Psychiatry Toronto Notes Abridged for the PDA To be used only in consultation with the printed Toronto Notes

Julianna Borbely and Ann Stewart, chapter editors John Hanlon and Andrea Mok, associate editors Caroline Collins, EBM editor Dr. Jodi Lofchy and Dr. Johanne Roberge, staff editors The Psychiatric Assessment History Mental Status Exam Summary of Axes Mini-Mental Status Exam (Folstein) Psychotic Disorders Differential Diagnosis of Psychosis Schizophrenia Mood Disorders Mood Episodes Depressive Disorders Bipolar Disorders Anxiety Disorders Panic Disorder Generalized Anxiety Disorder (GAD) Phobic Disorders Obsessive-Compulsive Disorder (OCD) Post-Traumatic Stress Disorder (PTSD) Eating Disorders Anorexia Nervosa Bulimia Nervosa Personality Disorders Pharmacotherapy Antipsychotics Antidepressants Mood Stabilizers Anxiolytics Electroconvulsive Therapy (ECT)

Diagnostic Criteria reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. 2000 American Psychiatric Association.

The Psychiatric Assessment

History
Identifying Data
name, sex, age, ethnicity, marital status, religion, occupation, education, living situation, referral source

Reliability of Patient as a Historian

may need collaborative source for history (e.g. parent, teacher) if patient unable/unwilling to co-operate

Chief Complaint
in patients own words duration, previous history of disorder or treatment

History of Present Illness

reason for seeking help THAT DAY, current symptoms (onset, duration, and course), stressors, relevant associated symptoms (pertinent positives and negatives)

Psychiatric Functional Inquiry

mood: depressed, manic anxiety: worries, obsessions, compulsions, panic attacks, phobias psychosis: hallucinations, delusions, thought form disorders suicide/homicide: ideation, plan, history of attempts organic: EtOH/drug use or withdrawal, illness, dementia

Past Psychiatric History

inquire about all previous psychiatric diagnoses, contact with psychiatrists or other therapists, treatments (successes and failures) and hospitalizations in chronological order also include past suicide attempts, substance abuse/use, and legal problems

Past Medical/Surgical History

all medical, surgical, neurological (e.g. head trauma, seizures), and psychosomatic illnesses medications, allergies

Family Psychiatry/Medical History

family members: ages, occupations, personalities, medical or genetic illnesses and treatments, relationships with parents/siblings family psychiatric history: any past or current psychiatric illnesses and hospitalizations, suicide, depression, substance abuse, history of nervous breakdown/bad nerves, any past treatment by psychiatrist or other therapist

Past Personal History

prenatal and perinatal history (desired pregnancy or not, maternal and fetal health, domestic violence, maternal substance use, complications of pregnancy/delivery) early childhood to age 3 (developmental milestones, activity/attention level, family stability, attachment figures) middle childhood to age 11 (school performance, peer relationships, fire-setting, stealing, incontinence) late childhood to adolescence (drug/EtOH, legal problems, peer and family relationships) adulthood (education, occupations, relationships) psychosexual history (paraphilias, gender roles, sexual abuse, sexual dysfunction) personality before current illness, recent changes in personality

Mental Status Exam (MSE)

General Appearance and Behaviour
dress, grooming, posture, gait, physical characteristics, apparent vs. chronological age, facial expression (e.g. sad, suspicious), attitude toward examiner (ability to interact, level of co-operation), psychomotor activity (agitation, retardation), body habitus, abnormal movements or lack thereof (tremors, akathisia, tardive dyskinesia, paralysis), attention level, and eye contact

Speech
rate (e.g. pressured, slowed), rhythm/fluency, volume, tone, articulation, quantity, spontaneity

Mood and Affect

mood subjective emotional state; in patients own words affect objective emotional state; described in terms of quality (euthymic, depressed, elevated, anxious), range (full, restricted, flat, blunted), stability (fixed, labile), appropriateness, intensity

Thought Process
coherence coherent, incoherent logic logic, illogical stream goal-directed circumstantiality speech that is indirect and delayed in reaching its goal; eventually comes back to the point tangentiality speech is oblique or irrelevant; does not come back to the original point loosening of associations illogical shifting between topics flight of ideas skipping verbally from one idea to another where the ideas are marginally connected word salad jumble of words lacking meaning or logical coherence perseveration repetition of phrases or words echolalia thought blocking sudden cessation of flow of thought and speech clang associations speech based on sound such as rhyming or punning

Thought Content
suicidal ideation/homicidal ideation low fleeting thoughts, no formulated plan, no intent intermediate more frequent ideation, well formulated plan, no active intent high persistent ideation and profound hopelessness/anger, well formulated plan and active intent, believes suicide/homicide is the only helpful option available obsession recurrent and persistent thought, impulse or image which is intrusive or inappropriate cannot be stopped by logic or reason causes marked anxiety and distress common themes: contamination, orderliness, sexual, pathological doubt/worry/guilt pre-occupations, ruminations (reflections/thoughts at length) overvalued ideas magical thinking ideas of reference (unusual/odd beliefs that are not of delusional proportions) delusion a fixed false belief that is out of keeping with a persons cultural or religious background and is firmly held despite incontrovertible proof to the contrary first rank symptoms: thought insertion/withdrawal/broadcasting; delusions of control belief that ones thoughts/actions are controlled by some external source

Perception
hallucination sensory perception in the absence of external stimuli that is similar in quality to a true perception; auditory (most common), visual, gustatory, olfactory, tactile illusion misperception of a real external stimulus depersonalization change in self-awareness such that the person feels unreal, detached from his or her body, and/or unable to feel emotion

 derealization feeling that the world/outer environment is unreal

Cognition
level of consciousness orientation: time, place, person memory: immediate, recent, remote intellectual functions attention, concentration, calculation, abstraction (proverb interpretation, similarities test), language, communication

Insight
patients ability to realize that he or she has a physical or mental illness and to understand its implications

Judgement
ability to understand relationships between facts and draw conclusions that determine ones action

Summary of Axes
Multiaxial Assessment Axis I Axis II Axis III Axis IV Axis V Formulation
a diagram outlining current issues and interrelations between an individual's biological, psychological, and social factors for each category: predisposing, precipitating, perpetuating, and protecting factors differential diagnosis of DSM-IV clinical disorders personality disorders; mental retardation general medical conditions that are potentially relevant to the understanding or management of the mental disorder psychosocial and environmental issues global assessment of functioning (GAF, 0 to 100) incorporating effects of Axes I to IV

