Psychiatric Essentials 31 August 2012 Presented By
Transcription
Psychiatric Essentials 31 August 2012 Presented By
Psychiatric Essentials 31 August 2012 Presented by AMA Victoria Section of Psychiatry AMA Victoria Advancing the Medical Profession. Advancing the health of Victorians www.amavic.com.au GRAHAM D. BURROWS, AO, CJSJ BSc, MB, ChB, DPM, MD, DipMHlthSc(Clinical Hypnosis),DSc, FRANZCP, FRCPsych, AFRACMA, FAChAM, Professorial Fellow - Psychiatry University of Melbourne The Melbourne Clinic Chairman, Mental Health Foundation of Australia Chairman of Council AMA Victoria Board Member AMA Victoria Chairman Section of Psychiatry AMA Victoria Chairman Mental Health Foundation Australia (MHFA) 1982 - present President Mental Health Foundation Victoria (MHFV) 1970 - present Member RANZCP Victoria 1970 - present Editor/Author of 104 Books Published over 743 scientific articles in refereed journals Contributor to other books – 180 chapters Editorial Board of 30 International and Australian Journals 1989 ‐Awarded the Officer of the Order of Australia (AO) – distinguished contributor to Medicine. 2010 ‐ Recipient of the Royal Australian & New Zealand College of Psychiatrists “College Medal of Honour” MENTAL HEALTH WEEK 7 – 13 OCTOBER 2012 MENTAL HEALTH – WHAT DO YOU KNOW? www.mentalhealthvic.org.au www.health.vic.gov.au/mentalhealth/mhweek.htm Dr Ajit Selvendra Chairperson 1 Premenstrual Disorders Professor Lorraine Dennerstein AO MBBS PHD DPM FRANZCP The University of Melbourne Introduction Clinical significance: premenstrual symptoms are frequent, up to 30% have PMS and 1-5% experience PMDD Burden of illness: women with moderate to severe premenstrual symptoms have increased work absenteism, decreased productivity, decreased activities of daily life and increased health care costs. HRQoL for PMDD similar to that of rheumatoid arthitis Impacts: woman, studies/occupation, family life, social relationships Objectives: Premenstrual Disorders Types of Premenstrual Disorders Prevalence Aetiology Role of Psychiatrist Diagnosis Treatments Premenstrual Disorders Timeline - 370 BC Hippocrates ”Women are subject to intermittent agitations which make their way from the head to the uterus whence they are expelled” - 1931 : Frank (New York) - Premenstrual Tension (PMT) - 1953 : Premenstrual Syndrome (PMS) (Dalton UK) - 1980s: Severe PMS / physiological symptoms - 1987 : LLPDD included in DSM III-R- appendix - 1994 : PMDD included in DSM-IV - appendix - 2000 : PMS ACOG Practice Bulletin - 2011 : Premenstrual Disorders, ISPMD - 2012 : PMDD included in DSM V under Mood Disorders Core / Typical PMD O’Brien PMS, Rapkin A, Dennerstein L, Nevatte T. Premenstrual Disorders: Diagnosis and Management. BMJ 2011;342:D2994. 1. Ovulation underlies Core PMD 2. Symptoms are not defined – there are typical symptoms 3. The number of symptoms is not proscribed 4. Physical and psychological symptoms are important 5. Symptoms must recur in the luteal phase 6. Symptoms must disappear by the end of menstruation 7. There is a symptom-free week between menstruation and ovulation 8. Symptoms must be prospectively rated 9. Symptoms are not an exacerbation of an underlying psychological or physical disorder 10. Symptoms must cause significant impairment Variants of the Core Premenstrual Disord (a) premenstrual exacerbation of an underlying physiological, somatic or medical condition (b) premenstrual symptoms with absent menstruation (after hysterectomy with ovarian conservation, endometrial ablation or with a levonorgestrel intra-uterine system) (c) progestogen-induced PMS occurring during progestogen therapy (cyclical menopausal hormonal therapy (HT), hormonal contraception) Premenstrual Disorders ICD-10- PMS- 1 symptom PMS – ACOG PMDD- DSM IV ►1 ►5 mood & 1 physical symptom premenstrually in each of last 3 cycles free phase postmenstrually ►Woman must be negatively affected in her daily life or relationships ►Prospective daily ratings for 2 months to confirm symptoms ( 1 mood) in the week before menses, alleviated during menses, in most cycles in last 12 months ►Symptom ►Symptom free phase postmenstrually ►Woman must be negatively affected in her daily life or relationships ►Prospective daily ratings for 2 months to confirm *PMDD Defining Symptoms 1*- Markedly depressed mood, feelings of hopelessness, or self-depreciating thoughts 2*- Marked anxiety, tension, feelings 'keyed up,' or 'on edge' 3*- Marked affective lability 4*- Persistent and marked anger, irritability, or increased