PSYCHIATRY

Dr. U. Jain and Dr. J. Lofchy

Crystal Baluyut, Ilan Fischler, and Stephanie Wiesenthal, chapter editors
Christopher Tam, associate editor
THE PSYCHIATRIC
ASSESSMENT . . . . . . . . . . 2
History
Mental Status Exam (MSE)
Summary

SOMATOFORM
DISORDERS . . . . . . . .
SLEEP DISORDERS
. . . . . . . 23
...................
Conversion Disorder
. . . . 25
Somatization Disorder

Somatoform Pain Disorder

Hypochondriasis
Body Dysmorphic
Disorder
Mini-Mental Status Exam (MMSE) Management of
(Folstein)
Somatoform Disorders

PSYCHOTIC DISORDERS
................... 5
Differential Diagnosis of Psychotic
Disorders
Schizophrenia
Schizophreniform Disorder
Brief Psychotic Disorder
Schizoaffective Disorder
Delusional Disorder
Shared Psychotic Disorder (Folie
Deux)

Differentiating Psychotic Disorders

MOOD DISORDERS
....................... 8
Mood Episodes
Depressive Disorders
Postpartum Mood Disorders
Bipolar Disorders
Medical/Substance-Induced Mood
Disorders
ANXIETY DISORDERS
. . . . . . . . . . . . . . . . . . . . . 11 Panic
Disorder
Panic Disorder with
Agoraphobia
Generalized Anxiety
Disorder (GAD)
Phobic Disorders
ObsessiveCompulsive Disorder
(OCD) PostTraumatic Stress
Disorder (PTSD)
Anxiety Disorders Due to a General
Medical Condition
ADJUSTMENT DISORDERS
. . . . . . . . . . . . . . . . 15
COGNITIVE DISORDERS
. . . . . . . . . . . . . . . . . . . 15
Delirium

Dementia
SUBSTANCE-RELATED
DISORDERS . . . . . . . . 18
Alcohol
Opioids
Cocaine
Cannabis
Amphetamines
Hallucinogens
Phencyclidine

New Drugs of Abuse

SUICIDE . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 22

Factitious Disorder

Primary Insomnia
Sleep Apnea
Nocturnal Myoclonus
Narcolepsy
SEXUALITY AND
GENDER . . . . . . . . . . .
. . . . . . 26

Normal Sexuality
Sexual Dysfunction
Paraphilias
Gender Identity
Disorder
EATING
DISORDERS . . . . . . .
. . . . . . . . . . . . . . . 28
Anorexia Nervosa
(AN)

Bulimia Nervosa (BN)

PERSONALITY
DISORDERS (PD) . . .
. . . . . . . . 29
CHILD PSYCHIATRY
....................
. . . 32

Developmental
Concepts
Attention-Deficit and
Disruptive Behaviour
Disorders
Tic Disorders
Learning Disorders
Pervasive
Developmental
Disorder (PDD)
Mental Retardation
Childhood
Schizophrenia
Adolescent Mood
Disorders
Anxiety Disorders
Elimination Disorders
Chronic Recurrent
Abdominal Pain
Sleep Disturbances

Child Abuse

PSYCHOTHERAPY . .
....................
. . . 39

Psychodynamic
Therapies
Varieties of
Psychodynamic
Therapy
Behaviour Therapy
Cognitive Therapy

Electroconvulsive
Therapy (ECT)
MEDICATIONS/THERAPEUTICS . Mood Stabilizers
Anxiolytics
. . . . . . . . . . . 40
Psychostimulants
Antipsychotics
Antidepressants
LEGAL ISSUES

Other Therapies

....................
. . . . . . . . 50

Common Forms
Consent
Community Treatment
Order

. . . . . . . . . . . . . .Dissociative Fugue

. 52
Dissociative Identity Disorder
DISSOCIATIVE
.REFERENCES
. . . . . . . 24
Dissociative
Depersonalization Disorder
.
.
.
.
.
.
.
.
.
.
.
.
.
.
DISORDERS . . . . . . . .
Amnesia
MCCQE Review
Psychiatry PS1
2002
Notes

THE PSYCHIATRIC ASSESSMENT

HISTORY

ciated
symptoms
(pertinent
positives and
negatives)

Identifying Data
name, sex, age, race,
marital status, religion, Psychiatric Functional Inquiry
occupation, education, 1
Mood:
sad
(depressed),
referral source
energetic (manic)
Organic: EtOH, drugs, illness,
Reliability of Patient 2dementia
as a Historian
3
Anxiety: worry, obsessions,
compulsions, panic attacks
may need
Psychosis:
hallucinations,
collaborative source for 4delusions
history if patient unable 5
Suicide:
ideation,
plan,
attempts
to co-operate
Past Psychiatric History
Chief Complaint
1
i
in patients own
words; include duration nquire
about
all
History of Present
previo
Illness
us
psych
1
iatric
reaso
disord
n
ers,
conta
fo
ct
r
with
se
psych
ek
iatrist
in
s,
g
treatm
he
ents
lp
and
T
hospit
H
alizati
ons in
A
chron
T
ologic
D
al
A
order
Y,
(with
cu
dates)
rr
2
also include past suicide
en
attempts, substance abuse/use, and
t
legal history
sy
Past Medical History
m
pt
1
all medical, neurological (e.g.
o
craniocerebral
trauma, convulsions),
m
and psychosomatic illnesses
s
2
medications, smoking, caffeine
(o
use, allergies
ns
et
Family History
,
1
d
fam
ur
i
at
l
io
y
n,
m
an
e
d
m
co
b
ur
e
se
r
),
s
:
st
a
re
g
ss
e
or
s
s,
,
re
o
c
le
c
va
u
nt
p
as
a
so
t

i
o
n
s
,
p
e
r
s
o
n
a
l
i
t
i
e
s
,
m
e
d
i
c
a
l
o
r
g
e
n
e
t
i
c
i
l
l
n
e
s
s
e
s
a
n
d
t
r
e
a
t
m
e
n
t
s
,
r
e
l
a
t
i
o
n
s
h
i
p
s
w
i
t
h
p
a
r
e
n
t
s
/
s
i
b
l

i
n
g
s

fami
l
y
p
s
y
c
h
ia
tr
ic
h
is
t
o
r
y
:
a
n
y
p
a
st
o
r
c
u
rr
e
n
t
p
s
y
c
h
ia
tr
ic
il
l
n
e
s
s
e
s
a
n
d
h
o
s
p
it
al
iz
at
i
o
n
s,
s
u
ic
i
d
e,
d
e
p
r
e
s
si
o
n,
s
u
b
st
a
n
c
e
a
b
u
s
e,
h
is
t
o
r
y
o
f

a
d
n
e
r
v
e
s

,
a
n
y
p
a
s
t
t
r
e
a
t
m
e
n
t
b
y
p
s
y
c
h
i
a
t
r
i
s
t

physical characteristics, apparent

vs. chronological age, physical
health, body habitus, facial
expression (e.g. sad, suspicious),
attitude toward examiner (e.g.
ability to interact, level of cooperation), psychomotor activity
(e.g.
agitation,
retardation),
abnormal movements

(e.g. tremors, akathisia, tardive

dyskinesia), attention level, and eye
contact
Speech
rate (e.g. pressured, slowed, muted),
rhythm/fluency, volume, tone,
articulation, quantity, spontaneity
Mood and Affect
1
mood - subjective emotional
state; in patients own words
2
affect - objective emotional
state; described in terms of quality
(euthymic, depressed, elevated,
anxious), range (full, restricted),
stability
(fixed,
labile),
appropriateness,
intensity
(flat,
blunted)
Thought Process Abnormalities
1
circumstantiality
1
speech that is indirect
and delayed in reaching its
goal; eventually comes back to
the point
2
tangentiality
1
speech is oblique or
irrelevant; does not come back
to the original point

Past Personal History 3

flight of ideas
1
prenatal
and
1
sk
perinatal history
i
2
ea
p
rly
p
childhoo
i
d to age
n
g
3 (e.g.
develop
v
mental
e
mileston
r
es,
b
activity/
a
attention
l
level,
l
firey
setting,
stealing,
f
incontin
r
ence)
o
m
3
middle
childhood to age 11
o
(e.g.
school
n
performance,
peer
e
relationships)
4
late childhood
i
to adolescence (e.g.
d
drug/EtOH,
legal
e
history)
a
5
adulthood (e.g.
t
education,
o
occupations,
relationships)
a
n
6
psychosexual
o
history
(e.g.
t
paraphilias,
gender
h
roles, sexual abuse)
e
7
personality
r
before current illness

MENTAL
STATUS EXAM
(MSE)
General Appearance
and Behaviour
1
dress,
grooming,
posture,
gait,

w
h
e
r
e
t
h
e
i
d
e
a
s

a
r
e
m
o
r
e
o
r
l
e
s
s

c
o
n
n
e
c
t
e
d

loosening of associations

illogical
shifting
between unrelated topics
PS2 Psychiatry MCCQE
2002 Review Notes

THE PSYCHIATRIC ASSESSMENT . . . CONT.

1 others include
1
thought blocking (sudden interruption in the flow of thought or speech)
2
neologisms (invention of new words)
3
clanging (speech based on sound such as rhyming or punning)
4
perseveration (repetition of phrases or words)
5
word salad (jumble of words lacking meaning or logical coherence)
6
echolalia (echoing words/phrases of anothers speech)
Thought Content Abnormalities
1 ideas, themes, worries, preoccupations, ruminations,
obsessions, overvalued ideas, magical thinking, ideas of reference,
delusions

4
5

suicidal ideation / homicidal ideation

1
low - fleeting thoughts, no formulated plan, no intent
2
intermediate - more frequent ideation, has formulated plan, no active intent
3
high - persistent ideation and profound hopelessness, well formulated plan and active intent,
believes suicide is the only helpful option available
4
poor correlation between clinical impression of suicide
risk and probability of attempt
delusion
1
a fixed false belief that is out of keeping with a persons cultural or religious background and is firmly
held despite incontrovertible proof to the contrary
2
types of delusions
1
persecutory (belief others are trying to cause harm)
2
delusions of reference (interpreting events as having direct reference to the patient)
3
erotomania (belief another is in love with you)
4
grandiose (belief of an inflated sense of self-worth or power)
5
religious
6
delusions of control (belief that ones thoughts/actions are controlled by some external source)
7
somatic (belief one has a physical disorder/defect)
first rank symptoms: thought insertion / withdrawal / broadcasting
obsession
1
recurrent and persistent thought, impulse or image which is intrusive or inappropriate
2
cannot be stopped by logic or reason
3
causes marked anxiety and distress

4
common themes: dirt/contamination, orderliness, sexual, pathological doubt
Perceptual Disturbances
1 hallucination
1

2
3
4

sensory perception in the absence of external stimuli that is similar in quality to a true perception;
auditory is most common; other types include visual, gustatory, olfactory, somatic
illusion
1
misperception of a real external stimulus
depersonalization
1
change in self-awareness such that the person feels unreal,
detached from his or her body, and/or unable to feel emotion
derealization

1
feeling that the world/outer environment is unreal
Cognition
1 level of consciousness (LOC)
2
3
4

orientation: time, place, person

memory: remote, recent, immediate
intellectual functions
1
attention, concentration and calculation
2
abstraction (proverb interpretation, similarities test)

3
intelligence
Insight
patients ability to realize that he or she has a physical or mental illness and understand its implications
Judgment
ability to understand relationships between facts and draw conclusions that determine ones action

SUMMARY
Multiaxial Assessment (Impression)
Axis I - clinical disorders - DSM IV; differential diagnosis Axis II
- personality disorders - DSM IV

- mental retardation

Axis III - general medical conditions (as they pertain to Axis I or other Axes) Axis IV

- psychosocial and environmental problems

Axis V - global assessment of functioning (GAF) GAF scale scored from 0 to 100
Formulation
1 biological, psychological, social factors
2 predisposing, precipitating, perpetuating, and protecting factors
MCCQE 2002 Review Notes

Psychiatry PS3

THE PSYCHIATRIC ASSESSMENT . . . CONT.

MINI-MENTAL STATUS EXAM (MMSE) (FOLSTEIN)
Orientation
1
orientation to time [5 points]
1
what year is this?
2
what season of the year is it?
3
what is the month?
4
what day of the month is it?
5
what day of the week is it?
2
orientation to place [5 points]
1
what country are we in?
2
what province are we in?
3
what city are we in?
4
what street are we on / what hospital are we in?
5
what is the number of this house / what floor or ward are we on?
Memory
1
immediate recall [3 points]
1
ask patient to immediately repeat the following 3 words: honesty, tulip, black
2
delayed recall [3 points]
1
ask patient to recall the 3 words previously given, approximately 5 minutes
after telling them to the patient
Attention and Concentration
1
attention [5 points]: do either one of
1
serial 7s
2
spell WORLD backwards
Language Tests
1
comprehension (three stage command) [3 points]
1
take this piece of paper in your right hand, fold it in half, and place it on the floor
2
reading [1 point]
1
ask patient to read the words close your eyes on a piece of paper, and then to do what
it says
3
writing [1 point]
1
ask patient to write any complete sentence
4
repetition [1 point]
1
repeat no ifs, ands, or buts
5
naming [2 points]
1
point to a watch and pen and ask patient to name them
Test of Spatial Ability
1
copying [1 point]
1
ask patient to copy the design in Figure 1 exactly
2
all ten angles must be present and two must intersect to score 1 point

Figure 1. Intersecting Pentagons

1
2

total score out of 30; abnormal if < 26

note: although not officially part of the Folstein, many examiners ask the patient to draw a clock
with the time showing 10 after 11

PS4 Psychiatry MCCQE 2002 Review Notes

PSYCHOTIC DISORDERS
schizotypal, schizoid, borderline,

paranoid
Definition
6
primary
psychotic
1
chara
schizophrenia,
cterized by disorder:
schizoaffective
a
significant SCHIZOPHRENIA
impairment
in realityEpidemiology
testing
1
prevalence: 0.5%-1%;
2
evide
M:F = 1:1
nce
can
mean age of onset:
come from 2
females - 27; males - 21
1
delusio Etiology
ns or
hallu 1
disorder
cinati is a multifactorial:
result of interaction
ons
witho between both biological and
ut
environmental factors
insig
2
ht
into
their
patho
logic
al
natur
e

genetic

50% concordance
in monozygotic (MZ)
twins
2
40% if both
parents schizophrenic
3
10% of dizygotic
2
(DZ) twins, siblings,
children affected
behavi
our 3
ne
so
urochem
disor istry dopami
gani
ne
zed
hypothe
that
it is sis
theory:
reas
excess
onab activity
le to in the
infer mesolim
bic
that
realit dopamin
e
y
pathway
testi
may
ng is mediate
distu the
rbed positive
sympto
of
DIFFERE ms
psychosi
s
(i.e.
NTIAL
delusion
DIAGNOS s,hallucin
ations,
IS OF
disorgan
PSYCHO ized
speech
and
TIC
behavio
ur,
DISORDE catatoni
c
behavio
RS
ur, and
1
gener agitation
al medical )
1
supportive
conditions:
evidence
tumour,
head
1 dopamine (DA)
agonists
trauma,
exacerbate
etc.
schizophrenia
2
deme
2
anti-psychotic
ntia/deliriu
drugs
act
by
m
blocking
postsynaptic
DA
3
substa
receptors
nce-induced
psychosis
3 potency of many
anti-psychotic
4
affecti
drugs correlates
ve disorders:
with D2 blockade
psychotic
of post-synaptic
depression,
receptors
bipolar
disorder
4 antipsychotic
manic
drugs
are
episode with
associated with
psychotic
an
increase
in
features
the number of
D2
and
D4
post5
perso
synaptic
nality
receptors
disorders:

decreas
ed
activi
ty in
the
meso 4
cortic
al
path
way
or
abnor
malit
ies in
the
NM
DA
recep
tors
whic
h
regul
ate
the
relea
se of
gluta
mate
may
be
respo
nsibl
e for
the
negat
ive
symp
toms
of
schiz
ophre
nia

3
o

t
h
e
r
n
e
u
r
o
t
r
a
n
s
m
i
t
t
e
r
s
:
s
e
r
o
t
o
n
i
n
(
5
H
T
)
,
n
o
r
e
p
i
n
e
p
h
r
i
n
e
,
G
A
B
A
,

1
i

and CCK
are
currently
being
investigate
d
neuroanatomy

m
p
l
i
c
a
t
i
o
n
o
f
3
b
r
a
i
n
s
t
r
u
c
t
u
r
e
s
:
d
e
c
r
e
a
s
e
d
f
r
o
n
t
a
l
l
o
b
e
f
u
n
c
t
i
o
n
,
a
s
y
m
m
e
t
r
i
c
t
e
m
p
o
r
a
l
l
i
m
b
i
c
f
u
n
c
t

i
o
n
,
d
e
c
r
e
a
s
e
d
b
a
s
a
l
g
a
n
g
l
i
a
f
u
n
c
t
i
o
n

subtle
chan
ges
in
thala
mus,
corte
x,
corpu
s
callo
sum,
and
ventr
icles

cytoarc
hitect
ural
abnor
malit
ies
5
neuro
endocrinolo
gy

abn
o
r
m
al
g
r
o
w
th
h
o
r
m
o
n
e
(
G
H
),
p
r
ol
a
ct
in
(
P
R
L
),
c
o
rt
is
ol
,
a
n
d
a

drenocorticotropin
hormone
(ACTH)
responses
to
pharmacological
challenges
(e.g.
bromocriptine,
fenfluramine)
in
schizophrenia
other
1
indirect evidence
of
1 geographical
variance
2 association with
winter season of
birth
3 association with
prenatal exposure
to viral epidemics

ne
uropsycho
logy:
global
defects
seen
in
attention,
language,
and
memory
suggest
lack
of
connectivi
ty
of
neural
networks
Pathophysiology
1
neurodegenerative
theory

2
g

l
u
t
a
m
a
t
e
s
y
s
t
e
m
m
a
y
m
e
d
i
a
t
e
p
r
o
g
r
e
s
s
i
v
e
d
e
g
e
n
e
r
a
t
i
o
n
b
y
a
n

natural history of
schizophrenia tends to be
a downhill course

e
x
c
i
t
o
t
o
x
i
c
m
e
c
h
a
n
i
s
m
w
h
i
c
h
l
e
a
d
s
t
o
t
h
e
p
r
o
d
u
c
t
i
o
n
o
f
f
r
e
e
r
a
d
i
c
a
l
s

nappropriate
apoptosis
during
neurodevelopm
ent resulting in
wrong
connections
being
made
between
neurons
Diagnosis

1. chara

neuro
developmen
tal theory

abnorm
al
devel
opme
nt of
the
brain
from
prena
tal
life

neurons
fail
to
migr
ate
corre
ctly,
make
inapp
ropri
ate
conn
ectio
ns,
and
break
down
in
later
life

3
i

cteris
tic
symp
toms
(Acti
ve
Phas
e): 2
or
more
of
the
follo
wing
,
each
prese
nt for
a
signi
fican
t
porti
on of
time
durin
ga1
mont
h
perio
d (or
less
if
succe
ssfull
y
treate
d)

1.
2.
3.
speech
4.
5
.

n
e
g
a
t
i
v
e
s
y
m
p
t
o
m
s
,
i
.
e
.
a
f
f
e
c
t
i
v
e
f
l
a
t
t
e
n
i
n
g
,

delusions **
hallucinations **
disorganized

grossly
disorganized or catatonic
behaviour

a
l
o
g
i
a
,
a
v
o
l
i
t
i
o
n
o
r
a
n
h
e
d
o
n
i
a
*
*
n
o
t
e
:
o
n
l
y
1
s
y
m
p
t
o
m
i
s
r
e
q
u
i
r
e
d
i
f
:

1)
de

l
u
s
i
o
n
s
a
r
e
b
i
z
a
r
r
e
,
o
r

2)
ha

l
l
u
c
i
n
a
t
i

o
n
s
c
o
n
s
i
s
t
o
f
a
v
o
i
c
e
k
e
e
p
i
n
g
u
p
a
r
u
n
n
i
n
g
c
o
m
m
e
n
t
a
r
y
o
n
p
e
r
s
o
n

s
b
e
h
a
v
i
o
u
r
/
t
h
o
u
g
h
t
s
o
r
t
w
o
(
o
r
m
o
r
e
)

v
o
i
c
e
s
c
o
n
v
e
r
s
i
n
g
MCCQE 2002
Review Notes

w
i
t
h
e
a
c
h
o
t
h
e
r
Psychiatry
PS5

PSYCHOTIC DISORDERS . . . CONT.

