K&S SAQ Flashcards
What are the elements of capacity for treatment decisions?
a. The person understands he suffers from a mental disorder b. He can appreciate the risks and benefits of treatment c. He understands the treatment alternatives d. He is aware of the potential outcomes of not taking treatment Note: consent involves that the patient understands the information and appreciates that the information applies to them
What are the factors for determining fitness to stand trial? (Bonus: What is this rule called?)
The basic test of fitness to stand trial is called the Taylor Test and states: 1. The patient understands the nature or object of the proceedings 2. The possible outcomes of the proceedings 3. Can communicate with council It uses a balance of probabilities (50% +1) to determine fitness. All individuals are presumed fit until proven otherwise. (Bonus: Section 2 of the criminal code)
How would you assess fitness to stand trial? (Give the specific questions)?
The patient must understand: a. The charge against him b. The pleas available (guilty or not guilty) c. The possible consequences of the a guilty finding d. The roles of the various officers in the court (what is the role of the Crown, the Defense, the judge) e. Must be able to communicate with council (not too agitated or delusional) f. The meaning of taking an oath g. The breach of such an oath
What are 2 outcomes of an individual “unfit to stand trial”? Explain the criteria for the order that is an outcome.
a. Remanded to the provincial review board b. Given a treatment order Criteria for the Treatment Order involves medical evidence that: i. The accused is suffering from a mental disorder or disease of mind and the treatment with a psychotropic medication is likely to render the accused fit to stand trial in a period not exceeding 60 days. ii. Without treatment, the accused will likely remain unfit iii. The risk of harm from giving the medication is not disproportionate to the anticipated benefits derived from such treatment (no ECT or psychosurgery)
- Describe McGarry’s criteria for fitness
a. Understand the nature and objectives of the proceedings i. Role of court personnel ii. The charges iii. Basics of court procedure iv. Ability to challenge witness b. Understand possible consequences of proceedings i. Possible penalties ii. Likely outcomes iii. Consequences of unmanageable behaviour iv. Possible legal defenses c. Communicate with counsel i. Relate to attorney ii. Communicate relevant facts iii. Testify coherently iv. No self defeating motivation Note: This is the same as regular fitness criteria, just a bit more specific.
What are the criteria for Not Criminally Responsible (NCR)?
This is called the McNaughton Rule. It states that “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 knowing that it was wrong. Bonus – This is under section 16 of the Criminal Code. (Example: Nature & quality – think stabbing someone is releasing demons and save them; Wrong – paranoid and think need to kill parent to save self from aliens)
What are 3 dispositions once someone is found NCR?
Three dispositions are: a. Detention order (under the ORB) b. Conditional discharge c. Absolute discharge
Briefly describe psychopathy and how you would measure it?
Psychopathy involves two dimensions, mainly affective or interpersonal features and antisocial or criminal behaviours. It occurs in 1% of the general population. It is measure using the Hare Psychopathy Checklist, which has 20 items. Scores of 30 meet criteria for psychopathy. (Bonus: Examples from PCL-R – glibness, grandiose self-worth, pathological lying, lack empathy, impulsive, juvenile delinquency)
Describe the relationship between psychosis and violence?
The relationship is not conclusive but psychosis and schizophrenia may be associated with an increased risk of violence. Among patients with delusions, 25-40% of patients with violence will be motivated by delusions. Command hallucinations may also increase the risk of violence but this is not conclusive as well.
What are some predictors for violence?
There are static and dynamic risk factors for predicting violence. Some static risk factors are: 1. Male gender 2. Age 18-25 years 3. Previous violent acts 4. Psychopathy 5. Younger age of violence 6. Childhood factors (separated from parents before 16 years, elementary school maladjustment/trouble) 7. Low IQ 8. Never married Some Dynamic factors are: 1. Current substance use 2. Current agitation 3. Supports 4. Access to weapons 5. Stressors 6. Positive attitude towards treatment (this is protective) 7. Insight (is protective) 8. Impulsivity 9. Access to victims
How can you differentiate paraphilias and OCD?
Paraphilias are recurrent, intense sexually arousing fantasies, sexual urges or behaviours involving nonhuman objects, children or other non-consenting persons or suffering or humiliation of oneself or one’s partner. OCD is the presence of recurrent, intrusive thoughts, impulses or wishes that are unwanted and distressing, you try to ignore and realize are a product of one’s own mind or compulsions, which are repetitive behaviours that a person feels driven to perform and are aimed at reducing or preventing a dreaded event. The thoughts in paraphilia are pleasurable and stimulating and are associated with masturbation. In OCD, the obsessions are distressing or ego-dystonic.
What are some treatments for paraphilia?
