Psychiatry

November 25, 2021

C. Ryan, Doctorials 2021/22

Obligatory meme

C. Ryan, Doctorials 2021/22

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Misperceptions

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Learning Objectives

• Explain the neuroanatomy of the limbic system, including the Papez circuit
• Explain the auditory pathway
• Explain the difference between illusion, delusion, hallucination, and psychosis
• Differentiate between brief psychotic disorder, schizophreniform disorder, schizophrenia, and schizoaffective disorder
• Understand the dopaminergic pathways and relate this to the effects of antipsychotics
• Explain the difference between mania and hypomania and between type 1 and type 2 bipolar disorder, and between unipolar and bipolar depression
• List the diagnostic symptoms of depression and differentiate this from bereavement. List risk factors for suicidality
• Differentiate between baby blues, postpartum depression, and postpartum psychosis
• Classify the different anxiety disorders and give distinguishing features of each
• Understand the difference between dementia and delirium
• Differentiate the different types of dementia
• Differentiate between the major toxidromes and withdrawals
• Differentiate between malignant hyperthermia, serotonin syndrome, and neuroleptic malignant syndrome
• Explain the difference between acute dystonia, extrapyramidal side effects, and tardive dyskinesia
• Briefly discuss personality disorders, emphasizing the difference between OCD personality and OCD the disorder, as well as emphasizing BPD
• Briefly differentiate between somatoform, factitious, and malingering disorders
• Briefly discuss anorexia nervosa, bulimia, and binge-eating disorder
• Discuss Wernicke-Korsakoff syndrome
• Briefly discuss psychiatric disorders found in childhood

C. Ryan, Doctorials 2021/22

LOs

Neuroanatomy of the Limbic System

• What is the limbic system?
• Above brainstem & below cortex – ‘primitive’ part of brain
• Deals with emotions and memory
• Regulates autonomic or endocrine function in response to emotional stimuli
• Involved in reinforcing behaviour
• Components of the limbic system
• Cingulate gyrus – physical manifestation of emotion (gesture, posture, movement) – link to cortex
• Hippocampus (seahorse)– learning and memory
• Amygdalae (almond)– emotional processing (eg fear/anxiety)
• Thalamus – relays sensory and motor signals, regulates consciousness and alertness
• Hypothalamus – homeostasis (temp, appetite etc), link between nervous and endocrine system, controls ANS

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Amygdala

Papez Circuit

• Purpose: Responsible for memory and learning consolidation
• Components: Neuronal projections from hippocampus -> fornix -> mamillary bodies -> thalamus -> cingulate cortex -> hippo…

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Spotter image

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Spotter

Auditory Pathway

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Overlap of mental health conditions

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BMC Psychiatry

Mood disorders

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Diagnostics of Depression, Suicidality

• Depression
• Episodes characterized by ≥5 of the 9 diagnostic symptoms (SIG E CAPS)
• Lasts ≥2wks (most of the day almost every day)
• Must include depressed mood or anhedonia
• Unipolar or bipolar
• Impairs functioning
• Not due to drug/ organic disease
• Biological changes: Quicker to REM & more REM, Increased cortisol

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• Persistent depressive disorder (Dysthymic disorder)
• Lasts 2 years, Chronic low mood but subthreshold (less than 5 criteria)

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• Atypical depression: rejection sensitivity, increased appetite & sleep, leaden feeling

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• Seasonal depression (SAD): less sunlight may contribute -> phototherapy can help
• Suicidality (SAD PERSONS)
• 95% of completed suicides are by people with Psychiatric DX

C. Ryan, Doctorials 2021/22

First Aid 2019, pg 549-550

PHQ-9 Beck Inventory (21 Qs)

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Bereavement & Grief

• Bereavement
• Situation in which someone who is close dies, rather than the reaction to that loss

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• Grief
• The natural response to bereavement
• Includes thoughts, feelings, behaviour, and physiological reactions (eg visions/voices of bereaved)

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• Kubler Ross Stages: denial, anger, bargaining, depression, acceptance

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• Can become ‘complex grief’ if longer than 6 months & interferes with functioning - can lead to MDD

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C. Ryan, Doctorials 2021/22

First Aid 2019, pg 549-550

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Treatment & Mgmt

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CBT

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• Cognitive Restructuring: Identify irrational unhelpful recurring negative thoughts -> Patient is guided to identify distortion & to rebut them!
• Behaviour: Set task to complete (desensitization / to test beliefs)
• Therapy: Therapeutic alliance, empathy & shared understanding of problem goals of care

