Chapter 28 Psychiatry Flashcards
5-HT
Seratonin
Seratonin acronym
5-HT
dopamine acronym
DA
MAOI acronym
monoamine oxidase inhibitor
monoamine oxidase inhibitor acronym
MAOI
MDD vs MDE
major depressive disorder vs episode
SGA
SGA second generation antipsychotics
SNRI
SNRI serotonin and norepinephrine reuptake inhibitors
TCA
TCA tricyclic antidepressant
Screening Questions for Major
-pearl from t notes 16
• Have you been feeling down, depressed or hopeless?
• Do you feel anxious or worry about things?
• Has there been a time in your life where you have felt euphoric, extremely talkative, had a lot of energy,
and a decreased need for sleep?
• Do you see or hear things that you think other people cannot?
• Have you ever thought of harming yourself or committing suicide?
Mental state Exam
Appearance Behavior Conversation (thought form and content ex:delusions) Affect, mood Perception (hallucination) Cognition Judgement Insight Rapport
Multiaxial Assessment
Axis I: differential diagnosis of DSM-5 clinical disorders
• Axis II: personality disorders, developmental disability
• Axis III: general medical conditions potentially relevant to understanding/management of the
mental disorder
• Axis IV: psychosocial and environmental issues
• Axis V: Global Assessment of Functioning (GAF, 0 to 100) incorporating effects of axes I to IV
Axis I:
Axis I: differential diagnosis of DSM-5 clinical disorders
• Axis II
• Axis II: personality disorders, developmental disability
Axis III
• Axis III: general medical conditions potentially relevant to understanding/management of the
mental disorder
• Axis IV:
• Axis IV: psychosocial and environmental issues
• Axis V:
• Axis V: Global Assessment of Functioning (GAF, 0 to 100) incorporating effects of axes I to IV
General management in psychiatry, 3 things
biological (e.g. pharmacotherapy),
psychological (e.g. CBT), and social (e.g. support group)
What is a delusion?
fixed, false beliefs
Hallucinations:
Hallucinations: perceptual experiences
without an external stimulus
Psychotic disorder definition
- characterized by a significant impairment in reality testing
- delusions or hallucinations
3 psychotic disorders based on time
brief psychotic disorder >one day to <1 month
schizophreniform disorder 1-6 months
schizophrenia >6months
Schizophrenia
1epidemiology, Etiology, Pathophysiology, Comorbidity, Management, Course and Prognosis
- prevalence: 0.3-0.7%, M:F = 1:1
- mean age of onset: females late-20s; males early- to mid-20s
- suicide risk: 10% die by suicide, 30% attempt suicide
Schizophrenia
epidemiology, 1Etiology, Pathophysiology, Comorbidity, Management, Course and Prognosis
multifactorial: disorder is a result of interaction between both biological and environmental factors
Schizophrenia
epidemiology, Etiology, 1Pathophysiology, Comorbidity, Management, Course and Prognosis
- neurodegenerative theory
* neurodevelopmental theory
Schizophrenia
epidemiology, Etiology, Pathophysiology, 1Comorbidity, Management, Course and Prognosis
• substance-related disorders
• anxiety disorders
• decreased life expectancy because of associated medical conditions (e.g. weight gain, diabetes,
metabolic syndrome, CV/pulmonary disease)
Schizophrenia
epidemiology, Etiology, Pathophysiology, Comorbidity, 1Management, Course and Prognosis
1 biological / somatic (acute treatment and maintenance: antipsychotics (haloperidol, risperidone, olanzipine,
paliperidone; clozapine if refractory);
adjunctive: ± mood stabilizers (for aggression/impulsiveness - lithium, valproate,
carbamazepine) ± anxiolytics ± ECT
treat for at least 1-2 years after the first episode, at least 5 years after multiple episodes
(relapse causes severe deterioration)
2 psychosocial
3 psychotherapy:
Schizophrenia
epidemiology, Etiology, Pathophysiology, Comorbidity, Management, 1Course and Prognosis
• 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 of the long-term outcome is not possible
• negative symptoms may be prominent early in the illness and may become more prominent and
more disabling later on; positive symptoms appear and typically diminish with treatment
• over time: 1/3 improve, 1/3 remain the same, 1/3 worsen
neurodegenerative theory
neurodegenerative theory
• natural history may be a 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
• 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
schitzophrenia good prognostic indicators
• Acute onset • Shorter duration of prodrome • Female gender • Good cognitive functioning • Good premorbid functioning • No family history • Presence of affective symptoms • Absence of structural brain abnormalities • Good response to drugs • Good support system
Schizoaffective DSM criteria A
A. concurrent psychosis (criterion A of schizophrenia) and major mood episode - uninterrupted
period of illness
Schizoaffective DSM criteria B
B. delusions or hallucinations for 2 or more wk in the absence of a major mood episode during the
lifetime duration of the illness
Schizoaffective DSM criteria C
C. major mood episode symptoms are present for the majority of the total duration of the active
and residual periods of the illness
Delusional disorder criteria A
A. the presence of one (or more) delusions with a duration of 1 mo or longer
Delusional disorder criteria B
B. criterion A for schizophrenia has never been met
Note: hallucinations, if present, are not prominent and are related to the delusional theme
Delusional disorder Treatment
• psychotherapy, antipsychotics, antidepressants
mood disorders defintion
mood disorders are characterized by the presence of diagnosable mood episodes
mood episodes definition
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). DSM-5
Criteria for mood episodes are listed below.