interpersonal conflicts from DSM-IV, 1994 PMDD + ONE OR MORE OF FOLLOWING SYMPTOMS Decreased interest in usual activities Subjective sense of difficulty concentrating Lethargy, fatigue, lack of energy Marked change in appetite, overeating, speciifc food cravings Hypersomnia or insomnia Feeling overwhelmed or out of control Breast tenderness or swelling, headaches, joint or muscle pain, bloating, weight gain Objectives: Premenstrual Disorders Types of Premenstrual Disorders Prevalence Aetiology Role of Psychiatrist Diagnosis Treatment Global Study of Premenstrual Symptoms Dennerstein L, Lehert P and Heinemann K. Menopause International 2011;17:88-95 Study Design (n=7226) Europe/Latin America: ► 4,085 women (500 women per country) ► subsampling used for age, region and education ► Women aged 15-49 years ► Europe: France, Germany, Italy, Spain, UK and Hungary ► Latin America: Brazil and Mexico Asia Pacific: ► Hong Kong, Pakistan, Thailand, (n=1200) ► Australia (n=400), Korea (n = 1,000); Japan (n=1,039) Methodology: ► CATI (Computer aided telephone interview) Europe/LAmerica ► Online (Australia, Japan, Korea), questionnaire- other Asian ► 23 different symptoms: ► Severity of the symptom (Mild, moderate, severe) ► Frequency of experiencing the symptom In the last 3 months In the last 12 months • Effect of premenstrual symptoms on Activities of Daily Living Premenstrual Symptom Prevalences. (Prevalence of at least moderately perceived symptom Dennerstein et al. A global study of women’s experiences of premenstrual symptoms and their effects on daily life. Menopause Int. 2011: 17:88-95 Abdominal Pain 31% Irritability Bloating 30% 29% Joint/back/muscle pain 25% Breast pain 24% Lack of Energy 23% Headaches 22% Mood swings 21% Anger 21% Appetite changes 19% Prevalence of PMS and PMDD - Region Asia Pacific PMDD LatAm + Europe 4% 3% PMS-ACOG criteria 22% 37% ICD 10 Definition 90% 93% 100% 100% definition Total female population (15-49) Prevalence of PMS and PMDD – By Country Australia Japan Hong Kong Pakistan Thailand PMDD 9% 0.7% 1% 5% 0.5% PMS-ACOG 43% 34% 17% 13% 15% ICD 10 Definition 94% 97% 94% 80% 94% Total female population (15-49) 100% 100% 100% 100% 100% Asia Duration X Severity Symptom Indexes by Age 1.4 1.2 1 Total DSI Score Mean 0.8 Mental Score DSM Mean Physical Score DSP Mean 0.6 0.4 0.2 0 Less 20 years 20<25 years 25<30 years 30<35 years 35<40 years 40<45 years 45 and more Objectives: Premenstrual Disorders Types of Premenstrual Disorders Prevalence Aetiology Role of Psychiatrist Diagnosis Treatment Aetiology PMDs-Stages with no symptoms Pre-puberty Pregnancy Menopause Hormonal Fluctuations and PMDs Triggers Ovulation Cyclical Progesterone (normal levels) = Trigger CNS Progesterone Sensitivity Proposed Aetiology of Premenstrual Disorders Genetic predisposition Neurotransmitters and neurohormonal systems* interact Vulnerability Increased sensitivity to changes in gonadal hormones with gonadal hormones and metabolites Altered responses to changes in gonadal hormone levels Premenstrual Symptoms * serotonin, renin-angiotensin-aldosterone system, -aminobutyric acid (GABA), cholecystokinin. Halbreich U. Psychoneuroendocrinology. 2003;28(suppl 3):55–99. Objectives: Premenstrual Disorders Types of Premenstrual Disorders Prevalence Aetiology Role of Psychiatrist Diagnosis Treatment What psychiatrists have to offer in treatment of PMDs • Diagnostic skills • PMDD, MDD, Anxiety Disorder, Personality Disorder • Identifying aetiological factors both psychosocial (eg marital conflict, stressors) and biological • Patience in evaluation • Experience in using rating scales • Ability to evaluate complex cases Objectives: Premenstrual Disorders Types of Premenstrual Disorders Prevalence Aetiology Diagnosis Treatments Achieving Accurate Diagnosis Obtain a careful history Rule out other psychiatric or medical disorders or psychosocial problems • medical disorders • major psychiatric disorders • substance/alcohol/domestic violence • premenstrual exacerbation of other disorders Establish severity and luteal cyclicity prospectively to clinch the diagnosis History Taking Menstrual History: pain, regularity, LMP, amenorrhoea Premenstrual Symptom History: severity, type, absence or presence following menstruation, symptom-free follicular phase week, Has there been any suicidal ideation. Impairment: work, school, hobbies, social activities, family, partner, work and colleagues. Distress ? Is the patient receiving hormonal therapy – combined or progestogen-only contraception, progestogen