OSCE Prep Flashcards

Question

Process of making an ADHD dx in an adult

Answer 1

- Screen questions - Evidence of a childhood hx of ADHD - Complete hx - Collateral hx - Parents, family, school records - Med workup (med hx, neuro exam, bloodwork, ECG) - Screening tools Conner's, SNAP, Adult ADHD symptom rating scale, Weiss, wisconsin, trails

Answer 2

Stimulants - long acting or short acting, long acting is considered first line - Increase dopaminergic and noradrenergic transmission - Methlyphenidate and amphetamine-based - Early onset of action - Has addictive properties - Use with caution in ppl with BAD, psychosis, substance use - Side effects - restlessness, anxiety, insomnia, decreased appetite, headche, stomach ache, elevated HR and BO Non-Stimulants = atomoxetine - SNRI - Takes much longer appprox 4 weeks - Recommended for use in people with BAD\< anxiety, psychosis, substance - less addictive - Side effects - nausea, vomiting, headache, insomnia, appetite, sexual problems, SI alpha2-agonists - guanfacine, clonidine - second line/third line agents - Must be dosed in small increments to avoid hypotension - when discontinuing, have to be tapered down slowly to prevent rebound HTN - somnolence, thirst, blood pressure decrease, postural dizziness, and constipation Other antidepressants such as bupropion

Answer 3

PICO Population Intervention Control/Comparison Outcome

Answer 4

Studies --\> syntheses --\> synopses --\> summaries --\> systems Studies - individual studies/journal articles, such as using pubmed. Prop, very up to date, con - all studies cant be applied, inefficient, time-consuming Syntheses - systematic reviews/meta-analysis - helpful when many small studies have been done and we want to pool effect size, or to explore differences in similar studies Con - if high quality evidence not available, "garbage in, garbage out" Synopses - filtered and pre-appraised evidence eg. Evidence-based med health journal - pro: contains succinct appraisals of studies that are selected by peers for high quality and relevance to clinical practice - con: these journals doe not include all important studies, and the synopsis is subject to the interpretation of its author Summaries - integrated evidence related to particular clinical problem - clin practice guidelines, UPtodate, dynamed - pro: easy access to a range of evidence relevant to the management of a particular condition - con: only as good as the process by which this information is selected, interpreted and kept up to date Systems - decision support technology where individual patient characteristics are matched with best available evidence, but this doesnt really exist yet

Answer 5

• Recruitment is of patients seeking treatment (as opposed to volunteers responding to advertisements) • Enrollment is high (as opposed to most potential subjects screened out or not consenting) • Sample size is adequate (minimum 30 – 50 subjects per arm) • Exclusion criteria are not overly restrictive (e.g. not excluding people with substance use, suicidal ideation, etc.) • Intervention is something that can actually be done in real life (as opposed one that is so specialized or resource intensive that it cannot readily be undertaken in the local setting) • Outcome is meaningful to clinicians and patients • Harms are measured (e.g. side effects, discontinuation of treatment, worsened suicidal ideation, changes in weight, etc.) • Duration of treatment is long enough to mimic actual practice and to observe potential adverse events • Costs are measured

Answer 6

• Allocation is concealed when the people responsible for enrolling subjects into the trial have no way of predicting the randomization sequence. • Protects against certain patients being included or excluded systematically from one or the other group. • For example, if an investigator knows that the next person enrolled in the study will be randomized to placebo, he/she may not enroll into the study a sicker person who is seen as needing active treatment. This would result in the placebo arm having fewer severely ill patients than the active arm, leading to a bias.

Answer 7

• Intention-to-treat analysis refers to a strategy for analyzing data where all subjects are included in the groups to which they were randomized. • For example, if a subject is allocated to the active medication arm but does not take any of the medication, she is still included in the medication arm (and not simply excluded from the analysis). • This is important because reasons for discontinuing treatment are often related to prognosis. Therefore, excluding subjects who discontinue treatment can bias the results.

Answer 8

The Number Needed to Treat (NNT) is the number of patients you need to treat to prevent one additional bad outcome (death, stroke, etc.). For example, if a drug has an NNT of 5, it means you have to treat 5 people with the drug to prevent one additional bad outcome. NNT = 1/ARR ARR = CER - EER

Answer 9

A systematic review answers a defined research question by collecting and summarising all empirical evidence that fits pre-specified eligibility criteria. A meta-analysis is the use of statistical methods to summarise the results of these studies.

Answer 10

• The p-value represents the probability that a difference as large or larger than the observed difference between groups would occur by chance alone if there was actually no true difference between groups.

Answer 11

anticholinergic delirium steroids pain infection CVA metabolic disturbance /DM

Answer 12

- Management environmental and pharmacological - Delirium = medical urgency, coordinated appraoch - Goal = address symptoms, ensure safety, ID and treat underlying causes · Supportive and environmental o Facilitating adequate sleep o Ensuring nutrition and fluid intake o Correcting sensory deficits (glasses, hearing aids) o Presence of a relative or known caregiver o Gentle reorientation by staff o Visible clock, calendar o If extremely agitated may require 1:1 · Pharmacological o Antipsychotics are the cornerstone of delirium treatment o Antipsychotics treat both hyperactive and hypoactive delirium o Haldol is most well studied medication and widely used agent in the treatment of delirium – has only one metabolite, less potential for anticholinergic, sedative and hypotensive effects, multiple routes of administration (PO/IM/IV) o Second generation antipsychotics also good efficacy, especially risperidone o Benzodiazepines generally should be avoided except in alcohol and benzodiazepine withdrawal or delirium secondary to seizures o Sedatives can reduce agitation, but they may worsen cognitive impairment, complicate mental status assessment, precipitate or perpetuate delirium due to other causes

Answer 13

o Onset is acute or subacute in delirium, gradual in dementia o Course of delirium is fluctuating, progressive in dementia o Consciousness is impaired in delirium, often intact until later stages in dementia o Sleep – disruption of sleep-wake cycle in delirium, night time disruption in dementia o Principle cognitive deficit in delirium is inattention, in dementia short term memory and executive dysfunction o Medical status – identifiable precipitant present in delirium, often less of relationship in dementia o Generalized EEG slowing – majority of those with delirium (80%), about one third of those with dementia

Answer 14

· Elderly individuals are particularly sensitive to anticholinergic effects o Blind as a bat (dilated pupils) o Red as a beet (vasodilation and flushing) o Hot as a hare (hyperthermia) o Dry as a bone (dry skin) o Mad as a hatter (hallucinations/agitation) o Bloated as a toad (ileus, urinary retention) o And the heart runs alone (tachycardia) · Bonus point: able to identify that several rating scales exist for determining anticholinergic burden of common medications

Answer 15

· Mania or hypomania o Euphoria or hypomania is a common psychiatric manifestation early in steroid therapy, and can be associated with agitation, insomnia, distractibility, irritability, affective lability o May require antipsychotic treatment for stabilization of mood · Depression o More common in longer courses of steroid therapy, but by far the most common psychiatric manifestation of steroid therapy o May require treatment with anti-depressants o Vulnerability to depression increased by effects of medical illness · Psychosis and Delirium o Delusions, hallucinations, thought form abnormalities o If possible a reduction in steroid dose often ameliorates symptoms o Requires antipsychotic medications

Answer 16

1. Treat underlying cause (eg. iron deficiency anemia) or DC causative agent 2. Non pharm - decrease ETOH, nicotine and caffeine; hot baths, hot or cold compresses, massage, sleep hygiene 3. Dopamine-agonists (Pramipexole, Ropinarole, then Levodopa) 4. Anticonvuslants (Gabapentin and pregabalin) 5. Benzodiazepenes 6. Low dose oxycodone

Answer 17

Chronotherapy (phase delay) Melatonin early PM Bright light early AM

Answer 18

* recurrent episodes of incomplete waking from sleep (first 1/3 of sleep) * sleepwalking * night terrors * none or littel of draems recalled * amnesia of episode

Answer 19

* SAFETY * Reassurance, education * Avoid precipitants (fll bladder, ETOH, noise, meds) * V little data on meds - ?SSRIs, TCAs, Benzos were used historically but coudl worsen because they suppress N3 sleep

Answer 20

* repeated episodes of arousal during sleep associated with **vocalizations**/**complex motor behaviour** * During REM, \>90min after sleep onset * 1 of the following * REM sleep without atonia on PSG/EMG (loss of skeletal muscle paralysis) * Hx suggestive of a-synucleinopathy

Answer 21

Ensure safety of patient and bed partner Clonazepam 0.5-2mg Melatonin 3-12 mg (always first line if OSA) ?Dopa agonists

Answer 22

\>450 men \>470 women

Answer 23

Topiramate

Answer 24

Lithium Topiramate Gabapentin Pregabalin \*Paliperidone \*Acamprosate

Answer 25

\>2 years (\>1yr in children) - * numerous periods with hypomanic symptoms **that do not meet** criteria for a hypomanic episode AND * numerous periods with depressive symptoms **that do not meet** criteria for a major depressive episode. * Symptomatic at least half the time * Criteria for a major depressive, manic, or hypomanic episode **have never been met**

Answer 26

* Flu-like symptoms (lethargy, fatigue, headache, achiness, sweating) * Insomnia (with vivid dreams or nightmares) * Nausea (sometimes vomiting) * Imbalance (dizziness, vertigo, light-headedness) * Sensory disturbances (“burning,” “tingling,” “electric-like” or “shock-like” sensations) * Hyperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness)

Answer 27

After cessation of drinking: 6-8 hours - tremulousness 8-12 hours - psychotic an perceptual disturbances 12-14 hours - seizure up to 72h to a week - DTs The syndrome of withdrawal sometimes skips the usual progression and, for example, goes directly to DTs.

Answer 28

Delirium occurring within 1 week after a person stops drinking Autonomic hyperacticity (tachycardia, Diaphoresis, fever, HTN) Anxiety Insomnia Perceptual distortions, most frequently visual or tactile hallucinations; Fluctuating levels of psychomotor activity, ranging from hyperexcitability to lethargy

Answer 29

Hypomanic episode only needs to be 4 days, manic at least a week (or hosp) Hypomanic = marked change in functioning, but NOT functioanl impairment Both need 3/7 DIGFAST criteria

Answer 30

Other specified bipolar disorder - Short-duration hypomanic episodes (2–3 days) and major depressive episodes - Hypomanic episodes with insufficient symptoms and major depressive episodes - Hypomanic episode without prior major depressive episode - Short-duration cyclothymia (less than 24 months)

Answer 31

* Symptoms * Mood reactivity brightening in response to circumstances * Overeating * Oversleeping * Leaden Paralysis * A long-standing pattern of interpersonal rejection sensitivity * Assoc with * Younger age of onset * more severe psychomotor slowing * COMO panic disorder, SUD, and somatization

Answer 32

Classic depression: severe anhedonia, early morning awakening, weight loss, and profound feelings of guilt

Answer 33

Confusion Agitation Lethargy Headaches Nausea Imbalance

Answer 34

Mirtazapine is a Noradrenergic/Specific Serotonergic Antidepressant (NaSSA) * Presynaptic a2-adrenergic antagonist effects--\> increased release of norepinephrine and serotonin * Potent antagonist of 5-HT2A, 5-HT2C, 5-HT3, and H1 receptors * Moderate peripheral a1-adrenergic and muscarinic antagonist;

Answer 35

1. Non-pharmacology appraoch 2. AcheI 3. Memantine 4. Antipsychotic

Answer 36

1. Behavioural/non-pharm 2. SSRI (Citalopram \>Trazodone, others) 3. Antipsychotic ONLY after 1 and 2 have failed 4. Memantine

Answer 37

Express Empathy Develop Discrepancy Roll with Resistance Support Self-efficacy

Answer 38

NREM - 75% REM - 25%

Answer 39

REM - hyperarousal state - increased blood pressure, resp rate, brain temp, glucose metabolism, cerebral blood flow NREM - Hypoarousal state - lower blood pressure, low resting muscle tone

Answer 40

* N1 = theta, 5% * N2 = sleep spindles and k-complexes, 45% * N3 = delta waves, "Slow wave" or "deep sleep", 25% - furthest from wakefulness Note - when awake, eyes opened - beta waves - when drowsy, eyes are clsoed, alpha waves

Answer 41

Detailed dreams and nightamres Near total skeletal muscle paralysis ("atonia") Cyclical, every 90-100mins

Answer 42

Suprachiasmatic nucleus Anterior hypothalamus

Answer 43

NREM - hypothalamus (also thalamus, forebrain, medulla) REM - Pons (pontine reticualr formation)

Answer 44

First part of sleep cycle

Answer 45

Towards the end of sleep cycle

Answer 46

90mins Decreased in depression and narcolepsy

Answer 47

Association of bed with state of arousal

Answer 48

CBT for Insomnia 3 stages 1. Sleep hygiene and education, stimulus control, sleep restructuring 2. Cognitive therapy, relaxation training 3. Medication taper

Answer 49

Use for short-term, trasnient insonia eg when in hospital Use lwoest effective dose, intermittent dosing, gradually taper off Not indicated for chronic insomnia EG. Temazepam, zopiclone, zolpidem, doxepin, orexin and melatonin antagonists

Answer 50

* Sleep 8-12h, very difficult to wake in am * naps and sleeps in day * sleep not restful * fall asleep fast, good sleep efficacy * Polysomnography, Multiple sleep latency test (multipel naps in a day) * 1. Modafinil, 2. Dexedrine, methlyphenidate

Answer 51

1. Cataplexy a few x/ month (sudden bilat loss of muscle tone precip by laughing or in children or early disease, tongue thrusting, global hypotonia) 2. Hypocretin deficiency (\<1/3 normal, \<110pg/ml) 1. PSG - REM sleep latency _\<_ 15 min ; MSLT _\<_8min + REM seen on 2 naps

Answer 52

1. Sleep attacks 2. Cataplexy 3. Hypnopompic/hypnogogic hallucinations 4. Sleep paralysis

Answer 53

1. Scheduled napping, sleep hygiene, lifestyle adjusments 2. Daytime sleepiness - 1) modafinil, 2) dexedrine and methylphenidate 3. Sleep paralysis and H/HH - REM suppressants TCAs, SSRIs, SNRIs (off label) - theory is that these suppress REM, because REM is intruding on to wakefulness

Answer 54

CPAP Nasal surgery Oral devices Don't sleep supine DO NOT use narcotics, benzos, opioids

Answer 55

Chronotherapy (phase delay) Melatonin early PM Bright light early AM

Answer 56

* recurrent episodes of incomplete waking from sleep (first 1/3 of sleep) * sleepwalking * night terrors * none or littel of draems recalled * amnesia of episode