Medical Workup for a Mood Disorder
• routine screening: physical exam, CBC, thyroid function test, extended electrolytes, urinalysis,
drug screen, medications list
• additional screening: neurological consultation, chest X-ray, ECG, CT head
Major Depressive Episode criteria A
≥5 of the following symptoms have been present during the same 2 wk period and represent a
change from previous functioning; at least one of the symptoms is either 1) depressed mood or
2) loss of interest or pleasure (anhedonia)
MSIGECAPS Mood: depressed Sleep: increased/decreased Interest: decreased Guilt Energy: decreased Concentration: decreased Appetite: increased/decreased Psychomotor: agitation/retardation Suicidal ideation
Major Depressive Episode criteria B
the symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning
Major Depressive Episode criteria C
the episode is not attributable to the direct physiological effects of a substance or a GMC
Manic Episode Criteria A
a distinct period of abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased goal-directed activity or energy, lasting ≥1 wk and present
most of the day, nearly every day (or any duration if hospitalization is necessary)
Manic Episode Criteria B
during the period of mood disturbance and increased energy or activity, ≥3
Criteria for Mania (≥3) GST PAID Grandiosity Sleep (decreased need) Talkative Pleasurable activities, Painful consequences Activity Ideas (flight of) Distractible
Manic Episode criteria C
the mood disturbance is sufficiently severe to cause marked impairment in social or occupational
functioning or to necessitate hospitalization to prevent harm to self or others, or there are
psychotic features
HypoManic Episode
• criterion A and B of a manic episode is met, but duration is ≥4 d
• episode associated with an uncharacteristic change in functioning that is observable by others
but not severe enough to cause marked impairment in social or occupational functioning or to
necessitate hospitalization
• absence of psychotic features. (If these are present the episode is, by definition, manic)
Major Depressive Disorder criteria A
presence of a MDE
Major Depressive Disorder criteria B
the MDE is not better accounted for by schizoaffective disorder and is not superimposed on
schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder NOS
Major Depressive Disorder criteria C
there has never been a manic episode or a hypomanic episode
MDD single vs recurrent
single vs. recurrent is an episode descriptor that carries prognostic significance. Recurrent is
classified as the patient having two or more distinct MDE episodes; to be considered separate the
patient must have gone 2 consecutive months without meeting criteria
MDD
1epidemiology, etiology, risk factors, treatment, prognosis
- lifetime prevalence: 12%
* peak prevalence age 15-25 yr (M:F = 1:2)
MDD
epidemiology, 1etiology, risk factors, treatment, prognosis
- biological
2. psychosocial
MDD
epidemiology, etiology, 1risk factors, treatment, prognosis
- sex: F>M, 2:1
- family history: depression, alcohol abuse, suicide attempt or completion
- childhood experiences: loss of parent before age 11, negative home environment (abuse, neglect)
- personality: neuroticism, insecure, dependent, obsessional
- recent stressors: illness, financial, legal, relational, academic
- lack of intimate, confiding relationships or social isolation
- low socioeconomic status
MDD
epidemiology, etiology, risk factors, 1treatment, prognosis
Treatment
• lifestyle: increased aerobic exercise, mindfulness-based stress reduction, zinc supplementation
• biological: SSRIs, SNRIs, other antidepressants, somatic therapies (see Pharmacotherapy, PS44, and
Somatic Therapies, PS52)
1st line pharmacotherapy: sertraline, escitalopram, venlafaxine, mirtazapine
more options, read toronto notes
• psychological
individual therapy (psychodynamic, interpersonal, CBT), family therapy, group therapy
• social: vocational rehabilitation, social skills training
• experimental: magnetic seizure therapy, deep brain stimulation, vagal nerve stimulation, ketamine
MDD
epidemiology, etiology, risk factors, treatment, 1prognosis
one year after diagnosis of MDD without treatment: 40% of individuals still have symptoms that
