Psychiatry

Question 1

What is the DSM-5 criteria for OCD?

Answer 1

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.

Question 2

What are obsessions?

Answer 2

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).

Question 3

What are compulsions?

Answer 3

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.

Question 4

What is PANDAS?

Answer 4

Pediatric autoimmune neuropsychiatric disorder associated with group A strep. Produces antibodies that damage caudate. These infections in kids can lead to severe OCD overnight!

Question 5

What are the risk factors for OCD?

Answer 5

o Genetic: neurological dysfunction, family history
o Environmental: adverse childhood experiences (i.e. abuse, behavioural inhibition), exposure to traumatic events, group A streptococcal infection

Question 6

What is the etiology of OCD?

Answer 6

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

Question 7

1st line treatment for OCD?

Answer 7

CBT: exposure and response prevention (tolerate, don’t avoid and don’t use avoidance strategies)

Question 8

Medical treatment for OCD?

Answer 8

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.

Question 9

What is the DSM-5 criteria for dysmorphic disorder?

Answer 9

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.

Question 10

Treatment for dysmorphic disorder?

Answer 10

SSRIs and/or CBT may reduce the obsessive and compulsive symptoms in many patients.

Question 11

What is the DSM-5 criteria for hoarding disorder?

Answer 11

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.

Question 12

Treatment for hoarding disorder?

Answer 12

• Very difficult to treat.
• Specialized CBT for hoarding.
• SSRIs can be used.

Question 13

What is the DSM-5 criteria for trichotillomania?

Answer 13

• 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.

Question 14

Trichotillomania and excoriation disorder are driven by ____?

Answer 14

Impulsions - feeling of anxiety/boredom/tension

Question 15

What do you need to rule out for trichotillomania?

Answer 15

Rule out: Rule out dermatological condition, body dysmorphic disorder

Question 16

Treatment for trichotillomania?

Answer 16

• Treatment includes SSRIs, bupropion, second-generation antipsychotics, lithium, or N-acetylcysteine.
• Specialized types of cognitive-behavior therapy (e.g., habit reversal training).

Question 17

What is the DSM-5 criteria for excoriation disorder?

Answer 17

• 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.

Question 18

What do you need to rule out for excoriation disorder?

Answer 18

Rule out: scabies, substance use (i.e. cocaine), psychotic disorder (delusions, tactile hallucinations), body dysmorphic disorder, stereotypic movement disorder, non-suicidal self-injury

Question 19

Treatment for excoriation disorder?

Answer 19

• Specialized types of cognitive-behavior therapy (e.g., habit reversal training).
• SSRIs have shown some benefit.

Question 20

What should be asked when taking a sleep history

Answer 20

BEARS – bedtime, excessive daytime somnolence, awakenings, restlessness(?) , snoring. Duration, meds, concurrent illnesses, mental health!

Question 21

What are the two sleep-wake disorder groups?

Answer 21

• Dyssomnias

- Parasomnias

Question 22

DSM-5 criteria of insomnia disorder?

Answer 22

• 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

Question 23

Clinical features of insomnia disorder?

Answer 23

• 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).

Question 24

Etiology of insomnia disorder

Answer 24

• Subclinical mood and/or anxiety disorders.
• Preoccupation with a perceived inability to sleep.
• Bedtime behavior not conducive to adequate sleep (poor sleep hygiene).
• Idiopathic

Question 25

____ is the most common PTSD symptom.

Answer 25

Insomnia

Question 26

What are the diagnoses that fall under dyssomnias?

Answer 26

- Insomnia Disorder - Hypersomnolence Disorder - Breathing-related sleep disorders - Narcolepsy - Circadian rhythm sleep-wake disorders

Question 27

Definition of insomnia disorder?

Answer 27

Refers to a number of symptoms that interfere with duration and/or quality of sleep despite adequate opportunity for sleep.

Question 28

Definition of dyssomnias?

Answer 28

Abnormalities in the amount, quality or timing of sleep.

Question 29

Treatment of insomnia disorder?

Answer 29

- 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

Question 30

Side effects of trazodone?

Answer 30

Side effects include development of tolerance, addiction, daytime sleepiness, and rebound insomnia.

Question 31

DSM-5 criteria of hypersomnolence disorder?

Answer 31

1. 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. 2. The hypersomnolence occurs at least three times per week, for at least 3 months. 3. The hypersomnolence is accompanied by significant distress 4. Other medical conditions, sleep-wake disorders or substances can explain the cause

Question 32

Etiology of hypersomnolence disorder?

Answer 32

- Viral infections (e.g., HIV pneumonia, infectious mononucleosis, Guillain-Barre). - Head trauma. - Genetic-may have autosomal dominant mode of inheritance in some individuals.

Question 33

Treatment of hypersomnolence disorder?

Answer 33

Life-long therapy with modafinil or stimulants such as methylphenidate; amphetamine-like antidepressants such as atomoxetine are second-line therapy.

Question 34

Diagnostic criteria for obstructive sleep apnea hypopnea?

Answer 34

1. 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

Question 35

Diagnostic criteria for central sleep apnea?

Answer 35

- Evidence by polysomnography of five or more central apneas per hour of sleep. - The disorder is not better explained by another current sleep disorder.

Question 36

Diagnostic criteria for sleep-related hypoventilation?

Answer 36

Polysomnography demonstrates episodes of decreased respiration associated with elevated CO2 levels

Question 37

Clinical features of sleep-related hypoventilation?

Answer 37

Individuals report frequent arousals, morning headaches, insomnia, and excessive daytime sleepiness.

Question 38

___ of chronic opioid users have central sleep apnea.

Answer 38

30%

Question 39

Treatment of central sleep apnea?

Answer 39

- Treat the underlying condition. - CPAP/BiPAP. - Supplemental O2.

Question 40

What are the breathing-related sleep disorders?

Answer 40

- Obstructive sleep apnea hypopnea - Central sleep apnea - Sleep-related hypoventilation

Question 41

Risk factors of obstructive sleep apnea hypopnea?

Answer 41

Obesity, increased neck circumference, airway narrowing.

Question 42

Treatment of obstructive sleep apnea hypopnea?

Answer 42

- Positive airway pressure: continuous (CPAP) and in some cases bilevel (BiPAP). - Behavioral strategies such as weight loss and exercise.

Question 43

Diagnosis (DSM-5 Criteria) of narcolepsy?

Answer 43

1. 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. 2. 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). 3. Hallucinations and/or sleep paralysis at the beginning or end of sleep episodes are common (Not included in the DSM-5)

Question 44

Pathophysiology of narcolepsy?

Answer 44

- Linked to a loss of hypothalamic neurons that produce hypocretin. - May have autoimmune component.

Question 45

Treatment of excessive daytime sleepiness from narcolepsy?

Answer 45

- 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).

Question 46

Treatment of cataplexy from narcolepsy?

Answer 46

- 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.

Question 47

Treatment of circadian rhythm sleep-wake disorders?

Answer 47

Melatonin

Question 48

Definition of circadian rhythm sleep-wake disorders?

Answer 48

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

Question 49

Definition of parasomnias?

Answer 49

Abnormal behaviour in sleep

Question 50

What are the diagnoses that fall under parasomnias?

Answer 50

- 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

Question 51

What are the diagnoses that fall under non-rapid eye movement (NREM) sleep arousal disorder?

Answer 51

- Sleepwalking | - Sleep terrors

Question 52

What is the definition of non-rapid eye movement (NREM) sleep arousal disorder?

Answer 52

Repeated episodes of incomplete arousals that are brief and usually occur during the first one-third of the sleep episode

Question 53

Clinical features of sleepwalking

Answer 53

- 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.

Question 54

Treatment of sleepwalking

Answer 54

- 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)

Question 55

Etiology of sleepwalking

Answer 55

- Unknown. - Family history in 80% of cases. - Usually not associated with any significant underlying psychiatric or psychological problems.

Question 56

Clinical features of sleep terrors?

Answer 56

- 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.

Question 57

Treatment of sleep terrors?

Answer 57

- Reassurance that the condition is benign and self-limited. | - Same as for sleepwalking.

Question 58

Define of nightmare disorder?

Answer 58

1. 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

Question 59

Treatment of nightmare disorder?

Answer 59

- 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.

Question 60

Diagnostic criteria of rapid eye movement (REM) sleep behavior disorder?

Answer 60

1. 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).

Question 61

Risk factors of rapid eye movement (REM) sleep behavior disorder?

Answer 61

- 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.

Question 62

Treatment of rapid eye movement (REM) sleep behavior disorder?

Answer 62

- 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.

Question 63

Diagnostic criteria of restless leg syndrome?

Answer 63

1. 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

Question 64

Risk factors of restless leg syndrome?

Answer 64

- Increases with age. - Strong familial component. - Iron deficiency. - Antidepressants, antipsychotics, dopamine-blocking antiemetics, and antihistamines can contribute to or worsen symptoms.

Question 65

Treatment of restless leg syndrome?

Answer 65

- 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.

Question 66

Diagnostic criteria of substance/medication-induced sleep disorder

Answer 66

1. A prominent and severe disturbance in sleep. 2. 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. 3. The disturbance is not better explained by a sleep disorder that is not substance/medication-induced. Such evidence of an independent sleep disorder

Question 67

Contributors to eating disorder risk?

Answer 67

Temperament, eating dysregulation, attachment issues, poor self-regulation, childhood abuse (BN especially), sociocultural ideas of health/beauty.

Question 68

Triage for danger zone/when to admit?

Answer 68

- <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.

Question 69

Diagnostic criteria for anorexia?

Answer 69

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.

Question 70

Anorexic patients normally have cluster __ traits

Answer 70

C

Question 71

Anorectic symptoms are ego-____

Answer 71

Syntonic

Question 72

What defines the restricting type of anorexia?

Answer 72

During the last 3mo, individual has not engaged in binge/purging. Just fasting/restriction or excessive exercise

Question 73

What defines the binge/purge type of anorexia?

Answer 73

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.

Question 74

Physical complications of restricting/malnutrition (anorexia):

Answer 74

- 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

Question 75

Treatment of anorexia?

Answer 75

- 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

Question 76

What is refeeding syndrome?

Answer 76

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

Question 77

Bulimic patients normally have cluster __ traits

Answer 77

B

Question 78

Diagnostic criteria for bulimia?

Answer 78

- 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.

Question 79

Bulimic symptoms are ego-____

Answer 79

Dystonic - Many bulimic patients feel like failed anorexics because they would like to have the self control to restrict their food intake

Question 80

Signs of purging?

Answer 80

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).

Question 81

Laboratory/imaging abnormalities of purging?

Answer 81

Hypochloremic hypokalemic alkalosis (purging), metabolic acidosis (laxative abuse), elevated bicarbonate (compensation), hypernatremia, increased BUN, increased amylase, altered thyroid hormone, cortisol homeostasis, esophagitis

Question 82

Pathophysiology of bulimia?

Answer 82

- 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.

Question 83

Treatment of bulimia

Answer 83

- CBT is BEST (20 sessions over 5 mo) and/or FLUOXETINE (60-80mg OD – good for short term). Vysanse (Dexedrine stimulant) can decrease binging!

Question 84

What is the difference between binge-eating disorder and bulimia/anorexia?

Answer 84

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.

Question 85

Diagnostic criteria of binge eating disorder?

Answer 85

1. 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

Question 86

Physical exam findings of binge eating disorder

Answer 86

Patients are typically obese and suffer from medical problems related to obesity including metabolic syndrome, type 2 diabetes, and cardiovascular disease.

Question 87

Which stimulant suppresses appetite and is used in the treatment of binge eating disorder?

Answer 87

Lisdexamfetamine (Vyvanse)

Question 88

Treatment of binge eating disorder?

Answer 88

- 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.

Question 89

What is pica?

