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Psychiatry and Addiction Medicine Lectures

PAAM - Introduction to Psychiatry
PAAM - Overview of Psychiatric Disorders
PAAM - History of Psychiatry
PAAM - Introduction to Addiction Medicine
PAAM - Assessment of Drug and Alcohol Use
PAAM - Schizophrenia
PAAM - Mood Disorders - Overview & Management
PAAM - Sleep wake cycle
PAAM - Cognitive Behavioural Therapy
PAAM - Prescription Drug Misuse
PAAM - Drug Seeking Patient
PAAM - Alcohol Withdrawal and Beyond
PAAM - Alcohol: Brief Intervention
PAAM - Stimulants & Management of Opioid Dependence
PAAM - Smoking Cessation
PAAM - Cannabis
PAAM - Psychostimulants
PAAM - Socio-cultural aspects of psychiatry
PAAM - Indigenous Mental Health
PAAM - Psychotherapies
PAAM - Anxiety Disorders
PAAM - Trauma, Life-Events and Mental Illness
PAAM - Trauma and its effects on development
PAAM - Psychiatric Emergencies/Safety Issues and Managem
ent of Aggression
PAAM - Personality: Normal Personality Development Attac
hment and Early Adversity
PAAM - Personality Disorders
PAAM - Intellectual Disability
PAAM - Perinatal Mental Illness
PAAM - Internalising Disorders in Childhood and Adolesce
PAAM - Externalising Disorders in Childhood and Adolesce
PAAM - Delirium
PAAM - Overlap of Physical and Psychiatric Illness
PAAM - Eating Disorders
PAAM - Taking a psychiatric history
PAAM - Psychiatry of Old Age
PAAM - Mental state examination
PAAM - Cognitive behavioural therapy
PAAM - Ethics Scenarios
PAAM - Behaviour management
PAAM - Interviewing the difficult adolescent
PAAM - Family interviewing
PAAM - Cardio-metabolic health and general adverse effec
PAAM - Personality webinar
PAAM - Introduction to Psychiatry
Low prevalence disorders
- Schizophrenia
- Bipolar disorder
- eating disorders
High prevalence disorders
- Depression

- Anxiety disorders
- Establishing rapport - Eliciting the symptoms - Checking for Suicidality and
Dangerousness - Assessing substance abuse - Presenting a good mental state exa
mination - Making a sensible differential diagnosis Suggesting sensible managem
ent strategies for frequently encountered conditions: - Biological, psychologic
al and social
---------------------------------PAAM - Overview of Psychiatric Disorders
abn -think, feel, behave
psych disorders
- disease state
- abn thinking, feeling, behaving
- 2 components = cause significant distress + impair
. ability to work / play / love
- epi - 40%
. anxiety most common
. then substance and affective disorders
The Sick Role - Talcott Parsons
- exempted from normal social responsibility and for own condition
- price = exclusion from full participation in society
- obligation = try and get well
- behaviour - change/suicide
- relationships
- emotion - depression, manic, anxiety, irritation
- thinking - content (delusions, obsessions, overvalued ideas), form
- perception - hallucinations, illusions
- cognition
- insight and judgement
Classifications = both categorical based on criterion
- DSM 5 (mental disorders only)
- ICD 10 (europe, physical and mental disorders)
Biopsychosocial model
- genetic vulnerability, environmental, pathophysical interaction
- high expressed emotion (negaive) - contributes to schizophrenia
- mutated 5HTTLPR gene + environmental stress = depression risk
- effect of violence in childhood = MAO-A gene
- trauma stress
. complex = experience of significant ongoing childhood adversit
y eg physical abuse
Comorbidity is common
- grouping of psychiatric disroders
- psych + medical problems
Gender difference
- men - substance
- female - anxiety
Case Formulaton
- explanatory description of why you think they are presenting today - personality, medical, stressor
- plan or effect matrix: predisposing, precipitating, perpetuating, patt
ern, protective prognosis
. Biological
. psychological
. social
Treatments can by medical, biologicall, psychological, social
- reintegration into culture and community

- satisfying relationships
- meaningful work and leisure activity
- spiritual dimension
- individual goals
Mental health Act
- care, treatment and control of persons who are mentally ill or mentall
y disordered
- to facilitate the involvement of persons and persons caring for them i
n decisions involving appropriate care, treatment and control
- definition mental illness
. seriously impairs temp/perm functioning - delusions, hallucina
tions, serious disorder of thought form, disturbance of mood, repeated irrationa
l bheaviour indicating symptoms
- Detain a person = section 14
. ground for believing that care, treatment or control of person
is necessary for their own protections from serious harm, or protection of othe
- mentally disordered person s15
. irrational behaviour - justifies on R grounds that temporary c
are, treatment or control is necessary for their own protection or for others
- involuntary admissions s12-13
.medical officer (RMO or registrar or consultant) .person is mentally ill or disordered + not other less restricti
ve is safe/effective, appropriate or reasonably available
Flow chart of detaining a person
- detaining + inform primary carer within 24 hours
- initial exam by authorised MO, 2nd exam by another MO if the first is
not a psychiatrist + complete form 1 within 12 hours
- can detain
Mental health review tribunal
Psychiatry and autonomy
---------------------------------PAAM - History of Psychiatry
no content
---------------------------------PAAM - Introduction to Addiction Medicine
What range of disorders does it cover?
What is the nature of the disorders?
What diagnoses are made? is it different from general medicine? How does it rel
ate to psychiatry?
Addiction medicine - deals with addictive disorders - substance abuse/ psychotropics
- electronic/gambling
substance abuse/ psychotropics
- aims
. prevention of hazardous use, addictive behaviours and harms, d
. behaviours
. recognition of disorder
. management
- spectrum of disorder
. non user -> hazardous use -> dependence syndrome/addiction/com
. substance abuse = harmful use + addiction

Development of dependence
- repeated consumption of substance with psychodependence activity (alco
hol, tobacco, drugs)
- repeated use of one or multiple causes profound changes in meso-limbic
system (ventral tegmental of mid brain AND nucleus accumbens of forebrain)
- develops enduring biological changes
- continue to use, abuse, addiction
Resetting of neurocircuitry
- 4 neurocicurits are reset in an enduring and difficult to reverse ways
of reward, stress, inhibitory control systems of the meso limbic systems
. changes result in
- under activity of the reward systems
- over activity of stress system responsises to psychoac
tive substances and triggers
- an internal (subconscious) driving force directing fur
ther substance use
- decr influence of voluntary control due to impaired in
hibitory system
- 1. reward system
. pyscho active substance initially activate reward pathways of
. main ones are dopaminergic systems (esp for psychostimualnts a
nd nictoine) + opioid system (alcohol + opioids)
- repeated used suppresses the systems, tolerance develops and more subs
tance required to maintain normal state
. normal activities with reward effects become blunted or ineffe
. negative mood and motivational state ensures
- 2. alertness or excitatory system
. with repeated activation there is activation of stress pathway
s (glutaminergic transmission) and CRF
. suppression + uncoupling of anti-stress systems (GABA and neur
opeptide Y)
. results in heightened activation from exposure to triggers
- 3. salience pathways (prioritisation)
. reset in favour of continued substance use = higher priority f
or thinking, anction over other tasks and responsibility
- 4. frontal inhibitory (behavioural) control pathways
. precentral gyrus of frontal lobe down to centers incl N accumb
ens and ventral tegmental
. impariemnt of behavioural control
. less control over the other neurocircuits then would normally
. assoc with def in executive functioning and frontal lobe impai
COre syndroms with diagnostic criterion: lesat to most severe (separate harms/cl
assifications from physiological complications eg hepatitis, cirrhosis etc)
Hazardous use (WHO, NHMRC)
. repeated use of substance with risk of harmful consequences
Harmful use (ICD 10)
. actual harm (physical, psychological)
Substance abuse (DSM-IV)

use disorder (DSM-5)

abuse, dependence
dependence (ICD 10 and DSM-IV)
neurobiological drivign force
requires at least 3 of 6 components occuring over 12 mo period

Substance withdrawal syndrome

Substance Abuse (DSM-IV)
. social harm
. maladaptive pattern of use causing clinically impairment or distress a
s evidenced by 1 or more of
-failure to fulfil major role obligations
-substance use in physically hazardous situations
-recurrent legal problems
-continued use despite social or occupational problems
Dependence Syndrome (DSM-IV and ICD10) - requires at least 3 of the 6 components
over a 12 mo period
- A syndrome of repetitive substance use which reflects an internal driv
ing force, and includes:
.a strong DESIRE to take a substance,
.impaired CONTROL over its use,
.a higher PRIORITIZATION given to substance use over other activ
ities and obligations,
.increased TOLERANCE (cannot control after only a small amount)
.sometimes a WITHDRAWAL state (oppositve of acute pharm effects
of substance; spontaneously; can be prevented by further substance abuse
.CONTINUATION use despite harm.
Long term affects of dependence
- reactivation of dependence processes even after a period of stopping
- ie reinstatement of dependence phenomonenon
- IMPLICATION - if a person has a dependence, they are advised to abstai
n from the substance in the long term
- ie abstinence require
Physical complications

from substance use:

Hepatitis B, hepatitis C, alcoholic liver disease
Gastritis, duodenitis, peptic ulcer
Gastrointestinal cancer
Endocarditis, alcoholic cardiomyopathy
Cerebral thrombosis and haemorrhage
Metabolic disorders
Malnutrition and vitamin deficiency syndromes
Blood disorders macrocytic anaemia
Blood-borne virus Infections e.g. HIV

Neuropsychiatric complications
.Wernickes encephalopathy
.Memory impairment (amnestic syndrome)
.Frontal lobe and other brain damage
.Cerebellar disease
.Brain contusion
.Intracranial haematoma
.Peripheral neuropathy
.Rarer conditions
Social complications
- Domestic and Allied Problems
.Loss of friends

.Deterioration in marital and other significant relationships

.Spouse has varied psychological symptoms e.g. stress, anxiety, ten

.Domestic arguments
.Domestic violence
.Neglect of children
.Absenteeism (especially Mondays)
.Poor work performance
.Unexplained absence during working day
.Failure to gain promotion
Financial Problems
.Loss of regular income from employment
.Hardship from money spent on alcohol
.Gambling debts
.Victim of fraud
Legal Problems
.Drink-driving offences
.Loss of motor vehicle licence
.Property crime
. Prostitution

Classification of psychoactive substances

- CNS depressants
- CNS stimulants
- Hallucinogens
CNS depressants
Other sedative-hypnotics
Heroin and other opioids
CNS stimulants
Betel nut
Nicotine (state-altering)


- life time use ie have ever used (2007)

90% alcohol
45% tobacco
34% cannabis
38% any illicit
6 % coaine
6% amphetamine
2% heroin
2 % IVDU


use - last 12 mo (2007)

80% EtOH
20% Tobacco
14% any illicit
9% cannabis
2% amphetamines
2% cocaine
1 % IVDU

Alcohol epi
- 90% adults
- ~20% hazardously + har,
- ~6% have dependence
- highest consumption in english world
- declining since 1977
- 4500 related deaths/yr
- 5% of all deaths
- 10% premature years of life lost
- $6000 million per year
- 40% of inpatients have underlyuing alcohol problem
- 20% of GP practice have underlyuing alcohol problme
Benzos/sedative-hypnotics epi
- 7% adults regularly (decr 13% in 1977)
- 350 deaths/yr (overdose)
- most widely used illicit drug
- prevalence varies with age
- 20-40 yrs
. 50% have tried > 1
. 20% used in last month
. 5% are dependent
- varies with age
- decr in heroin since 2000 due to difficulty in obtaining
- heroin
. 1.6% ever tried
. 75000 dependent in australia
- use has incr
- 10000/yr in 1998 but now decr
Amphetamines / psychostimulants
- 15% have tried>1
- crystal meth/ ICE is most common
- causes - agression, violence, psychotic phenomena
- 1/3 regular users experience psychosis

- 10 x incr in hospitalisation for psychosis in last decade

- uncommon cf USA and europe
- aggression, violence, mood swings, psychosis
- financial loss
- 2nd most common illict (after cannabis)
- prevalence has tripled in last decade
- cheap $40/tablet
- recreational use mostly
- use commonly combined with other drugs eg alcohol, amphetamines
- self-use of benzos in recovery phase
- decr LSD usage
- cheap $20/tablet
- msot users 13-16 yr

20% adults
decr prevalence
19000 related deaths/yr
$6500 million per annum cost
1/3 inpatients are current smokers
1/3 inpatients are exsmokers

---------------------------------PAAM - Assessment of Drug and Alcohol Use

PC wrt addiction
- seeking advice help
- intox, withdrawal
- physical, psych sx - - - most common reason for presentation
- drug seeking, requesting
What is a drug and alcohol diagnosis
Statement of the Drug(s) used
or Class of drugs
or Polydrug use
Definition of the core clinical syndrome (defined in prev lectur
Hazardous or at risk use
Harmful use or substance abuse
Substance dependence
Withdrawal syndrome
Listing of sequelae
Neuro-psychiatric and psychological
Coexisting disorders
Antecedent Factors
. strong fhx/genetic
. hx prev abuse/trauam

How to reach a diagnosis

1. key indicators
2. alcohol - drug history (use, dependence, consequences)
3. phys exam
4. corrobative info
5. screening questionairres
6. labs (esp alcohol), urine drug screening
Key indicators - the key is the clustering of problems with social, physical, ps
ychological domains - which don t have obvious single cause (other then aubstanc
e use disorder)
- Psychosocial Problems
.Stress, difficulty in coping
.Depression or anxiety
- Physical Symptoms - usually non-specific - but the key
.Loss of appetite, GIT
.Morning headache
.Numerous non-specific symptoms
- quantify amount, frequency, duration of use/intake
- dependence - urges/craving, impairment of control, reorientation of li
fe, continued use despite harm
- consequences - physical harm, psychosocial harm, neuropsychiatric diso
- reason for presentation now
- why now
- time of last drug use (intoxication, withdrawal)
Quantification of
- 1 SD
- 1.5 SD

alcohol = number of St drinks (10 g alcohol)

285 mL middy
100 mL glass wine
1 measure fortified wine
30 mL nip/tot spirit
425 mL schooner
375 ml can
375 mL stubby

Quantificaiton of other drug use

- benzos - diazepam equivalents per day (or number of 5mg diazepam tabs)

Cannabis: number of cones per day, grams per day, dollar amount
Heroin: dollar amount per day, weights or grams per day
Methamphetamine: number of points (0.1 gram) per day, dollar amount
Cocaine: number of lines, dollar amount
MDMA: number of tablets per occasion

OE - General appearance
. flush, erythematous face
. thin, gaunt malnourished
- Signs of intoxication
- Features of withdrawal
. tremor, sweating
- Evidence of tolerance evident when little or no impairment despite rec
ent high use of sedatives or elevated BAC

- Mental state
. Anxiety and agitation
. flat, distresed
- Cutaneous stigmata (alcohol)
. facial telangiectasis
. partoid gland enlargement
. overgrowht of skin - rosacea
. dupuytrens contractures
- Evidence of injecting use
. ante-cubital fossa
. forearms, hands
. femoral vein
- Complications occur in every system look for unexpected combinations e
.g. hepatomegaly and hypertension
Complications of IV route of admnistration
- scarring, obstruction
Corroborative info
- spouse, accompanying person
- GP, previous hospital record
Screening tools
- AUDIT for alcohol
1. how coften do you have a drink containing alcohol
2. how many SDs do you have on a typical day when u r drinking
3. how often do you have 6 or more drinks in one occassion?
4. How often during the last year have you found that you were n
ot able to stop drinking once you had started
5. How often during the last year have you failed to do what was
normally expected from you because of drinking?
6. How often during the last year have you needed a first drink
in the morning to get yourself going after a heavy
7. How often during the last year have you had a feeling of guil
t or remorse after drinking
8. How often during the last year have you been unable to rememb
er what happened the night before because you had been drinking
9. Have you or someone else been injured as a result of your dri
10. Has a relative, a friend, a doctor or another health worker
been concerned about your drinking or suggested you cut down?
- 0 - abstainer
- up to 7 - non hazardous safe drinker
- up to 12 - hazardus or harmful alcohol use
. feedback + brief intervention
- > 13 - alcohol dependence
. feedback
. referr to specialist
. ? need for detox
. pharmacotherapy
Lab markers of alcohol dependence
- incr GGT
- incr AST more then ALT
- incr uric acid
- incr HDL cholesterol
- CDT carbohydrate deficient transferrin
- etoh metabolites - ethyl glucuronide (urine), ethyl sulfate
- acetaldehyde-protein adducts (blood)

GGT - gmma glutamyl transferase

- most Sn
- but only positive in 30% of hazardous/harmful and 50% of alcohol depen
- t1/2 = 2 weeks
Carbohydrate deficient transferrin
- hi Sp for alcohol (also hi in pregnancy and primary biliary cirrhosis)
- incr in isoforms of transferrin with lower carbohydrate content
Labs for other drugs
- urine testing for cannabis, opioids, cocaine, amphetamines
- better accuracy with thin layer chromatography, ELISA assay
- GCMS = gold standard
Dependence criterion - requires at least 3 and over 12 mo period
Coincidence of substance use disorder with mental health disorders
1. mental health disorder may be a complication of the substnace use dis
. ie the substance use disorder develops well eg bad early life
experience, genetic vulnerability, peer group, work place environemnt
. eg amphetamine induced psychosis
2. mental health disorder may be a cause of the substance use disorder
. eg attention deficit hyperactivity disorder - causing person t
o self medicate with stimulants
. eg bipolar disorder who uses alcohol to reduce the swings up/d
own of bipolar illness
3. simultaneously
. late teens, early 30s
4. due to a 3rd disorder
---------------------------------PAAM - Schizophrenia
- ~75% rely on gov support
- rental property (40%) or homeless (5%)
- isolated from society - live alone 31%
- no friends 14%
- only see family 57%
- 69% not attended outreach/social programs
- 69% not attended recreational activities
Effect on

life and productivity compared to other disability

low prevalence but propotionally hi disbiliy
accounts for 7% DALY
90% had decr in fn
32% dysfunction in self care in past 4 mo
cost per individual $78,000/yr (lost productivity and health)

Schizo die younger then rest of population

- incr RFs, poor health behaviurs, medication adverse effects, redduced
access to tx, poor adherence

peak from 15-30 yrs

most have it throughout adult life (work, r/ships impact)
childhood onset is rare under 15 yr
slight incr in women from 30-45 yr (? estrogen effects on dopamine)
lifetime risk 7.2/1000 (~1% global)

- incr in emerging and developed countries

- incr incidence in men, urban environments, migrants (RR=5)
Grouping of RFs - major = rubella, CNS inf, bereavement, CNS dg, fhx
- Place time
. winter
. urban
- infection
. influenza, rubella, polio,
- prenatal
. famine
. bereavement
. flood
. unwantedness
. maternal depression
- obstetrc
. Rh compatibility
. hypoxia
. CNS damage
. low birth weight
. preeclampsia
. fhx
Course of schizo
- 1st 5 yr is the most important for setting the long term course
- "critical period" where sx stabilise and likelihood of hospitalisation
- by 3rd year after inpatient, only 1/3 still having symptoms, ~10% are
still in patients
- relapse is common - waxing and waning illness
. year 1 - 80% well
. year 2 - 39 % well
. year 5 - 4% still well
- RF for relapse
. medication nonadherence
. belief that they didn t need the medication
- each relapse incr risk of non-responsiveness and worsening of illness
Who is getting better vs recovery
- recovery = living fulfilling and satisfying life even though they may
have symptoms
- symptomatic recovery 40%
- if defined as no sx + psychosocial - then only 13%
Prognostic factors
- non modifiable
Age of onset
Family History
Pattern of onset
insidious vs rapid
Recovery from first episode
Neurological soft signs
Prior level of education
- modifiable
Social withdrawal

Negative sx
Duration of Undiagnosed Psychosis
- goals
. what is the dx
. why this person and
. why now in their life
- can the consent to the treatment
- which tx is best
- what location/site is best o tx pt (eg involuntary)
Detailed hx from pt + family
- duration of sx (duration of undiagnosed) psychosis
- individuals response to sx - aggression ?
- developmentla hx - functioning
- mental state examination
risk assessment
- danger - suicide, homicide
- tx adherence
- absconding
- vulnerability to exploitation, risk taking, to further deterioration
physical examination - neuro - bmi
- assume coexistence of following until proven wrong
. substance abuse
. mood disorder
. anxiety
. developmental
Ix after 1st episode - broad
- FBC, EUC, Ca++, LFT, TFT
- Fasting BSL, lipids
- Urine drug screen
- Immunological screen
- ECG (varies with medication, age)
- Neuroimaging (CT, MRI)
- EEG (if suggesting of epilepsy)
5 domaines of sx (pos, neg, cog, anx, disorg)
- positive
. hallucinations (auditory most common ~80%)
. delusions
- negative
. loss of function
. affective blunting (emotion, charm, modulation+expression of a
. anhedonia (cannot experience pleasure)
. amotivation
. alogia (poverty of thougt and content, concrete thinking, slow
ness of thought and movement)
. asociality (apathetic in pursuing social life, loss of meaning
of social connections)
- cognitive
. deficits present at 1st episode
. consistent profile of deficits

. exp verb acquisition, iq, speed of processing

- attention, memory, planning, problem solving, social cognition
- anxiety, depression
. suicide kills 5% schiz, 15% mood disorders
. depression can be a natural part of recovery/natural history
. psychosis itself is a marker of severity of depression.anxiety
. 40% shcizo also have anxiety disorder
- disorganisation
. hostility
. aggression (more likely to be victim of assault)
. thought disorder (circumstantial, loose associations, tangenti
al, derailed thought, flight of ideas, word salad
Hallucination - perception in absence of external stimulus (schizo, alcohol with
drawal, dementia)
Illusion - misinterpretatation of external stimulus
Delusions - false unshakeable belief that is out of keepin with persons culture
and educational background (persecutory, grandiose, reference, thought control b
y someone/thing, identity of people)
Schizo auditory hallucination - activation of heschl s gyrus (auditory cortex)
Psycho Tx

case management (brokerage model, assertive)

family therapy
cognitive remediation
supportive employment

Case manaement
- brokerage model - not best...hi case loads
- extended hours team
- assertive community care - better...lower case loads, direct intervent
ion, shared load
- educate pt + families about the illness and treatment
- improvements in rates of relapse, readmission, medication compliance
Supportve psychotherpay
- regular visits, time to vent, reflection
- support rxn to illness 0 denial, engulfment, acceptance
Family therapy
- decr relapse OR 0.6, NTT 6.5
- impro social fn, sx, employment
Interventions for anxiety and depression
- hi rates of anxiety 40%, depression 60%
- pharmacotherapy SSRIs
Problem solving
- rational approach to problem
- prioritise, brain storm solution, step by step, review and return to s
tage 1
Coping techniques
- relxation
- activity scheduling

social skills
self instruction

better to view hallucinations/delusions on continuum with normal phenomenon and

not dissimilar to other strongly held beliefs
. confirmation bias
. conviction
. poor logic
. consequences for person of changing their belief system
. beliefs guide behaviour
- aim = reduce distress
CBT fo schizo
. no benefit in longer term
. no effect on relapse/readmission rates

use of cognitive tasks best run using computer softward
self paced

Vocational rehabilitation - supported employment (finds them work)

- work place support = incr placement, money earned, hours worked
- early psychosis services
---------------------------------PAAM - Mood Disorders - Overview & Management
Epi depression
- 20% lifetime
- 1 yr prevalence
. 7% women
. 4% men
- only half seek tx
- over-dx - unhappiness is a human complaint, bipolar disorder, unfortun
ate childhood, alcohol abuse
- chronic, acute stress
- loss (an identity, r/ship)
- 40% genetic risk
- brain disease - MS, stroke
- substances - speed
- 2 weeks of
.depressed mood AND anhedonia
- additional
. sleep dist (early waking)
. appetite/wt
. ideas of self harm
. fatigue/loss of energy
. guilt/worthlessness
. concentration difficulty
. motor agitiation/ psycho-motor retardation
Subtypes of depression
- psychotic (DA + 5HT dysfunction)
. mood congruent = going along with the mood of the disorder ie.
the horrors - jesus or god telling them they are evil; believing that they are
dead or rotting inside

- melancholic
. marked insomnia, esp early morning wakening
. apetite and wt loss
. flat affect
. psychomotor change
. pervasive anhedonia
- non-melancholic
. depression w/o melancholic sx
. non-mood
. 5HT dysfunction (tx with 5HT antidepressants)
. mostly motor sx
Things to tell the pt pre-tx
- antidepressants take upt to 4 weeks to work
- SE being straight away
- non-addictive
- BUT don t stop suddenlty bc of withdrawal syndrome
- you can drink with them (except for MAO-Is)
- relapse is 100% when you stop the antidepressant
- must completely treat the episode to stop the relapse
Response vs remission = IN THE EXAM
- HAMD17 score of > 20+ = depressed
- response to treatment by HAMD17 score
. decr in HAMD by 50% = a response to the treatment
. (eg if score = 20, then response score = 10)
. around 2/3 people get a response with 1st agent
- remission definition on HAMD17 score
. decr of HAMD < 7 = remission
. about 1/2 people get a remission after 1st agent, 2/3 with 2-3
- message = have to be prepared to try multiple agents.
The problem with the HAMD17 evidence
- the evidence is skewed by psychiatrists would not put their melancholi
c patients on placebo
- people who are answering the advertisement will have less serious depr
ession, possibly where antidepressants wouldn t work anyway.
How long to reat
- 6 mo AFTER recovery from 1st breif episode
- 2 yr AFTER recovery from 1st LONG episode
- lifelong - if 3 previous episodes
- lifelong - if psychotic depression (hi recurrence rate, risk of suicid
e, homicide)
Can I stop antidepressant ?
- recurrence rate is hi
- it is a chronic illness
- risk of recurrence after 1st episode incr with subsequent episodes = 2
nd (50%), 3rd (75%), 4th (100%)
Maintenance antidepressants - NO - what gets you well, keeps you wel
- slowly
- withdrawal effects
- reduce over 7 several months to avoid relapse
- monoamine neurotransmitter system (5HT, NorEPI, DA)
- block depletion of this OR inhibitory receptors
- blocking of MAO enzyme (the enzyme usually degrades the neurotransmitt
Why does more monoamines help
- post synaptic cell
- monoamine binds receptor

cAMP pathway -> protein kinase A

brain derived neurotrophic factor BDNF produced
stimulates neurogenesis
incr survival of new neurons
incr complexity and stability of dendritic netowkrs
improves synaptic plasticity (learning)

Depressed people brains

- smaller hippocampus and orbitofrontal regions
How do you depress a rat lab ? - rat in a barrel repeatedly - learned helplessne
Critical factor in depression is not just neurotransmitters BUT also
- decr in neuronal numbers and
- decr in synapses
How to incr BDNF ?
- antidepressants - but not all equally effective
- lithium
- exercise
hierarchy effectiveness
. ssris, mirtazepine
. SNRIs (duloxetine, venlafaxine at hi dose)
. Tricyclic antidepressants
- very GOOD
. MAOIs (but side effects if taken with ?)
Efficacy studies by depressive sub-type
- non melancholic
. TCS, SSRI, CBT, St John s Wort
. these are only slightly better then placebo
- melancholic
. TCAs twice as good as SSRIs for this
- psychotic
. Best is either AD+antipsychotic OR ECT by itself
. AD by itself only has 25% response rate (still better then pla

weak antidepressants
good for anxiety disorders
harmless in overdose
SE - lost libido, slows down orgasm, fuzzy headedness
fluoxetine, sertraline, citalopram, escitalopram, fluvoamine

