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PS1!Psychiatry Toronto Notes 2023

Mood Episodes

DSM-5 DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE EPISODE

Reprintedwithpermission Itom the Diagnostic and Statistical Manual ol Mental Disorders.5th ed. 2013.American Psychiatric Association

A.>5of the following symptoms have been present during the same 2 wk period and represent a change

from previousfunctioning; at least one of the symptoms is either 1) depressed mood or 2) loss of

interest or pleasure (anhedonia)

Note: Do not include symptoms that are clearly attributable to another medical condition

• depressed mood most of the day, nearly every day, as indicated by either subjective report or

observation made by others

markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly

every day

significant and unintentional weight loss/weight gain,or decrease/increase in appetite nearly

every day

insomnia or hypersomnia nearly every day

• psychomotor agitation or retardation nearly every day

• fatigue or loss of energy nearly every day

feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly

every day (not merely self-reproach or guilt about being sick)

diminished ability to think or concentrate,or indecisiveness nearly every day

• recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific

plan, or a suicide attempt or a specific plan for committing suicide

B.the symptoms cause clinically significant distress or impairment in social, occupational, or other

important areas of functioning

C.the episode is not attributable to the direct physiological effects of a substance or a GMC

Criteria for Depression (>5)

MSIGECAPS

Mood:depressed

Sleep:increased/decreased

Interest decreased

Guilt

Energy: decreased

Concentration:decreased

Appetite:increased/decreased

Psychomotor:agitation/retardation

Suicidal ideation

<§) DSM-5 CRITERIA FOR MANIC EPISODE

Reprinted withpermission from the Diagnostic and Statistical Manual of Mental Disorders.5th ed. 2013.American Psychiatric Association

A.a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally

persistently increased goal-directed activity or energy, lasting £1 wk and present most of the day,

nearly every day (or any duration if hospitalization is necessary)

B.during the period of mood disturbance and increased energy or activity,>3of the following

symptoms have persisted (4 if the mood isonly irritable) and have been present to a significant degree

and represent a noticeable change from usual behaviour

inflated self-esteem or grandiosity

* decreased need for sleep (e.g. feels rested after only 3 h of sleep)

more talkative than usual or pressure to keep talking

flight of ideas orsubjective experience that thoughts are racing

distractibility (i.e.attention too easily drawn to unimportant or irrelevant externalstimuli)

increase in goal-directed activity (eithersocially,at work or school, orsexually) or psychomotor

agitation

• excessive involvement in pleasurable activities that have a high potential for painful consequences

(e.g. engaging in unrestrained shopping sprees,sexual indiscretions, or foolish business

investments)

C.the mood disturbance issufficiently severe to cause marked impairment in social or occupational

functioning or to necessitate hospitalization to prevent harm to self or others,or there are psychotic

features

D.the episode is not attributable to the physiological effects of a substance or another medical condition

Note: A full manic episode that emerges during antidepressant treatment but persists at a fully

syndromal level beyond the physiological effect of that treatment issufficient evidence for a manic

episode, and therefore, a bipolar 1 diagnosis

Note:Criteria A-D constitute a manic episode. At least one lifetime manic episode is required for the

diagnosis of bipolar I disorder

Hypomanic Episode

•criterion A and B of a manic episode is met, but duration is £4 d

•episode associated with an unequivocal change in functioning that is uncharacteristic of the

individual when not symptomatic and observable by others

•episode is not severe enough to cause marked impairment in social or occupational functioning or to

necessitate hospitalization

•absence of psychotic features(if these are present the episode is, by definition, manic)

Mixed Features

•episode specifier in a manic, hypomanic,or depressive episode of bipolar I or II (BDl/Ii) that indicates

the presence of both depressive and manic symptoms concurrently, classified by the disorder and

primary mood episode (i.e. BD1, current episode manic, with mixed features)

•clinical importance due to increased suicide risk and appropriate treatment

•if found in patient diagnosed with major depression, there is a high index ofsuspicion for BD

•while meeting the full criteria for a \1DE, the patient has on most days 3 of criteria B for a manic

episode

•while meeting the full criteria for a manic/ hypomanic episode, the patient has on most days 23of

criteria A for a depressive episode (the following criterion A cannot count: psychomotor agitation,

insomnia, difficulties concentrating, or weight changes)

Criteria tor Mania (s3)

and GST PAID

Grandiosity

Sleep (decreased need)

Talkative

Pleasurable activities, Painful

consequences

Activity (increased)

Ideas (flight of)

Distractiblc

r n

u

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PS12 Psychiatry Toronto Notes 2023

Depressive Disorders

Anlideprtssauts for Depression in Physically

IIIPeople

Cochrane MSysl Per 2010XOOO/SO3

Purpose:lo determine the efficacy of

antidepressants in treating depression in people with

comorbid physical illness.