Answer 57

CBT for Insomnia 3 stages 1. Sleep hygiene and education, stimulus control, sleep restructuring 2. Cognitive therapy, relaxation training 3. Medication taper

Answer 58

* recurrent episodes of incomplete waking from sleep (first 1/3 of sleep) * sleepwalking * night terrors * none or littel of draems recalled * amnesia of episode

Answer 59

Chronotherapy (phase delay) Melatonin early PM Bright light early AM

Answer 60

CPAP Nasal surgery Oral devices Don't sleep supine DO NOT use narcotics, benzos, opioids

Answer 61

1. Scheduled napping, sleep hygiene, lifestyle adjusments 2. Daytime sleepiness - 1) modafinil, 2) dexedrine and methylphenidate 3. Sleep paralysis and H/HH - REM suppressants TCAs, SSRIs, SNRIs (off label) - theory is that these suppress REM, because REM is intruding on to wakefulness

Answer 62

1. Sleep attacks 2. Cataplexy 3. Hypnopompic/hypnogogic hallucinations 4. Sleep paralysis

Answer 63

1. Cataplexy a few x/ month (sudden bilat loss of muscle tone precip by laughing or in children or early disease, tongue thrusting, global hypotonia) 2. Hypocretin deficiency (\<1/3 normal, \<110pg/ml) 1. PSG - REM sleep latency _\<_ 15 min ; MSLT _\<_8min + REM seen on 2 naps

Answer 64

* Sleep 8-12h, very difficult to wake in am * naps and sleeps in day * sleep not restful * fall asleep fast, good sleep efficacy * Polysomnography, Multiple sleep latency test (multipel naps in a day) * 1. Modafinil, 2. Dexedrine, methlyphenidate

Answer 65

Use for short-term, trasnient insonia eg when in hospital Use lwoest effective dose, intermittent dosing, gradually taper off Not indicated for chronic insomnia EG. Temazepam, zopiclone, zolpidem, doxepin, orexin and melatonin antagonists

Answer 66

Association of bed with state of arousal

Answer 67

90mins Decreased in depression and narcolepsy

Answer 68

Towards the end of sleep cycle

Answer 69

First part of sleep cycle

Answer 70

NREM - hypothalamus (also thalamus, forebrain, medulla) REM - Pons (pontine reticualr formation)

Answer 71

Suprachiasmatic nucleus Anterior hypothalamus

Answer 72

Detailed dreams and nightamres Near total skeletal muscle paralysis ("atonia") Cyclical, every 90-100mins

Answer 73

* N1 = theta, 5% * N2 = sleep spindles and k-complexes, 45% * N3 = delta waves, "Slow wave" or "deep sleep", 25% - furthest from wakefulness Note - when awake, eyes opened - beta waves - when drowsy, eyes are clsoed, alpha waves

Answer 74

REM - hyperarousal state - increased blood pressure, resp rate, brain temp, glucose metabolism, cerebral blood flow NREM - Hypoarousal state - lower blood pressure, low resting muscle tone

Answer 75

NREM - 75% REM - 25%

Answer 76

Express Empathy Develop Discrepancy Roll with Resistance Support Self-efficacy

Answer 77

Prove feigning symptoms

Answer 78

ANK3 - Voltage gated sodium channels CACNA1C on 12p13 - L type Ca Channels

Answer 79

1. Start opioid agonist treatment (OAT) with buprenorphine/naloxone whenver feasible 2. For poor responders to above, consdier transition to methadone 3. If good response to methadone, consider transitioning to buprenorphine naloxone

Answer 80

* Pt needs to be in at least moderate withdrawal to start (COWS \>12) * 12-24 hours of abstinence since last opiod dose * Begin at 2-4mg, increase by up to 8mg/day * Max 24mg/day

Answer 81

Precipitated withdrawal Resp depression/sedation Headache, fatiguw, occasional sexual SE

Answer 82

* Suboxone * Buprenorphone is a partial opiod antagonist at mu receptor * Has a higher affinity for opioid receptor so displaces otehr opioids * But its maximal opioid agonist effect is lower than FULL op-ags (methadone, morphine, heroin) * "Ceiling effect" lowers risk of resp depression, side effects, non-med use * Naloxone os mu opioid receptor antagonist, can block the effect of buprenorphine * Methadone * FULL opiod agonist at mu receptor * increased risk for AEs and OD and death * When used as directed, safe and effective for OUD tx

Answer 83

* QTC Prolongation * Black Box Warning * Addiction, abuse, misuse * Resp depression * 3A4, 2C19,2C9,2D6 inhibitors could icnrease methadone levels --\> resp depression * Serotonin syndrome if with other S-agents

Answer 84

WIthdrawal management alone should be avoided, and detox should always be followed by immediate transition to long term addiction tx

Answer 85

* Longer use- decreased seizure threshold * Psychosis - paranoia, visual, auditory and tactile hallucinations * Stereotypical behaviours

Answer 86

* Euphoria * ↓ appetite * ↑vigilance * ↑ autonomic activity (or possibly ↓) * ↑seizures * ↑psychosis - paranoid delusions * ↑ nausea vomiting * ↑ arrhythmias * ↑ psychomotor behaviour - agitation, stereotyped behaviour eg dyskinesias

Answer 87

* DYSphoria * ↑ appetite * ↓ energy * ↓ psychomotor activity (retardation) * ↓ or ↑ sleep * vivid unpleasant dreams

Answer 88

* Acute - ↑ serotonin (blocks reuptake, directly releases S) * Chronic - ↓ serotonin levels by depleting stores and inhibiting synthesis of new S

Answer 89

* Acute * serotonin levels by blocking reuptake, directly releasing S * Chronic * ↓ serotonin levels by depleting stores, inhibiting synthesis of new S

Answer 90

* Cocaine * Metabolizes **rapidly** * Effects last 1-2 hours * Withdrawal 1-2 days * Methamphetamine * Metabolizes **Slowly** * Effects can last 10-20 hours * Withdrawal can last several days * Recall meth --\> 1000% ↑ of DA in NA (vs food 150%, sex 200%)

Answer 91

1. NRT 2. Varenicline 3. Bupropion

Answer 92

* Discontinuation + 2 of * ↑ANS, ↑tremor, insomnia, NV, ↑anxiety, vis/aud/tactile, GTC sz, agitation * 6-8 - hr shakes * 8-12 - psychotic/perceptual probs * 12-24 - h seizures * 72h - DTs (1-3%) * monitor with CIWA \<15 mild, \>20 severe * Tx with Diazepam 1mg/drink QID, or Chlordiazepoxide 2.5mg/drink QID

Answer 93

Prove feigning symptoms

Answer 94

Prove feigning symptoms

Answer 95

* Discontinuation + 2 of * ↑ANS, ↑tremor, insomnia, NV, ↑anxiety, vis/aud/tactile, GTC sz, agitation * 6-8 - hr shakes * 8-12 - psychotic/perceptual probs * 12-24 - h seizures * 72h - DTs (1-3%) * monitor with CIWA \<15 mild, \>20 severe * Tx with Diazepam 1mg/drink QID, or Chlordiazepoxide 2.5mg/drink QID

Answer 96

1. NRT 2. Varenicline 3. Bupropion

Answer 97

* Cocaine * Metabolizes **rapidly** * Effects last 1-2 hours * Withdrawal 1-2 days * Methamphetamine * Metabolizes **Slowly** * Effects can last 10-20 hours * Withdrawal can last several days * Recall meth --\> 1000% ↑ of DA in NA (vs food 150%, sex 200%)

Answer 98

* Acute * serotonin levels by blocking reuptake, directly releasing S * Chronic * ↓ serotonin levels by depleting stores, inhibiting synthesis of new S

Answer 99

* Acute - ↑ serotonin (blocks reuptake, directly releases S) * Chronic - ↓ serotonin levels by depleting stores and inhibiting synthesis of new S

Answer 100

* DYSphoria * ↑ appetite * ↓ energy * ↓ psychomotor activity (retardation) * ↓ or ↑ sleep * vivid unpleasant dreams

Answer 101

* Euphoria * ↓ appetite * ↑vigilance * ↑ autonomic activity (or possibly ↓) * ↑seizures * ↑psychosis - paranoid delusions * ↑ nausea vomiting * ↑ arrhythmias * ↑ psychomotor behaviour - agitation, stereotyped behaviour eg dyskinesias

Answer 102

* Longer use- decreased seizure threshold * Psychosis - paranoia, visual, auditory and tactile hallucinations * Stereotypical behaviours

Answer 103

WIthdrawal management alone should be avoided, and detox should always be followed by immediate transition to long term addiction tx

Answer 104

* QTC Prolongation * Black Box Warning * Addiction, abuse, misuse * Resp depression * 3A4, 2C19,2C9,2D6 inhibitors could icnrease methadone levels --\> resp depression * Serotonin syndrome if with other S-agents

Answer 105

* Suboxone * Buprenorphone is a partial opiod antagonist at mu receptor * Has a higher affinity for opioid receptor so displaces otehr opioids * But its maximal opioid agonist effect is lower than FULL op-ags (methadone, morphine, heroin) * "Ceiling effect" lowers risk of resp depression, side effects, non-med use * Naloxone os mu opioid receptor antagonist, can block the effect of buprenorphine * Methadone * FULL opiod agonist at mu receptor * increased risk for AEs and OD and death * When used as directed, safe and effective for OUD tx

Answer 106

Precipitated withdrawal Resp depression/sedation Headache, fatiguw, occasional sexual SE

Answer 107

* Pt needs to be in at least moderate withdrawal to start (COWS \>12) * 12-24 hours of abstinence since last opiod dose * Begin at 2-4mg, increase by up to 8mg/day * Max 24mg/day

Answer 108

1. Start opioid agonist treatment (OAT) with buprenorphine/naloxone whenver feasible 2. For poor responders to above, consdier transition to methadone 3. If good response to methadone, consider transitioning to buprenorphine naloxone

Answer 109

ANK3 - Voltage gated sodium channels CACNA1C on 12p13 - L type Ca Channels

Answer 110

Prove feigning symptoms

Answer 111

* CBC, lytes, CAMP, albumin, LFTS, Cr, Urea * ECG

Answer 112

Psychological strategies preferred over medications in first trimester When meds are necessary, preference should be given to monotherapy and lowest effective dose

Answer 113

* Should be avoided due to risks of NTD (5%) * higher incidences of congenital abnormalities * striking degrees of neurodevelopmental delay in children at 3y, loss of 9 IQ pts

Answer 114

Pts may require higher doses of meds towards end of pregnancy because: Changes in physiology in 2nd and early 3rd trim Increased plasma volume Increased hepatice activity Increased renal clearance

Answer 115

Pts may require higher doses of meds towards end of pregnancy because: Changes in physiology in 2nd and early 3rd trim Increased plasma volume Increased hepatice activity Increased renal clearance

Answer 116

* Should be avoided due to risks of NTD (5%) * higher incidences of congenital abnormalities * striking degrees of neurodevelopmental delay in children at 3y, loss of 9 IQ pts

Answer 117

* CBC, lytes, CAMP, albumin, LFTS, Cr, Urea * ECG

Answer 118

* CBC, lytes, CAMP, albumin, LFTS, Cr, Urea * ECG

Answer 119

* CBC, lytes, CAMP, albumin, LFTS, Cr, Urea * ECG

Answer 120

* CBC, lytes, CAMP, albumin, LFTS, Cr, Urea * ECG

Answer 121

Pts may require higher doses of meds towards end of pregnancy because: Changes in physiology in 2nd and early 3rd trim Increased plasma volume Increased hepatice activity Increased renal clearance

Answer 122

* Should be avoided due to risks of NTD (5%) * higher incidences of congenital abnormalities * striking degrees of neurodevelopmental delay in children at 3y, loss of 9 IQ pts

Answer 123

* CBC, lytes, CAMP, albumin, LFTS, Cr, Urea * ECG

Answer 124

* mild vascular dementia (prior cognitive disorder) * “Vasculopathic” patients (those with multiple vascular risk factors (MVRF); e.g., DM, smoking, HTN, hyperlipidemia) often have co-morbid mild vascular disease-based cognitive impairment (which may be extensive enough to be diagnosed as vascular dementia). * ICU setting * General anaesthesia * Pain (and meds) * age, * sensory deprivation, prior cognitive disorder * etc.

Answer 125

* Clinical tests - CBC, lytes, extended lytes, glucose, LFTs, Cr, Urea, LDH, EEG * Non-pharmacologic apprpaches * Pharmacologic (best evidence Haldol, prolonged QT, Blakc box; atypicals) * Avoid benzos (except ETOH-withdrawal delirium)/sedatives, opioids, dopa-agonists, anticholinergic * Bedside MMSE/MOCA, frontal testing eg clock draw

Answer 126

* Available at all hours, and to COME IN TO HOSPITAL AT ANY TIME IF NEEDED * What PGY-year are you in? * How long have you been a senior resident in Emergency Psychiatry? * Who else is on with you tonight? * Residents, med students, nurses, Other? * How many available beds are in the system? * Male or Female? * Any seclusion available? * How many patients are currently in the department?

