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
How do you calculate Odds Ratio vs Relative Risk?
How to calculate odds ratio?
OR = odds of disease in exposed / odds of disease in the non-exposed
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
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 the adult attachment styles?
- Secure
- Insecure
- Dismissive/Avoidant
- Preoccupied/anxious/Ambivalent
- Disorganized/Fearful
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, 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)
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