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• Practical focus on the present (vs psychodynamic/ Freudian focus on past/unconscious)
• 10-15 wks, but also Empower with skill for rest of life, involves homework

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Anti-depressants

• SSRIs / SNRIs :
• Increase Serotonin/Norepinephrine in synaptic cleft by inhibiting re-uptake
• Take 4-6 wks to have effect
• Side effects: sexual dysfunction, GI, agitation/insomnia
• Toxicity -> risk for serotonin syndrome (Autonomic symptoms, Altered mental status, hyperActivity)
• Taper off (to avoid flu-like discontinuation syndrome)
• Not always effective -> Switch if one doesn’t work

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• TCAs:
• Not used due to S/E profile & OD potential
• Can be useful for neuropathic pain or migraine

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• MAOi:
• Not used due to S/E profile
• Be wary of cheese effect (tyramine-induced hypertensive crisis)

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Sketchy

Other

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• ECT
• Quite effective but risks
• Anesthetize and induce seizure (can cause some amnesia)
• Used for refractory, psychosis, catatonia, food refusal, suicidal

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Mania vs Hypomania vs Bipolar Disorder

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Mania vs Hypomania vs Bipolar Disorder

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First Aid 2019, pg 548-549

Bipolar Treatment

• Lithium for maintenance (mood stabilizer) - unclear MOA
• Lithium + antipsychotic during manic episode
• Anti epileptics can be useful 2^nd line
• Don’t use antidepressants as can induce mania

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• Be wary of lithium toxicity (narrow TI) & Side effects->
• Acute : tremor, Nausea/vomiting, kidney injury
• Toxicity : GI & neurologic
• Long term: Hypothyroid (goitrogen) , Cardiac (teratogen), Nephrogenic Diabetes insipidus (inhibits principal cell from absorbing water by ADH action)

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C. Ryan, Doctorials 2021/22

Pregnancy-Related Mood Disturbances

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First Aid 2019, pg 550

• Peripartum mood disturbances: onset during pregnancy or within 4wks of delivery
• Increased risk w/Hx of mood disturbances
• Postpartum/baby blues
• 50-85% incidence rate
• Characterized by depressed affect, tearfulness, and fatigue
• Usually resolves within 10 days
• Postpartum depression
• 10% incidence rate
• Characterized by depressed affect, anxiety, and poor concentration for ≥2wks
• Postpartum psychosis
• 0.1% incidence rate
• Characterized by mood-congruent delusions, hallucinations, and thoughts of harming self or baby
• Risk factors: Hx bipolar / psychotic disorder, recent discontinuation of psychotropic medication

Anxiety Disorders

• Persistent excessive experience of fear/worry and its physical manifestations
• incongruent with the magnitude of the stressor
• Symptoms are not attributable to another psychiatric disorder or medical condition

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First Aid 2019, pg 550-552

Anxiety Disorders

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First Aid 2019, pg 550-552

Stress Disorders

• Adjustment Disorder
• Psychosocial stressor (i.e. divorce, illness, move job/home) -> within 3 months -> Emotional symptoms (eg anxiety /depressive symptoms) -> Resolves with <6mo
• Post-Traumatic Stress Disorder (PTSD)
• Experiencing a potentially life-threatening situation (i.e. sexual abuse, witnessing death, war) for ≥1mo that impairs functioning
• Clinical features (HARD)
• Hypervigilance
• Avoidance of associated stimuli
• Reexperiencing the event (i.e. nightmares, flashbacks)
• Distress or changes in cognition/mood (i.e. fear)

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• Treatment: Trauma-focused CBT, EMDR, SSRIs, … Prazosin for nightmares

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Acute stress disorder: features of PTSD lasting 3days – 1mo

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C. Ryan, Doctorials 2021/22

First Aid 2019, pg 552

Panic Disorder

• Recurrent unexpected panic attacks involving intense fear of losing control of dying
• And 1 month of worry/ maladaptive avoidance
• Attacks peak in 10min with ≥4 of the following (P₃AN[ICS]₃)
• Palpitations, Paresthesia, Depersonalization (out of body),
• Abdominal distress
• Nausea
• Intense fear of dying, losing control, or going crazy
• LIghtheadedness
• Chest pain, Chills, Choking
• Sweating, Shaking, SOB
• Derealisation (detach from environment)