2. social/occu

ion
with
one
or
more
delu
sions
(typi
cally
pers
ecut
ory
or
gran
dios
e) or
freq
uent
audit
ory
hallu
cinat
ions

pational
dysfunction
3. continuous
signs
of
disturbance
for at least
6 months
including
at least 1
month of
active
phase
symptoms;
may
include
prodromal
or residual
phases
4. schizoaffec
2
relative
tive
and
preservation
of
mood
cognitive
disorders
functioning
and
excluded
affect; onset tends
to be later in life;
5. exclude if
thought to have the
substancebest prognosis
induced or
due
to 2
catatonic
general
1
at least two
medical
of: motor immobility
condition
(catalepsy or
(GMC)
stupor); excessive
6. if
motor activity
histo
(purposeless, not
ry of
influenced by
perva
external stimuli);
sive
extreme negativism
devel
(resistance to
opme
instructions/attempts
ntal
to be moved) or
disor
mutism; peculiar
der,
voluntary movement
addit
(posturing,
ional
stereotyped
movements,
diagn
prominent
osis
mannerisms);
of
echolalia or
schiz
echopraxia
ophr
enia
3
disorganized
is
1
made
all
only
o
if
f
prom
inent
t
delus
h
ions
e
or
hallu
f
cinati
o
ons
l
are
l
also
o
prese
w
nt for
i
at
n
least
g
1
mont
a
h
r
e
Subtypes
p
1
paran
r
oid
o
m
1
i
pr
n
e
e
o
n
c
t
c
:
u
p
d
a
i
t

s
o
r
g
a
n
i
z
e
d
s
p
e
e
c
h
a
n
d
b
e
h
a
v
i
o
u
r
;
f
l
a
t
o
r
i
n
a
p
p
r
o
p
r
i
a
t
e
a
f
f
e
c
t

a
n
d
i
n
s
i
d
i
o
u
s
o
n
s
e
t
,
a
n
d
c
o
n
t
i
n
u
o
u
s
c
o
u
r
s
e
w
i
t
h
o
u
t
s
i
g
n
i
f
i
c
a
n
t
r
e
m
i
s
s
i
o
n
s

po
o
r
p
r
e
m
o
r
b
i
d
p
e
r
s
o
n
a
l
i
t
y
,
e
a
r
l
y

undifferentiated
symptoms
of
criterion A met, but
does not fall into other
3 types
residual

1
ab

s
e
n
c
e
o
f
p
r
o

m
i
n
e
n
t

a
v
i
o
u
r

d
e
l
u
s
i
o
n
s
,

h
a
l
l
u
c
i
n
a
t
i
o
n
s
,
d
i
s
o
r
g
a
n
i
z
e
d
s
p
e
e
c
h
,
g
r
o
s
s
l
y
d
i
s
o
r
g
a
n
i
z
e
d
o
r
c
a
t
a
t
o
n
i
c
b
e
h

co

n
t
i
n
u
i
n
g
e
v
i
d
e
n
c
e
o
f
d
i
s
t
u
r
b
a
n
c
e
i
n
d
i
c
a
t
e
d
b
y
p
r
e
s
e
n
c
e
o
f
n
e
g
a
t
i
v
e
s
y
m
p
t
o
m
s
o
r
t
w
o

o
r
m
o
r
e
s
y
m
p
t
o
m
s
i
n
c
r
i
t
e
r
i
a
A
p
r
e
s
e
n
t
i
n
a
t
t
e
n
u
a
t
e
d

nt of side effects
psychosocial
1
psychotherapy
(individual,
family,
group):
supportive,
cognitive behavioural
therapy (CBT)
2
assertive
community treatment
3
social
skills
training
and
employment programs
4
housing (group
home, boarding home,
transitional home)
Prognosis
1
1/3 improve, 1/3 remain
the same, 1/3 worsen
2
good prognostic factors
1
acute onset
2
precipitating
factors
3
good cognitive
functioning
4
good premorbid
functioning
5
no
family
history
6
presence
of
affective symptoms
7
absence
of
structural
brain
abnormalities
8
good response
to drugs
9
good support
system

SCHIZOPHRENIFOR
M DISORDER
1

epidemiology: only a
slightly increased incidence in
the family
f
2
diagnosis: symptoms of
o
schizophrenia are met except
r
symptoms
last
from1-6
m
months
3
treatment: similar to
Management acute schizophrenia
4
prognosis: better than
of
begins and ends
Schizophreni schizophrenia;
more abruptly; good pre- and
a (see
post-morbid function
Medications/T
herapeutics BRIEF PSYCHOTIC
section)
DISORDER
1
phar1
macologica
d
l
i
a
1
acute g
treat n
ment o
and s
main i
tena s
nce :

antipsy a
choti c
cs
(PO u
and t
IM) e

manag p
eme s

y
c
h
o
s
i
s

r
i
t
e
r
i
a

(
p
r
e
s
e
n
c
e

A
1
4
)

o
f
1
o
r
m
o
r
e
p
o
s
i
t
i
v
e
s
y
m
p
t
o
m
s
i
n
c

l
a
s
t
i
n
g
f
r
o
m
1
d
a
y
t
o
1
m
o
n
t
h

can occur after stressful

event or post-partum
3
treatment:
secure
environment, antipsychotics,
anxiolytics
4
prognosis: good, selflimiting, should return to
premorbid function in about
one month
PS6 Psychiatry 2002 Review Notes
MCCQE

PSYCHOTIC DISORDERS . . . CONT.

SCHIZOAF
FECTIVE
DISORDER
1

mptoms

3. symptoms

that meet
criteria for
a
mood
episode
are present
for
a
substantial
portion of
total
duration
of active
and
residual
periods

diagnosi

1. uninterru

2. in

th
e
s
a
m
e
p
er
io
d,
d
el
u
si
o
n
s
o
r
h
al
lu
ci
n
at
io
n
s
f
o
r
at
le
a
st
2
w
e
e
k
s
w
it
h
o
ut
p
r
o
m
in
e
nt
m
o
o
d
s
y

pted
period of
illness
during
which, at
some
point,
treatment:
there is 2antipsychotics,
mood
either
stabilizers, antidepressants
major
prognosis: between
depressiv 3
e episode that of schizophrenia and
affective
disorder
(MDE),
manic
episode, DELUSIONAL
or mixed
episode DISORDER
concurren
1
diagnosis
t with
symptom
1
non-bizarre
s meeting
delusions for at least
criterion
1 month
A for
schizophr
2
crit
enia
erion A has
never been
met
(though
patient may
have tactile
or olfactory
hallucinatio
ns if they
are related
to
the
delusional
theme)
3
functioning
not
markedly
impaired; behaviour
not odd or bizarre
4
if
mood
episodes
occur
concurren
tly with
delusions,
total
duration
has been
brief
relative to
duration
of
the
delusions
2
subtypes: erotomanic,
grandiose,
jealous,
persecutory, somatic, mixed,
unspecified
3
treatment:
psychotherapy,
antipsychotics,
antidepressants
4
prognosis: chronic,
unremitting course but high
level of functioning

SHARED
PSYCHOTIC
DISORDER (FOLIE
DEUX)
1

diagnosis: a
delusion that
develops in an
individual who is
in close

relati
onshi
p
with
anoth
er
perso
n
who
alrea
dy
has a
psyc
hotic
disor
der
with
prom
inent
delus
ions

with schizophrenia
the symptoms last longer
than six months
Schizophreniform vs. Brief
Psychotic Disorder
1
inclusion
criteria for brief
psychotic
disorder are
broader and only
require the
presence of one
of: delusions,
hallucinations,
disorganized
speech,
disorganized /
catatonic
behaviour
2
t
2
with
reatm
brief psychotic
ent:
disorder these
separ
symptoms last
ation
less than one
of the
month
with
two
eventual full
peopl
return
to
e
premorbid
result
level
of
s in
functioning
the
3
in schizophreniform
disap
disorder the symptoms last
peara
greater
than one month
nce of
the
Schizophrenia vs.
delusi
on in
Schizoaffective Disorder
the
health
1
the
psychotic
ier
symptoms are the same in
memb
er
both disorders
3
prognos 2
in
is: good
schizoaffective
disorder, a manic
DIFFEREN or depressive
episode must be
present and the
TIATING
duration of the
symptoms
PSYCHOTI mood
cannot be brief
relative
to the
C
duration of the
DISORDER psychosis
3
to be
S
diagnosed with
schizoaffective
disorder there
Schizophrenia
must also be at
vs.
least a 2 week
during
Schizophrenifor period
which psychotic
symptoms
are
m
present in the
1
sympto
absence of mood
m complex is symptoms
the same forSchizophrenia vs. Delusional
both disorders Disorder
2
1
in
with
delusional
schiz
ophr
disorder, the
enifo
content of the
rm
delusion involves
disor
events that may
der
actually happen
the
to people in real
prod
life (i.e. nonroma
bizarre);
l,
hallucinations can
resid
occur but must be
ual,
and
limited to a few
activ
brief periods
e
2
bizar
phas
re
es
delusions,
last
prominent
less
hallucinati
than
six
ons,
mont
disorganiz
hs
ed

s
p
e
e
c
h
/
b
e
h
a
v
i
o
u
r
a
n
d
n
e
g
a
t
i
v
e
s
y
m
p

toms rule
out
delusional
disorder
Schizoaffective vs. Mood
Disorder with Psychotic
Features
1
in
a
mood
disorder
with
psychotic
features the
mood
symptoms
and
psychosis
must always
overlap in
time
2
in
schizoaffective
disorder,
psychotic
symptoms
must
be
present in the
absence
of
mood
symptoms for
at
least
2
weeks
Review Notes
Psychiatry
MCCQE 2002
PS7

MOOD DISORDERS
substances,
medications
Definitions
3
m
1
m
ood
ood
EPISO
DES
DISOR
represen
DERS
t
a
are
combin
ation of
defined
by the sympto
ms
presence compris
a
of mood ing
EPISOD predomi
nant
ES
mood
state
2
ty
1
types of
pes of
Mood
Mood
EPISODES:
DISOR
major
DERS
depressive,
1
manic, mixed,
depr
hypomanic
es
si
v MOOD EPISODES
e
( Major Depressive
m
aj Episode (MDE)
or
least 5
d 1. at
of
the
e
pr followin
es gsympto
si ms
v
present
e
2
di for
weeks,
s
one
of
or which
d
be
er must
either
,
depresse
d
d mood
y
loss
st or
of
h
interest
y
m
1
Mood ia
depressed
)
2
Sleep 2
increased
or
bipo
decreased
(if
la
decreased, often
r
early
morning
(
awakening)
B
3
Interest ip
decreased
ol
ar
4
Guilt/wo
I/
rthlessness
II
5
Energy di
decreased
or
s
fatigued
or
d
6
Concent
er
ration/difficulty
,
making
c
decisions
y
7
Appetite
cl
and/or weight
ot
increase
or
h
decrease
y
m
8
Psycho
ia
motor activity )
increased
or
decreased
3
seco
9
Suicidal
n
ideation
d 2. symptoms do not meet
ar criteria for mixed
y
to episode
G 3. symptoms
cause
M significant social or
C occupational
,
impairment/distress

4. exclude

5. s

y
m
p
t
o
m
s
n
o
t
b
e
t
t
e
r
a
c
c
o
u
n
t
e
d
f
o
r
b
y
b
e
r
e
a
v
e
m
e
n
t
(
a
c
o
n
s
t
e
l
l
a
t
i
o
n
o
f
d
e
p
r
e
s
s
i
v
e
s
y
m
p
t
o
m
s

if
substanc
einduced
or due
to
a
GMC

meeting
criteria
for
a
MDE
appearing
within
2 months of the death
of a close relative)

Manic Episode
1. a period of
abnormall
y
and
persistentl
y elevated,
expansive,
or irritable
mood
lasting at
least
1
week (or
less
if
hospitalize
d)
2. d
u
r
i
n
g
t
h
i
s
p
e
r
i
o
d
t
h
r
e
e
o
f
t
h
e
f
o
l
l
o
w
i
n
g
s
y
m
p
t
o
m
s
(
f
o
u
r
i
f
m
o
o
d
i
s

o
n
l
y
i
r
r
i
t
a
b
l
e
;
m
n
e
m
o
n
i
c
G
S
T
P
A
I
D
)

peech

Pleasura
ble
activities
with
Painful
consequences increased
(e.g. spending,
sex, speeding,
substance use,
inappropriate
speech)
5
Activity,
goal-directed or
psychomotor increased
6
Ideas,
flight of
7
Distracti
bility
3. symptoms do not meet
criteria for a mixed
episode
4. mood
disturbance is
severe enough
to cause
psychotic
features,
marked
impairment in
social/occupati
onal
functioning, or
necessitate
hospitalization
not
1 5. symptoms
Gra substance-induced or
n
due to a GMC
di
o Mixed Episode
si criteria met for both
ty
or manic episode and MDE
in nearly every day for 1
fl
at week
e
d Hypomanic Episode
se
lf 1
criteria A of
es mania but duration is
te at least 4 days
e 2
criteria B and E
m of mania
2 3
Slee de episo
p, associated
d
with
an
e
cr uncharacte
ristic
e
in
as change
functioning
e
that
is
d
observable
n
by others
e
chang
e 4
e
in
d
fo function is
NOT
severe
r
enough to
3
cause
Tal
marked
k
at impairment
social or
iv in
e, occupationa
pr lfunctioning
es or
to
s
ur necessitate
hospitalizati
e
on
d
absence
of
s 5
psychotic features
PS8 Psychiatry
MCCQE
2002 Review

Notes

MOOD DISORDERS . . . CONT.

DEPRE
SSIVE 3
DISOR
DERS
Major
Depressiv
e
Disorder
1
d
efinitio
n

hist
o
r
y
o
f
o
n
e
o
r
m
o
r
e
M
a
j
o
r
D
e
p
r
e
s
s
i
v
e
E
p
i
s
o
d
e
s
2
e
pidemi
ology

pre
v
a
l
e
n
c
e
:
m
a
l
e
2
4
%
,
f
e
m
a
l
e
5
9

% (M:F = 1:2)
mean age of
onset: ~ 30 years
etiology
1
genetic
1 65-75% MZ
twins
2 14-19% DZ
twins

ne
u
r
o
t
r
a
n
s
m
i
t
t
e
r
d
y
s
f
u
n
c
t
i
o
n
a
t
l
e
v
e
l
o
f
s
y
n
a
p
s
e
(
d
e
c
r
e
a
s
e
d
a
c
t
i
v
i
t
y
o
f
s
e
r
o
t
o
n
i
n
,
n
o
r
e

p
i
n
e
p
h
r
i
n
e
,
d
o
p
a
m
i
n
e
)

psy
c
h
o
d 5
y
n
a
m
i
c
(
e
. 6
g
.
l
o
w
s
e
l
f
e
s
t
e
e
m
)

cog
n
it
i
v
e
(
e
.
g
.
n
e
g
a
ti
v
e
t
h
i
n
k
i
n
g
)
4
ri
sk
factors

sex
:
f
e
m
a
l
e

age
:
o
n
s

et in 25-50 age
group
3
family
history: depression,
alcohol
abuse,
sociopathy
4
childhood
experiences: loss of
parent before 11
years old, negative
home environment
(abuse, neglect)
5
personality:
insecure,
dependent,
obsessional
6
recent
stressors
(illness,
financial, legal)
7
postpartum
8
lack
of
intimate, confiding
relationships (social
isolation)
diagnosis
1
history of
one or more MDE
2
absence of a
previous
manic,
hypomanic,
or
mixed episode
classification
1
MDD, with
psychotic features
(with hallucinations
or delusions; these
may
be
mood
congruent)
2
MDD,
chronic (lasting 2
years or more)
3
MD
D,
with
melancholic
features
(quality of
mood
is
distinctly
depressed,
mood
is
worse in the
morning,
early
morning
wakening,
severe
weight loss,
excessive
guilt,
psychomoto
r
retardation)

M
D
D
,
w
i
t
h
a
t
y
p
i
c
a
l
f
e
a
t
u
r
e
s
(
i
n
c

r
e Postpartum Mood
e
Disorders section)
a
6
MDD, with
s
seasonal
pattern
e
(pattern
of onset at
d
same time each
year)
s
l 7
depression in the
e
elderly
e
1
accounts for
p
about 50% of acute
,
psychiatric
admissions in the
w
elderly
e
i
2
affects
g
about
15%
of
h
community
t
residents > 65 years
old
g
3
a
h
i
i
n
g
,
h
l
e
s
a
u
d
i
e
c
n
i
d
p
e
a
r
r
a
i
l
s
y
k
s
i
d
s
u
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s
s
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o
n

chological:
psychodynamic,
cognitive,
behavioural, family,
and group therapy
3
social:
vocational
8
tr
rehabilitation,
eatment
(see
social skills training
Medica 9
differential
diagnosis
tions/T for MDE
herapeu
tics
1
adjustment
disorder
with
section)
depressed mood
1
2
bereavement
bio
l
3
dementia
o
g
4
mood
i
disorder due to GMC
c
5
substance
a
induced
mood
l:
disorder
a
n
6
anxiety
ti
disorder
d
e Dysthymia
p
diagnosis
r 1
e 1. depressed mood for
s
most of the day, for
s
more days than not,
a
and for at least 2 years
n
t 2. presence,
while
s
depressed, of at least
,
two of
li
1 poor appetite
t
or overeating
h
i
2
insomnia or
u
hypersomnia
m
3 low energy
,
or fatigue
e
l
4
low
selfe
esteem
c
5 poor
t
concentration
r
or difficulty
o
in
decision
c
making
o
n
6 feelings of
v
hopelessness
u 3. never
without
l
depressed mood for
s
more
than
2
months
at
i
a time
v
e 4. no evidence of past
t
MDE, manic, mixed,
hypomanic episodes,
h
cyclothymia
e
r 5. symptoms do not occur
a
with
a
chronic
p
psychotic disorder
y
( 6. not due to GMC or
substance use
E
C 7. symptoms
cause
T
significant social or
)
occupational
2
dysfunction
or
psy
marked distress
MCCQE 2002
Review Notes Psychiatry PS9

MOOD DISORDERS . . . CONT.

POSTP
ARTU
M
MOOD
DISOR
DERS

,
d
e
c
r
e
a
s
e
d

Postpartu c
o
m
n
"Blues" c
e
1
n
t
t
r
r
a
a
n
t
s
i
i
o
e
n
n
,
t
p
e
r
i
o
d
o
f
m
i
l
d
d
e
p
r
e
s
s
i
o
n
,
m
o
o
d
i
n
s
t
a
b
i
l
i
t
y
,
a
n
x
i
e
t
y

i
n
c
r
e
a
s
e
d
c
o
n
c
e
r
n
o
v
e
r
o
w
n
h
e
a
l
t
h
a
n
d
h
e
a
l
t
h
o
f
b
a
b
y

T
ask
about
oc
suicidal
and
curs in
infanticidal
50-80%
ideation
of
mothers 4
risk factors
; begins
1
previous
2-4
history of a mood
days
postpart
disorder
um
(postpartum
or
otherwise)
3
us
increases
risk
ually
lasts 48
2
psychosocia
hours,
l factors of primary
can last
importance
up to 10
days
1 stressful
life events
4
co
nsidere
2
unemploym
d to be
ent
normal
3 marital
emotion
conflict
al
changes
4 lack
of
related
support from
to the
spouse,
puerper
family
or
ium
friends
5
d
treatment
oes not 5
require
1
many
psychot
mothers may be
ropic
reluctant to take
medicat
medication
if
ion
breastfeeding
6
pa
2
at present
tient at
no evidence that
increase
medication
is
d risk
superior
to
of
psychotherapy in
develop
non-psychotic PPD
ing
postpart
3
short-term
um
safety of maternal
depressi
SSRIs
for
on
breastfeeding
infants established;
Postpartu
long-term
effects
unknown
m
4
supportive,
Depressio
non-directive
n (PPD)
counselling
by
trained
home
1
di
visitors shown to
be effective
agnosis:
MDE,
5
if
depression severe,
onset
consider ECT
within
6
treatment of
4 weeks
mother improves
postpart
outcome for child
um
at 18 months
2
et 6
impact on child
iology:
development
no
1
association
consiste
with
cognitive
nt
delay, especially in
evidenc
males
and
groups
e for a
biologic
with low SES
al
2
insecure
(hormo
attachments at 18
nal)
months
etiology
; occurs
3
increased
in 10%
behavioural
of
disturbance
at 5
mothers
years
3
cl
4
mechanism:
inical
impaired motherpresent
child
ation:
communication
typicall
y lasts 2
to
6Postpartum Psychosis
months;
residual 1
incidence: 1-2 per
sympto 1000 childbirths, more
ms can
last up common in primiparous
to
1 women
year
most often has an
1 2affective
basis, usually
M
U manic, but can be
S depressive

m
ean
onset 23 weeks
postpart
um,
range 2
days to
8 weeks
4
m
ay have
suicidal 2
/infanti
cidal
ideation
5
pr
evious
history
or
family
history
of
psychos
is
increase
s risk
6
tr
eat with
antidepr
essants,
mood
stabiliz
ers
and/or
antipsy
chotics;
conside
r ECT

ens to 20s
slight
increase in upper
socioeconomic
groups
5
60-65% of
bipolar
patients
have family history
of major mood
disorders
definition
1
Bipolar
I
Disorder
1 disorder in
which
at
least
one
manic
or
mixed
episode
is
present
2 commonly
accompanied
by one or
more MDE
but
not
required for
diagnosis
2
Bipolar II
Disorder
1 disorder in
which there
is one MDE
and
one
hypomanic
episode
2 no
past
manic
or
mixed
episode
diagnosis

BIPOL
AR
3
1
DISOR
m
o
DERS
Bipolar I /
Bipolar II
Disorder
1
ep
idemiol
ogy

pre
v
a
l
e
n
c
e
:
0
.
6
0
.
9
%

M:
F
=
1
:
1

age
o
f
o
n
s
e
t:
t
e

o
d
e
p
i
s
o
d
e
s
i
n
B
i
p
o
l
a
r
I
/
I
I
c
a
n
n
o
t
b
e
d
u
e
t
o
a
G

M
C
o
r
s
u
b
s
t
a
n
c
e
i
n
d
u
c
e
d

2
sy

bo
t
h
c
a
n
o
c
c
u
r
w
i
t
h
r
a
p
i
d
c
y
c
l

m
p
t
o
m
s
c
a
n
n
o
t
b
e
c
a
u
s
e
d
b
y
a
p
s
y
c
h
o
ti
c
d
i
s
o
r
d
e
r

i
n
g
(
p
r
e
s
e
n
c
e
o
f
a
t
l
e
a
s
t
4
m
o
o
d
e
p
i
s
o
d
e
s
w
i
t
h
i
n
1
y
e
a
r
;
m
u
s
t
b
e
s
y
m
p
t
o
m
f
r
e
e
f
o
r
a
t
l
e
a
s
t
2
m
o
n

t
h
s
b
e
t
w
e
e
n
PS10
Psychiatry

e
p
i
s
o
d
e
s
)
MCCQE
2002 Review
Notes

MOOD DISORDERS . . . CONT.

1
classification
1. classification of Bipolar disorder involves describing the current or most recent mood episode
as either manic, hypomanic, mixed or depressed
2. the most recent episode can be further classified as follows
1 without psychotic features, with psychotic features, with catatonic features,
with postpartum onset
2
treatment
1
biological: lithium, valproic acid, carbamazepine, lamotrigine, gabapentin,
topiramate, antipsychotics, ECT
2
psychological: supportive and psychodynamic psychotherapy, cognitive or behavioural
therapy
3
social: vocational rehabilitation, leave of absence from school/work, drug and EtOH
avoidance, substitute decision maker for finances, sleep hygiene, social skills training,
education for family members
3
differential diagnosis
1
cyclothymic disorder
2
psychotic disorder
3
substance induced mood disorder
4
mood disorder due to a GMC
5
delirium
Cyclothymia
1
presence of numerous periods of hypomanic and depressive symptoms (not meeting criteria
for MDE) for at least 2 years; never without symptoms for > 2 months
2
no MDE, manic or mixed episodes; no evidence of psychosis
3
not due to GMC/substance use

MEDICAL/SUBSTANCE-INDUCED MOOD DISORDERS

1
infectious: encephalitis, hepatitis, pneumonia, TB, syphilis
2
endocrine: hypothyroidism, hypopituitarism, SIADH
3
metabolic: porphyria
4
vitamin disorders: Wernicke's, beriberi, pellagra, pernicious anemia
5
collagen vascular: SLE, polyarteritis nodosa
6
neoplastic: pancreatic cancer, carcinoid, pheochromocytoma
7
cardiovascular (CV): cardiomyopathy, CHF, MI, CVA
8
neurologic: Huntingtons disease (HD), multiple sclerosis (MS), tuberous sclerosis,
Wilsons disease, personality disorder (PD)
9
drugs: antihypertensives, antiparkinsonian, hormones, steroids, antituberculous, antineoplastic
medications

ANXIETY DISORDERS
Definition
1
anxiety is a universal human characteristic which serves as an adaptive mechanism to warn about an
external threat by activating the sympathetic nervous system (fight or flight)
2
anxiety becomes pathological when
1
fear is greatly out-of-proportion to risk/severity of threat
2
response continues beyond existence of threat
3
social or occupational functioning is impaired
3
manifestations of anxiety can be described along a continuum of physiology, psychology, and
behaviour
1
physiology - main brain structure involved is the
amygdala; neurotransmitters involved include serotonin, CCK,
adrenaline
2
psychology - ones perception of a given situation is
distorted which causes one to believe it is threatening in some
way
3
behaviour - once feeling threatened, one responds by escaping/avoiding the
situation, thereby causing a disruption in daily functioning

PANIC DISORDER
Epidemiology
1
prevalence: 1.5-5%
2
onset: average late 20s, familial pattern
3
M:F = 1:2-3

one of the top five most common reasons to see a family doctor

Diagnosis
1. recurrent, unexpected panic attacks; at least one attack has been followed by at least 1 month or more
of either persistent concern about having another panic attack, worry about consequences of the
attack, or significant behavioural change related to the attack
MCCQE 2002 Review Notes
Psychiatry PS11

ANXIETY DISORDERS . . . CONT.