Some treatments include: a. CBT – mild evidence and treat for 2 years i. Teach responsibility and victim empathy ii. Address cognitive distortions iii. Recognize offence cycle/cognitive behavioural chain iv. Relapse prevention b. Medications i. SSRI’s to decrease libido ii. Medroxyprgoesterone (Provera), cyproterone iii. Gonadotropin releasing hormone agonists – Leuprolide
What are some investigations for pedophilic patients?
a. History of sexual abuse b. Sexual history – age of onset of sexual activity, abnormal sexual function, number of partners (male or female), sexual satisfaction, sex drive (masturbation, prostitutes, etc.) c. Rest of psychiatric history d. Phallometric testing
What are risk factors for recidivism in pedophilia?
a. Multiple victims b. Male victims c. Non-cohabiting victims d. Pre-pubescent victims e. Child porn offenses
What are the criteria for financial competency?
a. Understands the importance of financial competence and the purpose of the examination b. Can appreciate the weaknesses and the strengths in areas of financial competence c. Are aware of their assets and liabilities d. Have shown good judgment in the past and present (including use of resources)
What are risk factors for recidivism in pedophilia?
a. Multiple victims b. Male victims c. Non-cohabiting victims d. Pre-pubescent victims e. Child porn offenses
What are the criteria for financial competency?
a. Understands the importance of financial competence and the purpose of the examination b. Can appreciate the weaknesses and the strengths in areas of financial competence c. Are aware of their assets and liabilities d. Have shown good judgment in the past and present (including use of resources)
What are the criteria for testamentary competency?
a. Know the nature and quality of their property b. Nature of the act they are about to perform c. Know the person who is the object of their bounty and their relation to this person d. Can recall the decision e. Are not impaired by delusion or memory deficits affecting decision
What are the features of negligence?
a. Duty b. Dereliction (of duty) c. Damages d. Direct causation (due to deviation)
When is it acceptable to break doctor-patient confidentiality? Name at least 5.
a. Children at risk or harm (call CAS) b. Harm/threat to others c. Driving concerns d. Occupational hazards - pilots (Aeronautics Act), Merchant seaman, train conductor e. Doctor sexually abusing a patient f. Elder abuse g. Communicable sexual diseases h. Gunshot wounds i. Court ordered assessments
What are the 2 parts to Tarasoff’s law?
Tarasoff 1 established duty to warn – involves warning victim, notifying police. Tarasoff 2 established duty to protect – e.g. hospitalization (should be communicated to patient).
What are the emotional after effects of someone who has been the victim of violent crime?
a. World is an unjust place b. Helplessness c. Feeling Damaged by the crime d. Rage at being a victim e. Inability to trust others or be intimate with others f. Preoccupation with the crime
Rank order the paraphilias in terms of prevalence.
1- Pedophilia 2- Exhibitionism 3- Voyeurism 4- Frotteurism 5- Masochism 6- Transvestic Fetishism 7- Sadism 8- Fetishism 9- Zoophilia
Describe the features of Huntington’s Disease
It is an autosomal dominant neurodegenerative disorder. It has midlife onset, progressive course and presents as a combination of psychiatric, motor and cognitive symptoms. The genetic mutation is a CAG trinucleoside repeat on chromosome 4. It can present early as personality changes and depression and clumsiness or choreiform movements. Late changes include rigidity and dementia.
What are MRI findings in bipolar disorder (source K&S Study Guide)?
a. Enlarged third ventricle b. Decreased cerebellum and temporal lobe volumes
What are MRI findings in schizophrenia (K&S Study Guide)?
a. Unproven – have reduced prefrontal cortex and temporal regions b. Enlarged caudate – may be due to medications more than schizophrenia c. Enlarged ventricles
What are MRI findings in depression (K&S Study Guide)?
a. Smaller volumes in frontal lobes b. Smaller cerebellum c. Smaller caudate and putamen *Ventricular enlargement is not predominantly associated with extensive neuroleptic use
What are MRI findings in alcohol abuse (K&S Study Guide)?
a. Generalized reduction in brain mass (enlarged ventricles) (Can be reversed with abstinence in some cases)
What are hormones secreted by the posterior pituitary?
a. Oxytocin b. ADH
Where does COMT and MAO act?
COMT – cytoplasm of postsynaptic cell and glial cells MAO – presynaptic cleft
What neurotransmitters do MAO-A and MAO-B degrade?
MAO-A – 5-HT and NE, Dopamine, tyramine MAO-B – Dopamine (includes tyramine)
Where are the highest density of cholinergic neurons in the brain?
a. Basal forebrain b. Mesopontine complex
Name 5 second messengers.
a. Cyclic nucleotides – cAMP b. Calcium c. Phosphoinositol metabolites – IP3, DAG d. Eicosanoids – prostglandins, leukotrienes e. Gases – NO f. Jak-Stat Note: G-proteins bind to receptors to cause a state of high affinity for the receptor. They are linked to the second messengers.
List the triad for Balint’s Syndrome
a. Optic ataxia b. Oculomotor apraxia c. Simultanagnosia
Differentiate ideamotor apraxia and ideational apraxia.
