OSCE Prep Flashcards
What are absolute contraindications to ECT?
None
What are Diagnostic Indications for ECT?
Unipolar or bipolar depression, especially with psychotic features Mania, including mixed episodes Schizophrenia and related disorders (i.e. schizoaffective disorder) Catatonia Parkinson’s disease Neuroleptic malignant syndrome Delirium Intractable seizure disorders
What are clinical indications for ECT?
Treatment resistance Intolerance to pharmacotherapy Rapid definitive response required based on medical (i.e. deteriorating physical status) or psychiatric grounds (i.e. acute suicidal ideation) Prior favourable response to ECT Patient preference
How do you tell the difference between cognitive changes in dementia vs depression?
Depression faster onset MCI progressive decline over time Depression aware of cognitive problems Depression pt aware of functional decline Depression fully oriented Depression slower rate of forgetting Depression responds with “IDK” vs near-miss answers Depression Fx impairment secondary to decreased interest/effort Depression prior psych hx common
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 is duration of cog impairment of ECT?
Transient, within weeks and months Pt self reports of persistent cog dysfx, esp retrograde amenia, but usually correlated with persistent depressive symptoms ?objective testing systematic review - objective tests of autobiographical memory didnt show effects beyond 6 months post-ECT
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 pathogenesis of NMS?
Unknown Possible theory - excess dopamine bloackade in hypothalamus causes autonomic instability; NS areas –> rigidity Gaba, epi, Serotonin and Ach also maybe involved Or SNS dysregulated by desatblizing normal dopamine reg of sympathetic activity
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 is evidence for psychotherapy and pharmacotherapy for anorexia?
Best evidence is for Enhanced CBT (CBT-E) for Eating Disorders in adults; Family-Based Therapy (FBT) with teens. Also possible role for DBT (especially for BN, binge-eating disorder, or comorbid self-harm, BPD) but not as clear evidence for DBT. No clear evidence for medication for eating disorders. Generally reserved for treating comorbid conditions and symptoms (e.g. mood, anxiety disorders, OCD). Other medications can be used for symptom management, or in the case of medically unstable patients requiring treatment for the specific issue.
What is a differential dx of ADHD?
• Bipolar Disorder • Anxiety Disorders including GAD, OCD & PTSD • MDD • Substance Use Disorders • Personality Disorders including Borderline & Antisocial • Oppositional Defiant Disorder • Learning Disorders / Low IQ • Medical Conditions including head trauma, seizure d/o, thyroid dysfunction, FAS • Primary Psychotic Disorders
What disorders are most comorbid with ADHD?
• Estimates range from 70 – 85% of adults with ADHD have at least one co-exiting d/o • MDD • Bipolar Disorder • Anxiety Disorders including GAD, OCD & PTSD • Autism Spectrum Disorder • Personality Disorders including BPD & ASPD • Medical Disorders such as epilepsy, cardiac problems, tics, sleep-related disorders • Learning Disorders • Speech Disorders • Low OR High IQ
How would you tell the difference between bipolar disorder and ADHD?
Onset - bipolar late teens/early adulthood, ADHD before age 7 features - BD mood sx predominant ADHD inattention/hyperactivity predominant
Process of making an ADHD dx in an adult
- Screen questions - Evidence of a childhood hx of ADHD - Complete hx - Collateral hx - Parents, family, school records - Med workup (med hx, neuro exam, bloodwork, ECG) - Screening tools Conner’s, SNAP, Adult ADHD symptom rating scale, Weiss, wisconsin, trails
What are different classes of medications for ADHD and how do they work?
Stimulants - long acting or short acting, long acting is considered first line - Increase dopaminergic and noradrenergic transmission - Methlyphenidate and amphetamine-based - Early onset of action - Has addictive properties - Use with caution in ppl with BAD, psychosis, substance use - Side effects - restlessness, anxiety, insomnia, decreased appetite, headche, stomach ache, elevated HR and BO Non-Stimulants = atomoxetine - SNRI - Takes much longer appprox 4 weeks - Recommended for use in people with BAD< anxiety, psychosis, substance - less addictive - Side effects - nausea, vomiting, headache, insomnia, appetite, sexual problems, SI alpha2-agonists - guanfacine, clonidine - second line/third line agents - Must be dosed in small increments to avoid hypotension - when discontinuing, have to be tapered down slowly to prevent rebound HTN - somnolence, thirst, blood pressure decrease, postural dizziness, and constipation Other antidepressants such as bupropion
How do you structure a well-built clinical question?
PICO Population Intervention Control/Comparison Outcome
What are the categories of health research information?
Studies –> syntheses –> synopses –> summaries –> systems Studies - individual studies/journal articles, such as using pubmed. Prop, very up to date, con - all studies cant be applied, inefficient, time-consuming Syntheses - systematic reviews/meta-analysis - helpful when many small studies have been done and we want to pool effect size, or to explore differences in similar studies Con - if high quality evidence not available, “garbage in, garbage out” Synopses - filtered and pre-appraised evidence eg. Evidence-based med health journal - pro: contains succinct appraisals of studies that are selected by peers for high quality and relevance to clinical practice - con: these journals doe not include all important studies, and the synopsis is subject to the interpretation of its author Summaries - integrated evidence related to particular clinical problem - clin practice guidelines, UPtodate, dynamed - pro: easy access to a range of evidence relevant to the management of a particular condition - con: only as good as the process by which this information is selected, interpreted and kept up to date Systems - decision support technology where individual patient characteristics are matched with best available evidence, but this doesnt really exist yet
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 is, allocation: concealed?
• Allocation is concealed when the people responsible for enrolling subjects into the trial have no way of predicting the randomization sequence. • Protects against certain patients being included or excluded systematically from one or the other group. • For example, if an investigator knows that the next person enrolled in the study will be randomized to placebo, he/she may not enroll into the study a sicker person who is seen as needing active treatment. This would result in the placebo arm having fewer severely ill patients than the active arm, leading to a bias.
“intention-to-treat analysis.” What is that and why is it important?
• Intention-to-treat analysis refers to a strategy for analyzing data where all subjects are included in the groups to which they were randomized. • For example, if a subject is allocated to the active medication arm but does not take any of the medication, she is still included in the medication arm (and not simply excluded from the analysis). • This is important because reasons for discontinuing treatment are often related to prognosis. Therefore, excluding subjects who discontinue treatment can bias the results.
What is number needed to treat?
The Number Needed to Treat (NNT) is the number of patients you need to treat to prevent one additional bad outcome (death, stroke, etc.). For example, if a drug has an NNT of 5, it means you have to treat 5 people with the drug to prevent one additional bad outcome. NNT = 1/ARR ARR = CER - EER
What is a systematic review vs a meta-analysis?
A systematic review answers a defined research question by collecting and summarising all empirical evidence that fits pre-specified eligibility criteria. A meta-analysis is the use of statistical methods to summarise the results of these studies.
What does a p-value represent?
• The p-value represents the probability that a difference as large or larger than the observed difference between groups would occur by chance alone if there was actually no true difference between groups.
What are potential causes of delirium?
anticholinergic delirium steroids pain infection CVA metabolic disturbance /DM
What is a management strategy for a combative, delirios patient?
- Management environmental and pharmacological - Delirium = medical urgency, coordinated appraoch - Goal = address symptoms, ensure safety, ID and treat underlying causes · Supportive and environmental o Facilitating adequate sleep o Ensuring nutrition and fluid intake o Correcting sensory deficits (glasses, hearing aids) o Presence of a relative or known caregiver o Gentle reorientation by staff o Visible clock, calendar o If extremely agitated may require 1:1 · Pharmacological o Antipsychotics are the cornerstone of delirium treatment o Antipsychotics treat both hyperactive and hypoactive delirium o Haldol is most well studied medication and widely used agent in the treatment of delirium – has only one metabolite, less potential for anticholinergic, sedative and hypotensive effects, multiple routes of administration (PO/IM/IV) o Second generation antipsychotics also good efficacy, especially risperidone o Benzodiazepines generally should be avoided except in alcohol and benzodiazepine withdrawal or delirium secondary to seizures o Sedatives can reduce agitation, but they may worsen cognitive impairment, complicate mental status assessment, precipitate or perpetuate delirium due to other causes
How do you distinguish between delirium and dementia?
o Onset is acute or subacute in delirium, gradual in dementia o Course of delirium is fluctuating, progressive in dementia o Consciousness is impaired in delirium, often intact until later stages in dementia o Sleep – disruption of sleep-wake cycle in delirium, night time disruption in dementia o Principle cognitive deficit in delirium is inattention, in dementia short term memory and executive dysfunction o Medical status – identifiable precipitant present in delirium, often less of relationship in dementia o Generalized EEG slowing – majority of those with delirium (80%), about one third of those with dementia
What are symptoms of anticholinergic toxicity?
· Elderly individuals are particularly sensitive to anticholinergic effects o Blind as a bat (dilated pupils) o Red as a beet (vasodilation and flushing) o Hot as a hare (hyperthermia) o Dry as a bone (dry skin) o Mad as a hatter (hallucinations/agitation) o Bloated as a toad (ileus, urinary retention) o And the heart runs alone (tachycardia) · Bonus point: able to identify that several rating scales exist for determining anticholinergic burden of common medications
What are psychiatric effects of starting steroids?
· Mania or hypomania o Euphoria or hypomania is a common psychiatric manifestation early in steroid therapy, and can be associated with agitation, insomnia, distractibility, irritability, affective lability o May require antipsychotic treatment for stabilization of mood · Depression o More common in longer courses of steroid therapy, but by far the most common psychiatric manifestation of steroid therapy o May require treatment with anti-depressants o Vulnerability to depression increased by effects of medical illness · Psychosis and Delirium o Delusions, hallucinations, thought form abnormalities o If possible a reduction in steroid dose often ameliorates symptoms o Requires antipsychotic medications
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
In NREM sleep arousal disorder, what are main symptoms?
- recurrent episodes of incomplete waking from sleep (first 1/3 of sleep)
- sleepwalking
- night terrors
- none or littel of draems recalled
- amnesia of episode
In NREM sleep arousal disorder, what are the principles of management?
- SAFETY
- Reassurance, education
- Avoid precipitants (fll bladder, ETOH, noise, meds)
- V little data on meds - ?SSRIs, TCAs, Benzos were used historically but coudl worsen because they suppress N3 sleep
What are main symtpoms of REM sleep behaviour disorder?
- repeated episodes of arousal during sleep associated with vocalizations/complex motor behaviour
- During REM, >90min after sleep onset
- 1 of the following
- REM sleep without atonia on PSG/EMG (loss of skeletal muscle paralysis)
- Hx suggestive of a-synucleinopathy
What are principles of management of REM sleep behaviour disorder?
Ensure safety of patient and bed partner
Clonazepam 0.5-2mg
Melatonin 3-12 mg (always first line if OSA)
?Dopa agonists
What is prolonged QTC defined as for men and women?
>450 men
>470 women
Alcohol dependence. Renal failure. On morphine for pain control. Has a binge pattern of drinking (10-12 drinks on the weekends). Which medication to use?
a) Acamprosate
b) Naltrexone
c) Disulfiram
d) Topiramate
Topiramate
Which psychiatric medications are primarily renally excreted?
Lithium
Topiramate
Gabapentin
Pregabalin
*Paliperidone
*Acamprosate
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 is the timeline of alcohol withdrawal?
After cessation of drinking:
6-8 hours - tremulousness
8-12 hours - psychotic an perceptual disturbances
12-14 hours - seizure
up to 72h to a week - DTs
The syndrome of withdrawal sometimes skips the usual progression and, for example, goes directly to DTs.
What are symptoms of delirium tremens?
Delirium occurring within 1 week after a person stops drinking
Autonomic hyperacticity (tachycardia, Diaphoresis, fever, HTN)
Anxiety
Insomnia
Perceptual distortions, most frequently visual or tactile hallucinations; Fluctuating levels of psychomotor activity, ranging from hyperexcitability to lethargy
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 the types of Other Specified Bipolar and Related Disorder?
Other specified bipolar disorder
- Short-duration hypomanic episodes (2–3 days) and major depressive episodes
- Hypomanic episodes with insufficient symptoms and major depressive episodes
- Hypomanic episode without prior major depressive episode
- Short-duration cyclothymia (less than 24 months)
What are characteristics of Broca’s Aphasia vs Wernicke’s aphasia?
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 are the main features associated with hyponatremia?
Confusion
Agitation
Lethargy
Headaches
Nausea
Imbalance
What is the pharmacology of Mirtazapine?
Mirtazapine is a Noradrenergic/Specific Serotonergic Antidepressant (NaSSA)
- Presynaptic a2-adrenergic antagonist effects–> increased release of norepinephrine and serotonin
- Potent antagonist of 5-HT2A, 5-HT2C, 5-HT3, and H1 receptors
- Moderate peripheral a1-adrenergic and muscarinic antagonist;
What medication is helpful in treating opioid withdrawal symptoms?
clonidine
What is the treatment apprach to neuropsychiatric symptoms of dementia in Lewy Body Dementia?
- Non-pharmacology appraoch
- AcheI
- Memantine
- Antipsychotic
What is the treatment apprach to neuropsychiatric symptoms of dementia in FTD?
- Behavioural/non-pharm
- SSRI (Citalopram >Trazodone, others)
- Antipsychotic ONLY after 1 and 2 have failed
- Memantine
What are the 4 principles of motivational interviewing?
Express Empathy
Develop Discrepancy
Roll with Resistance
Support Self-efficacy
What are the two main states of sleep and how much time does the average adult spend in each?
NREM - 75%
REM - 25%
What level of arousal is associated with REM vs non-REM sleep?
REM - hyperarousal state - increased blood pressure, resp rate, brain temp, glucose metabolism, cerebral blood flow
NREM - Hypoarousal state - lower blood pressure, low resting muscle tone
What are the 3 main components of NREM sleep and which waveform is associated with each?
- N1 = theta, 5%
- N2 = sleep spindles and k-complexes, 45%
- N3 = delta waves, “Slow wave” or “deep sleep”, 25% - furthest from wakefulness
Note - when awake, eyes opened - beta waves
- when drowsy, eyes are clsoed, alpha waves
What phenomena occur during REM sleep?
Detailed dreams and nightamres
Near total skeletal muscle paralysis (“atonia”)
Cyclical, every 90-100mins
Which brain regions are responsible for setting the circadian rhythm?
Suprachiasmatic nucleus
Anterior hypothalamus
Which brain regiosn are responsible for NREM and REM sleep?
NREM - hypothalamus (also thalamus, forebrain, medulla)
REM - Pons (pontine reticualr formation)
During what part of the sleep period does most N3 sleep occur?
First part of sleep cycle
During what part of the sleep period does most REM sleep occur?
Towards the end of sleep cycle
How long is REM latency typically and in which conditions is it shortened?
90mins
Decreased in depression and narcolepsy
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
Hypersomnolence Disorder
- what is it characterized by?
- How is it diagnosies?
- What are typical treatments?
- Sleep 8-12h, very difficult to wake in am
- naps and sleeps in day
- sleep not restful
- fall asleep fast, good sleep efficacy
- Polysomnography, Multiple sleep latency test (multipel naps in a day)
- Modafinil, 2. Dexedrine, methlyphenidate
What are the three main criteria in narcolepsy, one of which must be present in order to make a diagnosis?
- Cataplexy a few x/ month (sudden bilat loss of muscle tone precip by laughing or in children or early disease, tongue thrusting, global hypotonia)
- Hypocretin deficiency (<1/3 normal, <110pg/ml)
- PSG - REM sleep latency < 15 min ; MSLT _<_8min + REM seen on 2 naps
What are 4 main symptoms seen in narcolepsy?
- Sleep attacks
- Cataplexy
- Hypnopompic/hypnogogic hallucinations
- Sleep paralysis
What are main treatments for narcolepsy?
- Scheduled napping, sleep hygiene, lifestyle adjusments
- Daytime sleepiness - 1) modafinil, 2) dexedrine and methylphenidate
- Sleep paralysis and H/HH - REM suppressants TCAs, SSRIs, SNRIs (off label) - theory is that these suppress REM, because REM is intruding on to wakefulness
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 NREM sleep arousal disorder, what are main symptoms?
- recurrent episodes of incomplete waking from sleep (first 1/3 of sleep)
- sleepwalking
- night terrors
- none or littel of draems recalled
- amnesia of episode
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
In NREM sleep arousal disorder, what are main symptoms?
