Psychiatry Flashcards
What is the DSM-5 criteria for OCD?
Experiencing obsessions and/or compulsions that are time-consuming (e.g., >1 hr/day) or cause significant distress or dysfunction.
Not caused by the direct effects of a substance, another mental illness, or another medical condition.
What are obsessions?
Recurrent, intrusive, anxiety-provoking thoughts, images, or urges that the patient attempts to suppress, ignore, or neutralize by some other thought or action (i.e., by performing a compulsion).
What are compulsions?
Repetitive behaviors or mental acts the patient feels driven to perform in response to an obsession, or a rule aimed at stress reduction or disaster prevention. The behaviors are excessive and/or not realistically connected to what they are meant to prevent.
What is PANDAS?
Pediatric autoimmune neuropsychiatric disorder associated with group A strep. Produces antibodies that damage caudate. These infections in kids can lead to severe OCD overnight!
What are the risk factors for OCD?
o Genetic: neurological dysfunction, family history
o Environmental: adverse childhood experiences (i.e. abuse, behavioural inhibition), exposure to traumatic events, group A streptococcal infection
What is the etiology of OCD?
o Significant genetic component: Higher rates of OCD in first-degree relatives and monozygotic twins than in the general population. Higher rate of OCD in first-degree relatives with Tourette’s disorder.
o Elevated CSF glutamate in OCD
1st line treatment for OCD?
CBT: exposure and response prevention (tolerate, don’t avoid and don’t use avoidance strategies)
Medical treatment for OCD?
o SSRIs: fluoxetine, fluvoxamine, sertraline; faster titration! Wait longer (8-12 weeks at therapeutic doses). Benzos – use early then taper – cover temporary worsening of anxiety.
▪ Step 1: SSR1 (2-3 types if necessary)
▪ Step 2: trial of clomipramine >250mg.
▪ Step 3: add antipsychotic (risperidone, aripiprazole, etc.), esp. if co-morbid tics.
What is the DSM-5 criteria for dysmorphic disorder?
o Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable by or appear slight to others.
o In response to the appearance concerns, repetitive behaviors (e.g., skin picking, excessive grooming) or mental acts (e.g., comparing appearance to others) are performed.
o Preoccupation causes significant distress or impairment in functioning.
o Appearance preoccupation is not better accounted for by concerns with body fat/weight in an eating disorder.
Treatment for dysmorphic disorder?
SSRIs and/or CBT may reduce the obsessive and compulsive symptoms in many patients.
What is the DSM-5 criteria for hoarding disorder?
o Persistent difficulty discarding possessions, regardless of value.
o Difficulty is due to need to save the items and distress associated with discarding them.
o Results in accumulation of possessions that congest/clutter living areas and compromise use.
o Hoarding causes clinically significant distress or impairment in social, occupational, or other areas of functioning.
o Hoarding is not attributable to another medical condition or another mental disorder.
Treatment for hoarding disorder?
- Very difficult to treat.
- Specialized CBT for hoarding.
- SSRIs can be used.
What is the DSM-5 criteria for trichotillomania?
- Recurrent pulling out of one’s hair, resulting in hair loss.
- Repeated attempts to decrease or stop hair pulling.
- Causes significant distress or impairment in daily functioning.
- Hair pulling or hair loss is not due to another medical condition or psychiatric disorder.
- Usually involves the scalp, eyebrows, or eyelashes. May include facial, axillary, and pubic hair.
Trichotillomania and excoriation disorder are driven by ____?
Impulsions - feeling of anxiety/boredom/tension
What do you need to rule out for trichotillomania?
Rule out: Rule out dermatological condition, body dysmorphic disorder
Treatment for trichotillomania?
- Treatment includes SSRIs, bupropion, second-generation antipsychotics, lithium, or N-acetylcysteine.
- Specialized types of cognitive-behavior therapy (e.g., habit reversal training).
What is the DSM-5 criteria for excoriation disorder?
- Recurrent skin picking resulting in lesions.
- Repeated attempts to decrease or stop skin picking.
- Causes significant distress or impairment in daily functioning.
- Skin picking is not due to a substance, another medical condition, or another psychiatric disorder.
What do you need to rule out for excoriation disorder?
Rule out: scabies, substance use (i.e. cocaine), psychotic disorder (delusions, tactile hallucinations), body dysmorphic disorder, stereotypic movement disorder, non-suicidal self-injury
Treatment for excoriation disorder?
- Specialized types of cognitive-behavior therapy (e.g., habit reversal training).
- SSRIs have shown some benefit.
What should be asked when taking a sleep history
BEARS – bedtime, excessive daytime somnolence, awakenings, restlessness(?) , snoring. Duration, meds, concurrent illnesses, mental health!
What are the two sleep-wake disorder groups?
- Dyssomnias
- Parasomnias
DSM-5 criteria of insomnia disorder?
- Complaint of dissatisfaction with sleep quantity or quality – difficulty initiating sleep or maintaining sleep or early-morning awakening with inability to return to sleep
- Causes significant distress
- At least 3 nights/week and for at least 3 months
- There is adequate opportunity for sleep
- Other medical conditions, sleep-wake disorders or substances can’t explain the cause
Clinical features of insomnia disorder?
- Difficulty initiating sleep (initial or sleep-onset insomnia).
- Frequent nocturnal awakenings (middle or sleep-maintenance insomnia).
- Early morning awakenings (late or sleep-offset insomnia).
- Waking up feeling fatigued and unrefreshed (nonrestorative sleep).
Etiology of insomnia disorder
- Subclinical mood and/or anxiety disorders.
- Preoccupation with a perceived inability to sleep.
- Bedtime behavior not conducive to adequate sleep (poor sleep hygiene).
