K&S SAQ Flashcards

Question

What are MRI findings in bipolar disorder (source K&S Study Guide)?

Answer 1

a. Enlarged third ventricle b. Decreased cerebellum and temporal lobe volumes

Answer 2

a. Unproven – have reduced prefrontal cortex and temporal regions b. Enlarged caudate – may be due to medications more than schizophrenia c. Enlarged ventricles

Answer 3

a. Smaller volumes in frontal lobes b. Smaller cerebellum c. Smaller caudate and putamen \*Ventricular enlargement is not predominantly associated with extensive neuroleptic use

Answer 4

a. Generalized reduction in brain mass (enlarged ventricles) (Can be reversed with abstinence in some cases)

Answer 5

a. Oxytocin b. ADH

Answer 6

COMT – cytoplasm of postsynaptic cell and glial cells MAO – presynaptic cleft

Answer 7

MAO-A – 5-HT and NE, Dopamine, tyramine MAO-B – Dopamine (includes tyramine)

Answer 8

a. Basal forebrain b. Mesopontine complex

Answer 9

a. Cyclic nucleotides – cAMP b. Calcium c. Phosphoinositol metabolites – IP3, DAG d. Eicosanoids – prostglandins, leukotrienes e. Gases – NO f. Jak-Stat Note: G-proteins bind to receptors to cause a state of high affinity for the receptor. They are linked to the second messengers.

Answer 10

a. Optic ataxia b. Oculomotor apraxia c. Simultanagnosia

Answer 11

Ideamotor apraxia – inability to perform an isolated motor task on command despite comprehension Ideational apraxia – can perform individual components of a sequence but entire series cannot be organized and performed as a whole

Answer 12

a. The molecule is synthesized in the neuron b. The molecule is present in the presynaptic neuron and is released on depolarization in physiologically significant amounts c. When administered exogenously as a drug, the exogenous molecule mimics the effects of the endogenous neurotransmitter d. A mechanism in the neurons or the synaptic cleft acts to remove or deactivate the neurotransmitter

Answer 13

a. The molecule is synthesized in the neuron b. The molecule is present in the presynaptic neuron and is released on depolarization in physiologically significant amounts c. When administered exogenously as a drug, the exogenous molecule mimics the effects of the endogenous neurotransmitter d. A mechanism in the neurons or the synaptic cleft acts to remove or deactivate the neurotransmitter

Answer 14

Agonist – a drug that binds to a specific receptor and produces identical effect to that usually produced by a neurotransmitter affecting that receptor Antagonist – a compound that binds to a receptor that blocks or reduces the action of another substance at the receptor site involved Partial Agonist – a compound, which possesses affinity for a receptor, but elicits a partial pharmacological response at the receptor involved. They are often structural analogues of agonist molecules. If the neurotransmitter is low, partial agonists may act like agonists. Inverse Agonist – an inverse agonist is an agent that binds to the same receptor as an agonist for that receptor and produces opposite pharmacological effect

Answer 15

The availability of tryptophan (not trytophan hydroxylase) Note: Tyrosine hydroxylase is the rate-limiting step in dopamine synthesis

Answer 16

The sub-type is 5HT-2C.

Answer 17

Median toxic dose is the dose at which 50% of patients experience toxic effects.

Answer 18

The patient related factors are: diagnosis, genetics, past treatment response, response in family members, concurrent medical or psychiatric disorders and lifestyle.

Answer 19

Remission on the HAM-D is 7 or less and 10 or less on the MADRS. MADRS rating – Study by Kearns et al. (1982) showed that the following mean scores correlated with corresponding severity: 44 = very severe, 31 = severe, 25 = moderate, 15 = mild, and 7 = recovered

Answer 20

Tranylcypromine (Parnate) – avoid use if insomnia, agitation and may exacerbate psychosis

Answer 21

a. Pindolol b. Propanolol c. Nadolol

Answer 22

Rivastigmine (Note: Donepezil is only AchE and Galantamine AchE and Nicotinic receptor modulation)

Answer 23

Dystonia a. Benztropine 1-2 mg IV/IM b. Diphenhydramine 50 mg IV/IM or 25-50 mg qid (Max: 400 mg/day) c. Lorazepam 1-2 mg IM [Source: Jeffries] Parkinsonism a. Biperiden (Akineton) 2 mg IM (Max: 6 mg day) b. Procyclidine (Kemadrin) 5 mg tid (Max: 30 mg per day) c. Trihexyphenidyl (Artane) 5-15 mg bid-qid (Max: 30 mg per day) [Source: Jeffries]

Answer 24

Least anticholinergic – desipramine (most: amitriptyline, clomipramine, trimipramine) Least sedating – desipramine and protriptyline (most: amitriptyline, doxepin, trimipramine) Least orthostatic hypotension – nortriptyline (can treat this S/E with fludrocortisone 0.05 mg bid) Psychomotor stimulation – desipramine and protriptyline EPS – amoxapine

Answer 25

Adults – 0.1% (prior to dosing guidelines) Children – 1-2%

Answer 26

CBZ + LTG: Week 1-2: LTG 50 mg./d, Week 3-4: LTG 100 mg./d; increase by 100 mg every 1-2 weeks (Max:300-500 mg/day) VPA + LTG: Week 1-2: LTG 12.5 mg daily; Week3-4: LTG 25 mg daily; increase by 25-50 mg every 1-2 weeks (Max: 150 mg/day)

Answer 27

Phentoloamine and chlorpromazine.

Answer 28

dBP\>120 palpitation occipital headache radiating frontally neck stiffness or soreness N/V Sweating (sometimes with fever) Tachy or brady, possibly with chest pain (from Stahl's Essential psychopharmacology)

Answer 29

From highest to lowest: #1 Cimetidine #2 Prednisolone #3 Theophyline #4 Digoxin #5 Nifedipine #6 Furosemide #7 Ranitidine #8 Isosorbide Dinitrate #9 Warfarin #10 Dipyridamole #11 Codeine #12 Captopril

Answer 30

4. Switch to Buproprion or Mirtazepine (Nefazodone no longer available) 5. Augment a. PDE Inhibitor - Sildenafil in men: 50 to 100 mg 1 -2 h prior to sex (ensure no nitrate therapy or vascular disease)

Answer 31

a. Trimipramine (highest)Study Notes 2008 Page 9 of 61 b. Amitriptyline / Clomipramine / Imipramine / Protriptyline (tied for second

Answer 32

(All are relative even and considered highly anticholinergic) a. Amitriptyline b. Clmomipramine c. Trimipramine

Answer 33

a. Imipramine (highest) b. Amitriptyline / Clomipramine / Trimipramine / Desipramine

Answer 34

1. Neural tube defects (1 – 5% increased risk) 2. Craniofacial abnormalities 3. Cardiovascular malformations 4. Limb defects 5. Genital anomalies 6. Hydrocephalus and microcephalus 7. Fingernail hypoplasia

Answer 35

a. Memantine – NMDA antagonist b. Donepezil – cholinesterase inhibitor

Answer 36

They are: a) CHF, b) pheochromocytoma and c) liver disease

Answer 37

a. Hyperventilate b. Give caffeine (500-200 mg IV) c. Check medications given previous night to ECT (benzodiazepines, anticonvulsant agents) d. Determine if anaesthetic can be switched (Note: K&S states propofol should be avoided due to its strong anticonvulsant effects, although it is used clinically) e. Switch to Bilateral if RUL being used ?sleep deprivation

Answer 38

a. Treatment-resistant depression b. Treatment-resistant schizophrenia (best if affective component) c. Acute Mania d. MDD with psychotic features e. Catatonia f. Depression during pregnancy g. NMS h. Unable to take medications due to physical illness i. Need for rapid response (i.e. not eating and poor health as a result) j. Parkinson’s disease (on-off phenomenon) k. Acute suicidal ideation (failed medications) l. Treatment refractory OCD

Answer 39

GREEN: WBC \>3500, ANC \>2500 – continue clozapine AMBER: WBC 2000-3500, ANC 1500-2500 – hold clozapine, CBC twice weekly until WBC \>3000 or ANC \> 1500 RED: WBC \<2000, ANC \<1500 – discontinue clozapine, daily CBC, watch for signs of infection, protective isolation, consider bone marrow biopsy +/- GSF

Answer 40

- Lorazepam - Oxazepam - Temazepam - Lithium (renal) - Gabapentin (renal) - Topiramate (unchanged in urine and not extensively metabolized) -Paliperidone

Answer 41

a. Double vision / Blurred vision b. Vertigo c. GI disturbance d. Task performance impairment e. Hematologic effects \*Not dose related – aplastic anemia, Stevens-Johnson, hepatic failure, rash, pancreatitis, agranulocytosis

Answer 42

Hyponatremia

Answer 43

chlorpromazine

Answer 44

Low potency (clozapine, olanzapine)

Answer 45

a. Irreversible retinal pigmentation – thioridazine b. Benign pigmentation of the eyes (lenticular deposits) – CPZ c. Quetiapine – cataracts (in beagles)

Answer 46

a. Paroxetine – increases warfarin anticoagulant effect b. Sertraline – displace warfarin from plasma proteins and may increase bleeding times c. Fluvoxamine – increases warfarin levels 2-fold

Answer 47

1. Supportive Measures – ICU consultation, IV hydration, cooling blankets, oxygentation 2. Dantrolene 1mg.kg/day for 8 days IV then continue PO for 7 days 3. Amantadine PO if necessary 200 to 400 mg PO/day in divided doses 4. Bromocriptine 2.5 mg PO bid or tid up to 45mg/day if necessary 5. Benzodiazepines may work if other meds have failed 6. ECT may work when meds have failed

Answer 48

- To treat Lithium induced tremor - Treatment of Social Phobia limited to performance anxiety - Treatment of neuroleptic induced akathisia

Answer 49

a. Lassitude b. Fatigue c. Dysphoria d. Insomnia e. Vivid nightmares f. Depression (rare) g. Psychosis (very rare)

Answer 50

GI upset Nausea Hair loss Tremor Weight gain Sedation

Answer 51

a. Enkephalins b. Endorphins c. Dynorphins

Answer 52

a. Increased plasma volume (up to 50%) b. Decreased albumin concentration (decreased protein bound drug) c. Enhanced GFR (increased elimination) d. Minimal delay in gastric emptying & reduced small intestine motility (due to progesterone) e. Nausea / vomiting early in pregnancy may reduce oral absorption