2. panic attack - a discrete period of intense fear in which at least four of the
following symptoms develop abruptly and reach a peak within 10 minutes

mnemonic STUDENTS FEAR the 3 Cs

1 Sweating
2 Trembling or shaking
3 Unsteadiness, light-headedness
4 Depersonalization, Derealization
5 Excessive heart rate (palpitations, pounding heart, or accelerated heart rate)
6 Nausea
7 Tingling (paresthesias)
8 Shortness of breath
FEAR of dying, of losing control or going crazy
Chest pain, Chills (or hot flushes), Choking

C. attacks are not substance induced (e.g. amphetamines, caffeine, EtOH) or due to a GMC
Treatment
1 supportive psychotherapy, relaxation techniques (visualization, box-breathing),
cognitive behavioural therapy (CBT) (correct distorted thinking, desensitization/exposure therapy)
2 pharmacotherapy
1
benzodiazepines dosed regularly (clonazepam, alprazolam), SSRIs (paroxetine, sertraline)
2
use of benzodiazepines should be short term with a low dose to avoid withdrawal or
tolerance - benzodiazepines are primarily used as a temporary therapy until SSRIs take effect
Prognosis
1 6-10 years post-treatment: 30% well, 40-50% improved, 20-30% no change or worse
2 clinical course: chronic, but episodic

PANIC DISORDER WITH AGORAPHOBIA

1 diagnosis: panic disorder + agoraphobia

2 agoraphobia
1
anxiety about being in places or situations from which escape might be difficult (or
embarrassing) or where help may not be available in the event of having an unexpected panic attack

2
fears commonly involve clusters of situations like being out
alone, being in a crowd, standing in a line, or travelling on a bus
3
situations are avoided, endured with anxiety or panic, or require companion

3 treatment: as per panic disorder

GENERALIZED ANXIETY DISORDER (GAD)

(includes overanxious disorder of childhood)
Epidemiology
1 1-year prevalence: 3-8%
2 most commonly presents in early adulthood
3 M:F = 1:2; if considering only those receiving inpatient treatment, ratio is 1:1
Diagnosis
1 excessive anxiety and worry for at least 6 months (chronic) about a
number of events and activities (e.g. money, job security, marriage, health)
2 difficult to control the worry
3 three or more of the following six symptoms (only one for children)
1
mnemonic - BE SKIM
1
Blank mind, difficulty concentrating
2
Easy fatigability
3
Sleep disturbance
4
Keyed up, on edge or restless feeling
5
Irritability
6
Muscle tension
4 significant impairment in social, occupational, or other areas of functioning
5 not due to a GMC or substance use
Treatment
1 psychotherapy, relaxation, and CBT
2 caffeine and EtOH avoidance, sleep hygiene
3 pharmacotherapy
1
venlafaxine (Effexor)

2
3
4
5

benzodiazepines (alprazolam)
buspirone
others: SSRIs, TCAs, beta blockers
combinations of above

PS12 Psychiatry

MCCQE 2002 Review Notes

ANXIETY DISORDERS . . . CONT.

Prognosis
1 chronically anxious adults become less so with age
2 depends on pre-morbid personality functioning, stability of
relationships, work, and severity of environmental stress

PHOBIC DISORDERS
Specific Phobia
1 marked and persistent fear cued by presence or anticipation of a specific object or situation
2 types:
animal,
natural
environment
(heights,
storms),
blood/injection/injury, situational (airplane, closed spaces), other (loud noise,
clowns)
Social Phobia
1 marked and persistent fear of social or performance situations in which person is exposed to
unfamiliar people or to possible scrutiny by others; person fears he / she will act in a way (or show
anxiety symptoms) that may be humiliating or embarrassing (e.g. public speaking)
2 6-month prevalence: 2-3%; lifetime prevalence: may be as high as 13-16%
Diagnosis
1 exposure to stimulus almost invariably provokes an immediate anxiety response; may take
form of panic attack
2 person recognizes fear as excessive or unreasonable
3 situations are avoided or endured with anxiety/distress
4 significant interference with daily routine, occupational/social functioning, or there is marked distress
5 if person is < 18 years, duration is at least 6 months
Treatment
1 specific phobia
1
exposure therapy/desensitization
2
beta blockers or benzodiazepines in emergencies
2 social phobia
1
CBT - exposure therapy
3 pharmacotherapy
1
SSRIs
2
MAOIs
3
benzodiazepines (short-acting)
4
beta-blockers for performance-type
4 insight oriented psychotherapy
Prognosis
chronic

OBSESSIVE-COMPULSIVE DISORDER (OCD)

Epidemiology
1 lifetime prevalence rates 2-3%
2 MZ twins = 75%, DZ = 32%
Diagnosis
1. either obsessions, compulsions, or both are present
1. obsessions
1
recurrent and persistent thoughts, impulses, or images that are
intrusive, inappropriate, and cause marked anxiety and distress
2
not simply excessive worry about real life problems
3
attempts made to ignore/neutralize/suppress obsession with other thoughts or actions
4
patient aware obsessions originate from own mind
2. compulsions
1
drive to perform repetitive behaviours (hand washing, ordering, checking) or
mental acts (praying, counting, word repetition) in response to obsession or in keeping
with rigidly applied rules
2
carried out with the goal of reducing distress or preventing dreaded event/situation,
although there is no realistic connection between compulsion and anticipated outcome
2. recognition that obsessions or compulsions are excessive or unreasonable
3. obsessions or compulsions cause distress, are time-consuming, or interfere with normal functioning
4. not due to GMC/substance use
Treatment
1 CBT - desensitization, flooding, thought stopping, implosion therapy, aversive conditioning
2 medications - clomipramine, SSRIs (higher doses and longer treatment needed, i.e. up to 8-12 weeks)

Prognosis
tends to be refractory and chronic
MCCQE 2002 Review Notes

Psychiatry PS13

ANXIETY DISORDERS . . . CONT.

a

POSTi
TRAUMA s
u
TIC
s
STRESS u
DISORDE al
R (PTSD) ly
Epidemiolog r
a
y
p
1
lifeti e
me
prevalence: o
r
1-3%
a
2
s
m
s
e
a
n
u

l
s
t
t
r
Diagnosis
a
u
1. exposed to a traumatic
m
event in which person
a
experienced, witnessed, or
was confronted with a
i
situation that involved
s
death or serious injury to
self or others
m
2. response involved intense
o
fear, helplessness,
or
s
horror
t
3. traumatic
event
is
c
persistently
reexperienced through one
o
or more of the following
m
m
1 recurrent,
o
distressing
n
recollections
l
(images,
thoughts)
y
2
recurrent,
c
distressing
o
dreams
m
3
acting
or
b
feeling as if
a
event
is
t
recurring
(flashbacks,
e
illusions,
x
hallucinations
p
)
e
4 distress at
r
exposure to
i
cues
that
e
resemble
n
event
c
e
5 physiologic
al reactivity
;
in response
to cues
w
o
4. three of the
m
following:
e
feelings of
detachment
n
(emotional

numbing),
s
anhedonia,
amnesia,
t
restricted affect,
r
avoidance of
a
thoughts or
u
activities that
m
may be a

re
F.
m
symptoms
in
present
d
for > 1
er
month
o
f
Complications
th
substance abuse,
e
relationship difficulties
e
v
e
Treatment
nt
CBT
(systematic
5. persistent 1
symptoms
desensitization, relaxation
of
techniques,
thought
increased
stopping)
arousal
(two
or
pharmacotherapy
more
of: 2
1
SSRIs
insomnia,
irritability,
2
benzodiaze
pines (for acute
d
anxiety)
i
f
3
lithium
f
i
ANXIETY
c
u
DISORDERS DUE
l
t
TO A
y
GENERAL
c
o
MEDICAL
n
CONDITION (GMC)
c
e
n
Diagnosis
t
1
m
r
ay
a
t
include
i
promin
n
ent
g
general
,
ized
anxiety
h
y
sympto
p
ms,
e
panic
r
attacks
v
,
i
obsessi
g
ons, or
i
l
compu
a
lsions
n
c
Differential
e
,
1
e
e
n
x
d
a
o
g
g
c
e
r
r
i
a
n
t
e
e
:
d
s
t
a
r
t
l
e
r
e
s
p
o
n
s
e
)

h
y
p
e
r
o
r
h
y
p
o
t

h
y
r
o
i
d
i
s
m
,
p
h
e
o
c
h
r
o
m
o
c
y
t
o
m
a
,
h
y
p
o
g
l
y
c
e
m
i
a
,

h
y
p
e
r
a
d
r
e
n
a
l
i
s
m

CVS:
congestive
heart failure, pulmonary
embolus,
arrhythmia,
mitral valve prolapse
3
respiratory: COPD,
pneumonia,
hyperventilation
4
metabolic: vitamin
B12 deficiency, porphyria
5
neurologic:
neoplasm,
vestibular
dysfunction, encephalitis
6
different
iate from
substanceinduced
anxiety
disorder:
drugs of abuse
(caffeine,
amphetamine,
cocaine),
medications
(benzodiazepi
ne
withdrawal),
toxins (EtOH
withdrawal)

PS14 Psychiatry
MCCQE
2002 Review Notes

ADJUSTMENT DISORDER
Diagnosis
1. emotional/behavioural symptoms in response to an identifiable stressor(s) occurring within 3 months of
the onset of the stressor(s)
2. symptoms/behaviours are either
1.
marked distress in excess of what would be expected from exposure to stressor or
2.
significant impairment in social/occupational (academic) functioning
3. disturbance does not meet criteria for another specific Axis I disorder, and is not merely an exacerbation
of a preexisting Axis I or Axis II disorder
4. symptoms do not represent bereavement
5. once the stressor (or its consequence) has terminated, the symptoms do not persist for more than
an additional 6 months
Types of Stressors
1
single (termination of romantic relationship)
2
multiple (marked business difficulties and marital problems)
3
recurrent (seasonal business crises)
4
continuous (living in crime-ridden neighbourhood)
5
developmental events (going to school, leaving parental home, getting married, becoming a
parent, failing to attain occupational goals, retirement)
Subtypes
1
adjustment disorder with: depressed mood, anxiety, mixed anxiety and depressed mood,
disturbance of conduct, mixed disturbance of emotions and conduct, unspecified
2
NB: the specific stressor is specified on Axis IV
Treatment
1
brief psychotherapy (group, individual)
2
crisis intervention
3
medications (e.g. benzodiazepines may be used for those with anxiety symptoms; SSRIs for both
depressed and anxiety symptoms)

COGNITIVE DISORDERS
DELIRIUM
Diagnostic Criteria
1. disturbance of consciousness (i.e. reduced clarity of awareness of the environment) with reduced
ability to focus, sustain or shift attention
2. a change in cognition (i.e. memory deficit, disorientation, language disturbance) or development of a
perceptual disturbance not better accounted for by a preexisting, established, or evolving dementia
3. disturbance develops over short period of time (hours-days) and tends to fluctuate over the course of the day
4. there is evidence from the history, physical examination or laboratory findings that the disturbance
is due to a physiological consequence of a GMC, substance intoxication/withdrawal, medication
use, toxin exposure, or a combination
Clinical Presentation and Assessment
1
risk factors
1
hospitalization (incidence 10-40%)
2
nursing home residents (incidence 60%)
3
childhood (i.e. febrile illness, anticholinergic use)
4
old age (especially males)
5
severe illness (i.e. cancer, AIDS)
6
pre-existing cognitive impairment or brain pathology
7
recent anesthesia
8
substance abusers
2
common symptoms
1
wandering attention
2
distractable
3
disorientation (time, place, rarely person)
4
misinterpretations, illusions, hallucinations
5
speech/language disturbances (dysarthria, dysnomia, dysgraphia)
6
affective symptoms (anxiety, fear, depression, irritability, anger, euphoria, apathy)
7
shifts in psychomotor activity (groping/picking at clothes, attempts to get out of bed
when unsafe, sudden movements, sluggishness, lethargy)
3
Folstein exam is helpful to assess baseline of altered mental state i.e. score will

improve as symptoms resolve

MCCQE 2002 Review Notes

Psychiatry PS15

COGNITIVE DISORDERS . . . CONT.

Differential
for Delirium
1
I
Infectious
(encephalit
is,
meningitis,
UTI,
pneumonia
)
W
Withdrawa
l (alcohol,
barbiturate
s,
benzodiaze
pines)
A
A
c
u
t
e
m
e
t
a
b
o
l
i
c
d
i
s
o
r
d
e
r
(
e
l
e
c
t
r
o
l
y
t
e
i
m
b
a
l
a
n
c
e
,
h
e
p
a
t
i
c
o
r
r
e
n
a
l

f
a
i
l
u
r
e
)
T
T
r
a
u
m
a
(
h
e
a
d
i
n
j
u
r
y
,
p
o
s
t
o
p
e
r
a
t
i
v
e
)
C
C
N
S
pa
th
ol
og
y
(st
ro
ke
,
he
m
or
rh
ag
e,
tu
m
ou
r,
se
iz
ur
e
di
so
rd
er,
Pa
rk
in
so
n
s)
H
H
yp
ox
ia
(a
ne
m
ia,
ca
rd
ia
c
fa

i
l
u
r
e
,
p
u
l
m
o
n
a
r
y
e
m
b
o
l
u
s
)

anesthetic
s,
anticholin
ergics,
narcotics)
H - Heavy
metals
(arsenic,
lead,
mercury)

Note:
can
use
alternative
classification:
intracranial, extracranial, drug
use, and drug withdrawal

Investigations
1
standard: CBC +
diff, lytes, calcium,
phosphate, magnesium,
glucose, ESR, LFTs
(AST,
ALT,
ALP,
albumin,
bilirubin),
D
- RFTs
(Cr,
BUN),
Deficiencie urinalysis, ECG
TSH,
s (vitamin 2CT as indicated: head,
toxicology/heavy
metal
B12, folic screen, VDRL, LP, LE
preparation, B12 and
acid,
folic acid levels, EEG
thiamine)
(typically
abnormal:
slowing or
E
- generalized
fast activity)
Endocrino
3
indications
for
pathies
radiological
intervention:
(thyroid,
glucose,
focal neurological deficit,
parathyroid acute change in status,
, adrenal)
anticoagulant use, early
gait
A - Acute incontinence,
abnormality, history of
vascular
cancer
(shock,
vasculitis,
hypertensi Management
ve
identify
and
treat
encephalop 1
athy)
underlying cause immediately
T
2
stop all non-essential
medications
3
maintain
nutrition,
T
hydration, electrolyte balance
and monitor vitals
o
x
4
environment should be
i
quiet and well-lit
n
5
optimize hearing and
s
vision
,
6
room near nursing station
s
for closer observation; constant
u
care if patient jumping out of
b
bed, pulling out lines
s
7
family member present
t
for reassurance and rea
orientation
n
c
8
calendar, clock for
orientation cues
e
9
pharmacological

u
haloperidol
(low
dose),
s
lorazepam; physical restraints
e
if patient becomes violent
,
10 up to 50% 1 year
mortality rate after episode of
m
delirium
e
d
i
DEMENTIA
c
a
Epidemiology
t
i
1
prevalence
increases
o
with age: 10% in patients
n
over 65 years; 25% in patients
(
over 85
a
l
2
prevalence is increased
c
in people with Down
o
syndrome
and head trauma
h
3
Alzheimers
dementia
o
comprises > 50% of cases;
l
vascular causes comprise
,

approximat
ely 15% of
cases
4
10%
of
dementia
cases
potentially
curable
Diagnosis
(for
Dementia of
Alzheimers
Type)
1. developme
nt
of
multiple
cognitive
deficits
manifested
by both

1
m

e
m
o
r
y
i
m
p
a
i
r
m
e
n
t
(
i
m
p
a
i
r
e
d
a
b
i
l
i
t
y
t
o
l
e
a
r
n
n
e
w
i
n
f
o
r
m
a
t
i
o
n
o
r
t
o
r
e

call previously
learned
information)
2
one or more of
the following cognitive
disturbances
1 aphasia
(language
disturbance)
2 apraxia
(impaired ability
to carry out
motor activities
despite
intact
motor function)
3 agnosia (failure
to recognize or
identify objects
despite
intact
sensory
function)

4
d
i
s
t
u
r
b
a
n
c
e
i
n
e
x
e
c
u
t
i
v
e
f
u
n
c
t
i
o
n
(
i
.
e
.
p
l
a
n
n
i
n
g
,
o
r
g
a
n
i
z
i
n
g
,
s
e
q
u
e
n
c
i
n
g

, nt decline from prior

functioning
a3. course
characterized
by
b gradual onset
and continuing
s cognitive decline
t
r4. cognitive deficits are not due
a to CNS conditions, systemic
c conditions, substance-induced
t conditions
do
not
occur
t5. deficits
during course of
h exclusively
i delirium
n6. disturbance is not better
k accounted for by another Axis
i I disorder (e.g. MDE,
n schizophrenia)
g
)Subtypes
with
or
without
2. cognitive 1behavioural
disturbance
(i.e.
deficits
wandering, agitation)
significa
ntly
2
early onset: age of onset
impair
< 65 years
social/oc
cupation 3
late onset: age of onset
al
> 65 years
functioni
ng and Other Causes of Dementia (see
are
a
significa Neurology Chapter)
MCCQE
2002 Review Notes
PS16 Psychiatry

COGNITIVE DISORDERS . . . CONT.

Investigations (rule out reversible causes)
1 standard: as above in Delirium section
2 as indicated: TSH, VDRL, B12, folic acid, albumin, SPECT, CT head in dementia
3 indications for CT head: as above in Delirium section plus: age < 60, rapid onset (unexplained
decline in cognition of function over 1-2 months), dementia of relatively short duration (< 2 years),
recent significant head trauma, unexplained neurological symptoms (new onset of severe
headache/seizures)
Management
1 treat medical problems and prevent others
2 provide orientation cues (e.g. clock, calendar)
3 provide education and support for patient and family (day programs, respite care, support groups, home care)
4 consider long term care plan (nursing home) and power of attorney/living will
5 inform Ministry of Transportation about patients inability to drive safely
6 consider pharmacological therapy
1
low-dose neuroleptics (haloperidol) and antidepressants (if behavioural or emotional
symptoms prominent); start low and go slow
2
anti-cholinesterase inhibitors (e.g. donepezil (Aricept))
3
some evidence supports Vitamin E, NSAIDS, estrogen (controversial)
4
reassess pharmacological therapy every 3 months

Table 1. Comparison of Dementia, Delirium and Pseudodementia of Depression

Dementia

Delirium

Depression

Onset

Gradual or step-wise decline

Acute (hours - days)

Subacute

Duration

Months-years

Days-weeks

Variable

Natural History

Progressive
Usually irreversible

Fluctuating, reversible
High morbidity/mortality in very old

Recurrent
Usually reversible

Level of
Consciousness

Normal

Fluctuating (over 24 hours)

Normal

Attention

Not initially affected

Decreased
(wandering, easy distraction)

Difficulty concentrating

Orientation

Intact initially

Impaired (usually to time and place),

fluctuates

Intact

Behaviour

Disinhibition, catastrophic
reaction impairment in ADL,
IADL, personality change,
loss of social graces

Severe agitation/retardation

Importuning,
self-harm/suicide

Psychomotor

Normal

Fluctuates between extremes

Slowing

Sleep Wake Cycle

Fragmented sleep at night

Reversed sleep wake cycle

Early morning awakening

Mood and Affect

Labile but not usually anxious

Anxious, irritable, fluctuating

Depressed, stable

Cognition

Decreased executive
functioning, paucity of thought

Fluctuating preceded by
mood changes

Fluctuating

Delusions

Compensatory

Nightmarish and poorly formed

Nihilistic, somatic

Memory Loss

Recent, eventually remote

Marked recent

Recent

Language

Agnosia, aphasia, decreased

comprehension, repetition,
speech: echolalia, palilalia

Dysnomia, dysgraphia,
speech: rambling, irrelevant,
incoherent, subject changes

Not affected

Hallucinations

Variable

Visual common

Less common, auditory

predominates

Quality of
Hallucinations

Vacuous/bland

Frightening/bizarre

Self-deprecatory

Medical Status

Variable

Acute illness, drug toxicity

R/O systemic illness, meds

MCCQE 2002 Review Notes

Psychiatry PS17

SUBSTANCE-RELATED DISORDERS
Types of Substance
Disorders
1. substance-use disorders
1. substance
dependence:
maladaptive pattern
of substance use
interfering
with
function; at least
three
of
the
following in 12
month period
1 tolerance
2 withdrawal/
use to avoid
withdrawal
3 taken
in
larger
amount
or
over longer
period than
intended
4 persistent
desire
or
unsuccessful
efforts to cut
down
5 excessive
time
to
procure, use
substance, or
recover from
its effects
6 important
interests/acti
vities given
up
or
reduced

7
c

o
n
t
i
n
u
e
d
u
s
e
d
e
s
p
i
t
e
p
h
y
s
i
c
a
l
/
p
s
y
c
h
o
l
o
g
i
c
a
l
p
r
o
b
l
e
m
c
a

u
s
e
d
/
e
x
a
c
e
r
b
a
t
e
d
b
y
s
u
b
s
t
a
n
c
e

2. substance

abuse:
maladapti
ve pattern
of
substance
use
interfering
with
function;
at
least
one of the
following
in
12
month
period
1 recurrent use resulting
in failure to fulfil major
role obligation
2 recurrent
use
in
situations in which it is
physically
hazardous
(i.e. driving)
3 recurrent substancerelated legal problems
4 continued use despite
interference with social
or interpersonal function
2. substance-induced disorders
1. substanc
e
intoxific
ation:
reversibl
e
physiolo
gical and
behaviou
ral
changes
due to
recent
exposure
to
psychoa
ctive
substanc
e

2. substanc

e
withdraw
al:
substanc
e specific
syndrom
e that
develops
followin
g
cessation
of or
reduction
in dosage
of
regularly
used
substanc

e
s
Classification of
Substances
1
mnemonic

CHEAP COCAINE
1
Cocaine
2
Hallucinoge
ns
3
Ethanol
4
Amphetami
nes,
sympathomimetics
5
Phencyclidi
ne (PCP)
6
Caffeine
7
Opioids
8
Cannabis
9
Anxiolytics/
hypnotics/sedatives
10
Inhalants
11
Nicotine
12
Ecstasy,
gamma
hydroybutyrate,
ketamine
(new
designer drugs)

ALCOHOL

r
f
e
e
l
G
u
i
l
t
y
a
b
o
u
t
y
o
u
r
d
r
i
n
k
i
n
g
E - ever need a drink first thing in
morning (Eye opener)
1
2 yes responses out
of 4 is considered positive for
an alcohol problem

History

screening

C - ever felt need to Cut

down on drinking
A
e
v
e
r
2
f
ask
e
l
H
t
A
n
d
n
o
o
y
y
e
o
d
u
a
e
t
v
e
c
r
r
i
d
t
r
i
i
c
n
i
k
s
m
t
o
o
f
g
e
y
t
o
u
H
r
i
g
d
h
r
i
A
n
k
i
n
d
g
o
G
y
o
u
e
e
v
v
e
e

if
positive
CAGE then
assess
further to
determine
if problem
drinker or
alcohol
dependence
(see
mnemonic
below)

other important questions to

r
d
r
i
n
k
A
l
o
n
e

L
d
o
y
o
u
e
v
e
r
L
o
o
k
f
o
r
w
a
r
d
t
o
d
r
i
n
k
i
n
g
T
a
r
e
y
o
u
T
o
l
e
r
a
n
t
t
o
a
l
c
o
h
o
l
B - have you ever had
Blackouts
U
d
o
y
o
u

e
v
e
r
u
s
e
E
t
O
H
i
n
a
n
U
n
p
l
a
n
n
e
d
w
a
y
M
d
o
y
o
u
e
v
e
r
u
s
e
E
t
O
H
f
o
r
M
e
d
i
c
i
n
a
l
r
e
a
s
o
n
s
P
d
o
y
o
u
t
e
n
d
t
o
P
r
o
t

e
c
t
y
o
u
r
E
t
O
H
s
u
p
p
l
y
F
a
n
y
F
a
m
i
l
y
h
i
s
t
o
r
y
o
f
E
t
O
H
p
r
o
b
l
e
m
s
A
e
v
e
r
b
e
e
n
a
m
e
m
b
e
r
o
f
A

A
T - do you Think you are an alcoholic

A
d
o
y
o
u
e
v
e
r
t
h
i
n
k
a
b
o
u
t
A
t
t
e
m
p
t
i
n
g
s
u
i
c
i
d
e
L
a
n
y
L
e
g
a
l
p
r
o
b
l
e
m
s
r
e
l
a
t
e
d
t
o
E
t
O
H

D - do you ever drink and Drive

T - do you use Tranquilizers to
steady your nerves
MCCQE 2002
PS18 Psychiatry
Review Notes

SUBSTANCE-RELATED DISORDERS . . . CONT.