Methods: Systematic review olICIs comparing

the efliucy of antidepressants vs. placebo in the

treatment of major depression,adpistment disorder,

and dystbyoia in adults with comorbid depression

and physical illness.Physical illnesswas defined as

any medical condition known to have a biological

underpinning where diagnosis is not purely symptom

based.

Results:fifty-one studies including 3003

participants were included in thisreview.Both

tricyclic antidepressants and selective serotonin

reuptake inhibitors were more effective than placebo

at treating depression m adultswith concunent

physical illness.Ory mouth and seual dysfunction

were more com man in patieatstreated with an

antidepressant.

MAJOR DEPRESSIVE DISORDER

DSM-5 DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE DISORDER (MDD)

Reprinted withpermission from the Diagnostic andStatistical Manual of Mental Disorders,5th ed.2013.AmericanPsychiatricAssociation

A.presence of a single MDE (vs. recurrent, which requires presence of two or more MDEs; to be

considered separate episodes, there must be an interval of at least 2 consecutive mo in which criteria

arc not met for a MDE)

B.the MDE is not better accounted for by schizoaffective disorder and is notsuperimposed on

schizophrenia,schizophreniform disorder, delusional disorder,or psychotic disorder NOS

C.there has never been a manic episode or a hypomanic episode

• note:

'

this exclusion does not apply ifall of the manic-like, or hypomanic-likc episodes are substance

or treatment-induced or are due to the direct physiological effects of another medical condition

• specifiers:with anxious distress, mixed features, melancholic features, atypical features,moodcongruent psychotic features,mood-incongruent psychotic features, catatonia, peripartum onset,

seasonal pattern

Epidemiology

• Canadian annual/lifetime prevalence:5%/ll%

• peak prevalence age 15-25 yr (M:F=l:2)

Etiology

• biological

genetic:65-75% MZ twins; 14-19% DZ twins, 2-4 fold increased risk in first-degree relatives

neurotransmitter dysfunction:decreased activity of 5-HT, NE, and DA at neuronalsynapse;

changes in GABA and glutamate; various changes detectable by fMRI

neuroendocrine dysfunction:abnormal HPA axis activity

neuroanatomy and neurophysiology:decreased hippocampal volume,increased size of ventricles;

decreased REM latency and slow-wave sleep; increased REM length

• immunologic: increased pro-inflammatory cytokines 1L-6 and TNI;

secondary to medical condition, medication,substance use disorder

• psychosocial

cognitive (i.e. distorted schemata. Beck’s cognitive triad: negative views of oneself, the world, and

the future)

environmental factors (i.e. job loss, bereavement, history of abuse or neglect, early life adversity)

comorbid psychiatric diagnoses(i.e. anxiety,substance use disorder, developmental disability,

dementia,eating disorders)

Risk Factors

• sex:E:M=2:1

• family history:depression, alcohol use disorder,suicide attempt or completion

• adverse childhood experiences:loss of parent before age 11, negative home environment (abuse,

neglect)

• personality: neuroticisni, insecure, dependent, obsessional

• recent stressors: illness, financial, legal,relational,academic

• lack of intimate,confiding relationships orsocial isolation

• low socioeconomic status

Clinically Significant Depressive Symptoms in the Elderly

• affects about 15% of community residents >65 ylo; up to 50% in nursing homes

• high suicide risk due to social isolation, chronic medical illness, and decreased independence

• suicide peak: males ages 80-90, females ages 50-65

• low mood or dysphoria may not be a reliable indicator of depression in those >70 y/o

• often present with somatic complaints (i.e. changesin weight,sleep, energy;chronic pain) or anxiety

symptoms

• may have prominent cognitive changes after onset of mood symptoms (dementia syndrome of

depression)

• see Table 3,PS26,for a comparison of delirium and dementia

Treatment

• lifestyle:increased aerobic exercise, mindfulness-based stress reduction,sleep hygiene

• biological:SSRIs, SNRls, other antidepressants, somatic therapies(see Pharmacotherapy; PS5I and

