'

SD, acute stress disorder, borderline personality disorder,somatic symptom disorder,

substance use disorder, CiMC (various neurologic disorders including complex/partialseizures,

migraine, Cotard syndrome)

Dissociative Identity Disorder

• disruption of identity characterized by >2 distinct personality states or an experience of possession

• can manifest assudden alterations in sense ofself and agency (ego-dystonic emotions, behaviours,

speech)

« features recurrent episodes of amnesia (declarative or procedural) as well as episodes of

depersonalization and derealization

• rare (<1%); can manifest at any age, although childhood physical/sexual abuse or neglect are a major

risk factor

• caution: high-risk of attempting suicide and/or self-harm

• DDx includes borderline personality disorder and PTSD

Dissociative Amnesia

• inability to recall important autobiographical information, usually of a traumatic or stressful nature,

that is inconsistent with normal forgetting and not attributable lo a psychiatric disorder, a medical

illness, or effects of a substance

• localized/selective amnesia: failure to recall all/some events during a prescribed period of time

(however procedural memory is preserved)

• can experience periods of flashbacks or nightmares related to associated trauma, increased risk of

suicide as amnesia resolves

• generalized amnesia (more rare): complete loss of memory for one’slife history, ± procedural

knowledge, ± semantic knowledge; usually sudden onset; often presents with perplexity,

disorientation, and aimless wandering

Dissociative Fugue

Sudden unexpected travel away from

home that Is accompanied by amnesia

for identity or other autobiographical

details

Depersonalization/Derealization Disorder

• persistent or recurrent episodes of one or both of:

depersonalization: experiences of detachment from oneself,feelings of unreality,or a sense of

being an outside observer to one’

sthoughts, feelings,speech, and actions (can feature distortions

in perception including time, as well as emotional and physical numbing)

derealization: experiences of unreality or detachment with respect to the surroundings(i.e.

feeling as if in a dream,or that the world is not real; external visual world is foggy or distorted)

• transient (s-h) experiences of this nature are quite common in the general population

• episodes can range from h-yr; patients are often quite distressed and verbalize concerns of "

going

crazy"

During depersonalization (detachment

from one'sself) or derealization

(detachment from one'ssurroundings),

patients usually have intact reality

testing, which adds to their alarming

nature

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PS36 Psychiatry TorontoXotes 2023

Sleep Disorders

•for more information regarding normal sleep cycles and the illnesses described,see

Disorders, N48

Overview

•adequate sleep is essential to normal functioning; deprivation can lead to cognitive impairment and

increased mortality

•circadian rhythms help regulate mood and cognitive performance

•neurotransmitters commonly implicated in psychiatric illnesses also regulate sleep

• increased ACh activity and decreased activity of monoamine neurotransmitters are associated

with greater REM sleep

decreased adrenergic and cholinergic activity are associated with NKEM sleep

•depression is associated with decreased A (deep,slow-wave) sleep, decreased REM latency, and

increased REM density

•criteria for sleep disorders:

must cause significant distress or impairment in normal functioning

not due to a General Medical Condition (GMC) or medications/drugs(unlessspecified)

Management

•sleep hygiene is a simple, effective, but often underutilized method for addressing sleep disturbances;

recommendations include:

waking up and going to bed at same time every day, including on weekends

avoiding long periods of wakefulness in bed

not using bed for non-sleep activities (reading, TV, work)

avoiding screens, especially smartphones and iPads in the hour before bed

avoiding napping

discontinuing or reducing consumption of alcohol, caffeine, drugs

• exercising at least 3-4 X /WK (but not in the evening if this interferes with sleep)

•cognitive behavioural therapy for insomnia (CBTi) is considered first

-line treatment for chronic

insomnia

•pharmacological treatments are illness-specific

avoid benzodiazepines:increased risk of abuse/dependence, rebound anxiety/insomnia, cognitive

impairment,daytime somnolence, and disturbed sleep architecture (suppresses deep and REM

sleep)

non-benzodiazepines (c.g. zopiclone/eszopiclone/zolpidem, lemborexant, low dose doxepin) are

preferred and effective for short

-term treatment; they should be re-evaluated regularly aslongterm use is associated with dependency

• “z-drugs": common side-effect is bitter metallic taste, which is improved by something acidic such

as orange juice; high doses increase risk of cognitive impairment and falls (particularly among

the elderly)

lemborexant (orexin receptor antagonist) reduces wake pressure/drive, as opposed to increasing

sleep pressure/drive with other sedating agents; avoid use in patients with narcolepsy or cataplexy

trazodone,mirtazapine, and quetiapine can be prescribed off-label if there are comorbid

psychiatric symptoms

low-dose amitriptyline can be prescribed for patients with comorbid pain

screen for complex sleep behaviours before and after prescribing a medication for insomnia

consider whether sleep issue is part of another psychiatric or medical illness and treat those

conditions

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Table 8. Major DSM-5 Sleep-Wake Disorders

Note:For more information regard rgspecific disorders,see Necrology.Sleep Disorders.N48: Family Medicine.Sleep Disorders.FM-8 and Respire:I ?.1

,SteepApnea.R29

Category Disorder Description Management

Dyssomnias

(insufficient,excessive.or

altered timingof sleep)

Insomnia disorder Difficulty initiating/maintaining sleep or early-morning

awakening with inability to return to sleep:can be acute

or chronic (»3 mo)

Sleep hygiene measures

CBT forinsomnia

*

on-beniodiazep:nes are first-line (“

z-drugs"

.

lemborejanL km dosedoxepin)

Excessive daytime sleepiness despitesleeping atleast7 HodafinJ or stimulant drugs

h;difficulty being fully awake after awakening at least3 Scheduled napping

limes per wk for at least 3 mo

Classic tetradconsists of recurrent attacks of irrepressible Sleep hygiene

need to sleep (sleep attacks).REM -related sleep

phenomena,hypnagogic or hypnopompic halkrcinations. Non- amphetamines (Uodafiml.sodium oxybate)

and cataplexy (sudden loss of tone evoked by strong

emotion without IOC)

Hypersomnolence disorder

Narcolepsy

Amphetam.nes (methamphetamine)

Circadian rhythm sleep-wake disorders Insomnia or excessive sleepiness dueto misalignment or Helaton.n

alteration in endogenous circadian rhythm Bright hghtphototherapy

Hodafinil if severe

Uncomfortable,frequent urge lo move legs at night:relief Dopamine agonists and benzodiazepines are first-line

Replace»onif low ferritin

Modify medications that may be exacerbating symptoms

Restless legs syndrome

with movement and aggravation with inactivity

Substance 'medication-induced sleep

disorder

Disturbance insleep (insomnia or daytime sleepiness)

caused by substancc/medication intoxication or

withdrawal

Breathing-RelatedSleep

Disorders

Obstructive sleep apnea hypopnea Breathing issues due to repetitive collapse of the upper Continuous positive airway pressure (CPAP)

airway during sleep - resulting in nonrestorative sleep and Weight loss exercise

excessive daytime sleepiness:snoring,disrupted sleep. Surgery

and morning headaches are common signs

Breathing issues due lo aberrant brain signaling

More common among chronic opioid users

Breathing issues due to decreased responsiveness to

carbon dioxide levels (decreased respiration)

Central sleep apnea CPAPbrierel positive airway pressure (BiPAP)

Supplemental oxygen

CPAPBtPAP

Medications that support breathing

Sleep-related hypoventilation

Incomplete awakening from sleep,complex motor

behaviour without conscious awareness:amnesia

regarding episodes;includes symptoms of:

Parasomnias

(unusual sleep-related

behaviours)

Non-rapid eyemovement sleep arousal

disorders

Sleepwalking: rising from bed and walking about,blank Most cases do cotrequire treatment aside from

addressing precipitating factors and education regarding

sleep hygiene

Severe cases may respond tolow-dose clonazepam

Often setf-limited and benign

face,unresponsive, awakened withdifficulty

Sleep terrors:recurrent episodes of abrupt terror

arousals from sleep,usually beginning with a panicky

scream,intense fear,and autonomic arousal:relative

unresponsiveness lo comfort during episodes

Specifiers:sleep-relatedsexual behaviour|sexsomnia)

and sleep-related eating

Repeated extended,extremely dysphoric,often very vivid. Reassurance

well-remembered dreams that usually involvesignificant Oesensitizaboninageryrehearsaltherapy

threats:rapid orientationand alertness on awakening Prazosin can behelpful for those with P1SD

withautonomic arousal

Nightmare disorder

Rapid eye movement sleep behaviour

disorder

Arousal during sleep,associated with vocalization and.