Table 2. Differentiating Problem Drinking from Alcohol Dependence
Problem Drinker

Alcohol Dependent

Withdrawal Symptoms

No

Often

Tolerance

Mild

Marked

Amount Consumed

> 14 per week

> 40-60 per week

Social / Physical / Legal Consequences

Nil or mild

Often severe

Neglect of Major Responsibilities

No

Yes

Alcohol Intoxication
1 clinical effects seen when blood alcohol level is above 30 mmol/L (150 mg/dL)
2 above 50 mmol/L (250 mg/dL), coma usually ensues, but depends on level of tolerance
Alcohol Withdrawal
within 12 to 48 hours after prolonged heavy drinking

Table 3. Signs and Symptoms of Alcohol Withdrawal

Autonomic Symptoms

Sleep Disturbance

Gastrointestinal

Tachycardia
Hypertension
Diaphoresis
Tremor
Fever
Respiratory distress

Sleep latency insomnia

Increased REM sleep
Decreased deep sleep

Anorexia
Nausea
Vomiting

Neurological
Generalized tonic clonic seizures
Restlessness

Psychological
Agitation
Anxiety
Irritability
Distractibility
Poor concentration
Impaired memory
Impaired judgment
Hallucinosis

Delirium Tremens (DTs)

1 within 2-10 days after cessation of alcohol
2 characterized by
1 symptoms of delirium
2 autonomic hyperactivity
3 perceptual distortions (visual or tactile hallucinations)
4 fluctuating levels of psychomotor activity
3 course: in young almost completely reversible; elderly often left with cognitive deficits
4 mortality rate 20% if untreated
5 treatment: chlordiazepoxide or lorazepam, plus supportive environment, +/ haloperidol
Management of Alcohol Withdrawal
1 basic protocol
1 diazepam 20 mg PO q1-2h until symptoms abate; tapering dose not required after load
2 observe for 1-2 h after last dose
3 thiamine 100 mg IM then 100 mg PO for 3 days
4 supportive care (hydration and nutrition)
2 if history of withdrawal seizures
1 diazepam 20 mg q1h for minimum of three doses
3 if oral diazepam not tolerated
1 diazepam 2-5 mg IV/min - maximum 10-20 mg q1h; or lorazepam SL
4 if severe liver disease, severe asthma or respiratory failure present
1 lorazepam SL, PO 1-2 mg tid-qid; or oxazepam 15-30 mg PO tid-qid
5 if hallucinosis present
1 haloperidol 2-5 mg IM/PO q1-4h - max 5/day
2 diazepam 20 mg x 3 doses as seizure
prophylaxis (haloperidol lowers seizure threshold)
6 admit to hospital if
1 still in withdrawal after > 80 mg of diazepam

2
3

delirium tremens, recurrent arrhythmias, or multiple seizures

medically ill
MCCQE 2002 Review Notes

Psychiatry PS19

SUBSTANCE-RELATED DISORDERS . . . CONT.

ular
Wernicke-Korsakoff
dysfunction,
delirium
Syndrome
4
Korsakoffs
1
alcohol-induced (chronic, only 20%
amnestic
disorders recover with treatment):
short-term
due
to
thiamine marked
memory loss, difficulty
deficiency
in
learning
new
anterograde
2
necrotic lesions - information,
mammillary
bodies, amnesia, confabulations
thalamus, brain stem 5
management
3
1
Wernickes: thiamine
We
100 mg PO od X 1-2 weeks
r
2
Korsakoffs: thiamine
n
100 mg PO bid/tid X 3-12
i
months
c
k
Treatment
of Alcohol Dependence
e

1
d
s
isulfira
(
m
a
(Antab
c
use):
u
blocks
t
normal
e
,
oxidati
r
on of
e
EtOH;
v
acetald
e
ehyde
r
s
accumu
i
lates
b
causing
l
tachyca
e
rdia,
)
:
vomitin
o
g; use
c
125u
250
l
mg/day
a
r
2
n
(
altrex
n
one:
y
opioid
s
antago
t
nist,
a
shown
g
to be
m
succes
u
sful in
s
reduci
,
ng the
6
high
t
obtain
h
ed
from
n
alcoho
e
l
r
v
3
SSRI, buspirone, Li, trazodone,
e
bromocriptine studied
4
be
p
haviour
a
modific
l
ation:
s
hypnosi
y
s,
,
relaxati
g
on
a
training,
z
aversion
e
therapy,
assertiv
p
eness
a
training,
l
operant
s
conditio
y
ning
)
,
5
supportive services: half-way
a
houses,
detoxification
centres,
t
Alcoholics Anonymous
a
6
psychotherapy
x
i
OPIOIDS
a
,
1
drugs in this category range
v
e
from heroin and morphine to
s
nonsteroidal prescription analgesics
t
i
2
major danger associated with
b
the use of contaminated needles;

increased risk of ce
hepatitis B and C, pt
bacterial
io
endocarditis, HIV
n,
se
Acute Intoxification
da
1
ti
o
d
n,
i
de
r
cr
e
ea
c
se
t
d
se
e
x
f
dr
f
iv
e
e
c
t
2
decreased
GI
motility
(constipation and anorexia)
o
3
respiratory depression
n
Toxic Reaction
r
1
e
typical
c
synd
e
rome
p
inclu
t
des
o
shall
r
ow
s
respi
ratio
i
ns,
n
mios
is,
C
brad
N
ycar
dia,
S
hypo
ther
r
mia,
e
decre
s
ased
u
level
l
of
t
cons
i
cious
n
ness
g
2
treatment: ABCs; IV glucose;
naloxone hydrochloride (Narcan):
i
0.4
n
mg
up
n
to 2
a
mg
u
IV
and
s
repe
e
at
a
as
/
nee
v
ded
o
ever
y 2
m
to 3
i
min
t
utes
i
to
n
cou
g
nter
resp
,
irat
ory
d
dep
e
ress
c
ion;
r
may
wea
e
r off
a
in
s
30
e
to
d
120
min
utes
p
;
a
ther
i
efor
n
e,
nee
p
d to
mo
e
nito
r

r
c
a
r
e
f
u
l
l
y
f
o
r
u
p
t
o
4
8
h
o
u
r
s

autonomic
signs
of
withdrawal
Treatment of Chronic Abuse
1
psychosocial treatment (e.g.
Narcotics Anonymous); usually
emphasize total abstinence
2
long term treatment may also
include maintainance on methadone
(a synthetic long-acting opioid that
produces
less
euphoria
than
morphine)
3
naltrexone or naloxone (opioid
antagonists) may also be used to
extinguish drug-seeking behaviour

COCAINE
1

alkaloid extracted from leaves

of the coca plant; potentiates the
actions of catecholamines
2
self-administered
by
inhalation or intravenous route
Intoxification

charact
Opioid Withdrawal
erize
1
increased
d by
sympathetic nervous elati
system activity plus on,
nausea,
vomiting, euph
oria,
diarrhea
pres
2
may
include sure
myalgias
and d
arthralgias,
restlessness, anxiety, spee
intense craving for ch,
opioid
restl
essn
3
treatment
ess;
1
sym
detox
path
ific
etic
ati
on
stim
per
ulati
for
on
me
inclu
d
ding
by
retach
ad
ycar
mi
dia,
nis
myd
teri
riasi
ng
an
s,
opi
swea
oid
ting
(m
eth
2
prolonged use may result in
ad
paranoia and psychosis
on
e
Overdose
oft
en
1
med
use
ical
d)
emergenc
unt
y; cocaine
il
toxicity
wit
hdr
produces
aw
hypertensi
al
on,
sy
tachycardi
mp
a, tonicto
ms
clonic
cea
seizures,
se
dyspnea,
the
and
n
ventricula
de
cre
r
asi
arrhythmi
ng
as
the
do
2
treat
se
ment with
of
IV
opi
diazepam
oid
to control
seizures
2
clonidi
ne:
for and
propanolol
alleviating
to manage

h
y
p
e
r
m
e
t
a
b
o
l
i
c

state and
arrhythmia
s
Treatment of Chronic Abuse
1
optimal
treatment
established

not

psychotherapy, group therapy,

and behaviour modification useful in
maintaining abstinence

studies of dopamine agonists

to block cravings show inconsistent
results
MCCQE 2002
PS20 Psychiatry
Review Notes

SUBSTANCE-RELATED DISORDERS . . . CONT.

and MDMA (ecstasy - see
below)
2
LSD is a
1
psychoactive
potent
substance
delta-9- highly
drug;
tetrahydrocannabinol
intoxification
produces
(THC)
tachycardia,
2
smoking is most hypertension,
common mode of self- mydriasis,
tremor,
administration
hyperpyrexia,
3
intoxification
and a variety
characterised by
of perceptual
tachycardia, muscle
and
mood
relaxation, euphoria,
changes
general sense of well3
treat
being; impaired
ment of
performance on
agitation
psychomotor tasks
and
including driving
psychosis
4
high doses can : support,
cause depersonalisation, reassuran
ce,
paranoia, and anxiety
5
chronic
use diminishe
associated with tolerance dstimulatio
and
an
apathetic, n;
amotivational state
benzodiaz
6
cessation does not epines or
produce
significant high
withdrawal phenomenon potency
antipsych
7
tre
otics
atment
seldom
of
required
depende
4
high doses can cause
nce
depersonalisation, paranoia, and
includes
anxiety
behavio
ural and
PHENCYCLIDINE
(PCP)
psychol
ogical
1
PCP, angel dust
interven
tions to
2
widely
maintai
used
in
n
veterinary
abstinen
medicine
to
t state
immobilize
large animals;
AMPHETAMINES
mechanism of
action not well
1
class of drugs understood
structurally related to3
taken
orally,
smoked,
or
IV;
catecholamine
produces amnestic,
neurotransmitters
euphoric,
hallucinatory state;
2
intoxificatio
horizontal/vertical
n
produces
nystagmus,
euphoria,
myoclonus, ataxia,
improved
and
autonomic
concentration,
instability common
sympathetic, and
behavioural
4
effects
hyperactivity
unpredictable
and
often
include
3
chronic
prolonged
agitated
use can
psychosis; individuals
produce a
at high risk for suicide
paranoid
or violence towards
psychosis
others
diagnosticall
y similar to
5
treatment of toxic
schizophreni
reaction:
room
with
a with
minimal
stimulation;
agitation,
diazepam IV for muscle
paranoia,
spasm/seizures;
delusions
haloperidol to suppress
and
psychotic behaviour
hallucination
s;
NEW DRUGS OF ABUSE
antipsychotic
s useful in
MDMA ("Ecstasy", "X", "E")
treatment of
stimulant
1
has
psychosis
properties of
4
withdrawal
symptoms
include a
dysphoria, fatigue, and hallucinogen
and
an
restlessness
amphetamine
HALLUCINOGENS ; acts on
serotonergic
1
includes
LSD, and
mescaline, psilocybin, dopaminergi

CANNABIS

c
path
ways

releases opiate-like substance

2
purported euphoric effects,
increased
aggression
and
impaired judgment
2
enhances
sensorium;
increased
adverse
feelings of well-being3effects:
and empathy
nystagmus,
ataxia,
3
amnesia,
advers
apnea
with
e
sudden
effe
awakening and
cts:
violence,
swe
bradycardia
atin
g,
4
one of several "date rape"
tach
drugs; consider in amnestic
ycar
sexual assault victim
dia,
fatig
Ketamine
("Special K", "Kitue,
mus
Kat")
cle
spas
1
an anaesthetic still in use to
ms
sedate
children
for
short
(esp
ecia
procedures
lly
2
NMDA receptor antagonist
jaw
clen
3
rapidchin
acting; produces
g),
"dissociative"
atax
state
with
ia
profound
4
severe
amnesia
and
complications:
analgesia;
also
unpredictable,
not hallucinations
necessarily
dose- and
dependent
sympathomimeti
c effects
5
hyperthermia,
arrhythmias,
DIC,4
strong
rhabdomyolysis, renal potential
for
failure, seizures, death
psychologic
al
distress
or
6
animal
studies
suggest
long-term accidents
to
neurotoxicity
to due
intensity of
serotonergic system
experience
lack of
Gamma Hydroxybutyrate and
bodily
control
(GHB, "G", "Liquid
5
may be packaged to look
Ecstasy")
like Ecstasy
1
produces biphasic6
toxicity: decreased LOC,
dopamine response and respiratory depression, catatonia
Review Notes
Psychiatry
MCCQE 2002
PS21

SUICIDE
Epidemiology
1 attempted:complete = 120:1
2 M:F = 3:1 for completed; 1:4 for attempts
Risk Factors and Clinical Presentation
risk factors: see Table 4
Table 4. Risk Factors Associated with Completed Suicide
Epidemiologic Factors

Psychiatric Disorders

Past History

Incidence increases with

age > 14 years
2nd cause of death in age 15-24 years

Mood disorders (15% lifetime risk in

depression; higher in bipolar)
Substance abuse (especially alcohol
- 15% lifetime risk)
Schizophrenia (10-15%)
Personality disorder- borderline, antisocial
Eating disorders - 5% lifetime risk
Adjustment, conduct, and anxiety
disorders (especially panic disorder)
Adolescents: impulsive, aggressive and
antisocial behavior; family violence

Prior suicide attempt

Age > 65 years

Male, white
Widowed/divorced
Lives alone; no children < 18 years
in the household
Stressful life events

Family history of suicide attempt

Access to firearms
Native Canadians on
reserves 2-3x increased risk
Adapted from: Gliatto MF, Rai AK. Evaluation and Treatment of Patients With Suicidal Intention. American Family Physician, Volume 59, Number 6, 1999 pp. 1500-14.

1 symptoms associated with suicide

1
hopelessness
2
anhedonia
3
insomnia
4
severe anxiety
5
impaired concentration
6
psychomotor agitation
7
panic attacks
2

SAD PERSONS scale for assessment and management of suicidal

ideation Sex-male
Age > 60 years
old Depression
Previous attempts
Ethanol abuse
Rational
thinking
loss
(delusion,
hallucination,
hopelessness) Suicide in family
Organized plan
No spouse (no support systems)
Serious illness, intractable pain
1
Score (total number of risk factors present):
0-2
consider sending home with family
3-4
close follow up, consider hospitalization
5-6
strongly consider hospitalization
7-10
hospitalize
Approach
1 assessment of suicidal ideation
1
Onset of suicidal thoughts? Stressors precipitating suicidal thoughts?
2
Frequency of suicidal thoughts? Feelings of being a burden? Or that life isn't worth living?
3
What makes them feel better (e.g. contact with family, use of substances)?
4
What makes them feel worse (e.g. being alone)?
5
How much control of suicidal ideas do they have? Can they suppress them or call someone for
help?
6
What keeps them alive? Stops them from killing themselves (e.g. family, religious beliefs)?
2 assessment of lethality
1
Is there a plan to end their life?
2
Do they own a gun, have access to firearms or potentially harmful medications?
3
Have they imagined their funeral, and how people will react to their death?

4
5

Have they "practiced" the suicide? (e.g., put the gun to head or held medications in hand)?

Have they changed their will or life insurance policy or given away possessions?
PS22 Psychiatry
MCCQE 2002 Review Notes

SUICIDE . . . CONT.
1

if an attempt was made

Planned or impulsive attempt? Triggers for attempt (stressors)?
Lethality of attempt? Chance of discovery? Reaction to being saved (intent)?
2
MSE - may reveal psychiatric disorder (e.g. depression),
perception disturbance (e.g. command hallucination), poor insight and
judgement

Clinical Pearls
1
Asking patients about suicide will not give them the idea or the incentive to commit suicide.
2
The best predictor of completed suicide is a history of attempted suicide.
3
The most common psychiatric disorders associated with completed suicide are major
depression and alcohol abuse.
Management
1
do not leave patient alone; remove potentially dangerous objects from room
2
patients with a plan, access to lethal means, recent social stressors, and
symptoms suggestive of a psychiatric disorder should be hospitalized immediately
3
if patients refuses to be hospitalized, form if criteria are met
4
depression: if severe, hospitalize; otherwise outpatient treatment with good supports and
SSRIs (fluoxetine, sertraline, paroxetine, fluvoxamine, venlafaxine, and nefazodone)
5
alcohol related: usually resolves with abstinence for a few days; if not, suspect depression
6
personality disorders: crisis intervention/confrontation
7
schizophrenia/psychotic: hospitalization
8
parasuicides/self mutilation: long term psychotherapy with brief crisis intervention when necessary
Clinical Pearls

Once antidepressant therapy is initiated, patients should be followed frequently as

there is a suicide window in which the patient may still be depressed, but has enough
energy to carry out suicide.
2
Avoid Tricyclicantidepressants (TCA) as high lethality in overdose!

SOMATOFORM DISORDERS
General Characteristics
1
physical signs and symptoms lacking a known medical basis in the presence of psychological
factors that are judged to be important in the initiation, exacerbation, or maintenance of the
disturbance
2
cause significant distress or impairment in functioning
3
symptoms are not the result of malingering or factitious disorder
4
types
1
conversion disorder
2
somatization disorder
3
somatoform pain disorder
4
hypochondriasis
5
body dysmorphic disorder

CONVERSION DISORDER
1

one or more symptoms or deficits affecting voluntary motor or

sensory function that suggest a neurological or general medical
condition

(e.g. impaired co-ordination, local paralysis, double vision)

1
psychological factors thought to be etiologically related to the
symptom as the initiation of symptoms is preceded by conflicts or other
stressors
2
primary gain: somatic symptom represents a symbolic resolution of
an unconscious psychological conflict; serves to reduce anxiety and
conflict
3
secondary gain: the sick role; external benefits obtained or unpleasant duties evaded (e.g. work)
4
La belle indifference - patients inappropriately cavalier attitude towards a serious symptom

SOMATIZATION DISORDER

recurring, multiple, clinically significant physical complaints

which result in patient seeking treatment or in impaired functioning

2
3

onset before age 30; extends over a period of years

at least eight physical symptoms that have no organic pathology
1
four pain symptoms
2
two gastrointestinal (GI) symptoms
3
one sexual symptom
4
one pseudo-neurological symptom
4
complications: anxiety, depression, unnecessary medications or surgery
5
often a misdiagnosis for an insidious illness so rule out all organic illnesses (e.g. multiple sclerosis
(MS))
MCCQE 2002 Review Notes
Psychiatry PS23

SOMATOFORM DISORDERS . . . CONT.

SOMATOFORM PAIN DISORDER
1
2

pain is primary symptom and is of sufficient severity to warrant medical attention

usually no organic pathology but when it exists reaction is excessive

HYPOCHONDRIASIS
1

preoccupation with fear of having, or the idea that one has, a serious disease based on a
misinterpretation of physical signs
2
evidence does not support diagnosis of a physical disorder
3
fear of having a disease despite medical reassurance
4
belief is not of delusional intensity (as in delusional disorder, somatic type) as person
acknowledges unrealistic interpretation
5
duration at least 6 months

BODY DYSMORPHIC DISORDER

1
2
3

preoccupation with imagined defect in appearance or excess concern around slight anomaly
usually related to face
may lead to avoidance of work or social situations

1
2
3
4
5
6
7

brief frequent visits

try to be patients only physician
focus on psychosocial not physical symptoms
biofeedback
psychotherapy - conflict resolution
minimize psychotropic drugs (anxiolytics in short term only; antidepressants for depressive symptoms)
minimize medical investigations; co-ordinate necessary investigations

MANAGEMENT OF SOMATOFORM DISORDERS

FACTITIOUS DISORDERS
1
2

not true somatoform disorders since symptoms are intentional

treatment: psychotherapy (conflict resolution)
Factitious Disorder
1
intentional production or feigning of physical or psychological signs or symptoms in order
to assume the sick role
2
external incentives (e.g. economic gain) are absent
Malingering
1
intentional production of false or grossly exaggerated physical or psychological symptoms
motivated by external rewards (e.g. drug-seeking, avoiding work, financial incentives)

DISSOCIATIVE DISORDERS
DISSOCIATIVE AMNESIA
1

diagnosis
inability to recall important personal information, usually of traumatic or stressful nature
symptoms cause distress or impaired functioning
rule out: DID, DF, PTSD, acute stress and somatization disorders, substances, medical
condition, homicidal ideation
treatment
1
memory recovery: barbiturates (e.g. thiopental, sodium amobarbital), benzodiazepines,
hypnosis
2
psychotherapy

1
2
3

DISSOCIATIVE FUGUE (DF)

1

2
3

diagnosis
sudden, unexpected travel away from home or work
inability to recall ones past and identity or assumptions of new identity
symptoms cause distress or impaired functioning
rule out: DID, substances, medical condition
usually brief with spontaneous recovery
treatment: similar to dissociative amnesia

1
2
3
4

DISSOCIATIVE IDENTITY DISORDER (DID)

1
2

formerly multiple personality disorder

diagnosis
1
two or more distinct personality states that recurrently take control of an individuals
behaviour

2
3
3
4

amnesia regarding personal history

rule out: substance abuse, medical conditions (e.g. complex partial seizures), imaginary
playmates in children

many patients report a history of sexual and/or physical abuse

treatment: insight-oriented psychotherapy, hypnosis, drug-assisted interviewing,

adjuvant antidepressants/anxiolytics/anticonvulsants
PS24 Psychiatry
MCCQE 2002 Review Notes

DISSOCIATIVE DISORDERS . . . CONT.

