeedback psychotherapy: conflict resolution minimize psychotropic drugs: anxiolytics in short term only, antidepressants for depressive symptoms attend to transference and countertransference

Conversion Disorder
one or more symptoms or deficits affecting voluntary motor or sensory function that mimic a neurological or general medical condition (e.g. impaired co-ordination, local paralysis, double vision, seizures or convulsions) psychological factors thought to be etiologically related to the symptoms as the initiation of symptoms is preceded by conflicts or other stressors 11-300/100,000 in general population; focus oftreatment in 1-3% of outpatient referrals to mental health clinics more common in rural populations and in individuals with little medical knowledge spontaneous remission in 95% of acute cases, 50% of chronic cases (>6 months)

Somatization Disorder
recurring, multiple, clinically significant physical complaints which result in patient seeking treatment or having impaired functioning physical symptoms that have no organic pathology including each of: four pain symptoms related to at least four different sites or functions two gastrointestinal symptoms, not including pain one sexual symptom, not including pain one pseudo-neurological symptom, not including pain (e.g. numbness, paresthesia} onset before age 30; extends over a period of years lifetime prevalence 0.2-2% among women and 0.2% among men cultural factors may influence sex ratio complications: anxiety, depression, unnecessary medications or surgery often a misdiagnosis for an insidious illness so rule out all organic illnesses (e.g. multiple sclerosis)

Toronto Notes 2011

Somatoform. Disorden/Di880clative Disorders

Psychiatry PS27

Pain Disorder
pain is primary symptom and is of sufficient severity to warrant medical attention usually no organic pathology but when it exists, reaction is excessive lifetime prevalence 12% psychiatric disorders (mood, anxiety, substance) may precede, co-occur or result from pain disorder

Hypochondriasis
preoccupation with fear of having, or the idea that one has, a serious disease based on a misinterpretation of one or more bodily signs or symptoms evidence does not support diagnosis of a physical disorder fear of having a disease despite medical reassurance belief is not of delusional intensity (as in delusional disorder, somatic type) as person acknowledges unrealistic interpretation duration is ;,:6 months; onset in 3rd-4th decade oflife community prevalence 1.1-4.5%; prevalence in general medical practice 4-9%; higher in psychiatric settings

Body Dysmorphic Disorder

preoccupation with imagined defect in appearance or excess concern around slight anomaly usually related to face M=F, prevalence 1-2.2% in the community; 6-15% in dermatology/cosmetic surgery clinics may lead to avoidance of work or social situations

Dissociative Disorders
Definition
dissociation so severe that the usually integrated functions of consciousness and perception of self break down sudden or gradual onset, transient or chronic course symptoms cause distress or impaired functioning

Manifestations
dissociative amnesia, dissociative fugue, dissociative identity disorder, and depersonalization disorder differential diagnosis: PTSD, acute stress disorder, somatization disorder, substance abuse, general medical condition (e.g. complex/partial seizures)
Tabla 7. Diaociativa Disorders

Amnaia
Diapsis Inability to 18call important pinOilill information, usually of a 1ntumlllic or stressfulllilture; may be localized, selective or generalized

fugUB
Suddan, unexpected trawl away from home or workplace with illilbility to recall some or all of one's past may assume new identity

Identity Di111nler Two or mor11 di5tinct per&Oilillitie& that lllke control of an individlllis behaviour, amnesia regardilg persollill history {a.k.a. Mulqlle Parsollillity Disordar) 1.3% prevalance, M:F=1 .3:9 May hava history of physical or sexual abuse Parsistant or IIDCpel'ience& of feelilg detached from one's menllll processes or body {i.e. like being in a dreamI

Epidemiology

6% pravalance lncr&BSed in survivors of lnluma (war, abusel

0.2% prevalanca
May occur undar lnlwnlllic circumstances {conilat. rape. natul81 disastersI Usually spontaneous recovery

Rn disordar Approximately 50% of adultll have experienced asingle brief episode of depersonalization, precipitated by

extreme stress
T1'811mant

Psychotherapy, hypnosis

No proven role for barbituratfll/

pharmacalogically-assisted interviewing

Psychotherapy, hypnosis
Ensura slllbility and safety No proven role for barbitul8te!/ pharmacologically-assisted intarviawing

Three stages: symptom stabilization, Psychotherapy attention to trauma, rein18gration Pharmacotherapy: clonazapam. Psychotherapy, hypnosis IIUDXBtine, clomipramine Symptorn-criented adjuvants {antidepressants, anxialyticsl No proven role for barbituratfll/ pharmacologically-assisted interviewing

PS28 Psychiatry

Sleep DiaordenJSexuality and Gender

Toronto Notes 2011

Sleep Disorders
Criteria for Diagnosis
causes significant distress or impairment in functioning not due to medications, drugs, or a GMC

Nocturnal Myoclonus
middle-aged and elderly myoclonic jerks every 20-40 seconds bed partner complaints treatment: benzodiazepines (clonazepam, nitrazepam)

Narcolepsy
SvmllfOIRS crt Narco"psy
Clllllplexy lllllucinltions Atlleks of Slaap

CHAP

l'lllllvsis on waking

irresistible sleep attacks (up to 30 minutes) and persistent day time drowsiness occurring daily for montlu cataplexy (sudden temporary episodes of paralysis with loss of muscle tone) sleep paralysis hypnogogic (while falling asleep)lhypnopompic (while waking) hallucinations are manifestations of recurrent invasions of rapid eye movement (REM) sleep into the transition between sleep and wakefulness incidence 4 in 10,000 cases; M=F treatment: stimulants (methylphenidate, D-amphetamine), TCAs, SSRis

PRIMARY INSOMNIA
see Family Medicine, FM46

SLEEP APNEA
see Respirolog)'. R32

Sexuality and Gender

Sexual Orientation
describes the degree of a person's erotic attraction to people of the same sex, the opposite sex, or both sexes individuals may fall anywhere along a continuum between exclusive homosexuality and exclusive heterosexuality homosexual and bisexual individuals undergo a developmental process of identity formation sensitization - sensation ofbeing different from one's peers identity confusion - after puberty, awareness of same-sex attraction may conflict with social expectations identity 8111U11ption - self-definition as homosexual or bisexual, but not yet fully accepted commitment - self-acceptance and comfort with identity; disclosure to family, social, occupational settings

Paraphilias
defi.oition: sexual arousal, fantasies, sexual urges or behaviour involving non-human objects, suffering or humiliation of oneself or one's partner, children or other non-consenting person subtypes: exhibitionism, fetishism, frotteurism, voyeurism, pedophilia, sexual masochism, sexual sadism, transvestite fetishism, not otherwise specified (NOS) rarely self-referred; come to medical attention through interpersonal or legal conflict person usually has more than one paraphilia; only 5% of paraphilia diagnoses attributed to women typical presentation begins in childhood or early adolescence; increasing in complexity and stability with age chronic, decreases with advancing age may increase with psychosocial stressors

treabnent anti-androgen drugs behaviour modification psychotherapy

Toronto Notes 2011

Sexuality and Gender/Eating Disorders

Psychiatry PS29

Gender Identity Disorder

gender identity is set at approximately 3 years of age

typiad presentation
strong and persistent cross-gender identification repeated stated desire or insistence that one is ofthe opposite sex preference for cross-dressing, cross-gender roles in make-believe plays intense desire to participate in the stereotypical games and pastimes of the opposite sex strong preference for playmates of the opposite sex significant distress or impairment in functioning and persistent discomfort with his or her sex or gender role treatment psychotherapy hormonal therapy sexual reassignment surgery

SEXUAL DYSFUNCTION see GY31 and

U30

Eating Disorders
Epidemiology anorexia nervosa (AN) - 196 of adolescent and young adult females; onset 13-20 years old bulimia nervosa (BN) - 2-496 of adolescent and young adult females; onset 16-18 years old F:M=10:1; mortality 5-10% Etiology multifactorial- psychological, sociological and biological associations individuah perfectionism, lack of control in other life areas, history of sexual abuse personality: obsessive-compulsive, histrionic, borderline familial: maintenance of equilibrium in dysfunctional family cultural factors: prevalent in industrialized societies, idealization of thinness in the media genetic factors AN: 6% prevalence in siblings, with one study of twin pairs finding concordance in 9 of 12 monozygotic pairs versus concordance in 1 of 14 dizygotic pairs BN: higher familial incidence of affective disorders than the general population Risk Factors physical factors: obesity, chronic medical illness (e.g. diabetes mellitus) psychological factors: individuals who by career choice are expected to be thin, family history (mood disorders, eating disorders, substance abuse), history of sexual abuse, homosexual males, competitive athletes, concurrent associated mental illness [depression, OCD, anxiety disorder (especially panic and agoraphobia), substance abuse (BN)]

Anorexia Nervosa
DSM-IV-TR Diagnostic Criteria for Anorexia Nervosa
Reprinbld with permiaion flllm the Dillgnostic and Slatistic:al Mlnual ol Menllll Disordel$,. Text Revision, Fourth Edition, (Copyright 2000]. American Psychilllric Association.

A. refusal to maintain body weight at or above a minimally normal weight for age and height
{e.g. weight loss leading to maintenance of body weight less than 8596 of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 8596 of that expected) B. intense fear of gaining weight or becoming fat, even though underweight C. disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial ofthe seriousness of the current low body weight D. in postrnenarcheal females, amenorrhea, i.e. the absence of at least three consecutive menstrual cycles

....

Alhledc 'Mild 1. Disonlered eatilg 2. AmenO!Thaa 3. Osteoporosis

Specific Type restricting: during the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behaviour (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas) binge-eating/purging: during the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

PS30 Psychiatry

Eating Disorden

Toronto Notes 2011

Associated Features deteriorating mood (irritable, anxious, extreme sensitivity, sadness) isolation trouble concentrating due to repetitive, intrusive, irresolvable and anxiety provoking thoughts about food and weight malnutrition poorsleep Management criteria for admission vary among hospitals admit to hospital if: <65% of standard body weight (<85% of standard body weight for adolescents), hypovolemia requiring intravenous fluid, heart rate <40 bpm.. abnormal serum chemistry or if actively suicidal agree on target body weight on admission and reassure this weight will not be surpassed psychotherapy (individuallgroup/famlly): addressing food and body perception, coping mechanisms, health effects monitor for complications of AN (see Table 8) monitor for refeeding syndrome: a potentially life-threatening metabolic response to refeeding in severely malnourished patients resulting in severe shifts in fluid and electrolyte levels complications include hypophosphatemia, congestive heart failure, cardiac arrhythmias, delirium and death prevention: slow refeeding, gradual increase in nutrition, supplemental phosphorus, close monitoring of electrolytes and cardiac status Prognosis early intervention much more effective with treatment, 70% resume a weight of at least 85% of expected levels and about SO% resume normal menstrual function eating peculiarities and associated psychiatric symptoms are common and persistent long-tenn mortality- 10% to 20% of patients hospitalized will die in next 10 to 30 years (secondary to severe and chronic starvation, metabolic or cardiac catastrophes, with a significant proportion committing suicide)

Bulimia Nervosa
DSM-IV-TR Diagnostic Criteria for Bulimia Nervosa
Reprinted with pennission from the DiagnOitic and Stlltiltical Manual of American Psychimic Assoc:iation.
Disorden,

Taxt Revision, Fourtll Edition. [Copyright 2000).

..... ,

A. recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following 1. eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat during a similar period oftime and under similar circumstances 2. a sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating) B. recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse ofla:xatives, diuretics, enemas, or other medications, fasting, or excessive exercise C. the binge eating and inappropriate compensatory behaviours both occur, on average, at least twice a week for 3 months D. self-evaluation is unduly influenced by body shape and weight E. the disturbance does not occur exclusively during episodes of Anorexia Nervosa Specific Type purging: during the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas non-purging: during the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviours, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse oflaxatives, diuretics, or enemas Associated Features fatigability and muscle weakness due to repetitive vomiting and fluid/electrolyte imbalance tooth decay swollen appearance around angle ofjaw and puffiness of eye sockets due to fluid retention reddened knuckles, Russell's sign (knuckle callus from self-induced vomiting) trouble concentrating weight fluctuation over time

lpues.,..
Was commonly uud to induce vomiting in accideniBI poisoning or

aug overd011. Uted chronielllly by some patients

with EO. to ind001 vomiting.

