uOttawa Psychiatry Objectives

Welcome to the uOttawa Psychiatry Objectives!

Mental health and related conditions are:

For this reason, it is essential that medical students become competent in recognizing, screening and treating patients with mental health needs.

This resource has been created to make it easier for medical students to learn about mental health.

Table of Contents

Suicide (SLM 1)

Introduction to Psychiatry (Lecture 1)

Differential Diagnosis of Mood Disorders (TBL)

Psychopharmacology of Mood Disorders (Lecture)

Mini Mental Status Exam (MMSE) (Workshop)

Lecture: Neurocognitive Disorders

Somatic Symptoms and Related Disorders (Lecture)

Mood Disorders (CBL)

Electroconvulsive Therapy (ECT) (Lecture)

Psychiatric Assessment and MSE of psychotic illness  (SLM 2)

Psychosis (Lecture)

Substance Use Disorders (Lecture)

Neurotransmitters and Psychosis (Lecture)

Psychopharmacology of Psychotic Disorders

Movement Disorders

Schizophrenia (CBL 2)

5179 Describe the impact of first episode psychosis on normal development and behaviour in young adults.

11371 Describe prodromal symptoms of psychotic illness seen in adolescents and young adults.

5180 Recognize the problems associated with loss of insight in patients with psychotic illness.

5201 Explain the risk of harm to self or others in persons with schizophrenia.

5181 Recognize the association between psychotic illness and substance use disorders.

5199 Describe the impact of substance use disorders on severity of psychotic symptoms.

5200 Describe treatment strategies for patients with concurrent substance use disorders and schizophrenia.

5183 Describe first line treatment for schizophrenia using an atypical antipsychotic medication, including counseling a patient regarding mechanism of action, side effects and length of treatment.

5187  Demonstrate knowledge of important considerations in management/treatment decisions when treating patients with first episode psychosis.

5189 Describe how to start an antipsychotic medication, including baseline medical workup.

5195 Describe the duration of treatment with antipsychotic medication for treatment of schizophrenia.

5194 Describe the follow‐up monitoring process necessary with for antipsychotic medication.

5182 Explain the concepts of recovery and rehabilitation as they relate to schizophrenia.

5196 Recognize evidence‐based psychologic treatments which are effective for treatment of schizophrenia.

5197 Recognize psychosocial interventions necessary for recovery from schizophrenia.

5198 Explain the importance of family and caregiver support in treating persons with schizophrenia.

5202 Describe the impact of stigma as it relates to persons with a diagnosis of schizophrenia.

Lecture: Eating Disorders

5294 Describe the diagnostic criteria and epidemiology of anorexia nervosa, bulimia nervosa and binge eating disorder.

5295 Describe the biopsychosocial interventions used for the management of anorexia nervosa, bulimia nervosa and binge eating disorder.

Mental Health Legislation (UDA)

5208 Recognize that there is legislation that influences the practice of medicine; including psychiatry

Assessment of Anxiety Disorders (SLM 3)

5310 List the key questions to ask a patient presenting with a complaint of anxiety in order to confirm a diagnosis of panic disorder.

5311 List the key questions to ask a patient presenting with anxiety to confirm a diagnosis of generalized anxiety disorder

5312 Describe the typical mental status findings seen during assessment of a person presenting with an anxiety disorder.

Anxiety & Stress Overview (Lecture)

5242 Describe the physical signs and symptoms associated with stress and anxiety.

5388 List the difference between normal levels of stress and anxiety, and when stress and anxiety become part of psychiatric illness.

5244 Describe how stress may be associated with onset of psychiatric illness.

5241 List different psychiatric illnesses associated with anxious affect.

5243 Explain the epidemiology of anxiety disorders.

5253 Outline the main features of separation anxiety disorder in children.

5255 Describe the presentation and management of anxiety disorders in elderly patients.

5288 Discuss differences in presentation, etiology and treatment considerations of anxiety disorders in children and the elderly as compared to younger adult populations.

11403 Describe the diagnostic criteria and epidemiology of social anxiety disorder.

11404 Describe the biopsychosocial interventions used for management of anxiety disorders, including social anxiety disorder and specific phobia.

