Psych Flashcards
Haldol
Typical antipsychotic
High potency
0.5-10mg
D2 antagonism
Loxapine
Typical antipsychotic
Medium potency
10-250mg
D1 and D2 antagonism + serotonin 5HT2 antagonism
Chlorpromazine
Typical antipsychotic
Low potency
200-1000mg
Broad antagonism: D1-D4, 5-HT1 and 5-HT2, histamine receptors, alpha1-2 adrenergic receptors, M1-2 muscarinic Ach receptors
Chlorpromazine S/E
Dopamine antagonism –> EPS
Serotonin antagonism –> weight gain, ejaculation difficulties
Histamine antagonism –> sedation, anti-emetic, weight gain, vertigo
Alpha adrenergic antagonism –> low BP, reflex tachycardia
Anti-ACh –> dry mouth, constipation, blurred vision, sinus tachy, urinary difficulties
Lithium starting dose
600 mg PO ohs
Lithium tx dose
900-1500mg PO per day
Lithium therapeutic levels
0.6-1.2 mEq/L
Lithium therapeutic level for mania
0.8-1.2 mEq/L
Lithium therapeutic level for maintenance
0.6-0.8 mEq/L
Lithium therapeutic level for elderly
0.4-0.6 mEq/L
Lithium mild toxicity level
1.5 mEq/L
Lithium medical emergency
> /= 2.5mEq/L
Lithium level for hemodialysis
> 5mEq/L or 4 mEq/L with renal impairment or > 2.5mEq/L with symptoms/renal insufficiency
Lamotrigine starting dose
25mg PO daily
Lamotrigine therapeutic dose
100-200 mg PO daily
Olanzapine starting dose
10-15mg PO daily
Olanzapine therapeutic dose
5-20mg daily
Quetiapine starting dose
50mg PO BID
Quetiapine XR titration
Start: 300 mg PO qhs
Increase by 150-300mg q1-4d
Target: 600-800mg PO qhs
Quetiapine therapeutic dose for BPD depression
300-600 mg daily
GAD
> /3 of the following 6 symptoms for the past 6 months
1. Wound up - muscle tension
2. Worn out - fatigue
3. Absent-minded - difficulty concentrating
4. Restless
5. Touchy - agitated
6. Sleepless
Difficulty controlling worry
Excessive anxiety/worry occurring more days than not for past 6 months about a number of events/activities
12 month prevalence of GAD
~3%
GAD 7
5 = mild anxiety
10 = moderate anxiety
15 = severe anxiety
Test is out of 21
First line tx for anxiety
CBT
Meds for anxiety
- SSRIs (start at half starting dose needed for depression then titrate up)
- Benzodiazepines, usually with SSRIs in the beginning then wean off after ~2 weeks
- Buspirone (5-HT1A receptor partial agonist)
- Venlafaxine (SNRI)
Specific phobia lifetime prevalence
11%
GAD lifetime prevalence
~5%
Specific phobia with highest familial tendency
Blood-injection injury
Social anxiety d/o 12mo prevalence
7%
Social anxiety lifetime prevalence
~10%
Specific criteria of social anxiety disorder for children
Must experience anxiety in peer settings, and not just with adults
Fear/anxiety may be expressed as crying, tantrums, freezing, clinging, shrinking, failing to speak
Lifetime prevalence of social anxiety disorder in school aged children
~1%
Lifetime prevalence of specific phobia d/o in school aged children
2.4%
Panic d/o 12mo prevalence
2-3%
Best medications for panic disorder
Alprazolam (xanax - benzodiaepine) and Paroxetine (SSRI)
Other SSRIs - Citalopram, escitalopram, fluvoxamine, sertraline
Agoraphobia 12m prevalence
1.7%
Agoraphobia
At least 2 of more of the following: - fear of open spaces - fear of line ups - fear of enclosed spaces - fear of public transport - fear of being outside of house alone Fear for 6mo or more
SSRI Discontinuation syndrome
2-4d after medication cessation Flu-like symptoms Insomnia Nausea Imbalance Sensory disturbances Hyperarousal - increased anxiety and irritability
Depression
5 or more of the following symptoms for at least 2 weeks, with at least 1 being depression or decreased interest: Suicidal thoughts Interest decrease Guilt Energy low Concentration difficulty Appetite change Psychomotor changes Sleep issues
Depression lifetime prevalence
16.5% (highest of any psych d/o)
Depression 12mo prevalence
6.7%
Mean number of depressive episodes
5-6 over 20yr period
Rate of depression recurring in 6mo
25%
Rate of depression recurring in 2yr
30-50%
Rate of depression recurring in 5y
50-75%
2 NTs most commonly implicated with depression
- Serotonin
2. NE
PHQ9
5-9 = Minimal symptoms –> F/U in 1 month
10-14 = Minor depression, dysthymia –> watchful waiting or meds/psychotherapy
15-19 = Major depression, mod - severe –> antidepressants or psychotherapy
>20 = Major depression, severe –> antidepressant and psychotherapy
Total score out of 27
First line psychotherapies for depression
Interpersonal
CBT
SSRIs affect on locus ceruleus
Decreased arousal
SSRIs affect on periaqueductal grey
Decreased escape behaviour
SSRIs affect on HPA axis
Decreased CRF from hypothalamus, thus decreased ACTH and decreased cortisol secretion
SSRIs affect on lateral nucleus of amygdala
Inhibits sensory excitation inputs from HPA/cortical pathways –> decreased physical symptoms
Serotonin Syndrome
HARMED:
Hyperthermia (severe severe due to muscle activity, not hypothalamic temperature set point so avoid antipyretics)
Autonomic instability (rapid HR, HTN, diarrhea, dilated pupils)
Rigidity
Myoclonus (loss of muscle coordination or twitching)
Encephalopathy (confusion)
