Child & Adolescent Psychiatry Flashcards
What are mental health outcomes associated with cannabis use in adolescents?
Depression
Psychosis
What are the most common scales used to assess Pediatric delirium?
The Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU)
Cornell Assessment for Pediatric Delirium (CAPD/CAPD-R)
What are evidence-based means of non pharmacologic pediatric delirium prevention?
reduction of pain
sleep disturbance
physical restraint use
addressing sensory and communication difficulties
ensuring early mobilization
providing frequent reorientation, including the use of familiar items from home
consistent presence of the child’s caregivers
What are evidence-based pharmacologic treatment of Pediatric delirium?
antipsychotics
alpha-2 agonists
melatonin
“Antipsychotics have been the mainstay of delirium treatment, with haloperidol, risperidone, olanzapine, and quetiapine showing equivalent safety profiles and improvement in agitation, sleep-wake disturbance, and symptom severity.,”
Name 5 social impacts of cannabis use in youth.
- Decreased performance in school, leading to lower educational attainment
- Higher unemployment levels
- Involvement in criminal activity
- Greater social assistance requirements
- withdrawal from their usual peer groups and conflict with family
- Lower Levels of Life Satisfaction
- Reduction in social, occupational or recreational activities
- Unable to fulfill major role obligations – school, work, family, friends
- Financial problems (leading to possible criminality)
- “gateway” to other drug use *
What is the relationship between cannabis and psychosis?
- Half of pts who develop induced psychotic symptoms with cannabis will go on to develop ongoing psychotic disorder
- Cannabis increases risk of psychosis from 40-400% (linked to how much use)
- The prevalence of schizophrenia is about 1% in the adult population, risk doubled in heavy cannabis users
- Use of cannabis and other illicit substances was associated with an earlier age at onset of psychotic disorders
What would you say to provide psychoeducation to a youth who vapes?
- Impact on respiratory system (Vaping Associated lung injury (VALI), chronic cough, bronchitis, asthma exacerbation, and decreased exercise tolerance)*
- Acute risk of injury (ie: burns, explosion)
- Highly addictive, quick tolerance/ dependence due to high nicotine content of pods (1 pod = 1 pack)
- Problematic use associated with the substances within the vapes (cannabis, nicotine, occasionally opioid, stimulants)
- Due to high concentration - acute nicotine intoxication/Nicotine toxicity – N/V, dizziness, H/A, confusion
- Vaping has been associated with high-risk behaviours and adverse mental health outcomes, notably depression and suicidality *
- Expensive
- Withdrawal
Dx of Catatonia. What are organic causes to be ruled out?
Neuro: Head trauma, cerebrovascular disease, encephalitis (e.g., anti-NMDAr or viral)
- Cancer: Brain tumor, paraneoplastic syndrome
- Metabolic: Hypercalcemia, diabetic ketoacidosis, hepatic encephalopathy, cerebral folate deficiency, homocystinuria
First psychotic episode. Parents asking for brain imaging. Explain why not and also what indications for brain imaging would be.
- Neurological exam is sufficient, and neuroimaging is not routinely recommended for first-episode psychosis (Canadian Schizophrenia Guidelines)
- Routine brain imaging often delays treatment and findings generally not contributory/ do not alter management in any meaningful way.
- Consider imaging if:
(a) History and neurological exam reveal: new/worsening headaches, n/v, seizures, focal neurological deficits
(b) Features of autoimmune encephalitis: rapid progression over <3 months, new focal findings, seizures
4M with imaginary friend. What is going on? Other DDx for visual hallucinations? What are 2 classes of medication that could cause VH?
Normal development
- DDx – adjustment d/o (severe stress), depression/ anxiety, PTSD, ASD, ID, sleep d/o
- Secondary to GMC – tumor, seizures, delirium, encephalitis
- Medications – steroids, opiate analgesics, anticholinergics
VH x 2 months, no other psychotic sx, no mood issues or bipolarity.
- PTSD, delirium, (temporal lobe) epilepsy, ASD
What is the therapeutic approach for pre-psychotic patients? Evidence-based approaches to treatment.
Approach to treatment for Clinical High Risk (Canadian Schizophrenia Guideline):
- Psychological interventions and medications can prevent or delay a first episode
- Offer Individual CBT +/- Family Intervention
- Offer Social Skills Training
- Treat comorbid conditions (e.g., depression)
- Monitor regularly for 3 years using validated tools
- Treatment should be provided by a psychiatrist or psychologist
- Use a staged and least-restrictive approach to treatment (e.g., CBT first then low dose SGA if needed)
What are the criteria for SIPS?
- SIPS – structured interview for psychosis-risk syndromes, which includes:
- Attenuated Positive Symptom Prodromal Syndrome (APS);
- Brief Intermittent Psychosis Prodromal Syndrome (BIPS);
- Genetic Risk & Deterioration Prodromal Syndrome (GRDS)
- SIPS assess:
- FHx
- GAF
- Scale of prodromal sx
- Schizotypal personality assessment
4F in hospital, seeing spiders. DDx? Recommendations?
- Delirium
- Work-up to determine cause
- Assessment – scales such as CAP-D (0-21yo), SOS-PD (0-16yo) or PAED (1-17yo) [pCAM-ICU is for >5yo]
CAPD: Cornell Assessment of Pediatric Delirium (age 0-21)
PAED: Pediatric Anesthesia Emergence Delirium Scale (age 1-17)
pCAM-ICU: Pediatric Confusion Assessment Method – ICU (age >5)
PsCAM-ICU: Preschool Confusion Assessment Method – ICU (age <5)
SOS-PD: Sophia Observation Withdrawal Symptoms – Pediatric Delirium (age 0-16)
- Non-pharmacological – early mobilization; remove unneeded unused lines; reorientation; parents at bedside; familiar items; maintain day-night cycle with multiple cues; reassurance
- Pharmacological – avoid polypharmacy + opiates + benzodiazepines + anticholinergic medications; Risperidone or Haldol/ Loxapine if hyperactive delirium. Titrate dose based on PRN use.
Metabolic syndrome criteria. What populations are most at risk? What are common secondary medical dx?
3 or more of the following
- Abdominal circumference >102cm for men, 88cm for women. For children 10-16 yo: the 90th percentile for waist circumference or adult cut point (whichever was lower) should define abdominal obesity.
- BP >130/85
- TG >1.7mmol/L
- HDL < 1.00mmol/L in men, <1.3mmol/L in women
- Fasting BG >5.6mmol/L
- Ethnicity – indigenous, blacks
T2DM, hypertension, cardiac disease, fatty liver, polycystic ovarian syndrome (PCOS), and pro-inflammatory states
Young child with cancer. Hospitalized x6 days. How do you explain why he is « not himself »?
- Ddx – delirium?
- Developmental regression in the context of critical illness (normal)
Which drugs cause VH?
- LSD, PCP, Amphetamines, Cannabis, Psylocibin
Which AP to avoid hyperPL?
1 Aripiprazole
Distant 3rd Clozapine
Secretion of prolactin by the pituitary gland is inhibited by dopamine in the hypothalamus. D2 blockade by antipsychotics in the hypothalamus releases this inhibition and causes hyperprolactinemia. D2 partial AGONISTS are not associated with hyperprolactinemia and can even treat it = Aripiprazole, Brexpiprazole, Cariprazine
Quetiapine is a D2 antagonist (not a partial agonist) but it (and Clozapine) have the lowest D2 blockade.
16 year old with schizophrenia. Attends a Section 23 school. Struggling with hallucinations.
a) Name 2 things that the teacher can do in order to support this student.
b) Name 2 things the teacher could do to decrease social isolation.
c) Name one intervention that a guidance counsellor can apply.
(a) Quiet room for evaluations and additional time for completion = (tests, exams); Headphones (+/- music) and ear plugs; Access to resource room/ supports; Body breaks; Technology adaptations (ie : Chromebook); Relaxation techniques. Adapt the schedule, workload and expectation according to capacities and absences with realistic expectations. Help with increased visual support.
(b) Integrate activities and projects of pre-selected groups; vocational projects; work in dyads or groups. Social skills training, tutoring from other student.
(c) IEP; specialized educator and decrease ratio; promote vocational projects; quiet and calm environment; cognitive remediation; cognitive remediation; build on strengths; consider school placement.
List two mental health disorders associated with hallucinations in youth (other than a psychotic disorder, SUD and bipolar disorder):
Anxiety disorders
Borderline Personality Disorder
PTSD
Depression
ASD/DD (less so)
Clinical vignette of an adolescent admitted and treated with an antipsychotic for acute psychosis. He is now febrile, delirious, and displays muscle stiffness. List two mandatory laboratory investigations. List three important components to evaluate on physical exam.
- Investigations – blood work, (CK, Creatinine, CBC, blood cultures, liver enzymes, LDH, Ca, PO4, Serum iron, urine myoglobin, ABG, coag, serum and urine toxicology)
- Most important is to rule out Ddx (ex. infection)
- Physical examination - Worry about NMS – (FARM)
- Temp
- HR/BP
- Rigidity
- Most important/dangerous: hyperthermia
List three features to differentiate schizophrenia from ASD in a child.
Temporal evolution/ onset of symptoms
Those with ASD do not spontaneously orient to emotional information
Origin of bizarre behaviours – delusions/ hallucinations/ disorganization vs. sensory hyper/hypo-sensitivities, adherence to routine/ rigidity
Period of normal or quasi-normal development before onset of symptoms (in scz)
Told of a family doctor who placed a youth on an antipsychotic and is now asking you what will be important to monitor over time. Asked to list five things.
Weight, BMI (Height), WC
Vitals – BP
Blood work – glucose/ HbA1c, lipid profile, PL (and effects of hyper-PL)
EPS + neurological exam
Psychotic Symptoms
Adolescent on clozapine. More lethargic past 2 weeks. Given most concerning side effect, name 3 signs or symptoms to do on history or physical exam. What lab investigation is most important to monitor? How often to check bloodwork in the first 6 months?
- Agranulocytosis – low NT count
- Fever, mouth ulcers, sore throat (maybe also HR/BP)
- Weekly for the first 6 months and biweekly for the next 6 months. CBC/ NT count weekly x 6 months. TnI and ERP weekly x first 4 weeks.
Prior to initiating treatment, obtain a baseline ANC; the ANC must be ≥2,000/mm3 in order to initiate treatment. Initiate treatment in an inpatient setting or an outpatient setting with medical supervision and monitor of vital signs for at least 6 to 8 hours after the first few doses. During the first 6 months (26 weeks) of treatment, ANC should be obtained at baseline and at least weekly. If count remains acceptable (ANC ≥2,000/mm3) during this time period, then may be monitored every other week for the next 6 months (26 weeks). If ANC continues to remain within these acceptable limits after the second 6 months (26 weeks) of therapy, monitoring can be decreased to every 4 weeks.
What is the indication for using clozapine? List three major side effects unique to clozapine.
Indication: treatment resistant schizophrenia (2 adequate trials of antipsychotics, 6-8 weeks duration)
Faster if self-injurious, suicidal behaviours, fast response needed
Side effects: agranulocytosis (low neutrophils), myocarditis/ cardiomyopathy, seizures, ileus/constipation, orthostatic changes in BP and HR/ bradycardia hypotension, QTc prolongation, NMS, anticholinergic toxicity, ileus/constipation
What do you check for bloodwork for clozapine and then monitor?
· CBC
· weekly x 6 months
· bi-weekly x 6 months
· q4weeks x thereafter
Name 4 parameters of metabolic syndrome? Which ethnic group in Canada at highest risk?
Waist circumference
BMI
BP
HBA1C/ fasting glucose
fasting lipid profile
Black and indigenous peoples ** not evidence-based, stupid
a) What are 3 signs/symptoms of hyperprolactinemia?
b) Which 2 antipsychotics least likely to increase prolactin?
a) Galactorrhea, gynecomastia, decreased libido, sexual dysfunction, decreased bone mass
In women specifically amenorrhea, oligomenorrhea, infertility *
b) aripiprazole, quetiapine, clozapine
9 year old with auditory hallucinations. Recently moved to Canada. Grandmother just died. Name 2 psychological triggers for AH and 2 symptoms need to ask to rule out psychosis.
- Severe emotional stress (grief/loss, recent immigration/ transition)
- Depression, in mood-congruent AH
- delusions
- disorganization
- functional change
- delusions
- mood incongruence
- Social withdrawal
- Language changes
AACAP “Hearing Voices and Seeing Things” 2017
Which medications are approved for the treatment of psychosis in pediatric patient?
HC – Aripiprazole (15+), JAMP Lurasidone is indicated for the management of the manifestations of schizophrenia in adolescents (15+)
FDA – Aripiprazole, Olanzapine, Paliperidone, Quetiapine, Risperidone , asenapine, brexpiprazole, lurasidone
Psychosis – treatment and good prognostic factors
- Antipsychotics are primary treatment
- Ongoing medication therapy should be provided to youth with schz
- Adjunctive meds to treat associated symptoms (agitation, depression, outbursts)
- Psychotherapeutic interventions should be provided in combination with medication therapies (cognitive-behavioral therapies, social skills training, cognitive remediation, and family interventions - FT, MI, CBT)
- Sudden onset + good pre-morbid function + good response to treatment + good insight + short duration of psychosis
- Poor long-term outcome is predicted by low premorbid functioning, insidious onset, higher rates of negative symptoms, childhood onset, and low intellectual functioning
Catatonia. Name two treatments.
ECT and benzodiazepines
Alternative - carbamazepine topiramate valproate zolpidem memantine and bromocriptine
Stem suggestive of psychosis prodrome
- Functional decline - 30% GAF in past year
- Sleep changes
- Social withdrawal
- Irritability/ anger
- Anhedonia, lack of motivation
- Negative symptoms – anhedonia, lack of motivation
- 3 different UHR groups: Genetic Risk & Deterioration (GRD), (Attenuated positive symptom syndrome) APSS, (brief Intermittent psychotic symptom syndrome) BIPS
Social withdrawal and isolation, idiosyncratic or bizarre preoccupations, unusual behaviors, academic failure, deteriorating self-care skills, and/or dysphoria. These changes may be associated with depression, anxiety, aggressive behaviors, or other conduct problems, including substance abuse, which often confuse the diagnostic picture. The prodromal phase may vary from an acute marked change in behavior to a chronic insidious deterioration.
NSSIB in ED. Parent are insisting on admission. Name 2 elements of psychoeducation to parents.
- NSSIB = not suicide attempt but maladaptive coping strategy
- Inpatient admission is not helpful and may actually result in further regression of distress tolerance/ emotional regulation skills.
- This learning is done in the community.
Youth with self-harm behavior. Asked to give 5 psychosocial strategies to address the behavior.
- Minimize alcohol/ substance use
- Skills
- Emotional regulation skills
- Improve communication
- Distraction
- Interpersonal effectiveness
- Problem-solving skills
- Conflict management Skills
- Affective Language Skills
- Psychotherapies
- DBT
- CBT (Individual, Family, Parent Training)
- FBT-Attachment for SI
- IPT – Individual for SI
- Psychodynamic therapy-Individual + Family
- Safety Planning
- Parent Skills Training
- Keep environment safe
Also Acceptable Answers:
- Interpersonal relationships/ supports
- Try to remove reinforcements/social contingencies
- Recognize warning signs
- Develop coping strategies (ex TIPP)
- Use friends, family and MH professionals for support
- Keep environment safe
- Motivational interventions/brief intervention
- Use mobile safety planning apps
- Mentalization-based treatment?
- Affective language skills
- Self-soothing skills
- Psycho-education for patient and family
- Cognitive problem-solving skills
Girl ingests 3 tabs x 325 mg acetaminophen. “3 safety questions?” What do you ask about?
- Where there any co-ingestions/ concurrent substance use?
- Was this a suicide attempt? (Clarify SI/ intent/ plan/ access to means (including guns))
- History of previous SA
- Precipitants - stressors, triggers
- Protective factors – supports, plans, evidence of future orientation
- Do you live alone?
- Are you still thinking of suicide?
(Screen for depression, mania, hypomania, severe anxiety)
Name 5 things to ask on safety/ risk assessment.
a) SI, plan, intent, access to means, future orientation
b) Triggers/ precipitants/protective factors
c) History of previous SA
d) Collateral history
e) Psychiatric diagnoses/comorbidities
f) Protective/ resiliency factors (ex: family, pets, religion)
g) Supports (ex : formal and informal)
h) Collateral information
i) Family history (of suicidality and mood d/o)
j) History of abuse, violence, bullying
k) Substance use
l) Exposure to suicide (ex. in media or friends/school)
m) Emotional/cognitive factors: hopelessness, helplessness, impaired problem-solving, agitation, despair, low SE, impulsivity
n) Familial conflict
o) If part of minority (first nation, lgbtq, …)
Young girl with self-harm behaviors. Name 4 strategies to reduce self-harm.
a) Distress tolerance skills
b) Emotional regulation skills
c) Distraction
d) Mindfulness, relaxation strategies
e) Anger management
f) Problem solving approach
g) Supports
h) Interpersonal effectiveness, friendships
i) Remove “means” – sharps, lighters, etc…
Girl ingested 100x100mg tabs of Quetiapine.What are 2 immediate steps for psychiatric care.
- Is this patient medically stable? ABC – vitals, LOC, QTc + involve other specialties as needed
- Assess Safety (+ Patient status in hospital – voluntary vs. involuntary)
- Assess for possible admission
Adolescent girl presents with self-injurious behavior. No mental health disorder present. List 5 techniques to decrease self-harming behavior.
- distraction (holding ice, cold shower)
- distress tolerance (TIPP= temperature, intense exercise, pace breathing, progressive muscle relaxation)
- emotion regulation techniques
- removing sharps and lethal means, and safety proofing home
- treat comorbidities
- meditation
- mindfulness
You write a prescription for AD in a child. The pharmacist does not want to dispense the medicine, stating it is not approved in patients <18yo. Give 2 reasons to explain the responses of the pharmacist and justify your prescription to the parent.
- AD not approved by Health Canada for those <18yo; although accepted in other countries (ie: USA). Treatment with AD is guided by Canadian and international treatment guidelines, such as CANMAT, Katzman, Canadian Pediatric Society and AACAP guidelines.
- There is a black box warning for increase in SI (not attempts). Note that untreated depression increases risk of SI and attempts.
- The FDA warning was based on an analysis published more than one decade ago about industry-sponsored randomized controlled trials (RCTs). However, since then, an increasing number of studies have questioned the methodological rigor of the FDA analysis
- Antidepressants very well studied in adolescents
3 important studies about SSRI (and their key findings) in children.
TADS – Treatment Of Adolescents With Depression (2007)
- TADS Key finding: Combination treatment (Fluoxetine + CBT) had the highest response rate
- Fluoxetine monotherapy better than CBT monotherapy
TORDIA – Treatment Of Resistant Depression In Adolescents 2010
- Adding CBT to either a new SSRI or an SNRI is superior to just switching meds alone
- No difference if SSRI vs. SNRI (but SNRI = less tolerability)
CAMS – child & adolescent anxiety multimodal study [separation/ social/ GAD]
- At 12 weeks, combo > (sertraline= CBT )> placebo
POTS – pediatric OCD treatment study
- At 12 weeks, combo > CBT > Sertraline > placebo
Name 5 differences in pharmacotherapy/ pharmacokinetics between methylphenidate and amphetamine.
In general, the primary pharmacologic effect of amphetamine and methylphenidate = increase central dopamine and norepinephrine activity, which impacts executive and attentional function.
Methylphenidate –
- Blocks reuptake of DA and NE (amp too)
- Metabolized by esterases in the liver (highly variable) – not CYP
Amphetamine –
- Inhibits VMAT-2 (which releases DA form vesicular storage)
- Inhibits MAO activity –> decreased breakdown of DA/NE
- Eliminated most via kidneys; excreted in urine mostly unchanged
Patient on fluoxetine and Strattera. What is the interaction? What is an example of another psychotropic that can interact with ?fluoxetine/ Strattera [unclear]?
- Fluoxetine inhibits 2D6 and therefore increases the serum concentration of Strattera. So beware of increasing the dose of Strattera.
- Other strong 2D6 inhibitors = bupropion, paroxetine; moderate = duloxetine
- Other 2D6 substrates = abilify, venlafaxine, risperidone, olanzapine
- Also: watch QTc as both SSRI and Strattera can increase QTc
Child on psychostimulant but difficulties with sleep and low weight. How do you switch from psychostimulant to Strattera?
CADDRA - Switching from a psychostimulant to atomoxetine or guanfacine XR:
- Since non-stimulants will take time to show clinical response, it is important to decide if the psychostimulant needs to be stopped before or if you combine both as you start atomoxetine or guanfacine XR.
- If the first medication shows no clinical effect despite optimal dosing, stop it and start the non-stimulant as monotherapy, following usual titration strategies.
- Only if it is not possible to stop the first medication (and if the first medication shows important clinical effect and needs to be continued until the non-stimulant shows its effects) then keep the first medication and add atomoxetine slowly, following usual titration strategies.
- If side effects occur, decide between reducing the psychostimulant versus atomoxetine or guanfacine XR dosage.
- Strattera – 0.5mg/kg/day x 7-14 days, then 0.8mg/kg/day x 7-14 days, then 1.2mg/kg/day x7-14 days. Max = 1.4mg/kg/day or 60mg (kids) or 100mg (youth)
- Guanfacine – Start at 1mg daily, maintain dose for 7 days, increase by no more than 1mg weekly Max = 4mg in age 6-12, 7mg in 13-17. As adjunct, max = 4mg.
Intoxication/ overdose on benzodiazepine. What is the antidote? What is the mechanism of action of benzodiazepine?
(a) Flumazenil.
But more generally, approach to management
- ABCs
- Naloxone if altered mental status and worried about opioid co-ingestion
- IV access, CCM
- If respiratory depression, definitive airway management
- Usually no decontamination
- Flumazenil indicated IF young children with isolated BZD ingestion with severe CNS depression – not in anyone who uses BZD chronically
(b) Bind to the GABA-A receptor of neurons; allosteric reaction –> increased activity of GABA at GABA receptor. Increase influx of Cl, which results in hyperpolarization of the inhibitory neuron –> less likely it will fire an action potential.
Aripiprazole – how does it differ from other AP. What are 2 advantages and 2 disadvantages of this medication?
- Partial D2 and 5HT1A agonist
- BENEFITS –
- Better metabolic profile
- Less hyperPL
- Slightly less weight gain then other AP
- There is an LAI (IM) formulation (Maintena)
- DRAWBACKS –
- Akathisia
- EPS/Parkinsonism
- Long half-life making reaching the steady state longer
Ethnic differences in metabolism. Name 4-5 approaches to how you would adjust your prescribing methods.
Practices:
- Start low, go slow
- Close monitoring of SE
- FHx of response
- Avoid polypharmacy
- Regularly reassess need for the medication and dc unnecessary agents
Summary:
- Caucasians, Blacks, Asians – slow metabolizer 2D6
- Blacks and Asians – slow metabolizer 2C19
- East Asians – slow metabolizer 3A4
- Differences in glycoproteins – drug transporter
- Polymorphisms of 5HT 2A and D3 receptors – more side effects, including EPS, respond to very low doses
- Indigenous and blacks: more risks Db2
Which AP to avoid hyperPL?
