Psych Toronto Notes Flashcards
What are the axes (from DSM IV)?
I: DDx of clinical disorders
II: personality disorders, developmental disability
III: general medical conditions potentially relevant to understanding/management of mental disorder
IV: psychosocial and environmental issues
V: Global Assessment of Function (0-100, incorporates effects of axes I-IV)
What are the 4 symptom clusters?
mood, anxiety, psychosis (thought), organic
Suicide risk factors
SADPERSONS: Sex - male Age >60 (or... 45-60?? source-dependent) Depression Previous attempts EtOH or other substance abuse Rational thinking loss (delusions, hallucinations, hopelessness) Suicide in family Organized plan No spouse, no social supports (additive: no spouse over and above no other social supports) Sick: serious illness, intractable pain
Best predictor of completion is past attempt.
What are evidence and non-evidence based interventions for SI?
Evidence: safety plan. Non-evidence: hospitalization.
Psychotic disorders: definition
significant impairment in reality testing
- delusion or hallucinations
- behaving such that reality testing is likely disturbed
delusion
fixed false belief
hallucination
perceptual experiences without an external stimulus
DDx for psychosis
- primary psychotic disorders: schizophrenia, schizophreniform, brief psychotic, schizoaffective, delusional disorder
- mood disorders: depressionw/ psychotic features, bipolar
- personality disorders: schizotypal, schizoid, borderline, paranoid, OCPD
- general medical conditions: tumour, head trauma, dementia, delirium, metabolic, infection, stroke, temporal lobe epilepsy
- substance-induced psychosis: intoxication or w/d, Rx, toxins
Timeline of psychosis for primary psychotic disorders
<1mo Brief psychotic disorder
1-6mo Schizophreniform disorder
>6mo Schizophrenia
DSM5 Criteria for Schizophrenia
A. 2 or more of:
A1. delusions
A2. hallucinations
A3. disorganized speech
A4. grossly disorganized or catatonic behaviour
A5. negative Sx
… at least 1 must be A1,2,3. Present for 1mo (or less if treated)
B. decreased level of function
C. at least 6mo of continuous Sx: A, + prodromal/residual
D. r/o schizoaffective, depressive, bipolar with psychotic features
E. r/o other causes
F. if Hx of ASD or other communication disorder of childhood onset: only if prominent delusions or hallucinations for at least 1mo (or less if treated)
Schizophrenia epidemiology
Prevalence: .3-.7%; M:F 1:1
mean age of onset: females late 20s, males early-mid 20s
suicide risk: 30% attempt, 10% die by suicide
Schizophrenia etiology - genetics
genetic: 40% concordance in monzygotic twins, 10% of dizygotic, siblings, children.
schizophrenia etiology - neurochemistry & neuroendocrine
neurochem: dopamine hypothesis: excess activity in mesolimbic pathway –> + Sx, decreased dopamine in prefrontal –> cognitive & mood Sx. GABA, glutamate, ACh also involved.
neuroendocrine: abnormal GH, prolactin, cortisol ACTH
schizophrenia etiology - neuroanatomy
decreased frontal lobe funtion, asymmetric temporal/limbic function, decreased basal ganglia function, subtle changes in thalamus, cortex, corpus callosum, and ventricles; cytoarchitectural abnormalities
schizophrenia etiology - neuropscyh & environemental
neuropsych: global deficits in attnetion, language, & memory suggest disrupted connectivity of neural networks
environmental: indirect evidence of MJ use, geographical variance, winter birth, OB complications, prenatal viral exposure
Schizophrenia management - biological
- acute treatment and maintenance: antipsychotics; IM q2-4w improve adherence
- adjunctive: ± mood stabilizers, ± anxiolytics, ± ECT
- treat for at least 1-2y after first episode, at least 5y after multiple episodes (relapse can cause severe deterioration)
Schizophrenia: antipsychotics
risperidone, aripiprazole, haloperidol, paliperidone; clozapine if resisitant
Schizophrenia: mood stabilizers - indication & eg
for aggression/impulsiveness
Li, valproate, carbamazepine
Schizophrenia management - psychosocial
- psychotherapy, supportive, CBT
- ACT (Assertive Community Treatment): mobile mental health teams in community
- social supports: social skills training, housing, employment programs, disability benefits
Schizophrenia course & prognosis
- majority have prodromal phase
- course is variable: some have exacerbations & remissions, some remain chronically ill; accurate long-term prediction not possible
- positive Sx diminish with treatment; negative Sx may be prominent early, or become more prominent later
- over time: 1/3 improve, 1/3 remain the same, 1/3 worsen
DUP in first-episode schizophrenia
Duration of Untreated Psychosis: shorter DUP associated with greater response to antipsychotic treatment.
DSM5 Schizophreniform disorder
At least 1mo, less than 6, of: A. 2 or more of: A1. delusions A2. hallucinations A3. disorganized speech A4. grossly disorganized or catatonic behaviour A5. negative Sx ... at least 1 must be A1,2,3. Present for 1mo (or less if treated)
D. r/o schizoaffective, depressive, bipolar with psychotic features
E. r/o other causes
Schizophreniform: treatment & prognosis
Similar to acute schizophrenia
Prognosis better than schizophrenia. Begins & ends more abruptly, and person has good pre- and post-morbid function.
DSM 5 - Brief psychotic disorder
A. 2 or more of:
A1. delusions
A2. hallucinations
A3. disorganized speech
A4. grossly disorganized or catatonic behaviour
… at least 1 must be A1,2,3. Present for 1mo (or less if treated)
D. r/o schizoaffective, depressive, bipolar with psychotic features
E. r/o other causes
Episode is at least 1d, but less than 1mo, with eventual full return to premorbid functioning.
Can occur after stressful event, or postpartum.
Brief psychotic disorder - treatment & prognosis
Treatment: secure environment, antipsychotics, anxiolytics
Prognosis: good, self-limiting; should return to premorbit function w/in 1mo
DSM5 - Schizoaffective Disorder
A. concurrent psychosis (criterion A of schizophrenia) and major mood episode - uninterrupted period of illness
B. delusions or hallucinations for 2 or more wk in the absence of a major mood episode during the lifetime duration of the illness [so – hx of psychosis w/o mood sx, at any point in life]
C. major mood episode Sx are present for the majority of the total duration of the active and residual periods of the illness
D. r/o substances, medical conditions
Schizoaffective - Epidemiology
1/3 as prevalent as schizophrenia; bipolar type more common in young adults, depressive type more common in older adults. Depressive correlates more strongly with suicide.
schizoaffective - treatment & prognosis
treatment: antipsychotics, mood stabilizers, antidepressants
prognosis: “between that of schizophrenia and of mood disorder” … coooool thanks.
DSM5 - Delusional disorder
A. 1 or more delusions, 1mo or longer
B. Never met criterion A of schizophrenia
C. functioning not markedly impaired (“aside from the impact of the delusion(s) or its ramifications”)
D. if manic or depressive episodes have occurred, have been brief relative to delusional periods
E. r/o substance, medical condition, other mental condition
subtypes: erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified; further specify: bizarre, content, 1st/multiple episodes, severity
Delusional disorder Treatment & prognosis
T: antipsychotics, psychotherapy, antidepressants
P: may respond to antipsychotics, but most pt refuse and have chronic course; some maintain high level of functioning, some progress to schizophrenia