Mini-Mental Status Exam (MMSE): Folstein

Orientation
time [1 point each for: year, season, month, date of month, day of week] place [1 point each for: country, province, city, street/hospital, house number/floor]

Memory
immediate recall [3 points] ask patient to immediately repeat the following 3 words: honesty, tulip, black delayed recall [3 points] ask patient to recall the 3 words previously given, after approximately 5 minutes

Attention and Concentration

attention [5 points] do serial 7s (counting backward from 100 in increments of 7) or spell WORLD backwards

Language Tests
comprehension (three stage command) [3 points] take this piece of paper in your left hand, fold it in half, and place it on the floor (Note: tell patient to take paper in non-dominant hand) reading [1 point] ask patient to read the words close your eyes on a piece of paper, and then to do what it says writing [1 point] ask patient to write any complete sentence repetition [1 point] repeat no ifs, ands, or buts naming [2 points] point to a watch and pen and ask patient to name them

Test of Spatial Ability

copying [1 point] ask patient to copy the design in Figure 1 exactly; all ten angles must be present and the two pentagons must intersect

Interpretation
total score out of 30, abnormal if < 24 needs further investigation gross screen for cognitive dysfunction: 20-24 mild; 10-19 moderate; < 10 severe other items not officially part of the Folstein include drawing a clock with the time showing 10 after 11; asking patient to name as many animals or words as possible beginning with the letter f in one minute; linking a series of numbers or letters in order; copying a diagram of alternating shapes (test for perseveration)
Source: Folstein MF, Folstein SE and McHugh PR (1975). Mini-Mental State: A practical method for grading the state of patients for the cllinician. Journal of Psychiatric Research. 12: 189-198.

Psychotic Disorders
Definition
characterized by a significant impairment in reality testing delusions or hallucinations (with/without insight into their pathological nature) behaviour so disorganized that it is reasonable to infer that reality testing is disturbed

Differential Diagnosis of Psychosis

primary psychotic disorder: schizophrenia, schizoaffective disorders, delusional disorder and brief psychotic disorder mood disorders: depression with psychotic features, bipolar disorder (manic episode with psychotic features), schizophreniform personality disorders: schizotypal, schizoid, borderline, paranoid, obsessive-compulsive general medical conditions: tumour, head trauma, dementia, delirium, metabolic substance-induced psychosis (intoxication or withdrawal)

Schizophrenia
DSM-IV-TR Diagnostic Criteria for Schizophrenia
A. characteristic symptoms (active phase): 2 or more of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): delusions hallucinations disorganized speech (e.g. frequent derailment or incoherence) grossly disorganized or catatonic behaviour negative symptoms, i.e. affective flattening, alogia (inability to speak), or avolition (inability to initiate and persist in goal-directed activities) Note: only 1 A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping a running commentary on the person's behaviour or thoughts, or 2 or more voices conversing with each other B. social/occupational dysfunction: ? 1 major areas of functioning (work, interpersonal relations, self-care) markedly below the level achieved prior to the onset of symptoms C. continuous signs of disturbance for at least 6 months, including at least 1 month of active phase symptoms; may include prodromal or residual phases D. schizoaffective and mood disorders excluded E. the disturbance is not due to the direct physiological effects of a substance or a general medical condition (GMC) F. if history of pervasive developmental disorder, additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least 1 month

Subtypes
paranoid preoccupation with one or more delusions (typically persecutory or grandiose) or frequent auditory hallucinations relative preservation of cognitive functioning and affect; onset tends to be later in life; believed to have the best prognosis catatonic at least two of: motor immobility (catalepsy or stupor); excessive motor activity (purposeless, not influenced by external stimuli); extreme negativism (resistance to instructions/attempts to be moved) or mutism; peculiar voluntary movement (posturing, stereotyped movements, prominent mannerisms); echolalia (repeating words/phrases of anothers speech) or echopraxia (imitative repetition of anothers movements, gestures or posture) disorganized

disorganized speech and behaviour; flat or inappropriate affect poor premorbid personality, early and insidious onset, and continuous course without significant remissions undifferentiated symptoms of criteria A met, but does not fall into the 3 previous subtypes residual absence of prominent delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behaviour continuing evidence of disturbance indicated by the presence of negative symptoms or two or more symptoms in criteria A present in attenuated form

Epidemiology
prevalence: 0.5%-1%; M:F = 1:1 mean age of onset: females ~27; males ~21

Etiology
multifactorial: disorder is a result of interaction between both biological and environmental factors genetic 50% concordance in monozygotic (MZ) twins; 40% if both parents have schizophrenia; 10% of dizygotic (DZ) twins, siblings, children affected neurochemistry dopamine hypothesis theory: excess activity in the mesolimbic dopamine pathway may mediate the positive symptoms of psychosis (i.e. delusions, hallucinations, disorganized speech and behaviour, and agitation) neuroanatomy decreased frontal lobe function, asymmetric temporal/limbic function, decreased basal ganglia function; subtle changes in thalamus, cortex, corpus callosum, and ventricles; cytoarchitectural abnormalities neuroendocrinology - abnormal growth hormone (GH), prolactin (PRL), cortisol, and adrenocorticotropic hormone (ACTH) indirect evidence of geographical variance, winter season of birth, and prenatal viral exposure neuropsychology: global defects seen in attention, language, and memory suggest lack of connectivity of neural networks

Pathophysiology
neurodegenerative theory natural history may be rapid or gradual decline in function and ability to communicate glutamate system may mediate progressive degeneration by excitotoxic mechanism which leads to production of free radicals neurodevelopmental theory abnormal development of the brain from prenatal life neurons fail to migrate correctly, make inappropriate connections, and break down in later life inappropriate apoptosis during neurodevelopment resulting in faulty connections between neurons

Management of Schizophrenia
pharmacological (see Pharmacotherapy, PS38) acute treatment and maintenance with antipsychotics anticonvulsants anxiolytics management of side effects psychosocial psychotherapy (individual, family, group): supportive, cognitive behavioural therapy (CBT) assertive community treatment (ACT) social skills training and employment programs housing (group home, boarding home, transitional home)

Course
the majority of individuals display some type of prodromal phase course is variable some individuals have exacerbations and remissions and others remain chronically ill; accurate prediction of the long term outcome is not possible early in the illness, negative symptoms may be prominent; positive symptoms appear

and typically diminish with treatment; negative symptoms persist between episodes of positive symptoms in many individuals; negative symptoms may become steadily more prominent in some persons during the course of the illness over time, 1/3 improve, 1/3 remain the same, 1/3 worsen