'

Melatonin

or complex motor behaviours; can cause violent injuries: Clonazepam

rapid orientation and alertness on awakening Discontinuation of causative medications such as ICAs.

SSRIs.and SNRIs

Sexuality and Gender

Gender Dysphoria

Definition

• discomfort or distress caused by a discrepancy between sex assigned at birth and a person’

s gender

identity

• gender identity1

refers to a person’

s intrinsic sense ofself as male, female, both, neither, or anywhere

along the spectrum

• for more details about Gender Dysphoria, please consult the DSM-5

r n

L J

Clinical Features

• strong and persistent cross-gender identification

• desire to be rid of primary/secondary sex characteristics and to gain the primary/secondary sex

characteristics of their identified gender

• repeated stated desire or insistence that one is of the opposite sex

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PS38 Psychiatry Toronto Notes 2023

•preference for cross-dressing, cross-gender roles in make-believe play

•intense desire to participate in the stereotypical games and pastimes of the opposite sex

•strong preference for playmates of the opposite sex

•significant distress or impairment in functioning and persistent discomfort with his or her sex or

gender role

Management

•supportive psychotherapy or other mental health counselling

•hormone therapy with feminizing (c.g. estrogen and anti-androgen) or masculinizing (e.g.

testosterone) agents

•gender affirming surgery

Paraphilic Disorders

Definition

• intense and persistentsexual arousal,over a period of at least 6 mo, that is elicited by something other

than genital stimulation or preparatory fondling with phenotypically normal, physically mature,

consenting human partners

• paraphilic disorder: when paraphilia causes distress or functional impairment to the individual, or a

paraphilia whose realization entails personal harm or risk of harming others

Clinical Features

• begins in childhood or early adolescence; increasing complexity and stability with age

• tends to be chronic but decreasesin intensity with advancing age; may increase with stress

• rarely self-referred;come to medical attention through interpersonal or legal conflict

• person usually has more than one paraphilia;more common in men (only 5% of patients with

paraphilia are women)

• subtypes:

voyeuristic -sexual arousal when spying intentionally on unsuspecting individuals

exhibitionistic - sexual arousal from the act or fantasy of exposing one’

s genitals to nonconsenting individuals

frotteuristic -sexual arousal from touching or rubbing one’s genitals up against non-consenting

individuals

sexual masochism - sexual arousal from being humiliated, beaten, bound, or otherwise made to

suffer

sexual sadism - sexual arousal from the psychological or physical suffering of a victim including

humiliation

pedophilic - sexual attraction to prepubescent children - may be exclusive (only children) or

nonexclusive (children and adults)

fetishistic - recurrent, intense sexual arousal from an inanimate object orspecific focus on a nongenital body part(s)

transvestic - sexual arousal from act or fantasies of cross-dressing

other specified paraphilic disorder or unspecified paraphilic disorder

Management

• anti

-androgen drugs(e.g. medroxyprogesterone or leuprolide)

• ssuis (e.g. high-dose fluoxetine)

• behaviour modification

• psychotherapy

Sexual Addiction

• definition:engaging in persistent and escalating patterns of sexual behaviour, despite increasing

negative consequences to self and others

• clinical features: may be characterized by compulsive searching for multiple sexual partners,

persistent thoughts of or craving for sex to the detriment of other activities, compulsive masturbation,

extensive use of pornography, compulsive sexuality in a relationship, and feelings of remorse or guilt

aftersex

• management:CBT, 12-step programs,SSRls to reduce libido

Sexual Dysfunction

ri

LJ

• important to identify treatable causes(e.g.atrophic vaginitis, diabetes, antidepressant medications)

• see Gynaecology,GY34 and Urology, U33

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Eating Disorders s

Definition

• eating disorders are characterized by a persistent disturbance of eating that impairs psychosocial

functioning or health

• disorders include: anorexia nervosa, avoidant/restrictive food intake disorder, binge eating disorder,

bulimia nervosa, pica, and rumination disorder

Eating Disorder Screening

Method to identity patients with

eating disorders. A "Yes" to two or

more questions is associated with a

sensitivity and specificity of 78 and 88%.

respectively

Epidemiology

• anorexia nervosa (AN): 1% of adolescent and young adult females; 0.3% males; onset in mid-teens

(14-18 yr)

• bulimia nervosa (BN ): 2-4% of adolescent and young adult females;0.5% males;onset in late teens or

early adulthood

• I

:

:M= I 0: I; mortality of AN 5- 10"

,,

t common comorhidities:depression (50-75%),substance misuse (35% in BN, 15% in AN ), OCD (25% in

AN )

SCOFF

Do you make yourself Sick because you

feel uncomfortably full?

Do you worry you have lost Control over

how much you eat?

Have you recently lost more than One

stone (M pounds or 6.35 kg) in a 3 mo

period?

Do you believe yourself to be Fat when

otherssay you are too thin?

Would you say that Food dominates

your life?

Etiology

• multifactorial: psychological,sociological, and biological associations

• individual: perfectionism, lack of control in other life areas, history of sexual abuse

• personality: anxiety, perfectionism, obsessionality, negative emotionality, cognitive inflexibility

• family & sociocultural:invalidating family structure, prevalent in industrialized societies,

idealization of thinness in the media,athletic demands

• puberty

• genetic factors

AN:6% prevalence in siblings,with one study of twin pairs finding concordance in 9 of 12

monozygotic pairs vs.concordance in 1 of 14 dizygotic pairs (lOx greater risk among first-degree

relatives)

BN:higher familial incidence of affective disorders than the general population

Risk Factors

• physical factors:obesity, chronic medical illness (e.g. DM)

• psychological factors:individuals who by career choice are expected to be thin,family history'

(mood disorders,eating disorders,substance use disorder), history ofsexual abuse (especially for

BN), competitive athletes, concurrent associated mental illness (depression, OCD, anxiety disorder

(especially panic and agoraphobia),substance use disorder (specifically for BN))

Complications

• growth delay, osteoporosis(40%), osteopenia (50%), cardiovascular complications (bradycardia,

QTc prolongation,starvation edema), gastrointestinal complications (irritable bowel syndrome,

constipation,gastric dilation), electrolyte disturbances(hypokalemia, hypomagnesemia,

hypophosphatemia), refeeding syndrome, and endocrine abnormalities (increased GH, reduced LH,

1'

SH, and T3)

Anorexia Nervosa

DSM-5 DIAGNOSTIC CRITERIA FOR ANOREXIA NERVOSA

Repiinled with permission from the Diagnostic and Slatislical Manual olMental Disorders, 5th cd. 2013. American Psychiatric Association

A.restriction of energy intake relative to requirements, leading to a significantly low body weight in

the context of age,sex, developmental trajectory, and physical health. Significantly low weight is

defined as a weight that isless than minimally normal or, for children and adolescents, less than that

minimally expected

B.intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight

gain, even though at a significantly low weight

C.disturbance in the way in which one'

s body weight orshape is experienced, undue influence of body

weight or shape on self-evaluation,or persistent lack of recognition of the seriousness of the current

low body weight

• specifiers: partial remission, full remission,severity based on BM1 (mild = BMI >17 kg/m -, moderate

= BMI 16-16.99 kg/m2 ,severe = BMI 15-15.99 kg/m5 extreme = BMI <15 kg/m2), type (restricting =

during last 3 mo no episodes of binge-eating or purging vs. binge-eating/purging type = in last 3 mo

have participated in recurrent episodes of binge-eating/purging)

Athletic Triad

Disordered eating

Amenorrhea

Osteoporosis

Some patients with insulin-dependent

DM may stop their insulin in order to

lose weight

r-t

Management

• standard svork-up:vitals (weight and orthostatic BP and HR), Woodwork (CBC, electrolytes,

creatinine, liver enzymes,B12,TSH), KCG

• psychotherapy:individual,group,family; address food and body perception, coping mechanisms,

health effects

• CBT:sets clear weight goals and expectations, makes use of recording sheets, targets maintaining

factorssuch as negative body image

• family-based treatment is primarily used in the paediatric system, main focus is on weight restoration

and return to physical health

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PSIO Psychiatry Toronto Notes 2023

