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104 Cards in this Set
- Front
- Back
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cromosome 22q11 dletion syndrome is also called
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DiGeorge syndrome or velocardiofacial syndrome
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factors that contribute to misdx scz in severly ill patients include
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- failure to consider lifetime hx of illness
- believe that all severe chronic psychosis with funtional impairment is SCZ - failure to appreciate irritability ( mania) - confusion btwen neg sx and dep. - |
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increase suicide risk in SCZ if
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depression
younger age being w/in 6 years of fisrt hospitalization high premorbid achievement and aspirations higher IQ awareness of lost of funtioning command AH recent D/C from hosp Tx-non-adherence akathesia |
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manifestation of hyponatremia secundary to polydipsia in SZ patients
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1. late afternoon restlessness
2. irritablity 3. NX and diarrhea 4. salivation 5. ataxia 6. stupor |
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suspect polydipsia if:
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1. fluid intake > 3l/d
2. frequent Bathroom use 3. wt gain > 2k/d 4. daytime enuresis |
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Metabolic syndrome if:
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FBG= 6.1 mmol/l
BP: 130/85 TG: 1.7 mmol/L HDL< 1.0 mmol/l (men) 1.3 mmol/l (women) Abdominal obesity= wait >103 cm (40') for men or 88 cm (35') for women |
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FEP patient who need longer treatment (>1-2y)
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ill for extended period or longer DUP
met criteria for SCZ at fisr contact suicidal behavior or violence hx |
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patient with multiple episodes who should be on ongoing treatment
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suicidality
violence hx family hx of SCZ inability to care for self |
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only medication with a RCT evidence for efficacy as an augmentation med in SZ after no response to clozapine
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lamotrigine
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what are the secundary negative sx or deficit syndrome in SCZ
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residual paranoid delusions
anxiety oversedation depression EPSEs |
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lifetime expectancy of suicide and suicide attempts in patients with SZ
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10 and 30% respectively
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women with SCZ
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later onset
more comorbid problems polypharmacy higher plasma concentration at equivalent dose and > S/E |
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risk of EPS with FGA?
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annual risk 4-5% accumulative risk 50%
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Neuroleptic dysphoria what is it? and what is associated with?
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subjective unpleasant changes in arousal, mood,thinking and motivation.
Assoc with: noncompliance, poor clinical outcome, increased suicidality and compromised QOL. FGA>SGA |
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risk factors for NMS
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young
male neurologic disability DHT exhaustation agitation rapid or parental administration of AP |
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tx of NMS
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d/c meds
supportive thera[y dopa agonist: dantrolene, amantadine and bromocriptine |
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Cochrane review of CBT for SCZ found:
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1. reduces psych sx
2. impact on time to d/c from hospital 3. impact on gral psychological funtioning 4. Unsure if impact on likelihood of repalse, although one other recent trial using CBT to show in early signs of relapsed show promising results |
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ACT do and don't
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Do:
improve QOL and service satisfaction reduce hospital readmission rates improves housing and occupational funtioning DON'T: change overal cost of care lead to any differential improvement in clinical state |
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Ultra high risk Mental state
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1. onset of attenuated psychotic sx not reaching threshold for psychosis or
2. brief intermittent psychotic sx lasting < 7 days or 3. A combination of a trait (+ve FHx of psychosis in 1st relative) and a significant decline in global funtioning in the previous year Transition to psychosis is 30-40% in the first year. |
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SCZ risk factors
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paternal age
maternal influenza cannabis season of birht obstetric complications |
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Da pathways
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Mesolimbic= VTA to nuc Accum ( + sx due to DA overactivity)
MEsocortical= VTA to cerebral cortex ( nef sx d/t Da unceractivity) Nigrostriatal= subst nigra in branstem to BG/striatum ( EPS d/t Da underactivity of DA) Tuberoinfundibular = Hypothalamus to ant pituitaria ( DA inh prol so increased in PRL d/t DA underactivity) |
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mechanism of action of FGA
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decreased pos Sx d/t d2 blockade in NAccum
incease neg sx d/t D2 Blockade in Cortex EPS d/t D2 blockade in BG |
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mechanism of action of SGA
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In Mesolimbic pathway: decreased pos + d/t D2 blockade. 5HT2 blockade not seem as robust here.