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• Acute Treatment: Benzos, reassurance, breathing exercises
• Long term : CBT , SSRIs

C. Ryan, Doctorials 2021/22

First Aid 2019, pg 551

Obsessive Disorders

• Obsessive compulsive disorder (OCD) -> Ego-dystonic (get in the way of goals)
• Obsessions that cause severe distress, relieved in part by compulsions
• Obsessions: recurring, intrusive thoughts, urges, images
• Compulsions: uncontrolled performance of repeating actions
• Eg. obsessed about germs on hands so washes hands constantly
• CBT & SSRI

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• Body dysmorphic disorder
• Preoccupation with minor or imagined defects in appearance
• Causes significant emotional distress and repetitive appearance-related behaviours (i.e. mirror checking, excessive grooming)
• CBT+SSRIs

C. Ryan, Doctorials 2021/22

First Aid 2019, pg 551

Generalized Anxiety Disorder

• Chronic Excessive anxiety and worry about different aspects of daily life (i.e. work, school, children) for most days of ≥6mo
• Associated with ≥3 of the following (for adults or ≥1 for children) - CRIFIM
• Concentration difficulties
• Restlessness, nervousness
• Irritability
• Fatigue/somnolence
• Insomnia Sleep disturbances
• Muscle tension

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• Tx: SSRIs + CBT
• Relaxation therapy, biofeedback

C. Ryan, Doctorials 2021/22

First Aid 2019, pg 551

Phobias

• Severe persistent (≥6mo) fear /anxiety due to the presence or anticipation of presence of a specific objection or situation – Leads to avoidance
• Person often recognizes that the fear is excessive
• Agoraphobia – Fear of Public Spaces
• Irrational fear/anxiety while facing or participating in ≥2 specific situations;
• Open or closed spaces, Queues, Crowds, Public transportation etc
• Fear of being unable to escape / fear of having panic attack in public
• Social anxiety disorder
• Exaggerated fear of embarrassment in social situations (i.e. public speaking, using public restrooms)
• Can use propranolol is specific to ‘performance anxiety’

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Treatment: systematic desensitization (imagined) or Exposure therapy (real)

Meds: Benzo or propanolol acutely. SSRI chronically.

C. Ryan, Doctorials 2021/22

First Aid 2019, pg 551

Psychosis & Psychotic disorders

• Psychosis = Loss of contact with reality

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• Features:
• Delusions -> fixed false beliefs
• Hallucinations -> no external stimuli
• Disorganised thought -> shown by patterns of speech:
• tangentiality, word salad, blocking

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Delusion vs Hallucination vs Illusion

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Schizophrenia

• 1 month of ≥2 symptoms (at least one must be from A-C )
• Recurrent Episodes of Psychosis
• (a) hallucinations (usually auditory)
• (b) delusions,
• (c) disorganized thought (eg tangential speech)
• (d) Disorganized/catatonic behaviour
• (e) negative symptoms ( alogia, avolition, asociality, anhedonia, flat affect)
• ….And at least 6 months of some symptoms

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• Pathophysiology:
• Excess CNS Dopamine activity in mesolimbic (D antagonists to treat)
• Less activity in frontal lobe
• Less volume in Prefrontal cortex & Limbic (hippocampus & amygdala)
• Lateral ventricle enlargement

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• Risk factors: urban area, migrants, cannabis-using adolescents, obstetric complications
• 2^nd trimester cortical malformation can predispose

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Dopaminergic Pathways

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First Aid 2019, pg 487

Psychotic Disorders

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B&B

Antipsychotics /Neuroleptics

• Dopamine D2 antagonists
• 1^st gen; haloperidol (high potency for acute psychosis), fluphenazine
• EPS symptoms possible

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• 2^nd gen also have Serotonin antagonism (less hallucinations) -> FIRST LINE
• quetiapine, clozapine, olanzapine, risperidone
• Less EPS symptoms
• Some cause metabolic / weight gain
• Clozapine for treatment-resistant -> can cause agranulocytosis (monitor cell count)
• Non-compliance -> long acting injectable

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All can potentially cause very rare but life threatening Neuroleptic malignant syndrome (NMS)

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Antipsychotic Related ADRs

• Extrapyramidal Symptoms (EPS) more common in 1^st gen
• (pyramids = corticospinal, extra = basal ganglia etc)
• AD A P T