Mood Disorders
Definitions
mood disorders are defined by the presence of episodes mood episodes represent a combination of symptoms comprising a predominant mood state, examples include: major depressive, manic, mixed, hypomanic types of mood disorders include: depressive (major depressive disorder, dysthymia) bipolar (bipolar I/II disorder, cyclothymia) secondary to general medical condition (GMC), substances, medications

Differential Diagnosis of Mood Disorders

infectious: encephalitis/meningitis, hepatitis, pneumonia, TB, syphilis endocrine: hypothyroidism, hyperthyroidism, hypopituitarism, SIADH metabolic: porphyria, Wilson's disease, diabetes vitamin disorders: Wernicke's, beriberi, pellagra, pernicious anemia collagen vascular diseases: SLE, polyarteritis nodosa neoplastic: pancreatic cancer, carcinoid, pheochromocytoma cardiovascular: cardiomyopathy, CHF, MI, CVA neurologic: Huntingtons disease, multiple sclerosis, tuberous sclerosis drugs: antihypertensives, antiparkinsonian, hormones, steroids, antituberculous, and antineoplastic medications

Medical Workup of Mood Disorder

routine screening physical examination complete blood count (CBC) thyroid function test electrolytes urinalysis, urine drug screen addtional screening neurological consultation chest x-ray electrocardiogram (ECG) CT scan

Mood Episodes
DSM-IV-TR Criteria for Major Depressive Episode
A. five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either 1) depressed mood or; 2) loss of interest or pleasure Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations (1) depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (3) significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day (4) insomnia or hypersomnia nearly every day (5) psychomotor agitation or retardation nearly every day (6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) (8) diminished ability to think or concentrate, or indecisiveness, nearly every day (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide B. the symptoms do not meet criteria for a Mixed Episode (see below) C. the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning D. the symptoms are not due to the direct physiological effects of a substance or a GMC E. the symptoms are not better accounted for by bereavement, i.e. after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation

DSM-IV-TR Criteria for Manic Episode

A. a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary) B. during the period of mood disturbance, 3 (or more) of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree: (1) inflated self-esteem or grandiosity (2) decreased need for sleep (e.g. feels rested after only 3 hours of sleep) (3) more talkative than usual or pressure to keep talking (4) flight of ideas or subjective experience that thoughts are racing (5) distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli) (6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. the symptoms do not meet criteria for a Mixed Episode D. the mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features E. the symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication, or other treatment) or a general medical condition (e.g. hyperthyroidism). Note: Manic-like episodes that are clearly caused by somatic anti-depressant treatment (e.g. medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder

Mixed Episode

 criteria met for both manic episode and MDE nearly every day for 1 week criteria D and E from manic episodes are met

Hypomanic Episode
criteria A of a manic episode is met, but duration is at least 4 days criteria B and E of manic episodes are met episode associated with an uncharacteristic decline in functioning that is observable by others change in function is NOT severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization absence of psychotic features

Depressive Disorders
DSM-IV-TR Diagnostic Criteria for Major Depressive Disorder
A. presence of two or more MDE. Note: To be considered separate episodes there must be an interval of at least 2 consecutive months in which criteria of MDE are not met B. the MDE are not better accounted for by Schizoaffective Disorder and are not superimposed on a psychotic disorder C. there has never been a manic, hypomanic or mixed episode (This does not apply if these episodes occur secondary to a substance or GMC) D. history of one or more MDE E. absence of a previous manic, hypomanic, or mixed episode

Features
psychotic with hallucinations or delusions; these may be mood-congruent chronic lasting 2 years or more melancholic quality of mood is distinctly depressed, mood is worse in the morning, early morning awakening, marked weight loss, excessive guilt, psychomotor retardation atypical increased sleep, weight gain, leaden paralysis, rejection hypersensitivity postpartum (see Postpartum Mood Disorders, PS11) seasonal (pattern of onset at same time each year)

Epidemiology
prevalence: male 2-4%, female 5-9% (M:F = 1:2) mean age of onset: ~30 years

Etiology
biological genetic: 65-75% MZ twins; 14-19% DZ twins neurotransmitter dysfunction at level of synapse (decreased activity of serotonin, norepinephrine, dopamine) secondary to general medical condition (GMC) psychosocial psychodynamic (e.g. low self-esteem) cognitive (e.g. negative thinking) environmental factors (e.g. job loss, bereavement, history of abuse) co-morbid psychiatric diagnoses (substance abuse, mental retardation, dementia, eating disorder)

Risk Factors
sex: female > male age: onset in 25-50 year age group family history: depression, alcohol abuse, sociopathy childhood experiences: loss of parent before 11 years old, negative home environment (abuse, neglect) personality: insecure, dependent, obsessional recent stressors (illness, financial, legal) postpartum < 6 months lack of intimate, confiding relationships or social isolation

Depression in the Elderly

accounts for about 50% of acute psychiatric admissions in the elderly affects about 15% of community residents > 65 years old high suicide risk due to social isolation, chronic medical illness suicide peak: males aged 80-90; females aged 50-65 often present with somatic complaints (e.g. changes in weight, sleep, energy) or anxiety symptoms refer to chart to compare with delirium and dementia

Treatment (see Pharmacotherapy, PS43)

biological: antidepressants, lithium, antipsychotics, anxiolytics, electroconvulsive therapy (ECT), light therapy

 psychological individual therapy: psychodynamic, interpersonal, cognitive behavioural therapy family therapy group therapy social: vocational rehabilitation, social skills training

Prognosis
one year after diagnosis of a MDE without treatment, 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full MDE, 20% continue to have some symptoms that no longer meet criteria for a MDE, 40% have no mood disorder

DYSTHYMIA DSM-IV-TR Diagnostic Criteria for Dysthymic Disorder

A. depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year B. presence, while depressed, of two (or more) of the following: (1) poor appetite or overeating (2) insomnia or hypersomnia (3) low energy or fatigue (4) low self-esteem (5) poor concentration or difficulty making decisions (6) feelings of hopelessness C. during the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 months at a time D. no MDE has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e. the disturbance is not better accounted for by chronic MDD, or MDD in partial remission E. there has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder F. the disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder G. the symptoms are not due to the direct physiological effects of a substance or a GMC H. the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Epidemiology
point prevalence: 3%, life prevalence 6%; M:F = 1:2-3