therapy, HT What are the patient’s contraceptive needs, current contraception, is family complete, is she trying to become pregnant. . History What treatment approaches would she find acceptable – non-medical, behavioural therapy, psychotropics, hormones, intrauterine hormones, surgical interventions Is she prepared to receive therapy that will usually prevent her getting pregnant during the treatment. Is she happy to use barrier methods of contraception during treatment? History of treatments experienced :self-administered or prescribed and effects. Examination Daily charting - www.symptometrics.com Daily Symptom Rating Chart Adapted from Dennerstein L et al Psychoneuroendocrinology: 19: 293-304 1994 Which Patients are Referred to Psychiatrists Those women with psychiatric disorders or psychosocial comorbidities PMDs or PMDD sufferers without adequate response to treatment Women at risk of suicide or violence premenstrually Objectives: Premenstrual Disorders Types of Premenstrual Disorders Prevalence Aetiology Role of Psychiatrist Diagnosis Treatment What psychiatrists have to offer in treatment of PMDs • Management • Experience in using psychotropic drugs, particularly SSRIs • CBT and other techniques to reduce stressors (internal and external) PMDs treated by Psychiatrists •PMDD •Premenstrual exacerbation of psychiatric disorders Whereas other PMDs- treated by gps or referred to gynecologists Therapies for Premenstrual Syndrome Pharmacologic agents • Antidepressants • Diuretics • Anti-Anxiety medications such as benzodiazapines • Induce pharmacologic menopause • Oral contraceptives (OCs) such as YAZ® Cognitive-behavioral therapy Evidence-based Management of PMDs [oestrogen meta-analysis awaited] favours placebo favours treatment vitamin B6 SSRIs(overall) SSRIs(continuous) SSRIs(luteal phase) progesterone(overall) progesterone(oral) progesterone(suppository) progestagens GnRHa danazol(luteal phase) danazol(continuous) danazol(breast symptoms) cognitive behavioural therapies 0.1 1 odds ratio 10 100 Anti-depressants Selective serotonin reuptake inhibitors (SSRIs) and SNRI Help lessen the impact of hormone changes on serotonin. May be used either daily or for the 14 days before menstruation Improve mood and physical symptoms within 48 hours Three SSRIs (fluoxetine, sertraline, and controlledrelease paroxetine) have FDA indication for PMDD1 Fluoxetine, paroxetine, citalopram, sertraline all sign. more effective than placebo Serotonin/norepinephrine reuptake inhibitors (SNRIs) (venlafaxine) 1.Brown C, Ling FW. In: Bieber EJ, Sanfilippo JS, Horowitz IR, eds. Clinical Gynecology. Philadelphia, PA: Churchill Livingstone Elsevier, 2006: 19–35 Luteal-phase (intermittent) SSRI dosing 14 days before expected menses thru to menses 11 RCTS of luteal dosing SSRIs, SNRIs and other serotonergic antidepressants show efficacy for PMDD Not as effective for physical symptoms Advantages: limiting drug exposure, rare to have serotonin withdrawal syndrome, potentially increasing compliance and decreasing side effects, less costly Side effects of SSRIs Fatigue, insomnia, nausea, gastrointestinal disturbance, headache, sweating and tremor. Continuous use - decreased libido and anorgasmia. Serotonin withdrawal- Dizziness, lethargy, nausea, irritability, decreased mood and vivid dreams (rare with intermittent therapy). SSRIs can be given concurrently with OCs. . Ovarian Suppression ► PMS not present in anovulatory cycles PMS not present after surgical and natural menopause (bilateral ovariectomy) ► GNRH - improvement in physical and behavioural symptoms ► LHRH agonist - successful versus placebo ► GNRH + addback CEE+MPA – 60% improvement ► GNRH + addback hormones may precipitate symptoms for some women ► (Muse et al 1984) (Hammarback and Backstrom 1988) (Mortola et al 1991) (Schmidt et al 1998) ► Danazol reduces severe PMS symptoms and cyclical menstrual psychosis (Dennerstein et al 1983; Sarno et al 1987; Halbreich et al 1991; O’Brien and Abukhalil 1999) ► High dose estradiol can prevent ovulation and reduce PMS (protect endometrium) (Watson et al 1989) ► Combined oral contraceptive (OC) use? Variable results! Progestins in Oral Contraceptives Progestins in OCs derived from 19-nortestosterone may cause these adverse effects1,2 • Irritability/nervousness • Headache • Bleeding irregularities • Weight gain 1. Mishell DR, Jr. In: Katz VL et al, eds. Comprehensive Gynecology, 5th edition. St. Louis: Mosby, 2001: 275-325. 