Clinodactyly Radial or ulnar deviation None (usually):it severe,osteotomy with grading

Oden middle phalanx

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PL-13 Plastic Surgery Toronto Notes 2023

Table 36. American Society for Surgery of the Hand (ASSH) Classification of Congenital Hand

Anomalies

Classification Example Features Treatment

Duplication Congenital duplication of digits Amputation of least functional digit

May beradial(increased in Asian Usually >1yr of age (when functional status can be

individuals andIndigenous peoples) assessed)

or central or ulnar (increased in

individuals ol African descent)

Polydactyly

Overgrowth None (if miId)

Soft tissue/bony reduction

Removal of nonfunctional stumps

Osteotomies/tendon transfers

Distraction osteogenesis

Phalangeal/free toe transfer

As above syndactyly release

Macrodactyly Rare

Undergrowth Brachydadyly Short phalanges

Symbrachydactyly

ftrachysyndactyly

i.e.amniotic (annular)

band syndrome

Short webbed Fingers

Constriction Band

Syndrome

Variety of presentations Urgent release for acute,progressive edema distal to

band in newborn

Other reconstruction is case specific

Generalized Skeletal Achondroplasia,Marfan Variety of presentations Treatment depends on etiology

Abnormality syndrome, Madelung's

deformity

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Barr JE.Principles of wound cleansing.Ostomy Wound Manage.199S:41|Suppl 7A):1S5- 225.

BetedjiklianPK,Bozenika DJ.Revievrof hand surgery.Philadelphia:WBSaunders, 2004.

Bolognia JL,Jorizzo JL,Rapim RP (editors).Textbook of dermatology.2nded.Vol.1and 2.Toronto:Mosby,2008.

Britt LD.Turnkey DO,Feliciano DV.Acute care surgery:principles and practice.New York:Springer,2007.

Brown 01,Borschcl GH.Michiganmanual ofplastic surgery.Philadelphia:WBSaunders.2004.

Capobianco CM. Zgonis T.An overview of negative pressure wound therapy foi the lower extremity. Clin Podiatr Med Surg. 2009 Oct:26(4):619- 31.

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Cereda E.Kletsy C.Serioli M.et at.A nutritional formula enriched with arginine,zinc,and anboxidanls for Ihe healing of pressure ulcers:a randomized trial.Ann Intern Med 2015:162(3) 167 174.

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Daver BM,Antia NH.Furnas DW.Handbook of plastic surgery for the general surgeon,2nd ed.New Delhi:Oxford University Press.1995.

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.Perth:Health Networks Branch.Oeparlmcnl of Health,Western Australia. 2011.

Dias JJ.Dhukatam V.Kumar P. The natural historyolunlrealed dorsal wrist ganglia andpatient reported outcome 6 years after intervention. J Hand Sutg-Eur Vol 2007;32(5):502-508.

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Giuffre JL,Kakar S.Bishop AT,et al. Current concepts of the treatment of adult brachial plexus injuries.J HandSurg Am 2010:35:678-688.

Gourgtolis S.VilliasC.GcrmanosS,el al. Acute hmb compartment syndrome:a review. J Surg Educ 2007:64:178-186.

Graham B.Regelir G.Naglie G.et al.Development and validation of diagnosbc criteria for caipal tunnel syndrome. JHand Suig 2006:31(61:919- 924.

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Gullelh Y.Goldberg N,Silverman R,et al.What is the best surgical margin for a basal cell carcinoma:a meta-analysis ol the literature.Plast Reconstr Surg 2010:126:1222-1231.

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Harrison V.The newborn baby.5th ed.Juta 4 Company.2008.Chapter:Congenital Abnormalities.

Hollmann H.Eren H.Sander K,et al.Orbital floor fractures - short- and intermediate-term complications depending on treatment procedures.Head Face Med 2016:12:1.

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Jants JE.Essentials ol plastic surgery:a U!Southwestern Medical Center handbook. St.Louis:Ouality Medical,2007.

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Psychiatry

Tania Da Silva, Kawaan Elsawi,and Rachel Goud, chapter editors

Ming Li and Dorrin Zarrin Khat, associate editors

Vijithan Sugumar, EBM editor

Dr. Saulo Castel, Dr.Tamara Milovic, and Dr.Jerome Perera,staff editors

PS2 Eating Disorders

Anorexia Nervosa

Bulimia Nervosa

Binge-Eating Disorder

Avoidant/Restrictive Food Intake Disorder

Personality Disorders

Child Psychiatry

Developmental Concepts

Mood Disorders in Children and Adolescents

Anxiety Disorders in Children and Adolescents

Neurodevelopmental Disorders

Autism Spectrum Disorder

Attention Deficit Hyperactivity Disorder

Disruptive,Impulse Control, and Conduct Disorder.

Oppositional Defiant Disorder

Conduct Disorder

Intermittent Explosive Disorder

Psychotherapy

Pharmacotherapy

Antipsychotics

Antidepressants

Mood Stabilizers

Anxiolytics

Somatic Therapies.

Repetitive Transcranial Magnetic Stimulation (rTMS)

Magnetic Seizure Therapy (Experimental)

Neurosurgical Treatments

Other Therapy Modalities

Canadian Legal Issues

Common Forms

Consent

Community Treatment Order (CTO)

Duty to Inform/Warn

Landmark Psychiatry ClinicalTrials

References

Acronyms PS39

Psychiatric Assessment

History

Mental Status Exam

Assessment andPlan

Suicide.