•medications of little value;however,SSRls may be helpful in treating concurrent mood and anxiety

disorders

•outpatient and inpatient programs are available (nutritional rehabilitation)

•inpatient psychiatric hospitalization for treatment of eating disorders is rarely on an acute basis

(unless there is a concurrent psychiatric reason for emergent admission (e.g. suicide risk));such

patients often require a specialized LD program

•criteria to admit to medical ward for hospitalization: <65% ofstandard body weight (<85% of standard

body weight for adolescents), hypovolemia requiring intravenousfluid, heart rate <40 bpm, abnormal

serum chemistry (e.g.low K+ , low Mg2+, Low PO43-, high creatinine),or if actively suicidal

•agree on target body weight on admission and reassure this weight will not be surpassed

•monitor for complications of AN (see Table 9, PS41)

•monitor for refeeding syndrome

• potentially life-threatening metabolic response to refeeding in severely malnourished patients

resulting in severe shifts in fluid and electrolyte levels

complications include hypophosphatemia, congestive heart failure, cardiac arrhythmias,

delirium, and death

prevention:slow refeeding,gradual increase in nutrition,supplemental phosphorus, and close

monitoring of electrolytes and cardiac status

Prognosis

•adolescent onset has much better prognosis than adult onset

•only about 50% make a full recovery

•witn treatment, 70% resume a weight of at least 85% of expected levels and about 57% resume normal

menstrual function

•eating peculiarities and associated psychiatric symptoms are common and persistent

•high rates of mortality (7%) secondary to severe and chronic starvation, metabolic or cardiac

catastrophes,with a significant proportion dying by suicide

Bulimia Nervosa

DSM-5 DIAGNOSTIC CRITERIA FOR BULIMIA NERVOSA

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

A.recurrent episodes of binge-eating; an episode of binge-eating is characterized by both of the

following:

eating, in a discrete period of time, an amount of food that is definitely larger than what most

individuals would eat during a similar period of time and under similar circumstances

• a sense of lack of control over eating during the episode

B.recurrent inappropriate compensatory behaviour in order to prevent weight gain,such asself-induced

vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise

C.the binge-eating and inappropriate compensatory behaviours both occur, on average, at least once a

week for 3 mo

D.self-evaluation is unduly influenced by body shape and weight

E.the disturbance does not occur exclusively during episodes of AN

• specifiers: partial remission, full remission,severity (mild = 1-3 inappropriate compensatory

behaviours/wk, moderate = 4-7 inappropriate compensatory behaviours/wk,severe

= 8-13

inappropriate compensatory behaviours/wk, extreme = 14+ inappropriate compensatory behaviours/

wk)

Associated Features

- fatigue and muscle weakness due to repetitive vomiting and fluid/electrolyte imbalance

• tooth decay, perioral irritation, mouth ulcers

• swollen appearance around angle of jaw and puffiness of eye sockets due to fluid retention, edema

• reddened knuckles, Russell’ssign (knuckle callus from self-induced vomiting)

• trouble concentrating,fatigue, headache, abdominal pain/reflux

• weight fluctuation over time

Management

• medical admission forsignificant electrolyte abnormalities

• biological: treatment ofstarvation effects,SSRls (60 mg fluoxetine has the most evidence) as adjunct

• psychological: develop trusting relationship with therapist to explore personal etiology and triggers,

CBT,family therapy, recognition of health risks

• social: challenge destructive societal views of women, use of hospital environment to provide external

patterning for normative eating behaviour

Prognosis

• relapsing/remitting disease

• good prognostic factors:onset before age 15,achieving a healthy weight within 2 yr of treatment

• poor prognostic factors:later age of onset, previous hospitalizations, individual and familial

disturbance

• 60% good treatment outcome, 30% intermediate outcome, 10% poor outcome (mortality rate of

approximately 2% per decade)

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Binge-Eating Disorder

Definition

• recurrent episodes of hinge-eating (as defined by criteria A of BN ) that are associated with eating

much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts when

not physically hungry, eating alone because embarrassed by how much one is eating, and/or feeling

disgusted with oneself/depressed/very guilty afterwards at least once/wk x 3 mo

• not associated with any compensatory behaviours

• dieting usually follows binge-eating (vs. BN where dysfunctional dieting typically precedes bingeeating)

• for more details about Binge- hating Disorder, please consult the DSM-5

Points for Differentiating Between

Eating Disorders

• AN of binge-eating/purging type

(significantly low body weight) takes

priority over a BN diagnosis (body

weight not in criteria)

• BN requires compensatory

behaviours

• Binge-eating disorder does not

involve compensatory behaviours

• Avoidant/restrictive food intake

disorder does not involve

disturbances in body image

Epidemiology

• F:M«2:1

• begins in adolescence or young adulthood

Treatment

• CUT

Avoidant/Restrictive Food Intake Disorder

Definition

• eating/feeding disturbance (i.e. apparent lack of interest in eating or food ) to the extent of persistent

failure to meet appropriate nutritional and/or energy needs, resulting in significant weight loss/

growth failure and nutritional deficiencies; patients experience disturbances in psychosocial

functioning and may become dependent on enteral feeding/oral nutritional supplementation

does not occur during an episode of AN or BN and not better explained by lack of available food

or culturally sanctioned practice

no evidence of distress in the way in which one’s body weight or shape is experienced

Risk Factors

• temperament (e.g. anxiety disorders), environment (e.g.familial anxiety), genetic (e.g.history of GI

conditions)

• begins in infancy and can persist into adulthood

Treatment

• psychoeducation

• behaviour modification

• psychotherapy

Important electrolytes in eating

disorders:KPMg (potassium,phosphate,

magnesium)

Table 9. Physiologic Complications of Eating Disorders

System Starvation/Restriction Binge-Purge

Russell'ssign (knuckle callus)

Parotid gland enlargement

Perioral skin irritation and mouth ulcers

Periocular and palatal pelechiae

loss of dental enamel and caries

Aspiration pneumonia

Metabolic alkalosissecondary to hypokalemia and loss of acid

Fatigue

General low BP

low HR

Significant oithostatic changesisyncopal episodes Low body tempeiature

Vitamin deficiencies

Emaciation

Sleep disturbances

fatiguefweakncss

Endocrine

Neurologic

Cutaneous

Primary or secondary amenorrhea, cold intolerance, decreased I3/ T 4

Seiture (decreased Ca*'

.M g P0r

!

)

Ory skin, lanugo hair, hair loss or thinning, brittle nails, yellow skin from high

carotene

GI Constipation.GERO.delayed gastric emptying, abdominal pain Acute gastric dilation/rupture, pancreatitis. GERD.hematemesissecondary to Mallory- Weiss

tear

CVS Arrhythmias.CHF

Osteoporosissecondary to hypogonadism

Pre-renal failure (hypovolemia),renal calculi

Pedal/periorbital edema (decreased albumin)

Starvation:decreased RBCs,decreased WBCs.decreased LH,decreased FSH,

decreased estrogen, decreased testosterone, increased GH.increased cholesterol

Dehydration:increased BUN

Arrhythmias, cardiomyopathy (from use olipecac).sudden cardiac death (decreased K )

Muscle wasting

Renal failure (electrolyte disturbances)

Pedal/periorbital edema (decreased albumin)

Vomiting:decreased Ni.decreased K;decreased Cf. decreased H *,increased amylase;

hypokalemia with metabolic alkalosis

Laxatives: decreased Na*

. decreased K

*

. decreased Cl ;increased H"

; metabolic acidosis

MSK

Renal r i

L J

Extremities

Lab Values

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Personality Disorders

•in the literature, personality and its disorders can be understood using a trait-based dimensional

approach (i.e. 5 major traits such as extraversion, agreeableness, conscientiousness, neuroticism,

and openness to experiences rated on a continuum of dysfunctional effects), rather than discrete

categories; however, the discrete categories still remain in the current DSM and will be referenced here

General Information

•an enduring pattern of inner experience and behaviour that deviates markedly from the expectations

of the individual’s culture; manifested in two or more of:cognition, affect, interpersonal functioning,

impulse control

•inflexible and pervasive across a range of situations

•pattern isstable and well-established by adolescence or early adulthood (i.e. not a sudden onset)