Ideamotor apraxia – inability to perform an isolated motor task on command despite comprehension Ideational apraxia – can perform individual components of a sequence but entire series cannot be organized and performed as a whole
What are 4 criteria for a neurotransmitter?
a. The molecule is synthesized in the neuron b. The molecule is present in the presynaptic neuron and is released on depolarization in physiologically significant amounts c. When administered exogenously as a drug, the exogenous molecule mimics the effects of the endogenous neurotransmitter d. A mechanism in the neurons or the synaptic cleft acts to remove or deactivate the neurotransmitter
What are 4 criteria for a neurotransmitter?
a. The molecule is synthesized in the neuron b. The molecule is present in the presynaptic neuron and is released on depolarization in physiologically significant amounts c. When administered exogenously as a drug, the exogenous molecule mimics the effects of the endogenous neurotransmitter d. A mechanism in the neurons or the synaptic cleft acts to remove or deactivate the neurotransmitter
Differentiate an agonist, antagonist, partial agonist and an inverse agonist medication
Agonist – a drug that binds to a specific receptor and produces identical effect to that usually produced by a neurotransmitter affecting that receptor Antagonist – a compound that binds to a receptor that blocks or reduces the action of another substance at the receptor site involved Partial Agonist – a compound, which possesses affinity for a receptor, but elicits a partial pharmacological response at the receptor involved. They are often structural analogues of agonist molecules. If the neurotransmitter is low, partial agonists may act like agonists. Inverse Agonist – an inverse agonist is an agent that binds to the same receptor as an agonist for that receptor and produces opposite pharmacological effect
What is the rate limiting step for serotonin synthesis?
The availability of tryptophan (not trytophan hydroxylase) Note: Tyrosine hydroxylase is the rate-limiting step in dopamine synthesis
Which subtype of the serotonin receptor is responsible for weight gain?
The sub-type is 5HT-2C.
Define median toxic dose.
Median toxic dose is the dose at which 50% of patients experience toxic effects.
List the patient-related factors that affect response to medication and sensitivity to side effects.
The patient related factors are: diagnosis, genetics, past treatment response, response in family members, concurrent medical or psychiatric disorders and lifestyle.
What is remission as per the Hamilton Depression Rating Scale or the MADRS?
Remission on the HAM-D is 7 or less and 10 or less on the MADRS. MADRS rating – Study by Kearns et al. (1982) showed that the following mean scores correlated with corresponding severity: 44 = very severe, 31 = severe, 25 = moderate, 15 = mild, and 7 = recovered
What MAOI has stimulant effects?
Tranylcypromine (Parnate) – avoid use if insomnia, agitation and may exacerbate psychosis
Which beta-blockers have some 5-HT1A antagonist activity?
a. Pindolol b. Propanolol c. Nadolol
What cholinesterase inhibitor acts by inhibiting both acetylcholinesterase and butyrylcholinesterase?
Rivastigmine (Note: Donepezil is only AchE and Galantamine AchE and Nicotinic receptor modulation)
List the doses of 3 agents for acute dystonia and 3 other agents for parkinsonism.
Dystonia a. Benztropine 1-2 mg IV/IM b. Diphenhydramine 50 mg IV/IM or 25-50 mg qid (Max: 400 mg/day) c. Lorazepam 1-2 mg IM [Source: Jeffries] Parkinsonism a. Biperiden (Akineton) 2 mg IM (Max: 6 mg day) b. Procyclidine (Kemadrin) 5 mg tid (Max: 30 mg per day) c. Trihexyphenidyl (Artane) 5-15 mg bid-qid (Max: 30 mg per day) [Source: Jeffries]
Which TCA is least anticholinergic? Least sedating? Least likely to cause orthostatic hypotension? Psychomotor stimulation? EPS?
Least anticholinergic – desipramine (most: amitriptyline, clomipramine, trimipramine) Least sedating – desipramine and protriptyline (most: amitriptyline, doxepin, trimipramine) Least orthostatic hypotension – nortriptyline (can treat this S/E with fludrocortisone 0.05 mg bid) Psychomotor stimulation – desipramine and protriptyline EPS – amoxapine
What is the risk of Stevens-Johnson syndrome in children and adults with lamotrigine?
Adults – 0.1% (prior to dosing guidelines) Children – 1-2%
How do you dose Lamotrigine when combining with: A)Valproate and B) CBZ?
CBZ + LTG: Week 1-2: LTG 50 mg./d, Week 3-4: LTG 100 mg./d; increase by 100 mg every 1-2 weeks (Max:300-500 mg/day) VPA + LTG: Week 1-2: LTG 12.5 mg daily; Week3-4: LTG 25 mg daily; increase by 25-50 mg every 1-2 weeks (Max: 150 mg/day)
What 2 agents are used to treat MAOI hypertensive crisis?
Phentoloamine and chlorpromazine.
Describe the symptoms of an tyramine hypertensive crisis
dBP>120 palpitation occipital headache radiating frontally neck stiffness or soreness N/V Sweating (sometimes with fever) Tachy or brady, possibly with chest pain (from Stahl’s Essential psychopharmacology)
List the 6 Drugs prescribed to the elderly that have high anticholinergic activity as a side effect.
