kLondon PDM 2009 course

ODD

1 to 16%

pre-teen, more boys ,after teens = and girls more overt

ADHD, MOOD, Anxiety, LD

Early age onset, ADHD comborb

1. Aggression to people & animals 2. Destruction property 3. Deceitful/theft 4. Rule breaking

Sexual Abuse

1 to 3%, increasing

late childhoold, early teens

more in urban

Male = female

ADHD, SU, Mood, Anx

Mood, Anx, ASPD (40%), SU

under-arousal, low cortisol, high testosterone, exposure to toxins, hyperactivity, cog problems, chronic illness

insecure attach, misattribution of hostility, lower empathy

poverty, violence, availability of rx, comercive family processes, lack of supervsion, inconsistend discipl, lack of positive parental involvement, marital discord, poor moderlling, overly permissive, neglectfu or punitive, abusive, rejecting parents, child abuse, peer rejection association with deviant peers

Cruelty, running away, breaking into a building

fighint, cruel behaviours, atypical behavior, unemotional

competence outside of school, 1 + relationship, prosocial peers, + school atmosphere

1. Alliance, 2. Data Gathe: comorbid, Child Behav Check, Collateral, Interview, ABC 3. Specific plan based on continuum matching severity 4. Tx comorbididity

1. Parent Education: discipline/supervision 2. School tx, 3. Multisystemic Fam Tx, 4. Individual Problem Solving 5. Contingency Mngmt 6. Intensive home therapy

Tx. Comorbd, Consider Atypicals i.e. Risperidone

PDD

Social, Lang, Behav Abnormalities

poor nonverbal, e.g. eye contact; <peer relations, <spontaneous,<social /emotional reciprocity

1. Delayed; no single words by two, phrases by 3; 2. <iniate/maintain conversation 3. stereotyped lang (e.g. delayed echolalia, reversed pro-nouns) 4. <spontaneous, <varied imaginative play

<variety in interests, <flexibility in routines/rituals - nonfunctional routines, stereotyped motor mannerisms, preoccup with parts of objects

Sx before age 3, Total Six Sx = 2 Social, 1 Lang, 1 behav + 2 others

No cog diff in Aspergers; IQ >70

Rett's, Childhood Disintigrative Ds

Decline in development, more in girls

MR, Language Ds, ADHD, Anxiety Ds (Social Phobia, OCD), Fragile X, Seizures Ds, Attachment Ds, Genetic Ds

1 /300 for all

1/ 1000 for Autism

2/3 have MR (up to 3/4)

20% develop

5% have chromosomal abn

Increased Brain Size ,by Age 1 at 90% for head circum

Sibling recurrence 5-10%, Heritability autism 90%, 5% have genetic abnormalities, "Unaffected" relatives have increased rates of social, language, and behav problems

People lack theory of mind - ability to understand other peoples thought processes

nil

Goal: descrease Negative Behaviors interfering with fxn, meds to enhance life

Not more than 1.5mg, 50% reduction, also helps reduce hyperactivity in open label studies

Not effective in open-label studies

SSRI's few studies, Anticonvulsants, a few, Lithium in older studies

Not according to DSm but there is about 5%

Reduces ADHD Sx in kids with Autism but less effective and more adverse side effects

Open label study may help

Aggression, Hyperactivity, Anxiety

Fluoxetine, Risperidone

Schizophrenia

Strong Genes: COMT, Chromo somal Abn: 22q11, 1q42; Burmelser M et Al. Nature Review 2008; Microdeletions: 1q21.1, 15q11.2, 15q13.3

1. Obstetric Complications 2. Season of Birth 3. Maternal Influenza 4. Paternal Age 5. Cannabis

Vulnerability, PreMorbid, Prodromal, Psychosis, Schizophrenia

Positive, -, Cog Sx

1. Loss of appetite, sleep or sexual drive. 2. Neglect of activities 3. Persectured 4. Avoiding other 5. Frightened or Anxious 6. Looks disorganized

Ultra High Risk Group or Clinical High Risk group: 1. + Sx attenuated 2. Brief intermittent psychotic state 3. Genetic risk + recent deterioration

1. PACE: Risp + CBT not much different after 1 year ; 2. PRIME: Olanz vs Placebo not stats difference to transitiont to psychosis 3. EDIE Cog therapy study NS at 12 months

1. Assess 2. Educate and Support 3. Monitor 4. Tx Sx

1. Public education 2. Educated gatekeepers 3. Provide easy access to care 4. Continous care 5. Pharmacotherapy 6. Family Therapy 7. Integrated Addictions 8. Patient Education 9. Case Management 10. Supported Employment

PE Eam, EPS, BMI, Metabolic, Endocrine Fxn, Blood work, CT, FISH for 22q11; Neurocognition (MATRIX Battery), IQ premorbid, Current IQ (Predicts future fxn)

1. Working Memory 2. Attention 3. Verbal Learning & Memory 4. Visual Learning and Memory 5. Reasoning and Problem Solving 6. Information Processing 7. Social Cognition

1. Acute Phase 2. Stabilization 3. Stable phase

1. Sx severity (SI/HI) 2. Fxn: self, social, work

Baseline, 3month, 6months (non intervention), Annually (interventional; i.e., blood work)

2 years

Lifetime, Level A recommendation

RCT, Systemic

Single RCT or Number of long Studies

B level

A, B, C

B

CATIE and CUTLASS

Clinical Antipsychotic Trials of Intervention Effectiveness N=1493, 18 months; Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia, Done in UK N 230 patients over 1 year

No major difference between +/- sx, adherence, QoL between FGA and SGA. Olanzapine longest to stopping.