are sufficiently severe to meet criteria for MDD, 20% continue to have some symptoms that no
longer meet criteria for MDD, 40% have no mood disorder
MDD biological Treatment options
1st line pharmacotherapy: sertraline, escitalopram, venlafaxine, mirtazapine
for partial or non-response can change class or add augmenting agent: buproprion,
quetiapine-XR, aripiprazole, lithium
typical response to antidepressant treatment: physical symptoms improve at 2 wk, mood/
cognition by 4 wk, if no improvement after 4 wk at a therapeutic dosage alter regimen
ECT: currently fastest and most effective treatment for MDD. Consider in severe, psychotic
or treatment-resistant cases
rTMS: early data support efficacy equivalent to ECT with good safety and tolerability
phototherapy: especially if seasonal component, shift work, sleep dysregulation
Persistent Depressive Disorder DSM, what length?
depressed mood for most of the day, for more days than not, as indicated either by subjective
account or observation by others, for ≥2 yr
MAJOR DEPRESSIVE DISORDER WITH PERIPARTUM ONSET
(POSTPARTUM DEPRESSION) definition
MDD that occurs during pregnancy or in the 4 wk following delivery
MAJOR DEPRESSIVE DISORDER WITH PERIPARTUM ONSET (POSTPARTUM DEPRESSION)
1clinical presentation, epidemiology, risk factors, treatment, prognosis
- typically lasts 2-6 mo; residual symptoms can last up to 1 yr
- may present with psychosis; rare (0.2%), usually associated with mania, but also with MDE
- severe symptoms include extreme disinterest in baby, suicidal and infanticidal ideation
MAJOR DEPRESSIVE DISORDER WITH PERIPARTUM ONSET (POSTPARTUM DEPRESSION)
clinical presentation, 1epidemiology, risk factors, treatment, prognosis
• occurs in 10% of mothers, risk of recurrence 50%
MAJOR DEPRESSIVE DISORDER WITH PERIPARTUM ONSET (POSTPARTUM DEPRESSION)
clinical presentation, epidemiology, 1risk factors, treatment, prognosis
Risk Factors
• previous history of a mood disorder (postpartum or otherwise), family history of mood disorder
• psychosocial factors: stressful life events, unemployment, marital conflict, lack of social support,
unwanted pregnancy, colicky or sick infant
MAJOR DEPRESSIVE DISORDER WITH PERIPARTUM ONSET (POSTPARTUM DEPRESSION)
clinical presentation, epidemiology, risk factors, 1treatment, prognosis
Treatment
• psychotherapy (CBT or IPT)
• short-term safety of maternal SSRIs for breastfeeding infants established; long-term effects
unknown
• if depression severe or psychotic symptoms present, consider ECT
MAJOR DEPRESSIVE DISORDER WITH PERIPARTUM ONSET (POSTPARTUM DEPRESSION)
clinical presentation, epidemiology, risk factors, treatment, 1prognosis
Prognosis
• impact on child development: increased risk of cognitive delay, insecure attachment, behavioural
disorders
• treatment of mother improves outcome for child at 8 mo through increased mother-child
interaction
Bipolar I Disorder definition
disorder in which at least one manic episode has occurred
Bipolar II Disorder definition
disorder in which there is at least 1 MDE, 1 hypomanic and no manic episodes
BIPOLAR
1epidemiology, risk factors, treatment, prognosis
lifetime prevalence: 1% BPI, 1.1% BPII, 2.4% Subthreshold BPD; M:F = 1:1
• age of onset: teens to 20s, usually MDE first, manic episode 6-10 years after, average age of first
manic episode 32 yr
BIPOLAR
epidemiology, 1risk factors, treatment, prognosis
genetic: 60-65% of bipolar patients have family history of major mood disorders, especially bipolar
disorders
• clinical features predictive of bipolar > unipolar diagnosis given history of MDE: early age of onset
(<25 yr), increased number of MDEs, psychotic symptoms, postpartum onset, anxiety disorders
(espescially separation, panic), antidepressant failure due to early “poop out” or hypomanic
symptoms, early impulsivity and aggression, substance abuse, cyclothymic temperament
BIPOLAR
epidemiology, risk factors, 1treatment, prognosis
• lifestyle: psychoeducation for patient and supports on cycling nature of illness, ensure regular
check ins, develop early warning system, “emergency plan” for manic episodes, promote stable
routine (sleep, meals, exercise)