Answer 127

* Safety of patients and staff first priority * Know comfort level and experience of the junior resident & medical student * Make use of the expertise of the multi-disciplinary staff available

Answer 128

* Prn means non-regularly scheduled medication * prn medication requires informed consent (either from patient or SDM) in most situations * Chemical restraint is a category of non-regularly scheduled medication that can be given without informed consent but _only_ in the event of behaviour which is causing a high likelihood of risk of harm coming to the patient or to others. * Chemical restraint orders must be reassessed on a daily basis

Answer 129

* Vital signs including BP (sitting & standing), HR, RR, Temp * Bloodwork including CBC with diff, lytes, BUN, CR, glucose, LFTs * Urine R & M * CT Head * ECG * CXR * COVID PCR * ? EEG to rule out delirium

Answer 130

* Assertive Community Treatment Team * interdisciplinary team treatment approach designed to provide comprehensive, intensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness who typically have a history of repeated hospitalizations and who do not generally attend appointments in clinic settings. * There is evidence that ACT teams significantly decrease rates of hospitalization * Case Management * less intensive than ACTT, but intended to provide a full range of individualized services. Patients have a case manager who acts as an advocate for them in accessing a range of psychosocial interventions * IM antipsychotics * CTO * legal documents that provide a framework to work with patients who have a history of non-adherence to medications. Community Treatment Plans outline how often a patient needs to be seen by their treating psychiatrist or team and also outlines their psychiatric medications. If the patient is not adherent to the Community Treatment Plan, in Ontario their treating psychiatrist can complete a Form 47 (order for Psychiatric Examination)

Answer 131

* Pros: helps with compliance, ensures a constant delivery of medication, some patients may prefer not to have to deal with pills, health care providers have accurate information about compliance * Cons: delayed release of drug can make dosing challenging and results in a prolonged period of time before the medication takes effect, the long half-life of injectable antipsychotics means that any adverse reactions last longer than with oral medications, many patients may not feel comfortable with the idea of receiving an injection

Answer 132

General criteria for admission to an ACT Team: 1. Having an Axis I disorder (typically a psychotic disorder, but not necessarily) 2. A history of multiple, sometimes lengthy psychiatric hospitalizations 3. A history of non-adherence to prescribed psychiatric medications 4. “Failure” of other more traditional outpatient management options 5. Often have co-existing conditions such as addiction issues, homelessness, involvement with the judicial system and/or developmental disabilities

Answer 133

Criteria for initiation of a CTO: 1. Having an Axis I disorder 2. A history of non-adherence to psychiatric follow-up and/or psychiatric medications 3. A history of at least 2 psychiatric hospitalizations in the last 3 years and/or a psychiatric hospitalization that lasts at least 30 days in the last 3 years 4. A history of improvement in psychiatric symptoms when patient is adherent to psychiatric treatment

Answer 134

**What are the advantages and disadvantages of Community Treatment Orders? (TOTAL 15 points)** A4. Advantages of CTOs: 1. Provides a framework for working with very challenging, non-adherent patients, allowing time to hopefully develop a therapeutic relationship 2. Decreases hospital days (by approximately 60%) 3. Allows for quicker treatment when a patient first becomes non-adherent to the treatment plan rather than letting them become very unwell before treatment could be given 4. Allows a patient to be sent to hospital for a psychiatric assessment if necessary even if they haven’t been seen by their psychiatrist within the last 7 days Disadvantages of CTOs: 1. The legal process involved in initiating and renewing CTOs can be tedious and time-consuming 2. Patients can view CTOs as restrictive and can resent what they perceive to be an intrusion on their lives and freedom

Answer 135

Assessment for diagnosis of Intellectual disability: IQ testing and assessment of adaptive functioning using an adaptive behaviour scale Diagnostic Criteria for Intellectual Disability: A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience, confirmed by both clinical assessment and individualized statrdized intelligence testing. B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life. C. Onset of intellectual and adaptive deficits during the developmental period.

Answer 136

Working with People who have a diagnosis of Intellectual disability: 1. simplify the language you use and shorten your sentences 2. May need to repeat your questions or rephrase them 3. People with developmental disabilities and comorbid psychiatric issues may present differently than the general population with psychiatric issues 4. “start low, go slow” due to the greater potential for adverse reactions and sensitivity to medications in this population

Answer 137

A. Marked incongruence between one’s experienced/expressed gender and assigned gender, for at least 6 months with 2 of the following: 1. Marked incongruence between experienced/expressed gender and primary and/or secondary sex characteristics 2. Strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender 3. Strong desire for the primary and/or secondary sex characteristics or the other gender 4. Strong desire to be of the other gender 5. Strong desire to be treated as the other gender 6. Strong conviction that one has the typical feelings and reactions of the other gender B. Causes clinically significant distress or impairment in social, occupation, or other important areas of functioning

Answer 138

Diagnostic criteria for Transvestic Disorder: 1. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving cross-dressing 2. The fantasies, sexual urges, or behaviours cause clinically significant distress or impairment in social, occupations or other important areas of functioning With fetishism: if sexually aroused by fabrics, materials or garments. With autogynephilia: if sexually aroused by thoughts or images of self as female

Answer 139

* Pre-contemplation: Not yet acknowledging that there is a [problem behavior](http://www.addictioninfo.org/articles/11/1/Stages-of-Change-Model/Page1.html) that needs to be changed, denial of the consequences and relation to the problem. * Contemplation: Acknowledging that there is a problem but not yet ready or sure of wanting to make a change, starting to recognize the disadvantages of using. * Preparation: Getting ready to change, planning strategies for change (e.g. joining group, setting a date to quit) * Action: Changing behavior, reduction of use, quitting * Maintenance: Maintaining the behavior change for 2-6 months

Answer 140

* Motivational interviewing * Motivational interviewing is a collaborative form of counselling aimed at addressing a person’s ambivalence about change. * Its goal is to strengthen the person’s own motivation and commitment to change by exploring their own thoughts and ideas about changing. * It is based on collaboration between the therapist and the patient, drawing out the patient’s own thoughts and ideas about the change in behaviour, and supporting the patient’s autonomy to make changes for themselves.

Answer 141

Severe irritability and anger, resulting in interpersonal conflict Marked vacillations in energy, creativity, enthusiasm, confidence, and productivity Erratic behavior at the office or hospital (ie, performing rounds at 3 am or not showing up until noon) Inappropriate boundaries with patients, staff, or peers Isolation and withdrawal Increased errors in or inattention to chart work and patient calls Personality change, mood swings Impulsivity or irrationality in decision making or action Inappropriate dress, change in hygiene Sexually inappropriate comments or behavior Diminished or heightened need for sleep Frequent job changes and/or moves Inconsistency in performance, absenteeism

Answer 142

* Call CMPA first * As per the CPSO Mandatory and Permissive reporting policy, physicians have a legal and professional obligation to maintain the confidentiality of patient information. There are circumstances, however, where physicians are either required or permitted to report particular events or clinical conditions to the appropriate government or regulatory agency. * Physicians are expected to take appropriate and timely action when they have reasonable grounds to believe that another physician or health-care professional is incapacitated or incompetent. This includes circumstances where a colleague’s pattern of care, health or behaviour poses a risk to patient safety. * Appropriate action may include, depending on the circumstances, contacting the Physician Health Program at the Ontario Medical Association, the College’s Physician Advisory Service, the individual’s friends and family and/or employer. In a hospital setting, appropriate action may involve notifying the individual to whom the physician is accountable.

Answer 143

* U.S. approximately 400 physicians die by suicide each year. There are no Canadian statistics. * Physicians have lower rates of death from disease than the general population. suicide is the only cause of death in physicians that is higher than the general population. * A review of 14 studies found that the relative risk of suicide in physicians compared with the general population is between 1.1 and 3.4 for men and 2.5 to 5.7 for women * This is 2-3 x rates seen in respective male/ female university graduates * Physicians also have increased rates of suicides relative to other educated and professional groups Factors that indicate a physician is at high risk for suicide: * A workaholic white male age ≥50 or female age ≥45 who is * divorced, * single, or * currently experiencing marital disruption and is * suffering from depression. * He or she has a substance abuse problem and a history of risk-taking (high-stakes gambling, etc.). * chronic pain or illness or with a recent change in occupational or financial status also are at risk. * Recent in- creased work demands, personal losses, diminished autonomy, and access to lethal means (medications, firearms) complete the profile. Protective factors that lower the risk of completed suicide include effective treatment, social and family support, resilience and coping skills, religious faith, and restricted access to lethal means.

Answer 144

* Depression and suicidal ideation in physicians is associated with a variety of factors including personal and work related stressors * Work stressors may play a role in precipitating suicide in some * Physicians are often reluctant to seek treatment due to stigma and issues of confidentiality, they may fear recrimination by colleagues and licensing boards * They may attempt to treat their mood disorders with self-prescribed medications.

Answer 145

* Seizures * Siallorrhea * Ileus * Agranulocytosis (leukopenia; neutropenia) * Myocarditis * Cardiomyopathy * Metabolic Syndrome/DM * Weight gain * * Hypotension or Hypertension * Tardive Dyskinesia (risk lower than with other antipsychotics)

Answer 146

1. PMHx and physical exam 2. CBC with differential with particular attention to the WRC and neutrophil count 1. treatment should not be initiated if the WBC count is less than 3.5x109/L and/or the absolute neutrophil count (ANC) is less than 2.0x109/L, or if the patient has a history of a myeloproliferative disorder, or toxic or idiosyncratic agranulocytosis or severe granulocytopenia 3. Fasting Blood Glucose – baseline, repeat at week 12, then repeat annually 4. Fasting lipid profile – baseline, repeat at week 12, then repeat at least q5years or more frequently 5. Serum C-reactive protein – baseline, day 7, day 14, day 21, day 28 6. Troponin levels - baseline, day 7, day 14, day 21, day 28 7. Serum potassium & magnesium levels – baseline; periodically during treatment 8. ECG – baseline 9. Echocardiogram – baseline 10. BP & HR – baseline, and then pre- and post-dose during initial number of doses 11. All vital signs – baseline and then q2days x first 28 days 12. Weight and BMI – baseline, week 4, week 8, week 12 and then quarterly 13. Waist circumference – baseline and then annually 14. EEG - baseline

Answer 147

1. Every week for the first 26 weeks of treatment, then 2. Every two weeks for the next 26 weeks and 3. Every four weeks for the duration of treatment. Results get sent to Gencan If Gencan does not receive bloodwork, they will not dispense meds

Answer 148

1. Consent, including sharing info with Gencan 2. Pre treatment assessment 3. Send registration forms to Gencan 4. Start dose 12.5 mg once or twice/ day. For day one and day two of treatment orthostatic blood pressure (sitting and standing) should be taken 6-8 hours post dose 5. Monitor for fever at day 1 and 2 of tx

Answer 149

1. If Clozapine treatment stops for 48 hours it is recommended that the patient’s dose return to 12.5 mg and be re-titrated. The blood monitoring frequency may remain the same 2. If Clozapine treatment is interrupted for more than 72 hours but less than 1 month it is recommended that the patient’s dose return to 12.5 mg and is re-titrated. It is recommended the blood monitoring frequency return to weekly for 6 weeks. 3. If Clozapine treatment is interrupted for more than 1 month the patient should be treated as a new start

Answer 150

* _Common side-effects_ are those typical of TCAs and include * sedation * dry mouth * urinary retention * dizziness * constipation * blurred vision * lowered seizure threshold * mental cloudiness * fatigue * weight gain * nausea * sweating * headache * sexual dysfunction _Rare or dangerous side-effects_ * orthostatic hypotension * tachycardia * arrhythmias * rare seizures (risk of seizure increases with dose, especially above 250 mg/day) * QTc prolongation * increased intraocular pressure * hepatic failure * paralytic ileus * rare induction of mania

Answer 151

CBT: structured and time limited therapy focused on symptoms premise that depression maintained by maladaptive behaviours and inaccurate thoughts and beliefs about self, others and future influenced by depression. Ix try to work through thoughts and evaluate accuracy negative thoughts and beliefs. Behaviours to increase pleasure. IPT: time limited therapy based on premise that our relational stressors including loss, change, transition, disagreement or sensitivity associated w/ onset or perpetuation of sx. Similar/diff: both time limited, structured therapies focused on present and symptoms at this time. IPT has 4 specific focuses and looks through a relational lens while CBT focuses on core beliefs and negative inaccurate thoughts. More structured with homework and can be administered via telephone of internet. Scales to monitor progression. All sessions start with setting agenda. 3 phases of IPT. 12-16 sessions. Therapist directive. IPT- psychodynamic origin versus CBT.

Answer 152

Grief Role Dispute Role Transition Interpersonal Defiicts

Answer 153

1. Focal area: Role transition (grief, role transition, IP sens, role dispute). 1. Start sessions with IP inventory, 2. develop rapport, 3. explain therapy, 4. assign sick role and choose focus. 2. Intermediate: work on comm analysis and bring back to focus area. What she has gained/loss with transition. 3. Termination: emphasize progress (scales) and work on relapse prevention, problem solving. If not successful blame therapy not pt.

Answer 154

Lithium Topiramate Gabapentin Pregabalin \*Paliperidone \*Acamprosate

Answer 155

\>2 years (\>1yr in children) - * numerous periods with hypomanic symptoms **that do not meet** criteria for a hypomanic episode AND * numerous periods with depressive symptoms **that do not meet** criteria for a major depressive episode. * Symptomatic at least half the time * Criteria for a major depressive, manic, or hypomanic episode **have never been met**

Answer 156

* Flu-like symptoms (lethargy, fatigue, headache, achiness, sweating) * Insomnia (with vivid dreams or nightmares) * Nausea (sometimes vomiting) * Imbalance (dizziness, vertigo, light-headedness) * Sensory disturbances (“burning,” “tingling,” “electric-like” or “shock-like” sensations) * Hyperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness)

Answer 157

After cessation of drinking: 6-8 hours - tremulousness 8-12 hours - psychotic an perceptual disturbances 12-14 hours - seizure up to 72h to a week - DTs The syndrome of withdrawal sometimes skips the usual progression and, for example, goes directly to DTs.

Answer 158

Delirium occurring within 1 week after a person stops drinking Autonomic hyperacticity (tachycardia, Diaphoresis, fever, HTN) Anxiety Insomnia Perceptual distortions, most frequently visual or tactile hallucinations; Fluctuating levels of psychomotor activity, ranging from hyperexcitability to lethargy

Answer 159

Hypomanic episode only needs to be 4 days, manic at least a week (or hosp) Hypomanic = marked change in functioning, but NOT functioanl impairment Both need 3/7 DIGFAST criteria

Answer 160

Other specified bipolar disorder - Short-duration hypomanic episodes (2–3 days) and major depressive episodes - Hypomanic episodes with insufficient symptoms and major depressive episodes - Hypomanic episode without prior major depressive episode - Short-duration cyclothymia (less than 24 months)

Answer 161

* Symptoms * Mood reactivity brightening in response to circumstances * Overeating * Oversleeping * Leaden Paralysis * A long-standing pattern of interpersonal rejection sensitivity * Assoc with * Younger age of onset * more severe psychomotor slowing * COMO panic disorder, SUD, and somatization

Answer 162

Classic depression: severe anhedonia, early morning awakening, weight loss, and profound feelings of guilt

Answer 163

Confusion Agitation Lethargy Headaches Nausea Imbalance

Answer 164

Mirtazapine is a Noradrenergic/Specific Serotonergic Antidepressant (NaSSA) * Presynaptic a2-adrenergic antagonist effects--\> increased release of norepinephrine and serotonin * Potent antagonist of 5-HT2A, 5-HT2C, 5-HT3, and H1 receptors * Moderate peripheral a1-adrenergic and muscarinic antagonist;

Answer 165

1. Non-pharmacology appraoch 2. AcheI 3. Memantine 4. Antipsychotic

Answer 166

1. Behavioural/non-pharm 2. SSRI (Citalopram \>Trazodone, others) 3. Antipsychotic ONLY after 1 and 2 have failed 4. Memantine

Answer 167

Express Empathy Develop Discrepancy Roll with Resistance Support Self-efficacy

Answer 168

* Should be avoided due to risks of NTD (5%) * higher incidences of congenital abnormalities * striking degrees of neurodevelopmental delay in children at 3y, loss of 9 IQ pts

