PS Psychiatry
Melanie Beswick, Tara McGregor and Chris Zroback, chapter editors
Kenneth Lee and Raheem Peerani, associate editors
David Katz, EBM editor
Dr. John Teshima, staff editor
Acronyms .............................. 2 Sexuality and Gender ................... 28
Paraphilias
The Psychiatric Assessment . . . . . . . . . . . . . . . 2 Gender Identity Disorder
History
Mental Status Exam Eating Disorders ....................... 28
Summary of Axes Anorexia Nervosa
Bulimia Nervosa
Psychotic Disorders ...................... 4
Differential Diagnosis of Psychosis Personality Disorders . ........... . ..... . 31
Schizophrenia
Schizophreniform Disorder Child Psychiatry ........................ 32
Brief Psychotic Disorder The Child Psychiatric Interview
Schizoaffective Disorder Developmental Concepts
Delusional Disorder Mood Disorders
Shared Psychotic Disorder (Folie a Deux) Anxiety Disorders
Childhood Schizophrenia
Mood Disorders ....... . ................. 7 Pervasive Developmental Disorders (POD)
Mood Episodes Attention Deficit Hyperactivity Disorder (ADHD)
Depressive Disorders Oppositional Defiant Disorder (ODD)
Postpartum Mood Disorders Conduct Disorder (CD)
Bipolar Disorders
Psychotherapy ......... . .............. . 38
Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . 11 Defense Mechanisms
Panic Disorder Psychodynamic Therapy
Generalized Anxiety Disorder (GAD) Behaviour Therapy
Phobic Disorders Cognitive Therapy
Obsessive-Compulsive Disorder (OCD) Cognitive Behaviour Therapy
Post-Traumatic Stress Disorder (PTSD) Dialectical Behaviour Therapy
Other Therapies
Adjustment Disorder . . . . . . . . . . . . . . . . . . . . 16
Pharmacotherapy................ . ..... . 40
Cognitive Disorders ..................... 16 Anti psychotics
Delirium Antidepressants
Dementia Mood Stabilizers
Anxiolytics
Substance-Related Disorders ......... . .. . 19 Electroconvulsive Therapy
Alcohol Experimental Therapies
Opioids
Cocaine Canadian Legal Issues ....... . ........ . .. 50
Cannabis Common Forms
Amphetamines Consent
Hallucinogens Community Treatment Order (CTO)
"Club Drugs" Duty to Inform/Warn
Suicide . . ............................. 24 References ............................ 51
Somatoform Disorders . . . . . . . . . . . . . . . . . . 25
Conversion Disorder
Somatization Disorder
Pain Disorder
Hypochondriasis
Body Dysmorphic Disorder Diagnostic Criteria reprinted with permission from the
Diagnostic and Statistical Manual of Mental Disorders,
Dissociative Disorders ................... 26
Fourth Edition, Text Revision. © 2000 American Psychiatric
Sleep Disorders . . . . . . . . . . . . . . . . . . . . . . . . 27 Association.
Nocturnal Myoclonus
Narcolepsy
Toronto Notes 2012 Psychiatry PSI
,PS2 Psychiatry Acronyms/Psychiatric Assessment Toronto Notes 2012
Acronyms
ACT assertive community treatment DA dopamine MAOI monoamine oxidase inhibitor ODD oppositional defiant disorder
ADHD attention deficit hyperactivity disorder ECT electroconvulsive therapy MOD major depressive disorder PD personality disorder
AN anorexia nervosa EPS extrapyramidal symptoms MOE major depressive episode POD pervasive developmental disorder
ASPD antisocial personality disorder EtOH ethanoValcohol MSE mental status examination PTSD post-traumatic stress disorder
BN bulimia nervosa GAD generalized anxiety disorder NOS not otherwise specified SNRI serotonin and norepinephrine reuptake inhibitors
CBT cognitive behavioural therapy GMC general medical condition OCD obsessive-compulsive disorder SSRI selective serotonin reuptake inhibitor
CD conduct disorder ITP interpersonal therapy DCPD obsessive-compulsive personality disorder TCA tricyclic antidepressant
CT cognitive therapy
Psychiatric Assessment
History
Identifying Data
Screening Questions for Major • name, sex, age, ethnicity, marital status, religion, occupation, education, type of residence, with
Psychiatric Disorders whom they are living, referral source
• Have you been feeling down,
depressed or hopeless?