Clozapine superior to BOTH FGA and SGA in TR-Sz

Olanz and Risp longer to d/c

Switching is hard if patient doing well, helps to specify topic

QoL: no difference between drugs

How long on drug

Ziprasidone

20 to 80mg, cited on Cochrane Review

Lose weight

less effective but less weight

more tolerable than risp

Active metab of risp, 3 to 12 mg, similar efficacy, more eps, less weight gain

A: Supported Employment, Family Education (after pharmacotherapy considered best), Comprehensive Care, ACT

Find out about past adherence, Patient centered approach, Negotiate, optimize efficacy, minimize side effects, psychoeducation with family, add community supports, Consider Cog strategies, Promote interests

Moderate severity abn movments in 1 or more body areas or mild severity in multiple sites

Response usually matches severity of trauma, Normal to have Re-exp, Intense Emotional reactions, Increased vigilance, Gradual Adjustment over weeks

94% at 1 week, 15% still at year

Re-experiencing, Elevated Arousal, Avoidance/Avoidance

MDD, Anxiety Ds, Sub Us

complex ptsd, disorders of extreme stress NOS: change in affective arousal, change in attention/consciousness (removing self from situation), somatization, Chornic chaterological change, Change in systems of meaning

MoodAnxSub; BPD, Brief Psychosis, Somatization Ds, Eating Ds, Dissociative Ds, Pain Disorder

Pain Ds, Neuro Problems, Cardiac/GI, Repro, Sexual

7.8%, men 5% women 10.4%

Female Gender, Hx of Psych Illness, Type of trauma (rape worse), Prolonged exposure, Childhood trauma, Poor social supports, Genetics, Life stressors, Feeling loss of control (external locus of control), Recent EtOH or Drug abuse)

highest suicide attempts in all anx ds; 6x more likely to atempt suicide,

3 billion a year, 3.6 works days a month, 5X medical visits

MDD is increased but in PTSD have lower cortisol; PTSD + MDD also have lower cortisol

4 major brain areas: Ant cingulate gyrus; Medial prefrontal cortex (reg emotions); Thalamus, Amygdala & Hippocampus

SSRI's; RCT's with paroxetine, sertraline, fluoxetine (civilian but not military)

Good if comorb BPD, Risp has placebo controlled as does Olanz; case reports seroquel

get additional 30% decrease in Sx

Benzo, Anticonvulsant

1. Stabilization 2. trauma-focused therapyy; grief work; making meaning of the trauma, Stage3: Reconnection with external life

Safety, Comorbidity, Extreme behavs like SI, Increasie coping, create stable relations, community support connection

easily flooded; inability to experience + emotion; alexithymia, active SI/HI, poor impulse control, significiant dissociative sx, unstable therapeuti alliance, Current other life crisis

Rx, PsychoEd, Anx Mngment, DBT if comorb with Bord Pers Ds

Structured method to get change by acceptance

Acceptance/Validation vs Change

Indiv, Group, Telephone contact, Therapist Consultation Group

Mindfulness, Interpersonal Effectivesnes, Emotional Regulation, Distress tolerance

Being in the now; aware of environment and internal body states >> Observe, Describe, One with experience

What do you feel in forehead, keep going down until able to identify body

Body sensations > Feelings >Emotions

Rational Mind … Wise Mind … Emotional Mind

Between hyperarousal and hypoarousal; Stages: Prompting event >Interpretation>Emotion>Action/Urge>Prompting Event … interrupt at Interpretation … switch to wise mind

Avoid Non-Acceptance … too much energy put into that; acceptance right now

personal rights, personal boundaries, express needs assertively and constructively

To be able to live in the present

1. Prolonged Exposure 2. EMDR 3. Stress Inoculation

Start with education, relaxation exercises; confront with all details of events … e.g. systematic desensitization, flooding … imaginal exposure, in vivo exposure (graded exposure to driving for example)

Let them wander in EMDR (in Exposure would stick with one), may go to other trauma and allow to follow; bilateral stimulation … eye movement, tapping, repetitive sound …. Some say allows to be in present and in past

1. Desensitization, 2. Strength of positive cognition 3. Body scan 4. Debriefing

assessment and safety

Reconnection to social life: friends, work, community, gradual return

1. Provide Maslow's basic needs 2. Connect to social support (most important predictor after trauma … who can be with that person)

hippocampus decreased volume (Key), anterior cingulate decreased volume, decreased volume amygdala

Sleep Disorders

75%

Stage 1: 5% Theta, 2 45% of time, spindles and K complexes; Stage 3/4 Delta waves and slow waves 25%

25% of sleep, EEG looks awake, SAWTOOTH WAVES 4-8 cps, penile erection normal, skeletal muscle paralysis

Every 90 minutes, 1st episode after 90minutes

Homeostasis, Circadian Rhythm

serotonin pro-sleep and so is Ach, NE

Primary: Dys and Para (abn behav during specific stages)

iniation, maintenannce, or non-restorative

women > men,

up to 25% in elderly, 1-10% in general poplation

CBT-I: Sleep hygiene, stimulus control therapy, sleep restricction tx; 2nd line Cognitive Therapy, Relaxation Tx, Medication Taper