- Idiopathic
____ is the most common PTSD symptom.
Insomnia
What are the diagnoses that fall under dyssomnias?
- Insomnia Disorder
- Hypersomnolence Disorder
- Breathing-related sleep disorders
- Narcolepsy
- Circadian rhythm sleep-wake disorders
Definition of insomnia disorder?
Refers to a number of symptoms that interfere with duration and/or quality of sleep despite adequate opportunity for sleep.
Definition of dyssomnias?
Abnormalities in the amount, quality or timing of sleep.
Treatment of insomnia disorder?
- Meds – trazodone (can cause priapism) and zopiclone. As effective as CBT during short periods of treatment (4-8 weeks); insufficient evidence to support long-term efficacy. Mirtazapine (in low doses) is often used to promote sleep in patients with coexisting depressive disorders. Releases norepinephrine and serotonin
- CBT-I – mostly good sleep hygiene
Side effects of trazodone?
Side effects include development of tolerance, addiction, daytime sleepiness, and rebound insomnia.
DSM-5 criteria of hypersomnolence disorder?
- Self-reported excessive sleepiness despite a main sleep period lasting at least 7 hours, with at least one of the following symptoms:
- Recurrent periods of sleep or lapses into sleep within the same day.
- A prolonged main sleep episode of more than 9 hours per day that is nonrestorative (i.e., unrefreshing).
- Difficulty being fully awake after abrupt awakening. - The hypersomnolence occurs at least three times per week, for at least 3 months.
- The hypersomnolence is accompanied by significant distress
- Other medical conditions, sleep-wake disorders or substances can explain the cause
Etiology of hypersomnolence disorder?
- Viral infections (e.g., HIV pneumonia, infectious mononucleosis, Guillain-Barre).
- Head trauma.
- Genetic-may have autosomal dominant mode of inheritance in some individuals.
Treatment of hypersomnolence disorder?
Life-long therapy with modafinil or stimulants such as methylphenidate; amphetamine-like antidepressants such as atomoxetine are second-line therapy.
Diagnostic criteria for obstructive sleep apnea hypopnea?
- Evidence by polysomnography of at least five obstructive apneas or hypopneas per hour of sleep and either of the following sleep symptoms:
- Nocturnal breathing disturbances: snoring, snorting/gasping, or breathing pauses during sleep.
- Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep that is not better explained by another mental disorder
Diagnostic criteria for central sleep apnea?
- Evidence by polysomnography of five or more central apneas per hour of sleep.
- The disorder is not better explained by another current sleep disorder.
Diagnostic criteria for sleep-related hypoventilation?
Polysomnography demonstrates episodes of decreased respiration associated with elevated CO2 levels
Clinical features of sleep-related hypoventilation?
Individuals report frequent arousals, morning headaches, insomnia, and excessive daytime sleepiness.
___ of chronic opioid users have central sleep apnea.
30%
Treatment of central sleep apnea?
- Treat the underlying condition.
- CPAP/BiPAP.
- Supplemental O2.
What are the breathing-related sleep disorders?
- Obstructive sleep apnea hypopnea
- Central sleep apnea
- Sleep-related hypoventilation
Risk factors of obstructive sleep apnea hypopnea?
Obesity, increased neck circumference, airway narrowing.
Treatment of obstructive sleep apnea hypopnea?
- Positive airway pressure: continuous (CPAP) and in some cases bilevel (BiPAP).
- Behavioral strategies such as weight loss and exercise.
Diagnosis (DSM-5 Criteria) of narcolepsy?
- Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day. These must have been occurring at least three times per week over the past 3 months.
- The presence of at least one of the following:
- Cataplexy - a medical condition in which strong emotion or laughter causes a person to suffer sudden physical collapse though remaining conscious.
- Hypocretin deficiency in the CSF
- Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep latency (time to reach REM sleep) less than or equal to 15 minutes (normal is 90-120 mins). - Hallucinations and/or sleep paralysis at the beginning or end of sleep episodes are common (Not included in the DSM-5)
Pathophysiology of narcolepsy?
- Linked to a loss of hypothalamic neurons that produce hypocretin.
- May have autoimmune component.
Treatment of excessive daytime sleepiness from narcolepsy?
- Amphetamines (d-amphetamine, methamphetamine).
- Non-amphetamines such as methylphenidate, modafinil, sodium oxybate, and pitolisant (a novel histamine H3 receptor inverse agonist that is effective for both daytime sleepiness and cataplexy).
Treatment of cataplexy from narcolepsy?
- Sodium oxybate (drug of choice).
- Tricyclic antidepressants (TCAs): Imipramine, desipramine, and clomipramine.
- REM suppression drugs such as selective serotonin reuptake inhibitor (SSRI)/serotonin-norepinephrine reuptake inhibitor (SNRI): Fluoxetine, duloxetine, atomoxetine, venlafaxine.
Treatment of circadian rhythm sleep-wake disorders?
Melatonin
Definition of circadian rhythm sleep-wake disorders?
Sleep disruption that is primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by an individual’s physical environment or social or professional schedule
Definition of parasomnias?
Abnormal behaviour in sleep
What are the diagnoses that fall under parasomnias?
- Non-rapid eye movement (NREM) sleep arousal disorder
- Nightmare disorder
- Rapid eye movement (REM) sleep behavior disorder
- Restless legs syndrome
- Substance/Medication-Induced Sleep Disorder
What are the diagnoses that fall under non-rapid eye movement (NREM) sleep arousal disorder?
- Sleepwalking
- Sleep terrors
What is the definition of non-rapid eye movement (NREM) sleep arousal disorder?