DEPERSONALIZATION DISORDER
1

diagnosis
1
persistent or recurrent experiences of feeling detached from
ones mental processes or body (i.e. feeling like one is in a dream)
2
normal reality testing
3
symptoms cause distress or impaired functioning
4
rule out: schizophrenia, panic disorder, acute
stress, other dissociative disorders, substances, medical
condition

SLEEP DISORDERS
Criteria for Diagnosis
1
causes significant distress or impairment in functioning
2
not due to medications, drugs, or a medical condition

PRIMARY INSOMNIA
1

difficulty initiating/maintaining sleep, or non-restorative sleep, for at least 1

month

psychophysiological (transient or persistent)

treatment - sleep hygiene, short-acting
benzodiazepines (for less than 1 month)
3
differential diagnosis: substance abuse, mood, anxiety or psychotic
disorders

SLEEP APNEA
1
2

night

most common cause of hypersomnolence in sleep disorder clinics

more than 30 episodes of apnea lasting greater than 10 seconds in one

types - central (decreased respiratory center output),

obstructive (upper airway obstruction), mixed
4
symptoms: loud snoring, thrashing of limbs in sleep,
excessive daytime sleepiness, hypertension, morning headache,
intellectual deterioration, decreased libido
5
aggravated by hypnotics and alcohol
6
treatment: continuous positive airway pressure (CPAP) via nose
mask, weight loss, respiratory stimulants (e.g. acetazolamide
[Diamox]); rarely surgical treatment (see Respirology Chapter)

NOCTURNAL MYOCLONUS
1
2
3
4

middle-age and elderly

myoclonic jerks every 20-40 seconds
bed partner complains
treatment: benzodiazepines (clonazepam, nitrazepam)

NARCOLEPSY
1

irresistible sleep attacks (up to 30 minutes) and

persistent day time drowsiness occurring daily for at least 3
months
2
cataplexy (sudden temporary episodes of paralysis with loss of muscle
tone)
3
sleep paralysis
4
hypnagogic/hypnopompic hallucinations
5
incidence 4:10,000 cases (more common than MS)
6
treatment: stimulants methylphenidate, D-amphetamine, TCAs, SSRIs

MCCQE 2002 Review Notes

Psychiatry PS25

SEXUALITY AND GENDER

NORMAL SEXUALITY
Table 5. The Sexual Response Cycle
Phase

Male Response

Female Response

Desire
Sexual fantasies and
the desire to have sex
Excitement
Increasing sexual
pleasure with
pre-orgasmic plateau
Orgasm
Peaking of sexual
pleasure

Resolution
Relaxation, sense of
well-being, reversal
of physiologic changes

Example of Dysfunction
Hypoactive sexual desire disorder
Sexual aversion disorder

Penile erection
Retraction of testes
Cowpers gland secretion

Clitoral enlargement
Vaginal lubrication
Breast engorgement

Male erectile disorder

Female sexual arousal disorder
(decreased lubrication)

Ejaculatory spurt
Rhythmic contractions of
seminal system
Skin flushing

Rhythmic vaginal and uterine

contractions
Skin flushing

Delayed ejaculation
Premature ejaculation
Female preorgasmia

Refractory to orgasm for

a period of time which
increases with age

No refractory period

Postcoital dysphoria
Postcoital headache

Source: Kaplan and Saddoch, 7th ed.

Sexual Orientation
1 describes the degree of a persons erotic attraction to people of the same
sex (homosexual), the opposite sex (heterosexual), or both sexes (bisexual)
2 individuals may fall anywhere along a continuum between
exclusive homosexuality and exclusive heterosexuality
3 homosexuals and bisexuals undergo a developmental process
of identity formation known as coming out
1
sensitization - before puberty, sensations of being different from ones peers
2
identity confusion - after puberty, heightened awareness of same-sex
attraction conflicts with social expectations of heterosexuality and/or
social stigma of homosexuality

identity assumption - self-definition as homosexual or

bisexual, but definition merely tolerated, not yet fully accepted

commitment - self-acceptance and comfort with homosexual or bisexual

identity; disclosure of identity in family, social, occupational settings

(Source: Troiden, 1989, Journal of Homosexuality. 17: 253-267)

SEXUAL DYSFUNCTION
1
2
3
4

involves both physical and psychological factors

physical factors present in 33% of men and 10% of women
medications are among the commonest causes of sexual dysfunction
classified according to disturbance in sexual response cycle
(desire, arousal, orgasm), pain, or medical conditions causing
dysfunction
Lowered Desire
1 greatest increase of any sexual dysfunction over the past decade
2 rule out medications, chronic disease, endocrine disorders, and menopausal decrease in hormones
3 individual psychological factors: history of incest, assault, other secret
4 couple factors: consider relationship stress, changes in life stages
5 treatment: 30% overall success rate; manage medical conditions and
medications; individual therapy for survivors (e.g. of incest, other abuse); couple
therapy
Male Erectile Disorder
1 more than 50% of erectile problems have physical causes
2 medications account for 25% of these (e.g. antihypertensives, sedatives)
3 rule out medications, medical conditions (vascular, neurological, endocrine)
4 individual factors: acuteness of onset, presence of waking or masturbatory
erections, global vs. situational dysfunction; these help distinguish organic from
psychological
5 couple factors: relationship stress, performance anxiety
6 treatment
1
manage medical conditions and medications
2
medical/ surgical: oral yohimbine, papaverine and prostaglandin (PG) injections,

implants, sildenafil (Viagra)

psychotherapy as applicable for psychiatric conditions (anxiety, depression,
other); couple therapy to address anxiety issues, marital counseling
PS26 Psychiatry
MCCQE 2002 Review Notes

SEXUALITY AND GENDER . . . CONT.

Female Sexual Arousal Disorder - Decreased Lubrication
1 usually presents as dyspareunia

2 rule out organic causes: vaginitis (atrophic, infectious, other), episiotomy, etc. (creates
cycle of: initial pain > anxiety > decreased lubrication > more pain)
3 psychological causes: expectations that intercourse will hurt (self-fulfilling prophecy), traumatic abusive
experiences, difficulties in forming trusting, intimate relationships; other relationship difficulties
4 treatment
1
medication for vaginitis (plus warning that lubrication may be decreased for a few weeks
as mucosa heals) and alternative sexual behaviour to intercourse
2
psychotherapy for individual factors, couple therapy, sex education - counsel longer foreplay
Female Orgasmic Disorder - Preorgasmia
1 1 in 7 women believe they have never had an orgasm

2 physical factors rare: denervation of lumbosacral spine

3 psychological: not yet learned how to have an orgasm (social conditioning,
unrealistic expectations of partner)
4 treatment: 95% success rate
1
individual, couple, group therapies
2
permission to explore own body
Male Orgasmic Disorder - Delayed Ejaculation
1 primary organic: congenital, neurological, endocrine

2 secondary organic: trauma, cord lesions, medication side effects (phenothiazines, sympatholytics)
3 psychological: most delayed ejaculation is situational; causes include rigid conservative sexual upbringing, fear
of pregnancy, hostility to women, repressed homosexuality, poor partnership factors
4 treatment: limited success rate
1
rule out medication and organic conditions
2
sufficient stimulation in relaxed environment
3
gradual involvement of partner
Premature Ejaculation
1 most common male sexual dysfunction: 33% affected

2 medical causes unknown

3 psychological: usually secondary to performance anxiety caused by
interrupted sexual experiences, intimacy fears, relationship difficulties
4 treatment: 90% success rate
1
goal: decrease performance anxiety
2
exercises to focus on experience vs. performance
3
increasing stimulation and control exercises
4
gradual partner involvement
Coital Pain Disorders - Dyspareunia and Vaginismus
1 vaginismus (a diagnosis of exclusion for dyspareunia) = sharp pain in anterior vagina, worse
during attempted penetration

2 32% of patients have associated physical factors

3 psychological: belief that intercourse is painful, abusive relationships (past, present), other factors
involving decreased trust
4 treatment
1
interventions: lubricating creams/jellies, change of positions, sex education materials,
permission, reassurance
2
pelvic anatomy review i.e. pubococcygeus muscle, teaching how to gain control of pelvic floor
muscles

PARAPHILIAS
1 diagnosis: sexual arousal, fantasies, sexual urges or behaviour involving non-human
objects, suffering or humiliation of oneself or ones partner, children or other nonconsenting
person

2 person usually has more than one paraphilia

3 subtypes: exhibitionism, fetishism, frotteurism, voyeurism, pedophilia,
sexual masochism, sexual sadism, transvestic fetishism and NOS
4 course
1
begins in childhood or early adolescence; more defined later
2
chronic, decreases with advancing age
3
may increase with psychosocial stressors
5 almost never diagnosed in women, except sexual masochism
6 treatment: anti-androgen drugs, behaviour modification, psychotherapy
1
rarely self-referred; come to medical attention through interpersonal or legal conflict

GENDER IDENTITY DISORDER

1 orientation (born with) vs. gender identity (learned)

2 gender identity is set at about 3 years of age

Diagnosis
1 strong and persistent cross-gender identification

2
3

manifested by repeated stated desire or insistence that one is of the opposite sex
children believe they will grow up to be the opposite sex
1
cross-dressing, cross-sex roles in play

4 significant distress or impairment in functioning

5 treatment: sexual reassignment surgery, psychotherapy
MCCQE 2002 Review Notes

Psychiatry PS27

EATING DISORDERS
Epidemiology
1 prevalence
1
anorexia nervosa (AN) - 1% of adolescent and young adult females
2
bulimia nervosa (BN) - 1-3% of adolescent and young adult females
2 F:M = 10:1
3 onset: AN - 13-20 years old; BN - 16.5-18 years old
4 mortality 5-10%
Etiology
1 multifactorial
2 individual: perfectionism and insistence on control when
little control in other life areas, history of sexual abuse
3 familial: maintenance of equilibrium in dysfunctional family
4 cultural factors: prevalent in industrialized societies,
idealization of thinness created by media
5 genetic factors
Risk Factors
1 women who by career choice are expected to be thin
2 family history (mood disorders, eating disorders, substance abuse)
3 psychiatric illness
4 obesity
5 chronic medical illness, especially diabetes mellitus
6 history of sexual abuse
7 gay men
8 competitive athletes

ANOREXIA NERVOSA (AN)

Diagnosis
1 refusal to maintain above 85% of expected weight for age and height
2 fear of becoming obese, even though underweight
3 abnormal perception of body image (weight, size, shape)
4 in females, absence of > 3 consecutive menstrual cycles
5 type
1
restricting - no binge eating or purging
2
binge eating/purging during episode of AN

BULIMIA NERVOSA (BN)

Diagnosis
1 recurrent binge-eating characterized by both
1. eating in a discrete period of time (e.g. < 2 hours) an
amount of food that is definitely larger than most people
would eat
2. loss of control over eating behaviour during binges
2 inappropriate compensatory behaviour to prevent weight gain:
self-induced vomiting, ipecac, laxatives, diuretics, amphetamines,
caffeine, dieting, vigorous exercise, etc.
3 frequency: both bingeing and compensatory behaviour occur
at least twice a week for 3 months
4 self-image unduly influenced by body shape and weight
5 not exclusively during episodes of AN
Treatment
1 biological
1
reversal of starvation effects
2
antidepressants (SSRIs) in BN
2 psychological
1
reality-oriented feedback
2
recognition of risk and perpetuating factors
3
education
4
develop trusting relationship with therapist
3 social
1
challenge destructive societal views of women
2
family therapy
3
use of hospital to provide external controls for disordered eating behaviour
Prognosis
1 few recover without recurrence

2 good prognosis associated with onset before age 15, weight

gain within 2 years after treatment
3 poor prognosis associated with later age of onset,
previous hospitalizations, greater individual and familial
disturbance

PS28 Psychiatry

MCCQE 2002 Review Notes

EATING DISORDERS . . . CONT.

Table 6. Physiologic Complications of Eating Disorders
System

Starvation

Binge - Purge

General

Low BP, low HR, low temperature

Endocrine

Amenorrhea, 9T3/T4

Vomiting
Russells sign (knuckle hypopigmentation)
Parotid gland enlargement
Perioral skin irritation
Periocular petechiae
Loss of dental enamel
Hematemesis
Aspiration pneumonia
Metabolic alkalosis (9K)

Neurologic

Grand mal seizure (9Ca, Mg, PO4)

Cutaneous

Dry skin, lanugo hair, hair loss or thinning,

brittle nails, yellow skin from high carotene

GI

Constipation, impaired taste, delayed

gastric emptying

Acute gastric dilation/rupture, pancreatitis

CV

Arrhythmias, CHF

Arrhythmias, cardiomyopathy (from use of ipecac),

sudden cardiac death (9K)

MSK

Osteoporosis

Renal

Pre-renal failure (hypovolemia),

renal calculi

Renal failure

Extremities

Pedal edema (9albumin)

Pedal edema (9albumin)

Table 7. Labs in Eating Disorders

Increased

Decreased

BUN (dehydration)
Amylase (vomiting)

Na+, K+, Cl (vomiting, laxatives)

LH, FSH, estrogen (starvation)

Cholesterol (starvation)

Testosterone (starvation)

Growth hormone (GH) (starvation)

H+ (laxatives)

H+ (vomiting)
RBCs (starvation)
WBCs (starvation)

PERSONALITY DISORDERS (PD)

General Diagnostic Criteria
1 an enduring pattern of inner experience and behaviour that
deviates markedly from the expectations of the individuals
culture; manifested in two or more of: cognition, affect,
interpersonal functioning, impulse control
2 inflexible and pervasive across a range of situations
3 causes distress or impaired functioning
4 usually age 18 for diagnosis but pattern well
established by adolescence or early adulthood
5 personality traits are only considered disorders when they
meet first two criteria
6 prevalence of the common PDs (% population affected)
1
borderline PD 1-2%
2
histrionic PD 1.3-3%
3
schizotypal PD 3-5.6%
4
dependent PD 1.6-6.7%

MCCQE 2002 Review Notes

Psychiatry PS29

PERSONALITY DISORDERS (PD) . . . CONT.

Table 8. Classification of the Personality Disorders
Diagnosis

Core Traits

CLUSTER A
MAD

Appear odd or eccentric

Common defense mechanisms:
projection, fantasy

1. Paranoid PD
2. Schizoid PD
3. Schizotypal PD
CLUSTER B
BAD
1. Borderline PD
2. Antisocial PD
3. Narcissistic PD
4. Histrionic PD
CLUSTER C
SAD
1. Avoidant PD
2. Dependent PD
3. ObsessiveCompulsive PD

Dramatic, emotional, erratic behavior

Common defense mechanisms:
denial, acting out, dissociation (HPD), splitting (BPD)

Anxiety, fearfulness, constriction

Common defense mechanisms:
isolation, avoidance, hypochondriasis

Table 9. Diagnosing the Personality Disorders

PD

Diagnosis

Treatment

Paranoid PD

Suspects others are exploiting, harming, or deceiving him/her

Doubts trustworthiness of others
Fears information given to others will be used against him/her
Interprets benign remarks/events as demeaning
Bears grudges
Quick to react angrily or to counterattack
Repeatedly questions fidelity of partner

Psychotherapy (but difficult to establish trust,

so poor prognosis)

Schizoid PD

Neither desires nor enjoys close relationships

Chooses solitary activities
Little interest in sexual experiences
Takes pleasure in few activities
No close friends except first-degree relatives
Indifferent to praise or criticism
Emotional detachment

Individual psychotherapy

Schizotypal PD

Odd thinking and speech

Odd, eccentric behavior
Ideas of reference
Odd beliefs or magical thinking (e.g. superstitiousness)
Unusual perceptual experiences
Paranoid ideation
Inappropriate or constricted affect
No close friends except first-degree relatives
Excessive social anxiety

Psychotherapy
Social skills training
Low-dose antipsychotics may be helpful

Borderline PD

Frantic efforts to avoid real or imagined abandonment

Unstable and intense relationships
Unstable sense of self
Impulsivity that is potentially self-damaging (e.g. spending,
promiscuity, reckless driving)
Affective instability
Chronic feelings of emptiness
Difficulty controlling anger
Transient dissociative symptoms

Psychotherapy (individual and/or group)

Cognitive behavioural therapy

Antisocial PD

Criminal, aggressive, irresponsible behaviour

Deceitfulness
Impulsivity
Irritability and aggressiveness
Reckless disregard for safety of self and others
Consistent irresponsibility
Lack of remorse
Symptoms of conduct disorder before age 15 (see Child Psychiatry Section)

Control of behaviour (hospitalization, imprisonment)

Control of substance abuse

PS30 Psychiatry

MCCQE 2002 Review Notes

PERSONALITY DISORDERS (PD) . . . CONT.

Table 9. Diagnosing the Personality Disorders (continued)
PD

Diagnosis

Treatment

Narcissistic PD

Exaggerated sense of self-importance

Preoccupied with fantasies of unlimited success, power, beauty, love
Believes he/she is special and should associate with other
special people
Requires excessive admiration
Sense of entitlement
Takes advantage of others
Lacks empathy
Often envious of others or believes that others are envious of him/her
Arrogant attitudes

Psychotherapy

Histrionic PD

Not comfortable unless center of attention

Inappropriately sexually seductive
Rapidly shifting and shallow expression of emotions
Uses physical appearance to attract attention
Speech is excessively impressionistic
Dramatic and exaggerated expression of emotion
Easily influenced by others
Considers relationships to be more intimate than they really are

Insight-oriented psychotherapy

Avoidant PD

Avoids occupational activities that involve significant interpersonal contact due to fear of
criticism or rejection
Unwilling to get involved with people unless certain to be liked
Restrained in intimate relationships
Preoccupied with being rejected in social situations
Inhibited in new interpersonal situations due to feelings of inadequacy
Views him or herself as inferior to others
Reluctant to engage in new activities due to embarrassment

Assertiveness training
Systemic desensitization
Cognitive therapy

Dependent PD

Needs others to assume responsibility for most major areas of his/her life
Difficulty making everyday decisions without excessive advice
Difficulty expressing disagreement, fear of loss of approval
Difficulty initiating projects due to lack of self-confidence
Goes to excessive lengths to obtain support
Uncomfortable when alone due to fears of being unable to care for self
Urgently seeks another source of care when relationship ends

Insight-oriented psychotherapy
Assertiveness training
Social skills training

ObsessiveCompulsive PD

Perfectionism interferes with task completion

Preoccupied with details so that major point of activity is lost
Excessively devoted to work
Inflexible about morality
Unable to discard worthless objects
Reluctant to delegate tasks to others
Miserly spending
Rigidity and stubbornness

Psychotherapy
Behavioural therapy

N.B. For each PD, the optimal criterion for diagnosis is indicated in italics (as per Allnutt and Links, Diagnosing Specific Personality Disorders and
the Optimal Criteria in Clinical Assessment and Management of Severe Personality Disorders. 1996, American Psychiatric Press)

Clinical Pearl
1 mnemonic for borderline personality disorder
Paranoid ideas
Relationship instability
Abandonment fears, Anger outbursts, Affective
instability Impulsion, Identity disturbance
Suicidal behavior
Emptiness
Clinical Pearl
1 A key distinction between OCD and OCPD is that in OCD the symptoms are
ego-dystonic (the patient realizes the obsessions are not reasonable) whereas in
OCPD the symptoms are ego-syntonic (i.e. consistent with the patient's way of
thinking).

2 OCD = obsessive compulsive disorder

3 OCPD = obsessive compulsive personality disorder

MCCQE 2002 Review Notes

Psychiatry PS31

CHILD PSYCHIATRY
DEVELOPMENTAL CONCEPTS
Table 10. Developmental Stages
Freud

Erikson

Piaget

Oral

Trust/mistrust
(0 - 1 years)

Sensorimotor
(0 - 2 years)

Anal

Autonomy/shame, doubt
(1 - 3 years old)

Object permanence (15 months)

Object constancy (18 months)

Oedipal

Initiative/guilt
(4 - 6 years old)

Preoperational
(2 - 7 years)

Latency

Industry/inferiority
(6 - 12 years old)

Concrete operations
(7 - 11 years)

Identity/role confusion
(adolescence)

Formal operations
(11 + years)

1 Erikson stages continue throughout life: intimacy/isolation (young

adult); generativity/stagnation (middle age); integrity/despair (later life)

2 stranger anxiety (8 months) - infants cry at approach of stranger

3 separation anxiety (10-18 months) - separation from
primary/attachment figure results in anxiety

4 object constancy - (Margaret Mahler) - 2-3 years; child

becomes comfortable with mothers absence by internalizing her

image and the knowledge she will return
5 object permanence - (Piaget) - objects exist even when not visible
6 attachment - (John Bowlby) - special relationship between child
and primary caretaker(s); develops during first 4 years
7 temperament - innate psychophysiological behavioural
characteristics of child; nine behavioral dimensions exist
8 parental fit - the fit between parenting style and childs
temperament
9 adolescence - most adolescents negotiate development well;
if signs of turmoil present (e.g. extreme rebelliousness),
consider psychiatric diagnosis

ATTENTION-DEFICIT AND
DISRUPTIVE BEHAVIOUR DISORDERS

1 NB. cannot adequately evaluate one disorder without

investigating the presence of others

Attention-Deficit / Hyperactivity Disorder (ADHD)

1 prevalence: 4-8% of school-aged children
1
M:F = 3.5:1
2
girls tend to have inattentive/distractible symptoms; boys
have impulsive symptoms
2 etiology
1
genetic - MZ twins > DZ twins, runs in families
2
minimal brain damage
3
neurotransmitter
(catecholamine)/neuroanatomical
hypothesis
4
child/family factors (i.e. difficult child temperament,
chaotic)
3 diagnosis
1. six or more symptoms of inattention and/or hyperactivityimpulsivity persisting for at least 6 months

PS32 Psychiatry

MCCQE 2002

Review Notes

CHILD PSYCHIATRY . . . CONT.