Psychotic Disorders

Differential Diagnosis of Psychosis

Schizophrenia

Schizophreniform Disorder

Brief Psychotic Disorder

Schizoaffective Disorder

Delusional Disorder

Mood Disorders

Mood Episodes

Depressive Disorders

Postpartum Mood Disorders

Bipolar Disorders

Anxiety Disorders

Panic Disorder

Agoraphobia

Generalized Anxiety Disorder

Social Anxiety

Phobic Disorders

Obsessive-Compulsive and RelatedDisorders.

Obsessive-Compulsive Disorder

Related Disorders

Trauma- and Stressor-Related Disorders

Post-Traumatic Stress Disorder

Adjustment Disorder

Bereavement

Neurocognitive Disorders,

Delirium

Major Neurocognitive Disorder (Dementia)

Substance-Related and Addictive Disorders

Nicotine

Alcohol

Opioids

Cocaine

Amphetamines

Cannabis

Hallucinogens

“Club Drugs”

Somatic Symptom and RelatedDisorders

Somatic Symptom Disorder

Illness Anxiety Disorder

Conversion Disorder (Functional Neurological Symptom Disorder)

Dissociative Disorders

Dissociative Identity Disorder

Dissociative Amnesia

Depersonalization/Derealization Disorder

Sleep Disorders

Sexuality and Gender.

Gender Dysphoria

Paraphilic Disorders

Sexual Addiction

Sexual Dysfunction

PS2

PS4

PS42

PS5

PS44

PS7

PS46

PS48 PS10

PS49

PS15 PS51

PS60

PS19

PS20

PS62

PS22

PS23

PS64

PS64

PS33

PS35

PS36

PS37 r n

L J

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PS1 Psychiatry Toronto Notes 2023

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PS2 Psychiatry Toronto Notes 2023

Acronyms

5-HT serotonin

acetylcholine

assertive community treatment EOT

attention deficit hyperactivity

disorder

activities of daily living

anorexia nervosa

autism spectrum disorder GMC

antisocial personality disorder IPT

dialectical behavioural therapy MET

dizygotic

electroconvulsive therapy

EPS extrapyramidal symptoms

ERP exposure with response

prevention

GAD generalized anxiety disorder

general medical condition

interpersonal therapy

IADL instructional activities of daily OCD

living

MBCT mindfulness-based cognitive

therapy

M6SR mindfulness-based stress

reduction

MDD major depressive disorder

MDE major depressive episode

DBT motivational enhancement

therapy

motivational interviewing

mental status examination

magnetic stimulation therapy

monozygotic

Narcotics Anonymous

neuroleptic malignant sy

not otherwise specified

obsessive-compulsive disorder

oral contraceptive pill

obsessive-compulsive

personality disorder

oppositional defiant disorder

phencyclidine

personality disorder

PDD pervasive developmental

disorder

post-traumatic stress i

repetitive transcranial

stimulation

second generation

antipsychotics

syndrome of inappropriate

antidiuretic hormone secretion

serotonin and norepinephrine

reuptake inhibitors

serotonin syndrome

selective serotonin rcuptake

inhibitor

tricyclic antidepr

tardive dyskinesia

extended-release

ACh D2

ACT Ml PTSD disorder

ADHD MSt rTMS magnetic

MST

ADL MZ SGA

AN NA

ASD NMS ndrome S1ADH

ASPD NOS

BN bulimia nervosa

CBT cognitive behavioural therapy

CD conduct disorder

CRA community reinforcement

SNRI

OCP

OCPD SS

SSRI

approac ODD

community treatment order

dopamine

CTO PCP TCA essant

DA PD ro

XR

Psychiatric Assessment

History

Introduction O • name, role, purpose, circumstances(i.e. approximate time)

• limits of confidentiality (i.e.safety of dependents, harm to self or others)

Identifying Data

• necessary: name, age, gender (preferred pronouns), living situation (accommodation, independently,

or with others), marital/relationship status, children,source of income/support,or occupation

• adjunct: outpatient/inpatient, referral source, known/unknown to provider

Chief Complaint

• in patient'

s own words, with duration of symptoms

History of Present Illness

• context: events,problems, stressors,losses, changes

• symptoms:onset, duration, intensity, progression, fluctuation with day/season

• impact on functioning:social, occupational, ADL/IADLs, personal care/survival

• coping strategies, treatments, personal/professional supports

• reason for seeking help that specific day

• prior episodes/experiences, longitudinal course (duration/frequency)

• last period of wellness, changes to usual personality when unwell

• opinions about cause/natureof concerns, willingness to engage, hopes/expectations of treatment

Psychiatric Functional Inquiry

• mood:depression, mania

• other: trauma, obsessions/compulsions, disordered eating

• anxiety: worries, panic attacks, phobias, or social anxiety

• psychosis:hallucinations, delusions

• safety/risk: self (suicidal ideation/intent/plan (see,S'mc/</c, PS5), self-harm, neglect), others (homicide,

aggression, violence), dependents (children, elderly,disabled,pets),driving,cooking/fires

Screening Ouestions for Major

Psychiatric Disorders

• Have you been feeling down,

depressed,or hopeless?

• Do you feel anxious or worry about

things?

• Has there been a time in your life

where you have felt euphoric,

extremely talkative,had a lot of

energy,and a decreased need for

sleep?

• Do you see or hear things that you

think other people cannot?

• Have you ever thought of harming

yourself or killing yourself?