- Aripiprazole
- Quetiapine
- Clozapine
- Brexpiprazole
13 year old female of Haitian descent with ?oppositional behaviour. On Fluoxetine 30mg x 10days. Risperidone 0.5mg BID added 4 days ago. Agitated, tremulous. Provide two metabolic/ pharmacokinetic/ dynamic explanations for her symptoms. Describe 3 cultural themes to explore if parent/ parent are consider dc of treatment.
- Risperidone is a substrate for 2D6. Fluoxetine is an inhibitor of 2D6.
Therefore, there are increased serum levels of Risperidone = increased SE
She could also be a slow metabolizer. Younger patients + certain cultural groups (black) are more susceptible to EPS. Synergism of SSRI + AP that both cause akathisia.
- Consider a cultural formulation:
- Understanding/ meaning of symptoms/ dx/ treatment – pharmacotherapy
- Culturally appropriate supports/ care
- Psychosocial stressors and cultural factors impacting vulnerability/ resilience
- Expression of distress/ idioms of distress
- Religious and spiritual beliefs/ implications
- Patient-physician relationship and understanding/ trust
- Cultural identity
- Cultural community implications
Name 2 paradoxical reactions to benzodiazepines in children.
- Agitation/ irritability
- Excessive Movements/Excitability
- Impulsivity
- Talkativeness
- Insomnia
Describe most common side effects as a result of combining fluoxetine to risperidone. What is the mechanism of action?
- Medication interaction
- Inhibition of CYP450 2D6 metabolism by fluoxetine and its active metabolite.
- Fluoxetine increases the serum levels of Risperidone
- EPS, sedation, dizziness
List two medications associated with hallucinations in children
Medications – steroids, opiate analgesics, anticholinergics
Provide mechanism of action of methylphenidate and atomoxetine.
- methylphenidate= Methylphenidate (MPH) non-competitively blocks the reuptake of dopamine and noradrenaline into the terminal by blocking dopamine transporter (DAT) and noradrenaline transporter (NAT), increasing levels of dopamine and noradrenaline in the synaptic cleft.
- atomoxetine= SNRI; thought to be related to selective inhibition of the pre-synaptic norepinephrine transporter
Describe what makes aripiprazole unique relative to other antipsychotics, and give two concerning side effects
[a] From a pharmacological perspective, aripiprazole is different to other antipsychotic agents , as it is the only approved antipsychotic that reduces dopaminergic neurotransmission through D2 partial agonism, not D2 antagonism. (Partial d2 agonist + partial 5HT1 agonist)
[b] akathisia; EPS; NMS
Told of a family doctor who placed a youth on an antipsychotic and is now asking you what will be important to monitor over time. Asked to list five things.
- height, weight, BMI, WC
- vitals= BP
- bloodwork= glucose/HbA1C, lipid profile, liver profile, prolactin
- neuro exam for EPS
- response to treatment
- lifestyle behaviours
8 yo with GAD. Not treated with psychotherapy. Wants to start SSRI. Name 5 pharmacokinetic principles of SSRIs in this patient (question is not any more clear than this).
- Pre-pubertal children have a higher rate of activating side effects on SSRI
- Maturation of pathways impacts effectiveness of medications
- Children metabolize medications faster due to larger liver (liver to body ratio) and more efficient glomerular filtration (shorter ½ life)
- Higher proportion of water = larger volume of distribution of hydrophilic meds
- Less adipose tissues = accumulate lipophilic meds to a lesser extent and consequently eliminate them faster
- Increased BBB permeability
Name 5 lab investigation prior to initiating lithium
- Blood work – 1)CBC, 2)electrolytes, 3)extended electrolytes (Ca + albumin), 4)renal function (Cr. BUN), 5)thyroid function (TSH, T4)
- Urinalysis
- ECG (*Guidelines say >40 years, but we will do it!)
- Pregnancy test
- Weight, BMI
What is the general prevalence of ADHD in:
a) children and adolescents?
b) adults?
a) 5-9%
b) 3-5%
What is true about the heritability of ADHD?
a) low or high?
b) Risk of child having ADHD if parent had ADHD?
c) What percentage of kids with ADHD have a parent with ADHD?
a) high
b) 50%
c) 25%
What is known about the genetic pathophys of ADHD?
- ADHD is heterogeneous disorder, so likely complex genetic etiologies
- Many genes have been linked such as DAT and DRD4
What are etiologic risk factors associated with ADHD?
- smoking and alcohol use in pregnancy
- low birth weight
- psychosocial adversity
What is a possible underlying neural mechanism in ADHD?
- dysfunction of frontal-striatal pathways
- dorsolateral and anterior cingulate
What did the Multimodal Treatment of ADHD (MTA) study find with regards to the prevalence of comorbidities in children with ADHD?
- Up to 70% have comorbid psych disorders such as anxiety, depression, ODD, tic, OCD
How many criteria are needed to make a diagnosis of ADHD?
- Hyperative - 6/9 hyperactive symptoms
- Inattentive - 6-9 inattentive symptoms
- Combined - 6/9 of each
(note in adults, 5/9 needed)
Medication Selection: Medication-related factors in ADHD
Active ingredient /mode of action/drug interactions
Delivery system / onset of action / duration of action
Available doses
Canadian clinical indications
Affordability, accessibility and reimbursement
(public/private)
What are patient specific factors in ADHD med selection?
Age and individual variation
Duration of effect required by timing of symptoms
Concurrent psychiatric and medical issues
Physician, family and patient attitudes
Adolescent on clozapine. More lethargic past 2 weeks.
a) Given most concerning side effect, name 3 signs or symptoms to do on history or physical exam.
b) What lab investigation is most important to monitor?
a) agranulocytosis= fever, tachycardia, tachypnea, hypotension/blood pressure, examination of oral mucosa
b) CBC with differential (absolute neutrophil count)
What are some of the disntinguishing criteria of pyromania?
- Deliberate and purposeful fire setting on more than one occasion.
- Tension or affective arousal before the act.
- Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences).
- Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath.
- The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one’s living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment (e.g., in major neurocognitive disorder, intellectual disability [intellectual developmental disorder], substance intoxication).
- The fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.
How often do you check clozapine bloodwork in first year?
Baseline (must
First 6 months, weekly.
Second 6 months, every other week (as long as counts acceptable)
After that, every 4 weeks
What are the values assoicated with the hematology toxicity monitoring of clozapine?
Hematologic toxicity monitoring:
ANC 1,500 to 2,000/mm3: Continue treatment; monitor ANC twice weekly until counts stabilize or increase, then return to previous monitoring schedule.
ANC <1,500/mm3: Discontinue treatment and do not rechallenge patient; continue to monitor WBC/ANC daily until hematologic abnormality is resolved; monitor for signs of infection.
If WBC falls <1,000/mm3 or ANC falls <500/mm3, place patient in protective isolation with close observation.
Adolescent on clozapine. More lethargic past 2 weeks. If you are concerned about TOXICITY specifically,
a) Name 3 signs or symptoms to do on history or physical exam
b) What lab investigation is most important to monitor?
a) hypotension, myoclonus/seizures, mental status changes (sedation), sialorrhea
b) CBC with differential, clozapine level
a) Name 2 symptoms of paradoxical reaction to benzodiazepines.
b) State 2 things you would warn family about if there is a paradoxical reaction.
a) agitation/irritability
excessive movements/excitability
impulsivity
talkativeness
insomnia
b) seek medical support/present to ER
increased supervision
down-titrate
ultimately discontinue benzodiazepine
a) Name 3 differences in drug metabolism in ethnic minorities.
b) Describe 4 ways to dose medications in ethnic minorities.
a)
- Caucasians, Blacks, Asians – slow metabolizer 2D6
- Blacks and Asians – slow metabolizer 2C19
- East Asians – slow metabolizer 3A4
- Differences in glycoproteins – drug transporter
- Polymorphisms of 5HT 2A and D3 receptors – more side effects, including EPS, respond to very low doses
- Indigenous and blacks: more risks Db2
b)
- Start low, go slow
- Close monitoring of SE
- FHx of response
- Avoid polypharmacy
- Regularly reassess need for the medication and dc unnecessary agents
Kid with 2 year history of absence seizures and 4 month history of generalized tonic clonic seizures. On carbamazepine (no timeline listed).
a) What is the most likely diagnosis?
b) Want to start Prozac - what if any interaction with carbamazepine?
a) Seizure disorder = likley diagnosis in a child with seizures. Most common psych comorbidities in epilepsy: ADHD, ASD, depression, anxiety, psychosis, OCD, PD. (Note answer key = depression)
b) Carbamazepine is metabolized by CYP3A4. Fluoxetine inhibits CYP3A4. So the patient will have higher levels of serum Carbamazepine. Side effects could include confusion, ataxia, nystagmus, GI symptoms, SJS.
Carbamazepine also cause 1A2, 3A4, 2C19, 2C9 and 2B6 induction which could decrease concentration of fluoxetine
But most dangerous/relevant effect is one stated above possibly causing CBZ toxicity
What treatment is contraindicated for depression in seizures?
Wellbutrin/ Bupropion (and TCAs)
Name a second generation antidepressants that causes somnolence and 2 that cause insomnia.
a) Mirtazapine
b) Bupropion, Venlafaxine, SSRIs in some cases
a) What is the indication for using clozapine?
b) List three major side effects unique to clozapine.
a) Treatment resistant schizophrenia
(2 failed antipsychotic trials of at least 6 weeks at midpoint or higher of therapeutic dose range, documentation of adherence, and persistence of 2 positive symptoms with at least moderate severity or a single severe symptom)
b) Ileus, Agranulocytosis, Myocarditis, Seizure
What do you check for bloodwork for clozapine and then monitor?
- CBC
- weekly x 6 months
- bi-weekly x 6 months
- q4weeks x thereafter
*CAMESA: fasting glucose, insulin, lipid profile, AST/ALT, prolactin (baseline, 3 months, 6 months, 12 months)
Child with seizure disorder and depression.
a) Which med to choose?
b) What is contraindicated?
a) SSRI (sertraline and fluoxetine)
b) Bupropion and TCA
What are 3 signs/symptoms of hyperprolactinemia?
Galactorrhea
Gynecomastia
Osteopenia/Osteoporosis
Sexual dysfunction/Decreased Libido
In women - infertility and amenorrhea
bWhich 2 antipsychotics least likely to increase prolactin?
Aripiprazole
Quetiapine
(… and clozapine a distant 3rd, lol)
a) How is Aripiprazole different than other SGAs?
b) What are 2 benefits of Aripiprazole?
c) What are 2 side effects?
a) Partial D2 agonist
Partial 5HT1 agonist
5HT2A Antagonist
b) Less metabolic side effects
Less weight gain
Less hyperPL
c) Akathisia, EPS
NMS. In stem, provide 5 risk factors.
- Male (2:1)
- Age 20-25
- AP naive
- Dose and potency of DA agent
- Hx of NMS (15-20% recur)
- IM AP
- agitation
- Iron deficiency
- Rapid increase in dose
- GDD/ID
- FHx catatonia
- History of catatonia
- polypharmacy
- physical restraints
- hyperthermia/fever
- hyperT4
- sudden discontinuation of anticholinergic drug
- dehydration
- Acute medical illness
- Inconsistent use
List some school/ academic accommodations for ADHD.
- instructional interventions= give clear, precise instructions; get the student’s attention before providing instructions; use direct requests (“when-then”)
- behavioural interventions= provide immediate and frequent feedback; use visual cues in the classroom or on the desk for transitions; Chunk and break down steps to initiate tasks
- environmental intervention= preferential seating away from distractions; proximity to teacher
- academic interventions= Actively engage the student by providing work at the appropriate academic level; Permit student to write quizzes, tests and exams in a quiet room
- executive function interventions= find a tutor/academic coach; establish a routine
- post-secondary interventions= contact the student accessibility/disability centres; allow for extended time on tests/exams
Intense anger outbursts x several months with irritability in between outbursts.
a) What is the most likely diagnosis?
b) What else is on your Ddx?
a) DMDD
b) ASD
ADHD
IED
ODD/ CD
Depression/ anxiety/ BAD
Recall, DMDD
- Young as 6, up to 18
- Symptoms must be present by age 10
- Can’t be diagnosed with ODD, MDD, BD
- Non-episodic irritability
Name 2 elements that differentiate ADHD and mania.
- ADHD is an ongoing condition where BD is episodic
- decreased sleep, hypersexuality, grandiosity, hallucinations or delusions, and homicidal or suicidal thoughts and actions occur with childhood mania, but are rare or absent in uncomplicated ADHD.
What are comorbidities of Pyromania?
CD
ADHD
Adjustment Disorder
Adults – ASPD, SUD, Gambling
What are features of Pyromania?
Dx:
*impulse control disorder
(1) The person has set fires deliberately and on purpose on more than 1 occasion (multiple episodes involved)
(2) The person feels a tension or affective arousal before setting the fire
(3) Fascination, interest, attraction and/or curiosity for fire making paraphernalia, fire fighting equipment or any fire-related topic
(4) Pleasure, gratification, or relief may be felt when setting fires, while witnessing a fire or when participating in the aftermath
Exclusion criteria:
- The fire setting cannot be better explained by another disorder (mania, antisocial personality conduct disorder, other).
- The fire setting is not done (1) for monetary gain–insurance etc (2) to express a sociopolitical ideology, (3) to conceal a criminal act, (4) as a conscious expression of anger or vengeance, (5) to improve one’s living circumstances, (6) in response to a delusion or hallucination, and (7) as a result of impaired judgement due to delusion or intoxication.
a) What is advice for teens with ADHD who will be starting to drive?
Driver Training
- Pharmacotherapy + adherence
- Jerome Driving Questionnaire (CADDRA)
- Do not use mobile device and minimize distractions
- Do not drive at evenings/ night/ weekends
- Automatic transmission
- Report to MOT if any concerns/ repeated accidents
- Curfews
- Staying off major highways
- Absolutely no drugs or alcohol
- PRN use of short acting medication in evenings if necessary
What is the increased risk for MVC for teens with ADHD?
2-4X increased risk of MVC
What cognitive functions do you need for driving that are affected by ADHD?
- memory and learning
- executive functions
- complex attention
- perceptual and motor functions
- Language
- Social Cognition
(fyi) Neurodevelopmental immaturities in executive functioning (resulting in problems with attention, impulse control and emotional regulation) combined with a lack of driving experience can lead to problem driving styles in young people in general
Young boy with ADHD with motor (facial) tics. Ddx?
- persistent motor or vocal tic disorder (more than 1 year and either motor OR vocal tics but not both) vs provisional tic disorder (less than 1 year) vs Tourette’s disorder (both motor AND vocal tics)
- psychostimulant induced
- stereotypies/ASD
- OCD
- PANDAS
Which medication would you recommend for severe tics?
A-2 agonists
- Guanfacine
- Clonidine
- Tetrabenzine
- Atomoxetine in cases where stimulant is exacerbating tics
Are there any medications contraindicated for ADHD + Tourette’s syndrome?
- No specific contra-indication for tics+ADHD (Stimulants not containdicated)
- Canadian guidelines recommend against cannabinoids, levetiracetam, IVIG, fluoxetine, ondansetron
Pharmacotherapy for severe behavioural issues.
- Multimodal, non-pharmacological approaches across settings – parent skills training, emotional regulation, anger management, problem solving therapy)
- ADHD – stimulant, non-stimulant (a2-agonist and atomoxetine), Risperidone
- ASD – Risperidone, Aripiprazole
- Not ADHD or ASD – Risperidone
Which medications to treat ADHD in a child with Tourette’s Syndrome?
CADDRA:
- Stimulant medication is a safe and effective treatment for ADHD + Tic Disorder but requires careful monitoring of potential tic worsening
- the alpha-2-adrenergic agonists, clonidine and guanfacine XR, have shown promise in the treatment of tics, particularly in combination with ADHD
- In patients where stimulants may cause tic exacerbation, atomoxetine may be also considered as an option as it will rarely cause worsening of symptoms
- Methylphenidate long acting – Biphentin, Concerta
- Amphetamine long acting – Adderall, Vyvanse
- Alpha- agonist – Guanfacine, Clonidine
- SNRI – Atomoxetine
What do you have to monitor when a child is on medications for ADHD?
- Height
- Weight
- BP/ HR
- ECG is NOT routine
- Monitor for cardiac symptoms (by history)
- Be alert for signs of misuse, diversion
- Symptoms
- Side effects
Name 2 Health Canada warnings about psychostimulants.
Sudden (cardiac) death
Seizures
Psychosis
- On Vyvanse monograph:
- **Potential of abuse/misuse/diversion (only “serious warning”)
- Cardiovascular adverse events and sudden death (with structural cardiac abnormalities)
- Suppression of growth (and weight loss)
- New onset or aggravation of psychotic and manic symptoms
- Aggressive behavior or hostility
- Suicidal behavior and ideation
- Seizures
- Tics
- Peripheral vasculopathy (Raynaud’s)
- Ophtalmo: difficulties accommodation and blurred vision
What are some considerations before started psychostimulants?
- Cardiac symptoms including syncope, palpitations, chest pain, shortness of breath or seizures during exercise
- Cardiac disease including a clinically significant murmur (not functional, or other symptomatic heart disease
- Psychosis
- Mania
- Seizure
- Medical Contraindications
- Treatment with MAOI and for up to 14 days after discontinuation.
- Glaucoma (narrow angle)
- Untreated hyperthyroidism
- Moderate to severe hypertension
- Pheochromocytoma
- Patient Preference
Family history
- Premature (sudden/unexpected) death in family members <40 years old
- Cardiac history including hypertrophic cardiomyopathy, clinically important arrhythmias including long QT syndrome (LQTS), Marfan syndrome
List 5 behavioural strategies for ADHD in the classroom
- Sit in front of the class
- Noise cancelling headphones
- Break up instructions into small chunks/ step by step
- Similarly, break down tasks into small steps
- Quiet space for test and evaluations to decrease distractions
- More time for test/ assignments/ projects
- Body breaks
- Transitions – visual aids, warnings about upcoming transition
- Eye contact when speaking to the child
- Immediate/ frequent feedback (daily report cards)
- Access to scribe / minimize note taking
- Focus on quality and not quantity
- Write down homework
- Token economy / positive reinforcement
- Access to fidget/sensory objects
- Possibility to move without disturbing
- Testing on computer or orally if possible
- “When… then”
- Frequent feedback
- Immediate feedback
- Sit next to a “more attentive” buddy
Comorbidities of oppositional behaviour disorders?
DSM 5
- ADHD
- Conduct Disorder
- Major Depressive Disorder
- Anxiety
- Substance Use Disorders (in adults)
- Bipolar Disorder
- LD/ID
*Increased risk of suicide attempts once other psych disorders controlled for
Best medications for behavioural issues in ADHD?
- # 1 - Psychostimulants
- # 2 – Guanfacine
- # 3 – Atomoxetine
- # 4 – Clonidine
- # 5 – Risperidone
- # 6 – Valproate
Comorbidities of tics?
- Tics
- ADHD & OCD
- Also anxiety, depression, ODD/CD, LD, Bipolar Disorder, SUD
a) Ddx for school truancy.
b) Name three strategies to address school truancy.
(a) “Refusal”: Anxiety, separation anxiety, social anxiety, phobia, depression, somatization/ somatic symptoms/ IBS, factitious disorder, Panic disorder, PTSD
Truancy: Conduct disorder, ODD
(b)
- Treat underlying anxiety disorder
- Consider psycho-ed testing to assess learning needs/barriers
- Adapt school work (ie what was missed, where can re-start, etc) / accommodation
- Limit secondary gains (no TV or video games at home, etc)
- Psychoeducation
- Involve caregiver
- Gradual Exposure
- Multidisciplinary Supports
11 year old with ADHD. Stealing, lying. Severe aggression with peers and adults. Young parents, homeless.
a) What are 2 other diagnostic consideration.
b) Name 3 risk factors.
(a) SUD, CD, PTSD/ trauma, ODD, Adjustment disorder with conduct symptoms, ASD, ID, FASD
(b) Antenatal substance exposure (tobacco and alcohol); low birth weight, psychosocial adversity, Lack of stimulation and supervision, Low socio-economic status, depressed mother,
3 criteria of CD with limited prosocial emotions.
CD + 2 of the following
- Lack of remorse/guilt
- Callous/lack of empathy
- Unconcerned about performance
- Shallow/deficient affect
Name 3 (non-pharmacological) management approaches in ADHD.
- Parenting skills training (Incredible Years)
- School adaptations/ accommodations
- Functional assessment
- Positive reinforcement
- Psychoeducation
- Anger management skills; emotional regulation skills
- Treatment of comorbidities
- Social skills training
- Vocational support
Pharmacotherapy for severe behavioural issues.
- Multimodal, non-pharmacological approaches across settings – parent skills training, emotional regulation, anger management, problem solving therapy)
- ADHD – stimulant, non-stimulant, Risperidone
- ASD – Risperidone, Aripiprazole
- Not ADHD or ASD – Risperidone
Stutter. What is the work-up and what do you evaluate?
Childhood-Onset Fluency Disorder (Stuttering)
- sensory deficits (assess hearing), normal speech dysfluencies, secondary to meds, adult onset dysfluencies, Tourette
- SLP assessment – language (productive, receptive), verbal fluency, phonation, social pragmatic use of language
- Are there any concurrent difficulties? Coordination, ID, etc…
- Comorbidities
Name 3 diagnosis in which there are communication difficulties.
ASD, ID, language disorder, LDs, speech sound disorder, childhood-onset fluency disorder, social communication disorder, hearing impairment
What is the differential diagnosis of stuttering?
sensory deficits (assess hearing)
normal speech dysfluencies
secondary to meds
adult onset dysfluencies
Tourette
What are two interventions that can be used in stuttering?
- SLP Treatment with involvement of parents
- Cognitive behavioural therapy can also be used to identify thoughts processes that worsen stuttering, and to identify coping strategies related to stress from stuttering.
- Electronic delayed auditory feedback tools can also be used to help individuals to slow down their speech.
Oppositional behaviour reported by teacher. None at home. What would you ask hockey coach to confirm dx?
- Question - The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic.
- Mood at practice, relation to peers, respect of authority/adults, frustration tolerance, tantrums (frequency and duration)
- Other dx to consider - ADHD, LD
Scales to diagnose ADHD
- Conners
- SNAP-IV Teacher and Parent Rating Scale
- ASRS (Adult ADHD Self-Rating Scale)
- WFIRS-P (Weiss Functional Impairment Rating Scale-Parent)
- WFIRS-S (Weiss Functional Impairment Rating Scale-Self)
- WSR II (Weiss Symptom Record II)
- CADDRA Teacher Assessment Form
- CADDRA Clinician ADHD Baseline/Follow-Up Form
- CADDRA Patient ADHD Medication Form
Child with ADHD. Mother worried that the child will become “drugged”/ “addicted”. Which ADHD medication has the least risk of diversion and addiction?