• biological: lithium, anticonvulsants, antipsychotics, ECT (if refractory); monotherapy with
antidepressants should be avoided
•psychological: supportive or psychodynamic psychotherapy, CBT, IPT or interpersonal social
rhythm therapy, family therapy
• social: vocational rehabilitation, consider leave of absence from school/work, assess capacity to
manage finances, drug and EtOH cessation, sleep hygiene, social skills training, education and
recruitment of family members
BIPOLAR
epidemiology, risk factors, treatment, 1prognosis
• high suicide rate (15% mortality from suicide), especially in mixed states
• BP I and II are chronic conditions with a relapsing and remitting course featuring alternating
manic and depressive episodes; depressive symptoms tend to occur more frequently and last
longer than manic episodes
• can achieve high level of functioning between episodes
• may switch rapidly between depression and mania without any period of euthymia in between
• high recurrence rate for mania – 90% will have a subsequent episode in the next 5 yr
• long term follow up of BP I – 15% well, 45% well with relapses, 30% partial remission, 10%
chronically ill
Bipolar x is quite often missed and many
patients are symptomatic for up to a
decade before accurate diagnosis and
treatment
II
Patients with x are at higher risk for suicide when they switch from mania to depression, especially as they become aware of consequences of their behaviour during the manic episode
bipolar disorder
x is among few agents with proven efficacy in preventing suicide attempts and completions and international research has found that populations with higher lithium levels in their drinking water have lower suicide rates in their general population
Lithium
The 4 L’s for Bipolar Depression
Lithium, Lamotrigine, Lurasidone,
SeroqueL
CYCLOTHYMIA
1Diagnosis, Treatment
Diagnosis
• presence of numerous periods of hypomanic and depressive symptoms (not meeting criteria for
full hypomanic episode or MDE) for ≥2 yr; never without symptoms for >2 mo
• never have met criteria for MDE, manic or hypomanic episodes
• 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 of functioning
CYCLOTHYMIA
Diagnosis, 1Treatment
Treatment
• similar to Bipolar I: mood stabilizer ± psychotherapy, avoid antidepressant monotherapy, treat any
comorbid substance use disorder
Anxiety Disorders
Panic Disorder
Agoraphobia
Generalized Anxiety Disorder
Phobic Disorders
part of brain responsible for fear conditioning
the amygdala (fear conditioning);
Panic disorder criteria A
recurrent unexpected panic attacks - a panic attack is an abrupt surge of intense fear or intense
discomfort that reaches a peak within minutes, and during which time four (or more) of the
Panic disorder criteria B
1 mo (or more) of “anxiety about panic attacks”
STUDENTS FEAR the 3 Cs
Criteria for Panic Disorder (≥4) STUDENTS FEAR the 3 Cs Sweating Trembling Unsteadiness, dizziness Depersonalization, Derealization Excessive heart rate, palpitations Nausea Tingling Shortness of breath Fear of dying, losing control, going crazy 3 Cs: Chest pain, Chills, Choking
Panic Attack vs. Panic Disorder
Panic disorder consists of panic attacks \+ other criteria Panic attack is not a codable disorder and can occur in the context of many different disorders
Panic Disorder
1Epidemiology, Treatment, Prognosis
- prevalence: 2-5% (one of the top five most common reasons to see a family doctor); M:F = 1:2-3
- onset: average early-mid 20s, familial pattern
Panic Disorder
Epidemiology, 1Treatment, Prognosis
• psychological
CBT, cognitive restructuring relaxation techniques
• pharmacological
SSRIs: fluoxetine, citalopram, paroxetine, fluvoxamine, sertraline
SNRI: venlafaxine
with SSRI/SNRIs start with low doses, titrate up slowly
Panic Disorder
Epidemiology, Treatment, 1Prognosis
- 6-10 yr post-treatment: 30% well, 40-50% improved, 20-30% no change or worse
- clinical course: chronic, but episodic with psychosocial stressors
Agoraphobia criteria A
A. marked fear or anxiety about two (or more) of the following five situations: using public transportation being in open spaces being in enclosed places standing in line or being in a crowd being outside of the home alone
Agoraphobia criteria B