- recurrent episodes of incomplete waking from sleep (first 1/3 of sleep)
- sleepwalking
- night terrors
- none or littel of draems recalled
- amnesia of episode
What is the main treatment of circadian rhythm sleep wake disorder?
Chronotherapy (phase delay)
Melatonin early PM
Bright light early AM
What are the main management strategies in OSA?
CPAP
Nasal surgery
Oral devices
Don’t sleep supine
DO NOT use narcotics, benzos, opioids
What are main treatments for narcolepsy?
- Scheduled napping, sleep hygiene, lifestyle adjusments
- Daytime sleepiness - 1) modafinil, 2) dexedrine and methylphenidate
- Sleep paralysis and H/HH - REM suppressants TCAs, SSRIs, SNRIs (off label) - theory is that these suppress REM, because REM is intruding on to wakefulness
What are 4 main symptoms seen in narcolepsy?
- Sleep attacks
- Cataplexy
- Hypnopompic/hypnogogic hallucinations
- Sleep paralysis
What are the three main criteria in narcolepsy, one of which must be present in order to make a diagnosis?
- Cataplexy a few x/ month (sudden bilat loss of muscle tone precip by laughing or in children or early disease, tongue thrusting, global hypotonia)
- Hypocretin deficiency (<1/3 normal, <110pg/ml)
- PSG - REM sleep latency < 15 min ; MSLT _<_8min + REM seen on 2 naps
Hypersomnolence Disorder
- what is it characterized by?
- How is it diagnosies?
- What are typical treatments?
- Sleep 8-12h, very difficult to wake in am
- naps and sleeps in day
- sleep not restful
- fall asleep fast, good sleep efficacy
- Polysomnography, Multiple sleep latency test (multipel naps in a day)
- Modafinil, 2. Dexedrine, methlyphenidate
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 is the main clinical feature of insomnia?
Association of bed with state of arousal
How long is REM latency typically and in which conditions is it shortened?
90mins
Decreased in depression and narcolepsy
During what part of the sleep period does most REM sleep occur?
Towards the end of sleep cycle
During what part of the sleep period does most N3 sleep occur?
First part of sleep cycle
Which brain regiosn are responsible for NREM and REM sleep?
NREM - hypothalamus (also thalamus, forebrain, medulla)
REM - Pons (pontine reticualr formation)
Which brain regions are responsible for setting the circadian rhythm?
Suprachiasmatic nucleus
Anterior hypothalamus
What phenomena occur during REM sleep?
Detailed dreams and nightamres
Near total skeletal muscle paralysis (“atonia”)
Cyclical, every 90-100mins
What are the 3 main components of NREM sleep and which waveform is associated with each?
- N1 = theta, 5%
- N2 = sleep spindles and k-complexes, 45%
- N3 = delta waves, “Slow wave” or “deep sleep”, 25% - furthest from wakefulness
Note - when awake, eyes opened - beta waves
- when drowsy, eyes are clsoed, alpha waves
What level of arousal is associated with REM vs non-REM sleep?
REM - hyperarousal state - increased blood pressure, resp rate, brain temp, glucose metabolism, cerebral blood flow
NREM - Hypoarousal state - lower blood pressure, low resting muscle tone
What are the two main states of sleep and how much time does the average adult spend in each?
NREM - 75%
REM - 25%
What are the 4 principles of motivational interviewing?
Express Empathy
Develop Discrepancy
Roll with Resistance
Support Self-efficacy
Person who presents with symptoms of guillain barre, knows a lot about the diagnosis. Factitious disorder, how do you confirm?
- Wants the sick role
- Prove feigning symptoms
- Rule out all medical possibilities
Prove feigning symptoms
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 is imporant to consider about withdrawal management programs in OpioidUD?
WIthdrawal management alone should be avoided, and detox should always be followed by immediate transition to long term addiction tx
What are sensitization effects of long term cocaine use?
- Longer use- decreased seizure threshold
- Psychosis - paranoia, visual, auditory and tactile hallucinations
- Stereotypical behaviours
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 are symptoms of cocaine withdrawal?
- DYSphoria
- ↑ appetite
- ↓ energy
- ↓ psychomotor activity (retardation)
- ↓ or ↑ sleep
- vivid unpleasant dreams
What pharmacotherapies have been found to be useful in treating cocaine use disorder?
None
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%)
What are the main pharmacologic treatments of nicotine addiction?
- NRT
- Varenicline
- Bupropion
What is the timeline of alcohol withdrawal?
- Discontinuation + 2 of
- ↑ANS, ↑tremor, insomnia, NV, ↑anxiety, vis/aud/tactile, GTC sz, agitation
- 6-8 - hr shakes
- 8-12 - psychotic/perceptual probs
- 12-24 - h seizures
- 72h - DTs (1-3%)
- monitor with CIWA <15 mild, >20 severe
- Tx with Diazepam 1mg/drink QID, or Chlordiazepoxide 2.5mg/drink QID
Person who presents with symptoms of guillain barre, knows a lot about the diagnosis. Factitious disorder, how do you confirm?
- Wants the sick role
- Prove feigning symptoms
- Rule out all medical possibilities
Prove feigning symptoms
Person who presents with symptoms of guillain barre, knows a lot about the diagnosis. Factitious disorder, how do you confirm?
- Wants the sick role
- Prove feigning symptoms
- Rule out all medical possibilities
Prove feigning symptoms
What is the timeline of alcohol withdrawal?
- Discontinuation + 2 of
- ↑ANS, ↑tremor, insomnia, NV, ↑anxiety, vis/aud/tactile, GTC sz, agitation
- 6-8 - hr shakes
- 8-12 - psychotic/perceptual probs
- 12-24 - h seizures
- 72h - DTs (1-3%)
- monitor with CIWA <15 mild, >20 severe
- Tx with Diazepam 1mg/drink QID, or Chlordiazepoxide 2.5mg/drink QID
What are the main pharmacologic treatments of nicotine addiction?
- NRT
- Varenicline
- Bupropion
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%)
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 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 pharmacotherapies have been found to be useful in treating cocaine use disorder?
None
What are symptoms of cocaine withdrawal?
- DYSphoria
- ↑ appetite
- ↓ energy
- ↓ psychomotor activity (retardation)
- ↓ or ↑ sleep
- vivid unpleasant dreams
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 are sensitization effects of long term cocaine use?
- Longer use- decreased seizure threshold
- Psychosis - paranoia, visual, auditory and tactile hallucinations
- Stereotypical behaviours
What is imporant to consider about withdrawal management programs in OpioidUD?
WIthdrawal management alone should be avoided, and detox should always be followed by immediate transition to long term addiction 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 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 associated with suboxone?
Precipitated withdrawal
Resp depression/sedation
Headache, fatiguw, occasional sexual SE
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 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
In bipolar disorder, which two Loci are most implicated?
ANK3 - Voltage gated sodium channels
CACNA1C on 12p13 - L type Ca Channels
Person who presents with symptoms of guillain barre, knows a lot about the diagnosis. Factitious disorder, how do you confirm?
- Wants the sick role
- Prove feigning symptoms
- Rule out all medical possibilities
Prove feigning symptoms
Eating disorder patient. What tests would you order as an initial workup?
- CBC, lytes, CAMP, albumin, LFTS, Cr, Urea
- ECG
According to CANMAT Bipolar 2018, for pregnant people, what is the best approach to treatment of BAD in first trimester?
Psychological strategies preferred over medications in first trimester
When meds are necessary, preference should be given to monotherapy and lowest effective dose
According to CANMAT Bipolar 2018, what are risks associated with divalproex in pregnancy?
- Should be avoided due to risks of NTD (5%)
- higher incidences of congenital abnormalities
- striking degrees of neurodevelopmental delay in children at 3y, loss of 9 IQ pts
According to CANMAT Bipolar 2018, in later pregnancy, what are considerations in dosing?
Pts may require higher doses of meds towards end of pregnancy because:
Changes in physiology in 2nd and early 3rd trim
Increased plasma volume
Increased hepatice activity
Increased renal clearance
According to CANMAT Bipolar 2018, in later pregnancy, what are considerations in dosing?
Pts may require higher doses of meds towards end of pregnancy because:
Changes in physiology in 2nd and early 3rd trim
Increased plasma volume
Increased hepatice activity
Increased renal clearance
According to CANMAT Bipolar 2018, what are risks associated with divalproex in pregnancy?
- Should be avoided due to risks of NTD (5%)
- higher incidences of congenital abnormalities
- striking degrees of neurodevelopmental delay in children at 3y, loss of 9 IQ pts
Eating disorder patient. What tests would you order as an initial workup?
- CBC, lytes, CAMP, albumin, LFTS, Cr, Urea
- ECG
Eating disorder patient. What tests would you order as an initial workup?
- CBC, lytes, CAMP, albumin, LFTS, Cr, Urea
- ECG
Eating disorder patient. What tests would you order as an initial workup?
- CBC, lytes, CAMP, albumin, LFTS, Cr, Urea
- ECG
Eating disorder patient. What tests would you order as an initial workup?
- CBC, lytes, CAMP, albumin, LFTS, Cr, Urea
- ECG
According to CANMAT Bipolar 2018, in later pregnancy, what are considerations in dosing?
Pts may require higher doses of meds towards end of pregnancy because:
Changes in physiology in 2nd and early 3rd trim
Increased plasma volume
Increased hepatice activity
Increased renal clearance
According to CANMAT Bipolar 2018, what are risks associated with divalproex in pregnancy?
- Should be avoided due to risks of NTD (5%)
- higher incidences of congenital abnormalities
- striking degrees of neurodevelopmental delay in children at 3y, loss of 9 IQ pts
Eating disorder patient. What tests would you order as an initial workup?
- CBC, lytes, CAMP, albumin, LFTS, Cr, Urea
- ECG
What are some risk factors for developing post-op delirium?
- mild vascular dementia (prior cognitive disorder)
- “Vasculopathic” patients (those with multiple vascular risk factors (MVRF); e.g., DM, smoking, HTN, hyperlipidemia) often have co-morbid mild vascular disease-based cognitive impairment (which may be extensive enough to be diagnosed as vascular dementia).
- ICU setting
- General anaesthesia
- Pain (and meds)
- age,
- sensory deprivation, prior cognitive disorder
- etc.
What is your approach to treating delirium in the ICU?
- Clinical tests - CBC, lytes, extended lytes, glucose, LFTs, Cr, Urea, LDH, EEG
- Non-pharmacologic apprpaches
- Pharmacologic (best evidence Haldol, prolonged QT, Blakc box; atypicals)
- Avoid benzos (except ETOH-withdrawal delirium)/sedatives, opioids, dopa-agonists, anticholinergic
- Bedside MMSE/MOCA, frontal testing eg clock draw
If you were the PES supervisor calling in to the senior resident at the start of the shift, what is important to articulate/ask?
- Available at all hours, and to COME IN TO HOSPITAL AT ANY TIME IF NEEDED
- What PGY-year are you in?
- How long have you been a senior resident in Emergency Psychiatry?
- Who else is on with you tonight?
- Residents, med students, nurses, Other?
- How many available beds are in the system?
- Male or Female?
- Any seclusion available?
- How many patients are currently in the department?
What are items for consideration when coordinating the team and prioritizing cases in PES?
- Safety of patients and staff first priority
- Know comfort level and experience of the junior resident & medical student
- Make use of the expertise of the multi-disciplinary staff available
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
When ordering investigation for an elderly person with change in behvaiour what should you order?
- Vital signs including BP (sitting & standing), HR, RR, Temp
- Bloodwork including CBC with diff, lytes, BUN, CR, glucose, LFTs
- Urine R & M
- CT Head
- ECG
- CXR
- COVID PCR
- ? EEG to rule out delirium
What are some options to support a person with SPMI who keeps getting hospitalized?
- Assertive Community Treatment Team
- interdisciplinary team treatment approach designed to provide comprehensive, intensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness who typically have a history of repeated hospitalizations and who do not generally attend appointments in clinic settings.
- There is evidence that ACT teams significantly decrease rates of hospitalization
- Case Management
- less intensive than ACTT, but intended to provide a full range of individualized services. Patients have a case manager who acts as an advocate for them in accessing a range of psychosocial interventions
- IM antipsychotics
- CTO
- legal documents that provide a framework to work with patients who have a history of non-adherence to medications. Community Treatment Plans outline how often a patient needs to be seen by their treating psychiatrist or team and also outlines their psychiatric medications. If the patient is not adherent to the Community Treatment Plan, in Ontario their treating psychiatrist can complete a Form 47 (order for Psychiatric Examination)
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 is general criteria for admission to an ACT team?
General criteria for admission to an ACT Team:
- Having an Axis I disorder (typically a psychotic disorder, but not necessarily)
- A history of multiple, sometimes lengthy psychiatric hospitalizations
- A history of non-adherence to prescribed psychiatric medications
- “Failure” of other more traditional outpatient management options
- Often have co-existing conditions such as addiction issues, homelessness, involvement with the judicial system and/or developmental disabilities
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 advantages and disadvantages of Community Treatment Orders?
What are the advantages and disadvantages of Community Treatment Orders? (TOTAL 15 points)
A4.
Advantages of CTOs:
- Provides a framework for working with very challenging, non-adherent patients, allowing time to hopefully develop a therapeutic relationship
- Decreases hospital days (by approximately 60%)
- Allows for quicker treatment when a patient first becomes non-adherent to the treatment plan rather than letting them become very unwell before treatment could be given
- Allows a patient to be sent to hospital for a psychiatric assessment if necessary even if they haven’t been seen by their psychiatrist within the last 7 days
Disadvantages of CTOs:
- The legal process involved in initiating and renewing CTOs can be tedious and time-consuming
- Patients can view CTOs as restrictive and can resent what they perceive to be an intrusion on their lives and freedom
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.
If a patient has an intellectual disability, would this change that way you interact with him or your management plan in any way?
Working with People who have a diagnosis of Intellectual disability:
- simplify the language you use and shorten your sentences
- May need to repeat your questions or rephrase them
- People with developmental disabilities and comorbid psychiatric issues may present differently than the general population with psychiatric issues
- “start low, go slow” due to the greater potential for adverse reactions and sensitivity to medications in this population
What are the diagnostic criteria for Gender Dysphoria Disorder?
A. Marked incongruence between one’s experienced/expressed gender and assigned gender, for at least 6 months with 2 of the following:
- Marked incongruence between experienced/expressed gender and primary and/or secondary sex characteristics
- Strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender
- Strong desire for the primary and/or secondary sex characteristics or the other gender
- Strong desire to be of the other gender
- Strong desire to be treated as the other gender
- Strong conviction that one has the typical feelings and reactions of the other gender
B. Causes clinically significant distress or impairment in social, occupation, or other important areas of functioning
What is diagnostic criteria for fetishistic disorder?
Diagnostic criteria for Transvestic Disorder:
- Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving cross-dressing
- The fantasies, sexual urges, or behaviours cause clinically significant distress or impairment in social, occupations or other important areas of functioning
With fetishism: if sexually aroused by fabrics, materials or garments.
With autogynephilia: if sexually aroused by thoughts or images of self as female
What are the stages of change in MI?
- Pre-contemplation: Not yet acknowledging that there is a problem behavior that needs to be changed, denial of the consequences and relation to the problem.
- Contemplation: Acknowledging that there is a problem but not yet ready or sure of wanting to make a change, starting to recognize the disadvantages of using.
- Preparation: Getting ready to change, planning strategies for change (e.g. joining group, setting a date to quit)
- Action: Changing behavior, reduction of use, quitting
- Maintenance: Maintaining the behavior change for 2-6 months
Are there any interventions or specific interviewing strategies that are used when talking with people who are in that pre-contemplation stage to help them to see that they have a problem?
*
- Motivational interviewing
- Motivational interviewing is a collaborative form of counselling aimed at addressing a person’s ambivalence about change.
- Its goal is to strengthen the person’s own motivation and commitment to change by exploring their own thoughts and ideas about changing.
- It is based on collaboration between the therapist and the patient, drawing out the patient’s own thoughts and ideas about the change in behaviour, and supporting the patient’s autonomy to make changes for themselves.
What are Manifestations of Mental Illness in Physicians?
Severe irritability and anger, resulting in interpersonal conflict
Marked vacillations in energy, creativity, enthusiasm, confidence, and productivity
Erratic behavior at the office or hospital
(ie, performing rounds at 3 am or not showing up until noon)
Inappropriate boundaries with patients, staff, or peers
Isolation and withdrawal
Increased errors in or inattention to chart work and patient calls
Personality change, mood swings
Impulsivity or irrationality in decision making or action
Inappropriate dress, change in hygiene
Sexually inappropriate comments or behavior
Diminished or heightened need for sleep
Frequent job changes and/or moves
Inconsistency in performance, absenteeism
What do you have to consider if you are treating a physician patient and you have concerns about their ability to work?