- Non-stimulant medications
- Atomoxetine, Guanfacine
- Long Acting Stimulants
- Vyvanse – pro (inactive) drug that requires first pass metabolism, so it cannot be injected
- Other long-active stimulants (ie: Concerta/ OROS)
Asked to provide three features to delineate ADHD from bipolar disorder
CADDRA and CANMAT Bipolar Guidelines (Children & Adolescents)
- Hyperactivity/distractibility are chronic and not episodic
- Insomnia is present but need for sleep is unchanged
- Grandiosity is not present
- No psychosis
Given case of child with features consistent with ADHD
a) asked to provide a medication you would use to treat.
b) List four symptoms more common among preschoolers than older children treated with stimulants.
a) Stimulant medication – methylphenidate, amphetamine (Health Canada approved for age 6+); long acting stimulant with shorter duration of action (e.g., biphentin – methylphenidate controlled release)
b) Sleep problems (Pre-schoolers metabolize methylphenidate more slowly than school age children (AACAP PP)
Higher rate of emotional adverse events (crabbiness, irritability, proneness to crying) – AACAP PP
a) Provide 4 characteristics of a child with ADHD associated with better treatment adherence.
b) Provide two features important in the parent - physician relationship important to treatment adherence.
a) Child factors:
- Increased symptom severity
- Combined subtype
- Comorbidities
- Fewer side effects
- Long-acting formulation
b) Family factors:
- Belief that medication is safe
- Belief that ADHD is neurobiological disorder
- Good relationship with doctor
Parent-Physician Relationship Factors:
- Parental trust in healthcare provider
- Shared decision making
a) Which medications are indicated for treatment of ADHD if person has Tourette’s.
b) Name one relative contraindicated medication.
(a) Methylphenidate, Amphetamines, Alpha-2 agonist (Guanfacine, Clonidine), SNRI (Atomoxetine)
(b) Monitor for new or worsening tics with psychostimulants. Some resources indicated AMPH may be worse than MPH in increasing tics.
a) Name 2 sleep related side effects of stimulants.
b) Name 2 sleep disorders of (associated with?) ADHD.
a) Sleep-Related effects of stimulants
- Insomnia (delayed sleep onset latency >30 minutes)
- Reduction in Slow Wave and REM Sleep
- Increased wakefulness during the sleep period
b) Sleep Disorders
- Insomnia
- Circadian Rhythm Sleep-wake Disorder (Delayed sleep phase)
- Restless leg syndrome
- OSA
4 year old with aggressive symptoms. Name 3 differential diagnosis other than neurodevelopmental disorder.
DDx:
- ADHD – but this is a neurodevelopmental disorder
- Adjustment disorder with disturbance of conduct
- ODD
- Attachment disorder (Reactive Attachment Disorder or Disinhibited Social Engagement Disorder)
- PTSD
4 year old with aggressive symptoms. Name 1 psychosocial treatment.
Parent Child Interaction Therapy
Parent Management Training (Incredible Years, Triple P)
Child with ADHD/ODD.
What are 4 pieces of school collateral to further establish diagnosis or rule out other co-morbidities?
Psychoeducational testing (to rule out LD)
mood and anxiety
suspensions/expulsions/conduct disorder behaviours
quality of social relationships
Child with ADHD/ODD.
Two standardized measures to assess?
SNAP-IV
Conners
What are common side effects of stimulant treatment in ADHD?
Increased HR and BP
Appetite suppression and weight loss
GI upset
Dry mouth
Headache
Anxiety/Irritability
Initial insomnia
Rebound effect
What are ways to manage the side effects of stimulant medications?
Duration of action of stimulant
redistribute caloric intake once stimulant wears off
start low and go slow
dose reduction
monitor vitals
minimize other sympathomimetic agents (caffeine)
What are some long-term consequences of stimulant use?
Growth suppression
(MTA Study: 1cm/year for first two years and no difference in 3rd year; 1-2 cm adult growth less when treated for 10 years; benefits of treatment generally outweigh the risk)
Which medication(s) indicated for ADHD + seizure?
Any methylphenidate or amphetamine based stimulant medication provided seizures are well controlled by antiepileptic medication
FYI
- Higher incidence of ADHD in kids with epilepsy (than gen pop)
- Higher incidence of epilsepy in kids with ADHD (than gen pop)
- When kid has ADHD, epilepsy can more severe
- No evidence that stimulants psychostimulants increase the severity or frequency of seizures in patients with stable epilepsy.
- Consider drug ineractions
Carbamazepine– Methylphenidate: decrease Meth
Phenytoin, Phenobarbital – Methylphenidate: increase anticonvulsant
Carbamazepine, Phenytoin, Pheno – Guanfacine: decrease Guanfacine (3A4)
Symptoms of methylphenidate crash
Irritability
“Rebound” - Symptoms return or appear worse than when treated (CADDRA)
3 executive (dys)functions in ADHD
Initation
Ability to complete multi step tasks
Organization
Planning
Self-directed activity
4M diagnosed with ADHD, Combined Type.
2 things to tell mother about diagnosis of ADHD in preschoolers.
- Inattention and hyperactivity in preschoolers can be influenced by a number of factors. These can include intellectual impairment, expressive language issues, and their response to child abuse and neglect as well as conflictual environments
- American Academy of Pediatrics has suggested that ADHD can be diagnosed in children as early as age four
- Nonpharmacological approaches should be first-line treatment
.4M diagnosed with ADHD, Combined Type. 1 Psychotherapeutic treatment.
Parent management training – Incredible Years or Triple P Positive Parenting Program
Parent-Child Interaction Therapy
4M diagnosed with ADHD, Combined Type. 2 medication side effects that are different in preschoolers.
Higher rate of emotional adverse events (crabbiness, irritability, proneness to crying) – AACAP PP
Insomnia (slower metabolism of methylphenidate)
Decreased appetite and weight loss (most serious)
Paradoxical agitation/ irritability/ anxiety
Emotional outbursts
13F. Marks C’s. Teachers reporting not applying herself. Difficulty focusing. Particular difficulty in math. Now using cannabis.
3 differential diagnoses?
ADHD
LDs
SUD
13F. Marks C’s. Teachers reporting not applying herself. Difficulty focusing. Particular difficulty in math. Now using cannabis.
2 standardized measures to make a diagnosis?
- Conners, SNAP-IV,
- For LD maths:
o WIAT (Wechsler Individual Achievement Test)
o Keymath diagnostic arithmetic test
Describe the difference in presentation of depression in children vs. adolescent or adult.
Child:
- mood lability, irritability (instead of sadness as DSM criterion)
- low frustration tolerance, temper tantrums
- somatic complaints
- social withdrawal
- mood congruent auditory hallucinations
- Fewer melancholic symptoms
- Fewer delusions and suicide attempts
- Less likely to verbalize feelings of depression/anhedonia than adults
Adolescent –
- more melancholic symptoms and suicide attempts than children
- more hypersomnia and hyperphagia (DSM-5)
- more pervasive anhedonia (K&S)
- psychomotor retardation
- more mood reactivity and may seek out activities for temporary improvements in mood (AACAP)
Manic patient. Parents do not want Li.
What are 2 indicated treatment options of mania?
First Line
lithium (level 1)
risperidone (level 1)
aripiprazole (level 2)
asenapine (level 2)
quetiapine (level 2)
(Risperidone may be preferable to lithium for non‐obese youth, and youth with ADHD)
Manic patient. Parents do not want Li.
What are two symptoms of Li toxicity?
General symptoms of low-grade lithium toxicity:
weakness
tremor (new-onset or worsening)
mild ataxia
poor concentration
tinnitus
nausea
diarrhea
More significant toxicity
vomiting
gross/coarse tremor
slurred speech
confusion
nystagmus disorder
dysarthria
lethargy
If not treated, it may lead to seizure (tonic-clonic), coma, neurological damage, and death.
Name 2 elements that differentiate ADHD and mania.
ADHD
Mania
Neurodevelopmental
Not
None
Insomnia
None
Hyper verbose
Not
Episodic
Psychosis
Decreased need for sleep
Elation, grandiosity
Flight of ideas
Name some Depression scales that are used in children
Children’s depression rating scale
Children’s depression inventory
Mood and feelings questionnaire
Center for Epidemiological Studies Depression Scale for Children (CES-DC)
16F with depression. What would be 2 treatment approaches if she does not want pharmacotherapy?
CBT, IPT, internet-based psychotherapy
16F with depression.
What work-up before starting SSRI?
- No need for any work-up pre-SSRI unless there is special concern OR rule out a physical health cause re: ECG (already on other QTc prolonging agents) and Na (PHx)
- If indicated: b-hCG, tox screen, relectrolytes?
Boy who is depressed and sleep during the day. DDx?
major depressive disorder
substance use withdrawal (alcohol, amphetamines, cocaine)
obstructive sleep apnea
hypothyrodisim
circadian rhythm sleep-wake disorders
Reasons to admit to hospital with depression
safety concerns (suicidal, homicidal, mental health is impairing patient’s ability to care for themself/is at risk of causing serious physical impairment of patient)
psychotic symptoms
catatonic features
-oor nutritional intake, putting patient’s physical health at risk
failure of outpatient treatment
Which is the most used/ (?most evidence-based) medication for the treatment of depression in adolescents and why?
- Fluoxetine
- Many RCT, well tolerated, works, relatively stable serum levels due to long half-life
- long half life lessens the impact of nonadherence* PP
5 risk factors for transition of depression to BAD.
- Early onset, sudden onset
- Mood congruent psychosis
- FHx of BAD
- Psychomotor retardation
- Mania/ hypomania on AD
- Mixed symptoms, labile mood
- Atypical Depression (Hypersomnia, hyperphagia)
- Emotional/Behavioural Dysregulation
Adolescent with ASD. Name 3 risk factors for depression.
Social isolation
awareness of deficits (level 1)
FHx
sudden loss
stress at home or at school
alexithymia
low self-esteem
ACEs/ abuse
higher cognitive functioning,
capacity for introspection
stressful life events
quality of social relationships
Adolescent with ASD. Name 2 factors for risk of suicidal behaviours.
high functioning autism
Physical and sexual abuse
bullying
Factors inherent to their diagnosis (deficit in expression of feelings and thoughts)
Factors pertaining to the general population (abuse, depression, anxiety, etc.).
Contrast features of MDD vs grief
- In grief the predominant affect is feelings of emptiness and loss, while in an MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure.
- Dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, “pangs of grief” associated with thoghts/memories of deceased
- Depressed mood of an MDE is more persistent and not tied to specific thoughts or preoccupations.
- Pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of MDE.
- The thought content associated with grief - preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in an MDE.
- In grief, self-esteem preserved
- In MDE feelings of worthlessness and self-loathing are common.
- If self-derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased
- In grief, thoughts about death and dying generally focused on the deceased and possibly about “joining” the deceased
- In MDE such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.
8 yo with GAD. Not treated with psychotherapy. Wants to start SSRI. Name 5 pharmacokinetic principles of SSRIs in this patient
- Pre-pubertal children have a higher rate of activating side effects on SSRI
- Maturation of pathways impacts effectiveness of medications
- Children metabolize medications faster due to larger liver (liver to body ratio) and more efficient glomerular filtration (shorter ½ life)
- Higher proportion of water = larger volume of distribution of hydrophilic meds
- Less adipose tissues = accumulate lipophilic meds to a lesser extent and consequently eliminate them faster
- Increased BBB permeability
Name 5 lab investigation prior to initiating lithium
- thyroid function tests
- urinalysis
- creatinine/Urea
- serum calcium levels
- pregnancy test in female adolescents
- complete blood cell counts
Once a stable lithium dose is obtained, lithium levels, renal and thyroid function, and urinalyses should be monitored regularly (every 3-6 months)
What are the factors of adolescent depression that increase risk for bipolar disorder?
· Rapid symptom onset
· Mood-congruent psychotic features
· Psychomotor retardation
· AD (medication-induced) activation/ hypomania/ mania
Child with seizure disorder and depression.
a) Which med to choose?
b) What is contraindicated?
a) SSRI
b) Bupropion and TCA
10F. Father committed suicide 3 years ago. Doing CBT and family therapy. 2 years history of social decline. Now has rituals, rigid thinking. Suicidal thoughts x 1 week and tried to jump out of a window.
Name 4 DDx.
- Adjustment Disorder, MDE
- OCD
- PTSD
- GAD, SAD
- Clinical High Risk Psychosis
16M. Presents to office on his own with 4 weeks of depressed mood and vegetative symptoms. What 5 items do you want to evaluate for diagnosis management?
- Presence of Depressive and Other Comorbid Psychiatric and Medical Disorders
- Functional impairment, clarify baseline function
- Safety – SI, intent, plan, gestures, SH, HI
- Evaluate child and family’s strengths, supports and protective factors
- Presence of Ongoing or Past Exposure to Negative Events, the Environment In Which Depression Is Developing, Support, and Family Psychiatric History
Other (not in the PP)
- Psychosis
- Capacity for consent
List 2 medications used in maintenance of Bipolar Disorder.
Aripiprazole
Lithium
Divalproex
Lamotrigine adjunct (age 13+)
List 5 medication classes commonly prescribed in <18 year olds that can cause depression.
Accutane (Isotretinoin)
Steroids
Methotrexate
OCP
Anticonvulsants (Levetiracetam/Keppra)
Case about childhood trauma (mother murdered by a ex-boyfriend).
Who do you want to speak with when doing your assessment (2)?
Parents or other caregivers should be included in the evaluation
Child
biological father
school
CAS
Case about childhood trauma (mother murdered by a ex-boyfriend).
What are some interventions to consider?
TF-CBT (first line; most evidence. PRACTICE components)
Other trauma-focused psychotherapies:
(Child-parent psychotherapy
Psychodynamic trauma-focused therapy
EMDR (Katzman))
SSRIs can be considered for PTSD or for comorbidities with PTSD (Sertraline alone or as adjunct to CBT is not more effective than placebo and cannot be recommended – Katzman)
Medications other than SSRIs can be considered (sleep, nightmares)
School-based accommodations
Case about childhood trauma (mother murdered by a ex-boyfriend).
What are some psychological interventions to consider?
- TF-CBT (first line; most evidence. PRACTICE components)
- Other trauma-focused psychotherapies
- Child-parent psychotherapy
- Psychodynamic trauma-focused therapy
- EMDR (Katzman)
- Psychoeducation
- Relaxation training
- Affective modulation skills
- Cognitive coping and processing
- Trauma narrative
- In-vivo mastery of reminders
- Conjoint child-parent sessions – engage caregiver, regain sense of control, improve attunement/ communication,
Difference in presentation of PTSD in a child.
- May not have flashbacks but often have trauma expressed through play - repetitive play, trauma themes, trauma-specific re-enactment
- Nightmares – may be without trauma-specific content
- May have new aggression, oppositional behaviour
- May have new separation anxiety, new fears not obviously related to traumatic event (fear of the dark)
- Developmental regression (toileting and speech)
- In adults, avoidance may be of memories, thoughts and feelings; in children it is exclusively external reminders
- Specific subtype of PTSD for children <6 in DSM-5 without criteria for cognitive distortions, memory of event, or avoidance of memories/thoughts/feelings
Boy loses his arm in an accident. He has PTSD. What 2 medications are approved to prevent PTSD?
- Propranolol, Morphine, SSRI
- To prevent, none is approved (anxiety guidelines 2014)
- Propranolol: conflicting evidence (improved on parent reports but not child report)
- Morphine: cohort studies suggest it might be helpful
Boy loses his arm in an accident. He has PTSD. Medication for nightmares?
Prazosin
Boy loses his arm in an accident. He has PTSD.
What is the therapeutic approach?
- Trauma-focused CBT – stabilization, integration of trauma, reconnection
- PRACTICE – psychoeducation/ parenting skills; Relaxation skills; Affective modulation skills; Cognitive coping and processing; Trauma narrative; In vivo master of trauma reminders; Joint child-parent sessions; Enhancing future safety.
6 year old with a fear of fires since the neighbor’s home caught fire. New onset nightmares.
Name three other symptoms (trauma).
- markedly diminished interest or participation in significant activities
- persistent negative emotional state
- exaggerated startle response
- hypervigilance
- problems with concentration
Case of PTSD provided (mother murdered by her partner). Asked to provide the most empirically supported treatment and several components of that treatment
Trauma-focused CBT:
- Phase 1 – stabilization – affect regulation, coping
- Phase 2 – integrate traumatic memories – re-experience symptoms
- Phase 3 – reintegration/ maintenance – consolidation and resilience
PRACTICE
- Psycho-education
- Relaxation techniques
- Affective modulation skills
- Cognitive coping and processing
- Trauma narrative
- In vivo mastery of triggers/reminders
- Conjoint sessions with parents
- Enhance future safety
Case of PTSD provided (mother murdered by her partner).
Asked to provide a class of medication with some empirical support for treatment of PTSD in youth.
SSRIs
Case of PTSD provided (mother murdered by her partner).
Asked to provide a list of several sources of information other than the child in order to complete evaluation.
Family (bio family, foster family)/caregivers
School
CAS
Asked for two medications with some evidence to support their use in preventing development of PTSD.
Propranolol
Morphine
Provide one medication indicated for treatment of sleep disturbance and nightmares associated with PTSD.
Alpha -1 – blocker - Prazosin
a) What are 3-4 meds you may consider using in someone exhibiting a trauma reaction?
b) Which agents may be contraindicated?
a)
Clonidine, guanfacine (may reduce intrusive and hyperarousal symptoms in children with PTSD symptoms)
Prazosin (Dyssomnias, including nightmares and frequent nighttime awakenings)
SSRIs (not efficiacious in children, but could be used in adolescent with co-occurring MDD or anxiety)
b) Benzodiazepines
How to prevent PTSD and what medication could you use for nightmares?
Maintain – secure attachment, peer relationships, routines/ predictability
Child and Family Traumatic Stress Intervention (CFTSI)
Pyschological First Aid
Caring adults (parents, teachers, and health professionals) to reassure children
Encourage (but not press) them to express their feelings
Normalize disaster reaction
Address fears, worries and cocnerns as they arrive
Help them to resume normal roles and routines
Help parents and teachers identify acute stress responses.
*POTENTIALLY morphine (burns) + propranolol
Nightmares – Prazosin
What is the PRACTICE mnemonic in TF-CBT (lewis)?
- *PRACTICE** mnemonic (Lewis) TF-CBT
- *P**sychoeducation and Parenting Skills Training
- *R**elaxation
- *A**ffective modulation skills
- *C**ognitive coping and processing
- *T**rauma narrative
- *I**n Vivo mastery of trauma reminders
- *C**onjoint Child-Parent sessions
- *E**nhancing future safety and development
Patient with symptoms of ARFID.
Name 2 ways in which you can differentiate between ARFID AND AN.
No body image disturbance in ARFID and No fear of weight gain in ARFID
Patient with symptoms of ARFID.
Name 3 situations that can precipitate ARFID.
Sensory aversion
choking episode
repeated emesis
traumatic GI investigation
reflux
PCRP
What differentiates binge eating from BN?
In binge eating, there is no compensatory behaviour to avoid weight gain.
Name pharmacotherapy for BN.
Fluoxetine
Some evidence for TCA, topiramate, sertraline and citalopram
NOTE: contraindication for bupropion (Sz)
AN. Name 5 interventions the family can implement around mealtime to help the patient take nutrition.
Pre-planned meal plan (determined by parents)
Max 20min for mealtime.
Substitutions/ supplementation if unable to complete nutrition as presented.
Distractions – during and after meal.
Externalize the ED.
Providing validation and support
Name scale to evaluate eating disorder.
AACAP PP:
- Eating Disorder Examination Questionnaire (EDE-Q)
- Eating Disorder Inventory (EDI)
- Eating Attitudes Test (EAT)
Validated in younger children:
- Kids’ Eating Disorder Survey (KEDS)
- Child EDE-Q
- EDI-Child
- Child-Eating Attitudes Test (CHEAT)
BN is caused by what factors (2)?
Dieting to try to accomplish thin ideal physique leading to physiological starvation and hunger, promoting binge eating and followed by guilt and fear of weight gain leading to purging
Genetics
Abuse, PTSD
Social pressures to be thin
Body dissatisfaction
Negative affect
Name risk factors for BN (4).
Genetics and family history of mood, anxiety, SUD, cluster B
Idealization of thinness and dieting
Early menarche
Childhood obesity
Volatile family environment or history of abuse
Temperament novelty seeking, impulsivity, affective instability
Female Sex
What are the criteria for ARFID?
Criterion A
An eating or feeding disturbance (e.g. - apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with at least 1 of the following:
- Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
- Significant nutritional deficiency
- Dependence on enteral feeding or oral nutritional supplements
- Marked interference with psychosocial functioning
Criterion B
The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
Criterion C
The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced
What is the approach to management of ARFID?
Stabilize the patient from a physical health perspective
…Once this has occurred, next steps can be taken
- -Target precipitating event that triggered ARFID eg. anxiety related to choking, treated with CBT and/or pharmacotherapy such as an SSRI
- If ARFID is related to family conflict, this could be managed via family based therapy, CBT, psychoeducation, parent psychoeducation
- If ARFID related to sensory aversion, consider a food hierarchy or food chaining
Provide two stages of the Maudsley Approach to treatment of anorexia nervosa.
Phase I: weight restoration via psychoeducation, externalizing illness, raising anxiety, parents take control of eating
Phase II: Returning control over eating to the adolescent gradually
Phase III: review of progress, return to normal family life, identifying potential challenges
Three parameters on physical exam important when considering hospitalization of child with anorexia nervosa.
<75% IBW
heart rate <50 (during the day); <45 (at night)
systolic BP < 90
arrhythmia
orthostatic changes= >20 BPM HR; >10mmHg BP
refusal to eat
ongoing weight loss despite intensive management
hypothermia (<36)
Three parameters on physical exam important when considering hospitalization of child with bulimia nervosa.
syncope
hematemesis
hypokalemia (<3.2)
low Cl (<88)
arrhythmia
failure to respond to outpatient treatment
esophageal tear
Name 2 co-morbidities of BN
Depression (50%)
Panic Disorder
Alcohol, Substance Abuse
Cluster B Personality Disorder – BPD
Traits – perfectionism, harm avoidance, novelty seeking, impulsive, affective instability
Name 1 treatment of BN
CBT modified for BN
IPT
Fluoxetine
Also – tricyclics, topiramate, sertraline, citalopram
Name 2 co-morbidities of AN.
Depression (50%)
OCD (30%)
Cluster C Personality – OCPD
Traits – perfectionism, harm avoidance
13F with postural hypotension. You suspect ED. Now, gained 2.5kg in one week, bloated, hypokalemic.
a) What is the Dx
b) how to you treat this?
a) refeeding syndrome
b)
- Gradual refeeding, monitor K, P and Mg
- Treatment:
- reduce caloric intake
- evaluate cardiovascular function (ECG monitoring)
- monitor closely (Check P daily for 5 days, then q2 days for 3 weeks)
- If necessary, supplement with P (correct electrolyte anomalies and mineral deficiencies (IV, PO4 supp, K supp, thiamine, multivitamins))
- Pediatrician involved
- Treatment:
13F with postural hypotension. You suspect ED.
a) Decision about disposition
b) Provide 2 reasons for your decision.
a) Admit for medical stabilization
b) Unstable vitals
What genes are associated with OCD?
- Complex and polygenic for OCD
- Genetic loading has a significant impact on risk of developing condition
- 1st degree relative of OCD pt 4x as likely to develop OCD
- 5HT2A (serotonergic) and SLC1A1 (glutamate) are implicated OCD
What is the heritability of OCD?
- MZ concordance 80-87%
- DZ concordance 47-50%
- ½ of phenotypic variation due to genetics
- 1st degree relative of OCD pt 4x as likely to develop OCD
- Relatives of childhood-onset OCD are 30 x more likely than relatives of those without OCD to be diagnosed with the disorder
- Ordering and hoarding more genetic
- Genetic studies most often implicate genes for 5ht and glutamate regulation
ASD vs OCD. How do you differentiat?