11405 Describe the indications for use of antidepressants in children and adolescents with anxiety disorders.

Psychotherapy (Lecture)

12722 Demonstrate the ability to use a specific problem described by a patient to highlight the links between thoughts, feelings and behaviours and to explain the rationale for various treatment options.

12914 Describe neural correlates of psychotherapy.

5245 Describe the general psychiatric indications for psychotherapy

5248 Define the purpose of psychological defense mechanisms and describe mature and immature defense mechanisms including: denial, splitting, projection, reaction formation, rationalization.

Disruptive Behaviour Disorders (UDA)

5270 Describe the diagnostic criteria, epidemiology, etiology, course, prognosis, and differential diagnosis of:

Attention deficit hyperactivity disorder (ADHD)

Oppositional defiant disorder and

Conduct disorder.

Normal child and adolescent development (Lecture)

5273 Describe the normal development of children, from infancy to adolescence.

5274 Explain the major theories of development, including the work of Sigmund Freud, Erikson and Piaget

Insomnia assessment and management (Workshop)

5286 List the common psychiatric and medical conditions associated with a presentation of insomnia

5287 Describe the key features in assessing insomnia.

5288 Propose a treatment plan for insomnia including being aware of the indications for pharmacologic and nonpharmacologic  interventions.

Trauma – Stressor related disorders

5281 List the different types of trauma that people may be exposed to at different times in their lives including sexual/physical  and emotional abuse, trauma in military settings, and trauma associated with refugees from different cultural settings.

5282 Describe the psychiatric sequelae associated with trauma including post traumatic stress disorder, acute stress disorder, dissociative disorders and borderline personality disorder.

5283 List common comorbid psychiatric illnesses associated with Post traumatic stress disorder

5284 Describe differences in presentation of PTSD in children and adults.

5285 Describe a biopsychosocial treatment plan for post traumatic stress disorder including use of medication and different  psychotherapeutic modalities.

Psychiatric assessment of children and adolescents (Lecture)

5291 Describe the differences in an assessment of a child / adolescent compared to an adult

5292 Discuss issues related to patient confidentiality with respect to the assessment of children and adolescents

5293 Recognize the unique challenges involved in interviewing children and adolescents

Personality Disorders (UDA)

5296 Describe the general diagnostic criteria for a personality disorder.

5297 State the classification of personality disorder in three clusters.

5298 Describe the main enduring pattern of each personality disorder type.

5300 Describe the mental disorders associated with self‐injurious behaviors.

5301 List the biological, demographic, economic, social and developmental factors associated with self‐injurious behavior.

5302 Describe the pertinent factors in the recognition of the potential of self‐injurious behavior.

5303 List criteria for borderline personality disorder.

5304 Describe common psychiatric comorbidities associated with borderline personality disorder.

5305 Describe a treatment approach to borderline personality disorder including use of hospitalization, outpatient care, pharmacological treatment and psychotherapy

Autism Spectrum Disorders (Lecture)

12413  Describe the diagnostic criteria, the epidemiology, the etiology and the prognosis of autism spectrum disorders

12414 Describe the biopsychosocial interventions that can be applied in the treatment of autism spectrum disorders.

Anxiety (CBL 3)

5269 Explain the risk of concurrent substance use disorders in people with anxiety disorders.

11409 Describe the risk of a substance use disorder and tolerance associated with use of benzodiazepines

5256 Describe the biopsychosocial interventions used for management of anxiety disorders including: panic disorder, generalized anxiety disorder and a related disorder, obsessive‐compulsive disorder.

5257 Propose a treatment plan for obsessive compulsive disorder that includes both pharmacological and nonharmacological interventions.

5260 Describe the indications for use of antidepressants in patients with anxiety disorders.

5261 Describe the indications for use of benzodiazepines in the treatment of anxiety disorders.

5266 Describe the length of treatment with antidepressants for treatment of obsessive‐compulsive disorder.

5267 Demonstrate knowledge of evidence‐based psychologic treatments which are effective for anxiety disorders across the life-span.

5268 Demonstrate awareness of psychosocial interventions necessary for recovery from anxiety disorders across the life-span.