- venlafaxine (>225mg = also get NorEPI with this level) and duloxetine
. good antiedepressant but SE of sweaty
- slow release venlafaxine (effexor) has prolonged cardiotoxicity in ove
- withdrawal syndrome

Tricyclic antidepressants
- most effective for AD
- SE - anticholinergic effects, weight gain, sedation, hpotension, dry m
outh, dental caries
- decr reuptake of norEPI nd serotonin
- cardiotoxic in overdose
Monoamine oxidase inhibitors
- very effective
- inhibit MAO in synapse and the gut (where MAO breaks down tyramine)
. the excess tyramine (bc the MAO is blocked) then displaces nor
epi and epi -> results in intracranial hypertension -> intracranial hemorrhage
. sources of tyramie
- matured cheeses
- salami
- yeasty beers
- chianti
- chocolate
- coffee
- liver
- pickled herring
- vegemit
- sauerkraut
- most effective anti-depressant therapy
- indicated for
. melanchholic and psychotic depression
. unable to eat or drink
. highly suicidal or tormented
. bipolar depression and mania
- regimen
. 6-18 treatments requireed
. 2-3 times per week
. 5 min GA + muscle relaxant
. 30 - 1100 mC
. aim for current thru R frontal/temporal lobe
. avoid L hippocampus where many memories are stored (major SE =
memory loss)
. generalised seixzure
. neurotransmitter + neutrophin incr
- SE
. memory,
. antero-grade memory impairment
. scattered retrograde losses
. post-ictal headache and confusion
. blood pressure instability
. post ictal bradcardia
- post ECT Mx
. requires maintenance ADs, lithium, maintenance ECT
What is the ADs are ineffective after 1 mo? - hierarchy of approach
- higher dose
- use more potent class
- consider whether it is a biological depression or some other cause
- Augmentaiton
. lithium
. 2nd gen antipsychotics (eg olanzepine)

Types of non-drug therapies
- individual and group psychotherapies
- exercise
- meditation
- r/ship
- social interventions
- psychoeducation
- interpersonal therpay IPT
- longer term psychodynamic therpay (for longer term depressin)
- should be doen for all pt
- gives then control and rapport
- 1-2 sessions
. cover eti
. natural hx
. tx effects and SE
. make them aware of their early warning signs (for when they ar
e better ) - as a red flag for representation
- early waking
- not talking as much
- change thoughts - theway they behave
Interpersonal psychotherapy
- 12-20 session
- r/ships influence onset of and or recovery from depression
- 4 interpersonal problem areas
1. grif
2. dispute
3. role transition
4. lack of r/ships
Psychodynamic psychotherapy (freudian type)
- explores childhood isses
- poor short term outcomes for depression
- good for chronic childhood trauma
- aim for deep changes to personality
For depression: CBT = IPT = ADs
but therapy + Pill works better

lifts mood
reduces anxiety
30 min 3-5 times a week improve depression
best for NON-melancholic depression
effect thry
. serotonin changes
. corticotrophin releaseing hormon CRH and cortisol
. endorphins
. neurotrophins

R?ship interventions

- couples therapy
- family therapy - must check whether kids are safe
Bipolar disorder (manic depression)
- both manic and depressive episodes
- some recovery bw episodes
- a primary mood disorder
- epi
. 2% life prevalence,
. M =F
. 90% recurrence
. avg onset 17-21 yr
. genetic ie 1/6 of a persons children will get it - risk 15% in
1st degree relative
. delayed diagnosis common ~8 yr
- at least 1 week of
. mood
- euphoric, angry
- affect - labile, intense, ecstatic
. activity and behaviour
- increased - purposeful and non-purposeful
- agitated - pacing
- poor judgement - risk taking
- pressure of speech
. thought
- racing thoughts, flight of ideas (mood congruent - del
usions of grandeur, special ability or talents, special artistry/creativity)
- little insight
- psychosis
- no psychotic symptoms
- not severe enough to cause significant impairment in functioning
NB mood incongruet = more persecution or paranoid
Depressive episodes of bipolar
- mj depression
- anergia, hypersomnia (sleeping 12 hour plus) or insominia
- chronic
- hi suicide risk
Dx bipolar disorder
- time lag to dx - 8 yr
- poor recall of highs
- typical pc
. young peolple with bipolar type depressoin
. pschotic depression
. postpartum psychosis
. severe postpartum depression
- Bipolar 1 = depressions + manias
- bipolar 2 = depression + hypomania
- bipolar 3 = depression but then if tx with ADs then go hi, but if not
tx with AD then never go hi
- bipolar 4 = depression + mixed
- bipolar 8 = mod instability of borderline personality disorder
Bipolar spectrum

Its ok not to give pt the wrong treatment

- wrong meds eg
. treating borderline PD with bipolar meds
. giving up on pt
- SE
. infertility
. obesity
. self loathing
Natural hx of bipolar
- 50% of time symptomatic
- comorbidiity
. substance abuse 50%
. anxiety disorders 40%
. gambling
. medical - obesity, risk taking
Cause of bipolar disorder
- 80% genetic
- susbtance - corticosteroids, stimulants, antidepressant
- stress, lack of sleep (shift work, international travel)
Mx of bipolar
- all the time + maintenance = MOOD STABILISER
- depressive episode = MOOD STABILISER +/- AD or ECT
- manic episode = MOOD STABILISER +/- ANTIPSYCH or ECT
Mood stabilisers
- can find therapeutic dose by taking blood level
- lifelong
- bad in pregnancy
- combine with ADs and Antipsychotics during depressive, manic episode
- reduces risk of suicide by 6 times
- NEVER cease => leads to relapse
- best mood stabiliser, reduce risk of suicide by 7 times
- SE
. renal impairment
. thyroid suppression in 30%
. toxicity
. need to check regular blood levels
. reduces Gs function
. inhibits steps in phosphoinositide pathway -> slows this 2nd m
essenger system
. neurotrophic - incr BDNF
- usually better tolerated but have breakthrough episodes
- +/- lithium
- SE - PCOS in young women
. mood stabilising effect
. weight gain and diabetes
. useful in mania - D2 blockers (typicals) more effective
. venlafaxine, tricyclics

- less powerful classes SSRI may not work -> ongoing disability and suic
---------------------------------PAAM - Sleep wake cycle
sleep histroy
- time to bed, sleep
- bed time rituals (contributing to anxiety)
- beliefs about sleeping/not sleeping (eg being depressed, losing jobs etc that raise the stakes of not sleeping)
- use of stimulants, alcohol
- exercise
- eating habits
- sleep environment
- time of arising
sleep hygiene
- winding down time
- avoid stimulants or blue light (tv screens, computer screens)
- cool, dark, quiet
- time of rising sets body clock -same time everyday, including weekends
- exercise enhances quality of sleep
- control of nocturnal worry
- lifestyle factors - factors, diet, alcohol, caffein
- underlying medical, psychiatric conditions (depression for early, midd
le and late insomnia; medications)
- sleep hygiene
- stimulus control - associating bed with sleep; exlcuding music, device
s; if they are not asleep within 15 minutes getting out of bed to wait for sleep
wave to come again.
- sleep restriction - keep a sleep diary for a week or two to chart the
time asleep. The sleep chart helps to get an idea of lseep efficiency.
---------------------------------PAAM - Cognitive Behavioural Therapy
COgnitive therapy = change unhelpful thinking
behavioural therpay = changing unhelpful behaviour and acheiving desired behavio
The premise is that how we feel emotionally is more determined y how we think ab
out ourselves, our environment and situations we encouter, rather than by what a
ctually happens to us
When is CBT helpful
- ups and downs of life - ordinary human suffering
- acute psychological distress (losses, disappointments)
- mental disorders
. primary therapy in - moderate depression, anxiety, eating diso
rder, presonality, susbtance use
- adjunct therapy in severe depression, schizophrenia, bipolar,
personality disorder
Targets of CBT
- enhanced problem solving VS dorsolateral prefrontal cortex
. executive funtion,
. working memory
. cognitive flexibility
- moediying persectives on self and relationships VS anterior cingulate

cortex and medial prefrontal cortex

. self related information processing
- regulation of distressing effect VS amygdala, anterior cingulate corte
x, prefrontal cortex
. anxiety
. emotion processing
CBT vs antidepressants in depression and anxiety
- better then antidepressants in anxiety bc if you stop antidepressants
you get relapse, but you get continuing gains in CBT
- better to use it with antidepressants in depression
- depression manifests chronicity as recurrence
- anxeity manifests chronicity as continous symptoms
Limitations of CBT
- requires homework and ocmmitment, skilled therapists, motivation
- not for highly distressed pt who cannot concentration or tolerate it
- drop out rates = those for medication = 25%
- medicare is for a set number of sessions, then there is a gap payment.
Fundamental principles of CBT
- operant conditions
- ABC model
- Beliefs about self
- it is possible to modify beleifs about self
Operant conditioning
- negative reinforcement = the negative part = taking something away ie
an aversive consequence, which ahs the result of causing that behavour in the fu
ture bc it caused a relief from something
. eg avoidance and escape from anxiety assoc = reinforces avoida
nce or escape as a coping mechanism
- punishment reinforcement
. eg pleasurable reward or consequence
. also includes negative/punishment or consequence
COngitive behaviour analsyis
- what are the feedback loops keeping the pt in the cycle of behaviour
Positive Reinf (apply a consequence)

Negative Rein (remove a conseque

Incr s the frequency or amount of target behaviour

apply pleasurable conseq)
ESCAPE (remove aversive conseq)
Decr s the frequency or amount of target behaviour
NT (apply aversive conseq)
EXTINCTION (withold or remove pl
easurable conseq)
ABC model
- Activating event -> Beliefs -> Consequences
- eg link bw thoughts and feelings and events
- eg imagine standing at bus stop waiting; 3 people in line; see
/hails bus but it passes; 1st person gets angry; 2nd person gets sad; 3rd person
starts laughing; If the event is what caused our reactions - everyone shooudl h
ave reacted the same way; only by understanding what they thought about the situ
ation taht we can understand the different reactions; 1st person thought - this
is a disgrace/unreliable/complaint; 2nd - already feeling a bit blue - nothign w
ill go right; 3rd - hooray, excuse to be late - go get a coffee.

We have a biological tendency to create and subscribe to beliefs about self, oth
ers and world around -> these can influecne emotions and behaviours and thought
processes; these beliefs may be inaccurate or not helpful
- eg I never succeed at things like this so that theres no point trying
. immediate failure cost: so they never try = fail = confirm own
opinion as incompetent and don t attempt in future
. reinforces/perpetuates the belief into behaviour back to reinf
orce the belief
. opportunity cost: also miss the opportunity for success, learn
ing and possible incr in skill and confidence
- eg I must never disagree with anyone or they will not like me
It is posible to identify and modify unhelpful beleifs
- reduces unpelasant psych symtpoms and 2nd physical
- help change undesired behaviour
- reduces vulnerability
- help improve mood and function
Core properties of CBT (difference from psychoanalytic therapy bc the therapist
is more active, there is more of a r/ship / collaboration to understand problems
and identify strategies; problem focused rather then symptom focused; rely on E
BM to match strategies to problems; pt has say in goals and mode of tx; time lim
ited and structured; should ahve a plan for every session and how many sessions
will be required)
Collaborative therapeutic relationship E
ducative focus P
atient-initiated goals
Guided discovery to gain insight into basic underlying beliefs (schemas)
Structured based on individualised formulation
"Homework" outside session considered essential - to practice the new sk
Key cognitive strategies
Socratic dialogue/guided discovery (to elicit in fo for greater understa
nding, involves asking questions to get pt to unearth greater understanding of t
Cognitive challenging
Worry control
Structured problem solving
Motivation enhancement therapy
Schema-focused work
Key behaviour strategies
Progressive muscular relaxation
Hyperventilation control
Graded exposure
Exposure and response prevention
Behavioural experiments
Activity scheduling
Interoceptive exposure
Social skills training
Sleep-wake cycle management

Stages of CBT in practice - focuses on the here and now - however you can to thi
s point, lets develop strategies to move forward.
1. Assessment of the problems (physical. emotional, psychological, behav
ioural, interpersonal )
2. Fonnulation: descriptive and explanatory statement about why have the
se problems developed and persisted; protective factors
3. Diagnosis
4. Psychoeducation regarding the causes. treatments and prevention of re
currence of the illness
5. Evidence-based Strategies selected to target the troublesome symptoms
6. The strategies are practiced by the patient
7. Outcome is measured (baseline measurment)
8. Relapse prevention strategies are planned
- automatic thoughts
Automatic thoughts
- premise - humans are constantly evaluating internal and external stimu
. influenced by underlying beliefs, previous exp, culutre and pe
rsonal factors
. they occurr rapidly, often outside of consc awareness
. represent repeated patterns of reacting to particular triggers
(situations, thoughts, feelings)
. cause emotional distress when they are unhelpful or unrealisti
. drive our emotional reactions and behaviour
- may be unhelpful, unrealistic, excessive, unreasonable
. it is not necessarily irrational to have negative reactions to
ambiguous situations, disappointments, losses, unfair tx
Changing automatic thoughts - STEPS
- 1st step is to identify the thoughts and patterns - become more aware
of the thoughts
- need to become more aware of the thoughts
- need to identify the emotional and behavoural consequences
- use the SUDS approach
- 2nd step is the challenge the thoughts
. whether they meet the aims of being helpful and realistic to l
- 3rd step is replace them with more helpful and realistic way of thinki
- 4th step is to base their behaviour on the more helpful and realistic
way of thinking (behaviour helps change thinking)
- subjective units of distress
- a unit to try and estimate how upsetting a thought is
- typically somwether bw 0-100 or upward / downward arrows
- try to get to the hot thought that is a core schema or core belief
about themselves
Typical examples of an exercise for a person
A. activating event or situation
. eg having to start work on a project
B. beliefs, interpreation
. it will be rubbish

. I can t do it
C. consequences, emotions
. anxiety 70
. sadness 80
. confusion 75
There is no clear link bw the statements and the emotions
Use socratic method to identify why eg tell me what went thru your mind.
what are the consequences of doing somethig ?
Try to identify the connection bw the thinking and the consequences.
Cannot use technique of cognitive challenging (how do you know it would
be rubbish...)
Downward arrow technique:
It will be rubbiish -> I can t concentration -> I feel confused
-> I m incompetent -> I m worthless = hot thought = hi levels of emtional distre
Cognitive challenging
- do the thoughts help us meet the aims of being helpful and realistic t
o life
- good questions for this
. What is the evidence?
. What alternative views are there? how else could i look at thi
s situation, how would my support person think of it
. How likely is it? has it ever happened
. How much would it really matter? (relative assessment)
. What do I gain by thinking this way?
. What do I lose by thinking this way?
Cognitivie error concept
- patterns in the way we habitually respond
. catastrophising - immediately jump to worst consequence
. black and white thinking - good or bad, closely related to per
fectionism; related to appraisal of r.ships (assoc with generalising)
. personalisation (everything taken personally)
. generalisation (based on one example)
. perfectionism
. mindreading (I know they thought I was an idiot; they didn t l
ike me)
. fortune telling (will never be able to do it..)
Case formulation
- developing hypotheses to explain why symptoms have arisen and why they
have persisted for this person. Knowledge of common risk and maintaining facto
rs assists in developing hypotheses Hypotheses are then used to guide individua
lly tailored treatment Useful to represent these hypotheses graphically. but no
set way to do this
- develop cognitive model and FEEDBACK LOOPS
Cognitive model
1. antecedents, risf factors
2. triggers
3. symtpoms and persistence
4. beliefs
5. coping strategies
6. feedback loops = PIONTS OF INTERVENTION
Treatment planning
- based on case formulation

- identify feedback loops as places to intervene

- use EBM strategies
- psychoeducation is incorporated - about the illness, about the case fo
rmulation, and what is eneded to recover
- provide information about illness and treatment
- discus cause of illness
- prodivding information and prevention
- EBM based
- tailored to individual
- itself therapeutic
- normalises and de-stigmatises the condition
Graded exposure
- = systematic desensitization
- NMDA receptors in amygdala are critical for fear conditions
- NMDA agonists such as D-cycloserine enhance the effects of exposure
by promoting
- exposures must be done repeatedly at close intervals
- they must stay in the situation until anxiety begins to reduce
- no distraction or use of safety behaviurs or escape or axiolytics
- step ladder approach of starting at 40/100 etc. (flooding is usually t
o confronting)
- stay at the same step of the step ladder until you decrease the levels
of anxiety etc
- with time the responses diminish
Structured problem solving
- good for crisis management
- aim is to transfer problem solving skills to patient to enhance slef c
onfidence and improve coping skills
- helps them work thru and examine life problems that are causing distre
- can also be used to assist decision making
- teaches an approach to overcome or adjust to life difficulties or make
- usually conducted over 4-6 weekly 15-30 min consultations
- steps
1. define the problem (unaware of link bw distress and life prob
lems OR aware of problems but cannot cope; distinguish from provided advice)
2. Brainstorm identify all possible solutions
. avoid giving solution options
. use guided discovery eg what else could you do ?
. avoid giving own opinion
. ask steering questioins if they identify inappropriate
. use weighing scale - adv vs disadv
. is more information needed to make a good decisions?
3. Weigh up the alternatives
4. Choose the best option/s
5. Formulate a plan to implement - assist them to develop a de
finit plan what will you say
6. Review progress - plan a review date / trial period
.problem, intervention, outcome
Behavioural activation
- aim = incr a persons activity level
- may include a goal directed activity as well as pleasurable activities
- impt bc inaction exacerbates

. unhelpful rumination, feelings of uselessness, loss of confide

nce, unpleasant affect, social isolation
- good for severe and mild depression, anxiety
- involves planning for - pleasant activity, social acitivity, tasks tha
t give sense of achievement, exercise
- make a scheduler for the week - help them at first
- so that when they wake up in the morning - gives them direction
- should eb realists, achievable goals
- checklists of pleasurable activities
- "going thru the motions IS HELPFUL" bc contributes to activity, and st
ops inactivity cycles
- err on the side of easier tasks then harder tasks - want them to have
Motivation enhancement therapy
- aim is to incr motivation to make desired changes
- basic principles
. express empathy
. develop discrepancy
. avoid argumentation
. roll with resistance
. support self efficacy
Phases of treatment
1. buidling motivation for change
1. Ellciting self-motivational statements
2. Listening with empathy
3. Questioning
4. Presenting personal feedback (e.g. questionnaire results: how these c
ompare to normal
5. Affirming the client (e.g. You ve taken a big atep by coming in and I
really respect you for it: You ve got some great ideas for things that might help
6. Handling resistance
7. Reframing (e.g. It seems like you started eating more as a way to keep
your mother happy, but now it s making you unhappy)
8. Summarislng
Phase 2: Strengthening Commitment to Change
1.Recognizing change readiness
2. Discussing a plan
3. Communicating free choice
4. Consequences of action and inaction
5. lnforrnation and advice
6. Emphasizing abstinence (in substance use disorders)
7 Dealing with resistance
8. The Change Plan Worksheet
9 Recapitulating
10. Asking for commitment
11. Involving a significant other
Phase 3: Follow-through Strategies
Reviewing progress
Reviewing commitment
Redoing committment
Stages of

change model
peopple vary in their state of readiness to change
typically < 20% of people are ready to take action
an individual may go forward or back in their state of readiness to ch

- transtheoretical model
. precontemplation
. contemplation
. preparation
. action
. maintenance
- readiness to change relies on the importance they place on the change
+ their confidence in being able to change
. eg smoking cessation - they know it is important, but they are
worried about being able to cope (ie the modern quit campaigns are on maintenan
. ie have to convince them it is do-able as well
- resistance to change = roll with resistance
- eg these tablets are the only thing that has worked for me
---------------------------------PAAM - Prescription Drug Misuse
What is prescription drug misuse
Substances Extent of problem
Recognising the problem
Managing the problem
Prescription drug misuse = use other then how indicated
Aberrant drug behaviours - behaiours suggesting substance abuse or addition ie t
hat the behavious are pathological (selling, sharing etc)
Spectrum = ingeston, diversion, injection, dependence
Medications commonly misused
- sedating, stimulant, performance enhancing
- sedating
. Opioids-prescribed and OVER THE COUNTER
. Benzodiazepines
. Non-benzodiazepine hypnotics
. Antipsychotics
. Gabapentinoids
. Propofol
. Ketamine
. Antihistamines-prescribed and over the counter
. Barbiturates (rarely)
- stimulant
. methyphenidate
. dexamphetamine
- performance enhancing
. Diuretics
. Anabolic Androgenic Steroids
. Hormones EPO, hGH, Insulin, glucocorticoids
. B Agonistsl B blockers
. Steroid antagonists
. Stimulants Opioids
Extent of

the problem
lifetime misuse of pharm ~10%
in the last 12 mo ~5%
in the last week ~1.2%

How to identify if drug being misued

- case reports, anecdotes
- post marketing surveillance
- national drug strategy household survey (a survey given to IVDU user g
- illicit drug reporting system (surveys actively using IVDUs in state)
. benzos, morphine, oxycodone

14% Injecting drug user have misused in last 6 mo
peak age 16-19
prevalence of non-prescribed stimulant use is 35%

Australian tranquiliser / sleeping pill misuse

- 1.6% population over 14 yr
Australian prescription opioid misuse
- 3.3% australians used painfillers for non medical purpose
- 0.2% misusing methadone buprenorphine
- fentanyl, oxycodone incr
- stable = methadone, morphine, tramadol
ED presentations for opioid misuse related things incr with opioid prescriptions
in community
proportionally more hospitalisations are for morphine/legal opiates
Performancing enhancing misuse
- steroid use is increasing amongst athletes
Recognising prescirption and OTC misuse
- corroborative hx from other health care providers
- frequent presentaitons with lost or stolen scripts
- consider RFs
. past hx of substance misuse
. smoking
- resultant complications - gastric erosion, CV events in an unexpected
population eg young
- reoutine screeing (eg athletes, family, probation, parol)
- pt, drug, prescriber, gov policy/legislative, pharmaceutical industry
- Pt factors
- prev subst abuse disoder RR = 100
- environment eg giving amphetamine to child with parents who ha
ve substance use disorder
- psychosocial setting
- identify Drugs with abuse potential
. opioids
. hypnotics
. psychostimulants
. performance enhancing
- prescriber
. hi index of suspicion with repeat scripts for hi risk drugs
. screening tools

. report aberrant prescribing

. identify colleagues and report appropriately
. aims
- focus on functonal outcomes not pain outcomes
- max trial fr 6 mo
- max dose of 100 mg oral morphine equivlanet
- slow release, long half life opioids
- DO NOT use injectable opioids
Treatment of prescription substance misuse
- Dx
. challenging if in intoxication-withdrawal cycle
- onsider need for ongoing pharmacotherpay
- consider cessation (gradual?)
- harm minimisation strategy
- pt contract
- doctor shopping agreements - signed by pt - give list of drugs previou
sly given to pt - to identify doctor shopper patients
- frequency pharmacy dispensing
- supervised dosing
- consider need for other treatment for underlying disorder (eg. anxiety
Gov and legislative intervention
- deregister rogue prescribers
s28 poisons and therapeutic goods cat 1966 NSW
- authority from dept of health
- if a person has drug dependence, or preparation of dexamphetamine/meth
ylphenidate, more then 2 mo buprenorphorine, flunitrazepam, alprazolam, hydromo
rphone, methadone other injectable drug of addition.
Gov and legislative requirements
- permission of state department to give drugs of dependence for longer
then 2 mo
- prescirption of methadone liquid, buprenorphine as subutex/suboxone th
ry OTP requires a separate authority.
- limit of the sceduling of OTC products
- rescheduling (eg ketamine)
- limit pack sizes in OTC product
- abuse deterrant formuatlions - suboxone (naloxone, buprenorphine)
Approach in a prescription misuse pt
- Dx
- corroborate
- ix
. FBC, euc for nsaid toxicities
. axr (perforation, obstruction, toxic megacolon), crp
- tx
- withdrawal mx
- maintenance tx
---------------------------------PAAM - Drug Seeking Patient
Reasons for drug seeking Epidemiology
Issues for doctors
Clinical presentations

Management (and resources to assist)

Case Discussion
drug seeking behaviour
. attempt to obtain prescriptions for psychoactive drugs by making false
or exaggerated claims of distress
prescription shopping
. 3 mo period
. people who are supplied with prescirption drugs by 6 or more prescribe
. or who have been prescribed a total of 25 target pharmaceutical benefi
. or > 50 pharmaceutical benefits in total.
Inappropriate prescriber behaviour
. persistent prescribing of opioids/psychoactive despite abseve of impor
vement infunction, a deterioration of fn or SE
reasons for drug seeking
- dependecing
- chronic pain
- using prescription drugs as relef from withdrawal from dependent opioi
- professional dealer
- recreational
Misuse incr with incr prescription
Oxycodone is more significant then heroin
COnsequences of the problem
- risk of overdose with concomittant usage with other CNS depressants (e
toh, benzos)
Drug seekers/shoppers predominantly get there prescriptions from a minority of G
Ps (7.5% of GPs who are in 1 of 10 residential postcodes)
Consequences for inappropriate prescribing
- ix by NSW health pharmaceutical services unit PSU +/- medicare austral
- initial counselling and educaiton and monitoring
- S8 prescribing and administration rights may withdrawn
- health care complaints commission referral for professional misconduct
- medical board - suspection or conditional registration
- medical tribunal - suspension or deregistration.
Typical PC of drug seeker
- pain
- insomnia
- emotional distress
- lost scripts or medications
- drug withdrawal
- difficult obtaining clear medical hx
- cannot confirm their story
- they claim they are travelling through
- declines a physical exam or signs not consistent with sx
- asks for their drug of choice by name
- refuses other therapeutic options
- pressure, threatens the doctor
- bail/bond
- needs medication to tx withdrawal
- wants takeaway supply for an emergency
Drugs commonly sought
- benzos, opioids/morphine/oxycodone
- sedatives, stimulants, anticholinergics

Anticholinergic commonly sought is Artane = Trihexyphenidyl is used to treat symp

toms of Parkinson s disease or involuntary movements due to the side effects of
certain psychiatric drugs (antipsychotics such as chlorpromazine/haloperidol). T
rihexyphenidyl belongs to a class of medication called anticholinergics that wor
k by blocking a certain natural substance (acetylcholine).
- Display a notice in the surgery stating that drugs of addiction are no
t prescribed on patient request
- Keep prescription pads and paper out of patient access to prevent thef
t and forgery
- Conceal the location of medication within the surgery
- Continue education in D&A issues
- Prescribe appropriately
Mx - when drug seeking suspected
- if suspected - establish whether visit is to request a drug
- take alcohol and drug hx
. etoh/drug hx is a RF for opioid dependence
. q what other dr they seen in last 3 mo
. any drug of addiction they ve been prescribed
- signs of intoxication or withdrawal
- consciously look for track marks (antecubical fossae, lower legs, neck
Mx - confirmation
- previous doctors
- Medicare prescription shopping program (info service 1800 631 181) - p
t consent not required
- Personal pharmaceutical benefits scheme PBS hx - needs patient consent
(names of prev doctors, iten, date, amount)
- NSW health pharmaceutical services unit PSU (02 9879 3214 duty pharmac
Mx - refuse to prescribe
- refuse + intervention + give reasons
- discuss Dx and Tx options
. withdrawal mx (anti-diarrhoeal, anti-spasmodic rather ten benz
. admission for detox
. D+A service referral
. referral to pain clinic
- referral to opioid treatment program
- follow up
- form contract (one doctor, one pharmacy,treatment plan)
- establish patient commitment
- consult with specialist in addiction or pain management before prescri
- communicate with doctor shoppers network
- if necessary obtain NSW halth authority permission to prescribe S8 dru
- control drug use with limited amounts at a time eg daily dispensing
- not how long prescirptions should last
- record the amount dispensed in both words and numbers
Withdrawal management
- need to be convinced of pt commitment to withrdrawl
. low dose benzo withdrawal in outpatient
. opioid withdrawal handled in opioid treatment service or metha

Acute pain in opioid dependence

- the opioid dependent are hyperalgesic to pain
- they are typically undertreated for pain
- non-opioid analgesia
- they have a high tolerance to opioids - so if opioid analgesia is used
- may need to be higher dose
- if on methadone, or buprenorphine, continue regular dose and add other
analgesia on top.
---------------------------------PAAM - Alcohol Withdrawal and Beyond
guidelines of treatment of alcohol problems
- 6 SD daily for
- onset within 1
- peak bw 1 to 2
- duration up to

more then 2 weeks will have a degress of alcohol wtihdr

d of last drink
days after last drink
6 d

- alcohol is a GABA agonist + causes release of endogenous opoids which
are depressors -> reward pathway linked
- GABA activity decr = less inhibitory
- glutaminergic activiy incr = more excitatory
- autonomic
. sweating, tachycardia, tremor, anxiety, fevers
. nausea, vomiting, diarrhoea
- insomnia
- seizures
Serious PC
- seizures - within 2 days
. in 10% of alcohol dependent
. recurrence in 25% within 12 hr
- delirium tremens DTs - from 36h to 5 days
. in 5% of alcoholic dependents
Predictors of severity
- past severe withdrawal
- past seizures
- amount of alcohol consumed
- needing a mornign eye opener (how early in the day they will drink) ie a drink needed to alleviate the withdrawal
Why do we

medically manage withdrawal ?

risk of DT, seizures, withdrawal
to engage in tx for addition, recovery
reduce collateral alcohol related damage
. physical, psychological, social harms
- personal reflection of peron
- court/maternity service mandated.