Answer 53

It involves 4 features: a. Manifestations of ego weakness (i.e. cannot modulate affects such as anxiety and lack impulse control) b. Regression to primary process of thinking – e.g. psychotic-like states c. Primitive defenses - Splitting, Primitive idealization, projection and projective identification, omnipotence and devaluation d. Pathological internalized object relations – objects are all good or all bad

Answer 54

He states that personality is made up of temperament (50%) and character (50%). Temperaments consist of: 1. Novelty-seeking 2. Harm-avoidance 3. Reward dependence – social attachment, dependence on approval of others 4. Persistence – capacity for perseverance despite frustration Character consists of: 1. Self-directedness – accept responsibility for one’s choice 2. Cooperativeness – object relatedness (e.g. empathy) 3. Self-transcendence – altruistic pursuits, identification beyond the self

Answer 55

Kohut:  Based on well-functioning outpatients with vulnerable self-esteem  Differentiates NPD for borderline personality states  Based on internalization of missing functions  Sees NPD patient as developmentally arrested  Accepts idealization as a normal developmental phase making up for missing psychic structure  Empathizes with patient’s feelings as understandable reaction to failure of parents  Accepts patient’s comments at face value (avoid confrontation)  Looks on positive side mainly  Calls attention to patients progress  Goal: Help patient to identify and seek out appropriate self-objects Kernberg:  Based on mixture of inpatients and outpatients with arrogant and aggressive grandiosity with shyness  NPD is a sub-category of borderline personality organization  Emphasizes envy and aggression  Views the self as highly pathological  Sees idealization as “defensive”  Helps patient see his own contribution to problem  Confronts and interprets resistances  Examines both positive and negative aspects of patient’s experience  Treatment goal of helping patient develop guilt and to integrate idealization & trust with rage and contempt

Answer 56

Negative predictors: a. History of felony arrest or conviction b. Repeated lying and aliases c. Unresolved legal situation d. Hospitalization forced as an alternative to incarceration e. History of violence towards others f. TBI or organic brain impairment Positive Predictor: Co-morbidity – depression, anxiety or other (excluding TBI, etc)

Answer 57

Repression and dissociation.

Answer 58

a. Extroversion / Introversion b. Openness c. Conscientiousness d. Agreeableness e. Neuroticism

Answer 59

Pre-trauma risk factors Female gender Past psychiatric history Family psychiatric history Childhood abuse (pre-existing trauma) Peri-trauma factors: Proximity/interpersonal nature of threat With combat – severity of trauma Chronicity Dissociation at time of trauma Perceived helplessness Death potential Post-trauma risk factors: Lack of social support Severity of acute symptoms Lack of early intervention or access to services Perceived shame Poor coping skills or poor perceived control Ongoing life stressors Acute physiological reactivity Meaning of traumatic event

Answer 60

a. Increased urine catacholamines b. Platelet alpha-2 and lymphocyte beta-adrenergic receptor downregulation c. Increase opioid response to stimuli d. Decreased 5-HT e. Decreased resting glucocorticoid levels f. Decreased GC response to stress and downregulation of GC receptors g. Hyperresonsiveness to DST

Answer 61

Early: Build trust and therapeutic alliance Define therapeutic limits and boundaries Psychoeducation Build safety and supports Develop skills of self-soothing (e.g. progressive relaxation) Middle: Trauma processing, reframing and reintegration Hypnosis may be helpful Validate affect not content Do not assume memory content is true Late: Consolidate therapeutic work and stabilization Existential, identity and attachment issues Master self-sufficiency Move towards long-term goals Termination

Answer 62

a. Increased frequent (close proximity) of treatment sessions b. Real exposure (not imaginal exposure) c. No avoidance within session d. Prolonged exposure e. Some therapist involvement

Answer 63

A. Yielding to compulsions B. Childhood onset C. Delusional beliefs D. Co-morbid depression E. Co-morbid personality disorder (especially schizotypal) F. Bizarre compulsions G. Need for hospitalization H. Presence of overvalued ideas

Answer 64

A. Start with a biological diathesis for anxiety B. Psychological predisposition (early life stressor or parenting style) – thus fails to develop feeling of competence about himself or the world C. False alarm (panic attack) – associated with interoceptive cues (interoceptive conditioning) D. Becomes a Learned alarm (Conditioned panic attacks) E. Causes further arousal and self-focused attention – anxious apprehension (i.e. the possibility of experiencing another panic attack) F. Now autonomic and cognitive symptoms trigger Learned Alarms in an unpredictable manner G. May lead to development of agoraphobic avoidance – no attacks when avoid so have negative reinforcement related to panic attacks

Answer 65

a. Educate – about the disorder and treatment, recommend self-help book b. Exposure Confront feared situations, memories, emotions, images Imaginal exposure or writing a trauma narrative In vivo exposure allows confrontation with avoided situations Eliminates safety behaviours c. Cognitive Approaches Identify dysfunctional cognitions Help patient challenge irrational cognitions and replace Reduce hypervigilance by refocusing d. Emotion Regulation Approaches Help with stress reduction skills Relaxation approaches (muscle, breathing, imagery) Refocus attention Practice acceptance based approaches to reduce avoidance of emotions e. Problem Solving Practice overcoming social withdrawal Address any coping through substance use or other unhealthy coping Help them engage in positive activities and goals f. Relapse Prevention Practice preparation for trauma related events that might occur in the future Practice preparation for periods of increased stress reminders

Answer 66

a. Detoxification – drug out to be able to work towards treatment b. Concentrated Rehabilitation – learn new skills and how to be sobriety i. Social skills training ii. CBT iii. Assertiveness training c. Supportive Rehabilitation i. Getting lives re-built on an individual basis ii. Reintegrating into society as a sober individual

Answer 67

a. Integrated treatment – treat substance use disorder and mental illness together at one site b. Parallel treatment model – treat both mental illness and substance use concurrently but not at same place c. Sequential treatment model – treat the addiction first, then go for psychiatric treatment

Answer 68

Inpatient admission would be indicated in the following scenarios: a. History of withdrawal seizures or delirium tremens b. Documented history of very heavy alcohol use and high tolerance – thus increasing their risk of a complicated withdrawal treatment c. Concurrent abuse of other substances d. Severe comorbid GMC or psychiatric disorder e. Repeated failure to cooperate or benefit from outpatient detoxification Note: Inpatient care should include medical detoxification and a program of rehabilitation.

Answer 69

a. Comprehensiveness b. Co-ordination c. Continuity-long term d. Accessible e. Acceptance f. Optimism and recovery g. Individualized treatment h. Cultural competency

Answer 70

It blocks aldehyde dehydrogenase and destroys enzyme for 7 days (takes 7 days to wear off). Note: It also blocks dopamine (so don’t use in SCZ), causes liver problems and may cause depression. Best for the binge drinker who has been sober.

Answer 71

a. Precontemplation b. Contemplation c. Determination/Preparation d. Action e. Maintenance f. Relapse prevention

Answer 72

a. Partial mu opioid receptor agonist (at low doses) b. Kappa antagonist at high doses

Answer 73

It modulates glutamate-NMDA receptor activity. It reduces craving by dampening the neurological expression of withdrawal that contributes to alcohol craving in the abstinent individual.

Answer 74

a. Amphetamine intoxication & psychosis b. Cocaine intoxication c. Alcohol withdrawal

Answer 75

a. Symptoms precede onset of substance use b. Symptoms persist for a substantial period of time (e.g. greater than 1 month) after cessation of acute withdrawal/intoxication c. Symptoms are in substantial excess of what would be expected for the type, duration or amount of substance used (e.g. Schneiderian symptoms of psychosis) d. Evidence that there exists an independent non-substance-induced disorder (e.g. history of prior episodes NOT RELATED to substance use)

Answer 76

1. Basal ganglia 2. Cerebellum 3. Hippocampus Note: Minimal CB receptors in brain stem and cortex. It is a G protein receptor and affects monoamines and GABA

Answer 77

1. Euphoria within minutes and peaks in 30 minutes, lasting up to 4 hours 2. Cognitive and motor effects last 5-12 hours

Answer 78

A pre-existing personality disorder.

Answer 79

1. Persistent withdrawal despite 80 mg or more of diazepam given in the ER or office 2. Delirium, recurrent dysrhythmias or multiple seizures 3. Unsafe to discharge (home or detox) due to ataxia, confusion, dehydration 4. Serious medical or psychiatric illness

Answer 80

It blocks reuptake at the dopamine transporter and results in increased dopamine in the synaptic cleft and activation of D1 and D2 receptors.

Answer 81

1. CVA – most common are non-hemorrhagic cerebral infarctions (hemorrhagic do occur) 2. Cardiac – MI (CP) or arrhythmias, cardiomyopathy 3. Seizures – 3-8% (most common substance causing seizures, amphetamine second) 4. IV use – infection (HCV, HIV), endocarditis, emboli 5. Death 6. Rhabdomyolysis 7. Respiratory – resp. failure from smoked cocaine 8. Bowel ischemia \*\*Most complications occur within first 3 hours after use.

Answer 82

1. Use of IV or crack cocaine 2. Males greater than females 3. Emergence of paranoid delusion or AH (less common to have VH or TH, although formication (classic?) can occur)

Answer 83

a. All psychiatric patients – 50% b. Bipolar I – 70% c. Substance use – 70% d. Schizophrenia – 90%

Answer 84

Develop discrepancies Empathy Avoid argumentation Roll with the resistance Support self-efficacy

Answer 85

a. CAGE Questionnaire – has 4 questions and a score of 2 or more is clinically significant (\>1 females) b. Alcohol Use Disorders Identification Test (AUDIT) – clinician or self-report, 10 items (MC and yes/no) that assess alcohol consumption (3Q’s), harmful drinking (3Q’s) and hazardous drinking (4Q’s), scored 0-4 and score of 8 is highly sensitive and 10 is highly specific for detecting alcohol use disorder c. Michigan Alcohol Screening Test (MAST) – self-report 25 yes/no and scored 0-53, with scores greater than 7 indicating probably alcoholism d. Drug Abuse Screening Test (DAST) – 20-item self-report score 0 or 1 for yes or no responses respectively, cut-off is 5 indicating probable drug use and scores range from 0-28 e. Clinical Institute Withdrawal Assessment for Alcohol (CIWA-D) – 8 items scored from 0-7, with 4 objective (pulse, sweating, hand tremor, agitation) and 4 subjective (anxiety, sensory disturbance, N/V, headache), clinician-administered, give diazepam/lorazepam based upon scores 10 or more on CIWA

Answer 86

1. Antisocial personality disorder: 60 to 80% 2. Bipolar disorder 56% 3. Schizophrenia 47% 4. Post-traumatic stress disorder: 30 to 50% 5. Panic disorder: 36% 6. Any anxiety disorder: 36% 7. ADHD: 23% 8. Depression: 17%