Table 11. Examples of Inattention, Hyperactivity, Impulsivity
Inattention

Hyperactivity

Impulsivity

Careless mistakes

Fidgets, squirms in seat

Blurts out answers before questions completed

Cannot sustain
attention in tasks/play

Leaves seat when expected

to remain seated

Difficulty awaiting turn

Does not listen when

spoken to directly

Runs, climbs excessively

Interrupts/intrudes on others

Fails to complete tasks

Cannot play quietly

Disorganized

On the go, driven by motor

Avoids, dislikes tasks

required sustained
mental effort

Talks excessively

Loses things necessary

for tasks/activities
Distractible
Forgetful

2. onset before age 7

3. symptoms present in at least two settings (i.e. at home, and at school or work)
4. interferes with academic, family, and social functioning
5. does not occur exclusively during the course of PDD, schizophrenia, or
other psychotic disorders, and is not better accounted for by another
mental disorder (e.g. mood, anxiety, dissociative, personality disorder)

Clinical Pearl
1 observe the child, watch for ATTENTION features: Annoying, Impulsive, Temperamental,
Energetic, Noisy, Task incompletion, Inattentive, Oppositional, Negativism.
2 key questions in history

1
2

family history for ADHD or co-morbid conditions

evidence
syndromes,
(alcohol/lead)

for: developmental delay, genetic

encephalopathies,
or
poisoning

Clinical Pearl
1 good indicator that child has ADHD: Inability to focus for 30 minutes when child
wants to focus!

2 course
1
average onset 3 years old
2
identification at school entry
3
remission prior to age 12, 70-80% continue into adolescence, 65% into adulthood
4
adult outcome - ASPD, ADHD, poor educational and employment performance
3 non-pharmacological treatment
1
parent management, anger control strategies, positive
reinforcement, social skills training, individual/family therapy,
resource room, tutor for homework, classroom intervention,
exercise routines, extracurricular activities
4 pharmacological treatment (see Table 21)
1
psychostimulants
2
antidepressants

3
4

-agonists

for comorbid symptoms: TCA, neuroleptics, clonidine, lithium, MAOI, carbamazepine

Conduct Disorder (CD)
1 prevalence
1
males: 6-16%, females 2-9%
2
M:F = 4-12:1
2 etiology

1
2
3
4
5

parental/familial factors
parental psychopathology (e.g. ASPD, substance abuse)
child rearing practices (e.g. child abuse, discipline)
low SES, family violence
child factors - difficult temperament, ODD, learning problems, neurobiology

MCCQE 2002 Review Notes

Psychiatry PS33

CHILD PSYCHIATRY . . . CONT.

1

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s
e
s
p
e
c
i
f
i
e
d
(

N
O
S
)

2
t

i
c
s
:
i
n
v
o
l
u
n
t
a
r
y
,
s
u
d
d
e
n
,
r
a
p
i
d
,
r
e
c
u
r
r
e
n
t
,
n
o
n
r
h
y
t
h
m
i
c
,
s
t
e
r
e
o
t
y
p
e
d
m
o
t
o
r
m
o
v
e
m
e
n
t
s
o
r
v
o
c
a
l
i
z
a
t
i

o
n
s

demiology

1
prevalence
4-5 per 10,000
2
M:F = 3:1
3
onset: motor

sim
pl
- age 7, vocal - age
e
11
ti
etiology
cs 2
1
genetic
e
y
2
MZ > DZ
e
twins,
autosomal
bl
dominant
in
3
Tourettes
ki
and chronic tic
n
disorder
aggregate
g,
within
same
n
families
os
e
4
dopamine
w
serotonin
ri
dysregulation
n 3
diagnosis
kl
in 1. multiple motor tics
g,
and at least one vocal
fa
tic
ci
al2. t
gr i
c
i
m s
ac
in o
g, c
sh c
u
o
ul r
d
er m
sh a
ru n
y
g
gi
t
n
i
g
m
2
e
com s
pl
a
e
x
d
ti
cs ay

,
h
a
n
e
n
a
d
r
g
es ly
tu
re e
s, v
ju e
m r
pi y
n
g, da
to y
u
c
f
hi o
r
n
g, 1
fa
ci y
al e
c
a
o
r
nt
or w
i
ti
t
o
h
n
o
s, u
c
t
o
pr a
ol t
al i
ia c
Tourettes
f
r
Disorder
e
1
epi e

p
e
r
i
o
d
o
f
m
o
r
e
t
h
a
n
3
c
o
n
s
e
c
u
t
i
v
e
m
o
n
t
h
PS34

3. onset before 18 years

4. disturbance not due to
4

direct
physiological
effects of substance or
GMC
presentation
1
50% initial
tic = eyeblinking;
others include head
jerking,
facial
grimace,
tongue
protrusion, etc.
2
vocal
tics
can include sniffing,
coughing,
throat
clearing (rule out
ENT problem)
course
1
social,
academic,
occupational
impairment due
to rejection by
peers; anxiety
about tics in
social
situations

Psychiatry

chronic and
life-long
with
periods
of
remission
and
exacerbations
MCCQE 2002
Review Notes

CHILD PSYCHIATRY . . . CONT.

1

tr
eatment

1
b

n
o
f
s
t
r
e
s
s
t
o
t
h
e
d
i
s
o
r
d
e
r

e
h
a
v
i
o
u
r
a
l
t
h
e
r
a
p
y
,
p
2
for
tics
s
atypical neuroleptics, -2
y
agonists, traditional nonc
h
tricyclic neuroleptics
o
3
when
t
h
associated
with
e
OCD
SSRI,
r
clomipramine
a
p LEARNING
y
f DISORDERS
o 1
prevalence: 2-10%
r
2
categorized by
b
1. individual scores on
o
achievement tests in
t
reading, mathematics
h
or written expression
(WISC III, WRAT)
f
significantly below
a
(> 2 SD) that
m
expected for age,
i
education, and IQ
l
y
2. interferes
with
academic achievement
a
or
ADLs
that
require
n
reading, mathematics
d
or writing skills
types:
reading,
i 3
mathematics, disorders of
n
written expression
d
i 4
associated features
v
1
low
selfi
esteem, poor social
d
skills
u
a
2
40% school
l
drop-out rate
;
5
psychiatric
i
comorbidity = 10-25% of
m
individuals with CD, MDD,
p
ODD, ADHD, dysthymia
o6
r
tm
a a
n y
t
t be
o
a as
d s
d
r o
e c
s i
s a
t
r e
e d
l
a w
t i
i t
o h

:
g
e
n
e
t
i
c
p
r
e
d
i
s
p
o
s
i
t
i
o
n
,
p
r
e
n
a
t
a
l
i
n
j
u
r
y
,
l
e
a
d
p
o
i
s
o
n
i
n
g
,
f
e
t
a
l
a
l
c
o
h
o
l
s
y
n
d
r
o
m
e
,
f
r
a
g
i
l
e
X
s
y
n
d
r

o
m
e

PERVASIVE
DEVELOPMENTAL
DISORDER (PDD)
1

types:
autistic
disorder, Retts disorder,
childhood
disintegrative
disorder,
Aspergers
disorder and PDD NOS
2
characterized by
1
severe
impairment
in
reciprocal
social
interaction
2
severe
impairment
in
communication skills
3
presence of
stereotyped
behaviour, interests
and activities

present in first
years of life, often
associated with some
degree
of
mental
retardation (Axis II)
and/or a GMC (i.e.
chromosomal
abnormality, congenital
infections) (Axis III)
Autistic Disorder
1
epidemiology
1
5:10,000
population; M:F =
4:1
2
onset prior
to age 3
2
diagnosis
1. at least six items from
the following
1 impaired
social
interaction (at
least two of
the following)
1 imp
aired
nonver
bal
behavi
ours
2 fail
ure to
develo
p peer
relatio
ns
3 no
shared
enjoym
ent or
interest
s with
others
4 lack
of
social
or
emotio
nal
recipro
city
2 communicati
on (at least
two)
1 limi
ted
langua
ge
develo
pment
2 ster
eotype
d,
repetiti

negrative disorder

3
3
a to
unable
s

2.

3.

s
o
c
4 ia
lackt
of
e
d
m
e
3 d
actii
c
a
l
c
o
n
d
i
t
i
o
n
s
:
p
h
e
1 ny
stereotype
l
k
e
t
2 o
u
preoccupa
r
i
a
3 (P
persistenc
K
U
)
,
4 Fr
restricted
a
dela gi
ys/a l
bno e
rma
l
X
fun
ctio ,
n in m
one a
of:
soci te
al
inte rn
ract a
ion, l
lan
gua r
ge,
sym ub
boli e
c or l
ima l
gin
ativ a,
e
pla
b
y
i
dist rt
urb
h
anc
e
a
not
bett no
er
x
acc
oun ia
ted
,
for
by
Rett en
s
c
or
chil ep
dho h
od
disi a

l
i
t
i
s
,
t
u
b
e
r
o
u
s
s
c
l
e
r
o
s
i
s

i
s
m
,
d
e
g
e
n
e
r
a
t
i
v
e
n
e
u
r
o
l
o
g
i
c
a
l
d
i
s
e
a
s
e
,
l
a
n
g
u
a
g
e
d
i
s
o
r
d
e
r
s
,
o
t
h
e
r
P
D
D

di
fferentia
l
diagnosi
s

1
d

e
a
f
n
e
s
s
,
m
e
n
t
a
l
r
e
t
a
r
d
a
t
i
o
n
(
7
5
%
)
,
c
h
i
l
d
h
o
o
d
s
c
h
i
z
o
p
h
r
e
n
i
a
,
e
l
e
c
t
i
v
e
m
u
t

prognosis

1
chronic
course
2
better

if
language
development and IQ
above 60
3
1/3 achieve
partial independence
4
up to 50%
develop convulsive
disorder
by
teens/early adulthood
treatment
1
no specific
treatment
2
early
intervention
important (2-4 years)
3
family
support, education
on nature of illness
4
behaviour
modification
5
consistency,
security, limit setting

6
s

e
o
c
r
i
k
a
s
l
h
i
o
z
p
e
s
d
a
e
n
d
d
u
c
c
a
o
t
m
i
m
o
u
n
n
i
a
t
n
y
d
g
t
r
h
o
e
u
r
p
a
p
h
e
o
u
m
t
e
i
s
c
f
s
o
e
r
t
t
t
i
e
n
e
g
n
s
s
/
f
a
o
d
r
u
l
y
t
o
s
u
n
7
pharmacolog
g
ical treatments: aim
only
to
control
c
targeted behaviours
h
i
1 haloperidol l
hyperactivity,
d
aggression,
r
stereotypies
e
2 methylpheni
n
date
;
hyperactivity
s
3 clomipramin
h
e
e
compulsive
l
and
t
perseveration
e
behaviours
r
4 naltrexone e
withdrawal,
d
self-injurious
w
behaviours
MCCQE 2002
Review Notes Psychiatry PS35

CHILD PSYCHIATRY . . . CONT.

Retts Disorder
1 epidemiology: only in females, less common than autism
2 onset before age 4, generally lifelong course
3 diagnosis: characterized by normal development after birth
which is interrupted by specific developmental deficits such as
1
loss of hand skills with development of stereotypies (e.g. hand washing/wringing)
2
head growth decelerations
3
loss of social engagement
4
gait/truncal incoordination
5
severe language impairment
Childhood Disintegrative Disorder
1 epidemiology: more common in males, less common than autism
2 diagnosis: appropriate development until age 2 followed by
deteriorating development in at least two areas: language,
social skills, toileting, motor skills, play
3 associated with severe MR (Axis II), seizures,
metachromatic leukodystrophy, Schilders disease
Aspergers Disorder
1 epidemiology: more common in males
2 diagnosis
1
impaired social interaction
2
restricted repetitive stereotyped patterns of behaviour,
interests, and activities causing social and occupational
impairment
3
no clinical impairment in language or cognitive development

MENTAL RETARDATION (MR)

Epidemiology
1 1% of general population
2 M:F = 1.5:1
3 highest incidence: ages 10-14
Etiology
1 genetic: Down syndrome, Fragile X, PKU
2 prenatal: rubella, fetal alcohol syndrome, prenatal exposure to heroin, cocaine, HIV;
maternal DM; toxemia; maternal malnutrition; cerebral hypoxia due to delivery complications
3 perinatal: prematurity, low birth weight, cerebral ischemia, maternal deprivation
4 childhood: infection, trauma
5 psychosocial factors: mild MR associated with low socioeconomic status (SES), limited parental
education, parental neglect, failure to thrive (FTT), teen pregnancy, family instability, limited stimulation of
children
Diagnosis
1 subaverage general intellectual functioning as defined by an IQ of approximately 70 or below
2 deficits in adaptive functioning in at least two of
1
communication, self-care, home-living, social skills, selfdirection, academic skills, work, leisure, health, safety
3 onset before 18 years of age
Table 12. Classification of Mental Retardation
Severity

% of MR

IQ

Diagnosis

Mild
Moderate
Severe
Profound

85%
10%
3-4%
1-2%

50-70
35-49
20-34
< 20

Late
Late
Early
Early

1 psychiatric comorbidity
1
3-4 times greater vs. general population
2
ADHD, mood disorders, PDD, stereotypic movement disorders

PS36 Psychiatry

MCCQE 2002 Review Notes

CHILD PSYCHIATRY . . . CONT.

f
Treatment
a
1
mai m
i
n
l
objective: y
enhance
e
adaptive
d
functioni
u
ng level
c
2
emp at
hasize
communi io
ty-based
treatment n
vs.
4
institutio
thera
nalization
py
3
:
e
in
d
di
u
vi
c
du
a
al/
t
fa
i
mi
o
ly
n
th
:
er
ap
l
y;
i
be
f
ha
e
vi
ou
s
r
k
m
i
od
l
ifi
l
ca
s
tio
,
n
(t
v
o
o
de
c
cr
a
ea
t
se
i
ag
o
gr
n
es
a
si
l
ve
/di
t
str
r
ac
a
tin
i
g
n
be
i
ha
n
vi
g
ou
,
rs)
c
CHILDHOOD
o
m
SCHIZOPHRENIA
m
u
1
prevalence
n
1
1/2,000 in
i
childhood
c
a
2
increases
t
after puberty to
i
reach adult rates
o
in
late
n
adolescence
2
diagnostic criteria
s
same as in adults
k
3
i
< 6
l
y
l
e
s
a
,

r
s
o
l
d
m
a
y
p
r
e
s
e
n
t
i
n
s
i
m
i
l
a
r
f
a
s
h
i
o
n
t
o
A
u
t
i
s
t
i
c
d
i
s
o
r
d
e
r
p
r
i
o
r
t
o

progn
osi
s
po
or
as
cog
niti
ve,
lan
gua
ge,
soc
ial
and
per
son
alit
y
dev
elo
pm
ent
are
dis
rup
ted
but
no
diff
ere
nt
fro
m
adu
lt
out
co
me
s

t
reatme
nt:
psych
othera
py,
family
educat
ion,
low
dose
antips
ychoti
cs for
target
behavi
ours,
hospit
alizati
on,
reside
ntial
place
ment

o
n
s
e
t

ADOLESCENT
MOOD
DISORDERS

o
f

Depressive Disorder
1
prevalence
1
prepuberty
1-2%
2
postpubert
y 8-10%
3
2.5% in
teenage
boys;
7.2% in teenage
girls
2
clinical
presentation
1
more
cognitive
and

c
o
r
e
s
y
m
p
t
o
m
s

fe
we
r
veg
etat
ive
sy 3
mp
to
ms
tha
n
adu
lts

icant
increased
risk of suicide
4
majority
never
seek
treatment
course
1
prolonged,
up to 1-2 years
2
adolescent
onset
predicts
chronic
mood
disorder
3
2/3
will
have
another
depression within
5 years
clinical sequelae
1
negative
impact upon peer
and
family
relationships
2
school
failure
3
substance
abuse
4
comorbid
diagnoses
of
anxiety, ADHD,
CD, and eating
disorders
treatment
1
individual/
family
psychotherapy
2
antidepres
sants; SSRIs are
safest

bored
om
,
irri 4
tab
ilit
y,
anh
edo
nia
,
dis
cou
rag
em
ent
,
hel
ple
ssn 5
ess
,
lo
w
self
est
ee
m, Bipolar Affective
det Disorder
eri
ora 1
prevalence
tio
estimates
vary
but
n
probably similar to
in
aca adults (0.8%)
de
look like children
mi 2
with ADHD
c
per
3
for
t
ma r
nce i
, a
hy d
per :
so
mn i
ia, n
so a
ma p
tic p
co r
mp o
lai p
nts, r
soc i
ial a
wit t
hdr e
aw
al, s
lac e
k x
of u
mo a
tiv l
ati
on, b
sub e
sta h
nce a
abuv
se i
3 o
signif u

r
s
,

r
a
p
i
d

p
h
y
s
i
c
a
l

o
n
s
e
t
o
f

v
i
o
l
e
n
c
e
,

d
e
p
r
e
s
s
i
o
n
,

m
o
o
d

p
s
y
c
h
o
m
o
t
o
r

s
w
i
n
g
s
w
i
t
h
i
n
2
4
h
o
u
r
s

mor
e likely to
have
bipolar II
or rapidcycling
particular
ly if early
onset
5
ofte
n
comorbid
or
preexisting
ADHD/c
onduct
disorder
6
uni
polar
depressio
n may be
early sign
of adult
bipolar
disorder

1
p
r
e
d
i
c
t
e
d
b
y

r
e
t
a
r
d
a
t
i
o
n
,
m
o
o
d
c
o
n
g
r
u
e
n
t
p
s
y
c
h
o
s
i
s
,
a
f
f
e
c
t
i
v
e
i
l
l

n
e
s
s
i
n
f
a
m
i
l
y
,
p
h
a
r
m
a
c
o
l
o
g
i
c
a
l
l
y
i
n
d
u
c
e
d
m
a
n
i
a

tment

trea

1
m
o
o
d
s
t
a
b
i
l
i

z
e
r
s
(
l
i
t
h
i
u
m
,
c
a
r
b
a
m
a
z
e
p
i
n
e
,
a
n
d
v
a
l
p
r
o
i
c
a
c
i
d
)
+
/

a
n
t
i
d
e
p
r
e
s
s
a
n
t
s

MCCQE 2002
Review Notes
Psychiatry
PS37

CHILD PSYCHIATRY . . . CONT.

ANXIET
Y
DISORD
ERS
1

chil
dhood
prevalenc
e 2-15%
2
post
pubertal
females >
postpuber
tal males
Separation
Anxiety
Disorder
1
prev
alence:
4%
of
children/t
eens
2
on
average
7.5 years
old
at
onset, 10
years old
at
presentati
on
3
com
mon for
mother to
have an
anxiety or
depressiv
e disorder
4
diag
nosis

schoo
l
ref
usa
l
(75
%)

ex
c
e
s
s
i
v
e
a
n
d
d
e
v
e
l
o
p
m
e
n
t
a
l
l
y
i
n

a
p
p
r
o
p
r
i
a
t
e
a
n
x
i
e
t
y
o
n
s
e
p
a
r
a
t
i
o
n
f
r
o
m
p
r
i
m
a
r
y
c
a
r
e
g
i
v
e
r
w
i
t
h
p
h
y
s
i
c
a
l
o
r
e
m
o
t
i
o
n
a
l
d
i
s
t
r
e
s
s

f
o
r
a
t
l
e
a
s
t
t
w
o
w
e
e
k
s

pe
r
s
i
s
t
e
n
t
w
o
r
r
y
,
s
c
h
o
o
l
r
e
f
u
s
a
l
,
r
e
f
u
s
a
l
t
o
g
o
t
o
s
l
e
e
p
,
c
l
i
n
g
i
n
g
,
n
i
g
h
t

m
a
r
e
s
,
s
o
m
a
t
i
c
s
y
m
p
t
o
m
s

comorbid major
depression
common
(66%)
6
differentia
l diagnosis:
simple or social
phobia,
depression,
learning
disorder,
truancy, conduct
disorder,
school-related
problems (e.g.
bullying)
7
course
1
symptoms
may wax and
wane
2
if
inadequately
treated early on
may present later
in a more severe
form
3
may
develop
into
panic
disorder
with/without
agoraphobia
8
treatment
1
primary
objective: child
returning
to
school
2
coordinat
ed
effort
by
school/family/ph
ysician
3
family
and
individual
psychotherapy
4
behaviour
modification
techniques, stress
reduction

TCAs
(incon
sistent
result
s),
SSRIs
(positi
ve
thoug
h
small
studie
s),
clona
zepa
m/bus
pirone
(case
report

s
)

f
a
m
i
l
y

Other
Anxiety
Disorders
Seen in
Children
(criteria
same as
adults)
1
Post
Traumatic
Stress
Disorder
(PTSD)

v
i
o
l
e
n
c
e
,
n
a
t
u
r
a
l

1
ex

a
m
p
l
e
s

d
i
s
a
s
t
e
r
s

o
f
t
r
a
u
m
a
i
n
c
l
u
d
e
:
s
e
x
u
a
l
/
p
h
y
s
i
c
a
l
a
b
u
s
e
,
w
i
t
n
e
s
s
i
n
g
e
x
t
r
e
m

treatment:
individual
and
group
psychotherapy;
parental
education
2
ObsessiveCompulsive
Disorder
(OCD)
1
0.3-1% of
children/teenager
s

2
tr

e
a
t
m
e
n
t
:
c
l
o
m
i
p
r
a
m
i
n
e
,
f
l
u
o
x
e
t
i
n
e
;
p
a
r
e
n
t

e
d
u
c
a
t
i
o
n
;
b
e
h
a
v
i
o
u
r
m
o
d
i
f
i
c
a
t
i
o
n
;
p
s
y
c
h
o
t
h
e
r
a
p
y

genetic/pa
rental
modeling/identifi
cation
hypothesized as
cause
2
often
parent with panic
or
depressive
disorder
3
treatment:
clonazepam;
parental
education;
family/individual
psychotherapy;
behaviour
techniques

ELIMINATION
DISORDERS (see
Pediatrics Chapter)

CHRONIC
RECURRENT
ABDOMINAL PAIN
(see Pediatrics Chapter)

SLEEP
DISTURBANCES
(see Pediatrics Chapter)

Pani
c
Disorder CHILD ABUSE (see
(PD)
Pediatrics Chapter)
PS38 Psychiatry
MCCQE
2002 Review Notes

PSYCHOTHERAPY
PSYCHODYNAMIC THERAPIES
1
2
3
4

assumption: ones present outlook is shaped by the past

attention to unconscious psychological forces
insight gained allows change in personality and behaviour
conflict - three stages of symptoms
1
unresolvable conflict
2
attempt to repress
3
return of conflict in disguised form (symptom or character trait)
5 emphasis on early development with caregiver
6 sources of information
1
past and present experiences and relationships
2
relationship with therapist
3
transference: unconscious; re-enact early interpersonal patterns in relationship with therapist
4
countertransference: therapists transference to patient
5
resistance: elements in the patient which oppose treatment
7 techniques
1
free association: patient says whatever comes to mind
2
dream analysis