Outcomes following withdrawal (data from 1983)

25% abstain > 3 yr

30% die
25% continue serious alcohol problem
20% gained control of drinking
. premorbid social stability
. period of sustained abstinence incr likelihood of remaining ab

. AA attendance
Relapse figures from 2007, USA
- after withdrawal, abstinence is the most stable state
- advise 1 yr of abstinence post withdrawal to allow control centeres to
Acute mx
- long acting benzos
. regular dose
. or PRN (symptomatic)
. front end loading (hi dose early)
. combination (most common - depedning on severity
- review is needed
- inpatient vs outpatient
. depends on patient selection
. only outpatient if no unstable medical/psych problems, no othe
r drug use and stable, supportive home environment
Thiamine deficiency vit B1
- def
. decr diet intake
. alcohol decr gut absorption
. decr ability to use thiamine in metabolic pathways
. thiamine requirements go up during withdrawal
- outocmes
. wernikes encephalopathy
- confusion
- ataxia
- nystagmus
- ophthalmoplegia
. korsakoff syndrome
- amneais (anterograde, retrograde)
- confabulation
- apathy
- tx
. 3 d of IV thiamine
. 100 mg 3/d for 3 days then switch to tablet
. if wernickle - then 500 mg 3/d continued for a week
- clincial institute withdrawal assessment OR acute withdrawal scales
- medical exam and assessment
Mx - acute
- long term (after hospital)
. comorbidities (med, psych)
- liver/psych - reconsider use of benzos
Relapse prevention

- requires planning
- meds
. naltrexone
. acamprosate
non PBS
. disulfiram
. baclofen
. topiramate
Naltrexone (rivia)
- 50 mg daily
- opioid antagonist
- moa
. etoh causes release of endogenous opioids which act via GABA-e
rgic interneuron to incr DA availability in nucleus accumbens
. by blocking the opioids we block the effect of DA
- indicated for
. reward drinkers (for feeling of buzz, or feel good)
. family history with OPRM1 mutation of mu-opioid receptor
. adherence, only need once daily use
- best if started before or after withdrawal period
. good bc if not ready for withdrawal, then can still use it
- main effect to reduce heavy drinking days
- in those that are already abstinent, it helps them to keep off it.
- contraindicatinos
. if pt LFTs (transaminases) are > 5 x normal
. hepatic metabolised
. it can cause idiopathic hepatitis
. if pt taking opiates
. naltrexone will trigger opioid withdrawal
Acamprosate (campral)
- 666 mg TDS
- bc TDS, adherence is an issue
. modulates GABA
. NMDA blocker
- effective if started after withdrawal period
- not effective if still drinking
- main use/effect is to helps maintain abstinence
- indications
. withdrawal avoidant drinkers (people who drink to avoid the ef
fects of withdrawal)
- contraindications
. LFT abn, liver diseaes, varices
. unstable cardiac and respiratory dz
- 200 mg/d
- not on PBS
. inhiits acetaldehyde dehydrogenase and B-hydroxylase
- buildup of acetaldehyde
- acetaldehyde toxicity causes
. facial flushing, sweating, N/V, diarrhoea, pain
. aversion therapy
- inhibiting b-hydroxylase inhibits the conversion of DA to nor-

. incr DA concentration in brain = helps those with crav
- only effective if you have superivision to make sure you take it bc no
n-adherence is high
- don t start it until ~4days after last drink
- has long half life = have to wait ~2 weeks after taking it to start dr
inking again
- indicated for
. motivated people with low risk of nonadherence
. thsoe who can be supervised
- contraindications
. severe liver dz, varices
. unstable cardiac/respiratory dz
pyschosocial tx to prevent relapse
- individual counselling - public clinics or GP arranged
- family counselling
- group therapy
. alcoholics anonymous
- 12 step program
. SMART self management and recovery therapy
- cognitive behaviour therapy
- new wave
. mindfulness based
- eg acceptance and commitment therapy
Motivational interviewing to prevent relapse
- a directed (guided), client centered (the client comes up with the rea
sons for change themselves) counseling stype to elecit behaviour change to help
them explore and resolve ambivalence
- aim is to strengthen the part of them that wants to change
which therapy is best ? Project MATCH 1998
- all had similar outcomes
- highly dependen on r/ship bw pt and counsellor rather then the mdoalit
- more angry people had better outcomes with motivational therpay
- social drinkers/lonely had better outcome with AA
- ~60% wil achieve lifelong abstinence
Recovery phase
- phase 1 - withdrawal/stabilisation (weeks)
- phase 2 - early remission (up to 1 yr)
- phase 3 - sustained remission (1-5 yr)
Recovery - what is needed = CHIME
- C - connectedness (to counter boredom and loniliness) - men s sheds
- H - hope
- I - identity
- M - meanng - why they are doing so
- E - empowerment - how motivated they are to make changes
---------------------------------PAAM - Alcohol: Brief Intervention
- 3rd most reversible cause of disease and disability
- effects fetal and home environment
- use any opportunity

- identify their priorities

. children, police, appearance
- how much
- how much
- how often
- how often > 6 drinks
. what is the size of the glass
. how often do you get thru a bottle/cask
- 7 SD/bottle
- brief internvetions have overall benefit (meta analysis)
- any reduction is good
- Is she likely to go thru withdrawal ?
. what is your modo like in the normal
. shakes
. what are you like before 1st drink
Elements of brief intervention - FLAGS
- F - feedback
- L - listen
- A - advice
- G - goals
- S - strategies
- effects on sleep
- brain, hallucinations, depression
- vomiting
- trembling
- unsafe/risky behaviour
- kidney, liver, pancreatitis damage
- blood pressure
- her priorities
- her reaction (shame, surprise of effects)
- previous attempts
- given them the information they need to come up with their own plans a
nd move forward
- how life can change for better if they change.
- depends if they are dependant on alcohol or not
- recommended SD/d = 2 (both sexes)
- max/d = no more then 4/d
- drink nothing
. pregnant
. hard to stop drinking
. poor health
. taking drugs
. driving, risky jobs
- advise that if they are dependent
. they will get symptoms (insominia, morning irritability)
. if no physical withdrawals - require at least 3 other criterio
- loss of control
- craving
- continued use despite awareness of harm
- tolerance
- prioritisation of alcohol
- outpatient or residential withdrawal

- get alcohol out of the house

- plan use of money instead of alcohol
- counselling
- relapse prevention medicines
- group based - SMART recovery, mens groups, womens groups
Drs advice
- specialist advisory servce
- Haber 2009 alcohol treatment guidelines
- NSW health withdrawal guidielines
---------------------------------PAAM - Stimulants & Management of Opioid Dependence
- epi
- why people use psychoactive drugs
- dependence
- tx - opioid substitution tx
- 16.5 mil users worldwide
- 0.4% adults
- highest consumtpion along trafficking routes form afghanistan (soviet
republic/eastern europe)
natural history
- dependence is long term relapsing condition
- fewer than 3 %/yr can permanently discontinu
- 3%/yr die
- physical
. vein damage
. blood born - cotnamination
. neglect - weight, hygeien, tooth care
- mental
. change in identity and outlook (they think of themselves negat
ively due to stigma )
. prevailing low mood and dermoralisation
- social
. disrupted r/ships
. involveent in crime
Heroin use and mortality
younger users
- overdose - commonest cause of death
- suicide, violence - other
older users
- HIV, liver disease
Why do people use drugs
- use of some psychoactive drugs is normalised eg. ETOH, opium chewing
- self medication - stimulant to stay awake, sedative for relaxatio, dis
inhibition, analgesics for distress
Neurobiology of drug use
- reward pathway (DA release in ventral tegmental pathway of brain = eup
- reduction in anxiety and stress are mediated thru this pathway
- this is why psychoactive drugs are reinforcing

- drugs which are delivered rapidly to the CNS by IV bolus or smoking ar

e most reinforcing
Opioid actions
- analgesia - especially the affective (fear and anxiety) aspect of acut
e pain
- SE reduces respiration, gut motility
- iatrogenic addition is rare
Tolerance and withdrawal
- repeated exposure - downregulates reward pathway
- withdrawal sx occurs due to this downregulation
. dysphoria, craving
. sweating, restlessness, nasal stuffines
. nausea, vomiting, diarrhoea
. abdominal bafk and legsl cramps
. dilated pupils
. sleep disturbance
- dilated pupils is most important sign of withdrawal
- tolerance an withdrawla are indcative of dependence
- maladaptive subsance use
- dependent use involves change from pursuing euphoric effects to avoidi
ng withdrawal
- DSM 5 criteria - need at least 3 of these
1. Taking the substance in larger amounts or for longer than the
you meant to
2. cannot cut down (even if they want to)
3. Spending a lot of time getting, using, or recovering from use
of the substance
4. Cravings and urges to use the substance
5. Not managing to do what you should at work, home or school, b
ecause of substance use
6. Continuing to use, even when it causes problems in relationsh
7. Giving up important social, occupational or recreational acti
vities because of substance use
8. Using substances again and again, even when it puts the you i
n danger
10. Continuing to use, even when the you know you have a physica
l or psychological problem that could have been caused or made worse by the subs
11. Needing more of the substance to get the effect you want (to
12. Development of withdrawal symptoms, which can be relieved by
taking more of the substance.
Biology of relapse
- relapse is hallmark of dependence
- easy relapse on re-exposure to drug after stopping it
- repeated exposure to ANY DRUGS OF ABUSE produce lasting changes in gen
e expression
- contribute to risk of relapse on re-exposure or switch dependence
- abstinence is the best solution
Who develops drug problems
- mostly young males < 40 yr
Groups that are vulnerableto drug problems ie adolescents

- RF of no stable social affilitation or social role

- esp
. adolescents
. marginalised eg indigenous
. de-regulated communities
Social factors contributing to dependence
- availability
- experience - each new generation sees the harm of current drugs, and s
witches to different drugs
- results in cyclical epidemics of heroin use
- bw epidemics there is slow recruitment from socially excluded (eg long
term unemployed, migrants)
- stigma can act as protective BUT entrenches marginalisation of drug us
ers AND complicated adherence to treatment/seeking treatment.
Treatment of heroin addiction
- 4 major modalities
- detox
- therapeutic community (rehab)
- self help groups (narcotic anonymous)
- opioid substitution treatment
- aim is not cure, but finding of alternative rewards (job, relationship
, family)
- role of tx is facilitate social reintegration and critical to this is
reducing drug misuse
Australian treatment outcome study
- detox does not work - relapse is common post detox
- rehab doesn t really work (only slightly more abstinence)
- best outcomes from maintenance therapies (methadone) + rehab together
- abrupt changes are unstable and easily reversed
- substitution treatment attracts and retiains people better then other
Why give methadone
- 5 ways substitution tx reduces harm
. Controlled Supply (lower cost, legal, reduces chaos)
. Block withdrawal - Stabilization (minimize intoxication and wi
. Diminish reinforcing effects of street heroin
. Structure attendance and monitoring
. Support
Minimising withdrawal
- methadone = long active agonist - stabilises blood levels, blocking w
- can be given as single daily supervised dose
- efficacy shown by phenomena of pt with biologically rapid methadone cl
earance who experience more withdrawal and more drug use and drug drop out
. it is not tha absolute level of opiate that controls withdrawa
l it is the difference between peak and trough levels
Suppress heroin use
- suppressing withdrawal is necessary but not sufficient
- 40mg/day people can avoid withdrawal, but still experience the reinfor
- Higher doses induce greater opioid tolerance, making injected heroin l
ess reinforcing

- Subtherapeutic dosing is common due to clinician practice, but attribu

ted to patient preference
Implications of inducing tolerance
- once people are on adequate methadone, they have much higher tolerance
then when they were on heroin so that if they inject heroin they won t have an
- but if you raise tolerance too quickly there is a risk of death (toxic
- esp in slow metabolism (hi toxic levels accumulated)
- worse if co-using benzos, TCSas, ETOH
- start low with 30 mg
- only partial agonist (cf methadone)
- hi my opioid recepto affinity = flat dose-response cruve
- at low dose it is potent agonist (100 time potency of morphine)
- at higher dose, it has much the same effect = flat dose response
- self limiting drug
- induces tolerance, blocks heroin action by occupying receptors
- safer in overdose (unless combined with benzos, etoh)
Methadone vs buprenorphine
- hi dose methadoen is more effective then buprenorphine in RETAINING pe
- both are equally effective in suppressing heroin use
Therapeutic r/ship
- tx works better if they see ONE clinician and consistently
- key aspect is preventing acting out behaviour
- safe from temptation (take away substitution is too risky)
- safe from exploitation and intimidation (no gathering/grouping of drug
- non judgemental
- non punitive
- belief in possibility of change

fdlear objectives and rationale for treatment

program rules for eligiviity for take home doses
systematic monitoring and review (health)
supervised administration as needed

Risks of OST
Death during induction onto methadone
Death in the month after leaving treatment (by overdose)
. due to decr in tolerance and then subsequent relapse
Diversion and misuse of unsupervised doses
.(most methadone related deaths occur in people not in treatment
) ie diversion = methadone going to people with low tolerance can result in deat
Persisting misuse of heroin, stimulants, sedatives and alcohol
Outcomes of OST
- People cycle in and out of treatment, with relapses between episodes a
nd little sustained change
- (12 month retention methadone 50%, bup 35%)
- With long-term treatment 50-75% cease heroin use

- ~25% of participants cease use of non-prescribed drugs

- Cannabis use and heavy drinking are common (and contribute to physical
and mental health problems)
Participation in treatment
- people enter when in crisis (money, housing) and leave when it passes
(don t want to be in treatment)
- many intermittently use
- many use and OST at same time
Reflections on smoking cessation
- nicotine replacement therapy = 10% abstinence at 1 yr (5% for placebo)
- continued abstinence declines year on year
- most use NRT and smoke at same time
- results are similar OST
- smoking allows us to view addictive behaviour without the distorting l
ens of stigma
- NRT is an aid to self management of smoking
- self management is the bass of management of addicitive disorders ( (b
rief intervention, self help groups
- key = medication + skilled management ot facilitate change
---------------------------------PAAM - Smoking Cessation
- 1/2 smokers dies from it
- higher in schizophrenics, psych comorbidities
Blood levels are in nanograms/mL
topography of smoking: how they smoke it eg breath holding, puffing lightly
holding breath with smoke - incr transit/absorption time
1 21mg/patch - delivers 10 nanograms/mL
. reason why they continue to stop
. but better to use patches whilst smoking - bc reduces there smoking
. reduction in carbon monoxide and particulate matter
Neuronal nicotinic ACh receptors
- pentameric with alpha and beta subtypes
- alpha-4-beta-2-alpha5 = responsible for dependence
- alpha-3-beta-4 = for appetite
- beta-4 = for cognition
- alpha-7 = fr memory and attention
- types and subtypes are heritable ie response to cigarettes
- eg hunger can be a response to withdrawal
Metaboilism of nicotine is also variable/heritable
- P450 CYP2A, racial variation
- fast metabolisers
. smoke more
. more addicted
. gr risk of lung ca (due to NNKs)
. don t respond well to replacement therapy
. inhale deeper with higher CO
. meditteranean, europeans, women in all groups, pregnant women

even faster
- slow metabolisers
. smoke less
. less addicted
. asians, japanese esp, african americans
Smoking anything
- polycyclic aromatic hydrocarbons eg burnt steak, cigarettes
. these induce other liver enzymes CYP1A2
. CYP1A2 metabolises caffeine
. smokers drink a lot of coffee
. caffeins toxicity seen in withdrawals
. alcohol intake is double in smokers
. tolerance to alcohol drops in withdrawal
- smokers need more of the following bc of induction of CYP1A2
. insulin, pain relievers, anti-psychotics, anti coag, caffeine,
. quitters need less of those things
- ie on hospitalisation, the effective dosage of things
Nicotine withdrawal - maybe confused with sx of drug toxicity
- craving, urges
- anxiety
- tension
- aggression
- incr in appetite
- inability to concentrate
- sleepinesss/sleeplessnes
- depression
- hunger
- mouth ulcers
- constipation
- worst in1st week
- sx diminish over time
- 62% relapse due to withdrawal within 2 wk
Smoking is negatively correlated with ulcerative colitis and parkinsons, alzheim
- potential treatment in aggression, anxiety
Toxicity from nictoine toxicity is vanishingly rare.

v low dose
patches take hours to peak
no eivdence that you need to wean people off patches
no benefit to start on lower dose
they downregulate subtype reecptors
best to use NRT (patches, gum, inhalers) and smoke at the same time
vaping/electric cigarettes are very addictive - delivery of nicotine
to help them wean of cigarettes
. advise they take gum, then patch, and use cigarettes at the en

. apply 24 hr 21 mg patches last thing at night so that it peaks
in the morning
Varenicline (campix)
- more then one type of nACh receptor responds to nicotine
- women do better on varenicline

- combining varenicline with NRT or buproprion is safe AND effective

- advise them to quit when they are ready after starting - quit date wil
l pick you
- no evidence of neuropsychic SE (except sleep disturbance or vivid drea
ms) - withdrawal itself causes these symptoms
removal of cues ?
- better to keep cues eg ash trays etc - so that extinction
the stimulus to smoke
---------------------------------PAAM - Cannabis
Describe the mechanism of action, pharmacology
Describe its desired and undesired effects
Describe the therapeutic uses of cannabis
Describe the prevalence of cannabis use
Assess cannabis use clinically, predisposing
factors, and associated harms
Understand the management of cannabis use

occurs of

Is there such a thing as cannabis withdrawal ?

can you be addicted to it
risks of cannabis use
tx for cannabis dependence ?
- leaves, flowers of female cannabis plant esp cannabis sativa and canna
bis indica
- cannabinoids in the plants have human body endogenous analogues, as we
ll as synthetically made counterparts
- delta-9-tetra-hydro-cannabinoid (= 2-arichidonyl glycerol in the body)
- delta-8 (= anandamide in the body)
- cannabidiol and cannabino
- tricyclic structure with lipophilic side chains
- cannabinod receptors
. CB1 - brain and peripheral tissues
. CB2 - immune system
- activat G-proteins, adenyl cyclase inhibition, reduction of cAMP
- modulate release of other neurotransmitters
- cannabinoid receptor distribution throughout brain
synthetic Cannabinoid receptor antagonists
- RImonabant = selective for CB1 over CB2
- not registered for human use
Pharmaceutical cannabinoid preparations
- sativex
. extract from cannabis
. licensed as medicinal drug
. mouth spray - THC and CBD content
. indicated for s
- spasticity, neuropathic pain in MS
- dronabinol
. only THC
Use of cannabinoid

neuropathic pain in MS
appetite stimulant
dependencies (obesity, tobacco, alcohol)
antagonists cause depression

- harmless, safer. no addiction, gateway drug, icnr potency, schizophren
THC content incr ?
- YES - incr
- in naive users - hi potency
. greater dysphoria and pscyhotic sx
. gr risk accidental injury
. ptoential for gr discontinuation
- in regular
. allows them to titrate the dose -> less repiratory risk
. greater dependence
Effects of cannabis
- mental - euphoria, appetite, disinhibition
- physical effects - vasodilation, bronchodilation

Lifetime illicit use, 35%

highest bw 20 to 40 yr
smaller numbers using more fequently and intensely
incr risk of dependence
vulnerable groups
. indigenous
. schizophrenia
- tendency to discontinue in 20s due to impact on life
- persistent use predicted by early initiation, heavy use
Gate way drug ?
- < 5% progress
- progression is predicted by early initiation, heavy use, psychosocial
- early use to tobacco is more predictive of hard drug use
- acute
. anziety, dysphoria, panic, paranoia
. cognitive impairment
. psychotic sx at hi dose thc
- accidental injury
. impaired cognition (reduced risk taking)
. impairment of motor tasks eg driving
- chronic
. dependence, learning, memory, respiratory dz, shcizophrenia, p
. cannabinoid receptors upregulated in liver disease (antagonist
s can be used to reduce insulin resistance and steatosis)
. decr volume of hippocampus and amygdala
. respiratory effects similar to tobacco smoke (ie COPD, declini
ng lung function)
. psychosis

. schizophrenia
cannabis psychoses
- rare (ie. as a result of heavy cannabis use)
- mild dose dependent paranoia common
Cannabis and schizophrenia
- can precipitate (RR=24) AND exacrbate schizophrenia
- naive schizophrenics have higher levels of anadamide in their CSF and
incr CB1 receptors
Cannabis use questions
- qantity, freq, route (cones v joints)
- gram amount
- $ spent per day/weel = impact
- dependence s?
- predisoposing factors - psychiatric illness, substance misuse
- complications
Features of dependence
- withdrawal syndrome
- compulsion
- tolerance
- prioritisation
- continued use despite evidence of harm
- ussage despite complications - schizophrenia, paranoia
Prevalence of dependence
- 4% population
- 9% of lifetime users are dependent
- 50% of daily users are dependent
- worse in first week
- mild sx
. irritable, anger, restless, anxiety, sleep dist, strange dream
s, craving, weight, depression
Tx for dependence
- self help
- intreventions
- psychotherpay
- for withdrawal
. dizepam 5 mg tds for 5 d
. lithium is ineffective
. cannabis antagonists ineffective
. agonists help (eg sativex)
- psychotherapy
1. How long is his withdrawal syndrome likely to last? 1 wk
2. What complications of his past cannabis use might you check for? Respiratory
complications (airways disease, wheeze); psychiatric complications (e.g. exacerb
ation of schizophrenia if ever present)
3. How might you reduce his risk of relapse? Brief intervention: reinforcing ben
efits of cutting down, identifying at risk periods
---------------------------------PAAM - Psychostimulants
2 groups - synthetic, natural
synthetics - pharmaceuticals, illicit

Methylphenidate (Ritalin)
Diethylpropion (Tenuate)
Phentermine (Duromine)
Amphetamine sulphate i.e. speed
Methamphetamine e.g. ice, base, speed
Amphetamine analogues
e.g. MDMA (Ecstasy), PMA
Tobacco (nicotine)
Cocoa (chocolate)



euphoria (elevated mood)

incr stamina, energy
reduced need for sleep
reduce appetite

MOA amphetamines
- work on monoamine synapse
- monoamines incl DA, 5HT, NA
- incr availability of monoamines in synaptic cleft by 5 ways
- 1. they block reuptake transporter DAT
- 2. direct agonists at post syndaptic membrane
- 3. symport exchange stimulator - pumps more DA, NA, 5HT back i
nto the cleft
- 4. inhibits VMAT (transport into vesicles) so that cytoplasmic
levels of DA is higher
- 5. inhibits MAO
- cuases sharp peak in DA
- stimuli - ventral tegmental - trhu nucleus accumbens - hippocampus + a
mygdala - frontal cortex - cingulate cortex
- nucleus accumbens involved in saliency (prioritisation - how important
is the substance to me right now = source of addiction)
- feeding forward, the drive to do something, comes from frontal orbital
cortex - (to take soemtime or not)
- amygdala (emotional memory) + hippocampus = form memory of salience (h
ow important the stuff is too you) = related to how much DA has been released
- how important is it to you
In addicted brain
- big DA release
- big salience (nucleus accumbens)
- strong memory (amygdala, hippocampus)
- strong drive (frontal cortex)
- weakens self control / inhibitory
- becomes automatic
- reduces agency or choice

amphetamines and methamphetamine

- powdered methamphetamine = speed (IV or snorted)
- base methamphetamine = waxy oly resin - IV
- crystalline meth (ice = smoked)
- metamphetamine pills = ingsted
- kinetics
- IV - immediate onset
- oral - 30 min onset
- t1/2 12 hr
- detectable in urine for 48 hr
- use of speed and base is decr
- use of ice is incr
- use of methamphetamine in general population is dropping
- Why is there a reason increase in the methamphetamine problem recently
in vulnerable groups
- Purity is increasing
- drives dependence

crack = neutralised base with sodium bicarb

salt is the hydrochloride fo the base
used by IVDU + heroin, or middle class
alkaloid from erythroxylon coca plant
. effects up to 60 min
. half life ~ 1hr
. half life of metabolid benzoylecognine is 8 hr (detectable in
urine for 48 hr)
. if taken with alcohol - preferential metabolit cocaethylene is
producted , prolongs the half life wih greater affinity for DAT
Dance party stimulants - MDMA, GHB
- ecstasy is a tablet that can containe MDMA but also contains other che
GBH (gamm

hydroxy butyrate)
direct agonist at GABA-B receptors and GHB receptors
GHB is metabolised to GABA
at low conc, GHB acts on GHB-receptors as a stimulant
at hi conc, GHB stimulated GABA-neurons and is a depressant
. t/12 - 60 min
. interacts with alcohol - causes it to be more of a depressant,
hypoventilation, aspiration
- a prodrug is gamma butyl lacterone
. the converting enzume is inhibited by etoh, prolongs the effec

- normal for amphetamine users
- co-use of nictoine, benzos, analgesics, etoh is common
- cocaine + etoh common bc cocaethylene has longer half life
Harms of psychostimulants
- amphetamine vs death
. incr since 2011
- amphetamines vs hospital pc