Low dose, intermitttent, Not indicated generally, Options: benzo, sedating antidepressants, antihistamines, antipsychotics, Melatonin Receptor Agonist: Ramelteon

Prolonged sleep episodes, can specify 3 days several times per year for 2 years

Young male, excessive sleep (20hour/day), up hypersexual,++eat

lifetime 16%, Incidence 4%

Epworth Sleep Scale >11, Multiple Sleep Latency Test

Modafinil, less potential for abuse, dose never later than noon

Cataplexy, REM Instrusion e.g. hallucinations (hypnoPOPout of bedmic, gogic=groggy/paralysis

HLA-DQB1*0602

yes

MSLT

Scheduled naps, Stimulant Modafinal, REM suppressant TCA, SSRI

Daytime sleepiness, Unrefreshing naps, dull headache on awakening for up to 2 hours

Abnormal tonsils

Delayed Sleep Phase, Jet Lag, Shift Work

go west, east travel harder, it takes a day per time zone

delayed 40%

Phase time: give melatonin 6 to 8 hours before sleep time; Bright light therapy, Chronotherapy

Naps, bright light

creepy crawly legs worse at night

Anemia, Iron stores, Normal Preg, Renal Failure, Rheumatoid Arth, Diabetes, Thyroid Abn, Peripheral Nerve dysfxn

Fam Hx, younger age

Diagnosed by Polysomnography

greater in males

Tx GMC, Sleep Hygiene, Rx: Dopaminergic agents: Ropinirole and Pramipixole; LevoDopa; Gabapentin; Less so: opiods, anticonv, benzo

REM problem, 2nd part of night therefore

SSRI's … possibly to suppress REM after psychosocial/therapy

1st part of night, abrupt arousal, cry, inconsolable; slow wave NON-Rem disorder

Just watch and support; more distressing for witness

Increased family risk; 10X in prev among 1st relatives

Consider benzo but usually no Rx

During Slow wave sleep

4-8 years, peak at 12 years, spont remit by 15 years

Psychosocial, Safety, Consider Rx like benzo or TCA

Loss of REM paralysis, very vivid dreams, sense of acting out; Possiblly go onto Parkinson's and Lewy Body

Ensure safety; Tx with Rx: Clonazepam

REM Suppression

Decrease slow wave … I think

REM Suppression

Wellbutrin only rx that might improve Restless Legs, as would benzo, gabapentin

ADHD

Inattention and or hyperactivity, before age 7, in at least two settings, with sig fxn impairment

Sx can persist into teens and adulthood in 50 to 70% of cases

Protective factors maybe?

Family Hx of ADHD, Comorbidity, Psychosocial adversity (maternal psychopathology, discordant families, large families)

6 or more of inattention and or 6 or more of Hyperactivity /Impulsivity

combined type, mainly inattentive, main hyperactive, NOS

Repeat a grade, STD, SU, Car Accidents, Arrested,

comparable to height, twin studies show 75-80%

DA & NE

Dopaminergic fxn: Dopamine type 4 receptor gene (DRD4), dopamine transporter gene (DAT1), NORadrenergic genes: ADRA@A, ADRA2C, DBH, NE T, Others: COMT, protein 25

CD, BAD, GAD, OCD, Reading Ds

Strongest evidence is in Fronto-Striatal Dysfunction, hypofusion mostly but some hyperfusion in hippocampus

Increase precision, help communicate between teams, help to quantify sx, and response to tx, set off values that approximates the normal non-adhd population, help make goal sx removal

SNAP-IV

Adult ADHD Self-Report Scale (ASRS)

1. Rx 2. Psychosocial, 3. Tx comorbidity

1. Parent and Child Psychoed, Behavioural Parent training, School and Child focused tx

8-16 weeks, psychoed, "time in skills" spending + time with child; "time out" planned ignoriing, losing privileges; limits - non-responders, $, not always available, lasting effects in doubt

Target behaviors, overlap with BTP, daily report card, academic enrichment of strengths, remediation of weakness, support, intensive summer programs

Multimodal Tx Study of Children 4 groups 1. Rx only 2.Psychosocial/BTP only for 14 months 3. Combined 4. Community, Rx with comm follow up

SNAP

Best group = 1 & 2, 1 did better than 4 because of monitoring and follow-up

no sig Group differences

Study group doing better but less well than classmates, strong response to initial treatment predicted good outcome regardless of tx group

25% of MTA youth met ODD/CD criteria

Sx severity, IQ, Supportive social network

ODD, Anx, CD, Tic, Mood

Low demographics, parental psychopathology, cognitions, child developmental level

Bipolar Disorder

MDQ … 2 or more positive responses = further assessment … I would add for GP and as psychiatrist need to do detalied questions

Overall sensitivity for the MDQ was 0.58, higher in bipolar I disorder (0.69) than in bipolar II. The sample was highly insightful, but the two patients with lowest insight both had false negative screens. Patients’ low ratings of severity of mania (question 3 of the MDQ) explained almost half of all false negative results. Specificity was 0.67. Conclusions: The MDQ demonstrates good sensitivity in insightful patients with bipolar I disorder, but may be less useful in patients with impaired insight or milder bipolar spectrum condition