Toronto Notes 2011

Eating Disorders/Personality Disorders

Psychiatry PS31

Management
criteria for admission: significant electrolyte abnonnalities biological treatment of starvation effects

SSRis
psychological develop trusting relationship with therapist to explore personal etiology and triggers reality-oriented feedback, cognitive behavioural therapy, family therapy recognition of health risks social challenge destructive societal views of women use of hospital environment to provide external patterning for normative eating behaviour

Prognosis
few recover without recurrence good prognostic factors: onset before age 15, achieving a healthy weight within 2 years of treatment poor prognostic factors: later age of onset, previous hospitalizations, individual and familial disturbance

Tabla 8. Physiologic Complications of Eating Disorders

General

Low BP. low HR. sigrificant orthostatic changes

:!:: syncopal episodes, low temperature. vitamin

deficiencies

Ru1188l's sign {knuckle calus) Plltltid gland enlargement Perioral skin irritation Pariocular and palatal petechiae Loss of dental anamalllld cariBB Aspiration pneumonia Metabolic alkalosis secoodary to hypokalemia llld loss of acid

Primary or secondary amenorrhea, decreased T3/T 4 Glllld mal seizure {decreased Ca, Mg. P0 4)

Cutillnu
Gl

Dry skin, lanugo hair, hair loss or thinning. brittle nals, yellow skin from high cal'lllene Constipation, GERD, dalayed gastric emptying ArrhylhmiBB, CHF Osteoporosis secondary to hypogonadism Pre-renal failure (hypDVlllemia), renal calculi Pedal edema (decreBSed albumin) Starvation: decreased RBCs, decreased WBCs, decreased LH, decreased FSH, decreased eslrogan, decreased testosterone, inCRIIISed growth hormone, increased cholesterol Delrylhtion: increased BUN

Acuta gasbic dilatiowrupture, panci'INI!itis, GERD, hematemesis secondary to Mallory-Weiss tear

Arrhythmias, cardiomyopathy (from use of ipecac), sudden cardiac death (decreased IQ Musde wasting Renal failure {electrolyte disturbances) Pedal edema (decre8Bed albumin) Vomiting: decreased Na, decreased K. decreased Cl, dacraasad H, increased anylase; hypokalemia with metabolic alkalosis Lamives: decreased N11, decreased IC. decreased Cl, incre8Bed H; metabolic acidosis

""' )-----------------, I
Screening t.r ......,.lity Dirden rdiklm at 1111111 qUIIIians about JOUT thaugllll llld leelogs Ill get1a llidillllllhwllyoo're

..

MSK
Renll

Extremities

LlbV.Iual

uulyila I. lllllild llilll in .ad: How often is J0U1 mood wil chq8 druli::llly _ .. COIQ8 r/ I illy, with sudden sli'ls flan feeling \'U AIJI!IIiil Ill rl duprvuiln, irrillbilily ar How kq has 11iis hlln going 1111?
2. Sollll
don't mind bllllling ido the bll:ligraood.

Unr:o....._.._.._...., .........: p bllhl ClllblIllattnianllld

hiD

How do describe youllll? Whit's lika when YIJ/re not the ode Ill llilnlillll? 3.Actnu.dllnnlds-....

Personality Disorders
General Diagnostic Criteria
an enduring pattern ofinner experience and behaviour that deviates markedly from the expectations of the individual's culture; manifested in two or more of. cognition, affect, interpersonal functioning, impulse control inflexible and pervasive across a range of situations causes distress or impaired functioning not necessarily for the person with the personality disorder, but for those around him/her pattern is stable and well established by adolescence or early adulthood assodated with many complications, such as depression, suicide, violence, brief psychotic episodes, multiple drug use and treatment resistance each personality disorder is present in 1% of the population personality disorders are lifelong and chronic the mainstay oftreatment is psychotherapy with the addition of pharmacotherapy to treat associated axis I disorders (ie. depression, anxiety, substance abuse)

llillllili:k lla lU getfruslnted w00 Cll1't haw whltygu MDI right 11WJY, !Min i wUing I itli longa- Wldd get 00 sometbD.I IMII1 b8l1li? Do ygu 1111 idel. lTIIal bi;pln and u.n kill inlnst blfln it gill afttlil t.IIIIIUII:IIIcPinil..,.biullnf _ , . . . fllln: llayw!AiartllltPIQIU don't get ID bMJWygu too wei11'1Jr whit JeiSIIIIS11la yguwandlr wClrllii lrilndlllld ac:qllllinm. m nol WI\' 111'(11 artrustwortlly?Wim 11111Bs ygu

concerned! 5. E....n. ncilllllllillly: Do you worry lbaut lrillllllil; yDlllllf in front "' alta" paopll. lkl s&ing biWIInglbDJ It I gllhllilgT Doll it llfllp ygu !ram 5llrting 1 CGIMII1IIIillll? How abn m ygu tlil one1o iOOucLa YIM'II? Ewnlullly Ml ygu rellx IIIII sllr!ID open 14> in social si\lltion?
&. U ...... IDgllilnlllllwillpllllll..._ l:llrllilll ......: How allen doygu hold blct !ram gllq 1o blow SDII'Illll'l becul YIJ/11 concerned IIIey miglt nolllYQ4fl DoN this llrit JOUIIIII!1ber of friendl'l

l'elld+ ......... =IO'foclllla Ill PD.

PS32 Psychiatry

Personality Disorders

Toronto Notes 2011

Table 9. Classification and Diagnosis crf Personality Disorders Note: For each personality disorder, the most recognizable feature is indicated in italics
C..ltllr A"Mad" Patients Sllllm ldi.BCCIIdric, withdrawn Familial usoc:iatian with psychotic disord11111 Cornman dalense mechanisms: inllllllctualillltian. projiiCiion, magical thinking
Paranoid Ptn.Uty llilordar (D.s-3%)

fllnlaslile

intrHpnlt IOOINes

a lllllle'Allent.

Blamep'Oblllms an atlas and 91111m qry and hostile. Diagnosis requires 4of: 1. Suspicious thlll oth11111 are 811Pioiting or diiCeiving them 2. Pre-occupied with 1rustworthiness of acquaintances 3. Reklctmrtto confide il 4. Interpret benign remarb as threatening, denaning 5. Holda IJII(Iges 6. Perceives atiBcb an chncter and is qlick to counteraiiBck 7. Ouastions fideily of pn.er without justificlllian
Sc:lizoid l'lnanUly.,.... NeiJrer desirw I)()( enjoys close rtlltionships including being, pad of I flm'ly; fJI'R$ Ill be llfone. lifelong J)BIIIm ofsocialllllihdtawlll Seen IB eccentric lfJJ f8C!usiw with I'BSt1icted llfect. !Mgnosis requires 4of: 1. Does not enjoy or dasir& close nllationlhips 2. Chooses solitary activities 3. lillie to no interest in sexuaiiiCiivity with othe11 4. Takes pleasure in lew (if any] activities 5. Few or no close friends 6. Indifference to pr11ise or criticism 7. Emotionaly cold, detached. or hiiVIIIIattened aflilct

Sclizaqpll Ptn.Uty llilordar (3-5.&%) PBttem af ecamtric beJravioln, pecu/iBI thourjJt plltlems. Diagnosis requires 5 af: 1. ldaes of rehr&nce 2. Odd beliefs, magical thinking (ilconsistent with cultural norms i.e. belef in telepdly, 1111per$titions) 3. UIIISUII perceptual experiences (i.e. bodily ilklsions)
5. or restrictEd allect 6. Odd, ecCIIdric appellllll1ce or behaviour (i.e. iiiiiUived in cutl8, str&nge religious Jnelices) 7. Few close friends 8. Odd thirling. odd speech (i.e. vague, stereotyped) 9. Excessivllsocial BIIXiety 4. Suspiciousness

C..ltllrB"Bad"
Patients seem malic, emotional, inconsi.rant Familial usociatian with mood disord11111 Cornman defense mechanisms: denial. acting out. ragrassion (histrionic PD), splitting (bordsrline PD],IJ'Ojacliva idlllllific:ation, idaelimliarv'devaluation

._.... . ' - l t y llilenllr (2-4%) Unstlble moods and behBIIioll; feel alone in lhe WDrll( piDb/ems wfth self imllge HistiJry oftapealtd seiJhllm belll'olioln

fnlgile- of llelf.

Nan:i11illic Swe

llll!lds coostant adninlfion. .Ilea IIIJil8lhr. but IM'th

Disorder [2%)

suicide,... Diagnosis raquii9S 5 of: 1. Fndc ellorts to avoid 111al or imagined abandonmant 2. Un.rable and inlllnse lllllllionships 3. Unstable -olsen

"speciBr and will exploi others for petSOMI gain.

It'

IMPULSIVE
Impulsive

4.1mpulsivity in two potentially harmful ways (sexual drugs, spending) 5. RecurT8nt 1111icidal behaviour/seHharm 6. Un.rable moodlallact 7. General feelings of emptinass 8. Difficulty controling anger 9. T111nsient dissociative &ymplorn$ or p1n110id ideation associated with stress

people 4. Requires excessive admiration 5. Sne of entitlement 6. Takes advantage of oth11111 7. lacb 8IJ1)IIIhy 8. Envious of oth8l1l or believes that atlas are envious of hinVher 9. Arrogant atliUiles

Diagnosis raquirv. 5 af: 1. Exaggerated sense of (grandiosity) 2. with fmtasies ol unlimited succass, power, beauty, kMI 3. Believes he/she is "special" and should associate with other "speciar

Moody Pa111noid undlll' strass

Unstabl1 SIH imag1 Labila intansa ratationships

Suicidal Inappropriate anger Vul1111rabla to llblndonmmt

Emptin-

Anlilocill ""--ity Dillard (M3%, F1 %) lack o f - for oldiOII.\ llllllliplialiv lfJJ often vioiiJie !he laYl May appw chamling on first ilrf/tNsion. Plltlem of r/ingtJff/ fol othars and l/iofiJOOIJ oftigiQ ofothers murt be {liJWt befol81he age of 1 holw1111; for the litgllosis afASPO ptllienl3 murtbe at /eBst 18. Diagnosis raquii9S 3 of the folowing: 1. Failu111 to conform to social norms by committing unlawful eels 2. Deceii!Uness,lying. manipulllling atlas for personal gain 3. lmplisive, fails to plan ahead 4. Irritable, aggressive. rapeated fights or assaults 5. Recklassness and disr8galll for personal salety, se1ety of others 6. IITISj)OIISible, cannot sustain work 7.lack ol r&morsa for actions
Avuidant tt.rsonlity Disordr [0.5-1.1%) Tllllid and socially INrlkwanJ with a peMISNe .renre afinadequacy and fear of Clitic:iim. Fear afembllmlssing or humiliating themleA!es in mcia/ silllstionuo l8lllllil withdlllwn lfJJ socitJ/it inhibited. Diagnosis raqui111s 4 of: 1. Avoids occupational activiliae that i!NOMI signilicent contact for fear of criticism or 111jaction 2. Unwilling to gut involved with people unless certain of being liked 3. Resllained in intimate llllationships for fear of being lhamad or ridiculed 4.1'19occupied with being 111jected or criticized in social situations 5. lmibillld in new inlllrpersonal silllations due to faar of inadequacy 6. Views him or IMnelf as inferior, socially inept or per$0fllllly unappealilg 7. Reluctant to engage in new activities for fear of enilalliSSIIlent

Hillrillri: ""--ity DiiGI'II (1 .3-3%) behBIIiour amalional. Alii rhmatic. flllmbovsnt and exlrolo'lltf8d Cannot fotm IIICIIIIlingful Oft8n -..all(inappmpriam. Diagnosis raquirv. 5 af: 1. Not comfortable uiHss cen1111 of attention 2. sesually seductivll 3. Uses jilysical appe81111ce to attract attention 4. Speech is impressionistic, lack$ detBil 5. Thaelrical and 8XII\lgeraled pPI'ISSian of emotion 6. Easily influenced by others 7. Parcaivlls relationsllips a mora intimate than 1hey actualy are

Qla C"Sid"

Patients seem BIIXious, fearful Fa lial 'llli with 'ely d'sorde 1 m USOCI on 111X1 r Connmon defense mechanisms: isolation, avoidance, hypochondriasis

5. Goas to excassive lengths to obtain 1111pport 6. lklcomfortllble or helpless when alone of fear of being unaHe to taka em of 7.lk!lenlly seekl anothar rallllionship at asource of ca111 and support

8. lklrealisticatv preoccupied with fea11 of being left to tab

when a close rallllionship ends

of

...._,, .l--------------,
A k8y di&tinction bstw1111n obsessive compulsive disorder (OCD) and ob.-ive compulsive p111101111lity disordll' (OCPD] is that in OCD tha symptom1aru ego-dystonic {i.e. the patient relllizes the obsessions are not rauonabl1) wharus in OCPD the symptoms are egosyniDnic (i.a. conaiatant with tha patiant's Wff'/ of thinking).