. psychosis 50%
. dependence 25%
stimulant psychosis
- PC
-Tactile hallucinations (formication or cocaine bugs)
-Suspiciousness, paranoid delusions
-Auditory hallucinations (voices)
-Visual (snow lights), gustatory, olfactory
-Repetitive, compulsive behaviour common
-Mood - fearful, agitated, often labile
-Orientated but no insight
-Violent behaviours
- behaviour sensitisation
. become more sensitive to the stimulant effects as you take the
. but become more sensitive to risk of psychosis
- kindling
. if you have one episode of psychosis, your recurrence will inc
r with the more episodes - can lead to constant psyshcosis/schziophrenia
- cross sensitisation - if other stimulants have caused psychosis, then
amphetamines can then cause psychosis as well
Toxic effects
Sympathomimetic Syndrome
HTN, atherosclerosis and ACS
Cerebrovascular event
Cardiomyopathy (reverse takotsubo = ballooning of basal segment
of heart)
Acute liver and kidney injury
Amphetamines smoked, cocaine: Crack lung (looks like ARDS)
MDMA: Hyponatraemia (SIADH + polydipsia/hi temperature/body heat
Cocaine: Pneumothorax, pneumomediastinum (snorting), vasoconstri
ction (lost nasal septum)
Risky behaviours
- IVDU/sex
. viruses - HIV, HVC HBV
- injuries - MVA, burns
- child safety issues
Impact on society
- poverty
- domestic violence
- crime
- maternal effect on fetus
Tx - amphetamines - withdrawal and relapse management
. 5 yr gap bw problme use and seeking help
. more likely to seek tx if risky use/IV, need help for other pr

. less likely to seek tx if female, migrant, employed, non-IVDU,

don t see it as a problme
- no evidence for use in withdrawal - amineptine, mirtazepine
- management
. harm reduction (injecting rooms)
. psychosocial
. pharm intervention
- dependence Mx
Buproprion (NA reuptake inhibitor)
Methylphenidate (psychostimulant)
D-amphetamine/Lis-d-amphetamine (used of ADHD)
Risperidone (atypical antipyschotic)
Naltrexone (opioid receptor antagonist)
Rivastigmine (ACH-I for dementia)
Varenicline (partial agonist at alpha-4-beta-2 nicotininc recept
or used for smoking cessation)

---------------------------------PAAM - Socio-cultural aspects of psychiatry

27 m refugees (2009) global
- 1.7 M iraq
- 3.1 M afghanistan
- 770,200 somalia
- 387,200 sudan
Australia - 14,000 refugees
- most from iraq
- 50,000 bw 2006-2012
Common disorders
- psychological disorders
- anxiety, depression
- psychosomatic disorders
- COnsequences of torture
- htn, diabetes
- dental
- TB
- intestinal parasites
- delayed development in children

---------------------------------PAAM - Indigenous Mental Health

- How does aboriginality affect the presentation and management of mental illnes
s ?
SEWB = Social, cultural and emotional wellbeing
- 25% (1/4) ATSIC had serious psychological distress (RR=2)
- RFs for poor SEWB
. Stressful life events,
widespread trauma,
grief and loss,
child removal,
cultural dislocation,
loss of cultural identity,

economic and social disadvantage,

physical health problems,
drugs and alcohol,
systematic discrimination
- sucide, self harm
- anger
- aggression
- D+A abuse (50% prevalence)
- gambling
protective factors
- social cohesion
- positive well being
- resilience
- connection to land, culture
Indices of social deprivation
- Difference in life expectancy is 17 years
- Gap in employment of 21% (54% cf 75%)
- Literacy standards of students 6 years
- Death rates for those <60 is several times
higher. Infant mortality
rates 3x higher.
- Higher rates of injury and chronic diseases (heart disease, diabetes)
- 20% prison population
Cultural competency
- awareness of ones own cultural world view - how that makes you interac
t with people from other cultural background
- awareness of cultural dominance an power relations
- attitude to and knowledge of different cultural practices and worldvie
- 1/2 mil populatiion indigenous aust (2006)
- 40% are < 15 yr
- most live in nsw and qld
- 1/2 have metnal health problems
- top problems = D+A, depression (+ grief)
- anxiety and depression are leading cause of disease bruden in aborigin
al women
- mental health disorders RR = 1.7
- higher mood disorders, psychotic disorders, behavioural disturbance du
e to psychoactgive substance use
- earlier age of onset of dementia
- 80% of PCshave comobrid mental health, D+A
- IHD major RF for depression
- management of mental illness on management of other health conditions
Referral rate
- double referral rate
- for 1. risk assesment, 2. depression,... behaviour problem, psychosis
- Dxs made = 1. D+A, 2. personality disorder..., no mental illness, depr
Deaths and suicide
- suicide = 5 x population
. bw 15-30
. impulsive, clustered
Guiding principles
- holistic
- centrality of rships

consumer is the whole family

avoid assumptions
importance of history
DSM5n ICD11 not validated in aboriginal people

IRIS indigenous risk impact screen

- scrrening docutment of anxiety, depression, D+A problems
---------------------------------PAAM - Psychotherapies
- therapist + pt
- both parties take part - talking, listening
- problem - pt with mood, feelings, behaviour or rships problems
- anywhere- office, hospital
- one session alone can be therapeutic
- aim is to relieve distress and instill hope
- unstructured, structures
- unstructured
. psychoanalysis )freud)
. psychoanalytic psychotherapy
- chairs diagonally placed, not face to face
- no direct eye contact
- structured
. short term dynamic
- aspect of long term model, practiced in short term
. short term interpersonal
. cognitive behaviour therapy- gold standard
. dialectival behaviour therapy
. metnalisation
why do people come for psychotherapy
- sx - anxierty, derpression, panic phobia
- interpersonal/rship probn
- grief bereavement
- physical illnes with psych sx
- family difficulties
- work related
- identity
- existential wrt
- serious illness, traumatic illnees
Assessment for psychotherpay
- 1-3 seession to assess pt
- find out about their difficulties
- try and detemrine whether psychotherapy is the mode of therapy indicat
ed and whether long term or short term or other structured
- atmosphere of comfort and acceptance
- allow therapeutic relationship develop
- duration of problems, triggers, maintaining factors, alleviating facto
- pmhx of problems, treatments
- developmental/fhx
- r.ship issues
. development is normalised by r/ship
. significant family r/ship
. significant adult partner r/ship
- coping mechaisms in times of stress
. how they relate to you and by directly asking them
- ability to cope currently

- id pt s strengths, reflect them back to pt and how to maximise them

- needs to pt ot be motivated to attend and be able to see that certain
psych factors, r/ships, stressors have triggered the problem and maintained the
problme - if they cannot see this then difficult to maintain the therapy
Therapists characterisits
- empathic, respectful accetpive
- place of safety for pt
- consistent, predictable and dependable
- able to explain, give info about the aims/structure etc of psychotherp
- patience, non intrusive, give space to talk
- avoid asking too many questions (causes closed answers) - best to refl
ect and represent what they say for the pt to elaborate their own difficulties.
- eg I feel sad, bu alcohol/drug helps me to feel better
- i feel alone, but when I go out I forget my lonliness
- you are feeling sad, using the substance helps to feel better, s
o without the substance you must be very representing to them what they
say, amplifying their statement, help them to focus more on their problems and
elaborate the issues
Dynamic case formulation
- occurs after 3 seeesstions of assessment
- take the info from the patient - rephrase it - tell them what I thing
is going on
- eg someone with panic attacks
. summarise duration
. triggers, exacerbations, alleviations
. did family problems influence
. how the problems started, how it is maintained, what are the c
oping mechanisms used
. that they have coped in certain ways, they have certain streng
ths, their manner of relating and life events may have contributed to the proble
- this formulation means that we can get the pt views
- ie collaborating with the pt
- attempt to foresee any difficulties that may arise
. eg if avoidance is an issue - then leaving th ehouse may be an
Therapists takss
- communicate a wish to understand
- clarify time, date, duration, contact after hours
- aspects of the process
- issues that mau interfere with the therapy
- assess the pts difficulties
- case formulation
- assure the pt of your desire to help and the need for them to attend r
Transfereance vs countertransferance
- past psycholgical experiences with a significant other, are revived fo
r the pt and applied to the terhapid
- counter transfereance = the prior experience of the therapist and thus
the reaction to the pts behaviour at this time
Therapeutic r.ship
- therapist quzlitys that are important - consistency, predictability, r
espect, acceptance, understanding, empathic listening, resonating with pt experi
ence allos emergence of safety in rship, recognisition of pt difficulties, impar
t positivity
Coping/Adaptive mechanisms (defences)
- non conscious strategies taht develop in response to threat in early c
are giving environment to maintian homeostasis
- adaptive and protective - to avoid disorganisation in serlf or environ

- including the infants distance regulation and conformity to care giver
- become maladaptive and then symptomatic
Separation anxiety - manifets as 1.insecure ambivalence or 2. insecure avoidant
- infant 18 mo - 3 yr
- anxiety when separated from care-giver
- anxious, restless, clingy
- decr after 3 yr
- why do some people experience the anxiety
. when r/ship is not safe enough, child has ambivalence to the c
aregiver and wants them alsways to be present
. ambivalence leads to clinging
- 1. in an adult, separation anxiety comes out in the form of difficulty
in managing bw sessions, bc they are unable to internalise the caregiving role
of the therapist
. results in frequent contacts, or presentaitons to ED for more
care, self-harming for more care
- if this type of behaviour - need to address by incr the number of sess
- 2. Another type is insecure or avoidance = indifferent or ambivalent c
aregiving - results in pseudo-independence, no fear of separation anxiety, self
. manifests in adults as a fear that the theapist will not be ab
le to help them - so they miss sessions, or arrive late to decr the talking time
- Boundaries are rquired to manage this separation anxiety ie locations,
time range, not exploit pt by receiving gifts/friendships/rships
- avoid provoking shame and humiliation
- reduce # questions
- supplant questions with empathic statements
- note pt affect or changes in it
- facilitate emotional expression
- if pt unable to talk other then in single word or non verbal,
. need to help them feel comfortable
. start with underttanding comments, validating comments then bu
ild to more mature language
Taking notice of trauma
- severely traumatised pt exhibit characteristics of fragility
. fragmentation of sentences
. monosyllabic
. disconnection
. confusion of time frames (past/prestn)
. loss of connection with the other person
. later experiences are interpreted consistently with past exper
- need to start from where the pt is at
. meet monosyllabilic with nonverbal, monoysllabic et
- most pt dissociate - causes mingling of time frames
- loss of sense of self and trust in the world
- best not to ask them direct questons, dwell or dig up past traumatic e
Personality disorders
- problems in thinking feeling and behaving in the r.ship bw self and ot
- tailored to suit the pt
- multiple personality disorders may be present in chronic depression, c
hronic anxiety

PAAM - Anxiety Disorders

Normal vs pathological anxiety
- criteria
. intensity
. duration
. quality - flooding, overwhelming, no control
. false alarms - fear reaction in absence of real danger (vs tru
e alarms)
. negative, disabling effects on behaviour and functioning
- dominant emotion = pathological anxiety and fear
- co-emotion = disgust, shame, guilt, anger
- absence of organic cause eg thyroid, substance
- absence of psychosis
- most common group of psych disorder
- hi lifetime prevalence ~25% population
- lead to secondary depression and drug abuse, attempted suicidie
- assoc with hi CVD
- diabling, hi personal/social cost, misdiagnosted
DSM-5 classifications of Anxiety and related
- Panic disorder (PD)
- Agoraphobia (AG)
- Generalised anxiety disorder (GAD)
- Social anxiety disorder/social phobia (SAD)
- Specific phobias
- Separation anxiety disorder
- Selective mutism
- obsesive cimpuslive disorder
- haording disorder
- body dysmorphic disorder
- trichotillomania (hair pulling disorder)
- excoriation (skin picking) disorder
- acute stress disorder
- post traumatic stress disorder PTSD
- adjustment disorder
- components
. panic attacks
. anticipatory anxiety
- panic
. sudden onset/out of clear blue
. multiple physcial sx esp autonomic hyperactivity = hi HR, SOB,
dizziness/fainting, flushes,
. psych = fear of dying suddenly, fainting, collapsing, losing o
f control/going mad, depersonalisation (person doesn t recognise themselves), de
realisation (surroundings no longer real)
. peaks within seconds/minutes
. lasts usually no longer then 30 min
- screening questions
. Q: Did you ever have an episode during which you suddenly deve
loped several physical symptoms, such as your heart racing or pounding, being sh
ort of breath or feeling dizzy, and you felt frightened that so nething terrible
might happen right then and there (e.g., that you might die, lose control or go

. IF YES - describe it
. How long did it take you from the beginning of an episode to t
he moment when you felt the worst (when you felt most anxious)? Was it a matter
of a few minutes? Or even seconds?
- panic attacks can conceal medical conditions t/f need to rule out unde
rlying medical conditions
. Racing heart, chest pain > Heart disease
. Breathlessness > Heart and pulmonary disease
. Dizziness > Vestibular and neurological conditions
. Trembling, numbness and tingling sensations (pins and needles) >
Neurological conditions
. Sweating, hot and cold flushes > Endocrinological (especially t
hyroid) disease
. Nausea, stomach churning, diarrhea > Gastrointestinal conditions
(especially irritable bowel syndrome)
- anticipatory anxiety
. fear of another panic attack = fear of fear, preoccupation of
sx of panic attack (fear of dying, loss of control, embarrassment, shame)
. screen for anticipatory anxiety
- Q: After one or more of these episodes (panic attacks)
, did you become preoccupied with having another one?
- If so, what are you concerned about? Why are you afra
id of panic attacks?
- What do you think could happen as a result of these ep
isodes? Why do you think so?
- epi
. lifetime 2 %
. 30% lifetime panic attack
. F:M = 3:1
. onset mean 25 yr
. hi prevalence 10%, in hospitals due to nature of symptoms
- natural history
. 30% recover
. 50% chronic + fluctuations
- mild, occasional tx req
. 20% chronic w/o fluctuation
- severe, interference with adl/fn, continous tx
- bio eti of panic attack
- resp disturbance
. CO2 inhalation,
. hyperventilation,
. lactate infusion
. hypersenstivity of CO2 brain stem chemoreceptors
. low threshold of suffocation alarm mechanism
- brains
. abn sensitivte anxiety regulating mechnism in amygdala
. hypersensitivity or pre-synaptic alpha-2 receptors (in
. failuyre of GABA systmen to inhibit locus coeruleus
- cognitive factors
. exaggerated perception of threat and danger (common to
. Threat is perceived to originate within ones body
. Hypervigilance about physical sensations and bodily fu
. Fear of anxiety and its (physical) symptoms because of
beliefs that anxiety and its (physical) symptoms are dangerous
. misinterpret phsyical sensations as sign of impending

- characteristics
. Avoidance of multiple situations: crowded places public transp
ort, shopping centres, cinemas, travelling ar away from home, standing in a queu
e, etc
- avoidance can be:
. panic driven ie to avoid panic attacks
. otherwise eg fear of getting lost, mugged etc
- Fear and avoidance of the cluster of situations
. When alone and/or outside of ones own safety zone, where immedi
ate medicalyor other help might not be available (e.g., travelling far away from
home) .
. Where it might be difficult or impossible to escape immediatel
y (e.g., crowded places, public transport)
. Where it might be awkward or embarrassing to escape immediate
ly (e.g., standing in a queue)
- screening questionws
. Q: Do you avoid several situations, such as crowded places, pu
blic transport, shopping centres, cinemas, travelling far away from home or stan
ding in a queue?
. If so, what exactly do you avoid? Can you ever go into these
situations on your own or do you regularly need someone to accompany you?
. Why do you avoid these situations? What do you think might hap
pen to you in these situations? Does it have something to do with panic?
. If so (related to panic), are you concerned that no one will b
e there to help you in case of a panic attack? Or that you wouldn t be able to g
et out? Why would you need help? Why would you want to escape?
- epi
. 3% lifetime
. F:M = 4:1
. onset mean ~17
. strong association with work disability
- eti
. learning = assoc of unpleasant anxiety sx, panic attacks with
certain situations
. avoidance then reinforces, maintains
- characterisitics
. Pathological worry
- endless worrying
- live in future (full of potential dangers)
- worry driven by uncertainty
- continuous doubt, no closure (constant anticipation of
possible problems, no solution in sight)
- difficulty in shifting focus of their attention
- fruitless thinking which inhibits problem solving and
decision making
. Symptoms of tension%
. physical symptoms (less prominent than in panic disorder)
. Chronic course, with some fluctuations at times or stress/stre
- cascade of pathological worrying describes condition
. flu -> what if serious illness (shld check it) -> what if test
results are wrong (even bf check) -> ask for 2nd opinion (what if I can t affor
d it) -> better check finances (what if I run out of sick leave) -> financial di
- screening questions
. Q: Do you tend to worry a lot about many different things?
. If so, what do you worry about? How often worry most of the t
ime (nearly every day, most of the day)?

. How intense are your worries? Would you consider yourself a wo

rrier? (frequency and intensity
. How does your worrying look like? Do you tend to imagine all
sor outcomes? Rehearsing :s of negative what if" scenarios?
Once you start worrying, can you stop? Can you prevent yourself
from worrying further?
- manifestations of tension in GAD
. Psychological aspects of tension
Nervousness, feeling keyed up/on edge, unable to relax
Hypervigilance, exaggerated startle response Irritabilit
Difficulty with concentration
. Physical (somatic) aspects of tension
- Muscle tightness/stiffness (muscle tension): stiff nec
k, back pain, shoulder pain, tension headache
Muscle spasms, ticlike movements, jerks, fine tremor, dif c
ulty swallowing
. Consequences of tension and worry
Sleep disturbance, agitation, fatigue, exhaustion
- epi
. 6% lifetime
. assoc iwth depression, SAD, panic disorder
. most common anxiety disorder in elderly
. F:M = 2
. onset - teens, but possible snytime
- eti
. genetic
. bio
- hyperactivity of Noradreniline system
- decr fn GABA-A receptor
. cognitive
- worry as a type of cognitive avoidance (by means of wo
rry, can avoid unpleasant somatic sx that accompany strong emotional states)
- beliefs about benefits of worry may maintain worry
- intolerance of uncertainty
General characteristics of all phobias - social, specific, agoraphobia
- phobic stimuli (objectis, situations, activities)
- fear out of proportion to actual threat
- preserved insight ath the fear is irrational or excessive
- exposure to stimuli has immediate response eg panic attack
- avoidance of stimuli
- fear is persistent, mo, yr
- significant distress, impaired fn
- 1. performance anxiety OR 2. social interactions
- Excessive and persistent fear of performancetype situations (performanci
e anxiety):
- Speaking in public - Eating or writing in front of others - Per
forming work duties under observation - Using public toilets in the presence of
- Social interactional situations: - Interpersonal communication - Speak
ing with authority figures, expressing an opinion - Asking for directions, retur
ning purchased goods
- They try to avoid social situations or endure them with anxiety /distr
- chronic course + significant distress, impairment, disability
- Preoccupying fears
. ngeative evlauation
. scrutiny

. making mistake
. having visible physical sx (blushing, sweating, trembling)
. of performing poorly
. when a shy person enters a social situation, they do feel anxi
ety, but this level goes down when they get positive feedback
. SAD people s level of anxiety remains hi no matter what feedba
ck they get
- screening q
. Q: Are of you afraid of certain social situations, do you feel
discomfort in them and/or do you avoid them? For example, speaking in front of
a group of people?
. If so, what are these situations? Why are you afraid of them?
What do you think would happen if you were in one of these situations?
. When you are inka social situation, does the level of your an
xiety ever go down? Especially when people seem nice to you? (distinguishes fr
om shyness)
Do you think that this fear and/or avoidance have significantly
interfered with your life? How?
- epi
. 3 % lifetime
. F:M = 3:2 in community (but equal in clinic)
. onset ~15 yr
. More likely to be single, unemployed, in the lower socio-econo
mic group, with lower levels of education (= consequence of SAD)
. Higher risk of alohol abuse than in people with other anxiety d
isorders (se|f-medication")
- eti
. genetic
. behavioural inhibition to the unfamiliar
- component of inborn temperament observable in 1st year
of life
Difficulty sleeping in unfamiliar surroundings
Irritability in novel s tuations
Avoidance of contacts with unfamiliar people, pl
aces and objects
. cognitive
- low self esteem + perception of social environment as
hostile => expectation to be evaluated negatively in social situations.
Specific phobias
- group of phobias eg animals etc
1. animal
- danger, disgust driven
2. needle/injection
- disgust
- 2 phases of pathophysiology
. initial tachycardia (fear)
. 2nd phase of vasovagal reaction - bradycardia, hypoten
sion, fainintg
- M:F = 1:1
3. environmental
- heights (acrophobia), water
3. situational
- enclosed places, flying, drying
5. other
- choking, vomiting, dentist
- 5% lifetime
- F:M = 2.5:1 (except for needle phobia which is equal)
- onset 10 yr overall

. animal, environmental, injection = childhood

. situational = teens
- few people seek professional tx
- genetic
- acquired thru learning
1. Traumatic conditioning (direct aversive experience wi
th phobic stimulus)
2. Vicarious learning (observation of the fear in others
3. Transmission of the relevant information (e.g., infor
mation on dangerousness of certain objects or situations)
- innate fear not a product of learning eg water, heights
- characteristics of obsessions
. Thoughts, impulses and/or images
. Recurrent/ repetitive
. Uncontrollable
. Not just excessive worries about real-life problems
. Cause marked anxiety or distress
. Usually (but not always) experienced as alien, intrusive, stra
nge, crazy, senseless, inappropriate and/or portending harm
. Compel the person to do somethingj, i.e., to attempt to ignore,
suppress or neutralize obsessions or resist them in some other way
- typical obsessions
. Contamination Doub ng Need for symmetry, precision, ordering, a
rranging, just right feelings"
. Unacceptable/taboo thoughts: aggressive (killing someone), sex
ual, religious
. multiple obsessions - either at the same time, or different ob
sessions changing over time
- characteristics of compulsions
. overt actions/behaviour OR unobserved mental (mental/cognitive
compulsions) - that the person feels driven to perform in response to the obses
sion (typically with strict rules
. repetitive
. performed in an attempt to achieve any of the following goals
Alleviation of anxiety or distress that is caused by obs
Undoing of obsession
Prevention of harm associated with the obsession
- typical compulsions
. washing/cleaning
. checking
. rearranging objects
. counting
. mental/thinking
. asking or confessing
. hoarding
- components of OCD
1. obessions (-> which need to be neutralised)
cause anxiety/distress
experienced as alien or harm-portending
2. neutralisation (forms of neutralisation are behavioural or me
alleviation of anx or distre +/undoing of obsession +/prevention of harm assoc with obssessions
3. behavioural
overt compulsions

reassurance seeking
4. mental (cognitive)
covert (metal, cognitive) compulsions
- screen for ocd
. Are you often preoccupied with thoughts, images or impulses th
at are unwanted, unpleasant or make you feel anxious? For example, tormenting th
oughts that you are dirty or contaminated or that you may have left your home un
locked or images of you harming someone even though you don t want to do that? S
omething else similar to this?
. If so, what thoughts, images or impulses do you have?
. How have you been coping with these thoughts, images or impuls
es? Do you have to do something? Perform a certain act, avoid something, ask for
reassurance? Why do you do that?
- epi
. lifetime ~1.5 %
. F:M = 1:1
. onset ~21 yr (earlier in males)
- natural history
. 50% chronic fluctuating or steady
. 20% recovery (minority)
. 15% progressive deteriorating
- eti
. bio
- serotonin neutrotransmitter dysfunction
- incr DA fn
- Implicated brain structures
Limbic system: orbitofrontal cortex, cingulate,
amygdala, thalamus
Basal ganglia: striatum (caudate nuclei)
- Dysfunction in the orbitofrontal (limbic)-basal gangli
a circuits or cortico-striato-thalamo-cortical
- Certain forms of OCD in childhood: autoimmune process
after an infection with group A beta- haemolytic streptococci
Goals of Mx (intensity, frequnecy, behaviours, coping, reoccurrence, functioning
, qol
- decrease in the intensity and frequency of anxiety and its manifestati
ons (especially physical symptoml of anxiety)
- decrease in behaviours (e.g., escape, avoidance, compulsions) that are
related to or are a consequence of anxiety
- Better coping with anxiety
- Decreased vulnerability and prevention of recurrences Prevention of c
- Improved functioning and quality of life
Most common modalities
- pharmacotherapy
- CBT (psychotherapy)
- combination
Modality options
- pharmacotherapy
- psychotherpay
. behav, congitive, CBT, mindufllness/acceptabnce,
. psychodynamic psychotherapy, marital, supportive
- symptoms control / dearousal technique
. relaxation techniques
. breathing retraining
- combinations

How to reduce the engative impact of anxiety

- contorll suppress sx of anxiety
. pharmacotherapy
. relaxation
- control responses to anxiety
. exposure therapy
- change maladaoptive patterns of thinking/beleifs eg anxiety sx are dan
gerous + developing more coping strategies
. cognitive therapy
- learn to live with it
. mindfulness/acceptance

of pharmacotherpay over CBT

rapid onset effect
better control of physical sx
indicated where
. severe, disabling
. comorbid conditions
- ease of administration
- availability
- lower cost

Adv of CBT over pharmacotherapy

- Changes dysfunctional patterns of thinking and maladaptive behaviours,
which improves coping and decreases vulnerability to anxiety and risk of relaps
e following cessation of treatment
- Fosters a more active attitude tbwards treatment (sense of ownership o
f treatment gains)
- Longer duration of therapeutic effects
- Absence of medication-related side effec;s and medication dependence i
Principles of pharamcotherapy
- aim is to achieve remission = decr sx, anx, distress to minimum and re
turn fn to normal
- drug
. needs to be used long enought (daily, at least 6 mo)
. highest recommended dose, unless remission occurs at lower
. switch meds, or add-on if it is not working
- most critical aspect of pharmacotherapy = medication cessation
. bc the medicatio is effective for as long as it is being taken
and DOES NOT improve coping with the anxiety
. cessation can occur if remission has lasted for at least 6 mo
and pt ready for it
. never cease abruptly (withdrawal)
. after cessation, recurrence less likely to occur if pt have le
arned new coping strategies (cbt)
- typical durgs = antidepressant
. zoloft (sertaline)
. prozac (fluoxetine)
. paxil (paroxetine0
- drugs vs type of anxiety disorder
. BEST for PD and GAD
. ok for SAD, OCD
. ineffective for AG, specific phobias
- drug types vs types of axiety disorders
. Imipramine

. Benzos + venlafaxine
. Classical MAOIs
. clomipramine
. pregabalin, duloxetine, agomelatine, quetiapine, buspirone, hy
- anxiety disorders vs drugs
. PD
- benzo
- venlafaxine
- ssri
- clomipramine
- benzo
- venlafazine
- imipramine
- ssri
- pregabalin
- duloxetine
- agomelatine
- quetiapine
- buspirone
- hydroxzine
- benzo
- venlafaxine
- ssri
- clomipramine
- ssri
- choice of pharmacotherapy when there is no difference in efficacy (eg

Need rapid response ? = benzos (X ssri or tca)

SE profile ? = benzos > ssri (X tca)
comorbid mental/depression ? = ssri > tca (X bdz)
OD safety ? = benzos = ssri (X tca)
hx etoh/subst ? = ssri - tca (X bzd)

- typical SE
Increased anxiety and agitation (jitteriness syndrome) at
the [beginning of treatment
. frequently leads to premature discontinuation
of treatment
Nausea, upset stomach and other GI disturbance, usually
at the beginning of treatment
Dizziness, headache, insomnia
Sexual dysfunction (most common and most troublesome, le
ads to discontination)
withdrawal/ Discontinuation symptoms
. TCAs
Sedation, anticholinergic effects, weight gain, sexual d
. Benzodliazepines