Repeated episodes of incomplete arousals that are brief and usually occur during the first one-third of the sleep episode
Clinical features of sleepwalking
- Behaviors may include sitting up in bed, walking around, eating, and in some cases “escaping” outdoors.
- Eyes are usually open with a blank stare and “glassy look.”
- Difficulty arousing the sleepwalker during an episode.
- Dreams aren’t remembered and there is amnesia for the episode.
- Episodes usually end with patients returning to bed or awakening (briefly) confused and disoriented.
Treatment of sleepwalking
- Most cases do not need to be treated.
- Patients may benefit from education, reassurance, addressing precipitating factors, ensuring a safe environment, and proper sleep hygiene.
- Refractory cases may respond to low-dose benzodiazepine (e.g., clonazepam)
Etiology of sleepwalking
- Unknown.
- Family history in 80% of cases.
- Usually not associated with any significant underlying psychiatric or psychological problems.
Clinical features of sleep terrors?
- Recurrent episodes of sudden terror arousals, usually beginning with screaming or crying, that occur during slow-wave sleep.
- Signs of autonomic arousal, including tachycardia, tachypnea, diaphoresis, and mydriasis.
- Difficulty arousing during an episode.
- After episode, patients usually return to sleep without awakening.
- Dreams aren’t remembered and there is amnesia for the episode.
Treatment of sleep terrors?
- Reassurance that the condition is benign and self-limited.
- Same as for sleepwalking.
Define of nightmare disorder?
- Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity
- On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.
- This occurs during REM sleep
Treatment of nightmare disorder?
- Not always needed. Reassurance may help in many cases.
- Desensitization/Imagery rehearsal therapy (IRT) involves the use of mental imagery to modify the outcome of a recurrent nightmare, writing down the improved outcome, and then mentally rehearsing it in a relaxed state.
Diagnostic criteria of rapid eye movement (REM) sleep behavior disorder?
- Repeated episodes of arousal during sleep associated with vocalization and/or complex motor behaviors, occurring during REM sleep.
- Upon awakening from these episodes, the individual is completely awake, alert, and not confused or disoriented.
- Either of the following:
o REM sleep without atonia on polysomnographic recording.
o A history suggestive of REM sleep behavior disorder and an established synucleinopathy diagnosis (e.g., Parkinson’s disease, multiple system atrophy).
Risk factors of rapid eye movement (REM) sleep behavior disorder?
- Older age, generally more than 50 years.
- Psychiatric medications such as TCAs, SSRIs, SNRIs, and B-blockers.
- Narcolepsy.
- Highly associated with underlying neurodegenerative disorders, especially Parkinson’s, multiple system atrophy, and neurocognitive disorder with Lewy bodies.
Treatment of rapid eye movement (REM) sleep behavior disorder?
- Discontinuation of likely causative medications if possible.
- Clonazepam is efficacious in most patients.
- Melatonin may also be helpful.
- Ensure environmental safety such as removing potentially dangerous objects from the bedroom and sleeping on the ground until behaviors can be managed effectively.
Diagnostic criteria of restless leg syndrome?
- An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant sensations in the legs, characterized by all of the following:
- The urge to move the legs begins or worsens during periods of rest or inactivity.
- The urge to move the legs is partially or totally relieved by movement.
- The urge to move the legs is worse in the evening or at night than during the day, or occurs only in the evening or at night.
- At least 3x/wk for 3 months
- Characterized by significant distress
Risk factors of restless leg syndrome?
- Increases with age.
- Strong familial component.
- Iron deficiency.
- Antidepressants, antipsychotics, dopamine-blocking antiemetics, and antihistamines can contribute to or worsen symptoms.
Treatment of restless leg syndrome?
- Behavioral strategies including regular exercise, reduced caffeine intake, and avoiding aggravating factors have been shown to be beneficial.
- Responds well to pharmacologic treatments.
- Remove offending agents if possible.
- Iron replacement if low ferritin.
- Dopamine agonists and benzodiazepines are first-line treatments.
- Gabapentin, gabapentin enacarbil (prodrug to gabapentin), and pregablin are also used.
Diagnostic criteria of substance/medication-induced sleep disorder
- A prominent and severe disturbance in sleep.
- There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):
- The symptoms in Criterion A developed during or soon after substance intoxication or after withdrawal from or exposure to a medication.
- The involved substance/medication is capable of producing the symptoms in Criterion A. - The disturbance is not better explained by a sleep disorder that is not substance/medication-induced. Such evidence of an independent sleep disorder
Contributors to eating disorder risk?
Temperament, eating dysregulation, attachment issues, poor self-regulation, childhood abuse (BN especially), sociocultural ideas of health/beauty.
Triage for danger zone/when to admit?
- <75% of IDEAL BODY WEIGHT = STARVATION.
- Correct K (<3 cause prolonged QTc), P, Mg, NA. ECG/lytes (including Phosphorous) is critical!
- Vitals: BP<85/50 or HR <40
- ECG: Prolonged QTc
- Be careful of refeeding syndrome – can cause hypophosphatemia, fluid/MSK issues.
Diagnostic criteria for anorexia?
Restriction of energy intake leading to significantly low body weight (behaviour), intense fear of gaining weight/fat or persistent behaviour that interferes with weight gain (psychopathology), and disturbance in the way one’s body weight OR shape is experienced/self-evaluated.
Anorexic patients normally have cluster __ traits
C
Anorectic symptoms are ego-____
Syntonic
What defines the restricting type of anorexia?
During the last 3mo, individual has not engaged in binge/purging. Just fasting/restriction or excessive exercise
What defines the binge/purge type of anorexia?
During the last 3mo, engaged in recurrent binging/purging. If your weight is LOW and you fulfill these criteria, you are NOT bulimic, still anorexic.