Contributing Authors

Editors

References:

Suicide (SLM 1)

5163 Describe the epidemiology of suicide.

5164 Compare and contrast suicide attempters versus suicide completers.

5165 Describe the assessment of a suicidal patient.

5166 Describe the difference between active and passive suicidal ideation.

5167 Describe the management of a suicidal patient.

5168 List the risk factors for suicide in different demographic groups (e.g., adolescents, elderly, aboriginal groups).

General Risk factors include:

Risk factors in different demographic groups:

individual

social

circumstance

CHILD

Gaps in ability to resolve problems

 

Psychiatric dx (particularly depressive disorders)

Trivialization of suicide by media

FHx of EtOH/drug abuse

Parental psychodx

Parental suicide or attempted suicide

Parental violence/abuse

Losses: Separation, divorce, death of parent

YOUTH

Lack of coping mechanisms

Previous suicide attempt

Problems with learning and impulsiveness

Psych dx, antisocial behavior, substance abuse

Problems with peer relationships

Loss of parent early in life

Difficulty accepting sexual orientation

Social isolation/lack of integration

Parental psychodx

Parental suicide or attempted suicide

Sensationalism of suicide (media)/suicide considered to be acceptable

Abuse/neglect

Losses: death or divorce of parent, loss of significant relationship

Easy access to means

Substance abuse

Conflict with family member, perception of being rejected by family or peers

Failure at school, expulsion, pressure to succeed

ADULT

Lack of problem solving/coping mechanisms

Previous suicide attempt

Legal/disciplinary sanction (arrest, charge)

Psych dx

Personality traits (anxiety, feeling a loss of control, low self-esteem, neurotic)

Substance abuse

Difficulty accepting sexual orientation

Social isolation

Unemployment rate

Suicide considered to be acceptable

Physical/sexual abuse of women

Access to means (firearm)

Substance abuse

Serious illness

Losses: Humiliating events, end of a significant relationship, serious interpersonal problems

SENIOR

Psych dx assoc with physical comorbidity

Chronic illness (dependence, pain)

Substance abuse

Social isolation

Poverty

Suicide considered to be acceptable

Substance/medication abuse

Losses: placement in a seniors home, widowhood (in men)

5169 List the preventive strategies for suicide.

5170 Recognize the need to support family/friends who have lost an individual to suicide

Intervention process has 2 steps:

General:

Introduction to Psychiatry (Lecture 1)

5112 Explain the difference between normal and abnormal emotions, thoughts and perceptions.

Mental Illness

12707 Recognize the impact of the stigma of mental illness.

5119 Demonstrate knowledge concerning psychiatric epidemiology

Prevalence of Mental Illness

Truths of Mental Illness:

5113 Describe the broad categories of psychiatric disorders.

5114 Describe the basics of the psychiatric interviewing process, including listing and defining the components of a psychiatric history.

Main Components of Psychiatric Evaluation:

5115 List  and define the components of a mental status exam.

5117 Explain the biopsychosocial model of understanding mental illness.

5118 Describe the importance of using a biopsychosocial approach to mental illness with respect to management

5120 Demonstrate awareness of medicolegal and ethical issues related to psychiatric practice, including involuntary hospitalization and treatment.

Differential Diagnosis of Mood Disorders (TBL)

12708 Describe the differential diagnosis of mood disorders including other medical conditions and substances that produce the same symptoms

DDX for Depressive D/O’s:

Other DDXs that are not Depressive D/O’s:
In any patient, regardless of age:

In peds:

In youth & young adults:

In adults:

In elderly:

Depression Caused by Another Medical Condition

12709 Describe how a diagnosis of a mood disorder is made.

Accurate diagnosis involves combination of psychiatric assessment, meeting certain DSM-5 criteria, full medical & psychiatric Hx, physical exam and lab workup (and possibly additional screening e.g. neuro consultation, CT head)

12710 List the depressive and bipolar disorders

Depressive Disorders

  1. Disruptive mood dysregulation d/o
  2. Major depressive disorder
  3. Persistent depressive disorder (dysthymia)
  4. Pre-menstral dysphoric disorder
  5. Substance/medication induced depressive d/o
  6. Depressive d/o d/t Another Medical Condition
  7. Other specified depressive disorders
  8. Unspecified depressive disorder
  9. Specifiers for depressive disorders