Sedation and interference with psychomotor Derformance

Pharmacotherapy of PD, GAD and SAD
- 1st line: SSRIs, venlafaxine (duloxetine and pregabalin also for GAD)
- 2nd line:
. PD:
-TCAs (imipramine, clomipramine),
- benzodiazepines (clonazepam, alprazolam)
. GAD: agomelatine (antedepr), benzodiazepines, quetiapine (anti
. SAD: benzodiazepines (clonazepam)
- 3rd line:
. GAD: imipramine, buspirone, hydroxyzine (antihistamine)
. SAD: classical or irreversible MAOIs
- Antidepressant + benzodiazepine (combination given for initial 6-12 we
eks, followed by treatment with an antidepressant only)
Pharmacotherapy of OCD
- Only medications with specific serotonergic effecs (clomipramine, SSRI
s) efficacious in OCD
. but only about 50% PT response
- Longer duration of treatment (at least 12 weeks) and higher doses are
needed for response to occur
- 1st and 2nd line: SSRIs (try one , then another
- 3rd line: clomipramine (it is 3rd line bc of the assoc SE profile)
- usually combianation of ssri/clomipraine with anti-psychotic
Cognitive therapy
- Changing of maladaptive thinking patterns in order to decrease or elim
inate pathological anxiety
- TARGETS point "B" in the "A > B > C" model
. A = Situation, event, object, phenomenon, behaviour, person
. B = The way in which one thinks about A (appraisals, interpret
. C = Fee|ings in relation to A (e.g., fear)
. there is no A to C without going through B
. Target "B" to change thinking/interpretation in order to chang
e feelings
- eg.
A = heart racing, pounding, chest tightness
B = this is a heart attack, I will die
C = fear
- techniques
. Identifying maladaptive thinking patterns (interpretations, as
sumptions, beliefs), and demonstrating how they maintain pathological anxiety
. Challenging the basis and cdirrectness of such thinking patter
ns searching for evidence, pros v cons
. Convincing patients that changing their thinking would lead to
. Patients acceptance of rational alternatives
- how to identify maladaptive thinking patterns
. socratic dialogue
- When you feel afraid,
what goes through your mind? what do you think would happen
- Uncovering of automatic patterns of thinking that caus
e, maintain or amplify anxiety and undermine problem-solving (what if thinking)
- One phobia, many underlying fears
. eg

- phobia of lifts
- no air -> wont be able to breath - lifts are dangerous
- i will screen -> they ll think i m crazy - lift are da
Behaviour therapy
- based on exposure treatments
. Changing and eliminating behaviours (e.g., avoidance, compulsi
ons) which help maintain pathological anxiety bc Pathological anxiety will great
ly diminish or disappear vvith disappearance of these behaviours
. Most effective in those anxiety disorders that are characteris
ed by pathological behaviours (e.g., avoidance in phobias and certain compulsion
s in OCD)
- need to demonstrate to pt how this works
- eg fear of useing public transport -> avoidance -> decr phobic fear on
ly whilst avoidance is possible -> reinforces avoidance + maintains the phobic f
. ie there are 2 loops, t/f importance of targeting avoidance
- gradual, self directed, in vivo
Which types of pschotherapy are good for which disorders
- PD = cognitive therapy + sx control (breathing retraining)
. Correcting misinterpretations of physical sensations and sympt
. Modifying beliefs about body-based threat and the dangerous na
ture of anxiety
. Learning not to be afraid of anxiety/panic and its symptoms
- AG = exposure/behavioural therapy
. Exposure (hierarchy-based, gradual, self- directed, in vivo) t
o phdbic situations
- GAD = sx control (muscle relax) + cognitive therapy
. Imagery exposure to the content of worries
. Identifying specific beliefs about the benefit of worrying + c
hallenging these beliefs
. Improving coping with uncertainty
. Improving decision-making and problem- solving processes
. exposure to social situation
First therapist-assisted (with role-play), then self-dir
First imaginal (often in-session), then in vivo
. social retraining if needed bc of deficit in social skills
. cognitive therapy
- modify assumptions, beliefs about self, others, social
- modifying appraisals of social situations as threateni
ng and perception of social environment as hostile
- specific phobias = behavioural/exposure therapy
. usually therapist directed gradual + imagery guided
. flooding is rare
- OCD = behavioural therapy (exposure + response prevention), 2nd line =
cognitive therapies
. Exposure (to the obsession- and compulsion-related cues) and
. Response prevention (abstaining from performing the compulsio
. cognitive
- targets beliefs by the pt that they are responsible fo
r having the obsession
- targets beleifs by the pt that having unacceptable/rep

ugnant thoughts is the same as acting in accordance with such thoughts

---------------------------------PAAM - Trauma, Life-Events and Mental Illness

stress diathesis model
- life events that exceed capacity to regulate and maintain homeostais,
assoc with onset of mental health probelms and stress system disorders (physical
- reaching threshold of coping determined by the stress factor, ambient
stress, and predisposition
Stress = environmental challenge that challenges ability to cope
Traumatic stress = overload for an organism
subjective perception of stress is often more important than some objective reality
- 90% match DMS-4 A1 criterion (experience/witnessed event of actual/thr
eatened death/injury + response involved intense fear, helplessness, horror
types of trauma
- isolated even outside normal experience
- cumulative trauma + consequences = accumulated/ circs/event
- chronic complex trauma = when cumulative trauma occurs early in develo
pment and is in the context of relationships
- massive trauma = violence, terrorits acts, wars, deprivation, torture,
natural disaster, forced migration, retention, slavery
- repeated microtrauma = sufficient to cause damage to developing self)
Trauma causes states of disconnection
- it breaks down
. self (causes a sad or dispirited view)
. attachment organisation (bw self, others and community)
. r/ships
. links bw brain states and body states and mind/body brain stat
es (ie dissociation)
. trust and assumptions about safety
- calls into question basic human rships, safety, continuity and meaning
Effects of trauma - impairs and disrupts
- development of a sense of self
- sense of self as formed
- stream of consciousness
- overthrows self reflectivity
- dissociates aspects of experience, sensation, feeling and cognition
- alienates people
- Porges model = hierarchy
. social soothing (myelinated vagal)
. flight and fight (SANS)
. withdrawal response (unmyelinated vagal)
- aim to promote social processing, decrease, arousal, promote rest and
How to define trauma ?
- Subjective experience versus objective reality
- The perception of threat to self or others
- Embodied experience of threat
- Attribution of meaning to events
- Pre Trauma variables
. family support

. coping style = active style vs avoidant/substance abuse

. genetics
. existing comorbidities
- Post Trauma Variables
. do they get the support
. family support availability
Terrs typology of trauma
- Type I trauma - acute or one-off traumas characterized by full, detailed
memories, "omens," and misperceptions eg car accident
- Type II Trauma - recurrent and chronic traumatic stress characterized
by denial and numbing, self-hypnosis and dissociation, and rage eg Repetitive Ph
ysical or Sexual Abuse
Role of development in stress
- family contribution
- personal development
- generational stress can influence stress vulnerabilities
. epigenetic, attachment related transgenerational transmission
of trauma
Post traumatic disorders/sequelae
- major = depression, anxiety, ptsd, substance abuse
Natural history
- event/trauma
- acute sx (2d - 1 mo) (deal with this using Porges hierarchy)
. MAIN = dissociate sx***
. reexperience
. avoidance
. numebing
. hyperarousal
. impairment
- PTSD (> 1 mo)
. MAIN = avoidance,
. main sx
- re-experiencing
- arousal
- avoidance
- dissociation
- 12 mo prevalence = 1 %
- lifetime 5%
- F>M
Dx - DSM-4
- > 90% point prevlance for criterion B sx
. recurrent intrusive recllections
. recurrent distressing dreams
. acting, feelng as if event occuring
. intense distress at exposure to cues
. physiologicl reactivity to cues
Screening questions for post-traumatic stress disorder (Forbes, MJA 2007, 187, 1
- Do you avoid being reminded of the experience by staying away from cer

tain places, people or activities?

- Have you lost interest in activities that were once important or enjoy
- Have you begun to feel more distant or isolated from other people? (wi
thdrawn = bottom of Porges hierarchy)
- Do you find it hard to feel love or affection for other people?
- Have you begun to feel that there is no point in planning for the futu
re? (given up - bototm of Porges hierarchy)
- Have you had more trouble than usual falling or staying asleep? (stil
l in flight/fight - Porges top)
- Do you become jumpy or easily startled by ordinary noise or movements?
(still in flight/fight - top of Porges)
- score > 4 = PTSD (PPV of 71%, NPV 98%)
Biology of psychological trauma
- defensive neurotransmitters - catecholamine,s opioid, neuropeptides
- glucocorticoid cascade hypothesis
. excess glucocorticoid damage CA-4 neuronal layer of hippocampu
. results in altered glucose metabolism, excitotoxicity due to g
lutamte, inhibited long term potentiation, impaire neurotrophin synthesis
. BUT parental PTSD assoc with low cortisol levels in offspring
- kindling - In PTSD repeated traumatisation eg CSA or repeated trauma o
r intrusive re-experiencing of traumatic stress might kindle limbic nuclei like
the amygdala or hippocampus leading to behaviour change such as startle reflex a
nd differences in cognitive and emotional processing i.e affect regulation
- limbic structures - amygdala, hippocampus
Treatments for PTSD
- better then no tx but worse then CBT or EMDR
. exposure therapy, stress innoculation therapy
. supportive counselling
. hypnotherapy
- not effective/no data
. brief eclective pscyhotherapy
. mindfulness psychotherapy
. acceptance commitemnt therapy
- harmful
. debriefing
. causes reliving
- acute/one off trauma
. psychological first aid
- safety, security, social support, practice assistance,
information, monitor metnal state
. trauma informed CBT and EMDR
. Eye movement desensitization and reprocessing EMDR = doing a
bilateral movement eg binaural beep, tapping, eye movemen - while thinking about
the memory - allows people to process memories that are traumatic
. look at guidelines
- if too unwell for psychological treatments alone - medicate
. acute PTSD 1st line = SSRI
. depressive components - SNRIs
. others . benzos
. anticonvulsants eg topiramate
. antipsychotics esp quetiapine, olazapine, respiridone
. BBs
. clonidine

- chronic

. buspirone
PTSD (Failure of other methods) - STRUCTURED TX is best
sequential approach
education + mx comorbidity
arousal reductio (breathing)

. structured treatments
- confront traumatic memory in controlled and safe envir
onment thru imaginal expsoure
- CBT = identify, challenge and modify distored thoughts
- in-vivo expsoure
. arousal reduction and exposure based
. long term and supportive
. aim to build up self and affect regulation needed in chronic c
omplex trauma
1. Acute and one-off trauma
The NHMRC-approved Australian guidelines for the treatment of adults with acute
stress disorder and posttraumatic stress disorder are currently rescinded but gu
idelines for the recovery from acute trauma are available at the websites of the
Australian Centre for Posttraumatic Mental Health (http://guidelines.acpmh.unim
2. Trauma-informed care for chronic complex trauma
(Adults Surviving Child Abuse) ASCA Practice Guidelines for Treatment of Complex
Trauma and Trauma Informed Care and Service Delivery
READ: *Bomyea J, Risbrough V, Lang AJ. A consideration of select pre-trauma fa
ctors as key vulnerabilities in PTSD. A consideration of select pre-trauma facto
rs as key vulnerabilities in PTSD. Clinical Psychology Review 32 (2012): 630-64
Forneris CA. Gartlehner G. Brownley KA. Gaynes BN. Sonis J. Coker-Schwimmer E. J
onas DE. Greenblatt A. Wilkins TM. Woodell CL. Lohr KN. Interventions to prevent
post-traumatic stress disorder: a systematic review. Am J Prev Med 2013;44(6):6
35 650
Rothbaum BO, Kearns MC, Price M et al. (2012) Early intervention may prevent the
development of posttraumatic stress disorder: a randomized pilot civilian study
with modified prolonged exposure. Biological Psychiatry 72: 95763
Jonas DE, Cusack K, Forneris CA et al. (2013) Psychological and pharmacological
treatments for adults with posttraumatic stress disorder (PTSD). Rockville, MD,
USA: Agency for Healthcare Research and Quality. Comparative Effectiveness Revie
w: 92
*Watts BV, Schnurr PP, Mayo L et al. (2013) Meta-analysis of the efficacy of tre
atments for posttraumatic stress disorder. Journal of Clinical Psychiatry 74: e5
- PTSD is reasonably common with a 12-month prevalence of 1.3%
Women are affected more commonly than men
The risk of PTSD is greater after some types of traumatic events
Premorbid factors increase the risk of PTSD
Psychological treatments are first-line; antidepressants may be used as
adjunctive treatment
Chronic complex trauma an important factor in mental health
Trauma an important factor in psychiatric and related stress system diso

---------------------------------PAAM - Trauma and its effects on development
General effect of trauma is to create a state of disconnection
1. Trauma has primary effects not only on the psychological structure of
self, but also on the systems of attachment and meaning that link individuals a
nd community.
2. Trauma destroys the person s fundamental assumptions about safety in
the home and in the outside world.
3. Trauma calls into question basic human relationships it breaches atta
chment it undermines the belief system trust - that gives meaning to human exper
types of trauma
1. emotional neglect/abuse
2. physical abuse
3. sexual abuse
4. combination
Effects of trauma
- disrupts sense of self
- in development
- if already formed
- interrupts stream of consciousness => causes fragmentation of time - t
hey live in the present as if the trauma has just occurred
- overthrows self reflectivity (which normally develops by age 5yr) - ca
nnot reflect on the effect they have on selves and on others
- alienates from other
- introduces feelings of self loathing, shame
Sense of self
- develops early
- affects other relationships and attachment
- intimate attachments to other humans are the hub around which a person
s life revolves, throughout life
- secure attachment is protective against fragmentation, maintainng equi
librium and continuity of self (stream of consciousness).
pathological attachment
- if there are no attachments to carfe-giver in early months of life - p
roper nurture impeded
- later in infancy - early childhoodthis trauma is often in the form of
devaluation of a repeated nature
Disorganised attachment
- traumatic in itself
- common in severe borderline states
- attachment to a fragile, depressed caregiver who rapidly shift from an
gry to hostile and back again
- causes rapid shifts in representation of self and other
- bc infants representation is fragmented and dissociated and they still
don t have a theory of mind (capacity of self-reflection which doesn t develop
until 5 yr) - they cannot attirbute what frightens them.
Effects of trauma at different leels
- somatic (straddle physical and psych)
psychogenic non-epileptic seizures
chronic abdominal pain
chronic migraines
- emotional
personality problems (they develop in early adolescent)
- cognitive

ways of thinkng and responding

- perceptual
as in psychosis (histories of many psychiatric disorders have co
mponents of trauma)
- behavours
attention deficit/adhd
antisocial behavour
conduct disorder
- characterlogical
personality disorder esp borderline personality disorder
Complex traumatic stress
- early age cumulative (natural, physcial, sexual, emotion, neglect, dep
rivation, ) - incr vulnerability to range of psych disorder
- psych disorders of enduring characterlogical and mental health problme
- may not present with characteristic signs and symptoms of PTSD - inste
ad with a symptom picture like PTSD except that the multiple incidents may have
occurred in their lifetime and be triggered by an additional trauma
- effects
1. Repeated, chronic, emotional, physical or sexual abuse jeopar
dizes the child s growth of self esteem. sense of trust. and view of the world.
2. Trauma results in the splitting of the child s healthy. devel
opmental needs and longings.
. when children are aware of the impact of their environ
emnt they develop coping mechanisms eg segregatiing needs/belonging
3. coping mechanism of segregating (dissociating) these needs an
d longings which are offensive to the pathologically vulnerable caretaker, ie th
ey cope in this situation of the pathological caregiver by regulating their rela
tedness with others/caregiver and attempt to apply these to other situations 4. They also dissociate memories of trauma, associated affects a
nd emotion charge of trauma and emtoions they experience
COping mechanisms
1. pathoogical accommodation - behaviour in way required by environment
2. pseudoindepdence and become themselves a care-giver
3. extreme care taking behaviour
4. stimulus entrapment ie taking everything that is happenng in teh envi
ronemnt but care little about themselves
5. somatisation/conversion eg psychogenic non epileptic seizure
6. magical thinking or perfectionism - in order to control environment
7. rigidity and controlling
8. denial
9. displacement, conversion, dissociation
10. idealise an abusive caregiver to maintain homeostasis (esp occurs in
young children)
what is dissociation
. disruption of normally integrated functions of consciousness,
memory, identity or perception of the environment or the body
- a way of coping with unbearable affect
- vulnerable to traumatic remiders
what happens to memory?
- trauma disturbs emergence of autobiographical memory - causing over-ge
neralisation to occur
- repeated activation of trauma system prevents assimilation of new mate
rial and prevents maturation
Associations between trauma and psychiatric disorders
1. The prevalence of trauma exposure among the psychiatric population ha
s been found to be higher than the rest of the population.

2. Psychiatry patients appear to have been more exposed to traumatic eve

nts than the general population.
3. Higher levels of dissociation are reported in groups of trauma victim
s compared to non-trauma groups
4. Patients who dissociate are significantly more likely to report child
hood abuse than those who do not
Family characteristics assoc with child abuse (so that we can identify it in pri
mary care)
1. parental psychopathology
2. family conflicts
3. emotionally cold, harsh environment
4. chronic criticism, rejection, physical punishment
5. parental loss, absence or abandonment
6. parental divorce
7. history of intergenerational abuse (each adverse experience sets up c
ircumstances that make it more likely thatother adverse experiences will occur)
- can be seen in 3rd generation
8. vicarious trauma from a parent who returns from war, refugee, from cu
stody, suffering of a parent

---------------------------------PAAM - Psychiatric Emergencies/Safety Issues and Management of Aggression

Aggression Suicidality assessment Other Psychiatric Emergencies . Illicit Subs
tance Emergencies . Sudden Cardiac Death . Neuroleptic Malignancy Syndron1e .
Serotonin Syndrome . Lithium Toxicity . Clozapine . Movement Disorders
AGGRESSION /violence
- RF
. mental disorder (but most of mental disorders aren t violent)
. acute symptoms
. pmhx violence
. D+A intox/withdrawal
. demographic
- male
- young
- poorly educated
- isolated
. brain injury
. disinhibitive neurological condition
. personality disorder (esp cluster B)
. maing threats of violence
- RF violence in acute psychosis
. delusions of persecution (NOT delusions of reference ie being
followed or watched)
. delusions of control (by something)
. command auditory hallucination
. D+A intox
. pmhx
- male, secluded room, section 22 taken int custody, diorganised/threate
ning to kill other, required capsicum spray
- approach to this person
. secuirty, staff presence
. proximity
. low stimulation environment
. alarms
. body same level at pt

. shake hand
. close to door, not obstructed
- engagement
. explain role
. simple lang
. empathise
. let them rant, lesten to why angry , thoughts of violenc
. don t interrupt
. open questions
. explain actions, delays
. offer blanket, food, drink
. USE MEDICAL PROBLEMS AS A WAY IN (pain, sleep problems, rash,
flu sx)

avoid eye contact

always show hands
don t argue, challenge
set limits

- pmhx
. comorbidities
. rule out ;hysiological causes
. contraindications of sedation
. mental health act
- document
Rx sedation
- Sudden cardiovascular collapse
- Respiratory Depression
- Brain injury
- Hypotension
- Irregular, slow pulse
- Acute dystonic reaction (past history)
- Limited history
- Unknown ingested/injected substances - - History/presentation not making sense
Rapid sedation
. dizepam
. olanzapine
. haloperiodol + bentropine
- IM


- IV
. GA
. benzo
. antipscyh
Suicidality - key assessment/management
- physical assessment
- engagement w pt to get real picture of whats going on
- immediate risk to selves
- mental state
- post assessment planning egspecialist review, D/C planning, admission
Initial assessment
- do thoroughly to avoid need to repeat


- detail pts who trehatent to leave
General cosideratoin
. RF
. stressors/triggers
. supportgs
, mental illness
. D+A
. suicide intent/plan/severity
RF for suicide
- b/g
- current
- future

mental illness
physical illness
mental state
acutive suicidal thought
access to harm
no change to circs that created trigger/stressor

Approach to suicide
- General opener ( your doing it tough at the moment huh?", life not wor
th living, better off dead, dark thoughts)
- Duration, intensity, frequency, distress
- Thoughts of how would harm self/kill self
- Speci c plans, access Preparations (wills, belongings, notes)
- What stopping, consequences
- previous suicide attempt
. how help was found or was it sought
. what did you think was going to happen ? eg vomit, never wake
. how do you feel now (shame, regret, anger, disappointment)
. potential for change
- epi of deaths
. 72% tobacco
. 25% alcohol
. 3% illicit drugs
- methamphetamine adverse effects at high dose
. htn
. arrhythmias
. MI
. aortic dissection
. hemorrhagic/non hemorrhagic stroke
- amphetamine effects
. euphoria, alertness, energy, confidence, stamina
. sleeplessness, reduced appetite, dry mouth
. sucidial, headache, teeth grinding, anxiety
. psychosis, incoherence, incr T, dehydration, thought disorder,

violent aggression, heart attack

- ecstasy effects unpredictable bc unknown content (eg amphetamine, caff
eine, glucose, benzos)
- hypothermia causes
. MDMA direct action on hypothalomus
. hot environment
. sustained physical activity (agitation, energy)
. poor fluid replacement
- overdose
. 2% pof OD result in death
. typically opiates
. sx - drowsy, slurring, NV, miosis, flushing, sweaty, decr resp
, PE
. tx - naloxone
RF for psych emergencies generally (suden cardiac death, lithium tox, nueroleptc
malignancy syndrome, serotonin syndrom, clozapine, movement disorders)
. changes to meds
. hi doses
. lithium
. 1st Gen (TYPICAL) antipsychotics
. clozapine
. haloperidole
Sudden cardiac death (esp schizophrenics, long QT)
. esp for schizophrenic
. CVD factors add to this (sedentary, diet, smoking, alcohol, substance
. prolonged QT
. results in TOrsades de pointes => VT and sudden cardiac death
. unpredictable
. ALL antipsychotics affect K+ channel in cardiac conduction
. definition
- QT > 450 ms male, > 470 ms female, > 460 ms child
- base line change > 60 ms
- any QT > 500
- correct for pulse rate = QTc =
- other factors that can alter QT ?
. diurnal variation
. plasma levels of meds
. stress,
. feeding
. RF
- Inheritable - signi cant risk - sudden cardiac death, pr
olonged QT Syndrome
- Medications - antipsychotics, antidepressants, methado
ne . Note dose related
- UECs - hypomagnesia, hyp"ocalcaemia, hypokalaemia
- Female
- Increasing age
- Cardiac conditions, Systemic disease liver, kidney, th
yroid CNS CVA
- Psychiatric factors - substance abuse, restraints, str
ess , arrest/tazer
- combination of psychotropics + non-psych meds eg Nonpsych medications - antiarrhythmics, antihistamines, macrolides, antifungals
Lithium and toxicity
- lithium indications
. bipolar

. affective disorder
. resistant depression
- sx toxicity
. Impaired consciousness
. Dysarthria
. Ataxia
. Course tremor
. Muscle twitches
. vomiting
. Increased tone, re exes Myocionus
. Seizures
. Arrhythmias, prolonged QTc C
- RF = lithium + the following
. Li level > 2
. hypovolaemic (low intake, vomiting, diarhoea, sweating, diuret
Neuroleptic malignant syndrome
- mortality in 20% of cases
- incidence ~3%
- assoc with ligactole and haloperiodol
- sx
- usually develop in 1st 2 wk of neuroleptic (antipsychotic) the
- but can occur after 1 dose
- RF
. switch to higher dose
. rapid dose escalation
. switching antipsychotics
. parenteral admin
. extreme agitation
. acute catatonia
. dehydration, lithium, depot, acute men
- TETRAD of sx = rigidity, mental state change, hyperthermia, autonomic
1. muscle rigidity
. lead pipe rigidity
. superimposed tremor + cogwheel rigidity
. opisthotonus
. trismus
. chorea
. sialorrhea
. dysarthria
. dysphagia
2. mental state change
. 1st sx in majority of pt
. usually agitation, delerium + confusion
. other = catatonia, mutism
. if severe can progress to encephalopathy and coma
3. hyperthermia
. > 38C
4. autonomic instability
. tachycardia
. htn
. tachypnoea
. dysthymia
. diaphoresis
- Dx
. CK > 1000 (can be up to 100,000) - degree of elevation related

to severity

hi wcc + left shift

incr ldh, alp. ast/alt
metabolic acidosis, hypo - Na / Mg / Ca
renal + proteinuria, myoglobulinuria
low serum Fe
LP + CT to exlcude ddx

- Mx
. stop agent
. supportive
- fluid replacement
- euc replacement
- cardiac support
- DIC consider
. control agitation - benzos
- Prognosis
. resolve by 2 wk
. mortality when comorbid D+A, renal impairment,, organic brain
Serotonin syndrome
- RF
. antidepressants
., antimigrain meds
. stimulants
. opiates
. psychedelics
. combination of SSRI + cheese/wine
- TRIAD = cognitive, autonomic, somatic
. cognitive effects
- headache
- agitation
- hypomania
- mental confusion
- hallucination
- coma
. autonomic
- shivering
- sweating
- hyperthermia
- htn
- tachycardia
- nausea
- diarrhoea
. somatic
- myoclonus (mm twitch)
- hyper-reflexia (+clonus)
- tremor
- indcations = schizophrenia
- death due to
. neutropenia (monthly blood levels)
. cardiac - myocarditis, arrhythmias
. respiratory depression
Acute dystonia (movement disorders)
- DA blockers (ie anti-psychotics IV/IM)
. esp 1st gen antipsychotic
- face, neck, trunk\

- larygneal spasm can be lethal

- sx
. Oculogyric crisis - Spasm of the extraorbital muscles, causing
upwards and outwards deviation of the eyes !
. Torticollis - Head held turned to one side
. Opisthotonus - Painful forced extension of the neck. When seve
re the back is involved and the patient arches off the bed.
. Macroglossia - The tongue does not swell. but it protrudes and
feels swollen
. Laryngospasm Uncommon but deadly
- can masquerade as allergies or drug reactions
. a dislocated jaw from prochlorperazine given for labyrinthitis
. an allergy with swollen tongue which was a dystonic reaction to
. a hyperventiIation who was exhibiting a classic oculogyric r
. increasingly strange behaviour caused by the overdose of tri uoper
azine for which a young man had been admitted two days previously.