In mesocortical pathway: D2 blockade lessened by 5HT2 blockade (lifts its tonic inh of DA in cortex)increasing dopamine causing less neg sx In nisogastriatal: D2 blockade is lessend by 5HT2 blockade (lifts its tonic inh of DA in BG) increasing dopa and decreasing less EPS Tuberoinfundibular pathway: D2 blockade lessened by 5HT2 blokade inhibiting prolactine realse in ant pituitaria, thus decreasnig prolactine. net effect of D2 (increas prl)blockade and 5HT2 blockade ( dec prl)is decreasing prolactine |
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risk factor for akathisia
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midlle age female
increase caffeine intake high potency NLP |
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risk for dystonia
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males <30
rapid dose increase recen cocaine use high potency NLP |
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risk for parkinsonism
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elderly female
neurol condtion high potency NLP |
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risk for TD
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elderly male
affective d/o substance abuse braind damage cognitive d/o prolonge NLP |
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prevalence of TD
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5% per year upto 25% with > 4 year
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prevalence and mortality of NMS
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0.02-2.4% and 10-20%
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order of risk to oproduce QT prolongation among AP from highest to lowest
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Thioridizine>ziprasidone>haloperidol>quetiapine>risperidone>lolanzapine.
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risk factors for QT prolongation
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bradycardia
cardiomyopathy lyte imbalance hepatic dysfuntion renal dysfuntion confenital QT prolongation pharmacological causes |
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Catie trial phase 1 findings;
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-High rates of DCT 64-82%/
-Olanzapine showed lowest rate to DCT, superior efficacy, greater reduction in psychophatology, longer duration of successful tx, lower rate of hospitalization for exacerbation of sx, greater s/e with increases n wt gain and indexes of glc and lipid metabolism. - no significant difference in effectivenes for other SGA and pherphenazine. no sig differences among drugs in the time until d/c of tx due to intolerable s/e - concerns in creased QTc with ziprasidone no found - concern of increase catarats wtih quetiapine no found |
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catie trial phase 2 Efficacy arm
findings |
69% of pt d/c at 5 months
clozapine more effective than switching to another SGA clozapine pt less likely to d/c for any reason than risperidone /quetiepine butn ot olanzapine clozapine pt less likely to d.c for inadequate response advantage with colzapine were strong enough to reach statistical significance despite the small treatment groups. |
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Catie trial phase 2 tolerability arm findings:
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olanzapine and risperidone were more effective than quetiapine and ziprasidone. (longer time to d/c for any reason)
ziprasidone was associated with wt loss and imprivemnte of lipid parametres. broad inclusion (mimicking real clinical practice) results were highly consiting with phase 1Catie tiral except for risperidone being more effective in this phase dosi may have affect results as quetiepine and risperidone dose were nop optimal although comparable to average rx doses. olanzapine was the most effective med for those who stopped their previous tx b/c of inefficacy but not for pt who stopped their previos tx b/c intolerability. Risperidone was similiarly effective among patients who d/c previos tx b/c intolerability and b/c inneficacy |
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prevalence of panic attacks and PD
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llifetime prevalence 15% and 4.7% respectively
1-year pervalence 7.3 and 2.7% respectively |
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risk of suicide in PD
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20x those with no psych d/o and twice in those with psych d/o
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differential dx in PD
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mitral valce prolapse
MI HTN hypotension pheochromocytoma hypotension hyperthyroidism hypothyroidism hypoglycemia DM migraine TLE vestibular dysf TIA asthma |
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lifetime and 1 year prevalence of Specific phobia
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12.5% and 8.7% respectively
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median onset of social phobia
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7 years
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most common phobias in childhood and adulthood
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blood injury and animal in child
situational and late adolescence and adulthood |
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most treatable anxiety d/o
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specifi phobia
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prevalence of Social anxiety
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lifetime; 8-12%
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CBT techniques for social anxiety
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exposure T
education cognitive restructuring social skills training relaxation |
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Lifetime and 1 year prevalence of OCD
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1.6% and .7-2.1% respectively
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most common obsessions
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contamination
symmetry and exactness safety sexual impulses agressive impulses somatic and religious preoccupations |
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most common compulsions
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checking
washing repeating ordering hoarding counting tocuhing |
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Lifetime and 1 year prevalence of OCD
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1.6% and .7-2.1% respectively
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most common obsessions
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contamination
symmetry and exactness safety sexual impulses agressive impulses somatic and religious preoccupations |
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most common compulsions
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checking
washing repeating ordering hoarding counting tocuhing |
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lifetime and 1 year prevalence for GAD
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6% and 1-3%
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evidence of buspirone in anxiety disorders
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second line treatment for GADand third line adjuntive tx in PTSD no recommended in SA, OCD, PD
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evidence of imipramine in anxiety d/o
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2nd line for GAD and PD and 3rd line tx for PTSD
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prevalence of PTSD and canada and USA
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Canada= 9.2
USA 6.8% |
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common causes of developing PTSD in Canada
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unexpected death of al oved one
parent whose children die in a violent way sexual assault caregiver of trauma victims seeing someone badly injured or killed |
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anxiety d/o in children facts
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most common mental d/o
lifetime 14-17% median 11 y sep anxiety/specific phobia=7y SAD= 13y ADHD 25% early onset OCD most common in boys rest of anxiety disorders most in girls common fears: fear of dark fear of harm to a family memeber overconcern about competence excessive need for reassurance somatic complain worries about dying or health worries about social contact |
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CBT components for PTSD and GAD
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Education
exposure cognitive approaches emotion regulation approaches problem solving relapse prevention |
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common components of CBT in OCD
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education
exposure response prevention cognitive interventions family involvement problem solving relapse prevention |
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self administered rating scales to assess anxiety disorders
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depression anxiety stress scale
obsessive compulsive inventory Davidson trauma scale anxiety sensitivity index social phobia inventory Sheenan disability scale fear questionnaire |
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describe exposure in GAD
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imaginal exposure to worry related imagery and feared catastrophes
practises eliminating unrealistic safety behavior involves learning to tolerate, rather than avoid, anxiety related experiences |
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cognitive interventions in GAD
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reappraise unrealistic beliefs concerning the value of worry
work on realistic estimation of likelihood of negative outcome ocurring and evaluation of the ham caused by these events deal with problems related to intolerance of uncertainty and prefeccionism |
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exposure in OCD
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offers in vivo exposure to situations provoking anxiety and compulsive behavior.