Answer 87

b. Absence of ASPD c. Absence of diagnosis of another substance abuse/dependence disorderStudy Notes 2008 Page 22 of 61 d. Life stability with a job e. Continuing close family contacts f. Absence of severe legal problems g. If patient stay full course of rehabilitation program (2-4 weeks) h. Presence of family/professional supports i. (Could also include absence of SPMI)

Answer 88

a. Type 1 (Milieu-limited) - Female, onset after age 25 years, environmental reactivity to drinking, minimal criminality, passive-avoidance / harm avoidance / low novelty seeking b. Type 2 (Male-limited) - Early onset, less dependent on environmental factors, more criminal activity, high novelty seeking, low harm avoidance c. Type 3 - Antisocial behaviour with alcohol abuse

Answer 89

Acute onset, family history of depressive disorders, no family history of schizophrenia, a stressful precipitating event, no evidence of premorbid schizoid personality, perplexity or confusion during episode and prominent affective symptoms

Answer 90

a. Auditory hallucinations i. Voices repeating one’s thoughts (Gedankenlautwerden or echo le pensee) ii. Two or more voices discussing the subject or arguing with him iii. Voices commenting on his thoughts b. Thought insertion or withdrawal c. Thought broadcasting d. Somatic passivity e. Passivity (thought or feeling of being controlled) f. Apophonous delusion (Delusional perception)

Answer 91

Phases of CBT: 1. Engagement – patient and therapist discuss events leading up to patients’ psychotic illness and develops a shared explanation of the psychological factors involved (formulation used to normalize their experience). Important focus on fostering therapeutic alliance. 2. Assessment of co-morbid conditions (depression, anxiety) that can be targeted with CBT. 3. Develop Alternate Explanations of Symptoms – use a vulnerability-stress model. The patient’s vulnerability, stressors and evaluation of the antecedent period. Working collaboratively with the patient, alternate explanations could be considered and possibly accepted by the patient. 4. Focus on specific positive symptoms – CBT for psychosis focuses on specific strategies to deal with symptoms a. Hallucinations – analyze patient’s beliefs about the origins and nature of voices. Attempts to normalize hallucinations (e.g. can occur with sleep deprivation) and later to debate content of voices (e.g. abusive statements can be tested). Strategies can include voice diaries, reattribution of causes of the voices, generating coping strategies (focusing or distraction). b. Delusions – use successive questions (“peripheral questioning”) to determine underlying belief and understand the specific details of belief. Then, one can attempt graded reality testing (e.g. research if microchips can be inserted into head without knowing) and exploring alternate explanations. Another approach is “inference chaining”, which focuses on looking at the patient’s personalized meaning underlying the delusion. c. Thought Disorder – ask patient to fill in gaps of conversation (for thought blocking) and clarify neologisms d. Negative Symptoms – work on this symptom domain after positive symptoms have been targeted – can use behavioural experiments

Answer 92

1. Onset of symptoms within 4 weeks of noticeable change in behaviour 2. Confusion or perplexity 3. Good premorbid social and occupational functioning 4. Absence of blunted or flat affect

Answer 93

a. Advanced age b. Sensory impairment c. Family history d. Social isolation e. Recent immigration f. Personality features (e.g. unusual interpersonal sensitivity)

Answer 94

a. Good premorbid adjustment b. Absence of schizoid traits c. Confusion or perplexity d. No family history of schizophrenia e. Affective symptoms f. No or little blunted affect g. Sudden onset of symptoms h. Short duration of symptoms i. Severe precipitating factor

Answer 95

m. Re-assess diagnosis and treat new cmo-morbidities n. Rule out non-compliance (educate and consider depot, case management /ACT) o. Optimize dose (consider drug levels) i. Ensure at least 4-6 week trials on previous medications at optimal dose p. Clozapine q. Augmentation i. Lamotrigine (2 RCT) ii. Another antipsychotic (RSP) iii. Valproate (mood instability, irritability) iv. Antidepressant (depressive symptoms) v. Lithium (schizoaffective) vi. Topiramate (small RCT, open label) vii. ECT (especially if affective symptoms) viii. Stimulants/L-dopa (transient benefit in negative symptoms but weight against risk of exacerbating psychosis) ix. Benzodiazepine (anxiety symptoms)

Answer 96

a. Drug refractory condition – at least 2 prior drug trials of 4-6 week duration at 400-600 mg of CPZ with no clinical improvement b. Persistence of Illness - \>5 years of no period of good social or occupational functioning c. Persistent psychotic symptoms – BPRS total score \>45 on 18 item scale and item score \> 4 on 2 of 4 positive symptoms

Answer 97

- Supported employment programs (vocational interventions) - Family interventions (mainly family psychoeducation) \*ACT has LEVEL A evidence for patients difficult to engage and with repeated hospitalizations

Answer 98

a. Waist circumference Men  102 cm Women  88 cm b. Any 2 of following: a. TG  1.7 mmol/L b. HDL-C Men \< 1.0 mmo/L Women \< 1.3 mmol/L c. Blood Pressure  135 mmHg systolic or  85 mmHg diastolic d. Fasting glucose  5.6 mmol/L or known Type 2 diabetes

Answer 99

A. Involuntary movements of tongue, jaw, trunk or extremities associated with neuroleptic use B. Involuntary movements present over a period of 4 weeks and occur in any of following: a. Choreiform (rapid, jerky) b. Athetoid (slow, sinuous) c. Rhythmic (sterotypies) C. Sings or symptoms of criteria A or B develop while treated with neuroleptic or 4 weeks upon withdrawal for oral or 8 weeks for depot D. Neuroleptic exposure for 3 months (1 month for age  60 years) E. Not due to GMC, other medications or ill-fitting dentures F. Not better accounted for by other neuroleptic-induced movement disorder Risk Factors for TD: Early development of EPS, prolonged antipsychotic use, increased age (biggest RF), female, mood disorder, neurological conditions (brain damage/cognitive disorder), substance abuse.

Answer 100

A. Involuntary movements of tongue, jaw, trunk or extremities associated with neuroleptic use B. Involuntary movements present over a period of 4 weeks and occur in any of following: a. Choreiform (rapid, jerky) b. Athetoid (slow, sinuous) c. Rhythmic (sterotypies) C. Sings or symptoms of criteria A or B develop while treated with neuroleptic or 4 weeks upon withdrawal for oral or 8 weeks for depot D. Neuroleptic exposure for 3 months (1 month for age  60 years) E. Not due to GMC, other medications or ill-fitting dentures F. Not better accounted for by other neuroleptic-induced movement disorder Factors for TD: Early development of EPS, prolonged antipsychotic use, increased age (biggest RF), female, mood disorder, neurological conditions (brain damage/cognitive disorder), substance abuse.

Answer 101

Criteria: a. Development of restlessness after neuroleptic exposure b. At least one of following: Fidgety movements or swinging legs, rocking from foot-to-foot, pacing, inability to sit or stand still c. Occurs with 4 weeks of antipsychotic treatment or reducing or discontinuing anticholinergic medications d. Not accounted for by other mental disorder e. Not due to GMC or substance Risk factors: A. Middle aged female B. High caffeine intake C. Antipsychotic treatment (Unable to suppress akathisia – MCQ question)

Answer 102

a. High level of occupational social and functional adjustments b. Female sex c. Onset before 30 d. Sudden onset e. Short duration of illness f. Precipitating factors \*Persecutory, somatic and erotomanic may have better prognosis than grandiose and jealous

Answer 103

a. Attention b. Executive functioning c. Episodic (working) memory

Answer 104

Type I SCZ (Type II summarized in parentheses) - Positive symptoms (Negative symptoms) - Good premorbid adjustment (Poor premorbid adjustment) - Responds to standard antipsychotic (Poor response to standard antipsychotic) - Fair prognosis (Poor prognosis) - Absence of CT or structural abnormalities (CT findings present indicating structural abnormalities)

Answer 105

Alzheimer’s dementia a. Insidious onset b. Progressive deterioration c. Impaired anterograde & retrograde memory d. Impaired episodic, semantic, language and przxis Amnestic disorder a. Abrupt onset b. Static or improvement c. Impaired anterograde memory d. Temporal gradient retrograde memory e. Impaired episodic memory f. Intact semantic, language and praxis Dissociative amnesia a. Lost orientation to self with preservation of other aspects of memory b. Associated with emotionally stressful life events

Answer 106

a. PTSD (70%) b. BPD c. Somatization disorder (40-60%) d. Other anxiety disorders (OCD) e. Depression f. Eating disorders g. Conversion

Answer 107

TGA has anterograde amnesia, generalized memory loss, and remote memory is better than recent. In dissociative amnesia there is no anterograde amnesia, memory loss is selective for certain areas and usually does not chow a temporal gradient. Dissociative amnesia must involve loss of personal identity where as personal identity is retained in TGA. The onset for TGA is 60-70’s due to a vascular etiology and dissociative amnesia has its onset in 20’s to 30’s.

Answer 108

a. A sensation of bodily changes b. Duality of self as both actor and observer c. Feeling cut off from others d. Feeling cut off from one’s emotions

Answer 109

a. Retrospective diagnosis of childhood ADHD i. Meet DSM IV criteria via parent interview (narrow criterion) ii. Parent reports both hyperactivity as child and childhood attention deficits (Broad criteria) b. Adult features (5 or more) including ongoing difficulties with hyperactivity and inattention and 3 more of following: i. Inattentiveness ii. Hyperactivity iii. Mood lability iv. Irritability v. Impaired stress tolerance vi. Disorganization vii. Impulsivity c. Exclude severe depression, PD or psychosis \*Approximately 50% of childhood ADHD cases go on to develop adult ADHD

Answer 110

a. Can have a disorganized response to the traumatic event b. Can have frightening dreams without recognizable content c. Can re-experience trauma through repetitive play (Can re-enact trauma in play) d. Can have trauma specific re-enactment

Answer 111

Depressed children: a. Mood-congruent auditory hallucinations b. Somatic complaints c. Withdrawn d. Sad Appearance e. Poor self-esteem Depressed adolescents: a. Pervasive anhedonia b. Severe psychomotor retardation c. Delusions d. Sense of hopelessness

Answer 112

a. Male b. Psychiatric illness (90% of suicide has psych illness; 50-65% had MDD) c. Aboriginal youth d. Substance use e. Prior attempts f. Pre-existing cognitive profile – rigidity, poor problem solving, pessimism, impulsivity g. Childhood abuse h. Family history of suicide i. Firearm availability j. Stressful life events

Answer 113

a. Parent & infant enter room b. Unfamiliar adult joins dyad c. Parent leaves, child and stranger in room d. Parent returns and stranger leaves e. Parent leaves, child left in room f. Stranger returns, child still in room with stranger g. Parent returns and stranger leaves (parent & infant left in room) \*65% of infants are securely attached by the age of 24 months.