---------------------------------PAAM - Personality: Normal Personality Development Attachment and Early Adversi

attachment theory
- model of development based on bond of infant to caregiver
- allows the care from the caregiver be a source of bio-psycho-social re
- they take time of be experienced
- then are internalised and become automatic and emerge at times of stre
- knowledge of this system - preidcts behaviour during times of stress a
nd trauma
- also indicated recovery pathways and appropriate care and psychotherap
y, motivational systems
- a motivation system
- early experience of caregiving, affects development of mind/selfand re
gulation of relationship
Development of relationships
- underpins interpersonal neurobiology
- our selves develop via relationship BUT are broken down by trauma (sma
ll, cumulative, child abuse, poverty, war, cataclysmic events)
attachment patterns don t solidify until 6 mo
Attachent states of mind
A. dismissive bc attachment hasn t been helpful - independence, avoidant
B. secure (free to ask for help)
C. preoccupied (can t do it themselves, anxious, helpless)
D. disorganised - can t do it - worsened by r/ship with other - fragment
ation - afraid
Behaviour after child/caregiver reunion
A. dismissive/avoidant - not bothered by attachment BUT BP, HR show dist
B. settle quickly and return to play

C. they don t settle after reunion

D. incoherent behaviours indicating dilema - the parent who should comfo
rt me is frightening or frightened - so I am in a double bind and I freeze, get
aggressive, hid, and back away
Attachment states vs Porges polyvagal theory
A. hyperaroused (flight/fight = removal of vagal brake and SANS activati
on = 2nd tier response)
B. soothing (via myelinated PS; top of hierarchyP
C. hyperaroused
D. any of these respones
Coping mechanisms are learnt during periods of dysregulation and become procedur
al the way things are
- presentations for tx arise when systems for coping break down
- eg child with separation anxiety can cling to mum at home, but this br
eaks down at school
- loss/trauma/negelct can cause disorganisation
- effects are profound during devleopment ie childhood
Healthy self/personality
- coping mechanisms and self regulation sufficientyly functional and dev
elops to allow rest, intimacy, play and work
- 2nd chance to develop in in childhood/ adolescent with teachres, mento
rs, friends, partners, therapists
Adult attachment interview - how a person organises themselves
- aska bout early experiences
- what and how they say (emotional and cognitive orgnaisation)
- reeveal state of mind wrt to losses and trauma
- B. The coherent narrative associated with a secure state of mind offer
s a story backed up by evidence (episodic memory)
- A. The dismissing narrative can give a story (semantic memory), but de
tailed memories are lacking or con ict (eg an idealizing account, or one without m
emories, or a conflicting account)
- C. The preoccupied narrative lacks semantic structure and appears to b
ecome lost in memory or angry affect or cannot progress with agency (i.e is pass
ive or angrily involved)
- D. The disorganizedl unresolved accounts shows lapses of monitoring of
reasoning, language. behaviour (and probably perception)
- security of adults caregiver predicts security of their infant in teh
stranger situation procedure (separation and reunion discussed above)
Key concept
- development across lifespan
- trauma can break down organisation of self
- recovery is about reubuilding conneciton and organisaation
- tx plans via multimodal to promote connectiviety of the invidi
vual with the community
- The emergent self has the property of a self-organizing system
with the capacity for reflection about self and other, a capacity to manage str
ess and strain, with liveliness and exibility
healthy self regulation vs dysregulation
- we can feel vs numb/dissociation
- embodied vs disembodied
- articulate vs inarticulate
- self pvs depersonalisation, derealisation
- relatioship vs isolation
Dissociation, disconnections and dysregulations of self and scoial life are core
to the chaos or rigidity that characterises personality disorder
Responses to dsyregulation fo stress systems
- acute chronic stress response
- autonomic

- prothombotic, inflammatory
- stress releiving strategies
- dysregulated social behaviour
Therapeutic goals
- aim for secure attachment state of mind
- robust sense of self with reflective capacity
- interpersonal sills and organisation
- autonomy
- flexible and spontaeenous
- symptoms reduction, relief from disorders and promotion of resilience
- interpersonal connectidness
Hesse E. (2008).The Adult Attachment Interview: Protocol, Method of Analysis and
Empirical Studies. Handbook of Attachment: Theory, Research and Clinical Applicat
ions, 2" ed, edited by Jude Cassidy and Phillip Shaver, 552-598. New York: The Gu
ildford Press, 2008.
---------------------------------PAAM - Personality Disorders
personality types
personality disorder
categorical vs dimensonal diagnosis
axis 2 vs 1
borderline personality disorder (most common)
separate from axis 1 disorder bc they are patterns of behaviour rather then a on
e off ilnnes
personality disorder . pattern of pervasive and inflexible behaviour and thought that deviate
s from culture acceptance
. early onset - adolescence, early adulthood
. stable over time
. causes distress and impairment
Essential features - DMS 5
- impairments in personality (self and interpersonal) functioning and
- presence of pathological personality traits.
- for Dx the following criteria must be met:
. Impairments in self and interpersonal functioning
. One or more pathological personality trait domains
. Stable across time and situations (ie workplace and home)
. Not normative to the individual s developmental stage or cultur
al environments
. Not due to a substance or general medical condition
- need long term functioning
- take into account ethnic, cultural social background
Personlity - total pattern of feeligs, thoughts, behavuiours, reactions, interac
3 clusters of personality disorders
. odd eccentric
. emotional, dramatic
. anxious
CLuster A = "odd and eccentric" = paranoid, schizoid, schizotypical
cluster B = "dramatic" = antisocial, histrionic, narcissistic, borderline
Cluster C = "anxious" = avoidant, dependent, obs essional

Paranoid personality = Moe ("simposns

- distrusting,
- suspicious,
- malevolent perception of other
- world it evil and they must fight against it
Scizoid personality = Comic book guy, howard hughes
- social detached
- restricted emotional range
Schizotypal personality (harry potter s professor trelawny)
- eccentric
- odd beliefs
- discomfort with intimacy
- confused boudnaries
- unrealistic goals
- psychoticism
- restricted affectivity
- suspiciousness
- (tell fortunes, believe in aliens from out of space, witch doctors
Anxious group
- avoidant

excessive sensitivity to negative evaluatin
feelings of inadequacy
social inhibition
avoid decisions, doing things


personaltiy (pettigrew from harry potter)

submissive, clinging
dependence of alcohol, drugs

OBSESSIONAL personlity (ned flanders from simpso)

- preoccupation with orderliness
- perfectionism
- like to be in control
- sense of worth derived from achievement
- r/ship secondary to work and productivity
- rigidity
- perseverance

(Monk detective)
- axis 1 disorder (different to obsessional personality)
- obsessions
- compulsions

Axis 1 vs 2
axis 1
- state based or episodic
- feel wrong for the person = ego dystonic
axis 2
- trait based or present enduringly
- feel right for the person = ego syntonic
Narcissistic personality (paris hilton)
- grandiosity

lacking empathy
will want to see the top doctor, won;t want to see a GP
consider themselves to be better then everyone else
needing approval
superficial relationships

Histrionic personality (Lletyon hewit

- attention seeking
- excessive emotionality
- female dress flamboyantly, wear a lot of make up
Personality disorder:
- Lifelong maladaptive pattern of behaviors attitudes and experiences an
- Consequent distress or disadvantage to self or to society.
antisocial pesonality (sideshow bob, chopper reed)
- disregard for and violation of others rights
- lack of guilt
- narcissism
- exploititive of other in a relationship (sexual, scamming friends/fami
- seeking personal gratification
- incapacity for intimacy,
- manipulative
Borderline (marilyn monroe) = most common
- criterion
. pervasive instability of interpersonal r.ships, self image and
affect with
. Avoids real or imagined abandonment (distressed when on their
. Unstable. intense idealized/devalued relationships *one week
they can be idealised, then devalued the following week
. Impulsivity in more than 2 self harming behaviors (substance a
buse, sex. bingeing, spending, driving)
. Recurrent suicidal behavior / gesturesl / threats / self mutil
. mood can swing dramatically but in the constellation of these
other things will not be bipolar
. Affective instability
. Chronic emptiness
. Intense inappropriate anger
. Transient stress related paranoia or dissociation
- eti
. temperaterament, genetic
. environmen - unstable, abusive (emotion, physical, neglect)
- mx
. crisis mx (after self harm)
- mx of counter transferance (your reaction when they co
e in displaying anger toward you)
- support
. mx of counter transferance
. supportive psychotherapy
. behavioural therapies
. psychodynamic psychotherapy
= gold standard
Eti of personality disorders as a whole

constitutional defects
environemntal (negative environemnt of development
organic brain dg
cerebral infection
prenatal and birth trauma
psych factors - culture, family in which they grew
social processes
psychoanalytic factors - defence mechanisms
cognitive, perceptual orgs
affective instability
degree of impulsivity, aggression

- Individual differences in the regulation and organization of cognitive
processes. affective reactivity, impulse/action patterns, and anxiety may in th
e extreme provide susceptibilities to personality disorders such as borderline a
nd schizotypal personality disorder.
- A low threshold for impulsive aggression, as observed in borderline an
d antisocial personality disorders, may be related to excessive amygdala reactiv
ity, reduced prefrontal inhibition, and diminished serotonergic facilitation of
prefrontal controls.
- Affective instability may be mediated by excessive Iimbic reactivity i
n gabaminergic/glutaminergiclcholinergic circuits. resulting in an increased sen
sitivity or reactivity to environmental emotional stimuli as in borderline perso
nality disorder and other cluster B personality disorders.
- Disturbances in cognitive organization and information processing may
contribute to the detachment, desynchrony with the environment, and cognitive/pe
rceptual distortions of cluster A or schizophrenia spectrum personality disorder
- A low threshold for anxiety may contribute to the avoidant, dependent,
and compulsive behaviours observed in cluster C personality disorders.
temperament and geentics vs downsyndrome (very happy people)
- poor agreement DSM 4
- lack of clear boundaries
- comorbidity
- 15% community prevalence
- M>F
- more women with borderline
- more men with antisocial
- decrease prevalence with age as people develop r/ships and learn how t
o interact with world
- more in urban community (more isolated)
- 20-70% prison (antesocial and borderline)
- Axis one disorder
Psychotic disorders
Mood disorder
Anxiety disorder
Post-traumatic stress disorder
Substance related disorder
Personality changed due to general medical condition
Personality traits

- 1st line = drugs (not for personality itself but for con-comittant axi
s 1 disorder eg hi rates of depression tf tx depression)
- psychotheraopy is main stay
- in patient discouraged esp borderline, bc they become dependent on inp
atient involveemtn
- self hlep, psychosurgery, (not in western places),
- day care
- comorbidity

depends on the personality

stable (eg obsessional) is lifelong
unstable (eg borderline) resolves in 40s
many disapppear with maturity
poor prognosis if there are comorbidities
good probosis if they only appear during axis 1 disorder
if tx early (teenagers) beter prognopsos
good interpersonal rships
not severe = better
no drug abuse = better

Monty burns - antisocial personality disorder

- exploitation
- swindling, scamming - friends, relatives, coworkers - out of money
---------------------------------PAAM - Intellectual Disability
- What is intellectual disability
- The relationship between intellectual disability and mental health pro
- How to assess someone with intellectual disability and suspected ment
al health problem
- Seeking and gaining substitute consent
case 1
- 45 M, intellectual disability
- group home, aggressive at home, assaulted staff and smashed wi
- BIBA sedated
- staff dont want him home until something is done
Is this anew problem, a chronic problem that is worse, or part o
f a usual pattern of behaviour
When are where
Has it happened before: Aggravating and relieving
Time course
What has been tried; effectiveness
Level of distress or risk
Could this be an acute medical problem: pain (dental abscess), delirium,
discomfort (constipation), seizure related, medication related
Could this be a psychiatric problem (past history, associated features s
uggestive of psychiatric illness), ASD
- new behaviour ? manic - more vocalising, depressed - irritable
/lost appetite, psyhotic

Environmental factors - bereavement, abuse, change

Intellectual disability
- developmental injury ie different to a brain injury that may occur in
an adult;
- globally affects development, your ability to learn in all areas has b
een affected
- 3 criterion
.IQ<70, 3% population
- mil 50-70 (75% of group)
- mod 35-50
- severe 20-35
- profound <20
. Impairments in adaptive function in at least 2 of:
- communication,
- self-care,
- home living,
- social/interpersonal skills,
- use of community resources,
- self-direction,
- functional academic skills,
- work,
- leisure,
- health and safety
. Onset before age 18years
- nomenclature equivalent to ID = learning disability, mental retardatio
n, developmental disability, mental handicap
- does not icnlude: dyslexia, learning difficulties, adhd, mental illnes
s, autism

identifiable cause in 80% of peole

prenatal 70%
perinatal 20%
postnatal 10%

- genetic, tri21**
- exogenoous
. infections
. toxins / medicaitons/ drugs/ alcohol
. maternal hypothyroidism
. placental insufficiency
- infections
- birth complications
- newborn issues
. hypoglycemia, hyperbilirubinemia


ID vs mental health problems

- ID is at risk for mental health problems, 30% of ID (vs 8 % in non-ID)
- especially schizophrenia and other psychoses but not bipolar or unipol

- rapid cycling/mixed states more common


vs ID
3% prevalence
unknown r.ship to level of ID
esp catatonic

Anxiety disorder vs ID
- more common in ID
- compulsive behaviours more common and worse in severe ID
Autistic spectrum disorder
- triad of impairment
. Impairments in social development
Problems in developing reciprocal relationships,
- impaired empathy,
- unusual eye to eye contact and facial expression
. Impairments in language and communication
- 50% no useful speech, delayed language development,
- repetition, echolalia,
- lack of reciprocal conversation,
- literal understanding,
- neologisms, pronoun reversal
. Impairments in thought and behaviour
- stereotyped and repetitive play,
- fascination with parts of objects/toys rather then who
le toy,
- preoccupation with topics,
- resistance to change,
- need for routine,
- stereotyped movements eg hand flapping
- comorbid ID and ASD = higher levels of emotional/behavioural disorder
. marker for poorer outcome
. higher levels of carer stress
- 80% autistic have an ID
- 10% mild ID have ASD
Personality disorder
- don t know what a normal personality is in a person with ID
Why are they an at risk population for mental health problems ?
- predisposing biological factor
- limited psychological coping mechanism
- incr exposure to risk factors for mental health problems
. stigma
. isolation
. unemployment
. povery
. abuse
ID at higher health risk
- lower life expectancy
- higher risk of health problems: obesity (poor health choices, group ho
ming,) malnutirtion, sensory (hearing, highlight), dental (esp non verbal popula
tion pain), epilepsy, dermatalogical, endocrine, htn, hpylori infection, constip
- ageing carers
- additional health needs eg tri21 - alzheimers
How is assessment different for mental helath in ID group

- Diagnostic over-shadowing
. attribution of problem to ID rather then considering MH
. there is actually no behaviour consistent with ID
- Communication problems; - difficulty participating interview
- Cognitive capacity to understand symptoms
- Difficulty applying diagnostic criteria
. how do you do the DSM criterion tests on a non-verbal person
- Developmental level Eg self talk, imaginary friends are things that ar
e normal as a means of normal processing
- Unusual symptom profiles Restricted range of experiences
. psychoses sx may become childlike rather then sophisticated pa
ranoia states eg. someone is spitting in my tea, rather then I am being monitore
d by satellite
- Reliance on corroborative information
- Need to be holistic in diagnostic formulation and assessment
Overcoming these difficulties
- appropriately safe place, and enough time + need to talk to a lot of p
- language appropriate to their developmental level and clearly + time t
o answer
- start with simple question - who have you brought with you today
- remember that it is easier to understand a language then express in it
- allow time for response
- use body language as well
- admit you don t understand
- let those who know the pt well help you
- establish rapport
- reassure
- identify times by locate time to an event eg birthday
- check comprehension
- don t suggest the answer you expect so to minimise acquiescence AND ch
eck answers later
If non verbal
- their receptive / understood language may still be ok
- other forms of communication
- is the interpreter ok
- make eye contact
- they may respond with eye movements etc
Psych hx in ID
- a history of change is important - when did the person change, how di
d they change, what is their baseline
- assessment has to be bio, psycho, social
- the only thing normal for a person with ID is the cognitive impairme
nt, there is no normal MH condition
Mental state exam in ID
- appearance and behaviour
. well dressed = level of care
. age appropriate dress
. dymorphology
. eye contact
. social appropriatenes
. stereotypic/self stimulating behaviours
. abn movement (neuroleptics)
. mobility/vision
. support peron

- mood
. difficult to explain it
- affect
. may be confused by their facial expression eg grimacing
. medication effects eg sedation
. check with someone who knows them well
- speech
. articulation problems are common
. check how long they have had the problem to check whether it i
s a medication issue
. assess receptive and expressive communication separately
- Thought
. Form
- perseveration is common
- illogicality is common
. content
- persecution ideation common
- delusions : consistency over time, out of keeping with
developmental level and normal fn
- suicidal/homicidal ideation - pt understandng of letha
- perception
. voices vs thoughts
- don t suffest - get them to describe
- assoc sx
- content of their voices
- self talk is common
- insigh
. maximise ability to consent
- congition
. validitiy of mmse
- risks
. risks to self, repettive self injurious, compulsive self injur
. D+A
. misadventure/absconding
. from others - exploitation, abuse, neglect
- loss of accommodation of support, community access
Who can conset = GUARDIANSHIP ACT
- cannot give consent if cannot understand nature and effects of tx or c
annot communicate their consent
- treatment classes = urgent, non urgent, special
- Special treatment requires consent of Guardianship Tribunal; this is e
xperimental or highly unusual or aversive treatment
- Urgent treatment (ie needed to save someones life, prevent significant
harm to the person s health or distress) does not require consent
- People under the MHA do not need consent regardless of whether or not
they have a Guardian
- People who have capacity to do so have the right to refuse treatment
. if they don t object (ie they give assent)
- non urgent tx = public guardian, responsible person, t
- urgent = no consent req
. if they object (ie do not give assent)
- require tribunal or guardian with specific powers
Responsible person - hierarchy
1. guardian

2. most recent spouse, defacto spouse

3. unpaid carer current or previous
4. relative or friend who has a close personal rship with person
---------------------------------PAAM - Perinatal Mental Illness
Conceptual model for understanding perinatal disorders
The disorders
Gestational depression
Postnatal depression
Postpartum psychosis
Perinatal depression
DSM 5 - peripartum onset - during pregnancy or 4 wk following delivery
Conceptual model for contributors to perinatal mood disorders
- maternal well being
- intimate rships
- social support
Importance of perinatal mood disorders
- predictable risk of hi morbidity for women
- opportunity for detection and intervention bc highest frequency of int
eraction with health professionals
- impact on fetus/infant/family
- peak prevalence of depression and anxiety during child bearing years
- during pregnancy
- post natal
- new onset due to being pregnant, hormonal, psychosocial
- psychosocial factors are predominant cause
. biological - physical, hormonal, fatigue
. psychosocial - changing role and r/ship dynamic, limited time
for self
. socioenvironmental - financial, social network
. intrapsychic - caring for a dependent being, own parenting exp
erience (patterns of neglect and abuse)
The disorders = BPAP = blues, puerperal psychosis, antenatal depression, postnat
al depressio
- The blues
. 70% prevalence
. post partum d 3-5
. sx
- Anxiety Depression Tearfuiness Labilitiy at mood irrit
ability emotionality
. course
- beign/temporary
. causal
- hormonal, stress response
- puerperal psychosis (a variant of bipolar)
. 0.1%
. post partum within 3 wk
. sx
- Psychotic symptoms (deluslons, hallucinations) Manic p
resenta1ion melancholic Indecislveness confusion
- infanticide risk
. course
- severe, +/- admission, remission w tx
. causal
- biological, estrogenic
- antenatal depresion (=gestational depression)

. 10%
. any time
. sx
- Symptoms of major depression, Low mood fatigue worry
. course
- variable
. cause
- relapse of pre-exisiting or denovo due to psychosocial
(stress, sleep disturbance, interrelational disturbance)
- postnatal depression
. 15%
. post partum gradual onset over 6 mo
. types
- most common = non psychotic non-melancholic major depr
. gradual onset 3 mo
. psycho social in origin
- less common = post partum melancholia
. within 4 wk
. clinical picture of melancholia
- early morning waking
- agitation
- psycho motor change
- loss of apetite
- diuranl mood variation
. biological form of depression
. related to decr estrogen after birth
. tx with antedepression or medication or ECT
. probably related to biopolar disorder and is a
RF for later biopolar
. sx = identical to depression as at other time of life cycle
- major depression, anxiety
. course
- gradual onset, possible chronicity
. causes
- mostly psychosocial (r./ship, support)
- dysfunctional personality
. RF for non-psychotic, nonn-melancholic major depression
- early life (genetics, trauma, their own parenting = ne
glect, abuse)
- sociodemographic (young < 16 yr, low SES, marital stat
- social environment (dysfunctional intimate relationshi
p, poor instrumental and emtional support from partner, poor social support)
- internal environment (estrogen sensitivity, personalit
y style, previous depression or anxiety)
. Impact of postnatal depression on the infant
- lower IQ
- lower interpersonal skills
- cognitive and r/ship problems later
Types of social support required
- cultural 40 day rule
- knowledge support from other females
- practical, instrumental support - help with looking after baby and hou
sehold chores; inverse relatinship bw PND and partner baby care
- emotional support
SCREENING = Edinburgh postnatal depression scale EPDS

10 item; score 0-3 for each item

score > 12 indicates major depression
follow up by clinical assessment
need to do it twice bc can get spuriously hi scores first time around

Tx of postnatal depression
- recognise it thru screening
- clarify risk factors and causation - take a history
- psychoeducation - explain to them about PND
- help them to prioritise eg
- necessary = feeding/bathing baby
- unnecessary = ironing
- they want to do = going to hair dresser, talking to friend
- non directive counseling
- CBT, IPT, antidepressant medications (cf breastfeeding)
- antidepressants
. indicated for
- moderate to severe depression
- comorbid panic disorder
- bipolar depression (+mood stabiliser)
- patient preference
. BUT little evdence wrt efficacy
. ? breastmilk effect
Implications of depression during pregnancy
- obstetric outcomes - preterm delivery, low birth weight, small for ges
tational age, gestational hypertension, placental function (steroid metabolism a
ffected in fetus ~CRF incr), developmental delays
Assessment of depression in pregnancy
- somatic sx: fatigue, appetite, wt change, sleep disturbance, change in
- cognition: poor concentration, worthless or guilt.
Risk vs benefits of antidepressants vs no antidepressants in pregnancy
- no antidepressants = doesn t help mum + fetal impact of depression (iq
, cognitive, social) vs no risk of antideprssant exposure
- antidepressants = helps mum BUT risk of infant exposure
Mx - depression in pregnancy
- New onset depression - Determine type and severity of depression >
- Mild-moderate depression
. Psychoeducation . Supportive counseling . CBT or other focused psychological treatment
. Moderate to severe depression
. SSR|s - Lower dose at 36-38 weeks - Liaise with GP / obstetric
team . TCAs for severe, melancholic depression
SSRIs vs pregnancy
- congenital heart defect RR = 2 (balance against background risk of def
ect = 2%)
- persistent pulmonary hypertension + getational htn/pre-eclampsia when
SSRIs after 20 wks gestation (1/1000)
- neonatal abstinence (= poor neonatal adaptation syndrome)(esp paroxeti
ne, venlafaxine)
. insomnia/somnolence
. agitated, jittery, shivering.
. poor feeding

. poor temperature control, hypoglycemia

. tachypnea, respiratory distress
. seizures
- effects

on mother
low matrenal weight gain
preterm delivery
low birth weight
gestational htn

disorders are childbirth

time of highest frequency of psychosis in womans life cycle
sx = delusions, hallucination, manic
new onset - = puerpal psychosis
preexisting bipolar = 50% chance of relapse if unmedicated within 3 w
preexisitng bipolar + post-partum are the most potent RF for psychosis
schizophrenia = gradual relapse within 4 mo

Puerpal psychosis - clinica picture

- within 3 wk post partum
- confusion, perplexity,
- psychotic: delusions, hallucination, disordered though
- mood: depression (melancholic, delusional), mania
- catatonic
Mx - Puerperal psychosis
- it is a psychiatric emergency = should be admitted bc of risk of harm,
- should be admissitted to mother/baby unit to maintain mother/baby r/sh
- WOmen should not be separated ffrom their infants if admitted to hospi
- tx
. 1st generation - antipsychotics, in low dose
. antidepressants
. mood stabilisers esp lithium which has quick effect (BUT breas
tfeeding contraindicated for lithium)
. benzodiazepines for catatonic features
- support for partner
Efects of psychotropic medications on fetus
- TYPICAL antipsychotics
. physical malformation/heart
.. neonatal toxicity, death
. neonatal toxicity, death
- lithium (mood stabiliser)
. physical malformation + neonatal death
- anticonvulsants
. deformities + spinabifida
. behavioural
. neonatal death
. heart/phsyical defect
. neonatal death
. physical defect

- benzo
. physical defect
. neonatal death
Categories of medicines in pregnancy
D, X - fetal dg/deformity - should not be used in pregnancy
Ebsteins anomaly and lithium
- b/g risk = 1/20,000
- w lithium = 1/1000 (RR = 20)
- anomaly
. atrial septal defect
. displaced tricuspid valve allowing blood back into RA
Lithium carbonate - prophylaxis
- avoid in 1st tri
- restart in last 2nd
- reduce dose to 1/3 in late 3rd
. serum 0.2-0.6 mmol/L
- full therapeutic dose 1 d post partum
- no breastfeeding
Drugs with incr risk of neural tube defects
- carbamazepine, valproate
Drugs with incr risk of epsteins anomaly
- lithium
Drugs with incr risk of cleft palate
- lamotrigine
Valproate fetal/infant effects
- neural tube defects (spina bifida)
- lower IQ in fetus
- should not be used in pregnancy women

side effects of ATYPICAL antipsychotics (clozapine, olanzapine, rispir

wt gain
insuline resistance
gestational diabetes

Incr r
---------------------------------PAAM - Internalising Disorders in Childhood and Adolescence
Anxiety disorders in children and adolescents
- F > M
- overall risk = 20% by time of 18 yr
- hi rates of comorbidity
- anxiety can be causal, or associated with, or resulted from other cond
itions eg substance use disorder
Anxiety disorders
- characterised by feelings of anxiety and fear, out of keeping with act
ual threat; worry about future events; phsyical sx of racing heart and shakiness
- subtypes
. Generalised anxiety disorder GAD
. social anxiety disorder SAD
. specific phobias (eg spiders)
. separation anxiety (esp in children)
. panic disorder
. agoraphobia

- PTSD is

Obsessive compulsive disorder

in its own category outside of anxieyt disorder
early attachment
traumatic incidents (war, environmental disasters), life event

. social adversity/financial impacting on parents capacityto hel
p with child fears and worries
- i/v child, as well as family
- devl + pediatric hx
- guided by formulation + comorbidities
- tx underlying medical disorders (refer to pediatrician, GP)
- address family dynamics, school concerns
- psycholigcal therapies
. behavioural approach
. graded appr for specific phobias
. family therapies
- pharmacological
. as part of the holistic approach
. SSRIs at low dose (fluoxetine, fluvoxamine, sertraline)
. some anti-d may WORSEN anxiety eg venlafaxine, other worsening
meds eg steroids, ventolin
. short term anxiolytics NOT RECOMMENDED eg BZPs
. quietiapine as adjunct
. Olanzapine and Risperidone NOT RECOMMENDED due to poor effect
and SE
Depression in adolescents + children
- epi
. 10% by yr 18
. F > M
- different presentation to adult depresion
. DSM-5: depressed or sad or irritable
. depending on age
- primary school - less verbal in expressing sx of low m
ood; mostly a behvaioural assessment
- adolescent - less common to have sustained or consiste
nt low mood; more common to have alternating with mood changes
- Sx
. low mood
. irritable, aggreession,
. insomnia, low appetite, lethargy
. anhedonia, social withdrawal
. reduced motivation
. poor concentration, memory issues
. deliberate self harm
- suicide in children and adolescent
. 25% of all deaths 15-19 yr
. unlike adult suicides, F>M
- assessment
. wholistic approach
. i/v with child - cntributing factors