Treatment
psychological treatment principle treatment for dysthymia individual, group, and family therapy medical treatment out patient antidepressant therapy (SSRIs/SNRIs)

Bipolar Disorders
BIPOLAR I / BIPOLAR II DISORDER Definition
Bipolar I Disorder disorder in which at least one manic or mixed episode has occurred commonly accompanied by at least 1 MDE but not required for diagnosis Bipolar II Disorder disorder in which there is at least 1 MDE and at least 1 hypomanic episode no past manic or mixed episode

Epidemiology
prevalence: 0.6-0.9%; M:F = 1:1 age of onset: teens to 20s

Risk Factors
slight increase in upper socioeconomic groups 60-65% of bipolar patients have family history of major mood disorders

Classification
classification of bipolar disorder involves describing the current or most recent mood episode as either manic, hypomanic, mixed or depressed the current or most recent episode can be further classified as without psychotic features, with psychotic features, with catatonic features, with postpartum onset, with seasonal pattern, with rapid cycling

Treatment
biological: mood stabilizers, anticonvulsants, antipsychotics, antidepressants, ECT psychological: supportive and psychodynamic psychotherapy, cognitive or behavioural therapy social: vocational rehabilitation, leave of absence from school/work, drug and EtOH cessation, substitute decision maker for finances, sleep hygiene, social skills training, education for family members

CYCLOTHYMIA Diagnosis
presence of numerous periods of hypomanic and depressive symptoms (not meeting criteria for MDE) for at least 2 years; never without symptoms for > 2 months no MDE, manic or mixed episodes; no evidence of psychosis not due to GMC/substance use symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Treatment
anticonvulsants psychotherapy

Anxiety Disorders
Definition
anxiety is a universal human characteristic involving tension, apprehension, or even terror, which serves as an adaptive mechanism to warn about an external threat by activating the sympathetic nervous system (fight or flight) manifestations of anxiety can be described along a continuum of physiology, psychology, and behaviour physiology main brain structure involved is the amygdala; neurotransmitters involved include serotonin, cholecystokinin, epinephrine, norepinephrine, dopamine psychology ones perception of a given situation is distorted which causes

one to believe it is threatening in some way behaviour once feeling threatened, one responds by escaping or facing the situation, thereby causing a disruption in daily functioning anxiety becomes pathological when fear is greatly out-of-proportion to risk/severity of threat response continues beyond existence of threat or becomes generalized to other similar/dissimilar situations social or occupational functioning is impaired

Differential Diagnosis
endocrine: hyper- or hypothyroidism, pheochromocytoma, hypoglycemia, hyperadrenalism, hyperparathyroidism CVS: congestive heart failure, pulmonary embolus, arrhythmia, mitral valve prolapse respiratory: asthma, pneumonia, hyperventilation metabolic: vitamin B12 deficiency, porphyria neurologic: neoplasm, vestibular dysfunction, encephalitis differentiate from substance-induced anxiety disorder: drugs of abuse (caffeine, amphetamine, cocaine), medications (benzodiazepine withdrawal), toxins (EtOH withdrawal)

Medical Workup of Anxiety Disorder

routine screening physical examination complete blood count (CBC) thyroid function test electrolytes urinalysis, urine drug screening additional screening neurological consultation chest x-ray electrocardiogram (ECG) CT scan

Panic Disorder
DSM-IV-TR Diagnostic Criteria for Panic Disorder without Agoraphobia
A. Both (1) and (2): (1) recurrent unexpected Panic Attacks A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes: palpitations, pounding heart, or accelerated heart rate sweating trembling or shaking sensations of shortness of breath or smothering feeling of choking chest pain or discomfort nausea or abdominal distress feeling dizzy, unsteady, lightheaded, or faint derealization (feelings of unreality) or depersonalization (being detached from oneself) fear of losing control or going crazy fear of dying paresthesias (numbness or tingling sensations), chills or hot flushes (2) at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: (a) persistent concern about having additional attacks

(b) worry about the implications of the attack or its consequences (e.g. losing control, having a heart attack, "going crazy") (c) a significant change in behavior related to the attacks B. absence of Agoraphobia C. the Panic Attacks are not due to the direct physiological effects of a substance or a GMC D. the Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia, Specific Phobia, Obsessive-Compulsive Disorder, Post-traumatic Stress Disorder, Separation Anxiety Disorder

Epidemiology
prevalence: 1.5-5% (one of the top five most common reasons to see a family doctor); M:F = 1:2-3 onset: average late 20s, familial pattern

Treatment
supportive psychotherapy, relaxation techniques (visualization, box-breathing), cognitive behavioural therapy (correct distorted thinking, desensitization/exposure therapy) pharmacotherapy benzodiazepines (short term, low dose, regular schedule, long half-life, no PRN) SSRIs/SNRI (start low, go slow, aim high since anxiety patients are very sensitive other antidepressants (serzone, trazodone, remeron, MAOIs); avoid wellbutrin

Prognosis
6-10 years post-treatment: 30% well, 40-50% improved, 20-30% no change or worse clinical course: chronic, but episodic with psychosocial stressors

Panic Disorder with Agoraphobia

diagnosis: panic disorder + agoraphobia agoraphobia anxiety about being in places or situations from which escape might be difficult (or embarrassing) or where help may not be available in the event of having an unexpected panic attack fears commonly involve situations: being out alone, being in a crowd, standing in a line, or travelling on a bus situations are avoided, endured with anxiety or panic, or require companion treatment: as per panic disorder

Generalized Anxiety Disorder (GAD)

DSM-IV-TR Diagnostic Criteria for Generalized Anxiety Disorder
A. excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance) B. the person finds it difficult to control the worry C. the anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children (1) restlessness or feeling keyed up or on edge (2) being easily fatigued (3) difficulty concentrating or mind going blank (4) irritability (5) muscle tension (6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) D. the focus of the anxiety and worry is not confined to features of an Axis I disorder, such as panic disorder, social phobia, etc. E. the anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning F. the disturbance is not due to the direct physiological effects of a substance or a GMC and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder

Epidemiology
1-year prevalence: 3-8%; M:F = 1:2; if considering only those receiving inpatient treatment, ratio is 1:1 most commonly presents in early adulthood (termed "overanxious disorder of childhood" in children)