From highest to lowest: #1 Cimetidine #2 Prednisolone #3 Theophyline #4 Digoxin #5 Nifedipine #6 Furosemide #7 Ranitidine #8 Isosorbide Dinitrate #9 Warfarin #10 Dipyridamole #11 Codeine #12 Captopril
List 5 strategies for SSRI-induced sexual dysfunction
- Switch to Buproprion or Mirtazepine (Nefazodone no longer available) 5. Augment a. PDE Inhibitor - Sildenafil in men: 50 to 100 mg 1 -2 h prior to sex (ensure no nitrate therapy or vascular disease)
List 2 TCA’s with the high cardiac conduction abnormalities.
a. Trimipramine (highest)Study Notes 2008 Page 9 of 61 b. Amitriptyline / Clomipramine / Imipramine / Protriptyline (tied for second
List 2 TCA’s with the high anticholinergic effects
(All are relative even and considered highly anticholinergic) a. Amitriptyline b. Clmomipramine c. Trimipramine
List 2 TCA’s that carry a high risk of orthostatic hypotension.
a. Imipramine (highest) b. Amitriptyline / Clomipramine / Trimipramine / Desipramine
What congenital anomalies can be seen with Valproic Acid
- Neural tube defects (1 – 5% increased risk) 2. Craniofacial abnormalities 3. Cardiovascular malformations 4. Limb defects 5. Genital anomalies 6. Hydrocephalus and microcephalus 7. Fingernail hypoplasia
What are 2 medications indicated for severe Alzheimer’s dementia (and briefly list their mechanism of action)?
a. Memantine – NMDA antagonist b. Donepezil – cholinesterase inhibitor
What are 3 medical contraindications to treatment with MAOI’s?
They are: a) CHF, b) pheochromocytoma and c) liver disease
What are 4 interventions if you fail to induce a seizure during ECT?
a. Hyperventilate b. Give caffeine (500-200 mg IV) c. Check medications given previous night to ECT (benzodiazepines, anticonvulsant agents) d. Determine if anaesthetic can be switched (Note: K&S states propofol should be avoided due to its strong anticonvulsant effects, although it is used clinically) e. Switch to Bilateral if RUL being used ?sleep deprivation
What are at least 6 indications for ECT?
a. Treatment-resistant depression b. Treatment-resistant schizophrenia (best if affective component) c. Acute Mania d. MDD with psychotic features e. Catatonia f. Depression during pregnancy g. NMS h. Unable to take medications due to physical illness i. Need for rapid response (i.e. not eating and poor health as a result) j. Parkinson’s disease (on-off phenomenon) k. Acute suicidal ideation (failed medications) l. Treatment refractory OCD
. What are the Canadian clozapine monitoring guidelines (Green, Amber, Red) & what are the corresponding interventions at each level?
GREEN: WBC >3500, ANC >2500 – continue clozapine AMBER: WBC 2000-3500, ANC 1500-2500 – hold clozapine, CBC twice weekly until WBC >3000 or ANC > 1500 RED: WBC <2000, ANC <1500 – discontinue clozapine, daily CBC, watch for signs of infection, protective isolation, consider bone marrow biopsy +/- GSF
Name 5 psychotropic medications that do NOT undergo conjugation and acetylation in the liver
- Lorazepam - Oxazepam - Temazepam - Lithium (renal) - Gabapentin (renal) - Topiramate (unchanged in urine and not extensively metabolized) -Paliperidone
List 3 dosage related side effects associated with carbamazepine
a. Double vision / Blurred vision b. Vertigo c. GI disturbance d. Task performance impairment e. Hematologic effects *Not dose related – aplastic anemia, Stevens-Johnson, hepatic failure, rash, pancreatitis, agranulocytosis
What is 1 side effect more common in oxcarbazepine as compared to CBZ?
Hyponatremia
What is the most sedating typical antipsychotic?
chlorpromazine
What potency typical antipsychotic is more likely to cause seizures?
Low potency (clozapine, olanzapine)
What antipsychotic agents can affect the eye (2 typicals and 1 atypical (theoretically))?
a. Irreversible retinal pigmentation – thioridazine b. Benign pigmentation of the eyes (lenticular deposits) – CPZ c. Quetiapine – cataracts (in beagles)
Which SSRI’s increase warfarin anticoagulant effects?
a. Paroxetine – increases warfarin anticoagulant effect b. Sertraline – displace warfarin from plasma proteins and may increase bleeding times c. Fluvoxamine – increases warfarin levels 2-fold
Outline your management of NMS.
- Supportive Measures – ICU consultation, IV hydration, cooling blankets, oxygentation 2. Dantrolene 1mg.kg/day for 8 days IV then continue PO for 7 days 3. Amantadine PO if necessary 200 to 400 mg PO/day in divided doses 4. Bromocriptine 2.5 mg PO bid or tid up to 45mg/day if necessary 5. Benzodiazepines may work if other meds have failed 6. ECT may work when meds have failed
List 3 of the most common uses for Beta Adrenergic Antagonists in Psychiatric Treatment
- To treat Lithium induced tremor - Treatment of Social Phobia limited to performance anxiety - Treatment of neuroleptic induced akathisia
List 5 Neuropsychiatric Side Effects of Beta Adrenergic Antagonist Treatment
a. Lassitude b. Fatigue c. Dysphoria d. Insomnia e. Vivid nightmares f. Depression (rare) g. Psychosis (very rare)
. List the most Common Side Effects Associated with Valproic Acid.