Physical complications of restricting/malnutrition (anorexia):
- Bone: osteopenia/porosis, fractures
- Brain: enlarged ventricles
- Cardiac: bradycardia, hypotension, orthostasis, hypothermia, arrhythmia, QTc prolongation, and ST-T wave changes on electrocardiogram
- Derm: lanugo hair (indicative of anorexia), dry skin, edema, hair loss, brittle nails
- GI: constipation
- Heme: pancytopenia
- Endo: sick euthyroid (low TSH), hypoglycemia, low LH/FSH/estrogen/testo
Treatment of anorexia?
- Weight restoration (FOOD and lots of it) - BMI 20 in teens
- Family intervention - non-blaming, wt restoration under parental control → return control → address delays → relapse prevention. ONLY FOR TEENS, otherwise CBT.
- Meds - Premeal anxiolytic (such as alprazolam) can help encourage eating by decreasing anticipatory anxiety. Quetiapine can be used for sedation and appetite stimulation. Treatment for constipation. Vitamin and mineral supplementation
- CBT
What is refeeding syndrome?
Refers to electrolyte and fluid shifts that occur when severely malnourished patients are refed too quickly. Look for fluid retention and decreased levels of phosphorus, magnesium, and calcium
Bulimic patients normally have cluster __ traits
B
Diagnostic criteria for bulimia?
- Recurrent episodes of binge eating (eating more than average in a 2hr period/an amount of food that is larger than most people would eat and a sense of lack of control over eating during the episode)
- Recurrent inappropriate compensatory behaviour to prevent weight gain (vomiting, laxatives, fasting, excess exercise)
- At least 1x/wk for 3mo with body shape/weight influencing self-evaluation.
- Does not occur exclusively during an episode of anorexia nervosa.
Bulimic symptoms are ego-____
Dystonic
- Many bulimic patients feel like failed anorexics because they would like to have the self control to restrict their food intake
Signs of purging?
Electrolytes abnormal (low K) Russel’s sign – more in bulimia (cuts on knuckles when putting fist into mouth to vomit), moth-eaten teeth erosion/caries, salivary gland swelling (Chipmunk Cheeks).
Laboratory/imaging abnormalities of purging?
Hypochloremic hypokalemic alkalosis (purging), metabolic acidosis (laxative abuse), elevated bicarbonate (compensation), hypernatremia, increased BUN, increased amylase, altered thyroid hormone, cortisol homeostasis, esophagitis
Pathophysiology of bulimia?
- ADDICTIVE DISORDER – high prevalence of substance use in these (30%). Involves dopaminergic system.
- Childhood obesity and early pubertal maturation increase risk for bulimia nervosa.
- Psychodynamic theories: Masochistic displays of control and displaced anger over one’s body.
Treatment of bulimia
- CBT is BEST (20 sessions over 5 mo) and/or FLUOXETINE (60-80mg OD – good for short term). Vysanse (Dexedrine stimulant) can decrease binging!
What is the difference between binge-eating disorder and bulimia/anorexia?
Patients with binge-eating disorder suffer emotional distress over their binge eating, but they do not try to control their weight by purging or restricting calories, as do individuals with anorexia or bulimia. Unlike in anorexia and bulimia, patients with binge-eating disorder are not as fixated on their body shape and weight.
Diagnostic criteria of binge eating disorder?
- Recurrent episodes of binge eating, marked distress associated with ≥3 of the following for at least 1/wk for 3mo but NO COMPENSATORY BEHAVOUR (vomiting) as in BN or ANOREXIA:
- Eating more rapidly than normal
- Eating till uncomfortable full
- Eating large amounts when not feeling hungry
- Eating alone due to embarrassment by amount of food
- Feeling disgusted with oneself/depressed/guilty after
Physical exam findings of binge eating disorder
Patients are typically obese and suffer from medical problems related to obesity including metabolic syndrome, type 2 diabetes, and cardiovascular disease.
Which stimulant suppresses appetite and is used in the treatment of binge eating disorder?
Lisdexamfetamine (Vyvanse)
Treatment of binge eating disorder?
- Individual (cognitive-behavioral or interpersonal) psychotherapy with a strict diet and exercise program coordinated by a registered dietician. Comorbid mood disorders or anxiety disorders should be treated as necessary.
- SSRIs are first-line treatment due to their efficacy and tolerability.
What is pica?
Persistent eating of non nutritive, non food substances for at least one month
What is avoidant restrictive food intake disorder?
An eating or feeding disturbance lack of interest in eating and food based on the secondary characteristics of food or about aversive consequences of eating. There is no concern about body weight and shape
What is rumination disorder?
Repeated regurgitation of food over at least one month – rechewed, reswallowed or spit out.
Differential diagnosis of anxiety?
- Cardiac: angina, post/impending-MI, arrhythmias, cardiac tamponade
- Endocrine: hyper(para)thyroidism, hyperadrenocorticism, diabetes, pheochromocytoma
- GI: gastroesophageal reflux disease, irritable bowel syndrome, peptic ulcer disease, acute alcohol withdrawal
- Metabolic: hyperkalemia, hyperthermia, hypoglycemia, hyponatremia, hypoxia, porphyria, or substance ingestion/overdose.
- Respiratory: asthma, PE, COPD
- Psychiatric: somatoform/psychotic disorders, mood disorders (depression/bipolar), personality disorders (OCPD)
- D – Drugs: EtOH/benzo withdrawal, amphetamines, caffeine, OTC for colds/decongestants
Investigations for anxiety?
- ECG* + CXR + CBC*
- TSH*, Ca2+, cortisol, fasting glucose/A1C, 24hr metanephrines
- Liver enzymes
- PFTs, D-dimer*
- Tox screen
What physical symptoms might a child display if anxious?