Psychiatric Functional Inquiry

MOAPS

Mood

Other (medical problems and

substance use)

Anxiety

Psychosis

Safety Past Psychiatric History

• previous psychiatric diagnoses and mental health contacts

• hospitalizations:approximate total, date of last discharge

• emergency department visits (for mental health crisis)

• suicide attempts: number,severity, medical intervention, most recent

• self-harming behaviour (cutting)

• aggression/violence, legal (charges)

• treatments: pharmacological and non-pharmacological (effectiveness, side effects)

r T

L J

Substance Use History

• type:tobacco, cannabis, alcohol, other (stimulants, hallucinogens, prescription drugs, gambling/

online)

• use:first, typical, last, periods of abstinence

• withdrawal symptoms (i.e. seizures, delirium tremens)

• previous treatments: counselling, detox, groups

• impact on symptoms, motivation to change

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PS3 Psychiatry Toronto Notes 2023

Past Medical/Surgical History

• all medical,surgical, neurological (i.e. head trauma,seizures) conditions/illnesses

• allergies

Medications

• names, doses, frequency

• adherence, effectiveness,side effects

• over the counter,supplements

Family Psychiatric/Medical History

• diagnoses, treatments, hospitalizations,suicide attempts,substance use, legal

• perceptions regarding mental illness, engagement witn treatments

• if relevant:any past medical or genetic illness

Always Remember to Ask About Abuse

See Family Medicine. FM30

Past Personal/Developmental History (as relevant)

• birthplace, immigration history (if applicable), ethnicity/nationality, religion/spirituality

• family members:ages,occupations, personalities, quality of relationships

• history of verbal, physical,orsexual abuse

• prenatal and perinatal history: desired vs. unplanned pregnancy, maternal and fetal health, domestic

violence, maternal substance use and exposures, complications of pregnancy/dclivery

• early childhood to age 3:developmental milestones, temperament, family stability, primary

caregivers/attachment figures

• middle childhood to age II:school performance, peer relationships, bullying, activity/attention level,

behavioural challenges

• late childhood to adolescence:school performance, drugs/alcohol, legal problems, peer and family

relationships, extra-curriculars

• sexuality: puberty,gender identity,sexual orientation,sexual functioning/experiences, romantic

relationships

• adulthood:education, employment, relationships

• hobbies, interests,sources of meaning,strengths, accomplishments, aspirations, hopes

Collateral History

• source, details provided

Mental Status Exam

General Appearance

• age (chronological vs. apparent), gender,ethnicity

• posture, grooming, hygiene, manner of dress, body habitus, distinguishing features

• eye contact,facial expression, alertness

• attitude: polite,friendly, collaborative, uncooperative,guarded/suspicious, evasive, agitated,

aggressive/hostile

• reliability (consistency, congruent with collateral), ease of building rapport

• gait, psychomotor changes (slowing/agitation), tics, tremors,tardive dyskinesia, dystonia, catatonia

Speech

• rate (i.e. pressured,slowed), rhythm, volume, tone, quantity,spontaneity, latency,language fluency,

articulation

Mental Status Exam

ASEPTIC

Appearance and behaviour

Speech

Emotion (mood and affect)

Perception

Thought content and process

Insight and judgment

Cognition

The MSE is analogousto the physical

exam. It focuses on currentsigns, affect,

behaviour, and cognition

Mood and Affect

• mood:subjective emotional state (in patient’s own words)

• affect:objective emotional state inferred from emotional responses to stimuli; described in terms of

quality (euthymic, depressed, elevated, anxious, irritable)

• range (full, restricted, flat, blunted)

• stability (continuum front fixed to labile)

• mood congruence (inferred by comparing the patient’ssubjective mood with their affect)

• many clinicians use a 0-10 scale (0:worst; 10:best) when rating mood to get a subjective norm for each

patient that can help to monitor changes over time and with treatment

Spectrum of Affect

Full > Restricted > Blunted > Flat:quality

(euthymic.depressed,anxious, elated)

Perception

• hallucination:sensory perception in the absence of appropriate stimuli that is similar in quality to a

true perception

• auditory (most common), visual, gustatory, olfactory, tactile

• illusion: misperception of a real externalstimulus (i.e.mistaking a coat on a rack as a person late at

night)

• depersonalization:change in self-awareness such that the person feels unreal,distant,or detached

from their body, and/or unable to feel emotion

• derealization:feeling that the world/outer environment is unreal

There Is poor correlation between

clinical impression of suicide risk and

frequency of attempts

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PS'l Psychiatry Toronto Notes 2023

Thought Process/Form

• coherence (coherent, incoherent)

• stream

goal-directed: clearly answers questions in a linear, organized, logical fashion

circumstantial:speech that is indirect and delayed in reaching its goal;eventually comes back to

the point

tangential: speech is oblique or irrelevant; does not come back to the original point

loosening of associations/derailment:illogical shifting between topics

flight of ideas:quickly skipping from one idea to another where the ideas are marginally

connected, usually associated with racing thoughts in mania

• word salad: jumble of wordslacking meaning or logical coherence

• perseveration: repetition of the same verbal or motor response to stimuli

• echolalia:repetition of phrases or words spoken by someone else

• thought blocking:sudden cessation of flow of thought and speech

• clang associations:speech based on sound such as rhyming or punning

• neologism: use of novel words or of existing words in a novel fashion

Thought Content

• major themes discussed by patient

• suicidal ideation/homicidal ideation:frequency and pervasiveness of thoughts, plan, intent, active vs.