1. Stabilize acute episode 2. Team approach 3. PsychoEd 4. Tailor psychosocial (CBT reduces relapse but not uniform) 5.Family/marital interventions 6. Occupational Rehab

Acute mania: change within 2 weeks

Limited, but manage environment

some data suggest say both, if side effects may wean one, usually AAP

carbamazepine

gabapentin (4 -trials), topiramate (4 - trials), lamotrigine (not in mania), carbamazepine + AAP, poor evidence for antidepressants

Metanalysis: antidepressants not doing much benefit in bipolar ds

sure, some evidence

Venlafaxine (Bob Hope group) has possibly higher switch at 12%; bupropion maybe less at 3% but only 17 patients, otherwise not much difference; older TCA had higher switch rate; MAOI's maybe not as bad as TCA … generally use SSRI (shorter half life) or Bupropion

never … rather go with Li, Lamotrigine, Quetiapine

valproate, carb not much help

Li, Lamotrig, Q, Li/Epival + SSRI, Olanzapine +SSRI; LI+ Epival

Negative trial, doesn't work

Less days depressed, adherence better, helps id prodrome, less SI

High likelihood relapse, natural hx says early on, inter-episode period is reasonable 1 to 2 years, so don't really know, less relapse with slow wean and good lifestyle

Lamotrigine hard to use for acute depression vs maintenance good for preventing recurrence of depression

Lithium, Lamotrigine for depression

Best evidence, Quetiapine study

Episodic; adverse developmental hx (abuse hx, mismatch);

If child bearing age, 50% unplanned

Verbal Learning (Hippocampus), Executive Fxn, Acutely ill: attentional problem; not as severe as Sz; working memory >problem in Sz; hypomania mild … perform well

If Parent with BAD, up to 25% risk of BPD

Maybe against psychosis

Personality Disorder

Persistent mood ds, number and degree of sx, response to stabilizers, interpersonal dynamics, family hx different MOOD quality: impulsivity, irritability, dysphoria

Police, Justice of Peace ; Doctors

Borderline PD

1. Provide time frame to assess Personality (3 sessions) 2. Describe if seen under state or trait conditions (i.e., under stress) 3. Take into account cultural factors (most important variable) 4. Collateral Hx 5. Structured Interview 6. Rating Scale 7. Psychological testing 8. 2nd opinion

Projective testing: Roschasch/Ink-blot; Objective testings: MMPI

General: Diagnostic Interview for DSM Personality Ds (DIPD-IV); SCID-II; Structured Interview for DSM-IV personality, Specific: Diagnostic Interview for BPD, Narcissitic Patients, Hare Checklist (ASPD)

Personality Ds due to GMC

Genetic, Temparement

Harm Avoidance (Serotonin), Novelty seeking (NE), Reward Dependence (Dopamine), Persistence; Factor analysis: what is the least number things that cause most outcomes; metaphor (plate tectonics causing earthquakes, tidal waves, etc.)

activity level, adaptability, approach or withdrawal, attention span/persistence, distrability, intensity of reaction, quality of mood, rhythmicity, threshold of responsiveness

NE

Serotonin

negative influences outweigh postive; character factors=deprivation, abuse, failure of attachment

0.60 to 0.80

Malignant Narcissism, Antisocial PD (mod to severe), Psychopathy, Sadism

Borderline Personality ORGANIZATION (Cluster B); Neurotic ORGANIZATION (Cluster C) >> Kernberg

Cluster A

Psychotherapy + Sx Treatment

CBT; remember personality not change with Rx; DBT

Small N, Lack of reproducibility; expert opinion; CBT not recommended (even though book on CBT for Pers Ds); errors in stats, overlooked cost-effectiveness

1/3 get better, worse, stay same

substance abuse

childhood sexual abuse (starts at young age)

Early BPD not associated with suicide

late BPD, Substance Abuse, Major Depression, Previous attempts, Level of Education

5%, 10% for BPD

Legal Issues in Psychiatry

2 years or less = provincial, >2 years = Federal System

Federal

Criminal (break law) vs Tort (harm … cases)

Tort ($): balance of prob; Criminal (Jail): beyond responsible doubt

Fact vs Expert (experience, judge decides if you are an expert)

70%, 20%

2 (Fitness to Stand Trial , definition of mental disorder = any ds of mind), 16 (NCR), 672 (big section on post-NCR, unfit … what to do )

unable bc of mental ds to conduct a defense at any stage of the proceeding before a verdict is rendered or to instruct counsel to do so, and in particular unable on account of mental ds to: understand nature or ojbect of proceedings, understand the possible consequences of the proceedings, or communicate with counsel

Low, Taylor Case

All people assumed fit to stand trial, must be raised by defense, crown, court

Who ever raises issues has burden of proof

5 to 30 days; in custody, rarely outpt

Trial of Fitness: Judge decides if patient fit or not: We (psychiatrists) say meet or not criteria for fitness

If not fit, go to jail or hospital … then seen by Review Board q6months or so UNTIL FIT

If Judge finds unfit, usually crown asks for treatment order, Judge recommends tx against will for up to 60 days to make fit

No ECT, No Psychosurgery, Risks not outweight benefits, Tx will likely make fit

Taylor was a lawyer (who was delusional). Do you need to act in your own best interest? Did not need to make rational decisions, Used the Limited Cognitive Capacity Test