Answer 169

Pts may require higher doses of meds towards end of pregnancy because: Changes in physiology in 2nd and early 3rd trim Increased plasma volume Increased hepatice activity Increased renal clearance

Answer 170

Adults 1. CBT Modified for BN (most evidence) 2. IPT (as effective as CBT, but slower) 3. DBT (case reports) Adolescents 1. Family Based Therapy (superior to supportive and CBT) 2. CBT for BN (not as effective as FBT)

Answer 171

* CBC, lytes, CAMP, albumin, LFTS, Cr, Urea * ECG

Answer 172

Adults 1. CBT Modified for BN (most evidence) 2. IPT (as effective as CBT, but slower) 3. DBT (case reports) Adolescents 1. Family Based Therapy (superior to supportive and CBT) 2. CBT for BN (not as effective as FBT)

Answer 173

Pts may require higher doses of meds towards end of pregnancy because: Changes in physiology in 2nd and early 3rd trim Increased plasma volume Increased hepatice activity Increased renal clearance

Answer 174

* Should be avoided due to risks of NTD (5%) * higher incidences of congenital abnormalities * striking degrees of neurodevelopmental delay in children at 3y, loss of 9 IQ pts

Answer 175

* CBC, lytes, CAMP, albumin, LFTS, Cr, Urea * ECG

Answer 176

* CBC, lytes, CAMP, albumin, LFTS, Cr, Urea * ECG

Answer 177

* CBC, lytes, CAMP, albumin, LFTS, Cr, Urea * ECG

Answer 178

Adults 1. CBT Modified for BN (most evidence) 2. IPT (as effective as CBT, but slower) 3. DBT (case reports) Adolescents 1. Family Based Therapy (superior to supportive and CBT) 2. CBT for BN (not as effective as FBT)

Answer 179

* CBC, lytes, CAMP, albumin, LFTS, Cr, Urea * ECG

Answer 180

Rivastigmine

Answer 181

Significant improvements seen in 16 weeks

Answer 182

Naltrexone 50 mg + relapse prevention techniques

Answer 183

Having lots of administrative responsibilities Others: * Female * Earlier in Career * Dissatisfaction with Work

Answer 184

Intellectual Disability

Answer 185

Stop VPA | (high ammonia, ALWAYS STOP)

Answer 186

Slow Waves

Answer 187

May require high dose benzo (up to 16mg/d ativan)

Answer 188

Kohut * *Narcissistic Transferences* * The therapist comes to represent, in Kohut's terms, either the grandiose self in *mirror transferences* or the idealized parental imago in *idealizing transferences.* In idealizing transferences, all power and strength are attributed to the idealized object, leaving the subject feeling empty and powerless when separated from that object.

Answer 189

Helps to establish goals of therapy

Answer 190

Exposure and response prevention (If "DIRT" specifically was an option, would go with that)

Answer 191

Habit reversal

Answer 192

Continue clozapine in pregnancy stop postpartum (Typically you would continue an agent in breastfeeding if they were exposed in utero, but exceptions are when there are severe side effects with conitnued exposre such as clozapine,infant appears to be having side effects) CLozapine has been associated iwth floppy baby syndrome, infants exposed in utero should be monitored for agranulocytosis first weeks of life

Answer 193

Rivastigmine Recall in PD dementia, tx is symptomatic. Usually start with ACHei or memantine in stepwise fashion

Answer 194

Citalopram * Serotonergic medications have been the most studied in bvFTD. The selective serotonin reuptake inhibitors (SSRIs) fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram have all been tested to treat the behavioral symptoms of FTD. There is evidence that these drugs can have some efficacy in reducing disinhibition, repetitive behaviors, sexually inappropriate behaviors, and hyperorality.

Answer 195

Cyclothymic disorder

Answer 196

Needs to treat his psychosis

Answer 197

Mirtazapine * CANMAT review comorbidities * SSRIs and NASSA preferred agent cardiac * Avoid venlafaxine and TCAs for high blood pressure

Answer 198

Rivastigmine

Answer 199

Rivastigmine

Answer 200

Mirtazapine * CANMAT review comorbidities * SSRIs and NASSA preferred agent cardiac * Avoid venlafaxine and TCAs for high blood pressure

Answer 201

Needs to treat his psychosis

Answer 202

Cyclothymic disorder

Answer 203

Citalopram * Serotonergic medications have been the most studied in bvFTD. The selective serotonin reuptake inhibitors (SSRIs) fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram have all been tested to treat the behavioral symptoms of FTD. There is evidence that these drugs can have some efficacy in reducing disinhibition, repetitive behaviors, sexually inappropriate behaviors, and hyperorality.

Answer 204

Rivastigmine Recall in PD dementia, tx is symptomatic. Usually start with ACHei or memantine in stepwise fashion

Answer 205

Continue clozapine in pregnancy stop postpartum (Typically you would continue an agent in breastfeeding if they were exposed in utero, but exceptions are when there are severe side effects with conitnued exposre such as clozapine,infant appears to be having side effects) CLozapine has been associated iwth floppy baby syndrome, infants exposed in utero should be monitored for agranulocytosis first weeks of life

Answer 206

Habit reversal

Answer 207

Exposure and response prevention (If "DIRT" specifically was an option, would go with that)

Answer 208

Helps to establish goals of therapy

Answer 209

Kohut * *Narcissistic Transferences* * The therapist comes to represent, in Kohut's terms, either the grandiose self in *mirror transferences* or the idealized parental imago in *idealizing transferences.* In idealizing transferences, all power and strength are attributed to the idealized object, leaving the subject feeling empty and powerless when separated from that object.

Answer 210

May require high dose benzo (up to 16mg/d ativan)

Answer 211

Slow Waves

Answer 212

Stop VPA | (high ammonia, ALWAYS STOP)

Answer 213

Mirtazapine * CANMAT review comorbidities * SSRIs and NASSA preferred agent cardiac * Avoid venlafaxine and TCAs for high blood pressure

Answer 214

Intellectual Disability

Answer 215

Needs to treat his psychosis

Answer 216

Having lots of administrative responsibilities Others: * Female * Earlier in Career * Dissatisfaction with Work

Answer 217

Cyclothymic disorder

Answer 218

Naltrexone 50 mg + relapse prevention techniques

Answer 219

Significant improvements seen in 16 weeks

Answer 220

Rivastigmine

Answer 221

Rivastigmine

Answer 222

Citalopram * Serotonergic medications have been the most studied in bvFTD. The selective serotonin reuptake inhibitors (SSRIs) fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram have all been tested to treat the behavioral symptoms of FTD. There is evidence that these drugs can have some efficacy in reducing disinhibition, repetitive behaviors, sexually inappropriate behaviors, and hyperorality.

Answer 223

Rivastigmine Recall in PD dementia, tx is symptomatic. Usually start with ACHei or memantine in stepwise fashion

Answer 224

Continue clozapine in pregnancy stop postpartum (Typically you would continue an agent in breastfeeding if they were exposed in utero, but exceptions are when there are severe side effects with conitnued exposre such as clozapine,infant appears to be having side effects) CLozapine has been associated iwth floppy baby syndrome, infants exposed in utero should be monitored for agranulocytosis first weeks of life

Answer 225

Rivastigmine

Answer 226

Habit reversal

Answer 227

Rivastigmine

Answer 228

Exposure and response prevention (If "DIRT" specifically was an option, would go with that)

Answer 229

Helps to establish goals of therapy

Answer 230

Kohut * *Narcissistic Transferences* * The therapist comes to represent, in Kohut's terms, either the grandiose self in *mirror transferences* or the idealized parental imago in *idealizing transferences.* In idealizing transferences, all power and strength are attributed to the idealized object, leaving the subject feeling empty and powerless when separated from that object.

Answer 231

May require high dose benzo (up to 16mg/d ativan)

Answer 232

Slow Waves

Answer 233

Stop VPA | (high ammonia, ALWAYS STOP)

Answer 234

Intellectual Disability

Answer 235

Having lots of administrative responsibilities Others: * Female * Earlier in Career * Dissatisfaction with Work

Answer 236

Naltrexone 50 mg + relapse prevention techniques

Answer 237

Significant improvements seen in 16 weeks

Answer 238

Rivastigmine

Answer 239

Candidate will review that to be found unfit to stand trial the patient must be unable on account of a mental disorder (any disease of the mind) to: (1) understand the nature or object of the proceedings, (2) understand the possible consequences of the proceedings, or (3) communicate with counsel. The exceptional candidate will know that this is from Section 2 of the Canadian Criminal Code, and the governing case law is R v Taylor, 1992.

Answer 240

The court can handle an unfit accused in 2 ways: 1. He could have been remanded directly to the provincial review board (waits in jail or hospital until review board) OR 1. A treatment order could have been obtained if the court had evidence that (a) he was suffering from a mental disorder AND that treatment with a psychotropic medication was likely to render the accused fit to stand trial in a period of 60 days maximum, (b) that without treatment the accused was likely to remain unfit, and (c) the risk of harm from the administration of medication was not disproportionate to the anticipated benefits of the treatment.

Answer 241

* “Not Criminally Responsible”. * In Canada no person is criminally responsible for an act committed or an omission made while *suffering from a mental disorder* that rendered the person *incapable of appreciating the nature and quality of the act* or omission or of *knowing it was wrong*. This is from Section 16 of the Canadian Criminal Code.

Answer 242

* Child Abuse * Driving * Gunshot * Health card fraud * Sexual misconduct (ex by a regulated health professional) * Railway safety (ex train conductor) * Aeronautics safety (ex pilot or air traffic controller) * Court order

Answer 243

* Supreme Court of Canada has held that a physician was permitted to warn police when aware of the serious, imminent danger posed by a patient to an identifiable group against whom the patient had made specific threats * A duty exists where there is * (1) a risk to a clearly identifiable person or group of persons * (2) the risk of harm includes severe bodily injury, death or serious psychological harm, * (3) element of imminence and sense of urgency.

Answer 244

* If the patient is not capable, they need to be informed of the finding of incapacity and that a substitute decision maker (SDM) will be sought. * The patient is informed that they have the right to challenge this decision if they do not agree. The finding and reasoning behind it must be documented. * A Form 33 is filled out and given to psychiatric inpatients in Ontario. * An SDM has to be over 16 and capable to make the decision and willing to take the role. The approved (hierarchical) list legislated in Ontario by the HCCA is: * Anyone appointed by the court or CCB * Power of Attorney if it exists * Spouse/Partner * Child/Parent * Parent with right of access * Sibling * Any other relative

Answer 245

* HCR 20 (Historical, Clinical Risk Management) * VRAG (Violence Risk Appraisal Guide) * PCL-R (Psychopathy Checklist-Revised) * McArthur-Iterative Classification Tree

Answer 246

* Interferon * Corticosteroids (e.g. prednisone) * Varenicline (Champix; used for smoking cessation) * Immune modulating treatments (interferon alpha, interleukins) * Mefloquine (used in the prevention of malaria) * Progestin-releasing implanted contraceptives * Propranolol

Answer 247

SAD PERSONS Scale: * Sex: Women attempt suicide 3 times more often than men, but men succeed more than 3 times as often as women * Age: High risk groups include men 45 years of age or more and adolescents 19 years of age and younger * Depression: 10% to 20% of patients [hospitalized for depression] commit suicide * Previous attempt: Patients who have previously tried to commit suicide are 64 times more likely than the general population to attempt suicide again. This increased risk is also a lifetime risk and does not diminish with time. * Ethanol abuse: An estimated 15% of patients with a history of alcohol abuse commit suicide * Rational-thinking loss: The presence of psychosis increases the risk of suicide * Social supports lacking: Social isolation from friends, relatives or community increases suicidal motivation * Organized plan: Patients with a specific plan outlining a lethal available method are at increased risk * No spouse: In older patients, widows and widowers have the highest rate of suicide * Sickness: The presence of a chronic or severe illness increases the risk of suicide.

Answer 248

SSRI antidepressants are associated with an increased risk of GI bleeding. The most recent meta-analysis estimated an OR of 2.36 with NNH of 441 (Loke et al 2008). Overall the risks of bleeding need to be weighed against the need for treatment and the patient should be helped to make a clinical decision based on the best available evidence.

Answer 249

potential increased risk of bleeding when SSRIs are combined with NSAIDs, which compounds the risk (OR 6.33, NNH 106 – Loke et al 2008).

Answer 250

* The 95% CI of an estimate will be the range within which we are 95% certain that the true effect will lie. * The width of a confidence interval indicates the precision of the estimate. * The wider the interval, the less the precision. * A very wide interval makes us less sure about the accuracy of the estimate of the effect. * If the confidence interval for relative risk or odds ratio for an estimate includes 1, then there is not a statistically significant difference between the groups being compared; if it does not include 1, then we say that there is a statistically significant difference.

Answer 251

The OR represents the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. Eg. If a study has an OR of 3, it means that the group with the the exposure has a 3x higher risk of the outcome of interest compared to the group without the exposure

Answer 252

- Probability that the null hypothesis is true - Null hypothesis says that there is no difference or no change between the two tests - A smaller p-value means the more confident we are that the alternate hypothesis is true - Alternative hypothesis is what we set out to investigate

Answer 253

Relative risk is a ratio of the probability of an event occurring in the exposed group versus the probability of the event occurring in the non-exposed group

Answer 254

Absolute risk is the actual risk of some event happening given the current exposure. For example, if 1 in 10 individuals with exposure develops the disease then the absolute risk of developing the disease with exposure is 10% or 1:10.

Answer 255

The odds ratio compares the odds of some event in an exposed group versus the odds in a non-exposed group and is calculated as the number of events / the number of non-events.

Answer 256

* All SSRIs are transmitted into the breastmilk, but importance should be paid to the relative infant dose (RID). * All SSRIs are excreted at 10% or less in the breastmilk, but concentrations do vary. * Sertraline is considered the safest of the SSRIs, with RID of 0.5-3% based on a therapeutic dose. * The next “safest” is generally considered escitalopram with doses of 3-6%. Some SSRIs are higher, with dose ranges in the 8-10% range. * Although studies are somewhat limited, there is no evidence to date that there are any negative sequelae in infants who have been breastfed by women taking SSRIs in the postpartum period.

Answer 257

* Psychological: Previous history of anxiety or depression; depression during pregnancy; negative attiude during pregnancy; history of sexual abuse. * Obstetric: Multiparity (2 or more); emergency caesarean section; hospitalization during pregnancy; postpartum complications; birth of baby who is low birth weight (\<1500 g). * Biological: Younger age; Moderate to severe PMS; anemia at day 7 after delivery; thyroid dysfunction in pregnancy. * Social: recent stressors; limited social supports; low income. * Lifestyle: Insomnia during pregnancy (if history of PPD); poor sleep in postpartum period; poor diet.