- Call CMPA first
- As per the CPSO Mandatory and Permissive reporting policy, physicians have a legal and professional obligation to maintain the confidentiality of patient information. There are circumstances, however, where physicians are either required or permitted to report particular events or clinical conditions to the appropriate government or regulatory agency.
- Physicians are expected to take appropriate and timely action when they have reasonable grounds to believe that another physician or health-care professional is incapacitated or incompetent. This includes circumstances where a colleague’s pattern of care, health or behaviour poses a risk to patient safety.
- Appropriate action may include, depending on the circumstances, contacting the Physician Health Program at the Ontario Medical Association, the College’s Physician Advisory Service, the individual’s friends and family and/or employer. In a hospital setting, appropriate action may involve notifying the individual to whom the physician is accountable.
Are physicians at an increased risk of suicide?
- U.S. approximately 400 physicians die by suicide each year. There are no Canadian statistics.
- Physicians have lower rates of death from disease than the general population. suicide is the only cause of death in physicians that is higher than the general population.
- A review of 14 studies found that the relative risk of suicide in physicians compared with the general population is between 1.1 and 3.4 for men and 2.5 to 5.7 for women
- This is 2-3 x rates seen in respective male/ female university graduates
- Physicians also have increased rates of suicides relative to other educated and professional groups
Factors that indicate a physician is at high risk for suicide:
- A workaholic white male age ≥50 or female age ≥45 who is
- divorced,
- single, or
- currently experiencing marital disruption and is
- suffering from depression.
- He or she has a substance abuse problem and a history of risk-taking (high-stakes gambling, etc.).
- chronic pain or illness or with a recent change in occupational or financial status also are at risk.
- Recent in- creased work demands, personal losses, diminished autonomy, and access to lethal means (medications, firearms) complete the profile.
Protective factors that lower the risk of completed suicide include effective treatment, social and family support, resilience and coping skills, religious faith, and restricted access to lethal means.
Why would a physician be more likely to commit suicide over the general population?
- Depression and suicidal ideation in physicians is associated with a variety of factors including personal and work related stressors
- Work stressors may play a role in precipitating suicide in some
- Physicians are often reluctant to seek treatment due to stigma and issues of confidentiality, they may fear recrimination by colleagues and licensing boards
- They may attempt to treat their mood disorders with self-prescribed medications.
What are side efftects associated with clozapine?
- Seizures
- Siallorrhea
- Ileus
- Agranulocytosis (leukopenia; neutropenia)
- Myocarditis
- Cardiomyopathy
- Metabolic Syndrome/DM
- Weight gain
- Hypotension or Hypertension
- Tardive Dyskinesia (risk lower than with other antipsychotics)
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
How often does CBC need to be done after initiation of clozapine?
- Every week for the first 26 weeks of treatment, then
- Every two weeks for the next 26 weeks and
- Every four weeks for the duration of treatment.
Results get sent to Gencan
If Gencan does not receive bloodwork, they will not dispense meds
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
What are parameters for hematological monitoring guidelines in clozapine?
What are side effects of TCAs?
- Common side-effects are those typical of TCAs and include
- sedation
- dry mouth
- urinary retention
- dizziness
- constipation
- blurred vision
- lowered seizure threshold
- mental cloudiness
- fatigue
- weight gain
- nausea
- sweating
- headache
- sexual dysfunction
Rare or dangerous side-effects
- orthostatic hypotension
- tachycardia
- arrhythmias
- rare seizures (risk of seizure increases with dose, especially above 250 mg/day)
- QTc prolongation
- increased intraocular pressure
- hepatic failure
- paralytic ileus
- rare induction of mania
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.
Which psychiatric medications are primarily renally excreted?
Lithium
Topiramate
Gabapentin
Pregabalin
*Paliperidone
*Acamprosate
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 is the timeline of alcohol withdrawal?
After cessation of drinking:
6-8 hours - tremulousness
8-12 hours - psychotic an perceptual disturbances
12-14 hours - seizure
up to 72h to a week - DTs
The syndrome of withdrawal sometimes skips the usual progression and, for example, goes directly to DTs.
What are symptoms of delirium tremens?
Delirium occurring within 1 week after a person stops drinking
Autonomic hyperacticity (tachycardia, Diaphoresis, fever, HTN)
Anxiety
Insomnia
Perceptual distortions, most frequently visual or tactile hallucinations; Fluctuating levels of psychomotor activity, ranging from hyperexcitability to lethargy
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 the types of Other Specified Bipolar and Related Disorder?
Other specified bipolar disorder
- Short-duration hypomanic episodes (2–3 days) and major depressive episodes
- Hypomanic episodes with insufficient symptoms and major depressive episodes
- Hypomanic episode without prior major depressive episode
- Short-duration cyclothymia (less than 24 months)
What are characteristics of Broca’s Aphasia vs Wernicke’s aphasia?
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 are the main features associated with hyponatremia?
Confusion
Agitation
Lethargy
Headaches
Nausea
Imbalance
What is the pharmacology of Mirtazapine?
Mirtazapine is a Noradrenergic/Specific Serotonergic Antidepressant (NaSSA)
- Presynaptic a2-adrenergic antagonist effects–> increased release of norepinephrine and serotonin
- Potent antagonist of 5-HT2A, 5-HT2C, 5-HT3, and H1 receptors
- Moderate peripheral a1-adrenergic and muscarinic antagonist;
What medication is helpful in treating opioid withdrawal symptoms?
clonidine
What is the treatment apprach to neuropsychiatric symptoms of dementia in Lewy Body Dementia?
- Non-pharmacology appraoch
- AcheI
- Memantine
- Antipsychotic
What is the treatment apprach to neuropsychiatric symptoms of dementia in FTD?
- Behavioural/non-pharm
- SSRI (Citalopram >Trazodone, others)
- Antipsychotic ONLY after 1 and 2 have failed
- Memantine
What are the 4 principles of motivational interviewing?
Express Empathy
Develop Discrepancy
Roll with Resistance
Support Self-efficacy
According to CANMAT Bipolar 2018, what are risks associated with divalproex in pregnancy?
- Should be avoided due to risks of NTD (5%)
- higher incidences of congenital abnormalities
- striking degrees of neurodevelopmental delay in children at 3y, loss of 9 IQ pts
According to CANMAT Bipolar 2018, in later pregnancy, what are considerations in dosing?
Pts may require higher doses of meds towards end of pregnancy because:
Changes in physiology in 2nd and early 3rd trim
Increased plasma volume
Increased hepatice activity
Increased renal clearance
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)
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)
According to CANMAT Bipolar 2018, in later pregnancy, what are considerations in dosing?
Pts may require higher doses of meds towards end of pregnancy because:
Changes in physiology in 2nd and early 3rd trim
Increased plasma volume
Increased hepatice activity
Increased renal clearance
According to CANMAT Bipolar 2018, what are risks associated with divalproex in pregnancy?
- Should be avoided due to risks of NTD (5%)
- higher incidences of congenital abnormalities
- striking degrees of neurodevelopmental delay in children at 3y, loss of 9 IQ pts
Eating disorder patient. What tests would you order as an initial workup?
- CBC, lytes, CAMP, albumin, LFTS, Cr, Urea
- ECG
Eating disorder patient. What tests would you order as an initial workup?
- CBC, lytes, CAMP, albumin, LFTS, Cr, Urea
- ECG
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)
Eating disorder patient. What tests would you order as an initial workup?
- CBC, lytes, CAMP, albumin, LFTS, Cr, Urea
- ECG
Geriatric with LBD, tx of choice for behavioural sx:
a. Rivastigmine
b. Memantine
c. Cipralex
d. Clonazepam
Rivastigmine
Memantine, all except?
a. Is indicated in mod-severe dementia (Health Canada)
b. Should be used in combination with AChEI for mod-severe dementia
c. Common side effects dizziness, headache, and somnolence
d. Significant improvements seen in 16 weeks
Significant improvements seen in 16 weeks
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 biggest factor in the development of physician burnout?
- Having a history of depression
- Having lots of administrative responsibilities
- Increased risk of litigation
- Age
Having lots of administrative responsibilities
Others:
- Female
- Earlier in Career
- Dissatisfaction with Work
What is the most common comorbidity with ASD?
Intellectual Disability
On VPA, topirimate, quetiapine Delirious, normal VPA, ataxia, normal LFTS, high ammonia
a. Stop VPA
b. Stop quetiapine
c. Treat with an antipsychotic
Stop VPA
(high ammonia, ALWAYS STOP)
Kid with night terrors, what on the EEG?
- Slow waves
- Sleep spindles
- Sawtooth waves
- Alpha waves
Slow Waves
Which of the following is true in the treatment of catatonia
- May require high dose benzo (up to 16mg/d ativan)
- Benzos treat retarted cataonia better than excited catatonia
- ECT contraindicated in neurological d/os
- In a patient with SCZ you treat catatonia with atypical psychotics
May require high dose benzo (up to 16mg/d ativan)
“Mirror transference” who did it?
- Kohut
- Anna Freud
- Melanie Klein
Kohut
- Narcissistic Transferences
- The therapist comes to represent, in Kohut’s terms, either the grandiose self in mirror transferences or the idealized parental imago in idealizing transferences. In idealizing transferences, all power and strength are attributed to the idealized object, leaving the subject feeling empty and powerless when separated from that object.
Which is true about establishing interpersonal inventory in IPT?
- Part can be done as homework
- Challenges the sick role
- Includes past and present relationships
- Helps to establish goals of therapy
Helps to establish goals of therapy
Patient with OCD, fear of germs and ++hand washing. Grew-up in home with sanitation issues. What is key component of therapy?
- Exposure and response prevention
- Explore past issues leading to her fears of contamination
- Have her chart thoughts about contamination on paper and cognitive restructuring
- Use downward arrow technique to uncover underlying fear
Exposure and response prevention
(If “DIRT” specifically was an option, would go with that)
Adult male with tics. Not on meds. Which therapy is most useful?
- Habit reversal
- Exposure response prevention
Habit reversal
Schizophrenia on clozapine and pregnant. Adamant that she wants to breastfeed. What do you advise patient?
- Continue clozapine in pregnancy and post-partum
- Continue clozapine in pregnancy stop postpartum
- Stop now and start after delivery
- Stop now and do not restart until after breastfeeding complete
Continue clozapine in pregnancy stop postpartum
(Typically you would continue an agent in breastfeeding if they were exposed in utero, but exceptions are when there are severe side effects with conitnued exposre such as clozapine,infant appears to be having side effects)
CLozapine has been associated iwth floppy baby syndrome, infants exposed in utero should be monitored for agranulocytosis first weeks of life
Patient with parkinson’s and cognitive dysfunction. Which is most likely to help with cognitive and IADL?
- Rivastigmine
- Memantine
- Pramipexole
- Pimavanserin
Rivastigmine
Recall in PD dementia, tx is symptomatic.
Usually start with ACHei or memantine in stepwise fashion
Woman in 60s with features of FTD (disinhibited, only eats white foods, some other stuff). MMSE 29/30. Husband ashamed to take her out in public because of her behaviour. What is the best treatment for impulsivity?
- Donepezil
- VPA
- Risperidone
- Citalopram
Citalopram
- Serotonergic medications have been the most studied in bvFTD. The selective serotonin reuptake inhibitors (SSRIs) fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram have all been tested to treat the behavioral symptoms of FTD. There is evidence that these drugs can have some efficacy in reducing disinhibition, repetitive behaviors, sexually inappropriate behaviors, and hyperorality.
Young adult male with 3 years of subsyndromal depressive symptoms. Has episodes of 2-3 hypomanic symptoms (stem described the symptoms). What is the diagnosis?
- Bipolar II
- Cyclothymic disorder
- Unspecified bipolar
- Other specified bipolar, inadequate duration of hypomania
Cyclothymic disorder
Psychotic man. Charged with theft >$5000. All of the following EXCEPT one are required for fitness to stand trial?
- Able to communicate with counsel/ advise his attorney
- Needs to know what his charges are
- Needs to understand nature of the proceedings in court
- Needs to treat his psychosis
Needs to treat his psychosis
What is the best choice of treatment in patient post cardiac event who has low appetite, poor sleep, early morning waking and depressed mood?
- Mirtazepine
- Venlafaxine
Mirtazapine
- CANMAT review comorbidities
- SSRIs and NASSA preferred agent cardiac
- Avoid venlafaxine and TCAs for high blood pressure
Geriatric with LBD, tx of choice for behavioural sx:
a. Rivastigmine
b. Memantine
c. Cipralex
d. Clonazepam
Rivastigmine
Geriatric with LBD, tx of choice for behavioural sx:
a. Rivastigmine
b. Memantine
c. Cipralex
d. Clonazepam
Rivastigmine
What is the best choice of treatment in patient post cardiac event who has low appetite, poor sleep, early morning waking and depressed mood?
- Mirtazepine
- Venlafaxine
Mirtazapine
- CANMAT review comorbidities
- SSRIs and NASSA preferred agent cardiac
- Avoid venlafaxine and TCAs for high blood pressure
Psychotic man. Charged with theft >$5000. All of the following EXCEPT one are required for fitness to stand trial?
- Able to communicate with counsel/ advise his attorney
- Needs to know what his charges are
- Needs to understand nature of the proceedings in court
- Needs to treat his psychosis
Needs to treat his psychosis
Young adult male with 3 years of subsyndromal depressive symptoms. Has episodes of 2-3 hypomanic symptoms (stem described the symptoms). What is the diagnosis?
- Bipolar II
- Cyclothymic disorder
- Unspecified bipolar
- Other specified bipolar, inadequate duration of hypomania
Cyclothymic disorder
Woman in 60s with features of FTD (disinhibited, only eats white foods, some other stuff). MMSE 29/30. Husband ashamed to take her out in public because of her behaviour. What is the best treatment for impulsivity?
- Donepezil
- VPA
- Risperidone
- Citalopram
Citalopram
- Serotonergic medications have been the most studied in bvFTD. The selective serotonin reuptake inhibitors (SSRIs) fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram have all been tested to treat the behavioral symptoms of FTD. There is evidence that these drugs can have some efficacy in reducing disinhibition, repetitive behaviors, sexually inappropriate behaviors, and hyperorality.
Patient with parkinson’s and cognitive dysfunction. Which is most likely to help with cognitive and IADL?
- Rivastigmine
- Memantine
- Pramipexole
- Pimavanserin
Rivastigmine
Recall in PD dementia, tx is symptomatic.
Usually start with ACHei or memantine in stepwise fashion
Schizophrenia on clozapine and pregnant. Adamant that she wants to breastfeed. What do you advise patient?
- Continue clozapine in pregnancy and post-partum
- Continue clozapine in pregnancy stop postpartum
- Stop now and start after delivery
- Stop now and do not restart until after breastfeeding complete
Continue clozapine in pregnancy stop postpartum
(Typically you would continue an agent in breastfeeding if they were exposed in utero, but exceptions are when there are severe side effects with conitnued exposre such as clozapine,infant appears to be having side effects)
CLozapine has been associated iwth floppy baby syndrome, infants exposed in utero should be monitored for agranulocytosis first weeks of life
Adult male with tics. Not on meds. Which therapy is most useful?
- Habit reversal
- Exposure response prevention
Habit reversal
Patient with OCD, fear of germs and ++hand washing. Grew-up in home with sanitation issues. What is key component of therapy?
- Exposure and response prevention
- Explore past issues leading to her fears of contamination
- Have her chart thoughts about contamination on paper and cognitive restructuring
- Use downward arrow technique to uncover underlying fear
Exposure and response prevention
(If “DIRT” specifically was an option, would go with that)
Which is true about establishing interpersonal inventory in IPT?
- Part can be done as homework
- Challenges the sick role
- Includes past and present relationships
- Helps to establish goals of therapy
Helps to establish goals of therapy
“Mirror transference” who did it?
- Kohut
- Anna Freud
- Melanie Klein
Kohut
- Narcissistic Transferences
- The therapist comes to represent, in Kohut’s terms, either the grandiose self in mirror transferences or the idealized parental imago in idealizing transferences. In idealizing transferences, all power and strength are attributed to the idealized object, leaving the subject feeling empty and powerless when separated from that object.