. i/v with family - identify social withdrawal, loss of interest

. other sources, GPs, schools
. DASS rating scale (depression, anxiety, stress scale for 14-18
. use child depression inventory for younger age group
- Mx
. psychological therapy
- CBT . cogntivie therapy (thinking)
. behavioural component (behaviours that are unh
elpful or worsens)
- IPT interpersonal therapy
. time limited psychodynamically informed
. focused on interpersonal/peer r/ship eg bw fri
ends or family members
. short term family therapy (marital discord)
. psychodynamic (rare)
. pharmacological
. fluoxetine, fluvoxamine (best evidence, TADS s
tudy = hi efficacy and response)
. AVOID paroxetine (incr suicide risk based on m
- non SSRI antdepressants (venlafaxine)
- tricyclics not recommended in children (whereas they a
re common in adults) - poor efficacy and SE
anxiety how would you go about appraising and addressing co-morbidity in a clie
nt referred for anxiety?
- clinical PC
- empathic/lengthy i/v - whether primary anxiety or related or caused by
other condition eg ADHD or medical condition
- i/v family, school - to get deeper understanding about comorbidity
- look at pediatric early developmental notes/letters
- input from OT, PT
depression what family factors, both from the assessment and in the history, mi
ght be important in establishing a tx. plan ?
- look at family hx which may indicates hx of mental illness or depressi
on in another memeber of family ie genetic RF
- dynamics and r/ships of family as key stressors, triggers, or sources
of support for chidl in developing mx plan
- assess wholistic family - cultural, religious, their conception of men
tal illness - to develop shared agender, therapeutic alliance - to make sure you
share what the issue is to develop what the issue and what the solution will be
anxiety how would you go about assessing and formulating a case of a primary-sc
hool age school refuser?
- empathic and wholistic i/v of child and family + broader historical de
tails in impt
- school refusal is not a dx in itself - an endpoint behaviour - typical
in kindergardten, yr 1/2
- range of underlying mental health or family psychosocial factors under
- eg is it primary anxiety disorder, or depression, or consequence of st
ressors in family, or post-natal depression problem resulting in attachment prob
depression- having established a diagnosis of depression in a teen, how would y

ou appraise the tx plan if the condition did not improve, or began to worsen?
- first thing to do is go back to re-assess situation, looking for addit
ional things you should be doing, more thorough assessment of familya nd child,
re-interview child/family, reconsider formulation - for factors/triggers identif
ied - the idea taht you have developed; determine how shared the formulation is
with the child or family
- vs tx - reconsider domains - therapy, family, school, medication based
- most likely CBT, how the rapport is with the therapist (typical proble
m in teenagers t/f change clinician)
- family work - what factors not addressed - family therapy
- meds - try a second antidepressant or change class
- biological ix eg cytochrome metabolism
beyong blue webiste
blackdog website
---------------------------------PAAM - Externalising Disorders in Childhood and Adolescence
Common externalising disorders
- Attention de cit hyperactivity disorder (ADHD) - 5% of childrehn
- Oppositional de ant disorder (ODD) - 4%
- Conduct disorder (CD) - 4%
- more common is males then female
Do they grow out of it?
- not always
- many adults manifest ODD
- CD morphs into antisocial personality disorder
- main features
. Inattention
. Problems regulating activity
. Impulsive behaviour
- sx are clinically significant IF
. Age inappropriate
. Maladaptive
. Commence before age 12 years
. Lead to signi cant impairment in two or more settings
- subtype
. combined
. predominant inattentive
. predominant hyperactive/impulsive
- WHY DO THESE CHILDREN PRESENT TO CLINIC ie - common problems associate
d with ADHD in children and why they present
. Non-compliant behaviour
. Sleep disturbance
. Aggression
. Temper tantrums
. Literacy and other learning problems
. Motor tics
. Mood swings
. Unpopularily with peers
. Clunulsincss
. Immature language
- Typical comorbid disorders
. CD

. mood, anxiety, learning


genetics is the cause of up to 70%

perinatal - hypoxia, maternal smoking, alcohol, heroin
toxins - lead
acquired brain injury
specific disorders - NF1
delayed cortical maturation
delayed cortical thinning


agry/irritable mood
argumentative/defiant behavior, or
lasting at lease 6 mo and not just directed to siblings
. Lose temper. touchy. angrylresenlful
. Argue with adults
. Non-compliant
. Annoy others
. Blame others for their misdemeanours
. Spitefull / vindictive
- pattern varies w age
. < 5 yr = every day
. > 5 yr = at least once per week
. genetic - MOA transporter gene (deficiency in MOA transporter)
. perinatal
. toxins - lead through cognitive impairment causing the problem
. psychosocial
- parenting sytle / maltreatment
- social adversity
- modelled behavoir
. best evidence pointing to combination of MOA transporter gene
mutation + maltreatment being required to produce the disorder, neither one alon
e sufficient.
. amygdala damage - (callous unemotional traits)
What is the difference bw these and normal child behaviours
- they cause significant impairment in function
- repeititve, reoccurent
- causes problmes at home or school
Conduct disorder = more malignant probelm
- persistent pattern of behaviour in which rights or other or age approp
riate sociatetal norms are violated
- onset in childhood or adolescent
- typically precededed by ODD
- Sx
. aggressive to peopoe and animals
. destruction of property
. deceitful
. theft
. abscond
- subtype
. childhood onset
. adolescent onset
- ETI - same as for ODD

Why more common in males

- ratio is 10: 1
- probably bc girls fly under radar bc they have the inattentive type an
d only in puberty or adolescence are the detected
to mental

normality ie age appropriate high spiritedness, or inattention

intellectual delay, specific learning disability (low IQ will perform
age not biological age)
overlapping of the 3 disorders
mood disorder (incl bipolar), anxiety disorder
autistic spectrum
reaction to neglect or abuse
personality disorder


genetics is the cause of up to 70%

perinatal - hypoxia, maternal smoking, alcohol, heroin
toxins - lead
acquired brain injury
specific disorders - NF1

Psychosocial factors contributing to disorder development

Eary childhood
- materal smoking in antenata period > 1/2 packet / day
- low maternal age
- low parental supervision
- harsh disciplie
Middle childhood
- parenting style (coercive, inconsistent, uncomitted, reacting
with temperatment of child)
- abuse and neglect
- school characteristic (absence of leadership, inconsistent dis
- neighborhood influence
- school
- neighborhood
- peer influence amplifying deviant behaviour and incr exposure
to other pathogenic influences eg substance misuse and early sexual experience
- Hx parent, shild, teacher
- behavioural checklists form eg Connor questionairre from school
- education, psychonmetric
- physical ex to rule out medical causes
- inx eeg, sleep study
- ADHD is a clinical diagnosese
- psycho educatoin
- advocacy by clinician, to get right education eg remedial education
- psychosocial management (more efective for ODD/CD and anxious comorbid
ities then ADHD)
- parent behaviour training

- Adolescents - family therapy

- pharmacotherapy
. 1st line = psychostimulants (methylphenidate, dexamphetamine)
. 2nd line = atomoxetine (takes longer for efficacy)
- ODD/CD targeting aggression symptoms
. 1st line - clonidine, fluoxetine
. 2nd line - risperidone (SE - weight gain, metabolic)
- Diet factors ?
. only in some individuals does food colouring or sugar
. but at population levels - no indication that it contributes
Natural history
- behaviours go from overt to covert
- overt behaviours of early presentation
. Disobedient Cheeky Blame others Brags Shows off Irritable. c
ruel Loud Temper tantrums Demanding Stubborn
- covert behaviours of older children = consequences of behaviour rather
then the behaviour itself
. Lies Destructive Steals Set res Bad companions Truants Runs
away In a gang Substance abuse
- progression of problems to delinquency, substance misuse
. ADHD -> overt ODD -> covert CD - > delinquency or susbtance ab
- progression of problems to mood distrubance
. ADHD -> overt ODD -> anxiety, CD, or early depression -> later
Adults with ADHD and propensity for MVA
- greater risk of MVA assoc
Performance in workplace vs ADHD
- more likely to be in workplace accident
- absenteeism
- sick days
- poorer performance.
---------------------------------PAAM - Delirium
- A psychiatric syndrome characterised by a TRANSIET disorganisation of
a wide range of cognitive functions due to a widespread derangement of cerebral
- [ also called = acute organic brain syndrome, acute confusional state,
acute organic reaction, toxic psychosis, exogenous psychosis, Confusion]

deficit of ATTENTION
FLUCTUATING level of arousal and severity
REVERSAL of sleep wake cycle (awake in night, asleep during day)
onset = hours/days
labile affect

- 4 components


AROUSAL (responsive, awake)

SUSTAINED attention
DIVIDED attention (ability to respond to more than one task at once)
SELECTIVE attention (concentration) - highlight one stimulus whilst su
awareness of others

MMSE related to delerium

- orientation
- short term memory (attention)
- concentration (serial 7 s, or WORLD backwards)]
- clock drawing (frontal lobe executive functions, parietal lobe spatial
awareness, occipital lobes (optic fields)
. dysphasia (comprehensive, experssive
. dysgraphia, speech
. construction apraxia
Cognitive testing for delirium
- BACKWARDS impt - months
- cannot maintain thread of conversation
- temporal sequencing of history
Orientation to time
- time of day
- how many days have you been in hospital for
Memory registration, orientation, concentation
Psychotic sx of delirium
- Hallucinations - usually visual (schizophrenic hallucinations are usua
lly misperceptions or illusion)
- brief, simple, environmentally based
- secondary delusions based on hallucinations eg I see my mother - based
on that I must be in the village
- persecutory delusions result from disorientation, poor memory and atte
- thought form : illogical, poverty
Importance of fluctuating course
- behaviour and sleep charts are helpful
- BUT they are best in morning, worst at night
- within an hour can be confused, drwosy, alert, orientated
DSM 5 criterion for delirium
- distrubance in attention (cannot direct, focus, sustain, shift attenti
on) + reduced awarenes
- onset over short period of time (hours, days) + fluctating course
- an additional disturbance in cognition (eg memory deficity, disorienta
tion, language, visuospatial ability, or perception)
- not explained by preexisintg neurocognitive disorder such as dementia
and does not occur in context of reduced arousal eg coma
- evidence that the disturbance is a direct phsiological consequence of
a medical condition, substance intoxication, withdrawal or toxin exposure
Types of delirium (DSM 5)
- hypoactive, hyperactive, mixed
- mixed = most common
- hypoactive - lethargic, drosy, no mobile; risk od dehydration, PE, red
uced mobility, bedsores, early discharge
- hyperactive - aggressive, combative, non-cooperative; risk of injury f
rom aggression, restraints, over sedation


1% people
25% acute hospital admission
50% post operative elderly
90% ICU elderly pt

Non modifiable RFs

- dementia or cognitive impairment (eg bipolar, developmental delay)
- age > 65
- hx of delirium, stroke, neuro dz, falls, gait disorder
- comorbidities
- male
- chronic renal/hepatic dz (electrolyte imbalance)
Modifiabke RF
- sensory deficity (hearing, vision)
- immobilisation (catheters, restraints)
- Medications (sedative hypnotics, narcotics, anticholinergics, corticos
teroids, withdrawal etoh)
- neurological dz (stroke, intracranial hemorrhage, meningitis)
- intercurrent illness (UTI, anaemia, dehydration, malnutrition, fractur
e, HIV)
- metabolic
- surgery
- environment
- pain
- sleep deprivation
- usually 3 things acting together leading to neurotransmitter imbalance
- 1. hypoxia or metabolic derangement -> impaired cerebal metabo
lism -> decr synth and releas of neurotransmitters -> neurotransmitter imbalance
= disurption of synaptic communication -> delirium
- 2. drugs -> neurotransmitter imbalance as above
- 3. systemic inflammation -> activaton of microglia -> incr cyt
okines in brain - > neurotransmitter imbalance as above
- Neurotransmitter imbalance responsible = AChe decr, DA incr
- cholinergic def
. anticholinergic drugs can cause it
. delerium reversed by cholinesterase inhibitors eg phyo
- dopamine incr
. anti parkinsons drugs cause derlium
. haloperidol used to tx
- typical medical disorder
. metabolic = main one
. metabolic disorder carcinoma infection neurological disorde
r inflammation pain dehydration (and constipation) malnutrition urinary reten
tion sensory impairment drug effects (and interactions) drug/alcohol withdrawa
l syndromes
What are the common ways derlium pt are referred to psychiatry
- psychosis/halluncations + UTI
How do I tell if someone has a co-morbid dementia
- deviation from baseline
- fluctuating
- sleep wake cycle reversal vs sundowning (dementia)
- poor concentration (derlium) vs memory tasks (dementia)

- nature of psychotic sx
How do I tell if someone has a comorbid psychotic illness
- SUDDEN deviation from baseline
- fluctuating arousal
- psychosis has deficit in frontal lobe and executive fn
- delerium has deficit in attention
Why is delerium such a big deal
- incr length of stay and institutionalisation
- twice as high costs of care
- reduced subsequent functional status (not easily reversible; change is
sudden vs dementia which has protracted decline)
- 62 % chance of dying in next year
Tx derlium
0. Non pharmacological intervention is the best treatment and prevention
. Medication is only used when behaviour is placing patient or others at risk of
physical injury or impacting on the patients health care
1. treat medical causs
2. non pharm = best tx and prevention
- reduce environmental stimulation (single room, low light, redu
ce staff changes)
- tx pain
- reorientate - repeat what day and why in hospital
- avoid restraints
- frequent turning to avoid bed sores, active physio for mobilis
int, DVT prophylaxis
- Chart sleep, behaviour, food, fluid
3. NEVER use benzodiazepines
- only for etoh r benzo withdrawal
4. AVOID antipsychotics
- until behavoural disturbance impacting on treatment or recover
5. Haloperidol
- most often used bc many admin routes
6. Quetiapine
- BEST bc can titrate dose (low potency)
- less extrapyramidal SE, so better for those with Parkinsons
- other = olanzapine, risperidone
Nb - med
- avoid polypharmacy
- hydration, nutrition
- pain relief
- correct sensory def
- early mobilisation

---------------------------------PAAM - Overlap of Physical and Psychiatric Illness

Multi-somatoform disorder: => 3 medically unexplained sx
- at least 2 yr duration
- 8% prevalence
- 1/5 nwe illnesses satisfy criterion for somatization

Epi of psychological syndromes in hospital

- 50% pt have psych disorder (as well as their medical disorder)
- 15% of pt have organic mental disorder (delirium or dementia)
- rates esp hi in specialised units eg HIV, oncology, renal
- somatisation/unexplained sx = functional diagnosis
- GIT - 50% have functional dx is IBS
- neuro - 50% have functional dx ie dizzy
- cardiac - 35% have functional ie chest pain
Medical disorders that produce psych syndrome or complicate treatment of psych d
Primary psych disorder that present somatically or alter course of physical illn
- depression, anxiety, substance use
Medical illnesses most commonly assoc with depression
- cancer (pancreatic, bowel. lymphoma),
stroke (frontal),
endocrinopathy (hypothyr,
estrogen withdrawal/tamoxifen),
viral, (EBV< hepatiis, influenza, HIV, CMV)
pernicious anaemia,
collagen dz
Medications assoc with depression
- Corticosteroids > 10 mg prednisone, > 40 mg causes mania
- Interferon - esp suicidal thinking and depression (hep C pt need to be
- Indomethacin
- Levodopa
- Cimetidine
- Antihypertensives (propanolol)
- narcotic analgesics
- Chemotherapeutic agents (procarbazine, vinca alkaloids)
- Amphotericin B
- Psychostimulants (amphetamines used at least once per week or cocaine
used chronically or in withdrawal)
Dx of depression in medically ill person
- Exclusive Dx criterion = don t count the physical sx toward the diagno
sis unless grossly disproportionate to stage of dx eg. pt has CD4 < 600, fatigue
d - he should not be fatigued bc of illness - especially if diurnal change .
. weight loss
. fatigue
. poor sleep
. miserbale feeling
. feeling of burden to others
- insttead emphasise cognitive sx esp anhedonia
. guilt, worthlessness, loss of reactivity of mood, diurnal vari
ation of mood or sx, anhedonia
- if in doubt trial tx
Organic disorders simulating anxiety syndromes

. arrhthmyias
. mitral valve prolapse
. myocarditis
. chronic airflow limitation
. Pulm embolism
. tia
. essential tremor
. myasthenia gravis
. thyrotoxicosis
. decr BSL
. adreno-cortical insuff
. caffein, amphetamines, sympathomimetics
etoh, benzo, barbituate withdrawal

Organic disorders simulating functional psychosis

- Alcohol hallucinosis or withdrawal
- Intoxication (organo- phosphates, LSD amphetamines)
- Drugs esp. in toxicity (corticosteroids digitalis, L-Dopa, atropine an
d other anticholinergics)
- Cerebral syphilis
- Hypothyroidism
- H IV
- Encephalitis
- Cerebral neoplasm
- CNS degenerative diseases (Picks, Huntingtons)
Use of Psychotropic medication in medical illness
- use lower doses, esp in elderly, start slowly
- interactions with CYP liver system
- SSRIs - care with sitalopram, sertraline, fluoxetine
- renal fn - use lower dose of lithium, mirtazapine
- low albumin - care bc most are albumin/protien bound - if you ve got l
ow albumin, then you have more free drug causing toxicity
- on a protease inhibitor - don t use sertraline due to interactions
- meclovamide and mirtazapine is usually ok wrt interactions
- tricyclics adn atypicals - cause arrhythmia in overdose
- ssris and antipsychotics - lower seizure threshold and cause seizure
- benzos - cause respiratory depression (risk in context of respiratory
Primary psychological disorders that present somatically
- OLD DEFINITION = if you have psychic distress and you don t express it
- you express is through physical symptoms
- NEW DEFINITION = a tendency to experience, conceptualise and communic
ate mental state and distress as physical sx or complaints of altered bodily fn"
. eg if you grew up in family where no one ever complained but s
aid i ve got a headache , then yuo are more likely to exhibit somatization
- soamtic sx are more comon presentaiton of psychic distress
- it is a cultural construct eg nervous exhaustion
Somatization in primary care
- anxiety and depression most commonly present somatically eg chest pain

in panic, fatigue in depression

. higher the anxiety, the more sx present
. screen for sleep disturbance, loss of interest in depression
. exclude D+A withdrawal
Somatization vs abnormal illness behaviour
- illness behaviour = the way in which an individual rsponsds or do not
respond to an illness or to a symptom
. how you deal with an illness eg someone who sits in emergency
for 3 hr
- abnormal illness behaviour overlaps with somatisation
- abn illness behaviour - maladaptive/inappririate mode of experiencing/
evaluating/acting to your state of health despite being given correct info about
the condition by the doctor based on examination, history and investigation
- the key difference is the attribution ie explanation of fatigue eg I m
tired and stressed VERSUS I have chronic fatigue syndrome ie label of an illnes
- people who label themselves as ill are more disable socially and occup
ationally, bc they spend all their time going to Drs etc
Mx - acute vs chronic somatizers
- ACUTE (first time)
. discuss with them to assert reatribution of symptoms to the di
. most resolve over time
. see themselves as ill and not amenable to change
. almost all have abn illness behaviour and make demands on medi
cal servies
. can contain
. usually limited by iatrogenic illness eg hysterectomy
. psychiatric referral
---------------------------------PAAM - Eating Disorders - better to check textbook for Anorexia disorder
EPI anorexia nervosa
- 3rd most common chronic in girls
- 1/200 girls
- Girls aged 15 - 19 (0.5%)
- More younger patients 8 -14
- More boys in younger age groups 1/3 versus older 1/10
- Duration = 5 years +
- Mortalitylchronicity rate = 20% in 20 years (1/5)
- least common of all eating disorders
DDX eating disorders - anorexia and selective eating and picky eating are the ma
in things
- ARFID Avoidant Restrictive Food Intake Disorder
- Food refusal (children & adolescents)
- Pervasive refusal (C&A)
- Selective eating, picky eaters
- Bulimia nervosa, OSFED (otherwise specified feeding and eating disorde
r = dx criteria for bulemia or anorexia is not met), BED (binge eating disorder
- binge eating without purging)
- loss of appetite due to depression
- Other psychiatric, medical or surgical disorder
- Pica + or assoc with developmental Disability
DSM-5 or ICD11
- Anorexia = BMI < 18.5

- Bulemia = normal body weight or higher + bingeing and purgining at lea

st 2/week over 3mo period
- Anorexia ~1% population
- Bulemia - 2%
- EDNOS eating disorder not otherwise specified (= OSFED) = 10%
- binge eating disorder 10% (esp obese population)
- obese (25%)
- other ED 20% (food restriction, dieting, over exercising etc)
- sudden incr in anorexia during 60 s (twiggy model effect) - incrs in 7
0 s and has remained high - probably plateaued due to combiation of metabolic, g
enetic factors required for the disorder
What is an eating disorder
- Psychological/Psychiatric body dissatisfactn. drive for thinness, preo
ccupatns re wt shape food. low SE. depression. anxiety
- Behavioural weight losing behaviours eg restrictn, over exercise. Purg
ation (laxative, vomiting), binge eating
- Medical/Physiological uids (dehydration), temp. (decr) CVS/ANS downregu
latn (low HR, low BP), electrolytes. blood (aneamia + low wcc due to BM suppress
ion). oral. skin. hair, endocrine (eg amenorrhea). bone. growth/ pubertal delay.
brain changes (loss of white and grey matter esp frontal lobes)
ANOREXIA NERVOSA relentless pursuit of thinness
BULIMIA NERVOSA the body fights back
EDNOS/OSFED on the way to AN or BN
BED self perpetuating obesity
Causes of eating disorders
- epigenetic (eg mother is anorexic; if pregnant lady is restrictive, th
en low metabolism child results)
- genetic
- society + social media
- puberty (dissatisfaction with weight gain)
- trauma (sexual, physical)
- change
- loss/grief
- physical illness
Med, Surg ddx for anorexia
- Chronic viral illness (Inf Mono/EBV, Hepatitis. CMV)
- Neoplastic illness
- In ammatory bowel disease
- Malabsorption syndromes (coeliac disease)
- Thyroid disease (hyper/hypo sick euthyroid )
- Mesenteric artery syndrome = lost fat pad and mesentery bw aorta and
ceoliac plexus and 2nd part of duodenum cuasing pressure/pain after meals.
- Chronic fatigue syndrome
Comorbid associations with anorexia
- depression
- anxiety disorders exp OCD and PTSD
- autisic spectrum disorder (20% of anorexia pt)
- body dysmorphic disorder (a facet of anorexia itself)
- personality disorders/derailment (do not develop emotional maturity)
- somatoform dis r incl munchausens
- schizophrenia
- addictions

- organic brain syndromes

- chronic illnees
Anorexia - Special features in younger patients
- dehydration, ketosis
- hypoglycemic
- growth retardation
- osteoporosis/osteopenia
- delayed puberty, stunting
- brain changes
- sudden death
Anorexia - older
- A - adaptive
- B - brains, bones/osteopenia, babies
- C - comorbidities and compulsory tx (mental health act)
- D - diagnosis (chronic, tardive (20 s), palliative, medically ill)
- E - eventual goals
Treatment principles
- intervention ASAP
- medical and psych stabilisation (getting some control on their behavio
ur to contain them - for nourishment - may be to admit them and then do the psyc
- behavioural management, containment
- nutritional rehab
- psychotherpay
- structure supportive milieu
- multidisciplinary program including medication
- family friendly setting
- developmentally appropriate (in teenagers - they need to be in supervi
sed location)
Indications for hospitalisation in anorexia
- LACK OF PROGRESS as outpatient
- Major medical problems - collapse, cardiac arrhythimias
- Vomiting persistant or blood
- Refeeding syndrome (RFS)
- Psychiatric or medical problem
- Crisis
- Family dysfunction
- Preference
Eating disorders are biologically based serious mental illnesses
- A condition that current medical science af rms is caused by a neurobiolo
gical disorder of the brain, signi cantly impairs cognitive function. judgment and
emotional stability. and limits the life activities of the person with the ill
MARSIPAN - management of really sick patients with anorexia nervosa
Whats diferent abour eating disorders
- relucatance to engage or lose symptoms (due to genetics, denial, perve
rse energy)
- treatment ambivalence/sabotage (they are still wishing to lose weight)
- and when they do attain the set point they haven t resolved the problem and a
re still unhappy, so they continue to lose weight)
- disagreeable patients (fathers who aren t supportive and make negative
- highest mortality rate of any psychiatric disordeer

- developmental and social issues

Frequent complaint

- don t feel sick

- I m not sick enough (vulnerable person
ality disorder patients - competitive/need to have attention)
- rule rather then exception
Child/adolescent presentation
- Weight loss, food refusal, XS exercise
- Dehydration ketosis halitosis
- Syncope/collapse hypotension
- Standing BP down >20mmHg
- Standing PR up >20bpm
- Bradycardia STI T wave changes.
- Delayed puberty
- Stunted growth (check bone density)
Adult presentations
- concern of others
- menstrual disturbance, infertility, PCOS
- low libido, erectile/ejacultatory failure
- dysparaeunia, atrophic vaginitis, pelvic floor
- cold fatigue, raynauds, sleep dist
- fractures
- emaciation/collapse
- fluid and electrolyte problems
Other Hx

hasty trips to bathroom
chewing gum
laxative packets
diet coke
avoidance of meals
academic success then problems
mood swings
blocked drains

- Sudden death, hypoK, hypothermia, dehydration, hypoglycemia, hypothyro
idism (do not treat with thyroxine)
- Cardiac failure, arrhythmias (altered HRV)
- Pancytopenia (bone marrow suppression - reversible - infection can be
missed bc of overlying hypothermia)
- Brain/cognitive changes, peripheral neuropathy (eg foot drop)
- Immune suppression, major infection
- Osteoporosis and infertility
- Dental decay (bulimia, parotid swelling), sialadenosis
- Upper GIT, constipation (low intake), rectal prolapse
- Renal failure, secondary diabetes insipidus, hyperaldosteronism
- Skin, hair, eyes. ENT, body odour (laxatives, ketotic breath), oedema
Psychatric complications
- psychosis
- depression

anxiety ocd
autistic spectrum
personality derailment
substance abuse
dsh somatisation suicide
duty of care
compulsory treatment

Does anyone get better

- Anorexia - 80% get to weight with comorbidities; 50% full recover
- bulimia - 70% asymptomatic
- OSFED - depends on similarity to AN or BN
- BED prognosis is determined by the complications of obesity
- mortality rate 20 yr AN survival
- OSFED - similar to AN

things to note
rapiditiy of weight loss
duration of semi-starvation
extent of starvation
highest weight they were, Lowest weight they were
purging behaviuor
fluid intake incl caffein and alcohol
chewing and then spitting rather then swallowing

Risk assessment in anorexia nervosa

1.Body mass index: weight (kg)/height2 (m2)
. anorexia <17.5
. medium risk 13-15 (hi risk of refeeding)
. high risk <13
2.Physical examination:
. low pulse (tachy on standing), blood pressure and core tempera
. muscle power reduced
. Sit upSquat-Stand (SUSS) test
3.Blood tests:
. sodium low: suspect water loading (<125mmol/L high risk)
. potassium low: vomiting or laxative abuse (<3mmolll high risk)
Note: low sodium and potassium can occur in malnutrition with or
without water loading or purging
. raised transaminases
. hypoglycaemia blood glucose <3mmo|I| (if present. suspect occu
lt infection, especially with low albumin or raised c-reactive protein)
4. ECG:
. bradycardia,
. raised QTc(>450 ms)
. hypokalaemic changes
Metabolism changes in AN ??? need to read around this
- Vicious cycle of anorexia nervosa
- Critical weight
- Metabolic impediments to weight gain
- metabolic rate incr when low in weight
- DIT PPY PP non suppressed fat oxidation
- Stress NPY and abdominal fat
- Fear/anxiety and AN (amygdala)
- Choline ACC ? Autocannabalisation
- Neurocognitive changes (myeline breakdown for fat for metabolism)

In AN - avoid 5% dextrose for hypoglycemia

Tx nutrition in AN
- Energy = 130% of REE + EXERCISE =XTRA DIT ?repair
- Avoid high CHO 40 -50% of energy only
- Adequate protein 20-30% of energy
- Adequate fat 20-30% of energy
- Usual supplements: Ensure, Ensure Plus, Fortisip, Osmolyte, - Fibresource, Twocal, Resource
- Electrolytes vitamins and minerals eg vit B1, phosphate Mg Zn, B-comp
lex, Ca, Fe,
- Fluids 30-35m|s/kg per day + electrolytes as needed 1/2 NS for rehydra
tion + oral or NG feeds
nb B1 protects against delerium
phosphate protects against cardiac pain
General practice
- The patient hasn t been eating anything
- Encourage half cup MILK 2-3 hourly
- Family or friends to help
- Multivitamins B1
- Blood tests ECG Check phosphate ?rep|ace
- Keep warm no exercise
- Consider - Insurance status Hospital
- Mental health act or Guardianship or press on as O/P