•associated with many comorhiditiessuch as depression,suicide, violence, brief psychotic episodes,

substance use, and treatment resistance

•relationship building and establishing boundaries are important; focus should be placed on

validating, finding things to be truly cmpathetic about, and speaking to the patient'

s strengths

•mainstay of treatment is psychotherapy (e.g. CUT, interpersonal psychotherapy, psychodynamic

psychotherapy, DBT); add pharmacotherapy to treat associated psychiatric disorders (e.g. depression,

anxiety,substance misuse)

Classification

•personality disorders are divided into three clusters (A, B, and C), with shared features among

disorders within each

A flag for personality disorders in clinical

setting is the reaction that a patient is

eticiting in you

Personality disorders with familial

associations: schizotypal, antisocial,and

borderline

Table 10. Description and Diagnosis of Personality Disorders

Cluster A:"Mad" Personality Disorders

• Patients seem odd.eccentric,withdrawn

• Familial association with psychotic disordcis

• Common defense mechanisms:inlellectualuation.projection,magical thinking

ParanoidPersonality Disorder (1-4% ot general population)

Pervasive distrust and suspiciousness of others,interpret motives as malevolent

Blame problemson others and seem angry and hostile

Diagnosis requires 4» of:SUSPECT

1.Suspicious that others are exploiting or deceiving them (withoutsufficient basis)

2.Unforgiving (bears grudges)

3.Spousal infidelity suspected without justification

4.Perceive attacks on character,counterattacks quickly

5.Enemies ot Inends? Preoccupied with acquaintance trustworthiness

6. Confiding in others Is feared

/.fluents interpreted in benign icmaiks

(Hole:Must rule oulpsychotic disorder wheieno true delusions or hallucinations present)

SchizotypalPersonality Disorder (4-5% of general population)

Pervasive pattern of social and interpersonal deficits,cognitive/perceptual distortions,eccentric

behaviours,and peculiar thought patterns

Diagnosis requires 5*

01:ME PECULIAR

1.Magical thinking

2.Experiences unusualperceptions (including body illusions)

3.Paranoid ideation

4.Eccentric behaviour or appearance

5. Constricted or inappropriate alfect

6. Unusual Ihinkmgfspccch (e.g, vague,stereotyped)

1.Lacks closeItiends

8.Ideas of relcrcnce

9.Anxiety in social situations that does not diminish with familiarity (related to fears)

(Note:Rule out psychotidpervasive developmental disorders this is not part of the criteria:the

more lixed and systematic a belief is.the more likely itisof delusional intensity)

Schizoid Personality Disorder (3-5% of general population)

Neither desires nor enjoys close relationships including being a part ot a family:prefers to be alone.Lifelong pattern of social withdrawal. Seen as eccentric and reclusive with restricted affect in a

variety of contexts

Diagnosis requires 4*

ot:DISTANT

1.Oetachcd/flat alfect, emotionally cold

2.Indifferent to praise or criticism

3.Sexual experiences ol little interest

4.Tasks done solitarily

5.Absence ol close friends (other than lirsl degiee relatives)

6.Neither desires nor enjoys close relationships (including family)

7.Takes pleasure inlew (if any) activities

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Table 10. Description and Diagnosis of Personality Disorders

Cluster B:"Bad"Personality Disorders

• Patients seem dramatic,emotional,inconsistent,and impulsive

• Sensitive to perceived criticism,abandonment,or lack ol attention;dilficulty with interpersonal relationships due to self-serving,hostile,or erratic behaviour

• Familial association with mood disorders

• Common defense mechanisms:denial,acting out. regression (histrionic PD),splitting (borderline PD),projective identification,idealication/devatualion

Borderline Personality Disorder (1-2% of general population)

A pervasive pattern of instability of interpersonalrelationships,self-image,and affects; maiked

impulsivily.Strong correlation with a history of childhood sexual abuse. Charactericed by

inlerpersonal.cognilivc.behavioural,and affective deficits. Often exposed loan emotionally

invalidating environment. The morcdramatic behavioui tends lo diminish as patients age. DBT is

the principal treatment (see Psychotherapy./>549)

"10% suicide rale"

Diagnosis requires 5* ol IMPULSIVE

1. Impulsive (minimum of 2 sell-damaging ways.e.g.sex/drugs/spending)

2.Mood/affect instability

3.Paranoia or dissociation under stress

4. Unstable self-image

5.labile intense relationships (extremes of idealization and devaluation)

6.Suicidal gestures/self-harm

7.Inappropriate anger

8.Voiding abandonment (real or imagined,frantic efforts lo)

9.Emptiness (feelings of)

(Note:More frequently diagnosed in females but research suggests equal gender distribution)

AntisocialPersonality Disorder (M:2-4%.F:0.5-1%)

lack of remorse for actions,manipulative and deceitful,often violate the law.May appear

charming on first impression.Pervasive pattern of disregard for others and violation of others'

rights must be present before age15:however,for the diagnosis of ASPD,patients must be at least in females butstudies suggest equal prevalence

18.Must have evidenceof conduct disorder before age15:history of trauma/abuse common (see

Child Psychiatry.PS44

Diagnosis requires 3- of:CORRUPT

1.Cannot conform to law and/or social norms(repeated illegalacts)

2.Obligations ignored (irresponsible)

3.Reckless disregard for safety of self or others

4. Remorseless

5.Underhanded (deceitful:conning others for personal profitor pleasure)

8.Planning insufficient (impulsive)

7.Temper (irritable and aggressive)

Narcissistic Personality Disorder (around 6% of generalpopulation)

Sense of superiority,needs constant admiration,lacks empathy,but with fragile sense of self.

Consider themselves "special" and will exploit others for personal gain.Beginning by early

adulthood and present in a variety of contexts

Diagnosis requires 5* ol: GRANDIOSE

1.Grandiose sense of self-importance (e.g. exaggerates achievements and talents)

2.Requires excessive admiration

3.Arrogant

4 Needs lo be special (and associate with other special or high status people)

5.Dreams ol success,power,beauty,love (preoccupied with these fantasies)

6.Inlerpcrsonally exploitative

7.Olliers (lacks empathy,unable lo recognize feelings/needs ol others)

8.Sense of entitlement

9.Envious (or believesothers are envious)

Histrionic Personality Disorder(2% of generalpopulation)

Attention-seeking behaviour and excessively emotional.Are dramatic,flamboyant,and

extroverted.Cannot form meaningfulrelationships.Often sexually inappropriate.Diagnosed more

Diagnosis requires 5»of:ACTRESSS

1.Appearance used to attract attention

2.Centre of attention (else uncomfortable)

3.Theatrical

4.Relationships (believed to be more intimate than they are)

5.Easily influenced

6.Seductive behaviour

7.Shallow expression of emotions (whichrapidly shift)

8.Speech (impressionistic and vague)

Cluster C:"Sad"Personality Disorders

• Patients seem anxious,fearful

• Familial association with anxiety disorder

• Common defense mechanisms:isolation,avoidance,hypochondriasis

AvoidantPersonality Disorder (2.4% of generalpopulation)

fimid and socially awkward with a pervasive sense of inadequacy,social inhibition,and

hypersensitivity tocriticism.Fear olembarrassing or humiliating themselves in social situations so closed-off.and inefficient.Highly comorbid with mood/anxiety andeating disorders

Diagnosis requires 4* of:SCRIMPER

1.Stubborn

2.Cannot discard worthless objects

3.Rule /detail obsessed (lo poinlof activity lost)

4.Inflexible in mailers of morality,ethics,values

5.Miserly

6.Perfecbonislic lo the extern that it hampers task completion

7.Excludes leisure due lo devotion lo work

8.Reluctant lodelegate lo olhers

Obsessive-Compulsive Personality Disorder (2.1-7.9%)

Preoccupation with orderliness,perfectionism,and menial and interpersonal control.Is inflexible.