Which of the following is true in the treatment of catatonia
- May require high dose benzo (up to 16mg/d ativan)
- Benzos treat retarted cataonia better than excited catatonia
- ECT contraindicated in neurological d/os
- In a patient with SCZ you treat catatonia with atypical psychotics
May require high dose benzo (up to 16mg/d ativan)
Kid with night terrors, what on the EEG?
- Slow waves
- Sleep spindles
- Sawtooth waves
- Alpha waves
Slow Waves
On VPA, topirimate, quetiapine Delirious, normal VPA, ataxia, normal LFTS, high ammonia
a. Stop VPA
b. Stop quetiapine
c. Treat with an antipsychotic
Stop VPA
(high ammonia, ALWAYS STOP)
What is the best choice of treatment in patient post cardiac event who has low appetite, poor sleep, early morning waking and depressed mood?
- Mirtazepine
- Venlafaxine
Mirtazapine
- CANMAT review comorbidities
- SSRIs and NASSA preferred agent cardiac
- Avoid venlafaxine and TCAs for high blood pressure
What is the most common comorbidity with ASD?
Intellectual Disability
Psychotic man. Charged with theft >$5000. All of the following EXCEPT one are required for fitness to stand trial?
- Able to communicate with counsel/ advise his attorney
- Needs to know what his charges are
- Needs to understand nature of the proceedings in court
- Needs to treat his psychosis
Needs to treat his psychosis
- What is the biggest factor in the development of physician burnout?
- Having a history of depression
- Having lots of administrative responsibilities
- Increased risk of litigation
- Age
Having lots of administrative responsibilities
Others:
- Female
- Earlier in Career
- Dissatisfaction with Work
Young adult male with 3 years of subsyndromal depressive symptoms. Has episodes of 2-3 hypomanic symptoms (stem described the symptoms). What is the diagnosis?
- Bipolar II
- Cyclothymic disorder
- Unspecified bipolar
- Other specified bipolar, inadequate duration of hypomania
Cyclothymic disorder
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
Memantine, all except?
a. Is indicated in mod-severe dementia (Health Canada)
b. Should be used in combination with AChEI for mod-severe dementia
c. Common side effects dizziness, headache, and somnolence
d. Significant improvements seen in 16 weeks
Significant improvements seen in 16 weeks
Geriatric with LBD, tx of choice for behavioural sx:
a. Rivastigmine
b. Memantine
c. Cipralex
d. Clonazepam
Rivastigmine
Geriatric with LBD, tx of choice for behavioural sx:
a. Rivastigmine
b. Memantine
c. Cipralex
d. Clonazepam
Rivastigmine
Woman in 60s with features of FTD (disinhibited, only eats white foods, some other stuff). MMSE 29/30. Husband ashamed to take her out in public because of her behaviour. What is the best treatment for impulsivity?
- Donepezil
- VPA
- Risperidone
- Citalopram
Citalopram
- Serotonergic medications have been the most studied in bvFTD. The selective serotonin reuptake inhibitors (SSRIs) fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram have all been tested to treat the behavioral symptoms of FTD. There is evidence that these drugs can have some efficacy in reducing disinhibition, repetitive behaviors, sexually inappropriate behaviors, and hyperorality.
Patient with parkinson’s and cognitive dysfunction. Which is most likely to help with cognitive and IADL?
- Rivastigmine
- Memantine
- Pramipexole
- Pimavanserin
Rivastigmine
Recall in PD dementia, tx is symptomatic.
Usually start with ACHei or memantine in stepwise fashion
Schizophrenia on clozapine and pregnant. Adamant that she wants to breastfeed. What do you advise patient?
- Continue clozapine in pregnancy and post-partum
- Continue clozapine in pregnancy stop postpartum
- Stop now and start after delivery
- Stop now and do not restart until after breastfeeding complete
Continue clozapine in pregnancy stop postpartum
(Typically you would continue an agent in breastfeeding if they were exposed in utero, but exceptions are when there are severe side effects with conitnued exposre such as clozapine,infant appears to be having side effects)
CLozapine has been associated iwth floppy baby syndrome, infants exposed in utero should be monitored for agranulocytosis first weeks of life
Geriatric with LBD, tx of choice for behavioural sx:
a. Rivastigmine
b. Memantine
c. Cipralex
d. Clonazepam
Rivastigmine
Adult male with tics. Not on meds. Which therapy is most useful?
- Habit reversal
- Exposure response prevention
Habit reversal
Geriatric with LBD, tx of choice for behavioural sx:
a. Rivastigmine
b. Memantine
c. Cipralex
d. Clonazepam
Rivastigmine
Patient with OCD, fear of germs and ++hand washing. Grew-up in home with sanitation issues. What is key component of therapy?
- Exposure and response prevention
- Explore past issues leading to her fears of contamination
- Have her chart thoughts about contamination on paper and cognitive restructuring
- Use downward arrow technique to uncover underlying fear
Exposure and response prevention
(If “DIRT” specifically was an option, would go with that)
Which is true about establishing interpersonal inventory in IPT?
- Part can be done as homework
- Challenges the sick role
- Includes past and present relationships
- Helps to establish goals of therapy
Helps to establish goals of therapy
“Mirror transference” who did it?
- Kohut
- Anna Freud
- Melanie Klein
Kohut
- Narcissistic Transferences
- The therapist comes to represent, in Kohut’s terms, either the grandiose self in mirror transferences or the idealized parental imago in idealizing transferences. In idealizing transferences, all power and strength are attributed to the idealized object, leaving the subject feeling empty and powerless when separated from that object.
Which of the following is true in the treatment of catatonia
- May require high dose benzo (up to 16mg/d ativan)
- Benzos treat retarted cataonia better than excited catatonia
- ECT contraindicated in neurological d/os
- In a patient with SCZ you treat catatonia with atypical psychotics
May require high dose benzo (up to 16mg/d ativan)
Kid with night terrors, what on the EEG?
- Slow waves
- Sleep spindles
- Sawtooth waves
- Alpha waves
Slow Waves
On VPA, topirimate, quetiapine Delirious, normal VPA, ataxia, normal LFTS, high ammonia
a. Stop VPA
b. Stop quetiapine
c. Treat with an antipsychotic
Stop VPA
(high ammonia, ALWAYS STOP)
What is the most common comorbidity with ASD?
Intellectual Disability
- What is the biggest factor in the development of physician burnout?
- Having a history of depression
- Having lots of administrative responsibilities
- Increased risk of litigation
- Age
Having lots of administrative responsibilities
Others:
- Female
- Earlier in Career
- Dissatisfaction with Work
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
Memantine, all except?
a. Is indicated in mod-severe dementia (Health Canada)
b. Should be used in combination with AChEI for mod-severe dementia
c. Common side effects dizziness, headache, and somnolence
d. Significant improvements seen in 16 weeks
Significant improvements seen in 16 weeks
Geriatric with LBD, tx of choice for behavioural sx:
a. Rivastigmine
b. Memantine
c. Cipralex
d. Clonazepam
Rivastigmine
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 are scales that can be used to assess risk of violence?
- HCR 20 (Historical, Clinical Risk Management)
- VRAG (Violence Risk Appraisal Guide)
- PCL-R (Psychopathy Checklist-Revised)
- McArthur-Iterative Classification Tree
What are common medications that cause psychiatric symtpoms?
- Interferon
- Corticosteroids (e.g. prednisone)
- Varenicline (Champix; used for smoking cessation)
- Immune modulating treatments (interferon alpha, interleukins)
- Mefloquine (used in the prevention of malaria)
- Progestin-releasing implanted contraceptives
- Propranolol
What are risk factors for suicide?
SAD PERSONS Scale:
- Sex: Women attempt suicide 3 times more often than men, but men succeed more than 3 times as often as women
- Age: High risk groups include men 45 years of age or more and adolescents 19 years of age and younger
- Depression: 10% to 20% of patients [hospitalized for depression] commit suicide
- Previous attempt: Patients who have previously tried to commit suicide are 64 times more likely than the general population to attempt suicide again. This increased risk is also a lifetime risk and does not diminish with time.
- Ethanol abuse: An estimated 15% of patients with a history of alcohol abuse commit suicide
- Rational-thinking loss: The presence of psychosis increases the risk of suicide
- Social supports lacking: Social isolation from friends, relatives or community increases suicidal motivation
- Organized plan: Patients with a specific plan outlining a lethal available method are at increased risk
- No spouse: In older patients, widows and widowers have the highest rate of suicide
- Sickness: The presence of a chronic or severe illness increases the risk of suicide.
What is risk of GI bleed on SSRI?
SSRI antidepressants are associated with an increased risk of GI bleeding. The most recent meta-analysis estimated an OR of 2.36 with NNH of 441 (Loke et al 2008). Overall the risks of bleeding need to be weighed against the need for treatment and the patient should be helped to make a clinical decision based on the best available evidence.
What is risk of NSAIDs and SSRI?
potential increased risk of bleeding when SSRIs are combined with NSAIDs, which compounds the risk (OR 6.33, NNH 106 – Loke et al 2008).
What does a 95% CI mean?
- The 95% CI of an estimate will be the range within which we are 95% certain that the true effect will lie.
- The width of a confidence interval indicates the precision of the estimate.
- The wider the interval, the less the precision.
- A very wide interval makes us less sure about the accuracy of the estimate of the effect.
- If the confidence interval for relative risk or odds ratio for an estimate includes 1, then there is not a statistically significant difference between the groups being compared; if it does not include 1, then we say that there is a statistically significant difference.
What is an Odds Ratio?
The OR represents the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure.
Eg. If a study has an OR of 3, it means that the group with the the exposure has a 3x higher risk of the outcome of interest compared to the group without the exposure
What is a p-value?
- Probability that the null hypothesis is true
- Null hypothesis says that there is no difference or no change between the two tests
- A smaller p-value means the more confident we are that the alternate hypothesis is true
- Alternative hypothesis is what we set out to investigate
What is relative risk?
Relative risk is a ratio of the probability of an event occurring in the exposed group versus the probability of the event occurring in the non-exposed group
What is Absolute Risk?
Absolute risk is the actual risk of some event happening given the current exposure. For example, if 1 in 10 individuals with exposure develops the disease then the absolute risk of developing the disease with exposure is 10% or 1:10.
What is an Odds ratio?
The odds ratio compares the odds of some event in an exposed group versus the odds in a non-exposed group and is calculated as the number of events / the number of non-events.
How do you calculate Odds Ratio vs Relative Risk?
What are risks of SSRIs in pregnancy?
- All SSRIs are transmitted into the breastmilk, but importance should be paid to the relative infant dose (RID).
- All SSRIs are excreted at 10% or less in the breastmilk, but concentrations do vary.
- Sertraline is considered the safest of the SSRIs, with RID of 0.5-3% based on a therapeutic dose.
- The next “safest” is generally considered escitalopram with doses of 3-6%. Some SSRIs are higher, with dose ranges in the 8-10% range.
- Although studies are somewhat limited, there is no evidence to date that there are any negative sequelae in infants who have been breastfed by women taking SSRIs in the postpartum period.
What are risk factors for postpartum depression?
- Psychological: Previous history of anxiety or depression; depression during pregnancy; negative attiude during pregnancy; history of sexual abuse.
- Obstetric: Multiparity (2 or more); emergency caesarean section; hospitalization during pregnancy; postpartum complications; birth of baby who is low birth weight (<1500 g).
- Biological: Younger age; Moderate to severe PMS; anemia at day 7 after delivery; thyroid dysfunction in pregnancy.
- Social: recent stressors; limited social supports; low income.
- Lifestyle: Insomnia during pregnancy (if history of PPD); poor sleep in postpartum period; poor diet.
What are DSM criteria for Schizophrenia?
The DSM 5 criteria for schizophrenia are:
- Two or more of the following, each present for a significant portion of the time during a 1-month period (or less if successfully treated), at least one must be (1) (2) or (3)
- Delusions
- Hallucinations
- Disorganized speech (frequent derailment or incoherence)
- Grossly disorganized or catatonic behaviour
- Negative symptoms (diminished emotional expression or avolition
- For a significant portion of the time since the onset of disturbance, level of functioning in one or more major areas, such as work, interpersonal relations or self-care is markedly below the level achieved prior to onset
- Continuous signs of the disturbance last for at least 6 months . the 6-month period must include at least 1 month of active symptoms and may include periods of prodromal residual symptoms
- Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been rule out
- Disturbance is not attributable to the physiological effects of a substance or another medical condition
- If there is a history of ASD or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations in addition to the other required symptoms are also present for at least one month
Specifiers:
First episode, currently in acute episode
First episode, currently in partial remission
First episode currently in full remission
Multiple episodes currently in acute episode/partial remission/full remission
Continuous
With catatonia
What is a differential for hyponatremia in someone with psychosis?
DDX for hyponatremia:
Hypovolemic
- Renal loss- diuretics, low magnesium, hypoadrenalism
- GI loss- vomiting, diarrhea
- Skin loss- sweat, burns
- Blood loss
Euvolemic
- Hypothyroidism
- Psychogenic polydipsia
- SIADH (ADH released and free water increases thereby diluting the blood and decreasing Na)- stress ,pain, cancer, lung disease, medications (CBZ, SSRI, morphine)
- Hypervolemic*
- CHF, cirrhosis, malnutrition, nephrotic syndrome
Exceptional candidate will note that hyponatremia extends beyond the psychosis and so it is important to consider a broad differential
What psych medications can impact sodium levels?
- The ones that are most common in psychiatry include carbamazepine and antidepressant medications
- Antidepressant medications; usually cause this in older adults however it can also occur in younger people
- Hyponatremia is uncommon with divalproex with a <1% occurrence
- First and Second-generation antipsychotic medication (i.e. risperidone); is known to cause antidiuretic hormone dysfunction called PIP (polydipsia, intermittent hyponatremia and psychosis syndrome)
- Illicit substances- MDMA can also cause hyponatremia
What are symptoms of low sodium?
- Symptoms usually develop within 2 weeks of treatment initiation
- Presentation is usually of: confusion, somnolence, fatigue, delirium, hallucinations, urinary incontinence, hypotension and vomiting
What should we be aware of hematologically when prescribing psychotropic drugs?
Almost all classes of psychotropic agents have been reported to cause blood dyscrasias. Mechanisms include direct toxic effects upon the bone marrow, the formation of antibodies against haematopoietic precursors or involve peripheral destruction of cells.
- Thrombocytopenia
- Agranulocytosis
- Anemia
- Sometimes neuropenia (eg epival in children)
What is an approach to improving quality of care?
CQI
-
PDSA: Plan, Do, Study, Act
- The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).
- Six Sigma DMAIC: Define, Measure, Analyze, Improve, Control
Define what problem needs to be solved. Measure Performance. Analyze Data. Improve process. Control - to sustain the gain.
How do you undertake an audit?
Step 1: Select Topic and Aims of audit
Step 2: Agree on Target Criteria and Standards
Step 3: Collect data
Step 4: Compare Data with Target Criteria and Standards
What is the best method for collecting data for a chart review/audit?
With a retrospective audit, data are collected after care has been given.
Random sampling is the preferred method. Patients’ charts are chosen on the basis of numbers generated by a computer or random-numbers table.
With systematic (or quasi-random) sampling, every “nth” chart is selected. For example, in a population of 1,000 patients, with a desired sample size of 100, every 10th chart would be chosen.
What can be done if a chart audit shows low adherence to targets?
- Provide feedback to the clinicians
- Provide education and training
- Distribute guidelines
- Build in point-of-care tools or prompts into the electronic record
- Revamp team roles in care delivery
What outpatient performance indicators could we put in place for ongoing monitoring of quality of care and safety?”
- admission rates to hospital of registered outpatients
- number of suicide attempts by outpatients of service
- number of emergency room visits by outpatients
- ongoing review of complaints
- incident reporting
- side effects reporting
- rates of no-shows
- dropout rates
- patient satisfaction surveys
- referring source satisfaction surveys
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
How would you explain rTMS?
- rTMS stands for Repetitive Transcranial Magnetic Stimulation
- It is a kind of neurostimluation treatment, like ECT.
- Although ECT is more efficacious than rTMS, patients may prefer rTMS because it is better tolerated, does not require anesthesia or induction of seizures.
- Indicated for patients with unipolar major depression who have failed at least one antidepressant medication
- It treats major depression by modulating activity in cortical regions and associated neural circuits
- Uses an alternating current passed through a metal coil placed against the scalp to generate rapidly alternating magnetic fields, which pass through the skull, inducing electric currents that depolarize neurons in a focal area of the surface cortex
- The magnetic field generated by rTMS is comparable to that of a standard magnetic resonance imaging (MRI) device (approximately 1.5 to 3 Tesla)
- The mechanism of action of repetitive TMS is unknown. Hypotheses include:
- Stimulation alters pathologic activity within a network of brain regions involved in mood regulation. This is supported by functional imaging studies
- Molecular effects including increased monoamine turnover and normalization of the hypothalamic pituitary axis
What are side effects of rTMS?