OblauMCompuiiM tt.rsonllity Disora (S.10%) wilh petfectionism,lllld maniBI and intttpersonBI coniTol. Is intlellible. ckJ$ed.off, and inefliciant. Diagnosis ra(Jiii9S 4 of: 1. with details, rulae, lists, older, organimlion, or schediM to liXIBnt that point of activity is lost 3. Excessivaly devoted to work to the excklsion of leisura activities and
lriendsllips 5.lk!able to discalll worthies objects ol no value 6. Reluctant to delegate tasks to oth11111 7. Miselly spending style [monay is hoallled lor futln disesters) 8. Rigid and stubborn
2. Perfectionism interferes with task completion

Dilficully llllllting elll1t)'I1By Diagnosis raqui111s 5 of: 1. Difficulty rrmking IIVIIIyday dacisions withaul advice and IIIISiurance lromoth11111 2. Naeds others to ISIIUm8 rasponsiblity lor most mlljor IU'IIIIS of hilthMr life 3. Difficulty disag1118111811t 4. Difficulty initiating projects due to lack of seK-Qlnlidence

Dapendlnl: Personalty Di10rder (I .&-1.7%) lllld to be iiJjen Cllle !( seplll!llion. clinging and submissive behtwiouts.

fearaf

4. Inflexible about morallty/sthiCf/values

Toronto Notes 2011

Chlld Payc:biatry

Psychiatry PS33

Child Psychiatry
The Child Psychiatric Interview
ID
name, age. family situation, school grade chief complaint onset, time course, stressors, impact on child's and family's functioning, supports child's functioning and behaviour at home, at school and with peers mental status (see adult mental status exam) history of present illness symptoms and features ofmost likely diagnostic area (e.g. disruptive behaviour disorders (ADHD, CD, ODD), developmental disorders, learning disorders, abuse, mood disorders, and anxiety disorders) in adolescents, consider psychotic disorders, eating disorders, and substance abuse disorders screen for comorbid conditions risk assessment physical/sexual abuse, suicidality, aggression/homicidality, firesetting, risky behaviour past assessments (e.g. psychiatric, psychological, educational), treatments, risk issues (past suicide attempts, past aggression), previous contact with child protection services brief developmental history - pregnancy, birth, milestones, general behaviour, parents' method of discipline, school functioning, peer relationships

HEADSSS lntii.W.W Home environment

ActivitiH DruglO'"Diet Sex

Safety

Suicidvldeprenion

Developmental Concepts
Tabla 1D. DIIVlllopmantal Stagas
Freud Oral

-----------------------------

Eribon
{bir1h-1

Piagat

year)

Sl!llsorimotor (birtll-2 years old) Object permanence (15 roonths)Child begins ID understand the concept that objects exist even when not visible Object conslillcy (18 month5)Child becomes comfortable with mother's absence by internalizing her image and 1he knowledge she will return Preoperational (2-7 years old)
openditllS (7-11years old) Fonnal operations (11 + years)

Anal

Autooomy/slume. doubt (1-3 years okl)

Oedipal
Latency

nitiatiw/guilt (4-6 years old) ndustry{l'lferiority (6-12 years old) Identity/role confusion (adolescence)

Erikson stages continue throughout life: ntimecy/isolation (V!JWIU Generativity/staption (middle age) (later life)

temperament: innate psycho-physiological and behavioural characteristics of a child (e.g. emotionality, activity, and sociability); spectrum from "difficult" to "slow-to-warm-up" to easy plotted on nine parameters: activity level adaptation, attention span and persistence, distractibility, intensity of reaction, quality of mood, response to a new stimulus, rhythmicity, threshold of responsiveness parental fit: the congruence between parenting style (authoritative, authoritarian, permissive) and child's temperament attachment: special relationship between child and primary caretaker(s); develops during first year (see Table 11 ), best predictor of a child's attachment style is their parent's attachment style stranger anxiety (8 months): infants cry at approach of stranger separation anxiety (10-18 months): separation from attachment figure results in distress
Tabla I I. Attachment Models
Loving, consistently available, sensitive, and receptive Inconsistent insensitive responses, role reversal Frightening. dissociated, sexualized, or atypical Secure Insecure (antiwlenVnesistant) Disorganized Able to use caregiver to cam seW Not reliant on caregiver for soothing

....

Attac:i1ment type can be assessed in inflln._ 1o-18 months ohge uaing m. St!ano- Situation tat. in which the child is mssed by 1he caregiver being ramoved from the situation and the s1ranger staying. A1tlchment style is 1111111.ured by the child's behllviour dll'ing 1h1 riUnion with m. carevivlr.

....

Rejecting. unavailable psychologically, insensitive responses Insecure (avoidant]

Attachment problems may present as a child who is diflicult to soothe, has difficulty sleeping. problems feeding. lllntrums or behavioun;.

PS34 Psychiatry

Child Psychiatry

Toronto Notes 2011

11,

Mood Disorders
MAJOR DEPRESSIVE DISORDER
Epidemiology
pre-pubertal1-2%; post-pubertal4-8%; F:M =2:1

Health c-da advises Canadians undar 1he age of 18 ID consult physicillllS if thlf 1111b8ing b'lmd with SSRis, SNRis or mirtlll.pine. This request was made u a result of intematiOfllll reports thllt some of these drugs may be IIADCillled with n ilcreased risk of suicidal id.non in patilnts undar the age of 18. The111 wu no incruued risk of suicide completion.

Clinical Presentation see Adult Mood Disorders, PS7

more cognitive and fewer vegetative symptoms than adults physical factors: insomnia (children), hypersomnia (adolescents), somatic complaints, substance abuse psychological factors: boredom, irritability, anhedonia, discouragement, helplessness, low self-esteem, deterioration in academic performance, social withdrawal, lack of motivation comorbid diagnoses of anxiety, ADHD, conduct disorder, and eating disorders

Sllllctill Serobdi . . . . IM!ibilln ill CIMIIDII.....-: . . .IIi: lllnilw rl I'UIIIIIII-........ IIIII L&ar21l04; 363:1341-45 Study: Mall-lllllylii ofdill ... 51111dami11d c:oatded lrilll1hll MI.IIIBd SSRI '1. Pllcebo
lhlt-]dlbhed Ollllpj)llhed. 1'11i1111: Age >II di.-1 wi1h dlprlaiall. llamillill, JllllCIIIIIIIItr81bnri,

Treatment
majority never seek treatment individual (CBT, IPT)/family psychotherapy and education, modified school program SSRis, SNRis (see below) ECT: only in adolescents light therapy, self-help books

suicideiliiiiBII bebmon,llld ciscon1iJualion of

lrllllrWit blclusl al iiiMIII Mnll.

ICGIII,IMIIIMIIS,

lnt!tvenlion: Fu.tile, pncetine, Slllnh. cilllopmn.end......._

111111111: FUriie hasfMinble rilt-llendit Jdri, .upplll18d by pub.hed IIIII IIIPubhed dell. l'llmlilllllld llllnllinllww -k-JIIIIiiM riek-liunl(t ]ldi by dill, end UJ8IIa' rilk111en hllllfit by unpla!Jished d111.

Prognosis
prolonged, up to 1-2 years adolescent onset predicts chronic mood disorder; up to 2/3 will have another depressive episode within 5 years complications negative impact on family and peer relationships school failure significantly increased risk of suicide attempt (10%) or completion substance abuse

.......
Trill

DlpnRiiiC Tnlllmlnlt. M.._.. wilb DlpnRion SlUr (TADSIIIDIIDII c.nlad

.JAA6\ 200t; 2t2(71:80H21l Study: lllndanimd can1!11111d trilllt13 us IICIIdilri: end CIIIIIUity clirics

BIPOLAR DISORDER
Clinical Presentation
see adult bipolar disorder/mania (DSM-IV-TR) mixed presentation more common in adolescent population than adult population unipolar depression may be an early sign of adult bipolar disorder -30% of psychotic depressed adolescents receive a bipolar diagnosis within 2 years of presentation associated with rapid onset of depression, psychomotor retardation, mood-congruent psychosis, affective illness in family, pharmacologically induced mania

21lllhlrrnr 21103. l'llillll: 431 pelillll1 ages 121 7wi1h I prinary

DSM IV ngnlllis olllllljor dlpi'Diiw dilordlr. CIDIIIII'slleJnlsion RmJSaltRMed (CIJ!Sll)lalll IA:IIIll.

(I

(2) CST, (3) CST

+1\loQtine (1 0.

111111111: FUiluJiinl will! CIIT hid lllltistiCIIIy liQni&cart CDftSR ICON as COil1PIIId 1D pllcaho (P D.OOI)witlu 71hsponse111L llis coll'ilo wu g11111r tt.. ILIDiinl1kml CBT IDne (P=O.Dn Fluaxetine llbJe- greltlr
1fwl CBhlana

or (4) pllclba.

Treatment

1"1 line: mood stabilizers antipsychotics 2nd line: antidepressants, benzodiazepines (careful of disinhibiting effect)

Anxiety Disorders
prevalence 2-15%; F:M = 2:1

Diagnosis
school problems, recurrent physical symptoms (stomach aches, headaches) especially in mornings, social and relationship problems, social withdrawal and isolation, family conflict, irritability and mood symptoms, alcohol and drug use in adolescents

Treatment
family psychotherapy behaviour modification techniques, stress reduction, parental education, predictive and supportive environment, relaxation techniques pharmacotherapy: SSRis (e.g. fluo.xetine), benzodiazepines (e.g. clonazepam- use with caution, may have disinhibiting effect) fluvoxamine and sertraline also have good evidence, particularly for OCD

Toronto Notes 2011

SEPARATION ANXIETY DISORDER

Chlld Payc:biatry

Psychiatry PS35

Epidemiology
prevalence: 4% of children/adolescents on average 7.5 years old at onset, 10 years old at presentation common for mother to have an anxiety or depressive disorder

Differential Diagnosis
simple or social phobia, depression, learning disorder, truancy; conduct disorder, school-related problems (e.g. bullying)

Clinical Presentation
school refusal (75%) excessive and developmentally inappropriate anxiety on separation from primary caregiver with physical or emotional distress for at least two weeks persistent worry, refusal to sleep, clinging, nightmares, somatic symptoms comorbid major depression common (2/3) worry about something happening to parent or themselves

Prognosis
if inadequately treated early on, may present later in a more severe form may develop into panic disorder with/without agoraphobia
SOCIAL ANXIETY DISORDER must distinguish between shy child and child with social anxiety diagnosis only if anxiety interferes significantly with daily routine, social life, academic functioning. or if markedly distressed features: temper tantrums, freezing, clinging behaviour, mutism, excessively timid, stays on periphery, refuses to be involved in group play must be capable of developing social relationships must occur in settings with peers, not just adults selective mutism: does not speak in front of others; no problems speaking at home must rule out language or communication problems severe form of social anxiety POST-TRAUMATIC STRESS DISORDER (PTSD) diagnostic criteria same as adults (see PS15) in children, one often sees repetitive play involving the event, generalized nightmares, psychosomatic symptoms, omen formation common examples of trauma include: sexual/physical abuse, witnessing family violence, natural disasters can also be associated with onset of sexual activity OBSESSIVE-COMPULSIVE DISORDER (OCD) diagnostic criteria same as adults, except it is not necessary for child to recognize thoughts or actions as excessive or unreasonable (see PSIS) 0.3-1% of children/adolescents; tends to begin earlier in boys than girls tend to engage in rituals at home rather than in front of others associated with Tourette's Disorder, tics, and ADHD PANIC DISORDER diagnostic criteria same as adults (see PS13) genetic/parental modeling!identification hypothesized as cause often parent with panic or depressive disorder GENERALIZED ANXIETY DISORDER (GAD) diagnostic criteria same as adults (see PS13) often redo tasks, show dissatisfaction with their work and tend to be perfectionistic often require reassurance and support to take on new tasks SPECIFIC PHOBIA common phobias in childhood include a fear of heights, small animals, doctors, dentists, darkness, loud noises, thunder and lightning

\,
Thl shy child is quifi IIJid r.luctant to participllle but slowly 'wll'l115 up.