remain withdrawn and socially inhibited

Diagnosis requires 4*

of:CRINGES

1. Criticism or rejection preoccupies thoughts in social situations

2. Restraint in relationships due lo lear olbemgshamed

3.Inhibited in new relationships due lofeat of inadequacy

4. Needs to be sure of being liked before engaging socially

5.Gels around occupational activities requiring interpersonal contact

G. Embarrassment prevents new activity or taking risks

7.Self-viewed as unappealing or inferior

Dependent Personality Disorder (0.5 0.6% of generalpopulation)

Pervasive and excessive need lo be taken care of.eiccssivc fear ol separation,clinging and submissive behaviours.Difficulty making everyday decisions. Useful to set regulated treatment schedule

(regular,briel visits) and being firm about in between issues.Encourage palienl to do more lor themselves,engage In own problem-solving

Diagnosis requires 5*

of: RELIANCE

1. Reassurance and/or advice required for everyday decisions (excessive)

2.Expressing disagreement difficult

3.life responsibilities assumed by others

4.Initiating projects difficult [because lack of self-confidence)

5.Alone (feels helpless and uncomfortable when alone)

6.Nurturance (goes toexcessive lengths to obtain)

7.Companionship sought urgently

8.Exaggerated fears of being left to care for self

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Table 11, Key Differences Among Schizoid, Schizotypal, and Schizophrenia

Schizoid Schizotypal Schizophrenia

Organized Organized,bulvague and

circumstantial

Disorganized,tangential,

loosening of associations

Thought Form OCPD vs. OCD

OCPD OCD

Thought Content No psychosis:may have ideas of Psychosis

reference, paranoid ideation,odd

beliefs, and magical thinking

lacks close relationships,

INIERESIED in relationships but

has difficulty forming them

No psychosis Ego-Syntonic Ego-syntonic Ego dysteme

orEgo- Dystoak

Thought

Coaleat

Solitary. NO desire for social

relationships

Socially marginalized, but nol

by choice

Relationships Obsessional Obsessions and

thinking. no compulsions,

compulsions, rituals, anxiety

strict routine provoking

and rigidity unwanted

in day-to-day intrusive

matters, more thoughts

perfectiomstic

and rigid

Child Psychiatry

Developmental Concepts

• temperament: a child '

s innate psycho-physiological and behavioural characteristics (i.e. emotionality,

activity, and sociability);spectrum from “difficult" to “slow-to-warm-up" to “easy temperament”

• parental fit: the congruence between parenting style (authoritative, permissive) and child’s

temperament

• attachment:special relationship between child and primary caretaker(s);develops during first year,

the caretaker’s attachment style isthe best predictor of their child’s attachmentstyle,see Table 12

• separation anxiety (normal between 10-18 mo): where separation from attachment figure results in

distress

Consider speaking to children alone.

Always consider child abuse in your ODx.

See Paediatrics. P18

Tips

Q

for the Child Interview

• Use language the child will

understand (e.g. don't ask about

feelings of worthlessness,ask about

whether they feel like they are a

bad kid)

• Use developmentally-appropriate

questions (e.g. don't ask about lack

of interest in activities, ask children

whether they feel bored)

Table 12. Attachment Models

ParentfCaregiver Features In Child (during Strange Situation

experiment)

Attachment Type

Loving, consistently available,

sensitive,and receptive

Secure Freely explores and engages with strangers well (aslong as

mother in close proximity), upset with caregiver'

s departure,

happy with return

Ignores caregiver,shows little emotion with arrival or

departure, little exploration

Clingy but inconsolable, often displays anger or helplessness,

little exploration

Simultaneous approachfavoidancc and stress-related

straining behaviour

Rejecting, unavailable

psychologically,insensitive responses

Inconsistent, insensitive responses. Insecure (ambivalcnt/resistant)

role reversal

Frightening,dissociated,sexualized. Disorganized

or atypical

Often history of trauma or loss

Insecure (avoidant)

Mood Disorders in Children and Adolescents

MAJOR DEPRESSIVE DISORDER

Epidemiology

• lifetime prevalence for prc- puhertal I -2% (l

'

:M= l:l ); adolescents -1 - 18".'

. (1-

'

:M=2:I )

Clinical Features

• only difference in diagnostic criteria for children and adolescents is that irritable mood may replace

depressed mood

• physical features:insomnia (children), hypersomnia (adolescents),somatic complaints,substance

misuse, decreased hygiene

• psychological features: irritability, boredom, anhedonia,low self-esteem, deterioration in academic

performance, social withdrawal, lack of motivation, listlessness

• common comorbid diagnoses: anxiety, ADHD, ODD, conduct disorder, eating disorders, and

substance misuse

HEEADSSS Interview

Home enviionment

Education/Employment

Eating

Activities

Dzugs

S:

Safety

Suicide/depression

Treatment

• majority never seek treatment

• supportive therapy including psvchoeducation, active listening, and lifestyle advice helpful in mild

depressive episode

• CBT or 1PT, internet-based therapy if in-person options unavailable

• 1stline SSR1: fluoxetine

• 2nd line SSRls:escitalopram,sertraline, citalopram

• close follow-up for adolescents starting SSRls to monitor for increased suicidal ideation or behaviour

• in severe depression, best evidence for combined pharmacotherapy and psychotherapy

• EO'

or rTMS: limited evidence in this population, only for use in adolescents 212 y/o with severe

illness, psychotic features, catatonic features, persistently suicidal

• light therapy,self-help books, and applications can he used as adjuncts

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Prognosis

« prolonged episodes, up to 1-2 yr = poor prognosis

• prognosis variable; adolescents with depression more likely to have depression in adulthood than

adolescents without

• approximately 2% of adolescents with depression will develop bipolar disorder within 4 yr

• complications: negative impact on family and peer relationships,school failure,significantly increased

risk of suicide attempt or completion (however,suicide risk low for pre-pubertal children),substance

use disorder

DISRUPTIVE MOOD DYSREGULATION DISORDER

Clinical Features

• severe, developmental^

inappropriate,recurrent verbal or behavioural temper outbursts at least 3x/

wk with persistently irritable mood in between

• symptom onset before age 10, occurring for 212 mo, in 22 settings, with no more than 3 consecutive

mo free from symptoms

• diagnosisshould be made between ages 6-18

• criteria not met for intermittent explosive disorder nor bipolar disorder ( no mania/hypomania)

• supersedes diagnosis of ODD if criteria for both are met

• common comorbidities: ADHD, anxiety'disorders, depressive disorders

BIPOLAR DISORDER

Clinical Features

• mixed presentation and psychotic symptoms ( hallucinations and delusions) more common in

adolescent population than adult population

often misdiagnosed in the adolescent population

• unipolar depression may be an early sign of adult bipolar disorder

• associated with rapid onset of depression, psychomotor retardation, mood-congruent psychosis,

affective illness in family, and pharmacologically-induced mania

Attachment type can be assessed

ininfants 10-18 mo of age using the

Grange Situation test,in which the

child is stressed by the caregiver being

removed from the situation and the

stranger staying. Attachment style is

measured by the child's behaviour

during the reunion with the caregiver

Treatment

• lack of research in adolescent population, treatment guidelines based off of adult recommendations

• pharmacotherapy: mood stabilizers (lithium, anticonvulsants) and/or antipsychotics (risperidone,

olanzapine, quetiapine, aripiprazole)

• psychotherapy:CBT, family-focused therapy (a therapeutic modality designed for bipolar disorder

that combines psychoeducation, communication skills training, and problem-solving skills training)

Attachment

8

problems may present as

a child who is difficult to soothe,has

difficulty sleeping, problems feeding,

tantrums,or behavioural problems

Anxiety Disorders in Children and Adolescents

•prevalence 10% in childhood/adolescence; 1-

'

:M=2:I

•often not recognized

•

Clinical

becomes

Features

problematic when it interferes with typical academic/social functioning

o

•children and adolescents may not vocalize their anxiety and instead may exhibit behavioural

manifestations

•associated with school problems, unrealistic worries, physical/somatic symptoms(abdominal pain,

headaches),social and relationship problems,social withdrawal and isolation,sleep difficulties,

tearful episodes or temper tantrums, lack of confidence, irritability and mood symptoms, alcohol and

drug use in adolescents

•tension may look like fidgeting

Differential Diagnosis

•depressive disorders,ODD, truancy

•persistence and impairment to daily functioning differentiates anxiety disorder from normal anxiety

•for school avoidance, differentiate social anxiety (fear of performance and humiliation) from

generalized anxiety

•consider anxiety about separation, and rule out bullying and school refusal due to learning disorder