Diaphoresis
Serotonin syndrome tx
- Stop meds
- May need benzos to help control agitation and fever by reducing muscle agitation (prevent rhabdo)
- Serotonin blocking agents (cryptoheptadine)
- O2 and fluids
- HR and BP control
Wellbutrin/Bupropion class
NDRI
Good for atypical MDD
Mirtazapine class
NaSSA
Good for melancholic MDD
NT affected by TCA
NE, Serotonin and GABA
TCA Overdose antidote
Sodium bicarbonate
NT affected by MAOI
NE, Serotonin and Dopamine
MAOI risk
Hypertensive crisis (inhibits monoamine oxidase --> can't break down tyramine --> tyramine build up --> BP crisis) Tyramine avoiding diet (strong cheese, cured meats, pickled/fermeted foods, beans, snow peas, dried fruits, alcohol)
Hypertensive crisis
Severe headache Vision changes N/V Sweating Severe anxiety Nosebleed Fast HR Chest pain SOB Confusion
Hypertensive crisis tx
No antidote
Aggressive decontamination via gastric lavage or charcoal
Do not usually need to treat HTN, should come down on its own, but may use shorter acting agents (ie. nitro) - avoid beta blockers
Transcranial magnetic stimulation (TMS) indication
For adults with depression who have failed one prior antidepressant medication at or above minimal effective dose and duration
TMS frequency
Daily for 4-6wks
No anesthesia needed
TMS contraindication
Implanted metallic devices or non-removable metallic objects in or around head
Dysthymia (Persistent Depressive D/O)
HE'S 2 SAD Hopelessness Energy loss or fatigue Self-esteem low 2 years at least of depressed mood most of the day for more days than not (at least 1 year in children/teens); never been without symptoms for more than 2mo at a time Sleep increased/decreased Appetite increased/ decreased Decision making or concentration impaired
Mania
1 week period of elevated mood AND increased energy/goal-directed energy plus 3 of the following: DIGFAST - Distractibility - Indiscretion - Grandiosity - Flight of ideas - Activity increased - Sleep decreased - Talkativeness
Lifetime prevalence of ALL bipolar disorders
0-2.4%
12 month prevalence of bipolar disorders
0.6%
Distribution of BPD amongst men and women
EQUAL
-Women are more likely to have rapid cycling and mixed stated, more likely to have comorbidities, more likely to experience depressive symptoms, higher lifetime risk of EtOH use d/o
Bipolar disease is at high risk of…
Suicide (15x rest of population)
Epidemiology of bipolar disease
- More common in high-income countries
- More common in separated, divorced or widowed individuals
- Strongest most consistent risk factor = family history
Valproate starting dose
250-500mg PO ohs
Valproate therapeutic dose
1200-1500mg PO daily
Olanzapine
Greatest risk of weight gain
Aripiprazole
Longest half-life (75h)
Ziprasidone
QT prolongation risk (periodic ECGs)
3 options for treating depression phase of bipolar
- Switch to lithium, lamotrigine or quetiapine mono therapy (AVOID antidepressant monotherapy)
- Add SSRI or bupropion
- Add mood stabilizer for combo therapy (ie. lithium and divalproex)
BPD drug to avoid in reproductive-aged women
Valproic acid
General tx regimen for ACUTE MANIC EPISODE
Lithium or valproic acid or 2nd generation antipsychotic (ie. Quetiapine)
General tx regimen for DEPRESSED BIPOLAR EPISODE
Lamotrigine +/- antimanic drug if hx of manic episodes
General tx regimen for MIXED BIPOLAR EPISODE
Valproate or 2nd generation antipsychotic
General tx regimen for maintenance tx in bipolar disorder
Lithium or valproate or lamotrigine (in its without recent mania) or 2nd generation antipsychotic
Hypomanic episode
4 consecutive day period of elevated mood and energy with 3 or more of DIGFAST
NOT sever enough to cause marked impairment in social, occupational functioning or to necessitate hospitalization
Bipolar Type II
1 hypomanic epi and 1 major depressive epi
Bipolar Type I
Manic episode
Risk of developing bipolar disorder in general population
0.5-1.5%
Risk of developing bipolar disorder in 1st degree relatives of ppl with bipolar d/o
8-10%
MOA of Li and VPA
(1) Inhibit Glycogen Synthase kinase-3 (apoptotic enzyme that leads to neuronal death)
(2) Increased expression of brain derived neurotrophic factor = promotes neuronal survival
Cyclothymic Disorder
- At least 2yrs (1 yr in children/adolescents), numerous periods with hypomanic symptoms that do not meet criteria for hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for major depressive episode
- Hasn’t been without symptoms for more than 2mo at a time
Types of delusions (6)
- Reference
- Erotomanic
- Grandiose
- Persecutory
- Nihilistic
- Somatic
Schizophrenia
2 or more of the following, for at least 1 month, with at least one being one of the first three:
-Delusions
-Hallucinations
-Disorganized speech
-Grossly disorganized or catatonic behaviour
-Negative symptoms
Continuous signs of disturbance persist for at least 6 months
12 mo prevalence of schizophrenia
1%
Sex differences for schizophrenia (male vs female)
Male = female
Female dx later in life with bimodal distribution
Men = 10-25y.o,
Women = 25-35y.o.