• Do you feel anxious or worry about
Reliability of Patient as a Historian
things? • may need collateral source (e.g. parent, teacher) if patient unable/unwilling to co-operate
• Has there been a time in your life
where you have felt euphoric, Chief Complaint
extremely talkative, had a lot of energy, • in patient's own words
and a decreased need for sleep? • duration
• Do you see or hear things that you
think other people cannot?
History of Present Illness
• Have you ever thought of harming
yourself or committing suicide?
• reason for seeking help (that day), current symptoms (onset, duration and course), stressors,
supports, functional status, relevant associated symptoms (pertinent positives and negatives)
• safety screen: Is the patient endangering self or others? Dependents at home (e.g. children, pets),
ability to drive safely, ability to care for self (e.g. eating, hygiene, taking medications)
Psychiatric Functional Inquiry
• mood: depressed, manic
• anxiety: worries, obsessions, compulsions, panic attacks, phobias, history of trauma
Psychiatric Functional Inquiry • psychosis: hallucinations, delusions, thought form disorders
• suicide/homicide: ideation, plan, intent, history of attempts
MOAPS
Mood
• organic: EtOH/drug use or withdrawal, illness, dementia
Organic (e.g. substances)
Anxiety Past Psychiatric History
Psychosis • all previous psychiatric diagnoses, psychiatric contacts, treatments (pharmacological and
Safety non-pharmacological) and hospitalizations
• also include past suicide attempts, substance use/abuse, and legal problems
Past Medical/Surgical History
• all medical, surgical, neurological (e.g. head trauma, seizures), and psychosomatic illnesses
• medications, allergies
Family Psychiatric/Medical History
• family members: ages, occupations, personalities, medical or genetic illnesses and treatments,
relationships with parents/siblings
• family psychiatric history: any past or current psychiatric illnesses and hospitalizations, suicide,
depression, substance abuse, history of"nervous breakdown/bad nerves;' forensic history, any
past treatment by psychiatrist or other therapist
Past Personal History
Always Remember to Ask About Abuse • prenatal and perinatal history (desired vs. unwanted pregnancy, maternal and fetal health,
See Family Medicine, FM27. domestic violence, maternal substance use, complications of pregnancy/delivery)
• early childhood to age 3 (developmental milestones, activity/attention level, family stability,
attachment figures)
• middle childhood to age 11 (school performance, peer relationships, fire-setting, stealing,
incontinence)
• late childhood to adolescence (drug/ alcohol, legal problems, peer and family relationships)
• physical or sexual abuse in childhood/adolescence
to• • adulthood (education, occupations, relationships)
Mental Status Exam • psychosexual history (paraphilias, gender roles, sexual abuse, sexual dysfunction)
• personality before current illness, recent changes in personality
ASEPTIC
Appearance and behaviour
Speech
Emotion (mood and affect) Mental Status Exam (MSE)
Perception
Thought content and process General Appearance and Behaviour
Insight and judgment • dress, grooming, posture, gait, physical characteristics, body habitus, apparent vs. chronological
Cognition age, facial expression (e.g. sad, suspicious)
,Toronto Notes 2012 Psychiatric Assessment Psychiatry PS3
• psychomotor activity (agitation, retardation), abnormal movements or lack thereof (tremors,
akathisia, tardive dyskinesia, paralysis), attention level and eye contact, attitude toward
examiner (ability to interact, level of co-operation) The MSE is analogous to the physical
exam. It focuses on current signs, affect,
Speech behaviour and cognition.