Somatic Therapies,PS60)

for MDE of moderate or greaterseverity, 1st line pharmacotherapy are used: most 2nd generation

antidepressants, with escitalopram, mirtazapine, sertraline, venlafaxine, agomelatine,and

dtalopram showing evidence for superiority

for non or partial response, optimize the dose,switch to antidepressant with superiority, or add

augmenting agent (i.e.aripiprazole, quetiapine,risperidone)

typical response to antidepressant treatment:physical symptoms improve at 2 wk, mood/

cognition by 4 wk;if no improvement after 4 wk at the highest tolerated therapeutic dosage, alter

regimen

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PS13 Psychiatry Toronto Notes 2023

ECT: currently fastest and most effective treatment for MDD.Consider in severe, psychotic,or

treatment-resistant cases

tTMS: 1st line treatment for MDD for patients who have failed at least I antidepressant treatment.

Efficacy equivalent to medications (but not to ECT) with good safety and tolerability

phototherapy:especially ifseasonal component,shift work,sleep dysregulation

•psychological

individual therapy (CUT, interpersonal, behavioural activation, dynamic), group therapy, family

therapy

•social:vocational rehabilitation,socialskillstraining

•experimental: magnetic seizure therapy, deep brain stimulation, ketamine

Prognosis

•1 yr after diagnosis of MDD without treatment: 40% of individuals will still have symptoms that are

sufficiently severe to meet criteria for MDD, 20% will continue to have some symptoms that no longer

meet criteria for MDD, 40% will have no symptoms

PERSISTENT DEPRESSIVE DISORDER

Sec landmark Psychiatry Trials table

(or mote information on TRANSFORM-2,

which detailsthe use of esk etamine

nasalspray for patients with treatmentresistant depression.

DSM-5 DIAGNOSTIC CRITERIA FOR PERSISTENT DEPRESSIVE DISORDER

Note:in DSM-1V-TR this was referred to as Dysthymic Disorder

Reprinted withpermission from the Diagnostic and Statistical Manual of Men

A.depressed mood for most of the day, for more days than not, asindicated either by subjective account

or observation by others, for S2 yr

Note:In children and adolescents, mood can be irritable and duration must be at least 1 yr

B.presence, while depressed, of 2 of the following

poor appetite or overeating

insomnia or hypersomnia

low energy orfatigue

low self-esteem

poor concentration or difficulty making decisions

feelings of hopelessness

C.during the 2 yr period (1 yr for children or adolescents) of the disturbance,the person has never been

without the symptoms in criteria A and B for more than 2 mo at a time

D.criteria for a major depressive disorder may be continuously present for 2 yr

E.there has never been a manic episode or a hypomanic episode, and criteria have never been met for

cyclothymic disorder

F. the disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia,

delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic

disorder

G.the symptoms are not due to the direct physiological effects of a substance or another medical

condition

H.the symptoms cause clinically significant distress or impairment in social, occupational, or other

important areas of functioning

•specifiers:

with anxious distress, mixed features, melancholic features, atypical features, mood-congruent

psychotic features, mood-incongruent psychotic features, catatonia, peripartum onset,seasonal

pattern

partial remission,full remission

early onset (<21 y/o), late onset (>21 y/o)

with pure dysthymic syndrome (full criteria for MDE have not been met in at least preceding 2

yr), with persistent MDE (full criteria for MDE have been met throughout preceding 2 yr)

with intermittent MDEs,with current episode:full criteria for a MDE are currently met, but

there have been periods of at least 8 wk in at least the preceding 2 yr with symptoms below the

threshold for a full MDE

with intermittent MDEs, without current episode:full criteria for a MDE are not currently met,

but there has been one or more MDEs in at least the preceding 2 yr

specify current severity: mild, moderate,severe

tal Disorders,5th ed.2013.American Psychiatric Association

Epidemiology

•lifetime prevalence: 2-3%; M=F

Treatment

•psychological

traditionally, psychotherapy was the principal treatment for persistent depressive disorder;

recent evidence suggests some (but generally inferior) benefit for pharmacological treatment.

Combinations of the two may be most efficacious

n

L J

•biological

antidepressant therapy:SSRls (e.g.sertraline,escitalopram),

'

l

'

CAs (e.g. nortriptyline) +

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PS14 Psychiatry Toronto Notes 2023

Postpartum Mood Disorders

Selective Serotonin IteuptakeInhibitors in

Pregnancy and Infant Outcomes

PttdiitrChM Health 2011;16:S62 63

Canadian Paediatric Society|CPS) clinical practice

guideline recommendations:It is important tn treat

depression in pregnancy.There is noevidence that

SSHIS increase the risk of major matformations. there

Is conflicting tmdenct concerning the association of

paroxetine and cardiac malformations.SSRIs are not

contraindicated nhile breast-feeding.