VARIETIES OF PSYCHODYNAMIC THERAPY

1 psychoanalysis (exploratory psychotherapy)

1
original therapy developed by Freud
2
emphasis on early childhood experiences
3
4-5 times/week for 3-5 years, use of couch
4
for individuals who can tolerate ambiguity (healthier end of spectrum)
2 supportive psychotherapy
1
goal is not insight but lessening of anxiety
2
strengthen defense mechanisms to assist day-to-day functioning
3
techniques include: enhancing self-esteem, clarification,

confrontation, rationalization, reframing, encouragement,

rehearsal/anticipation, tracking, universalizing,
decatastrophizing, allowing ventilation
3 short term/brief psychotherapy
1
resolution of particular emotional problem, acute crisis
2
number of sessions agreed at outset (6-20)
4 interpersonal psychotherapy
1
short-term treatment containing supportive principles
2
focus on personal social roles and relationships to help deal with problem in current functioning

BEHAVIOUR THERAPY

1 modification of internal or external events which precipitate or maintain emotional distress

2 systematic desensitization - mastering anxiety-provoking situations by
approaching them gradually and in a relaxed state that inhibits anxiety
3 flooding - confront feared stimulus for prolonged periods until it is no longer frightening
4 positive reinforcement - strengthening behaviour and causing it to occur more frequently by rewarding it
5 negative reinforcement - causing behaviour to occur more frequently by
removing a noxious stimulus when desired behaviour occurs
6 extinction - causing a behaviour to diminish by not responding to it
7 punishment (aversion therapy) - causing a behaviour to diminish by applying a noxious stimulus
8 used for anxiety disorders, substance abuse, paraphilias

COGNITIVE THERAPY

1 assumption: moods and feelings influenced by thoughts

2 psychiatric disturbances are frequently caused by habitual errors in thinking
3 goal is to help patient become aware of automatic thoughts
and correct assumptions with more balanced view
4 useful for depression, anxiety disorders, self-esteem problems
5 use of this therapy presupposes a signficant level of functioning

OTHER THERAPIES

1 group psychotherapy
1
goals: self-understanding, acceptance, social skills
2
creates a microcosm of society
2 family therapy
1
family system considered more influential than individual
2
structural focus
1
here and now
2
re-establish parental authority

3
4

strengthen normal boundaries

re-arrange alliances

3 hypnosis
1
good for pain, phobias, anxiety, smoking
MCCQE 2002 Review Notes

Psychiatry PS39

MEDICATIONS/THERAPEUTICS
ANTIPSYCHOTICS
1 indications: schizophrenia and other psychotic disorders, mood disorders

with psychosis, violent behaviour, autism, organic mental disorders,

Tourettes, somatoform disorders (low dose), symptoms of dementia, OCD
2 onset: immediate calming effect and decrease in agitation;
thought disorder responds in 2-4 weeks
3 mechanism of action
1
typical - block D2 receptors (dopamine); treats only
positive symptoms
2
atypical - block D2 and/or D1, 5-HT receptors
(dopamine + serotonin); treats both positive and negative
symptoms
4 classification of typical antipsychotics
1
low potency (e.g. chlorpromazine): very sedating; +++
cardiovascular, anticholinergic and antiadrenergic side effects
2
mid-potency (e.g. perphenazine): few side effects
3
high potency (e.g. haloperidol): ++ risk of movement
disorder side effects and neuroleptic malignant syndrome
(NMS)
Rational Use of Antipsychotics (see Tables 13 and 14)
1 no reason to combine antipsychotics (see Figure 2)
2 choosing an antipsychotic
1
all antipsychotics (except clozapine) are equally effective
2
choice depends on side effect profile
3
choose a drug patient responded to in the past or was
used successfully in a family member
4
route: PO (pills or elixir); short-acting or long-acting
depot IM injections (i.e. Haldol LA, Modecate, Imap,
Clopixol)
5
clozapine is used in refractory cases (risk of agranulocytosis and
cost hinder routine use, but has a low incidence of extrapyramidal symptoms (EPS))
3 minimum 6 months, usually for life

Table 13. Common Antipsychotics

Starting Dose

Maintenance

Maximum

CPZ (Largactil)

10-15 mg PO b/t/qid

400 mg/d

1000 mg/d

thioridazine (Mellaril)

25-100 mg PO tid

100-400 mg PO bid

800 mg/d

methyltrimeprazine
(Nozinan)

2-8 mg PO tid

Based on clinical effect

1000+ mg/d

loxapine HCL (Loxitane)

10 mg PO tid

60-100 mg/d

250 mg/d

perphenazine (Trilafon)

8-16 mg PO b/tid

4-8 mg PO t-qid

64 mg/d

fluphenazine enanthate
(Moditen)

2.5-10 mg/d

1-5 mg PO qhs

20 mg/d

haloperidol (Haldol)

2-5 mg IM q4-8h
0.5-5 mg PO bid/tid

Based on clinical effect

100 mg/d

pimozide (Orap)

0.5-1 mg PO bid

2-12 mg/d

20 mg/d
0.2 mg/kg/d

clozapine (Clozaril)

25 mg od/bid

300-600 mg/d

900 mg/d

risperidone (Risperdal)

1-2 mg od/bid

4-8 mg/d

olanzapine (Zyprexa)

5 mg/d

10-20 mg/d

quetiapine (Seroquel)

25 mg/bid

300-600 mg/d

Typicals (in order of potency)

Atypicals

PS40 Psychiatry
Notes

MCCQE 2002 Review

MEDICATIONS/THERAPEUTICS . . . CONT.

acute psychosis

complications or
inadequate response

select agent:
high potency conventional antipsychotic,
risperidone or olanzapine
continue for at least 3 weeks

good response, no
complications
o

agitation or insomnia
acute parkinsonism
refractory parkinsonism
acute akathisia

neuroleptic malignant syndrome (NMS)

add
benzodiazepin
e
u
s
e
l
o
w
e
s
t

r
i
s
p
e
r
i
d
o
n
e
o
r

e
f
f
e
no response after 3 weeks
c
t
i
switch to risperidone or olanzapine if unresponsive or unable to v
e
tolerate, switch to clozapine

o
l
a
n
z
a
p
i
n
e

d
o
s
e
,

u
s
e

partial response after 3 weeks of therapy

adequate response tolerable side effects

a
d
d
a
n
t
i
c
h
o
l
i
n
e
r
g
i
c
s
s
w
i
t
c
h
t

l
o
w
e
s
t
e
f
f
e
c
t
i
v
e
d
o
s
e
a
d
d
a
n
t
i

cholinergics or beta-blocker

m
a
i
n
t
a
i
n

switch to clozapine
continue medication for 2-9 weeks more
or increase dose

o
n

inadequate response or intolerable

side effects

a
adequate response tolerable side n
effects
t
i
p
s

e
n

Figure 2. Treatment of
Schizophrenia
Atypical Antipsychotics
1
fewer EPS than typicals
2
serotonin-dopamine
antagonism
3
often more efficacious for
treating negative symptoms than
placebo
4
often effective for treating
symptoms
refractory
to
conventional antipsychotics
Clozapine (Clozaril)
1
a dibenzodiazepine
2
blocks
a
spectrum
of
receptors, including D1-D4, 5-HT2,
5-HT3, muscarinic, histaminic
3
indications
1
treatment-resistant
schizophrenia

severe
neur
olog
ical
side
effec
ts
(i.e.
tardi
ve
dysk
inesi
a)
limit
ing
use
of
othe
r
agen
ts
(cloz
apin
e
does
not
wors

4
a

b
o
u
t
5
0
%
o

y
c
h
o
t
i
c
m
e
d
i
c
a
t
i
o
n

f
it
h
p
o
a
ns
t
t
et
a
i
af
r
e
te
d
n
r
i
t
2
v
s
0
e
ye
b
ar
s
e
s
y
n
ol
m
e
d
p
f
5
si
t
i
de
o
t
effects:
m
,
agranu
s
locytos
;
e
is (1i
s
2%),
t
p
drowsi
m
e
ness,
a
c
hypers
i
y
alivati
a
on,
l
a
tachyc
l
c
ardia,
y
t
sedatio
u
n,
p
a
orthost
a
l
atic
r
l
hypote
a
nsion,
y
n
nausea,
o
vomiti
t
i
ng,
r
d
atropin
e
ic side
a
p
effects,
t
a
weight
t
t
gain,
h
i
extrap
e
e
yramid
m
n
al,
)
t
fever,
s
seizure
, NMS,
a
droolin
n
g
d
6
weekly blood counts for
at least 1 month, then q2
t
h
weeks, due to risk of
o
agranulocytosis
s
7
do not use with
e
carbamazepine because of
agranulocytosis risk
w
MCC QE 2002 Review Notes
Psychiatry PS41

MEDICATIONS/THERAPEUTICS . . . CONT.
neuroleptics (i.e. Haldol)
Risperidone
5
favourable
tardive
dyskinesia (TD) profile but may
(Risperdal)
not be as good as clozapine
1
a benzisoxazole 6
side effects:
2
blocks 5-HT2 mild sedation,
minimal
and D2
mild
3
low incidence anticholinergic,
dizziness, sexual
of EPS
dysfunction, early
4
indications
AST and ALT
elevation in some
1
schizo
individuals, weight
phrenia
gain, restlessness
2
negativ
e symptoms Quetiapine (Seroquel)
3
intoler
structurally related to
ance to side 1
effects
of clozapine and olanzapine
conventional 2
blocks 5HT2A, D1-D2,
neuroleptics
adrenergic, and histaminergic
5
advantages
receptors
limited to a narrow 3
overall efficacy superior
dose range:
4-8 to Haldol
mg/day only
4
incidence of EPS much
6
less
with
traditional
side
neuroleptics (i.e. Haldol)
effect
5
associ
s:
ated
with
sedati
less weight
on,
gain
as
hypot
compared
ensio
with
n,
clozapine
weig
and
ht
olanzapine
gain,
impai
Ziprasidone
rment
of
1
not yet approved in
ejacul
Canada
ation/
2
a
3-benzisothiazolylorgas
piperazine derivative with 5m,
HT2A
incre
and
ased
moderate D2
prola
antagonism;
ctin
moderately
levels
potent
,
adrenergic
hyper
and
saliva
histaminergi
tion,
c blocker
inso
mnia,
3
similar profile to other
atypical drugs
agitat
ion,
4
dos
heada
ing
che,
recomme
anxie
ndations
ty,
not yet
rhinit
known;
is
range of
efficacy
expected
Olanzapine (Zyprexa)
to
1
blocks
5- between
HT2,3,6,
D1-D4, 40-80
mg/day
muscarinic,
5
side effects
adrenergic,
1
expe
histaminergic
cted to have
2
overall efficacy
a
is superior to Haldol;
favourable
well
tolerated;
profile with
comparable
to
respect to
risperidone
weight gain
and to exert
3
not for use in
minimal
treatment-resistant
effects on
schizophrenia
prolactin
4
incidence
of
2
sedation may be
EPS much less than
the most common side
traditional

effect
Long-Acting
Preparations

1
a

n
t
i
p
s
y
c
h
o
t
i
c
s
f
o
r
m
u
l
a
t
e
d
i
n
o
i
l
f
o
r

deep
IM
inject
ion
recei
ved
on an
outpa
tient
basis
every
few
week
s

indications:
schizophrenia or
other
chronic
psychoses
who
relapse because of
noncompliance
3
available
preparations (all
high potency typical
antipsychotics):
fluphenazine
decanoate,
fluphenazine
enanthate,
haloperidol
decanoate, clopixol
acuphase, clopixol
decanoate (every 2-4
weeks)
4
dosing:
start at low
dosages
and
then titrate to
maximize
safety
and
minimize side
effects; should
be exposed to
oral form prior
to
first
injection
5
side effects: risk of EPS,
parkinsonism
PS42 Psychiatry
MCCQE 2002
Review Notes

MEDICATIONS/THERAPEUTICS . . . CONT.
Malignant Syndrome
1 due to
massive
Table 14. Side
dopamine
Effects of
blockage;
increased
Antipsychotics
incidence
with high
System/Syndrome
potency
and depot
Anticholinergic
neurolepti
cs
2 risk factors
1
sudden increase
in dosage, or starting a
new drug
Cardiovascular
2
medical illness
(anti- 1 adrenergic)
3
dehydration
4
exhaustion
5
poor nutrition
CNS
6
external heat load
7
sex: male
8
age: young adults
3 symptoms
1
classic
4
Endocrine (due to dopamine
symptoms (mnemonic
blockage which increases
FARM)
prolactin (PRL))
1
Fever
2
Autonom
ic changes (i.e.
increased
HR/BP,
sweating)
3
Rigidity
4
Mental
Ocular
status changes
(i.e. confusion)
2
develops over 24Hypersensitivity reactions
72 hours
4 labs: increased CPK,
leukocytosis, myoglobinuria
5 treatment:
discontinue
drug, hydration, cooling
Altered temperature regulation
blankets,
dantrolene,
bromocriptine
6 mortality: 5%
Neuroleptic
MCCQE 2002 Review
Notes Psychiatry
PS43

MEDICATIONS/THERAPEUTICS . . . CONT.
Extrapyramidal Side Effects (EPS) of Antipsychotics
1 incidence related to increased dose and potency
2 acute vs. tardive (late-onset)
Table 15. Extrapyramidal Side Effects
Dystonia

Akathisia

Pseudoparkinsonism

Dyskinesia

Acute or tardive

Both

Both

Acute

Tardive

Risk group

Acute: young Asian males

Acute: elderly females

Elderly females

Elderly females

Presentation

Sustained abnormal posture

Torsions, twisting, contraction
of muscle groups, muscle
spasms (e.g. oculogyric crisis,
laryngospasm, torticollis)

Motor restlessness;
cant sit down
Crawling sensation in legs
relieved by walking

Tremor
Rigidity/cogwheeling
Akinesia
Postural instability
(decreased/absent
armswing, stooped posture,
shuffling gait, decreased stride,
difficulty pivoting)

Purposeless constant movements

usually involving facial and mouth
musculature, or less commonly, the
limbs

Onset

Acute: within 5 d
Tardive: > 90 d

Acute: within 10 d
Tardive: > 90 d

Acute: within 30 d

Tardive: > 90 d

Treatment

Acute: lorazepam or benztropine

Acute: lorazepam, propranolol Acute: benztropine (or

or diphenhydramine; reduce
benzodiazepine if side
or change neuroleptic to lower
effects); reduce or change
potency
neuroleptic to lower potency

Tardive: no good treatment; may try

clozapine; discontinue drug or
reduce dose

Antiparkinsonian Agents (Anticholinergic Agents)

1 do not always prescribe with neuroleptics; give only if at high risk for EPS
2 do not give these for tardive syndromes; they worsen the condition
3 types
1
benztropine (Cogentin) 2 mg PO, IM or IV od (~1-6 mg)
2
procyclidine (Kemadrin) 15 mg PO od (~5-30 mg)
3
biperiden (Akineton) 2 mg PO, IM or IV bid (2-10 mg)
4
amantadine (Symmetrel) 100 mg PO bid (100-400 mg)
5
trihexyphenidyl (Artane) 1 mg-15 mg PO od
6
diphenhydramine (Benedryl) 25-50 mg PO/IM qid

ANTIDEPRESSANTS

1 onset of effect
1
neurovegetative symptoms 1-3 weeks
2
emotional/cognitive symptoms 2-6 weeks
2 indications - depression, depressive phase of bipolar disorder, dysthymia, anxiety disorders,

obsessive-compulsive disorders (clomipramine), chronic pain, enuresis, bulimia, cocaine withdrawal

Table 16. Common Antidepressants

Class

Drug

Starting
Dose (mg)

Therapeutic
Dose (mg)

TCA
(30 Amines)
TCA
(20 Amines)
MAOI

amitriptyline (Elavil)
imipramine (Tofranil)
nortriptyline (Aventyl)
desipramine (Norpramin)
phenelzine (Nardil)
tranylcypromine(Parnate)

25-75
25-75
20-50
25-75
15
10

150-300
150-300
75-150
150-300
45-90
10-90

RIMA

moclobemide (Manerix)

150

150-600

SSRI

fluoxetine (Prozac)
fluvoxamine (Luvox)
paroxetine (Paxil)
sertraline (Zoloft)
citalopram (Celexa)

20
50-100
10
50
10

20-80
150-300
20-60
50-200
20-60

SNRI

venlafaxine (Effexor)

20

75-225

SDRI

buproprion (Wellbutrin)

200

300-450

TCA

tricyclic antidepressants

MAOI =

monamine oxidase inhibitors

RIMA =

reversible inhibition of MAO-A

SSRI

selective serotonin reuptake

inhibitors

SNRI

= serotonin and norepinephrine

reuptake inhibitors

SDRI

serotonin and dopamine

reuptake inhibitors

Other cyclics

nefazodone (Serzone)

100

100-600

PS44 Psychiatry

MCCQE 2002 Review Notes

MEDICATIONS/THERAPEUTICS . . . CONT.
Rational Use of Antidepressants (see Tables 16 and 17)
1
taper TCAs slowly (over weeks-months) because they can cause withdrawal
reactions; MAOIs and SSRIs can be tapered over 1 week (see Figure 3)
2
patient education regarding drug effects
Treatment Strategies for Refractory Depression (see Figure 3)
1
optimization: ensuring adequate drug doses for the individual
2
augmentation or combination: addition to ongoing treatment
of drugs that are not antidepressants themselves (e.g. T3 or lithium)
3
substitution: change in the primary drug

MEDIC

start SSRI
reassess in 3-4 weeks

full response

partial response

continue starting dose

no response

optimization

full response

partial response

no response

continue treatment

augment
T3 or LiCO3

substitute

reassess in 2 weeks
full response

partial or no response
adjuvant (if partial response)

continue treatment

substitute (another SSRI or another class)

Figure 3. Treatment of Depression

ATIONS/THERAPEUTICS . . . CONT.
ELECTROCONVULSIVE THERAPY (ECT)
1

induction of a grand mal seizure using an electrical pulse

through brain under general anesthesia
2
indications
1
depression refractory to adequate pharmacological trial
2
high suicide risk
3
medical risk in addition to depression (dehydration, electrolytes, pregnancy)
4
previous good response to ECT
5
familial response to ECT
6
elderly
7
psychotic depression
8
catatonic features (negativism)
9
marked vegetative features
10
acute schizophrenia
11
mania unresponsive to meds
3
side effects: risk of anesthesia; memory loss (may be
retrograde and/or anterograde, tends to resolve by 6 to 9 months,
permanent impairment controversial); headaches; muscle aches
4
some evidence that unilateral ECT causes less memory
loss than bilateral but may not be consistently as effective
5
contraindications: increased intracranial pressure (ICP)

MCCQE 2002 Review Notes

PS45

Psychiatry

MCCQE 2002 Review Notes

Table 17. Antidepressants

TCA

SSRI

MAOI

RIMA

Nefaz

Specific
Indications

Kids

Anxiety states, BN (fluoxetine),

OCD, seasonal depression, atypical
depression

Atypical depression (e.g. in elderly,

coexisting anxiety or panic,
hypochondriacal symptoms,
reversed functional shift, increased
sleep/food intake, insomnia
Treatment refractory depression

Outpatient management of
depression

Depre

Mode of Action

Block NE and serotonin reuptake

Block serotonin reuptake only

Irreversible inhibition of
monoamine oxidase A and B
Leads to increased norepinephrine
and serotonin

Reversible inhibition of
MAO A only

Block
Post-s
anta

Side Effects

Anticholinergic: dry mouth, blurry

glaucoma,
vision, acute
constipation, urinary retention,
delirium
1 adrenergic: orthostatic
hypotension

Fewer than TCA, therefore increased

compliance

Hypertensive crises: with tyramine

Rare to have hypertensive crises

because MAO B is not affected;

Well t
Some

however, wise to avoid tyramine

rich food anyway
Well tolerated
Nausea, dizziness, insomnia

Ortho
may
Sexua

GI: N/V, diarrhea, ab. cramps,

weight loss
CNS: restlessness, tremor, insomnia,
headache, drowsiness

rich food (get headache, flushes,

palpitations, N/V, photophobia)
Anti- 1 adrenergic: orthostatic
hypotension
Weight gain

Antihistamine: sedation, weight gain

CVS: increased HR, conduction
delay
Neuro: sedation, stimulation,
decreased seizure threshold

Sexual dysfunction (impotence,

anorgasmia)
EPS

Energizing
Minimal anticholinergic and
antihistamine effects

Risk in Overdose

Toxic in OD
3 times therapeutic dose is lethal
Presentation: Ach effects, CNS
stimulation then depression, then
seizures
EKG: prolonged QRS (duration
reflects OD severity)
Treatment: activated charcoal,
cathartics,
supportive treatment,
IV diazepam for seizure,
physostigmine salicylate for coma
Do NOT give ipecac, as can cause
rapid neurologic deterioration
and seizures

Very safe; hard to OD on them

Toxic in OD, but wider margin of

safety than TCA

Drug
Interactions

MAOI, SSRI
EtOH

SSRIs inhibit P450 enzymes;

therefore will increase levels of drugs
metabolized by P450 system

EtOH
Hypertensive crises with
noradrenergic medications
(e.g. TCA, decongestants,
amphetamines)
Serotonin syndrome with
serotonergic drugs (e.g. SSRI,
tryptophan, dextromethorphan)

Serotonin syndrome with MAOI: nausea,

diarrhea, palpitations, hyperthermia,

chills, neuromuscular irritability,
altered consciousness

MEDICATIONS/THERAPEUTICS . . . CONT.