Side Effects
- Generally safe and well-tolerated
- Headache (about 25-30%) and scalp pain (30-40%)
- Generalized tonic-clonic seizure seizures (less than 0.1 to 0.5 %)
- Hypomania and mania have been described
- Transient (<4 hours) increase in auditory threshold (Caused by repeated clicks current passes through the coil) - hearing loss is prevented with foam earplugs or noise protection ear coverings
- Vasovagal syncope (management generally consists of reassurance)
What are contraidnications to rTMS?
- People at increased risks for seizures* (ex. Hx of seizures)
- Implanted metallic hardware (eg, aneurysm clips or bullet fragments)
- Cochlear implants
- Implanted electrical devices (eg, pacemakers, intracardiac lines, and medication pumps)
- Unstable general medical disorders
**It may be possible to safely use in people with a personal or family history of seizures if the stimulation frequency is low (≤1 pulse per second) and stimulation intensity does not exceed the recommended safety range. However, patients at increased risk for seizures should be considered for rTMS only if the potential benefit outweighs the increased risk.
What is effect size?
Effect size (d) is a quantitative measure of the magnitude of the experimental effect. The larger the effect size the stronger the relationship between two variables.
(Mean of Exp Group - Mean of control group) / standard dev of either group
Effect size values correspond roughly to small (0.3 range), medium (0.5 range) or large effects (>0.8), therefore this effect is small.
What is the cause of ASD?
· Considered to be a polygenetic neurodevelopmental disorder.
§ There are multiple genetic causes
§ Brain development and function are affected
§ Brain development is disrupted very early on: as early as in utero, and certainly within the first year
Children with ASD do continue to grow and develop skills over their lifetime but are generally delayed with respect to social and communication development
What are criteria for ASD?
· The following are core social communication criteria – name 1 criterion + give example (4 points – for all 6 points should give main domain and subdomains and at least two overall examples)
o Children must show persistent deficits across multiple contexts, currently or by history in:
o 1. Social-emotional reciprocity: e.g., abnormal social approach; failure to engage in normal back-and-forth conversation; reduced sharing of emotions, interests or affect; failure to initiate or respond to social interactions
o 2. Nonverbal communicative behaviors used for social interaction: e.g., poorly integrated verbal and nonverbal communication; abnormalities in eye contact and body language; deficits in understanding or use of gestures; total lack of facial expressions and nonverbal communication
o 3. Developing, maintaining and understanding relationships; e.g., problems adjusting behavior to suit different social contexts, difficulty sharing in imaginative play, problems making friends, absence of interest in peers
The following criteria outline restricted/repetitive behaviours or interests (2 points, give at least 2 examples for full marks):
- Stereotyped or repetitive movements, use of objects or speech
- Insistence on sameness, inflexible adherence to routines, ritualized patterns of verbal or nonverbal behaviour
- Highly restricted, fixated interests that are abnormal in intensity or focus
- Hyper- or hyporeactivity to sensory input
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%
What would help you differentiate between LBD and PDD?
‘The one year rule’. The key differentiating feature is the temporal sequence in with the parkinsonism and the neurocognitive disorder appear. In PDD the cognitive decline should not reach the stage of major NCD until at least one year after Parkinson’s Disease has been diagnosed. If less than a year has passed since the onset of motor symptoms the diagnosis is LBD.
What are criteria for Major NCD due to LBD?
Core diagnostic features:
- Fluctuating cognition with pronounced variations in attention and alertness.
- Recurrent visual hallucinations that are well formed and detailed.
- Spontaneous features of parkinsonism, with onset subsequent to the development of cognitive decline.
Suggestive diagnostic features:
- Meets criteria for rapid eye movement sleep behavior disorder.
- Severe neuroleptic sensitivity.
How to treat hallucinations in LBD?
Clozapine – most evidence but concerns re use in the elderly
Quetiapine – no clear evidence but is often used in practice
Rivastigmine
What are considerations in prescribing antipsychotics to people with LBD?
- Risks of antipsychotic use in patients with LBD and PDD due to severe neuroleptic sensitivity
- Risks attendant with use of antipsychotics In patients with Dementia
risk of all cause mortality and cardiovascular events with atypical antipsychotics (1/100 patients will die, relative risk 0.7 – 0.9).
- Mentions Health Canada Black Box warning regarding the use of Atypical Antipsychotics with patients with Dementia (NCD)
- A discussion of the need to weigh the risks and benefits of treatment eg noting potential risk to wife given delusional beliefs and distress of patient
What are criteria for FTD?
- The criteria are met for major or mild neurocognitive disorder.
- The disturbance has insidious onset and gradual progression.
- Either (1) or (2):
- Behavioral variant:
Three or more of the following behavioral symptoms:
- Behavioral disinhibition.
- Apathy or inertia.
- Loss of sympathy or empathy.
- Perseverative, stereotyped or compulsive/ritualistic behavior.
- Hyperorality and dietary changes.
- Prominent decline in social cognition and/or executive abilities.
Language variant:
- Prominent decline in language ability, in the form of speech production, word finding, object naming, grammar, or word comprehension.
- Relative sparing of learning and memory and perceptual-motor function.
The disturbance is not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of a substance, or another mental, neurological, or systemic disorder.
What are main criteria for Alzheimer’s Dementia?
- Clear evidence of decline in memory and learning and at least one other cognitive domain (based on detailed history or serial neuropsychological testing).
- Steadily progressive, gradual decline in cognition, without extended plateaus.
- No evidence of mixed etiology (i.e., absence of other neurodegenerative or cerebrovascular disease, or another neurological, mental, or systemic disease or condition likely contributing to cognitive decline).
What are criteria for Narcissitic Personality Disorder?
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
- Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
- Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
- Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
- Requires excessive admiration.
- Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
- Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
- Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
- Is often envious of others or believes that others are envious of him or her.
- Shows arrogant, haughty behaviors or attitudes
What are criteria for Dependent PD?
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
- Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
- Needs others to assume responsibility for most major areas of his or her life.
- Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.)
- Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
- Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
- Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.
- Urgently seeks another relationship as a source of care and support when a close relationship ends.
- Is unrealistically preoccupied with fears of being left to take care of himself or herself.
What are criteria of avoidant PD?
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
- Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
- Is unwilling to get involved with people unless certain of being liked.
- Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
- Is preoccupied with being criticized or rejected in social situations.
- Is inhibited in new interpersonal situations because of feelings of inadequacy.
- Views self as socially inept, personally unappealing, or inferior to others.
- Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
What i
Key defense mechanism used in OCPD
Reaction Formation - taking an unacceptable impulse, and behaving in the opposite, corrective way
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
32 yo woman with schizophrenia, on risperidone. Experiences weight gain, galactorrhea, learns these are side effects of her medication and requests an alternative.
What is the best option?
- Aripiprazole
- Lurasidone
- Typical
Abilify
- Typicals and Lurasidone block D2 receptors in pituitary, increasing PL
- Lurasidone causes ++ weight gain
Do atypicals cause galactorrhea?
Yes, Typicals and Lurasidone and RIsperidone block D2 receptors in pituitary, increasing PL
In OCD, which treatments are second line?
citalopram, clomipramine, venlafaxine, mirtazapine
What psychosocial treatments can be reccommended for Bipoalr 1?
Maintenance -
psychoeducation**** reccommend to all pts and fam at disaease onset
cognitive behavioural therapy (CBT)
family-focused therapy (FFT),
IPSRT
Peer Support
Mania - no evidence, no reccommendations
Which antidepressant is best used in setting of QTC prolongation?
Wellbutrin - does not prolong QT at all
First line treatment for depression in Menopause
Antidepressants
CBT + other first line psychotherapy
Criteria for Eating Disorder admission
Unstable Vitals: HR<40, BP 80/60 or symptomatic
Weight <70% IBW or <15 BMI
- Cardiac dysrhythmia
- Heart, renal liver compromise
- Dehydration
- Complications of malnutrition
- Refeeding syndrome
- Poor response to outpatient tx
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
How to calculate odds ratio?
OR = odds of disease in exposed / odds of disease in the non-exposed
What is sensitivity and how to calculate it?
The sensitivity of that test is calculated as the number of diseased that are correctly classified, divided by all diseased individuals.
Sn = True Positives/Total Diseased
What are the contraindications to Naltrexone?
Pregnant
Using Opioids
LFTs 3x upper limit normal or cirrhosis
(needs FU liver enzymes after 3 weeks)
In a patient with LBD (depressed, visual hallucinations, parkinsonism), what is the best treatment of psychosis?
- Consider cholinesterase inhibitor & Consider lowering dose of antiparkinson med
- If necessary, can use AP, but only atypical.
RIsk: Limited efficact in LBD, increased risk of death
Meds used in Panic Disorder Augmentation
Clonazepam
Alprazolam
Olanzapine
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
Sleep changes in older adults?
Reduced total sleep time
Reduced Sleep efficiency
Decreased SWS
Increased sleep fragmentation
Increased sleep latency
REM declines after age 65
Phase advance (to bed earlier and wake earlier)
In ECT treatment, if repeatedly cannot get a seizure, do the following:
Assess and reduce or discontinue and anticonvulsant medications
Caffeine
hyperventilation
Indications for Head CT in dementia
- Age < 60 years
- Rapid (e.g., over 1–2 months) unexplained decline in cognition or function
- Short duration of dementia (< 2 years)
- Recent and significant head trauma
- Unexplained neurologic symptoms (e.g., new onset of severe headache or seizures)
- History of cancer (especially types that metastasize to the brain)
- Use of anticoagulants or history of bleeding disorder
- History of urinary incontinence and gait disorder early in the course of dementia (as may be found in normal pressure hydrocephalus)
- Any new localizing sign (e.g., hemiparesis or a Babinski reflex)
–Unusual or atypical cognitive symptoms or presentation (e.g., progressive aphasia
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
30 yo woman no psych history or family history. Comes in with abrupt change, paranoia toward neighbors, confusion, jerky movements, history of “flu-like symptoms” a couple weeks ago, as per her mother. What investigation?
Head imaging - CT or MRI - first
Then
Will likely need LP later
Blood culture
Patient is on Lithium, stable dose, doing well. Asks you what OTC medications may interfere with his Lithium should he become ill with a cold/flu?
- ibuprofen
- ASA
- Chlorpheniramine
- Phenylephrine
Nonsteroidal Anti-Inflammatory Agents:
May increase the serum concentration of Lithium.
Management: Consider reducing the lithium dose when initiating a NSAID
What findings on neuroimaging in schizophrenia?
Reduction in cortical grey matter
Reduced hippocampal volume
Enlarged ventricle size (lat and 3rd)
decreased amygdala and thalamus
↓symmetry,
↓limbic size (e.g. amygdala),
↓thalamus (ind. of tx)
basal ganglia inc volume (englarged caudate)
What are the top 4 antipschotics associated with elevated prolactin?
Paliperidone
Risperidone
Amisulpuride
Haldol
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
Patient with severe renal and liver disease on linezolid. In hospital, what sleep med would you suggest?
- Temazepam
- Trazodone
- Quetiapine
- Nortriptyline
Temazepam
Do not administer Linezolid with:
TCAS
SSRIs
High tyramine containg foods - bc of risk of serotonin syndrome
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
Approach to treating insomnia in Parkinson’s Disease
- Insomnia – sleep hygiene
- Melatonin
- Doxepin/trazodone
- Clonazepam = rem sleep disorder
What is risk of lithium + ECT?
- ECT + lithium is associated with 12-fold higher odds of delirium compared to ECT alone
- The odd for cognitive impairment is 542% higher for ECT + lithium compared to ECT only.
. 40 year old male, severe alcohol use, 750 ml whiskey day, history of withdrawal seizures, liver normal, diabetes, HTN (it was clear he needed monitored withdrawal), you are admitting this patient, what should you do
- 1000 mg thiamine PO clonazepam regular
- 100 mg thiamine IM, Chlordiazepoxide 50 mg BID
- 100 mg IM thiamine, diazepam 5mg PRN TID
- 1000 mg po thiamine, Ativan 1-2 mg PRN q4h
100 mg thiamine IM, Chlordiazepoxide 50 mg BID
. Lady on dopaminergic meds for Parkinson’s. Having visual hallucination “little people dancing around”. Doctors have decreased meds to try and reduce symptoms, but still hallucinating. What is the best treatment for hallucinations in Parkinson’s disorder?
Clozapine
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.
Lady talking about sex in church and only eating white food. MMSE 29/30. Family history includes multiple members with earlier onset dementia. What can you treat with?
- Citalopram
- Donepezil
- Risperidone
Citalopram
*In FTD, Citalopram or Trazodone as initial pharmacotherapy for patients with troubling behavioral symptoms
What is the essential component of brief psychodynamic?
- early corrective emotional experience by early transference interpretation
- systematic analysis
Correct: early corrective emotional experience by early transference interpretation
Recall that systematic analysis = psychoanalysis
What leads to the most stigma for mental illness in the world?
- Rural location
- being in an Islamic country
- being male
- having a diagnosis of schizophrenia
Having a diagnosis of schizophrenia
Note that:
- stigma may be lesss sevre in Asian and African countries/ islamic
- Women and people living in rural areas more stigmatized
- men more discrimination in job, women moreso in family/spcial areas
What are first line adjunctive agents in OCD?
Abilify
RIsperidone
Bipolar 45 year old gentleman. CKD from long term lithium. No longer taking lithium. Started Epival but is now depressed. You are starting lamictal, what should you do?
- Halve starting dose of lamictal
- Double Epival
- Halve epival
- double starting dose of Lamictal
Halve starting dose of lamictal
(as epival increases lamotrigine levels)
. 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
Lady talking about sex in church and only eating white food. MMSE 29/30. Family history includes multiple members with earlier onset dementia. What can you treat with?
- Citalopram
- Donepezil
- Risperidone
Citalopram
*In FTD, Citalopram or Trazodone as initial pharmacotherapy for patients with troubling behavioral symptoms
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.
What main findings on EMG Sleep Study for NREM and REM sleep disorder?
NREM – low resting muscle tone
REM- near paralysis of skeletal muscle (loss of REM atonia)
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
40 year old male, severe alcohol use, 750 ml whiskey day, history of withdrawal seizures, liver normal, diabetes, HTN (it was clear he needed monitored withdrawal), you are admitting this patient, what should you do?
100mg IM Thiamine
Diazepam 5mg TID OR Chlordiazepoxide 50mg BID or Lorazepam 1mg QID or Oxazepam 15mg BID
NOT prn because pt has hx of withdrawalseizures
Approach to treating insomnia in Parkinson’s Disease
- Insomnia – sleep hygiene
- Melatonin
- Doxepin/trazodone
- Clonazepam = rem sleep disorder
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
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
Lady pregnant in 3rd trimester. History of bipolar, stable, off meds. Develops depressive symptoms. Wants treatment. Also wants to breastfeed. Best option?
- Quetiapine
- Sertraline
- Lithium
- Valproate
Quetiapine
- All antipsychotics are pregnancy Category C (except for clozapine, which is B)
- Li, VPA = D
- Lamotrigine C
When providing a differential for a formulation station, think through the following
Axis I
Substance- Induced … mood/anxiety/psychotic/OCD disorder/NCD/Sleep
Mood/anxiety/psychotic disorder/OCD/ NCD/ Personality Change… Due to another medical condition
Substance Use Disorders/ Intoxication/ Withdrawal
Personality Disorders
What are environmental reccommendations for dementia and delirium?
ABC
Environment
Underlying Causes - Pain, hunger, constipation
Exercise, routine
Staff education
Speak slowly and gently
Parkinson’s disease, elderly, severe fluctuating motor symptoms (often immobile, described as “freezing”). He only feels depressed when he has the symptoms above. What is the best choice to treat his depressive symptoms?
- Pramipexole
- Bupropion
- Citalopram
- Imipramine
- Seroquel
Pramipexole
In a woman with postpartum psychosis, what is the risk of same in subsequent pregnancies?
40-50% if not treated
Which mood stablizer is a) ideal in breastfeeding and b) which is less preferable?
a) Valproate or atypical antipsychotics (ziprasidone and quetiapine less preferable according to ACOG)
b) Lithium - not recommended, but some studies recently showing overall risk to baby is low. If it is used in breastfeeding, must monitor Li levels of fetus as well as mother
What are factors indicating a good candidate for psychodynamic psychotherapy/expressive therapy?