Postpartum “Blues"

• transient period of mild depression, mood instability, anxiety, decreased concentration; considered

to be normal in response to fluctuating hormonal levels, the stress of childbirth, and the increased

responsibilities of motherhood

• occurs in 50-80% of mothers;begins 2-4 d postpartum, usually lasts 48 h, can last up to 10 d

• does not require psychotropic medication

• usually mild or absent:feelings of inadequacy, anhedonia, thoughts of harming baby,suicidal

thoughts

MAJOR DEPRESSIVE DISORDER WITH PERIPARTUM ONSET

(POSTPARTUM DEPRESSION)

Antidepressant Use in Pregnancy and the Disk of

Cardiac Defects

ItJM 2014 Jun19;370(25):2397-2407

Purpose: It is oncerUin whetherselective serotoninreuptake inhibitors (SSRIs) and other antidepressants

during pregnancy are associated mth increased risk

uf congenital cardiac defects.There areconcerns

about an association between paroxetine use and

right ventricular outflow tract obstruction, and

between sertraline use and ventricular septal defects.

Methods:Cohortstudy Including 949S04 women

enrolled in Medicaidfor a 7 yr period.The risk oT

major cardiacdelects among infants born to women

who took antidepressants during thelst trimester

wot compared with the fish among infants bom

to women rnhodid not useanbdtpreisonti.tn

unadjusted analysis was used, possible conTounders

were considered.

Results:Overall, the chance of infants not exposed

to antidepressants born with a cardiac defect was

72.3 per 10000 infants,and infantswith exposuro

was90.1 per 10000 infants, the relative risks of

any cardiacdefect w ilb the useof SSRIs were106

(95% Cl,0.93to1.22) in the fuly adjusted a na lysis

restricted towomen with depression.No significant

association wasfoond belwtrn the use ol paroxetine

and right reotricolir outflow trad obstruction (11.

1.07|or between the use of sertraine and ventricular

septal defects(PR,1.04).

Conclusions:No substantial increase in risk uf

cardiac malformations attributable to antidepressant

use during thelst trimester.

Clinical Features

• thisspecifier can apply to a MDE with onset during pregnancy or within 4 wk following delivery

• typically lasts 2-6 mo; residual symptoms can last up to I yr

• may present with psychosis (rare, 0.2% - more frequent with prior postpartum mood episodes and

postpartum mania)

• severe symptoms may include complete disinterest in baby,suicidal and infanticidal ideation

Epidemiology

• occurs in up to 3-6% of mothers, up to 50% risk of recurrence

Risk Factors

• previous history of a mood disorder (postpartum or otherwise),family history of mood disorder

• psychosocial factors:stressful life events, unemployment, marital conflict, lack of social support,

unwanted pregnancy, colicky orsick infant

Treatment

• psychotherapy (CBT or IPT)

• short-term safety of maternal SSRIs for breastfeeding infants established; long-term effects unknown

• if depression severe or psychotic symptoms present,consider ECT

Prognosis

• impact on child development; increased risk of cognitive delay, insecure attachment, behavioural

disorders

• treatment of mother improves outcome for child at 8 mo through increased mother-child interaction

Bipolar Disorders

BIPOLAR I/BIPOLAR II DISORDER

Definition

• Bipolar I Disorder

disorder in which at least one manic episode has occurred

if manic symptomslead to hospitalization, or if there are psychotic symptoms, the diagnosis is

bipolar I

• commonly accompanied by at least 1 MDE but not required for diagnosis

time spent in mood episodes:53% asymptomatic,32% depressed,9% cycling/mixed,6% hypo/

manic

• Bipolar II Disorder

disorder in which there is at least 1 MDE, 1 hypomanic episode, and no manic episodes

• while hvpomania isless severe than mania, bipolar 11 is not a “milder"

form of bipolar I

time spent in mood episodes:46% asymptomatic,50% depressed, 1% cycling/mixed, 2% hypo/

manic

• bipolar 11 is often missed due to the severity and chronicity of depressive episodes and low rates of

spontaneous reporting and recognition of hypomanic episodes

Classification

• classification of BD involves describing the disorder (1 or II) and the current or most recent mood

episode as either manic, hypomanic, or depressed

• specifiers; with anxious distress, hypo/manic/depressed with mixed features, rapid cycling,

melancholic features, atypical features, mood-congruent or -incongruent psychotic features,catatonia,

peripartum onset,seasonal pattern, rapid cycling (>4 mood episodes in 1 yr)

