Psych Toronto Notes

Question 1

What are the axes (from DSM IV)?

Answer 1

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)

Question 2

What are the 4 symptom clusters?

Answer 2

mood, anxiety, psychosis (thought), organic

Question 3

Suicide risk factors

Answer 3

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.

Question 4

What are evidence and non-evidence based interventions for SI?

Answer 4

Evidence: safety plan. Non-evidence: hospitalization.

Question 5

Psychotic disorders: definition

Answer 5

significant impairment in reality testing

• delusion or hallucinations
• behaving such that reality testing is likely disturbed

Question 6

delusion

Answer 6

fixed false belief

Question 7

hallucination

Answer 7

perceptual experiences without an external stimulus

Question 8

DDx for psychosis

Answer 8

• 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

Question 9

Timeline of psychosis for primary psychotic disorders

Answer 9

<1mo Brief psychotic disorder
1-6mo Schizophreniform disorder
>6mo Schizophrenia

Question 10

DSM5 Criteria for Schizophrenia

Answer 10

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)

Question 11

Schizophrenia epidemiology

Answer 11

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

Question 12

Schizophrenia etiology - genetics

Answer 12

genetic: 40% concordance in monzygotic twins, 10% of dizygotic, siblings, children.

Question 13

schizophrenia etiology - neurochemistry & neuroendocrine

Answer 13

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

Question 14

schizophrenia etiology - neuroanatomy

Answer 14

decreased frontal lobe funtion, asymmetric temporal/limbic function, decreased basal ganglia function, subtle changes in thalamus, cortex, corpus callosum, and ventricles; cytoarchitectural abnormalities

Question 15

schizophrenia etiology - neuropscyh & environemental

Answer 15

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

Question 16

Schizophrenia management - biological

Answer 16

• 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)

Question 17

Schizophrenia: antipsychotics

Answer 17

risperidone, aripiprazole, haloperidol, paliperidone; clozapine if resisitant

Question 18

Schizophrenia: mood stabilizers - indication & eg

Answer 18

for aggression/impulsiveness

Li, valproate, carbamazepine

Question 19

Schizophrenia management - psychosocial

Answer 19

• psychotherapy, supportive, CBT
• ACT (Assertive Community Treatment): mobile mental health teams in community
• social supports: social skills training, housing, employment programs, disability benefits

Question 20

Schizophrenia course & prognosis

Answer 20

• 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

Question 21

DUP in first-episode schizophrenia

Answer 21

Duration of Untreated Psychosis: shorter DUP associated with greater response to antipsychotic treatment.

Question 22

DSM5 Schizophreniform disorder

Answer 22

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

Question 23

Schizophreniform: treatment & prognosis

Answer 23

Similar to acute schizophrenia

Prognosis better than schizophrenia. Begins & ends more abruptly, and person has good pre- and post-morbid function.

Question 24

DSM 5 - Brief psychotic disorder

Answer 24

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.

Question 25

Brief psychotic disorder - treatment & prognosis

Answer 25

Treatment: secure environment, antipsychotics, anxiolytics
Prognosis: good, self-limiting; should return to premorbit function w/in 1mo

Question 26

DSM5 - Schizoaffective Disorder

Answer 26

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

Question 27

Schizoaffective - Epidemiology

Answer 27

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.

Question 28

schizoaffective - treatment & prognosis

Answer 28

treatment: antipsychotics, mood stabilizers, antidepressants
prognosis: “between that of schizophrenia and of mood disorder” … coooool thanks.

Question 29

DSM5 - Delusional disorder

Answer 29

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

Question 30

Delusional disorder Treatment & prognosis

Answer 30

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