Signfiicant Suffeirng
Strong motivation to understand, persevere and change
Psychological mindedness
Ego Strength
Ability to form relationship
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
You are treating a 34M with schizophrenia. In his last episode of psychosis he stabbed a neighbor who he thought was the devil. He has been stable for the last 6 months on Invega IM q4wks. Recently he has begun to complain of gynecomastia and galactorrhea. You check PRL, which is high. You are convinced that the symptoms are a side-effect of his medication. What is the best initial step?
- Add Abilify.
- Switch to Seroquel.
- Switch to Zuclopenthixol.
- Repeat PRL in 3 months.
Add Abilify
- Abilify is a partial D2 receptor agonist, has been reported to improve AP-related HPL
- Seroquel is not long acting
- Zuclopenthixol good because long acting, but also can cause HPL
- No need to repeat PRL, as of little clinical benefit, and he is symptomatic
What is the definiton of specificity?
Specificity measures the proportion of negatives that are correctly identified (i.e. the proportion of those who do not have the condition (unaffected) who are correctly identified as not having the condition).
It is a measure of validity.
What is the definition of sensitivity?
One measure of test validity is sensitivity, i.e., how accurate the screening test is in identifying disease in people who truly have the disease. When thinking about sensitivity, focus on the individuals who, in fact, really were diseased.
It is a measure of validity.
What is the definition of positive predictive value?
Positive predictive value is the probability that subjects with a positive screening test truly have the disease.
What is the definition of negative predictive value?
Negative predictive value is the probability that subjects with a negative screening test truly don’t have the disease.
What is a test validity?
What is accuracy?
Test validity is the ability of a screening test to accurately identify diseased and non-disease individuals. An ideal screening test is exquisitely sensitive (high probability of detecting disease) and extremely specific (high probability that those without the disease will screen negative).
The validity of a screening test is based on its accuracy in identifying diseased and non-diseased persons, and this can only be determined if the accuracy of the screening test can be compared to some “gold standard” that establishes the true disease status. The gold standard might be a very accurate, but more expensive diagnostic test.
What is characteristic of EEG tracings at the onset of a true episode of narcolepsy?
- low voltage high frequency waves.
- 2-7/sec spikes.
- generalized slowing of alpha waves.
- low voltage high frequency waves.
Lady in 30s with schizophrenia with onset 3 years ago. Which factor leads to worse prognosis?
- Avolition
- Her age of onset
- Gender
- Hallucinations
Avolition
What factors are associated with a better overall prognosis in schizophrenia?
- being female
- rapid onset of symptoms
- older age at first episode
- predominantly positive > neg symptoms
- presence of mood symptoms
- good pre-illness functioning
Male with rapid cycling bipolar disorder (4 episodes/ year). On epival. Gives level, which is high end of normal. What is the most important thing to check for this case?
- Liver
- Thyroid
- CBC
Thyroid
Bipolar patient recovered from manic episode. What is the best psychotherapy to offer?
- Psychoed
- IPSRT
- Peer support
- MBCT
Psychoeducation
In maintenance, psychoed is first line
In depression, no first line, but CBT and FFT are second line
Patient with LBD, visual hallucinations, parkinsonism. What to give?
a) Risperidone
b) Citalopram
c) Acetylcholinesterase inhibitor
d) Quetiapine
Acetylcholinesterase inhibitor
(Note that cholinesterase inhibitors are efficacious in DLB, with reported benefit not only in cognition, but also for fluctuations, psychotic symptoms, and parkinsonian symptoms.)
What would be seen on neuroimaging in schizophrenia?
a) Increased amygdala
b) Decreased hippocampus
c) Decreased ventricle size
Decreased hippocampus
59yo female with hx of schizophrenia has been stable on risperidone for several years. Her family noticed lip puckering. This is highly distressing, and the patient wants it treated. A dose reduction did not help. What has the best evidence?
a) Abilify
b) Clozapine
c) Add Cogentin
d) Add propranolol
Clozapine
Recall Strategies for TD
- DC agent if possible
- Clozapine or quetiapine
- Clonazepam
- Botox
- Valbenazine/tetrabenazine
- Trihexanphenaydl/Cogentin – not usually reccommende
66yoF has symptoms of FTD (inappropriate sexual comments, disinhibited). Her mother died in a psychiatric institution at age 69. Her husband is embarrassed to take her outside. Treatment?
a) Citalopram
b) Risperidone
c) Memantine
Citalopram
EEG findings in delirium
Decreased alpha and generalized delta theta.
Patient overweight, GI bleed, hypertension, atypical depression. Best antidepressant:
a) venlafaxine
b) moclobemide
c) phenelzineu
d) fluoxetine
Moclobemide
- Venlafaxine and Fluox risk of HTN
- Irreversible MAOIS always risk HTN crisis when ingested with tyrosine
- Venlafax and Flux small risk of GI bleed 1 in 300 pt years
- Atypical depression – MAOs may have superiority
- Still very small risk of htn crisis with Moclobemide even thnogh reversible
Woman who is 6 weeks pregnant. 6 months ago she had a 1 month manic episode, she is 6 weeks pregnant. What to do with Lithium?
a) Half lithium dose until second trimester
b) Discontinue Lithium until second trimester
c) Start lamotrigine
d) Continue lithium at therapeutic dose
Continue lithium at therapeutic dose
What is risk of lithium during pregnancy?
- Risk of Ebstein Abnormality 1st trimester
- Recently, found that this defect only occurs in less than 1% of exposed children.
- Also been associated with perinatal toxicity, including case reports of hypotonia, cyanosis, neonatal goiter, and diabetes insipidus.
- In severe BD, risk of recurrence may overshadow risk of Ebstein
- For women with significant periods of euthymia and few past mood episodes, slowly tapering off lithium and reintroducing lithium after the first trimester may help reduce the risk of relapse.
Patient with recent stroke is having episodes of spontaneous crying and is very embarrassed. No depressive symptoms. She is avoiding going out because of episodes. Best treatment?
a) nortiptyline
b) citalopram
c) Risperidone
d) Trazodone
Nortriptyline OR citalopram
Treatment of PBA
TCAs (nortrip, amitrip)
SSRIs fluox, citalopram, setraline
Dextromethorphan-quinidine
Best evidence for managing agitation in mild to moderate dementia
a) trazodone
b) risperidone
c) citalopram
Risperidone
(even better than citalopram)
Indication for supportive therapy?
a) Ego deficits
b) Has high frustration tolerance
c) Has good interpersonal relationships
Ego Deficits
- Supportive psychotherapy is generally indicated for those patients for whom classic psychoanalysis or insight-oriented psychoanalytic psychotherapy is typically contraindicated—those who have poor ego strength and whose potential for decompensation is high
Best evidence to treat visual hallucinations in Parkinson’s’?
CLozapine
Which of the following is not true re: delusional disorder?
a) M>F
b) May be an indicator of neurocog disorder
c) Not increased w/ life stressors
a) M>F
- Slight more F>M, but very similar
- F more likely to have erotomania
- M more likely paranoid
- Pts married and employed
- Some assoc with recent immigration and low SES
- May appear to be delusional disorder, but can be an ealry sign of dementing illness
- Other Risk Factors
- Advanced age
- sensory impairment
- isolation
- fam hx
- Personality featues (interpersonal sensitivity)
Who coined “ambivalence, autism, association, affect”?
a) Bleuler
b) Schneider
c) Kraeplin
Bleuler
First coined the term shcizophrenia
Defined with the 4 As
Man on Clozapine x 6 years with BMI 35. Lipids elevated, glucose normal. 1 month fatigue and shortness of breath. Next ix after exam and ECG?
- echo
- exercise stress
- holter
Echo
- Any cardioresp symptoms –> ED
- Myocarditis fatal 1/3 of time
Man on Lithium. Given CBZ and Naprosyn and Lamotrigine. What would indicate drug drug interaction?
a) Tender hepatomegaly/ increased liver enzymes
b) Lesions on mucous membranes
c) Dysarthria
d) Fever
Dysarthria
When Naproxen and Li combined can increase Li levels –> confusion, tremor, slurred speech, and vomiting
Woman is 3rd trimerster. Feels depressed, has history of depression. Wants to start something, also plans to breastfeed. Best option?
a) Paroxetine
b) Sertraline
c) Fluoxetine
Setraline
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
Decreased perfusion tempoparietal lobe on PET, which disorder?
a) HIV neurocog
b) LBD
c) Alzheimer’s
d) Vascular
Alzheimer’s
Target for Deep Brain Stimulation in Depression?
subcallosul cingulum
Neurotransmitter involved in mechanism of relapse
Glutamate
Patient develops first episode psychosis. Good prognostic factor?
a) young onset
b) family history affective disorder
family history affective disorder
What are criteria for inpatient admission for Eating Disorder?
- <40BPM
- BP <80/60 or presyncope
- QTc >499 or any rhythm other than normal sinus rhythm or sinus bradycardia.
- Wt <70% IBW
- BMI 14-15
- Cardiovascular, hepatic, or renal compromise requiring medical stabilization.
- dehydration.
- Serious medical complication of malnutrition (eg, syncope, seizures, cardiac failure, liver failure, pancreatitis, hypoglycemia, or marked electrolyte disturbance).
- Moderate to severe refeeding syndrome:
- Marked edema
- Serum phosphorous <2 mg/dL
●Poor response to outpatient treatment
80 yo Woman started on Citalopram 40 mg. Has GERD. Most important investigation?
a) ECG
b) Na
ECG
Max dose in elderly 20mg
Who should get EEG prior starting clozapine?
a) alcohol use disorder
b) Parkinson’s
c) over 65
d) child and adolescent
Child and adolescent
Who should get EEG prior starting clozapine?
a) alcohol use disorder
b) Parkinson’s
c) over 65
d) child and adolescent
Child and adolescent
80 yo Woman started on Citalopram 40 mg. Has GERD. Most important investigation?
a) ECG
b) Na
ECG
Max dose in elderly 20mg
What are criteria for inpatient admission for Eating Disorder?
- <40BPM
- BP <80/60 or presyncope
- QTc >499 or any rhythm other than normal sinus rhythm or sinus bradycardia.
- Wt <70% IBW
- BMI 14-15
- Cardiovascular, hepatic, or renal compromise requiring medical stabilization.
- dehydration.
- Serious medical complication of malnutrition (eg, syncope, seizures, cardiac failure, liver failure, pancreatitis, hypoglycemia, or marked electrolyte disturbance).
- Moderate to severe refeeding syndrome:
- Marked edema
- Serum phosphorous <2 mg/dL
●Poor response to outpatient treatment
Patient develops first episode psychosis. Good prognostic factor?
a) young onset
b) family history affective disorder
family history affective disorder
Neurotransmitter involved in mechanism of relapse
Glutamate
Target for Deep Brain Stimulation in Depression?
subcallosul cingulum
Decreased perfusion tempoparietal lobe on PET, which disorder?
a) HIV neurocog
b) LBD
c) Alzheimer’s
d) Vascular
Alzheimer’s
How to tell between NMS and anticholinergic?
a) hyperthermia
b) tachycardia
c) diaphoresis
diaphoresis
Man with anticholinergic toxicity from OTC sleep aids. What is treatment?
a) Phyostigmine
b) Cyproheptadine
c) flumazenil
Phyostigmine
Woman is 3rd trimerster. Feels depressed, has history of depression. Wants to start something, also plans to breastfeed. Best option?
a) Paroxetine
b) Sertraline
c) Fluoxetine
Setraline
Man on Lithium. Given CBZ and Naprosyn and Lamotrigine. What would indicate drug drug interaction?
a) Tender hepatomegaly/ increased liver enzymes
b) Lesions on mucous membranes
c) Dysarthria
d) Fever
Dysarthria
When Naproxen and Li combined can increase Li levels –> confusion, tremor, slurred speech, and vomiting
Man on Clozapine x 6 years with BMI 35. Lipids elevated, glucose normal. 1 month fatigue and shortness of breath. Next ix after exam and ECG?
- echo
- exercise stress
- holter
Echo
- Any cardioresp symptoms –> ED
- Myocarditis fatal 1/3 of time
Who coined “ambivalence, autism, association, affect”?
a) Bleuler
b) Schneider
c) Kraeplin
Bleuler
First coined the term shcizophrenia
Defined with the 4 As
Which of the following is not true re: delusional disorder?
a) M>F
b) May be an indicator of neurocog disorder
c) Not increased w/ life stressors
a) M>F
- Slight more F>M, but very similar
- F more likely to have erotomania
- M more likely paranoid
- Pts married and employed
- Some assoc with recent immigration and low SES
- May appear to be delusional disorder, but can be an ealry sign of dementing illness
- Other Risk Factors
- Advanced age
- sensory impairment
- isolation
- fam hx
- Personality featues (interpersonal sensitivity)
Best evidence to treat visual hallucinations in Parkinson’s’?
CLozapine
Indication for supportive therapy?
a) Ego deficits
b) Has high frustration tolerance
c) Has good interpersonal relationships
Ego Deficits
- Supportive psychotherapy is generally indicated for those patients for whom classic psychoanalysis or insight-oriented psychoanalytic psychotherapy is typically contraindicated—those who have poor ego strength and whose potential for decompensation is high
Best evidence for managing agitation in mild to moderate dementia
a) trazodone
b) risperidone
c) citalopram
Risperidone
(even better than citalopram)
Patient with recent stroke is having episodes of spontaneous crying and is very embarrassed. No depressive symptoms. She is avoiding going out because of episodes. Best treatment?
a) nortiptyline
b) citalopram
c) Risperidone
d) Trazodone
Nortriptyline OR citalopram
Treatment of PBA
TCAs (nortrip, amitrip)
SSRIs fluox, citalopram, setraline
Dextromethorphan-quinidine
What is risk of lithium during pregnancy?
- Risk of Ebstein Abnormality 1st trimester
- Recently, found that this defect only occurs in less than 1% of exposed children.
- Also been associated with perinatal toxicity, including case reports of hypotonia, cyanosis, neonatal goiter, and diabetes insipidus.
- In severe BD, risk of recurrence may overshadow risk of Ebstein
- For women with significant periods of euthymia and few past mood episodes, slowly tapering off lithium and reintroducing lithium after the first trimester may help reduce the risk of relapse.
Woman who is 6 weeks pregnant. 6 months ago she had a 1 month manic episode, she is 6 weeks pregnant. What to do with Lithium?
a) Half lithium dose until second trimester
b) Discontinue Lithium until second trimester
c) Start lamotrigine
d) Continue lithium at therapeutic dose
Continue lithium at therapeutic dose
Patient overweight, GI bleed, hypertension, atypical depression. Best antidepressant:
a) venlafaxine
b) moclobemide
c) phenelzineu
d) fluoxetine
Moclobemide
- Venlafaxine and Fluox risk of HTN
- Irreversible MAOIS always risk HTN crisis when ingested with tyrosine
- Venlafax and Flux small risk of GI bleed 1 in 300 pt years
- Atypical depression – MAOs may have superiority
- Still very small risk of htn crisis with Moclobemide even thnogh reversible
Man with Lithium level 0.6 who has CHF. Now tremor, ataxia, dysarthria. What is best next step?
a) Hold lithium
b) increase lithium
c) keep lithium same
d) decrease lithium
Hold lithium
Which required for fitness to stand trial?
a) mental disorder
b) not understand consequences
c) not act in best interest
not understand consequences
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
Woman with PMDD symptoms. First line treatment?
a) SSRI
b) OCP
SSRI
Unless contraception is a high priority
Patient is taking tranylcypromine, patient has paresthesia. What deficiency?
a) B3
b) B6
c) B12
B6
How long trial of light therapy before can say unsuccessful?
a) 2 weeks
b) 4-6 weeks
c) 3-4 months
4-6 weeks
- CANMAT - The standard protocol is 10,000 lux (light intensity) for 30 minutes per day during the early morning for up to 6 weeks, with response usually seen within 1 to 3 weeks.
Multiple depressive episodes, rarely well x 3 years. Periods 2-3 days increased productivity, decreased sleep. Dx?
a) BAD II
b) Other specified bipolar disorder
c) cyclothymia
Other specified bipolar disorder
- Short-duration hypomanic episodes (2–3 days) and major depressive episodes
- Hypomanic episodes with insufficient symptoms and major depressive episodes
- Hypomanic episode without prior major depressive episode
- Short-duration cyclothymia (less than 24 months)
Diabetes and schizophrenia:
a) Diabetics without schizophrenia have the same mortality as diabetics with schizophrenia
b) AP choice makes no difference in management
c) Scz less likely get regular monitoring
Scz less likely get regular monitoring
Elderly women with schizophrenia are more likely than males to:
a) have hyperprolactinemia
b) more unnatural death
c) more negative symptoms
d) more substance use
have hyperprolactinemia
- Which is not a risk factor for Delusional disorder?