PS36 Psychiatry

Child Psychiatry

Toronto Notes 2011

Childhood Schizophrenia
Epidemiology 1/2,000 in childhood; increases after puberty to adult rates (1 %) in late adolescence diagnostic criteria same as in adults (see PS4) <6 yt:ars old may present in similar fashion to autism prior to onset of core symptoms prognosis poor as cognitive, language, social and personality development arc disrupted Treatment psychotherapy, family education low dose antipsychotics for target behaviours (ie. aggression, hyperactivity, impulsiveneas) hospitalization or residential placement, if severe

Pervasive Developmental Disorders (PDD)

include autism, asperger's, childhood disintegrative disorder, Rett's disorder, and PDD NOS (not otherwise specified) M:F = 3-4:1 (except for Rett's with female predominance)

Differential Diagnosis mental retardation. childhood schizophrenia. social phobia, OCD, communication disorder, non-verballearning disorder, ADHD, abuse, hearing or visual impairment. seizure disorder, motor impairment Management hearing test to rule out impairment psychological testing to assess intellectual functioning and learning chromosomal analysis to rule out abnormalities (e.g. trisomy 21, fragile X syndrome) rule out psychotic disorders, social problems, depression, anxiety, abuse Treatment team-based: school, psychologist. occupational therapist. physiotherapist, speech and language therapy, audiology, pediatrics, psychiatry family education and support treat concomitant disorders such as tics, OCD, anxiety, depreasion, and seizure disorder behaviour management, school programming pharmacotherapy: atypical antipsychotics (for bizarre behaviours, agitation, self-mutilation, tics), SSRis (for anxiety, depression), stimulants (for associated hyperactivity) Prognosis variable, but improves with early intervention better if IQ >60 and able to communicate

AUTISM
prevalence 1/1,000 abnormalities in three areas aoclal interaction- impaired non-verbal behaviours (eye contact, facial expression, hand gestures), failure to develop appropriate peer relationships, lack of social/emotional reciprocity communication - delayed or absent speech or marked impairment to initiate or sustain a conversation; stereotyped/repetitive or idiosyncratic use oflanguage; absence of appropriate make-believe play restricted and repetitive behaviours, interests, and activities - inflexible adherence to specific, non-functional routines, stereotyped hand or body movements (e.g. rocking) at least 6 features before 3 yt:ars old (at least 2 from social interaction and 1 from other 2 categories)

ASPERGER'S DISORDER
prevalence 3/1,000 no early speech and language delay, no cognitive deficits, normal to high intelligence impaired social interaction with of nonverbal interactions, peer relationships, spontaneous sharing of enjoyment/activities, soctallemotional reciprocity reatricted repetitive patterns of behaviour/interests with >1 of reatricted interest with high intensity, inflexible nonfunctional routines, repetitive mannerisms, preoccupation with parts causes impairment, no delay in language or cognitive development, not caused by another POD

Toronto Notes 2011

Chlld Payc:biatry

Psychiatry PS37

CHILDHOOD DISINTEGRATIVE DISORDER (COD)

similar to autism, but there must be a period of at least 2 years (and up to ten years) of nonnal development rule out degenerative brain disease, schizophrenia

....

',
lld'a
COD

RETT'S DISORDER
X-linked dominant disorder, therefore predominantly in girls restriction ofbrain growth beginning in first year oflife nonnal development between 6 months to 4 years, then regression (loss of purposeful hand movements, mental retardation, seizures, neurological, respiratory and motor deficits)

Development NDmlll Nonnlll dMiapnwnt IIIII diiiiiiiPf!WII held mell11il tar 2:2 JIIIS

lncidlnct
Dllficits

6-7/11Jl,llll lerrales
Dacmsad hlld gruwth,

1/lOO.IDI boys>gills

Dac-d

POD NOS
marked deficits in above areas, but does not meet full criteria for another PDD

skill hnlnvwmtllli, (llngiJIQII, IOCial, rnotorf, coord...tion, . .11111 cantral play

Attention Deficit Hyperactivity Disorder (ADHD)

prevalence: 5-12% of school-aged children; M:F = 4:1, although girls may be under-diagnosed girls tend to have inattentive/distractible symptoms; boys have impulsive/hyperactive symptoms

Etiology
genetic - dopamine candidate genes, catecholamine/neuroanatom.ical hypothesis cognitive - MR, inhibitory control and other errors of executive function arousal- alterations in the sensory system filters

Diagnosis
differential: learning disorders, hearing/visual defects, thyroid, atopic conditions, congenital problems (PAS, Fragile X), lead poisoning, history of head injury; traumatic life events (abuse) diagnosis (using Conner's Teacher's and Parent's ADHD Scales) six or more symptoms of inattention and/or hyperactivity-impulsivity persisting for at least 6montha onset before age 7 symptoms present in at least two settings (ie. home, school, work) interferes with academic, family, and social functioning does not occur exclusively during the course of another psychiatric disorders

ObsiMI child for "ATENnDN" feiiLRS: Annoying

Tempenmenml Enurvetic
Noisy

T..t incompletion
lnlllt8ntiw Oppo1itional Negativism

Table 1Z. Cora Symptoms of ADHD (DSMIV)

lnaltlllllion Can!less mistakes Camet sustain attention in tasks or play Does nat listen when spoken to directly Fails to complete msks Disa1111nized
Avoids, dislikes tasks that require
sustained mental eflart

ltwJnctivity
Fidgets, squirms i1 seat Leaves seat when expected to ranain
seated

Runs and climbs excessively Camet play quietly On the "go", driven by amo1llr Talks excessively

lmpulaivity Blurts aut answen befure questions cQII1lleted Difficulty awaiting tum on others

Lases things necessary far tasks or activities

Distractible

.Mil 1999; 56:1073-108S .......: To irNwtiglle the lllnttlrm ef&:IIC'{ rl ph1111111C01henipy IIIICI bei!INiulllmp>f, u Mil n 1lllif t:umbirlldDB. llldy CllncllriltiDI: Singllliildad ACT widi 571 clidr8n, IIIII 1 4 month follow-up. PrilipiiD: 7-1.9 widi dimctlrilticl1ypicll rl 1111 ADHD llrTiples. lnllrnnllan: 14mlllils rl 11111 rllour ilderwldons: 11 medic:ll mngemed, will fimline.,t.luiOMid
111d chikll; 31 tllll\\9 curnbilad; 4llllndiwd
cormui\yCIIII.

.,......,.....

A1'-nti......._.CIIillll1iillaf

...._....._farMIIIiiMiitl

by lllhlr drugusliiPicllllld mfolklw.!Jp; 21 iduniMt brihlviolnllhullpr (puonl,

Forgetful

Features average onset 3 years old identification upon school entry rule out developmental delay, genetic syndromes, encephalopathies or toxins (alcohol, lead) risk of substance abuse, particularly cannabis and cocaine, depression, anxiety, academic failure, poor social skills, risk of comorbid CD and/or ODD, risk of adult ASPD associated with family history ofADHD, difficult temperamental characteristics Treatment non-pharmacological: parent management. anger control strategies, positive reinforcement, social skills training, individual/family therapy, resource room, tutors, classroom intervention, exercise routines, extracurricular activities pharmacological standard treatment stimulants (methylphenidate- Ritalin, Concerta [long-acting]; dextroamphetamine; mixed amphetamine salts - Adderall), SNRI (atomoxetine - Strattera) for comorbid symptoms: antidepressants, antipsychotics

._.AI

IQgressie 'YIIIptmns. IIICill skills, iniEmlllilg pnnl-<:ilild '*ion. IIIICIICldemic ac:lliemnert PJp!l-.-al8lb;tion il Mllblion -flllld ID 1111 114*ia11D buhll'ioinllrR1nntfor AllHD

noothlr 11e1tmert 11'111 rnd:ltion did rr:Jt dller s9flcdv IC1UIS 1111 damail in dilct c:amplliml. MTA medican 1llllmenbi were 1114111rior 111 - . dalljlia Ill& flct1111ttwo.!Mds rl C0111111dy1lelled Ujecls rtceiued lllldic:alion durilg the lludv plriDd. c:.l111in: U af ]JICIIoslirlilllll madicllions is llflriar1D beblvioulll iiiiMIImll or cormui\y Clll in AllHD Ccnined medic:llllld is not men llbc:ious dWI madicllion abll in llllting

PS38 Psychiatry Prognosis

Child Psychiatry

Toronto Notes 2011

65% continue into adulthood; secondary personality disorders and compensatory anxiety disorders are identifiable 70-80% continue into adolescence, but hyperactive symptoms usually abate

Oppositional Defiant Disorder (ODD)

----------------------

prevalence: 2-16%
IE' ODD kids "ARE BRATS":
Annoying llauntful EIISilylllllloyed Blames ot11ar1

Diagnosis
pattern of negativistic/hostile and defiant behaviour for months with of loses temper, argues with adults, defies adult rules, deliberately annoys, blames others, touchy/easily annoyed, angry and resentful, spiteful or vindictive behaviour causes significant impairment in social, academic or occupational functioning behaviours do not occur exclusively during the course of a psychotic or mood disorder criteria not met for CD; if 18 years or older, criteria not met for ASPD features that typically differentiate ODD from transient developmental stage: onset <8 years, chronic duration (>6 months), frequent intrusive behaviour impact of ODD: poor school performance, few friends, strained parent/child relationships may progress to CD

Rule breaker
Arl!uas with

llmplf
lpit&fuVvindicliw

Treatment
establish boundaries parent management training and psychoeducation individual/family therapy pharmacotherapy for comorbid disorders school/daycare interventions to help with behaviour management

Conduct Disorder (CD)

prevalence: 1.5-3.4% (M:F =4-12:1)

Etiology
parental/familial factors- parental psychopathology (e.g. ASPD, substance abuse), child rearing practices (e.g. child abuse, discipline),low SES, family violence child factors - difficult temperament, ODD, learning problems, neurobiology
IE'

Diagnosis
differential: ADHD, depression, head injury, substance abuse diagnosis: use multiple sources (Achenbach Child Behavioural Checklist, Teacher's Report Form) pattern of behaviour that violates rights of others and age appropriate social norms with in past 12 months and 1 in past 6 months: aggression to people and animals (bullying, physical fights, use of weapons, forced sex) destruction of property, firesetting with intent to damage deceitfulness or theft (breaking and entering. car theft) violation of rules (out all night before 13, runaway times or for long periods of time, often truant from school before 13) disturbance causes clinically significant impairment in social. academic or occupational functioning if individual is 18 years or older, criteria not met for antisocial personality disorder diagnostic types childhood onset: at least one criterion prior to age 10 poor prognosis: associated with ODD, aggressiveness, impulsiveness adolescent onset: absence of any criteria until age 10 better prognosis; least aggressive, gang-related delinquency mild, moderate, severe

Conduc:t Dilordlr ou..-.

Theft - bnlaking 1111d e!Qring, deceiving, nort-confrontll1ionalllealing Rille brvaking- running IIWiy,aJcWing
school, out lab AggreAion - J180pl&, anifnah;, weapo1111, forcldsu. Property destruction

TRAP

Treatment
early intervention necessary and more effective, long-term follow-up required parent management training. anger replacement training. CBT, family therapy, education/ employment programs, social skills training, medications for aggressiveness or comorbid disorders pharmacotherapy is insufficient; mainly used for treatment of comorbid disorders

Prognosis
poor prognostic indicators include early-age onset, high frequency and variety of behaviours, pervasiveness (ie. in home, community), comorbid ADHD, early sexual activity, substance abuse 50% of CD children become adult ASPD

Toronto Notes 2011

Child Psychiatry/Psychodynamic Therapies

Psychiatry PS39

see Pediatrics: Child Abuse, PIS Chronic Recurrent Abdominal Pain, P42 Developmental Delay, P26 Elimination Disorders, P12 Learning Disability, P28 Intellectual Disability, P26 Sleep Disturbances, Pl3

Psychodynamic Therapies
theory: one's present outlook is shaped by one's past and unconscious psychological forces insight allows change in personality and behaviour conflict - tlm:e stages non-resolvable conflict attempt to repress return of conflict in disguised form (symptom or character trait) emphasis on early interaction with caregiver sources of information past and present experiences and relationships relationship with therapist transference: unconscious re-enactment of early interpersonal patterns in relationship with therapist countErtran&ference: therapist's transference to patient resistance: elements in the patient which oppose treatment techniques free association: patient says whatever comes to mind dream analysis stage of change important for all conflict resolutions
........ ...,......, llllll'lwiiiiiiiiiMpyiiiiiiDIIt: ...... il lhlllllilnlllllltitull riMiml llullli Tllllllllltlll Clillllanlhl a....dll'rapl JClll-'ail 1196; 64(31:532-t lludy: lllndDnized c:linicll1lill. l'lrlicltllnll: 255 mll'ld - h crillria lo!ll'lljor dltnai'la apisodaand v.lloc:amplllld {lllbll tl611

..,..._: Foor lllllmlnt arms: cognN-

bellniJoolllherlpy. idelpenonll thenpy. plus clnicllll'llniiQimlllllllll plallo

pbs cliicll mgement. lll6llds: CinicllllllriiCOIIId vidaallp111 tl81Jtt. midcle 11111 Ill! thmtJI' session. Outclnl: l'llilntJ'IIId cilicillll' penpeclivlll
buill: Tlmpallic IIIIIC8 WllbniiDhiMII

Defense Mechanisms
defense mechanisms are unconsciously activated by the patient in response to anxiety provoking events and feelings
Table 13. Defense Mechanisms I.MI1: Plydtolic Defenlell
C1111mon in psychosis; 110111111lly seen 11roughout childhood and il cnams Dial: raplecing txlemalraality with wishful fantasy Dillorlion: rvshaping d reality to meet inner beliefs, illllrealistic and overvalued ideas Pnljeclion: interpreting internal ini)!Jses as 1hough 1hey are outside self; in psychosis seoo as frank delusion about reality {e.g. persecuttry delusionsI