Can be lethal
CCF, chest pain, MVP, QTC > 470ms
Delirium ?Wernickes encephalopathy
Beri beri (wet and dry) ie B1 de ciency
Peripheral oedema (insulin, sodium, protein)
Putative cause = hypophosphatemia
Adaptation to uid depletion and low intake
HRV (heart rate variability), arrhythmias

Who is at risk of refeeding syndrome

- bariatric surgeyr, low weight people
Extreme risk of refeeding syndrome
- Anorexia nervosa
- mainutrition - Less than 500kcal per day for more than a week - BMI <
- Rapid weight loss of >1kg per week for last 3 months
- Prolonged QTc interva|(> 450ms)
- Patients with low levels of potassium, phosphate and magnesium - Be ca
reful if dehydrated - Volume depletion - High carbohydrate intake - Low prealbu
Prophylactic supplementation to avoid refeeding syndrome
- electrolytes (potassium, phosphate, magnesium)
- multivitamin, zinc
- thiamine
- slow reintro of feeding
Nrutional rehab
- stead, medically supervised
- renutrition

wt restoration
therapeutic age appropriate millieu
PT and psychotherapy
social integraiton
dischrage planning

future tx
Medications FLX OLZ quetiapine topirimate
Heating Jackets
Mandometer W
Opioid antagonists
EBM tx
- family based counselling
---------------------------------PAAM - Psychiatry of Old Age
- > 65 yr: 2012-61 - 14%->24% (11 mil)
- > 85 yr: 2007-61 - 2-6% (3 mil)
- median age: 2012-61 - 38-46 yr
- # people working age: 2002-42 - 5->2.5
Prevalence of mental disorders in old age
- organic
. dementia 10%
. delerium 2%
- major depression 2.5%
- mania 0.5%
- schizo 2%
- anxiety 4%
- alcoholism 3%
- personality disorders
Higher rates of mental disorder in residential care or hospital: dementia, depre
ssion, delirium
Elderly people have lower prevalence of mental disorders
Location of assessmnet
- home, residence, outpt, inpt
- carers will be present
- home: look at medications, compliance issues
- functional illness, memory clinics
Risk assessment
- wandering, judgement, gas/taps off, driving, neglect, abuse?, suicidal
- murder, aggression, disinhibited, poor driving, gas
Cognitive fn on 1st interview
- screening tests: MMSE or RUDAD, clock drawing test
. impacted by age, educational, lanuage
. doesn t test frontal lobe/executive fn

. tests mostly attention and short term ememory

. limited language and visuospatial ability
. cannot pick up mild cognitive impairment, frontal and subcorti
cal pathology
. mild demetia is < 21
- RUDAS rowlands universal demental assessment scale
. not influence by language or education
. tests executive fn
. < 23 = cognitive impairment
. 1. memory - shopping list
. 2. visuospatial orientation (show me ur right foot, left hand)
. 3. praxis - copy exercise of alternating hand movement
. 4. visuoconstruction - drawing
. 5. judgement - crossing road safely where no crossing
. 6. remember shopping lsit
. 7. word generation how many different animals a person can thi
nk of
1. Understand the facts and choices involved
2. Weigh up the consequences
3. Communicate their decision
- NSW capacity tool kit
- hierarchy of personl responsible
. Enduring Guardian with the appropriate powers
. Spouse or de facto with a close and continuing relationship
. A person who arranges care regulariy who is unpaid
. Close friend of relative
. If none available - application to the Guardianship Division N
Consent for treatment
- Urgent = no consent required
. (save life, prevent injury, alleviate/prevent pain/distress)
- major treatment but not urgent = no objection from person responsible
. general aneasthetic
. meds for CNS (ie psychotropics eg for person with dementia for
. long acting injectable hormones
. to eliminate menstruation
. testing for HIV
. which has a substantial risk
. dental removal of teeth or that affects cheweing
- minor treattment = person responsible OR if not available , no conset
. GA for fractured/dislocated limbs or endoscopes
. CNS medications
- Analgesic. antipyretic. antiparkinsonian. antiemetic.
anticonvulsant PRN not more than three times per month Sedation for minor proce
dures When used only once
- special tx = guardianship division NCAT
. sterilisation
. drugs of addction for > 30 d
. androgens for behaviour control
. off label CNS medicatons
- IF person or person responsible objects = guardianship division NCAT
- sx exacerbated by drugs
. confusion, anxiety, psychosis

. change meds
. compliance
- use dosette box
- supervision if cognitively impaired
- allergies
Functional assessment
- ADLs - how much assistance, hygiene, continence, dressing, eating
- necessities - finance, home appliances, drive, organise medicines
Environmentla assessment
- house - safety ?
- neighborhood
- financial
- services/transport
- home support

carer stress
formal services

Elder abuse
- repeated acts against or failure to act for older person causing distr
ess, dg
- 4 % older people
- drug interactions
- SE
. tardive dyskinesia with anti-psychotics (irreversible mvoement
. deliriium with anticholinergics
. postural hypotension
. icnr risk of cerebrovascular accident in those prescribed anti
psychotic medications
- start low and go slow
- absorption
. decr oral absorption
- distribution
. incr in fat mass
. plasma binding
- metabolism
. induction or inhibition of CYP450
- excretion
. renal impairment - lithium, aim for lower serum lithium levels
Psychological treatments
- indications
. 1st line tx for disorder
. their preference
. to help distressed care giver
. releive psychological problems assoc with ageing
Mwhat causes behaviour problems in people with dementia
- deliirum

substance abuse
executive impairment/frontal lobes
psychotic disorders
personality disorder

- progressive neuro degeneration
. cognitive, psych, behavioural, personality factors
- depression common
Cognitive impairment in dementia
- affects higher cortical fn eg emmory, planning
Psych sx in dementia
- depression (commonest and earlist)
- anxiety, paranoia, hallucinations, delusions, disinhibitio, theft, apa
BPSD Behavioural and psychological symptoms of dementia
- sx of disturbed perception, thought content, mood or behaviour frequen
tly occuring in pt with dementia
- 3 sx clusters: agitation, psychosis, mood disturbance
BPSD - agitation
- wandering
- purposeless activity (hoarding, rummaging thru possessions, restlessne
ss, pacing)
- verbal aggression or persistent screaming
- physical aggression (scratching, biting, pushing, spitting)
- sexual disinhibition
BPSD - psychosis
- delusions (persecutory, spousal infidelity, abandoned by family, posse
ssion being stolen, intruders, decesased relatives still alive)
- hallucinations (usually visual, people on TV are real, reflection in m
irror not real)
BPSD - mood disturbance
- apathy (loss of initiative and motivation - change to frontal lobe/exe
cutive fn)
- depression
- fear and anxiety of upcoming events - esp with change in routine
- mood lability
Epi of BPSD
- alzheimer, vascualr dementia, FTD: up to 85% show BPSD
- higher in dementia with lewy bodies
- ~50% pt in residential care have BPSD
BPSD - natural history
- sx usually persist but may fluctate
- worse at evening (sundowning), meal times, dressing, undressing, toile
ting, when things are being done to the person
- depression and hallucinations may resolve
- agigation more likely to persist
Triggers of BPSD
1. Biological

- infections - pneumonia, UTI

- meds - benzos, anticholinergics, antiparkinsonians
- pain
- constipation
- urinary retention
- dehydration
- akathisia with antipsychotic medication (motor restlessness)
- sleep deprivation
- substance intoxication/withdrawal
2. psychological
- depression, lonliness, boredom, frustration
3. environmental
- change in usual carer/staff
- inexperienced/pushy carers
- change of risdence
BPSD - management principles 1. INITIAL
- exclude organic or other causes
- exlcude delirium (illness, substance abuse, medicaitos)
- exclude pain, constipation, urinary retention
- avoid unnecessary changes to carers/routine
2. BEHAVIOURAL or psychological management
- ABC approach
. idedntify problem behaviour and antecedent of problem
. becomes verbally abusive and hits his wife whe
n she tries to shower him
. problem Behaviour
. Consequnece of problem behaviour
. consequence = wife becomes ang
ry and tries to force him into shower
- alter behaviour
. eg move shower time to mroning
, dress in clothes easily remove, stop and try again later if porblemative
3. Non pharm mx
- should be 1st line for mild to moderate BPSD (after inital, be
havioural approaches)
- person centered care
- structured social interactions
- personalised music
- planned positive activityes
- exercise
- reminiscence
- clinical psychologist
4. Pharm
- indications
. hi risk to self or others
. hi distress
. severe depression
. behavioural mx not effective
- 3 T approach
. target the behaviour
. titrate dose by starting low and going slow
. time limited esp antipscyhotic, mood stabilisers
- mild to moderate sx - ssri antidepressants or cholinesterase i
- severe sx (agitiation or psychosis) - antipsychotics
. add on mood stabiliser if ineffective
- Sx that improve with drug tx

. aggression, hostility, agitation

- Sx that don t improve with drug tx
. Screaming Shoutng Swearing Touching Resistant beha
viours eg toileting Inappropriate voiding or spitting Hoarding
- SSRI antidepressants - for agitation and psychosis in BPSD
. citalopram (max 20 mg for prolong Qtc)
- equivalent efficacy as risperidone for agitati
on and aggression in mild to moderate BPSD
.indicated for severe depression - 1st line = sertraline
. SE
- hyponatremia
- Akathisia
- sleep disturbance
- falls and fractures
- cholinesterase inhibitors - for anxiety , apathy, depression
. indicated for anxieyt, apathy, depression
. take weeks
- mood stablisers
. carbamazepine for agitation and aggression
. valproate is ineffective
- antipsychotics in BPSD
. some benefit from ATYPICAL antipsychotics, eg low dose
halperidol or risperidone
. avoid TYPICALs = hi risk of tardive dyskinesia
. use lower doses then for younger people
- risperidone 0.5-1.5 mg
. at higher doses, can cause akasthisia whcih can worsen
- discontinuing antipscyhotics
. trial withdrawal after 3 mo
. but continue > 3 mo if
- severe BPSD
- poor response to withdrawal
- sx respond well to antipsychotics
- no alternative
- you have documented it
. why withrawal
- incr risk of CVA, RR=2.5 (esp in hi risk group
of > 80, obese, DM, htn, smoking, cardiac arrhythmias)
- incr risk of death, RR = 1.5 (heart failure, i
nfections; MOA - anticholinergic, QTc prolong, EPSE)
- in 3 mo - although ~20% improve BPSD sx, there
are 1% deaths, 2% CVA, 7% EPSD/gait, no incr in falls
- at 2 yr - ~15% extra death
- impairment of reality testing
- perceptual abnormalities
- distortions of thought content - delusions

sx in elderly
female predominance
social isolation
sensory impairment
many comorbid with dementia

DDx psychosis in elderly = major = dementia, delirium, depression

delirium (meds, infection, withdrawal, exacerbation of illness)
drugs - meds, abuse (etoh, benzos)
primary pscyhotic disorder: depresson, bipolar, delusion, schizophreni

- primary medical disorder: myxedema, hyperPTH, CVA, metabolic

acute brain failure of gonitive function

cognitive (memory, orientation, language, perception, visuospatial)
worse at night
hyper or hypo active
30% of hospital inpat over 65 yr has delirium

Medications that can case psychotic sx

- benzos (withdrawal or excess)
- anticholinergics (tricyclic antidepressants, urinary incontinence oxyb
- antihistamines - cimetidine
- antiparkinson - levodopa, amantadine, bromocriptine, procylidine
- opiates
- anti-arrhythmics - digoxin, propranolol, quinidine, procainamide
- anti inflamm - aspirin, indomethacin
- anti convulsants - phenytoin, primidone, carbamazepine
- steroids - predisolone
Assessment of psychosis in elderly
- social, cognitive
- corroborative
- med hx
- rule out causes of delirium
- cognitive testing
- risk assessment
Paranoid psychosis in older age
- graduates (had it as young and grown old) - have cognitive cahgnes of
- late onset schizophrenia (5%)
. auditory + visual hallucinations
. partition delusions
. personality intact
- delusion disorders are rare

delusions of people, animals, objects or radiation
things that can pass thru impermeable barrier
up to 70% in late schizoprehnia

Onset age of schizophrenia

- peak at 16-25 (mostly males)
- 2nd peak after 65 (mostly females)
Management of late onset schizophrenia
- therapeutic alliance
. isolated, alienated neighbours, GP, friends
. loney
. may want to talk about their persecutory believe

. encourage them to talk to mental health team and not their nei
- re housing doesn t work
- antipsychotics DO WORK esp as DEPOT in low dose, to ensure compliance
Late life

melancholic depression common
psychotic features more likely esp delusios (hypochondriacal, nihilist
assoc with cerebrovascular disease

Differences in presentation of depression in elderly

- will not admit sx spontaenously
- anxiety, hopelessness, anhedonia, slowness, obsessional
- somatisation
- biological features
. sleep dist
. appetitde dist
. wt loss
. reduce energy
. diurnal mood variation
- pseduo-dementia
. congitive impairment due to a depressive illness
Depression and organic psychiatry depression
-30% of alzheimers develop depression
- derlium in hypoactive state can look depression
- frontal lobe lesion - can look like apathy of depression
Vascular depression in older people
- cerebral ischaemic dg to frontal striatal circuits that predispose/per
petuate depression
- higher rates of whate matter hyperintensities in imagine
- greater cognitive impairment
- poor response to treatment
- no family hx
- thse indicate de novo cause
Depression and physical illness
- inter-related and reciprocal
- depression more common in parkinsons, dementia, cva, ihd, diabetes, pa
in (arthritis), disabilty, drugs, medications
Treating depression in older age
- ECT for
. melancholic, parkinsons disease
. but confusion can be a problem
- antidepressants
. all are anticholinergics : TCAs > SSRIs, or SNRI
. more SE - hyponatremia and falls in SSRI; confusion and falls
in TCA
- psychotherapy can work
- anxiolytics DO NOT WORK
Bipolar disorder in older ager
- graduate from youthful Dx or 10% after 50 yr
- mixed manic states common in elderly
Causes of secondary mania
- Neurologic - Dementia. CVA. head injury

- Endoc ne - Hypo. hyperthyroidism. hyperoortisolaemia

- Toxic - Substances. medications
- Infectious - HIV. syphilis. viral encephalitis
Medications associated with mania in older age
- Corticosteroids Antidepressants Amphetamines and other sympathomimet
ics L-Dopa Cocaine
Mx of mania in older age
- reversible causes
- start low go slow
- lower lithium doses to get lower blood levels bc of renal impairment ~
0.8 mmol/L
Risk factors for elderly suicide
- older age > 80
- male
- living alone for whatever reason
- functional impairment (feel useless, being a burden)
- psychiatric illness
- previous suicide attempt
- vulnerable personality traits - decr openes to experience, obssessiona
l and anxious
EPi of suicide
- suicide rates have fallen
- better use of antidepressants
- better recognised depression
- better treatment of painful phsycial disorders
Prevention of late life suicide
- collaborative care models, using depression care managers
- psychoeducation for pt and family
- identifying and addressing comorbid psych/med factor
- monitoring
- lithium (depression/bipolar), and clozapine (schizophrenia)
- ECT for profound depression or resistant mania

---------------------------------PAAM - Taking a psychiatric history

- consent, explain who and why interviewing
- confidentiality - limits eg harm
- How have things been in the last few weeks
- symptom review for common psychiatric problems eg anxiety
- previous psychiatric treatments, symptoms, distress
- physical health, sx review, medications, adverse reactions
- recent past drug and alcohol use
- legal problems
- Pregnancy, birth, milestones
> Early relationships


School age academic and peer adjustment

Intimate relationships
Sexual functioning
Work history
Social supports and usual coping mechanisms

Psychosocial stressors
> Interpersonal disputes
> Losses
> Role changes
> Disruption or lack of support
ssessment of suicidality
> Previous self-harm or suicide attempts
> Losses and lack of social resources
> Role of alcohol or other disinhibiting factors
> Mental state features - hopelessness, distress in response to psychosi
s, command hallucinations
ssessment of Dangerousness
> Pre-existing vulnerabilities e.g. perinatal period (FAS), personality
> Mental illness
> Drugs or alcohol
> Current symptoms/state of mind e.g. paranoid psychosis
g a specific individual or group
> Long-term social factors and stressors
> Current social situation and triggers
Summarise and check as you go
MENTAL STATE EXAMINATION - distinct part of psychiatric assessment - objective a
(reflect pt mental status at tiem of interview, not in the past)
includes verbala nd non verbal communication
- Appearance
> Contextual
> Level of self care
> Appropriateness of attire
> Evidence of physical injury
> Tattoos, body art, piercing
> Stigmata of physical disease
- Behaviour
> Quality of rapport and examiners countertransference
> Movements
> Interpersonal behaviours
- Hostile or menacing
- Avoidant or tentative
- Charming
- Coy or seductive
- Overfamiliar
- Expansive
- Abnormal movements
- Neurological signs
- Medication induced e.g. akathisia
- Mannerisms
- Stereotypies
- Compulsions
- Catatonic phenomena
- Psychomotor change: agitation, retardation or acceleration

- Abnormal movements in schizophrenia

> Catatonia
> Echopraxia
> Mannerisms
> Posturing
> Medication related - tardive dyskinesia, dystonia,
tremor, bradykinesia, motor restlessness
- DDx - movement - tardive dyskinesia, parkinsons dz
- SPeech
> Volume
> Amount e.g. poverty of speech
> Rate e.g. pressure of speech
> Rhythm and prosody
> Articulation e.g. slurred, dysarthric
- Mood
> pt own workds
> how it relates to affect, is it congruent
- Affect
- emotional state
- range, labile, restricted
- reactivity
- intensity
- type
- appropriateness to content
- descriptors
> Depressed
> Flat total or near lack of emotional expression
> Blunted- sig. in intensity and range of emotional expre
- context

Fatuous - silly or childlike

Shallow - lacking any substance or authenticity
Irritable, angry
Euphoric - high but not infectious
Elated - infectiously high
of schizophrenia
incongruous with circumstances - laughing when talking

about suicide
- fatuous
- perplexed, confused
- suspicious, guarded
- THought

capacity to process info
normal = logical, sequential
poverty of speech
flight of ideas
. ideas/concepts in their mind
. bizaree, delusional
. poverty of thought content
. in context of depression, cognitive disorders
- Delusions
- unshakeable beliefs, incosistent with persons cultureal and so
cial background

- false, fixed beliefs, despite evidence to the contrary

- types
. primary vs secondary
. persecutory
. passivity
. guilt
. nihilistic
. hypochondriacal
. erotomanic
. misidentification syndrome
- over valued ideas
- rentention of insight, assumes prominence in their thought
- being overweight in anorexia
- dysmorphobia, morbid jealousy
- obsessions
- recurrent, intrusive dieas
- assoc with resistance
- insight retained
- compulsive rituals, or neutralising thoughts
- eg contamination, patterns, sexual, harm coming to others
- risk
. suicidal ideation
. self harm
. harm to others - family, children, objects of persecutory idea
. neglect
. reputation
- perceptual disturbance
. illusions = misperception of a stimulus
. hallucination = perception w/o stimulus
. pseudohallucination = perceptual disturbance assoc with retent
ion of insight
- hallucinations
- auditory, verbal non verbal, first person, 2nd person, echo de
- visual incl lilluputian
- olfactory = pathognomonic of TLE
- tactile or haptic
- gustatory
- dissociative sx
. depersonalisation
. de realisation
. psychic numbing
. psychic amnesia
. dissociative identity disturbance
- Insight = level of understanding of their illness process
. recognising the phenomena as abnormal
. attributing abnormal phenomena to illness process
. seeking and accepting treatment for an illness
- Cognitive assessment
. orientation, attention, concentration
. days of week backward, moths of year backward, serieal 3, 7,
. digit span
. working memory- one thing a nation must have to become rich a
nd great is a large secure supply of wood
. short term - 3 item recall, name, address, recent events
. long term memory - episodic/personal details - semantic - PM,
historical dates, general knowledge
. aphasia - expressive, receptive

. quality of narrative - paraphrasic errors

. naming
. verbal and written comprehension
. praxis - dressing self care, hemineglevt
. ideomotor apraxia
. astereognosis
. prosopagnosia
. agnosagnosia
. visuospatial funt = intersecting pentagons, cube
. clockface
- executive fn
. interpret proverb, similarities, difference
. word generation tests
. new learning
. perseveration
. set shifting, go no go test for inhibition
. primitive reflexes
. triangle and sqares
. stroop test
. trail making test-B
- judgement
. hypotheticals - fire in theatre
. ability to set reasonable goals and approach in appropriate wa
y eg. decision in relation to current psychiatric problems
---------------------------------PAAM - Mental state examination
see psych interview
---------------------------------PAAM - Case studies 2
CASE 1: Psychotic experiences persisting for 3 months
- Nature of experiences is schizophreniform so say schizophreniform psychos
is until rule out organic causes e.g. drug use
- Brief psychosis = psychotic Sx for 1 day to < 1month duration w/ retur
n to normal
- Schizophreniform psychosis psychotic Sx for 1-6 months
- Schizophrenia = continuous signs of disturbance (e.g. delusions, hallu
cinations, disorganised behaviour, negative symptoms) for 6 months with at least 1
month of psychotic symptoms; PLUS functional decline
- Interventions to consider:
Referral to Early Psychosis Intervention Service
Family therapy
Antipsychotic at minimal therapeutic dose
- Start wih minimal antipsychotic therapy
. aripiprazole - lowest SE profile
CASE 2.2 - 64M, chronic schizophrenia, delusions, paranoia, recently stopped his
holaperidol 5 mg nocte PO due to uncontrolled face movement
- good adherence
- uncontrolled movements = tardive dyskinesia
- change to 2nd Gen antipsychotic - for this abnormal movements to settl
- measure his current sx to determine whether improving or worsening
CASE 2.3 - 34M, chronic schnizophrenia, paranoid features, 4mo Hx of olansapine
10 mg PO BD after psych ward admision, has put on 5 kg since discharge
- BM I 29, wasit 120 cm, BP 145/90, BSL 7.2, chol 8, TAG 3, HDL-C 0.8

- metabolic syndrome
- dietician education
- help meal planning and budgeting
- rehab for exercise
- statins, metformin
- avoid changing to different antipsychotic due to risk of relapse ie ol
anzapine is effective for him
CASE 2.4 - 34M, married, sad, teary, trouble sleeping, feeling exhausted. Lost a
petitie, cared for by wife. Feels worthless and guilty. Considering suicide
- major depression
- melancholic features = guilt, psychomtor retardation, diurnal mood var
- start antidepressant
. SNRI (dual acting on more then one neurotransmitter)
- malncholic features are assoc with greater likelihood of response to a
- investigate his suicidal ideation
CASE 2.5 - 83M - sad, teary, other same as 2.4
- older = consider other medical conditions and risk of medications and
- risk of hyponatremia for antidepressants and elderly - monitor electro
- SNRI still appropriate
CASE 2.6 - Josiah is an 83 year old married man whose wife says that he has been
terribly sad and teary over the last couple of months. He is often awake in th
e early hours of the night. He has stopped doing things he used to enjoy, like w
alking the dog and seeing friends. He doesnt want to get up in the morning. He ea
ts a little when his wife pushes him to, but isnt eating as much as usual and has
lost 8 kg over the past 3 months. Several times his wife has returned from outi
ngs to find him sitting in the dark exactly where she left him he gets agitated
about having lights on or using the air conditioner, saying that they have no mo
ney (this is not true) and he doesnt deserve to be comfortable. He has recently b
een saying that his wife would be better off if he wasnt alive.
- melancholic features (psychomotor retardation, inanition, complete anh
edonia, diurnal mood variation (worse in mronig)
- psychotic features - beleif they have no money, underlying delusions o
f guilt
- these delusions are mood congruent ie gloomy, negative and in keeping
with depressed mood and outlook
- he need admission to mental helalth unit
- ECT or pharmacotherapy
- ECT for distressed, depressed pt in whom pharmacotherapy is ineffectiv
e or pt who are at imminent risk of serious harm eg not eating or drinking
- in this case, not yet so severe, so SNRI + antipsychotic
CASE 2.7 - Jed is a 16 year old high school student brought in by his mother who
says that he has been very irritable and withdrawn over the last couple of mont
hs. He says hes been having trouble sleeping, and feeling exhausted during the d
ay. He says that hes lost interest in seeing friends, and even just getting up i
n the morning is an effort. His grades have dropped because he cant concentrate o
n his schoolwork. He says hes lost his appetite and lost some weight also. Hes f
eeling worthless and guilty about the effect it is having on his family. He has
been wondering whether things would be better if he wasnt alive, though he hasnt
had any specific thoughts about killing himself.
- major depression
- exclude - home (parents fighting etc), school (bullying)
- psychotherapy should be first line

- SSRIs best for suicidal ideation and depression in children - fluoexti

ne is best
CASE 2.8 - Jordan is a 16 year old high school student who complains that he has
been terribly sad and teary over the last couple of days, since his girlfriend
broke up with him. He says hes been having trouble sleeping, and feeling exhaust
ed during the day. He says that hes lost interest in seeing friends, and even ju
st getting up in the morning is an effort. He says hes lost his appetite and cant
concentrate. Hes feeling worthless and guilty about the effect it is having on
his family. He has been wondering whether things would be better if he wasnt ali
ve, though he hasnt had any specific thoughts about killing himself.
- brief sx as an acute response to loss
- needs support from those close to him - should engage in usual activit
---------------------------------PAAM - Ethics Scenarios
Capacity at common law
- they can understand information about the condition and the proposed t
- they can use and weigh the info in order to reach a decision
- be able to communicate the decision
Competent decision
- does not have to be sensible or well considered, rational
having an active mental illness does not necessarily preclude a finding
of competence - Re C (UK) - active psychotic with gangrene, drs recommended ampu
tation, he thought he was an internationally recognised orthopedic surgeon and i
n his expert opinion, he refused it.
Psychiatric medicine
- has the Mental Health Act NSW
. person is a mentally ill person
. treatment or control of the person is necessary - for their ow
n protection or others
. no other care of a less restrictive kind is appropriate and re
asonable availble
- note
. no restrictions on what treatment can be used
. doesn t address capacity - ie if you are mentally ill and even
though you have capacity, it doesn t matter, what you want doesn t matter.
- mental illness definition = symptom based and not syndrome based (ie w
on t find it in the DSM)
. Menta/i//ness means a condition that seriously impairs, either
temporarily or permanently, the mental functioning of a person and is character
ised by the presence in the person of any one or more of the following symptoms:
(a) delusions
(b) hallucinations
(c) serious disorder of thought form
(d) a severe disturbance of mood
(e) sustained or repeated irrational behaviour indicatin
g the presence of any one or more of the symptoms referred to in paragraphs (a)(d
. A person is a mentally disordered person if the person s behav
iour for the time being is so irrational as to justify a conclusion on reasonabl
e grounds that temporary care, treatment or control of the person is necessary:
(a) for the person s own protection from serious physica
l harm, or

(b) for the protection of others from serious physical h


used for upset people eg suicidal

can only detain for 3 days
doesn t cover being drunk alone
harms might include - reputation, giving away money et

---------------------------------PAAM - Behaviour management
---------------------------------PAAM - Interviewing the difficult adolescent
---------------------------------PAAM - Family interviewing
---------------------------------PAAM - Cardio-metabolic health and general adverse effects
---------------------------------PAAM - Personality webinar