Bipolar Disorders

  1. Bipolar I disorder
  2. Bipolar II disorder
  3. Cyclothymic disorder
  4. Substance/medication-induced bipolar and related disorder
  5. Bipolar and related disorder due to another medical condition
  6. Other specified bipolar and related disorder
  7. Unspecified bipolar and related disorder
  8. Specifiers for bipolar and related disorder

5333 Recognize treatment strategies to address mood symptoms presenting as part of a medical condition or substance use disorder.

Strategies:

  1. Diagnosis based on timing and proportionality 

      2) Address both mood disorder and cause 

AND

Psychopharmacology of Mood Disorders (Lecture)

5153 Describe the neurotransmitter systems and neuroanatomical pathways that are implicated in mood disorders

NEED PICS for Clarity

Monoamine Neurotransmitters:

1. Serotonin (5HT)

2. Norepinephrine (NE)

3.Dopamine (DA)

- All 3 removed from synapse by reuptake pumps  (SSRI block these pumps)

- Inactivated by Monoamine Oxidase (MAO) (MAOI - inhibit this enzyme)

Monoamine Circuits

 

          NE Circuit                        Dopamine Circuit                     Serotonin Circuit

Pathophysiology of Depression:

  1. Monoamine hypothesis: insufficient monoamine NTs
  2. Neurotransmitter receptor hypothesis: depleted monoamines cause compensatory up-regulation of post-synaptic NT receptors

3) Monoamine hypothesis of gene expression: insufficient monoamine and up regulation of receptors cause stress induced changes in monoamine signal transduction cascade, leading to inappropriate decreased gene expression

Therefore an increase in NTs will cause return to normal state by:

5154 List the common classes of antidepressant medications and give one example from each

5156 Explain the mechanism of action and side effect profile of selective serotonin reuptake inhibitors (SSRIs), serotoninnorepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs) and lithium and valproic acid.

5158 Describe monitoring of SSRIs and mood stabilizers.

SEE ABOVE

5157 List the common drug interactions with lithium.

5155 Describe first line pharmacologic treatment of major depressive disorder and bipolar disorder, across the lifespan.

MDD Treatment Guidelines:

BPD Treatment Guidelines:

5159 Describe the role of antipsychotic medication in the treatment of mood disorders.

Atypical Antipsychotics

Mini Mental Status Exam (MMSE) (Workshop)

 (* Notes from this lecture are unclear--need better explanations?)

5140 Perform the screening Folstein (mini‐mental status examination) MMSE and (Montreal Cognitive Assessment) MoCA exam.
5141 Explain the indications for use of the Folstein MMSE and MoCA exam.

Use of Cognitive Tests

Cognitive Test as Screening for Cognitive Impairment

Mini-Mental State Examination (MMSE)

Advantage of MMSE 

Disadvantage of MMSE 

Administration of MMSE

MMSE Test 


Interpretation of Scoring:

Factors Affecting Score

Montreal Cognitive Assessment (MoCA)

I think we should have a pic of the MoCA here, as long as it’s not copyrighted material

Used the pic below for time being, but I think it’s copyrighted

Note that MoCA has same domains as MMSE plus abstraction 

Domains and Related Anatomy

Orientation

Registration and recall

Attention

Language functions

Spatial Ability

Abstraction

Scoring

5142 Interpret results of the MoCA and Folstein MMSE exam.

MMSE Scoring

Factors Affecting Score

MOCA Scoring

Lecture: Neurocognitive Disorders

Background:

Dementia

12711 Given a clinical scenario, recognize delirium and differentiate from neurocognitive disorders.

Feature

Delirium

Dementia

ONSET

Acute

Insidious

COURSE

Fluctuates

Stable, slowly progress

DURATION

Hrs to Wks

Months to Yrs

ATTENTION

Hypo or hyper

Normal

ORIENTATION

Impaired

Impaired

MEMORY

Impaired

Impaired

THINKING

Disorganized

Impoverished

PERCEPTION

Illusions & Halluc

May be normal

SLEEP-WAKE

Always Disrupted

May be disrupted

PHYSICAL ILLNESS or DRUG TOXICITY

Either or both

Usually absent

12712 Discuss how depression in an elderly patient can present as a neurocognitive disorder.

Dementia

Depressive “Pseudodementia”