Headaches, stomach aches, muscle tension and muscle twitches, sleep problems
Most anxiety disorders benefit from which class of medications?
Sertraline (or any other SSRI)
What could you augment with if no benefit from >12weeks of SSRI for anxiety?
- Antipsychotics (risperidone in OCD, PTSD) – esp. if co-morbid tics; usually see improvement in first 4 weeks.
- Consider clonazepam, buspirone – short term use (OCD, GAD, panic, SP)
- Gabapentin (panic, SP, PTSD pain, bipolar anxiety),
- Lamotrigine (OCD, PTSD, bipolar depression), valproic acid.
How should you titrate SSRI/SNRI for anxiety?
Start low (1/2 normal starting dose), go slow (4-6 weeks titration – OCD faster), aim sufficient (higher doses than MDD), and wait longer (8-12 weeks at therapeutic doses).
Side effects of SSRI/SNRI?
Headache, irritability, GI complaints, insomnia, fatigue, sexual dysfunction, weight gain
____ has proven effective for anxiety disorders. It examines the relationship between anxiety-driven cognitions (thoughts), emotions, and behavior.
Cognitive behavioral therapy (CBT)
Types of panic attacks?
- Unexpected = panic disorder
- Situational = everything else!
Symptoms of panic attacks?
Da PANICS
- Dizziness, disconnectedness, derealization (unreality), depersonalization (detached from self)
- Palpitations, paresthesias
- Abdominal distress
- Numbness, nausea
- Intense fear of dying, losing control or “going crazy”
- Chills, chest pain, choking
- Sweating, shaking, shortness of breath
Define panic attacks?
An abrupt surge of intense fear or discomfort that reaches a peak within minutes, during which time => 4 sx occur
Diagnosis (DSM-5 Criteria) of panic disorder?
- Recurrent, unexpected panic attacks without an identifiable trigger.
- One or more of panic attacks followed by >1 month of continuous worry about experiencing subsequent attacks or their consequences, and/or a maladaptive change in behaviors (e.g., avoidance of possible triggers).
- Not caused by the direct effects of a substance, another mental disorder, or another medical condition.
Etiology of panic disorder?
- Genetic factors: Greater risk of panic disorder if a first-degree relative is affected.
- Psychosocial factors: increase incidence of stressors (especially loss) prior to onset of disorder; history of childhood physical or sexual abuse.
Course/prognosis of panic disorder?
- Panic disorder has a chronic course with waxing and waning symptoms.
- Relapses are common with discontinuation of medication.
- Only a minority of patients have full remission of symptoms.
- Up to 65% of patients with panic disorder also have major depression.
Treatment of panic disorders
- First-line: SSRIs (e.g., sertraline, citalopram, escitalopram) – there’s a lower dose of sertraline for panic disorder specifically
- SNRIs (e.g., venlafaxine) are also efficacious.
- If above options are not effective, can try TCAs (e.g., clomipramine, imipramine).
- Can use benzodiazepines (e.g., clonazepam, lorazepam) as scheduled or PRN, especially until the other medications reach full efficacy.
- Use beta-blockers
Define agoraphobia?
Agoraphobia is an intense fear of being in public places where escape or obtaining help may be difficult. It often develops with panic disorder.
Diagnosis (DSM-5 Criteria) of agoraphobia?
- Intense fear/anxiety about more than two situations due to concerns of difficulty escaping or obtaining help in case of panic or other humiliating symptoms:
- Outside of the home alone.
- Open spaces (e.g., bridges).
- Enclosed places (e.g., stores).
- Public transportation (e.g., trains).
- Crowds/lines. - The triggering situations cause fear/anxiety out of proportion to the potential danger posed, leading to endurance of intense anxiety, avoidance, or requiring a companion. This holds true even if the patient suffers from another medical condition such as inflammatory bowel disease (IBS) which may lead to embarrassing public scenarios.
- Symptoms cause significant social or occupational dysfunction.
- Symptoms last >6 months.
- Symptoms not better explained by another mental disorder.
Epidemiology of agoraphobia?
Mean age of onset 17 (without preceding panic disorder, onset is 25-29). Persistent and chronic. Without treatment, complete remission is rare (10%). More than 1/3 completely housebound and unable to work.
Etiology of agoraphobia?
- Strong genetic factor: Heritability about 60%.
- Psychosocial factor: Onset frequently follows a traumatic event.
Treatment of agoraphobia?
Although SSRIs are considered the first-line agents for treatment of panic disorders with or without agoraphobia, the tricyclic drugs clomipramine (Anafranil) and imipramine (Tofranil) are the most effective in the treatment of these disorders. Therapies: supportive psychotherapy, behaviour therapy, cognitive therapy and virtual therapy. Benzodiazepines have the most rapid onset of action against panic.
Define a specific phobia.
A phobia is defined as an irrational fear that leads to endurance of the anxiety and/or avoidance of the feared object or situation. A specific phobia is an intense fear of a specific object or situation (i.e., the phobic stimulus).
Diagnosis (DSM-5 Criteria) of a specific phobia?
- Persistent, excessive fear elicited by a specific situation or object which is out of proportion to any actual danger/threat.
- Exposure to the situation triggers an immediate fear response.
- Situation or object is avoided when possible or tolerated with intense anxiety.
- Symptoms cause significant social or occupational dysfunction.
- Duration >6 months.
- Symptoms not solely due to another mental disorder, substance (medication or drug), or another medical condition.
___ are the most common psychiatric disorder in women and second most common in men (substance-related is first).
Phobias
Treatment of specific phobias
CBT Model for Specific Phobia: exposure is highly effective. More effective if sessions are grouped closely together, exposure if prolonged, real (not imagined), and provided in multiple different settings.