Can make idiotic decisions, can be unwell but if know whats happening pass test

No person criminally responsible for act made or omission made while suffering mental disorder that 1)rendered the person incapable of APPRECIATING the nature and quality of the act or omission OR 2) of knowing it was wrong ; WRONG can be legal (the law) or morally (so invested in psychosis) wrong

51%

Defense can raise at any point, Crown can not raise until guilt proven, Burden on side raising, Balance of probalities, Not guilty by reason of insanity (states …we don't use that word)

Actus Rea Need Guilt Act and Guilty Mind (Mens Rea); Except volitionally taken substance only need actus rea

led to NCR Rules, to establish insanitiy, not know nature of act, or if did know, did not know was wrong

McNaughten criteria modified, court orders, in hosp, 30days

NCR is a defence, not a must be required thing

Automatism (Insane, Non-Insane), Alcohol-Drug Intox, Sleep Walking, Battered Women Syndrome

Covers review Boards

unfit, NCR … to get out under review board … not a signifcant threat to public, burden of proof not on accussed … board/hospital must find

Permanently unfit

Low base rate of serious events

PD, SU, Sz (Paranoid D, Comman H, Threat/Control Over-ride); BAD, Anxiety Ds

Stalking, erotomania, PTSD

HCR 20 (SFU), VRAG (gives 10 year risk), PCL-R (Hare), McArthur-Iterative Classification Tree

better at prediciting longer time?

Associatd with violence repeat

Static (Not changeable) ; Dynamic (Changeable)

structured professional judgement

must be for 6 months, recurrent intense SEXUALLY arousing fantasies, sexual urges, or behaviors involving non human objects, suffering, children

Sex Drive Reduction (PxTx, Rx hormonal, SSRI)

Patients right

Child Abuse, Driving, Gunshot, Health Card Fraud, Sexual Misconduct; Railways, Plane Drivers; Public safety

Duty Through Patients (not to); Tarasoff case in states

Give just enough information; advice essence of potential breach,

Smith vs Jones Case is TRUMP: Clarity, seriousness, imminence; Duty exists where there is a risk to a cleary identifiable person (s), risk of harm is serious (bodily/psycho harm); sense of imminence/urgency

Substance

16.7%, Sz 47% (85% if include nicotine), Mood 32%, Anx 24%

80%

Bio: GMC (liver.e.g) HIV, STD, Psycho:SI/Violence Social: Jail, Hosp

Bio-Psycho-Social-Cultural-Spirituality

SU Ds + Other Axis I

Other before SU; or SU to I; Shared etiology (e.g. Abuse); Independent model: completely unrelated

1. Cog Difficulties 2. Affective Deficits 3. Interpersonal Diff 4. Insight poor 5. Stigma: Public/Self

Integrate Tx, Person Centered, Hreduction, Match Tx to Stage: Least intensive/intrusive, Choice

DALI, MAST, DST, AUDIT (level II screening vs CAGE-AID Level I)

1. Engagement and alliance building 2. Severity of Sx 3. Crisis Tx 4. Stabilize 5. Diagnostic effectors with multiple contact, longtidunal tx

Scoring 2+ Car, Relax, Alone, Forget, Friends, Trouble

Axis I other; Temperament, Trauma, Family Factor, Peer Group, Low resilience, social variables, Gateway SU

HAIR

1. Avoid Arguing 2. Dev Discrep 3. Empathize 4. Roll with Resistance 5. Support Self-efficacy

Augment: Tx intox/withdrawal; Decrease Reinforcing, Discourage Use, Tx Comorbidity, Substitute

No agent

Naltrexone, Disulfram, SSRI's,

Methadone, Buprenorphine

Zyban, Verenecline,

Dementia

Depression, Delirium

Oreintation, Registration, Attention/Calculation Verbal memory; Short Term Recall,

Exectuive Fxn, Organization Skills, Planning, Concept of Time, Attention, Visuo-Motor Coordination and Spacing

Cornell Scale for Depression in Dementia; interview based and takes family and patient information into account

Invalid in Dementia because self-rating

Hosp, Monitoring- Serial Assessments, AChE

Driving, Safety (fire), Med intake

May be delirium, R/O GMC

DDX: Acute Reversible Condition, Chronic Persistent Change …. And or Acute on Chronic

Hx, PE, Collateral, Screening Tools,Bwork: CBC/diff, chem, B, Folic, Thyroid, Urine VDRL; Genetic

1. Pre-Morbid baseline 2. Current Sx: cog/neuro/psychiatric 3. Course 4. Tx 5. Past Hx 6. Risk Factors

Memory, Lang, Visuo-Spatial, Praxis

Neuro: Abn mvmts, gait, focal signs, ocular signs (Up and down gaze), release signs (front lobe disconnect to …)

MAP

1. Alert 2. Language a. Expressive and b. Receptive 3. A. Memory B. Exec Fxn C. VS Sensory D. Praxis

Declarative /Explicit Conscious Memory: Personal/World

Non-Declerative /Implicit/Semiconscious: Procedural; Priming; Conditioning

Working Memory: 7 +/-2; Encoding: recent minutes/days; Storage: longterm, months; Retrieval

Anterograde: forward and Retrograde: back wards recall

Hx pt/colletaral, MMSE, Clock and Functional Ability Questionnaire (Am Acad Neurology) (iadls)