Answer 89

Persistent eating of non nutritive, non food substances for at least one month

Question 90

What is avoidant restrictive food intake disorder?

Answer 90

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

Question 91

What is rumination disorder?

Answer 91

Repeated regurgitation of food over at least one month – rechewed, reswallowed or spit out.

Question 92

Differential diagnosis of anxiety?

Answer 92

- 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

Question 93

Investigations for anxiety?

Answer 93

- ECG* + CXR + CBC* - TSH*, Ca2+, cortisol, fasting glucose/A1C, 24hr metanephrines - Liver enzymes - PFTs, D-dimer* - Tox screen

Question 94

What physical symptoms might a child display if anxious?

Answer 94

Headaches, stomach aches, muscle tension and muscle twitches, sleep problems

Question 95

Most anxiety disorders benefit from which class of medications?

Answer 95

Sertraline (or any other SSRI)

Question 96

What could you augment with if no benefit from >12weeks of SSRI for anxiety?

Answer 96

- 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.

Question 97

How should you titrate SSRI/SNRI for anxiety?

Answer 97

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).

Question 98

Side effects of SSRI/SNRI?

Answer 98

Headache, irritability, GI complaints, insomnia, fatigue, sexual dysfunction, weight gain

Question 99

____ has proven effective for anxiety disorders. It examines the relationship between anxiety-driven cognitions (thoughts), emotions, and behavior.

Answer 99

Cognitive behavioral therapy (CBT)

Question 100

Types of panic attacks?

Answer 100

- Unexpected = panic disorder | - Situational = everything else!

Question 101

Symptoms of panic attacks?

Answer 101

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

Question 102

Define panic attacks?

Answer 102

An abrupt surge of intense fear or discomfort that reaches a peak within minutes, during which time => 4 sx occur

Question 103

Diagnosis (DSM-5 Criteria) of panic disorder?

Answer 103

- 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.

Question 104

Etiology of panic disorder?

Answer 104

- 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.

Question 105

Course/prognosis of panic disorder?

Answer 105

- 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.

Question 106

Treatment of panic disorders

Answer 106

- 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

Question 107

Define agoraphobia?

Answer 107

Agoraphobia is an intense fear of being in public places where escape or obtaining help may be difficult. It often develops with panic disorder.

Question 108

Diagnosis (DSM-5 Criteria) of agoraphobia?

Answer 108

1. 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. 2. 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. 3. Symptoms cause significant social or occupational dysfunction. 4. Symptoms last >6 months. 5. Symptoms not better explained by another mental disorder.

Question 109

Epidemiology of agoraphobia?

Answer 109

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.

Question 110

Etiology of agoraphobia?

Answer 110

- Strong genetic factor: Heritability about 60%. | - Psychosocial factor: Onset frequently follows a traumatic event.

Question 111

Treatment of agoraphobia?

Answer 111

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.

Question 112

Define a specific phobia.

Answer 112

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).

Question 113

Diagnosis (DSM-5 Criteria) of a specific phobia?

Answer 113

- 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.

Question 114

___ are the most common psychiatric disorder in women and second most common in men (substance-related is first).

Answer 114

Phobias

Question 115

Treatment of specific phobias

Answer 115

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.

Question 116

Epidemiology of social anxiety

Answer 116

12-14% lifetime prev, F>M in epi samples, F:M in clinical samples. Age of onset ~ mid-teens (13).

Question 117

Define social anxiety

Answer 117

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.

Question 118

Diagnosis (DSM-5 Criteria) of social anxiety

Answer 118

- 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

Question 119

Treatment of social anxiety

Answer 119

- 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

Question 120

Diagnosis (DSM-5 Criteria) of separation anxiety disorder

Answer 120

1. 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. 2. Lasts for >4 weeks in children/adolescents and >6 months in adults. 3. Symptoms cause significant social, academic, or occupational dysfunction. 4. Symptoms not due to another mental disorder.

Question 121

At what age does separation anxiety disorder occur?

Answer 121

Tends to peak around 9-18 months and decrease after age 2. Can increase again at age 4-5 when starting school

Question 122

Treatment of separation anxiety disorder

Answer 122

- Psychotherapy: CBT, family therapy. | - Medications: SSRIs can be effective as an adjunct to therapy.

Question 123

Define selective mutism

Answer 123

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.

Question 124

Diagnosis (DSM-5 Criteria) of selective mutism

Answer 124

- 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).

Question 125

Treatment of selective mutism

Answer 125

- Psychotherapy: CBT, family therapy. | - Medications: SSRIs (especially with comorbid social anxiety disorder).

Question 126

Epidemiology of Generalized Anxiety Disorder

Answer 126

6% lifetime prev F>M 2:1. Median age at onset 30 but spread over broad range (GAD sx often in childhood).

Question 127

Diagnosis (DSM-5 Criteria) of Generalized Anxiety Disorder?

Answer 127

- 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.

Question 128

Treatment of Generalized Anxiety Disorder?

Answer 128

- 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

Question 129

Define Posttraumatic stress disorder (PTSD)

Answer 129

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.

Question 130

Diagnosis (DSM-5 Criteria) of Posttraumatic stress disorder (PTSD)

Answer 130

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.

Question 131

Epidemiology of Posttraumatic stress disorder (PTSD)

Answer 131

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.

Question 132

Etiology/Risk Factors of Posttraumatic stress disorder (PTSD)

Answer 132

- 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).

Question 133

Pathophysiology of Posttraumatic stress disorder (PTSD)

Answer 133

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).

Question 134

Pharmacological treatment of Posttraumatic stress disorder (PTSD)

Answer 134

- 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.

Question 135

Psychotherapy treatment of Posttraumatic stress disorder (PTSD)

Answer 135

- Specialized forms of CBT (e.g., exposure therapy, cognitive processing therapy). - Supportive and psychodynamic therapy. - Couples/family therapy.

Question 136

What are delusions?

Answer 136

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.

Question 137

What are delusions of persecution/paranoid delusions

Answer 137

Irrational belief that one is being persecuted. Example: "The Central Intelligence Agency (CIA) is monitoring me and tapped my cell phone."

Question 138

What are ideas of reference

Answer 138

Belief that cues in the external environment are uniquely related to the individual. Example: "The TV characters are speaking directly to me."

Question 139

What are delusions of control

Answer 139

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).

Question 140

What are delusions of grandeur

Answer 140

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."

Question 141

What are delusions of guilt

Answer 141

Belief that one is guilty or responsible for something. Example: "I am responsible for all the world's wars."

Question 142

What is an illusion

Answer 142

Misinterpretation of an existing sensory stimulus (such as mistaking a shadow for an evil spirit).

Question 143

What are somatic delusions

Answer 143

Belief that one has a certain illness or health condition. Example: A patient believing she is pregnant despite negative pregnancy tests and ultrasounds.

Question 144

Differential diagnosis of psychosis?

Answer 144

- 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.

Question 145

What are hallucinations?

Answer 145

Sensory perception without an actual external stimulus.

Question 146

Investigations for psychosis?

Answer 146

- 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

Question 147

What kind of hallucinations are most commonly exhibited by schizophrenic patients?

Answer 147

Auditory

Question 148

Which type of hallucination may accompany drug intoxication, drug and alcohol withdrawal, or delirium?

Answer 148

Visual

Question 149

Epidemiology of schizophrenia

Answer 149

- 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

Question 150

First-degree biological relatives of persons with schizophrenia have a ___ greater risk for developing the disease than the general population.

Answer 150

Ten times

Question 151

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.

Answer 151

- Winter | - Early spring

Question 152

Epidemiological data show a high incidence of schizophrenia after prenatal exposure to ____ during several epidemics of the disease

Answer 152

Influenza

Question 153

The lifetime prevalence of any drug abuse (other than tobacco) in schizophrenia is often greater than ____

Answer 153

50 percent

Question 154

Diagnosis of schizophrenia

Answer 154

- 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.

Question 155

What are the dopamine pathways

Answer 155

- 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)

Question 156

Mesolimbic hyperactivity is the cause of ___ in schizophrenics

Answer 156

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.

Question 157

Mesocortical (originates in the VTA and projects to the frontal cortex) – dopamine deficiency here (prefrontal cortex) may be responsible for the ___ in schizophrenics

Answer 157

Negative/cognitive symptoms. Thus – dopamine receptor blockade could lead to worsening of negative/cognitive symptoms

Question 158

The medication we give for schizophrenia affect this area and cause Parkinson-like symptoms

Answer 158

Nigrostriatal

Question 159

Medications used for schizophrenia also affect here, and cause excess prolactin secretion

Answer 159

Tuberinfundibular

Question 160

Too much mesolimbic dopamine causes ___ and too little mesocortical dopamine causes ____.

Answer 160

+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.

Question 161

Neuropathology findings in schizophrenics?

Answer 161

- 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.

Question 162

Neurodevelopmental hypothesis for schizophrenia?

Answer 162

- 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)

Question 163

The classic feature of the catatonic type is a marked disturbance in ______

Answer 163

The classic feature of the catatonic type is a marked disturbance in motor function; this disturbance may involve stupor, negativism, rigidity, excitement, or posturing.

Question 164

Subtypes of schizophrenia?

Answer 164

- Paranoid Type - Disorganized Type - Catatonic Type - Undifferentiated Type - Residual Type

Question 165

Classically, the paranoid type of schizophrenia is characterized mainly by the presence of

Answer 165

Delusions of persecution or grandeur

Question 166

Patients who clearly have schizophrenia cannot be easily fit into one type or another

Answer 166

Undifferentiated Type

Question 167

What is the residual type of schizophrenia?

Answer 167

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

Question 168

The classic feature of the catatonic type of schizophrenia is a marked disturbance in ______

Answer 168

The classic feature of the catatonic type is a marked disturbance in motor function; this disturbance may involve stupor, negativism, rigidity, excitement, or posturing.

Question 169

What is the disorganized type of schizophrenia?

Answer 169

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

Question 170

What is the disorganized type of schizophrenia?

Answer 170

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

Question 171

What are delusions of influence?

Answer 171

Body or actions are being acted on by an outside influence

Question 172

What is tangential speech?

Answer 172

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.

Question 173

What is derailment (loosening of association) speech?

Answer 173

No logical connections b/w topic changes

Question 174

What is neologism?

Answer 174

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

Question 175

What are the positive symptoms of schizophrenia?

Answer 175

- Hallucinations - Delusions - Disorganized speech - Disorganized behaviour - Motor

Question 176

What is automatic obedience?

Answer 176

Individual obeys all orders, commands, and instructions from another person without question or concern.

Question 177

What is catalepsy?

Answer 177

A medical condition characterized by a trance or seizure with a loss of sensation and consciousness accompanied by rigidity of the body.

Question 178

What are the negative symptoms of schizophrenia?

Answer 178

- 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

Question 179

What are the cognitive symptoms of schizophrenia?

Answer 179

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

Question 180

____ is the most frequent prodromal symptom appearing 4 years prior to the 1st hospital admission.

Answer 180

Depression

Question 181

Risk factors of suicidal behaviours in schizophrenics?

Answer 181

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

Question 182

Risk factors of hostile symptoms in schizophrenics?

Answer 182

Exhibiting violent behaviour? A victim of violence in past 6 months. Male, young, nonadherence to meds. Persecutory delusions, prior antisocial behaviour prior to psychosis

Question 183

What eye findings are found in schizophrenics?

Answer 183

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.

Question 184

Investigations for schizophrenias?

Answer 184

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)

Question 185

Comorbidities of schizophrenia

Answer 185

- 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

Question 186

Relapse of psychotic symptoms in schizophrenia occurs in up to ___ of patients within 2 years of being hospitalised

Answer 186

40-60%

Question 187

Men are more likely to be impaired by _____ (worse prognosis), and women are likely to have better premorbid social functioning than men, and are more likely to have _____

Answer 187

Negative symptom | Positive symptoms

Question 188

Good prognostic factors for schizophrenia?