GI upset Nausea Hair loss Tremor Weight gain Sedation
What are 3 classes of endogenous opioids?
a. Enkephalins b. Endorphins c. Dynorphins
What some pharmokinetic changes observed during pregnancy?
a. Increased plasma volume (up to 50%) b. Decreased albumin concentration (decreased protein bound drug) c. Enhanced GFR (increased elimination) d. Minimal delay in gastric emptying & reduced small intestine motility (due to progesterone) e. Nausea / vomiting early in pregnancy may reduce oral absorption
Define Kernberg’s Borderline Personality Organization
It involves 4 features: a. Manifestations of ego weakness (i.e. cannot modulate affects such as anxiety and lack impulse control) b. Regression to primary process of thinking – e.g. psychotic-like states c. Primitive defenses - Splitting, Primitive idealization, projection and projective identification, omnipotence and devaluation d. Pathological internalized object relations – objects are all good or all bad
Describe Cloninger’s psychobiological model of personality
He states that personality is made up of temperament (50%) and character (50%). Temperaments consist of: 1. Novelty-seeking 2. Harm-avoidance 3. Reward dependence – social attachment, dependence on approval of others 4. Persistence – capacity for perseverance despite frustration Character consists of: 1. Self-directedness – accept responsibility for one’s choice 2. Cooperativeness – object relatedness (e.g. empathy) 3. Self-transcendence – altruistic pursuits, identification beyond the self
Contrast Kohut’s and Kernberg’s view of narcissistic personality disorder.
Kohut: Based on well-functioning outpatients with vulnerable self-esteem Differentiates NPD for borderline personality states Based on internalization of missing functions Sees NPD patient as developmentally arrested Accepts idealization as a normal developmental phase making up for missing psychic structure Empathizes with patient’s feelings as understandable reaction to failure of parents Accepts patient’s comments at face value (avoid confrontation) Looks on positive side mainly Calls attention to patients progress Goal: Help patient to identify and seek out appropriate self-objects Kernberg: Based on mixture of inpatients and outpatients with arrogant and aggressive grandiosity with shyness NPD is a sub-category of borderline personality organization Emphasizes envy and aggression Views the self as highly pathological Sees idealization as “defensive” Helps patient see his own contribution to problem Confronts and interprets resistances Examines both positive and negative aspects of patient’s experience Treatment goal of helping patient develop guilt and to integrate idealization & trust with rage and contempt
What are 3 predictors of response of ASPD on inpatient unit? What is a good predictor of treatment response on inpatient unit for ASPD (1 main point)
Negative predictors: a. History of felony arrest or conviction b. Repeated lying and aliases c. Unresolved legal situation d. Hospitalization forced as an alternative to incarceration e. History of violence towards others f. TBI or organic brain impairment Positive Predictor: Co-morbidity – depression, anxiety or other (excluding TBI, etc)
What are 2 major defense mechanisms for histrionic personality disorder?
Repression and dissociation.
Name the “big 5” dimensions of personality
a. Extroversion / Introversion b. Openness c. Conscientiousness d. Agreeableness e. Neuroticism
List risk factors for PTSD (use the following categories: pre-trauma risk factors, peri-trauma risk factors and post-trauma risk factors)
Pre-trauma risk factors Female gender Past psychiatric history Family psychiatric history Childhood abuse (pre-existing trauma) Peri-trauma factors: Proximity/interpersonal nature of threat With combat – severity of trauma Chronicity Dissociation at time of trauma Perceived helplessness Death potential Post-trauma risk factors: Lack of social support Severity of acute symptoms Lack of early intervention or access to services Perceived shame Poor coping skills or poor perceived control Ongoing life stressors Acute physiological reactivity Meaning of traumatic event
What are neurochemical findings of PTSD?
a. Increased urine catacholamines b. Platelet alpha-2 and lymphocyte beta-adrenergic receptor downregulation c. Increase opioid response to stimuli d. Decreased 5-HT e. Decreased resting glucocorticoid levels f. Decreased GC response to stress and downregulation of GC receptors g. Hyperresonsiveness to DST
Explain the phases of trauma treatment.
Early: Build trust and therapeutic alliance Define therapeutic limits and boundaries Psychoeducation Build safety and supports Develop skills of self-soothing (e.g. progressive relaxation) Middle: Trauma processing, reframing and reintegration Hypnosis may be helpful Validate affect not content Do not assume memory content is true Late: Consolidate therapeutic work and stabilization Existential, identity and attachment issues Master self-sufficiency Move towards long-term goals Termination
What are key features (5 features) essential to exposure therapy for specific phobia?
a. Increased frequent (close proximity) of treatment sessions b. Real exposure (not imaginal exposure) c. No avoidance within session d. Prolonged exposure e. Some therapist involvement
What are poor prognostic indicators for OCD?
A. Yielding to compulsions B. Childhood onset C. Delusional beliefs D. Co-morbid depression E. Co-morbid personality disorder (especially schizotypal) F. Bizarre compulsions G. Need for hospitalization H. Presence of overvalued ideas
What is David Barlow’s cognitive model for panic and agoraphobia?