Treatment
psychotherapy, relaxation, and CBT caffeine and EtOH avoidance, sleep hygiene pharmacotherapy: benzodiazepines (short term, low dose, regular schedule, long half-life, no PRN) buspirone (TID dosing) others: SSRIs/SNRI, TCAs, beta blockers combinations of above

Prognosis
chronically anxious adults become less so with age depends on pre-morbid personality functioning, stability of relationships, work, and severity of environmental stress difficult to treat

Phobic Disorders
Specific Phobia
definition: marked and persistent fear that is excessive or unreasonable, cued by presence or anticipation of a specific object or situation 1year prevalence 9%, lifetime prevalence 12-16%; M:F ratio variable depending on nature of specific phobia types: animal/insect, environment (heights, storms), blood/injection/injury, situational (airplane, closed spaces), other (loud noise, clowns)

Social Phobia
definition: marked and persistent fear of social or performance situations in which person is exposed to unfamiliar people or to possible scrutiny by others; person fears

he/she will act in a way that may be humiliating or embarrassing (e.g. public speaking, initiating or maintaining conversation, dating, eating in public) 6-month prevalence = 2-3% lifetime prevalence may be as high as 13-16%; M:F = 1:1 in clinical setting, but M<F in community

Diagnostic Criteria for Phobic Disorders

exposure to stimulus almost invariably provokes an immediate anxiety response; may present as a panic attack person recognizes fear as excessive or unreasonable situations are avoided or endured with anxiety/distress significant interference with daily routine, occupational/social functioning, and/or marked distress if person is < 18 years, duration is at least 6 months

Treatment
exposure therapy/desensitization, insight-oriented psychotherapy pharmacotherapy beta blockers or benzodiazepines in acute situations (i.e. public speaking) SSRIs, MAOIs; no TCAs behavioural therapy is more efficacious than medication

Prognosis
chronic

Obsessive-Compulsive Disorder (OCD)

DSM-IV-TR Diagnostic Criteria for Obsessive Compulsive Disorder
A. either obsessions or compulsions: obsessions as defined by (1), (2), (3), and (4): (1) recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress (2) the thoughts, impulses, or images are not simply excessive worries about reallife problems (3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action (4) the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion) compulsions as defined by (1) and (2): (1) repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly (2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive B. at some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children C. the obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships D. if another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g. preoccupation with food in the presence of an Eating Disorder) E. the disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition

Epidemiology
lifetime prevalence rates 2-3%; M=F MZ twins = 75%, DZ = 32% rate of OCD in first-degree relatives is higher than in the general population

Treatment
CBT desensitization, flooding, thought stopping, implosion therapy, aversive conditioning pharmacotherapy clomipramine, SSRIs (higher doses and longer treatment needed, i.e. up to 8-12 weeks) atypical and typical antipsychotics pimozide, haloperidol

Prognosis
tends to be refractory and chronic

Post-Traumatic Stress Disorder (PTSD)

DSM-IV-TR Diagnostic Criteria for Post-Traumatic Stress Disorder
A. the person has been exposed to a traumatic event in which both of the following were present: (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behaviour B. the traumatic event is persistently re-experienced in one (or more) of the following ways: (1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed (2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content (3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event (5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event C. persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma (2) efforts to avoid activities, places, or people that arouse recollections of the trauma (3) inability to recall an important aspect of the trauma (4) markedly diminished interest or participation in significant activities (5) feeling of detachment or estrangement from others (6) restricted range of affect (e.g. unable to have loving feelings) (7) sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal life span) D. persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: (1) difficulty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hypervigilance (5) exaggerated startle response E. duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month F. the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Epidemiology
lifetime prevalence: 1-3% mens trauma is most commonly combat experience; womens trauma is usually physical or sexual assault

Complications
substance abuse, relationship difficulties, depression, impaired social and occupational functioning, Axis II disorders

Treatment
CBT systematic desensitization, relaxation techniques, thought stopping pharmacotherapy

SSRIs benzodiazepines (for acute anxiety) 1st line adjunct atypicals (quetiapine, olanzapine, risperidone)

Suicide
Epidemiology
attempted:complete = 120:1 M:F = 3:1 for completed; 1:4 for attempts

Risk Factors
epidemiologic factors age: increases after age 14; 2nd cause of death for ages 15-24; highest rates in persons > 65 years sex: male race/ethnic background: white or native Canadians on reserves marital status: widowed/divorced living situation: lives alone; no children < 18 years old in the household other: stressful life events; access to firearms psychiatric disorders mood disorders (15% lifetime risk in depression; higher in bipolar) anxiety disorders (especially panic disorder) schizophrenia (10-15% risk) substance abuse (especially EtOH 15% lifetime risk) eating disorders (5% lifetime risk) adjustment disorder conduct disorder personality disorders (borderline, antisocial) past history prior suicide attempt family history of suicide attempt

Clinical Presentation
symptoms associated with suicide hopelessness anhedonia insomnia severe anxiety impaired concentration psychomotor agitation panic attacks

Approach
assessment of suicidal ideation Onset of suicidal thoughts? Stressors precipitating suicidal thoughts? Frequency of suicidal thoughts? Feelings of being a burden? Or that life isn't worth living? What makes them feel better (e.g. contact with family, use of substances)? What makes them feel worse (e.g. being alone)? How much control over suicidal ideas do they have? Can they suppress them or call someone for help? What keeps them alive? Stops them from killing themselves (e.g. family, religious beliefs)? assessment of lethality Is there a plan to end their life? Do they own a gun, have access to firearms or potentially harmful medications? Have they imagined their funeral, and how people will react to their death? Have they "practiced" the suicide? (e.g. put the gun to head or held medications in hand)? Have they changed their will or life insurance policy or given away possessions? if an attempt was made: Planned or impulsive attempt? Triggers for attempt (stressors)? Lethality of attempt? Chance of discovery? Reaction to being saved? MSE may reveal psychiatric disorder (e.g. depression), perception disturbance (e.g. command hallucination), poor insight and judgement

Management
see SAD PERSONS scale do not leave patient alone; remove potentially dangerous objects from room patients with a plan, access to lethal means, recent social stressors, and symptoms suggestive of a psychiatric disorder should be hospitalized immediately if patients refuses to be hospitalized, complete form for involuntary admission depression: if severe, hospitalize; otherwise outpatient treatment with good supports and SSRIs/SNRIs alcohol related: usually resolves with abstinence for a few days; if not, suspect depression personality disorders: crisis intervention/confrontation schizophrenia/psychotic: hospitalization parasuicides/self-mutilation: long term psychotherapy with brief crisis intervention when necessary