passive,protective factors

• preoccupations, ruminations:reflections/thoughts at length, not fixed or false

• obsession:recurrent and persistent thought, impulse,or image which is intrusive or inappropriate and

unwanted

cannot be stopped by logic or reason

• causes marked anxiety and distress

common themes:contamination, orderliness, sexual, pathological doubt/worry/guilt

• magical thinking (i.e.superstition, belief that thinking something will make it happen), normal in

children and certain cultures

• ideas of reference:similar to delusion of reference, but less fixed (the reality of the belief is questioned)

• overvalued ideas: unusual/odd beliefs that are not of delusional proportions

• first rank symptoms of schizophrenia: thought insertion/withdrawal/broadcasting (all delusional

ideas)

• delusion:a fixed false belief that is out of keeping with a person’

s cultural or religious background and

is firmly held despite incontrovertible proof to the contrary

Cognitive Assessment

Use MMSE to assess

• Orientation (time and place)

• Memory (immediate and delayed

recall)

• Attentlon and concentration

• Language (comprehension, reading,

writing, repetition, naming)

• Spatial ability (intersecting

pentagons)

Grossscreen for cognitive dysfunction:

Total score is out of 30; <26 abnormal.

20-25 mild,10-19 moderate,<10severe

The key to differentiating between

obsessions and delusions is that

obsessions are usually egodystonic,

meaning unwanted and not fitting in

with a person '

s goals and self-image,

while delusions are ego syntonic

Delusions (Absolute Beliefs)

. Persecutory:belief that others are

trying to cause harm to you

• Reference:interpreting ordinary,

regular events/celebrities as having

direct reference to you

• Erotomania:belief that another is in

love with you

• Grandiose: belief that he or she has

special powers, talents, or abilities

• Religious: belief of receiving

instructions/powers from a higher

being; of being a higher being

• Somatic: belief that you have a

physical disorder/defect

• Nihilistic:belief that things do not

exist; a sense that everything is

not real

Insight

• ability to realize that they have a mental health concern and to appreciate its implications as it relates

to functioning and benefits of treatment: none,limited, partial,or full

Judgment

• recent behaviours as they relate to safety,social functioning, treatment decisions

Assessing Insight and Judgment

Insight

• Acknowledgment of symptoms as a

departure from baseline orsource

of suffering

• Attribution of symptoms to illness or

acceptance assuch explanation as

part of the process

• Acknowledgement of need for

treatment (Why are you in the

hospital? Why are you taking this

medication? What would happen If

you stopped taking it?)

Cognition

• level of consciousness(alert, reduced, obtunded)

• orientation:time, place, person

• memory: immediate, recent, or remote

• global evaluation of intellect ( below average, average, or above average, in keeping with person'

s

education)

• intellectual functions:attention, concentration, calculation, abstraction (proverb interpretation,

similaritiestest), language, communication

• Mini Mental Status Exam (MMSE)/Montreal Cognitive Assessment (MoCA) useful asstandard

screening assessments of cognition

Judgment

Can be observed from collected history

and patient'

s appearance and actions.

Are they:

• Dressed a ppropriately for the

weather?

• Acting appropriately in the given

situation?

• Taking care of self and/or

dependents?

Assessment and Plan

Historical Multiaxial Model

• since DSM-5, this model is no longer used for psychiatric diagnosis. Instead,relevant psychiatric

and medical diagnoses are simply listed. Nevertheless, we otter it here as a possible framework for

psychiatric patient assessment, as many physiciansstill employ it

Multiaxial Assessment rt

• Axis I: DSM-5 diagnoses (preferred and differential)

• Axis II:personality disorders, intellectual disability

• Axis III:medical conditions potentially relevant to understanding/management of the mental

disorder

• Axis IV: psychosocial and environmental issues

• Axis V:Global Assessment of Functioning (GAF,0 to 100) incorporating effects of axes 1 to IV

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PS5 Psychiatry Toronto Notes 2023

After History and MSE,the assessment and plan is recorded

Assessment/Problem Formulation

• identify predominant symptom cluster (mood, anxiety, psychosis) that causes the most distress/

interference and persists when othersymptom categories are not present (i.e.psychosis in the absence

of mood symptoms)

• dominating symptoms will direct differential

• consider current issues as they relate to an individual across the three domains: biological,

psychological, and social

• for each category: predisposing, precipitating, perpetuating, and protecting factors are considered

Approach to Management

• considershort-term and long-term, and three types: biological (i.e. pharmacotherapy, ECT),

psychological (i.e. CBT), and social (i.e.supports, finance/employment/return to work, housing,social

activity, recreation, medication/psychotherapy coverage)

Always rule outsubstance use and other

medical causes before considering

psychiatric causes

Suicide s

Importance

•

Approach

must be screened for in every encounter: part of risk assessment along with violent /homicidal ideation m • ask every patient:i.e. “Have you had any thoughts of wanting to harm or kill yourself?

"

• classify ideation

passive ideation (“death wish”): where patient would rather not be alive, but currently has no

active plan for suicide

• i.e. “1 would rather not wake up"or “ I would not mind if a car hit me"

active ideation

Suicidal Ideation Assessment

• Asking patients aboutsuicide will not

give them the idea or the incentive to

die by suicide

• The best predictor of completed

suicide is a history of attempted

suicide

• The most common psychiatric

disorders associated with completed

suidde are mood disorders and

alcohol use disorders

i.e. “1 think about killing myself ”

• assess risk

plan: “Do you have a plan as to how you would end your life?"

• intent: “Do you think you would actually carry out this plan?” “If not, why not?"

past attempts: number, lethality, outcome, medical intervention, while intoxicated?, prccipitants

• if intoxicated on the first approach, reassess when sober

• assesssuicidal ideation

onset and frequency of thoughts:“When did thisstart?” or “How often do you have these

thoughts?”

control over suicidal ideation: “How do you cope when you have these thoughts?” “Could you call

someone for help?"