Cancbinl: alllnCtl ilia camnan fldDr wllich lignilicllr-.ty inllll111:8i auk:uma.

lignilic:lntllltctlll aull:111111 in altralll'llrillll'll. l'ltienl comibution ID lliiiiCe had I siQiificlnl tlact Ill DW:omas, "'-therapist contiliub ID lilnce hid no signiliclrt e11ect

1..11112: lmllllture Dllenla

C1111mon in discnlers, Sllll!re depression. Normally seoo tluoughout adolescence

AcliJg aut expr&S$ uncoii$Cious wish through iqlul5iw lll1la thilll ofthinking.llffecl. or iqlulse llypodlandriuil: exaggeration of illness in order to avoid anxietyiJ!OWking situlllions
lntrajeclion: internalizing of an object (i.e. victim identifying with aggressorj PaliwHggrative Wlniaur: exp111Ss agg185$ion throl91 passivity nl masochism Ragraaion: returning to an earlier !lage of developnent to avoid pment stressors Samllization: unc011$CiOUS expression rl psychic pairv'llmsion as physical symptoms

1..11113: Nralic lllfln111

C1111mon in adults

Canlralq: managilg evmts ID reduce imer conflict Disp11C8181: shifting emotional response to ill1 objectlidea rasembflng 1hat which is anxiety provoking Exllnllimion: attributing (e.g. conflictsl to BXIBITIBI world and objects ln.ibilian: to avoid anxiety producing inteiTIBI conflicts lnlllllllctualizllian: usilg intellectual processing to avoid experiencing affect
lsalllion: separating objeclf{ldeas from their associated !llect {which is repressed! llatianllzatian: using rationaluplanations to justify behaviours thd ara unacceptable Diltacidian: tl!mporary modification ct sense of sel to avoid emotional distress

Rlllctian famltion: 1rlnsforming an unacceptable impulse into opposite Repraaion: withholding or removing from consciousness an idellfeeling SeJIIIIIimia: bestowing sexual importance to objects

I.MI4: Mlbn Defenlell C1111mon in emotionally healthy adults

Altruism: constructive service to to empathy Anticipllian: for future discomfort Asceticism: denying pleasurable effects of an experience (i.e. gratification tom reramcialionl Humaur: overt expression of feelings in a comic fashion Suppression: pol'lponellllllntion to impulse or conflict

PS40 Psychiatry

Psychodynamic Therapies

Toronto Notes 2011

Varieties of Psychodynamic Therapy

psychoanalysis (exploratory psychotherapy) original therapy developed by Freud, goal is self-revelation and insight the exploration ofthe meaning of early experiences and how they affect emotions and patterns of behaviour presently time intensive (e.g. 4-5 times/week for 3-7 years) for individuals who can tolerate ambiguity in explorations offeelings and treatment

supportive psychotherapy
goal is not insight but reduction of anxiety strengthen healthy defense mechanisms to assist day-to-day functioning techniques include: enhancing self-esteem, clarification, confrontation, rationalization, reframing, encouragement, rehearsal/anticipation, de-catastrophizing, allowing "venting" of frustrations short term/brief psychotherapy resolution of particular emotional problems, or acute crisis number of sessions agreed on at outset (6-20) interpersonal psychotherapy short-term treatment looking at relationship patterns and teaching coping mechanisms focus on personal social roles and relationships to help deal with problems in current functioning

Behaviour Therapy
modification of internal or external events which precipitate or maintain emotional distress; useful in the treatment of anxiety disorders, substance abuse, paraphilias systematic desensitization: mastering anxiety-provoking situations by approaching them gradually and in a relaxed state that limits anxiety flooding: confronting feared stimulus for prolonged periods until it is no longer frightening positive reinforcement: strengthening behaviour and causing it to occur more frequently by rewarding it negative reinforcement: causing behaviour to occur more frequently by removing a noxious stimulus when desired behaviour occurs extinction: causing a behaviour to diminish by not rewarding it punishment (aversion therapy): causing a behaviour to diminish by applying a noxious stimulus

Cognitive Therapy
theory: moods and feelings are influenced by one's thoughts psychiatric disturbances are frequently caused by habitual errors in thinking goal is to help patient become aware of automatic thoughts and correct assumptions with a more balanced view useful for depression, anxiety disorders, self-esteem problems use ofthis therapy presupposes a significant level of functioning patients asked to keep thought journal (often in chart form, with column headings "thought" and "cognitive distortion") to monitor their thoughts, when/where they think these thoughts, how the thoughts make them feel and what their underlying error in thinking might be

Cognitive Behaviour Therapy

combines cognitive and behaviour therapies to teach the patient to weaken connections between thinking patterns, habitual behaviours and mood/anxiety problems good for treatment of mild/moderate depression/anxiety

Toronto Notes 2011

Psychodynamic Therapies/Pharmacotherapy

Psychiatry PS41
.....,.... lllndenlirld c.tnw Tlill ... r.IIIIIHp rllllllctillll Bllhnillr llwlpy w. llqyby bpn far ..iciHI Blhninn IIIII lloldllll'nlnlty Dinnlw !#1:11 6tn 63(71:757-t& Ml dlllmiDI haw Ntli 11Ditliehlvicll P"jddoti!IIIP'f. l1udy: l))e_,...!Bbnilld CCIIIId8d trill MIMed byGIIII yell psiod. 100WQII'IIInNtlllVQ1111U:idllllld 1 -injurious hiiiMIIn milling DSM ciDrillllnd mEIIIIIIID YlriiiUI d11111111J1Fhic: dlltl. IIIIMnlill: One Ylllfi DBT ar 0111 111hellmnl thenipy. IMaamn: Trimllllr rJU:idll
bellniu, BlniiQiillcylmices 1151, II'Jf1llli

Other Therapies

---------------------------------------------

group psychotherapy goals: self-understanding, acceptance, social skills creates a microcosm of society family therapy family system considered more influential than individual structural focus here and now re-establish parental authority strengthen nonnal boundaries re-arrange alliances hypnosis: mixed evidence for the treatment of pain, phobias, anxiety, and smoking cessation dialectical behaviour therapy: a fonn of CBT originally developed for borderline patients but since found to be effective for the treatment of several other disorders; focuses on four types of skills: mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance; individual and group therapy settings mindfuloeas-based cognitive therapy: derived from Buddhist meditative practices; aims to help people attend to thoughts, behaviours and emotions non-judgmentally and in the moment using guided breathing exercises

lllltdtll: l'llieab recei'li1g lilT Wille I'd aslletf ID 111111mpt U:ida, raqLirad lals holpiblillllion far IIJic:idlll idntiarl. hid bwlr 1111dicll rilk far llicidl waralals illllyiD IRp oLt rltimpy 111:1 hid iMwiii'IIIVI!ItY _, visiiJ foriiJicidll

idelltion. Can&binl: lilT is llllctM in llicidlll bellniu in pllieab with bonlerine persallllily dilordar.

Pharmacotherapy
Anti psychotics
"antipsychotics" and "neuroleptics are terms used interchangeably indications: schizophrenia and other psychotic disorders, mood disorders with or without psychosis, violent behaviour, autism, Tourette's, somatoform disorders, dementia, OCD onset: immediate calming effect and decrease in agitation; thought disorder responds in 2-4weeks Tabla 14. Pathophysiology of Schizophrenia vs. Mechanism of Action of Antipsychotics
Brain Arel
il

Typical Alllipsychalic 02 blockade

Atypical Antipsychllli:

Umbic Sya1111

ExcessDA +ve symptoms (hallucinations, dulusions) Decreased DA

Treats +ve syr1'"9toms

D2 blockade

Weak 5-HT block, 07/1 blockade msintei'led Trua!$ +ve symptoms

Robust 5-HT block increases DA tnm1mis1ion

fnlntll Cortu

-w

impairment

(flat affect. anhedonia.

May wol18n -w symptoms

and cognitive imptJinnent

Theoretical improvement in negative/co!Jlitive syr1'"9toms

observed with clolllpine

BuaiGangll

Unchanged

D2 blockade Relative ACh exciiS causes EPS symptoms

Robust 5-HT block increases DA 1ransmission D9Cn1Bsed EPS incidance

Tuberoinfundibul;u Tract Unchanged

DZ blockade Hyperprolacti'lemill

5-HT block i'lcreas11 DA Less hyperprolectinemill

DA dapunine; S.IIT serotonin; ACh acelythaile; EPS o!rlpyrlmidll symp1mi Noll: specific "typical" and atypiclr ripsychatics WJY in tam1 rJ llinclng ID llhllargic, S.KT. cholinergic end histlminllllic liallaedirG to lifenlllt Bid a aflact profiles

Rational Use of Antipsychotics no reason to combine antipsychotics

choosing an antipsychotic all antipsychotics are equally effective atypical antipsychotics are as effective as typical antipsychotics but have better side effect profiles choose a drug patient has responded to in the past or that was used successfully in a family member route: PO; short-acting or long-acting depot 1M injections; sublingual minimum 6 months, usually for life

PS42 Psychiatry

Pharmacotherapy Table 15. Common Antipsychotic Agents Starting Dose

Mlinlln111ce Mlllimum

Toronto Notes 2011

Relative
Palency (mg)

Typic:als Un order of potency from high to low) Pirnuzide (OI!Ip<) 0.51 mg PO bid
Haloperidol (Haldor) 2-5 mg IM q4-8h 0.5-5 mg PO b/lid 0.2 mwtw'd PO 2.510rngfd PO

212 mQid PO
Based on clinical effect

20 m!Vd PO 20 m!Vd PO
2

Fluphenazinellllil1that8

1-5 mg PO qh& 25 mg IM/SC q1-3 weeks

20 m!Vd PO

2
4

for IM fon11Jiatiun)

HCI (CiupixoP)

21J.30 mQid PO 51H50 mg IM q43-72h 100 mg IM ql-4 weeks 2-5 mg PO bid 3-16 mg PO 11/tid 1DmgPOtid 12.550 mg IM q4-6h 25-100 mg PO tid 1(}.15 mg PO hNqid 1-2 mg 00/oid

21J.40 mQid PO

100 m!Vd PO
400 mg IM (q2 weeks}

Zuclupenthixol Bcetllle
decanullle

151J.300 mg IM q2 weeks 215 mg PO bid

4-8 mg PO Vqid

600 mg IM'week 60m!Vd PO 64m!VdPO 250 m!Vd PO 5 10 10 100

(Ciaxipol Deput4')

Trifluoperazine

Psphenazine
Loxapine HCI (l..oxitane) Thiaridazine (MellariP) Chlorpromazine (L.argactiP)
Atypic aIs

61H 00 mQid PO
100-400 mg PO bid

800 m!Vd PO
1000m!Vd PO
8 m!Vd PO

400 mg/d PO 4-8 rngfd PO

100
High potency

Risperidone (Rispenlal8 , Rispardal Consta" for IM long acting prapallllion) Olalllllpile (Zypraxa3 , Zydis"'} liprasidona (Zaldgxlt) Clazapine (CiolllriP) Ouetiapine (Seroquel8 ) Aripipnllllle

25 mg IM q2 weeks 5 mg/d PO
40mg/diM

1020 m!Vd PO 8(}.160 m!Vd IM

30()..600 m!Vd PO 400-800 m!Vd PO

30m!Vd PO 160 mg/d IM 900 m!Vd PO

25mg PO bid 25mgPO bid 11H5 mQid PO

BOO m!Vd PO
30m!Vd PO

11J.15 mQid PO

Low potency

Side Effects of Typical Antipsychotics low potency: anticholinergic, antiadrenergic, anti histaminic side effects high potency: risk of movement disorder side effects (extrapyramidal side effects) and neuroleptic malignant syndrome (allergic reaction)

Toronto Notes 2011 Table 16. Commonly Used Atypical Antipsychotics

Pharmacotherapy

Psychiatry PS43

Clozlpine (CkaiPI Macllanilm Blocks 5-IfT2- 02 111d adrenergic receptors Blocks 5-HTu&o 01-04, muscarinic, adrenergic, hisllminergic receptors

Zipnllsidlllll (llldoxll]

Blacks 5-HTZA, 01-Z. Blacks 5-HTUo 01-4. muscarinic. Blocks 5-IfTZA and moderate adrenergic and histlrnilergic histaminergic receptors DZ receptor antagonism; receptors moderatEly potent anergic and histaminergic blockar Mast effective lor treabnentresistant schizoph1111ia Does nat worsen tardiw symptoms; may treat them Approximately 50% of patients benefit, especially pnnaid plllierrts llld those with onset afterZOyears