A. Start with a biological diathesis for anxiety B. Psychological predisposition (early life stressor or parenting style) – thus fails to develop feeling of competence about himself or the world C. False alarm (panic attack) – associated with interoceptive cues (interoceptive conditioning) D. Becomes a Learned alarm (Conditioned panic attacks) E. Causes further arousal and self-focused attention – anxious apprehension (i.e. the possibility of experiencing another panic attack) F. Now autonomic and cognitive symptoms trigger Learned Alarms in an unpredictable manner G. May lead to development of agoraphobic avoidance – no attacks when avoid so have negative reinforcement related to panic attacks
List the components of CBT for the Treatment of PTSD.
a. Educate – about the disorder and treatment, recommend self-help book b. Exposure Confront feared situations, memories, emotions, images Imaginal exposure or writing a trauma narrative In vivo exposure allows confrontation with avoided situations Eliminates safety behaviours c. Cognitive Approaches Identify dysfunctional cognitions Help patient challenge irrational cognitions and replace Reduce hypervigilance by refocusing d. Emotion Regulation Approaches Help with stress reduction skills Relaxation approaches (muscle, breathing, imagery) Refocus attention Practice acceptance based approaches to reduce avoidance of emotions e. Problem Solving Practice overcoming social withdrawal Address any coping through substance use or other unhealthy coping Help them engage in positive activities and goals f. Relapse Prevention Practice preparation for trauma related events that might occur in the future Practice preparation for periods of increased stress reminders
Describe the stages of addictions treatment
a. Detoxification – drug out to be able to work towards treatment b. Concentrated Rehabilitation – learn new skills and how to be sobriety i. Social skills training ii. CBT iii. Assertiveness training c. Supportive Rehabilitation i. Getting lives re-built on an individual basis ii. Reintegrating into society as a sober individual
Describe three models for delivering substance use treatment.
a. Integrated treatment – treat substance use disorder and mental illness together at one site b. Parallel treatment model – treat both mental illness and substance use concurrently but not at same place c. Sequential treatment model – treat the addiction first, then go for psychiatric treatment
What are criteria for inpatient treatment of a patient with alcohol dependence?
Inpatient admission would be indicated in the following scenarios: a. History of withdrawal seizures or delirium tremens b. Documented history of very heavy alcohol use and high tolerance – thus increasing their risk of a complicated withdrawal treatment c. Concurrent abuse of other substances d. Severe comorbid GMC or psychiatric disorder e. Repeated failure to cooperate or benefit from outpatient detoxification Note: Inpatient care should include medical detoxification and a program of rehabilitation.
What are components of integrated treatment?
a. Comprehensiveness b. Co-ordination c. Continuity-long term d. Accessible e. Acceptance f. Optimism and recovery g. Individualized treatment h. Cultural competency
How dose disulfiram work?
It blocks aldehyde dehydrogenase and destroys enzyme for 7 days (takes 7 days to wear off). Note: It also blocks dopamine (so don’t use in SCZ), causes liver problems and may cause depression. Best for the binge drinker who has been sober.
What are the stages of change according to Prochaska and Diclemente?
a. Precontemplation b. Contemplation c. Determination/Preparation d. Action e. Maintenance f. Relapse prevention
What receptors does buprenorphine affect?
a. Partial mu opioid receptor agonist (at low doses) b. Kappa antagonist at high doses
How does acamprosate work for alcohol dependence?
It modulates glutamate-NMDA receptor activity. It reduces craving by dampening the neurological expression of withdrawal that contributes to alcohol craving in the abstinent individual.
What substances are associated with the symptom of formication?
a. Amphetamine intoxication & psychosis b. Cocaine intoxication c. Alcohol withdrawal
When you are presented with a patient with symptoms that may be a part of a primary psychiatric disorder or a substance-induced disorder, what features would suggest that the disorder is better accounted for by a disorder that is not substance-induced?
a. Symptoms precede onset of substance use b. Symptoms persist for a substantial period of time (e.g. greater than 1 month) after cessation of acute withdrawal/intoxication c. Symptoms are in substantial excess of what would be expected for the type, duration or amount of substance used (e.g. Schneiderian symptoms of psychosis) d. Evidence that there exists an independent non-substance-induced disorder (e.g. history of prior episodes NOT RELATED to substance use)
Where are most of the cannabinoid receptors located?
- Basal ganglia 2. Cerebellum 3. Hippocampus Note: Minimal CB receptors in brain stem and cortex. It is a G protein receptor and affects monoamines and GABA
- Describe the sequence of events in smoking cannabis.
- Euphoria within minutes and peaks in 30 minutes, lasting up to 4 hours 2. Cognitive and motor effects last 5-12 hours
What one factor is correlated with increased likelihood of cannabis-induced psychotic disorder?
A pre-existing personality disorder.
What are the criteria for hospital admission for alcohol-withdrawal?
- Persistent withdrawal despite 80 mg or more of diazepam given in the ER or office 2. Delirium, recurrent dysrhythmias or multiple seizures 3. Unsafe to discharge (home or detox) due to ataxia, confusion, dehydration 4. Serious medical or psychiatric illness
How does cocaine increase dopamine?
It blocks reuptake at the dopamine transporter and results in increased dopamine in the synaptic cleft and activation of D1 and D2 receptors.
What are medical complications of cocaine use?
- CVA – most common are non-hemorrhagic cerebral infarctions (hemorrhagic do occur) 2. Cardiac – MI (CP) or arrhythmias, cardiomyopathy 3. Seizures – 3-8% (most common substance causing seizures, amphetamine second) 4. IV use – infection (HCV, HIV), endocarditis, emboli 5. Death 6. Rhabdomyolysis 7. Respiratory – resp. failure from smoked cocaine 8. Bowel ischemia **Most complications occur within first 3 hours after use.
What substance of abuse (excluding alcohol) is most likely to cause seizures?
Cocaine.
What are symptoms or risks associated with cocaine-induced psychotic disorder?