Bipolar It is quite often missed and many

patients are symptomatic for up to a

decade before accurate diagnosis and

treatment

Patients with bipolar disorder are at

higher risk for suicide when they switch

(tom mania to depression, especially as

they become aware of consequences

of their behaviour during the manic

episode

Lithium is among few agents with

proven efficacy in preventing suicide

attempts and completions LJ

+

Epidemiology

• lifetime prevalence: 1% BD 1, 1.1% BD II, 2.4% Subthreshold BD;M:F=1:1

• mean age of onset:25 yr, usually MDE first, manic episode 6-10 yr after; average age of first manic

episode: 32 yr

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PS15 Psychiatry Toronto Notes 2023

Risk Factors

• genetic: 60-65% of bipolar patients have family history of a major mood disorder, especially bipolar

disorder

• clinical features of MDE history favouring bipolar over unipolar diagnosis:early age of onset (<25 yr),

increased number of MDEs, psychotic symptoms, postpartum onset, anxiety disorders (especially

separation, panic), antidepressant failure due to early “poop out"or hypomanic symptoms, early

impulsivity and aggression, substance misuse,cyclothymic temperament,family history of bipolar

disorder

Monotherapy with antidepressants

should be avoided in patients with

bipolar depression as patients can

switch horn depression into mania

The 4 L's for Bipolar Depression

Lithium, lamotriginc. Lurasidonc.

SeroqueL

Treatment

• lifestyle:psychoeducation regarding cycling nature of illness, ensure regular check ins,develop early

warning system, “emergency plan” for manic episodes, promote stable routine (sleep,meals, exercise)

• biological:lithium, anticonvulsants, antipsychotics,ECT (if resistant); monotherapy with

antidepressants should be avoided

• mood stabilizers vary in their ability to treat (reduce symptoms acutely) orstabilize (prevent

relapse and recurrence) manic and depressive symptoms; multi-agent therapy is common

treating mania:lithium,divalproex, carbamazepine (2nd line), SGA,ECT (2nd line),

benzodiazepines (for acute agitation)

preventing mania:same as above but usually at lower dosages, minus ECT and benzodiazepines

treating depression:lithium,lurasidone, quetiapine, lamotrigine,antidepressants (2nd line,only

with mood stabilizer), ECT (2nd line)

preventing depression:same as above plus aripiprazole, divalproex (note: quetiapine is first line in

treating bipolar II depression)

mixed episode or rapid cycling:multi-agent therapy:lithium or divalproex + SGA (lurasidone,

aripiprazole)

• psychological:supportive psychotherapy, CBT, 1PT or interpersonal social rhythm therapy, family

therapy

• social: vocational rehabilitation,consider leave of absence from school/work, assess capacity to

manage finances, drug and EtOH cessation,sleep hygiene,social skills training, recruitment and

education of family members

A Randoumed Controlled Trialof Cognitive

Therapyfor Bipolar Disorder:focus onloug-Teim

Orange

J Clin Psychiatry 2006:67:277 86

Purpose: lo evaluate long term change with

cognitive therapy plus emotive techniqueslor the

treatment of bipolar disorder.

Methods: 3 - ded RCI including patents with DSM-IV

b poiar I or it disorder allocated to either a (mo trial

o!cognitive therapy (Cl) with emotive techniques

or treatment as usual.Both groups received mood

stobilirers. Main outcomes were relapse rates,

dysfunctional attitudes, psychosocialfuncliomag,

hopelessness,self-control, and medication

adherence.Patients were assessed by independent

raters htnded to treatmentgroup.

Results:At 6no.CT patientserepe rienced fewer

depressive symptoms and fewer dysfunctional

attitudes,

(here was a non sgr ficant (p-0.06) trend

to greater time to depressive relapse.At12mo followup,CT patents had lower Toung Mania Rating scores

and improved behavioural self -control. At IB mo.Cl

patients repotted letssoveiity ol illness.

Conclusions:Cl appearsto piovide benefitsin the12

mo after completion ol therapy.