Insidious

Subacute

Slow progression

Rapid progression

Labile mood

Consistently depressed

Can enjoy things

Cannot enjoy things

Cognitive changes first

Mood changes first

Cooperative

Uncooperative or does not try

Aphasia, word-finding difficulties

No aphasia

No history  of mood disorder

Hx of mood d/o

12713 List potentially reversible causes of cognitive impairment.


MNEMONIC: “DEMENTIA”

How can I tell if it’s a medical cause?

12715 Recognize behavioural and psychological symptoms of neurocognitive disorders.

Behavioural & Psychological Symptoms of Dementia (BPSD):

Clues of Dementia on History

5149 Describe the pharmacologic and non‐pharmacologic interventions to be considered in the treatment of neurocognitive disorders, including Alzheimer disease, as described in the guidelines of the 2008 Canadian Consensus Conference on the Diagnosis and Treatment of Dementia.

12714 Employ pharmacological treatments for neurocognitive disorders.

12716 Discuss psychosocial treatments for neurocognitive disorders.

Goals of tx depend on stage of dementia/level of cognitive decline:

Management:

Non-pharmacological Interventions:

12717 Identify medications which may contribute to cognitive impairment in the elderly.

5146 Explain the diagnostic criteria for major and minor (?) neurocognitive disorder and delirium.(I copied and pasted this right from T.O. Notes. Since the diagnosis depends on this DSM criteria, I wasn’t sure what changes I could make or what wording would be appropriate). Reference: Toronto Notes 2016, which adapted the info right from DSM-5.

Diagnostic Criteria for Major Neurocognitive Disorder:

A.  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.  substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment

B.  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)

        Note: if do not interfere in B, and impairments are mild-moderate in A, considered “mild neurocognitive disorder”

C.  cognitive deficits do not occur exclusively in the context of a delirium

D.  cognitive deficits are not better explained by another mental disorder (e.g. major depressive disorder, schizophrenia)

Diagnostic Criteria for Delirium:

A. attention and awareness: disturbance in attention (i.e. reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment)

B.   acute and fluctuating: disturbance develops over short period of time (usually hours to days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day

C.   cognitive changes: an additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability, or perception)

D. not better explained: disturbances in criteria A and C are not better explained by another neurocognitive disorder (pre-existing, established, or evolving) and do not occur in the context of a severely reduced level of arousal (e.g. coma)

E.   direct physiological cause: evidence that disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e. due to a drug of abuse or medication), toxin, or is due to multiple etiologies

*Note: can have HYPERactive, HYPOactive, or MIXED presentation

5147 List the most common causes and differential diagnoses for major neurocognitive disorder and other conditions causing cognitive changes in the elderly.

5148 Differentiate the course and presenting features of neurocognitive disorders, delirium and depressive disorders.


Dementia: acquired cognitive deficits
, sufficient to interfere w/ functioning in a person without depression (pseudodementia) or delirium

Delirium: an acute, potentially reversible, condition characterized by fluctuating attention and awareness, disorientation, disorganized thinking, disrupted sleep/wake cycle

Depression: alteration in usual mood w/ sadness, despair, lack of enjoyment in previously enjoyed activities and vegetative symptoms sufficient to interfere w/ functioning

5150 Describe the epidemiology, course and prognosis of neurocognitive disorders, including Alzheimer disease, vascular disease, Lewy Body disease and frontotemporal lobar degeneration.

Somatic Symptoms and Related Disorders (Lecture)

5306 Describe in general terms the clinical features of somatic symptoms and related disorders, including somatic symptom disorder, illness anxiety disorder, conversion disorder (functional neurologic symptom disorder), psychological factors affecting other medical conditions, as well as body dysmorphic disorder (an obsessive compulsive and related disorder).