ASD
OCD
Neurodevelopmental
Egosyntonic
Stereotypies
Socio-emotional difficulties
Communication/ language and non-verbal difficulties
Chronic, pervasive rigidity/concreteness
Not
Egodystonic
Compulsions to decrease anxiety
Not
Not
Rgidity re: obsessions/ compulsions
Alopecia in an adolescent. Provide 2 differential diagnoses.
- Trichotillomania
- Telogen Effluvium / Alopecia due to…
- GMC (autoimmune, low iron, hypothyroid) (Telogen effluvium)
- Meds like VPA, antithyroid agents, hormones, anticonvulsants, anticoagulants, beta blockers, angiotensin-converting enzyme inhibitors, and lithium.
- OCD
- ASD
- Dermatologic Alopecias
- Telogen effluvium
- Tinea capitis
- Traction alopecia
- Alopecia areata
- ID – stereotypies
- Body Dysmorphic Disorder
- NSSI
- Normal behaviour/ intentional hair removal
Trichotillomania. Explain Habit Reversal therapy.
HRT –
(a) awareness training – such as triggers
(b) competing response training – replacement behaviour
(c) motivation and compliance – cons list, positive reinforcement
(d) relaxation training – to help prevent the behaviour
(e) generalization training
OCD x 8 years, mild to moderate in severity. Name 2 effective/ evidence-based treatments.
CBT (ERP) is first line.
Second line is CBT in combination with SSRI (Sertraline, Citalopram, Fluoxetine, Fluvoxamine). You may consider augmentation with Risperidone or Aripiprazole.
Third line is CBT with Clomipramine.
(In moderate to severe OCD, inadequate response to CBT (ERP), patient preference (refusal of psychotherapy) or patient is >12yo – you may (should) consider combination treatment.)
OCD x 8 years, mild to moderate in severity. Name 2 comorbidities that worsen prognosis.
AN, Depression, LD, psychosis, BAD, depression, hoarding
ODD, Tics, ADHD associated with worse response to meds
Name 2 common obsessions in children
Obsessions - Contamination/ germs/ getting sick; something bad happening; thing being “just right”; sexual.
Name 2 common compulsions in children
Compulsions - Washing/ cleaning/ disinfection; arranging/ ordering/ repeating until “just right”; checking/ symmetry.
Trichotillomania. Name 3 cognitive behavioral techniques.
a) Habit reversal training - primary treatment for trichotillomania. How to recognize situations (urges/ preceding thoughts and emotions) where you are likely to pull your hair and how to substitute other behaviors instead (which may include relaxation and mindfulness techniques). For example, you might clench your fists to help stop the urge or redirect your hand from your hair to your ear.
b) Cognitive therapy - This therapy can help you identify and examine distorted beliefs you may have in relation to hair pulling. Cognitive restructuring.
c) Relaxation training (progressive muscle relaxation)
d) Acceptance and commitment therapy - can help you learn to accept your hair pulling urges without acting on them.
e) Exposure and response prevention (ERP)
FDA approved medications for treatment of OCD
Fluoxetine
Sertraline
Fluvoxamine
Clomipramine
C-YBOCs question – What are 4 features of establishing severity of OCD?
Time occupied by obsessive thoughts
Interference due to obsessive thoughts
Distress associated with obsessive thoughts
Resistance against obsessions
Degree of control over obsessive thoughts
Time spent performing compulsive behaviours
Interference due to compulsive behaviours
Distress associated with compulsive behaviours
Resistance against compulsions
Degree of control over compulsive thoughts
Trichotillomania. What are 3 steps in providing behavioral therapy?
HRT –
(a) awareness training – such as triggers
(b) competing response training – replacement behaviour
(c) motivation and compliance – cons list, positive reinforcement
(d) relaxation training – to help prevent the behaviour
(e) generalization training
Trichotillomania. Describe 2 principles behind operant conditioning.
Operant conditioning: process of learning through reinforcement and/or punishment
Positive reinforcement: response or behavior is strengthened by rewards, leading to the repetition of desired behavior. The reward is a reinforcing stimulus.
Negative reinforcement: the termination of an unpleasant state following a response.Negative reinforcement strengthens behavior because it stops or removes an unpleasant experience.
Punishment: an aversive event that decreases the behavior that it follows.
Which medications are approved for the treatment of OCD?
HC – Clomipramine (10+)
FDA – Sertraline (6+), Fluoxetine (7+) and Fluvoxamine (8+)
What are the criteria for Disinhibited Social Engagement Disorder?
A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:
- Reduced or absent reticence in approaching and interacting with unfamiliar adults.
- Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
- Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
- Willingness to go off with an unfamiliar adult with minimal or no hesitation.
Behaviors in Criterion A are not limited to impulsivity (as in attention-deficit/hyperactivity disorder) but include socially disinhibited behavior.
Child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
- Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
- Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
- Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios)
Child has developmental age of at least 9-months
What are some general features of Disinhibited Social Engagement Disorder?
In general:
- May approach unfamiliar adults without any fear;
- May seek comfort from unfamiliar adults;
- Wander away from caregiver without checking back
- Attaches indiscriminately
- Attention seeking, shallow, superficial interpersonally
- “impulsive-type behaviors”, attention-seeking and more shallow relationships
Case that is obviously DSED. What are some specific therapies to consider?
Management approach:
- Safety! (especially of current placement)
- Ensure they are provided with an emotionally available attachment figure.
- Dyadic therapist such as Circle of Security, Parent Child Interaction Therapy (PCIT), Dyadic developmental psychotherapy (DDP)), Attachment and Biobehavioural Catch-up (ABC), Video-based Intervention to Promote Positive parenting (VIPP), Child-Parent Psychotherapy
- Limit contact with noncaregiving adults (young children)
- Adjunctive interventions for children who display aggressive/oppositional behaviour
No therapeutic holding, “rebirthing” or other such nonsense.
4 year old child has been in foster homes for the last 2 year. Doesn’t settle with mom.
What is the most likely diagnosis?
Attachment disorder – Reactive Attachment Disorder and/or DSED
4 year old child has been in foster homes for the last 2 year. Doesn’t settle with mom.
Name 2 behaviors common in institutionalized kids but not in parent reared kids.
Do not seek comfort from or interaction with caregivers.
Do not feel reassured by caregivers/ difficult to calm/ reassure.
Agitation.
Mood lability.
Temper tantrums.
Reduced emotional responsiveness.
Restricted positive affect/ superficiality of affect.
Indiscrimination of attachment figures.
Unstable interpersonal relationships.
Lack of empathy.
Impulsivity.
4 year old child has been in foster homes for the last 2 year. Doesn’t settle with mom.
Name 2 symptoms that are unlikely to remit even with consistent care after institutionalized kids.
Symptoms of Reactive Attachment Disorder tend to disappear once placed in foster care or adopted.
Symptoms that are unlikely to remit despite adequate placement are linked to DSED
Children: indiscrimination, no safety base, familiarity
Teen: superficial, shallow or frequently changing interpersonal relations and interpersonal conflicts
Antisocial patient, hospitalized for repeated SA.
When do you formally re-evaluate suicide risk?
At daily/each assessments
if making threats or reporting ideation
with any mental status change
before passes/going off unit
before discharge
Antisocial patient, hospitalized for repeated SA. Other than suicide risk, what are two other risks to evaluate?
HI
physical impairment
elopement risk
risk of substance use
driving
boundaries around interactions with other patients
risk of harm to others
Why are some physicians weary of making a Dx of PD?
Stigmatization
developmental perspective
need a longitudinal assessment
sometimes subjective to make assessment
perception that they are “untreatable”
Are there any potential benefits to making the dx of a personality disorder?
appropriate treatment/ intervention
validation
psychoeducation
avoid unnecessary treatments/ pharmacotherapy/ side effects
stop contributing to auto-stigmatisation
What are some diagnoses associated with difficult temperament?
ODD
CD
IED
DMDD
What are some diagnoses associated with slow to warm up temperament?
Social Anxiety
GAD
MDD
Concerning temperament, what are 3 school environmental effects on a child’s adaptation?
- Safety at school (social-emotional and physical safety owing to standards and rules, prevention of bullying/intimidation),
- connectedness to school
- Relationship/interaction between teacher and student
- Learning environment at school
NSSIB in ED. Parent are insisting on admission.
Name 2 elements of psychoeducation to parents.
- NSSIB = not suicide attempt but maladaptive coping strategy
- Inpatient admission is not helpful and may actually result in further regression of distress tolerance/ emotional regulation skills.
- This learning is done in the community.
Youth with self-harm behavior.
What are 5 psychosocial strategies to address the behavior?
- Minimize alcohol/ substance use
- Skills
- Emotional regulation skills
- Improve communication
- Distraction
- Interpersonal effectiveness
- Problem-solving skills
- Conflict management Skills
- Affective Language Skills
- Psychotherapies
- DBT
- CBT (Individual, Family, Parent Training)
- FBT-Attachment for SI
- IPT – Individual for SI
- Psychodynamic therapy-Individual + Family
- Safety Planning
- Parent Skills Training
- Keep environment safe
Also Acceptable Answers:
- Interpersonal relationships/ supports
- Try to remove reinforcements/social contingencies
- Recognize warning signs
- Develop coping strategies (ex TIPP)
- Use friends, family and MH professionals for support
- Keep environment safe
- Motivational interventions/brief intervention
- Use mobile safety planning apps
- Mentalization-based treatment?
- Affective language skills
- Self-soothing skills
- Psycho-education for patient and family
- Cognitive problem-solving skills
Girl ingests 3 tabs x 325 mg acetaminophen.
What are 3 safety questions that should be asked?
- Where there any co-ingestions/ concurrent substance use?
- Was this a suicide attempt? (Clarify SI/ intent/ plan/ access to means (including guns))
- History of previous SA
- Precipitants - stressors, triggers
- Protective factors – supports, plans, evidence of future orientation
- Do you live alone?
- Are you still thinking of suicide?
Name 5 things to ask on safety/ risk assessment.
a) SI, plan, intent, access to means, future orientation
b) Triggers/ precipitants/protective factors
c) History of previous SA
d) Collateral history
e) Psychiatric diagnoses/comorbidities
f) Protective/ resiliency factors (ex: family, pets, religion)
g) Supports (ex : formal and informal)
h) Collateral information
i) Family history (of suicidality and mood d/o)
j) History of abuse, violence, bullying
k) Substance use
l) Exposure to suicide (ex. in media or friends/school)
m) Emotional/cognitive factors: hopelessness, helplessness, impaired problem-solving, agitation, despair, low SE, impulsivity
n) Familial conflict
o) If part of minority (first nation, lgbtq, …)
Young girl with self-harm behaviors. Name 4 strategies to reduce self-harm.
a) Distress tolerance skills
b) Emotional regulation skills
c) Distraction
d) Remove “means” – sharps, lighters, etc…
e) Anger management
f) Problem solving approach
g) Supports
h) Interpersonal effectiveness, friendships
i) Mindfulness, relaxation strategies
Girl ingested 100x100mg tabs of Quetiapine. What are 2 immediate steps for psychiatric care?
- Is this patient medically stable? ABC – vitals, LOC, QTc + involve other specialties as needed
- Assess Safety (+ Patient status in hospital – voluntary vs. involuntary)
- Assess for possible admission
Adolescent girl presents with self-injurious behavior. No mental health disorder present. List 5 techniques to decrease self-harming behavior.
Distraction (holding ice, cold shower)
Distress tolerance (TIPP= temperature, intense exercise, pace breathing, progressive muscle relaxation)
Emotion regulation techniques
Removing sharps and lethal means, and safety proofing home
Treat comorbidities
Meditation
Mindfulness
Sleep in kids. The child falls to sleep very late every night.
What is most likely diagnosis?
Delayed sleep-wake phase disorder (DSWPD)
Sleep in kids. The child falls to sleep very late every night.
What is the effect of melatonin on sleep?
Melatonin is a hormone with chronotropic effects.
Can advance or delay sleep phase depending on when it is taken.
Light sedative effects.
Sleep in kids. The child falls to sleep very late every night.
What are the effects of stimulants on sleep?
Stimulants may contribute to:
initial insomnia/increased sleep latency
decreased overall sleep
decreased REM sleep
increased restlessness
3 interventions for delayed sleep phase in adolescents.
- Anchoring a wake time (even on weekends; max 2 hours difference between week and weekend)
- Melatonin
- Avoid naps
- Avoid caffeine, chocolate and other stimulants
- Avoid screens/ blue light
- No exercise within 2 hours of desired sleep time
- Bedtime routine, low stimulation
- Remain in bed only for sleep
- Bright light in the morning, such as SAD lamp
- CBTi
What are three features of restless leg syndrome?
URGE –
urge to move legs
worse with rest
gets better when move around
worse in evening
What is the treatment of restless leg syndrome in chidlren?
Gabapentin
Clonidine
Clonazepam
Avoid caffeine and SSRI
Iron supplements if ferritin <50mcg/L
**(dopamine agonists like pramipexole for adults not children)
IPT. Name 2 adaptations for adolescents.
Involvement of parents - to educate them, support the adolescent’s treatment, sometimes work on the interpersonal problem area in dyadic sessions with the adolescent.
Limited sick role - Doing the activity but revising expectations, recognize performance may fall below the predepression level. Therapist reassures pt things will get better when depression improves
Discussion within areas relevant to adolescence
Techniques employed in the treatment geared towards adolescents (rating scales 1-10, more basic social skills work, perspective-taking skills, negotiation with parents)
12 weeks instead of 16 weeks
IPT.
Name 2 or 3 indications for IPT in youth/ adolescents.
- Depression
- Persistent Depressive Disorder
- Adjustment disorder
(IPT for BN only in adults)
Case about motivation and asks you what stage of change the patient is in. What are the stages of change?
Precontemplation
Contemplation
Preparation
Action
Maintenance
Relapse
Name 2 principles of motivational interviewing.
Develop discrepancy between current behaviour and desired behaviour
Roll with resistance
Exploring ambivalence about change
Express empathy
Develop autonomy
Avoid arguments and confrontation – resist the “righting” reflex
Support self-efficacy/ empower the patient
Open ended questions + Validate + Reflect + Summarize
Patient with social anxiety. Patient declines your offer of group therapy. Name reason why this patient would benefit from group therapy.
Universality, identification, normalization
Interpersonal skills training
Exposure therapy
Cohesion
Hope, supportive environment
Validation
Role modelling
Motivation
What are 3 benefits of Group Therapy?
(Yalom)
Instillation of Hope
Universality
Imparting Information
Altruism
The corrective recapitulation of primary family group
Development of socializing techniques
Imitative behvaiour
Interpersonal learning
Group cohesiveness
Catharsis
Existential Factors
Compare CBT and IPT
Similarities – short-term, 16-20 sessions, chases affect, role-plays, therapist led; developed for research on depression
CBT
IPT
- Link between thoughts, actions and emotions
- Socratic questioning, collaborative empirical approach
- No sick role
- May have multiple goals
- Automatic thoughts/ cognitive restructuring
- Operant conditioning
- Homework
- Link between emotions and interpersonal relationships
- Specific work on the link to changes in relationships vs. changes in symptoms
- Limited sick role
- 4 areas of focus – grief/ loss, interpersonal deficits, transition and interpersonal disputes
- Interpersonal inventory/ closeness circle/ communication analysis
- Rooted in attachment theory
- Interpersonal experiments
MI approach to a schizoaffective patient who smokes THC but wants to stop.
- In general = Develop discrepancy + Deal with resistance + Express empathy + Develop Autonomy + Support Self-Efficacy
- He seems to be in the “preparation” stage of change = pro/cons list; outline goals; smart goals and how will maintain goals; contingency planning; psychoeducation re: relapse.
How does parental participation improve care?
Skills transition to home
Adherence to treatment
Therapeutic alliance
Alignment of goals
Modification of environmental factors
Validation and support
Collateral information
Psychoeducation
ASD with normal IQ has a bee phobia.
How do you modify CBT?
Psychoeducation
Progressive exposure to trigger (ie: photos of bees) + relaxation techniques
Regulation of emotions, problem solving, cognitive restricting
Use more visuals; repetition; collateral/ increased involvement from parents
Incorporate more ABA principles? Functional behavior analysis
Use child’s talents and special interests
Frequent movement breaks or sensory activities
More repetitive, more visual, more concrete
Ex. instead of naming level of anxiety 1-10, drawing in on thermometer
Factors influencing access to care for minorities.
Language barrier
Financial barriers (access to transportation, baby-sitting, etc)
Stigmatization
Difficulty navigating the system
Systemic biases/ racism/ discrimination
Cultural factors –
patient factors and practitioner factors; interpretation of symptoms; idioms of distress; cultural/ religious models of disease; different coping and help-seeking behaviours.
Multi systemic therapy – principles?
- Involve all systems in treatment (school, community, etc)
- Intensive treatment with case management (contacts at least once a week, usually more, usually just 4 families/case load)
- 24/7 Availability with on call system
- Present-focused, action-oriented and well-defined – what are the contributiong factors to behvaiour?
- Increase skills of parents and their self-efficacy to manage their child
Multi systemic therapy – Indications?
Serious juvenile offenders with possible SUD, and their families
Multi systemic therapy – Where is it delivered?
Everywhere – home, community, institution
Name 5 elements of resistance in therapy in children and teens
Absences/lateness
Splitting (therapist)
Silence/ superficial subjects
Acting Out
Not completing homework
Social withdrawal
No progress
Family therapy. Name 1 concept of systemic therapy.
Bowen Family Systems:
Differentiation of self
Triangulation
Emotional cutoffs
Family emotional system
Sibling position
Family therapy.
Name 3 stages to be evaluated in the McMaster problem solving approach.
Problem Solving
Communication
Roles
Affective Responsiveness
Affective Involvement and Behavioral Control.
Give five indications for why DSM 5 considers incorporation of cultural understanding is important for understanding distress.
- Avoid misdiagnosis
- To obtain useful clinical information
- Improve clinical rapport and engagement
- Clarify cultural epidemiology
- Improve therapeutic efficacy
- To guide clinical research
- Improve treatment adherence
- Understand precipitants, perpetuating factors, stressors
Case of child who recently lost grandmother and immigrated to Canada; concerns raised because child is not speaking at school. Asked to provide two psychosocial factors in keeping with biopsychosocial formulation to account for presentation
loss
transition
immigration
Case of child who recently lost grandmother and immigrated to Canada; concerns raised because child is not speaking at school.
Provide 3 considerations on differential diagnosis.
- Ddx – selective mutism, social anxiety, learning a new language, communication disorder, ASD, adjustment disorder, MDD, “other cultural syndromes – cultural conceptualization of distress”
- 3 “considerations” when considering differential
- Learning new language
- Mood/anxiety
- Cultural considerations/conceptualizations of distress
List 5 principles of motivational interviewing.
“DREAS”:
- Develop Discrepancy
- Roll with Resistance
- Express Empathy
- Avoid Argumentation
- Support Self-Efficacy
Stem of a teenager who lost a grandfather he is close with + girlfriend broke up with him + changed school + having trouble finding new friends + arguments with mom (parents recently divorced and is living with mom through week) about chores and rules.
Going to do IPT – name 5 things to focus on.
Conflict in interpersonal relationships/ interpersonal deficits (ex: conflict with mother, lack of friendships, break-up)
Role dispute/ transitions (ex: divorce)
Grief and loss/ complicated bereavement (ex: death of grandfather)
Role transition (ex: school)
Name 3 features of borderline personality and corresponding module of DBT for each.
Chaotic/difficult interpersonal relationships –> Interpersonal effectiveness
Emotional lability –> Emotional regulation
Suicidal ideation/ urges to self-harm –> Distress tolerance
Name 2 techniques in DBT.
Techniques - Chain analysis; “walking the middle path”; mindfulness
Dialectics accepting (radically) and changing; using wise mind; motivational interventions (foot in door, door in face, cheerleading, etc)
What is the basis of Trauma-Focused CBT?
Psychoeducation
Parenting Skills
Relaxation
STABILIZATION PHASE
Affect Modulation
Cognitive Processing
Trauma Narration & Processing
TRAUMA NARRATIVE PHASE
In vivo Mastery
Conjoint Child-Parent Sessions
INTEGRATION/CONSOLIDATION PHASE
Enhancing Safety
What are IPT-A contraindications?
Acutely suicidal or homicidal
Psychotic
Intellectually disabled
Bipolar mania
Actively abusing substances
What are the DBT skills/ modules?
“DIME”
Distress tolerance
Interpersonal effectiveness
Mindfulness
Emotional regulation
Name 2 dx treated with group therapy
depression
generalized anxiety disorder
substance use disorder
Name 2 contraindications to group therapy
Patients with a demonstrated history of assaultive behavior
psychotic patients who pose a potential for violence should not participate in a group
Modify CBT for children.
Involve parents – homework, generalization
Externalize the anxiety disorder
Less “c”, more “B” in cBT
More graduated exposures, less “flooding”
Address family accommodation
Sit/ discuss the physical sensations vs. emotions
What 3 things would you discuss with adolescent and parent before committing to therapy?
Management of SI/ safety
Confidentiality (limits)
Psychoeducation about the modality
Duration and alternatives to this modality
For parents:
Need to take active role
Engagement for at least 4 sessions for assessment/first part
3 “dimensions” that you would want to determine for suitability for family therapy.
Availability and willing to participate (all members)
Dx in family members
Ability to respect the framework; accepting that there is familial issue (and not just prob in patient)
Name 2 contraindications to family therapy.
Abuse/ DV
Active psychosis
Active SU (not able to be sober for sessions)
Adolescent with Crohns. Recent bowel resection, medically doing better. Now sad, withdrawn from family, difficulty sleeping due to anxiety about future/health.
Name 2 principles of family therapy in this case.
- Re-establishment of roles with recovery and reintegration
- Expression of emotions and sharing of emotional experience within the family
-
Psychoeducational family intervention:
- caregiving in chronic illness, skill in family relationships and community living skills
- Stress-diathesis model of biologically based disorders
- information, coping skills, and social support for family management of chronic illness, stress and stigma reduction
- Adolescence is usually the time for separation-individuation; this might be difficult in context of disease
Adolescent with Crohns. Recent bowel resection, medically doing better. Now sad, withdrawn from family, difficulty sleeping due to anxiety about future/health.
1 principle about each psychodynamic/supportive/CBT approaches.
Psychodynamic: regression during the course of the disease that may conflict with the patient’s developmental needs. Explore the role of his symptoms.
Supportive: need to express potentially traumatic experience and bring reflection on impacts of this period and diagnosis/anticipations p/r to the future. Coping methods.
CBT: address potential anticipation of recurrence and disease-related avoidance.
Name 5 criteria for fitness to stand trial.
Understand nature/object of proceeding
Understand possible consequences of proceedings
Ability to distinguish possible pleas (guilty vs non-guilty)
Ability to communicate with lawyer/ counsel
Understand the function/ structure of the court (key personnel, procedures, goals of the Court)
Understand and engage in trial process
7 year old with nocturnal enuresis. No UTI.
What is the natural history of enuresis?
Spontaneous resolution at rate of 5-10% per year
7 year old with nocturnal enuresis. No UTI. Name 2 non-pharmacological interventions.