Answer 114

General a. Low self-esteem b. Alcohol and tobacco use in school years c. Early drug use d. Poor frustration tolerance e. Mood lability Psychiatric e. Conduct disorder f. ADHD g. Depressive disorder

Answer 115

a. Pharmacotherapy for co-morbid disorders b. CBT approaches (problem solving, communication, impulse control) c. Family therapy (improve communication skills) d. Peer group therapy (improve social skills)

Answer 116

Childhood onset  Prior to age 10 years  Usually male  Frequent display of physical aggression  Have disturbed peer relationships  More likely to have persistent conduct disorder and more likely to develop ASPD  Poorer prognosis Adolescent onset  Absence of any criteria prior to age 10  More likely to achieve social and occupational adjustment as adult  Less likely to display aggressive behaviours  Normal peer relationships  Ratio of males to females is lower  Better prognosis

Answer 117

Strongest a. Prior antisocial behaviour (males) b. Antisocial peer groups (gangs) c. Alone socially (low popularity and few social acitivties) d. Male gender e. Substance use (before age 12 years) f. Antisocial parents (convicted) Moderate e. Early aggression f. Low family SES g. Risk taking and impulsiveness h. Inconsistent/punitive disciplining, poor supervision, minimal or detached involvement i. Medical or physical conditions j. Rejected or unwanted pregnancy k. Lower IQ (8 points) Weak h. Large family size i. Marital discord j. Abusive parents k. High family stress (Ottawa Notes)

Answer 118

a. Caused by deficiency in purine metabolism b. X-linked rare disorder c. Associated with: MR, microcephaly, seizures, choreoathetosis, spasticity, self-mutilation of mouth and fingers

Answer 119

Hypothyroidism Substance use Female gender

Answer 120

a. Valproic acid b. Olanzapine c. ECT d. If no other options, use lithium & valproic acid combination

Answer 121

a. History of postpartum psychosis (70%) b. History of postpartum depression (50%) c. History of bipolar disorder (20-50%) d. History of MDD (30%)

Answer 122

\<7-10 is nondepressed 10-14 is mildly depressed 15-22 is moderately depressed 23+ is severely depressed Note: CES-D (Centre for Epidemiologic studies scale for depression) is another validated self-report scale. It is a 20-item scale scored from 0-3 with scores ranging from 0-60. Scores of 16 or higher indicates depressive illness. Designed for community samples as opposed for psychiatric patient populations, which is the case for the BDI

Answer 123

a. 0-7 = no depression b. 8-13 = mild depression c. 14-18 = moderate depression d. 19-22 = severe depression e. \>23 = very severe depression

Answer 124

a. Mood disorder questionnaire (MDQ) i. Self-report ii. 3 questions - Question 1 has 13 yes-no items iii. Positive test = Q1 at least 7/13 + Q2 “yes” (all at same time) + Q3 at least moderate problems iv. Informs you to screen more closely for mania and bipolar disorder b. Young Mania Rating Scale (YMRS) i. Clinician rated ii. 11 items with 7 items 0-4 and 4 items 0-8 iii. Scoring cut-offs: \<13 = not significant symptoms, 13 = minimal severity, 20 = mild, 26 = moderate and 38 = severe (max = 60)

Answer 125

The agents are: Lithium, Divalproex, Olanzapine and Lamotrigine (if patient has mild manias and mainly depression). For rapid cycling, only divalproex and lithium are 1st line (olanzapine monotherapy is 2nd line)

Answer 126

Quetiapine at 300 mg daily.

Answer 127

None. Lithium, DVP, LTG, quetiapine, antipsychotic + antidepressant, Li + DVP and Li/DVP + antidepressant are all 2nd line. LTG and Li are recommended for bipolar II disorder maintenance

Answer 128

i. 6 months – 25% ii. 2 years – 50% iii. 5 years – 70%

Answer 129

a. Prior psychiatric history (e.g. MDD) b. Younger age at time of abortion c. Second trimester \> first trimester d. Lack of social supports e. Sociocultural groups antagonistic to abortion \*Psychological problems immediately post-abortion is not a risk factor

Answer 130

a. Early onset mood symptoms b. Psychotic depression prior to age 25 c. Post-partum depression (especially if psychotic features present) d. Rapid onset and offset of depressive symptoms e. Depression with psychomotor retardation f. Antidepressant induced hypomania g. Repeated loss of efficacy of antidepressants h. Family history of bipolar disorder i. Trait mood lability or hyperthymic temperament j. Seasonality of mood symptoms k. Atypical depressive symptoms (reverse vegetative symptoms)

Answer 131

Baby Blues 30 to 75% of women who give birth Onset after 3 – 5 days post partum Lasts days to weeks No identifiable stressors No family history No personal history of mood disorder No anhedonia Absent or mild guilt Rarely infanticidal and suicidal thoughts Occassional sleep disturbance Postpartum Depression 10-15% of women who give birth Onset between 3 to 6 months Lasts months Lack of social supports is usually a stressors Often family history of mood disorders Often personal history of mood disorder Often anhedonia Guilt usually present and excessive Suicidal and infanticidal thoughts can be present Frequent sleep disturbance

Answer 132

- Lack of pleasure in all activities OR lack of reactivity to pleasurable stimuli - 3 of 6 of the following - Distinct quality of depressed mood - Early morning awakening - Worse mood in AM - Guilt is excessive or inappropriate - Anorexia or weight loss - Psychomotor retardation

Answer 133

#1 – Down’s #2 – Fragile X #3 – PKU

Answer 134

Approximately 1/3 boys and ¼ girls

Answer 135

1. MVA’s (37%) 2. Homicide (14%) 3. Suicide (12%) 4. Other accidents (12%)

Answer 136

a. Family conflict b. Academic difficulties c. Comorbid psychiatric disorders (e.g. conduct, depression) d. Parental and peer substance use e. Impulsivity f. Early onset of cigarette use

Answer 137

a. They are often brought to treatment unwillingly – Must work harder to establish therapeutic relationship b. They have limited capacity for self-observation c. They use regressive behavioural and communicative modes that can wear down therapist (primitive defenses)

Answer 138

a. Increased GFR b. Less fatty tissue – lower volume of distribution for lipophilic agents c. Greater hepatic capacity

Answer 139

a. Separation anxiety disorder b. Social phobia c. Specific phobia d. Panic disorder e. PTSD f. MDD or adjustment disorder g. Truancy associated with ODD and CD h. Stressor – academic, bullying, abuse at school, recent school change \*Occurs in 0.4-5% children with peak onset at ages 5-7 years (school entry) and age 11 years.

Answer 140

Facial tics worst prognosis.

Answer 141

IQ score between 71-84.

Answer 142

Core ADHD: MED = COMB \> BEH (parent training, school based, summer tx program) \> Community care (could use pharmacological treatment) Non-ADHD (Oppositional/aggression, social skills, internalizing, parent-child relations, academic) COMB\>MED\>BEH\>Comm Care

Answer 143

Depression (point prevalence 5% in adolescents): Initial trial (12 weeks) – Combined \> FLX \> CBT = CM/PLB (response rate CBT 48%) Follow-up trial (36 weeks) – CBT closer to FLX (69% vs. 65% response rate) Suicidal ideation: PLB/CM \< CBT \< combination \< FLX

Answer 144

a. Circle – 3 years b. Cross – 4 years c. Square – 5 years d. Triangle – 6 years

Answer 145

Dresses and undresses self – 5 years Counts age on one hand – 3 years Walks down stairs one step at time – 4 years Skips – 5 years

Answer 146

The K-SADS-PL (Schedule for affective disorders and schizophrenia for school-age children: present and lifetime version) is an interviewer-based, semi-structured interview for children ages 6-18 years. It focuses on assessing episodes of psychopathology and to make categorical diagnoses by interviewing parents and children. It uses a 3-point scale (previous K-SADS versions used a 6-point scale) from 0-3 and has 82 items. It contains five supplement checklists for affective disorders, psychotic disorders, anxiety disorders, behavioural disorders and substance abuse and other disorders. The single module K-SADS (e.g. depression) can be used for follow-up sessions to monitor response to treatment.

Answer 147

Abusive parents - Often abused themselves - Brought up with harsh corporal punishment and cruel treatment - Mother \> father for physical abuse - Parents suffering from mental disorders Environment - Overcrowding - Poverty - Social isolation - Time of crises (housing, financial, unemployment) Child - Premature - MR or physically disabled - Cry frequently or unusually demanding - Hyperactive

Answer 148

a. Tuberous sclerosis b. Neurofibromatosis I c. Cri du chat d. Williams syndrome

Answer 149

Encoporesis – at least 4 years old & occurs once monthly for 3 months Enuresis – at least 5 years & clinically significant distress or twice a week for 3 months

Answer 150

a. ADHD (50%) b. OCD (40%)

Answer 151

Angelman syndrome – 90% have epilepsy

Answer 152

a. Attention b. Executive functioning c. Episodic (working) memory

Answer 153

Animal studies show that the locus ceruleus plays a major role in attention. It is hypothesized that the peripheral (not central) sympathetic system is important in ADHD. There is thought to be dysfunction in the peripheral epinephrine, resulting in its accumulation and providing feedback to the central sympathetic system. The result is resetting of the locus ceruleus.