2. Moghissi KS. In: Ransom SB, ed. Practical Strategies in Obstetrics and Gynecology. Philadelphia: W. B. Saunders Company, 2000: 3–14. Oral contraceptive pill YAZ®, the first oral contraceptive pill approved to treat the emotional and physical symptoms of PMDD Contains 3 mg drospirenone and 20 mcg ethinyl estradiol in a 24-day active hormone pill and 4day placebo pill (24/4) regimen Drospirenone is derived from 17-spirolactone 30 hour half life Causes less hormonal fluctuations than traditional 21-day active pill regimen Safe and well-tolerated in majority of women in clinical trials Significant improvement in mood, physical and behavioral symptoms A greater proportion of women recorded a decrease in mood, physical and behavioral symptoms with YAZ® vs. placebo *p<0.005; change from baseline assessed in subscales from Daily Record of Severity of Problems (DRSP) Yonkers et al. Obstet Gynecol 2005;106:492–501 PMDD: Effect Size (standardized mean difference) of a low dose COC (Drospirenone/EE20) vs SSRIs Drospirenone/EE 20 parallel study Drospirenone/EE20 crossover study SSRI`s pool ed data from 13 RCT`s 844 patients Yonkers et al. JAMA 1997 (Wyatt et al. Cochrane Library 2002) Cohen et al. ACOG 2002 * Pooled data from SSRI studie s * (incl. 774 parti cipants) using DRSP scale as outcome Halbreich et al. ACOG 2002 -2 -1,5 -1 -0,5 Favours treatment Large medium small 0 favours placebo (by convention, Cohen 1969) Treatments for PMDs with evidence from at least 1 RCT Femal (Swedish herbal) – for premenstrual insomnia St John’s wort and Vitex agnus-castus (Chasteberry) for PMS Alprazolam (GABAergic): 6 RCTS : 4 showed efficacy,0.25 to 0.5 mg bd to tds luteal phase only Buspirone : 2 small RCTs at up to 60 mg divided dose/day Spironolactone: 100mg daily for 8 days premenstrually Calcium: 1200 mg/day Complex carbohydrate suppl. for affective PMS symptoms Soy supplementation for physical but not mood symptoms Vit B6 – 80 mg/day, Saffron CBT for mental symptoms Massage, biofeedback, hand acupuncture Conclusions ► Physical symptoms are the most prevalent premenstrual symptoms experienced ► Psychiatrists treat predominantly exacerbations of underlying psychiatric disorders (with better control of those disorders or increase or addition of SSRI in second part of cycle) ► Some psychiatrists treat PMDD, usually with SSRI ► Psychiatrists also use CBT and stress reduction techniques for PMDs ► Need for evaluation of combined therapies, eg Yaz + SSRIs Acknowledgements Data was made available by Bayer Schering pharma for independent analysis. Statistical analysis by Prof. Philippe Lehert Profs Dennerstein and Lehert received a research grant to fund analysis Co-investigators Drs. K. Heinemann, T. Backstrom, Lam Siu Keung ,Sadiah Ahsan Pal, Dooseok Choi Questions? Dr Jane Hendtlass Risk Assessment Psychiatric Essentials for International Medical Graduates RISK ASSESSMENT Dr Jane Hendtlass B.Sc.(Hons.), LL.B.(Hons.), Ph.D, A.R.A.C.I., F.A.I.C.D., A.I.M.M. 31 August 2012 Outline A Coroner’s Perspective Risk Assessment including Definition of risk Risk assessment Management of assessed risk Evaluation of risk assessment and management Summary Role of a Coroner The coronial system of Victoria plays an important role in Victorian society. That role involves the independent investigation of deaths for the purpose of finding the causes of those deaths and to contribute to the reduction of the number of preventable deaths and the promotion of public health and safety and the administration of justice. Coroners Act 2008 We are all trying to LEARN FROM OUR MISTAKES Deaths Reportable to the Coroner include A death that appears to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from an accident or injury; or The death of a person who immediately before death was a person placed in custody or care; Coroners Act 2008 A Person Placed in Custody or Care includes— a patient in an approved mental health service within the meaning of the Mental Health Act 1986; a person under the control, care or custody of the Secretary to the Department of Human Services or the Secretary to the Department of Health; a person under the control, care or custody of the Secretary to the Department of Justice or a member of the police force; … Coroners Act 2008 Reportable Deaths In effect, reportable deaths include all deaths of: Voluntary and involuntary inpatients in an approved mental health service; Involuntary patients of community mental health services; Patients subject to section 10 of the Mental Health Act 1986 or otherwise in police