Eating Disorders
Epidemiology
anorexia nervosa (AN) - 1% of adolescent and young adult females; onset 13-20 years old bulimia nervosa (BN) - 2-4% of adolescent and young adult females; onset 16-18 years old F:M = 10:1; mortality 5-10%

Etiology
commonly multifactorial - psychological, sociological and biological associations individual: perfectionism, lack of control in other life areas, history of sexual abuse personality: obsessive-compulsive, histrionic, schizoid/schizotypal familial: maintenance of equilibrium in dysfunctional family cultural factors: prevalent in industrialized societies, idealization of thinness in the media genetic factors: AN: 6% prevalence in siblings, with one study of twin pairs finding concordance in 9 of 12 monozygotic pairs versus concordance in 1 of 14 dizygotic pairs BN: higher familial incidence of affective disorders than the general population

Risk Factors
physical factors: obesity, chronic medical illness (e.g. diabetes mellitus) psychological factors: individuals who by career choice are expected to be thin, family history (mood disorders, eating disorders, substance abuse), history of sexual abuse, homosexual men, competitive athletes, concurrent associated mental illness (depression, OCD, anxiety disorder (especially panic and agoraphobia), substance abuse (BN))

Anorexia Nervosa (AN)

DSM-IV-TR Diagnostic Criteria for Anorexia Nervosa
A. refusal to maintain body weight at or above a minimally normal weight for age and height (e.g. weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected) B. intense fear of gaining weight or becoming fat, even though underweight C. disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight D. in postmenarcheal females, amenorrhea, i.e. the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g. estrogen, administration)

Specify Type
Restricting Type: during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas) Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Other Features
deteriorating mood (irritable, anxious, extremeness of sensitivity, sadness) isolation (e.g. free time devoted to studying, social circle sacrificed)

 trouble concentrating due to repetitive, intrusive, irresolvable and anxiety provoking thoughts about food and weight malnutrition poor sleep

Management
criteria for admission vary among hospitals admit to hospital if: < 65% of standard body weight, hypovolemia requiring intravenous fluid, abnormal serum chemistries or if actively suicidal agree on target body weight on admission and reassure this weight will not be surpassed psychotherapy (individual/group/family) addressing food and body perception, coping mechanisms, health effects monitor for complications (see Table 6)

Prognosis
early intervention much more effective with treatment, 70% resume a weight of at least 85% of expected levels and about 50% resume normal menstrual function eating peculiarities and associated psychiatric symptoms are common and persistent long-term mortality - 10% to 20% of patients hospitalized will die in next 10 to 30 years, secondary to severe and chronic starvation, metabolic or cardiac catastrophies, with a significant proportion committing suicide

Bulimia Nervosa (BN)

DSM-IV-TR Diagnostic Criteria for Bulimia Nervosa
A. recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: (1) eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances (2) a sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating) B. recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise C. the binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months D. self-evaluation is unduly influenced by body shape and weight E. the disturbance does not occur exclusively during episodes of Anorexia Nervosa

Specify Type
Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Other Features
fatiguability and muscle weakness due to repetitive vomiting and fluid/electrolyte imbalance tooth decay swollen appearance around angle of jaw and puffiness of eye sockets due to fluid retention reddened knuckles, Russells sign (knuckle callus) trouble concentrating weight fluctuation (rhythmic pattern) over time

Management
criteria for admission: significant electrolyte abnormalities biological (see Table 6) treatment of starvation effects, SSRIs psychological develop trusting relationship with therapist to explore personal etiology and triggers reality-oriented feedback, cognitive behavioural therapy, family therapy recognition of health risks social challenge destructive societal views of women use of hospital environment to provide external patterning for normative eating behaviour

Prognosis
few recover without recurrence good prognostic factors: onset before age 15, achieving a healthy weight within 2 years of treatment poor prognostic factors: later age of onset, previous hospitalizations, individual and familial disturbance

Personality Disorders (PD)

General Diagnostic Criteria
an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture; manifested in two or more of: cognition, affect, interpersonal functioning, impulse control inflexible and pervasive across a range of situations causes distress or impaired functioning not necessarily for the person with the personality disorder, but for those around him/her usually age 18 for diagnosis, but pattern well established by adolescence or early adulthood associated with many complications, such as depression, suicide, violence, brief psychotic episodes, multiple drug use and treatment resistance

Pharmacotherapy
Antipsychotics
antipsychotics and neuroleptics are terms used interchangeably indications: schizophrenia and other psychotic disorders, mood disorders with psychosis, violent behaviour, autism, Tourettes, somatoform disorders, dementia, OCD onset: immediate calming effect and decrease in agitation; thought disorder responds in 2-4 weeks mechanism of action typical - blocks D2 receptors (dopamine); treats only positive symptoms (hallucinations, delusions) atypical - blocks D2 and/or D1, 5-HT receptors (dopamine + serotonin); treats both positive and negative symptoms (flat affect, anhedonia, avolition) specific typical and atypical antipsychotics vary in terms of binding to adrenergic, 5-HT, cholinergic and histaminergic sites leading to different side effect profiles

Rational Use of Antipsychotics

no reason to combine antipsychotics (see Figure 4) choosing an antipsychotic all antipsychotics are equally effective (except clozapine, for refractory cases) choice depends on side effect profile choose a drug patient has responded to in the past or was used successfully in a family member route: PO; short-acting or long-acting depot IM injections minimum 6 months, usually for life low potency (e.g. chlorpromazine): very sedating; cardiovascular, anticholinergic and antiadrenergic side effects mid-potency (e.g. perphenazine): few side effects high potency (e.g. haloperidol): risk of movement disorder side effects, neuroleptic malignant syndrome (NMS), and extrapyramidal side effects (EPS) (see Table 12)

ATYPICAL ANTIPSYCHOTICS
fewer EPS than typicals often effective for treating symptoms refractory to conventional antipsychotics Risperidone, Olanzapine, Quetiapine are the first line atypical antipsychotics no significant difference in efficacy, speed of response and stability of remission between first line atypicals disadvantages: expensive, lack of injectable forms