Answer 188

acute onset, shorter prodromal period, treatment compliant, female gender, good pre-morbid cognitive function, good pre-morbid social functioning, positive symptoms, precipitants, older age of onset, no family history, presence of affective symptoms, good response to drug, good support system

Question 189

______ is the major effect of antipsychotics

Answer 189

Dopamine (D2 blockage)

Question 190

Antipsychotics help the ____ symptoms but not the ____ symptoms in schizophrenia?

Answer 190

Positive, negative | These do not help negative sx since they only block the mesolimbic path

Question 191

What is the dopamine D2 receptor blockage target?

Answer 191

>65%

Question 192

What can happen if the dopamine D2 receptor blockage is >72% or >78%.

Answer 192

However, blockage leads to other collateral damage: >72% block = hyperprolactinemia (tuberoinfundibular tract), >78% block = Parkinsonism + extrapyramidal symptoms (nigrostriatal tract) Nigrostriatal tract is involved in motor planning and purposeful movement - can lead to involuntary movement)!

Question 193

Examples of 1st gen typical antipsychotics

Answer 193

- Haloperidol – high potency, used for acute agitation, - Methotrimeprazine, chlorpromazine – low potency, - Loxapine – medium potency

Question 194

What causes neuroleptic malignant syndrome?

Answer 194

Caused from dopamine blockade

Question 195

Side effects of 1st gen typical antipsychotics

Answer 195

- Acute dystonia - Parkinsonism - Akathisia - Tardive dyskinesia

Question 196

What is acute dystonia?

Answer 196

Characterized by involuntary contractions of muscles which may include writhing, or torsional movement and VERY painful rolling eyes into their head – oculogyric crisis, arching back – retrocollis and craning neck to one side – torticollis.

Question 197

When does acute dystonia occur?

Answer 197

Occurs a few days after starting med (5days)

Question 198

Treatment of acute dystonia?

Answer 198

Anticholinergic (benztropine) or antihistamine (diphenhydramine), diazepam 3Bs

Question 199

What is tardive dyskinesia?

Answer 199

Causes stiff, jerky movements of your face and body that you can't control. Sometimes doesn’t go away even if off the drug

Question 200

Treatment of tardive dyskinesia?

Answer 200

Decrease dose, Vit E, atypical, botox? CLOZAPINE

Question 201

When does tardive dyskinesia occur?

Answer 201

Occurs a 3 months after starting med.

Question 202

What are the symptoms of Parkinsonism

Answer 202

Coarse, rhythmic, resting tremor affecting limbs, head, mouth and tongue. Bradykinesia. TRAP (tremor, rigidity, akinesia, postural instability).

Question 203

What is akathisia

Answer 203

Movement disorder that makes it hard for you to stay still/restless.

Question 204

When does Parkinsonism occur

Answer 204

Occurs within a few weeks of starting med.

Question 205

When does akathisia occur?

Answer 205

Occurs a 4 weeks after starting med – worse with Abilify.

Question 206

Treatment of Parkinsonism?

Answer 206

Decrease dose, anticholinergic – D/C AC in 2-3 weeks

Question 207

Treatment of akathisia?

Answer 207

B-blocker, anticholinergic, lorazepam

Question 208

What are the symptoms of neuroleptic malignant syndrome?

Answer 208

FARM (fever, autonomic instability, rigidity and mental change)

Question 209

Diagnosis of neuroleptic malignant syndrome?

Answer 209

Antipsychotic + muscle rigidity + hyperthermia + 2.. - Labs: CK or WBC - Autonomic instability: labile BP, diaphoresis, tachycardia - Neuro: tremor, confusion, fluctuating levels of consciousness

Question 210

Treatment of neuroleptic malignant syndrome?

Answer 210

D/c antipsychotic and wait 2 weeks. ICU, supportive – hydrate, temp control. BROMOCRIPTINE or DANTROLENE

Question 211

Examples of 2nd gen typical antipsychotics

Answer 211

Clozapine, risperidone (most like the typicals), ziprasidrone, paliperidone, quetiapine, olanzapine (short acting, use in acute situations)

Question 212

MOA of 2nd gen typical antipsychotics

Answer 212

Serotonin-dopamine antagonists

Question 213

Side effects of 2nd gen typical antipsychotics

Answer 213

- Metabolic – weight gain, dyslipidemia, orthostatic hypotension (alpha blocker), somnolence/sedation (antihistamine) - Clozapine and Olanzapine have the most metabolic side effects (don’t give to big ppl/high BP/high sugars)

Question 214

Examples of 3rd gen typical antipsychotics

Answer 214

Aripiprazole

Question 215

MOA of 3rd gen typical antipsychotics

Answer 215

Partial dopamine agonists

Question 216

How should you start antipsychotics?

Answer 216

START AP, wait 2 weeks. If poor response, med adherence? Substance use? If no response after 4 weeks at optimal dose than change AP, If partial response wait up until 8 wks. If no response with 2 APs then trail of clozapine. If you discontinue meds – continue monitoring for s/s of relapse for at least 2 years.

Question 217

____ is the only antipsychotic that reduces suicide risk to normal

Answer 217

Clozapine

Question 218

Which antipsychotic has less weight gain and EPS and no sexual symptoms?

Answer 218

Aripiprazole

Question 219

Side effects of clozapine?

Answer 219

- Increased threshold of seizure, agranulocytosis, cardiac, sedation/wt/sialorrhea/anticholinergic (constipation!). - Need to do CBC weekly for 6 months and then monthly thereafter

Question 220

Psychosocial therapies for schizophrenia?

Answer 220

- Social Skills Training - Assertive Community Treatment: . - Group therapy is effective in reducing social isolation, increasing the sense of cohesiveness, and improving reality testing for patients with schizophrenia. - CBT: Cognitive behavioral therapy has been used in schizophrenia patients to improve cognitive distortions, reduce distractibility, and correct errors in judgment. - Vocational Therapy: Enabling patients to become gainfully employed is both a means toward, and a sign of, recovery.

Question 221

What is assertive community treatment?

Answer 221

These include home delivery of medications, monitoring of mental and physical health, in vivo social skills, and frequent contact with family members. There is a high staff-to-patient ratio (1:12). ACT programs can effectively decrease the risk of rehospitalization for persons with schizophrenia, but they are labor-intensive and expensive programs to administer

Question 222

Ways to improve compliance with antipsychotics?

Answer 222

- Establish links between treatment and attainment of goals, avoid S/E, involve patient and family in med decisions, improve anxiety, depression and sense of well-being. Can use a depot (injectable antipsychotic) - Long-acting forms of risperidone, paliperidone, aripiprazole, and olanzapine are also available. - CTO

Question 223

What is schizophreniform disorder

Answer 223

Schizophreniform disorder differs from schizophrenia in that the symptoms have a duration of at least 1 month but less than 6 months

Question 224

Prognosis of schizophreniform disorder

Answer 224

One-third of patients recover completely; two-thirds progress to schizoaffective disorder or schizophrenia.

Question 225

Diagnosis (DSM-5 Criteria) of schizoaffective disorder

Answer 225

- Meet criteria for either a major depressive or manic episode during which psychotic symptoms consistent with schizophrenia are also met. - Delusions or hallucinations for 2 weeks in the absence of mood disorder symptoms (this criterion is necessary to differentiate schizoaffective disorder from a mood disorder with psychotic features). - Mood symptoms present for a majority of the psychotic illness. - Symptoms not due to the effects of a substance (drug or medication) or another medical condition.

Question 226

Treatment of schizoaffective disorder

Answer 226

- Hospitalization (if necessary) and supportive psychotherapy. - Medical therapy: Antipsychotics (second-generation medications may target both psychotic and mood symptoms); mood stabilizers, antidepressants, or electroconvulsive therapy (ECT) may be indicated for treatment of mood symptoms.

Question 227

What are the two subtypes of schizoaffective disorder and who is more likely to have them?

Answer 227

- Bipolar type (+manic) – young, better prognosis | - Depressive type (-manic) – old, worse prognosis

Question 228

Treatment of Brief Psychotic Disorder

Answer 228

Brief hospitalization (usually required for workup, safety, and stabilization), supportive therapy, course of antipsychotics for psychosis, and/or benzodiazepines for agitation.

Question 229

Diagnosis (DSM-5 Criteria) of brief psychotic disorder

Answer 229

- Patient with psychotic symptoms as in schizophrenia; however, the symptoms last from 1 day to 1 month, and there must be eventual full return to premorbid level of functioning. Symptoms must not be due to the effects of a substance (drug or medication) or another medical condition - There may also be a precipitating traumatic event.

Question 230

Risk factors of delusional disorder

Answer 230

Delusional disorder occurs more often in middle-aged or older patients (after age 40). Immigrants, the hearing impaired, and those with a family history of schizophrenia are at increased risk.

Question 231

Diagnosis (DSM-5 Criteria) of delusional disorder

Answer 231

- A: One or more delusions (fixed and firm) for 1 month - B: Hallucinations if present are not prominent and related to delusional theme - C: Apart from the impact of delusions, functioning is not markedly impaired and behaviour is not obvious or bizarre

Question 232

Treatment of delusional disorder

Answer 232

Difficult to treat, especially given the lack of insight and impairment. Antipsychotic medications are recommended despite somewhat limited evidence. Supportive therapy is often helpful.

Question 233

Define drug abuse

Answer 233

Drug use that deviates from the approved social or medical pattern, usually causing impairment or disruption to function in self or others

Question 234

Pathophysiology of substance disorders?

Answer 234

Almost all drugs (and activities) of abuse increase dopamine in the nucleus accumbens, an action that contributes to their euphoric properties and, with repeated use, to their ability to change signaling pathways in the brain's reward system

Question 235

What are the different forms dependence can manifest?

Answer 235

- behavioural: substance-seeking activities and pathological use patterns - physical: physiologic withdrawal effects without use - cognitive: continuous or intermittent cravings for the substance to avoid dysphoria or attain drug state

Question 236

Etiology of substance disorders?

Answer 236

Substance use disorders arise from multifactorial interactions between genes (personality, neurobiology) and environment (low socioeconomic status, substance-using peers, abuse history, chronic stress)

Question 237

Diagnosis (DSM-5 Criteria) of substance use disorders?

Answer 237

PEC WITH MCAT - use despite Physical or psychological problem (i.e. alcoholic liver disease or cocaine related nasal problems) - failures to fulfill External roles at work/school/home - Craving or a strong desire to use substance - Withdrawal - continued use despite Interpersonal problems - Tolerance, needing to use more substance to get same effect - use in physically Hazardous situations - More substance used or for longer period than intended - unsuccessful attempts to Cut down - Activities given up due to substance - excessive Time spent on using or finding substance

Question 238

Investigations of substance use disorders?

Answer 238

1. Stimulant toxidrome - Urine General Toxicology Panel (UGTP) - Blood glucose - Acetaminophen and salicylate levels (ACET, SAL) - ECG - Pregnancy test in women of childbearing age 2. Alcohol intoxication - Blood Alcohol Level (ETOH) - Electrolytes and Blood glucose 3. Diagnostic tools

Question 239

Treatment options for substance use disorder?

Answer 239

- Behavioral counseling should be part of every substance use disorder treatment. - Psychosocial treatments are effective and include motivational intervention (MI), cognitive-behavioral therapy (CBT – SMART recovery), contingency management, and individual and group therapy. - Reddit subgroup – stopdrinking - Poundmaker’s or Henwood treatment programs - Ponoka Concurrent Disorders Program - Twelve-step groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) should also be encouraged as part of the treatment. - Al-Anon Family Groups

Question 240

Nicotine withdrawal symptoms?

Answer 240

Intense craving, dysphoria, anxiety, poor concentration, increase in appetite, weight gain, irritability, restlessness, and insomnia.