custody; Prisoners; Homicides; Motor vehicle incidents; Suicides. Coronial Investigation A coroner investigating a reportable death must find, if possible— (a) the identity of the deceased; and (b) the cause of death; and (c) the circumstances in which the death occurred… Coroners Act 2008 Powers to Obtain Information A coroner may— require a person to prepare a statement addressing matters specified by the coroner and give the statement to the coroner; order a police officer to take copies of any documents relevant to the investigation; seize things (including documents) and take samples, which may be relevant to the investigation; summon a person to attend as a witness or to produce any document or other materials; order a witness to answer questions. Coroners Act 2008 Mandatory Inquest A coroner must hold an inquest into a death if the death or cause of death occurred in Victoria and— (a) the coroner suspects the death was the result of homicide; or (b) the deceased was, immediately before death, a person placed in custody or care; Coroners Act 2008 Reports and Recommendations A coroner may make recommendations to any Minister, public statutory authority or entity on any matter connected with a death which the coroner has investigated, including recommendations relating to public health and safety or the administration of justice. If a public statutory authority or entity receives recommendations made by the coroner, the public statutory authority or entity must provide a written response, not later than 3 months after the date of receipt of the recommendations. Coroners Act 2008 Publication of findings and reports Unless otherwise ordered by a coroner, the findings, comments and recommendations made following an inquest must be published on the Internet. The coroner must— publish the response of a public authority or entity on the Internet. A Coroners’ Perspective Summary We only investigate circumstances where death has occurred. We investigate deaths of people with mental illness who die in traumatic circumstances or in hospital or custody of police or prison or are otherwise subject to involuntary treatment. We must hold an inquest if a person with a mental illness was in custody or care or it is otherwise warranted. We make comment and recommendations intended to help prevent further deaths and promote public health. Our comments and recommendations are public documents We also learn from the formal responses from Ministers, government agencies or entities. We are all trying to LEARN FROM OUR MISTAKES Risk Risks for a person presenting with suspected mental illness include: Self harm and suicide and Deliberate or unintentional harm to others As well as risk of: Absconding Unintentional harm, such as the effects of physical restraint, intolerance to medication, adverse effects of treatment or assault by another Effect of alcohol and/or other drugs alone and in combination with prescribed medications Risk Assessment and Management By definition, risk assessment and management are important issues in the circumstances surrounding deaths of people with a mental illness and in exercising our prevention role. Further, coroners rarely consider the circumstances of people with a mental illness when their risk assessment and management was effective in preventing their death or their causing someone else’s death. Risk Assessment includes: Mental state and diagnosis History and circumstances of referral Physical health Prior admission history Previous and recent risk assessments Self reported immediate and long-term intentions Family, cultural and community circumstances Dual diagnosis and/or effects of alcohol and other drugs Risk Management includes Management plan Admission status Medication Security and opportunity of allocated bed: seclusion, high dependency, low dependency Observations and physical needs Leave arrangements Discharge plan Referrals Communications with family and community supports Documentation in the medical record Evaluation of Information Assessment of risk requires evaluation of information obtained from: Communication with referring agencies Documentation in medical record. including: oThe Patient, family members, general practitioner oPolice and police medical officers oECATT and emergency department medical officer oCommunity treating team including case manager Communication of Information Management of risk requires communication of information through: Communication with referral agencies including: oThe Patient, family