Memorize Last-Minute For Exam

Question 0

Epidemiology of panic disorder

Answer 0

• 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 20’s, familial pattern

Question 1

Medical Workup of Anxiety

Answer 1

• routine screening: physical examination, CBC, thyroid function test, electrolytes, urinalysis, urine drug screening
• additional screening: neurological consultation, chest x-ray, ECG, CT

Question 2

Px of panic disorder

Answer 2

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

Question 3

Definition of agoraphobia

Answer 3

ƒ 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
ƒ fears commonly involve situations such as 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

Question 4

Time frame for GAD

Answer 4

occurring more days than not for at least 6 mo

Question 5

In GAD, the anxiety and worry are associated with ≥3 of the following 6 symptoms (with at least some symptoms present for more days than not for the past 6 mo)
Note: Only one item is required in children

Answer 5

restlessness or feeling keyed up or on edge
ƒ being easily fatigued
ƒ difficulty concentrating or mind going blank
ƒ irritability
ƒ muscle tension
ƒ sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

Question 6

GAD epidemiology and Px

Answer 6

• 1-yr prevalence: 3-8%; M:F = 1:2
ƒ if considering only those receiving inpatient treatment, ratio is 1:1
• most commonly presents in early adulthood

Px:
• 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

Question 7

Specific phobia lifetime prevalence

Answer 7

lifetime prevalence 12-16%; M:F ratio variable

Question 8

Social phobia lifetime prevalence

Answer 8

• lifetime prevalence may be as high as 13-16%; F>M

Question 9

OCD lifetime prevalence

Answer 9

lifetime prevalence rates 2-3%; M=F

Question 10

Acute stress d/o

Answer 10

Acute Stress Disorder
May be a precursor to PTSD
Criteria:
• Exposure to traumatic event
• Dissociative symptoms
• Event is persistently re-experienced
• Avoidance of stimuli
• Symptoms of anxiety or increased arousal
• Causes clinically significant distress or impairment in social, occupational or other important areas of functioning
• Symptoms last 2 d to 4 wk and occur within 4 wk of event

Question 11

Criteria for Post-Traumatic Stress Disorder

Answer 11

TRAUMA
Traumatic event 
Re-experience the event
Avoidance of stimuli associated with 
the trauma
Unable to function
More than a Month
Arousal increased

Question 12

PTSD epidemiology

Answer 12

• prevalence in general population: 7%
• men’s trauma is most commonly combat experience/physical assault; women’s trauma is usually
physical or sexual assault

Question 13

Medical Workup of Mood Disorder

Answer 13

• routine screening: physical examination, CBC, thyroid function test, electrolytes, extended
electrolytes, urinalysis, drug screen
• additional screening: neurological consultation, chest x-ray, ECG, CT

Question 14

Time frame for MDE

Answer 14

≥5 of the following symptoms have been present during the same 2-wk 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 (anhedonia)

Question 15

Criteria for Mania

Answer 15

. a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting ≥1 wk (or any duration if hospitalization is necessary)

GST PAID - (≥3) (4 if the mood is only irritable)
Grandiosity
Sleep (decreased need)
Talkative
Pleasurable activities, Painful consequences
Activity
Ideas (flight of)
Distractible

Question 16

Mixed Episode

Answer 16

• criterion met for both manic episode and MDE nearly every day for 1 wk
• criteria D and E of manic episodes are met
• Note: in DSM-5, mixed episode is no longer a separate mood diagnosis; instead, depressed episodes and manic episodes can have a “with mixed features” specifier

Question 17

Hypomanic episode

Answer 17

• criterion A of a manic episode is met, but duration is ≥4 d
• 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

Question 18

MDD risk factors

Answer 18

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

Question 19

MDD epidemiology

Answer 19

Epidemiology
• prevalence: 12.2%
ƒ lifetime prevalence: male 2.9%, female 5%
ƒ annual prevalence: peak prevalence age 15-25 yr (M:F = 1:2)

• genetic: 65-75% MZ twins; 14-19% DZ twins

Question 20

Neurotransmitters in MDD

Answer 20

neurotransmitter dysfunction: decreased activity of 5HT, NE and DA at the level of the synapse; changes in GABA and glutamate

Question 21

MDD Px

Answer 21

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

Question 22

Dysthymia (PDD) time lines

Answer 22

ƒDepressed mood for most of the day, for more days than not, for ≥2 yr
Note: In children and adolescents, mood can be irritable and duration must be at least 1 yr