offers imaginal exposure to to feared obsessive thoughts offers imaginal exposure to catastrophic consequences of feared thoughts and accions teaches response prevention so exposure takes place without engaging in safety and other rituals behaviors teaches that exposure involves learning to tolerate rather than avoid anxiety experiences |
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cognitive interventions in OCD
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reappraisal of beliefs concerning danger involved in situations that provoke obsessions and compulsions ( this involve estimation of likelihood of a negative outcome)
reappraisal of beliefs concerning danger associated with the obsessions themselves. reducing inflated sense of responsibility about creating harm addressing belief that the occurrence of a thought makes it more likely that the feared outcome will happen deal with problems related to intolerance of uncertainty and prefeccionism |
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cognitive approaches in PTSD
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reducing hypervigilance by refocusing attention
teach pt to challenge irrational cognition and replace them with functional realistic beliefs identify dysfuntional thinking pattern asssociated with anxiety, depression, shame, and anger |
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exposure in PTSD
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Helps patients to gradually confront feared situations, memories,emotions snd images asscociated with the traumatic experience until there is a sig. reduccion in distress
in vivo exposure provide confrontation with avoided situations related to the event. eliminatesunrealistic safety behav. imaginal exposure offers repeated review of the truama based on memories of the experience and its aftermath, including emotions accompanying the experience |
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types of phobias by DSM IV
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anymal type
Blood injury type situational type natural environment type other type |
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common components of CBT for PD
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education
interoceptive exposure cognitive interventions real life situations to avoided situations emotional regulation approaches problem solving relapse prevention |
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what is interoceptive exposure
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exposure to feared bodily sx experienced during episodes of panic
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cognitive approaches in PD
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illustrates the castastrophic thinking and cognitive errors that often accompany panic attacks
demosntrating strategies for replacing anxious thoughts and with alternative interpretations and coping thoughts. |
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common components of SA
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education
exposure cognitive restructuring social skills training emotion regulation approaches |
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cognitive restructuring in SA
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aims to reduce negative beliefs about self and others
whork to reduce the excessive self focus characteristic in SA examines and changes perfectionist attitudes |
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exposure in SA
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offer imaginal exposure to situations that are difficult to practice inreal life
offers in vivo exposure to situations provoke social anxiety during treatment and homework provides exposure role playing simulations reduce safety behaviors insocial situations |
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MRI finding in Bipolar disorder
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Frontal lobe is smaller
smaller anterior cingulate white matter densitiy increases |
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who are at most risk for a manic eposidoe in BAD
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mood incongruent psychotic features
mixed mood episode rapid cyclng > 2 manic episodes in the past 2 months subsyndromal symptoms residual symtpoms after a mood episode |
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best tx for dysphoric mania
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atypical or valproate or combination
not lithium |
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life time suicide in BAD I
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17-19% complete
25-50% attempts |
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risk factor for suicide in BAD
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personal/fam hx, SI, severity and number of depressive episodes, pessimism, impulsivity/aggressiveness, cormorbidity, substance, younger onset
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Criteria for BAD NOS
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unable to determine if BAD is primary, substance induced or related to GMC
manic or mixed episose superimposed on delusional psychotic disorder recurent hypimania w/o intercurrent depressive symtpoms. very rapid alternation bwen depresive and manic sx that do not meet criteria for duration |
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When to consider ECT earlier for bipolar depression (currently 3r line)
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ECT considered earlier in severe psychotic MDE, medical complications, little po, hx AD non-response or AD induced rapid cycling
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High non-adherence, risk factors in BAD
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younger age, single, male., low education, low support, hypomanic denial, psychosis, cormobid PD/substance abuse, poor inight, medication s/e, unfavourable attitudes towards tx
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CBT finding in BAD
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dec recurrences, mood fluc, need for meds, hosp, inc fn and adherence
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clinical features of mania in children