members, general practitioner oInpatient treating team and case manager oCATT and Community treating team including case manager oSpecialist medical and other professionals oPolice, community and cultural supports Documentation in medical record. Evaluation The Coroner will review your risk assessment and management against: The patient’s subsequent history and death and Your communication with and consideration of: The Patient The family The treating teams Community and cultural supports General practitioner/local medical officer Specialist medical and other professionals, and Documentation in medical record Summary Risk includes self harm, harm to others, unintended consequences of professional actions and decisions. Risk assessment includes acute and chronic risk factors and information provided by The Patient, family members, the treating team and the community including police. Management of assessed risk includes communication with The Patient, family members, the treating team and the community including police. The patient’s subsequent history and the medical record are the principal sources of information used to evaluate the appropriateness of your risk assessments. We are all trying to LEARN FROM OUR MISTAKES Questions? Lunch MOOD STABILIZERS, ATYPICAL ANTIPSYCHOTICS & BIPOLAR DISORDER Professor Isaac Schweitzer Medical Director, The Melbourne Clinic Healthscope Chair of Psychiatry Department of Psychiatry University of Melbourne Today’s Talk 1. 2. 3. 4. Bipolar Disorder: Basic facts Classification and Defining Bipolar Disorder Psychotherapy for Bipolar Disorder Pharmacotherapy of Bipolar Disorder 1. Mania 2. Depression 3. Maintenance Some Basic Facts Onset: 15 - 24 years old Lifetime prevalence: ◦ ◦ Bipolar I – 1% Bipolar II – 2% Age of 1st treatment: 10 years later 1/3 attempt suicide and 10% to 15% succeed 90% recurrence rate Goodwin and Jamison. Manic-Depressive Illness 1990 Woods. J Clin Psychiatry 2000;61(suppl 13): 38-41 Bipolar Mood Disorders Bipolar I Bipolar II Cyclothymic disorder Bipolar Disorder NOS Bipolar I Disorder Manic episodes and episodes of Major Depression 10% patients do not have Major Depression but are still classified as Bipolar I Bipolar II Disorder Hypomanic episodes and episodes of Major Depression Cyclothymic Disorder Hypomanic episodes and episodes of “Minor” Depression ie < 5/9 symptoms A diagnosis that is rarely made! Bipolar Disorder is defined by presence of episodes of elevated mood ie hypomania or mania DSM IV TR criteria for Hypomania A distinct period of persistently elevated, expansive or irritable mood lasting throughout at least 4 days. Three (or more) of the following symptoms have persisted (four if the mood is only irritable): DSM IV TR criteria for Hypomania ◦ inflated self-esteem or grandiosity ◦ decreased need for sleep ◦ more talkative than usual or pressure to keep talking ◦ flight of ideas or subjective experience that thoughts are racing DSM IV TR criteria for Hypomania distractibility increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. excessive involvement in pleasurable activities that have a high potential for painful consequences DSM IV TR criteria for Hypomania The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. The disturbance in mood and the change in functioning are observable by others. DSM IV TR criteria for Hypomania The episode is not severe enough ◦ ◦ ◦ to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. DSM IV TR criteria for Mania Descriptively the same features except: ◦ ◦ ◦ The episode is at least seven days duration unless hospitalization occurs There is marked impairment in social or occupational functioning, ie more severe, and there may be psychotic features. Burden of bipolar depression Time spent in phases of illness: dominated by depression Bipolar Depression The diagnosis of Bipolar Disorder is often missed Patients typically present with depression and neglect to mention their elevated mood states - use appropriate probes. The index episode for Bipolar Disorder is often Major Depression When is Depression More Likely to be Bipolar? Reversed vegetative symptoms Psychomotor retardation Psychotic features Affective lability Family history of Bipolar Disorder Mitchell et al, 2008 Diagnostic guidelines for bipolar depression: a probabilistic approach “There are no pathognomonic characteristics of bipolar I depression compared to unipolar depressive disorder.” “There are………clinical characteristics that are more common in both bipolar I depression