Provide psychoeducation and reassure
Limit water intake/fluids before bedtime
toileting before bed
behavioural treatment (bell and pad; >50% treatment success)
7 year old with nocturnal enuresis. No UTI. List 2 treatments.
Desmopressin (DDAVP) first line with 60-70% response but high rate of relapse after discontinuing treatment
Imipramine
Child of divorced parents. Name 5 consequences of parental divorce.
Psychological: higher likelihood of aggression, impulsivity, mood and anxiety symptoms
Lower academic achievement
Greater risk of injury
Greater chances of divorce
Higher suicide rates
Child with history of theft, no history of violence. Forensic question asking to list 3 additional investigation techniques/ sources of information important to pre-sentencing evaluation.
Look at: Dangerousness/Risk, Amenability to treatment, Developmental Maturity
Sources:
assessment tools
collateral from third party (family, school, juvenile justice staff)
interviews with the young person
Past personal history including past assessments and past legal hx
Asked for
a) five clinical indicatory of mental health in the youth according to the Mental Health Commission of Canada
b) one source for this information
[a]
- vulnerable children–general population
- suicide rate–youth
- serious consideration of suicide
- self-rated mental health
- anxiety and/or mood disorders
[b]
- Canadian Community Health Survey
- Statistics Canada
- Public Use Microdata File
Provide three recommendations regarding screen time and youth.
- Screen time for children younger than 2 years is not recommended.
- For children 2 to 5 years, limit routine or regular screen time to less than 1 hour per day.
- Ensure that sedentary screen time is not a routine part of child care for children younger than 5 years.
- Maintain daily ‘screen-free’ times, especially for family meals and book-sharing.
- Avoid screens for at least 1 hour before bedtime, given the potential for melatonin-suppressing effects.
- Be present and engaged when screens are used and, whenever possible, co-view with children.
- Be aware of content and prioritize educational, age-appropriate and interactive programming.
List 5 tasks for chair of a meeting.
Set the agenda for the committee
Lead the meeting
Moderate debate/maintain order and decorum
Delegate tasks to members
Monitor the implementation of agreements and action points from previous meetings
Name 3 common comorbid diagnoses with excessive screen time.
obesity
depression
social anxiety
ADHD/ ODD
addiction
PCRP
Name 4 ways that cultural or ethnic minorities are disadvantaged in mental health care
Language barrier
SES/ social determinants of health – finances, transportation, education
Stigmatization/ marginalization in the cultural community
Groups represented in research/ applicability of research results
Culturally – sensitive/ competent care
Young biological male who does not want to use male bathrooms and prefers female play.
Identify 3 features of a boy with gender dysphoria.
- In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
- A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender
- A strong preference for playmates of the other gender
- Incongruence between assigned/ birth gender and experienced/ expressed gender
- 6months duration of at least 6 of the following criteria:
- A strong desire to be the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
- A strong preference for cross-gender roles in make-believe play or fantasy plan.
- In boys (assigned gender), a strong rejection of typically masculine toys, games and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games and activities
- A strong dislike of one’s sexual anatomy
- A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender
Research in children – Ethics? Consequences? Participation?
- Should involve a statistically appropriate number of subjects
- Risk : benefit ratio must be favorable
- Developmentally appropriate explanations
- Should not be undertaken primarily for financial or professional advantage
- Confidentiality is more strict, but the limitations of confidentiality where there is a child protection issue must be clearly stated
- Obligations to make results/ data public
Explain what can make coping with an illness more difficult (two reasons)
- Intra-individual variables:
- Cognitive functioning
- developmental level
- temperament (high anxiety may lead to avoidance)
- capacities for coping
- History of illness/medical experiences
- Disease-related influences:
- Restrictions in physical mobility
- chronicity of pain
- central nervous system involvement.
What are challenges for parents when coping with a child’s illness?
Challenges for Parents
- Reorganization of intra-family relationships.
- Stress of hospitalizations
- Associated costs (work absenteeism)
- Parental Anxiety
- Parental Psychopathology
What are indications for ECT child based on practice parameters?
Severe depression (resistant to multiple meds and therapy, where patient is not eating, drinking or suicidal–at least 2 trial of appropriate meds, unless life at risk)
Mania with or without psychotic features
Schizophrenia
Catatonia
NMS
Symptoms must be severe, persistent and life-threatening – refusing to eat or drink, suicidal
Demonstrate a lack of treatment response – at least two trials of appropriate meds unless waiting for a response will endanger their life
What are principles of grief counselling for children?
Treated with respect to their own level of emotion and cognitive maturity
They need to be told that death is real and irreversible.
They need to know that they are blameless. (Not to be blamed)
Feelings and concerned should be expressed
Questions should be invited and answered with simplicity, candor and clarity.
They need ritual to commemorate their loved ones
Attending the funeral and participation in mourning may be beneficial first step
A teenager with diabetes who will not comply with treatment. Explore reasons why this may be the case.
Struggle with stage : identity vs. role confusion – desire to be accepted by peers and belong.
This can have a strong influence on their health and they can be concerned about fitting in.
Fears about medication and their appearance.
May also want to be independent and push limits when it comes to diabetes medication
?Eating disorder
Why are teens susceptible to substance use?
Dorsolateral PFC still maturing (more impulsive, more unplanned behaviour / behavioural disinhibition, more sensation seeking)
The reward system of brain (nucleus accumbens) already matured -→ more risk-taking
Name two medications that are contraindicated in eating dsiorders
SNRIs – no evidence.
Mood Stabilizers - no evidence.
Buproprion - not recommended for use in eating disorders, due to the elevated risks of seizures in this population.
What factors would make you consider Lithium in an adolescent patient?
CANMAT - first line treatment of Mania is Lithium and Risperidone ( Level 1 )
Classic Euphoric Grandiose Mania
Few prior episodes
Mania-depression-euthymia course
Family history BAD or Li response
Lithium is the only mood stabilizer HEALTH CANADA approved for treatment of BAD in children 12 years or older ( manic episode )
Lithium is efficient in the management of aggression behaviour disorder.
It covers two phases of treatment ( acute and maintenance )
What factors would make you avoid Lithium in an adolescent patient?
Non-obese Manic adolescent with ADHD - consider Risperdone ( CANMAT)
Patient who is not going to adhere or follow instructions about regular diet, water and over the counter medication might be very susceptible for lithium toxicity
The Treatment of Early Age Mania (TEAM) study : showed that Risperidone was superior than Valproate or Lithium
Patient with renal impairment or cardiac abnormalities.
What are recommendations for acute mania in adolescent?
First line : lithium, Risperdone, Quetiapine, Asenapine, Aripiprazole
Second line : Olanzapine , Zipradizone , Quetapine (adjunctive therapy )
Third line treatment : valproic acid
How do you diagnose catatonia?
3/12 of “WRENCHES MPG”
- Waxy flexibility
- Rigidity
- Echopraxia
- Negativism
- Cataplexy
- High level of motor activity (agitation)
- Echolalia
- Stupor, Stereotypy
- Mutism, Mannerism
- Posturing
- Grimacing
Difficulties with reading (sounded like dyslexia). What would you observe in dyslexia?
- Specific Learning Disorder, With Impairment in Reading
- Can include
- Word reading accuracy
- Reading rate or fluency
- Reading comprehension
- Alternatively, can label certain pattern of reading disabilities “dyslexia”
- Can include
- Dyslexia Features
- Decoding (Difficulty reading due to problems identifying speech sounds and learning how they relate to letters/ words)
- Slower pace, less fluid
- Inversion of syllables
- Difficulty with word recognition
- Poor Spelling
What are comorbdities of dyslexia?
LDs (writing, math)
ADHD
ODD
CD
DCD
ASD
anxiety/ depression
ASD. How to you diagnose ASD and gauge severity?
Persistent deficits in communication and social interactions (3/3)
- Deficits in socio-emotional reciprocity
- Deficits in non-verbal
- Deficits in establishing, maintaining and understanding relationships
Restricted patterns of behaviour/ interests/ activities RRBIS (2/4)
- Stereotyped or repetitive motor movements, use of objects or speech
- Insistence on sameness, inflexible adherence to routine, ritualized patterns of verbal or nonverbal behavior
- Highly restricted, fixated interests that are abnormal in intensity or focus
- Hyper or hypo-reactivity
Present in early developmental period and impair function
Clinically Significant Impairment
Not better explained by ID/GDD
Severity:
- “Requiring very substantial support”
- “Requiring substantial support”
- “Requiring support”
What info do you need to diagnose ASD?
- Developmental, medical, family, social history
- Info from school, child care, community
- Audiology, vision assessment
- Direct Clinical Observation
- +/- ASD Diagnostic tool (eg. ADOS)
- DSM-5 Diagnostic Criteria
Name 3 genetic disorders associated with ID/ ASD and how they are transmitted.
- Fragile X – X-linked d/o, FMR1 gene is turn off by a large expansions (n >200) of a (CGG) (n) trinucleotide repeat in the promoter region of the FMR1 gene.
- Tuberous Sclerosis – autosomal dominant; mutation in either TSC1 or TSC2 gene; most often spontaneous mutation
- PKU – autosomal recessive; mutation on chromosome 12 (between q22-24) leading to deactivation of the enzyme that converts phenylalanine to tyrosine.
How is Fragile X transmitted?
Fragile X – X-linked d/o, FMR1 gene is turn off by a large expansions (n >200) of a (CGG) (n) trinucleotide repeat in the promoter region of the FMR1 gene.
How is tuberous sclerosis transmitted?
Tuberous Sclerosis – autosomal dominant; mutation in either TSC1 or TSC2 gene; most often spontaneous mutation
How is PKU transmitted?
PKU – autosomal recessive; mutation on chromosome 12 (between q22-24) leading to deactivation of the enzyme that converts phenylalanine to tyrosine.
How is Down Syndrome Transmitted?
- Down Syndrome – Recombination/ translocation mutation called Trisomy 21, extra full or partial copy of chromosome 21
How is Prader Willi Syndrome transmitted?
- Prader- Willi - loss of active genes in a specific part of chromosome 15, the 15q11-q13 region; occurs when the paternal copy is partly or entirely missing.
How is Angelman Syndrome transmitted?
- Angelman Syndrome – 15 q12 deletion, maternal (the copy from father is silent)
What heart defects do you see in FASD?
- Prenatal ETOH exposure induces the following abnormalities in developing heart
- Atrial and ventricular abnormalities
- Valve formation abnormalities
- Specific Defects associated with prenatal ETOH exposure
- Atrioventricular valve defects
- Ventricular septal defects
- Enlargement of left ventricle
- Increased risk of cardiac disease in adulthood
Other than cardiac, what other systems are affected in FASD?
- Renal - hypoplastic kidney, horseshoe
- Skeletal - contractures, pectus excavatum
- Ocular - strabismus, nerve hypoplasia
- Auditory - conductive and sensorineural hearing loss
- Endocrine - IUGR, FTT
- Neurological - small head size, coordination difficulties, developmental delays, LDs
Name 3 community/ school resources for ID?
School – increased (EA) supports, IEP, specialized classrooms, school psychologist evaluation, Applied Behavioural Analysis for school setting
Extracurricular – sports/ camps, adapted jobs
Family – respite, environmental modifications, caregiver training, disability tax credit (DTC- federal)
Name neuroimaging findings in ASD (3).
Enlarged Brain Volume of frontal and temporal lobes
Bigger amygdala
Corpus collosum reduced in size
Increased cortical thickness and atypicalities in gyration patterns
Bigger head/ brain size (macrocephaly)
Bigger ventricles (ventriculomegaly)
Corpus collosum reduced in size
*No diagnostic findings
What are some physical signs of FASD?
Thin upper lip (4 or 5 on Univ of Washington scale)
Smooth philtrum (4 or 5 on Univ of Washington scale)
Short palpebral fissures (<3rd Percentile)
Short epicanthal folds
Short, up-turned nose
Flat midface
Microcephaly
“rail road track” ears
Short interpupilary discharge (eyes closer together)
Under-developed jaw
Pectus excavatum
Septal heart defects
Renal problems
Auditory and vision problems
Deformities in limbs and fingers
What are the diagnostic criteria for FASD?
CMAJ Guidelines:
With facial features
- 3 facial features
- Confirmed or unknown in utero ROH exposure
- Impairment in 3 or more neurodev domains OR microcephaly if infant
Without facial features
- Impairment in 3 or more neurodev domains
- AND confirmed in utero exposure to alcohol at recognized dose (more than 13 drinks per month, more than 2 drinks per setting)
Describe the phenotype of FAS
IUGR/ low birth weight, small head size, shorter than average + see other physical markers (desribed elsewhere)
Poor coordination, hyperactivity, inattention, poor memory, LDs, speech and language delays, vision and hearing problems, poor executive and adaptive functioning skills, difficulty with emotional regulation.
What is the name of a scale used to quantify the phenotype of FASD?
University of Washington Lip-Philtrum Guide
What are symptoms of Prader-Willi syndrome?
15q11 - Absence of expression of paternally active genes in a region of long arm of Chromosome 15 (15q11.2-13)
Physical: hypotonia; FTT/ obesity; small hands and feet; almond-shaped eyes; fair hair and light skin; flat face; narrowing of the head at the temples; prominent forehead; turned-down mouth; thin upper lip; scoliosis (37%); seizures (25%); hypothyroidism (30%); short stature; under-developed genitals
Psycho-emotional: hyperphagia; hoarding; impulsive; borderline to moderate ID; emotional lability and tantrums; excessive daytime sleepiness; skin picking/ excoriation (85%) ; obsessions/ compulsions; anxiety; aggression
Strengths – reading, visual-spatial.
Adolescent with ASD. Name 3 risk factors for depression.
Social isolation
Awareness of deficits (level 1)
Sudden loss; stress at home/ school
Low self-esteem
ACEs/ abuse
FHx of depression
Adolescent with ASD. Name 2 factors for risk of suicidal behaviours.
Comorbid disorders - anxiety, depression, etc…
High functioning ASD
ACEs (abuse/ trauma/ bullying)
Big transitions/ changes in routine
DiGeorge Syndrome. Name 5 associated mental health co-morbidities. Indicate 1 preserved executive function.
Comorbidities:
Schizophrenia
Intellectual disability
Specific learning disorder
Major Depression
Anxiety Disorder
ADHD
Preserved Executive Function: Verbal IQ (receptive language better than expressive and verbal memory better than visuospatial memory)
ASD. Name 3 associated neurological or genetic disorders.
Fragile X
PKU
Tuberous Sclerosis
Grade 4 student, difficulties with grammar and punctuation, as well as putting together paragraphs.
a) What is the most likely diagnosis?
b) What are two tests to confirm the diagnosis?
a) Specific learning disorder, in written expression
b) WIAT (Weshcler Individual Achievement Test
Test of written language (TOWL)
WISC (Weschler Intelligence Scale for Children)
What are common comorbidities of a specific learning disorder in written expression?
Concurrent LDs, ADHD, Language/ communication disorders, Developmental Coordination Disorder ASD, anxiety/ depression
Provide five cognitive and behavioral difficulties in an FASD adolescent.
Cognitive and behavioural difficulties (DSM-5 Condition for Further Study):
- Impaired executive functioning
- Attention deficit
- Impaired impulse control
- Impaired adaptive/daily living skills
- Impaired affect regulation
Other: IQ<70, Impaired learning, impaired memory, impaired visual-spatial reasoning, communication deficit, impaired social interaction, impaired motor skills
List two investigations to assist in evaluation of FASD
Investigations:
- Physical exam for sentinel facial features: Palpebral fissure length >2 SDs below mean; Philtrum rated 4/5, Upper lip rated 4/5 on University of Washington Lip-Philtrum Guide
- Psychoeducational testing
Other: EEG if seizures, PT/OT assessment
Question regarding three features consistent with Specific Learning Disorder with impairment in reading.
Word reading accuracy
Reading rate/fluency
Reading comprehension
Provide two behaviors to differentiate ASD from communication disorders in children.
-
B criteria – RRBIs, 2/4:
- Stereotyped or repetitive motor movements,
- Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior
- Highly restricted, fixated interests
- Hyper- or hyporeactivity to sensory input
List three features to differentiate schizophrenia from ASD in a child.
Florid delusions and hallucinations rarely seen in ASD
Temporal evolution/onset of symptoms (ASD deficits in social communication within first 3 years of life, onset of childhood schizophrenia typically after age 7)
ASD more pronounced repetitive behaviours and stereotyped language
What are the common comorbidities in fragile X?
ADHD
ASD
Seizures (does this count?)
Anxiety
Mood disorders (depression, PDD)
What is a med to treat aggression in fragile X?
Treatment with stimulants if ADHD is present (80% comorbidity in males)
Risperidone, Aripiprazole
Patient with both ASD and ID presenting with increased aggression. Name 4 things on history to help determine etiology.
physical health review of systems/rule out GMC= pain, constipation, infection
mental health review of systems/rule out other MH diagnosis= mood, anxiety, sensory sensitivities, hx of aggression, sleep
triggers= being denied something child wants; transitions; trauma; new intervention
substance use
Patient with both ASD and ID presenting with increased aggression.
Name 1 medication FDA or Canadian approved.
FDA-approved for irritability in ASD:
Risperidone (5-16 years)
Aripiprazole (6-17 years)
WHat is the Differential DIagnosis of ASD?
Neurodevelopmental disorders
Attention-deficit hyperactivity disorder
Global developmental delay or intellectual disability
Language or learning disorder
Social (pragmatic) communication disorder*
Stereotypic movement disorder
Tourette’s disorder or a tic disorder
Mental/Behavioural disorders
Anxiety disorders
Conduct disorder
Depressive disorders
Disruptive mood dysregulation disorder
Obsessive compulsive disorder
Oppositional defiant disorder
Reactive attachment disorder
Schizophrenia
Selective mutism
Genetic conditions
Fragile X syndrome
Rett syndrome
Other genetic variants (e.g., 16p11 deletion) and genetic syndromes**
Neurological and other medical conditions
Cerebral palsy
Epilepsy
Landau-Kleffner syndrome
Mitochondrial disorders
Neonatal encephalopathy
Stem about a child whose mother used alcohol for first 4 months of pregnancy. He is just expelled for aggressive behavior. Height and weight less than 10%. Very active in the office.
3 things to make a diagnosis.
Prenatal etoh history
3 sentinel facial fts
Evidence of deificts in 3 neurocog domains +/- microcephaly
Stem about a child whose mother used alcohol for first 4 months of pregnancy. He is just expelled for aggressive behavior. Height and weight less than 10%. Very active in the office.
2 pharmacological treatment classes and an example from each that are indicated in this population.
Atypicals – Risperidone
Adrenergic Agents – clondiidne
Amphetamine-based stimulants – lisdexamphetamine
ASD child. Stung by a bee and now afraid of bees. Name 5 ways to adapt therapy for this patient population.
- Emotion recognition training
- Greater use of visual information
- More cognitively concrete and structured approach; simplify cognitive activities
- Involve parents to support implementation of intervention
- Offer regular breaks to maintain attention
- Use Child’s interests in therapy
ASD + ID presenting with increased aggression. Name 4 things on hx to help determine etiology.
physical health review of systems/rule out GMC= pain, constipation, infection
mental health review of systems/rule out other MH diagnosis= mood, anxiety, sensory sensitivities, hx of aggression, sleep
triggers= being denied something child wants; transitions; trauma; new intervention
substance use
ASD + ID presenting with increased aggression.
Name 1 approved medication.
FDA-approved for irritability in ASD:
- Risperidone (5-16 years)
- Aripiprazole (6-17 years)
2 ways communication difficulties in Asperger’s are similar to psychosis.
Socio-emotional communication challenges
Blunted affect and alexythmimia
Alteration of theory of mind and alteration of interpretations and use of non-verbal language and facial expressions.
Name 3 comorbidities often found in Fragile X
ADHD
ASD
Seizures (does this count?)
Anxiety
Mood disorders (depression, PDD)
Name 1 medication you could use for treatment of aggressive behaviour in a pediatric patient with Fragile X?
Treatment with stimulants if ADHD is present (80% comorbidity in males)
Risperidone, Aripiprazole
Case briefly introduces pediatric bipolar disorder.
Name 2 first line treatment for mania.
Lithium, Risperidone, Quetiapine
Name 2 first or second line treatments for bipolar depression in children/youth
Lurasidone
Lithium
Lamotrigine
Case describes an adolescent girl. Difficulties with sleep - initial insomnia, intermittent awakening, restless. “legs feel funny”. Parents think she may be experiencing “growing pains”. Sleepy during the day and difficulty paying attention in school. Both father and the patient snore.
Name 3 Ddx.
RLS (or PLMD theoretically)
OSA (+limb jerks associated with OSA)
ADHD
Delayed sleep-wake phase disorder
Hypnagogic foot tremor
Anxiety/MDD
Case describes an adolescent girl. Difficulties with sleep - initial insomnia, intermittent awakening, restless. “legs feel funny”. Parents think she may be experiencing “growing pains”. Sleepy during the day and difficulty paying attention in school. Both father and the patient snore.
What investigations would you order?
- Polysomnography
- Blood work - ferritin, iron, Mg, thyroid, renal/ liver indicators, CBC
Case describes a young child with encopresis.
(a) Name 2 comorbidities seen in encopresis.
ADHD
ODD
anxiety (separation anxiety, specific phobia, generalized anxiety)
ID/ASD
Name 2 strategies to treat encopresis with overflow diarrhea.
Bowel Retraining
- Disimpaction (for children with a large rectal stool mass or fecal incontinence)
- Prolonged laxative treatment and behavioral therapy to achieve regular evacuation and avoid recurrent constipation
- Dietary changes (primarily increasing fiber and fluid content) to maintain soft stools
- Gradual tapering and withdrawal of laxatives as tolerated
Behaviour Modification
- Toilet Sitting
- Rewards
Name 5 therapeutic benefits of parent support groups.
Educational/ skill building
Empowerment
Sense of belonging
Universality; support network
Self-care/ restorative
Motivating for Parents
Hope
What are temperament/ personality traits that put a young person at risk of developing anxiety?
Temperamental Risk (DSM-5):
behavioural inhibition
negative affectivity
neuroticism
harm avoidance
anxiety sensitivity (disposition to believe that symptoms of anxiety are harmful)
shyness
? Name age-appropriate fears in a young child - preschool age, school age, adolescent.
Infants: loud noises, being startled, strangers
Preschool age: imaginary creatures, darkness, separation
School age: injury, natural events (e.g., storms)
Adolescent: school performance, social competence, health issues
Compare and contrast depressive symptoms [they listed the following: anhedonia, sleep
disturbance, poor concentration, appetite] in a pediatric patient vs. adolescent vs. adult [and
we had to indicate who each symptom difference in depression based on age).
What is the approach for the treatment of depression in an adolescent?
Confirm diagnosis + comprehensive psychiatric assessment + risk assessment (pt and collateral)
Treatment has three phases: (psychoed, supprto for pt, fam, school)
acute
continuation
maintenance
Mild MDE -→ Supportive clinical care may reduce symptoms (psychoed, restoration of hope, empathetic listening, lifestyle advice, coping skills, sleep hygiene, exercise)
Psychotherapy is first line for mild-mod MDD (either CBT or IPT)
Mod-severe MDD /not responded to psychotherapy/ pt pref-→ Meds (fluoxetine, escitalopram, sertraline, venlafaxine)
If med started, assess weekly x4 weeks, then every 2 weeks for one month, then after 12 weeks to assess for side effects
Start on low-end of therapeutic dose range and consider dose adjustments q 4 weeks
Treat for 6-12 months if first episode and taper slowly during stress-free time
When using medications, combine with psychotherapy
Anorexia Nervosa. Name two evidence-based psychotherapies.