Answer 258

The DSM 5 criteria for schizophrenia are: 1. Two or more of the following, each present for a significant portion of the time during a 1-month period (or less if successfully treated), at least one must be (1) (2) or (3) 1. **Delusions** 2. **Hallucinations** 3. **Disorganized speech** (frequent derailment or incoherence) 4. Grossly disorganized or catatonic behaviour 5. Negative symptoms (diminished emotional expression or avolition 1. For a significant portion of the time since the onset of disturbance, level of functioning in one or more major areas, such as work, interpersonal relations or self-care is markedly below the level achieved prior to onset 2. Continuous signs of the disturbance last for at least 6 months . the 6-month period must include at least 1 month of active symptoms and may include periods of prodromal residual symptoms 3. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been rule out 4. Disturbance is not attributable to the physiological effects of a substance or another medical condition 5. If there is a history of ASD or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations in addition to the other required symptoms are also present for at least one month **Specifiers:** First episode, currently in acute episode First episode, currently in partial remission First episode currently in full remission Multiple episodes currently in acute episode/partial remission/full remission Continuous With catatonia

Answer 259

DDX for hyponatremia: *Hypovolemic* * Renal loss- diuretics, low magnesium, hypoadrenalism * GI loss- vomiting, diarrhea * Skin loss- sweat, burns * Blood loss *Euvolemic* * Hypothyroidism * Psychogenic polydipsia * SIADH (ADH released and free water increases thereby diluting the blood and decreasing Na)- stress ,pain, cancer, lung disease, medications (CBZ, SSRI, morphine) * Hypervolemic* * CHF, cirrhosis, malnutrition, nephrotic syndrome **Exceptional candidate will note that hyponatremia extends beyond the psychosis and so it is important to consider a broad differential**

Answer 260

* The ones that are most common in psychiatry include carbamazepine and antidepressant medications * Antidepressant medications; usually cause this in older adults however it can also occur in younger people * Hyponatremia is uncommon with divalproex with a \<1% occurrence * First and Second-generation antipsychotic medication (i.e. risperidone); is known to cause antidiuretic hormone dysfunction called PIP (polydipsia, intermittent hyponatremia and psychosis syndrome) * Illicit substances- MDMA can also cause hyponatremia

Answer 261

* Symptoms usually develop within 2 weeks of treatment initiation * Presentation is usually of: confusion, somnolence, fatigue, delirium, hallucinations, urinary incontinence, hypotension and vomiting

Answer 262

Almost all classes of psychotropic agents have been reported to cause blood dyscrasias. Mechanisms include direct toxic effects upon the bone marrow, the formation of antibodies against haematopoietic precursors or involve peripheral destruction of cells. * Thrombocytopenia * Agranulocytosis * Anemia * Sometimes neuropenia (eg epival in children)

Answer 263

CQI * **PDSA**: Plan, Do, Study, Act * The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act). * **Six Sigma DMAIC**: Define, Measure, Analyze, Improve, Control Define what problem needs to be solved. Measure Performance. Analyze Data. Improve process. Control - to sustain the gain.

Answer 264

Step 1: Select Topic and Aims of audit Step 2: Agree on Target Criteria and Standards Step 3: Collect data Step 4: Compare Data with Target Criteria and Standards

Answer 265

With a retrospective audit, data are collected after care has been given. Random sampling is the preferred method. Patients' charts are chosen on the basis of numbers generated by a computer or random-numbers table. With systematic (or quasi-random) sampling, every "nth" chart is selected. For example, in a population of 1,000 patients, with a desired sample size of 100, every 10th chart would be chosen.

Answer 266

1. Provide feedback to the clinicians 2. Provide education and training 3. Distribute guidelines 4. Build in point-of-care tools or prompts into the electronic record 5. Revamp team roles in care delivery

Answer 267

1. admission rates to hospital of registered outpatients 2. number of suicide attempts by outpatients of service 3. number of emergency room visits by outpatients 4. ongoing review of complaints 5. incident reporting 6. side effects reporting 7. rates of no-shows 8. dropout rates 9. patient satisfaction surveys 10. referring source satisfaction surveys

Answer 268

* **Schizophrenia:** * Primary symptoms are psychosis (delusions, hallucinations, disorganized thoughts, disorganized / catatonic behaviour, negative symptoms) * No major depressive or manic episodes occur concurrently with active phase symptoms for a prolonged duration of the illness. * If mood episodes (depressive or manic) have occurred during active phase symptoms, they have been present for a minority of the total duration of the active and residual phases of the illness. * **Schizoaffective Disorder:** * Characterized by a combination of symptoms of schizophrenia, and symptoms of a mood disorder, such as mania and/or depression. * There must be an uninterrupted period during which there is a major mood episode (manic of depressive), occurring at the same time that symptoms of schizophrenia are present. * The symptoms meeting criteria for a major mood episode must be present for the majority of the duration of illness * BUT there _must_ be psychotic symptoms (delusions or hallucinations) for at least two weeks in the absence of a major mood episode, during the course of illness * **Major Depressive Disorder:** * Primary symptoms are those required for diagnosis of depression: * five or more symptoms during the same 2-week period, at least one of which is depressed mood or loss of interest or pleasure. (Depressed mood; Anhedonia; Reduced appetite or weight loss; Slowed thoughts or movements; Reduced energy; Feelings of worthlessness or guilt; Reduced concentration; Recurrent thoughts of death or suicidal ideation) * If there are psychotic symptoms, these resolve as depression improves (often first Sx to improve) and do not persist after depression resolves

Answer 269

* rTMS stands for Repetitive Transcranial Magnetic Stimulation * It is a kind of neurostimluation treatment, like ECT. * Although ECT is more efficacious than rTMS, patients may prefer rTMS because it is better tolerated, does not require anesthesia or induction of seizures. * Indicated for patients with unipolar major depression who have failed at least one antidepressant medication * It treats major depression by modulating activity in cortical regions and associated neural circuits * Uses an alternating current passed through a metal coil placed against the scalp to generate rapidly alternating magnetic fields, which pass through the skull, inducing electric currents that depolarize neurons in a focal area of the surface cortex * The magnetic field generated by rTMS is comparable to that of a standard magnetic resonance imaging (MRI) device (approximately 1.5 to 3 Tesla) * The mechanism of action of repetitive TMS is unknown. Hypotheses include: * Stimulation alters pathologic activity within a network of brain regions involved in mood regulation. This is supported by functional imaging studies * Molecular effects including increased monoamine turnover and normalization of the hypothalamic pituitary axis

Answer 270

Side Effects * Generally safe and well-tolerated * Headache (about 25-30%) and scalp pain (30-40%) * Generalized tonic-clonic seizure seizures (less than 0.1 to 0.5 %) * Hypomania and mania have been described * Transient (\<4 hours) increase in auditory threshold (Caused by repeated clicks current passes through the coil) - hearing loss is prevented with foam earplugs or noise protection ear coverings * Vasovagal syncope (management generally consists of reassurance)

Answer 271

* People at increased risks for seizures\* (ex. Hx of seizures) * Implanted metallic hardware (eg, aneurysm clips or bullet fragments) * Cochlear implants * Implanted electrical devices (eg, pacemakers, intracardiac lines, and medication pumps) * Unstable general medical disorders \*\*It may be possible to safely use in people with a personal or family history of seizures if the stimulation frequency is low (≤1 pulse per second) and stimulation intensity does not exceed the recommended safety range. However, patients at increased risk for seizures should be considered for rTMS only if the potential benefit outweighs the increased risk.

Answer 272

Effect size (d) is a quantitative measure of the magnitude of the experimental effect. The larger the effect size the stronger the relationship between two variables. (Mean of Exp Group - Mean of control group) / standard dev of either group Effect size values correspond roughly to small (0.3 range), medium (0.5 range) or large effects (\>0.8), therefore this effect is small.

Answer 273

· Considered to be a polygenetic neurodevelopmental disorder. § There are multiple genetic causes § Brain development and function are affected § Brain development is disrupted very early on: as early as in utero, and certainly within the first year Children with ASD do continue to grow and develop skills over their lifetime but are generally delayed with respect to social and communication development

Answer 274

· The following are core social communication criteria – name 1 criterion + give example (4 points – for all 6 points should give main domain and subdomains and at least two overall examples) o Children must show persistent deficits across multiple contexts, currently or by history in: o 1. Social-emotional reciprocity: e.g., abnormal social approach; failure to engage in normal back-and-forth conversation; reduced sharing of emotions, interests or affect; failure to initiate or respond to social interactions o 2. Nonverbal communicative behaviors used for social interaction: e.g., poorly integrated verbal and nonverbal communication; abnormalities in eye contact and body language; deficits in understanding or use of gestures; total lack of facial expressions and nonverbal communication o 3. Developing, maintaining and understanding relationships; e.g., problems adjusting behavior to suit different social contexts, difficulty sharing in imaginative play, problems making friends, absence of interest in peers The following criteria outline restricted/repetitive behaviours or interests (2 points, give at least 2 examples for full marks): 1. Stereotyped or repetitive movements, use of objects or speech 2. Insistence on sameness, inflexible adherence to routines, ritualized patterns of verbal or nonverbal behaviour 3. Highly restricted, fixated interests that are abnormal in intensity or focus 4. Hyper- or hyporeactivity to sensory input

Answer 275

‘The one year rule’. The key differentiating feature is the temporal sequence in with the parkinsonism and the neurocognitive disorder appear. In PDD the cognitive decline should not reach the stage of major NCD until at least one year after Parkinson’s Disease has been diagnosed. If less than a year has passed since the onset of motor symptoms the diagnosis is LBD.

Answer 276

Core diagnostic features: 1. Fluctuating cognition with pronounced variations in attention and alertness. 2. Recurrent visual hallucinations that are well formed and detailed. 3. Spontaneous features of parkinsonism, with onset subsequent to the development of cognitive decline. Suggestive diagnostic features: 1. Meets criteria for rapid eye movement sleep behavior disorder. 2. Severe neuroleptic sensitivity.

Answer 277

Clozapine – most evidence but concerns re use in the elderly Quetiapine – no clear evidence but is often used in practice Rivastigmine

Answer 278

1. Risks of antipsychotic use in patients with LBD and PDD due to severe neuroleptic sensitivity 2. Risks attendant with use of antipsychotics In patients with Dementia risk of all cause mortality and cardiovascular events with atypical antipsychotics (1/100 patients will die, relative risk 0.7 – 0.9). 3. Mentions Health Canada Black Box warning regarding the use of Atypical Antipsychotics with patients with Dementia (NCD) 4. A discussion of the need to weigh the risks and benefits of treatment eg noting potential risk to wife given delusional beliefs and distress of patient

Answer 279

- The criteria are met for major or mild neurocognitive disorder. - The disturbance has insidious onset and gradual progression. - Either (1) or (2): - Behavioral variant: Three or more of the following behavioral symptoms: 1. Behavioral disinhibition. 2. Apathy or inertia. 3. Loss of sympathy or empathy. 4. Perseverative, stereotyped or compulsive/ritualistic behavior. 5. Hyperorality and dietary changes. 6. Prominent decline in social cognition and/or executive abilities. Language variant: 1. Prominent decline in language ability, in the form of speech production, word finding, object naming, grammar, or word comprehension. 2. Relative sparing of learning and memory and perceptual-motor function. The disturbance is not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of a substance, or another mental, neurological, or systemic disorder.

Answer 280

1. Clear evidence of decline in memory and learning and at least one other cognitive domain (based on detailed history or serial neuropsychological testing). 2. Steadily progressive, gradual decline in cognition, without extended plateaus. 3. No evidence of mixed etiology (i.e., absence of other neurodegenerative or cerebrovascular disease, or another neurological, mental, or systemic disease or condition likely contributing to cognitive decline).

Answer 281

A pervasive pattern of **grandiosity** (in fantasy or behavior), need for **admiration**, and **lack of empathy,** beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). 2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. 3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). 4. Requires excessive admiration. 5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations). 6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends). 7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others. 8. Is often envious of others or believes that others are envious of him or her. 9. Shows arrogant, haughty behaviors or attitudes

Answer 282

A pervasive and excessive need to be **taken care of that** leads to **submissive** and **clinging** behavior and **fears of separation**, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. 2. Needs others to assume responsibility for most major areas of his or her life. 3. Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.) 4. Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy). 5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. 6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. 7. Urgently seeks another relationship as a source of care and support when a close relationship ends. 8. Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Answer 283

A pervasive pattern of **social inhibition**, feelings of **inadequacy**, and **hypersensitivity** to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection. 2. Is unwilling to get involved with people unless certain of being liked. 3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed. 4. Is preoccupied with being criticized or rejected in social situations. 5. Is inhibited in new interpersonal situations because of feelings of inadequacy. 6. Views self as socially inept, personally unappealing, or inferior to others. 7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

Answer 284

Reaction Formation - taking an unacceptable impulse, and behaving in the opposite, corrective way

Answer 285

Nasuea/Vomiting Bradycardia Sedation Hypotension

Answer 286

Confirm compliance Rule out substance use Start clozapine (best if olanzapine was one of meds tried)

Answer 287

* Major mental illness, where stirring up affect may lead to decompensation of their illness * Violence in family * Inflexible in considering there may be a problem in family * Therapy counter to family belief systems * Key members in family don’t participate * Where FT is not first line treatment; eg. Detoxing or treating a psychosis

Answer 288

Abilify * Typicals and Lurasidone block D2 receptors in pituitary, increasing PL * Lurasidone causes ++ weight gain

Answer 289

Yes, Typicals and Lurasidone and RIsperidone block D2 receptors in pituitary, increasing PL

Answer 290

citalopram, clomipramine, venlafaxine, mirtazapine

Answer 291

Maintenance - psychoeducation\*\*\*\* reccommend to all pts and fam at disaease onset cognitive behavioural therapy (CBT) family-focused therapy (FFT), IPSRT Peer Support Mania - no evidence, no reccommendations

Answer 292

Wellbutrin - does not prolong QT at all

Answer 293

Antidepressants CBT + other first line psychotherapy

Answer 294

Unstable Vitals: HR\<40, BP 80/60 or symptomatic Weight \<70% IBW or \<15 BMI * Cardiac dysrhythmia * Heart, renal liver compromise * Dehydration * Complications of malnutrition * Refeeding syndrome * Poor response to outpatient tx

Answer 295

Propranolol = first line Benztropine = second line Benzos = non-responders

Answer 296

Pragmatic language

Answer 297

Ventricular enlargement Reduced voume of corpus callosum Increased periventricular white matter changes

Answer 298

OR = odds of disease in exposed / odds of disease in the non-exposed

Answer 299

The sensitivity of that test is calculated as the number of diseased that are correctly classified, divided by all diseased individuals. Sn = True Positives/Total Diseased