• intention:“Do you want to end your life?"or "Do you wish to kill yourself?”

intended lethality:“What do you think would happen if you actually took those pills?"

accessto means: “How will you get a gun?

"

or “Which bridge do you think you would go to?"

time and place:

“Have you picked a date and place?" “Is it in an isolated location?"

provocative factors:“What makes you feel worse (i.e. being alone)?"

• protective factors: “What keeps you alive (i.e. friends,family, pets, faith, therapist)?"

final arrangements: “Have you written a suicide note?" “Made a will? “Given away your

belongings?

"

» practiced suicide or aborted attempts:

“Have you ever put the gun to your head?" “Held the

medications in your hand?” “Stood at the bridge?"

ambivalence: “1 wonder if there is a part of you that wantsto live, given that you came here for

help?"

• determine level of risk and develop treatment/safety plan

Assessment of Suicide Attempt

• setting (isolated vs. others present/chance of discovery)

• planned vs. impulsive attempt, triggers/stressors

• substance use/intoxication

• medical attention (brought in by another person vs. brought in by self to ED)

• time lag from suicide attempt to ED arrival

• expectation of lethality, dying

• reaction to survival (guilt/remorse vs.disappointment/self-blame)

• evidence of escalation in potential lethal means

Suicide Risk Factors

SAO PERSONS

Sex (male)

Age >60 yr

Depression

Previous attempts

Ethanol abuse

Rational thinking loss(delusions,

hallucinations, hopelessness)

Suicide in family

Organized plan

No spouse (no support systems)

Seriousillness, intractable pain

n

LJ

Epidemiology

• attempted:completed = 20:1 (100:1 in younger persons; 4:1 in older persons)

• M:l

'

=l:4 for attempts, 3:1 for completed +

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PS6 Psychiatry Toronto Notes 2023

Risk Factors

• epidemiologic factors

age: increases after age 14,second most common cause of death for ages 15-24, highest rates of

completion in persons >75 yr

sex: male

race/ethnic background: White people or Indigenous peoples in Canada

marital status: widowed/divorced

living situation:alone; no children <18 ylo in the household

other:stressful life events,or access to firearms

• psychiatric factors

pastsuicide attempt(s)

eating disorders

bipolar disorder

major depression

mixed drug misuse

• panic disorder

schizophrenia

personality disorders

alcohol use

• psychosocial factors

recent,severe stressful life event (relationship,financial, trauma)

• psychiatric disorders

mood disorders (15% lifetime risk in depression; higher in bipolar disorder)

anxiety disorders (especially panic disorder)

schizophrenia (10-15% risk)

substance use disorder (especially alcohol- 15% lifetime risk)

eating disorders(5% lifetime risk)

adjustment disorder

conduct disorder

personality disorders(borderline, antisocial)

• past history

priorsuicide attempt(s), most recent attempt

family history ofsuicide attempt/completion

Clinical Features

• symptoms associated with suicide:

hopelessness

anhedonia

insomnia

severe anxiety

impaired concentration

psychomotor agitation

Management

• proper documentation of the clinical encounter and rationale for management is essential

• for higher risk patients (with a plan and intention to act, have access to lethal means, recentsocial

stressors, and symptomssuggestive of a psychiatric disorder)

hospitalization should be strongly considered

do not leave patient alone; remove potentially dangerous objectsfrom room

if patient refuses to be hospitalized, complete form for involuntary admission (Form I ) and must

give patient Form 30 to notify them of their admission (in Ontario)

• for lower risk patients(not actively suicidal,with no active plan, or access to lethal means)

discuss protective factors and supports in their life, remind them of what they live for, promote

survival skills that helped them through previoussuicide attempts

make a safety plan that could include an agreement that they will:

not harm themselves

avoid alcohol,drugs, and situations that may trigger suicidal thoughts

follow-up with you at a designated time

contact a health care worker, call a crisisline, or go to an emergency department if they feel

unsafe or if theirsuicidal feelings return or intensify

• patients with depression:consider hospitalization ifsymptoms are severe or if psychotic features are

present;othenvise outpatient treatment with good supports and pharmacotherapy

• patients with alcohol- orsubstance-related issues:suicidality usually resolves with abstinence for a

few days;if not,suspect depression

• patients with personality disorders:crisis intervention, may or may not hospitalize

• patients with schizophrenia/psychosis: hospitalization might be necessary

• patients with parasuicidal behaviours/self-mutilation:long-term psychotherapy with brief crisis

intervention when necessary

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PS7 Psychiatry Toronto Notes 2023

Psychotic Disorders

Definition

• characterized by a significant impairment in reality testing

• positive symptoms

• delusions or hallucinations(with or without insight into their pathological nature)

grossly disorganized or abnormal motor behaviours ( including catatonia)

formal thought disorder

• negative symptoms ofschizophrenia

diminished emotional expression (i.e. affective flattening)

• anhedonia

avolition

• alogia

asociality

Delusions:fixed,false beliefs that

are not amenable to change in light of

conflicting evidence

Hallucinations: perceptual experiences

occurring without an external stimulus

Duration of Time Differentiates the

following 3 Psychotic Disorders

Brief Psychotic

Oisoider

<1 mo

Schizophreniform

Disorder

1 6 mo

Schizophrenia

>6 mo

> Differential Diagnosis of Psychosis

Figure 1. Differentiating psychotic

disorders by duration Approach

• differentiate among psychotic disorders and distinguish them from other primary diagnoses with

psychotic features

• considersymptoms, persistence,and time

• symptoms: the primary diagnosis needs full criteria to be met

mood: depressive episodes with psychotic features, manic episodes with psychotic features

psychotic: consider symptoms in Criterion A ofschizophrenia (see Criteria for Schizophrenia,