Course and Prognosis

• high suicide rate ( 15% mortality from suicide), especially depressive episodes in mixed states

• bipolar I and II disorder are chronic conditions with a relapsing and remitting course featuring

alternating manic and depressive episodes;depressive symptoms tend to occur more frequently and

last longer than manic symptoms

• can achieve high level of functioning betsveen episodes

• may switch rapidly between depression and mania without any period of euthymia in between

• high recurrence rate for mania -90% will have a subsequent episode in the next 5 yr

• long term follow-up of bipolar 1 - 15% well, 45% well with relapses, 30% partial remission, 10%

chronically ill

Efficacy of Cognitive-Behavioural Therapy in

Patients withBipolar Disorder: A Meta-Analysis

dRandomited Controlled Trials

PLoS One 20U;12|5|:e01/6849

Purpose:lo determine the efficacy of cognitive

behavioural therapy (CBT)in the treatment of type I

and II bipolar disorder.

Methods:A systematic review and meta-arutyui of

RCIs of Cll in the trealmeof of adultswith bipolar

disorder.

Results:It nefeen RCIs includmg1284 patients with

type I or II BO weie included.C81 lowered the relapse

rate|pooUd 0R*0.506;95\ 0*

0.218 -0.921) end

improved depieisme symptoms|g

—0.494;95%

CI--0.963 to-D.026), mania seventy )

-0.581:95%

CM.127to-0.035), and psychosodal functioning

|g*

0.45J;95\0*

0.106-0.809). treater effects

weie seen with CBI treatment duration >90 mil.

Relapse rates were lower in people with type I bipolar

disorder.

CYCLOTHYMIA

Diagnosis

• presence of numerous periods of hypomanic and depressive symptoms(not meeting criteria for full

hypomanic episode or MDE) for 2 yr; never without symptoms for >2 mo

• have never met criteria for MDE, manic, or hypomanic episodes

• symptoms are not due to the direct physiological effects of a substance or GMC

• symptoms cause clinically significant distress or impairment in social, occupational,or other

important areas of functioning

Treatment

• similar to Bipolar I:mood stabilizer ± psychotherapy

Anxiety Disorders

Definition

• fear is a universal human experience which can serve as an adaptive mechanism to facilitate

appropriate reactions to external threat

• anxiety may be seen as pathological fear when:

fear is greatly out of proportion to risk/severity of threat

response continues beyond existence of threat (prolonged, excessive, etc.) or becomes generalized

to othersimilar or dissimilar situations

social or occupational functioning is impaired

r i

L J

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PS16 Psychiatry Toronto Notes 2023

•manifestations of anxiety are a result of the activation of the sympathetic nervous system and can be

described through:

physiology:main brain structure involved is the amygdala;neurotransmitters involved include

5-HT,cholecystokinin, epinephrine, norepinephrine,and DA

psychology:one’

sthoughts about a given situation orstimulus contribute to the feeling of fear and

perception of threat

• behaviour:anxiety can lead to avoidance which can perpetuate the fear/avoidance

• often comorbid with substance use and depression; more than 50°u have multiple anxiety

disorders

• when starting medication for anxiety:start low, go slow, aim high, and explain symptoms to

expect prior to initiation of therapy to prevent non-adherence due to side effects

• psychotherapy:individual or group CBT

Differential Diagnosis

Table 2. Differential Diagnosis of Anxiety Disorders

Post-Ml.arrhythmia,congestive heart failure,pulmonary embolus,mitral valve prolapse

Asthma.COPD.pneumonia

Hyperthyroidism,hypoglycemia,hyperadrenalism.hyperparathyroidism

Vitamin BUleficiency,folate deficiency,porphyria,hypoxemia.hypercalcemia

Neoplasm,vestibular dysfunction,encephalitis,trauma (contusion or hematoma).MS.temporal lobeepilepsy,migraine

Cerebral (meningitis,HIV.syphilis) or systemic

Gastritis,esophageal spasm

Substance-Induced Intoxication (caffeine,cannabis, amphetamines,cocaine,thyroid replacement,OTC for colds/decongestants, steroids),

withdrawal (benzodiazepines, alcohol)

Cardiovascular

Respiratory

Endocrine

Metabolic

Neurologic

Infectious

Gl

Medical Workup of Anxiety Disorder

• only proceed with medical workup as clinically indicated

• routine screening:vitals, physical exam, CBC, electrolytes,thyroid function test, glucose, EGG

• additionalscreening: extended electrolytes, vitamin Bi:, (5-HCG,folate, chest x-ray, any other tests as

per DDx in Table 2

Risk Factors for the Development of Anxiety Disorders

• biological

endocrine disorders (i.e. hyperthyroidism), respiratory conditions (i.e. asthma), CNS conditions