Question 241

Nicotine use disorder treatments?

Answer 241

- Varenicline (Chantix): - Bupropion (Zyban or Wellbutrin): - Nicotine replacement therapy (NRT): Available as transdermal patch, gum, lozenge, nasal spray, and inhaler. - Behavioral support/counseling should be part of every treatment. Relapse after abstinence is common.

Question 242

MOA of varenicline (Chantix)?

Answer 242

Partial nicotinic receptor agonist, and partial nicotinic receptor competitive antagonist

Question 243

Side effects of varenicline (Chantix)?

Answer 243

Nausea, vomiting, constipation, headache, dream disorder, insomnia, increased risk of psychosis, depression, suicidal ideation

Question 244

MOA of bupropion (Zyban or Wellbutrin)?

Answer 244

Inhibits re-uptake of dopamine and/or norepinephrine

Question 245

Side effects of bupropion (Zyban or Wellbutrin)?

Answer 245

Insomnia, dry mouth

Question 246

Contraindications of bupropion (Zyban or Wellbutrin)?

Answer 246

Seizure disorder, Eating disorder, MAOI use in past 14 d, Simultaneous use of bupropion (Wellbutrin®) for depression

Question 247

Use NRT cautiously with?

Answer 247

Use with caution: immediately post-MI, worsening angina, arrhythmia

Question 248

Asians often have less _____, resulting in flushing and nausea with alcohol use.

Answer 248

Aldehyde dehydrogenase

Question 249

What is the CAGE questionnaire?

Answer 249

- C ever felt the need to Cut down on your drinking? - A ever felt Annoyed at criticism of your drinking? - G ever feel Guilty about your drinking? - E ever need a drink first thing in morning (Eye opener)? For men, a score of ≥2 is a positive screen; for women, a score of ≥1 is a positive screen

Question 250

Most adults will show some signs of intoxication with BAL ___ and obvious signs with BAL ____.

Answer 250

> 100 mg/dL | > 150 mg/dL

Question 251

Stage 1 (onset 4-12 h after last drink) alcohol withdrawal?

Answer 251

"The shakes" tremor, sweating, agitation, anorexia, cramps, diarrhea, sleep disturbance, anxiety, insomnia, headache

Question 252

Stage 2 (onset 12-24 h) alcohol withdrawal?

Answer 252

Alcoholic hallucinosis: visual, auditory, olfactory or tactile hallucinations

Question 253

Treatment of alcohol intoxication

Answer 253

- Parenteral thiamine (to prevent or treat Wernicke's encephalopathy) and folate. Remember thiamine must be given before glucose, as it's a necessary cofactor for glucose metabolism. - Naloxone may be necessary to reverse effects of co-ingested opioids. - A computed tomography (CT) scan of the head may be necessary to rule out subdural hematoma or other brain injury. - Severely intoxicated patients may require mechanical ventilation with attention to acid-base balance, temperature, and electrolytes while they are recovering.

Question 254

Risk factors of delirium tremens?

Answer 254

- A history of sustained drinking - A history of alcohol withdrawal seizures - A history of DT - Age greater than 30 - The presence of a concurrent illness - The presence of significant alcohol withdrawal in the presence of an elevated blood alcohol concentration - A longer period since the last drink

Question 255

Stage 3 (onset 24-48 h) alcohol withdrawal?

Answer 255

Alcohol withdrawal seizures, usually tonic-clonic, non-focal, and brief

Question 256

Symptoms of delirium tremens?

Answer 256

DT is defined by hallucinations, disorientation, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis in the setting of acute reduction or abstinence from alcohol.

Question 257

Stage 4 (onset 48-72 h) of alcohol withdrawal?

Answer 257

Delirium tremens, confusion, delusions, hallucinations, agitation, tremors, autonomic hyperactivity (fever, tachycardia, HTN)

Question 258

Onset of delirium tremens?

Answer 258

DT typically begins between 48 and 96 hours after the last drink and lasts one to five days

Question 259

Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) scoring system, areas of assessment include:

Answer 259

- physical (5): nausea and vomiting, tremor, agitation, paroxysmal sweats, headache/fullness in head - psychological/cognitive (2): anxiety, orientation/clouding of sensorium - perceptual (3): tactile disturbances, auditory disturbances, visual disturbances

Question 260

Basic treatment protocol for alcohol withdrawal

Answer 260

- Diazepam 20 mg PO q1-2h prn until CIWA-A <10 points - Thiamine 100 mg IM then 100 mg PO OD for 3 d - Supportive care (hydration and nutrition) - Hypomagnesemia may predispose to seizures; thus, it should be corrected promptly.

Question 261

If age >65 or patient has severe liver disease, severe asthma or respiratory failure use what for alcohol withdrawal

Answer 261

- Use a short acting benzodiazepine Lorazepam PO/SL/IM 1-4 mg q1-2h

Question 262

If history of withdrawal seizures use what for alcohol withdrawal

Answer 262

- Diazepam 20 mg PO q1h for minimum of three doses regardless of subsequent CIWA scores

Question 263

What is Wernicke-Korsakoff Syndrome?

Answer 263

Alcohol-induced amnestic disorders due to thiamine deficiency (poor nutrition or malabsorption)

Question 264

Korsakoff's syndrome symptoms?

Answer 264

Anterograde amnesia and confabulation (unconsciously making up answers when memory has failed); cannot occur during an acute delirium or dementia and must persist beyond usual duration of intoxication/withdrawal

Question 265

Wernicke's encephalopathy triad?

Answer 265

Triad of oculomotor dysfunction such as nystagmus (CN VI palsy), gait ataxia, and confusion

Question 266

Management of Wernicke-Korsakoff Syndrome?

Answer 266

- Wernicke's preventative treatment (any patient in withdrawal): thiamine 100-250mg IM/IV x 1 dose - Wernicke's acute treatment: thiamine 500 mg IV BID/TID x 72,h then reassess - Korsakoff's: IV treatment as for Wernicke's followed by thiamine 100mg PO TID x3-12mo

Question 267

Investigations of alcohol use disorder?

Answer 267

- BAL - GGT and MCV for baseline and follow-up monitoring - AST, ALT (usually AST:ALT approaches 2:1 in an alcoholic) - CBC (anemia, thrombocytopenia), INR (decreased clotting factor production by liver)

Question 268

Treatment of alcohol use disorder?

Answer 268

- Naltrexone: Effective in reducing EtOH consumption (IF STILL DRINKING) but less effective in promoting abstinence - Acamprosate: Major advantage is that it can be used in patients with liver disease. - Disulfiram - enhances negative effects of EtOH by inhibiting acetaldehyde dehydrogenase ‚ acetaldehyde accumulation when EtOH consumed ‚adverse symptoms (flushing, tachycardia, hypotension, sweating, SOB, nausea, vomiting) - Topiramate – used for maintenance, helps reduce cravings

Question 269

MOA of naltrexone

Answer 269

mu-opioid antagonist, blocks dopaminergic response involved with EtOH consumption, reduces positive reinforcement effects of EtOH.

Question 270

MOA of acamprosate

Answer 270

NMDA glutamate receptor antagonist

Question 271

Symptoms of opioid intoxication

Answer 271

Drowsiness, nausea/vomiting, constipation, slurred speech, constricted pupils, seizures, and respiratory depression, which may progress to coma or death in overdose.

Question 272

Treatment of opioid intoxication

Answer 272

- ABCs - IV glucose - naloxone hydrochloride (Narcan): 0.4 mg up to 2 mg IV for diagnosis - Intubation and mechanical ventilation, ± naloxone drip, until patient alert without naloxone (up to >48 h with long-acting opioids)

Question 273

____ is the exception to opioids producing miosis.

Answer 273

Meperidine is the exception to opioids producing miosis. “Demerol Dilates pupils”

Question 274

Opioid withdrawal symptoms?

Answer 274

Dysphoric mood, insomnia, drug-craving, myalgias, nausea or vomiting, yawning, chills, lacrimation, rhinorrhea, pupillary dilation, piloerection, sweating, diarrhea, fever

Question 275

Onset of opioid withdrawal symptoms?

Answer 275

Onset: 6-12 h (depending on half-life of opioid used); duration: 5-10 d

Question 276

Treatment of opioid withdrawal?

Answer 276

- Moderate symptoms: Symptomatic treatment with clonidine (for autonomic signs and symptoms of withdrawal), nonsteroidal anti- inflammatory drugs (NSAIDs) for pain, loperamide for diarrhea, dicyclomine for abdominal cramps, etc. - Severe symptoms: Detox with buprenorphine or methadone.

Question 277

Treatment of opiate use disorder?

Answer 277

- Buprenorphine (1st line) - can precipitate withdrawal if used too soon after full opioid agonists. comes as Suboxone, which contains buprenorphine and naloxone; this preparation prevents intoxication from intravenous injection. - Methadone (2nd line) - Restricted to federally licensed substance abuse treatment programs. - Naltrexone - precipitates withdrawal if used within 7 days of heroin use. Either daily oral medication or monthly depot injection. It is a good choice for highly motivated patients such as health care professionals - Naloxone – full antagonist. Works minutes to hours. No restrictions

Question 278

MOA of buprenorphine?

Answer 278

Partial opioid receptor agonist

Question 279

Can cause Qtc interval prolongation: screening electrocardiogram is indicated

Answer 279

Methadone

Question 280

MOA of methadone?

Answer 280

Long-acting opioid receptor agonist

Question 281

MOA of naltrexone?

Answer 281

Competitive opioid antagonist

Question 282

MOA of cocaine

Answer 282

Cocaine blocks the reuptake of dopamine, epinephrine, and norepinephrine from the synaptic cleft, causing a stimulant effect.

Question 283

Signs and symptoms of cocaine intoxication?

Answer 283

Euphoria, heightened self-esteem, increase or decrease in blood pressure, tachycardia or bradycardia, nausea, dilated pupils, weight loss, psychomotor agitation or depression, chills, and sweating.

Question 284

Signs and symptoms of a cocaine overdose?

Answer 284

Seizures, cardiac arrhythmias, hyperthermia, paranoia, and hallucinations (especially tactile). Since cocaine is an indirect sympathomimetic, intoxication mimics the fight-or-flight response.

Question 285

Management of cocaine overdose/intoxication?

Answer 285

- For mild-to-moderate agitation and anxiety: Reassurance of the patient and benzodiazepines (IV diazepam) - For severe agitation or psychosis: Antipsychotics (e.g., haloperidol). - Symptomatic support (i.e., control hypertension, arrhythmias). - Temperature of >102F should be treated aggressively with an ice bath, cooling blanket, and other supportive measures.

Question 286

Signs and symptoms of cocaine withdrawal?

Answer 286

- Initial "crash" (1-48h): increased sleep, increased appetite, dysphoria - Withdrawal (1-10wk): dysphoric mood plus fatigue, irritability, vivid unpleasant dreams, insomnia or hypersomnia, psychomotor agitation or retardation

Question 287

Symptoms of amphetamine intoxication

Answer 287

Euphoria, dilated pupils, increased libido, tachycardia, perspiration, grinding teeth, and chest pain, psychomotor agitation or retardation

Question 288

Symptoms of amphetamine overdose

Answer 288

Cause hyperthermia, dehydration (especially after a prolonged period of dancing in a club), rhabdomyolysis, and renal failure (monitor CK and for acute kidney injury). Amphetamine withdrawal can cause prolonged depression.

Question 289

Treatment of amphetamine intoxication?

Answer 289

Rehydrate, correct electrolyte balance, and treat hyperthermia.

Question 290

Symptoms of amphetamine withdrawal?

Answer 290

Dysphoric mood and 2+ of the following developing within a few hours to days - Fatigue - Vivid, unpleasant dreams - Insomnia or hypersomnia - Increase appetite - Psychomotor retardation or agitation

Question 291

What is sexual desire?