Canadian practice guidelines for the treatment of children and adolescents with eating disorders (2020)
- Family-based treatment (FBT) (strong recommendation)
- CBT for AN (weak recommendation)
- Adolescent Focused Psychotherapy for AN (weak recommendation)
Name a medication with evidence for weight gain in AN.
Olanzapine
But there is little actual research evidence for weight gain in AN:
- Only DBPCT (Bissada, 2008) was negative
- Three case-control studies “Those in the medication group demonstrated a significantly higher rate of weight gain in the first 4 weeks, although approximately one third of participants discontinued olanzapine early due to side effects”
- Two positive case series
What medication classes are contraindicated in AN?
Bupropion, seizure risk
How is Li metabolized?
Lithium is not metabolized, it is rapidly and completely absorbed, with a bioavailability of 80-100%
Half-life in children is 27 hours, adults 18-36 hours
Excreted in the urine (unchanged drug)
Clearance: 80% of filtered lithium is reabsorbed in the proximal convoluted tubules in pediatric patients
Name 2 pharmacokinetic differences of Li in a child
Half-life shorter
Clearance faster than in adults
What predicts good response to Li (name 1 factor]?
Family History of Response to Lithium
Family History of Bipolar Disorder
Classic Symptomatology of BP (eg, euphoric mania)
Later age of disease onset
Fewer hospitalizations preceding treatment
What are predictors of poor response to lithium?
Chronic Clinical Course
Rapid cycling
ECT. What are the indications for ECT in a pediatric patient?
Before an adolescent is considered for ECT, must meet 3 criteria:
Diagnosis
Severe, persistent major depression or mania with or without psychotic features, schizoaffective disorder, or, less often, schizophrenia. Or catatonia and NMS
Severity of symptoms
Symptoms must be severe, persistent, and significantly disabling. Eg. refusal to eat or drink, severe suicidality, uncontrollable mania, and florid psychosis
Lack of treatment response
Failure to respond to at least two adequate trials of appropriate psychopharmacological agents accompanied by other appropriate treatment modalities. Both duration and dose determine the adequacy of medication trials. It may be necessary to conduct these trials in a hospital setting.
ECT considered earlier in cases in which
(a) adequate medication trials are not possible because of the patient’s inability to tolerate psychopharmacological treatment,
(b) the adolescent is grossly incapacitated and thus cannot take medication, or
(c) waiting for a response to a psychopharmacological treatment may endanger the life of the adolescent
What are the most common risks/ complications of ECT in a pediatric patient?
Impairment of memory and new learning
Tardive seizures
Prolonged seizures
Risks associated with general anesthesia
Adults, fatality rate is 0.2/10,000 treatments, adolescents not believed to be at increased risks
Headaches, nausea, vomiting, muscle aches, confusion, agitation
What are the most common risks/ complications of ECT in a pediatric patient?
Impairment of memory and new learning
Tardive seizures
Prolonged seizures
Risks associated with general anesthesia
Adults, fatality rate is 0.2/10,000 treatments, adolescents not believed to be at increased risks
Headaches, nausea, vomiting, muscle aches, confusion, agitation
What are the most common risks/ complications of ECT in a pediatric patient?
Impairment of memory and new learning
Tardive seizures
Prolonged seizures
Risks associated with general anesthesia
Adults, fatality rate is 0.2/10,000 treatments, adolescents not believed to be at increased risks
Headaches, nausea, vomiting, muscle aches, confusion, agitation
What are the most common risks/ complications of ECT in a pediatric patient?
Impairment of memory and new learning
Tardive seizures
Prolonged seizures
Risks associated with general anesthesia
Adults, fatality rate is 0.2/10,000 treatments, adolescents not believed to be at increased risks
Headaches, nausea, vomiting, muscle aches, confusion, agitation
What are poor prognostic factors for the treatment of anxiety?
Comorbid MDD
Younger age of onset
Duration of symptoms
Other comorbid anxiety disorders
No longer attending school/school phobic
Clonidine. What are indications for the use of Clonidine?
Tourette Syndrome & Tic Disorder (CADDRA)
Third Line treatment of ADHD (along with Bupropion, Imimpramine, Modafinil)
Others with limited data to support:
PTSD
Insomnia, with neurodevelopmental disorder as alternate therapy
What is the mechanism of action of clonidine?
alpha-2-adrenergic agonists
Stimulates alpha-2 adrenoceptors in the brain stem, thus activating an inhibitory neuron, resulting in reduced sympathetic outflow from the CNS, producing a decrease in peripheral resistance, renal vascular resistance, heart rate, and blood pressure
In ADHD, unknown, proposed that postsynaptic alpha-2 agonist stimulation regulates subcortical activity in the prefrontal cortex
What are side effects of clonidine?
Somnolence and sedation
BP, risk of hypotension
Bradycardia, syncope
Elevated BP and HR upon abrupt discontinuation – should always be tapered down progressively if discontinuing
QTc interval (to be monitored if underlying conditions or other medication increase the risk of prolonged QTc interval)
What are 2 indications for Risperidone in ASD?
Irritability
Physical Aggression
Severe tantrum behaviour
Self-Injury
“Quickly changing moods” (UpToDate)
Treatment of repetitive/stereotypic behaviours
Psychosis/bipolar mania/tics
Name 3 risk factors for NSSIB.
Adverse childhood experiences
Bullying
“mental disorders”:
Anxiety, depression, personality disorders
female gender (maybe less so?)
physical symptoms:
disabilities and sleep problems
low health literacy
problem behaviours
alcohol/substance use, smoking, problematic mobile phone use, having run away from home, suicide attempt, internet/mobile phone abuse, intentional misuse of prescription medications, avoidance, opioid misuse, sedative misuse, and gaming disorder
What are Adverse Childhood experiences?
Physical abuse
Sexual abuse
Emotional abuse
Physical neglect
Emotional neglect
Mental illness
Divorce
Substance abuse
Violence against your mother
Mental illness
Having a relative who has been sent to jail or prison
Name 3 risk factors for development of PTSD.
Female gender
previous trauma exposure
multi- ple traumas
greater exposure to the index trauma
presence of a preexisting psychiatric disorder (particularly an anxiety disorder)
parental psychopathology
lower socioeconomic status
lower education and intelligence
childhood adversity
cultural characteristics
lack of social support
Peritrauma factors - severity of the trauma, degree of perceived threat to life, personal injury, degree of interpersonal violence
Temperamental traits - inappropriate coping strategies and negative appraisals
What are factors that prevent against development of pediatric PTSD?
parental support
lower levels of parental PTSD
resolution of other parental trauma-related symptoms
Name 3 risk factors for ADHD, specifically as it pertains to pre-pregnancy/pregnancy/ delivery
pre-pregnancy= family/parental history of ADHD; family/parental history of conduct disorder
pregnancy= maternal stress; exposure to tobacco/alcohol/drugs/toxins; low birth weight; prematurity
delivery= neonatal anoxia/brain injury; exposure to lead/toxins
infancy/childhood= family conflict; inconsistent parenting; early deprivation
Name 2 co-morbidities of FASD
Attention Deficit Hyperactivity Disorder (ADHD)
Intellectual Disability
Learning Disorders
Oppositional Defiant Disorder
depressive and anxiety disorders
substance use
suicidality
ODD. What is the prevention intervention in the community/ school?
Social skills school based programs ****
Parent training for ODD
School-based prevention programs offer an efficient mechanism for delivering prevention interventions
Clinicians who serve as consultants to schools need to be familiar with these programs. A detailed discussion of this complex literature is contained in the recent summaries by
ODD. What parenting style puts a child at risk of developing ODD?
Harsh
Inconsistent
Neglectful
…child-rearing practices are common in families of children and adolescents with oppositional defiant disorder
ODD. Name the diagnostic symptom categories
Angry/irritable mood
Argumentative/Defiant behaviour
Vindictiveness
What are 3 risks associated with an ODD
Dx.
- Anxiety and mood problems
- Risk for developing conduct disorders
- Increased risk of suicide attempts
Name 3 differences between AD and social anxiety disorder [compare and contrast].
Social and Communication impairments are seen in ASD and not anxiety disorders
Developed social insight in anxiety disorders is not seen in ASD
RRBIs seen in ASD not present in Social Anxiety Disorder
Early Development not affected in anxiety disorders compared to ASD
Name 3 differences between ASD and reactive attachment disorder compare and contrast.
Children with RAD have deficits in attachment and social responsiveness but these improve substantially if adequate caretaking is provided whereas in ASD they do not improve to the same degree
No selective impairments in symbolic representation (e.g., pretend play and language) out of proportion with cognitive level in RAD compared to ASD
Restricted interests and preoccupations seen in ASD are not found in RAD
Patient with AD. Aggression well controlled on Olanzapine 2.5mg. Fever and antibiotics x 7days. Now increasing paranoia/ psychotic symptoms and EPS symptoms.
a) What are 3 DDx?
b) What investigations do you want to order?
a) Delirium secondary to infectious process
Neuroleptic Malignant Syndrome (Fluoroquinolones e.g., Ciprofloxacin inhibit CYP1A2, can increase levels)
Encephalitis
?Substance induced psychosis
b) Physical exam + neuro exam, vitals
CBC, lytes, glucose, extended lytes, CK, Cr and Urea, Liver Enzymes, Fe, blood cultures
Urine myoglobin
Referral to Pediatrics or send to ED
?Imaging ?Lumbar puncture
Urinalysis
CXR
UDS
What are absolute contraindications to ECT?
None
What are cognitive side effects of ECT?
Transient Disorientation post session
Subjective and objective CI
Retrograde amnesia
Anterograde amnesia
Mild, ST impairment in memory and other cog domains
What can be done to reduce risk of cog impairment with ECT?
Right unilateral electrode placement (vs bilateral)
Bifrontal electrode placement vs bitemporal
Ultra brieff pulse width vs brief pulse width
Decrease electrical stimulus
Reduced frequency and # of sessions
Reduce anaesthetic agent DC meds that with known side effects prior to ECT esp Lithium
What is the differential diagnosis for NMS?
Dystonia/EPS
Encephalitis
Head Trauma
CVA
Delirium
Systemic Infection
Malignant catatonia
Malignant Hyperthermia
Seizure – status epilepticus
Alcohol/sedative withdrawal
Serotonin syndrome
What are clinical manifestations of NMS?
- Fever (>38) - Altered mental status - Autonomic instability (tachycardia and HTN) Also, dysrhythmias, diaphoresis, sialorhea, dysarthria, dysphagia, tremor, dystonia
What investigations should be ordered in suspected NMS?
CBC, lytes, Cr, LFTs, Lactate, ext lytes, ABG or VBG Urinalysis, urine drug screen Blood Culture, LP CT/MRI, EEG
What are typical lab, imaging, and EEG findings in NMS?
CBC - leukocytosis CK - increased, >1000 LFTs - mild increase Lactate - mild increase Cr - increased if renal failure secondary to rhabdo Lytes - increased/decreased Na, decreased Ca, decreasged Mg ABg - acidosis Imaging - usually normal, except in prolonged acidosis/hyperthermia, cerebral edema LP - normal, maybe slight increase in protein EEG - to rule out non-convulsive status, generalized slowing
What are risk factors for NMS?
- Antipsychotic use = major risk factor
Previous NMS
High potency typicals - initiated in last 2 weeks - dose increased quickly - if switch was made from another agent
if IM/depot
Aggravating factors - Lithium
Como substance use
neuro dx
recent med illness
dehydration (or early complication)
What is treatment of NMS?
- Stop the causative agent – discontinue all antipsychotics.
- Discontinue other potential contributors, including lithium, anticholinergics, SSRIs, and MAOIs.
- Treat agitation with benzodiazepines as needed.
- Aggressive supportive care:
a. ICU setting – including monitors, ventilation and antiarrhythmics prn.
b. Aggressive IV hydration is necessary.
c. Urine alkalization may be considered if CK is very high to help eliminate myoglobin to prevent renal failure.
d. Cooling blankets for high fevers are necessary. - Possible treatments are few, and evidence is limited:
a. Dantrolene IV to relax skeletal muscles has been used with success in some cases.
b. Bromocriptine (a dopamine agonist) may restore lost dopamine tone. Amantadine is another alternative agent acting in this manner.
c. ECT has been met with some success clinically in severe cases, but risks in this sick population is very high. Arrhythmias and status epilepticus have been reported.
What are the complications of NMS?
VTE
Dehydration
Electrolyte Imbalance
Acidosis
Rhabdomyolisis
Renal failure 2 to rhabdo
cardiac arrhythmias
MI 2 to hyperthermia/lyte
DIC
Liver failure
sepsis
seizures
What is prognosis of NMS?
- Most resolve within 2 weeks wo sequelae if proper supp care given and no prolonged hyperthermia or hypoxia - maybe takes longer if depot APs given - 5-20% mortality rate (usually highest with increased myoglobin, acute renal failure, preesxisting organic brain disease, substance abuse)
Can you reinitiate antipsychotics following NMS? If so, describe how.
- Yes - NMS may occur, idiosyncratic rxn, 10-90% - Risks for recurrence first few weeks after NMS use of high potency IM/Depot Concomitant li Dehydration
What are some medical conditions that mimic an eating disorder?
Endocrine/GI issues - Addisions -Hyperthyroid - Malabsorption - IBD - Celiac - Some cancers (lymphoma, b-symptoms)
What screening investigations should be done for people who have an eating disorder? What about an eating disorder together with diabetes?
Orthostatic vitals
CBC
Electrolytes Magnesium, Calcium, Phosphorus
Creatinine (+/- Urea)
Liver enzymes, including Alkaline phosphatase
Ferritin
Folate,
B12 levels
TSH
EKG
Urine pregnancy test
Urinalysis Bone Density scan (DEXA)
For DM, also add: Capillary blood glucose monitoring HbA1c Serum pH and urine for ketones (if DKA suspected)
What are major medical complications of an eating disorder?
- Neuro: cognitive decline (with possible grey/white matter changes), seizures, decreased LOC, myopathies, smooth muscle wasting
- Dental: generally in cases where vomiting is used in purging (so not this patient)
- Skin: lanugo hair, xerosis/dry skin, edema, nail changes, cold intolerance, + many, many more
- Respiratory: decreased lung function secondary to malnutrition/muscle wasting
- CVS: bradycardia, prolonged QT, orthostatic hypotension, dysrhythmias, anaemia
- GI: salivary gland enlargement/changes (again in cases with vomiting, so not likely in this patient), decreased esophageal/gastric/bowel motility (often leading to postprandial bloating), constipation or loose stools, poor digestion
- Endocrine: amenorrhea/infertility, hypothermia/cold intolerance, hypoglycaemia, decreased libido, + many, many more
- Renal: decreased urine volume, nocturia, urinary frequency
- Bones: osteopaenia, osteoporosis (generally only AN)
What are absolute contraindications to ECT?
None
What are cognitive side effects of ECT?
Transient Disorientation post session
Subjective and objective CI
Retrograde amnesia
Anterograde amnesia
Mild, ST impairment in memory and other cog domains
What can be done to reduce risk of cog impairment with ECT?
Right unilateral electrode placement (vs bilateral)
Bifrontal electrode placement vs bitemporal
Ultra brieff pulse width vs brief pulse width
Decrease electrical stimulus
Reduced frequency and # of sessions
Reduce anaesthetic agent DC meds that with known side effects prior to ECT esp Lithium
What is the differential diagnosis for NMS?
Dystonia/EPS
Encephalitis
Head Trauma
CVA
Delirium
Systemic Infection
Malignant catatonia
Malignant Hyperthermia
Seizure – status epilepticus
Alcohol/sedative withdrawal
Serotonin syndrome
What are clinical manifestations of NMS?
- Fever (>38) - Altered mental status - Autonomic instability (tachycardia and HTN) Also, dysrhythmias, diaphoresis, sialorhea, dysarthria, dysphagia, tremor, dystonia
What investigations should be ordered in suspected NMS?
CBC, lytes, Cr, LFTs, Lactate, ext lytes, ABG or VBG Urinalysis, urine drug screen Blood Culture, LP CT/MRI, EEG
What are typical lab, imaging, and EEG findings in NMS?
CBC - leukocytosis CK - increased, >1000 LFTs - mild increase Lactate - mild increase Cr - increased if renal failure secondary to rhabdo Lytes - increased/decreased Na, decreased Ca, decreasged Mg ABg - acidosis Imaging - usually normal, except in prolonged acidosis/hyperthermia, cerebral edema LP - normal, maybe slight increase in protein EEG - to rule out non-convulsive status, generalized slowing
What are risk factors for NMS?
- Antipsychotic use = major risk factor
Previous NMS
High potency typicals - initiated in last 2 weeks - dose increased quickly - if switch was made from another agent
if IM/depot
Aggravating factors - Lithium
Como substance use
neuro dx
recent med illness
dehydration (or early complication)
What is treatment of NMS?
- Stop the causative agent – discontinue all antipsychotics.
- Discontinue other potential contributors, including lithium, anticholinergics, SSRIs, and MAOIs.
- Treat agitation with benzodiazepines as needed.
- Aggressive supportive care:
a. ICU setting – including monitors, ventilation and antiarrhythmics prn.
b. Aggressive IV hydration is necessary.
c. Urine alkalization may be considered if CK is very high to help eliminate myoglobin to prevent renal failure.
d. Cooling blankets for high fevers are necessary. - Possible treatments are few, and evidence is limited:
a. Dantrolene IV to relax skeletal muscles has been used with success in some cases.
b. Bromocriptine (a dopamine agonist) may restore lost dopamine tone. Amantadine is another alternative agent acting in this manner.
c. ECT has been met with some success clinically in severe cases, but risks in this sick population is very high. Arrhythmias and status epilepticus have been reported.
What are the complications of NMS?
VTE
Dehydration
Electrolyte Imbalance
Acidosis
Rhabdomyolisis
Renal failure 2 to rhabdo
cardiac arrhythmias
MI 2 to hyperthermia/lyte
DIC
Liver failure
sepsis
seizures
What is prognosis of NMS?
- Most resolve within 2 weeks wo sequelae if proper supp care given and no prolonged hyperthermia or hypoxia - maybe takes longer if depot APs given - 5-20% mortality rate (usually highest with increased myoglobin, acute renal failure, preesxisting organic brain disease, substance abuse)
Can you reinitiate antipsychotics following NMS? If so, describe how.
- Yes - NMS may occur, idiosyncratic rxn, 10-90% - Risks for recurrence first few weeks after NMS use of high potency IM/Depot Concomitant li Dehydration
What are some medical conditions that mimic an eating disorder?
Endocrine/GI issues - Addisions -Hyperthyroid - Malabsorption - IBD - Celiac - Some cancers (lymphoma, b-symptoms)
What screening investigations should be done for people who have an eating disorder? What about an eating disorder together with diabetes?
Orthostatic vitals
CBC
Electrolytes Magnesium, Calcium, Phosphorus
Creatinine (+/- Urea)
Liver enzymes, including Alkaline phosphatase
Ferritin
Folate,
B12 levels
TSH
EKG
Urine pregnancy test
Urinalysis Bone Density scan (DEXA)
For DM, also add: Capillary blood glucose monitoring HbA1c Serum pH and urine for ketones (if DKA suspected)
What are major medical complications of an eating disorder?
- Neuro: cognitive decline (with possible grey/white matter changes), seizures, decreased LOC, myopathies, smooth muscle wasting
- Dental: generally in cases where vomiting is used in purging (so not this patient)
- Skin: lanugo hair, xerosis/dry skin, edema, nail changes, cold intolerance, + many, many more
- Respiratory: decreased lung function secondary to malnutrition/muscle wasting
- CVS: bradycardia, prolonged QT, orthostatic hypotension, dysrhythmias, anaemia
- GI: salivary gland enlargement/changes (again in cases with vomiting, so not likely in this patient), decreased esophageal/gastric/bowel motility (often leading to postprandial bloating), constipation or loose stools, poor digestion
- Endocrine: amenorrhea/infertility, hypothermia/cold intolerance, hypoglycaemia, decreased libido, + many, many more
- Renal: decreased urine volume, nocturia, urinary frequency
- Bones: osteopaenia, osteoporosis (generally only AN)
What are features of studies that make them more useful to clinicians?
• Recruitment is of patients seeking treatment (as opposed to volunteers responding to advertisements) • Enrollment is high (as opposed to most potential subjects screened out or not consenting) • Sample size is adequate (minimum 30 – 50 subjects per arm) • Exclusion criteria are not overly restrictive (e.g. not excluding people with substance use, suicidal ideation, etc.) • Intervention is something that can actually be done in real life (as opposed one that is so specialized or resource intensive that it cannot readily be undertaken in the local setting) • Outcome is meaningful to clinicians and patients • Harms are measured (e.g. side effects, discontinuation of treatment, worsened suicidal ideation, changes in weight, etc.) • Duration of treatment is long enough to mimic actual practice and to observe potential adverse events • Costs are measured
What are the principles of management of Periodic Limb Movement Disorder/Restless Leg?
- Treat underlying cause (eg. iron deficiency anemia) or DC causative agent
- Non pharm - decrease ETOH, nicotine and caffeine; hot baths, hot or cold compresses, massage, sleep hygiene
- Dopamine-agonists (Pramipexole, Ropinarole, then Levodopa)
- Anticonvuslants (Gabapentin and pregabalin)
- Benzodiazepenes
- Low dose oxycodone
What is the main treatment of circadian rhythm sleep wake disorder?
Chronotherapy (phase delay)
Melatonin early PM
Bright light early AM
What are key features of cyclothymia?
>2 years (>1yr in children) -
- numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode AND
- numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.
- Symptomatic at least half the time
- Criteria for a major depressive, manic, or hypomanic episode have never been met
What are symptoms associated with antidepressant discontinuation syndrome?
- Flu-like symptoms (lethargy, fatigue, headache, achiness, sweating)
- Insomnia (with vivid dreams or nightmares)
- Nausea (sometimes vomiting)
- Imbalance (dizziness, vertigo, light-headedness)
- Sensory disturbances (“burning,” “tingling,” “electric-like” or “shock-like” sensations)
- Hyperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness)
What differentiates a manic episode from a hypomanic episode?
Hypomanic episode only needs to be 4 days, manic at least a week (or hosp)
Hypomanic = marked change in functioning, but NOT functioanl impairment
Both need 3/7 DIGFAST criteria
What are “atypical features” in a depression?
Who is most likely to experience atypical features?
- Symptoms
- Mood reactivity brightening in response to circumstances
- Overeating
- Oversleeping
- Leaden Paralysis
- A long-standing pattern of interpersonal rejection sensitivity
- Assoc with
- Younger age of onset
- more severe psychomotor slowing
- COMO panic disorder, SUD, and somatization
What are melancholic features of depression?
Classic depression: severe anhedonia, early morning awakening, weight loss, and profound feelings of guilt
What medication is helpful in treating opioid withdrawal symptoms?
clonidine
What is the main clinical feature of insomnia?
Association of bed with state of arousal
What is first line treatment of insomnia?
CBT for Insomnia
3 stages
- Sleep hygiene and education, stimulus control, sleep restructuring
- Cognitive therapy, relaxation training
- Medication taper
What is the principle in using medication to treat insomnia?