• rate (e.g. pressured, slowed), rhythm/fluency, volume, tone, articulation, quantity, spontaneity
Mood and Affect
• mood - subjective emotional state; in patient's own words
• affect - objective emotional state; inferred from emotional responses to stimuli, described in Spectrum of Affect
terms of: Full > Restricted > Blunted > Flat
• quality (euthymic, depressed, elevated, anxious)
• range (full, restricted, flat, blunted)
• stability (fixed, labile)
• mood congruence (inferred by reader by comparing mood and affect descriptions)
• appropriateness to thought content
Thought Process
• coherence - coherent, incoherent There is poor correlation between
• logic - logical, illogical clinical impression of suicide risk and
• stream frequency of attempts.
• goal-directed
• 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 - illogical shifting between topics
Delusions
• flight of ideas - quickly skipping from one idea to another where the ideas are marginally • Persecutory - belief that others are
connected, associated with mania trying to cause harm
• word salad - jumble of words lacking meaning or logical coherence • Reference - interpreting publicly
• perseveration - repetition of the same verbal or motor response to stimuli known events/celebrities as having
• echolalia - repetition of phrases or words spoken by someone else direct reference to the patient
• thought blocking - sudden cessation of flow of thought and speech • Erotomania - belief that another is in
• clang associations - speech based on sound such as rhyming or punning love with you
• Grandiose - belief of an inflated sense
• neologism - use of novel words or of existing words in a novel fashion
of self-worth or power
• Religious - belief of receiving
Thought Content instructions/powers from a higher
• suicidal ideation/homicidal ideation being; of being a higher being
• low - fleeting thoughts, no formulated plan, no intent • Somatic- belief that one has a
• intermediate - more frequent ideation, well formulated plan, no active intent physical disorder/defect
• high - persistent ideation and profound hopelessness/anger, well formulated plan, active • Nihilistic - belief that things do not
intent, believes suicide/homicide is the only helpful option available exist; a sense that everything is
• pre-occupations, ruminations - reflections/thoughts at length, not fixed or false unreal
• obsession- recurrent and persistent thought, impulse or image which is intrusive or inappropriate
• cannot be stopped by logic or reason
• causes marked anxiety and distress
• common themes -contamination, orderliness, sexual, pathological doubt/worry/guilt Cognitive Assessment
• magical thinking - belief that thinking something will make it happen; normal in kids Use Folstein Mini Mental State Exam
• ideas of reference - similar to delusion of reference but the reality of the belief is questioned (MMSE) to assess:
• overvalued ideas- unusual/odd beliefs that are not of delusional proportions • Orientation (time and place)
• first rank symptoms of schizophrenia - thought insertion/withdrawal/broadcasting • Memory (immediate and delayed
• delusion- a fixed false belief that is out of keeping with a person's cultural or religious recall)
background and is firmly held despite incontrovertible proof to the contrary • Attention and Concentration
• Language (comprehension, reading,
• progression of increasing pathology, decreasing insight: ideas/themes < preoccupations writing, repetition, naming)
< ruminations < obsessions < magical thinking < ideas of reference < overvalued ideas • Spatial ability (intersecting
< first rank symptoms < delusions pentagons)
Gross screen for cognitive dysfunction:
Perception Total score is out of 30; <24 abnormal,
• hallucination - sensory perception in the absence of external stimuli that is similar in quality to 20-24 mild, 10-19 moderate, < 10 severe
a true perception, auditory (most common), visual, gustatory, olfactory, tactile
• illusion - misperception of a real external stimulus
• depersonalization - change in self-awareness such that the person feels unreal, detached from
his or her body, and/or unable to feel emotion
• derealization - feeling that the world/outer environment is unreal
Assessing Insight and Judgement
Cognition Insight
• level of consciousness • Do you think that you have a mental
• orientation - time, place, person illness?
• memory - immediate, recent, remote • Why are you taking this medication?
• Why are you in the hospital?
• global evaluation of intellect (below average, average, above average)
• intellectual functions - attention, concentration, calculation, abstraction (proverb Judgement
interpretation, similarities test), language, communication Can be observed from collected history
and patient's appearance and actions.
• Is he/ she dressed appropriately for
Insight the weather?
• patient's ability to realize that he or she has a physical or mental illness and to understand • Is he/ she acting appropriately in the
its implications given situation?
• Is he/ she taking care of self and/or
Judgement dependents?