Answer 300

Pregnant Using Opioids LFTs 3x upper limit normal or cirrhosis (needs FU liver enzymes after 3 weeks)

Answer 301

1. Consider cholinesterase inhibitor & Consider lowering dose of antiparkinson med 2. If necessary, can use AP, but only atypical. RIsk: Limited efficact in LBD, increased risk of death

Answer 302

Clonazepam Alprazolam Olanzapine

Answer 303

Family Intervention - reinforce more prosocial behaviors and to diminish undesired behaviors at the same time (form of CBT) Individual Play therapy - sometimes benefit

Answer 304

Reduced total sleep time Reduced Sleep efficiency Decreased SWS Increased sleep fragmentation Increased sleep latency REM declines after age 65 Phase advance (to bed earlier and wake earlier)

Answer 305

Assess and reduce or discontinue and anticonvulsant medications Caffeine hyperventilation

Answer 306

* Age \< 60 years *  Rapid (e.g., over 1–2 months) unexplained decline in cognition or function *  Short duration of dementia (\< 2 years) *  Recent and significant head trauma *  Unexplained neurologic symptoms (e.g., new onset of severe headache or seizures) *  History of cancer (especially types that metastasize to the brain) *  Use of anticoagulants or history of bleeding disorder *  History of urinary incontinence and gait disorder early in the course of dementia (as may be found in normal pressure hydrocephalus) *  Any new localizing sign (e.g., hemiparesis or a Babinski reflex)  –Unusual or atypical cognitive symptoms or presentation (e.g., progressive aphasia

Answer 307

Amygdala Hyperactivity

Answer 308

SI (7x) Depression mania delirium confusion disorientation

Answer 309

Depression Suicide risk (case reports) Psychosis

Answer 310

Head imaging - CT or MRI - first Then Will likely need LP later Blood culture

Answer 311

Nonsteroidal Anti-Inflammatory Agents: May increase the serum concentration of Lithium. Management: Consider reducing the lithium dose when initiating a NSAID

Answer 312

Reduction in cortical grey matter Reduced hippocampal volume Enlarged ventricle size (lat and 3rd) decreased amygdala and thalamus ↓symmetry, ↓limbic size (e.g. amygdala), ↓thalamus (ind. of tx) basal ganglia inc volume (englarged caudate)

Answer 313

Paliperidone Risperidone Amisulpuride Haldol

Answer 314

Hypophosphatemia (most concerning aspect of refeeding syndrome) Also: * Hypokalemia * Congestive heart failure * Peripheral edema * Rhabdomyolysis * Seizures * Hemolysis

Answer 315

Temazepam Do not administer Linezolid with: TCAS SSRIs High tyramine containg foods - bc of risk of serotonin syndrome

Answer 316

Reassure they will improve with time - indications for nocturnal polysomnography (PSG) include - •Habitual snoring, observed apneas, nocturnal enuresis, or other symptoms suggesting OSA. - •Significant safety concerns, excessive disruption of the family members' sleep, or contemplation of pharmacotherapy. - •Atypical features that raise concern for nocturnal seizures, such as daytime neurologic symptoms, older age group, family history of seizures, and multiple occurrences on a single night

Answer 317

* Insomnia – sleep hygiene * Melatonin * Doxepin/trazodone * Clonazepam = rem sleep disorder

Answer 318

* **ECT** + **lithium** is associated with 12-fold higher odds of **delirium** compared to **ECT** alone * The odd for cognitive impairment is 542% higher for **ECT** + **lithium** compared to **ECT** only.

Answer 319

**1**00 mg thiamine IM, Chlordiazepoxide 50 mg BID

Answer 320

Adults * depression * anxiety disorders * suicidality and self-harming behaviors * substance abuse. Children * depressive disorders * anxiety disorders * impulse-control disorders.

Answer 321

Citalopram \*In FTD, Citalopram or Trazodone as initial pharmacotherapy for patients with troubling behavioral symptoms

Answer 322

Correct: early corrective emotional experience by early transference interpretation Recall that systematic analysis = psychoanalysis

Answer 323

Having a diagnosis of schizophrenia Note that: * stigma may be lesss sevre in Asian and African countries/ islamic * Women and people living in rural areas more stigmatized * men more discrimination in job, women moreso in family/spcial areas

Answer 324

Abilify RIsperidone

Answer 325

Halve starting dose of lamictal (as epival increases lamotrigine levels)

Answer 326

Stereotypic movement disorder \*Note * Stereotypic movement disorder - Repetitive, seemingly driven, and apparently purposeless motor behavior (e.g., hand shaking or waving, body rocking, head banging, self-biting, hitting own body).Interferes, occurs in early developmental period * DCD - motor skills far below what is expected for developmental age

Answer 327

Citalopram \*In FTD, Citalopram or Trazodone as initial pharmacotherapy for patients with troubling behavioral symptoms

Answer 328

Adults * depression * anxiety disorders * suicidality and self-harming behaviors * substance abuse. Children * depressive disorders * anxiety disorders * impulse-control disorders.

Answer 329

NREM – low resting muscle tone REM- near paralysis of skeletal muscle (loss of REM atonia)

Answer 330

* CBT, IPT, DBT * Imipramine, sertraline, citalopram, topiramate (Grade a evidence) * Vyvanse approved for moderate to severe BED

Answer 331

100mg IM Thiamine Diazepam 5mg TID OR Chlordiazepoxide 50mg BID or Lorazepam 1mg QID or Oxazepam 15mg BID NOT prn because pt has hx of withdrawalseizures

Answer 332

* Insomnia – sleep hygiene * Melatonin * Doxepin/trazodone * Clonazepam = rem sleep disorder

Answer 333

Reassure they will improve with time - indications for nocturnal polysomnography (PSG) include - •Habitual snoring, observed apneas, nocturnal enuresis, or other symptoms suggesting OSA. - •Significant safety concerns, excessive disruption of the family members' sleep, or contemplation of pharmacotherapy. - •Atypical features that raise concern for nocturnal seizures, such as daytime neurologic symptoms, older age group, family history of seizures, and multiple occurrences on a single night

Answer 334

Hypophosphatemia (most concerning aspect of refeeding syndrome) Also: * Hypokalemia * Congestive heart failure * Peripheral edema * Rhabdomyolysis * Seizures * Hemolysis

Answer 335

Quetiapine - All antipsychotics are pregnancy Category C (except for clozapine, which is B) - Li, VPA = D - Lamotrigine C

Answer 336

Axis I Substance- Induced ... mood/anxiety/psychotic/OCD disorder/NCD/Sleep Mood/anxiety/psychotic disorder/OCD/ NCD/ Personality Change... Due to another medical condition Substance Use Disorders/ Intoxication/ Withdrawal Personality Disorders

Answer 337

ABC Environment Underlying Causes - Pain, hunger, constipation Exercise, routine Staff education Speak slowly and gently

Answer 338

Pramipexole

Answer 339

40-50% if not treated

Answer 340

a) Valproate or atypical antipsychotics (ziprasidone and quetiapine less preferable according to ACOG) b) Lithium - not recommended, but some studies recently showing overall risk to baby is low. If it is used in breastfeeding, must monitor Li levels of fetus as well as mother

Answer 341

Signfiicant Suffeirng Strong motivation to understand, persevere and change Psychological mindedness Ego Strength Ability to form relationship

Answer 342

* Depression (acute, recurrent, maintenance, subsyndromal, geriatric, adolescent, HIV+, postpartum, antepartum) * Adjunctive Tx in BAD * Bulimia * Initial/limited evidence in * Dysthymic disorder * Social phobia * PTSD

Answer 343

* Stop offending agent * Admit to ICU * Provide supportive care - airway, fever, fluids * Involve CL psych early * Possibly use cyproheptadine (5HT2a-blocker) or benzos

Answer 344

Add Abilify * Abilify is a partial D2 receptor agonist, has been reported to improve AP-related HPL * Seroquel is not long acting * Zuclopenthixol good because long acting, but also can cause HPL * No need to repeat PRL, as of little clinical benefit, and he is symptomatic

Answer 345

Specificity measures the proportion of negatives that are correctly identified (i.e. the proportion of those who do not have the condition (unaffected) who are correctly identified as not having the condition). It is a measure of validity.

Answer 346

One measure of test validity is sensitivity, i.e., how accurate the screening test is in identifying disease in people who truly have the disease. When thinking about sensitivity, focus on the individuals who, in fact, really were diseased. It is a measure of validity.

Answer 347

Positive predictive value is the probability that subjects with a positive screening test truly have the disease.

Answer 348

Negative predictive value is the probability that subjects with a negative screening test truly don't have the disease.

Answer 349

Test validity is the ability of a screening test to accurately identify diseased and non-disease individuals. An ideal screening test is exquisitely sensitive (high probability of detecting disease) and extremely specific (high probability that those without the disease will screen negative). The validity of a screening test is based on its accuracy in identifying diseased and non-diseased persons, and this can only be determined if the accuracy of the screening test can be compared to some "gold standard" that establishes the true disease status. The gold standard might be a very accurate, but more expensive diagnostic test.

Answer 350

1. low voltage high frequency waves.

Answer 351

* being female * rapid onset of symptoms * older age at first episode * predominantly positive \> neg symptoms * presence of mood symptoms * good pre-illness functioning

Answer 352

Psychoeducation In maintenance, psychoed is first line In depression, no first line, but CBT and FFT are second line

Answer 353

Acetylcholinesterase inhibitor (Note that cholinesterase inhibitors are efficacious in DLB, with reported benefit not only in cognition, but also for fluctuations, psychotic symptoms, and parkinsonian symptoms.)

Answer 354

Decreased hippocampus

Answer 355

Clozapine Recall Strategies for TD 1. DC agent if possible 2. Clozapine or quetiapine 3. Clonazepam 4. Botox 5. Valbenazine/tetrabenazine 6. Trihexanphenaydl/Cogentin – not usually reccommende

Answer 356

Citalopram

Answer 357

Decreased alpha and generalized delta theta.

Answer 358

Moclobemide - Venlafaxine and Fluox risk of HTN - Irreversible MAOIS always risk HTN crisis when ingested with tyrosine - Venlafax and Flux small risk of GI bleed 1 in 300 pt years - Atypical depression – MAOs may have superiority - Still very small risk of htn crisis with Moclobemide even thnogh reversible

Answer 359

Continue lithium at therapeutic dose

Answer 360

* Risk of Ebstein Abnormality 1st trimester * Recently, found that this defect only occurs in less than 1% of exposed children. * Also been associated with perinatal toxicity, including case reports of hypotonia, cyanosis, neonatal goiter, and diabetes insipidus. * In severe BD, risk of recurrence may overshadow risk of Ebstein * For women with significant periods of euthymia and few past mood episodes, slowly tapering off lithium and reintroducing lithium after the first trimester may help reduce the risk of relapse.

Answer 361

Nortriptyline OR citalopram Treatment of PBA TCAs (nortrip, amitrip) SSRIs fluox, citalopram, setraline Dextromethorphan-quinidine

Answer 362

Risperidone (even better than citalopram)

Answer 363

Ego Deficits - Supportive psychotherapy is generally indicated for those patients for whom classic psychoanalysis or insight-oriented psychoanalytic psychotherapy is typically contraindicated—those who have poor ego strength and whose potential for decompensation is high

Answer 364

a) M\>F * Slight more F\>M, but very similar * F more likely to have erotomania * M more likely paranoid * Pts married and employed * Some assoc with recent immigration and low SES * May appear to be delusional disorder, but can be an ealry sign of dementing illness * Other Risk Factors * Advanced age * sensory impairment * isolation * fam hx * Personality featues (interpersonal sensitivity)

Answer 365

Bleuler First coined the term shcizophrenia Defined with the 4 As

Answer 366

Echo * Any cardioresp symptoms --\> ED * Myocarditis fatal 1/3 of time

Answer 367

Dysarthria When Naproxen and Li combined can increase Li levels --\> confusion, tremor, slurred speech, and vomiting

Answer 368

Phyostigmine

Answer 369

diaphoresis

Answer 370

Alzheimer’s

Answer 371

subcallosul cingulum

Answer 372

family history affective disorder

Answer 373

* \<40BPM * BP \<80/60 or presyncope * QTc \>499 or any rhythm other than normal sinus rhythm or sinus bradycardia. * Wt \<70% IBW * BMI 14-15 * Cardiovascular, hepatic, or renal compromise requiring medical stabilization. * dehydration. * Serious medical complication of malnutrition (eg, syncope, seizures, cardiac failure, liver failure, pancreatitis, hypoglycemia, or marked electrolyte disturbance). * Moderate to severe refeeding syndrome: * Marked edema * Serum phosphorous \<2 mg/dL ●Poor response to outpatient treatment

Answer 374

ECG Max dose in elderly 20mg

Answer 375

Child and adolescent

Answer 376

Child and adolescent

Answer 377

ECG Max dose in elderly 20mg

Answer 378

* \<40BPM * BP \<80/60 or presyncope * QTc \>499 or any rhythm other than normal sinus rhythm or sinus bradycardia. * Wt \<70% IBW * BMI 14-15 * Cardiovascular, hepatic, or renal compromise requiring medical stabilization. * dehydration. * Serious medical complication of malnutrition (eg, syncope, seizures, cardiac failure, liver failure, pancreatitis, hypoglycemia, or marked electrolyte disturbance). * Moderate to severe refeeding syndrome: * Marked edema * Serum phosphorous \<2 mg/dL ●Poor response to outpatient treatment

Answer 379

family history affective disorder

Answer 380

subcallosul cingulum

Answer 381

Alzheimer’s

Answer 382

diaphoresis

Answer 383

Phyostigmine

Answer 384

Dysarthria When Naproxen and Li combined can increase Li levels --\> confusion, tremor, slurred speech, and vomiting

Answer 385

Echo * Any cardioresp symptoms --\> ED * Myocarditis fatal 1/3 of time

Answer 386

Bleuler First coined the term shcizophrenia Defined with the 4 As

Answer 387

a) M\>F * Slight more F\>M, but very similar * F more likely to have erotomania * M more likely paranoid * Pts married and employed * Some assoc with recent immigration and low SES * May appear to be delusional disorder, but can be an ealry sign of dementing illness * Other Risk Factors * Advanced age * sensory impairment * isolation * fam hx * Personality featues (interpersonal sensitivity)

Answer 388

Ego Deficits - Supportive psychotherapy is generally indicated for those patients for whom classic psychoanalysis or insight-oriented psychoanalytic psychotherapy is typically contraindicated—those who have poor ego strength and whose potential for decompensation is high

Answer 389

Risperidone (even better than citalopram)

Answer 390

Nortriptyline OR citalopram Treatment of PBA TCAs (nortrip, amitrip) SSRIs fluox, citalopram, setraline Dextromethorphan-quinidine

Answer 391

* Risk of Ebstein Abnormality 1st trimester * Recently, found that this defect only occurs in less than 1% of exposed children. * Also been associated with perinatal toxicity, including case reports of hypotonia, cyanosis, neonatal goiter, and diabetes insipidus. * In severe BD, risk of recurrence may overshadow risk of Ebstein * For women with significant periods of euthymia and few past mood episodes, slowly tapering off lithium and reintroducing lithium after the first trimester may help reduce the risk of relapse.