PS8 )

• persistence: is there a time when certain symptom clusters are present without other clusters?

i.e. if there is a period of time with mood symptoms, but not psychotic symptoms, consider mood

disorder

i.e. if psychotic symptoms occur only with mood symptoms, consider mood disorder with

psychotic features

• i.e. if during a 2 wk period where psychotic symptoms persist in the absence of mood symptoms,

consider schizoaffective disorder

i.e. if long periods with psychotic symptoms and brief or rare mood symptoms, consider

schizophrenia

• time: how long have the symptoms been present?

DDx for Psychosis

• Primary psychotic disorders:

schizophrenia,schizophreniform,

brief psychotic,schizoaffective,

delusional disorder

• Mood disorders: MOD with psychotic

features, bipolar disorder (manic or

depressive episode with psychotic

features)

• Personality disorders: schizotypal,

schizoid, borderline, paranoid,

obsessive-compulsive (they

predispose to psychosis, but

presence of psychotic symptoms

require another diagnosis)

• General medical conditions:tumour,

head trauma,dementia,delirium,

metabolic,infection,stroke, temporal

lobe epilepsy

• Substance-induced psychosis: onset

during intoxication or withdrawal,

prescribed medications,toxins

Table 1. Differentiating Psychotic Disorders

Disorder Psychotic Symptoms Duration

Brief Psychotic Disorder >1 positive symptoms ol Criterion A <1mo with eventual full return to premorbid

functioning

1-Gmo

>6 mo

>1mo

Schizophreniform Disorder

Schizophrenia

Schizoaffective Disorder

Criterion A

Criterion A

Criterion A* major mood episode ( MDE or

manic). >2 wk of psychotic symptoms without

mood symptoms

>1delusions|if hallucinations, lelatedto

delusional theme)

Delusions or hallucinations

Management of Acute Psychosis and

Mania

• Ensure safety of self, patient, and

other patients

• Have an exitstrategy

• Decrease stimulation

. Assume a non-threatening stance

• IM medications (benzodiazepine

and antipsychotic) often needed as

patient may refuse oral medication

• Physical restraints may be necessary

• Do not use antidepressants or

stimulants

Delusional Disorder >1mo

Substance-Induced Psychotic Disorder Onset during intoxication/withdrawal,resolve

In <1mo without use

Psychosis maybe present only lor the duration

of the mood episode

2” lo Mood Disorder Mood symptoms dominant * delusions/

hallucinations jmood congruent)

Relevant Investigations

• CBC, electrolytes (including extended electrolytes), creatinine, glucose, urinalysis, urine drug screen,

1 SH, and vitamin Bl2

• LFTs,fasting lipids, HbAlC to obtain baseline levels prior to antipsychotic initiation

• ECG (several antipsychotics affect cardiac conduction )

• if clinically indicated, order infectious work-up, inflammatory markers, and brain imaging

r n

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PS8 Psychiatry Toronto Notes 2023

Schizophrenia

Relationship Between Duration of Untreated

Psychosis(DUP) andOntcomc in First!pisodc

Schizophrenia

toJ Psychiatry 2005;162:1785-1804

Purpose:To review theassociation between DUP

and symptom senilityat hist treatment contact, and

between DUP and treatmentoutcomes.

Methods:Critical review and meta-analysis ol

studiesinvolving patientswith non-affective

psychotic disorders at or dose to lirtt treatment.

Results:43 studies with 4177 patientswere included.

Shorter DUPwas associated with greater response

to antipsychotic treatment,as measured by global

psychopathology, postme symptoms,negative

symptoms,and functnxal outcomes,it the time

of treatment initiation,longer OUP wasassociated

with the severity of negativesymptoms but not

with the severity of positive symptoms,global

psychopathology, or nenrocogmtive function.

Condasions:DUP may be a potentially modifiable

prognostic factor.

DSM-5 DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA

Repiinled with permission from the Diagnostic and Statistical Manual of Mental Disorders.5th ed. 2013. Ameiican Psychiatric Association

A.two (or more) of the following, each present for a significant portion of time during a 1 mo period (or

less ifsuccessfully treated).At least one of these must be (1), (2),or (3)

1. delusions

2. hallucinations

3. disorganized speech (e.g.frequent derailment or incoherence)

4. grossly disorganized or catatonic behaviour

5. negative symptoms(i.e. diminished emotional expression oravolition)

B.for a significant portion of time since the onset of the disturbance,level of functioning in one or more

major areas (e.g. work, interpersonal relations,self-care) is markedly below the level achieved prior to

the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level

of interpersonal, academic,or occupational functioning)

C.continuoussigns of the disturbance persist for at least 6 mo.