- Sensory impairment
- Immigration
- Advanced age
- MDD
MDD
- Treatment resistant 37 year old man with OCD, failed with medication which target is area for surgical ablation?
- Cingulate gyrus
- Globus pallidus
Cingulate gyrus
- Which area do you stimulate in rTMS?
- Broadmann area 25
- DLPFC
- Supplementary motor cortex
- Nucleus accumbens
DLPFC
- Anesthesiologist with h/o of opioid use d/o. Abstinent but does not want substitution rx. What is the best rx?
- Buprenorphine
- Naltrexone
- Clonidine
Naltrexone
(recall that Bup = substitution, clonidine just for withdrawal. Naltrexone is antagonist to prevent relapse)
What are your options for treating a pregnant patient with Bipolar Depression?
Lurasidone is Preg Category B
Lamotrigine and Quetiapine are Preg Category C
Li and VPA are Preg Category D
- 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
Pregnant female, ruminating about being bad mother towards first child, Bipolar depression, pregnant at 10 weeks, lots of guilt and other depressive symptoms. Which rx has the best risk/benefit ratio for the mother and foetus?
- Fluoxetine
- Lamotrigine
- ECT
- Aripirazole
ECT
(but quetiapine even better)
- Which is true about postpartum psychosis:
- Late onset (after 4 weeks of delivery) has better prognosis than early onset
- Family history of post-partum psychosis predicts recurrence
- Has a better prognosis than non-puerperal psychosis
Family history of post-partum psychosis predicts OCCURRENCE
Has a better prognosis than non-puerperal psychosis is also true
The risk factors for postpartum psychosis:
●History of postpartum psychosis
●Family history of postpartum psychosis
●History of bipolar disorder, schizophrenia, or schizoaffective disorder
●Family history of bipolar disorder
●First pregnancy
●Discontinuation of psychiatric medications for pregnancy
Woman tells you that her friends say about her that “she sees the glass half empty rather than half full”. This is an example of which cognitive distortion?
- Overgeneralization
- Selective abstraction
- Dichotomous thinking
- Catastrophization
Selective abstraction
- EKG with Torsades de pointes. Which medication was most likely recently added and can cause this rhythm?
- Olanzapine
- Ziprasidone
- Haldol
Ziprasidone
Stem of someone with MMSE 23/30, spontaneous parkinsonism, 6 months of visual hallucinations, dramatic motor side effects in response to olanzapine. What is the most appropriate treatment?
- AChEI
- SSRI
- MDMA antagonist
- Risperidone
AChEI
Which of the following tasks would you not do in the middle phase of IPT?
- Interpersonal inventory
- Linking interpersonal events to mood symptoms.
- Focusing on affect related to chosen interpersonal focus.
- Focus on the task specific to the chosen focus.
Interpersonal inventory
Guy in psychotherapy for anxiety, He is very vague in his answers. When therapist asks how he feels toward him [therapist], the patient looks down and is again very vague. The vagueness represents which part of Malan’s triangle of conflict?
- Defense
- Anxiety
- Impulse
- Transference
Defense
What are areas that can be used to describe patterns from a psychodynamic perspective?
- Self
- Self-perception
- Identity
- Fantasies about self
- Self-esteem
- vulnerability to threats
- internal response to threats
- use of others to regulate self-esteem
- Self-perception
- Relationships
- trust
- sense of self and other
- security
- intimacy
- mutuality
- Adapting
- thresholds and ways of adapting to int/ext stimulation
- Defense mechanism
- impulse control
- managing emotions
- sensory regulations
- Cognition
- general cog abilities
- decison-making and prob-solving
- self reflection/reality testing
- mentalization
- judgment
- Work and Play
What is ego psychology?
- Adult problems and patterns can be linked to unconscious conflicts and defenses
- Unconscious conflict happens when opposing thoughts, feelings, wishes collide
- This conflict is out of our awareness, causes anxiety, and prompts us to use our defenses to work out compromises
- Parts of the mind in constant conflict with each other
- Id
- Superego
- Ego
What is object relations?
- Links problems and patterns to the unconscious repetition of early relationships with others
- Young children take in their experiences with important caregivers through a process called internalization
- These internalized relationshipo patterns are called templates
- Templates remain in unconscious mind through development, affecting the way people think about themselves and others
- Object relations suggests that people reactivate their early relationship templates with the therapist in transference
What is self psychology?
- Self psychology is an organzing idea about development that LINKS problems and patterns to development of self
- Early caregivers perform functions that are essential for the child’s development of self called Selfobject functions because they are experiened by child as part of the self
- EG.
- Mirroring - caregiver’s empathic ability to appropriately reflect the child’s abilities and internal states
- Idealization - caregiver’s ability to be idealized by child
- Grandiosity - children need to be made to feel special and powerful
What are the adult attachment styles?
- Secure
- Insecure
- Dismissive/Avoidant
- Preoccupied/anxious/Ambivalent
- Disorganized/Fearful
What are primitive defense mechanisms?
- Acting Out
- Denial
- Dissociation
- Introjection (internalizing qualities of another person, eg. identification with the aggressor)
- Omnipotent control
- Primitive idealization and devaluation (seeing others as all good or all bad)
- Projection
- Projective Identification
- Splitting
What are secondary/higher order defense mechanisms?
- Altruism
- Anticipation
- Blocking
- Controlling
- Displacement
- Externalization
- Humour
- Hypochondriasis
- Identification
- INtellectualization
- Isolation of affect
- Passive aggressive behaviour
- Rationalization
- Reaction formation
- Regression
- Repression
- Somatization
- Sublimation
- Suppression
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 techniques used in IPT?
- Clarification
- including directive questioning, empathic listening, reflective listening and encouragement of spontaneous discourse
- Communication analysis
- Clarifying Interpersonal incidents
- Use of affect
-“content affect” vs “process affect”
- Role Playing
- Problem solving
- Homework
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
In CBT, what is a core belief?
- Core beliefs, or schemas, are deeply held beliefs about self, others and the world.
- Core beliefs are generally learned early in life and are influenced by childhood experiences and seen as absolute.
- The cognitive triad of negative core beliefs captures how they relate to:
The self, e.g. ‘I’m useless’
The world/others, e.g. ‘the world is unfair’
The future, e.g. ‘things will never work out for me’
In CBT, what is a dysfunctional belief?
Dysfunctional assumptions are rigid, conditional ‘rules for living’ that people adopt. These may be unrealistic and therefore maladaptive. For example, one may live by the rule that ‘It’s better not to try than to risk failing’.
In CBT, what is a negative automatic thought?
Negative automatic thoughts (NATs) are thoughts that are involuntarily activated in certain situations. In depression, NATs typically centre on themes of negativity, low self-esteem and uselessness. For example, when facing a task, a NAT may be ‘I’m going to fail’. In anxiety disorders, automatic thoughts often include overestimations of risk and underestimations of ability to cope.
In CBT, how is a person formulated?
- Longitudinally (Beck)
- Early experiences (e.g. rejection by parents) contribute to the development of –>
- Core beliefs, which lead to the development of –>
- Dysfunctional assumptions (e.g. ‘Unless I am loved I am worthless’), which are later activated following a critical incident (e.g. loss), leading to –>
- NATs (Neg automatic thoughts) and the symptoms of depression.
- Cross-Sectional/Hot-Cross Bun (Padesky)
What are techniques that are used in CBT?
- Cognitive Techniques
- Socratic questioning
- Positive Data Logs
- Thought Records - NATs
- Evidence for/against - dysfunctional assumptions
- Behavioural Techniques
- Activity Scheduling
- Graded Task assignments
- Behavioural Experiments
- Progressive Relaxation
In Bipolar disorder in the postpartum period, which medications are preferred due to lowest RID?
Quetiapine
Olanzapine
How do we select medications for Bipolar Disorder in pregnancy?
- Avoid Divalproex and lithium if we can (but risk benefit always!) Preg Category D
- All Atypicals preg category C
- All SSRIs preg category C (except paroxetine = D)
What should we be aware of when treating bipolar in breastfeeding?
- L4 (avoid) - Li, DVP
- L3 (avoid) - Clozapine
- L2 - atypicals esp OLZ and quetiapine, lamotrigine, carbamazepine, all SSRIs
- ALWAYS discuss risks and benefits and how to monitor infant for signs of toxicity
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.
What is a differential of TD?
- Differential dx: Movement disorders – examples: Wilson’s Disease and Huntington’s Disease
- Schizophrenia and other psychoses can be associated with spontaneous movement disorders with no other demonstrable etiology.
- Other drugs may cause or exacerbate TD:
- Any dopamine receptor blocker (eg antiemetics such as Stemetil, metoclopramide)
- Rarely, SSRIs or SNRIs have been associated with TD
- Anticholinergics may worsen TD (in contrast to beneficial effects on acute EPS)
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.
What is off-label use of medications?
It is use of the drug for a non-approved indication.
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 are the main types of studies?
Randomized controlled trials (RCTs)
Cohort studies
Case-control studies
Qualitative studies
What is a RCT?
- Randomized trials provide the most reliable answers to the question of how effective a tx or dx test is
- RCTs only possible method to draw reliable conclusions about cause and effect
- People are allocated at random to receive one of several clinical interventions.
- One of these interventions is the standard of comparison or control.
- Someone who takes part in a randomized controlled trial (RCT) is called a participant or subject.
- RCTs seek to measure and compare the outcomes after the participants receive the interventions.
- Because the outcomes are measured, RCTs are quantitative studies.
- RCTs are quantitative, comparative, controlled experiments in which investigators study two or more interventions in a series of individuals who receive them in random order.
What is a cohort study?
- A cohort is a group of people who are observed frequently over a period of many years – for instance, to determine how often a certain disease occurs.
- Two (or more) groups that are exposed to different things are compared with each other
- Observe how the health of the people in both groups develops over the course of several years, whether they become ill, and how many of them pass away.
- Can have a prospective (forward-looking) design or a retrospective (backward-looking) design.
- Useful if you want to find out how common a medical condition is and which factors increase the risk of developing it.
- Eg.How does high blood pressure affect heart health?
What is a case control study?
- Compare people who have a certain medical condition with people who do not have the medical condition, but who are otherwise as similar as possible, for example in terms of their sex and age.
- Then the two groups are interviewed, or their medical files are analyzed, to find anything that might be risk factors for the disease
- Generally retrospective.
- Good for studying rare diseases
- Can help to investigate the causes of a specific disease, eg. Do HPV infections increase the risk of cervical cancer?
- Not as expensive or time-consuming as RCTs or cohort studies. But it is often difficult to tell which people are the most similar to each other and should therefore be compared with each other. Because the researchers usually ask about past events, they are dependent on the participants’ memories. But the people they interview might no longer remember whether they were, for instance, exposed to certain risk factors in the past.
What is a cross-sectional study?
- Classic = survey: A representative group of people – usually a random sample – are interviewed or examined in order to find out their opinions or facts.
- Data is collected only once, cross-sectional studies are relatively quick and inexpensive.
- Can provide information on things like the prevalence of a particular disease (how common it is)
- Can’t tell us anything about the cause of a disease or what the best treatment might be
- Eg. How tall are German men and women at age 20?
What is a qualitative study?
- Helps us understand, for instance, what it is like for people to live with a certain disease.
- Based on information collected by talking to people who have a particular medical condition and people close to them. Written documents and observations are used too.
- The information that is obtained is then analyzed and interpreted using a number of methods.
Qualitative studies can answer questions such as these:
How do women experience a Cesarean section?
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 is supportive psychotherapy? Who is it indicated for?
- Supportive psychotherapy aims at the creation of a therapeutic relationship as a temporary buttress or bridge for the deficient patient.
- The primary form used in the general practice of medicine and rehabilitation, frequently to augment other measures, such as prescriptions of medication to suppress symptoms, rest to remove the patient from excessive stimulation, or hospitalization
- Places major etiologic emphasis on external rather than intrapsychic events, particularly on stressful environmental and interpersonal influences on a severely damaged self.
- Indicated for those patients for whom classic psychoanalysis or insight-oriented psychoanalytic psychotherapy is typically contraindicated—those who have poor ego strength and whose potential for decompensation is high.
- Amenable patients fall into the following major areas:
- (1) individuals in acute crisis or a temporary state of disorganization and inability to cope
- (2) patients with chronic severe pathology with fragile or deficient ego functioning
- (3) patients whose cognitive deficits and physical symptoms make them particularly vulnerable and, thus, unsuitable for an insight-oriented approach
- (4) individuals who are psychologically unmotivated, although not necessarily characterologically resistant to a depth approach (e.g., patients who come to treatment in response to family or agency pressure)
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 are criteria for Major Neurocognitive Disorder?
- Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:
- Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and
- A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.
- The cognitive deficits interfere with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications).
- The cognitive deficits do not occur exclusively in the context of a delirium.
- The cognitive deficits are not better explained by another mental disorder
- With behavioural distrubance
- Without behavioural disturbance
- Mild, mod, severe
What are criteria for Mild Neurocognitive Disorder?
- Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:
- Concern of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in cognitive function; and
- A modest impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.
- The cognitive deficits do not interfere with capacity for independence in everyday activities (i.e., complex instrumental activities of daily living such as paying bills or managing medications are preserved, but greater effort, compensatory strategies, or accommodation may be required).
- The cognitive deficits do not occur exclusively in the context of a delirium.
- The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).
What are common types of bias?
- Recall bias
- When survey respondents remember things differently
- Selection bias
- Research samples can sometimes under-represent certain people or groups, and over–represent others. Solution: randomization
- Observation bias (also known as the Hawthorne Effect)
- When participants in a study are aware that they are being observed by scientists and alter the way they act or the answers they give.
- Confirmation bias
- When researchers, consciously or unconsciously, look for information or patterns in their data that confirm the ideas or opinions that they already hold.
- Publishing bias
- Studies with negative findings (i.e. trials in which no significant results are found) are less likely to be submitted by scientists or published by scientific journals because they are perceived as less interesting. This can skew our understanding of a topic because, for example, when carrying out a review or a meta-analysis on a new drug treatment, if this type of data is missing, it can make it seem like a drug is more or less effective than it actually is. This is called publishing bias.
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
What is the difference between a systematic review and meta-analysis?
A systematic review answers a defined research question by collecting and summarising all empirical evidence that fits pre-specified eligibility criteria.
A meta-analysis is the use of statistical methods to summarise the results of these studies.
What features should a systematic review include?
- clearly stated objectives with pre-defined eligibility criteria for studies
- explicit, reproducible methodology
- a systematic search that attempts to identify all studies
- assessment of the validity of the findings of the included studies (e.g. risk of bias)
- systematic presentation, and synthesis, of the characteristics and findings of the included studies
What is a Forest Plot?
- A graphical display of estimated results from a number of scientific studies addressing the same question, along with the overall results
- A means of graphically representing a meta-analysis of the results of randomized controlled trials.
- Usually OR used
Which is correct regarding panic-focused psychodynamic therapy?
- There is no evidence for use in panic disorder
- Interpreting the transference is key
- Equivalent to CBT evidence.
- Therapy focuses on graded exposure
Interpreting the transference is key
Process in brief psychodynamic therapy
- Focus on corrective emotional experience in the transference interpretation early on
- Free association
- Key is the work on conflict resolution people outside of therapy
Focus on corrective emotional experience in the transference interpretation early on
Bill C-14 added the designation “high risk accused” to which population does this apply?
- NCR
- Dangerous offenders
- Unfit to stand trial
- Civilly committed
NCR
- Cognitive symptoms with SCZ. What is the main theory?
- Hyperactivity of DA in mesocortical cortex
- Hypoactivity of DA in mesocortical cortex
- Hypoactivity of DA in mesolimbic cortex
- Hyperactivity of DA in mesolimbic cortex
Hypoactivity of DA in mesocortical cortex
What is the phenotype of a child with FASD?
- smooth philtrum
- thin upper lip
- upturned nose
- flat nasal bridge and midface
- epicanthal folds
- small palpebral fissures
- small head circumference.
Which do you include in the basic tests for dementia?
- Folate and Syphilis
- CT and EEG
- MRI
- Ca and Glucose
Ca and Glucose
- Most characteristic of amphetamine use disorder ?