Use for short-term, trasnient insonia eg when in hospital
Use lwoest effective dose, intermittent dosing, gradually taper off
Not indicated for chronic insomnia
EG. Temazepam, zopiclone, zolpidem, doxepin, orexin and melatonin antagonists
What are the main management strategies in OSA?
CPAP
Nasal surgery
Oral devices
Don’t sleep supine
DO NOT use narcotics, benzos, opioids
What is the main treatment of circadian rhythm sleep wake disorder?
Chronotherapy (phase delay)
Melatonin early PM
Bright light early AM
In bipolar disorder, which two Loci are most implicated?
ANK3 - Voltage gated sodium channels
CACNA1C on 12p13 - L type Ca Channels
What is the overall appraoch to opioid use disorder clinical management?
- Start opioid agonist treatment (OAT) with buprenorphine/naloxone whenver feasible
- For poor responders to above, consdier transition to methadone
- If good response to methadone, consider transitioning to buprenorphine naloxone
What is important to consider when starting suboxone?
- Pt needs to be in at least moderate withdrawal to start (COWS >12)
- 12-24 hours of abstinence since last opiod dose
- Begin at 2-4mg, increase by up to 8mg/day
- Max 24mg/day
What are adverse effects associated with suboxone?
Precipitated withdrawal
Resp depression/sedation
Headache, fatiguw, occasional sexual SE
What is the main pharmacological difference between methadone and suboxone?
- Suboxone
- Buprenorphone is a partial opiod antagonist at mu receptor
- Has a higher affinity for opioid receptor so displaces otehr opioids
- But its maximal opioid agonist effect is lower than FULL op-ags (methadone, morphine, heroin)
- “Ceiling effect” lowers risk of resp depression, side effects, non-med use
- Naloxone os mu opioid receptor antagonist, can block the effect of buprenorphine
- Methadone
- FULL opiod agonist at mu receptor
- increased risk for AEs and OD and death
- When used as directed, safe and effective for OUD tx
What are adverse effects/precautions with prescribing methadone?
- QTC Prolongation
- Black Box Warning
- Addiction, abuse, misuse
- Resp depression
- 3A4, 2C19,2C9,2D6 inhibitors could icnrease methadone levels –> resp depression
- Serotonin syndrome if with other S-agents
What are symptoms of cocaine intoxication?
- Euphoria
- ↓ appetite
- ↑vigilance
- ↑ autonomic activity (or possibly ↓)
- ↑seizures
- ↑psychosis - paranoid delusions
- ↑ nausea vomiting
- ↑ arrhythmias
- ↑ psychomotor behaviour - agitation, stereotyped behaviour eg dyskinesias
What is the neurobiology of ecstacy addiction?
- Acute - ↑ serotonin (blocks reuptake, directly releases S)
- Chronic - ↓ serotonin levels by depleting stores and inhibiting synthesis of new S
What is the neurobiology of stimulant abuse?
- Acute
- serotonin levels by blocking reuptake, directly releasing S
- Chronic
- ↓ serotonin levels by depleting stores, inhibiting synthesis of new S
What are key differences in metabolism of methamphetamine and cocaine with respect to duration of effects and withdrawal
- Cocaine
- Metabolizes rapidly
- Effects last 1-2 hours
- Withdrawal 1-2 days
- Methamphetamine
- Metabolizes Slowly
- Effects can last 10-20 hours
- Withdrawal can last several days
- Recall meth –> 1000% ↑ of DA in NA (vs food 150%, sex 200%)
Eating disorder patient. What tests would you order as an initial workup?
- CBC, lytes, CAMP, albumin, LFTS, Cr, Urea
- ECG
What is the definition of chemical restraint and how is it different from a prn?
- Prn means non-regularly scheduled medication
- prn medication requires informed consent (either from patient or SDM) in most situations
- Chemical restraint is a category of non-regularly scheduled medication that can be given without informed consent but only in the event of behaviour which is causing a high likelihood of risk of harm coming to the patient or to others.
- Chemical restraint orders must be reassessed on a daily basis
What are pros and cons to treatment with an IM antipsychotic?
- Pros: helps with compliance, ensures a constant delivery of medication, some patients may prefer not to have to deal with pills, health care providers have accurate information about compliance
- Cons: delayed release of drug can make dosing challenging and results in a prolonged period of time before the medication takes effect, the long half-life of injectable antipsychotics means that any adverse reactions last longer than with oral medications, many patients may not feel comfortable with the idea of receiving an injection
What are criteria for a CTO?
Criteria for initiation of a CTO:
- Having an Axis I disorder
- A history of non-adherence to psychiatric follow-up and/or psychiatric medications
- A history of at least 2 psychiatric hospitalizations in the last 3 years and/or a psychiatric hospitalization that lasts at least 30 days in the last 3 years
- A history of improvement in psychiatric symptoms when patient is adherent to psychiatric treatment
What are the diagnostic criteria for intellectual disability?
Assessment for diagnosis of Intellectual disability: IQ testing and assessment of adaptive functioning using an adaptive behaviour scale
Diagnostic Criteria for Intellectual Disability:
A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience, confirmed by both clinical assessment and individualized statrdized intelligence testing.
B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life.
C. Onset of intellectual and adaptive deficits during the developmental period.
Child with ADHD. Mother worried that the child will become “drugged”/ “addicted”. Which ADHD medication has the least risk of diversion and addiction?
- Non-stimulant medications
- Atomoxetine, Guanfacine
- Long Acting Stimulants
- Vyvanse – pro (inactive) drug that requires first pass metabolism, so it cannot be injected
- Other long-active stimulants (ie: Concerta/ OROS)
Youth using substances with friends. Missing school. Not following rules. What is the differential and how would you diagnose?
SUD Dx:
At least 2 sx for 12months
In this case: missing school and interpersonal problems so 2 sx (likely more in the stem) = mild (2-3sx)
ODD Dx:
At least 4 sx for 6 months
In this case: not following rules so 1sx (likely more in the stem)
CD Dx:
At least 3 sx for 12 months (with 1 in last 6 months)
In this case: missing school
What can parents do:
- Promote positive social activities
- Improve parent-child relationship
- Positive reinforcement of abstinence
Youth using substances with friends. Missing school. Not following rules. What can parents do to minimize substance use?
What can parents do:
- Promote positive social activities
- Improve parent-child relationship
- Positive reinforcement of abstinence
Psychological vs. medical/ physical effects of THC withdrawal.
Physical/ medical:
• GI symptoms such as abdominal pain, fever, chills, diaphoresis, headaches, tremors
Psychological:
• Depression, anxiety, irritability/ anger, insomnia, appetite changes, restlessness
Withdrawal symptoms commonly occur 24 h to 72 h after last use and persist for 1 to 2 weeks. Sleep disturbance is often reported for up to 1 month.
Which recreational drugs cause visual halluicnations?
Intoxication:
LSD
Phencyclidine (PCP
Psylocibin (“mushrooms)
Ketamine
Dextromethorphan (DMT) (in high doses)
Withdrawal: alcohol
VH is less common with MDMA and much less common with cocaine
*Serotonin is the major neurotransmitter in the neurochemical pathway of hallucinogens (including LSD, PCP, and Psylocibin)
*DMT and Ketamine are NMDA-receptor antagonists
*Dopamine is released from classical amphetamines (e.g. methamphetamine, methylphenidate)
*Dopamine, NE, and serotoin are implicated in the designer amphetamines (e.g. MDMA)
*Dopamine reuptake is blocked by cocaine
17 year old using cocaine. Name 5 family interventions.
1) Psychoeducation
2) Parent skills training (e.g., treatment entry training and safety training and communication skills training)
3) Re-establish hierarchy and boundaries
4) Use of positive reinforcement and contingency management
5) Engage in pro-social/positive activities (sport, arts, etc)
6) Motivational enhancement
A) Community Reinforcement and Family Training
B) Multisystemic Therapy (as for conduct disorder/antisocial behaviours)
C) Brief Strategic Family Therapy
D) Multidimensional Family Therapy
E) Functional Family Therapy
iList 2 pharmacologic properties of cannabinouds
- (THC) stimulates cannabinoid receptors type-1 (CB1) throughout the CNS (highest concentrations in amygdala, hippocampus, basal ganglia, anterior cingulate cortex and prefrontal cortex) and CB2 receptors peripherally
- CBD has little binding affinity for either CB1 or CB2 receptors, but it is capable of allosterically binding and antagonizing them in the presence of THC (reducing the effect of THC)
Compare anxiety vs. developmentally appropriate fear.
Disorder – persistent, significant distress, impaired function/ development
Remember:
- Fear is seen as a reaction to a specific, observable danger
- Developmentally normal does not cause clinically significant distress, impairment in function
- Anxiety is seen as a diffuse, a kind of unfocused, objectless, future-oriented fear
- Normative fears do not typicallly persist beyond specific developmental stage
* Children at younger ages may have difficulties in communicating cognition, emotions, and avoidance, as well as the associated distress and impairments, to the diagnostician because they might lack the cognitive capabilities used to communicate information vital to the application of the diagnostic classification system. Thus, developmental differences (eg, cognition, language skills, emotional understanding) must be carefully considered when assessing anxiety in young people to make a diagnostic decision
Genes/ neurotransmitters/ genetics of anxiety disorders?
- Highly complex, polygenic
- Susceptible genes within the serotonergic and catecholaminergic systems (5HTT, 5HT1A, MAOA) & BDNF gene
-
Short 5HT allele – 5HT transporter, 5-HTTLPR
- Associated with lower 5-HTT expression and function, as well as anxiety and negative mood
- Stress/early trauma interact with molecular plasticity markers
What SSRI is approved 1st line for all of the anxiety disorders?
- None in child and adolescent psychiatry by Health Canada
- Fluoxetine is 1st line for anxiety disorders according to guidelines
- Sertraline, citalopram, fluvoxamine, clomipramine
Young female with epilepsy. ?pseudoseizures?
What is the differential diagnosis?
What aspects are important on history are helpful in making the diagnosis?
- DDx: conversion disorder; factitious d/o; somatic symptoms d/o; PTSD/ dissociation; MDD; Seizure disorder; panic disorder
- Additional history: aura, urinary incontinence, post-ictal confusion. Gradual start of pseudo-seizure, pelvic thrusting, head side-to-side, normal reflexes post-ictal, crying/talking/distress per-ictal. No nocturnal sz
Waxing and waning
Eyes Closed
Side to side head movements (>4)
Time (>3 minutes)
Crying out
Out of phase limb movements
Pelvic thrusting
Soft toy
Young female with epilepsy. ?pseudoseizures? Work-up and investigations?
Work-up: physical examination including neurological exam
blood work including PL
EEG
Inconsistency of symptoms on examination - Eg. normal EEG during seizure, active resistance to eye opening during pseudo-seizure.
PRL post-ictal
Which anxiety disorders in children > adults?
- Selective mutism
- Separation anxiety
How does anxiety manifest in our youngest patients?
- Somatic symptoms like headaches and belly aches
- Irritability, temper tantrums, crying fits
- Oppositional behaviour
- Regression (skills, behaviour)
- School refusal
- Sleep difficulties, nightmares
How can parents influence the way in which anxiety manifests in their children?
- Attachment
- Modelling – social learning theory, co-regulation
- Accommodation
- Parenting style/ fit
- Positive reinforcement
Severe GAD. Name 3 interventions to help with exam-taking.
Name 2 interventions to help with anxiety overall?
- Consider :
- Study plan
- Calm, quiet environment. Noise-blocking headphones. Separate space/ room to write the exam.
- Cognitive restructuring
- Tutor
- More time to complete the exam.
- Body breaks
- Desensitization – “worst care scenario”
- Consider :
- SMART goals - Specific, Measurable, Achievable, Relevant, and Time-Bound
- Relaxation/ mindfulness
- Cognitive restructuring/ CBT
- Healthy lifestyle including sleep hygiene, diet, recreation
Name 4 criteria of selective mutism.
- Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g. - at school) despite speaking in other situations.
- The disturbance interferes with educational or occupational achievement or with social communication.
- The duration of the disturbance is at least 1 month (cannot be during first month of school).
- The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
- The disturbance is not better explained by a communication disorder (e.g. - childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.
What is the best treatment of selective mutism?
Behavioral therapy.
2 phases –
1) Positive/ negative reinforcement, contingency management, parent management training;
2) Gradual exposure (desensitization, social skills training, positive reinforcement) and treat comorbidities.
Identify 2 sleep hygiene recommendations for a kid with separation anxiety disorder
a) Nightlight (because of anxiety/ fear; otherwise for sleep hygiene – cool/ dark room)
b) Comfort/ transition item (ex: stuffy)
c) Bedtime routine including avoidance of screens/ triggers
d) Relaxation techniques, storytelling/ visualization, positive self-talk
e) Extinction procedure re: parents
f) Do not co-sleep with parents
Child with Social Anxiety Disorder. Name 3 child factors around etiology. Name 2 parental factors.
- Child Factors*
- Temperament (behavioural inhibition)*
- Stressful or humiliating experience; bullying*
- Childhood abuse and adversity*
- Parent Factors*
- Genetics (first deg relatives 2-6x odds)*
- Parenting style (accommodating, harsh punishment, authoritarian)*
- Vicarious conditioning (anxiety thru observation)*
- <>*
Child with Social Anxiety Disorder. Name 3 child factors around etiology. Name 2 parental factors. Name 2 evidence based treatments.
- Evidence based treatments:*
- Psychological: CBT, Social Effectiveness Therapy*
- Pharmacological: SSRIs (Fluoxetine, Sertraline+CBT, Venlafaxine)*
- Evidence-based treatment for social anxiety disorder combines social skills training and behavioral therapy in group and individual sessions. Included lessons on initiating and maintaining conversation, joining groups of peers, nonverbal skills like eye contact and “peer generalization” of the skills (Lewis)*
What is the difference between anxiety in a child vs. adolescent?
- differences in sources of anxiety= for example, for adolescents, one of the main themes of anxiety is related to rejection from peers, whereas in the younger population, themes of anxiety may be more likely related to fear of separation from parents, fear of death
- Expression of anxiety: children are more likely to express anxiety symptoms as somatic complaints, have tantrums/crying/freezing/clinging as compared to adolescents
- younger children are more likely to experience separation anxiety vs adolescents, who are more likely to experience SAD
Child with separation anxiety. Name 2 etiological factors.
- parental overprotection and intrusiveness
- heritability/family history
- major life stressors (death of a family member, parental divorce)
- modelling from parents/family
- innate temperament
Child with Social Anxiety Disorder. Name 3 child factors around etiology. Name 2 parental factors. Name 2 evidence based treatments.
What should be done in a pre-clozapine workup?
- PMHx and physical exam
- CBC with differential with particular attention to the WRC and neutrophil count
- treatment should not be initiated if the WBC count is less than 3.5x109/L and/or the absolute neutrophil count (ANC) is less than 2.0x109/L, or if the patient has a history of a myeloproliferative disorder, or toxic or idiosyncratic agranulocytosis or severe granulocytopenia
- Fasting Blood Glucose – baseline, repeat at week 12, then repeat annually
- Fasting lipid profile – baseline, repeat at week 12, then repeat at least q5years or more frequently
- Serum C-reactive protein – baseline, day 7, day 14, day 21, day 28
- Troponin levels - baseline, day 7, day 14, day 21, day 28
- Serum potassium & magnesium levels – baseline; periodically during treatment
- ECG – baseline
- Echocardiogram – baseline
- BP & HR – baseline, and then pre- and post-dose during initial number of doses
- All vital signs – baseline and then q2days x first 28 days
- Weight and BMI – baseline, week 4, week 8, week 12 and then quarterly
- Waist circumference – baseline and then annually
- EEG - baseline
What is the overall process of starting clozapine?
- Consent, including sharing info with Gencan
- Pre treatment assessment
- Send registration forms to Gencan
- Start dose 12.5 mg once or twice/ day. For day one and day two of treatment orthostatic blood pressure (sitting and standing) should be taken 6-8 hours post dose
- Monitor for fever at day 1 and 2 of tx
What should you do if a patient missed their clozapine dose?
- If Clozapine treatment stops for
48 hours it is recommended that the patient’s dose return to 12.5 mg and be re-titrated. The blood monitoring frequency may remain the same - If Clozapine treatment is interrupted for more than 72 hours but less than 1 month it is recommended that the patient’s dose return to 12.5 mg and is re-titrated. It is recommended the blood monitoring frequency return to weekly for 6 weeks.
- If Clozapine treatment is interrupted for more than 1 month the patient should be treated as a new start
Compare and contrast IPT and CBT
CBT: structured and time limited therapy focused on symptoms premise that depression maintained by maladaptive behaviours and inaccurate thoughts and beliefs about self, others and future influenced by depression. Ix try to work through thoughts and evaluate accuracy negative thoughts and beliefs. Behaviours to increase pleasure.
IPT: time limited therapy based on premise that our relational stressors including loss, change, transition, disagreement or sensitivity associated w/ onset or perpetuation of sx.
Similar/diff: both time limited, structured therapies focused on present and symptoms at this time. IPT has 4 specific focuses and looks through a relational lens while CBT focuses on core beliefs and negative inaccurate thoughts. More structured with homework and can be administered via telephone of internet. Scales to monitor progression. All sessions start with setting agenda. 3 phases of IPT. 12-16 sessions. Therapist directive. IPT- psychodynamic origin versus CBT.
What are the 4 areas of focus in IPT?
Grief
Role Dispute
Role Transition
Interpersonal Defiicts
What is the process of starting IPT with a patient?
- Focal area: Role transition (grief, role transition, IP sens, role dispute).
- Start sessions with IP inventory,
- develop rapport,
- explain therapy,
- assign sick role and choose focus.
- Intermediate: work on comm analysis and bring back to focus area. What she has gained/loss with transition.
- Termination: emphasize progress (scales) and work on relapse prevention, problem solving. If not successful blame therapy not pt.
Eating disorder patient. What tests would you order as an initial workup?
- CBC, lytes, CAMP, albumin, LFTS, Cr, Urea
- ECG
What are psychological therapies for bulimia, in adults and adolescents?
Adults
- CBT Modified for BN (most evidence)
- IPT (as effective as CBT, but slower)
- DBT (case reports)
Adolescents
- Family Based Therapy (superior to supportive and CBT)
- CBT for BN (not as effective as FBT)
Man with ETOH dependence. Quits x 2 weeks then relapses with significant drinking (26oz/day x 1week). Motivated for abstinence. How do you treat?
- Naltrexone 50 mg + relapse prevention techniques
- Dilsulfram and motivational interviewing
- Acamprosate + group addictions therapy
Naltrexone 50 mg + relapse prevention techniques
What is the most common comorbidity with ASD?
Intellectual Disability
Kid with night terrors, what on the EEG?
- Slow waves
- Sleep spindles
- Sawtooth waves
- Alpha waves
Slow Waves
What are criteria for fitness to stand trial?
Candidate will review that to be found unfit to stand trial the patient must be unable on account of a mental disorder (any disease of the mind) to:
(1) understand the nature or object of the proceedings,
(2) understand the possible consequences of the proceedings, or
(3) communicate with counsel.
The exceptional candidate will know that this is from Section 2 of the Canadian Criminal Code, and the governing case law is R v Taylor, 1992.
What are the consequences if someone is found unfit to stand trial?
The court can handle an unfit accused in 2 ways:
- He could have been remanded directly to the provincial review board (waits in jail or hospital until review board)
OR
- A treatment order could have been obtained if the court had evidence that (a) he was suffering from a mental disorder AND that treatment with a psychotropic medication was likely to render the accused fit to stand trial in a period of 60 days maximum, (b) that without treatment the accused was likely to remain unfit, and (c) the risk of harm from the administration of medication was not disproportionate to the anticipated benefits of the treatment.
What does NCR mean?
- “Not Criminally Responsible”.
- In Canada no person is criminally responsible for an act committed or an omission made while suffering from a mental disorder that rendered the person incapable of appreciating the nature and quality of the act or omission or of knowing it was wrong.
This is from Section 16 of the Canadian Criminal Code.
What are mandatory exceptions to confidentiality?
- Child Abuse
- Driving
- Gunshot
- Health card fraud
- Sexual misconduct (ex by a regulated health professional)
- Railway safety (ex train conductor)
- Aeronautics safety (ex pilot or air traffic controller)
- Court order
What is duty to warn and when does it exist?
- Supreme Court of Canada has held that a physician was permitted to warn police when aware of the serious, imminent danger posed by a patient to an identifiable group against whom the patient had made specific threats
- A duty exists where there is
- (1) a risk to a clearly identifiable person or group of persons
- (2) the risk of harm includes severe bodily injury, death or serious psychological harm,
- (3) element of imminence and sense of urgency.
- A duty exists where there is
What are steps to take if a patient is not capable of consenting to treatment?
- If the patient is not capable, they need to be informed of the finding of incapacity and that a substitute decision maker (SDM) will be sought.
- The patient is informed that they have the right to challenge this decision if they do not agree. The finding and reasoning behind it must be documented.
- A Form 33 is filled out and given to psychiatric inpatients in Ontario.
- An SDM has to be over 16 and capable to make the decision and willing to take the role. The approved (hierarchical) list legislated in Ontario by the HCCA is:
- Anyone appointed by the court or CCB
- Power of Attorney if it exists
- Spouse/Partner
- Child/Parent
- Parent with right of access
- Sibling
- Any other relative
What is the difference between schizophrenia, schizoaffective disorder, depression?
- Schizophrenia:
- Primary symptoms are psychosis (delusions, hallucinations, disorganized thoughts, disorganized / catatonic behaviour, negative symptoms)
- No major depressive or manic episodes occur concurrently with active phase symptoms for a prolonged duration of the illness.
- If mood episodes (depressive or manic) have occurred during active phase symptoms, they have been present for a minority of the total duration of the active and residual phases of the illness.
- Schizoaffective Disorder:
- Characterized by a combination of symptoms of schizophrenia, and symptoms of a mood disorder, such as mania and/or depression.
- There must be an uninterrupted period during which there is a major mood episode (manic of depressive), occurring at the same time that symptoms of schizophrenia are present.
- The symptoms meeting criteria for a major mood episode must be present for the majority of the duration of illness
- BUT there must be psychotic symptoms (delusions or hallucinations) for at least two weeks in the absence of a major mood episode, during the course of illness
- Major Depressive Disorder:
- Primary symptoms are those required for diagnosis of depression:
- five or more symptoms during the same 2-week period, at least one of which is depressed mood or loss of interest or pleasure. (Depressed mood; Anhedonia; Reduced appetite or weight loss; Slowed thoughts or movements; Reduced energy; Feelings of worthlessness or guilt; Reduced concentration; Recurrent thoughts of death or suicidal ideation)
- If there are psychotic symptoms, these resolve as depression improves (often first Sx to improve) and do not persist after depression resolves
What is prevalence of ASD?
1 in 100
ASD, ratio of boys: girls?
4:1
What percentage of children with ASD have intellectual disabilities?
25%
Possible side effects of guanfacine?
Nasuea/Vomiting
Bradycardia
Sedation
Hypotension
In a patient who has failed two antipsychotic trials, what are your next steps?
Confirm compliance
Rule out substance use
Start clozapine
(best if olanzapine was one of meds tried)
Contraindications to family therapy?