- Use of IV or crack cocaine 2. Males greater than females 3. Emergence of paranoid delusion or AH (less common to have VH or TH, although formication (classic?) can occur)
What are the rates of smoking for the following psychiatric patient populations: all psychiatric outpatients, bipolar I disorder, substance use disorder and schizophrenia?
a. All psychiatric patients – 50% b. Bipolar I – 70% c. Substance use – 70% d. Schizophrenia – 90%
What are the core elements of motivational interviewing?
Develop discrepancies Empathy Avoid argumentation Roll with the resistance Support self-efficacy
What are some scales for alcohol and substance use?
a. CAGE Questionnaire – has 4 questions and a score of 2 or more is clinically significant (>1 females) b. Alcohol Use Disorders Identification Test (AUDIT) – clinician or self-report, 10 items (MC and yes/no) that assess alcohol consumption (3Q’s), harmful drinking (3Q’s) and hazardous drinking (4Q’s), scored 0-4 and score of 8 is highly sensitive and 10 is highly specific for detecting alcohol use disorder c. Michigan Alcohol Screening Test (MAST) – self-report 25 yes/no and scored 0-53, with scores greater than 7 indicating probably alcoholism d. Drug Abuse Screening Test (DAST) – 20-item self-report score 0 or 1 for yes or no responses respectively, cut-off is 5 indicating probable drug use and scores range from 0-28 e. Clinical Institute Withdrawal Assessment for Alcohol (CIWA-D) – 8 items scored from 0-7, with 4 objective (pulse, sweating, hand tremor, agitation) and 4 subjective (anxiety, sensory disturbance, N/V, headache), clinician-administered, give diazepam/lorazepam based upon scores 10 or more on CIWA
What percentage of patients with ASPD have co-morbid substance use? How about schizophrenia? Bipolar disorder? PTSD? Depression?
- Antisocial personality disorder: 60 to 80% 2. Bipolar disorder 56% 3. Schizophrenia 47% 4. Post-traumatic stress disorder: 30 to 50% 5. Panic disorder: 36% 6. Any anxiety disorder: 36% 7. ADHD: 23% 8. Depression: 17%
What are good prognostic factors for ETOH users entering a formal treatment program?
b. Absence of ASPD c. Absence of diagnosis of another substance abuse/dependence disorderStudy Notes 2008 Page 22 of 61 d. Life stability with a job e. Continuing close family contacts f. Absence of severe legal problems g. If patient stay full course of rehabilitation program (2-4 weeks) h. Presence of family/professional supports i. (Could also include absence of SPMI)
What are Cloninger’s subtypes of alcoholism?
a. Type 1 (Milieu-limited) - Female, onset after age 25 years, environmental reactivity to drinking, minimal criminality, passive-avoidance / harm avoidance / low novelty seeking b. Type 2 (Male-limited) - Early onset, less dependent on environmental factors, more criminal activity, high novelty seeking, low harm avoidance c. Type 3 - Antisocial behaviour with alcohol abuse
What are Vaillant’s predictors of good prognosis in schizophrenia?
Acute onset, family history of depressive disorders, no family history of schizophrenia, a stressful precipitating event, no evidence of premorbid schizoid personality, perplexity or confusion during episode and prominent affective symptoms
List the Schneiderian first rank symptoms
a. Auditory hallucinations
i. Voices repeating one’s thoughts (Gedankenlautwerden or echo le pensee)
ii. Two or more voices discussing the subject or arguing with him
iii. Voices commenting on his thoughts
b. Thought insertion or withdrawal
c. Thought broadcasting
d. Somatic passivity
e. Passivity (thought or feeling of being controlled)
f. Apophonous delusion (Delusional perception)
Describe the phases of CBT in schizophrenia.
Phases of CBT: 1. Engagement – patient and therapist discuss events leading up to patients’ psychotic illness and develops a shared explanation of the psychological factors involved (formulation used to normalize their experience). Important focus on fostering therapeutic alliance. 2. Assessment of co-morbid conditions (depression, anxiety) that can be targeted with CBT. 3. Develop Alternate Explanations of Symptoms – use a vulnerability-stress model. The patient’s vulnerability, stressors and evaluation of the antecedent period. Working collaboratively with the patient, alternate explanations could be considered and possibly accepted by the patient. 4. Focus on specific positive symptoms – CBT for psychosis focuses on specific strategies to deal with symptoms a. Hallucinations – analyze patient’s beliefs about the origins and nature of voices. Attempts to normalize hallucinations (e.g. can occur with sleep deprivation) and later to debate content of voices (e.g. abusive statements can be tested). Strategies can include voice diaries, reattribution of causes of the voices, generating coping strategies (focusing or distraction). b. Delusions – use successive questions (“peripheral questioning”) to determine underlying belief and understand the specific details of belief. Then, one can attempt graded reality testing (e.g. research if microchips can be inserted into head without knowing) and exploring alternate explanations. Another approach is “inference chaining”, which focuses on looking at the patient’s personalized meaning underlying the delusion. c. Thought Disorder – ask patient to fill in gaps of conversation (for thought blocking) and clarify neologisms d. Negative Symptoms – work on this symptom domain after positive symptoms have been targeted – can use behavioural experiments
What are good prognostic factors for schizophreniform disorder?