- Paranoid delusions
- Visual hallucinations
- Loosening of associations
- Thought Disorder
Paranoid delusions
(somatic delusions also very common)
- BPD on venlafaxine and buprenorphine (suboxone), D/c from detox for EtOH.
- Disulfiram
- Acamprosate
- Naltrexone
- Topiramate
Acamprosate
(Because Naltrexone + suboxone not inidicated first line)
- 55 years old man with apathy and binge eating. Mother had ALS, what is in the differential?
- Lewy Body Dementia
- Alzheimer’s
- Frontal Temporal Dementia
Frontal Temporal Dementia
- MCI. Hypercholesterol and diabetes well controlled. Risk factors to develop AD (strongest risk)?
- Low education
- Low vitamin E and D
- Cholesterol
- Current depression
Current depression
What is the annual conversion from MCI to Alzheimer’s Disease?
5-10%
(25% revert to normal)
What are markers determinng risk progression from MCI to dementia?
- b-amyloid and tau protein levels
- CSFP
- APOE
- homocysteine levels
- high LDL
- serum IL-6
- olfactory dysfunction
- changes hippocampal volume on PET
- amyloid plaque on PET
- delayed verbal recall and executive function in neuropsych
What are non-genetic risk factors for Alzheimer’s Disease?
systolic HTN >160mm/Hx (evidence to treat)
- serum cholesterol >6.5mmol/L
- Smoking, current
- hyperlipidemia ( no evidence for statins dec risk though)
- head injury with loss of consciousness
- low education <12 yrs
- Diabetes (vascular dem RF)
- estrogen alone or in combo with progesterone
- occup exposure environmental toxins- pesticides, fertilizers, fumigants and defoliants
- 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
- Elderly man with BAD II, stabilized on Lithium 1200mg, Effexor 75mg and one other medication. Presenting with symptoms of fatigue, poor concentration, and weight gain. Which should you measure?
- TSH
- Sodium
- Calcium
- Renal function
TSH
- Question on a single man with alcohol abuse history on live transplant list. He had refused residential treatment. He has been sober for three months. What is the main risk factor for his relapse after the transplant?
- Abstinent for less than 6 months prior to transplant
- Unemployed prior to transplant
- Didn’t go to rehab before becoming abstinent
- Single
Abstinent for less than 6 months prior to transplant
Predictors of Relapse:
dx SUD vs. abuse
fam hx add
failed rehab
multiple substances
poor soc support
short pretransplant length abstinence.
- Surgeon refers patient with history of GI bleeds and depression. Best choice:
- Paroxetine
- Fluoxetine
- Bupropion
- Fluvoxamine
Buporopion
SSRIs and SNRIs both show increased risk of bleeding in some studies
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
Which is a prodromal sign for Schizophrenia?
- Attenuated positive symptoms
- Substance abuse
- Negative symptoms
- Brief Psychotic symptoms more than one week
Attenuated positive symptoms
these are MOST related
Cognitive difference in MDD vs. neurocognitive disorder
- Alexia
- Visual anosia
- Paraphasia
- Executive dysfunction
Executive Dysfunction
What would you do prior to initiating a cholinesterase inhibitor?
- EKG
- Liver function
- Renal function
- Electrolytes
EKG
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 Investigations are necessary in anorexia nervosa?
- CBC (possible reductions in all cell lines)
- Lytes
- BUN, Cr
- Hypercholesterolemia common
- LFTs may be elevated
- Decreased Mg, Zn, Phosphorous
- Metabolic alkalosis if vomiting (hypochloremic, hypokalemic)
- Metabolic acidosis with laxatives
- Thyroid - T4 low-normal, T3 decreased, reverse T3 elevated
- Low E for females, Low T for males
- ECG - bradycardia, prolonged QTC
- BMD, if 6 months amenorrhea
What are symptoms of lithium toxicity?
- Nausea
- vomiting
- diarrhea
- sluggishness
- ataxia
- confusion
- agitation
- neuromuscular exictability (coarse tremor, fasciculation, myoclonic jerks)
- Severe - seizures, encephalopathy
Which history is consistent with seasonal pattern mood disorder?
a) Man with 2 seasonal depression and 7 non-seasonal depressions
b) Man has had one previous hypomanic episodes and past 3 years has had depressions starting in winter and resolving in spring, related to seasonal employment
c) Man has had depressive episode for past 3 years with onset in winter and resolution in spring, and one previous manic episode 5 years ago
Man has had depressive episode for past 3 years with onset in winter and resolution in spring, and one previous manic episode 5 years ago
Panic disorder, what is true?
a) Combination of CBT and meds are more effective
b) medication is more effective than CBT
c) CBT is more effective than medication
d) Using Lorazepam is detrimental during exposure therapy
Combination of CBT and meds are more effective
Which psychosocial intervention has evidence in PTSD?
a) Critical incident debriefing
b) CBT
c) ?
d) ?
CBT
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
Which is NOT an evidence-based pharmacologic treatment for aggression/impulsivity in Borderline PD?
a) Antipsychotic
b) mood stabilizer
c) SSRI
d) Clonazepam
Clonazepam
Recall in BPD
a) Antipsychotic (Aripiprazole)
b) mood stabilizer (Topiramate?)
c) SSRI (Fluoxetine?)
Woman with Bipolar disorder, stable on Lithium long-term. In hospital with abdominal pain, nausea, vomiting, disorientation. What is likely underlying cause?
a) hypercalcemia
b) hypothyroid
c) renal
d) ?
hypercalcemia
*Remember that lithium can cause hyperparathyroidism and hypercalcemia
Which is NOT a feature of catatonia?
a) Abulia
b) Negativism
c) Posturing
d) Mutism
Abulia
Recall:
WiN MaC -SP GAME2S
- Waxy flexibility – slight, even, resistance to positioning by examiner
- Negativism – do the opposite of what is asked/ no response to instructions or external stimuli
- Mutism – no/very little verbal response
- Catalepsy –passive induction of a posture held against gravity
- Stupor – no psychomotor activity; not actively relating to environment
- Posturing – spontaneous & active maintenance of a posture against gravity /adoption of unusual bodily postures continuously for a long time
- Grimacing
- Agitation – not influenced by external stimuli
- Mannerism – repeated movements that appear to have some functional significance e.g. saluting
- Echolalia – mimicking another’s speech
- Echopraxia – mimicking another’s movements
- Stereotypy – repetitive, abnormally frequent non-goal directed movements e.g. rocking to and fro
Patient started on clozapine for treatment refractory schizophrenia. Develops tachypnea, tachycardia, chest pain, pulmonary edema. Afebrile, auscultation reveals basilar crackles bilaterally. Inverted T-waves on ECG. Most likely Dx?
a) Clozapine-induced tachycardia
b) MI
c) Clozapine-induced myocarditis
d) Pneumonia due to agranulocytosis
Clozapine-induced tachycardia
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
21 year old male with schizophrenia, diabetes, and cannabis use disorder. On Risperidone. Which of the following is most significant risk factor for developing tardive dyskinesia?
a) Age
b) Male
c) Cannabis use
d) Diabetes
Diabetes
Risk Factors for TD
- Older
- female
- First > SGA
- Duration
- dose
- early occurrence of drug induced movement disorders
- Shchiz
- ID
- ETOH or SUD
- Dementia
- Diabetes
- Prior ECT
Neurotransmitter responsible for REM sleep?
a) Serotonin
b) Acetylcholine
c) Dopamine
d) Norepinephrine
Acetylcholine
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
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.
Treatment of Lithium induced tremor:
a. propanolol
b. lorazepam
c. cogentin
propanolol
Which is true regarding specific phobia?
a. virtual reality exposure is an effective treatment
b. medications are important part of treatment
c. a long treatment period is necessary
virtual reality exposure is an effective treatment
Which of the following assesses frontal lobe functioning:
A. Olfactory testing
B. Luria’s three-step test
C. Evoked potentials
D. Nystagmus
Luria
(Fist edge palm)
Woman in her 30’s with her 3rd episode of depression, how long should she stay on treatment for?
1) 6 months
2) 12 months
3) 60 months
4) 24 months or longer
24 months or longer
What is true of ECT in elderly?
a) no difference in complication rate between adults and elderly – higher comolications
b) response rate is lower in elderly – false – response rate is actually higher
c) elderly have lower seizure threshold – they have a higher
d) elderly have lower mortality with ECT versus other therapeutic options
elderly have lower mortality with ECT versus other therapeutic options
Why other options are wrong:
a) no difference in complication rate between adults and elderly – higher complications in elderly
b) response rate is lower in elderly – false – response rate is actually higher
c) elderly have lower seizure threshold – they have a higher sz threshold
Risk factors for TD, except
a. Lack of Affective disorder
b. Brain lesion
c. Elderly
d. Female
Lack of Affective disorder
Recall, Risk Factors for TD:
- older
- female
- white and african descent
- longer illness duration
- ID and bran damaga
- Neg symptoms in schz
- Mood DIsorders
- Cog sx in mood disorders
- DM
- Smoking
- ETOH and substance abuse
- FGA vs SGA tx
- higher cumulative and current AP dose or plasma levels
- early PD side efects
- anticholinergic co tx
- akathisa
- emergent dyskinesia
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
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.
Patient presenting with panic disorder and benzodiazepine dependence. She has escalated her use of alprazolam but not getting relief for her panic attacks. She is now using 10-12 mg of alprazolam daily and has panic attacks despite paroxetine 40 mg PO daily. What is the next step as an outpatient?
a) Increase paroxetine to 60 mg daily
b) Switch to diazepam 100-120 mg po daily in divided doses and then gradually taper
c) Switch to phenobarbital 300 mg PO daily and taper
d) Cross taper to sertraline 100-200 mg daily
Switch to diazepam 100-120 mg po daily in divided doses and then gradually taper
Though increase paroxetine is also correct, but not the *next step*
Stress management therapy includes all of the following except:
a) Problem solving
b) Peer group support
c) Relaxation techniques
d) Cognitive restructuring
Peer group support
What decreases likelihood of physician burnout and improves communication with patients?
a) Mindful communication training
b) Physician assistance program
c) 2 obvious incorrects
Mindful communication training
First line treatment for delirium. Post CABG.
a) Haloperidol
b) Ziprasidone
c) Risperidone
d) Chlorpromazine
Risperidone
IPT does not have evidence for treatment of which condition?
a) Delusional disorder – neither does schz
b) Social Anxiety Disorder
c) Anorexia Nervosa
d) Depression
Delusional disorder
(Also no evidence for IPT in schizophrenia)
Alcohol dependence. Renal stones. On morphine for pain control. Has a binge pattern of drinking (10-12 drinks on the weekends). Which medication to use?
a) Acamprosate
b) Naltrexone
c) Disulfiram
d) Topiramate
Acamprosate
* recall, topiramate has risk of renal stones
ETOH + schizophrenia in liver failure. Would need to reduce dose, if on any of the following, except:
a) Paliperidone
b) Risperidone
c) Haloperidol
d) Olanzapine
Paliperidone
Recall, Paliperidone doesn’t undergo CYP 450 metabolism
(also LOT and desvenlafaxine)
Deep brain stimulation – what is the most common target in depression?
a) Sub-callosal cingulum
b) Left OFC
c) Dorsolateral PFC
d) Amygdala
Sub-callosal cingulum
Recall, Dorsolateral PFC = for TMS
What are the main modalities of psychotherapy in PTSD?
CBT is an effective first line option (TF-CBT, EMDR, PE, and stress management therapy)
Which medications are first line for PTSD?
Fluoxetine
Paroxetine
Sertraline
Venlafaxine
What is the most likely to cause elevated prolactin?
- Paliperidone
- Quetiapine
- Abilify
- Lurasidone
Paliperidone
35 yo female patient with MS. Was on prednisone last year for exacerbation of MS. Now Started Interferon for MS and retinoic acid for acne. What is the most contributory to current symptoms of suicidality?
- Interferon beta
- Retinoic Acid
- Prednisone
- Sertraline
Prednisone
(7x SI HR)
63 yo M with a history of decline in MOCA from 25 to 19 over the past year. Remote history of head trauma 10 years ago. What is the indication for CT head in this patient?
- Age
- Rate of cognitive decline
- History of head trauma
Rate of cognitive decline
Recall
- CT recommended if one or more of the following are present
- – Age < 60 years
- – Rapid (e.g., over 1–2 months) unexplained decline in cognition or function
- – Short duration of dementia (< 2 years)
- – Recent and significant head trauma
- – Unexplained neurologic symptoms (e.g., new onset of severe headache or seizures)
- – History of cancer (especially types that metastasize to the brain)
- – Use of anticoagulants or history of bleeding disorder
- – History of urinary incontinence and gait disorder early in the course of dementia (as may be found in normal pressure hydrocephalus)
- – Any new localizing sign (e.g., hemiparesis or a Babinski reflex)
- – Unusual or atypical cognitive symptoms or presentation (e.g., progressive aphasia)
Woman in ECT treatment. 3rd treatment, can’t get a seizure despite 2 tries. What do you do for next time?
- Give wellbutrin
- Sleep deprivation
- Assess and reduce or discontinue and anticonvulsant medications
Assess and reduce or discontinue and anticonvulsant medications
- Next steps
- Caffeine
- Hyperventilation
- Consider adding ketamine to propofol
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
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
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
Which medication can be used in augmentation of panic disorder treatment?
Clonazepam
Risperidone
Abilify
Buspirone
Clonazepam
Elderly patient who is depressed, visual hallucinations, parkinsonism. What to use for treatment?
- Antipsychotic
- SSRI
- Ach inhibitor
Ach inhibitor
- Recall, in LBD
- If a patient experiences severe, disabling psychosis, a trial of a cholinesterase inhibitor and/or lowering the dose of antiparkinson medication should be considered first.
- When antipsychotic therapy is required, drugs are associated with an increased risk of death when used in older adult patients with dementia.
- If antipsychotic therapy is required in patients with DLB, only atypical antipsychotic drugs, such as olanzapine, quetiapine, pimavanserin, ziprasidone, aripiprazole, paliperidone, or clozapine, should be used in very small doses in order to reduce the risk of severe reaction
- The older, conventional antipsychotics should be avoided entirely
34 yo woman bioplar I, 5 previous admission. Now stable 2 years on Lithium 1200mg and Quetiapine 300mg. Wants to discuss decreasing meds. What do you tell her?
- Decrease both lithium and quetiapine
- Leave the same for relapse prevention
- Discontinue quetiapine for metabolic risk
- Discontinue lithium for long term renal risk
Leave the same for relapse prevention
Recall
- Maintenance is whatever worked to get them out of acute symptoms
- Quetiapine maxes out on sedation and weight gain at 150
Patient in ER, required IM haldol 10 mg yesterday for acute agitation. Now presents pacing, can’t sit still. What do you give him?
- Abilify
- Propranolol
- More haldol
- Benztropine
Propranolol
- In treating akathisia, propranolol now first line
- Benztropine second line
- Benzos for non-responders
Man uses polysubstances - heroin, benzos, PCP and cannabis. Now in ER has elevated HR and BP, tremor, sweating. What is he withdrawing from?
- Alprazolam
- Heroin
- Cannabis
- PCP
Alprazolam
You are seeing a patient with QTC prolongation, depressed, insomnia in ICU. What antidepressant is safest?
- Wellbutrin
- Escitalopram
- Desipramine
- Mirtazapine
Mirtazapine
Recall, regarding QTC prolongation:
- TCAs highest (clomipramine best of them)
- Then Citalopram, escitalopram, venlafaxine
- Wellbutrin does not prolong QTC at all, Mirtazapine very low risk
Which of the following is true of schizophrenia?
a. Correlates with urban density in small cities
b. Incidence is increased in industrialized countries
c. Higher prevalence in low SES
Higher prevalence in low SES
Bipolar I, recent manic episode in hospital, now stable for 1 month. What psychosocial treatment can be recommended?
- Psychoeducation
- IPSRT
- MBCT
- Peer support
Psychoed
(Superior to IPSRT)
With regards to violence assessment
a) Area under curve predicts violence
b) Clinical judgment has good positive predictive value
c) Structured clinical judgment assessment tools provide individualized measure of risk
Structured clinical judgment assessment tools provide individualized measure of risk
What are key differences between MOCA and MMSE?
- MMSE
- brief
- no exec function
- lower sensitivity for lower impairment/higher IQ
- FP for older, lower education
- MOCA
- more domains
- higher sensitivity for lower impairment/higher IQ
- longer to administer
- Lower specificity with cut-off of 26
- Proprietary