Brain abnormalities in schizophrenia
Smaller prefrontal cortex/hippocampus/limbic system
Enlarged ventricles
Reduced symmetry
4 main dopaminergic pathways
- Mesocortical*
- Nigrostriatal
- Tuberoinfundibular
- Mesolimbic*
Mesocortical
Brainstem –> pre-frontal cortex
A/W memory, executive function, motivation
= negative symptoms
Atypical antipsychotics help b/c improve DA and decrease serotonin in this pathway
Nigrostriatal
Substantia nigra –> basal ganglia
80% of brains dopamine
=EPS and tardive dyskinesia
Typical antipsychotics worsen TD b/c decrease DA in this pathway; atypical don’t affect b/c no major change in DA
Tuberoinfundibular
Hypothalamus –>neurohypophysis
DA tonically INHIBITS prolactin
= Prolactin levels
Typical antipsychotics cause hyperprolactinemia; atypical don’t affect b/c no major change in DA
Mesolimbic
Ventral tegmentum –> limbic system
Role in motivation, emotions, rewards
= Positive symptoms
Both typical and atypical decrease DA levels in this pathwayy –> improved positive symptom (atypical to higher degree)
First degree relatives of ppl with schizophrenia have ____x greater risk
10x
Factors associated with increased schizo risk
- Prenatal exposures (infection, poor nutrition)
- Late winter/early spring time of birth
- EtOH and cannabis exposure
- Advanced paternal age at conception
Nicotine use in schizo %
90%
Typical antipsychotics
Haloperidol
Loxapine
Fluphenazeine
Thiothixene
Thioridazine (low potency)
Chlorpromazine (low potency)
Classic PRN combo to settle patients
Haloperidol 5mg IM + Lorazepam 2mg IM
PRN combo TO AVOID
Olanzapine + lorazepam = respiratory depression
Atypical antipsychotics - DA and serotonin antagonists
Risperidone Ziprasidone Lurasidone Paliperidone Iloperidone
Risperidone risk
Acts like typical at high dose (EPS risk)
Ziprasidone risk
QTc prolongation
Lurasidone risk
Unsafe in pregnacy
Antipsychotic available in monthly depot
Paliperidone
Atypical antipsychotics - multi receptor
Olanzapine
CLozapine
Antipsychotic associated with weight gain
Olanzapine
Fast dislocating D2 antagonist antipsychotic
Quetiapine
Partial dopamine agonist antipsychotic
Aripiprazole - At lower doses --> DA agonist - At higher doses --> DA antagonist = less weight gain and metabolic S/E High potency
Clozapine S/E
Agraulocytosis Hypotension Diabetes Myocarditis Seizures
When to use clozapine
Tx-resistant schizophrenia, needed to have failed at least 2 antipsychotic regimens
Clozapine b/w
CBC/diff weekly for 6mo then q2wks for 6mo then q4wks thereafter
Clozapine titration
Takes about 2-3wks
Starting dose = 12.5mg OD –> increase by 12.5-25mg q3d
Target dose = 300-600mg PO qhs
Adequate trial = 4-6mo period at target dose
Risperidone IM titration
Long-acting injectable starting dose: 25mg IM q2weeks
Increase = 12.5mg q2-3 injections
Target dose: 25-50mg IM q2 weeks
Risperidone PO titration
PO tablet starting dose: 1mg PO qdaily
Increase by 1mg q24h
Target dose: 4-6mg PO qdaily
Olanzapine titration
PO tablet starting dose: 5-10mg PO qhs
Increase by 2.5-5mg q3-4d
Target dose: 10mg-20mg PO qhs
Aripiprazole titration
PO tablet starting dose: 5-10mg PO qhs
Increase by 2.5-5mg q3-4d
Target dose: 10mg-20mg PO qhs
S/E unique to typical antipsychotics
EPS/TD
Lowered seizure threshold
Hyperprolactinemia
If first episode of psychosis, pt needs _____ minimum on meds with signs of functional recovery
1-2 years
Highest suicide risk period for schizophrenics
1yr after first psych hospitalization
Multi-episode patients should receive maintenance tx for at least ____ with pharmacotherapy on indefinite basis
5 years
Approach to manage poor responders
SWITCH TX
Do not add another antipsychotic
Strategies for switching pharmacotherapy (4)
Abrupt discontinuation Taper switch (taper one, start the other immediately) Cross-taper switch (taper one, titrate the other) Plateau cross-taper switch (keep original, titrate the other, then taper original)
Parkinsonian syndrome
TRAP Tremor Rigidity (cogwheel) Akinesia Postural instability
Tx for EPS
Best = switch to antipsychotic with less EPS
Reduction in antipsychotic dose if possible
Benztropine (anticholinergic)
Or beta blockers, benzodiazepine
EPS vs TD
EPS = acute reaction TD = chronic reaction
TD symptoms
Sucking/smacking lips, tongue twisting, facial grimacing, lateral jaw movements, choreiform movements
S/E more common in LOW potency medications
Sedation (chlorpromazine, clozapine, quetiapine)
Drugs that cause Anti-Ach S/E
Chlorpromazine, clozapine, olanzapine
Drugs that cause QTc prolongation S/E
Clozapine, Ziprasidone , Haloperidol
QTc numbers
> 440ms for men
460ms for women
500ms = TdP risk
Neuroleptic Malignancy syndrome (symptoms and lab findings)
Related to DA antagonism (esp high potency ie. haldol)
FARM
- Fever (>38)
- Autonomic instability (tachycardia, labile BP, tachypnea, dysrhythmias)
- Rigidity (lead-pipe)
- Mental status change
Elevated CK, leukocytosis, low Fe
NMS tx
Stop med, intensive management for CV support, control of hyperthermia and fluid/lyte balance
Medical tx = dantrolene, bromocriptine and amantadine (dan’s a man who’s a dope bro) = dopamine agonists
ECT if not response to medical tx for 1 wk
NMS prognosis
Resolves within 2 weeks without neuro sequelae
Wait at least 2 weeks before restarting antipsychotics
Delusion d/o
> /1 delusion for 1 month or longer
Fxn not markedly impaired
Mania or major depressive epis brief relative to duration of delusions
Most freq subtype of delusional d/o
Persecutory
Brief psychotic d/o
One or more of the following, with at least one being one of the first three: - Delusions - Hallucinations - Disorganized speech - Grossly disorganized behaviour More than 1d, less than 1 mo Eventual return to premorbid level of functioning ~50% go onto develop chronic psych
Schizophreniform d/o
Same criteria is schizophrenia but for at least 1 month and <6months
Return to baseline
60-80% progress to schizophrenia
Schizophreniform epidemiology
Common in young adults/teens
Men»_space; women (5x)
Less common than schizo («1%)
Tx for schizophreniform d/o
Brief course of antipsychotic drugs (3-6mo)