Answer 291

Energy that allows an individual to initiate or respond to sexual stimulation

Question 292

What is sexual arousal?

Answer 292

Physical and emotional stimulation leading to breast and genital vasodilation and clitoral engorgement

Question 293

What is an orgasm?

Answer 293

Physical and emotional stimulation is maximized, allowing the individual to relinquish their sense of control

Question 294

What is sexual resolution?

Answer 294

Most of the congestion and tension resolves within seconds, complete resolution may take up to 60 min

Question 295

Criteria for sexual dysfunction disorders?

Answer 295

- The disorder causes clinically significant distress. - The dysfunction is not better explained by a nonsexual mental disorder, as a consequence of severe relationship distress or other stressors, and not attributable to the effects of a substance/medication or another medical condition.

Question 296

Etiology of erectile or orgasmic dysfunctions

Answer 296

- Psychological or emotional - depression, abuse - Neurologic dysfunction - spinal cord injury - Vascular insufficiency – diabetes, atherosclerosis - Drug adverse effects - B-blockers - Aging

Question 297

Diagnostic criteria for erectile disorder?

Answer 297

Marked difficulty obtaining or maintaining an erection, or marked decreased in erectile rigidity for more than 6 months. Commonly referred to as erectile dysfunction (ED) or impotence.

Question 298

Non-invasive treatment of erectile disorder?

Answer 298

- lifestyle changes (alcohol, smoking), psychological (sexual counselling and education) - change precipitating medications - treat underlying causes (DM, CVD, HTN, endocrinopathies)

Question 299

Pharmacological treatment of erectile disorder?

Answer 299

Phosphodiesterase-5 inhibitors (e.g., sildenafil) are given orally, which enhance blood flow to the penis; they require psychological or physical stimulation to achieve an erection. Alprostadil, either injected into the corpora cavernosa or transurethral, acts locally; it produces an erection within 2 to 3 minutes and works in the absence of sexual stimulation.

Question 300

Diagnostic criteria of premature (early) ejaculation

Answer 300

Recurrent pattern of ejaculation during sex within 1 minute and before the individual wishes it for more than 6 months.

Question 301

Treatment of premature (early) ejaculation

Answer 301

SSRIs and tricyclic antidepressants (TCAs) pro-long the time from stimulation to orgasm – common side effect of SSRIs. Squeeze technique

Question 302

Diagnoistic criteria of genito-pelvic pain or penetration issues (dyspareunia)

Answer 302

Persistent or recurrent difficulties in one of the following: vaginal penetration during intercourse, marked vulvovaginal or pelvic pain during intercourse or penetration, marked anticipatory fear or anxiety about vulvovaginal or pelvic pain, or marked tensing or tightening of pelvic floor muscles during attempted vaginal penetration for more than 6 months.

Question 303

Etiology of genito-pelvic pain or penetration issues (dyspareunia)

Answer 303

- Trauma - episiotomy - Hormonal - vulvovaginal atrophy postmenopause – decreased levels of estrogen - Other pelvic pathology - endometriosis, pelvic inflammatory disease (pelvic adhesions), vaginismus, vulvodynia

Question 304

Treatment of genito-pelvic pain or penetration issues (dyspareunia)

Answer 304

- Kegel and reverse Kegel exercises - dilator treatment - comfort with self-exam - psychotherapy, other behavioural techniques - female on top position: allows for control of speed and duration - vestibulitis: remove local irritants, change in contraceptive methods, dietary changes (increased citrate, decreased oxalate), and vestibulectomy (rare) - vulvodynia: local moisturization, cold compresses, systemic nerve-blocking therapy (amitriptyline, gabapentin) orally or topically, topical anesthetics, estrogen cream - pain clinic - removal of environmental factors: bubble baths, soaps, perfumes, sanitary pads with plastic lining

Question 305

Etiology of substance- or medication-induced sexual dysfunction

Answer 305

- Alcohol, sedatives - Antihypertensives, anticholinergics, antidepressants (especially selective serotonin reuptake inhibitors [SSRIs]), and anti psychotics

Question 306

Diagnosis (DSM-5 Criteria) of gender dysphoria?

Answer 306

- A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months' duration, as manifested by at least two of the following: 1. A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics). 2. A strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one's experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics). 3. A strong desire for the primary and/or secondary sex characteristics of the other gender. 4. A strong desire to be of the other gender (or some alternative gender different from one's assigned gender). 5. A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender). 6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender). - The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Question 307

Requirements to have gender affirmation surgery covered by Alberta Health

Answer 307

- Permanent resident of Canada and in Alberta for at least 12 months - >18 YOA - Registration of intent form submitted by psychiatrist - Diagnosed with gender dysphoria by a psychiatrist - Preliminary surgeries completed (?hysterectomy, mastectomy, etc) - Completion of at least 12 months appropriate hormone therapy - Completion of at least 12 months of "real-life experience" (incl name change) - Letters from 2 psychiatrists that confirm patient is physically fit, psychologically prepared for surgery, no substance abuse, adequate support network - Must not have an axis 1 psychiatric disorder (anxiety, major depression) that is symptomatic or likely to become so - Must not have significant problems with personality disorder (acting out, antisocial)

Question 308

Hormonal treatment for male transition to female?

Answer 308

Antiandrogen therapy (spironolactone or cyproterone acetate) or GnRH agonist therapy, combined with estrogen therapy (transdermal or oral 17-beta-estradiol).

Question 309

Hormonal treatment for female transition to male?

Answer 309

Either testosterone esters (IM or SQ) or testosterone gels, depending upon pt preference. Higher testosterone levels are more easily achieved with parenteral therapy

Question 310

Define paraphilic disorders?

Answer 310

Intense and persistent sexual arousal that is elicited by something other than genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners

Question 311

Treatment paraphilic disorders?

Answer 311

- anti-androgen drugs - behaviour modification - psychotherapy

Question 312

Diagnostic criteria for female sexual interest/arousal disorder

Answer 312

Absence or reduced sexual interest, thoughts/fantasies, initiation of sex, sexual excitement/pleasure, sexual arousal, and/or genital/nongenital sensations during sex for more than 6 months (unclear prevalence of DSM-5 disorder, but low sexual desire in up to 26-43% of women).

Question 313

Diagnostic criteria for male hypoactive sexual desire disorder

Answer 313

Absence or deficiency of sexual thoughts, desire, or fantasies for more than 6 months (occurs in 5% of men).

Question 314

Treatment of male/female arousal disorders

Answer 314

Testosterone is used as replacement therapy for men with low levels. Low doses may also improve libido in women, especially in postmenopausal women. Low-dose vaginal estrogen replacement may improve vaginal dryness and atrophy in postmenopausal women.

Question 315

Diagnostic criteria of female orgasmic disorder

Answer 315

Marked delay in infrequency/absence/reduced intensity of orgasm for more than 6 months.

Question 316

Diagnostic criteria of delayed ejaculation

Answer 316

Marked delay in infrequency/absence of ejaculation for more than 6 months. Estimated prevalence likely less than 1%.

Question 317

Treatment of female orgasmic disorder

Answer 317

Self-exploration/pleasuring, relationship therapy if needed, bridging techniques (different sexual positions, clitoral stimulation during intercourse)

Question 318

What are the types of mood disorders

Answer 318

- depressive (major depressive disorder, persistent depressive disorder) - bipolar (bipolar I/II disorder, cyclothymia) - induced by or due to ("secondary to") a general medical condition, substance, medication, other psychiatric condition

Question 319

Medical workup of mood disorder

Answer 319

- Routine screening: physical exam, CBC, extended electrolytes, renal, liver and thyroid function tests, drug screen, medications list - Additional screening: B12 (in older people), neurological consultation, chest X-ray, ECG, head imaging

Question 320

DSM-5 Diagnostic Criteria for major depressive episode

Answer 320

- Criterion A: > 5 Sx must include depressed OR loss of interest/pleasure for 2 wks: Depressed mood + SIGECAPS (suicidality [thoughts/plan/intent], interest/pleasure (loss of), guilt (worthlessness, hopelessness, psychosis), energy (loss of), concentration (loss of/indecisive), appetite/weight changes, psychomotor retardation/agitation, sleep changes (insomnia/hypersomnia). - B. the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning - C. the episode is not attributable to the direct physiological effects of a substance or a GMC

Question 321

DSM-5 Diagnostic Criteria for manic episode

Answer 321

- Criterion A: Manic episode (Need to have one for Bipolar I) involves a distinct period of abnormal/persistent elevated, expansive or irritable mood + abnormally increased goal-directed activity or energy for at least 1 week present for most of the day, nearly every day - Criterion B: with ≥3sx or ≥4sx if irritable mood: DIGFAST – distractibility, increased goal-directed activity, grandiosity, flight of ideas/racing, activities pleasurable with painful consequences (e.g. spending lots), talkative, sleep (rested after 3h). - Criterion C: The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. - Criterion D: The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or there are psychotic features.

Question 322

Hypomanic episode criteria:

Answer 322

- Criterion A: A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. - Criterion B: with ≥3sx or ≥4sx if irritable mood: DIGFAST – distractibility, increased goal-directed activity, grandiosity, flight of ideas/racing, activities pleasurable with painful consequences (e.g. spending lots), talkative, sleep (rested after 3h). - Criterion C: The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. - Criterion D: The disturbance in mood and the change in functioning are observable by others. - Criterion E: The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.

Question 323

DSM-5 Diagnostic Criteria for Major Depressive Disorder (MDD)

Answer 323

- Criterion A. presence of a MDE - Criterion B: major depressive episode not better explained by schizophrenia spectrum/psychotic disorders - Criterion C: there has never been manic/hypomanic episode (this exclusion does not apply if episodes substance-induced or attributable to another condition)

Question 324

Which SIGECAPS symptoms are more common in younger and older patients?

Answer 324

Hypersomnia + hyperphagia more common if younger vs. psychomotor disturbances if older

Question 325

What is the definition of MDE with mood-congruent psychotic features

Answer 325

The content of all delusions and hallucinations is consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.

Question 326

What is the definition of MDE with mood-incongruent psychotic features

Answer 326

The content of the delusions or hallucinations does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment, or the content is a mixture of mood-incongruent and mood-congruent themes.

Question 327

What is the definition of MDE with catatonia

Answer 327

The catatonia specifier can apply to an episode of depression is catatonic features are present during most of the episode.

Question 328

What is the definition of MDE with peripartum onset

Answer 328

This specifier can be applied to the current of, if full criteria are not currently met for a major depressive episode, most recent episode of major depression if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery.

Question 329

Strongest predictor of PDD is ______

Answer 329

MDD during pregnancy

Question 330

Treatment of MDE with peripartum onset

Answer 330

Meds used when risk to mom/fetus of MDD outweighs risk of pharmacotherapy (sertraline low levels in breast milk, if smoker bupropion, use whatever has worked in the past as first line!)

Question 331

What is recurrent MDD?

Answer 331

Recurrent is classified as the patient having two or more distinct MDE episodes; to be considered separate the patient must have gone 2 consecutive months without meeting criteria

Question 332

Epidemiology of Major Depressive Disorder (MDD)?

Answer 332

Lifetime prevalence 12% (highest prevalence out of all psychiatric disorders), 2x higher incidence in women, mean onset is 40s - 50 percent of all patients having an onset between the ages of 20 and 50 years. More common in rural than urban areas

Question 333

Biological etiology of Major Depressive Disorder (MDD)?