Answer 154

They are: a) GAD (6.5%), b) separation anxiety disorder (2.4%), c) social phobia (2.2%)

Answer 155

a. Lower IQ b. Earlier age of onset (especially \< age 10) c. Developmental delay d. Poor premorbid functioning (also related to co-morbidity) e. Premorbid behavioural disorders (ADHD, Conduct) f. Limited recovery of functioning after 1st episode g. Poor support

Answer 156

a. Capacity for age appropriate relationships b. Anxiety for situations with peers and adults c. Anxiety manifest by freezing, tantrums, crying or shrinking for unfamiliar d. Duration under 18 years, duration is at least 6 months e. Does not need to recognize fear as excessive

Answer 157

a. Response to phobic stimulus can be freezing, tantrums, or clinging (instead of PA) b. Duration is 6 months for under 18 years age c. Phobias can include: loud sounds or costume characters d. Does not need to recognize fear as excessive

Answer 158

MASC – Multidimensional Anxiety Scale for Children

Answer 159

Klein-Levin syndrome a. Periodic hypersomnia (lasting 2-3 weeks) b. Withdrawal from social contacts c. Apathy or irritability d. Sexual disinhibition e. Hyperphagia f. Onset during adolescence and remits spontaneously before age 40 years g. Disorientation or hallucinations in rare cases h. More common in males Kluver-Bucy Syndrome a. Visual agnosia b. Compulsive licking and biting c. Hyperorality d. Placidity e. Inability to ignore any stimulus f. Hypersexuality g. Hyperphagia

Answer 160

a. GH – increased basal level b. T3 – mildy decreased c. TSH – normal (but response to TRH is delayed or blunted) d. LH/FSH – decreased e. Plasma cortisol – mildly increased f. Insulin – delayed release

Answer 161

g. Cachexia – loss of muscle mass, reduced thyroid metabolism (low T3), cold intolerance h. Cardiac – small heart (loss of cardiac muscle), arrhythmia, prolonged QT, V. Tachycardia i. GI – delayed gastric emptying, bloating, constipation, abdominal pain j. Reproductive – amenorrhea, low LH and FSH k. Derm – lanugo, edema l. Heme – leucopenia m. Skeletal – osteoporosis n. Neuropsych – depression, mild cognitive disorder

Answer 162

a. Metabolic – HYPOkalemia. Hypochloremic alkalosis; hypomagnesemia b. GI – inflamed salivary gland and pancreas, increased serum amylase, esophageal/gastric erosion, dysfunctional bowel c. Dental erosion and caries d. Neuropsychiatric – seizures, mild neuropathies, cognitive disorder

Answer 163

a. Persistent decline in oral intake or rapid weight decline (\>4 kg/month) in adult patients who have already lost 20% of estimated health weights despite outpatient treatment b. Abnormal vital signs: marked orthostatic hypotension of increase pulse 20 bpm or drop BP 20mmHg, HR \<40bpm, HR\>110bpm or inability to sustain core body temperature c. Metabolic abnormalities – Na\<125, K\<2.5, MG\<0.55, Glc\<2.5 d. If uncontrolled diabetes and no supervision for food intake, exercise or insulin e. Pregnancy if felt there is risk to fetus

Answer 164

a. Nutritional rehabilitation – 2-3 lbs per week if hospitalized or 0.5-1 lb/week for outpatients (I) b. Psychotherapeutic management during acute refeeding (supportive psychotherapy) (I) c. CBT and IPT once weight stable (II) d. SSRI’s not useful in terms of weight gain (I) e. SSRI + psychotherapy in weight restored for depression, anxiety or OCD (II) f. Only offer estrogen for menses after weight restoration attempted (I) g. Use Calcium and Vit D only if poor Ca intake or lack of sunlight, they do not reverse bone mineral density (I) h. Family therapy if adolescent (I)

Answer 165

a. Nutritional rehabilitation with structured meals, nutritional counselling (I) b. CBT most effective for acute BN (I) c. If poor response to CBT, use IPT or fluoxetine (II) d. Family therapy for adolescents (II) or couples therapy if married (II) e. SSRI are effective as part of initial treatment program & use higher doses than for depression (I)

Answer 166

AN @ 10 years: a. 25% completely recover b. 50% have improved and functioning fairly well c. 25% poor outcomes and underweight – 5.6% mortality rate per decade \*Note: Early age of onset has a better prognosis

Answer 167

a. Disturbance in body image and body concept of delusional proportions b. Inaccurate and confused perception and cognitive interpretation of stimuli arising in the body – most pronounced deficiency is failure to recognize signs of nutritional needs c. Paralyzing sense of ineffectiveness pervading all think and activities in patient (act in demands to others & not able to do what they want to)

Answer 168

Long history, later age of onset (as opposed to early adolescence), severe weight loss, substance abuse (alcohol use predicts mortality), OCPD traits, binge/purge sub-type.

Answer 169

Prevalence = 1-2% Males (25%), females (75%) [as opposed to AN and BN – 90% females) Age of onset – 40’s

Answer 170

Chromosome 1 for AN (chromosome 10 for BN)

Answer 171

a. Desire b. Excitement c. Orgasm d. Resolution

Answer 172

a. Congenital Virilizing Adrenal Hyperplasia (Androgenital syndrome) - Enzymatic defect in production of adrenal cortisol leading to excess & virilization of female fetus b. Androgen Insensitivity Syndrome (Testicular feminization) - Person has XY karyotype but tissue cells unable to use testosterone or other androgens; raised as girl but later has cryptorchid testes secreting testosterone with no response from tissues. Female features. c. Turner’s Syndrome - X karyotype, short, female genitalia, ovary dysfunction, webbed neck and require exogenous estrogen to develop female secondary sex characteristics d. Klinefelter’s Syndrome - XXY karyotype and male at birth. Excessive gynecomastia in adolescence and small testes. High rates of gender identity disorder. e. 5-alpha-Reductase deficiency - Prevents conversion of testosterone to dihydrotestosterone needed for prenatal virilization of genitalia – raised as female and may preserve female gender identity by removing testes f. Pseudohemaphroditism - Presence of virilized genitals in a person who is XX (commonly due to androgenital syndrome)

Answer 173

a. Erection – dopamine enhances, alpha-adrenergic decreases, beta-adrenergic enhances (beta-blockers cause impotence, dopamine antagonists case impotence) b. Ejaculation / Orgasm – 5-HT decreases, alpha-1 enhances (1-blockers impair ejaculation, 5-HT agents impair)

Answer 174

a. Jet lag type b. Delayed sleep phase type c. Shift work type d. Unspecified type (e.g. advanced sleep phase (opposite direction of delayed sleep phase), non-24 hour sleep pattern)

Answer 175

a. Prolonged sleep latency b. Increased intermittent wakefulness c. Early morning awakening d. Reduced NREM (Stage 3 & 4) e. Decreased REM latency f. Increased REM density (number of REM per night) g. Increased duration of REM sleep early in night \*These occur in 40-60% of depressed outpatients and 90% of inpatients. These abnormalities may persist after clinical remission.

Answer 176

a. REM diminished early in acute exacerbation b. REM latency reduced c. Total sleep time reduced d. Slow wave sleep is reduced e. RLS / PLMD secondary to antipsychotic and hypodopaminergic state

Answer 177

Restless leg syndrome is characterized by:  Desire to move legs or arms associated with uncomfortable sensations (creepy, crawly, tingling)  Move frequently to relieve sensations  Symptoms worse at rest  Can delay sleep onset  Can lead to daytime sleepiness and fatigue  PLM’s occur in many of RLS patients  Increased risk with age and equal gender distribution  Co-morbid: Pregnancy, renal failure, RA, PVD, peripheral nerve dysfunction, FE deficiency Periodic Limb Movements are characterized by:  Repeated low amplitude brief limb jerks (commonly in lower extremities)  PLM’s begin near sleep onset and decreased during SWS & REM  Occur rhythmically every 20-60 seconds with brief arousals  Individuals are often not aware of movements  Occur in a majority of patients with RLS  Increased with age and occur in 1/3 over 65 years  Men affected more than women  Etiology: Renal disease, pregnancy, CHF, PTSD, Fe deficiency

Answer 178

Nightmare disorder: a. Occur late in night b. Occur during REM c. Produce vivid dream imagery d. Cause complete awakenings e. Detailed recall of event and fully alert on awakening f. Mild autonomic arousal g. Prevalence: 10-50% of children ages 3-5 years have nightmares (prevalence of disorder unknown) Sleep Terror Disorder a. Occur in first third of night b. Occurs during SWS (Stages 3 & 4) c. Lead to partial awakenings where person is confused and disoriented d. Can be accompanied by panicky scream on awakening e. No recall of dream or content f. Partially responsive on awakening g. Significant autonomic arousal h. Prevalence: 1-6% in children and less than 1% adults Sleep terrors have onset between 4-12 years and most resolve by adolescence. The adult type has onset in 20-30 years. There is a positive family history for sleep terror disorder and it occurs with sleep-walking disorder. Nightmare disorder onset is 3-6 years and they also resolve spontaneously.

Answer 179

Serotonin: i. Promote sleep (i.e. ingestion of L-trytpophan) ii. Reduce nocturnal awakenings and reduce sleep latency Norepinephrine iii. Increased firing of NE neurons reduces REM (REM-off neurons) iv. Increases wakefulness Acetylcholine v. Promotes REM (REM-on neurons)

Answer 180

a. Arise at same time daily b. Limited daily in-bed time to the usual amount before sleep problems started c. Only use bed for sleep and sex d. Discontinue CNS activating drugs e. Avoid daytime naps f. Establish physical fitness – graded program g. Avoid evening stimulation h. Try had 20-minute bath i. Eat meals at regular times j. Practice evening relaxation exercises k. Maintain comfortable sleeping conditions

Answer 181

a. Loss of muscle tone b. Increased pulse, BP, RR c. Poikilothermia d. Partial or full penile erection (also Dreaming)

Answer 182

NREM (75%) – Stage 1 (5%), Stage 2 (45%), Stage 3 (12%), Stage 4 (13%) REM (25%) \*Note: REM accounts for 50% of sleep in neonates and decreases with age

Answer 183

Delta – 0.5-3 Hz - SWS Theta – 3-7 Hz – REM, Stage 1 Alpha – 8-12 Hz – Awake Beta – 16-25 Hz – Awake Spindle & K-complex – 12-14 Hz – Stage 2-4 (both a characteristic feature of Stage 2) Sawtooth – REM

Answer 184

a. Brief sleep latency b. High sleep efficiency c. Approximately 40% of sleep in REM d. Short REM latency e. Easy awakening

Answer 185

a. Increased REM latency b. Decreased REM sleep c. Decreased nocturnal awakening d. Decreased sleep latency

Answer 186

a. Phase advance b. Increased wakefulness c. Increased sleep latency d. Decreased REM latency e. Decreased total REM f. Decreased stage 3 and 4 sleep

Answer 187

Children: conduct disorder and anxiety disorder Adults: ASPD, NPD, BPD

Answer 188

You should suspect major depression when the patient has: e. Guilt about things other than actions not taken by the survivor at the time of the death f. Presence of thoughts of wanting to die that are outside of wanting to join the deceased or being better off dead g. Morbid preoccupation with worthlessness h. Profound psychomotor retardation i. Prolonged and marked functional impairment j. Hallucinatory experiences other than hearing the voice or transiently seeing the image of the deceased