- Major mental illness, where stirring up affect may lead to decompensation of their illness
- Violence in family
- Inflexible in considering there may be a problem in family
- Therapy counter to family belief systems
- Key members in family don’t participate
- Where FT is not first line treatment; eg. Detoxing or treating a psychosis
What is the treatment for akathisia?
Propranolol = first line
Benztropine = second line
Benzos = non-responders
In ASD, what is most impaired part of language?
Pragmatic language
What is the rate of inheritance of bipolar disorder in MZ twins? (note = same as having two first degre relatives with BAD)
45-75%
What findings in bipolar MRI?
Ventricular enlargement
Reduced voume of corpus callosum
Increased periventricular white matter changes
What are the contraindications to Naltrexone?
Pregnant
Using Opioids
LFTs 3x upper limit normal or cirrhosis
(needs FU liver enzymes after 3 weeks)
Primary Treatment of ODD?
Family Intervention - reinforce more prosocial behaviors and to diminish undesired behaviors at the same time (form of CBT)
Individual Play therapy - sometimes benefit
PTSD FInding on functional imaging
Amygdala Hyperactivity
Glucocorticoids increase the risk of which neuropsychiatric phenomena?
SI (7x)
Depression
mania
delirium
confusion
disorientation
Retionoin can cause
Depression
Suicide risk (case reports)
Psychosis
AN, not eating for 6 weeks, in hospital now. Started an IV of saline/dextrose. What do you worry about?
- Hypophosphatemia
- Hypomagnesemia
- Hypokalemia
- Hyponatremia
Hypophosphatemia (most concerning aspect of refeeding syndrome)
Also:
- Hypokalemia
- Congestive heart failure
- Peripheral edema
- Rhabdomyolysis
- Seizures
- Hemolysis
What is first step for child with freqent night terrors?
When to do sleep study?
Reassure they will improve with time
- indications for nocturnal polysomnography (PSG) include
- •Habitual snoring, observed apneas, nocturnal enuresis, or other symptoms suggesting OSA.
- •Significant safety concerns, excessive disruption of the family members’ sleep, or contemplation of pharmacotherapy.
- •Atypical features that raise concern for nocturnal seizures, such as daytime neurologic symptoms, older age group, family history of seizures, and multiple occurrences on a single night
Young female with binge eating disorder. What would be the best treatment long-term?
- CBT, IPT, DBT
- Imipramine, sertraline, citalopram, topiramate (Grade a evidence)
- Vyvanse approved for moderate to severe BED
What is the most common comorbidity with gender dysphoria?
Adults
- depression
- anxiety disorders
- suicidality and self-harming behaviors
- substance abuse.
Children
- depressive disorders
- anxiety disorders
- impulse-control disorders.
. 6 year old presents with mother. Since infancy, 18 months, has had repetitive, purposeless movements, which involve arm shaking and rotating neck/arms(?). Constant severity. Sometimes seems to enjoy movements. Can be stopped with distraction. Now bullied. What’s the diagnosis?
- Tourette’s
- Pure motor tic disorder
- Stereotypic movement disorder
- Developmental coordination disorder
Stereotypic movement disorder
*Note
- Stereotypic movement disorder - Repetitive, seemingly driven, and apparently purposeless motor behavior (e.g., hand shaking or waving, body rocking, head banging, self-biting, hitting own body).Interferes, occurs in early developmental period
- DCD - motor skills far below what is expected for developmental age
In what conditions does IPT have best evidence?
- Depression (acute, recurrent, maintenance, subsyndromal, geriatric, adolescent, HIV+, postpartum, antepartum)
- Adjunctive Tx in BAD
- Bulimia
- Initial/limited evidence in
- Dysthymic disorder
- Social phobia
- PTSD
What is your approach to management of serotonin syndrome?
- Stop offending agent
- Admit to ICU
- Provide supportive care - airway, fever, fluids
- Involve CL psych early
- Possibly use cyproheptadine (5HT2a-blocker) or benzos
Man with anticholinergic toxicity from OTC sleep aids. What is treatment?
a) Phyostigmine
b) Cyproheptadine
c) flumazenil
Phyostigmine
How to tell between NMS and anticholinergic?
a) hyperthermia
b) tachycardia
c) diaphoresis
diaphoresis
Patient develops first episode psychosis. Good prognostic factor?
a) young onset
b) family history affective disorder
family history affective disorder
What are the McGarry Criteria for Fitness to Stand Trial?
Patient must be able to understand
- Understand harges & potential consequences
- Understand and enage in Trial process
- Capacity to participate with an attorney in a defense
- Potential for courtroom participation
What is true regarding children and adult dosage?
a) Children have lower body water volume so lower doses
b) Children require higher by weight doses than adults
Children require higher by weight doses than adults
- ASD – risk factor – which IS?
- Advance parental age
- Prematurity before 34 weeks
- Vaccinations
Advance parental age
Prenatal Factors
- advanced maternal and paternal age at birth
- maternal gestational bleeding
- gestational diabetes
- first-born baby
Perinatal Risk Factors
- umbilical cord cx
- birth trauma
- fetal distress
- SGA
- low birth weight
- low 5 min apgar score
- congenital malformation
- ABO/Rh blood factor incompatibility
- hyperbilirubinemia
What are general principles of IPT?
- Focus on the interpersonal relationships and how this relates to the onset/maintenance of the depression
- Based on the biopsychosocial model
- Aim is to alleviate suffering and improve interpersonal functioning
- May also help to improve the patient’s social network so they are better able to manage their interpersonal distress
- Affective expression encouraged (especially emotions related to mourning or loss of social roles)
- Time limited (usually between 12-16 sessions)
- Dynamically informed therapy but the focus is here-and-now and the interventions used do not directly address the patient-therapist relationship
What are basic principles of CBT?
- CBT is based on the cognitive model of mental illness, initially developed by Beck (1964).
- People’s emotions and behaviours are influenced by their perceptions of events.
- How people feel is determined by the way in which they interpret situations rather than by the situations per se.
- Three levels of cognition:
- Core beliefs
- Dysfunctional assumptions
- Negative automatic thoughts
Why does TD occur?
- Antipsychotic drug treatment can cause tardive dyskinesia, it can also mask/suppress tardive dyskinesia
- Antipsychotic withdrawal or dosage reduction can unmask tardive dyskinesia; and thus, tardive dyskinesia can appear to worsen after dosage reduction or discontinuation of the perceived offending agent.
- Although use of first generation antipsychotics are associated with a higher risk of tardive dyskinesia, second generation antipsychotics are not free from risk of tardive dyskinesia
What is the risk for getting TD with a FGA vs a SGA?
- Reports of risk vary
- 5% yearly incidence for tardive dyskinesia on first generation antipsychotics compared to a 1% incidence on a second generation antipsychotic.
- There is currently insufficient data to determine differences in risk between different second generation antipsychotic drugs.
- clozapine carries the lowest risk for tardive dyskinesia.
What are risk factors for TD?
- The most clearly established risk factor for tardive dyskinesia is age. Although figures vary, in patients over 65, the risk of TD is at least double – and in some studies up to 5X as high – as compared with a younger population.
- Other risk factors include:
- duration of antipsychotic treatment
- previous head injury
- mood disorder
- possibly female gender
- possibly dose
- possibly early presence of significant EPS.
- Iron deficiency can be a risk factor for exacerbation of movement disorders
What are signs and symptoms of TD?
- Beyond lips, tongue and jaw, one needs to assess the face for grimacing movements and abnormal eye blinking.
- Choreoathetoid movements in fingers, wrists, ankles and toes
- Rocking or torsion movements of neck and/or trunk.
- Diaphragmatic involvement, which may result in grunting or non-rhythmic breathing.
- Other late-onset movement disorders associated with chronic antipsychotic treatment, including tardive dystonias and tardive akathisia.
How can TD be treated?
- There is no good evidence for any specific drug treatment for tardive dyskinesia.
- TD may gradually improve over time (months or years) if the offending agent is withdrawn.
- Can switch patient to an antipsychotic medication with less propensity to cause TD.
- The data is strongest for clozapine as it appears to have the lowest risk for TD.
- Switching from an older generation antipsychotic to another second generation atypical antipsychotic may also be helpful.
Are there different implications for the use of a drug for an off-label compared to an indicated use? For the prescriber? For the patient?
- In off-label use of a drug, one needs to inform the patient that the drug is not approved for the purpose for which you intend to prescribe it. One would also provide information on the benefits and risks in the same manner as would for an approved drug. For a non- approved use however, there may be less good information on risks and benefits.
- Additional caution and judgment is required when prescribing a drug for a non-indicated use. The physician must distinguish between off-label use where safety and efficacy is reasonably well-established versus off-label use based on anecdotal reports, open label studies, a single small RCTs, poorly designed studies, etc.
What are scales that can be used to assess abnormal movements?
AIMS - TD
Simpson Angus Scale - EPS
Barnes Akathisia Scale - Akathisia
What is DBT?
- Dialectical behavior therapy (DBT) is the psychosocial treatment that has received the most empirical support for patients with borderline personality disorder
- Method is eclectic, drawing on concepts derived from supportive, cognitive, and behavioral therapies.
- 4 primary modes of treatment in DBT: group skill training, individual therapy, phone consultation, and consultation team.
- Seen weekly, with the goal of improving interpersonal skills and decreasing self-destructive behavior.
- Patients with BPD receive help in dealing with the ambivalent feelings that are characteristic of the disorder
- DBT assumes all behavior (including thoughts and feelings) is learned and that patients with borderline personality disorder behave in ways that reinforce or even reward their behavior, regardless of how maladaptive it is
What are the three basic approaches to a benzo taper?
- use the same medication for tapering
- switch to a longer-acting equivalent
- use adjunctive medications to help mitigate potential withdrawal symptoms.
- Initial reduction of 25-30% for high dosage chronic users, followed by a 5-10% daily to weekly reduced dose.
What is main difference between Reactive Attachment Disorder and Disinhibited Social Engagement Disorder?
- RAD = A) The child rarely or minimally seeks comfort when distressed.
AND/OR responds to comfort when distressed. WITH persistent emotional disturbance
* Before Age 5 * DSED = A)
Reduced or absent reticence in approaching and interacting with unfamiliar adults.
Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
Willingness to go off with an unfamiliar adult with minimal or no hesitation
- Both
- The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).
* Must be 9 months of age
- Most characteristic of amphetamine use disorder ?
- Paranoid delusions
- Visual hallucinations
- Loosening of associations
- Thought Disorder
Paranoid delusions
(somatic delusions also very common)
- Female with history of one prior depressive episode that responded well to meds. Now looks manic, thought she could fly and talk to God. Up for five nights. What is a good prognostic factor:**REPEAT
- Previous good response to antidepressants
- Female gender
- Psychotic features
- Insomnia less than 7 days
Female gender
Poor Prognostic Factors in BAD
- older age
- male
- psychosis
- mixed episodes
- substance use
- younger onset
- rapid cycling
Which is NOT true about how structural family therapy would define a healthy family?
- Absence of alliances crossing intergenerational boundaries
- Subsystems
- Boundaries
- Derouting conflict through a child
Derouting conflict through a child
What are symptoms and signs of anorexia?
- food restriction
- excessive exercises
- preoccupied with food, eating, calories
- social isolation
- mood irritability, depression, obsessive compulsive behaviour
- cold intolerance
- lanugo hair
- hair loss
- poor sleep (early am waking)
- dizziness, fainting
- GI symtpoms
What is the DSM 5 Criteria for Stimulant Intoxication?
DSM 5 criteria for Stimulant Intoxication:
Two (or more) of the following signs or symptoms, developing during, or shortly after, stimulant use:
- Tachycardia or bradycardia.
- Pupillary dilation.
- Elevated or lowered blood pressure.
- Perspiration or chills.
- Nausea or vomiting.
- Evidence of weight loss.
- Psychomotor agitation or retardation.
- Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias.
- Confusion, seizures, dyskinesias, dystonias, or coma.
Buprenorphine mechanism of action?
a) Opioid antagonist
b) Opioid full agonist
c) Opioid partial agonist
d) Opioid partial antagonist
Opioid partial agonist
at MU receptor
Which of the following is NOT a risk factor for rapid cycling?
a) hypothyroid
b) antidepressant use
c) substance use
d) male gender
male gender
Rapid Cycling RF
- Younger, onset <17
- Women > men (70%)
- Hypothyroidism *** NOT hyperthyroid
- SSRIs
What best describes the neurobiological basis of relapse?
a) exposure to/use of low doses of substance results in lower than expected dopamine response
b) substance cues to use lead to glutamate mediated activation
c) GABA increases in withdrawal
substance cues to use lead to glutamate mediated activation
Treatment of Lithium induced tremor:
a. propanolol
b. lorazepam
c. cogentin
propanolol
12 yo kid with behavioural problems, meets criteria for ODD. Parents don’t want meds. What best therapy?
- Play therapy
- Psychodynamic
- CBT
- IPT
CBT
- Recall
- KS - primary treatment of ODD is family intervention using both direct training of the parents in child management skills and careful assessment of family interactions.
- The goals of this intervention are to reinforce more prosocial behaviors and to diminish undesired behaviors at the same time
- CBT - teach parents how to alter their behavior to discourage the child’s oppositional behavior by diminishing attention to it, and encourage appropriate therapy focuses on selectively reinforcing and praising appropriate behavior and ignoring or not reinforcing undesired behavior
A child has DMDD. What is not true about DMDD?
- Key is that irritability is non-episodic
- Predictive of BAD in later life
- More predictive of unipolar depression
- Episodic irritability more associated with BAD in later life
Predictive of BAD in later life
What is the normal target for clozapine treatment?
- 250-300ng/L normal target OR 1000-2500nmol/L
- 50 – 150 =low
- 200 – 300 good initial target
- 350 – 400 could be tried if response insufficient
What are the main modalities of psychotherapy in PTSD?
CBT is an effective first line option (TF-CBT, EMDR, PE, and stress management therapy)
Teenager with panic disorder and CBT – she is against medication. What would you tell them about psychotherapy?
a) Medication is first-line for her disorder
b) CBT is equally effective as medication and CBT combination
c) CBT alone has more dropouts than medications alone
d) No psychotherapy has shown benefits in panic disorder
CBT is equally effective as medication and CBT combination
ADHD. What are evidence-based parental interventions to target oppositional/ disruptive
behaviours in ADHD?
As per the CADDRA Guidelines, Parent Training interventions such as Incredible Years, Triple P Parenting, and Parent-Child Interaction Therapy are evidence-based interventions to target oppositional and disruptive behaviours in ADHD. The central principles are:
- Consistently reinforcing positive behaviours
- Ignoring low-level provocative behaviours
- Providing clear, consistent, safe responses to unacceptable behaviours
What are harmful short-term side effects of cannabis?
Anxiety or panic attack-like symptoms
Impairment in short term memory
Impairment in motor skills
Impairment in attention
Acute/transient psychosis
Toxicity
Impairs concentration and reaction time as well as attention and coordination
Makes it harder to learn and remember things
Affects mood and feelings (anxiety, panic, fear)
Affects mental health (can trigger a psychotic episode)
9 year old boy. Parents getting divorced. Name 5 interventions by parents to help support their child through the divorce.
Effective parenting: warmth and nurturance along with effective discipline and limit-setting
Healthy Parent-Child relationships: characterized by warmth, supportiveness, effective problem-solving skills, positive communication, and low levels of conflict and negativity
Protection from conflict between parents
Cooperative parenting
Household structure and stability
Vignette describing a patient with ASP symptoms.
A) What os this patient’s diagnosis?
B) What PD cannot be diagnosed before the age of 18?
C) Name a PD that can “fade” over time?
D) Name 2 non-pharmacological interventions for the patient in the vignette.
A) CD likely, because <18. Recall, in Cd, symptom clusters are: Aggression
- Destruction of Property*
- Deceitfulness/Theft*
- Serious violation of Rules*
- B) ASPD*
- C) BPD*
- D)* Multimodal treatments - behavioral interventions rewarding prosocial and nonaggressive behaviors, social skills training, family education and therapy, and pharmacologic interventions
- An environmental structure that provides support, along with consistent rules and expected consequences
- A Violence and Aggression prevention plan in school
- Parental Psychiatric Assessment & Intervention if necessary
- Behaviorally based individual psychotherapy targeting problem-solving skills with appropriate rewards
- Group therapy if imobilized/insitutionalized
(You need 3/12 symptoms of make a diagnsois of CD)
Vignette describing an adolescent with Bipolar 1. Name 3 features specific to an adolescent that decrease medication compliance.
Good family functioning
Parents who believe the medical disorder is serious and that the treatment is effective
Having close friends
An internal locus of control
Perceived empathy from one’s clinicianGreater illness severity scores
Medication tolerability (Adverse effects of medications)
Higher sensitivity to metabolic and CV risks on this population
Complicated (>1x daily) dosing schedules
Complex medication regimens
Cognitive Difficulties/ Developmental Stage/ Concrete Thinking
Denial of One’s Illness
Concerns about BAD as part of one’s identity; fitting in with peers
Impaired Family Functioning
Need for monitoring of some medications
Polypharmacy
Time since follow-up
Undertreatment (leading to belief that med is ineffective)
. FAS.
a) Name 1 neuropsychiatric symptom.
b) Name 1 behavioral symptom.
c) Name 2 impacts on adaptive functioning.
d) Name 1 comorbidity.
{a} 1 neuropsychiatric symptom:
motor skills
neuroanatomy/neurophysiology
cognition
language
academic achievement
memory
attention
executive function, including impulse control and hyperactivity
affect regulation
adaptive behaviour
social skills
social communication.
{b} 1 behavioural symptom:
Aggression
Insomnia
Agitation
Anger
Mood Swings
Restless movement
{c} 2 impacts on adaptive functioning:
adaptive skills significantly below cognitive potential
global cognitive or intellectual deficits representing multiple domains of deficit
social skills
social communication.
Documented dysfunction in meeting key adaptive functioning goals – hygiene expected for age, follow safety rules etc
Documented difficulty in social competence as manifested by being financially victimized or unintentionally involved in criminal behaviour due to social gullibility a
{d} 1 comorbidity:
ADHD, tic disorder, learning disorder
a) Define what is a tic.
b) What medication is indicated for treatment of tics?
c) Explain what may influence your decision to treat or not.
- A tic is a sudden, rapid, recurrent, non-rhythmic motor movement or vocalisation (DSM-5).
- Alpha-2 agonists (clonidine and guanfacine); Risperidone; Tetrabenzine
- Tourette Syndrome is often mild and therefore no treatment is required. In general terms, one needs to initiate treatment when the symptoms are distressing and/or when symptoms interfere with function
Majority of patients symptoms improve substantially by the end of adolescence, providing a clear diagnosis and information about etiology, prognosis and treatment options is reassuring and may be the only intervention required.
When treatment is necessary one should select an effective treatment with the least likelihood of inducing adverse effects following the appropriate evidence based treatment guidelines.
Social anxiety disorder. Name 5 symptoms in children that are not part of DSM5 Dx/criteria.
anxiety must occur in peer settings, and not just during interactions with adults.
may be expressed by
crying,
tantrums,
freezing,
clinging,
shrinking
failing to speak in social situations
Prodrome [(schizophrenia]. Name 5 risk factors for early-onset schizophrenia. Name 4
treatment/ intervention approaches for early-onset schizophrenia.
Risk Factors for Early Onset
- paternal age
- in utero exposure to maternal malnutrition or infectious agents
- cannabis use during adolescence
- Immigration
- Family history of psychiatric conditions in first degree relatives
- Place of Birth (urbanicity)
- Season of birth
- Pre-natal and Peri-natal Risk Factors
- complications of pregnancy (bleeding, diabetes, pre-eclampsia)
- abnormal intrauterine development (low birth weight, congenital malformations, reduced head circumference)
- complications of delivery (**hypoxia, uterine atony, asphyxia, emergency Caesarean section)
- Also, APSS, BIPS & Genetic Risk & Deterioration (GRD)
Early Intervention Approaches (Canadian Schz Guidelines)
- Urgently refer to specialized mental health/early psychosis clinic
- Offer antipsychotic medication in conjunction with psychological/psychosocial interventions (once dx confirmed)
- Discuss use of cannabis and substances
- Clinicians should work in partnership with parents or carers, as well as children and young people with schizophrenia, while taking into consideration their developmental level, emotional maturity and cognitive capacity. (Family-based, psychoeducation, communication, problem-solving)
- Encourage parents to seek their own support
- Offer CBT to assist in promoting recover
- Offer employment programs to young people with schizophrenia who wish to find or return to work
- Consider supported education programs
- Clinicians should give children and young people with schizophrenia, and their parents or carers, information regarding psychosis or schizophrenia
- Cognitive remediation therapy may be considered for young individuals diagnosed with schizophrenia who have persisting problems associated with cognitive difficulties
Girl with BPD. Comes home one day and not acting like herself - confused, talkative,
aggressive and disorganized. Name 5 possible medical causes to consider.
- Drugs
- Medication overdose (intentional or accidental) - sympathomimetic, serotonin syndrome, sedative-hypnotic (?), hallucinogenic, anticholinergic
- Intoxication – alcohol, Hallucinogen, stimulant, sedative-, hypnotic- or anxiolytic-
- Withdrawal – cannabis, alcohol, stimulant, sedative-, hypnotic- or anxiolytic-
- Infectious/Inflammatory
- Sepsis
- CNS infection such as meningitis
- Pneumonia
- Urinary/STI
- Encephalitis (eg anti-NMDA)
- Metabolic/Endocrine
- DKA/hypoglycemia
- Thyrotoxicosis
- Structural
- brain injury, subdural hematoma, post-ictal, stroke, tumour, brain mets
Mindfulness. Define mindfulness. Differentiate mindfulness and meditation/ relaxation.
Differentiate between mindfulness and CBT.
- Definition: Mindfulness (or MBSR) practices focus on paying sustained attention to moment-to-moment stimuli without engaging in cognitive judgments or self-criticism, and promoting an attitude of acceptance. (KS 31.18)
- Mindfulness vs Relaxation/Meditation: mindfulness practices teach acceptance of present moment internal events, while relaxation practices teach strategies to change internal events. (Eg. Body Scan/Breath Awareness/Sitting meditation vs. Progressive Muscle Relaxation/Deep Breathing/guided imagery)
- Differences in intention generally come down to accepting internal events (mindfulness) and changing internal events (relaxation). [i]
- Classical CBT focused on focused on directly changing individuals’ thoughts, emotions, physical sensations, and behaviors using strategies such as cognitive restructuring, behavioral experiments, and relaxation techniques
- Classical/traditional CBT mphasized relaxation practices as a way to change uncomfortable internal experience
- Third-wave CBT interventions emphasize mindfulness practices over relaxation practices to help patients develop open, nonjudgmental, and nonreactive relationships to internal experiences.
- Core components of mindfulness in third-wave CBT include present moment awareness, attention regulation, and a nonjudgmental attitude
- Examples of Third-Wave CBT interventions include: Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), and Acceptance-Based Behavior Therapy (ABBT)
What are pros/cons/barriers of school-based interventions?
Pros:
Increased access and reach
Support prevention and early intervention
Fewer barriers to care
Reduce stigma
Cons:
Generally no parent or caregiver involvement
May not reach children with school avoidance
Barriers:
Lack of trained personnnel
Resource and financial limitations including competing demands on educator and school personnel time
Generally less evidence base than clinic-based interventions