Schizoaffective d/o
Major mood eps CONCURRENT with Criterion A of schizo
Delusions/hallucinations for 2 or more weeks WITHOUT major mood eps during duration of illness
Major mood eps symptoms present for majority of total duration of active portions of illness
Schizoaffective epidemiology
Bipolar = equal in men and women, more common in young Depression = 2x more common in females. more common in older
Schizoaffective tx
Tx appropriate symptoms
BPD –> mood stabilizers
Depression –> SSRIs
Psychotics –> antipsychotics
Catatonia
3 or more of the following:
♣ Stupor (ie. no psychomotor activity; not actively relating to environment
♣ Catalepsy (ie. passive induction of posture held against gravity)
♣ Waxy flexibility (ie. slight, even resistance to positioning by examiner)
♣ Mutism (ie. no or very little verbal response)
♣ Negativism (ie. opposition or no response to instructions or external stimuli)
♣ Posturing (ie. spontaneous and active maintenance of posture against gravity)
♣ Mannerism (ie. odd, circumstantial caricature of normal actions)
♣ Stereotypy (ie. repetitive, abnormally frequent, non-goal-directed movements)
♣ Agitation, not influenced by external stimuli
♣ Grimacing
♣ Echolalia (mimicking another’s speech)
♣ Echopraxia (mimicking another’s movements)
Catatonia related to which mental health illness most frequently
Mood disorders (depression/BPD) > schizophrenia
Catatonia tx
Benzos can provide temporary improvement
ECT for severe
Scale for testing TD S/E from antipsychotics
Abnormal Involuntary Movement Scale (AIMs)
Rate items from 0-4
Score of 2 in two or more movements
or Score of 3 or 4 in single movement = TD
Atypical antipsychotics in order of potency
High –> Low
Risperidone > paliperidone > aripiprazole > Lurasidone (mod) > clozapine > quetiapine > olanzapine
Two antipsychotics affected by smoking
Olanzapine and clozapine
Smoking increases CYP1A2 activity
GOOD prognostic features of sz
Older age of onset Female Shorter duration of untreated psychosis Tx adherence Absence of illicit substance use Stable support network Abrupt onset Absence fof pre-morbid disturbance Fam hx of affective illness
Personality Disorder
Enduring pattern Deviates from individual's culture 2 or more of the following areas: - Cognition - Affectivity - Interpersonal functioning - Impulse control
General population % affected by PD
10-20%
Projection
Defense mechanism; pt attributes own unacknowledged feelings to others
Projective identification
Defense mechanism; pt projects part of a past, internalized relationship onto therapist and exerts subtle, interpersonal pressure on therapist to become like projected part
Transference
Displacement of feelings/thoughts/behaviours experienced in relation to significant figures during childhood onto person involved in current interpersonal relationship
Counter-transference
Displacement of feelings, thoughts and behaviour from psychiatrist to patient
Cluster A personality d/o
Odd or eccentric cluster
Paranoid
Schizoid
Schizotypal
Paranoid personality d/o
4 or more of: SUSPECT - Spousal infidelity suspected - Unforgiving - Suspicious - Perceives attacks - Enemy or friend? - Confiding in others is feared - Threats perceived in benign events
Paranoid PD prevalence in general population
2-4%
Paranoid PD tx of choice
Psychotherapy
Schizoid PD
Detachment from social relationships and restricted range of expression of emotions in interpersonal settings
4 or more of
- Neither desires nor enjoys close relationships
- Always chooses solitary activities
- Little interesting in sexual experiences
- Takes pleasure in few activities
- Lacks close friends other than relatives
- Appears indifferent to praise of others
- Shows emotional coldness, detachment or flattened affectivity
Schizoid PD prevalence in general population
5%
Schizoid PD tx of choice
Psychotherapy
Pharmacotherapy
Schizotypal PD
Acute discomfort with and reduced capacity for close relationships and cognitive or perceptual distortions and eccentricities of behaviour 5 or more of: ME PECULIAR - Magical thinking - Experiences unusual perceptiokns - Paranoid ideation - Eccentric behaviour/appearance - Constricted or inappropriate affect - Unusual thinking/speech - Lacks close fiends - Ideas of reference - Anxiety in social situations - Rule out psychotic or pervasive developmental d/o
Schizotypal PD prevalence in general population
3%
Schizotypal tx
Psychotherapy
Pharmacotherapy - antipsychotics, antidepressants
Cluster B personality d/o
Dramatic, emotional, erratic cluster Antisocial Borderline Histrionic Narcissistic
Antisocial PD
Disregard for and violation of rights others since 15y.o. 3 or more of: CORRUPT - Cannot conform to law - Obligations ignored - Reckless disregard for safety - Remorseless - Underhanded (deceitful) - Planning insufficient (impulsive) - Temper (irritable and aggressive) Must be at least 18 Conduct d/o with onset before age 15
Antisocial PD prevalence rate in 12 month period
0.2-3%
Antisocial PD epidemiology
More common in poor urban areas
Most common in men with EtOH use, prison populations
5x more common among first degree relatives of men with d/o
Antisocial PD tx
Psychotherapy
Pharmacotherapy - psychostimulants if signs of ADHD, anticonvulsants to control impulsive behaviours, beta blockers for aggression
Borderline PD
Instability of interpersonal relationships, self image and affects, marked impulsivity 5 or more of: DESPAIRER - Disturbance of identity - Emotionally labile - Suicidal behaviour - Paranoia or dissociation - Abandonment (fear of) - Impulsive in at least 2 areas that are self-damaging - Relationships unstable - Emptiness (feelings of) - Rage (inappropriate)
Borderline PD prevalence in population
1-2%
Women»_space; men
Neurobiological theory of borderline PD
Impaired serotonergic control of amygdala by prefrontal cortex –> loss of control over emotional expression
Histrionic PD
Excessive emotionality and attention seeking
5 or more of:
PRAISE ME
- Provocative or seductive behaviour
- Relationships considered more intimate than they are