Course and Prognosis

•better prognosis with later age of onset, fewer comorbidities, early initiation of treatment, ability to

maintain school attendance and peer relationships, and absence of social anxiety disorder

•with treatment, up to 80% of children will not meet criteria for their anxiety disorder at 3 yr followup, but up to 30% will meet criteria for another psychiatric disorder

Treatment

•similar principles for most childhood anxiety disorders due to overlapping symptomatology and

frequent comorbidity

•psychoeducation of child and family

•psychotherapy: CBT has been shown to be effective in children and adolescents with anxiety

•pharmacotherapy: SSRls can be helpful

The shy child is quiet and reluctant to

participate but slowly ‘warms up'

Fluoxetine,Cognitive Behavioural Therapy

and Their Combination for Adolescents with

Depression: Treatment lor Adolescents with

Depression Study (TAOS) landomired Controlled

Trial

JAMA 2004:292^

07-820

Purpose:To evaluate effectiveness of fluoxetine

alone, cognitive behavioural therapy(CBT) akme.CBT

with fluoxetine,and placebo among adolescents with

major depiessive disorder (MOD)

Methods:Randomized controlled trialat13 IIS

academic and community chores between spring

2000-summer 2003, including patients12-17 yfo with

a piimary OSMIV diagnosis of MOO aligned to one ol

the afoiemenlloned lour treatment arms.The primary

outcome wasthe Children'sDepression Bating ScaleRevised (CORSR) totad score.

Results:Fluoxetine with CBT bad a statisticaly

significant CORSR score as compared to placebo

|P*

O.OOI|with a 71% response rate.This combination

wasgieater than fluoxetine alone (M.D2],and CBT

alone (P^O.01). fluoxetine alone was greater than CBT

alone (P-0.01).

Conclusion: Combination of fluoxetine with CBI

offered the most favourable benebt nsl tradeoff for

adolescents with MOD.

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SEPARATION ANXIETY DISORDER

• excessive and developmentally inappropriate anxiety on real, threatened, or imagined separation from

attachment figures or home,with physical or emotional distressfor at least 4 wk

• persistent worry about losing attachment figures or experiencing an untoward event to self;reluctance

to go places, be alone, orsleep alone; nightmares involving separation;physicalsymptoms when

separated

• often associated with school refusal, comorbid major depression

Efficacy and Safety of Selective Serotonin

Reoptake Inhibitors, Serotonin-Norepinephrine

feuplake Inhibitors, an if Placebo forCommoa

Psychiatric Disorders Among Children and

Adolescents:aSystematic Review and MetaAnalysis

JAMA Psychiatry 201f;M(10):l0ll 1020

Purpose:iuminelhe relativeefllcacyand safety

of SSfllt.Stills, and placebo for the treatment

of depressive disorders (DDs), timely disorders

(AOs), obsessive compuisi it disorder (OCD), and

posttraomatc stressdisorder (P1S0) in thildrenand

adolescents.

Methods:Meta-analysis of RCTs regarding use

of SSRIsor SNRts i n youths with DD.AD, OCO.or

PI5D.Effectsires,calculated asstandardized mean

differences(Hedges gland risk ratios(tits) for

advene events,were assessed in a random-effects

model.

desalts:thirty-sir trials were eligible and analysis

showed that SStlsand SNRIs weie more beneficial

compa red with placebo(g•0.32; 95% Cl , 0.25 0.40:

P

-,00|t .AOs|g•0.51;95% Cl , 0,40-0.72; P * .00l|

had larger belwten-group effectsuesthan 00s

(g •0.20;95% Cl, 0.13-0.27; P

- ,00|l .Patients with

DDs eihiMed signiticantly larger placebo responses

(9-1.57:95% Ct 1

-36-1.78;P< .001) compared

with those with AOs (g

-1.03; 95% Cl, 0.84-1.21;

P‘

.0Ot).IheSStls produced a relatively large effect

size for AOs(g

-0.71;95%Cl, 0.45-0.92; P <.001).

Patients receiving an antidepressant vs.a placebo

reported sigoibcantly moie treatment-emergent

advene events(RR.1.07;95% Cl,1.01-1.12;P-.01

or 9t,l49;95% CI, 1.22-1.82; P« .001, depending

on Hie reporting me!hod|,severe adverse events

(88.1.76:95% Cl, 1.34-2.32; P< .001). and study

discontvruationduelo adverse events (RR.1.79; 95%

Cl.1 382.J2; P« .001).

Conclusion: Compared with placebo,SSRIs and

SMIs are more beneficial than placebo in children

and adolescents; however, the benefit issmall and

disorder specific,yielding a larger drug-placebo

difference for AD than far other conditions.Response

to placebo islarge,especially in DD.Severe adverse

eventsaresigniticantly m ore common with SSRIs and

SNRIs than placebo.

SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)

• anxiety, fear, and/or avoidance provoked by situations where child feels under the scrutiny of others

• must distinguish between shy child, child with issues functioning socially (e.g. autism), and child with

social anxiety

diagnosis only if anxiety interferessignificantly with daily routine,social life, academic

functioning, or if markedly distressed. Must occur in settings with peers, not just adults

• features:crying, tantrums,freezing, clinging behaviour,mutism, excessively timid,stays on

periphery, refuses to be involved in group play

• significant implication for future quality of life if untreated; lower levels ofsatisfaction in leisure

activities, higher rates ofschool dropout, poor workplace performance, increased rates of remaining

single

SELECTIVE MUTISM

• consistent failure to speak in specific social situations where speaking is expected, despite speaking in

other situations for 21 mo

• the disturbance interferes with educational or occupational achievement or with social

communication

• not due to lack of knowledge of language or communication disorder

GENERALIZED ANXIETY DISORDER

• diagnostic criteria same as adults (note; only 1 item is required in children for Criteria C)

• children worry about many things(e.g.school,future,family, past)

• often redo tasks,show dissatisfaction with their work, and tend to be perfectionistic

• often fearful in multiple settings and expect more negative outcomes when faced with academic or

social challenges, and require reassurance and support to take on new tasks

SPECIFIC PHOBIA

• common phobias in childhood:fear of heights,small animals, physicians, dentists, darkness, loud

noises, thunder, lightning

OCD

• diagnostic criteria same as adults

• note:young children may not be able to articulate the aims of their compulsions

Neurodevelopmental Disorders

Autism Spectrum Disorder

Diagnosis

• persistent deficits in social communication and interaction,manifested in three areas;

social-emotional reciprocity: abnormalsocial approach and failure of normal back-and-forth

conversation; reduced sharing of interests, emotions, or affect;failure to initiate or respond to

social interactions

nonverbal communicative behaviours: poorly integrated verbal and nonverbal communication;

abnormalities in eye contact and body language or deficits in understanding and use of gestures;

total lack of facial expressions and nonverbal communication

developing, maintaining, and understanding relationships: difficulties adjusting behaviour to

suit various social contexts;difficulties in sharing imaginative play or in making friends;absence

of interest in peers

• restricted, repetitive patterns of behaviour, interests,or activities manifested by >2 of:stereotyped or

repetitive motor movements,insistence on sameness, highly restricted fixated interests, hyper-/hyporeactivity to sensory input

• symptoms must be present in early developmental period

• symptoms cause clinically significant impairment in social,occupational, or other important areas of

current functioning

• not better explained by intellectual disability or global developmental delay

• specifiers

• current severity; requiring very substantial support, requiring substantial support, requiring

support

± language impairment, ± intellectual impairment, ± catatonia

• associated with known medical or genetic condition or environmental factor

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PS47 Psychiatry Toronto Notes 2023

Differential Diagnosis

• neurodevelopmental:global delay, intellectual disability, language disorder,social communication

disorder, learning disorder, developmental coordination disorder,stereotypic movement disorder

• mental and behavioural: ADHD, mood disorder, anxiety disorder,selective mutism, attachment

disorder, ODD, conduct disorder, OCD, childhood schizophrenia

• conditions with developmental regression:Rettsyndrome, epileptic encephalopathy (LandauKleffner)