Past Definition of Somatization

Clinical Presentation: Somatization

Clinical Presentation: Somatic Symptom Disorder

Clinical Presentation: Illness Anxiety Disorder

Clinical Presentation: Conversion Disorder (aka Functional Neurological Symptom Disorder

Clinical Presentation: Psychological Factors Affecting Other Medical Conditions

Clinical Presentation: Factitious Disorder

Clinical Presentation Body Dysmorphic Disorder

5307 Describe the general principles behind biopsychosocial interventions used for the management of somatic symptoms and related disorders.

Important Components of Management

Acute Somatization Support

Chronic Somatization Support

Treatment of Somatic Symptom Disorder

Psychotherapy

Relaxation Training

Behavioural Management

Sleep 

Medication

5308 Describe the diagnostic criteria of factitious disorders: including with predominantly psychological signs and symptoms and physical signs and symptoms

Clinical Presentation

Diagnostic Criteria

5309 Describe the condition of Malingering.

Mood Disorders (CBL)

5126  Create a differential diagnosis of depressive symptoms in child, adolescent, adult and elderly populations, including other  psychiatric and medical illnesses that may present with similar symptoms.
11370 Describe how depressive symptoms differ in the elderly compared to a younger adult population

Children

Youth

Adult

Elderly

- Insidious

- Somatic complaints

- Agitation/anxiety/irritability

- Withdrawal from family/peers

- Phobias (e.g. school)

- Intense mood, behavior changes, aggression, excessive clinging to parents

-Sudden onset w/ stressor

- Poor hygiene

- Substance abuse, antisocial behavior

- Restlessness, running away

- Poor academic performance, truancy, other school difficulties

- Promiscuity

- Atypical features*: rejection hypersensitivity, hypersomnia, hyperphagia

- Somatic complaints*: CV, GI, GU, lower back pain and other ortho sx

- Self-medication through substance abuse, agitation, irritability

-Insidious +/- stressors

- Cognitive deficits/pseudo-dementia (see below)

- Somatic complaints ++ (especially GI)

- Decreased interests

- More likely to be psychotic

*Classic

DDx “Depression”

o   Major depressive disorder

o   Mood depressed, negative thinking

o   Sleep changes: increased during the day or decreased at night

o   Interest (loss): in activities that used to interest them

o   Guilt (worthless), hopelessness, helplessness

o   Energy (lack), heaviness, numbness

o   Cognition/Concentration

o   Appetite (weight loss/gain)

o   Psychomotor (anxiety, irritability, lethargic)

o   Suicide/death preoc.

5127 Explain the concept of pseudo‐dementia.

5128 Describe how to start an antidepressant medication in the general population, and in more medically frail populations

5132 Describe the follow‐up monitoring process necessary for common antidepressant treatment

General guidelines:

o   (best evidence for fluoxetine in peds; other SSRIs next)

o   Symptom profile

o   S/E of patient

o   Patient preference

o   Cost

o   Hx of response in previous family

5130 List the common and dangerous side effects of commonly prescribed antidepressant medications SEE Pharmacology Lecture Week 1

5133 Describe the length of treatment with antidepressants for depressive disorders and with mood stabilizers for bipolar disorder.

5131 Describe the expected course of recovery from depressive disorder and bipolar disorder when appropriately treated.

Depression

Bipolar Affective Disorder

Treatment:

·       -Takes at least 1 month to get optimal response to tx from antidepressant meds.

·       -Maintenance depends on # of MDE episodes: 1 year for a single MDE episode, at least 2 years for recurrent depression (potentially 3+yrs or more for more MDEs).

-The highest risk of recurrence is in the first year. That is why min 1yr maintenance is required.

Recovery:

·      -The course of MDD is variable: some do not achieve remission, while others experience years with few/no sx between discrete episodes.

·       -Recovery typically within 3mo in 2/5 and 1yr in ⅘

     -The longer one has been depressed, the less likely near-term recovery (i.e. only several months of sx is good). Risk of recurrence becomes lower over time as the duration of remission increases.

Treatment:

·       -They need to remain on meds for life, no exceptions.

-They are at significant risk of relapse if they are to stop treatment.