and unipolar depressive disorder, respectively,” Bipolar Depression: Not a Unitary Condition Biological reaction to elevated mood state – rebound neurochemical changes. Psychological response to manic/hypomanic episode Co-morbid depressive disorder eg associated with current psychosocial circumstances; Bipolar Depression: Not a Unitary Condition Co-morbid substance abuse disorder Co-morbid personality disorder Demoralization due to effects of chronic illness; Bipolar Depression: Not a Unitary Condition Medication side-effect – substance induced mood disorder (mood stabiliser or neuroleptic). Combination of factors Bipolar Disorder & Co-morbid Anxiety Disorder Otto et al 2006 1000 outpatients with BPD were followed for 12months 31.9% co-morbid anxiety disorder Anxiety associated with fewer days well, less likely to recover from depression, poorer quality of life and diminished role function Psychotherapy for the Bipolar Disorders MAPS program Combines Psycho-educational, CBT and Social Rhythms approaches including: ◦ ◦ ◦ ◦ M - monitoring mood and activities A - assessing prodromes P - preventing relapse and S - SMART goal setting ie MAPS. Method 84 participants randomised to receive: ◦ MAPS (12 week intervention plus 3 booster sessions), or ◦ Treatment as usual (TAU). follow up: ◦ face to face interviews (at baseline, 3 and 12 months) and ◦ monthly telephone interviews (for 9 months post-intervention). Results Participants who received MAPS programme were significantly less likely to have a relapse of any type and spent less time unwell. Results There was reduced rate of relapse in the treatment group compared to control, for pooled relapses of ◦ any type (hazard ratio 0.44; 95%CI 0.20 to 0.96, z=2.06, p= 0.04), ◦ depressive episodes (hazard ratio 0.28; 95% CI 0.09 to 0.84, z = -2.27, p = 0.02) and ◦ manic/mixed episodes (hazard ratio 0.15; 95% CI 0.02 to 1.24, z = -1.76, p = 0.08). 0.00 Estimated survivor function 0.25 0.50 0.75 1.00 1st relapse of any type 0 100 200 Time (post treatment, days) Treatment Control 300 Pharmacotherapy of Bipolar Disorders Note – most RCT trials have been performed on Bipolar I subjects. Most evidence for the treatment of Bipolar II is based on the above studies or small studies or open label studies. Patient Adherence in Bipolar Disorder 6 year longitudinal study of 1594 lithium users in HMO. Lithium use mostly sporadic – median use was 76 days. Discontinuation associated with hospitalization. Johnson & McFarland 1996 Pharmacological Treatment of Acute Mania: First Line Monotherapy ◦ ◦ ◦ ◦ ◦ ◦ ◦ Lithium, Valproate, Olanzapine, Risperidone, Quetiapine, Ziprasidone & Aripiprazole Monotherapy versus Combination Therapy for Acute Mania Response rates sig higher with combination therapy (RR 1.53) compared with lithium ⁄ divalproex alone. A meta-analysis of 24 studies (n = 6,187), found that adding atypical antipsychotic agents to lithium ⁄divalproex was significantly more effective than treatment with lithium ⁄ divalproex alone for the treatment of acute mania (Scherk etal, 2007). Pharmacological Treatment of Acute Mania: First Line Combined Therapy – ◦ Lithium or Valproate plus Risperidone or Olanzapine or Quetiapine or Aripiprazole Pharmacological Treatment of Acute Mania: Second Line Carbamazepine, ECT Lithium + Valproate Asenapine Asenapine + Lithium or Valproate Paliperidone Pharmacological Treatment of Acute Bipolar I Depression: First Line Lithium Lamotrigine Quetiapine Lithium or Valproate + SSRI Olanzapine + SSRI Lithium + Valproate Pharmacological Treatment of Acute Bipolar I Depression: Second Line Quetiapine + SSRI Valproate Lithium or Valproate + Lamotrigine Adjunctive Modafinil Maintenance Pharmacotherapy for Bipolar: First Line Lithium Valproate Olanzapine Quetiapine Maintenance Pharmacotherapy for Bipolar: First Line Lithium or Valproate + Quetiapine Risperidone LAI – alone or adjunctive Aripiprazole (mania only?) Lithium or Valproate + Ziprasidone Maintenance Pharmacotherapy for Bipolar: Second Line Carbamazepine, Lithium & Valproate Lithium & Carbamazepine Lithium or Valproate & Olanzapine Lithium + Risperidone Lithium + Lamotrigine Olanzapine + Fluoxetine Conclusions The Bipolar Disorders are a group of mood disorders characterized by episodes of elevated mood and depression. The diagnosis of Bipolar disorder is often missed and delayed. Though elevated mood states define the disorder, patients spend more of their lives depressed. Conclusions The management of Bipolar Disorder requires a biopsychosocial