- Attention (need to be centre of)
- Influenced easily
- Style of speech (lacking detail, impressionistic)
- Emotions (rapidly shifting, shallow)
- Make up (physical appearance)
- Emotions exaggerated
Histrionic PD prevalence in general population
1-3%
Women > men
Narcissistic PD
Grandiosity, need for admiration and lack of empathy 5 or more of : GRANDIOSE - Grandiose - Requires attention - Arrogant - Need to be special - Dreams of success and power - Interpersonally exploitative - Others (unable to recognize needs of) - Sense of entitlement - Envious
Narcissistic PD prevalence
1-6%
Cluster C
Anxious, fearful cluster
Avoidant
Dependent
Obsessive-compulsive
Avoidant PD
Social inhibition, inadequacy and hypersensitivity to negative evaluation
4 or more of:
CRINGES
-Criticism or rejection preoccupies thoughts in social situations
-Restraint in relationships d/t fear of shame
-Inhibited in new relationships
-Needs to be sure of being liked before engaging socially
-Gets around occupational activities with need for interpersonal contact
-Embarassment prevents new activity
-Self-viewed as unappealing or inferior
Avoidant PD prevalence in general population
2-3%
Avoidant vs schizoid PD
Avoidant WANTS social interaction but are fearful vs schizoid want to be alone
Dependent PD
Submissive and clinging behaviour and fears of separation
5 or more of:
RELIANCE
- Reassurance required
- Expressing disagreement difficult
- Life responsibility assumed by others
- Initiating projects difficult
- Alone
- Nurturance (goes to excessive lengths to obtain)
- Companionship sought urgently when relationship ends
- Exaggerated fears of being left to care for self
Dependent PD prevalence in general population
0.6%
Women > men
More common in children
Obsessive compulsive PD
Orderliness, perfectionism and mental and interpersonal control 4 or more of: SCRIMPER - Stubborn - Cannot discard worthless objects - Rule obsessed - Inflexible - Miserly - Perfectionistic - Excludes leisure d/t devotion to work - Reluctant to delegate to others
Obsessive-compulsive PD prevalence rate
2-8%
Men > women
More common in older siblings
PD with good insight and where tx often sought on pt’s own
Obsessive compulsive PD
Anxiety affects ___ of children and adolescents
10-20%
Common forms of anxiety in youth
Separation anxiety d/o
GAD
Social anxiety disorder
Normal anxiety in infancy/toddlerhood
Loss of physical contact to caregivers, loud noise, separation
Normal anxiety in preschooler
Animals, dark, separation, imaginary characters (monsters)
Normal anxiety in school/age children
Natural disasters, performance, illness, mortality, germs
Normal anxiety in adolescent
Rejection in social or intimate relationships, existential, future
S/E of SSRI in youth
Small decrease in growth rate (reversible upon d/c)
Agitation and disinhibition in younger children
VERY rare increased rate of suicidal thoughts and behaviours
Normal separation anxiety peaks btwn __ and __ months and should diminish by about ___ y.o. Most common between ages ___.
9 and 18 months
2.5 y.o.
7-8 y.o.
Separation anxiety d/o (8)
Beyond developmental expectations
At least 3 symptoms for at least 4 weeks
- Fear of untoward event separating them from caregiver
- Unable to sleep without being near caregiver
- Reluctance to go to school b/c fear of separation
- Repeated nightmares with theme of separation
- Physical symptoms when separation anticipated
- Distress with anticipated separation from home or caregiver
- Worry about harm to caregiver
- Reluctance to be alone
GAD prevalence in school-aged children and teens
School-aged children = 3%
Teens = 3.7%
Prevalence of social anxiety disorder in children
1%
Social anxiety d/o
Must experience anxiety in peer settings, not just with adults
6 mo or more
May be restricted to performance only
Prevalence of specific phobias in school-aged children
~2.4%
Specific phobia
Marked fear or anxiety about specific object or situation
6mo or more
Panic d/o
Recurrent unexpected attacks - abrupt surge of fear or intense discomfort reaching peak within MINUTES during which time 4 or more of the following occur: - Palpitations, pounding heart, high HR - Sweating - Trembling/shaking - Blurred vision - Light-headedness - Chills or heat sensations - Paresthesias - Derealization - Fear or losing control - Fear of dying - Sensation of SOB or smothering - Feelings of choking - CP or discomfort - Nausea At least one attack followed by 1 mo or more of one or both of: - persistent corn or worry about more panic attacks or their consequences -Significant maladaptive change in behaviour related to attacks
Selective mutism
Consistent failure to speak in specific social situations in which there’s an expectation for speaking despite speaking in other situations
At least 4 weeks
Not d/t lack of knowledge of spoken language
Tic d/o
Tourette’s
- Multiple motor and one or more vocal tics (not necessarily concurrently)
- May wax and wane in frequency, but present for more than 1y since onset
- Onset before age 18
Chronic Motor OR vocal tic d/o
- Single or multiple motor OR vocal tics but NOT BOTH
- May wax and wane in frequency, but present for more than 1y since onset
- Onset before age 18
Provisional tic d/o
- Single or multiple motor and/or vocal tics
- Present for less than 1y since first tic onset
- Onset before age 18
- Not fully met criteria for Tourette’s d/o or chronic motor/vocal tic d/o
Sensory phenomenon which occurs before person does tic
Premonitory urge
Classifications of tics
Simple motor (ie. blinking, grimacing, mouth widening, nose scrunching. eyebrow raising, shoulder struggling)
Simple vocal tics (ie. throat clearing, sniffing, squeaking, grunting)
Complex motor tics (ie. ie. touching things multiple times, obscene gestures/copropraxia, self-biting)
Complex vocal tics (ie. coprolalia/swearing, echolalia, palilalia/repeating own words)
2 major common comorbidities with tic d.o
OCD
ADHD
Tic d/o tx
Behaviour tx (need premonitory urge)
Tic neutral environment
Education
Meds - alpha agonist (clonidine), dopamine blockers (risperidone)