MOCA

Demographics: Age, Educ, Lang, Culture; Medical: Sensory Deprivation, Pain; Psychiatric: MAP; Meds and Substances: anticholinergics

A memory problem:phasia, praxia, gnosia, exectuvie fxn

Neurodegen Dementias: proteinopathies … ; Repeated Insults: Vasc Dementia, Alcohol and toxins, Dementia due to head injury, AIDS

AD, Picks, CJD

PD, HD, Aids

VD, LBD, PSP, CBD, Etoh

Predom cortical signs, normal speed of processing, mo motoro, elss apathy, preserved personality

slow, motor, apathy, pers changes

Alz2/3s, vasc, others

Age, gender > in females; ApoE4, PS1/2 Causative genes, Lifestyle factors: education, nutrition, sexual practices Medical morb: vasc, toxins, infections, injury, PD

Safety: driving, home, harm; Capacity and Consent: medical and $; Abuse Risk

Caregiver: society, psychotherapy, respite, placement decisions

Behavioral Tx, IPT, CBT

Donepezil, Rivastigmine, Galantanimve

keep at same level for year (s?)

GI, Muscle Cramps, Insomnia, Bradycardia/Syncope; Contraindicated: sick sinus syndrome and malignant av block, active bleeding

Moderate to advanced stages; delays problem behavior

Neuropsychiatric Inventory; Cohen-Mansfield Agitation Inventory

Unmet needs approach

ABC, Reality oreintation (reminders), Validation rx (feelings), Reminiscenece

not clear

CVA: 2.2 (vs 0.8), Mort: 3.5 vs (2.3) …. About a 1% increase in risk

NNT-5 in depression

Trazodone NOT recommended for BPSD

Carbamaz best evidence for aggression

ACheI does help with behavior dif

Would I hand patient over?

axis I, II, III, IV, V

Time, Fxn, Mood/Anhedonia

Psychotic (ECT, or AAP)

Earlier age of onset Fam Hx BP1/2; TR, Comorb Anx SU, Atypical Sx, Post-Partum Dep

Demographic: Male, Teen or Geri; Unemployed, Socially Isolated, Single/sep/divorced; Fam Hx; Recent Hosp D/C

Hopeless, Impulsivenes

MINI, HAMD

Major Social Implications; Offspring, Work Presenteeism (working below)Absenteeism/Unemployment

Emphysema/COPD 2.7, Migraine 2.6, MS 2.3, Back 2.3, Cancer 2.3

MADRS >30, HAMD >24; Chronic >2 years, TR: Failed 2 adequate Tx

8-12 weeks in Acute Phase up to 6 months (gain after 4 to 6 weeks decreases but do see increases up to 12 weeks); Maintenance 6 to 24 months

Acute and Maint: CBT; Acute: IPT

see table, Bibliotx,Computer Based and Telephone (have a nurse call)

Active, Time Limited, Manualized

Can do psychotherapy and improve adherence

Relapse Prevention, Elderly, Women, Patient Preference

respond within 2 weeks

Acceptable and Efficacious; Escitalopram, Sertraline stand out in Multiple Treatments Meta-Analysis; Use Response and All-Cause Drop-Out

Level 1: 2876 Citalopram 2: Switch to BupropionSR, Sertraline, VenXR or Augment BUS/SR

Delayed response to 3 weeks

High GMC

Tolerability, Adherence, Dosing, Timing, Formulation

Avoids Intx, No extra side fx, D/C Sx, Takes longer

Potential Intx, Reverse Side Fx, Target residual Sx, Faster onset

10-15%; Industy has benefit

3 or more episodes; older age, chronic episodes, psychosis, severeity, difficutl to tx episodes, residual sx, hx of recurrence during d/c rx

Fluoxetine, Fluvox, Paroxetine, Sertraline

Bupropion, Stimulants, Amantadine = Increase DA Activity; Nitric Oxide … most effective Sildenafil; Yohimbine (unblocks a-adrenergic/cholinergic receptors; undoes agonism of 5ht2 and 5ht3 receptors: mirtazapine, nefazodone, atypicals, granisetron, cyproheptadine

Non Benzo Hypnotics

pick weight netural

Serotonin Syndrome, GI Bleeds with NSAIDS, Fractures in elderly, Hyponatreamia, Agranulocytosis, Seizures, TCA, Bupropion … dose dependent, Venlafaxine CARDIAC TOXICITY

Citalopram, Desvenlafaxine, Escitalopram, Venlafaxine

Light for seasonal or adjunct mild/moderate depression

Wellbutrin

Mild to moderate Depression : monotx & add-on level 1 evidence, 2nd line recommendatoin

level I evidence, 2nd line recommendation

level 1, 1st line St. John's

level 1, 1st line;

SI, MDE with P; TRD, Catatonia, Prior Response, Repeated medical intol; reapid deteriotating physical status, Pregnancy

1. Right with high dose right unilateral or lower dose bitemporal 2. No response after 6 sessions switch to bitemporal 3. If get improvement continue for 8-10 sessions

N/Headaches, Muscle Pain, Oral Lac, Dental Injuries, Myalgia

Anterograde, Retrograde Word finding, autobiographical memory

0.2 per 100 000

hippocampal volume reduction in repeated depression, in unipolar depression; amygdala early on increased volume then shrinking