Answer 189

Intermittent explosive disorder

Answer 190

- The winning phase (big win hooks person) - The progressive-loss phase (structure life around gambling, take considerable risks) - The desperate phase (gamble large amounts, large debts) - The hopeless stage of accepting that losses can never be made up

Answer 191

- Screening – underreported and underdiagnosed - Gamblers Annonymous - Psychotherapy – wait 3 months and after insight developed; can use individual psychodynamic or CBT - Limited evidence for pharmacotherapy – SSRI or clomipramine; treat co-morbid conditions

Answer 192

a. Loss of a parent before 15 years old b. ADHD c. Inappropriate parental discipline d. Family emphasis on material objects e. Childhood encephalitis f. Perinatal trauma

Answer 193

- Pursue the correct diagnosis - Minimize harm from medical interventions/investigations - Interdisciplinary meetings - Behavioural strategies such as the double bind - Treat comorbid axis I and II disorders - Appoint a primary medical gatekeeper - Involve risk management - Consider prosecution for fraud as a behavioural disincentive

Answer 194

Prerequisites are: r. High motivation s. Able to form relationships t. Psychological mindedness and capacity for insight u. Ego strength Contraindications are: h. Absence of suffering i. Poor impulse control j. Inability to tolerate frustration and anxiety k. Low motivation to understand l. Concrete thinking or absence of psychological mindedness m. Dishonesty or ASPD n. Close relationship with analyst o. Low intelligence

Answer 195

 Oral Phase – to develop a trusting dependence on nursing and sustaining objects  Anal Phase – strive for independence and separation from dependence and control of parents  Urethral Phase – issues of control and loss of control (similar to anal)  Phallic Phase – focus on erotic interest in the genital area and genital functions  Latency – further integration of oedipal identifications and consolidation of sex role  Genital – ultimate separation from dependence on and attachment of the parents

Answer 196

Primary process refers to a primitive mode of cognitive activity characterized by bizarre, illogical and absurd images that seem incoherent. It involves mechanisms of displacement, condensation and symbolic representation. Secondary process is the mature activity of waking life and is associated with the secondary revision, where dreams become more rational.

Answer 197

i. Universality ii. Instillation of hope iii. Interpersonal learning iv. Group Cohesion v. Imparting information vi. Existential factors vii. Imitative Behaviours viii. Catharsis ix. Altruism x. Developing socializing techniques xi. Corrective recapitulation of primary family xii. Others from K&S: Insight, Reality testing, transference, empathy

Answer 198

xiii. Clarify misconception or fears xiv. Establish clear rule and boundaries (e.g. extragroup socializing) xv. Anticipate potential problems or obstacles for patient xvi. Clarify group expectations of patient (e.g. attend each session) xvii. Description of group treatment (length of session, duration) xviii. Review confidentiality xix. Provide guidelines how to participate in group xx. Instil faith in group

Answer 199

a. Denial b. Projection c. Distortion

Answer 200

Structural family therapy:  Salvador Minuchin  Developed for children/adolescents with emotional problems  Focuses on organization of family and how it promotes/inhibits task performance  Therapist analyzes task performance to determine: o Closeness/Nature o Flexibility  Explores (i) Enmeshment and (ii) Disengagement and fluctuation between these extremes

Answer 201

 Murray Bowen  Views the family as an emotional relationship system  Goal of this therapy is to promote engagement, foster differentiation & avoid fusion  Try to get family to triangulate with therapist (3rd party)  Work through intergenerational and introjected difficulties in pattern

Answer 202

 Milan group  Symptomatic behaviour is thought to be due to family patterns of communication and family relationships  Therapist will develop and prescribe tasks/behaviours to disrupt these patterns of interaction (through patient education and behavioural techniques)  Techniques include: circular questioning (explore patterns of communication by having one family member describe pattern in another), posing hypotheses, externalizing blame and positive connotation

Answer 203

Dialectical behaviour therapy is derived from supportive, CBT and Zen philosophies and was developed by Marsha Linehan. Its essential functions are: a. Distress tolerance b. Interpersonal effectiveness c. Mindfulness d. Emotion regulation It uses four modes of treatment: a. Individual therapy b. Phone consultations c. Group skills training d. Consultation team

Answer 204

a. Decreasing high-risk suicidal behaviours b. Decreasing responses of behaviours (by either therapist or patient) that interfere with therapy c. Decreasing behaviours that interfere with/reduce quality of life d. Decreasing and dealing with post-traumatic stress response e. Enhancing respect for self f. Acquisition of the behavioural skills taught in group g. Additional goals set by patient

Answer 205

a. To enhance and expand patient’s repertoire of skilful behavioural patterns b. To improve patient motivation to change by reducing maladaptive behaviours, dysfunctional cognition and emotion c. To ensure generalization of new behaviours from therapeutic setting to patient’s environment d. To structure the environment so that effective behaviours, rather than dysfunctional behaviours, are reinforced e. To enhance motivation and capabilities of the therapist so that effective treatment is rendered

Answer 206

Systemic desensitization involves gradually exposing an individual to imagined scenes of the feared stimulus paired with relaxation techniques. Exposure occurs in a graded fashion. The components can be outlined as follows:  Relaxation training  Hierarchy construction (imaginal)  Desensitization of the stimulus – patient re-experiences anxiety in graded fashion starting in relaxed states, thus pairing the two and resulting in reciprocal inhibition  Note: Therapeutic graded exposure does not use the concept of paired relaxation. Flooding is exposure without the hierarchy and without relaxation.  Also, systemic desensitization is used for phobias, obsession and compulsions.

Answer 207

 Acting out  Patient has severe incompatibility with another group member  Acute psychosis  Severe distrust  Inability to tolerate group setting  Excessive use of denial  Assume deviant role (also possibly ASPD)  Major difficulties with self-disclosure or intimacy ?not speaking group's language as primary language?

Answer 208

1. Idealizing 2. Mirroring 3. Twinship

Answer 209

1. Altruism 2. Anticipation 3. Asceticism (Eliminating the pleasurable effects of experiences) 4. Humour 5. Sublimation 6. Suppression

Answer 210

 Introjection  Hypochondriasis  Regression  Schizoid fantasy  Somatization  Passive-aggressive behaviour  Blocking  Acting out

Answer 211

a. Shock and denial b. Anger c. Bargaining d. Depression e. Acceptance

Answer 212

a. Protest b. Yearning for the deceased c. Despair and disorganization d. Acceptance

Answer 213

 Chronic grief – most common type & highlighted by bitterness and idealization; occurs when relationship with deceased was extremely close, ambivalent or dependent  Hypertrophic grief – seen with sudden unexpected death and is an intense grief reaction  Delayed grief – absent or disinhibited grief when one expects to find normal signs and symptoms of grief

Answer 214

a. Encourage grieving person to talk about their feelings of loss and person who has died b. Help grieving person recognize feelings (i.e. anger) and normalize experience c. Therapist should be active and participate in planning with patient

Answer 215

The McMaster model incorporates a family systems and behavioural approach. It does not focus on the pathology of the individual but instead focuses on the system. It employs a problem-solving approach by examining each of the following dimensions: 1. Provision of resources 2. Nurturance and support 3. Sexual gratification 4. Life skills development (i.e. child start & go to school, personal development) 5. Maintenance & management of family systems (i.e. leadership, decision-making, boundaries) 6. Role Allocation (i.e. assignment of family responsibilities) 7. Role accountability

Answer 216

a. Sensorimotor (0-2 years) – primary circular (imitation, smiles), secondary circular (looks for partially hidden objects), and tertiary circular (explores objects, drops it), object permanence (remembers object once out of sight) b. Preoperational (2-7 years) – egocentric, animistic, irreversibility c. Concrete operational (7-11 years) – reversibility, conservation d. Formal operational (11+ years) – abstract thinking

Answer 217

Object relations theory encompasses the transformation of interpersonal relationships into internalized representations of relationships (they do not just internalize objects or persons, they internalize the whole relationship).

Answer 218

 First few months of life, child experiences fear of annihilation – similar to death instinct (Freud)  Result is the ego splits this terror and projects all “badness” onto the mother  Infant fears mother’s persecution and that mother will destroy goodness inside infant = paranoidschizoid position  May reintroject badness and continue cycle of projection-introjection  Infant realizes good mother and bad mother are one – depressive position  Child develops guilt and tries to resolve it through reparation

Answer 219

Attachment is a close emotional relationship with mutual affection and desire to maintain proximity. It is a primary drive for survival and the sensitive period for its development is the first 3 years of life. Attachment theory originated from Bowlby and is related to Harry Harlow’s work with monkeys. Mary Ainsworth described 4 attachment patterns in infants, building on Bowlby's work: a. Secure b. Insecure-ambivalent c. Insecure avoidant d. Insecure-disorganized Main describes 4 adult attachment patterns based on adult’s own early attachment experiences and their internal working model: a. Secure – capable of high levels of both autonomy and intimacy. Descriptors include: adaptable, capable, trusting, understanding. b. Preoccupied – high intimacy but low levels of autonomy. Descriptors include: anxious, impulsive, approval seeking, dependent. c. Dismissing – high levels of autonomy but low intimacy. Descriptors include: independent, cold, competitive, selfreliant. c. Fearful/Unresolved – Difficulty with both autonomy and intimacy. Descriptors include: cautious, doubting, selfconscious, shy, isolated.

Answer 220

 Preconventional – punishment and obedience of parent are determining factors  Conventional Role-conformity – children conform to gain approval & maintain good relationships  Self-Accepted Morals- children voluntarily complies with rules

Answer 221

Winnicott believed that children begin life in a state of non-integration and mothers provide the relationship that enables the infant’s incipient self to emerge. Mothers provide the holding environment, which contains the infant and his/her experiences. The mother need not be perfect but good enough in terms of resonating the infant’s needs. This will allow the infant to evolve one’s sense of self.