During the 2-yr period (1 yr for children or adolescents) of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 mo at a time

Question 23

Dysthymia Epidemiology & Tx

Answer 23

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

Treatment
• psychological 
 ƒ principal treatment for dysthymia 
 ƒ individual, group, and family therapy
• biological 
 ƒ antidepressant therapy (SSRIs/SNRIs) as an outpatient

Question 24

Postpartum Depression (PPD)

Answer 24

• diagnosis: MDE, onset within 4 wk postpartum • most lasts 2 to 6 mo; residual symptoms can last up to 1 yr ƒ may present with psychosis – rare (0.2%) and/or mania ƒ • epidemiology: occurs in 10% of mothers, risk of recurrence 50% • risk factors: ƒ previous history of a mood disorder (postpartum or otherwise) ƒ psychosocial factors: stressful life events, unemployment, marital conflict, lack of social support, unwanted pregnancy, colicky or sick infant • treatment: ƒ psychotherapy (CBT or IPT) ƒ short-term safety of maternal SSRIs for breastfeeding infants established; long-term effects unknown ƒ if depression severe, consider ECT • prognosis: ƒ impact on child development: increased risk of cognitive delay, insecure attachment, behavioural disorders ƒ treatment of mother improves outcome for child at 8 mo through increased mother-child interaction

Question 25

Bipolar I and II criteria

Answer 25

• Bipolar I Disorder ƒ disorder in which at least one manic or mixed episode has occurred • Bipolar II Disorder ƒ disorder in which there is at least 1 MDE and at least 1 hypomanic episode; no past manic or mixed episodes

Question 26

Bipolar epidemiology and risk factors

Answer 26

``` Epidemiology • prevalence: 0.6-0.9%; M:F = 1:1 • age of onset: teens to 20’s Risk Factors • high SES • genetic: 60-65% of bipolar patients have family history of major mood disorders ```

Question 27

Bipolar: rapid cycling criteria

Answer 27

rapid cycling (at least 4 episodes of a mood disturbance in the previous 12 mo that meet criteria for a major depressive, manic, mixed, or hypomanic episode)

Question 28

Bipolar Tx

Answer 28

Treatment • biological: lithium, anticonvulsants, antipsychotics, antidepressants, ECT • psychological: supportive or psychodynamic psychotherapy, CBT, ITP or interpersonal social rhythm therapy • social: vocational rehabilitation, consider leave of absence from school/work, consider substitute decision maker for finances, drug and EtOH cessation, sleep hygiene, social skills training, education for family members

Question 29

Bipolar Px

Answer 29

Course and Prognosis • high suicide rate (15% mortality from suicide) • relapsing and remitting course with alternating manic and depressive episodes; depressive symptoms tend to occur more frequently and last longer than manic episodes • patients spend almost half of their lives symptomatic • may switch rapidly between depression and mania without any period of euthymia in between • high recurrence rate for mania – 90% will have a subsequent episode in the next 5 yr

Question 30

Cyclothymia: Dx & Px

Answer 30

Diagnosis • presence of numerous periods of hypomanic and depressive symptoms (not meeting criteria for MDE) for ≥2 yr; never without symptoms for >2 mo • no MDE, manic or mixed episodes, no evidence of psychosis • symptoms are not due to the direct physiological effects of a substance or GMC • symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning Treatment • similar to Bipolar I: anticonvulsants ± psychotherapy

Question 31

DDx of psychosis

Answer 31

``` GASPP General medical condition Affective disorders Substance induced Psychotic disorders Personality disorders ``` * primary psychotic disorders: schizophrenia, schizophreniform, brief psychotic, schizoaffective, shared psychotic, delusional disorder * mood disorders: depression with psychotic features, bipolar disorder (mania or depression with psychotic features) * personality disorders: schizotypal, schizoid, borderline, paranoid, obsessive-compulsive * general medical conditions: tumour, head trauma, dementia, delirium, metabolic, infection, stroke, temporal lobe epilepsy * substance-induced psychosis: intoxication or withdrawal, prescribed medications, toxins