Epidemiology of social anxiety
12-14% lifetime prev, F>M in epi samples, F:M in clinical samples. Age of onset ~ mid-teens (13).
Define social anxiety
Social anxiety disorder (social phobia) is the fear of scrutiny by others or fear of acting in a humiliating or embarrassing way. The phobia may develop in the wake of negative or traumatic encounters with the stimulus. Social situations causing significant anxiety may be avoided altogether, resulting in social and academic/occupational impairment.
Diagnosis (DSM-5 Criteria) of social anxiety
- The diagnostic criteria for social anxiety disorder (social phobia) are similar to specific phobia except the phobic stimulus is related to social scrutiny and negative evaluation. The patients fear embarrassment, humiliation, and rejection. This fear may be limited to performance or public speaking, which may be routinely encountered in the patient’s occupation or academic pursuit. NOT due to impaired capacity for socialization as in ASD
- For youth: Children must experience discomfort with peers, not only with adults
Treatment of social anxiety
- Treatment of choice: CBT.
- First-line medication, if needed: SSRIs (e.g., sertraline, fluoxetine) or SNRIs (e.g., venlafaxine) for debilitating symptoms.
- Benzodiazepines (e.g., clonazepam, lorazepam) can be used as scheduled or PRN.
- Beta-blockers (e.g., atenolol, propranolol) for performance anxiety/public speaking. Also can use benzos
Diagnosis (DSM-5 Criteria) of separation anxiety disorder
- Excessive and developmentally inappropriate fear/anxiety regarding separation from attachment figures, with at least three of the following:
- Separation from attachment figures leads to extreme distress.
- Excessive worry about loss of or harm to attachment figures.
- Excessive worry about experiencing an event that leads to separation from attachment figures.
- Reluctance to leave home, or attend school or work.
- Reluctance to be alone.
- Reluctance to sleep alone or away from home.
- Complaints of physical symptoms when separated from major attachment figures.
- Nightmares of separation and refusal to sleep without proximity to attachment figure. - Lasts for >4 weeks in children/adolescents and >6 months in adults.
- Symptoms cause significant social, academic, or occupational dysfunction.
- Symptoms not due to another mental disorder.
At what age does separation anxiety disorder occur?
Tends to peak around 9-18 months and decrease after age 2. Can increase again at age 4-5 when starting school
Treatment of separation anxiety disorder
- Psychotherapy: CBT, family therapy.
- Medications: SSRIs can be effective as an adjunct to therapy.
Define selective mutism
Selective mutism is a rare condition characterized by a failure to speak in specific situations for at least 1 month, despite the intact ability to comprehend and use language.
Diagnosis (DSM-5 Criteria) of selective mutism
- Consistent failure to speak in select social situations (e.g., school) despite speech ability in other scenarios.
- Mutism is not due to a language difficulty or a communication disorder.
- Symptoms cause significant impairment in academic, occupational, or social functioning.
- Symptoms last >1 month (extending beyond first month of school).
Treatment of selective mutism
- Psychotherapy: CBT, family therapy.
- Medications: SSRIs (especially with comorbid social anxiety disorder).
Epidemiology of Generalized Anxiety Disorder
6% lifetime prev F>M 2:1. Median age at onset 30 but spread over broad range (GAD sx often in childhood).
Diagnosis (DSM-5 Criteria) of Generalized Anxiety Disorder?
- Excessive, anxiety/worry about various daily events/activities ‚>6 months.
- Difficulty controlling the worry.
- Associated >3 symptoms (BESKIM): blank mind/impaired concentration, easily fatigued, restlessness, fatigue, irritability, muscle tension, insomnia.
- Symptoms are not caused by the direct effects of a substance, or another mental disorder or medical condition.
- Symptoms cause significant social or occupational dysfunction.
Treatment of Generalized Anxiety Disorder?
- CBT
- SSRIs (e.g., sertraline, citalopram) or SNRIs (e.g., venlafaxine).
- Can also consider a short-term course of benzodiazepines or augmentation with buspirone.
- Much less commonly used medications are TCAs and MAOIs
Define Posttraumatic stress disorder (PTSD)
Posttraumatic stress disorder (PTSD) is characterized by the development of multiple symptoms after exposure to one or more traumatic events: intrusive symptoms (e.g., nightmares, flashbacks), avoidance, negative alterations in thoughts and mood, and increased arousal. The symptoms last for at least a month and may occur immediately after the trauma or with delayed expression.
Diagnosis (DSM-5 Criteria) of Posttraumatic stress disorder (PTSD)
A – Exposure to death, serious injury or sexual violence (1/4)
- Witness, Repeated occupational exposure to aversive situations, learning about someone close to the person, directly
B – Re-experiencing (1/5)
- Recollections, revieller, reliving, resembling cues cause distress, reactivity of body
C – Avoidance associated w/ stimuli (1/2)
- Thoughts/feelings, people/places/conversations
D - Negative change cognitions/mood (2/7)
- Inability to remember, negative beliefs, blames themselves (common in children), loss of interest in activities
E - Alterations in arousal/reactivity (2/6) – behaviour, sleep disturbance, hypervigilance, irritable, task completion, startled (acryonym: BSHITS)
- Those in D and E are not specific for PTSD – E can be confused for mania
F - Lasts >1mo.
Epidemiology of Posttraumatic stress disorder (PTSD)
M>F for trauma exposure, but women exposed 2x likely to develop PTSD (lifetime prev. 2x, 10.4%) – due to the type of trauma (rape), 20% soldiers.