Low incidence of EPS at lawar das111 ( <:8 mg)

Better overall eflicacy compared Associated with less weight to haloperidol gain to dozapila Wei tolerated and olanzapine Low incidence of EPS and TD

Diudvantq SE: ilsomnia, agitation, EPS, HIA, anxiety, prolactin, postural hypotansion, constipation, dizziness, weight gain

SE: mild sedlllian, insomnia,

dizziness, minimal anticholinergic, early AST and ALT elevation, restlessness Weight pin soc:illllld with incl'lllsed risk of diabetes

SE: HIA. sedlrtion, dizziness, SE: d-awsiness/sedatian,

constipation Malt sedating of first line atypiclll

SE: sedlrtion, neusee,

constipation, dyspepsia

hypersaliVII'Iian, tachycardia, dizziness, EPS, NMS 1% agranuloeylllsis

melitul and hypelfipidemia

Cammanll Quick dissolve (M-tabs), and lang-acting (Cansta41 ) formulations BYIIilable Quick dissaMI formulation (Zydis41 ) used commonly in ER setting for better compliance IM form BYIIilable
Weekly blood colllls far at IIIIISt 1 montll, til qz-a Do nat usa with drugs which may

causa bona marrow suppreaion due to risk of agranulocytosis

Nail: Risk af Might !!lin: ClallpinWDIIII!IPilll >

> qniibla

Atypical Antipsychotics
fewer EPS than typicals (except risperidone above 8 mg/d) risperidone, olanzapine, quetiapine are the "first line atypical antipsychotics" no significant difference in efficacy; speed of response and stability ofremission between first line atypicals disadvantage: expensive, metabolic side effects

eo..monty u .... Atypieal

Antipsyabatias
Risperidone Oillnlllpine

ROCS

Clozapine
Seroquel (quetiapine)

Long-Acting Preparations
antipsychotics formulated in oil for deep IM injection (see Table 15) received on an outpatient basis indications: individuals with schizophrenia or other chronic psychoses who relapse because of non-adherence dosing: start at low dosages, and then titrate every 2 to 4 weeks to maximize safety and minimize side effects should be exposed to oral form prior to first injection side effects: risk of EPS, parkinsonism, increased risk of neuroleptic malignant syndrome

Canadian Guidelines for the Treatment of Acute Psychosis in the Emergency Setting
haloperidol5 mg IM 2 mg 1M lorazepam olanzapine 2.5-10 mg (PO, 1M, quick dissolve) risperidone 2 mg (M-tab, liquid)

Table 17. Side Etfecu of Antipsychotics

Symm
Antichalinargic AlphNdrenergic blockade Side Elfactl

Dry mouth, difficulty urinflling, constipation, blurred vision. toxic-confusional states

Orthostatic hypotension, impotence. failure to ejaculate

Anlicholillll!lic Effects Red lSI beet

Hal ua Dry lSI Blind as a
lSI

Dapaminqic blaclalde
Anti-llistamine

Extrapyramidal syndromes (dystonia, akathisia, pseudo-Patinsonism, dyskinesiaf, galactormea, amenorrhea, impatanca. Wllight gain
Sedation Agranulocytosis (clozapinel

han bone bat

Mq

hatter

.....

Hamatalagic
Hyparanllitivity l'lllcti-

,.l------------------, ,

LM!r dysfunction Blood dyscrasia Skin rashes Neuroleptic rnalignlllt syntome Altered temperature regulation (hypothermia or hyperthermial
Matabalic syndrome (see side barf

Endocrine

M.tabollc Syndr1111111 Atypical antipsyc:hotics have been linked to weight gain, hypervlycemia. and Hpid abnormalities and are associated wilh an incraMed risk of malllbolic syndrome {a coU.ction of clinical and llbonatafy abnormalities including

abdominal obesity, insulin resistance,

hypertension, low level$ of 6popratllin cholnt.rol, and high l.v.ls oftriglyceridesl.

PS44 Psychiatry

Pharmacotherapy

Toronto Notes 2011

FIIVBr

FAIM

ligidily of muscles lllenllll sta1u1 chllnv (e.g. confusionI

BP. sW8111ingl

Autonomic chllngH (a.g. inc11aslld HAl

FARM symptoms an also snn in

Serotonin Syndrome (SSI. SS can ba distinguishad from NMS by

the following:

SS

NMI
rigidity

Twitchy, shivering, Severe glabill

mtleH

Flushed, sweaty

PaDor
No Gl symptoms

abdamilllll pain

Neuroleptic Malignant Syndrome (NMS) psychiatric emergency due to massive dopamine blockade; increased incidence with high potency and depot neuroleptics risk factors medication factors sudden increase in dosage, or starting a new drug patient factors medical illness dehydration exhaustion poor nutrition external heat load sex: male age: young adults clinical presentation fever, autonomic reactivity; rigidity, mental status changes (usually occur first) develops over 24-72 hours labs: increased CPK, leukocytosis, myoglobinuria treatment: discontinue drug. hydration, cooling blankets, dantrolene (hydrantoin derivative, used as a muscle relaxant), bromocriptine (DA agonist) mortality: 5% Extrapyramidal Symptoms (EPS) incidence related to increased dose and potency acute (early-onset; reversible) vs. tardive (late-onset; often irreversible) Table 11. Extrapyramidal Symptoms
Dyslanil Al:utaar Tardiwe Akathisia PuudOIJIIkinsonism Acute Dyskinaia Tardive

Bath
Acute: Young Asian and Black males

Bath

,, ,

Risk Group

Bderty females

Bderty females Purposeless, constant

movements, invelving facial and mouth rnUICUIIIIIn, or

TanliVII Dpki.-ill may includa

grimacing, tongue prutrusian, lip

smacking, and rapid aye mavarnent.

Molar IISIIISIIIISS; Crawling sensation in twisting, cantr&ction legs reliiiVIId by walking; Ill muscle groups; very distressing. increased rruscle spasms risk of suicide and poor (e.g. oculogyric aisil. adherence llrynpiJIIIII,
posture; torsions,

Sustained abnonnll

Tremor Rigidity (cogwheelingl Akinesia

Postural instability
(decreased/absent ann-swing. Slllaped postU18, siU!Iing gait, difficulty pivoting! Acute: within 30 d Acute: benzlropine (or benzodiazepine H side effactsl; reduce or change nauroleptic to

less commonly, 1he limbs

torticallil)
Dnut

Acute: within 5 d Tardive: >90 d Acute: benztropine or

dipherl!ydrarnine

Acute: within 10 d Tardive: >90 d Acute: lorazepam, propanolol or diphailydramine; relilce or clunge

Tardive: >90 d Tardive: no good trel!tment; may try ciDllpine; discontinue drug or reduce dose

Trutment

neuroleptic to lower potency

lower potency

Antiparkinsonian Agents (Anticholinergic Agents) types benztropine (Cogentin) 2 mg PO, IM or IV OD (-1-6 mg) amantadine (Symmetrel) 100 mg PO bid (100-400 mg) diphenhydramine (Benadryl) 25-50 rn.g PO/IM qid do not always prescribe with neuroleptics give only if at high risk for acute EPS or if acute EPS develops do not give these for tardive syndromes because they worsen the condition

Toronto Notes 2011

Pharmacotherapy

Psychiatry PS45

Antidepressants
onset of effect neurovegetative symptoms- 1-3 weeks emotional/cognitive: symptoms- 2-6 weeks may usc: mild stimulant (e.g. methylphenidate) fur severe neurovegetative: symptoms briefly and taper down as antidepressant effect increases taper TCAs slowly (over weeks-months) because they can cause withdrawal reactions tapering of any kind of antidepressant may be: required based on the: half-life ofthe medication and the patient's individual sensitivity it is important to be particularly vigilant over the: first 2 weeks oftherapy as neurovegetative symptoms may start to resolve: while emotional and cognitive: symptoms may not (patients may be: particularly at risk fur suicidal behaviour during this time) treatment of bipolar depression: monotherapy with antidepressants is not advisable as a switch from depression to mania can occur. If the patient is medication-nai:ve, initiate: therapy with a mood stabilizer plus an SSRI or buproprion. For patients taking mood stabilizers, consider adding or switching to lithium or lamotrigine, or adding an SSRI or buproprion

,....................

- Otlw AltidlpniiBifllo Dlpnl*l

This !lyltlmlllic I'IViiW af 98 Rcrs CGII1llfld 1lle ellil:acy II SSIUs will! olher kills II llllid....-.a illlle 1Jultmlrt.. plliertJ Ylitb

il:lcln.llllilw) C<me Brllilllse IISjtSIMitic ll'eriews 2U04; lssue3

depreat,.e disordm. c.tUiin: n.nt in lllllllllc:tiwnlllof SSIIIs11WU TCAI. Caasidll lllltiw plli8rt lllC8fllll*y.taxicity IIIII COli

Tabla 19. Common Antidepressants

an.
SSRI

Drug fluoxetina fliiYOXIII'line (I.!Jvox) paroxetine (Paxillt] sarlrllline (Zolofl'l]

Daily Starting DDII(mg)

20 50-100 10 50 20 10 3U-75 40 100 75-100 75-100 75-100 100-200

Tha!lpllutic DDII (mg)

20-80 150-300 20-60 50-200 20-60 10-20 75-225 40-60 300-450 150-300 150-300 75-150 150-300 60-90 10-60 300-600 15-45

Tips On Cllonlng Anlidepreunb All SSRis have similar effectiveness, but consider side effect profiles and haW-lives. Bupropion CBUIIIIS IIIIIIIIIXIIIII dysfunction. Might gain, and sedation but is contraindiclll8d for patients with history of saiZIJI'8, stroke, brllin brain surverv or closad hlld injury. Also unci to 111N1! eating di&orderl. Nat racommended for anxi8ty because of ttimulllting

citaiDIJllll
escitalopram (Cipralex)

SNRI

venlafaxine (EIIexotl') duloxetine (Cynilalta) buprnpion (Wellbutrinlt) imipnrnine (Tofranii)

(Eiavil]

NDRI
TCA (3" Aninl TCA (2" Amines) MAOI RIMA
NASSA

nortriptyline {AventyiJ desipramine

phenelzine (Nardi!) 1rllnylcypramile (Pamate) modobemide (Manenx] mirtmpine (Remeronit)

45
30 300 15

1\Airlllzlpine uselull insomnia or agitation are prominent. or to treat depression with cachaxil. Trazodone mainly used u adjunct for SSRI-inducad $Jeep dis1urbiii1Ces. Serlnlline, citalopram. and escibdopnm have the lem interactions o1h drugs and ara sleep-wake neutral. FIU0X1ti1111111d pai'DXIItinlln thll most activeting drugs and should be tllkln in the momilg. FIIIYDXIIITiine is always sedating and should be blcen in 1he 8V811ing.

.....

,,

(SSII=seleetiYe sero1Dnin reullt* inliitln; SNRI=saolllniu11d inhibin; tllRI=raepineplnile Blld d011111ile reuptairll inlibitort; MAOI= IIWlii0-8 oUia mibilrn; RMA=FM1$ible ilhibition rl MAO-A; NASSA=n011dQ!gic and IIJIICiic R1llJir:DI an!Jgoni$1$1

Treatment Strategies for Refractory Depression (sae Figure 2) optimization: ensuring adequate drug doses for the individual augmentation: the addition of a medication that is not considered an antidepressant to an antidepressant regimen (e.g. thyroid hormone, lithium, atypical antipsychotics) combination: the addition of another antidepressant to an existing treatment regimen (e.g. the: addition of bupropion to an SSRI or SNRI) subrutute: change: in the primary antidepressant (within or outside: a class) Note:: itis important to fully treat the symptoms of depression in order to decrease rates and severity of relapses
Stllrt SSRI or o1hur finrt line agent

How long tu Trellt? &-12 mDIIIbl: if lim or second episode 2 yaan: if 1hird episode, elderly, psychotic faaturas, refractory depression, > 2 episodes il 5 yam

.....

,,

Reassess wery

... 1-2
I

.....

l'lychophumacology of SSR11

ElflaiSidl Efllct

s..tonin

weeks lor 3-4 weeks

No or partial response

Stinullllld 5HT1A centrWly Relief of d11preaion

5lmA in spinal coni

Full response
...
Continue

Mciolvticeflect

Optimiza dose

...