'

this 6 mo period must include at least 1

mo of symptoms (or less ifsuccessfully treated) that meet Criterion A (i.e. active-phase symptoms)

and may include periods of prodromal or residual symptoms. During these prodromal or residual

periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more

symptoms listed in Criterion A present in an attenuated form (e.g.odd beliefs, unusual perceptual

experiences)

D.schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled

out because either I ) no major depressive or manic episodes have occurred concurrently with the

active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they

have been present for a minority of the total duration of the active and residual periods of the illness

E.the disturbance is not attributable to the physiological effects of a substance (e.g. drug of abuse,

medication) or another medical condition

E.if there is a history of autism spectrum disorder or a communication disorder of childhood onset,

the additional diagnosis ofschizophrenia is made only if prominent delusions or hallucinations,in

addition to the other required symptoms of schizophrenia are also present for at least 1 mo (or less if

successfully treated)

• specifiers: type of episode (e.g.first episode, multiple episodes, continuous), in acute episode/

partial/full remission, with catatonia, current severity based on quantitative assessment of primary

symptoms of psychosis

Epidemiology

• prevalence: 0.3-07%, M:E=I:1

• mean age of onset:femaleslate-20s with a 2nd peak in mid-life;males early- to mid-20s (some cases

with late onset)

• suicide risk:5-6% die by suicide, 20% attemptsuicide

Duiation el Uiatieatcd Psychosis as Piedictor of

long-term Outcome in Schizophienia:Systematic

Review and Meta-analysis

Brit J Psychiatry 2014:205:88-94

Puipose lo review tbe association between DUP and

long term outcomesof schizophienia.

Methods:A systematic review and meta-analysis

no the effects of duiation ol untreated psychosison

clinical,social,or quality ol life outcomes at least 2 yi

following psychosis in people with schizophienia.

Results:33studieswere Included.Longer DUP

was associated with poorei generalsymptomatic

outcome, moie seveie positive and negative

symptoms,lesser likelihood ol remission,and poorer

social Functioning and global outcomes, linger DUP

was not associated with employment,quality of hie.

oihospltalueatment

Disorganized Behaviours in

Schizophrenia

• Catatonic stupor:fully conscious but

mute,unresponsive,immobile,and

maintaining bizarre positions for a

long time

• Catatonic excitement:uncontrolled

and aimless motor activity,extreme

agitation

• Stereotypy:repeated but non-goaldirected movement (i.e. rocking)

. Mannerisms:goat-directed activities

that are odd or out of context (i.e.

grimacing)

• Echopraxia:imitates movements and

gestures of others

• Automatic obedience: carries out

simple commands in robot-like

fashion

• Negativism:refuses to cooperate

with simple requests for no apparent

reason

• Inappropriate affect, neglect of selfcare,other odd behaviours (random

shouting)

Etiology

• multifactorial:disorder is a result of interaction between both biological and environmental factors

genetic:40% concordance in monozygotic (MZ) twins;46% if both parents have schizophrenia;

10% of dizygotic (DZ) twins,siblings, children affected; vulnerable genes include Disruptedin-Schizophrenia 1 (DISCI); neuregulin I (NRG l);dystrobrevin binding protein/dysbindin

(DTNBP1); catechol-O-methyltransferase (COMT);d-amino acid oxidase activator (DAOA);

metabotropic glutamate receptor 3 (GRM3); and brain-derived neurotrophic factor (BDNE)

neurochemistry (“dopamine hypothesis"):excess activity in the mesolimbic dopamine pathway

may mediate the positive symptoms of psychosis, while decreased dopamine in the prefrontal

cortex may mediate negative and cognitive symptoms.GABA,glutamate, and ACh dysfunction

are also thought to be involved

neuroanatomy:decreased frontal lobe function; asymmetric temporal/limbic function; decreased

basal ganglia function;subtle changes in thalamus,cortex, corpus callosum, and ventricles;

cytoarchitectural abnormalities

neuroendocrinology: abnormal growth hormone, prolactin, cortisol, and ACTH

• neuropsychology:global defects seen in attention, language, and memory suggest disrupted

connectivity of neural networks

environmental: indirect evidence of cannabis use, geographical variance, winterseason of birth,

obstetrical complications, and prenatal viral exposure

Pathophysiology

• neurodegenerative theory: natural history may be a rapid or gradual decline in function and ability to

communicate

glutamate system may mediate progressive degeneration by excitotoxic mechanism which leads to

production of free radicals

• neurodevelopmental theory:abnormal development of the brain from prenatal life

neurons fail to migrate correctly, make inappropriate connections, and undergo apoptosis in later

C]

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Comorbidity

• substance use disorders(>50% use tobacco)

• anxiety disorders

• reduced life expectancy secondary to medical comorbidities (i.e. obesity, diabetes, metabolic

syndrome,CWpulmonary disease)

Cannabis Use and Earlier Onset of Psychosis

Arc^ Gen Psychiatry 2011:68:555 561

Rttpose: lo examine the eitenttowhnhcannabiv

alcohol,and other psychoactive drugsaffect the age

of onset of psychosis.

Method:

^

systematic review and meta analysis.

Eegbsh studieswere included that compared two

cohorts:patientswho used substances vs. patients

whodid not use substances.

Retails: 83 studies were Included,the age of

onset In cannabis userswas 2.7 yr younger than

hr nonusers.For broadly defined substance use,

ageof onset of psychosis was 2.0 yr earlier than

loc ronusers. Alcohol use was not associated with

sigmtcanlly earlier age ol psychosis.

Conclusions:These results provide evidence that

ca nnabis plays a role in earlier onset of psychosis.