(Le.temporal lobe epilepsy),substances/medications(Le.excessive stimulant use), chronic

medical illness

personal or family history of anxiety or mood disorder

• XX>XY chromosomes

• psychological

• current stress,early childhood adversity or trauma, early parental loss, parental factors

Panic Disorder

DSM-5 DIAGNOSTIC CRITERIA FOR PANIC DISORDER

Reprintedwithpermission from the Diagnostic and Statistical Manual of Mental Disorders.Sth ed.2013.American PsychiatricAssociation

A.recurrent unexpected panic attacks; a panic attack is an abrupt surge of intense fear or intense

discomfort that reaches a peak within minutes, and during which time four (or more) of the following

symptoms occur

palpitations, pounding heart, or accelerated heart rate

sweating

trembling orshaking

sensations ofshortness of breath orsmothering

feelings of choking

• chest pain or discomfort

• nausea or abdominal distress

• feeling dizzy, unsteady,light-headed,or faint

• chills or heat sensations

paresthesias (numbness or tingling sensations)

• derealization (feelings of unreality) or depersonalization (being detached from oneself)

• fear of losing control or "

going crazy”

• fear of dying

B. at least one of the attacks has been followed by 1 mo (or more) of one or both of the following:

persistent concern or worry about additional panic attacks or their consequences

« a significant maladaptive change in behaviour related to the attacks

C.the disturbance is not attributable to the physiological effects of a substance or another medical

condition

D.the disturbance is not better explained by another mental disorder

Situational trigger Panic attack

t ]

Mentally

associated with

situation

Increased anxiety

and generalization

to other situations

Figure 2. Mechanism of panic

attacks

<§>

Criteria for Panic Attack (>4)

STUDENTS FEAR the 3 Cs

Sweating

Trembling/shaking

Unsteadiness,dizziness

Depersonalization.Derealization

Excessive heart rate,palpitations

Nausea 'abdominal distress

Tingling numbness

Shortness of breath

Fear of dying,losing control,going

crazy

3 Cs:Chest pain,Chills

'

hot flashes.

Choking

i.j

+

Duration typically 5-10 min

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PS17 Psychiatry Toronto Notes 2023

Epidemiology

• lifetime prevalence:5% (one of the top five most common reasons to see a family physician); M:l

'

=l:2-

3

• onset:average early-mid 20s, familial pattern

• comorbidities: depression, agoraphobia, medical comorbidity

Treatment

• pharmacological and psychological treatment together can be very effective

• psychological

CBT:exposure (graduated exposure to unpleasant sensations of arousal associated with a panic

attack for experiential disconfirmation of their fears), cognitive restructuring (addressing

underlying beliefs regarding the panic attacks),relaxation techniques (visualization, boxbreathing), psychoeducation

• pharmacological (first line agents)

• SSKIs:fluoxetine, citalopram, escitalopram, paroxetine,sertraline, fluvoxamine

SNR!: venlafaxine extended release

• with SSKI/SNKls,start with low doses and titrate up as tolerated

• anxiety disorders often require treatment at higher doses for a longer period of time than

depression (full response may take up to 12 wk)

treat for up to 1 yr aftersymptoms resolve to avoid relapse

explain expected adverse effects prior to initiation of therapy to prevent non-adherence

other antidepressants:(mirtazapine,TCAs)

benzodiazepines considered 2nd line (short-term,lowest effective dose, helpful while titrating

antidepressant)

Panic Attack vs. Panic Disorder

. Panic disorder requires recurrent

unexpected panic attacks + fear of

another panic attack

. Panic attacks can occur in the

context of many different disorders

Starting Medication for Anxiety

Start low. go slow, aim high, and explain

symptoms to expect prior to initiation of

therapy to prevent non-adherence due

to side effects

Prognosis

• 85% can achieve good results, 10-20% continue with significant symptoms. Longer term, 65% achieve

remission

• clinical course: chronic, but episodic with psychosocial stressors

Agoraphobia

DSM-5 DIAGNOSTIC CRITERIA FOR AGORAPHOBIA

Reprinted with permission from the Diagnostic and Statistical Manual ol Mental Disorders, 5th cd. 2013.American Psychiatric Association