• ability to understand relationships between facts and draw conclusions that determine one's actions
, PS4 Psychiatry The Psychiatric Assessment/Psychotic Disorders Toronto Notes 2012
Summary of Axes
Axis V: Global Assessment of
Functioning Multiaxial Assessment
91-100 Superior functioning in awide range • Axis I
of activities • differential diagnosis ofDSM-IV clinical disorders
81-90 Absent or minimal symptoms • Axis II
71-80 are present, they are • personality disorders, developmental disability
transient and expected reactions to • Axis III
psychosocial stressors
• GMCs that are potentially relevant to the understanding or management of the mental
61-70 Some mild symptoms or some difficulty
but generally functioning well disorder
51-60 Moderate symptoms or difficulty • Axis IV
41-50 Serious symptoms or difficulty • psychosocial and environmental issues
31-40 Some impainnent in reality testing! • AxisV
communication, impainnent in several • global assessment offunctioning (GAF, 0 to 100) incorporating effects of axes I to IV
areas
21-30 Behaviour is influenced by delusions/ Formulation
hallucinations or serious impainnent in
communicatiorVjudgment • a diagram outlining current issues and interrelations between an individual's biological,
11-20 Some danger of hurting self or others psychological, and social factors
or occasionally fails to maintain • for each category: predisposing, precipitating, perpetuating, and protecting factors
minimal hygiene or gross impainnent in
communication Approach to Management
1-10 Persistent danger of severely hurting
self or others or persistent inability to
L biological (e.g. pharmacotherapy)
maintain minimal personal hygiene or 2. psychological (e.g. CBT)
serious suicidal act 3. social (e.g. support group)
Inadequate infonnation
Psychotic Disorders
Definition
• characterized by a significant impairment in reality testing
• delusions or hallucinations (with/without insight into their pathological nature)
• behaviour so disorganized that it is reasonable to infer that reality testing is disturbed
Differential Diagnosis of Psychosis
• primary psychotic disorders: schizophrenia, schizophreniform, brief psychotic, schizoaffective,
Differential Diagnosis of Psychosis
delusional disorder
• mood disorders: depression with psychotic features, bipolar disorder (manic episode with
GASPP
General medical condition
psychotic features)
Affective disorders • personality disorders: schizotypal, schizoid, borderline, paranoid, obsessive-compulsive
Substance induced • general medical conditions: tumour, head trauma, dementia, delirium, metabolic
Psychotic disorders • substance-induced psychosis: intoxication or withdrawal
Personality disorders
Schizophrenia
DSM-IV-TR Diagnostic Criteria for Schizophrenia
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Fourth Edition, (Copyright 2000).
American Psychiatric Association.
A. characteristic symptoms (active phase): of the following, each present for a significant
Management of Acute Psychosis and portion of time during a 1-month period (or less if successfully treated)
Mania • delusions
• Ensure safety of self, patient and • hallucinations
other patients
• Have an exit strategy
• disorganized speech (e.g. frequent derailment or incoherence)
• Decrease stimulation • grossly disorganized or catatonic behaviour
• Assume a non-threatening stance • negative symptoms, e.g. affective flattening, alogia (inability to speak), or avolition (inability
• IM medications (benzodiazepine + to initiate and persist in goal-directed activities)
antipsychotic) often needed as patient
may refuse oral meds
Note: only 1 "Pl.' symptom is required if delusions are bizarre or hallucinations consist of a voice
• Physical restraints may be necessary keeping a running commentary on the person's behaviour or thoughts, or 2 or more voices
• Do not use antidepressants or conversing with each other
stimulants B. social/occupational dysfunction: major areas of functioning (work, interpersonal relations,
self-care) markedly below the level achieved prior to the onset of symptoms
C. continuous signs of disturbance for months, including month of active phase symptoms;
may include prodromal or residual phases
D. schizoaffective and mood disorders excluded