Management of Schizophrenia

• biological/somatic

acute treatment and maintenance:antipsychotics(risperidone, aripiprazole, haloperidol,

paliperidone; clozapine if resistant); regimens of IM q2-4 svk. Long-acting injectables(LAI or

depot) shown to be more effective in reducing relapse and rehospitalization compared with oral

alternatives

adjunctive: ± mood stabilizers(for aggression/impulsiveness - lithium, valproate, carbamazepine)

± anxiolytics ± ECT

maintenance treatment for at least 1-2 yr after the first episode, at least 5 yr after multiple

episodes (relapse causessevere deterioration)

• psychosocial

psychotherapy (individual, family,group),supportive,CBT (see Table N , PS50)

ACT (Assertive Community Treatment):mobile mental health teams that provide individualized

treatment in the community and help patients with medication adherence, basic living skills,

social support, job placements,resources

social skillstraining, employment programs, disability benefits

housing (group home, boarding home, transitional home)

Good Prognostic Factors

. Acute onset

• Later age of onset

• Shorter duration of prodrome

• Female gender

. Good cognitive functioning

. Good premorbid functioning

• No family history

• Presence of affective symptoms

• Absence of structural brain

abnormalities

• Good response to drugs

• Good support system

Course and Prognosis

• majority of individuals display some type of prodromal phase

• course is variable:some individuals have exacerbations and remissions while others remain

chronically ill; accurate prediction of the long-term outcome is not possible

• positive symptomstypically diminish with treatment; negative symptoms tend to be most persistent

and cognitive symptoms may not improve

• over time: 1/3 improve, 1/3 remain the same, 1/3 worsen

Schizophreniform Disorder

Diagnosis

• criteria A, D, and E of schizophrenia are met; an episode of the disorder lasts for >1 mo but <6 mo

if the symptoms have extended past 6 mo the diagnosis becomesschizophrenia

specifiers:with/without good prognostic features (e.g. acute onset, confusion/perplexity,good

premorbid functioning, absence of blunt/flat affect), with catatonia, current severity based on

quantitative assessment of primary symptoms of psychosis

Treatment

• similar to acute schizophrenia

Prognosis

• better than schizophrenia; 1/3 recover within 6 mo, 2/3 progress to schizophrenia

Brief Psychotic Disorder

Diagnosis

• criteria A1-A4, D, and E ofschizophrenia are met; an episode lasts for at least 1 d, but less than I mo

with eventual full return to premorbid level of functioning

• specifiers:with/without marked stressors, with postpartum onset, with catatonia,currentseverity

• can occur after a stressful event or postpartum (see Postpartum Mood Disorders, PS14)

Treatment

• secure/safe environment, antipsychotics, and anxiolytics

Prognosis

• good,self-limiting,should return to premorbid function within 1 mo

Schizoaffective Disorder t

_ J

DSM-5 DIAGNOSTIC CRITERIA FOR SCHIZOAFFECTIVE DISORDER

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

A.an uninterrupted period of illness during which there is a major mood episode concurrent with

Criterion A ofschizophrenia

B.delusions or hallucinationsfor 2 or more wk in the absence of a major mood episode during the

lifetime duration of the illness

Nonbizarre delusions involve situations

that could occur in real life(i.e. being

followed,poisoned, loved at a distance)

Bizarre delusions involve situations

that cannot occur in real life (i.e. being

kidnapped by aliens, having one's

organs stolen)

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C.symptomsthat meet criteria for a major mood episode are present for the majority of the total

duration of the active and residual periods of the illness

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

•specifiers: bipolar type, depressive type, with catatonia, type of episode (i.e. first episode, multiple

episode), severity

Epidemiology

•one-third as prevalent asschizophrenia;schizoaffective disorder bipolar type more common in young

adults,schizoaffective disorder depressive type more common in older adults

•depressive symptoms correlated with higher suicide risk (lifetime risk 5%)

Treatment

•antipsychotics, mood stabilizers, and antidepressants

Prognosis

•between that of schizophrenia and of mood disorder

Delusional Disorder

DSM-5 DIAGNOSTIC CRITERIA FOR DELUSIONAL DISORDER

Reprinted with permission from I he Diagnostic and Statistical Manual of Mental Disorders.5th cd.2013.American Psychiatric Association

A.the presence of one (or more) delusions with a duration of I mo or longer

B.criterion A forschizophrenia has never been met

Note:hallucinations, if present, are not prominent and are related to the delusional theme

C.apartfrom the impact of the delusion(s) or itsramifications,functioning is not markedly impaired,

and behaviour is not obviously bizarre or odd

D.if manic or major depressive episodes have occurred, these have been brief relative to the duration of

the delusional periods

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

condition and is not better explained by another mental disorder

• subtypes: erotomanic,grandiose, jealous, persecutory,somatic, mixed, unspecified

furtherspecify: bizarre content, type of episode (e.g.first episode, multiple episode), severity

Treatment

• antipsychotics, psychotherapy, and antidepressants

Prognosis

• may respond well to antipsychotics, but most patients refuse them and have chronic, unremitting

course;some maintain a high level of functioning;some progress to schizophrenia

Mood Disorders

Definitions

• accurate diagnosis of a mood disorder requires a careful past medical and psychiatric history to detect

past mood episodes and to rule out whether these episodes were secondary to substance use, a medical

condition, etc.

• mood episodes represent a combination ofsymptoms comprising a predominant mood state that is

abnormal in quality or duration (Le.major depressive, manic, mixed, hypomanic). DSM-5 Criteria for

mood episodes are listed below

• types of mood disorders include:

depressive (MDD, persistent depressive disorder)

bipolar (bipolar I /ll disorder, cyclothymia)

• induced by or due to (“secondary to") a general medical condition,substance, medication, or

other psychiatric condition

Medical Workup of Mood Disorder

• routine screenin

drug screen, mo

• additionalscreening:Bn (in older people), neurological consultation, chest x-ray, ECG, head imaging

g:physical exam,CBC, extended electrolytes, LFT, renal and thyroid functi

dicationslist

on tests.

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