Answer 392

Continue lithium at therapeutic dose

Answer 393

Moclobemide - Venlafaxine and Fluox risk of HTN - Irreversible MAOIS always risk HTN crisis when ingested with tyrosine - Venlafax and Flux small risk of GI bleed 1 in 300 pt years - Atypical depression – MAOs may have superiority - Still very small risk of htn crisis with Moclobemide even thnogh reversible

Answer 394

Hold lithium

Answer 395

not understand consequences

Answer 396

Patient must be able to understand 1. Understand harges & potential consequences 2. Understand and enage in Trial process 3. Capacity to participate with an attorney in a defense 4. Potential for courtroom participation

Answer 397

Children require higher by weight doses than adults

Answer 398

SSRI Unless contraception is a high priority

Answer 399

4-6 weeks * CANMAT - The standard protocol is 10,000 lux (light intensity) for 30 minutes per day during the early morning for up to 6 weeks, with response usually seen within 1 to 3 weeks.

Answer 400

Other specified bipolar disorder - Short-duration hypomanic episodes (2–3 days) and major depressive episodes - Hypomanic episodes with insufficient symptoms and major depressive episodes - Hypomanic episode without prior major depressive episode - Short-duration cyclothymia (less than 24 months)

Answer 401

Scz less likely get regular monitoring

Answer 402

have hyperprolactinemia

Answer 403

Cingulate gyrus

Answer 404

Naltrexone (recall that Bup = substitution, clonidine just for withdrawal. Naltrexone is antagonist to prevent relapse)

Answer 405

Lurasidone is Preg Category B Lamotrigine and Quetiapine are Preg Category C Li and VPA are Preg Category D

Answer 406

Advance parental age Prenatal Factors * advanced maternal and paternal age at birth * maternal gestational bleeding * gestational diabetes * first-born baby Perinatal Risk Factors * umbilical cord cx * birth trauma * fetal distress * SGA * low birth weight * low 5 min apgar score * congenital malformation * ABO/Rh blood factor incompatibility * hyperbilirubinemia

Answer 407

ECT (but quetiapine even better)

Answer 408

Family history of post-partum psychosis predicts OCCURRENCE Has a better prognosis than non-puerperal psychosis is also true The risk factors for postpartum psychosis: ●History of postpartum psychosis ●Family history of postpartum psychosis ●History of bipolar disorder, schizophrenia, or schizoaffective disorder ●Family history of bipolar disorder ●First pregnancy ●Discontinuation of psychiatric medications for pregnancy

Answer 409

Selective abstraction

Answer 410

Ziprasidone

Answer 411

Interpersonal inventory

Answer 412

* Self * Self-perception * Identity * Fantasies about self * Self-esteem * vulnerability to threats * internal response to threats * use of others to regulate self-esteem * Relationships * trust * sense of self and other * security * intimacy * mutuality * Adapting * thresholds and ways of adapting to int/ext stimulation * Defense mechanism * impulse control * managing emotions * sensory regulations * Cognition * general cog abilities * decison-making and prob-solving * self reflection/reality testing * mentalization * judgment * Work and Play

Answer 413

* Adult problems and patterns can be linked to unconscious conflicts and defenses * Unconscious conflict happens when opposing thoughts, feelings, wishes collide * This conflict is out of our awareness, causes anxiety, and prompts us to use our defenses to work out compromises * Parts of the mind in constant conflict with each other * Id * Superego * Ego

Answer 414

* Links problems and patterns to the unconscious repetition of early relationships with others * Young children take in their experiences with important caregivers through a process called **internalization** * These internalized relationshipo patterns are called **templates** * **Templates** remain in unconscious mind through development, affecting the way people think about themselves and others * Object relations suggests that people reactivate their early relationship templates with the therapist in **transference**

Answer 415

* Self psychology is an organzing idea about development that LINKS problems and patterns to development of self * Early caregivers perform functions that are essential for the child's development of self called **Selfobject** functions because they are experiened by child as part of the self * EG. * **Mirroring** - caregiver's empathic ability to appropriately reflect the child's abilities and internal states * **Idealization** - caregiver's ability to be idealized by child * **Grandiosity** - children need to be made to feel special and powerful

Answer 416

* Secure * Insecure * **Dismissive/**Avoidant * **Preoccupied**/anxious/Ambivalent * **Disorganized**/Fearful

Answer 417

* Acting Out * Denial * Dissociation * Introjection (internalizing qualities of another person, eg. identification with the aggressor) * Omnipotent control * Primitive idealization and devaluation (seeing others as all good or all bad) * Projection * Projective Identification * Splitting

Answer 418

* Altruism * Anticipation * Blocking * Controlling * Displacement * Externalization * Humour * Hypochondriasis * Identification * INtellectualization * Isolation of affect * Passive aggressive behaviour * Rationalization * Reaction formation * Regression * Repression * Somatization * Sublimation * Suppression

Answer 419

* Focus on the interpersonal relationships and how this relates to the onset/maintenance of the depression * Based on the biopsychosocial model * Aim is to alleviate suffering and improve interpersonal functioning * May also help to improve the patient’s social network so they are better able to manage their interpersonal distress * Affective expression encouraged (especially emotions related to mourning or loss of social roles) * Time limited (usually between 12-16 sessions) * Dynamically informed therapy but the focus is here-and-now and the interventions used do not directly address the patient-therapist relationship

Answer 420

* Clarification - including directive questioning, empathic listening, reflective listening and encouragement of spontaneous discourse * Communication analysis * Clarifying Interpersonal incidents * Use of affect -“content affect” vs “process affect” * Role Playing * Problem solving * Homework

Answer 421

* CBT is based on the cognitive model of mental illness, initially developed by Beck (1964). * People’s emotions and behaviours are influenced by their perceptions of events. * How people feel is determined by the way in which they interpret situations rather than by the situations per se. * Three levels of cognition: * Core beliefs * Dysfunctional assumptions * Negative automatic thoughts

Answer 422

* Core beliefs, or schemas, are deeply held beliefs about self, others and the world. * Core beliefs are generally learned early in life and are influenced by childhood experiences and seen as absolute. * The cognitive triad of negative core beliefs captures how they relate to: The self, e.g. ‘I’m useless’ The world/others, e.g. ‘the world is unfair’ The future, e.g. ‘things will never work out for me’

Answer 423

Dysfunctional assumptions are rigid, conditional ‘rules for living’ that people adopt. These may be unrealistic and therefore maladaptive. For example, one may live by the rule that ‘It’s better not to try than to risk failing’.

Answer 424

Negative automatic thoughts (NATs) are thoughts that are involuntarily activated in certain situations. In depression, NATs typically centre on themes of negativity, low self-esteem and uselessness. For example, when facing a task, a NAT may be ‘I’m going to fail’. In anxiety disorders, automatic thoughts often include overestimations of risk and underestimations of ability to cope.

Answer 425

* Longitudinally (Beck) * **Early experiences** (e.g. rejection by parents) contribute to the development of --\> * **Core beliefs**, which lead to the development of --\> * **Dysfunctional assumptions** (e.g. ‘Unless I am loved I am worthless’), which are later activated following a critical incident (e.g. loss), leading to --\> * **NATs (Neg automatic thoughts)** and the symptoms of depression. * Cross-Sectional/Hot-Cross Bun (Padesky)

Answer 426

* Cognitive Techniques * Socratic questioning * Positive Data Logs * Thought Records - NATs * Evidence for/against - dysfunctional assumptions * Behavioural Techniques * Activity Scheduling * Graded Task assignments * Behavioural Experiments * Progressive Relaxation

Answer 427

Quetiapine Olanzapine

Answer 428

* Avoid Divalproex and lithium if we can (but risk benefit always!) Preg Category D * All Atypicals preg category C * All SSRIs preg category C (except paroxetine = D)

Answer 429

* L4 (avoid) - Li, DVP * L3 (avoid) - Clozapine * L2 - atypicals esp OLZ and quetiapine, lamotrigine, carbamazepine, all SSRIs * ALWAYS discuss risks and benefits and how to monitor infant for signs of toxicity

Answer 430

* Antipsychotic drug treatment can cause tardive dyskinesia, it can also mask/suppress tardive dyskinesia * Antipsychotic withdrawal or dosage reduction can unmask tardive dyskinesia; and thus, tardive dyskinesia can appear to worsen after dosage reduction or discontinuation of the perceived offending agent. * Although use of first generation antipsychotics are associated with a higher risk of tardive dyskinesia, second generation antipsychotics are not free from risk of tardive dyskinesia

Answer 431

* Reports of risk vary * 5% yearly incidence for tardive dyskinesia on first generation antipsychotics compared to a 1% incidence on a second generation antipsychotic. * There is currently insufficient data to determine differences in risk between different second generation antipsychotic drugs. * clozapine carries the lowest risk for tardive dyskinesia.

Answer 432

* The most clearly established risk factor for tardive dyskinesia is age. Although figures vary, in patients over 65, the risk of TD is at least double – and in some studies up to 5X as high – as compared with a younger population. * Other risk factors include: * duration of antipsychotic treatment * previous head injury * mood disorder * possibly female gender * possibly dose * possibly early presence of significant EPS. * Iron deficiency can be a risk factor for exacerbation of movement disorders

Answer 433

* Beyond lips, tongue and jaw, one needs to assess the face for grimacing movements and abnormal eye blinking. * Choreoathetoid movements in fingers, wrists, ankles and toes * Rocking or torsion movements of neck and/or trunk. * Diaphragmatic involvement, which may result in grunting or non-rhythmic breathing. * Other late-onset movement disorders associated with chronic antipsychotic treatment, including tardive dystonias and tardive akathisia.

Answer 434

* Differential dx: Movement disorders – examples: Wilson’s Disease and Huntington’s Disease * Schizophrenia and other psychoses can be associated with spontaneous movement disorders with no other demonstrable etiology. * Other drugs may cause or exacerbate TD: * Any dopamine receptor blocker (eg antiemetics such as Stemetil, metoclopramide) * Rarely, SSRIs or SNRIs have been associated with TD * Anticholinergics may worsen TD (in contrast to beneficial effects on acute EPS)

Answer 435

* There is no good evidence for any specific drug treatment for tardive dyskinesia. * TD may gradually improve over time (months or years) if the offending agent is withdrawn. * Can switch patient to an antipsychotic medication with less propensity to cause TD. * The data is strongest for clozapine as it appears to have the lowest risk for TD. * Switching from an older generation antipsychotic to another second generation atypical antipsychotic may also be helpful.

Answer 436

It is use of the drug for a non-approved indication.

Answer 437

* In off-label use of a drug, one needs to inform the patient that the drug is not approved for the purpose for which you intend to prescribe it. One would also provide information on the benefits and risks in the same manner as would for an approved drug. For a non- approved use however, there may be less good information on risks and benefits. * Additional caution and judgment is required when prescribing a drug for a non-indicated use. The physician must distinguish between off-label use where safety and efficacy is reasonably well-established versus off-label use based on anecdotal reports, open label studies, a single small RCTs, poorly designed studies, etc.

Answer 438

AIMS - TD Simpson Angus Scale - EPS Barnes Akathisia Scale - Akathisia

Answer 439

Randomized controlled trials (RCTs) Cohort studies Case-control studies Qualitative studies

Answer 440

* Randomized trials provide the most reliable answers to the question of how effective a tx or dx test is * RCTs only possible method to draw reliable conclusions about cause and effect * People are allocated at random to receive one of several clinical interventions. * One of these interventions is the standard of comparison or control. * Someone who takes part in a randomized controlled trial (RCT) is called a participant or subject. * RCTs seek to measure and compare the outcomes after the participants receive the interventions. * Because the outcomes are measured, RCTs are quantitative studies. * RCTs are quantitative, comparative, controlled experiments in which investigators study two or more interventions in a series of individuals who receive them in random order.

Answer 441

* A cohort is a group of people who are observed frequently over a period of many years – for instance, to determine how often a certain disease occurs. * Two (or more) groups that are exposed to different things are compared with each other * Observe how the health of the people in both groups develops over the course of several years, whether they become ill, and how many of them pass away. * Can have a prospective (forward-looking) design or a retrospective (backward-looking) design. * Useful if you want to find out how common a medical condition is and which factors increase the risk of developing it. * Eg.How does high blood pressure affect heart health?

Answer 442

* Compare people who have a certain medical condition with people who do not have the medical condition, but who are otherwise as similar as possible, for example in terms of their sex and age. * Then the two groups are interviewed, or their medical files are analyzed, to find anything that might be risk factors for the disease * Generally retrospective. * Good for studying rare diseases * Can help to investigate the causes of a specific disease, eg. Do HPV infections increase the risk of cervical cancer? * Not as expensive or time-consuming as RCTs or cohort studies. But it is often difficult to tell which people are the most similar to each other and should therefore be compared with each other. Because the researchers usually ask about past events, they are dependent on the participants’ memories. But the people they interview might no longer remember whether they were, for instance, exposed to certain risk factors in the past.

Answer 443

* Classic = survey: A representative group of people – usually a random sample – are interviewed or examined in order to find out their opinions or facts. * Data is collected only once, cross-sectional studies are relatively quick and inexpensive. * Can provide information on things like the prevalence of a particular disease (how common it is) * Can't tell us anything about the cause of a disease or what the best treatment might be * Eg. How tall are German men and women at age 20?

Answer 444

* Helps us understand, for instance, what it is like for people to live with a certain disease. * Based on information collected by talking to people who have a particular medical condition and people close to them. Written documents and observations are used too. * The information that is obtained is then analyzed and interpreted using a number of methods. Qualitative studies can answer questions such as these: How do women experience a Cesarean section?