AAP for 1 year or ECT (Risk Benefit discussion)

Eating Ds

Current Medical Status, Vitals Signs, Highest Weight, Lowest Weight, Current weight, Estimation of BMI; Attempts to gain weight; Current Rx, Co-morbid and psychiatric conditions

CBC, Lytes, BN, CR, Glucose, Liver Fxn, TSH; EKG, Serum Albumin, Calcium, Magnesium and Phosphate; Amylase

1. Refusal to meet weight < 85%, 2. Amenorrhea for 3 months 3. Intense fear of gaining weight 4. Disturbance in their perception of body weight

Mood: Depression; Anxiety - Panic: OCD; Substance Use; OCD; OCPD/BPD; Bulimia Nervosa

85% < weight, brady cardia 40; electrolyte, syncope, SI, Refusal to eat; instability of vitals, hypothermia, very rapid weight loss, failure of outpatient therapy

Dietician, Social worker (family), Psychologist, Peditrician, Psychiatrist

Refeeding proram with goal 1-2 pounds per week; supportive psychotherapy; behavioral program to gain priviliges with weight gain, compliance and medical stability; Rx for comorbidities (antidepressant for OCD, antipsychotic meds for extreme resistance); Monitoring: vitals BID, Bloodwork (CBC, Lytes, BUN, Cr for 3 days); Potassium and Phosphate refeeding syndrome

Vital Sign Instability, Edema, CV Collapse; Descreased Phosphate; ATP used to switch from catabolic to anaolic state; not enough energy to beat the heart

Usually start 1000 to 1500; or think add 500

start low because low weight

Daily for 5 days, q2days for 3 weeks

Good exam resource

Restricting Type; Binge-Eating Purging Type

Binges: large amoun in time, loss of control; inapprop compensatory behav; binging and comp 2x/week for >3mo; Self eval unduly influenced by body shape; exclue AN; Non-Purging Fasting/Exercise, Thyroid Meds; Purging type

BN: Impulsive AN: Compulsive

Abrain on hand/knuckle because of somitting

Over-evaluation of shape and weight; extreme weight control

AN- underweight, amenorrhea critera BN Normal weight; AN Obsessive Personality Traits

Depression, OCD, Cluster C OCPD, Traits perfectionism, harm avoidance

Depression, Panic, EtoH/SU, Cluster B- BPD; Traits: perfectionism, harm avoidance, novelty seeking, impulsivity, affective instability

Heart, Bone, Lytes, Brain, Fert, Death

Lytes, Heart, Dental, Stomach/Esophagus tears

Ventricles enlarged, reduced grey and white matter; gain weight get back white matter but not grey matter; Widened sulci (like AN) less pronounced brain volume loss

impaired set-shifting ability in acute illness and post weight restoration; also seen in healthy sisters

Goes up as An continues; 5-18% die; 10-20% have intractable course; risk of death increases 0.56% per year; many develop bulimic sx (40-50%) death is due to suicide in 50% of cases and 50% from GMC

Early age of onset; short history; good parent-child relationship

Long HX of illness (duration of illness), severity of weight loss, Vomiting, Substance Abuse (Alcohol predicts mort); OCPD

many untx; with tx 2/3 improve; relapse up to 50%; better than AN

Motivated, able to engage

Childhood obeseity, low self-esteem, personality disorder, substance abuse

0.5% while BN is 1-2%; onset 14-18, late teens, and early 20s

Gull and Lesegue 1800s, both could not find physical cause

1979 Russell

BN (AN more stable over time)

BN not AN

Became preoccupied with food, depressed, anxious; as re-fed went through period of binge eating

up to 55%, 11% in DZ;

No difference between MZ and DZ twins

Chromo 1 (serotonin)

Low Serotonin associated with binge eating; SSRI tx BN

serotonin even lower if impulsive, borderline

Low dopamine; atypicals help AN; in BN not as important but does recover on own

BDNF in low levels in both, CCK low in BN, Leptin low in BN, Acute AN low leptin; hypersecretion after recover

hyperactivity in AN might be food seeking behavior

early menarche

Minuchin - Psychosomatic family (enmeshed, inflexible, conflict avoidant, overprotective … just like in cancer) … Structural approach; Strategic: paradoxical interventions, agnostic (don't know what causes) view of illness; Milan: homeostasis, ask family to solve own problem

AN first line treatment, combination of models: parents in charge, agnostic view, acting as consultant Vs Director

Supportive Therapy = to Dynamic = CBT; Hilda Bruch - body image disturbance, introceptive disturbance (not read body cues), all persasive view of ineffectiveness

Olanzapine … gained weight and decreased obsessive thinking; start at 1.25mg Olanzapine (mean dose in study 6.61mg), increase in 5 days to 2.5mg … target 5mg in teens; start 2.5 in adults

SSRI … no benefit in weight; no evidence prevent relapse; TCA not much, Little for Risp/Seroquel

Cyproheptadine, THC, Zinc, Estrogen (not because),

Not Rx, Psychotx, Depression may resolve with weight gain alone, watch for cardiac side effects

1-2 or 2-3 pound per week

Daily for 5 days, 3 weeks q2days

CBT for BN

1. Normalize Eating 2. Cog Ds 3. Relapse Prevention; use a food log (vs mood)

Slower recovery in IPT, Family Based Therapy

Fluoxetine only Rx for adults 60mg /day to reduce binging; sertraline also works

Bupropion contraindicated

Combo CBT and Fluoxetine highest rates remission

See Guidelines, Potassium, Serious

CBT, IPT: Focus on binging behavior

See Table

London PDM

Psychotherapy Station

Mild to Moderate Depression: IPT/CBT is first line treatment; IPT slightly better than CBT for Severe depression; Level 1 evidence (well controlled RCT's); Rx better for Severe … Reference CPA Guidelines

Psychotx alone not recommended; combo better but level 2 evidence

Pleasurable activity scheduling, activity ratings

Cognitive Therapy Rating Scale: bridge from previous session, seeting the agenda, review homework, etc.