the individual fears or avoids these situations because of thoughts that escape might be
difficult
Agoraphobia treatment
• as per panic disorder
Agoraphobia Definition
“Anxiety about not being able to escape, > 6 mo”
Generalized Anxiety Disorder Criteria A
excessive anxiety and worry (apprehensive expectation), occurring more days than not for at
least 6 mo, about a number of events or activities (such as work or school performance)
Generalized Anxiety Disorder Criteria B
the individual finds it difficult to control the worry
Generalized Anxiety Disorder Criteria C
the anxiety and worry are associated with three (or more) of the following six symptoms (with at
least some symptoms having been present for more days than not for the past 6 mo)
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)
Generalized Anxiety Disorder
1Epidemiology, Treatment, Prognosis
• 1 yr prevalence: 3-8%; M:F = 1:2
if considering only those receiving inpatient treatment, ratio is 1:1
• most commonly presents in early adulthood
Generalized Anxiety Disorder
Epidemiology, 1Treatment, Prognosis
• lifestyle: caffeine and EtOH avoidance, sleep hygiene
• psychological: CBT including relaxation techniques, mindfulness
• biological
SSRIs and SNRIs are 1st line (paroxetine, escitalopram, sertraline, venlafaxine XL)
2nd line: buspirone (tid dosing), bupropion (caution due to stimulating effects),
add-on benzodiazepines (short-term, low dose, regular schedule, long half-life, avoid prn
usage)
β-blockers not recommended
Generalized Anxiety Disorder
Epidemiology, Treatment, 1Prognosis
• 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
2 Types of phobic disorders
Specific phobia vs Social phobias
Specific phobia def
definition: marked and persistent (> 6 mo) fear that is excessive or unreasonable, cued by presence
or anticipation of a specific object or situation
Social Phobia
definition: marked and persistent (> 6 mo) fear of social or performance situations in which one is
exposed to unfamiliar people or to possible scrutiny by others; fearing 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
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
Phobia disorder treatment
• psychological
cognitive behaviour therapy (focusing on both in vivo and virtual exposure therapy,
gradually facing feared situations)
behavioural therapy is more efficacious than medication
• biological
SSRIs/SNRIs (e.g. fluoxetine, paroxetine, sertraline, venlafaxine), MAOIs
β-blockers or benzodiazepines in acute situations (e.g. public speaking)
Phobia disorder prognosis
chronic
OCD criteria A
A. presence of obsessions, compulsions, or both
OCD criteria B
B. the obsessions or compulsions are time-consuming (e.g. take >1 h/d) or cause clinically
significant distress or impairment in social, occupational, or other important areas of
functioning
rate of OCD in x is higher than in the general population
first-degree relatives
OCD
1Epidemiology, Treatment, Prognosis
- 12 mo prevalence 1.1-1.8%; females affected at slightly higher rates than males
- rate of OCD in first-degree relatives is higher than in the general population
OCD
Epidemiology, 1Treatment, Prognosis
• CBT: exposure with response prevention (ERP) – involves exposure to feared situations with
the addition of preventing the compulsive behaviours; cognitive strategies include challenging
underlying beliefs
• pharmacotherapy: SSRIs/SNRIs (12-16 week trials, higher doses vs. depression), clomipramine;
adjunctive antipsychotics (risperidone)
OCD
Epidemiology, Treatment, 1Prognosis
• tends to be refractory and chronic
Acute Stress Disorder
• May be a precursor to PTSD
• Similar symptoms to PTSD
• Symptoms persist 3 d after a trauma
until 1 mo after the exposure
PTSD
Too many criteria
1Epidemiology, Treatment, Complications
• prevalence of 7% in general population
• men’s trauma is most commonly combat experience/physical assault; women’s trauma is usually
physical or sexual assault
PTSD
Too many criteria
Epidemiology, 1Treatment, Complications
• psychotherapy, CBT
ensure safety and stabilize: e.g. emotional regulation techniques (e.g. breathing, relaxation)
once coping mechanisms established, can explore/mourn trauma - challenge dysfunctional
beliefs, etc.