MEDICATIONS/THERAPEUTICS . . . CONT.
MOOD
STABILIZERS
Rational Use of
Mood Stabilizers
(see Table 18)

1
b

e
f
o
r
e
i
n
i
t
i
a
t
i
n
g
l
i
t
h
i
u
m
:
s
c
r
e
e
n
f
o
r
p
r
e
g
n
a
n
c
y
,
t
h
y
r
o
i
d
d
i
s
e
a
s
e
,
s
e
i
z
u
r
e
d
i
s
o
r
d
e
r
,

other
neurological,
renal,
cardiovascul
ar diseases

get
baseline:
CBC,
ECG (if
patient >
45 years
old
or
cardiova
scular
risk),
urinalysi
s, BUN,
Cr, lytes,
TSH
3
u
se
lithium
or
valproic
acid
first
(plus or
minus
an
antipsy
chotic);
use
carbam
azepine
in nonrespond
ers and
rapid
cyclers
4
a
clinical
trial of
lithium
lasts 3
weeks at
therapeutic
blood
levels; a
trial of
carbamaze
pine or
valproic
acid lasts 3
weeks
(blood
levels do
not
correlate
well)
5
give lithium as a single dose
at bedtime, others 2-3x per day
6
ca
n
combine
lithium
and
carbama
zepine or
valproic
acid
safely in
lithium
nonresponde
rs

olanzep
ine is
also
a
moo
d
stabil
izer;
used
in
com
binat
ion
with
other
moo
d
stabil
izers
Lithium Toxicity
1
CLINICAL diagnosis, as

toxicity can occur

at
therapeutic
levels

presentation
GI:
severe
N/V
and diarrhea 3
2
cereb
ellar: ataxia,
slurred
speech,
incoordination

3
c

e
r
e
b
r
a
l
:
m
y
o
c
l
o
n
u
s
,
c
h
o
r
e
i
f
o
r
m
o
r
P
a
r
k
i
n
s
o
n
i
a
n
m
o
v
e
m
e
n
t
s
,
u
p
p
e
r
m
o
t
o
r
n
e
u
r
o
n
(
U
M
N
)
s
i
g
n
s
,
s
e

izur
es,
deli
riu
m,
com
a
management
1
discontinue lithium
2
serum Li levels,
BUN, lytes
3
saline infusions

hemodial
ysis if
Li > 2
mmol/
L,
coma,
shock,
severe
dehydr
ation,
failure
to
respon
d
to
treatme
nt after
24
hours,
or
deterio
ration

ANXIOLYTICS
1

types:
azapirones
zopiclone)

benzodiazepines,
(e.g. buspirone,

indications
anxiety disorders,
insomnia, alcohol
withdrawal (especially
delerium tremens (DT)),
barbiturate withdrawal,
organic brain syndrome
(agitation in dementia),
akathisia due to
antipsychotics, seizure
disorders, musculoskeletal
disorders
relative contraindications

majo
r
de
pr
es
sio
n
(e
xc
ep
t
as
an
ad
ju
nc
t
to
ot
he
r
tre
at
m
en
t),
his
tor
y
of
dr
ug
/al
co
ho
l
ab
us
e,
pr
eg
na
nc
y,
br
ea
st
fe

e
d
i
n
g

buspirone: partial
agonist of 5-HT type IA
receptors
Rational Use of Anxiolytics (see
4
mechanism of
Table 19)
action
1
1
anxiolytics
mask
or
b
alleviate symptoms, they do not
e
cure
n
z
o
d
i
a
z
e
p
i
n
e
s
:
p
o
t
e
n
t
i
a
t
e
b
i
n
d
i
n
g
o
f
G
A
B
A
t
o
i
t
s
r
e
c
e
p
t
o
r
s
;
r
e
s
u
l
t
s
i
n
d
e
c
r
e
a
s
e
d
n
e
u
r
o
n
a
l
a
c
t
i
v
i
t

benzodiazepines
should be used for
limited periods (weeksmonths)
to
avoid
dependence

1
2

have
similar
efficacy
,
so
choice
depends
on halflife,
metabol
ites and
route of
adminis
tration

3
day
4
tape
r
sl
o
w
l
y
o
v
e
r
w
e
e
k
sm
o
n
t
h
s
b
e
c
a
u
s
e
t
h
e
y
c
a
n
c
a
u
s
e
w
it
h
d
r
a
w
al
r
e
a
ct
i
o
n
s

give once or twice a

1
lo

w
d
o
s
e
w
i
t
h

d
r
a
w
a
l
:
t
a
c
h
y
c
a
r
d
i
a
,
h
y
p
e
r
t
e
n
s
i
o
n
,
p
a
n
i
c
,
i
n
s
o
m
n
i
a
,
a
n
x
i
e
t
y
,
i
m
p
a
i
r
e
d
m
e
m
o
r
y
a
n
d
c
o
n
c
e
n
t
r
a
t
i
o
n
,
p
e
r
c
e
p
t
u
a
l
d
i
s

t
u
r
b
a
n
c
e
s

2 high

dose
withdrawal:
hyperpyrexia,
seizures, psychosis,
death
5
avoid
alcohol
because of potentiation of
CNS depression

oth
e
r
u
s
e
s:
s
e
d
at
i
v
e,
m
u
s
cl
e
r
el
a
x
a
n
ts
,
E
t
O
H
w
it
h
d
r
a
w
al
,
c
at
at
o
n
ia
,
n
a
r
c
o
a
n
al
y
si
s

1
C

N
S
:
d
r
o
w
s
i
n
e
s
s
,
c
o
g
n
i
t
i
v
e

side effects

i
m
p
a
i
r
m
e
n
t
,
r
e
d
u
c
e
d
m
o
t
o
r
c
o
o
r
d
i
n
a
t
i
o
n
,
m
e
m
o
r
y

MCCQE
2002 Review
Notes
Psychiatry
PS47

i
m
p
a
i
r
m
e
n
t

2 physical

dependence,
tolerance develops
8
commonly used
drug in overdose
1 overdose is rarely
fatal
2 in combination
with other drugs is
more
dangerous
and may cause
death
buspirone
1
primary
use:
generalized
anxiety
disorder (GAD)
2
nonsedating;
therefore,
may
be
preferred
over
benzodiazepines
3
does not: alter
seizure threshold, interact
with EtOH, act as a
muscle relaxant
4
onset: 2 weeks
5
side
effects:
restlessness, nervousness,
extrapyramidal

MCCQE 2002 Review Notes

Table 18. Mood Stabilizers
Lithium

Carbemazepine (Tegretol)

Valproic Acid (Epival)

Gabapentin

Indications
*BAD = Cluster B
Personality PD

Prophylaxis of BAD*
Treatment of acute mania
Augmentation of antidepressants in
MDE and OCD
Schizoaffective disorder
Chronic aggression and antisocial
behaviour
Recurrent depression
Less common: mental retardation,
Borderline PD, alcoholism

Prophylaxis of BAD
Treatment of acute mania
Rapid cycling BAD

Prophylaxis of BAD
Treatment of acute mania
Rapid cycling BAD

Second-line or adjuvant
Treatment of acute mania
Treatment of depression

MOA

Unknown

Depresses synaptic transmission

Raises seizure threshold

Depresses synaptic transmission

Raises seizure threshold

May increase GABA turnover in

brain or interfere with glutamat
metabolism

Usually tid dosing

Usually bid dosing

750-3000 mg/day

300-1600 mg/day

350-700 mol/L

17-50 mmol/L

Dosage

Therapeutic Level

Adult 600-1500 mg/day

Geriatric 150-600 mg/day
Usually OD dosing
Adult 0.5-1.2 mmol/L
Geriatric 0.3-0.8 mmol/L

900-2400 mg/day

Monitoring

Monitor serum levels (always wait

12 hours after dose) until
therapeutic; then biweekly or
monthly until a steady state is
reached, then q2 months
Also monitor thyroid function q6
months, Cr q6 months, urinalysis
q1 year

Weekly blood counts for first month,

due to risk of agranulocytosis
Also watch for signs of blood
dyscrasias: fever, rash, sore throat,
easy bruising

LFTs weekly X 1 month, then

monthly, due to risk of liver
dysfunction
Also watch for signs of liver
dysfunction: nausea, edema,
malaise

Side Effects

GI: N/V, diarrhea

Hematologic: transient leukopenia,

GI: liver disease (can be fatal), N/V,

diarrhea

GU: polyuria, polydipsia, GN,

renal failure, nephrogenic DI

CNS: tremor, lethargy, fatigue,

headache
Hematologic: reversible
leukocytosis
Other: teratogenic, weight gain,
edema, psoriasis, hypothyroidism,
hair thinning, muscle weakness
Interactions

NSAIDS decrease clearance

agranulocytosis

CNS: ataxia, dizziness, slurred speech,

drowsiness, confusion, nystagmus,
diplopia
Skin: rash (5% risk; should d/c drug

CNS: tremor, sedation, ataxia,

CNS: sedation, ataxia, dizziness

Other: increased cycling

drowsiness
Other: hair loss, weight gain,
transient thrombocytopenia

because of risk of Steven-Johnson

syndrome (SJS))
GI: N/V, diarrhea

No interaction with valproic acid

carbamazepine

MEDICATIONS/THERAPEUTICS . . . CONT.

MEDICATIONS/THERAPEUTICS . . . CONT.
Table 19. Common Anxiolytics
Class

Drug

Dose
Range
(mg/day)

t1/2

Benzodiazepines
Long-acting

clonazepam (Rivotril)

1.5-2.0

18-50

diazepam (Valium)

5-40

30-100

chlordiazepoxide (Librium)
flurazepam (Dalmane)
alprazolam (Xanax)

25-200
15-30
1-4

30-100
50-160
6-20

Sleep, anxiety
Sleep
Panic disorder,
sublingual available for very rapid action

lorazepam (Ativan)
oxazepam (Serax)
temazepam (Restoril)
triazolam (Halcion)

2-6
30-120
15-30
0.125-0.5

10-20
8-12
8-20
1.5-5

Sleep, generalized anxiety

Sleep, generalized anxiety
Sleep
Shortest t1/2, rapid sleep but rebound
insomnia

buspirone (Buspar)
zopiclone (Imovane)

20-60
7.5

Short-acting

Azapirones

Appropriate Use

Akathisia, generalized anxiety

seizure prevention, panic disorder
Generalized anxiety, seizure prevention,
muscle relaxant

Generalized anxiety
Sleep

Benzodiazepine Antagonist - Flumazenil (Anexate)

1 use for suspected benzodiazepine overdose
2 mechanism of action: a competitive benzodiazepine antagonist

PSYCHOSTIMULANTS
Table 20. Treatment of ADHD
Psychostimulants

Antidepressants

-agonist

Methylphenidate
(Ritalin)

Dextroamphetamine
(Dexedrine)

Dextroamphetamine
salts
(Adderal)

TCA

Clonidine

Indications

First line therapy

First line therapy

Available by
limited access

Used when
psychostimulants
fail or cannot be
tolerated

Used when
psychostimulants or
TCAs fail or cannot
be tolerated

Side Effects

Insomnia, irritability, paradoxical worsening

of behaviour
Anorexia, nausea, abdominal pain
Increased heart rate, headaches
Tics
Growth restriction

Dry mouth
GI upset
Dizziness

Sedation
Dry Mouth
Constipation
Dizziness

Contraindications

(Relative)-Tourettes, tics, substance abuse, weight/growth

retardation, psychosis, cardiac illness

Monitoring

Checklists (Child behaviour, Conners Teacher)

Side effects
Baseline ECG with clonidine

Impaired liver/renal
function
Heart disease
Baseline ECG

Baseline ECG

TREATMENT ALGORITHMS
MCCQE 2002 Review Notes

Psychiatry PS49

LEGAL ISSUES
COMMON FORMS
Table 21. Common Forms Under The Mental Health Act (in Ontario)
Form

Form 1:
Application by
physician to hospitalize
a patient for psychiatric
assessment against
his/her will (Form 42 to
patient)
Form 2:
Order for hospitalization
and medical examination
against his/her will by
Justice of the Peace

Form 3:
Certificate of
involuntary admission
(Form 30 to patient,
notice to rights advisor)

Form 4:
Certificate of renewal
of involuntary
admission (Form 30
to patient, notice to
rights advisor)
Form 5:
Change to
informal/voluntary
status

Who Signs

When

Expiration Date

Right of Patient
to Review
Board Hearing

Options
Before Form
Expires

Any MD

Within 7 days
after examination

72 hours after
hospitalization
Void if not
implemented within
7 days

No

Form 3
Voluntary
admission
Send home
+/ follow-up

Justice of the
Peace

No statutory
time restriction

7 days from when

filled out
Purpose of form is
complete once
patient brought to
hospital

No

Form 1
Send home
+/ follow-up

Attending MD
(different than
MD who
completed Form 1)

Before expiration
of Form 1
Any time to
change status
of an informal
patient

2 weeks

Yes
(within 48 hours)

Form 4
Form 5

Attending MD
following patient
on Form 3

Prior to
expiration of
Form 3

First: 1 month
Second: 2 months
Third: 3 months

Yes
(within 48 hours)

Form 4
Form 5

Attending MD
following patient
on Form 3/4

Whenever
deemed
appropriate

N/A

N/A

N/A

CONSENT
Definition
1 the voluntary agreement to what another person proposes
2 in medical care, consent is geared toward making the patient a
partner in a joint enterprise based on expectation that the physician is
pursuing the patients best interests
Health Care Consent Act (HCCA), 1996
1 covers consent to treatment (cosmetic, diagnostic, palliative,
preventive, or therapeutic), admission to care facility, and personal
assistance services (i.e. care outside of hospital) proposed by health
practitioners
2 consent to treatment will be the focus in this section
Valid Consent to Treatment - Five Criteria
1 specific - detailed treatment plan (a person may be capable
to consent/refuse one treatment but incapable for another)
2 informed - receives information about his/her medical condition, nature
of treatment, risks and benefits, side effects, alternative options,
consequences of not having treatment
3 voluntary - of the patients own will
4 honest - on the part of the practitioner proposing the treatment
5 capacity standards (see below)

PS50 Psychiatry

MCCQE 2002 Review Notes

LEGAL ISSUES . . . CONT.

Capaci ca
n
ty
Assess u
n
ment d
e
1
r
HCCA s
requi ta
res n
MD d
to t
asses h
s
e
patie i
nts n
abilit f
y too
cons rm
ent a
(deci t
sion io
maki n
ng
capa re
city) l
e
2
formal va
capa n
city t
asses
smen t
t iso
not
nece m
ssary a
- ink
most i
cases n
capa g
city
can a
be
presu d
med e
unles c
s
there is
are i
reaso o
nable n
grou
nds a
to n
belie d
ve
the a
perso p
n isp
incap r
able e
c
3
i
a
a
t
p
e
a
t
t
i
h
e
e
n
t
r
e
i
a
s
s
o
c
n
a
a
p
b
a
l
b
y
l
e
f
o
i
r
f
e
s
h
e
e
e
/
a
s
b
h
l
e

e
c
o
n
s
e
q
u
e
n
c
e
s
o
f
a
d
e
c
i
s
i
o
n
o
r
l
a
c
k
t
h
e
r
e
o
f

4
M
D
s
h
o
u
l
d
s
c
r
e
e
n
f
o
r
p
s
y
c
h
i
a
t
r
i
c
s
y
m
p
t
o
m
s
t
h
a
t
m
a
y
a
f
f
e
c
t

c
a
p
a
c
i
t
y
(
e
.
g
.
d
e
n
i
a
l
o
f
i
l
l
n
e
s
s
,
f
e
a
r
o
f
p
r
o
c
e
d
u
r
e
,
c
o
g
n
i
t
i
v
e
d
i
s
o
r
d
e
r
s
u
c
h
a
s
d
e
l
i
r
i
u
m
/
d
e
m
e
n
t
i
a
,
s
e
v
e
r

n
a
p
s
y
c
h
i
a
t
r
i
c
Treatm f
ent of a
c
the
i
Incapa li
t
ble
y
Patient )
a
1
docume nd
nt
opini c
on inon
chart t
a
2
c
n
t
o
t
r
i
i
f
g
y
h
t
p
s
a
t
a
i
d
e
v
n
i
t
s
o
o
r
f

e
d
e
p
r
e
s
s
i
o
n
)

d
e
t
e
r
m
i
n
a
t
i
o
n
b
y
F
o
r
m
3
3
(
f
o
r
p
s
y
c
h
i
a
t
r
i
c
t
r
e
a
t
m
e
n
t
i

obtain consent
from
substitute
decision maker (SDM)
using the following
hierarchy
1
court
appointed
guardian
2
power
of attorney for
personal care
3
capacit
y and control
board appointed
representative
4
spouse/
partner
5
child >
16 or custodial
parent
6
sibling
7
other
relative
8
public
guardian
and
trustee
4
SDM must be >
16 unless they are
parents deciding for a
child

5
b

e
g
i
n
t
r
e
a
t
m
e
n
t

u
n
l
e
s
s
p
a
t
i
e
n
t
w
i
s
h
e
s
t
o
a
p
p
e
a
l
t
h
e
d
e
c
i
s
i
o
n
t
o
t
h
e
C
o
n
s
e
n
t
a
n
d
C
a
p
a
c
i
t
y
B
o
a
r
d
(
C
C
B
)

Consent

1
a

c
t
i
n
a
c
c
o
r
d
a
n
c
e
t
o
w
i
s
h
e
s
e
x
p
r
e
s
s
e
d
p
r
e
v
i
o
u
s
l
y
b
y
t
h
e
p
a
t
i
e
n
t
,
a
p
p
l
i
c
a
b
l
e
t
o
Princip
t
les
h
SDM e
Must c
follow i
when rc
decidin u
m
g to
s
Give t

a
n
c
e
s
,
w
h
i
l
e
c
a
p
a
b
l
e

w
i
n
g
i
n
t
o
c
o
n
s
i
d
e
r
a
t
i
o
n

2
i

f
a
b
o
v
e
u
n
k
n
o
w
n
,
S
D
M
m
u
s
t
a
c
t
i
n
t
h
e
p
a
t
i
e
n
t

s
b
e
s
t
i
n
t
e
r
e
s
t
s
a
n
d
t
a
k
e
t
h
e
f
o
l
l
o

3
t

h
e
f
i
n
a
l
d
e
c
i
s
i
o
n
o
f
t
h
e
S
D
M
s
h
o
u
l
d
b
e
m
a
d
e
i
n
c
o
n
s
u

values
and beliefs held
by the patient
while capable
2
whether
medical
condition/wellbeing is likely
to improve with
vs.
without
treatment
3
whether
the
benefit
expected by the
treatment
outweighs the
risk of harm to
the patient
4
whether
a less intrusive
treatment would
be as beneficial
as
the
one
proposed

l
t
a
t
i
o
n
w
i
t
h
M
D
;
i
f
M
D
f
e
e
l
s
t
h
e
S
D
M
i
s
n
o
t
a
c
t
i
n
g
i
n
t
h
e
p
a
t
i
e
n
t

s
b
e
s
t
i
n
t
e
r
e
s
t
s
,
t
h
e
n
M
D
c
a
n
a
p
p
l
y
t
o

t
h
e
C
C
B
f
o
r
a
n
o
t
h
e
r
S
D
M
Can an Incapable
Patient be Forced to
Stay in Hospital to
Receive Treatment?
1
no - HCCA
does not address the
issue of detaining
incapable patients

an
incapable
patient
can only
be
detained
against
his/her
will to
receive
treatment
if he/she
meets the
criteria for
certificati
on under
the
Mental
Health
Act
(MHA)
(Form 1
or 3)

to apply the
above, the hospital in
question must be a
schedule 1 facility
What about Treatment
of an Incapable Patient
in an Emergency
Situation?

1
e

m
e
r
g
e
n
c
y
t
r
e
a
t
m
e
n
t
m
a
y

b
e
a
d
m
i
n
i
s
t
e
r
e
d
w
i
t
h
o
u
t
c
o
n
s
e
n
t
i
f
t
h
e
p
h
y
s
i
c
i
a
n
b
e
l
i
e
v
e
s
t
h
e
i
n
c
a
p
a
b
l
e
p
a
t
i
e
n
t
i
s
:

experiencing
severe suffering
2
at risk
of
sustaining
serious bodily
harm
if
treatment is not
administered
promptly
2
MD
must
document reasons for
incapacity and why
situation is emergent

since
the
SD
M
is
not
usu
ally
im
me
diat
ely
ava
ilab
le,
M
D
can
trea
t
wit
hou
t
con
sen
t
unt
il
the
SD
M
is
ava
ilab
le
or
the
situ
atio
n is
no
lon
ger
an
em
erg
enc
y
Pediatric Aspects of
Capacity Covered by
the HCCA
1
no
age
of
consent - consent
depends on ones
decision-making
ability (capacity)

2
t

h
i
s
c
a
u
s
e
s
a
d
1 i
ap l
pe
am
rm
ea
n
tw
li
yt

h
p
a
t
i
e
n
t
s
w
h
o
a
r
e
i
n
f
a
n
t
s
o
r
c
h
i
l
d
r
e
n
a
d
o
l
e
s
c
e
n
t
s
a
r
e
u
s
u
a
l
l
y
t
r
e
a
t
e
d
a
s
a
d
u
l
t
s

they should still be

involved (e.g. be
provided the
information
appropriate to their
comprehension level)
4
most
likely
SDM in hierarchy is a
parent
or
legal
guardian

5
s

u
p
p
o
r
t
f
o
r
t
h
e
f
a
m
i
l
y
a
n
d
p
a
t
i
e
n
t
i
s
e
s
s
e
n
t
i
a
l
a
n
d
c
a
n
i
n
v
o
l
v
e
t
h
e
a
t
t
e
3
n
it is
assu d
med i
that n
infan g
ts
and p
child h
ren y
lack s
matu i
re c
decis i
ion- a
maki n
ng ,
capa
city n
for u
cons r
ent s
but e

s
,
c
h
a
p
l
a
i
n
s
,
e
t
c
.

g
in
th
e
c
hi
ld
s
b
es
t
in
te
re
st
,
a
n
a
6
p
i
p
n
e
al
t
c
h
a
e
n
b
e
e
v
m
e
a
n
d
t
e
to
t
th
h
e
a
pr
t
o
vi
t
n
h
ci
e
al
c
p
hi
h
ld
y
w
s
el
i
fa
c
re
i
a
a
ut
n
h
or
b
iti
e
es
l
i
Other Types of
e
Capacity Not Covered
v
e
by the HCCA
s
1
testamentary
t
(ability to make a
h
will)
e
2
fitness (ability to
S
stand trial)
D
3
financial (ability
M
to manage property Form 21 of the MHA)
i
s
4
personal (ability
to care for oneself)
n
5
areas
of
o
capacity
are
t
independent
a
a
person
may
be
c
incapable in some
t
areas but capable in
i
others
n
CQE 2002 Psychiatry
Review Notes PS51
MC

LEGAL ISSUES . . . CONT.

Criteria for Financial Competence
1
covered by the Mental Health Act (section 54) and Substitute Decision Act (section 16,27)
2
patient must
1
appreciate importance of financial capability and reason for exam
2
have realistic appreciation of own strengths/weaknesses in managing finances
3
understand nature and extent of assets, liabilities, income, and expenses
4
have recently demonstrated ability to make sound
reasonable financial decisions and be expected to do so in
future
5
have appropriately used available resources, and indicate willingness to do so in future
3
if MD determines the patient is incapable of managing property, a
Form 21 is completed and the Public Guardian and Trustee becomes the
temporary guardian until a substitute can be found; those eligible as
substitute guardians are the patients spouse/partner, relative, or attorney
4
Form 21 can only be filled out if the patient is an
inpatient of a psychiatric facility

COMMUNITY TREATMENT ORDER (CTO)

1

purpose: to provide a person who suffers from a serious

mental disorder with a comprehensive plan of community-based
treatment or care and supervision that is less restrictive than being
detained in a psychiatric facility
2
intended for those who, as a result of their serious mental
disorder, experience a pattern of admission to a psychiatric
facility where their condition is usually stabilized; who after
being released often stop treatment or care and supervision after
discharge to community; whose condition then changes, and, as a
result, requires admission to hospital

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PS52 Psychiatry

MCCQE 2002 Review Notes