Etiology/Risk Factors of Posttraumatic stress disorder (PTSD)
- Pretrauma (temperamental/physiological/genetic – prior mental disorders, female, enviro – lower SES/intelligence, exposure to prior trauma, family psychiatric history)
- Peritrauma (type, severity)
- Posttrauma (poor coping, social support, subsequent adverse life events).
Pathophysiology of Posttraumatic stress disorder (PTSD)
Hippocampal volume reduction (failure to distinguish between safe and dangerous) + increased amygdala activation + decreased activation of ratio of PFC (extinction memory) LOWER:ACC (fear memory) HIGHER. Therefore failure of top-down learning (insufficient top-down modulation of amygdala).
Pharmacological treatment of Posttraumatic stress disorder (PTSD)
- First-line antidepressants: SSRIs (e.g., sertraline, citalopram) or SNRIs (e.g., venlafaxine).
• Step 1: any of above for 8 weeks
• Step 2: add risperidone or olanzapine (mixed results)
• Step 3: add anti-convulsant esp. if mood lability or anger (lamotrigine or topiramate) - Prazosin, alpha-receptor antagonist, targets nightmares and hypervigilance.
- May augment with atypical (second-generation) antipsychotics in severe cases.
Psychotherapy treatment of Posttraumatic stress disorder (PTSD)
- Specialized forms of CBT (e.g., exposure therapy, cognitive processing therapy).
- Supportive and psychodynamic therapy.
- Couples/family therapy.
What are delusions?
Delusions are fixed, false beliefs that persist despite evidence to the contrary and that do not make sense within the context of an individual’s cultural background.
What are delusions of persecution/paranoid delusions
Irrational belief that one is being persecuted. Example: “The Central Intelligence Agency (CIA) is monitoring me and tapped my cell phone.”
What are ideas of reference
Belief that cues in the external environment are uniquely related to the individual. Example: “The TV characters are speaking directly to me.”
What are delusions of control
Includes thought broadcasting (belief that one’s thoughts can be heard by others) and thought insertion (belief that outside thoughts are being placed in one’s head).
What are delusions of grandeur
Belief that one has special powers beyond those of a normal person. Example: “I am the all-powerful son of God and I shall bring down my wrath on you if I don’t get my way.”
What are delusions of guilt
Belief that one is guilty or responsible for something. Example: “I am responsible for all the world’s wars.”
What is an illusion
Misinterpretation of an existing sensory stimulus (such as mistaking a shadow for an evil spirit).
What are somatic delusions
Belief that one has a certain illness or health condition. Example: A patient believing she is pregnant despite negative pregnancy tests and ultrasounds.
Differential diagnosis of psychosis?
- Psychotic disorder due to another medical condition.
- Substance/Medication-induced psychotic disorder.
- Delirium/Major neurocognitive disorder (dementia).
- Bipolar disorder, manic/mixed episode.
- Major depression with psychotic features.
- Brief psychotic disorder.
- Schizophrenia.
- Schizophreniform disorder.
- Schizoaffective disorder.
- Delusional disorder.
What are hallucinations?
Sensory perception without an actual external stimulus.
Investigations for psychosis?
- CBC, electrolytes (including extended lytes), creatinine, glucose, urinalysis, urine drug screen, TSH, Vit B12
- LFTs, fasting lipids, HbA1C to obtain baseline levels prior to antipsychotic initiation
- ECG (several antipsychotics affect cardiac conduction)
- If clinically indicated, order infectious work-up, inflammatory markers, brain imaging
What kind of hallucinations are most commonly exhibited by schizophrenic patients?
Auditory
Which type of hallucination may accompany drug intoxication, drug and alcohol withdrawal, or delirium?
Visual
Epidemiology of schizophrenia
- Disease of youth (onset late teens-mid30s). 1% lifetime prevalence. Equally prevalent in men and women - Onset is earlier in men than in women.
- Modal age of onset is between 18 and 25 for men and between 25 and 35 for women, with a second peak (bimodal for women) occurring around menopause/middle age i.e. >40 (>45 = late onset). Only 50% obtain treatment
First-degree biological relatives of persons with schizophrenia have a ___ greater risk for developing the disease than the general population.
Ten times
Persons who develop schizophrenia are more likely to have been born in the ___ and ____ and less likely to have been born in late spring and summer.
- Winter
- Early spring
Epidemiological data show a high incidence of schizophrenia after prenatal exposure to ____ during several epidemics of the disease
Influenza
The lifetime prevalence of any drug abuse (other than tobacco) in schizophrenia is often greater than ____
50 percent
Diagnosis of schizophrenia
- A: 2 (or more) of the following for at least one month period (but at least 1 criteria in red): delusions, hallucinations, or disorganized speech. Grossly disorganized/catatonic behaviour. Negative symptoms (avolition, alogia, apathy, asociality).
- B: Also need a social/occupational decline in function. Cognitive, depressive sx can also occur but not in DSM.
- C: 6mo sx (with at least 1mo of criterion A unless successfully treated)
- D: Schizoaffective and Mood Disorder exclusion.
- E: Substance use/other medical condition exclusion.
What are the dopamine pathways
- Mesolimbic (originates in the VTA and innervates limbic system)
- Mesocortical (originates in the VTA and projects to the frontal cortex)
- Nigrostriatal (projects from substantia nigra to the striatum)
- Tuberinfundibular (connects hypothalamus to the pituitary gland)
Mesolimbic hyperactivity is the cause of ___ in schizophrenics
Mesolimbic hyperactivity is the cause of positive symptoms. Evidence – paranoia can be induced by constant stimulant abuse. Therefore, want to block this hyperactivity using dopamine (D2) blockade.