• other: hearing/visual impairment, abuse

Treatment

• team-based:school, psychologist, occupational therapist, physiotherapist,speech-language

pathologist, paediatrics, psychiatry

• psychosocial:family education and support,school programming, behavioural therapy,socialskills

training

• treat concomitant disorders such as ADHD, tics, OCD, anxiety, depression,and seizure disorder

• adjunctive pharmacotherapy (does not treat ASD itself): atypical antipsychotics (for irritability,

aggression, agitation,self-mutilation, tics),SSRls (for anxiety,depression),stimulants (for associated

inattention and hyperactivity)

Prognosis

• variable, but improves with early intervention

Attention Deficit Hyperactivity Disorder

•prevalence: 5-12% of school-aged children; M:l

;

=4:l, although girls may be under-diagnosed

•girls tend to have inattentive symptoms;boys tend to have impulsive/hyperactive symptoms

Etiology

•genetic: 75% heritability, dopamine candidate genes DAT1, DRD4

•neurobiology: decreased catecholamine transmission, low prefrontal cortex (FTC) activity, increased p

activity on HHCi

•cognitive: developmental disability, poor inhibitory control, and other errors of executive function

Diagnosis

•diagnosis requires: onset before age 12, persistent symptoms 26 mo,symptoms present in 22 settings

(i.e. home,school, work), interferes with academic, family, and social functioning, and is divided into

3subtypes

combined type: 26 symptoms of inattention and 26 symptoms of hyperactivity-impulsivity

predominantly inattentive type: 26 symptoms of inattention

» predominantly hyperactive-impulsive type:>6 symptoms of hyperactivity-impulsivity

• for older adolescents and adults(> age 17), >5 symptoms required

•does not occur exclusively during the course of another psychiatric disorder

•DDx:learning disorders, hearing/visual defects, thyroid, atopic conditions, congenital problems (fetal

alcohol syndrome, fragile X syndrome), lead poisoning, history of head injury, traumatic life events

(abuse)

•specify currentseverity (mild/moderate/severe); if in partial remission (past diagnosis, has not met

full criteria >6 mo,still functional impairment present)

Comparative Efficacy and Tolerability of

Medicationsfor Attention-Deficit Hyperactivity

Disorder iaChildren, Adolescents, and Adults:A

Systematic leview and Network Meta-Analysis

lancet 2018:5:727738

Purpose Estimate the comparative efficacy and

tolerability of oral medications for ADHO in children,

adolescents,and adults.

Methods:Reviewof double-blind RCTscocnparing

amphetamines,atomoxetine. bupropion,donidne.

guanfacine.methylphenidate. and modafiiti]with

each other or placebo.

Conclusions lei mg into account both efficacy and

solely, evidence from this mela-analysissupports

methylphenidate in children and adolescents,and

amphetamines in adults,as preferred hrst-cheice

medicationsfor theshort-term treatment of ADHD.

Contrary to the concerns of many

parents and health care providers,

treatment with stimulant medications

of ADHD in childhood does not increase

the likelihood of substance misuse later

in life

Table 13. Core Symptoms of ADHD (DSM-5)

Inattention Hyperactivity Impulsivity

Careless mistakes

Cannotsustain attention in tasksot play

Does not listen when spoken to directly

failsto complete tasks

Disorganized

Avoids and/or dislikes tasksthat require

sustained mental effort

losesthings necessaty for tasksor activities

Distractible

Forgetful

Fidgets,squirms in seal

Leavesseal when expected to remain sealed Difficulty awaiting turn

Runs and climbs excessively

Cannot play quietly

“On the go",driven by a motor

Talks excessively

Blurts out answers before questions completed

Interrupts/inlrudes on others

n

Clinical Features

• difficult to differentiate from highly variable normative behaviour before age 4, but often identified

upon school entry

• present across multiple settings(i.e.school, home, extracurricular)

• rule out developmental delay,sensory impairments, genetic syndromes, encephalopathies,or toxins

(alcohol,lead)

• increased risk ofsubstance use disorder, depression, anxiety, academic failure,poor social skills,

comorbid CD and/or ODD, adult ASFD

• associated with family history of ADHD, difficult temperamental characteristics

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Treatment

• non-pharmacologicai:psychoeducation, behavioural management (e.g. parent training, classroom

management,socialskillstraining)

• pharmacological: 1st line:stimulants(methylphenidate. amphetamines); 2nd line: atomoxetine and

guanfacine XK; 3rd line: donidine, bupropion, imipramine

• for comorbid symptoms:antidepressants, antipsychotics

• psychosocial intervention is first line for children <6,whereas psychosocial intervention plus

medication is considered first line for children >6

Prognosis

• 70-80% continue into adolescence, but hyperactive symptoms usually abate

• 65% continue into adulthood;secondary personality disorders and compensatory anxiety disorders

are identifiable

Disruptive,Impulse Control,and Conduct

Disorder

Oppositional Defiant Disorder

Children

(D

with ODD like MRATs and

•prevalence: 2 BEARS" -16%, M=T after puberty

Rule breaker

Annoying

Temper

Diagnosis

•pattern of negativistic/hostile and defiant behaviour for >6 mo,with >1 non-sibling,with >4

symptoms manifested in 3 areas of:

angry/irritable mood:easily loses temper, touchy or easily an noyed, often angry and resentful

argumentative/defiant: argues with adults/authority figure,defies requests/rules, deliberately

annoys, blames others for their own mistakes or misbehaviour

vindictiveness:spiteful or vindictive twice in past 6 mo

note: difference between normal behaviour and ODD is frequency of symptoms (most days if age

<5 yr, weekly if age >5 yr) exceeds what is normative for one’

s age,gender, culture

•behaviour causessignificant distress or impairment in social,academic, or occupational functioning

•behaviours do not occur exclusively during the course of a psychotic,substance use,or mood disorder

•severity (mild/moderate/severe) according to number ofsettings in which symptoms are present

•diagnosis of disruptive mood dysregulation disordersupersedes ODD if criteria for both are met

Blames others

Easily annoyed

Argues with adults

Resentful

Spiteful/vindictive

A SystematicReviewaidAnalysis of tong-Term

Outcomes in Attention Deficit Hyperactivity

Diorder: Effects of Treatment and Non-Treatment

BMC Med 2012:10:95

Purpose: lo determine Ike long-term outcomes of

AOHDand whether there is an effect on long-term

outcomes with treatment.

Methods:Systematic reriew of studies, including

patients with diagnosed orsymptomatic presentation

of ADHD, assigned to pharmacological, nonpharmacological.multi-modal treatments, or a notreatment control.Outcome measures included use/

addictive behaviour,academic outcomes,antisocial

behaviour,social function,occupation,sell-esteem,

driving outcomes,services use.a nd obesity.

Results: Unnealed parlkpeelt with AOHO had

poorer outcomes vs.non-AOKD participants in 74%

(n'244|of studies, wtrde 26% (n'89)showed similar

outcomes.72% (n-37) of studiesshowed a benefit

from ADHD treatment vs.untreated ADHD and 28%

(n-15|showed no benefit Treatment ol ADHD was

found to be beneficial in studies looking at driving

P00%), obesity (100%).self-esteem|90%),social

function (13%). academicoutcomes|?1%|, drag usef

addictive behaviour (67%).antisocial behaviour

|SO%|, andoccupatron (33%).

Conclusion:Overal.people with ADHD have poorer

long-term outcomesthan controls(those without

ADHD|.For those with ADHD,treatment improves

long-term outcomes.