Transference, Patient vs Therapist directed; Structured, Here and Now; Less Homework;

Greater tolerance of ambiguity, no homeowrk, developmental model, more frequetn session, longer term tx, greater orle of insight, >relational focus, possible couch

Dispute, Grief, Role Transition; Interpersonal Deficits

Freud vs Other: Know table in K&S

Interpretation, Confrontation, Clarification, Encouragement to elaborate, Empathic validation, Advise and Praise, Affirmation

Theory of unconscious: unconscious, pre, conscious

all behavior has meaning, meaning determined by unconsc conflict

Id, Ego, Superego

Oral, Anal, Phallic, Latency, Genital

hypnosis, catharsis, explore trans, dreams, free association

1. Ego 2. Object Relations 3. Self-Psychology 4. Attachment

Defenses … by Anna Freud: Classification of defenses

Expanded ego psychology, focusing on adaptation

manage instinct drive and mood, unconscious, discrete, dynamic , reversible, adaptive and pathological

Vs Ego (away from Drive, increase interest on relationships): focus on Transference; Klein, Winnicott, Kernberg, Mahler

Heinz Kohut; need responses from environment to develop and maintain self-esteem and well-being; role of external relationship in creating self

JAMA 2008 - Leichsenring & Rabung; effect size 0.96 to 1.8 (large), small N, small number of studies

12-16 sessions, here and now, manualized, interpersonal not intrapsychic, tx- active, supportive, hopeful,

illness, sick role

1. sick role, interpersonal inventory, Rx, PyschoEd, ID problem area

Focus on each area

support sense of independence

nonpsychotic mild, to mod and BN; similar outcome to imipramine; growing evidence to BAD, Anxiety, Medical settings

Classical Conditioning: Systematic Desensitization, Flooding, Exposure (panic interoceptive, ex and response prevention); Operant Conditioning; Behavioral: activation, graded task assignement, problem solving role playigng behavior rehearsal (social learning); Relaxation Training: breathing re-training, PMR, Guided imagery relaxation, autogenic relaxation, bio feedback); Social Skills, Assertiveness Training, Communication Skills, Habit Reversal (trichotillomania)

How we think can affect the way we feel; events not causes distress but interpretation

Distorted interpretations: dysfxnal thoughts; cognitive deficits: poor problem solving strategies

Negative view of self, world, future

Core Belief leads to intermediate belief leads to (in context of situation) Automatic thoughts … which lead to emotion)

Intermediate Beliefs

target is thinking and behaviour (i.e. activation, increase pleasure activity)

65-70%, advantage preventing relapse

Situation . Thoughts . Feeling . Cog error type . Challenge Alternate view . Rate after.

Behav … Cog … Spiritual

Universality, Altruism, Instillation of hope, Imparting information

0.82

Client Factors 40%, Relationship 30%, Placebo/Hope/Expectancy, Model

OCD

ego dystonic vs syntonic

bimodal onset, =men and women,

dental gum abrasions from excessive brushing, skin lesions (dry skin on hand),

BioPsychoSocial from guidelines

can't ignore/neutralize, product of own mind, not everyday worries; recurrent; persistent, thoughts-impulses-images

repetitive, feels driven, aimed to reduce stress or prevent event, not connected to obsessions or excessive

Excessive, unreasonable, >1h day, Exclusion

with poor insight 8%, 5% lifetime prevalence

20% 10, 1/3 by 15, most later, males earlier onset later in females

MDD, Other Anxiety, Eating Ds, Cluster C, 30% tics

>severity, >compulsions, >Axis I (Mood, Anx, ADHD, Tic)

most waxing waning, 15% deteriorate, other episodic

about 1/3 without tx improve

Pre-Frontal; Basal Ganglia; Thalamic; Pre-Frontal

Serotonin and Da

4x

Heratability 50%

Goals, Setting, Adherence, PsychoEducation, Alliance, Rating Scale, Team Plan

7 no illness, 8-15 mild, 16-23 mod, 24-31 severe, 32-40 very severe

CPA Guidelines

Exposure and Response Prevention: Behavioral

Create Hierachy of Anxiety, Expose to stimulus, Not allowed to respond, Wait until Anxiety subsides, Continue through hierachy …. Stop activity only until bored; Trying to control thoughts not useful; obsessive thoughts are deliberately provoked

ERP = Rx effectiveness, works especially for checking and washing

ERP 62%, … Psychotx alone, Rx alone roughly equal

1-2 years; gradual taper 10 to 25%

booster session 3 to 6 months

Antipsychotic Augmentation; TMS, ECT,

Yoga