Answer 445

* Dialectical behavior therapy (DBT) is the psychosocial treatment that has received the most empirical support for patients with borderline personality disorder * Method is eclectic, drawing on concepts derived from supportive, cognitive, and behavioral therapies. * 4 primary modes of treatment in DBT: group skill training, individual therapy, phone consultation, and consultation team. * Seen weekly, with the goal of improving interpersonal skills and decreasing self-destructive behavior. * Patients with BPD receive help in dealing with the ambivalent feelings that are characteristic of the disorder * DBT assumes all behavior (including thoughts and feelings) is learned and that patients with borderline personality disorder behave in ways that reinforce or even reward their behavior, regardless of how maladaptive it is

Answer 446

* Supportive psychotherapy aims at the creation of a therapeutic relationship as a temporary buttress or bridge for the deficient patient. * The primary form used in the general practice of medicine and rehabilitation, frequently to augment other measures, such as prescriptions of medication to suppress symptoms, rest to remove the patient from excessive stimulation, or hospitalization * Places major etiologic emphasis on external rather than intrapsychic events, particularly on stressful environmental and interpersonal influences on a severely damaged self. * Indicated for those patients for whom classic psychoanalysis or insight-oriented psychoanalytic psychotherapy is typically contraindicated—those who have poor ego strength and whose potential for decompensation is high. * Amenable patients fall into the following major areas: * (1) individuals in acute crisis or a temporary state of disorganization and inability to cope * (2) patients with chronic severe pathology with fragile or deficient ego functioning * (3) patients whose cognitive deficits and physical symptoms make them particularly vulnerable and, thus, unsuitable for an insight-oriented approach * (4) individuals who are psychologically unmotivated, although not necessarily characterologically resistant to a depth approach (e.g., patients who come to treatment in response to family or agency pressure)

Answer 447

1. use the same medication for tapering 2. switch to a longer-acting equivalent 3. use adjunctive medications to help mitigate potential withdrawal symptoms. - Initial reduction of 25-30% for high dosage chronic users, followed by a 5-10% daily to weekly reduced dose.

Answer 448

1. Evidence of **significant cognitive decline** from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on: 1. **Concern** of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and 2. A **substantial impairment in cognitive performance**, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment. 2. The **cognitive deficits interfere** with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications). 3. The cognitive deficits do not occur exclusively in the context of a delirium. 4. The cognitive deficits are not better explained by another mental disorder - With behavioural distrubance - Without behavioural disturbance - Mild, mod, severe

Answer 449

1. Evidence of **modest cognitive decline** from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on: 1. **Concern** of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in cognitive function; and 2. **A modest impairment in cognitive performance**, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment. 2. The cognitive deficits **do not interfere** with capacity for independence in everyday activities (i.e., complex instrumental activities of daily living such as paying bills or managing medications are preserved, but greater effort, compensatory strategies, or accommodation may be required). 3. The cognitive deficits do not occur exclusively in the context of a delirium. 4. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).

Answer 450

* Recall bias * When survey respondents remember things differently * Selection bias * Research samples can sometimes under-represent certain people or groups, and over–represent others. Solution: randomization * Observation bias (also known as the Hawthorne Effect) * When participants in a study are aware that they are being observed by scientists and alter the way they act or the answers they give. * Confirmation bias * When researchers, consciously or unconsciously, look for information or patterns in their data that confirm the ideas or opinions that they already hold. * Publishing bias * Studies with negative findings (i.e. trials in which no significant results are found) are less likely to be submitted by scientists or published by scientific journals because they are perceived as less interesting. This can skew our understanding of a topic because, for example, when carrying out a review or a meta-analysis on a new drug treatment, if this type of data is missing, it can make it seem like a drug is more or less effective than it actually is. This is called publishing bias.

Answer 451

* RAD = A) The child rarely or minimally seeks comfort when distressed. AND/OR responds to comfort when distressed. WITH persistent emotional disturbance * Before Age 5 * DSED = A) Reduced or absent reticence in approaching and interacting with unfamiliar adults. Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries). Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings. Willingness to go off with an unfamiliar adult with minimal or no hesitation * Both * The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios). * Must be 9 months of age

Answer 452

A systematic review answers a defined research question by collecting and summarising all empirical evidence that fits pre-specified eligibility criteria. A meta-analysis is the use of statistical methods to summarise the results of these studies.

Answer 453

* clearly stated **objectives** with pre-defined **eligibility criteria** for studies * explicit, reproducible methodology * a **systematic search** that attempts to identify all studies * assessment of the **validity of the findings** of the included studies (e.g. risk of bias) * systematic **presentation, and synthesis,** of the characteristics and findings of the included studies

Answer 454

* A graphical display of estimated results from a number of scientific studies addressing the same question, along with the overall results * A means of graphically representing a meta-analysis of the results of randomized controlled trials. * Usually OR used

Answer 455

Interpreting the transference is key

Answer 456

Focus on corrective emotional experience in the transference interpretation early on

Answer 457

Hypoactivity of DA in mesocortical cortex

Answer 458

* smooth philtrum * thin upper lip * upturned **nose** * flat nasal bridge and midface * epicanthal folds * small palpebral fissures * small head circumference.

Answer 459

Ca and Glucose

Answer 460

Paranoid delusions (somatic delusions also very common)

Answer 461

Acamprosate (Because Naltrexone + suboxone not inidicated first line)

Answer 462

Frontal Temporal Dementia

Answer 463

Current depression

Answer 464

5-10% (25% revert to normal)

Answer 465

* b-amyloid and tau protein levels * CSFP * APOE * homocysteine levels * high LDL * serum IL-6 * olfactory dysfunction * changes hippocampal volume on PET * amyloid plaque on PET * delayed verbal recall and executive function in neuropsych

Answer 466

systolic HTN \>160mm/Hx (evidence to treat) - serum cholesterol \>6.5mmol/L - Smoking, current - hyperlipidemia ( no evidence for statins dec risk though) - head injury with loss of consciousness - low education \<12 yrs - Diabetes (vascular dem RF) - estrogen alone or in combo with progesterone - occup exposure environmental toxins- pesticides, fertilizers, fumigants and defoliants

Answer 467

Female gender Poor Prognostic Factors in BAD * older age * male * psychosis * mixed episodes * substance use * younger onset * rapid cycling

Answer 468

Abstinent for less than 6 months prior to transplant Predictors of Relapse: dx SUD vs. abuse fam hx add failed rehab multiple substances poor soc support short pretransplant length abstinence.

Answer 469

Buporopion SSRIs and SNRIs both show increased risk of bleeding in some studies

Answer 470

Derouting conflict through a child

Answer 471

Attenuated positive symptoms these are MOST related

Answer 472

Executive Dysfunction

Answer 473

* food restriction * excessive exercises * preoccupied with food, eating, calories * social isolation * mood irritability, depression, obsessive compulsive behaviour * cold intolerance * lanugo hair * hair loss * poor sleep (early am waking) * dizziness, fainting * GI symtpoms

Answer 474

* CBC (possible reductions in all cell lines) * Lytes * BUN, Cr * Hypercholesterolemia common * LFTs may be elevated * Decreased Mg, Zn, Phosphorous * Metabolic alkalosis if vomiting (hypochloremic, hypokalemic) * Metabolic acidosis with laxatives * Thyroid - T4 low-normal, T3 decreased, reverse T3 elevated * Low E for females, Low T for males * ECG - bradycardia, prolonged QTC * BMD, if 6 months amenorrhea

Answer 475

* Nausea * vomiting * diarrhea * sluggishness * ataxia * confusion * agitation * neuromuscular exictability (coarse tremor, fasciculation, myoclonic jerks) * Severe - seizures, encephalopathy

Answer 476

Man has had depressive episode for past 3 years with onset in winter and resolution in spring, and one previous manic episode 5 years ago

Answer 477

Combination of CBT and meds are more effective

Answer 478

substance cues to use lead to glutamate mediated activation

Answer 479

Clonazepam Recall in BPD a) Antipsychotic (Aripiprazole) b) mood stabilizer (Topiramate?) c) SSRI (Fluoxetine?)

Answer 480

hypercalcemia \*Remember that lithium can cause hyperparathyroidism and hypercalcemia

Answer 481

Abulia Recall: **W**i**N M**a**C -SP GAME₂S** 1. Waxy flexibility – slight, even, resistance to positioning by examiner 2. Negativism – do the opposite of what is asked/ no response to instructions or external stimuli 3. Mutism – no/very little verbal response 4. Catalepsy –passive induction of a posture held against gravity 5. Stupor – no psychomotor activity; not actively relating to environment 6. Posturing – spontaneous & active maintenance of a posture against gravity /adoption of unusual bodily postures continuously for a long time 7. Grimacing 8. Agitation – not influenced by external stimuli 9. Mannerism – repeated movements that appear to have some functional significance e.g. saluting 10. Echolalia – mimicking another’s speech 11. Echopraxia – mimicking another’s movements 12. Stereotypy – repetitive, abnormally frequent non-goal directed movements e.g. rocking to and fro

Answer 482

Clozapine-induced tachycardia

Answer 483

male gender Rapid Cycling RF * Younger, onset \<17 * Women \> men (70%) * Hypothyroidism \*\*\* NOT hyperthyroid * SSRIs

Answer 484

Diabetes Risk Factors for TD * Older * female * First \> SGA * Duration * dose * early occurrence of drug induced movement disorders * Shchiz * ID * ETOH or SUD * Dementia * Diabetes * Prior ECT

Answer 485

Acetylcholine

Answer 486

Opioid partial agonist at MU receptor

Answer 487

*DSM 5 criteria for Stimulant Intoxication:* Two (or more) of the following signs or symptoms, developing during, or shortly after, stimulant use: 1. Tachycardia or bradycardia. 2. Pupillary dilation. 3. Elevated or lowered blood pressure. 4. Perspiration or chills. 5. Nausea or vomiting. 6. Evidence of weight loss. 7. Psychomotor agitation or retardation. 8. Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias. 9. Confusion, seizures, **dyskinesias**, dystonias, or coma.

Answer 488

propanolol

Answer 489

virtual reality exposure is an effective treatment

Answer 490

Luria (Fist edge palm)

Answer 491

24 months or longer

Answer 492

elderly have lower mortality with ECT versus other therapeutic options Why other options are wrong: a) no difference in complication rate between adults and elderly – higher complications in elderly b) response rate is lower in elderly – false – response rate is actually higher c) elderly have lower seizure threshold – they have a higher sz threshold

Answer 493

Lack of Affective disorder Recall, Risk Factors for TD: * older * female * white and african descent * longer illness duration * ID and bran damaga * Neg symptoms in schz * Mood DIsorders * Cog sx in mood disorders * DM * Smoking * ETOH and substance abuse * FGA vs SGA tx * higher cumulative and current AP dose or plasma levels * early PD side efects * anticholinergic co tx * akathisa * emergent dyskinesia

Answer 494

CBT is equally effective as medication and CBT combination

Answer 495

1. use the same medication for tapering 2. switch to a longer-acting equivalent 3. use adjunctive medications to help mitigate potential withdrawal symptoms.

Answer 496

Switch to diazepam 100-120 mg po daily in divided doses and then gradually taper Though increase paroxetine is also correct, but not the \*next step\*

Answer 497

Peer group support

Answer 498

Mindful communication training

Answer 499

Risperidone

Answer 500

Delusional disorder (Also no evidence for IPT in schizophrenia)

Answer 501

Acamprosate \* recall, topiramate has risk of renal stones

Answer 502

Paliperidone Recall, Paliperidone doesn't undergo CYP 450 metabolism (also LOT and desvenlafaxine)

Answer 503

Sub-callosal cingulum Recall, Dorsolateral PFC = for TMS

Answer 504

CBT is an effective first line option (TF-CBT, EMDR, PE, and stress management therapy)

Answer 505

Fluoxetine Paroxetine Sertraline Venlafaxine

Answer 506

Paliperidone

Answer 507

Prednisone (7x SI HR)

Answer 508

Rate of cognitive decline Recall * CT recommended if one or more of the following are present *  – Age \< 60 years *  – Rapid (e.g., over 1–2 months) unexplained decline in cognition or function *  – Short duration of dementia (\< 2 years) *  – Recent and significant head trauma *  – Unexplained neurologic symptoms (e.g., new onset of severe headache or seizures) *  – History of cancer (especially types that metastasize to the brain) *  – Use of anticoagulants or history of bleeding disorder *  – History of urinary incontinence and gait disorder early in the course of dementia (as may be found in normal pressure hydrocephalus) *  – Any new localizing sign (e.g., hemiparesis or a Babinski reflex) *  – Unusual or atypical cognitive symptoms or presentation (e.g., progressive aphasia) 

Answer 509

Assess and reduce or discontinue and anticonvulsant medications * Next steps * Caffeine * Hyperventilation * Consider adding ketamine to propofol

Answer 510

* 250-300ng/L normal target OR 1000-2500nmol/L * 50 – 150 =low * 200 – 300 good initial target * 350 – 400 could be tried if response insufficient

Answer 511

Predictive of BAD in later life

Answer 512

CBT * Recall * KS - primary treatment of ODD is family intervention using both direct training of the parents in child management skills and careful assessment of family interactions. * The goals of this intervention are to reinforce more prosocial behaviors and to diminish undesired behaviors at the same time * CBT - teach parents how to alter their behavior to discourage the child's oppositional behavior by diminishing attention to it, and encourage appropriate therapy focuses on selectively reinforcing and praising appropriate behavior and ignoring or not reinforcing undesired behavior

Answer 513

Clonazepam

Answer 514

Ach inhibitor * Recall, in LBD * If a patient experiences severe, disabling psychosis, a trial of a cholinesterase inhibitor and/or lowering the dose of antiparkinson medication should be considered first. * When antipsychotic therapy is required, drugs are associated with an increased risk of death when used in older adult patients with dementia. * If antipsychotic therapy is required in patients with DLB, only atypical antipsychotic drugs, such as olanzapine, quetiapine, pimavanserin, ziprasidone, aripiprazole, paliperidone, or clozapine, should be used in very small doses in order to reduce the risk of severe reaction * The older, conventional antipsychotics should be avoided entirely

Answer 515

Leave the same for relapse prevention Recall * Maintenance is whatever worked to get them out of acute symptoms * Quetiapine maxes out on sedation and weight gain at 150

Answer 516

Propranolol * In treating **akathisia**, propranolol now first line * Benztropine second line * Benzos for non-responders

Answer 517

Alprazolam

Answer 518

Mirtazapine Recall, regarding QTC prolongation: * TCAs highest (clomipramine best of them) * Then Citalopram, escitalopram, venlafaxine * Wellbutrin does not prolong QTC at all, Mirtazapine very low risk

Answer 519

Higher prevalence in low SES

Answer 520

Psychoed (Superior to IPSRT)

Answer 521

Structured clinical judgment assessment tools provide individualized measure of risk

Answer 522

* MMSE * brief * no exec function * lower sensitivity for lower impairment/higher IQ * FP for older, lower education * MOCA * more domains * higher sensitivity for lower impairment/higher IQ * longer to administer * Lower specificity with cut-off of 26 * Proprietary

OSCE Prep Flashcards

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