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C. Ryan, Doctorials 2021/22

Personality Disorders

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First Aid 2019, pg 553

Personality traits are things like OCEAN

Becomes a personality Disorder when disrupt function /

Difficult to treat

Factitious, Malingering, and Somatoform Disorders

• Physical symptoms not explained by medical disease
• Factitious Disorder
• Symptoms are intentional, motivation is unconscious
• Want to assume “sick role” and get primary internal gain (i.e. medical attention, sympathy)
• Classification
• Factitious disorder imposed on self (Munchausen syndrome)
• Factitious disorder imposed on another (Munchausen by proxy) “caregiver role”
• Malingering (not a Disorder)
• Symptoms are intentional, motivation is intentional
• Pts consciously fake, profoundly exaggerate, or claim to have a disorder in order to gain specific 2° external gain (i.e. avoiding work, obtaining compensation)
• Somatoform Disorder
• Symptoms are unconscious, motivation is unconscious
• Characterized by chronic physical symptoms causing significant distress and impairment (head, back, GI, cardiac, neuro..)
• Consistent GP, reassure PT, goals of improvement
• Classification
• Somatic symptom disorder (chronic)
• Conversion disorder (after acute stressor) -> usually neurologic (cant speak/move/see)
• Illness anxiety disorder (Hypochondriasis)

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C. Ryan, Doctorials 2021/22

First Aid 2019, pg 554

Eating Disorders

• Anorexia Nervosa
• Intense fear of weight gain, overvaluation of thinness, and body image distortion 🡪 calorie restriction and weight loss (inappropriately low BMI<18.5)
• Often co-exists with other disorders
• Significant physical effects: amenorrhea, Increase CK, Hyponatremia, low bone density, marrow suppression, cardiomyopathy/arrhythmia
• Highest mortality in Psych
• Classifications
• Binge eating/purging type: recurrent purging behaviours or binge eating over the last 3mo
• Restricting type : 1° disordered behaviours, includes dieting, fasting, or overexercising
• Refeeding syndrome: sudden increases in caloric intake 🡪 use up phosphate in glucose metabolism -> low ATP -> cardiac complications, rhabdomyolysis, and seizures

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Treatment: nutritional rehab & psychotherapy, olanzapine

• Bulimia Nervosa
• Recurring episodes of binge eating w/compensatory purging behaviours at least weekly over the last 3mo
• BMI is often normal or slightly overweight
• Sialadenosis & Russels sign

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• Binge Eating Disorder
• Recurring episodes of binge eating (compulsive, lacks control, then feels shame) without purging at least weekly over the last 3mo …. Tx with CBT

C. Ryan, Doctorials 2021/22

First Aid 2019, pg 555

Dementia vs Delirium

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Amboss

Types of Dementia

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• Alzheimers Dementia = most common = corticol atrophy & amyloid plaques
• Vascular Dementia = step-wise (multiple infarcts)
• Dementia with Lewy body = has parkinsonism and halluciations
• Picks /Fronto-temporal = personality changes in middle age
• Peudo-dementia = Depression

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Pseudo-dementia

• Depressed mood,
• Rapid onset & progression (dementia is slow)
• Patient will emphasis disability (Dementia Patient will downplay)
• Will answer Qs but dismissive ”I don’t know” (dementia Pt tries but not able)

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Wernicke-Korsakoff Syndrome

• Caused by vitamin B (Thiamine) deficiency -> Treat with IV Thiamine (& glucose)
• Wernicke encephalopathy: -> can progress to Chronic irreversible Korsakoff syndrome
• Associated with necrosis of mammillary bodies

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AMBOSS, First Aid 2019

Toxidromes, Tolerance, and Dependence

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Interesting ADRs

• Malignant hyperthermia
• Occurs in response to anesthetics
• Fever, muscle rigidity, arrhytmias -> treat with dantrolene
• Serotonin syndrome
• Use of SSRI + other serotonergic drug -> increased serotonergic activity in the CNS -> Potentially life-threatening
• Agitation (Altered mental status changes), Autonomic hyperactivity, and hyperActivity
• Neuroleptic malignant syndrome
• Life-threatening antipsychotics
• Characterized by distinctive clinical syndrome of Mental status change, rigidity, fever, and dysautonomia (elevated CK)

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UptoDate

Childhood Psychiatric Disorders

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First Aid 2019, pg 545

• Attention-Deficit Hyperactivity Disorder (ADHD)
• ≥ 6mo of limited attention span and/or poor impulse control
• Onset before age 12