4 attachment styles
Secure
Insecure - avoidant
Insecure - ambivalent
Disorganized-inhibited or disinhibited
Secure attachment style
Healthy, good enough parenting
Child learns that they will get attention when they need help
60% of children
Mentally healthy adolescents and adults
Insecure - avoidant attachment style
Emotionally rejecting parenting style
Child learns they will not receive attention when they need help and try to avoid expressing distress/do not seek parents for help
20% of children
May be at higher risk of behaviour d/o
Emotionally inhibited adults but still live fulfilling lives
Insecure - ambivalent attachment style
Inconsistent parenting
Seek caregiver for help but difficult to soothe
Show increased distress in face of stressors
More problems in relationships as teens/adults
Increased risk of future psych d/o (esp anxiety)
Disorganized-inhibited or disinhibited attachment style
Scary or fearful caregiver
Unable to organize strategy for seeking help
Inhibited –> child won’t go to anyone for help –> reactive attachment d/o
Disinhibited –> child will go to anyone for help –> disinhibited social engagement d/o
HIGHEST RISK for later developing psychopathology
Attachment
First 3 years of life critical
Can change over time
Dyadic therapy
Therapy with infant and parent
Reactive attachment d/o
A. Pattern of inhibited, emotionally withdrawn behaviour towards caregivers, manifested by BOTH of:
- Rarely seeks comfort when distressed
- Rarely responds to comfort when distressed
B. Persistent social and emotional disturbance characterized by at least 2 of:
- Minimal social/emotional responsiveness
-Limited positive affect
- Epis of unexplained irritability, sadness ,or fearfulness
C. Experienced pattern of extremes of insufficient care as evidenced by at least 1 of:
- Social neglect or deprivation in form of persistent lack of having basic emotional needs for comfort, stimulation and affection
- Repeated changes of primary caregivers that limit opportunities to form stable attachments
- Rearing in usual settings that severely limit opportunities to form selective attachments
Disturbance before age 5
Developmental age of at least 9mo
Disinhibited social engagement d/o
A. Child actively approaches unfamiliar adults and exhibits at least 2 of:
- Reduced or absent reservation in approaching unfamiliar adults
- Overly familiar verbal or physical behaviour
- Diminished or absent checking back with adult caregiver after venturing far away
- Willingness to go off with unfamiliar adult
B. Behaviours not limited to impulsivity but include socially disinhibited behaviour
C. Child experienced pattern of extremes of insufficient care by at least one of:
- Social neglect or deprivation in form of persistent lack of having basic emotional needs for comfort, stimulation and affection
- Repeated changes of primary caregivers that limit opportunities to form stable attachments
- Rearing in usual settings that severely limit opportunities to form selective attachments
Autism Spectrum D/O
A. Persistent deficits in social communication and social interaction across multiple contexts as manifested by:
- Deficits in social-emotional reciprocity
- Deficits in nonverbal communicative behaviours used for social interaction
- Deficits in developing, maintaining and understanding relationships
B. Repetitive patterns of behaviour interests or activities manifested by at least 2 of:
- Stereotyped or repetitive motor movements, use of objects or speech
- Insistence on sameness
- Highly restricted, fixated interests that are abnormal in intensity or focus
- Hyper or hyperactivity to sensory input or unusual interest in sensory aspects of enviro
C. Symptoms present in early development
Mild intellectual disability
Grade 6 level
Moderate intellectual disability
Elementary level
Severe intellectual disability
Language limited to single words or phrases
Support required for all ADLs
Profound intellectual disability
Very few conceptual skills gained
Dependent on others
ASD Screening Instruments (2)
Autism Screening Questionnaire (ASQ)
ADI-R (Structured Interview of parents used to dx autism)
Locus ceruleus
Mostly affected by NE
Panic/stress response
Percent of school-aged children affected by ADHD
5-10%
Percent of adults affected by ADHD
2.5%
____% of children continue to meet criteria for ADHD in adolescence
60-85%
Up to ____% of ADHD children meet criteria for comorbid psych d/o
70%
Superior and temporal cortices
Focusing attention
External parietal and corpus striatal regions
Motor executive functions
Hippocampus
Memory
Pre-frontal cortex
Shifting from one stimulus to another
ADHD prognosis
60-85% continue to have symptoms in adolescence and adulthood
Sometimes hyperactivity disappears but inattentive/impulsivity remains
Mixed or predominantly hyperactive-impulsive are more likely to have stable dx over time than just inattentive
ADHD - 1st line pharmacologic tx
CNS STIMULANTS
- Methylphenidate
- Dextroamphetamine
- Dextroamphetamine and amphetamine salt combos
Methylphenidate
Ritalin, Concerta, Biphentin (small granules that can be sprinkled into food)
Dopamine AGONIST
Dextroamphetamine
Dexedrine, Vyvanse
Dopamine AGONIST
Dextroamphetamine and amphetamine salt combos
Adderall
ADHD non-stimulant medications
Atomoxetine HCl (Straterra)
Clonidine and guanfacine
Wellbutrin
ADHD CNS stimulant C/O
V rare risk of sudden cardiac death
C/I in pts with known cardiac risk
Cardiac consult needed for anyone with high risk
NO risk factors = routine ECG/cardio referral not needed
Atomoxetine HCl
Straterra
NE uptake inhibitor
BLACK BOX WARNING - increased suicidal thoughts or behaviours
Clonidine and guanfacine
Alpha agonists
Clonidine works on prefrontal cortex –> decreased BP and HR
Often used n children with comorbid tic d/o
Monitoring while on stimulants
Height (decrease growth by ~2cm)
Weight (may have weight loss/decreased appetite)
BP (systolic may increase 3-8mmHg; diastolic 2-14mmHg)
Pulse (increase 3-10BPM)
on quarterly basis
P/E annually
1st line tx for ADHD In preschool aged children (4-5 y.o.)