Answer 333

- genetic: 65-75% MZ twins; 14-19% DZ twins, 2-4 fold increased risk in first-degree relatives - neurotransmitter dysfunction: decreased activity of 5-HT, NE, and DA at neuronal synapse; changes in GABA and glutamate; various changes detectable by fMRI - neuroendocrine dysfunction: abnormal HPA axis activity - neuroanatomy and neurophysiology: decreased hippocampal volume, increased size of ventricles; decreased REM latency and slow-wave sleep; increased REM length - immunologic: increased pro-inflammatory cytokines IL-6 and TNF - secondary to medical condition, medication, substance use disorder

Question 334

Psychosocial etiology of Major Depressive Disorder (MDD)?

Answer 334

- cognitive (i.e. distorted schemata, Beck's cognitive triad: negative views of the self, the world, and the future) - environmental factors (i.e. job loss, bereavement, history of abuse or neglect, early life adversity) - comorbid psychiatric diagnoses (i.e. anxiety, substance abuse, developmental disability, dementia, eating disorder)

Question 335

Risk factors of Major Depressive Disorder (MDD)?

Answer 335

- sex: F>M, 2:1 - family history: depression, alcohol abuse, suicide attempt or completion - childhood experiences: loss of parent before age 11, negative home environment (abuse, neglect) - personality: neuroticism, insecure, dependent, obsessional - Recent stressors: illness, financial, legal, relational, academic - Lack of intimate, confiding relationships or social isolation - Low socioeconomic status

Question 336

Unique clinical features of depression seen in elders?

Answer 336

Somatic complaints, anhedonia, apathy, psychomotor retardation, cognitive changes

Question 337

Comorbidity of Major Depressive Disorder (MDD)?

Answer 337

- Anxiety, a common symptom of depression, affects as many as 90 percent of all depressed patients. Social anxiety disorder, OCD, panic disorder - Alcohol use disorder - Depressed patients often use stimulants, such as cocaine and amphetamines, to relieve their depression

Question 338

Treatment of depression in elderly?

Answer 338

- Biological: SSRI or mirtazapine – usually start at ½ the regular dose, titration is slower, osteoporosis and bleeding are some S/E to watch out for, ECT is a valid option - Psychological: CBT - Social: Day Programs, Support Groups

Question 339

Treatment of MDD in pregnancy?

Answer 339

- Mild/moderate MDD – CBT or IPT (2nd line meds listed next). - Severe MDD – Sertraline (first line), citalopram. Psychotherapy as monotherapy NOT recommended, ECT not first-line but considered if psychotic or treatment-resistant

Question 340

Children and adolescents can have ___ mood instead of depressed mood to fulfill MDD criteria

Answer 340

irritable

Question 341

Depression with atypical features may be more common in youth

Answer 341

Mood reactivity (mood brightens in response) 2 or more of: significant weight gain or increase in appetite, hypersomnia, leaden paralysis, longstanding pattern of interpersonal rejection sensitivity

Question 342

Treatment of depression in children and youth?

Answer 342

- CBT and IPT are first line for mild and moderate - SSRIs are for more severe – fluoxetine (level 1). Escitalopram and sertraline (level 2) - SNRIs usually avoided

Question 343

First line treatment for MDD?

Answer 343

- Selective serotonin reuptake inhibitors (SSRIs) - Venlafaxine (Effexor), Desvenlafaxine (SNRI) – dose-dependent effects for depression: serotonin effects <150mg, norepinephrine effects >150mg. HTN and sweaty at higher doses. Better for depression than anxiety - NE/DA reuptake inhibitor (NDRI): bupropion lower SE profile; can be added to SSRIs but worsens anxiety!

Question 344

Side effects of SSRIs?

Answer 344

GI upset, insomnia, headache. Weight gain, sexual dysfunction. Withdrawal syndrome, serotonin syndrome, hyponatremia, RLS

Question 345

Examples of selective serotonin reuptake inhibitors (SSRIs)?

Answer 345

- Fluoxetine (Prozac) – longest half-life (one week), effective for bulimia, first line SSRI for youth age 10-21. Weight neutral. - Sertraline – most diarrhea of SSRIs - Citalopram (SSRI) – least drug interactions, can’t use citalopram > 40mg or escitalopram > 20 mg→ increased QT interval→ Torsades de pointes. Can cause seizures

Question 346

S/E profile of bupropion?

Answer 346

No sexual SE, less weight gain, no emotional blunting/anhedonia, facilitates smoking cessation

Question 347

Lifestyle treatments for MDD?

Answer 347

Increased aerobic exercise, mindfulness-based stress reduction

Question 348

Second line treatment for MDD?

Answer 348

Tricyclic antidepressants (TCAs): (imipramine, nortriptyline (norepinephrine), amitriptyline - sedation, clomipramine (serotonin) - OCD)

Question 349

Side effects of tricyclic antidepressants (TCAs)?

Answer 349

Anticholinergic SEs, cardiac toxicity lethal if OD.

Question 350

Third line treatment for MDD?

Answer 350

- Monoamine oxidase inhibitors (MAOIs): stops monoamines from being broken down (phenelzine, tranylcypromine) - Maca root (women) and SAMe (men) may help sexual SE - Modafinil: may help with fatigue + apathy - Used in treatment resistant

Question 351

Monoamine oxidase inhibitors (MAOIs) side effects?

Answer 351

Hypertension crisis, temp, increased HR + arrhythmia, must avoid tyramine containing foods (aged cheese, fermented/dried meat, beers on tap, soy)

Question 352

Psychotherapy for MDD?

Answer 352

CBT or IPT alone can be used for mild depression; combined with SSRI for mod/severe

Question 353

First-line recommendation to patients with MDD who failed at least 1 AD

Answer 353

rTMS

Question 354

Side effects of ECT

Answer 354

Possible loss of memory, anesthesia complications.

Question 355

When to use ECT?

Answer 355

Not responding to/not wanting meds, prior favourable response, need a rapid fix (acute suicidal, catatonic), needing acute changes during pregnancy (suicidal, catatonic, severe sx…) or in general, any psychotic MDD!

Question 356

What is discontinuation syndrome?

Answer 356

FINISH (flu-like symptoms, insomnia, neurological symptoms, irritability, sensory symptoms, hyperactivity).

Question 357

What is serotonin syndrome?

Answer 357

SHIVERS (shivering, hyperreflexia, increased temperature, vital sign instability, encephalopathy, restlessness and sweating)

Question 358

Severe discontinuation syndrome with which antidepressants?

Answer 358

Severe discontinuation with paroxetine (Paxil) and venlafaxine (SNRI):

Question 359

Approach to starting antidepressants for MDD?

Answer 359

Try the above SSRIs, then reassess every 1-2 weeks for 3-4 weeks; full response? Continue

Question 360

For Partial/Non-Response after 3-4 weeks on antidepressants for MDD?

Answer 360

- Optimize dose, then reassess regularly for 4-8 weeks; full response? Continue - No-Response: change class - Partial Response: add agent (bupropion or other SN or SSRI) or augment (risperidone, quetiapine-XR, aripiprazole, lithium) - Switch vs Adjunctive: Consider switch AD when: first trial, poorly tolerated, no response to initial AD, more time to wait for response

Question 361

How long should antidepressant treatment should be maintained for in MDD?

Answer 361

Antidepressant treatment should be maintained for at least 6 months or the length of a previous episode, whichever is greater. Ongoing management should include assessment in key domains (school, home, social settings), reassessment and referral recommended if no improvement after 6-8 weeks of treatment

Question 362

DSM-5 Diagnostic Criteria for Persistent Depressive Disorder

Answer 362

- Criterion A: Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. - Criterion B: Presence, while depressed, of two (or more) of the following: • Poor appetite or overeating. • Insomnia or hypersomnia. • Low energy or fatigue. • Low self-esteem. • Poor concentration or difficulty making decisions. • Feelings of hopelessness. - Criterion C: During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time. - Criterion D: Criteria for a major depressive disorder may be continuously present for 2 years - Absence of manic/hypomanic episodes, not better explained by schizophrenia/substances/illnesses

Question 363

Treatment of Persistent Depressive Disorder

Answer 363

1. Psychological - traditionally, psychotherapy was the principal treatment for persistent depressive disorder; recent evidence suggests some (but generally inferior) benefit for pharmacological treatment. Combinations of the two may be most efficacious 2. Biological - antidepressant therapy: SSRIs (i.e. sertraline, escitalopram), TCAs (i.e. nortiptyline)

Question 364

In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the predominant affect is feelings of ____, while in MDE it is ____.

Answer 364

- emptiness and loss | - persistent depressed mood and the inability to anticipate happiness or pleasure.

Question 365

Bereavement/Grief vs MDE

Answer 365

- The dysphoria in grief is likely to decrease an intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. - The depressed mood of MDE is more persistent and not tied to specific thoughts or preoccupations. - The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of MDE. - The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased rather than the self-critical or pessimistic ruminations seen in MDE. - In grief, self-esteem is generally preserved, whereas in MDE feelings of worthlessness and self-loathing are common. - If a bereaved individual thinks about death and dying, such thoughts are general focused on the deceased and possibly “joining” the deceased, whereas in MDE, such thoughts are focused on ending one's own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.

Question 366

What is Bipolar I disorder

Answer 366

- Disorder in which at least one manic episode has occurred - if manic symptoms lead to hospitalization, or if there are psychotic symptoms, the diagnosis is BP I - commonly accompanied by at least 1 MDE but not required for diagnosis

Question 367

What is Bipolar II disorder

Answer 367

Disorder in which there is at least 1 MDE, 1 hypomanic episode, and no manic episodes

Question 368

What are the 6 S's you should ask about in Bipolar II disorder

Answer 368

6S’s – sex, sleep, socializing, spending, speeding, special projects

Question 369

What is bipolar disorder with melancholic features

Answer 369

Melancholia is sometimes referred to as “endogenous depression” or depression that arises in the absence of external life stressors or precipitants.

Question 370

What is bipolar disorder with catatonic features

Answer 370

The hallmark symptoms of catatonia—stuporousness, blunted affect, extreme withdrawal, negativism, and marked psychomotor retardation

Question 371

What is bipolar disorder with rapid cycling

Answer 371

Likely to be female and to have had depressive and hypomanic episodes. Patient must have at least four episodes within a 12-month period.

Question 372

Manic episodes are more common in __, and depressive episodes are more common in ___.

Answer 372

men | women

Question 373

Risk factors for switching from BP2 to mania:

Answer 373

2+ prior depressions, rapid cycling, Hx of suicide attempts, younger age, earlier age at onset. More manic symptoms during depressive episode

Question 374

Risk Factors for bipolar disorder?

Answer 374

- Genetic: 60-65% of bipolar patients have family history of a major mood disorder, especially bipolar disorder - Clinical features of MDE history favouring bipolar over unipolar diagnosis: early age of onset (<25yr), increased number of MDEs, psychotic symptoms, postpartum onset, anxiety disorders (especially separation, panic), antidepressant failure due to early “poop out” or hypomanic symptoms, early impulsivity and aggression, substance abuse, cyclothymic temperament

Question 375

What is the suicide risk in bipolar disorder?

Answer 375

Suicide risk is 15-20x general pop

Question 376

Mood stabilizers used for the treatment of acute bipolar mania

Answer 376

- Lithium - Valproic Acid - Carbamazepine

Question 377

Side effects of lithium

Answer 377

- LITH: Leukocytosis, Insipidus (polyuria/dipsia – dose only once a day at bedtime (kidneys not as active overnight)), Tremor, Hypothyroidism - Others: GI upset (N/V), weight gain, cognitive slowing

Question 378

Lithium monitoring

Answer 378

Creatinine, TSH, Calcium. Within 9-12hours after dose, then 4-5d for steady state + check lithium levels. Pregnancy test, ECG (if >40) – brugada pattern. Do this 2x first 6months then 1x/year

Question 379

Which drugs will increase lithium levels

Answer 379

CANT drugs (Ca blockers, ACEi, NSAID, thiazides)

Question 380

Valproic acid monitoring

Answer 380

Need to follow: LFTs and platelets (thrombocytopenia). Do this 2x first 6months then 1x/year

Question 381

Side effects of valproic acid?