Question 32

SCZ criteria

Answer 32

A. characteristic symptoms (active phase): ≥2 of the following, each present for a significant portion of time during a 1-mo period (or less if successfully treated) ƒ delusions ƒ hallucinations ƒ disorganized speech (e.g. frequent derailment or incoherence) ƒ grossly disorganized or catatonic behaviour ƒ negative symptoms [e.g. 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 ≥6 mo, including ≥1 mo of active phase symptoms; may include prodromal or residual phases

Question 33

SCZ epidemiology

Answer 33

Epidemiology • prevalence: 0.5%-1%; M:F = 1:1 • mean age of onset: females ~27; males ~21 genetic: 40% concordance in monozygotic (MZ) twins; 46% if both parents have schizophrenia; 10% of dizygotic (DZ) twins, siblings, children affected

Question 34

SCZ good prognostic factors

Answer 34

``` Good Prognostic Factors • Acute onset • Later age at onset • Shorter duration of prodrome • Female gender • Good cognitive functioning • Good premorbid functioning • No family history • Presence of affective symptoms • Absence of structural brain abnormalities • Good response to drugs • Good support system ```

Question 35

Management of SCZ

Answer 35

Management of Schizophrenia • biological ƒ acute treatment and maintenance with antipsychotics ± anticonvulsants ± anxiolytics • psychosocial ƒ psychotherapy (individual, family, group): supportive, CBT (see CBT, PS41) ƒ assertive community treatment (ACT): mobile mental health teams that provide individualized treatment in the community and help patients with medication adherence, basic living skills, social support, job placements, and community resources ƒ social skills training, employment programs, disability benefits ƒ housing (group home, boarding home, transitional home)

Question 36

SCZ Px

Answer 36

• 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 may become more prominent and more disabling • over time: 1/3 improve, 1/3 remain the same, 1/3 worsen

Question 37

Schizophreniform

Answer 37

* diagnosis: criteria A, D and E of schizophrenia are met; an episode of the disorder lasts from 1-6 mo. If the symptoms have extended past 6 mo the diagnosis becomes schizophrenia * treatment: similar to acute schizophrenia * prognosis: better than schizophrenia; begins and ends more abruptly; good pre- and post-morbid function

Question 38

Brief psychotic disorder - note time line

Answer 38

* diagnosis: acute psychosis (presence of 1 or more positive symptoms in criteria A 1-4 of schizophrenia) lasting from 1 day to 1 mo, with eventual full return to premorbid level of functioning * can occur after a stressful event or postpartum * treatment: secure environment, antipsychotics, anxiolytics * prognosis: good, self-limiting, should return to pre-morbid function in about 1 mo

Question 39

Schizoaffective criteria

Answer 39

A. uninterrupted period of illness during which there is either a MDE, manic episode, or a mixed episode concurrent with symptoms meeting criteria A for schizophrenia B. in the same period, delusions or hallucinations for ≥2 wk in the absence of prominent mood symptoms C. symptoms that meet criteria for a mood episode are present for a substantial portion of total duration of active and residual periods of the illness * treatment: antipsychotics, mood stabilizers, antidepressants * prognosis: between that of schizophrenia and of mood disorder

Question 40

Delusional disorder criteria

Answer 40

A. The presence of one (or more) delusions with a duration of 1 month or longer. B. Criterion A for schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation). C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd. D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods. E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder. Specify if: With bizarre content: Delusions are deemed bizarre if they are clearly implausible, not understandable, and not derived from ordinary life experiences (e.g., an individual’s belief that a stranger has removed his or her internal organs and replaced them with someone else’s organs without leaving any wounds or scars). Individuals with delusional disorder may be able to factually describe that others view their beliefs as irrational but are unable to accept this themselves (i.e., there may be “factual insight” but no true insight).

Question 41

Delusional disorder Tx & Px

Answer 41

* treatment: psychotherapy, antipsychotics, antidepressants | * prognosis: chronic, unremitting course but high level of functioning

Question 42

Atypical depression "criteria"

Answer 42

atypical: mood reactivity (brightens with real or potential positive events), increased sleep, weight gain, leaden paralysis, rejection hypersensitivity

Question 43

Melancholic depression "criteria"

Answer 43

melancholic: quality of mood is distinctly depressed, mood is worse in the morning, early morning awakening, marked weight loss, excessive guilt, psychomotor retardation or agitation

Question 44

Catatonic depression "criteria"

Answer 44

catatonic: at least two of: motor immobility, excessive motor activity, extreme negativism or mutism, peculiarities of voluntary movement, echolalia or echopraxia