Recovery

·       -Full remission is highly likely in all patients with appropriate pharmacologic tx and CBT

 

5134 Demonstrate knowledge of evidence‐based psychological treatments which are effective for depressive disorders and  bipolar disorder across the life span.

CBT

Electroconvulsive Therapy (ECT) (Lecture)

5143 Explain the indications, contraindications and side effects of electroconvulsive therapy (ECT)

5144 Describe the procedure of ECT.

5145 Discuss issues of stigma associated with use of ECT.

WEEK 2

Psychiatric Assessment and MSE of psychotic illness  (SLM 2)

5238 Discuss the key questions to ask a patient presenting with auditory hallucination.

5239 Discuss the key questions to ask a patient presenting with paranoia.

5240 Discuss the typical mental status findings seen in a patient presenting with a psychotic illness.

The Mental Status Exam (MSE) is the “physical exam” of psychiatry: “ASEPTIC”

A – appearance and behaviour → disorganized behaviour

S - speech

E - emotion (mood and affect)

P - perception → hallucinations

T - thought (content and process) → delusions, disorganized thought process

I – insight and judgement

C – cognition

DDx for Psychotic Sx:

Psychosis (Lecture)

5171 Recognize the epidemiology of psychotic illness.
(* lecture notes only provided data for schizophrenia)

Schizophrenia

5172 Explain the role of genetics in the etiology of psychotic illness.

5173 Describe the symptoms and signs seen in psychotic illnesses.

5174 Compare and contrast schizophrenia with other psychotic disorders.

Schizophrenia

See above

Schizoaffective Disorder

Diagnostic Criteria

Schizophreniform Disorder

Brief Psychotic Disorder

Delusional Disorder

5175 Describe psychotic disorders due to a general medical condition and substance use disorders.

Psychotic Disorder Due to Another Medical Condition


Diagnostic Criteria
 
A) delusion and / or hallucination
B) evidence from history, physical examination and lab findings that disturbance is direct pathophysiological consequence of another medical condition
C) other mental illnesses ruled out
D) disturbance does not occur exclusively during delirium
E) disturbance cause distress and impair psychosocial function

Substance / Medication Induced Psychotic Disorder

Substance as Cause

Medication as Cause

Diagnostic Criteria

5176 Describe the presentation and management of psychoses across the lifespan

Schizophrenia

PIC TAKEN FROM LECTURE SLIDES→ copyrighted?

  1. prodrome symptoms are the lead into schizophrenia that usually start in adolescence and last >1 year

B) active phase usually has characteristic psychosis features plus

C) residual phase have attenuated positive and negative symptoms as well as cognitive defects

Course and Prognosis

Management

5177 Describe the biopsychosocial interventions used for the management of schizophrenia, schizoaffective disorder and delusional disorder

Psychosocial Interventions

5178 Explain the extent of disability associated with psychotic illness

Substance Use Disorders (Lecture)

5218 Demonstrate an understanding of substance use disorders

Addiction:

Epidemiology of Substance Abuse

Reasons for Substance Abuse

5227 Describe the mesolimbic dopaminergic pathway (reward pathway) related to substance use disorders.

WE SHOULD HAVE A PIC HERE

Pathophysiology of Addiction

5226 Describe the presentation and management of substance use disorders across the life span.

Presentation of Substance Abuse:

Common Clinical Presentation

Adolescents:

Adults:

Elderly:

General Management of a Substance Use Disorder:

Stages of Change Model 

1) pre-contemplation: patient does not view their substance use as a problem and has no intention to change behaviour, defined as not planning to change in the next 6 months

2) contemplation: patient is ambivalent, weighing the pros and cons of changing behaviour (i.e. quitting) versus staying the same (i.e. continue substance use)

3) preparation: patients are committed to changing their substance use but have not begun to change behaviour

4) action: patients have changed their behaviour within the last 30 days

5) maintenance: patients have completed a treatment program for their substance use and have reached their treatment goal (i.e. substance free) for 6 months

Intervention at Different Stages:

Intervention at Precontemplation:

Intervention at Contemplation: 

Intervention at Preparation and Action:

Intervention at Maintenance

Intervention at Relapse

Treatment Decision Tree

  1. does patient want to stop?