Clozapine
blocks a spectrum of receptors, including D1-D4, 5-HT2, 5-HT3, muscarinic, histaminergic indications treatment-resistat schizophrenia (i.e. other antipsychotics not effective) severe EPS limiting use of other agents advantages clozapine does not worsen tardive symptoms; it may actually treat them about 50% of patients benefit, especially paranoid patients and those with onset after 20 years old disadvantages: side effects: drowsiness/sedation (39%), hypersalivation (31%), tachycardia (25%), dizziness (19%), headache (7%), fever (5%), significant weight gain (4%), nausea/vomiting (3-5%), seizure (3%), agranulocytosis (1-2%), extrapyramidal, NMS weekly blood counts for at least 1 month, then q 2 weeks, due to risk of agranulocytosis

do not use with drugs which may cause bone marrow suppression due to risk of agranulocytosis

Risperidone
blocks 5-HT2, D2 and adrenergic indications psychosis negative symptoms intolerance to side effects of typical antipsychotics advantages: low incidence of EPS and lower doses (< 8) disadvantages side effects: insomnia (26%), agitation (22%), EPS (17%), headache (14%), anxiety (12%), rhinitis (10%), constipation (7%), nausea/vomiting (5-6%), dizziness (4%), sedation (3%), hypersalivation (2%), weight gain, impairment of ejaculation/orgasm, increased prolactin levels benefit limited to a narrow dose range: 4-8 mg/day only quick dissolve formulation will soon be available

Olanzapine
blocks 5-HT2,3,6, D1-D4, muscarinic, adrenergic, histaminergic indications psychosis intolerance to side effects of typical antipsychotics advantages overall efficacy is superior to haloperidol; well tolerated; comparable efficacy to risperdone quick dissolve formulation (ZydisTM) increasingly used in ER setting and for better compliance incidence of EPS and tardive dyskinesias (TD) much less than traditional neuroleptics disadvantages side effects: mild sedation (29%), insomnia (12%), dizziness (11%), dry mouth (9%), fever (6%), weight gain (5%), minimal anticholinergic, sexual dysfunction, early AST and ALT elevation in some individuals, restlessness weight gain associated with an increased risk of diabetes mellitus and hyperlipidemia

Quetiapine
blocks 5HT2A, D1-D2, adrenergic, and histaminergic receptors advantages associated with less weight gain as compared with clozapine and olanzapine disadvantages questionable effectiveness in treating both positive and negative symptoms, dose needs to be pushed (> 600mg/day) in order for drug to have any effect side effects: headache (19%), sedation (18%), dizziness (10%), constipation (9%), dry mouth (7%), hypotension (7%), tachycardia (7%), weight gain (2%) most sedating of the first line atypicals

Ziprasidone
5-HT2A and moderate D2 antagonism; moderately potent adrenergic and histaminergic blocker in process of gaining approval in Canada; difficulty with approval due to prolongation of Q-T interval dosing recommendations not yet known; range of efficacy expected to be between 40-80 mg/day, IM injection also available side effects: sedation (14%), nausea (10%), constipation (9%), dyspepsia (8%), dizziness (8%), akathisia (8%), asthenia (5%), EPS (5%), diarrhea (5%), tachycardia (2%)

LONG-ACTING PREPARATIONS
antipsychotics formulated in oil for deep IM injection received on an outpatient basis weekly or bimonthly

 indications: individuals with schizophrenia or other chronic psychoses who relapse because of noncompliance available preparations (all high potency typical antipsychotics) dosing: start at low dosages, and then titrate every 2 to 4 weeks to maximize safety and minimize side effects should be exposed to oral form prior to first injection side effects: risk of EPS, parkinsonism, increased risk of neuroleptic malignant syndrome Figure 4. Treatment Algorithm for Schizophrenia

SIDE EFFECTS OF ANTIPSYCHOTIC THERAPY

Table 11. Side Effects of Antipsychotics System Anticholinergic Side Effects Acute delirium Dry mucous membranes Blurred vision, acute glaucoma Constipation Urinary retention Sweating Delayed/retrograde ejaculation Orthostatic hypotension Dizziness Fainting Tachycardia Weight gain Sedation Confusion Decreased seizure threshold Movement disorders Men: Decreased libido Gynecomastia Women Breast engorgement, lactation Amenorrhea, menstrual irregularities Changes in libido Lenticular pigmentation Pigmentary retinopathy Liver dysfunction Blood dyscrasias Skin rashes NMS Altered temperature regulation (hypothermia or hyperthermia)

Cardiovascular (anti- 1 adrenergic)

CNS

Endocrine

Ocular Hypersensitivity reactions

Neuroleptic Malignant Syndrome

due to massive dopamine blockade; increased incidence with high potency and depot neuroleptics risk factors: medication factors sudden increase in dosage, or starting a new drug patient factors medical illness dehydration

exhaustion poor nutrition external heat load sex: male age: young adults clinical presentation: fever, autonomic reactivity, rigidity, mental status changes (usually occur first) develops over 24-72 hours labs: increased CPK, leukocytosis, myoglobinuria treatment: discontinue drug, hydration, cooling blankets, dantrolene (hydantoin derivative-used as a muscle relaxant), bromocriptine (DA agonist) mortality: 5%

Extrapyramidal Side Effects (EPS)

incidence related to increased dose and potency acute (early-onset; reversible) vs. tardive (late-onset; often irreversible)

Antiparkinsonian Agents (Anticholinergic Agents)

do not always prescribe with neuroleptics; give only if at high risk for acute EPS or if develop acute EPS do not give these for tardive syndromes, because they worsen the condition types benztropine (Cogentin) 2 mg PO, IM or IV od (~1-6 mg) procyclidine (Kemadrin) 15 mg PO od (~5-30 mg) biperiden (Akineton) 2 mg PO, IM or IV bid (2-10 mg) amantadine (Symmetrel) 100 mg PO bid (100-400 mg) rihexyphenidyl (Artane) 1-15 mg PO od diphenhydramine (Benadryl) 25-50 mg PO/IM qid

Antidepressants
onset of effect neurovegetative symptoms 1-3 weeks emotional/cognitive symptoms 2-6 weeks may use mild stimulant (e.g. methylphenidate) for severe neurovegetative symptoms; briefly and taper down as antidepressant effect increases taper TCAs slowly (over weeks-months) because they can cause withdrawal reactions MAOIs and SSRIs can be tapered over 1 week

Treatment Strategies for Refractory Depression (see Figure 5)

optimization: ensuring adequate drug doses for the individual augmentation or combination: addition to ongoing treatment of drugs that are not antidepressants themselves (e.g. thyroid hormone or lithium) substitution: change in the primary drug