E. the disturbance is not due to the direct physiological effects of a substance or a GMC
F. if history of pervasive developmental disorder, additional diagnosis of schizophrenia is made
only if prominent delusions or hallucinations are also present for at least 1 month
Melanie Beswick, Tara McGregor and Chris Zroback, chapter editors
Kenneth Lee and Raheem Peerani, associate editors
David Katz, EBM editor
Dr. John Teshima, staff editor
Acronyms .............................. 2 Sexuality and Gender ................... 28
Paraphilias
The Psychiatric Assessment . . . . . . . . . . . . . . . 2 Gender Identity Disorder
History
Mental Status Exam Eating Disorders ....................... 28
Summary of Axes Anorexia Nervosa
Bulimia Nervosa
Psychotic Disorders ...................... 4
Differential Diagnosis of Psychosis Personality Disorders . ........... . ..... . 31
Schizophrenia
Schizophreniform Disorder Child Psychiatry ........................ 32
Brief Psychotic Disorder The Child Psychiatric Interview
Schizoaffective Disorder Developmental Concepts
Delusional Disorder Mood Disorders
Shared Psychotic Disorder (Folie a Deux) Anxiety Disorders
Childhood Schizophrenia
Mood Disorders ....... . ................. 7 Pervasive Developmental Disorders (POD)
Mood Episodes Attention Deficit Hyperactivity Disorder (ADHD)
Depressive Disorders Oppositional Defiant Disorder (ODD)
Postpartum Mood Disorders Conduct Disorder (CD)
Bipolar Disorders
Psychotherapy ......... . .............. . 38
Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . 11 Defense Mechanisms
Panic Disorder Psychodynamic Therapy
Generalized Anxiety Disorder (GAD) Behaviour Therapy
Phobic Disorders Cognitive Therapy
Obsessive-Compulsive Disorder (OCD) Cognitive Behaviour Therapy
Post-Traumatic Stress Disorder (PTSD) Dialectical Behaviour Therapy
Other Therapies
Adjustment Disorder . . . . . . . . . . . . . . . . . . . . 16
Pharmacotherapy................ . ..... . 40
Cognitive Disorders ..................... 16 Anti psychotics
Delirium Antidepressants
Dementia Mood Stabilizers
Anxiolytics
Substance-Related Disorders ......... . .. . 19 Electroconvulsive Therapy
Alcohol Experimental Therapies
Opioids
Cocaine Canadian Legal Issues ....... . ........ . .. 50
Cannabis Common Forms
Amphetamines Consent
Hallucinogens Community Treatment Order (CTO)
"Club Drugs" Duty to Inform/Warn
Suicide . . ............................. 24 References ............................ 51
Somatoform Disorders . . . . . . . . . . . . . . . . . . 25
Conversion Disorder
Somatization Disorder
Pain Disorder
Hypochondriasis
Body Dysmorphic Disorder Diagnostic Criteria reprinted with permission from the
Diagnostic and Statistical Manual of Mental Disorders,
Dissociative Disorders ................... 26
Fourth Edition, Text Revision. © 2000 American Psychiatric
Sleep Disorders . . . . . . . . . . . . . . . . . . . . . . . . 27 Association.
Nocturnal Myoclonus
Narcolepsy
Toronto Notes 2012 Psychiatry PSI
,PS2 Psychiatry Acronyms/Psychiatric Assessment Toronto Notes 2012
Acronyms
ACT assertive community treatment DA dopamine MAOI monoamine oxidase inhibitor ODD oppositional defiant disorder
ADHD attention deficit hyperactivity disorder ECT electroconvulsive therapy MOD major depressive disorder PD personality disorder
AN anorexia nervosa EPS extrapyramidal symptoms MOE major depressive episode POD pervasive developmental disorder
ASPD antisocial personality disorder EtOH ethanoValcohol MSE mental status examination PTSD post-traumatic stress disorder
BN bulimia nervosa GAD generalized anxiety disorder NOS not otherwise specified SNRI serotonin and norepinephrine reuptake inhibitors
CBT cognitive behavioural therapy GMC general medical condition OCD obsessive-compulsive disorder SSRI selective serotonin reuptake inhibitor
CD conduct disorder ITP interpersonal therapy DCPD obsessive-compulsive personality disorder TCA tricyclic antidepressant
CT cognitive therapy
Psychiatric Assessment
History
Identifying Data
Screening Questions for Major • name, sex, age, ethnicity, marital status, religion, occupation, education, type of residence, with
Psychiatric Disorders whom they are living, referral source
• Have you been feeling down,
depressed or hopeless?