reconnect and integrate - exposure therapy, etc.
• biological
SSRIs (e.g. paroxetine, sertraline)
prazosin (for treating disturbing dreams and nightmares)
benzodiazepines (for acute anxiety)
adjunctive atypical antipsychotics (risperidone, olanzapine)
• 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 (its use is
controversial because of limited evidence)
PTSD
Too many criteria
Epidemiology, Treatment, 1Complications
Complications
• substance abuse, relationship difficulties, depression, impaired social and occupational functioning
disorders, personality disorders
Adjustment Disorder
definition
a versatile clinical entity designed to capture patients who have difficulty coping with a stressful
life event or situation and develop acute, often transient, emotional or behavioural symptoms that
resemble less severe versions of other psychiatric conditions
Adjustment Disorder
Criteria A
the development of emotional or behavioural symptoms in response to an identifiable stressor(s)
occurring within 3 mo of the onset of the stressor(s)
Adjustment Disorder
Criteria B
these symptoms or behaviours are clinically significant as evidenced by either of the following:
marked distress that is in excess of what would be expected from exposure to the stressor
significant impairment in social or occupational (academic) functioning
Adjustment Disorder
1Classification, Epidemiology, Treatment
• 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)
Adjustment Disorder
Classification, 1Epidemiology, Treatment
• F:M 2:1, prevalence 2-8% of the population
Adjustment Disorder
Classification, Epidemiology, 1Treatment
• brief psychotherapy: individual or group (particularly useful for patients dealing with unique and
specific medical issues; e.g. colostomy or renal dialysis groups), crisis intervention
• biological
benzodiazepines may be used for those with significant anxiety symptoms (short-term, lowdose,
regular schedule)
Bereavement
define
Clinical Presentation
• bereavement is a normal psychological and emotional reaction to a significant loss, also called
grief or mourning
Risk Factors for Poor Bereavement
Outcome
• Poor social supports • Unanticipated death or lack of preparation for death • Highly dependent relationship with deceased • High initial distress • Other concurrent stresses and losses • Death of a child • Pre-existing psychiatric disorders, especially depression and separation anxiety
• if a patient meets criteria for MDD, even in the context of a loss or bereavement scenario
• if a patient meets criteria for MDD, even in the context of a loss or bereavement scenario, they are
still diagnosed with MDD
presence of the following symptoms may indicate abnormal grief/presence of MDD
guilt about things other than actions taken or not taken by the survivor at the time of death
thoughts of death other than the survivor feeling that they would be better off dead or should
have died with the deceased person; morbid preoccupation with worthlessness
marked psychomotor retardation; prolonged and marked functional impairment
hallucinatory experiences other than thinking that the survivor hears the voice of or
transiently sees the image of the deceased person
dysphoria that is pervasive and independent of thoughts or triggers of the deceased, absence
of mood reactivity
after 12 mo, if patient continues to yearn/long for the deceased, experience intense sorrow/
emotional pain in response to the death, remain preoccupied with the deceased or with their
circumstance of death, then may start to consider a diagnosis of “x”
persistent complex bereavement
disorder
Treatment of bereavement
• support and watchful waiting should be first line, as well as education and normalization of the
grief process
• screen for increased alcohol, cigarette and drug use
• normal grief should not be treated with antidepressant or antianxiety medication, as it is important
to allow the person to experience the whole mourning process to achieve resolution
• psychosocial: for those needing additional support, complex grief/bereavement, or significant
MDD, grief therapy (individual or group) is indicated