Answer 222

1. Narrative Coherence – associated with a secure attachment a. Congruence of affect and content b. Fluid and complete time lines in telling personal history c. Detailed descriptions of others d. Specific examples that illustrate generalizations e. Examples of Narrative Incoherence i. Preoccupied: over inclusive with too many words that convey little substance, overly dramatic, confusing present and past tense, assuming an unreasonable familiarity from the therapist, all evidence but no conclusion ii. Dismissing: little to say, lacking affect, idealized or undetailed descriptions, contradictory description or no examples, all conclusion but no evidence 2. Reflective Functioning (mentalizing or metacognition) a. The ability to distance oneself sufficiently from the moment or interaction to think about the situation. b. The ability to empathize; to recognize that another person has motivations and interests c. The ability to keep people “in mind” (relates to the belief that others are able to keep them in mind) d. The ability to keep one’s different states over time in mind. 3. Internal Working Model a. Self other boundaries (dismissing = rigid, preoccupied = porous) b. Trust and intimacy c. Exploration and Autonomy d. View/Expectation of others e. View/Expectation of self 4. Patterns of Anger a. Secure i. Healthy assertiveness ii. Reflective distance – talking about being angry iii. Recovery from confrontation b. Dismissing i. Passive aggressive ii. Adept, logical confrontation iii. Intimidation or disengagement c. Preoccupied i. Draws others into collusion or recapitulation ii. Theme of victimization 5. Non-verbal Communication a. Dismissive i. Harsh unmodulated tone of voice ii. Intimidation b. Preoccupied i. Monotonous, rambling discourse ii. Unwarranted or premature familiarity iii. Superficially pleasant and irritatingly apologetic 6. Defensive Functioning and Coping Style a. Dismissive i. Suppression, repression, denial ii. Isolation of affect iii. Self-criticism, self control, confrontation b. Preoccupied i. Projection and projective identification ii. Ineffective/excessive support seeking

Answer 223

Trust vs. Mistrust (0-18 mos.) – Hope Autonomy vs. Shame/Doubt (18months-3years) – Will Initiative vs. Guilt (3-5 years) – Purpose Industry vs. Inferiority (5-13 years) – Competence Identity vs. Role confusion (13-20) – Fidelity Intimacy vs. Isolation (20-40) – Love Generativity vs. Stagnation (40-60) – Care Integrity vs. Despair (60+) – Wisdom

Answer 224

a. Latent Content – unconscious thoughts and wishes that threaten to awaken dreamer b. Manifest Content – what is recalled by dreamer

Answer 225

This describes infants suddenly separated from their mothers due to hospitalization for varying times and developed depressed, withdrawn, nonresponsive and vulnerable to physical illness. They recovered when returned to their mothers or had surrogate mothering

Answer 226

(Expressive psychotherapy indications listed in parentheses) a. Significant ego deficits (Strong motivation to understand, ability to regress into the service of the ego) b. Severe life crisis (Significant suffering) c. Poor frustration tolerance (Tolerance for frustration) d. Lack of psychological mindedness (capacity for insight) e. Poor reality testing (Intact reality testing) f. Severely impaired object relations (Meaningful object relations) g. Poor impulse control (good impulse control) h. Low intelligence (Ability to sustain work) i. Little capacity for self-observation (Capacity to think in metaphors and analogy) j. Organic based cognitive dysfunction (Reflective responses to interpretations) k. Tenuous ability to form therapeutic alliance

Answer 227

Grief - Re-construct patient’s relationship with the deceased - Explore negative and positive feelings associated with deceased - Consider ways of becoming involved with other people Interpersonal deficits - Review positive and negative relationships - Explore repetitive patterns in relationships - Note problematic interpersonal patterns in session and relate to patterns in patient’s life Interpersonal role disputes - Determine stage of dispute – renegotiation, impasse, dissolution - Understand how nonreciprocal role expectations relate to dispute - Identify resources to bring about change in relationship Role transitions - Review positive and negative aspects of old and new roles - Explore feelings about what is lost - Encourage development of social support system and new skills for new role

Answer 228

Initial - Structure sessions to encourage appropriate self-disclosure & facilitate norms for effective communication - Help members understand their reactions in the context of interpersonal differences in their outside social lives Middle - Facilitate connections amongst group members - Encourage practice of acquired interpersonal skills in and outside of groups Final Sessions - Help members consolidate their work and plan for continued work - Assist members grieving the loss of group

Answer 229

a. Asthma b. Migraine / Tension headaches c. Cardiac arrhythmias d. Idiopathic hypertension and postural hypotensions e. Grand mal epilepsy f. Myofascial / TMJ pain g. Raynaud’s syndrome h. Dysmenorrhea a. Insomnia b. Somatoform disorders c. Anxiety symptoms

Answer 230

He divided suicide into three social categories: a. Egoistic suicide – those who are not strongly integrated into society b. Altruistic suicide – those susceptible to suicide due to their excessive integration into a group (e.g. Japanese soldier who sacrifices himself in battle) c. Anomic suicide – persons with disturbed integration into society who cannot follow customary norms of behaviour (e.g. drastic change in financial situation increases vulnerability to suicide)

Answer 231

a. Mild – 1.5-2.0 mmol/L i. Ataxia, nystagmus, vomiting, abdominal pain, slurred speech, dizziness, lethargy, weakness b. Moderate – 2.0-2.5 mmol/L i. Anorexia, persistent N/V, blurred vision, muscle fasciculations, convulsions, clonic limb movements, choreoathetoid movements, delirium, coma/stupor, hyperreflexia c. Severe - \>2.5 mmol/L i. Oliguria, generalized convulsions, death

Answer 232

Risk factors are: Prior NMS, agitation, dehydration, high dose of neuroleptics, rapid dose increase, IM injection of neuroleptic and concurrent treatment with lithium. Males and younger age are also at higher risk

Answer 233

a. The Beck Hopelessness Scale – self-administered, 20 yes/no items on the scale, scored 0-1, and has the following classification of scores: 0-3 minimal, 4-8 mild, 9-14 moderate and 15-20 severe. b. The Beck Scale for Suicide – self-administered, 21 items score scored 0-2, no cut-offs and higher scores (max = 38) indicate greater increasing suicidal ideation and risk

Answer 234

They studied the relation of social class to the prevalence of treated mental disorders in New Haven, Connecticut. They found a higher incidence and prevalence of mental disorders in lower than in the upper social classes. Lower classes had more psychosis and higher classes had more neurosis. Higher classes received treatment from private hospitals and psychiatrists and low classes were treated in public and state hospitals

Answer 235

This was a cross-sectional study of mental health in Manhattan. It found that 18.5% of respondents were “well” and 23.4% were mentally “impaired”. It found that social status was the single most significant variable affecting mental illness (persons of low SES had 6 times as many symptoms as high SES)

Answer 236

This study was conducted in the mid-1930s and looked at admissions to mental hospitals in Chicago. It found that first hospital admissions for schizophrenia were highest among person from central Chicago. Rates decreased as one moved away from Chicago. It led to the following hypotheses: a The Drift Hypothesis - holds that impaired persons slide down the social scale because of their illness (relates to the Social Selection Theory) b. Social Causation Theory – holds that being a member of low SES is a significant factor in causing mental illness

Answer 237

It was performed in rural Nova Scotia. It aimed to study the relationship between the degree of community integration and disintegration and mental health of its inhabitants. Community disintegration was defined by frequency of broken homes, strength of associations, strength and number of leaders, patterns of recreation, frequency of recreation, frequency of hostility and fragmentation of networks of communications. Findings: a. 57% interviewed had some mental disorder b. More psychiatric difficulties in lower SES c. Sociocultural disintegration associated with a higher risk of psychiatric disorder than community integration d. Disintegrated communities that became more integrated had decreased prevalence of psychiatric disorders

Answer 238

a. Equity b. Effective c. Efficient d. Patient Centred e. Timely f. Safety g. Reward

Answer 239

a. Quality planning – define customers, needs, respond to needs with development of products b. Quality control – evaluated product performance, compare product to goals c. Quality improvement – design infrastructure to improve products, provide teams with resources, diagnose causes for poor quality \*Total Quality Management aims to continuously improve patient care and services. Looks at processes and uses a system. Avoids blame.

Answer 240

a. Plan – objective, questions/predictions, plan to answer questions, plan data collection b. Do – carry out plan, collect data, begin analysis c. Study – complete analysis, compare predictions, summarize findings d. Act – what changes need to be made, how can we build on this (next cycle) \*\*Called the PDSA cycle.

Answer 241

Type 1 error (alpha) – when you reject a null hypothesis when it is true Type 2 error (1-beta) – when you accept a null hypothesis when it is false

Answer 242

Relative risk is the ratio of disease incidence in exposed and unexposed groups. It is useful in the study of disease causation. Attributable risk = incidence rate of disease in exposed – incidence rate of disease in unexposed (usually a expressed as a percentage)

Answer 243

Sensitivity = True positive / (True positive + False negative) - prob test is positive if you have disease Specificity = True negative / (False positive + True negative) - prob test is negative if you don’t have disease Positive Predictive Value = TP / (TP + FP) - How likely you have the disease if your test is positive Negative Predictive Value = TN / (FN + TN) - How likely you don’t have the disease if your test is negative

Answer 244

Relative risk is the ratio of the probability of the event (or disease) occurring in the exposed group versus the control (nonexposed) group. RR = Probability in exposed / Probability in control Odds ratio is the ratio of an event (disease) occurring in one group versus another. OR = (Prob Exposed / 1- Prob Exposed) / (Prob Unexposed / 1- Prob Unexposed)

Answer 245

a. Longer acute episode b. Longer time from index episode to second episode c. More likely to have MDE as first episode d. Less likely to have family history of Bipolar disorder e. Less substance use / alcohol use f. Less euphoria / more mixed episode g. Less paranoid delusions h. More irritability i. Rarely but more often than younger can have Delirious mania

Answer 246

Highest suicide rate – men ages 80-85 years = 38/100 000 (30/100 000) for 20-24 years) Highest suicide rate – women ages 45-49 years (9/100 0000)

Answer 247

Men = #1 – Firearms (28%) Women - #1 – Self-poisoning

Answer 248

a. Non-modifiable – male, increased age, widowed or divorced, losses (health, role), previous SA b. Modifiable – affective d/o, psychotic d/o, anxiety d/o, SUD, low social supports, presence of SI, presence of pain, neurobiological (low 5-HT or NA), exposure/access to firearms

Answer 249

a. Reduced hepatic oxidation b. Reduced splanchnic (portal) blood flow (a & b lead to reduced hepatic metabolism) c. Decreased plasma albumin (increased free drug) d. Decreased GFR e. Increased fat-muscle ratio (decreased concentration of lipophilic drugs) f. Reduced total body water (increased concentration of water soluble drugs)

Answer 250

a. Increased receptor sensitivity (Except decreased baroreceptor sensitivity with age) b. Decreased receptor numbers (Decreased D2 receptors with age) c. Decreased neurotransmitters (Decreased Ach with age) \*Also: Increased MAO with age

Answer 251

a. Type of depression and urgency b. Previous response to medication c. Co-morbid medical problems d. Concurrent medications e. Drug half-life (low potential for accumulation) f. Symptom profile (anticholinergic qualities if patient already has dry mouth)

Answer 252

Approximately 30% - mainly paranoid content.