Answer 381

GI upset (nausea), sedation, tremor, alopecia

Question 382

Symptoms of lithium toxicity?

Answer 382

Symptoms may include a tremor, increased reflexes, N/V, trouble walking, kidney problems, and an altered level of consciousness

Question 383

Treatment of lithium toxicity?

Answer 383

Treat by stopping the lithium, rehydrating. Lithium levels drop by 50% in 24 hours. Severe toxicity use dialysis

Question 384

Side effects of carbamazepine

Answer 384

Rash - SJS, GI upset, sedation, ataxia, hyponatremia, hepatic inducer, agranulocytosis, teratogenic

Question 385

What should be checked with carbamazepine

Answer 385

CBC (agranulocytosis) + LFTs

Question 386

____ are first line treatment in someone who is acutely manic and are used in the short term while the mood stabilizers are titrated to therapeutic doses

Answer 386

Atypicals

Question 387

Examples of atypical antipsychotics?

Answer 387

- Risperidone, Quetiapine, Aripiprazole (less weight gain), Ziprasidone, Asenapine, Lurasidone (Latuda) - Quetiapine: 1st line treatment, consider if diagnostic uncertainty and there are psychotic symptoms and sleep disturbances

Question 388

ECT can be considered first in acute bipolar mania if?

Answer 388

High suicide risk, psychotic bipolar depression, or if mood stabilizers are contraindicated – pregnancy, elderly, epileptic patients, CV disease

Question 389

1st line treatment of acute bipolar depression?

Answer 389

Lithium, Lamotrigine (good for younger females), Lurasidone.

Question 390

2nd line treatment of acute bipolar depression?

Answer 390

DVP, SSRI/bupropion – best antidepressant (adjunctive – don’t give antidepressant without a mood stabilizer. ADs added to a mood stabilizer probably cause no harm and can help treat co-morbid anxiety disorders).

Question 391

For a BP1 patient, you would never use an ____ without also using lithium or another mood stabilizer. For a BP2 patient, you might just use an ____ if that's their primary symptom right now.

Answer 391

antidepressant antidepressant Bottom line is that you can safely use antidepressants on their own for BP2 and might start with them cause less S/E

Question 392

Alternative & psychosocial treatments of bipolar disorder

Answer 392

- Psychoeducation – the only first-line psychosocial intervention for the maintenance phase - CBT, IPT and family – help as an adjunct to pharmacotherapy - Social: time off work, AISH, life skills training

Question 393

What treatments are indicated for BPI in pregnancy?

Answer 393

Lithium probably safest, for Li nonresponders use lamotrigines or ECT if needing quick treatment

Question 394

Women of childbearing age should NOT be on ____ for BPI as it has the highest risk of ____

Answer 394

- Divalproex | - Ebstein’s anomaly

Question 395

Predictors of poorer response in bipolar disorder?

Answer 395

Male, mixed states, AUD, depressive features between the mania and depression, prior exposure to antidepressants, anticonvulsants, poorer adherence to Rx at 3 months

Question 396

An untreated manic episode can last __ months, treatment can cut that in half

Answer 396

3-6

Question 397

Diagnosis of cyclothymic disorder

Answer 397

- Presence of numerous periods of hypomanic and depressive symptoms (not meeting criteria for full hypomanic episode or MDE) for >2 yr; never without symptoms for >2 mo - Never have met criteria for MDE, manic or hypomanic episodes - Symptoms not better explained by any psychotic disorder (including schizoaffective, schizophrenia, schizophreniform, delusional disorder, or other specified/unspecified) - Symptoms are not due to the direct physiological effects of a substance or GMC - Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Question 398

Treatment of cyclothymic disorder

Answer 398

Similar to Bipolar I: mood stabilizer ± psychotherapy, avoid antidepressant monotherapy, treat any comorbid substance use disorder

Question 399

What is primary gain?

Answer 399

Goal of patient is to assume the ‘sick role’ in the absence of any obvious external advantages.

Question 400

What is secondary gain

Answer 400

Goal is to avoid a financial, societal or interpersonal obligation.

Question 401

What is somatization?

Answer 401

The process by which psychological distress manifests/are converted to physical symptoms. It is unconscious and a normal phenomenon. Considered pathological when it becomes primary mode of behaving and gets in the way of function.

Question 402

Diagnosis (DSM-5 Criteria) of somatic symptom disorder

Answer 402

- ≥1 somatic symptom that is distressing/impairing function. - Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following: 1. disproportionate and persistent thoughts about the seriousness of one’s symptoms 2. persistently high level of anxiety about health or symptoms 3. excessive time and energy devoted to these symptoms or health concerns - Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (>6 mos).

Question 403

Epidemiology of somatic symptom disorder

Answer 403

Starts early, F>M (20:1), more common in lower SES (more stress, less stability), familial or antisocial personality in male relatives, associated with sexual abuse, substance abuse, depression, GAD, phobias as well as histrionic, borderline, and dependent personality disorders.

Question 404

Management of somatic symptom disorder

Answer 404

- The patient should have regularly scheduled visits with a single primary care physician, who should minimize unnecessary medical workups and treatments. - Address psychological issues slowly. Patients will likely resist referral to a mental health professional. - Not cure and use non-invasive tx (CBT, physio), praise and validate adaptive behaviour/coping.

Question 405

Diagnosis (DSM-5 Criteria) of conversion disorder

Answer 405

- ≥1 symptoms of altered voluntary motor or sensory function - Findings provide evidence of incompatibility between symptom and recognized neurological condition. - Not better explained by physical or mental issue - Causes significant distress or impairment in social or occupational functioning or warrants medical evaluation.

Question 406

Common symptoms of conversion disorder

Answer 406

Paralysis, weakness, blindness, mutism, sensory complaints (paresthesias), seizures, globus sensation (globus hystericus or sensation of lump in throat).

Question 407

Epidemiology of conversion disorder

Answer 407

- More common in females. - Onset at any age, but more often in adolescence or early adulthood. - High incidence of comorbid neurological, depressive, or anxiety disorders.

Question 408

Management of conversion disorder

Answer 408

- Main 3 modalities of tx for motor symptoms: 1. Withdraw medical/social attention from movements/gait (ignore behaviour) 2. PT and OT to retrain patient. 3. CBT targeted at developing methods of coping with stress. - Often is short-lived (no preoccupation with the somatic symptoms), responds to almost any therapy, may require social intervention, might need hypnosis or benzo to even interview.

Question 409

Diagnosis (DSM-5 Criteria) of Illness Anxiety Disorder

Answer 409

- Preoccupation with having or acquiring illness with excessive health-related behaviour for ≥6mo. - NONE or mild SOMATIC SYMPTOMS – high anxiety about health. - Heightened awareness of bodily sensation, excessive worry with that. - Specify whether care-seeking type or care-avoidant type

Question 410

Epidemiology of Illness Anxiety Disorder

Answer 410

F=M. Generally dissatisfied with care received, believe not taken seriously. Can result in countertransference. 2/3 have a least one other comorbid major psychiatric disorder

Question 411

Management of Illness Anxiety Disorder

Answer 411

Therapeutic alliance (AVN). Limit your investigations (arrange for regular, timed appointments). CBT

Question 412

Diagnosis (DSM-5 Criteria) of Psychological Factors Affecting Other Condition

Answer 412

A present medical condition (not mental) whose course is adversely affected by psychological factors that interfere with treatment/well-being of the individual (not better explained by any other disorder).

Question 413

Management of Psychological Factors Affecting Other Condition

Answer 413

Psychoeducation (discuss nature/cause), response prevention (refrain from behaviours that maintain health anxiety), stress/behaviour mgmt., SSRIs, treat psych co-morbidities, mindfulness approaches, CBT

Question 414

Diagnosis (DSM-5 Criteria) of Factitious Disorder

Answer 414

- Falsification of physical signs or symptoms, or induction of injury or disease to SEEK CARE, associated with identified deception (false hx, simulation, exaggeration, aggravation – contaminating own wounds, self induction). - Evident even if no obvious external rewards. - Specify if single episode or recurrent

Question 415

Commonly feigned symptoms of Factitious Disorder

Answer 415

- Psychiatric-hallucinations, depression. | - Medical-fever (by heating the thermometer), infection, hypoglycemia, abdominal pain, seizures, and hematuria.

Question 416

Epidemiology of Factitious Disorder

Answer 416

- More common in women. - Higher incidence in hospital and health care workers (who have learned how to feign symptoms). - Associated with personality disorders. - Many patients have a history of illness and hospitalization, as well as childhood physical or sexual abuse.

Question 417

Management of Factitious Disorder

Answer 417

Hard to diagnose. Avoid confrontation and tx same way as somatic symptom disorder. Tempting to fire them

Question 418

The fundamental difference between malingering and factitious disorder is in the intention of the patient; in malingering, the motivation is ___, whereas in factitious disorder, the motivation is ____.

Answer 418

external | internal

Question 419

What is malingering

Answer 419

Malingering involves the intentional reporting of physical or psychological symptoms in order to achieve personal gain.

Question 420

Presentation of malingering

Answer 420

- Patients usually present with multiple vague complaints that do not conform to a known medical condition. - They often have a long medical history with many hospital stays. - They are generally uncooperative and refuse to accept a good prognosis even after extensive medical evaluation. - Their symptoms improve once their desired objective is obtained.

Question 421

Is malingering more common in men or women

Answer 421

Significantly more common in men than women.

Question 422

Management of malingering

Answer 422

- In your assessment, remember your ABCS (avoid accusations, beaware of countertransference, clarification and security measures

Question 423

Criteria for personality disorder

Answer 423

1. Enduring pattern of behavior/inner experience that deviates from the person's culture and is manifested in two or more of the following ways (CAPRI): - Cognition - Affect - Interpersonal functioning - Impulse control 2. The pattern: - Is pervasive and inflexible in a broad range of situations. - Is stable and has an onset no later than adolescence or early adulthood. - Leads to significant distress in functioning. - Is not accounted for by another mental/medical illness or by use of a substance.

Question 424

What are the cluster A personality disorders

Answer 424

Schizoid, schizotypal, and paranoid

Question 425

What are the cluster B personality disorders

Answer 425

Antisocial, borderline, histrionic, and narcissistic

Question 426

What are the cluster C personality disorders

Answer 426

Avoidant, dependent, and obsessive-compulsive

Question 427

What is projection (transference)?

Answer 427

Reacting to unacceptable inner impulses as though they were outside self. Involves taking our own unacceptable qualities or feelings and ascribing them to other people. Transference is commonly used to describe this – transferring feelings about someone who was a figure from early life like your dad to another (e.g. a psychiatrist).

Question 428

What is countertransference?

Answer 428

Clinician’s emotional reaction to the patient – e.g. reacting to the transference with a strong emotional reaction.

Question 429

What is splitting?

Answer 429

Dividing emotions/relationships into all good or all bad – have a hard time dealing with grey. Can lead to staff splitting too – some are thought to be awesome, some not leading to divides in treatment teams.

Question 430

What is acting out?

Answer 430

Expressing unconscious impulse through action to avoid being conscious of a feeling.

Question 431

Diagnosis (DSM-5 Criteria) of paranoid personality disorder?

Answer 431

1. Pervasive distrust/suspiciousness of others thought to be malevolent. e.g. Dwight from the Office. 2. At least four of the following must also be present: - Suspicion (without evidence) that others are exploiting or deceiving him or her. - Preoccupied with unjust doubts - Reluctant to trust others - Interpretation of benign remarks as threatening or demeaning. - Persistence of grudges. - Perception of attacks on his or her character that is not apparent to others; quick to counterattack. - Suspicions regarding fidelity of spouse or partner.

Question 432

Treatment of paranoid personality disorder?