- Onset of symptoms within 4 weeks of noticeable change in behaviour 2. Confusion or perplexity 3. Good premorbid social and occupational functioning 4. Absence of blunted or flat affect
What are risk factors for delusional disorder?
a. Advanced age b. Sensory impairment c. Family history d. Social isolation e. Recent immigration f. Personality features (e.g. unusual interpersonal sensitivity)
What are good prognostic features for brief psychotic episode?
a. Good premorbid adjustment b. Absence of schizoid traits c. Confusion or perplexity d. No family history of schizophrenia e. Affective symptoms f. No or little blunted affect g. Sudden onset of symptoms h. Short duration of symptoms i. Severe precipitating factor
What is your approach to treatment-resistant schizophrenia?
m. Re-assess diagnosis and treat new cmo-morbidities n. Rule out non-compliance (educate and consider depot, case management /ACT) o. Optimize dose (consider drug levels) i. Ensure at least 4-6 week trials on previous medications at optimal dose p. Clozapine q. Augmentation i. Lamotrigine (2 RCT) ii. Another antipsychotic (RSP) iii. Valproate (mood instability, irritability) iv. Antidepressant (depressive symptoms) v. Lithium (schizoaffective) vi. Topiramate (small RCT, open label) vii. ECT (especially if affective symptoms) viii. Stimulants/L-dopa (transient benefit in negative symptoms but weight against risk of exacerbating psychosis) ix. Benzodiazepine (anxiety symptoms)
What are the modified Kane criteria?
a. Drug refractory condition – at least 2 prior drug trials of 4-6 week duration at 400-600 mg of CPZ with no clinical improvement b. Persistence of Illness - >5 years of no period of good social or occupational functioning c. Persistent psychotic symptoms – BPRS total score >45 on 18 item scale and item score > 4 on 2 of 4 positive symptoms
What psychosocial interventions have LEVEL A evidence according to the Canadian Schizophrenia guidelines?
- Supported employment programs (vocational interventions) - Family interventions (mainly family psychoeducation) *ACT has LEVEL A evidence for patients difficult to engage and with repeated hospitalizations
What are the criteria for metabolic syndrome?
a. Waist circumference Men 102 cm Women 88 cm b. Any 2 of following: a. TG 1.7 mmol/L b. HDL-C Men < 1.0 mmo/L Women < 1.3 mmol/L c. Blood Pressure 135 mmHg systolic or 85 mmHg diastolic d. Fasting glucose 5.6 mmol/L or known Type 2 diabetes
What are the criteria for neuroleptic-induced tardive dyskinesia? What are the risk factors for TD?
A. Involuntary movements of tongue, jaw, trunk or extremities associated with neuroleptic use B. Involuntary movements present over a period of 4 weeks and occur in any of following: a. Choreiform (rapid, jerky) b. Athetoid (slow, sinuous) c. Rhythmic (sterotypies) C. Sings or symptoms of criteria A or B develop while treated with neuroleptic or 4 weeks upon withdrawal for oral or 8 weeks for depot D. Neuroleptic exposure for 3 months (1 month for age 60 years) E. Not due to GMC, other medications or ill-fitting dentures F. Not better accounted for by other neuroleptic-induced movement disorder Risk Factors for TD: Early development of EPS, prolonged antipsychotic use, increased age (biggest RF), female, mood disorder, neurological conditions (brain damage/cognitive disorder), substance abuse.
What are the criteria for neuroleptic-induced tardive dyskinesia? What are the risk factors for TD?
A. Involuntary movements of tongue, jaw, trunk or extremities associated with neuroleptic use B. Involuntary movements present over a period of 4 weeks and occur in any of following: a. Choreiform (rapid, jerky) b. Athetoid (slow, sinuous) c. Rhythmic (sterotypies) C. Sings or symptoms of criteria A or B develop while treated with neuroleptic or 4 weeks upon withdrawal for oral or 8 weeks for depot D. Neuroleptic exposure for 3 months (1 month for age 60 years) E. Not due to GMC, other medications or ill-fitting dentures F. Not better accounted for by other neuroleptic-induced movement disorder Factors for TD: Early development of EPS, prolonged antipsychotic use, increased age (biggest RF), female, mood disorder, neurological conditions (brain damage/cognitive disorder), substance abuse.
What are the criteria and risk factors for akathisia?
Criteria: a. Development of restlessness after neuroleptic exposure b. At least one of following: Fidgety movements or swinging legs, rocking from foot-to-foot, pacing, inability to sit or stand still c. Occurs with 4 weeks of antipsychotic treatment or reducing or discontinuing anticholinergic medications d. Not accounted for by other mental disorder e. Not due to GMC or substance Risk factors: A. Middle aged female B. High caffeine intake C. Antipsychotic treatment (Unable to suppress akathisia – MCQ question)
What are good prognostic factors for delusional disorder?
a. High level of occupational social and functional adjustments
b. Female sex
c. Onset before 30
d. Sudden onset
e. Short duration of illness
f. Precipitating factors
*Persecutory, somatic and erotomanic may have better prognosis than grandiose and jealous
List 3 cognitive domains that are affected by schizophrenia?
a. Attention b. Executive functioning c. Episodic (working) memory