Mesocortical (originates in the VTA and projects to the frontal cortex) – dopamine deficiency here (prefrontal cortex) may be responsible for the ___ in schizophrenics
Negative/cognitive symptoms. Thus – dopamine receptor blockade could lead to worsening of negative/cognitive symptoms
The medication we give for schizophrenia affect this area and cause Parkinson-like symptoms
Nigrostriatal
Medications used for schizophrenia also affect here, and cause excess prolactin secretion
Tuberinfundibular
Too much mesolimbic dopamine causes ___ and too little mesocortical dopamine causes ____.
+ve sx
–ve/cognitive sx
Since this is the case, we need agents that decrease mesolimbic dopamine to reduce +ve sx and increase mesocortical to treat –ve sx.
Neuropathology findings in schizophrenics?
- Loss of brain volume widely reported in schizophrenic brains appears to result from reduced density of the axons, dendrites, and synapses that mediate associative functions of the brain
- Functional Neuroimaging – Hypofrontality
- Structural Neuroimaging - Temporal lobe reductions in grey matter. Enlarged ventricles due to hippocampal loss in volume.
Neurodevelopmental hypothesis for schizophrenia?
- 2nd trimester defect in neuronal migration. Neuronal loss due to hypoxia-associated obstetric complications
- Excessive synaptic pruning occurring during adolescence leading to psychosis (too little connections)
The classic feature of the catatonic type is a marked disturbance in ______
The classic feature of the catatonic type is a marked disturbance in motor function; this disturbance may involve stupor, negativism, rigidity, excitement, or posturing.
Subtypes of schizophrenia?
- Paranoid Type
- Disorganized Type
- Catatonic Type
- Undifferentiated Type
- Residual Type
Classically, the paranoid type of schizophrenia is characterized mainly by the presence of
Delusions of persecution or grandeur
Patients who clearly have schizophrenia cannot be easily fit into one type or another
Undifferentiated Type
What is the residual type of schizophrenia?
The residual type of schizophrenia is characterized by continuing evidence of the schizophrenic disturbance in the absence of a complete set of active symptoms or of sufficient symptoms to meet the diagnosis of another type of schizophrenia
The classic feature of the catatonic type of schizophrenia is a marked disturbance in ______
The classic feature of the catatonic type is a marked disturbance in motor function; this disturbance may involve stupor, negativism, rigidity, excitement, or posturing.
What is the disorganized type of schizophrenia?
The disorganized type of schizophrenia is characterized by a marked regression to primitive, disinhibited, and unorganized behavior and by the absence of symptoms that meet the criteria for the catatonic type
What is the disorganized type of schizophrenia?
The disorganized type of schizophrenia is characterized by a marked regression to primitive, disinhibited, and unorganized behavior and by the absence of symptoms that meet the criteria for the catatonic type
What are delusions of influence?
Body or actions are being acted on by an outside influence
What is tangential speech?
In which the train of thought of the speaker wanders and shows a lack of focus, never returning to the initial topic of the conversation.
What is derailment (loosening of association) speech?
No logical connections b/w topic changes
What is neologism?
Words that only have meaning to the person using them, either made up words or real words that they believe have meanings other than their common meaning
What are the positive symptoms of schizophrenia?
- Hallucinations
- Delusions
- Disorganized speech
- Disorganized behaviour
- Motor
What is automatic obedience?
Individual obeys all orders, commands, and instructions from another person without question or concern.
What is catalepsy?
A medical condition characterized by a trance or seizure with a loss of sensation and consciousness accompanied by rigidity of the body.
What are the negative symptoms of schizophrenia?
- Avolition - decreased motivation to start or perform purposeful activities
- Alogia - inability to speak or reduction in the amount of speech
- Anhedonia - inability to feel pleasure
- Asociality - preference for solitary activities, inability to engage in social interactions
- Secondary “negative symptoms” – depression, pre-existing PD, SUD, hypothyroidism
What are the cognitive symptoms of schizophrenia?
SMARTS (speed of processing, memory, attention, reasoning, tact and synthesis. Good working memory, NOT reducing positive symptoms, helps improve social recovery. NEGATIVE SYMPTOMS AND COGNITIVE IMPAIRMENT strongly affects functional outcomes
____ is the most frequent prodromal symptom appearing 4 years prior to the 1st hospital admission.
Depression
Risk factors of suicidal behaviours in schizophrenics?
Presence of a major depressive episode, early age onset, high SES/IQ, deteriorating course with relapses/hospital dependence. Greater insight associated with higher risk of being suicidal (shaming, self-blame) – therefore insight needs to be monitored as part of suicide risk. Also having negative beliefs about psychosis
Risk factors of hostile symptoms in schizophrenics?
Exhibiting violent behaviour? A victim of violence in past 6 months. Male, young, nonadherence to meds. Persecutory delusions, prior antisocial behaviour prior to psychosis
What eye findings are found in schizophrenics?
The disorder of smooth ocular pursuit (saccadic movement), patients with schizophrenia have an elevated blink rate. The elevated blink rate is believed to reflect hyperdopaminergic activity.
Investigations for schizophrenias?
Tox screen, GGT, rule out med causes (CBC, lytes, BUN, LFT, TSH, VDRL (for neurosyphilis), CT – not routine – used if massive change in neurological presentation)
Comorbidities of schizophrenia
- Obesity - This is due, at least in part, to the effect of many antipsychotic medications, as well as poor nutritional balance and decreased motor activity
- Diabetes Mellitus – clozapine. Insulin resistance. Glucose tolerance
- Cardiovascular Disease
- HIV
- COPD – smoking
- Less likely to get RA
Relapse of psychotic symptoms in schizophrenia occurs in up to ___ of patients within 2 years of being hospitalised
40-60%