Answer 253

The triad is: urinary incontinence, ataxia and dementia.

Answer 254

Rivastigmine has 2 RCT’s demonstrating improvement in neuropsychiatric symptoms, cognition and functioning. Studies for other cholinesterase inhibitors or other medications are limited.

Answer 255

MCI involves mild cognitive deficits including a score of 24-26 on the MMSE and NO functional impairment. Approximately 10-15% (amnestic type) convert to Alzheimer’s dementia per year. Risk factors for MCI include: a. Hypertension b. Hypercholesterolemia in mid-life c. Low level of education d. African-American descent e. Cerebral infarcts on MRI f. Depression

Answer 256

65-74 years – approximately 2.5% 75-84 years – approximately 15% 85\< years – approximately 30% (actual 34%)

Answer 257

a. Neurofibrillary tangles (medial temporal lobe & nucleus basalis of Meynert) b. Amyloid plaques c. Cell degeneration and loss (neuronal and synaptic loss, granulovascular degeneration)

Answer 258

a. Insiduous onset and gradual progression b. Loss of insight c. Early decline in social interpersonal conduct (inappropriate) d. Early impaired regulation personal conduct (disinhibition) e. Early emotional blunting

Answer 259

a. fvFTD (frontal variant) / bvFTD (behavioural variant FTD) b. Progressive non-fluent aphasia (L. frontal) – expressive dysfunction, nonfluent speech c. Semantic dementia (temporal, L\>R) – receptive dysfunction, loss of semantic memory

Answer 260

Alzheimer’s & DLB

Answer 261

a. COPD / Asthma b. LBBB or sick sinus syndrome c. Peptic ulcers

Answer 262

e. Alzheimer’s dementia f. Parkinsons-dementia complex of Guam and post-encephalitic dementia g. Hallervorden-Spatz disease h. Normal aging brains i. Dementia pugilistica j. Progressive supranuclear palsy k. CJD (Prion disease) l. Down’s syndrome m. Pick’s Disease

Answer 263

a. Cortex b. Hippocampus c. Substantia nigra d. Locus ceruleus

Answer 264

a. Alzheimer’s b. Down’s c. Normal aging \*\*Senile plaques correlate to severity of disease

Answer 265

It is associated with late-onset DAT. One APOE4 gene – 3 times risk Two APOE4 genes – 8 times risk

Answer 266

a. Amyloid precursor protein (APP on Chromosome 21) b. Presenilin 1 and 2 (PS1 on Chromosome 14 and PS2 on Chromosome 1) c. Ubiquilin 1 (UBQLN1) \*10% of AD are hereditary. 7-80% of hereditary AD attributable to PS1 on chromosome 14, which cause onset age 40-50 years. Another 20-30% of hereditary are due to PS2 on chromosome 1. About 2-3% of hereditary AD is due to APP on chromosome 21. PS2 and APP have onset of AD at age 50 years. APOE3 and more so, APOE4, increase susceptibility to tau and account for the 90% of sporadic AD cases. Onset with APOE4 is 60 years.

Answer 267

a. Spongiform vacuolization b. Neuronal loss c. Astrocyte proliferation in cerebral cortex (BG and Cortex most affected in CJD)

Answer 268

This study examined the effects of antipsychotics (risperidone, olanzapine, queitapine) vs. placebo on BPSD in AD patients (n=421). It used time to discontinuation as its primary outcome and patients were randomized to 1 of the 4 treatment/placebo arms. The findings showed that time to discontinuation for efficacy was better for risperidone and olnazapine vs. placebo BUT time to discontinuation due to adverse effects was better for placebo. Therefore, it suggested that the benefits of antipsychotic medications for BPSD did not outweigh the risks. Criticisms: No washout pre-study, could be randomized to drug treatment failed previous, time to discontinuation not suitable for dementia patients (should only use short-term and have trial off), quetiapine dose too low, studied outpatients so might not have severe BPSD

Answer 269

a. Antipsychotics – atypicals preferred due to greater mortality risk with typicals b. Cholinesterase inhibitors – evidence for moderate BPSD (but takes time) c. SSRI (citalopram) – one RCT, but mainly good if co-morbid depression d. Carbamazepine – RCT positive result but limited due to serious side effects \*Trazodone – conflicting data, Valproate – RCT negative and poor tolerability in elderly

Answer 270

DLB and Parkinson’s dementia.

Answer 271

a. Decreased NE b. Increased 5-HT c. Increased MAO activity d. Increased transport across B-B-B e. Decreased CBF and oxygenation f. Increased size of ventricles

Answer 272

a. Motor – involuntary movements, tics, seizures, abnormal gait, astasia-abasia, aphonia, weakness b. Sensory defecits – anaethesia, midline anaesthesia, blindness c. Visceral symptoms – psychogenic vomiting, pseudocyesis, globus hystericus

Answer 273

a. Ophthalmoplegia b. Ataxia c. Mental status changes (delirium, confusion)

Answer 274

a. Colicky abdominal pain b. Motor polyneuropathy c. Psychosis (can also get depression or anxiety) Pearls: Barbiturates precipitate pain. It is autosomal dominant and investigated by urine porphyrins

Answer 275

a. 3-months – 23-33% b. 12-months – up to 50%

Answer 276

Postcardiotomy patients – up to 90%. Cancer/terminally ill patients = 80%. Hip surgery 40-50%. ICU = 30% and medically ill 10-30%.

Answer 277

Alcohol withdrawal or delirium tremens – low voltage, fast activity on EEG.

Answer 278

Screening Instruments  NEECHAM Confusion Scale, Confusion Rating Scale, Clinical Assessment of Confusion, Nursing Delirium Rating Scale Diagnostic Instruments  Delirium Symptom Interview, Confusion Assessment Method (can be administered by non-psychiatric clinician & has ICU version), Delirium Scale, Saskatoon Delirium Checklist, Organic Brain Syndrome Scale, Global Assessment Rating Scale Delirium Symptom Severity Rating Scale  Delirium Rating Scale (DRS) – 26 items and needs to be psychiatrically trained clinician, Memorial Delirium Assessment Scale (MDAS) Note: The MMSE is only 96% sensitive and 38% specific for delirium.

Answer 279

a. Sertraline (SADHART & ENRICHD) b. Citalopram (CREATE) c. Mirtazapine (MIND-IT)

Answer 280

None. CREATE failed to show difference with IPT (but could be to high response in clinical management control). ENRICHD showed transient benefit with CBT regarding social support and depression but females actually did worse with CBT and differences levelled off over course of study.

Answer 281

It inhibits 2D6 and 3A4 substantially. Watch out for the following drugs: paroxetine, fluoxetine, clonazepam

Answer 282

a. MS b. Epilepsy c. Cerebrovascular disease d. AIDS e. Huntington’s disease f. TBI g. Cerebral tumors h. Neurosyphilis i. Heavy metal poisoning j. Herpes encephalitis k. SLE (Lupus cerebritis)

Answer 283

a. Extremely unusual symptoms or inexplicable physiologically b. Repeated hospitalizations or work-ups by numerous caregivers fail to provide conclusive diagnosis or cause c. Physiological parameters are consistent with feigned illness (can see abnormal tracings on apnea monitor prior to resp. arrest of child indicating struggle) d. Patient fails to respond to appropriate treatment e. Vitality of patient inconsistent with lab findings f. Signs and symptoms abate when mother does not have access to child g. Mother is only witness to onset of signs and symptoms h. The unexplained illness has occurred in mother and/or in her other children i. Mother has nursing or medical background or exposure to models of the illnesses affecting the child j. Mother welcomes invasive or painful tests k. Mother grows anxious if child improves l. Mother’s lying is proved. m. Medical direct observations contradict mother’s reports

Answer 284

n. Active and prompt diagnosis can minimize mortality and morbidity risk with tests o. Avoid confronting patient on their lie p. Avoid unnecessary tests or procedures to minimize harm q. Liaise with treatment team to manage their countertransference (regular interdisciplinary meetings) r. Allow patient to save face – double-bind or face-saving behavioural techniques (biofeedback, self-hypnosis) s. Steer patient towards psychiatric ward in nonconfrontational, empathic manner t. Treat underlying psychiatric disturbance u. Appoint primary care provider as gatekeeper v. Consider consulting bioethicist or risk management professionals w. Consider appointing guardian for medical and psychiatric decisions x. Consider prosecution for fraud

Answer 285

a. Apathy (most common) b. Depressive syndrome (irritable mood and anhedonia) c. Psychosis

Answer 286

A. Steroid-induced affective states – mania \> depression B. Steroid-induced delirium C. Steroid-related cognitive impairment D. Steroid-withdrawal phenomena – depression, mania, depersonalization, delirium

Answer 287

These findings were based on 3 studies evaluated in a Cochrane Review: A. Haloperidol – most evidence but no difference in comparison trials of low dose haloperidol with RSP or OLZ B. Risperidone C. Olanzapine

Answer 288

a. Death of spouse b. Divorce c. Marital separation from mate d. Detention in jail or other institution e. Death of close family member f. Major personal injury/illness g. Marriage

Answer 289

He demonstrated that stimulation of the sympathetic nervous system resulted in the fight or flight response (hypertension, tachycardia and increased cardiac output).

Answer 290

a. The alarm reaction b. Stage of resistance in which adaptation is ideally achieved c. Stage of exhaustion – adaptation or resistance may be lost He believed that stress is a non-specific bodily response to any demand and can be pleasant or unpleasant (distress).

Answer 291

A. Psychiatric: Dysphoria, anxiety, mood lability, insomnia, psychosis (delusion,VH in severe cases), delirium (severe), cognitive (decreased attention, impaired recent memory & exaggerated startl) B. Physical: tachycardia, arrhythmias, hypertension, fine tremor, heat intolerance, sweating, weight loss, tachycardia, menstrual irregularities, exophthalmos

Answer 292

High amplitude, low frequency and triphasic waves on EEG.

Answer 293

Partial complex seizures

Answer 294

Valproate is first line according to K&S. Do not use CBZ, as it worsens seizures

Answer 295

Risk factors include: Female, Left-handedness, Left-sided lesion and onset before puberty. (Psychosis occurs in 10% of patients with complex-partial seizures)

Answer 296

Dermatitis, diarrhea, delirium, dementia and death. (Also: peripheral neuropathies, apathy, irritability).

Answer 297

Franz Alexander was a psychoanalyst from Chicago who studies psychosomatic ailments and his specificity hypothesis stated that specific unresolved emotional conflicts led to chronic tensions that cause dysfunction through structural changes in target organs.

K&S SAQ Flashcards

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