Behaviour modification in classroom and at home
Child-centred play, positive reinforcement, ignore poor behaviour
ADHD
A. Inattention AND/OR hyperactivity-impulsivity that interferes with fining or development
- Inattention: 6 or more of (for at least 6 months)
* Fails to pay close attention to details
* Difficulty staying focused
* Does not listen when spoken to
* Doesn’t follow instructions
* Avoids tasks that requires sustained mental effort
* Loses things necessary for tasks
* Easily distracted by extraneous stimuli
* Forgetful in daily activities
- Hyperactivity and impulsivity: 6 or more of (for at least 6months) or 5 or more if older teen/adult
* Fidgets with or taps hands/feets
* Leaves seat when not supposed to
* runs or climbs a lot/feels restless
* unable to play or engage in leisure activities quietly
* On the go, acting as if driven by motor
* talks excessively
* blurbs out answers
* can’t wait his/her turn
* interrupts or intrudes on others
Symptoms present before age 12
Symptoms present in 2 or more settings
OCD epidemiology
0.5% children/teens affected
Lifetime prevalence of 2-4%
Females > males (Slightly) but boys > girls
More prevalent than schizophrenia or BPD
4th most common psych d/o after substance use d/o, phobias and MDD
Mean AOO = 20y.o.
Most commonly reported obsession
Extreme fears of contamination
Second most commonly reported obsession
Worries related to harm to themselves, family or fear of harming others d/t losing control over aggressive impulses
Initial intervention for OCD
CBT
Pharmacotherapy for OCD
- SSRI
- If SSRI doesn’t work –> clomipramine (TCA with highest selectivity for serotonin reuptake)
- If neither SSRI nor clomipramine work, ADD valproate, lithium, carbamazepine OR try another drug (ie. venlafaxine, MAOI, buspirone, clonazepam, or atypical antipsychotic)
SCOFF questions for ED
Do you make yourself feel Sick b/c you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you recently lost more than One stone (14lbs) in a 3 month pre?
Do you believe you’re Fat when others say you’re thin?
Would you say that Food dominates your life?
If >2, likely AN or BD
Female athlete triad
- Disordered eating
- Amenorrhea
- Osteopenia
Medication C/I with ED d/t increase in seizure risk
Bupropion
2 different subtypes of AN
- Restricting type
2. Binge eating/purging type
Anorexia nervosa
- Significant low body weight
- Fear of gaining weight
- Disturbance in body weight self-evaluation
AN severity
Mild: BMI >/= 17
Moderate: BMI 16-16.99
Severe: BMI 15-15.99
Extreme: BMI <15
AN prevalence rate
0.5%
Sick euthyroid syndrome
TSH normal but peripheral conversion from T4 to T3 is decreased, leading to signs and symptoms of hypothyroidism
Anorexia tx
Maudsley Family-Based Therapy
Phase 1= Weight-restoration
Phase 2 = Returning control back to child
Phase 3 = Set healthy adolescent identity
Anorexia prognosis
Rule of thirds
1/3 recover fully
1/3 recover but relapse when stressed
1/3 have chronic relapsing course
Bulimia nervosa prevalence rate
1-2%
Bulimia nervosa
- Binge eating
- Inappropriate compensatory behaviours to prevent weight gain
- Bing eating and inappropriate compensatory behaviours occur at least 1x/wk for 3mo
- Self-evaluation influenced by body shape/weight
- Disturbance not occurring exclusively during episode of AN
Binge eating
Both of:
- Eating more than one normally would in a set period of time
- Sense of lack of control during eating episode
Bulimia nervosa severity
Mild: 1-3epis/wk
Mod: 4-7 epis/wk
Severe: 8-13 epis/wk
Extreme: 14 or more epis/wk
Russel’s sign
Calluses on knuckles or back of hand due to repeated self-induced vomiting caused by incisor teeth during gag reflex
Tx for bulimia nervosa
CBT
SSRI sometimes
Binge eating d/o
- Recurrent epis of binge eating
- Epis associated with 3 or more of:
- Eating more rapidly than normal
- Eating alone b/c embarrassed
- Feeling gross with oneself afterwards
- Eating until uncomfortably full
- Eating large amounts when not hungry
- Marked distress regarding binge eating
- Occurs ~1x/wk for 3mo
- NOT associated with recurrent use of inappropriate compensatory behaviour
Oppositional defiant disorder
At least 6mo at least 4 symptoms from any of the categories when interacting with at least 1 person who is not a sibling: - Angry or irritable mood - Argumentative/defiant behaviour - Vindictiveness
ODD severity
Mild - confined to one setting
Moderate - Present in at least 2 settings
Severe - Present in 3 or more settings
ODD prevalence
1-11%
ODD general course
ODD > conduct disorder > antisocial personality disorder but not always
Usually appears during preschool
ODD tx
Parent training
Parent-child interaction therapy
Individual/family therapy
Conduct disorder
3/15 symptoms present in past 12mo with at least 1 criterion present in past 6months
- Aggression to people and animals
- Destruction of property
- Deceitfulness or theft
- Serious violation of rules (missing school, staying out, running away from home)
CD prevalence/gender distribution
2-10%
Males > females
Earlier onset generally worse prognosis
PTSD
- Exposure to actual or threatened death, serious injury or sexual violence (actually experiencing, witnessing, learning it happened to close family member/friend, repeatedly experiencing exposure)
- Presence of >/1 intrusive symptoms:
- Recurrent memories
- Recurrent distressing dreams
- Dissociative rxns (flashbacks)
- Intense psych distress at exposure to int/ext cues that symbolize aspect of traumatic event
- Marked psych runs to internal or ext cues that symbolize or resemble an aspect of trauma
- Persistent avoidance of stimuli a/w trauma (memories or reminders)
- Negative changes in cognitions/mood a/w traumatic event
- can’t remember important parts of event
- Exaggerated -ve beliefs about oneself or world
- Distorted cognitions about cause or consequences of trauma
- Persistent -ve emotional state etc.