• pharmacotherapy: MDD present, past history of mood disorders, severe or autonomous symptoms
Neurocognitive Disorders
Delirium
Major Neurocognitive Disorder (Dementia)
Delerium
DSM criteria A
attention and awareness: disturbance in attention (i.e. reduced ability to direct, focus, sustain,
and shift attention) and awareness (reduced orientation to the environment)
Delerium
DSM criteria B
acute and fluctuating: disturbance develops over short period of time (usually hours to days),
represents a change from baseline attention and awareness, and tends to fluctuate in severity
during the course of a day
Delerium
DSM criteria C
cognitive changes: an additional disturbance in cognition (e.g. memory deficit, disorientation,
language, visuospatial ability, or perception)
Delerium
DSM criteria D
not better explained: disturbances in criteria A and C are not better explained by another
neurocognitive disorder (pre-existing, established, or evolving) and do not occur in the context
of a severely reduced level of arousal (e.g. coma)
Delerium
DSM criteria E
direct physiological cause: evidence that disturbance is a direct physiological consequence of
another medical condition, substance intoxication or withdrawal (i.e. due to a drug of abuse or
medication), toxin, or is due to multiple etiologies
Delerium Risk Factors
- hospitalization (incidence 10-56%)
- previous delirium
- nursing home residents (incidence 60%)
- polypharmacy (e.g. anticholinergic)
- old age (especially males)
- severe illness (e.g. cancer, AIDS)
- recent anesthesia or surgery
- substance abuse
- pre-existing cognitive impairment, brain pathology,psychiatric illness
Delerium Acronym
I WATCH DEATH
I WATCH DEATH
I
Infectious (encephalitis, meningitis, UTI, pneumonia)
I WATCH DEATH
W
Withdrawal (alcohol, barbiturates, benzodiazepines)
I WATCH DEATH
2A
Acute metabolic disorder (electrolyte imbalance, hepatic or renal failure)
Acute vascular (shock, vasculitis, hypertensive encephalopathy)
I WATCH DEATH
2T
Trauma (head injury, post-operative)
Toxins: substance use, sedatives, opioids (especially morphine), anesthetics, anticholinergics,
anticonvulsants, dopaminergic agents, steroids, insulin, glyburide, antibiotics (especially
quinolones), NSAIDs
I WATCH DEATH
C
CNS pathology (stroke, hemorrhage, tumour, seizure disorder, Parkinson’s)
I WATCH DEATH
2H
Hypoxia (anemia, cardiac failure, pulmonary embolus)
Heavy metals (arsenic, lead, mercury)
I WATCH DEATH
D
Deficiencies (vitamin B12, folic acid, thiamine)
I WATCH DEATH
E
Endocrinopathies (thyroid, glucose, parathyroid, adrenal)
Delerium
Inx
Investigations
• standard: CBC and differential, electrolytes, Ca2+, PO4
3-, Mg2+, glucose, ESR, LFTs, Cr, BUN, TSH,
vitamin B12, folate, albumin, urine C&S, R&M
• as indicated: ECG, CXR, CT head, toxicology/heavy metal screen, VDRL, HIV, LP, blood cultures,
EEG (typically abnormal - generalized slowing or fast activity, can also be used to rule out
underlying seizures or post-ictal states as etiology)
• indications for CT head: focal neurological deficit, acute change in status, anticoagulant use, acute
incontinence, gait abnormality, history of cancer
Delerium
managmeent
Management
• intrinsic
identify and treat underlying cause immediately
stop all non-essential medications
maintain nutrition, hydration, electrolyte balance and monitor vitals
• extrinsic
environment: quiet, well-lit, near window for cues regarding time of day
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
frequent orientation - calendar, clock, reminders
• biological
low dose, high potency antipsychotics: haloperidol has the most evidence; reasonable
alternatives include risperidone, olanzapine (more sedating, less QT prolongation),
quetiapine (if EPS), aripiprazole
benzodiazepines only to be used in alcohol withdrawal delirium; otherwise, can worsen
delirium
try to minimize anticholinergic side effects
• physical restraints if patient becomes violent
Delerium
Prognosis
• up to 50% 1 yr mortality rate after episode of delirium
Another term for dementia
Major Neurocognitive Disorder
The 4 As of Dementia
The 4 As of Dementia Amnesia Aphasia Apraxia Agnosia