S.Wal dysllllCtian: dellyed ejaculation, anorve1111ia,

Reassess reguli for 4-8 weeks

5HTZI:JSHT2A in brain

decleiS8d irteresV libido Rx with buproprion Adivation: anxiuty, iiiSOfMil

Full r!rp_on_se ___ Pa_rt_ia-Jt-sp-o_n_se_ _ _ No-ra-,!onse

warn patients lfWetv

SHTJA in aut

Win! with ftuoxatine, paAIXItirw

Combine

Augment

Switch

maywor1811ilfitst 1-2 weeks ol trntment

Gl upHI: -

bloating Tllk& with food

Figure Z. Treatment of Depression

PS46 Psychiatry
Table 20. Commonly Used Antidepressants
TCA
Considerations OCD (clomipramine) Meln:halic depression Block norepinephrine llld serotonin

Pharmacotherapy

Toronto Notes 2011

SSRI

MAD I

SNRI

Anxiety states, OCD, eating disorders, For moderate/severe that Depression, anxiety disorders SIIIISonal depression, typicalllld does not respond to SSRI atypical depression Atypical depr9SSion Block serotonin reuptake only Irreversible inhibition of monoamine oxidase A 111d B Leads to 1' norepinephrine llld serotonin Block norepinephrine and serotonil

Mode of Action

rauptakll

rauptakll

Side Efrecls

Anlidro/inargic llffiK:a: (see Table 17) Notachn81gk: fllftct3: tremcn, tachycardia, sweating, insomnia, erectile and ejaculation problems a I adrenetr1ic elfects: orthostatic hypotension Antihistamine elfects: sedation, weight gain CNS: sedation, stiroolation, seizure 1hreshold CVS: 1' HR, conduction delay

-v

Hypertensive crises witll tyramine ric foDds {e.g. wine, chcBH) develop heedache, Bushes, palpillltions, NN. photo!Rlbia Dizziness, r&flax tachycardia, pDStural hypotansion, sedation, insomnia Weight gain Sexval 111orgasmia Social dysfunction CVS: inCI'IIIIsed HR. conduction delay Energizing Serotonin syndrome, EPS, SIADH Mininal anticholinergic and antihistamile Blfacts Relatively safa in OD Toxic in OD, but widsr margin of safety than TCA

Fewer than TCA.. therefore inCI'IIIIsed compliance CNS: restlessness, tremor, insonrie, headache, drowsiness Gl: NN, dilllhea, abdominal cramps, weight loss

Low dose side effects ilclude insomnia (serotonergicl Higher dose side effects include: tremors, tachycardia, sweating, insomnia. dose-dependent increase in diastolic BP {noradrenergicl

Rille. in

Toxic in OD

3 times therapeutic dOE is lethal Presentlltion: anticholinergic Blfacts,

CNS stiiTlllation. then depression and seizures ECG: 1' QT (duration reflects severity) Trlllllm8nt activated charcoal, cathartics, supportive treatment, IV diazupam for seizure, salicylate for coma

Tachycardia and NN seen in acute avatlose

Do not give ipecac, es can cause lllPid neurologic detErioration 111d seizures
MAOI, SSRI

EtOH

SSRis inhibit P450 enzymes; 1hereftre EtOH MAOI,SSRI will1' levels of drugs metabolized by Hypertensive crises with Does not seem to P45D systam noradrenergic medications [e.g. TCA, dacongestants,llrf)hetarnines) Ssrotonin syndrome with ssrotonergic drugs (e.g. SSRI, tryptophan. dextrumethorphan)

P450 system

NDRI
Consilerations Depression. seesonal depression Block norepinephrine and dopamine reuptake

RIMA
Depression unrespCIISive to other 1he!11pies Reversible inhibitor of monoamine oxidase A Leads to 1' norepinephrine llld serotonin

NASSA
Useful in patients with insomnia, agitation or depression with cachexia Enhance central noradrenergic and ssrotonergic activity by lf'e5YilepliC aZ adrenergic receptcn

Mode of Al:tion

SideEffeca

CNS: dizziness, headache, tremor, ilsomnia CVS: dysrhythmia, hypertension Gl: dry mouth, NN. constipation, 1'appetite Other: agitation, anxiety, anaphylaclllid reaction

CNS: dizziness, headache, tremor, ilsornnia CVS: dysrhythmia, hypotansioo Gl: dry mDUih, NN. diarrhea, abdominal pail. dyspepsia GU: delayed ejaculation Other. diaphoresis

CNS: somnolence, dizziness, seizure [rare) Endocrine: 1' choleslllrol, 1' triglycerides Gl: Constipation, 1' ALT

Rille. il O..nl111e Tramo11111d saiues seen in acute DVIII'dDS8

DIUIIInllradians MAOI

Risk of fatal DVIII'dose whan combined Mild symptoms with overdose with citelopram or clomipramine MAOI, SSRI, TCA Narcotics MAOI, SSRL SNRI, RIMA

Drugs that reduce seizure threshold:

antipsychotics, systemic steroids, "-'inolone llltibiotics, antimalarial

drugs

Toronto Notes 2011

Pharmacotherapy

Psychiatry PS47

Serotonin Syndrome
thought to be due to over-stimulation of the serotonergic system can result from medication combinations such as SSRI+MAOI, SSRI+tryptophan, MAOI+meperidine, MAOI+tryptophan rare but potentially life-threatening adverse reaction to SSRis, especially when switching from an SSRI to an MAOI symptoms include nausea, diarrhea, palpitations, chills, restlessness, confusion, and lethargy but can progress to myoclonus, hyperthermia, rigor and hypertonicity treatment: discontinue medication and administer emergency medical care as needed important to distinguish from NMS (see side box, PS44)
It' Symptums gf AnliQ,........t

FINISH
Flu-like symptums

Insomnia
Nausea
lmbalslce S.nsary disturbllnca Hypelllrcusal (lllXiety/avilldionl

Discontinuation Syndrome
caused by the abrupt cessation of an antidepressant observed most frequently with paroxetine, fluvoxamine, and venlafaxine symptoms usually begin within 1-3 days, and include: anxiety, insomnia, irritability, mood lability, NN, dizziness, headache, dystonia, tremor, chills, fatigue, lethargy and myalgia treatment: symptoms may last between 1-3 weeks, but can be relieved within 24 hours by restarting antidepressant therapy at the same dose the patient was taking, and initiating a slow taper over several weeks consider drug with longer half-life such as fluoxetine

Sequneed hllniiMirnlllvlsiD ......

46:21..24 Sludr.l'laspedive mdulrimd rm-depreslllll 11111tmart1rill. l'llilnll: 4101 pllienls Mill major dep!ISSive

......

cllllllllr. Objeamc Ta CIJITIIIIIIIIIIIIiclcy IIIII ti Vlrioullnlidlplsslnl tllellpi8111'111191 r.r

saqumlltllllmlrt IMls.

Mood Stabilizers
First-Line
llthiumNalproic Acid ( antipsychotic) before initiating, get baseline: CBC, ECG (if patient >45 years old or cardiovascular risk), urinalysis, BUN, Cr, electrolytes, TSH before initiating lithium: screen for pregnancy, thyroid disease, seizure disorder, neurological, renal, cardiovascular diseases may need acute coverage with benzodiazepines or antipsychotics use carbamazepine in non-responders and rapid cycling can combine lithium and carbamazepine or valproic acid safely in lithium non-responders olanzapine may be used as a mood stabilizer, in conjunction with other mood stabilizers lithium and la.motrigine have established antidepressant efficacy

.....
....

1Ml2-cilllapllm +bupropian Sit llfiiUnl. WlnineXR, or LM 2MMdl tllblfropian or wnliaxina XR. LMI Hiller mitmpne or TICII1rirtYb +llhiLWT\ lliMI4-trln,tcypnlllina or vanllfai1111 XR +

...........! 1M 1-citabprlm trellpse

....a Ramillion -mr.LMI1.

17\lor Levei2.12-Mior Level3, IIIII 7-141for

1Ml4. When 11101111r811Jrent- In! 18quiraj, liM'II remilliln IIIH, delfBII Uld higillf- of !lllpi8.

,,

Lithium Toxicity (see Table 21)

clinical diagnosis, as toxicity can occur at therapeutic levels

long tllfiTl lithlm use Clll1 lead hi a I!IPhropethy and diabltn insipidus in
some pmients.

common ClUUie5
overdose sodium or fluid loss concurrent medical illness clinical presentation GI: severe nausea/vomiting and diarrhea cerebellar: ataxia, slurred speech, lack of coordination cerebral: drowsiness, myoclonus, choreifunn or Parkinsonian movements, upper motor neuron signs, seizures, delirium, coma management discontinue lithium for several doses and begin again at a lower dose when lithium level has fallen to a nontoxic range serum lithium levels, BUN, electrolytes saline infusion hemodialysis if lithium >2 mmol/L, coma, shock, severe dehydration, failure to respond to treatment after 24 hours, or deterioration

It' Lithium Side Elfllats

LITHIVM
L1111kDcytosis ln&ipidU& (diabetus)

Tl8mar, llraiDgenicity
Hypothyrcidi11111 Wlight

"V"'omiting. nausea

MisceUena- {a.g. ECG chlnga, acna)

Second-Line/Adjuvant Mood Stabilizers

Lamotrigine (Lamictai) o indications: treatment of dysphoric mania, mixed episodes and rapid cycling BAD, bipolar type 1 depression, prevention of mania and depression o mechanism: may inhibit 5-HT3 receptors and potentiate DA activity side effects CNS: dizziness, headache, ataxia, nausea, somnolence, fever, anxiety skin: rash, Stevens-Johnson syndrome (0.1 %)

PS48 Psychiatry
Table 21. Commonly Used Mood Stabilizers
lithium
l1dications Mailtenence 1helliPV of bipolar disordll' Traatrnant al acute mania Augmentation al antidepressants in MDE and DCD Sclizcctllectiva disorder Chronic aggrBSSion and entisocial behaviour Recurrent depression Unknown

Pharmacotherapy

Toronto Notes 2011

Llmatrigine
Treatment al bipolar disord1r Rapid cyclilg bipolll" disorder Mixed mania Prevention ol111111ia end depression

Divllprau (Epiftl8)
Maintenance 1herapy al bipolll" disorder T reatmant of acute menia Rapid cycling bipolar disorder Mixed phasa/Dysphoric 111111ia Maintenance theraP'f of bipolar disorder Treatment of aarte mania Rapid cycling bipolar disorder

Mode of Action

Therapeutic response within 7-14

days

May inhibit 5-HT3 recepto11 May potentiate DA activity Starting: 12.5-15 mQ"day Maximum: 500 mQ"day Dose adjusted in patients taking o1her anfi.convulsants established Dosing based on 1herapeutic response

Depresses synaptic transmission Raises seizure 1hreshold 750.2500 mlfday Usually tid dosing

Depresses synaptic transmission Raises seizure ttreshold 400.1600 mglday Usually bid or tid dosing

Adult 600-1500 ll"(llday Geriatric: 150-600 mlfday Usually dosilg

Tharapeutic Lsnl Adult 0.5-1.2 mmolll. (1.0-1.25 rmlDI/L Therapeutic plasma level not
for aarte mania) Geriatric: 0.3-{1.8 rmlDIII. MoniiDring

17-50 mmolll.

350.700 llllloiA.