Clinical Features

•firstsymptoms usually appear during preschool and rarely later than early adolescence

•associated with poor school performance, few friends,strained parent/child relationships,

developing mood disorderslater on, often precedes CD

risk of

Treatment

•parent: parent management training, psychoeducation for parents and family

•behavioural therapy: to teach, practice, and reinforce prosocial behaviour

•social:school/day-carc interventions

•pharmacotherapy for comorbid disorders

Conduct Disorder

•prevalence:1.5-3.4% (M:l

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'

=4:1)

Etiology

•parental/familial factors: parental psychopathology (e.g. ASPD,substance use disorder), child-rearing

practices (e.g. child abuse, discipline), low socioeconomic status(SKS), family violence

•child factors: difficult temperament, ODD, learning problems,ADHD, neurobiology

Diagnosis

•pattern of behaviour that violates rights of others and age appropriate social norms with S3 criteria

noted in past 12 mo and Si in past 6 mo:

aggression to people and animals: bullying, initiating physical fights, use of weapons, forced sex,

cruel to people and/or animals,stealing while confronting a person (i.e. armed robbery) Conduct Disorder Diagnosis

destruction of property: arson, deliberately destroying others’ property

deceitfulness or theft: breaking and entering, conning others,stealing nontrivial items without TRAP

Theft: breaking and entering,

deceiving, non-confrontational stealing

Rule breaking:running away,skipping

school, out late

Aggression:people,animals, weapons,

forced sex

Property destruction

confrontation

violation of rules:out all night before age 13, often truantfrom school before age 13,runaway >2

times at least overnight or forlong periods of time

disturbance causes clinically significant impairment in social, academic, or occupational

functioning

if 18 yr, criteria not met for ASPD

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PS-19 Psychiatry Toronto Notes 2023

•diagnostic types

• childhood-onset (>1 criterion prior to age 10)

• adolescent-onset (no criteria until age 10)

unspecified onset (insufficient information)

mild, moderate,severe

•differential:ADHD, depression, head injury,substance misuse

Treatment

•early intervention necessary and more effective:long-term follow-up required

•psychosocial: parent management training, anger replacement training, CBT, family therapy,

education/employment programs,social .skills training

• pharmacotherapy for comorbid disorders

Prognosis

•poor prognostic indicators include:early-age onset, high frequency, variety of behaviours,

pervasiveness (i.e.in home,school, community), comorbid ADHD, early sexual activity,substance

misuse

•50% of children with CD develop ASPD as adults

Intermittent Explosive Disorder

Diagnosis

• recurrent behavioural outbursts representing a failure to control aggressive impulses in children ages

S6, manifested as either:

verbal or physical aggression that does not damage others or property,occurring >2 times per wk

for 3mo

3 outbursts involving physical damage to another person,animal,or piece of property in the last

12 mo

• outbursts are out of proportion to triggers and are not premeditated/for primary gain

• outbursts cause clinically significant distress or impairment in occupation or interpersonal

functioning, or financial/legal consequences

See Paediatrics

• Child Abuse, PIS, Chronic Abdominal Pain, P48, Developmental Delay, P2<>. Intellectual Disability.

P27, Learning Disabilities, P29, Sleep Disturbances, P15

See Neurology

• Tic Disorders, N35, Tourette'

s Syndrome, N35

Psychotherapy

•treatment in which a person with mental or physical difficulties aims to achieve symptomatic relief

through interactions with another person

•psychotherapy is delivered by a trained counsellor,social worker, nurse, psychologist, general

practitioner, or psychiatrist

•various types of therapy exist based on diverse theories of human psychology and mental illness

etiology

Common Factors of Psychotherapy

•good evidence that effective psychotherapy creates observable changesin brain circuitry and

connectivity, but these changes are different from those observed with successful pharmacologic and

other treatment modalities

•studies suggest that up to 60-90% of therapy outcome is due to common factors with only 10-40% due

to specific factors

•common factors are warmth (unconditional positive regard), accurate empathy,genuineness,

goodness of fit, relationship with provider; predict positive outcomes

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PS50 Psychiatry Toronto Notes 2023

Table 14. Summary of Psychotherapeutic Modalities

Type Indications Approach. Technique,and Theory Ideal Candidates Duration

Supportive Therapy Adjustment disorders,somatic Uses empathy,validation,and reflection to facilitate Individuals in crisis or with severe

symptoms andrelated

disorders, severe psychotic or Help patients leel sale, secuie,and encouraged

personality disorders

Adjunct to pharmacologic

management in most disorders

Interpersonal Therapy Mood disorders

Variable Isingle session to years,

adaptation and coping symptoms in acute or chronic settings though often short- intermittent)

Focuses on how interpersonal relationships impact Individuals with depression or bipolar

disorder with some insightand difficult

Weekly sessions,12-20 sessions

symptoms

4 key problem areas addressed:1. grief and loss.2. social functioning

role transitions.3.conflict,4.interpersonaldeficits Absence of severe psychotic process.

Break the interpersonal cycle:depression,selfesteem.social withdrawal

personality disorder,or comorbid

substance use disorder

CognitiveBehavioural Most mental health disorders Combines theory and method from cognitive and Individuals with motivation to change

including:mood,anxiety.0C0. behavioural therapies to leach the patient to change and who are able to participate in

personality,eating,substance connections between thinking patterns,habitual homework

use,psychotic disorders behaviours,and mood/anxiety problems

Cognitive component includes using thought records

to helpmonitor thoughts and identify inaccurate

automatic thoughts

Behavioural component includes techniques

such as systematic descnsiliialion (mastering

aniiety-provoking situations by approaching them

gradually and m a relaxed stale that limits anxiety),

flooding (confronting feared stimulus foi prolonged

periodsuntil it is no longer frightening),positive

reinforcement (strengthening behaviour and causing

it to occur more frequently by rewarding it),negative

reinforcement (causingbehaviour to occur more

frequently by removing a noxious stimulus when

desired behaviour occurs),extinction (causing a

behaviour to diminish by not rewarding il),and

punishment/aversion therapy (causing a behaviour to

diminish by applying a noxious stimulus)

Dialectical Behavioural Borderline personality disorder Therapy that combines CBT techniques with 8uddhist Individuals with borderlinepersonality

Zen mindfulness practices and dialectical philosophy disorder or borderline personality trait

Focuses on 4 types of skills:mindfulness,emotional and severe problems of emotional

regulation,interpersonal effectiveness, and distress dysregulation,impulsivity.orself-harm

tolerance

Involves 4 components:individual therapy,

group skillstraining,phone consultations,and a

consultation team

Spiritol Ml (CAPE):Compassion, Acceptance,

Partnership.Evocation

Principles ol Ml (RULE): Resist"righting reflex".

Understand client andIhcir reasons for change,

listen.Empower by conveying hope and supporting

autonomy

Icchniqucsof Ml(OARS):Open-ended questions.

Affirmations lovalidate client. Reflections (the skill

of accurale empathy),Summaries lo helpclient

organize self

Croup Psychotherapy Most mental health disorders Aims topromote self-understanding,acceptance,

including mood,anxiety.OCD. social skills

personality,eating, substance

use.and psychotic disorders

can benefitfrom group therapy

as part of treatment

Family Therapy Most mental health disorders Familysystem considered more influential than

including mood,anxiety.OCD. individual,especially for children

personality,eating,substance Focus on here and now.re-establishing parental

use.and psychotic disorders authority,strengthening normal boundaries,and

can benefit from group therapy rearranging alliances

as part of treatment

Emerging evidence for treating Derived from Buddhist meditative and philosophical Individuals who aremotivated and

adjustment disorder. MDD practices;aims to help people attend lo thoughts. willing lo engage in therapy

(relapse prevention),anxiety. behaviours,and emotions in the moment and nonpain disorders,insomnia. judgmentally using guided breathing exercises

substance use disorder

(relapse prevention)

Anxiety,obsessional

thinking, conversion disorder, and how they affect emotions and patterns of

behaviour

Recollection (remembering), repetition (reliving with Able to withstand difficult emotions

the therapist),working through (gaining insight) without fleeing or self- destructive acts

Techniques:free association,dreaminterpretation. High level of function

transference analysis

Typically weekly or twice weekly

sessions.12-20 sessions

Maintenance therapy can be carried out

over years

Therapy

Typically1yr

Therapy Weekly individual and group therapy

Motivational

Interviewing

and Motivational

Enhancement hcrapy change inmost psychological

problems

Substance use disorders

Techniques can be applied

to facilitate behavioural

Individuals with problematic substance

use. maladaptive behaviour patterns

[therapy disengagement,medication

noncompliancc.poor healthhabits)

Brief interventions (efficacy with as

little as 15 inm,single session),better

result with more sessions

Addiction is a chronic condition, often

need boosters over lime

MET - 4 sessions

Adolescents,individuals not currently

in crisis,absence of severe psychotic

symptoms

Variable

Often time-limited (e.g. weekly

sessions for 12 wk)

Children and adolescents with families

willing to engage in treatment

Often short-term (e.g.12 sessions)

Mindfulness-based

Cognitive Therapy/

Mindfulness-based

Stress Reduction

Generally weekly sessions for 8 wk

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