• Do you feel anxious or worry about
Reliability of Patient as a Historian
things? • may need collateral source (e.g. parent, teacher) if patient unable/unwilling to co-operate
• Has there been a time in your life
where you have felt euphoric, Chief Complaint
extremely talkative, had a lot of energy, • in patient's own words
and a decreased need for sleep? • duration
• Do you see or hear things that you
think other people cannot?
History of Present Illness
• Have you ever thought of harming
yourself or committing suicide?
• reason for seeking help (that day), current symptoms (onset, duration and course), stressors,
supports, functional status, relevant associated symptoms (pertinent positives and negatives)
• safety screen: Is the patient endangering self or others? Dependents at home (e.g. children, pets),
ability to drive safely, ability to care for self (e.g. eating, hygiene, taking medications)
Psychiatric Functional Inquiry
• mood: depressed, manic
• anxiety: worries, obsessions, compulsions, panic attacks, phobias, history of trauma
Psychiatric Functional Inquiry • psychosis: hallucinations, delusions, thought form disorders
• suicide/homicide: ideation, plan, intent, history of attempts
MOAPS
Mood
• organic: EtOH/drug use or withdrawal, illness, dementia
Organic (e.g. substances)
Anxiety Past Psychiatric History
Psychosis • all previous psychiatric diagnoses, psychiatric contacts, treatments (pharmacological and
Safety non-pharmacological) and hospitalizations
• also include past suicide attempts, substance use/abuse, and legal problems
Past Medical/Surgical History
• all medical, surgical, neurological (e.g. head trauma, seizures), and psychosomatic illnesses
• medications, allergies
Family Psychiatric/Medical History
• family members: ages, occupations, personalities, medical or genetic illnesses and treatments,
relationships with parents/siblings
• family psychiatric history: any past or current psychiatric illnesses and hospitalizations, suicide,
depression, substance abuse, history of"nervous breakdown/bad nerves;' forensic history, any
past treatment by psychiatrist or other therapist
Past Personal History
Always Remember to Ask About Abuse • prenatal and perinatal history (desired vs. unwanted pregnancy, maternal and fetal health,
See Family Medicine, FM27. domestic violence, maternal substance use, complications of pregnancy/delivery)
• early childhood to age 3 (developmental milestones, activity/attention level, family stability,
attachment figures)
• middle childhood to age 11 (school performance, peer relationships, fire-setting, stealing,
incontinence)
• late childhood to adolescence (drug/ alcohol, legal problems, peer and family relationships)
• physical or sexual abuse in childhood/adolescence
to• • adulthood (education, occupations, relationships)
Mental Status Exam • psychosexual history (paraphilias, gender roles, sexual abuse, sexual dysfunction)
• personality before current illness, recent changes in personality
ASEPTIC
Appearance and behaviour
Speech
Emotion (mood and affect) Mental Status Exam (MSE)
Perception
Thought content and process General Appearance and Behaviour
Insight and judgment • dress, grooming, posture, gait, physical characteristics, body habitus, apparent vs. chronological
Cognition age, facial expression (e.g. sad, suspicious)
,Toronto Notes 2012 Psychiatric Assessment Psychiatry PS3
• psychomotor activity (agitation, retardation), abnormal movements or lack thereof (tremors,
akathisia, tardive dyskinesia, paralysis), attention level and eye contact, attitude toward
examiner (ability to interact, level of co-operation) The MSE is analogous to the physical
exam. It focuses on current signs, affect,
Speech behaviour and cognition.