Monitor &81111llewl& unti11harapautic Monitor for suicidality, pilticula1y (always wait 12 hou1111fter dose) 111ihlm initiating treatment Then monitor biweekly or mOIIIHy until a steady state is reached, 1hen q2months Monitor thyroid function q6 months, avatinina q6 months, urinalysis q1 year

LFTs weakly x 1 month. than monthly, due to risk of liver dysfunction Watch for signs of liver dysfunction: nausea, edema, malaise

Weakly blood count& for fim month. dua to risk of agranulocytosis Watch for signs of blood dyscrasias: fever, rash. sore 1hroat, easy bruising

Gl: NN, diarmea. stomach pain Gil: polyuria, polydipsia, GN, renal failure, nephrogenic Dl CNS: fine tramor, la1hargy, fatigue, headache Hematulogic: ravnibla laulrllcytosis . . Other: teratogenic (Ebste1n's anomaly), weight gain, edema, psoriasis, hypothyroidism, hair 1himing, muscle waaknBSS, ECG changes

Gl: NN, cianhea CNS: ataxia, dilziness, diplopia, headache, somnolence Skin: (should d/c drug beciUII af risk of S... Johnsen syndrome), increased lamotrigine level& = ilcreasad risk of rash . Other: 1111X18Iy

Gl: liver dysfunction. NN, dianh81 CNS: ataxia, drowsiness, tremor, sedation, cognitiw blull"ilg Othflr. har loss, weight gain, llansiant 1hrombocytopenia, neural tube delects when used in pregnancy

Gl: NN, dianh81, hepatic toxicity

(1' AST, 1' All, 1' LDH) CNS: ataxia, dizzinBSS, slulllld spaach, confusion, nystagmus, dlpiOpll Hemstologic: tJansient leukopenia (1 D%1, aplastic anemia Sldn: rash [5% risk; should die drug because of risk of Steveni-Johson

Other: neural tube delects when used in

pregnancy

IIIBI"II:tima

NSAIDs decrease clearance

OCP

DCP

Toronto Notes 2011

Pharmacotherapy

Psychiatry PS49

Anxiolytics
indications short term treatment of transient fonns of anxiety disorders, insoDIDia, alcohol withdrawal (especially delirium tremens), barbiturate withdrawal, organic brain syndrome (agitation in dementia), EPS and akathisia due to antipsychotics, seizure disorders, musculoskeletal disorders relative contraindications major depression (except as an adjunct to other treatment), history of drug/alcohol abuse, pregnancy, breast feeding mechanism of action benzodiazepines: potentiate binding of GABA to its receptors; results in decreased neuronal activity buspirone: partial agonist of 5-HT type lA receptors

Rational Usa of Anxiolytics (see Table 22) anxiolytics mask or alleviate symptoms; they do not cure them Benzodiazepines
should be used for limited periods (weeks-months) to avoid dependence all benzodiazepines are sedating have similar efficacy, so choice depends on half-life, metabolites and route of administration, ODor BID taper slowly over weeks-months because they can cause withdrawal reactions low dose withdrawal: tachycardia, hypertension, panic, insomnia, anxiety, impaired memory and concentration, perceptual disturbances high dose withdrawal: hyperpyrexia, seizures, psychosis, death avoid alcohol because of potentiation of CNS depression; caution with drinking and use of machinery side etfects CNS: drowsiness, cognitive impairment, reduced motor coordination, memory impairment physical dependence, tolerance develops

withdrawal
symptoms: anxiety, insomnia, dysperceptions, autonomic hyperactivity (less common) onset 1-2 days (short-acting), 2-4 days (long-acting) duration: weeks/months complications: above 50 mg diazepam/day: seizures, delirium, arrhythmias, psychosis management: taper with long-acting benzodiazepine similar to, but less severe than alcohol withdrawal; can be fatal overdose commonly used drug in overdose overdose is rarely fatal benzodiazepines are more dangerous and may cause death when combined with alcohol, other CNS depressants or TCAs

Benzodlazeplne Antagonist- Flumazenll (AnexateGD)

use for suspected benzodiazepine overdose specific antagonist at the benzodiazepine receptor site

Buspirona (Buspar8) primary use: generalized anxiety disorder

may be preferred over benzodiazepines because:

non-sedating no interaction with alcohol does not alter seizure threshold not prone to abuse onset of action: 2 weeks side efi'ects: cllzziness, drowsiness, nausea, headache, nervousness, extrapyramidal

PSSO Psychiatry

Pharmacotherapy

Toronto Notes 2011

Teble 22. Common Anxiolytics

It'

Cls

DRill

DDII Ringe
(mt'diJ)

tv.z (bOll'S)
18-50 30-100 30-100 50-160 6-20 10-20 8-12 8-20 1.5-5 2-11 3.8-6.5

Appraprilil Use

O.illric BenmdilzlpiLorBZIJPIIm Oxampllll Tem121l!lam Also 11ft in liver disease because not melllbolized by liver

Lar

Benzodiazepin

Long-:ting

0.25--4
2.-40

Akathisia, generalized anxiety seizure prevention, panic disorder Generalized anxiety, seizure prevention,. muscle relaxant, alcohol withdrawal Sleep, anxiety, alcohol withdrawal Sleep Panic disorder, high dupendsncy rcrt11 Sleep, generalized anxiety, akathisia, alcohol withdrawal, sublingual available for V!rf rapid action Slesp, generalized anxiety, alcohol Sleep Shortlist t11Z> rapid 1leep, but ruboWld insomnia Generalized iiiXiety Slesp

..... 1-----------------, ;
IIMmiiiAII b Alcollol Willlll,_.. Diazipllm 20 mg POJIV q1 h pm l.orllzapam 2-5 mu PO!lV/SL for plltiants with liver disease, chronic lung disease, or elderly

'

chlordiazepoxide (Librium"l

flurazepam (Damane"l
Short-:ting alprazolam (Xanax8 ) larazepan (AtivanJ oxazepam
telli8ZIIpam (Restaril) triazolam (Halcion)

5-300 15-30 0.25--4.0 0.5-M 1[}-120 7.5-30 0.125-{).5

Azlpiranes

buspiune (Bu&parl') zopiclone (lmOYilne)

5-7.5

ECT in Soa.ty Prior to the 1940't, ECT wa1 performed

the use

Electroconvulsive Therapy
induction of a grand mal seizure using an electrical pulse through the brain while the patient is under general anesthesia and a muscle relaxant unilateral vs. bilateral electrode placement indications depression refractory to adequate pharmacological trial high suicide risk medical risk in addition to depression (dehydration, electrolytes, pregnancy) previous good response to ECT familial response to ECT elderly psychotic depression catatonic features marked vegetative features acute schizophrenia mania unresponsive to meds side effects: risk of anesthesia. memory loss (may be retrograde and/or anterograde, tends to resolve by 6 to 9 months, pennanent impairment controversial), headaches, myalgias evidence that unilateral ECT causes less memory loss than bilateral but may not be as effective contraindicatiom: increased intracranial pressure

of muscle r!Hxlnb,

mulling ilnizum with full-scale convulsions and rare but serious complicriont such 81 vartebrlll and lang-bont1 fnlcturas. This practic1 may have led to negiltive sociellll perceptions of ECT. fldl.- PlrpebJited by batbaric depictions in papular culture. Ofllllq ongoing sligmirtiziltion, ECT 81 it is practicld todll'f is an llfectiwand 11ft option far piltienb struggling with mental

EffacyriECT il u.-iiEA llllilw J liECT2004; 20:13-20

Slullr: Mlla-nlylis of1ll1lbnizld 11"111 111111rmbnimd canlnlllrills. l'llillls; IIMiii'Uis end bipolw *'-ion. 11_. MBlUNE s.-ch

ham 1986-2003.
lllil..._ll"eHamilon DeptSiion

scala- ulld ID dallnnill JIII)OIISIID llllbiWII. Allulll: ItT- fTUid ID be ..,erior ID siiUited Ea, pllctho, TtAI, MAllis, ll"lllllllli-dlimllflll
in gllllnl.

Experimental Therapies
Deep Brain Stimulation (DBS) constant electrical stimulation of neuroanatomical targets that have been identified in the biological model of depression areas identified include the nucleus accwnbens, internal capsule and subgenual cingulate cortex parameters such as active electrode location, pulse width, frequency and voltage may be manipulated Transeranial Magnatic: Stimulation (TMS) non-invasive magnetic stimulation of superficial neurons in the frontal cortex (main target: dorsolateral prefrontal cortex) hypothesized to nonnalize cortical activity in depressed patients meta-analyses show modest acute efficacy

s.n-y: Ea illllllllficlciOIJS1llllmant modally,

pri:Uarly in IM!e IVId 1lellment-TeSislart dlplaion.

Toronto Notes 2011

Canadian Lep1 Issues

Psychiatry PS51

Canadian Legal Issues

Common Forms
Tabla 23. Common Forms Undar tha Mantel Haalth Act (in Ontario) Form Who Signs
When Expindion OIIB
Rightaf l'lllillnt IDRiview

Options Balon form

....

,;

Boardllwing Form 1: Any MD Application by physici1r1 Ill hospillllize a patiant for psychia1ric assessment against his,tber will to a schecklle 1facility (Farm 42ginnlll pltientj Within7dlyl altar examination 72. hours altar hospillllizetion Void if not implementl!d within 7 days No

Fonn 1: A Pri-

Form3 Voluntary admission (Form 5)

or

Fillad out a patiant is suspel:l&d of being an imminent tlarm to themselves (suicidal or others (homicide) or when they an af sal-can (e.g. not dressed lor freezing weather) and are suffering frum an apparent menbd
disorder. Based an any cambinlllion of the physician's own oburvldions and

or

Send home :!: Follow-up Form 2: Order for hospitalillllion and medical axamination against his,tber will by Justice of the Peace Form 3: Cer1ificllle of involuntary admission to a schecklle 1 fllcility (Form 30 givunlll patient. natica to rights advisor) Form 4: Cer1ificllle of renewal of involuntary admission to a schedule 1 fllcility (Form 30 ginn to plliant, latiCII to rightlldvisorl Form 5: Change to informaVvoluntary Justice altha Pllace No statutotv time r851riction 7 days from when No c0111l18l8d Purpose of form is cOII1llete once plllient brought to hospital Form 1

facb communicated by otmn. Box Aor Box B complrtad. Box A: Seri011s Hann Test

or
Send home :!: Follow-up

Thll'ast/Prwlnt Tilt ISSISSIS

currart behaviourw'thre!Q'
ltt8mpts. The Future Test assesses the likalihaod af seriDIIS tlarm

Attanding MD (dilfarant than MD who coll'1lleted Form 1)

Before expirlllian 14days of Form 1 Any tine to change status alan informal patient

Vas Form4 (within 48 hours) or FormS

occurring 111 result of the presenting menbd disordar. Box II: Pllliants with a known mental disorder, who are incapable of conslnling to 11W1mi!Tt (IXisting substitute have improved, and are currently at risk of sllrioua harm due 1D the same menbd
disorder.
racaived tnlllmllnt and

Attending MD Prior to expiration following patient o!Form3 an form 3

First: 1 month Yes Form4 Second: 2 months (within 48 hours) or Third: 3 months (max) Form5

status

Attending MD Whenever deemed N/A following paliant appropriel8 an Form 3/4 Whanever deemed N/A approprillle

N/A

N/A

Form 33: Notice to patiantthlll pllliant Attanding MD is incompel8nt to consant to treatment of mental disorder and/or m-gement of property

N/A

N/A

Consent
see Ethical. Legal and Organizational Mpt:cts of Medicine. ELOAM2, ELOAM8

Community Treatment Order (CTO)

known as "Brian's Law," Ontario passed legislature regarding CTOs on December 1, 2000 similar CTOs have been implemented in Saskatchewan (1995), Manitoba (1997) and British Columbia (1999} purpose: to provide a person who suffers from a serious mental disorder with a comprehensive plan of community-based treatment and supervision that is less restrictive than being detained in a psychiatric facility intended for those who: as a result of their serious mental disorder, experience a pattern of admission to a psychiatric facility where their condition is usually stabilized after being released, these patients often lack supervision and stop treatment due to the destabilization of their condition, these patients usually require re-admission to hospital

PS52 Psychiatry

Canadian Legal IBSuelliReferences

Toronto Notes 2011

criteria for a physician to issue a CTO patient with a prior history of hospitalization a community treatment plan for the person has been made examination by a physician within the previous 72 hours before entering into the CTO plan ability of the person subject to the CTO to comply with it consultation with a rights adviser and consent of the person and the person's substitute decision maker, if any CTOs are valid for six months unless they are renewed or terminated at an earlier date where the person fails to comply with the CTO when the person or his/her substitute decision-maker withdraws consent to the community treatment plan CTO process is consent-based and all statutory protections governing informed consent apply the rights of a person subject to a CTO include: the right to a review by the Consent and Capacity Board with appeal to the courts each time a CTO is issued or renewed a mandatory review by the Consent and Capacity Board every second time a CTO is renewed the right to request a re-examination by the issuing physician to determine if the CTO is still necessary for the person to live in the community the right to review findings of incapacity to consent to treatment provisions for rights advice

Duty to Inform/Warn
see Ethical. and Aspects of Medicine, ELOAMS

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Slahl SM.I'Iycliopliarrnacology of Antipsyclloti:L London: Marti! Dunill, 1199. 5awczyk.M. "Wamln's Health: Dlpmlionand Aelllld DiiDnlm." PrinuyC111, Volume 24, tbrber 1,1997, pp. 83-101. Tasman. Psychiatry 1st ad. 1997. p.1208. Troiden, 1989,Joumal ol Homo181WIIity. 11:253-267. WlrneU L rl abseRiveCIIII'Idsive dilonler." Callldiln Journal rl Diagnasis,llei:eriel 199&, h. ]JIVe. Weier EB, Weier RA, Frislld MA. "Bipolu llsonler in Clildrtn: lhlrilgnosis, and Future Directions." Joufllllfi tile Americ1111 Academy rl Child IUid AdoiiiiCiflt Psycllilltry, Von34, fUrbr &, ms, pp.7o!l-m. Wlittington CJ, lflndall t fllnegy P. Cotlrlll D. CotarM A, Boddington E. Salectiw llflllril11upblkll inhilitors in childhood deprlllion: systametic lll'iaw af publisllad veru dltll. LII!Cfl2004;363!9418]:13415. Zimmerman, M. lntarviaw liide for EVIUI!irQ IISM-IV Psyclillric Disonlers and the Mllntlll Status Examination. Elst (Muwich, RL Psych l'rulllctll'rels. 1994.

2000, liP 33-t.