A. marked fear or anxiety about two (or more) of the following five situations:

• using public transportation

being in open spaces

being in enclosed places

standing in line or being in a crowd

being outside of the home alone

B. the individual fears or avoids these situations because of thoughts that escape might be difficult or

help might not be available in the event of developing panic-like symptoms or other incapacitating

or embarrassing symptoms

C. the agoraphobic situations almost always provoke fear or anxiety

D. the agoraphobic situations are actively avoided, require the presence of a companion,or are

endured with intense fear or anxiety

L. the fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and

to the sociocultural context

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'

.the fear, anxiety, or avoidance is persistent, typically lasting S6 mo

G. the fear, anxiety, or avoidance causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning

H. if another medical condition is present,the fear,anxiety, or avoidance is clearly excessive

I. the fear, anxiety,or avoidance is not better explained by the symptoms of another mental disorder

and are not related exclusively to obsessions, perceived defects or flaws in physical appearance,

reminders of traumatic events,or fear ofseparation

Note: agoraphobia is diagnosed irrespective of the presence of panic disorder.If an individual'

s

presentation meets criteria for panic disorder and agoraphobia, both diagnosesshould be assigned

Treatment

• as per specific panic disorder

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PS18 Psychiatry Toronto Notes 2023

Generalized Anxiety Disorder

DSM-5 DIAGNOSTIC CRITERIA FOR GENERALIZED ANXIETY DISORDER

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Sth ed. 2013. American PsychiatricAssociation

A.excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6

mo, about a number of events or activities (such as work or school performance)

B.the individual finds it difficult to control the worry

C.the anxiety and worry are associated with three (or more) of the following six symptoms(svith at least

some symptoms having been present for more days than not for the past 6 mo)

1.restlessness orfeeling keyed up or on edge

2.being easily fatigued

3. difficulty concentrating or mind going blank

4. irritability

5. muscle tension

6.sleep disturbance (difficulty falling orstaying asleep,or restless, unsatisfying sleep)

D.the anxiety,worry,or physicalsymptoms cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning

E.the disturbance is not attributable to the physiological effects of a substance or another medical

condition

l

:

. the disturbance is not better explained by another mental disorder

Epidemiology

• I yr prevalence: 1-4%, lifetime prevalence 6%; M:l =l:2

8% of all who seek primary care treatment (WHO)

• in primary care: 70% initially present with physical symptoms as main concern

• bimodal age of onset: before 20 or middle adulthood

Source:Depression and other common mental disorders:Global health estimates.Geneva:World Health Organization. 2017.

Criteria for GAD (>3)

C-FIRST

Concentration issues

Fatigue

Irritability

Restlessness

Sleep disturbance

Tension (muscle)

Treatment

• lifestyle:avoid caffeine and EtOH,sleep hygiene

• psychological:CBT (cognitive restructuring), muscle relaxation techniques, mindfulness

• biological

1st line:SSRIs (escitalopram,sertraline, paroxetine),SNRls (venlafaxine XR, duloxetine),

pregabalin

benzodiazepines considered 2nd line (short-term, lowest effective dose, helpful while titrating

antidepressant)

• (1-blockers not recommended

Prognosis

• good with treatment

• depends on pre-morbid personality functioning,stability of relationships, work, and severity of

environmental stress

Social Anxiety

• definition:marked and persistent (>6 mo) fear ofsocial or performance situations in which one is

exposed to unfamiliar people or to possible scrutiny by others. They fear that they will be negatively

evaluated in a way that may be humiliating, embarrassing,or lead to rejection (e.g.public speaking,

initiating or maintaining conversation,dating, eating in public)

• situations are avoided or endured with intense anxiety and causes significant distress or impairment

in functioning

• lifetime prevalence 8-12%;M:F ratio approximately equal

Phobic Disorders

Specific Phobias

• definition: marked and persistent (>6 mo) fear that is excessive or unreasonable, cued by presence or

anticipation of a specific object or situation

• lifetime prevalence 10-13%; M:l

;

ratio variable

• types: animal/inscct, environment (e.g. heights,storms), blood/injection/injury,situational (e.g.

airplane, closed spaces), other (e.g. loud noise,clowns), multiple fears

Diagnostic Criteria for Phobic Disorders

• marked fear/anxiety about a specific object/situation

• exposure to stimulus almost invariably provokes an immediate fear/anxiety response; may present as

a panic attack

• phobic object/situation is actively avoided or endured with intense anxiety.

• fear/anxiety out of proportion to actual danger/sociocultural context and persistent (lasting 6 mo or

more)

• person recognizes fear as excessive or unreasonable

• significant impact on daily routine, occupational/social functioning, and/or marked distress

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