• rate (e.g. pressured, slowed), rhythm/fluency, volume, tone, articulation, quantity, spontaneity
Mood and Affect
• mood - subjective emotional state; in patient's own words
• affect - objective emotional state; inferred from emotional responses to stimuli, described in Spectrum of Affect
terms of: Full > Restricted > Blunted > Flat
• quality (euthymic, depressed, elevated, anxious)
• range (full, restricted, flat, blunted)
• stability (fixed, labile)
• mood congruence (inferred by reader by comparing mood and affect descriptions)
• appropriateness to thought content
Thought Process
• coherence - coherent, incoherent There is poor correlation between
• logic - logical, illogical clinical impression of suicide risk and
• stream frequency of attempts.
• goal-directed
• 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 - illogical shifting between topics
Delusions
• flight of ideas - quickly skipping from one idea to another where the ideas are marginally • Persecutory - belief that others are
connected, associated with mania trying to cause harm
• word salad - jumble of words lacking meaning or logical coherence • Reference - interpreting publicly
• perseveration - repetition of the same verbal or motor response to stimuli known events/celebrities as having
• echolalia - repetition of phrases or words spoken by someone else direct reference to the patient
• thought blocking - sudden cessation of flow of thought and speech • Erotomania - belief that another is in
• clang associations - speech based on sound such as rhyming or punning love with you
• Grandiose - belief of an inflated sense
• neologism - use of novel words or of existing words in a novel fashion
of self-worth or power
• Religious - belief of receiving
Thought Content instructions/powers from a higher
• suicidal ideation/homicidal ideation being; of being a higher being
• low - fleeting thoughts, no formulated plan, no intent • Somatic- belief that one has a
• intermediate - more frequent ideation, well formulated plan, no active intent physical disorder/defect
• high - persistent ideation and profound hopelessness/anger, well formulated plan, active • Nihilistic - belief that things do not
intent, believes suicide/homicide is the only helpful option available exist; a sense that everything is
• pre-occupations, ruminations - reflections/thoughts at length, not fixed or false unreal
• obsession- recurrent and persistent thought, impulse or image which is intrusive or inappropriate
• cannot be stopped by logic or reason
• causes marked anxiety and distress
• common themes -contamination, orderliness, sexual, pathological doubt/worry/guilt Cognitive Assessment
• magical thinking - belief that thinking something will make it happen; normal in kids Use Folstein Mini Mental State Exam
• ideas of reference - similar to delusion of reference but the reality of the belief is questioned (MMSE) to assess:
• overvalued ideas- unusual/odd beliefs that are not of delusional proportions • Orientation (time and place)
• first rank symptoms of schizophrenia - thought insertion/withdrawal/broadcasting • Memory (immediate and delayed
• delusion- a fixed false belief that is out of keeping with a person's cultural or religious recall)
background and is firmly held despite incontrovertible proof to the contrary • Attention and Concentration
• Language (comprehension, reading,
• progression of increasing pathology, decreasing insight: ideas/themes < preoccupations writing, repetition, naming)
< ruminations < obsessions < magical thinking < ideas of reference < overvalued ideas • Spatial ability (intersecting
< first rank symptoms < delusions pentagons)
Gross screen for cognitive dysfunction:
Perception Total score is out of 30; <24 abnormal,
• hallucination - sensory perception in the absence of external stimuli that is similar in quality to 20-24 mild, 10-19 moderate, < 10 severe
a true perception, auditory (most common), visual, gustatory, olfactory, tactile
• illusion - misperception of a real external stimulus
• depersonalization - change in self-awareness such that the person feels unreal, detached from
his or her body, and/or unable to feel emotion
• derealization - feeling that the world/outer environment is unreal
Assessing Insight and Judgement
Cognition Insight
• level of consciousness • Do you think that you have a mental
• orientation - time, place, person illness?
• memory - immediate, recent, remote • Why are you taking this medication?
• Why are you in the hospital?
• global evaluation of intellect (below average, average, above average)
• intellectual functions - attention, concentration, calculation, abstraction (proverb Judgement
interpretation, similarities test), language, communication Can be observed from collected history
and patient's appearance and actions.
• Is he/ she dressed appropriately for
Insight the weather?
• patient's ability to realize that he or she has a physical or mental illness and to understand • Is he/ she acting appropriately in the
its implications given situation?
• Is he/ she taking care of self and/or
Judgement dependents?