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• Autism Spectrum Disorder (ASD)
• Poor social interactions, communication deficits, repetitive and ritualized behaviors, and restricted interests
• May be accompanied by intellectual disability or unusual abilities
• Must present in early childhood

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• Conduct Disorder
• Repetitive, pervasive behavior violating societal norms or the basic rights of others …. (20-40% go on to Antisocial PD as adult)

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• Oppositional Defiant Disorder (ODD)
• Enduring pattern of hostile, defiant behavior toward authority figures but without serious violations of social norms

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• Separation Anxiety Disorder
• Overwhelming fear of separation from home or attachment figure lasting ≥ 4 weeks
• Can be normal up to age 3-4

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• Tourette Syndrome
• Sudden, rapid, recurrent, non-rhythmic, stereotyped motor and vocal tics that persist for > 1 year
• Onset before age 18
• Often co-occurs with OCD or ADHD

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Sample SAQ

• A 58-year old woman has had low energy and has lost interest in things that normally make her happy.

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1. Name 3 symptoms which support a diagnosis of depression.

SIGECAPS

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2. How would you assess this patient for risk factors of suicide?

SAD PERSONS

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C. Ryan, Doctorials 2021/22

Sample SAQ

• A 21-year-old man is brought into the ED by his family who are concerned by his increasingly bizarre behavior and belief the neighbor was trying to kill him. He recently dropped out of university and has become withdrawn. He is assessed by a psychiatrist who tell him that there is a problem with a chemical called dopamine.
• Name the 4 dopaminergic pathways in the brain.

Mesolimbic: VTA 🡪 Ventral Striatum of Basal Ganglia

Mesocortical: VTA 🡪 Pre-frontal cortex

Nigrostriatal: Substantia Nigra 🡪 Striatum

Tuberoinfundibular: Hypothalamus 🡪 Pituitary

2. How does risperidone (i.e. an atypical antipsychotic) cause hyperprolactinemia?

Dopamine inhibits prolactin secretion from the pituitary gland.

Atypical antipsychotics (DA antagonists) 🡪 Decrease DA production in the tuberoinfundibular pathway 🡪 Increased production of prolactin from the anterior pituitary.

C. Ryan, Doctorials 2021/22

Sample EMQ

1. A patient has an exaggerated distrust of others and is suspicious of their motives
2. A patient believes that other individuals are in love with them
3. A patient hears voices speaking to them every time they get in a car
4. A patient believes they are experiencing a bodily function when there is none
5. A patient believes they have special powers or importance
6. A patient has reduced ability to initiate purposeful activities
7. A patient experiences a lack of emotion or concern towards matters that are normally considered important

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1. Apathy
2. Avolition
3. Visual Hallucination
4. Auditory Hallucination
5. Delusion of Grandiosity
6. Delusions of Paranoia
7. Gustatory Hallucination
8. Erotomania
9. Persecutory Delusions
10. Somatic Delusions

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Sample EMQ

1. A 24-year old woman, treated for drug-induced psychosis last year, presents complaining of voices commanding her to kill herself. She denies drug use since the last episode but explains that the voices never fully resolved and she is “sick of them taking her thoughts for their own purposes”.
2. A 48-year old man took an overdose of 38 paracetamol tablets with a bottle of gin. His wife states that he has been in a low mood for the past 3-months, doesn’t seem to enjoy spending time with their children anymore, and drags himself around the house. He has not been eating well and wakes very early in the morning. She says that he doesn’t normally drink heavily.
3. A 32-year old woman presents to ED with 2 lacerations on her wrist. She has no previous psychiatric history. Having snorted cocaine at a friend’s house, she reported feeling cockroaches crawling under her skin which she tried to remove with a knife. Nothing like this has ever happened before.

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C. Ryan, Doctorials 2021/22

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1. Schizophrenia
2. Acute and Transient Pyschotic Episode
3. Drug-Induced Psychosis
4. Mania
5. Bipolar Affective Disorder
6. Alcohol Dependence
7. Depression
8. Delirium Tremens

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QUESTIONS

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R. Chisvin & S. Gasior, Doctorials 2020/2021

Look after yourself & each other

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Self-care

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References

• www.uptodate.com
• Amboss, 2020
• First Aid, 2019
• Toronto Notes, 2020
• R. Chisvin & S. Gasior Doctorials Slides 2020
• Jenna McEwan-Doris’s Doctorial Slides, 2019
• Google Images
• Medcomic

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C Ryan, Doctorials 2021