- Marked alterations in arousal/reactivity a/w trauma
- Duration MORE THAN 1 MONTH
PTSD prevalence among adults
3.5%
PTSD lifetime prevalence in general population
8%
PTSD gender differences
Women > men
PTSD course and prognosis
Delay can be as short as 1wk or as long as 30yrs
After 1yr, 50% recover
PTSD tx
SSRIs are FIRST LINE tx for PTSD
Psychotherapy - CBT, exposure therapy, stress management, eye movement desensitization and reprocessing (EMDR), group therapy, family therapy
___% of older adults have depressive symptoms
15
Depressive symptoms more common in older patients
Somatic symptoms
Memory complaints
Psychotic features/paranoia
Scale for geri depression
Geriatric Depression Scale (GDS) 0-4 = Normal 5-9 = Mild depression 10-15 = Severe depression Differs from PHQ-9 because has less focus on somatic symptoms which are very common in older pts so can give false positive
MOCA score
26/30 or above is normal
Major neurocognitive disorder (dementia)
Insidious onset Lasts months to years Stable and progressive course Orientation usually impaired to time and then later to place Slowed thoughts/word finding difficulty/poor judgements/paranoid and delusions common \+/- Visual hallucinations Labile/irritable emotions Difficulty sleeping Poor insight
Geri depression tx
Studies have shown combined therapy of pharmacy and psychotherapy superior to either modality alone
Common SSRIs
Citalopram Escitalopram Fluoxetine Sertraline Paroxetine Fluvoxamine
Trazodone drug class
SARI (Serotonin antagonist and reuptake inhibitor)
Common MAOI
Phenelzine
Age group with highest rate of suicide
Elderly
Especially white me over age 65
Suicide Risk Assessment
SAD PERSONS Sex (+1 if male) Age (+1 if under 19 or over 45) Depression (+1 if present) Previous Attempt (+1 if present) Ethanol abuse (+1 if present) Rational thinking loss (+1 if psychotic for any reason) Social support lacking (+1 if lacking0 Organized plan (+1 if plan made and method legal) No spouse Sickness
0-2 = low risk 3-4 = moderate risk, follow closely 5-6= high risk, consider hospitalization 7-10 = very high risk, hospitalize or commit
Drugs associated with delirium
Sedatives Opioids Anticholinergics EtOH Drug withdrawal
1yr mortality rate for pt with delirium episode while in hospital
As high as 50%
Delirium: major NT involved, major neuroanatomical area involved, major neuro pathway involved
ACh, reticular formation of brainstem (attention and arousal), dorsal tegmental pathway
Delirium treatment
Environmental support (calendars, clocks, pictures) Pharmacotherapy - benzos first line, halloo PRN, atypical antipsychotics not as well studied
Areas of cognition affected in major neurocognitive disorder
Complex attention Executive function learning and memory Perceptual motor Social cognition
Top 3 most common forms of major neurocogntivie disorder
- Alzheimer’s Type (50-60%)
- Vascular dementia (15-30%)
- Mixed vascular and alzheimer
Prevalence of major neurocognitive disorder in population >65 and >85
5%, 20%
Alzheimer’s type dementia
Amyloid deposits, neurofibrillary tangles, neuronal loss (in cortex and hippocampus especially)
Evidence of causative gene on chromosome 21 in family hx OR all 3 of:
1. clear decline in memory and learning and at least 1 other domain
2. steadily progressive, gradual decline in cognition, no plateaus
3. No evidence of mixed forms of dementia
Vascular dementia
More focal neuro symptoms but may affect wide areas of brain
Atherosclerotic plaques or thromboembolisms in small-medium sized cerebral vessels
Frontotemporal dementia/Pick’s disease
Men > women
Personality/behaviour changes with relative preservation of cognitive function
Pick bodies = build-up of tau proteins in neurons
Lewy body disease
Visual hallucinations, parkinsonism features and EPS
Lewy body build up in cerebral cortex (alpha synuclein proteins)
Neurocognitive disorder tx
Benzos for insomnia and anxiety
Antidepressants for depression
Antipsychotics for delusions/hallucinations (risperidone is only one actually approved for this use)
Cholinesterase inhibitors (Dementia a/w LOW ACh) - donepezil*, rivastigmine, galantamine, tacrine
Lamotrigine major S/E
Steven Johnson
Associated with rate of increase (don’t increase by more than 25mg/wk)
Divalproex and lamotrigine interaction
Divalproex can cause lamotrigine levels to be significantly higher than expected base on dose alone (~2x dose)
Most likely comorbidity with specific phobia d/o
Other anxiety disorders
Best tx for specific phobia
CBT
Exposure response prevention therapy
Form of CBT for OCD