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atypical features, erratic change is mood, agitation, excitement, reckless behaviour, mood incongruent psychotic sx, thought d/o, severe deterioration in behaviour, leads to misdx as SCZ
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Risk factors for mania in children and adolescent
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include MDE with rapid onset, psychomotor retardation and psychotic features, fam hx affective d/o, AD induced psychomotor agitation or hypomania/mania
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When to use ECT in children
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when there is lack of response to 2 or more trials of rx
or when the severity of sx precludes waiting for a response to pharmachological rx. |
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differential dx of early onsetbipolar d/o and ADHD
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tue euphoria
decreased need for sleep hypersexuality onset of sx of inattention earlier in ADHD fam hx of BAD > in BAD children while fam hx of dysruptive d/o 9 CD) more common in ADHD children period of normal function seen in BAD not in ADHD |
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prevalence of Anxiety d/o in BAD? which one are more common
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65-90%
PD,GAD,specifc phobia and PTSD |
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High risk factors to develop BAD II
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of fam hx BAD2, earlier onset, more recurrence/anxiety disorder/substance abuse than MDD
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US National comorbidity survey 2007 lifetime prev
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BAD I 1.0%
BAD II 1.2% |
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BAD compared to MDD
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• BAD compared to MDD has earlier onset, more recurrences, atypical/mixed depressions, fam hx BAD and suicide
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STEPS BD findings
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pts randomized to intensive psychotherapy or collaborative care. ), d/c rates were similar but psychotx pts has significantly higher year end recovery rates (64.4 vs 51.5) and shorter times to recovery, psychotx assoc with better total fn, reln’s fn and life satisfaction but not work/role fn
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Which study demonstrated the efficacy of seroquel asm onotherapy for BAD dep
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BOLDER I and BOLDER II
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EMBOLDEN i AND II RESULTS
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EMBOLDEN I- compared quetiapine and LiCO3, with quetiapine effective but low serum Li levels,
EMBOLDEN II- quetiapine and paroxetine, quetiapine effective but low paroxetine dose of 20mg |
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Suicide rates in SCZ
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competed: 10%
attempted: 30% |
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lifetime prevalence of MDD
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Canada: 10.8%
USA= NCS 17.1 |
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difference bwen remission and response in MDD
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response: 50% reduction in score of dep scales
remission: rating scale score within normal limits |
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how many patients show improvement with citalopram after 8 weeks in the STARD trial?
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56%
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What did the PREVENT TRIAL showed?
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Venlafaxine shows 2 year benefit for recurrent MDD.
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Risk factors supporting long term ( 2 years orlifetime) AD maintenance
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older age
recurent episodes (3 or >) psychotic episodes chronic episodes severe episoes difficult to treat episodes significant comorbidity Residual symptoms Hx of recurrent during D/C of AD also for longer tx: early onset dep psychosocial adversity chronic medical illness short allele of sertononin trasnporter gene neuroticism cognitive vulnerability |
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ACOG criteria for the lactation risk of psych med
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L1: safest
L2safer: olanzapine, CBz, epival L3; moderately safe : risperidone, aripiprazole lamotigine and clozapine L4 possible hazardous : lithium, seroquel and ziprasidone. L5 Contraindicated |
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what is the recurrence rate of mania in pregnancy after d/c lithium
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52%
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TF_CBT therapy for children with PTSD
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PRACTICE:
psychoeducation/parenting skilss relaxation techniques affective modulation cognitive coping and processing in vivo master of trauma reminders conjoined child-[parent sessions enhance future safey and development |
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Valid reasons for combining medication
and psychotherapy in PSTD in children |
the need for acute
symptom reduction in a child with severe PTSD, a comorbid disorder that requires concurrent treatment, or unsatisfactory or partial response to psychotherapy and potential for improved outcome with combined treatment. |
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Risk factors for PTSD in chilfren
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Female gender, previous trauma exposure, multiple
traumas, greater exposure to the index trauma, presence of a preexisting psychiatric disorder (particularly an anxiety disorder), parental psychopathology, and lack of social support |
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ultrarapid cycling in juvenile bipolar definied by Geller (2000)
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define ultrarapid cycling as having 5 to 364
cycles per year. |
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Ultradian cycling
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> 364 cycles
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