Answer 432

- Psychotherapy is the treatment of choice, although, as stated above, patients rarely initiate treatment. - Group psychotherapy should be avoided due to mistrust and misinterpretation of others' statements.

Question 433

Diagnosis (DSM-5 Criteria) of schizoid personality disorder

Answer 433

- Pervasive pattern of detachment from social relationships and restricted range of expression of emotions in interpersonal settings. - At least 4 of: neither desires nor enjoys human interaction, usually chooses solitary activities, little interest in sex, lacks close friends, appears indifferent to praise/criticism of others, emotional coldness.

Question 434

Treatment of schizoid personality disorder

Answer 434

- Hard to tease apart from autism. - Lack insight for individual psychotherapy, and may find group therapy threatening; may benefit from day programs or drop-in centers. - Antidepressants if comorbid major depression is diagnosed.

Question 435

Diagnosis (DSM-5 Criteria) of schizotypal personality disorder

Answer 435

- A pattern of social deficits marked by eccentric behavior, cognitive or perceptual distortions, and discomfort with close relationships, beginning by early adulthood and present in a variety of contexts. - Indicated by at least 5 of: ME PECULIAR - M magical thinking or odd beliefs - E experiences unusual perceptions - P paranoid ideation - E eccentric behaviour or appearance - C constricted or inappropriate affect - U unusual thinking and speech - L lacks close friends - I ideas of reference (excluding delusions of reference). - A anxiety in social situations

Question 436

Schizotypal personality disorder vs schizophrenia?

Answer 436

Unlike patients with schizophrenia, patients with schizotypal personality disorder are not frankly psychotic (though they can become transiently so under stress), nor do they have fixed delusions.

Question 437

Schizotypal personality disorder vs schizoid personality disorder?

Answer 437

Patients with schizoid personality disorder do not have the same eccentric behavior seen in patients with schizotypal personality disorder.

Question 438

Treatment of schizotypal personality disorder

Answer 438

- Psychotherapy is the treatment of choice to help develop social skills training. - Short course of low-dose antipsychotics if necessary (for transient psychosis). Antipsychotics may help decrease social anxiety and suspicion in interpersonal relationships.

Question 439

Diagnosis (DSM-5 Criteria) of antisocial personality disorder

Answer 439

1. Antisocial: pervasive pattern of disregard/violation of rights of other since 15. 2. Patients must be at least 18 years old for this diagnosis; history of behavior as a child/adolescent must be consistent with conduct disorder 3. Need 3 or more of: CORRUPT - C cannot follow law - O obligations ignored - R remorselessness, - R reckless disregard for safety, - U underhanded (deceitful) - P planning deficit (impulsive) - T temper (irritable, aggressive)

Question 440

Treatment of antisocial personality disorder

Answer 440

- Psychotherapy is generally ineffective. - Before treatment can begin, firm limits are essential. Therapists must find ways of dealing with patients' self-destructive behavior. And to overcome patients' fear of intimacy, therapists must frustrate patients' desire to run from honest human encounters. In doing so, therapists face the challenge of separating control from punishment and of separating help and confrontation from social isolation and retribution. - Pharmacotherapy may be used to treat symptoms of anxiety or depression, but use caution due to high addictive potential of these patients.

Question 441

Diagnosis (DSM-5 Criteria) of borderline personality disorder?

Answer 441

1. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: AM SUICIDE - A abandonment avoidance - M mood instability (marked reactivity of mood) - S suicidal (or self-mutilating) behaviour - U unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. - I impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) - C control of anger - I identity disturbance: markedly and persistently unstable self-image or sense of self. - D dissociative (or paranoid) symptoms that are transient and stress related - E emptiness

Question 442

Clinical features of borderline personality disorder?

Answer 442

- Mood swings are common. Patients can be argumentative at one moment, depressed the next, and later complain of having no feelings. - Patients can have short-lived psychotic episodes (so-called micropsychotic episodes) - circumscribed, fleeting, or doubtful - The painful nature of their lives is reflected in repetitive self-destructive acts. Such patients may slash their wrists and perform other self-mutilations to elicit help from others, to express anger, or to numb themselves to overwhelming affect. - Patients with borderline personality disorder cannot tolerate being alone - Functionally, patients with borderline personality disorder distort their relationships by considering each person to be either all good or all bad. BLACK OR WHITE THINKING - Patients can exhibit defence mechanisms, splitting (idealization)!

Question 443

Treatment of borderline personality disorder?

Answer 443

- Dialectical Behaviour Therapy - Duration: A full round takes about 6 months to complete - Pharmacotherapy should be considered an adjunct to psychotherapy. Various medications (e.g., mood stabilizers, antipsychotics, antidepressants) have been found to be somewhat effective in treating certain symptoms of BPD.

Question 444

Borderline personality disorder is diagnosed three times more often in ___ than ___.

Answer 444

women | men

Question 445

Diagnosis (DSM-5 Criteria) of histrionic personality disorder

Answer 445

1. Pervasive pattern of excessive emotionality and attention-seeking, beginning in early adulthood. 2. Need 5 or more of: PRAISE ME - P provocative behaviour - R relationships considered more intimate than they are - A attention (uncomfortable when not centre of attention) - I influenced easily - S style of speech (impressionistic, lacks detail) - E emotions (rapidly shifting and shallow) - M made up (uses physical appearance to draw attention) - E emotions exaggerated

Question 446

Treatment of histrionic personality disorder

Answer 446

- Psychotherapy (e.g., supportive, problem-solving, interpersonal, group) is the treatment of choice. - Pharmacotherapy to treat associated depressive or anxious symptoms as necessary.

Question 447

Diagnosis (DSM-5 Criteria) of narcissistic personality disorder

Answer 447

- Pervasive pattern of grandiosity, need for admiration, lack of empathy. E.g. Steve Carell in the Office. - Need 5 of: grandiose sense of self-importance, preoccupied with fantasies of success/power/brilliance, believes he/she is special or unique, requires excessive admiration, sense of entitlement, lacks empathy, is interpersonally exploitive, envious of others, arrogant/haughty.

Question 448

Narcissistic personality disorder vs antisocial personality disorder

Answer 448

Both types of patients exploit others, but NPD patients want status and recognition, while antisocial patients want material gain or simply the subjugation of others. Narcissistic patients become depressed when they don’t get the recognition they think they deserve.

Question 449

Treatment of narcissistic personality disorder

Answer 449

- Psychotherapy is the treatment of choice. | - Psychotropics may be used if a comorbid psychiatric disorder is also diagnosed.

Question 450

Diagnosis (DSM-5 Criteria) of avoidant personality disorder?

Answer 450

1. Pervasive pattern of social inhibition, feeling inadequate, hypersensitive to negative evaluation beginning in early adulthood. Need 4 of: CRINGES - C certainty of being liked before willing to get involved with others - R rejection or criticism preoccupies ones’ thoughts in social situations - I intimate relationships (restraint in intimate relationships due to hear of being shamed) - N new interpersonal relationship (is inhibited in) - G gets around occupational activity - E embarrassment prevents new activity or taking personal risks - S self viewed (as socially inept)

Question 451

Avoidant personality disorder vs schizoid personality disorder?

Answer 451

Patients with avoidant personality disorder desire companionship but are extremely shy, whereas patients with schizoid personality disorder have little or no desire for companionship.

Question 452

Avoidant personality disorder vs social anxiety disorder (social phobia)

Answer 452

Both involve fear and avoidance of social situations. If the symptoms are an integral part of the patient's personality and have been evident since adolescence, personality disorder is the more likely diagnosis. Social anxiety disorder involves a fear of embarrassment in a particular setting (speaking in public, urinating in public, etc.), whereas avoidant personality disorder is an overall fear of rejection and a sense of inadequacy. However, a patient can have both disorders concurrently and should carry both diagnoses if criteria for each are met.

Question 453

Treatment of avoidant personality disorder?

Answer 453

- Psychotherapy, including assertiveness and social skills training, is most effective. - Group therapy may also be beneficial. - Selective serotonin reuptake inhibitors (SSRIs) may be prescribed for comorbid social anxiety disorder or major depression.

Question 454

Diagnosis (DSM-5 Criteria) of dependent personality disorder?

Answer 454

- Pervasive and excessive need to be taken care of that leads to submissive/clinging behaviour and fear of separation. - Need 5 of: difficulty with decisions without reassurance needs others to assume responsibility, difficulty disagreeing, difficulty initiating projects, excessive lengths to obtain nurturance/support from others, feels uncomfortable/helpless when alone, seeks another relation as a source of care/support when one ends, fearful of taking care of oneself

Question 455

Treatment of dependent personality disorder?

Answer 455

- Psychotherapy, particularly cognitive-behavioral, assertiveness, and social skills training, is the treatment of choice. - Pharmacotherapy may be used to treat associated symptoms of anxiety or depression.

Question 456

Diagnosis (DSM-5 Criteria) of obsessive compulsive personality disorder

Answer 456

1. Pervasive pattern of orderliness, perfectionism, mental/interpersonal control at the expense of flexibility, openness, efficiency. 2. Need 4 or more of: - Preoccupation with details, rules, lists, and organization such that the major point of the activity is lost. - Perfectionism that is detrimental to completion of task. - Excessive devotion to work. - Excessive conscientiousness and scrupulousness about morals and ethics. - Will not delegate tasks. - Unable to discard worthless objects. - Miserly spending style. - Rigid and stubborn

Question 457

Obsessive-compulsive disorder (OCD) vs obsessive compulsive personality disorder

Answer 457

Patients with OCPD do not have the recurrent obsessions or compulsions that are present in OCD. In addition, the symptoms of OCPD are ego-syntonic rather than ego-dystonic (as in OCD); OCD patients are aware that they have a problem and wish that their thoughts and behaviors would go away.

Question 458

Narcissistic personality disorder vs obsessive compulsive personality disorder

Answer 458

Both personalities involve assertiveness and achievement, but NPD patients are motivated by status, whereas OCPD patients are motivated by the work itself.

Question 459

Treatment of obsessive compulsive personality disorder

Answer 459

- Psychotherapy is the treatment of choice. Cognitive-behavior therapy may be particularly useful. - Pharmacotherapy may be used to treat associated symptoms as necessary.

Question 460

What is passive suicidal ideation

Answer 460

Would rather not be alive but has no active plan for suicide. e.g. “I’d rather not wake up” or “I would not mind if a car hit me”

Question 461

What is active suicidal ideation

Answer 461

Thoughts of actively ending life

Question 462

What should you consider when assessing suicide intent

Answer 462

Assessed based on planned vs impulsive attempt, precautions against being found, seeking help after act/reaction to survival, dangerousness of method and presence of “final act”, expectation of lethality/dying, substances use/intoxication

Question 463

Risk factors for suicidality?

Answer 463

SADPERSONS: sex (male), age (men peaks at 45, women peaks after 65, rapid rise in males 15-24), depression (50% of all people who kill themselves are depressed, 15% of people who have depression commit suicide), previous attempt, EtOH, rational thinking loss (psychosis), social supports lacking, organized plan, no spouse, sickness//chronic illness (schizophrenia, BPT, anxiety disorders, dementia)

Question 464

What is the ratio of attempted: completed suicides

Answer 464

Attempted: completed = 20:1

Question 465

Management of higher risk suicidal patient?

Answer 465

- Patients with a plan and intention to act on the plan, access to lethal means, recent social stressors, and symptoms suggestive of a psychiatric disorder - Do not leave patient alone; remove potentially dangerous objects from room - If patient refuses to be hospitalized, complete form for involuntary admission (Form 1)

Question 466

Management of lower risk suicidal patient?

Answer 466

- Patients who are not actively suicidal, with no plan or access to lethal means - Discuss protective factors and supports in their life, remind them of what they live for, promote survival skills that helped them through previous suicide attempts - *Suicide contracts are not effective