       2) is it safe for patient to stop?

3) can patient stop using substance?

5219 List the different symptoms and signs of alcohol, opioid, benzodiazepine, stimulants (cocaine, amphetamine) and cannabis withdrawal and intoxication.

Alcohol

Opioid

Benzodiazepines

Stimulants

Cannabis

5220 Explain the management of different substance use disorders (alcohol, opioid, benzodiazepine, stimulants and cannabis),  including detoxification and treatment.

Alcohol

Opioid

Benzodiazepines

Stimulants

Cannabis

Treatment Options:

5221 Describe what is meant by harm reduction

Harm reduction strategies

5222 Define the concepts associated to a substance use disorder, including tolerance and withdrawal

Tolerance: when a person uses a substance for an extended period of time and

  1. they need more of it to achieve intoxication or desired effect
  2. there’s a markedly diminished effect with continued use of the same amount

Withdrawal: Symptoms that a patient may experience when the substance is decreased or discontinued (e.g. anxiety, shaking, headaches, insomnia, etc)

5223 Describe the epidemiology of alcohol use disorders

Epidemiology 

5224 Apply the CAGE questionnaire & understand the implications

Screening for Alcohol Use Disorder
CAGE questionnaire: used to screen for alcohol use disorder in any patient NOT already known to have an addiction

5225 Differentiate between normal alcohol consumption and problem drinking

Drinking Limits

Spectrum of Alcohol Use
abstinence -> low risk drinking -> at risk drinking -> harmful drinking (abuse) -> dependent drinking -> chronic dependent drinking

5228 Describe the risks associated with relapse in substance use disorders

Relapse rates:

5264 Describe a pharmacological strategy to taper and discontinue benzodiazepines

Reasons for Tapering and Discontinuing Benzodiazepines:

Benzodiazepines Detoxification:

Tapering Benzodiazepines

UDA: Clinical vignettes: substance intoxication and withdrawal

12721 Understand how to use laboratory investigations in cases of suspected substance use disorder.

5262 List the common and dangerous side effects of benzodiazepines.

Common & Dangerous Side Effects of Benzodiazepines

5337 List symptoms of sedative, hypnotic or anxiolytic use disorder, as well as intoxication and withdrawal.

5338 Describe a treatment plan for a patient with sedative, hypnotic or anxiolytic use disorder.

Benzodiazepine Intoxication:

Benzodiazepine Withdrawal:

Reasons for Tapering and Discontinuing Benzodiazepines:

Benzodiazepines Detoxification:

Tapering Benzodiazepines

5334 List symptoms of alcohol use disorder, as well as intoxication and withdrawal.

Symptoms of alcohol use disorder and/or intoxication:

Symptoms of alcohol withdrawal:

5335 Describe a treatment plan for a patient who wishes treatment for alcohol use disorder.

Non-pharmacological

Pharmacological (*reference: T.O. Notes)

5336 Describe the assessment and treatment of  alcohol withdrawal.

Alcohol Withdrawal

Medical Management of Alcohol Withdrawal

5339 List the signs and symptoms of opioid withdrawal

5340 Describe a treatment plan for opioid use disorder.

3 options:

1) quit cold turkey (abstinence) with use of non-opioid medication support

2) taper using long acting opioid

3) substitution with methadone or suboxone (buprenorphene / naloxone)

Neurotransmitters and Psychosis (Lecture)

5341 Explain the dopamine pathways and their function

4 Dopaminergic Pathways of the Brain

NEED PICS HERE FOR CLARITY

1) Mesolimbic pathway

2) Mesocortical pathway

3) Nigrostriatal pathway

4) Tuberoinfundibular pathway

Serotonin in Dopaminergic Pathways 

5342 Describe the dopamine hypothesis of schizophrenia.

5343 Describe the interplay between serotonin and dopamine receptors with respect to the mechanism of atypical antipsychotic medication.

5344 Recognize the differences in affinity for the dopamine receptor among different antipsychotic pharmacological medications.

1st generation Antipsychotics (Typical/Conventional)

Potency of Typical Antipsychotics

2nd generation Antipsychotics (Atypicals)