• ability to understand relationships between facts and draw conclusions that determine one's actions
, PS4 Psychiatry The Psychiatric Assessment/Psychotic Disorders Toronto Notes 2012
Summary of Axes
Axis V: Global Assessment of
Functioning Multiaxial Assessment
91-100 Superior functioning in awide range • Axis I
of activities • differential diagnosis ofDSM-IV clinical disorders
81-90 Absent or minimal symptoms • Axis II
71-80 are present, they are • personality disorders, developmental disability
transient and expected reactions to • Axis III
psychosocial stressors
• GMCs that are potentially relevant to the understanding or management of the mental
61-70 Some mild symptoms or some difficulty
but generally functioning well disorder
51-60 Moderate symptoms or difficulty • Axis IV
41-50 Serious symptoms or difficulty • psychosocial and environmental issues
31-40 Some impainnent in reality testing! • AxisV
communication, impainnent in several • global assessment offunctioning (GAF, 0 to 100) incorporating effects of axes I to IV
areas
21-30 Behaviour is influenced by delusions/ Formulation
hallucinations or serious impainnent in
communicatiorVjudgment • a diagram outlining current issues and interrelations between an individual's biological,
11-20 Some danger of hurting self or others psychological, and social factors
or occasionally fails to maintain • for each category: predisposing, precipitating, perpetuating, and protecting factors
minimal hygiene or gross impainnent in
communication Approach to Management
1-10 Persistent danger of severely hurting
self or others or persistent inability to
L biological (e.g. pharmacotherapy)
maintain minimal personal hygiene or 2. psychological (e.g. CBT)
serious suicidal act 3. social (e.g. support group)
Inadequate infonnation
Psychotic Disorders
Definition
• characterized by a significant impairment in reality testing
• delusions or hallucinations (with/without insight into their pathological nature)
• behaviour so disorganized that it is reasonable to infer that reality testing is disturbed
Differential Diagnosis of Psychosis
• primary psychotic disorders: schizophrenia, schizophreniform, brief psychotic, schizoaffective,
Differential Diagnosis of Psychosis
delusional disorder
• mood disorders: depression with psychotic features, bipolar disorder (manic episode with
GASPP
General medical condition
psychotic features)
Affective disorders • personality disorders: schizotypal, schizoid, borderline, paranoid, obsessive-compulsive
Substance induced • general medical conditions: tumour, head trauma, dementia, delirium, metabolic
Psychotic disorders • substance-induced psychosis: intoxication or withdrawal
Personality disorders
Schizophrenia
DSM-IV-TR Diagnostic Criteria for Schizophrenia
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Fourth Edition, (Copyright 2000).
American Psychiatric Association.
A. characteristic symptoms (active phase): of the following, each present for a significant
Management of Acute Psychosis and portion of time during a 1-month period (or less if successfully treated)
Mania • delusions
• Ensure safety of self, patient and • hallucinations
other patients
• Have an exit strategy
• disorganized speech (e.g. frequent derailment or incoherence)
• Decrease stimulation • grossly disorganized or catatonic behaviour
• Assume a non-threatening stance • negative symptoms, e.g. affective flattening, alogia (inability to speak), or avolition (inability
• IM medications (benzodiazepine + to initiate and persist in goal-directed activities)
antipsychotic) often needed as patient
may refuse oral meds
Note: only 1 "Pl.' symptom is required if delusions are bizarre or hallucinations consist of a voice
• Physical restraints may be necessary keeping a running commentary on the person's behaviour or thoughts, or 2 or more voices
• Do not use antidepressants or conversing with each other
stimulants B. social/occupational dysfunction: major areas of functioning (work, interpersonal relations,
self-care) markedly below the level achieved prior to the onset of symptoms
C. continuous signs of disturbance for months, including month of active phase symptoms;
may include prodromal or residual phases
D. schizoaffective and mood disorders excluded
E. the disturbance is not due to the direct physiological effects of a substance or a GMC
F. if history of pervasive developmental disorder, additional diagnosis of schizophrenia is made
only if prominent delusions or hallucinations are also present for at least 1 month