Serotonin Syndrome
rare but potentially life-threatening adverse reaction to SSRIs, especially when switching from an SSRI to an MAOI thought to be due to over-stimulation of the serotonergic system involves restlessness, confusion, and lethargy but can progress to myoclonus, hyperthermia, rigor and hypertonicity treatment: discontinue medication and administer emergency medical care as needed

Mood Stabilizers
before initiating get baseline: CBC, ECG (if patient > 45 years old or cardiovascular risk), urinalysis, BUN, Cr, lytes, TSH before initiating lithium: screen for pregnancy, thyroid disease, seizure disorder, neurological, renal, cardiovascular diseases use lithium or valproic acid first ( an antipsychotic) use carbamazepine in non-responders and rapid cycling can combine lithium and carbamazepine or valproic acid safely in lithium non-responders olanzapine may be used as a mood stabilizer, in conjunction with other mood stabilizers

Lithium Toxicity (refer to Table 13 for more information about Lithium)

clinical diagnosis, as toxicity can occur at therapeutic levels common causes: overdose sodium or fluid loss concurrent medical illness clinical presentation: GI: severe nausea/vomiting and diarrhea cerebellar: ataxia, slurred speech, lack of coordination cerebral: drowsiness, myoclonus, choreiform or Parkinsonian movements, upper motor neuron signs, seizures, delirium, coma management: discontinue lithium for several doses and begin again at a lower dose when lithium level has fallen to a nontoxic range serum Li levels, BUN, lytes saline infusion hemodialysis if Li > 2 mmol/L, coma, shock, severe dehydration, failure to respond to treatment after 24 hours, or deterioration

Second-line/Adjuvant Mood Stabilizers

Gabapentin: indications: treatment of acute mania and depression mechanism: increase GABA turnover or interfere with glutamate metabolism

 side effects: fever (10%), nausea/vomiting (8%), sedation (8%), hostility (8%), dizziness (2.5%), increased cycling Lamotrigine (Lamictal): indications: treatment of dysphoric mania, mixed episodes and rapid cycling BAD mechanism: may inhibit 5-HT3 receptors and potentiate DA activity side effects: CNS: dizziness (38%), headache (29%), ataxia (22%), nausea (19%), somnolence (14%), fever (6%), anxiety (4%) Skin: rash (10%), Stevens-Johnson syndrome

Anxiolytics
indications: short term treatment of transient forms of anxiety disorders, insomnia, alcohol withdrawal (especially delirium tremens), barbiturate withdrawal, organic brain syndrome (agitation in dementia), EPS and akathisia due to antipsychotics, seizure disorders, musculoskeletal disorders relative contraindications: major depression (except as an adjunct to other treatment), history of drug/alcohol abuse, pregnancy, breast feeding mechanism of action: benzodiazepines: potentiate binding of GABA to its receptors; results in decreased neuronal activity buspirone: partial agonist of 5-HT type IA receptors

Rational Use of Anxiolytics (see Table 16)

anxiolytics mask or alleviate symptoms, they do not cure

Benzodiazepines
should be used for limited periods (weeks-months) to avoid dependence all benzodiazepines are sedating have similar efficacy, so choice depends on half-life, metabolites and route of administration, OD or BID taper slowly over weeks-months because they can cause withdrawal reactions low dose withdrawal: tachycardia, hypertension, panic, insomnia, anxiety, impaired memory and concentration, perceptual disturbances high dose withdrawal: hyperpyrexia, seizures, psychosis, death avoid alcohol because of potentiation of CNS depression; caution with drinking and use of other machinery side effects: CNS: drowsiness (23%), cognitive impairment, reduced motor coordination (3%), memory impairment physical dependence, tolerance develops

Withdrawal (see Table 3 in Substance Abuse section) similar, but less severe, to alcohol withdrawal; can be fatal commonly used drug in overdose overdose is rarely fatal in combination with alcohol, other CNS depressants, or TCAs is more dangerous and may cause death Buspirone (Buspar)
primary use: generalized anxiety disorder (GAD) non-sedating and not prone to abuse; therefore, may be preferred over benzodiazepines does not interact with or show cross tolerance to other sedating drugs (e.g. alcohol, barbiturates, benzodiazepines) does not alter seizure threshold, interact with EtOH, act as a muscle relaxant onset of action: 2 weeks side effects: dizziness (12%), drowsiness (10%), nausea (8%), headache (6%), nervousness (5%), extrapyramidal

Benzodiazepine Antagonist - Flumazenil (AnexateTM)

use for suspected benzodiazepine overdose specific antagonist at the benzodiazepine receptor site Table 16. Common Anxiolytics
Class
Benzodiazepines Long-acting

Drug
clonazepam (Rivotril)

Dose Range (mg/day)

0.25-4

T1/2 (hours)
18-50

Appropriate use
Akathisia, generalized anxiety seizure prevention,

diazepam (Valium)

2-40

30-100

chlordiazepoxide (Librium) flurazepam (Dalmane ) Benzodiazepines Short-acting alprazolam (Xanax)

5-300 15-30 0.25-4.0

30-100 50-160 6-20

panic disorder Generalized anxiety, seizure prevention, muscle relaxant Sleep, anxiety, alcohol withdrawal Sleep Panic disorder, sublingual available for very rapid action, high dependency rate Sleep, generalized anxiety, akathisia Sleep, generalized anxiety Sleep Shortest t1/2, rapid sleep, but rebound insomnia Generalized anxiety Sleep

lorazepam (Ativan) oxazepam (Serax) temazepam (Restoril) triazolam (Halcion) Azapirones buspirone (Buspar) zopiclone (Imovane)

0.5-6.0 10-120 7.5-30 0.125-0.5 20-60 7.5

10-20 8-12 8-20 1.5-5

Electroconvulsive Therapy (ECT)

induction of a grand mal seizure using an electrical pulse through brain under general anesthesia unilateral vs. bilateral electrode placement indications: depression refractory to adequate pharmacological trial high suicide risk medical risk in addition to depression (dehydration, electrolytes, pregnancy) previous good response to ECT familial response to ECT elderly psychotic depression catatonic features marked vegetative features acute schizophrenia mania unresponsive to meds side effects: risk of anesthesia, memory loss (may be retrograde and/or anterograde, tends to resolve by 6 to 9 months, permanent impairment controversial), headaches, myalgias evidence that unilateral ECT causes less memory loss than bilateral but may not be as effective contraindications: increased intracranial pressure