approach ie a combination of psychotherapy and pharmacotherapy. Mood stabilizers are drugs which are used in bipolar disorder to ameliorate symptoms of mania, hypomania, bipolar depression and to prevent episodic relapse. Conclusions Lithium remains the gold standard mood stabilizer Valproate and Carbamzepine are classic mood stabilizers Increasingly atypical anti-psychotics are being used in bipolar patients and are showing effective mood stabilizing properties. Conclusions Choice of agent requires careful consideration and a weighing of the pros and cons. Most agents have potentially significant side effects, particularly over the long term. Combination of medications is often needed for effective treatment. Questions? Professor Graham Burrows Chairperson 2 Dr Angelo Ferraro FRANZCP Old Age Psychiatrist North West Aged Persons Mental Health Disclosure Statement I, or an immediate family member including spouse/partner, have at present and/or have had within the last 12 months, or anticipate NO financial interest/arrangement or affiliation with one or more organisations that could be perceived as a real or apparent conflict of interest in context to the design, implementation, presentation, evaluation, etc, of CPD activities – Angelo Ferraro, FRANZCP What is Cognition? Cognition: The process of knowing (which includes) being aware, thinking, learning, and judging…from the Latin root “cognoscere” meaning “to be acquainted with” 1 Memory: Is one important component of cognition, which includes other faculties such as attention, language (expression and comprehension), executive function, reasoning, visuospatial functioning 1 Adapted from Webster’s New World Medical Dictionary Memory Deficits Retrieval deficits versus Storage deficit Diagnostic significance Use of cues during recall Ultra Brief Cognitive Screening MINI-COG (Borson S, 2000, International Journal of Geriatric Psychiatry) 1. Remember 3 words 2. Draw a clock (11:10) 3. Recall 3 words, with cues if required Mini Mental Status Examination Not to be confused with the MSE MMSE, Folstein & Folstein. Maximum score 30 Orientation, Memory and Recall, Concentration, Language Weaknesses: Best for English speaking Anglo-Americans Excessive focus on language; no assessment of executive function Confusion re scoring – do standardised MMSE Montreal Cognitive Assessment (MOCA) www.mocatest.org Maximum score 30 Translated into several languages Incorporates testing of executive function Memory test and naming more difficult than the MMSE Rowland Universal Dementia Assessment Scale (RUDAS) http://www.rudas.com.au On line video training minimises the effects of cultural learning and language diversity on the assessment of cognition Maximum score 30 Factors influencing results Education Culture Normal aging IQ Ability and willingness to attend to task Distraction Cut off scores Is it normal ageing? Brain is an organ, like heart and kidneys When an older adult is interrupted while completing a task, it is likely that the original task at hand can be forgotten “..now what was I doing when I was interrupted..” source information is also impaired Ie. remembering the information but forgetting where they obtained the information Is it Mild Cognitive Impairment? Have more memory problems than would be accounted for by ageing able to accomplish their usual daily tasks Trouble remembering names, the flow of conversation, and a greater tendency to misplace things It can be difficult to define how much cognitive impairment is considered ‘more than normal’ Increased risk of developing dementia Depressive Pseudodementia Depressed Slow monotonous speech Long time to respond “I don’t know” responses Quick to give up Poor attention Incomplete responses Forgetfulness Aware of cognitive problems Believes they are going mad or losing their memory…”do I have Alzheimer’s? See, I can’t remember anything!” No evidence of aphasia, apraxia or agnosia Cognitive deficits of schizophrenia Memory, attention, executive function A subgroup of patients will worsen over time Neuroimaging findings overlap Disorders with cognitive symptoms active symptoms of mental illness: motivation, distraction. Medication related effects (eg anticholinergic, sedatives, APs, ADs, mood stabilisers) Substance misuse Visual and hearing deficits Neurodegenerative disorders Obstructive Sleep Apnoea Delirium Post surgery Active medical illness Normal Pressure Hydrocephalus Head injury Autoimmune/collagen vascular disorders Neoplasms Now what? Obtain an accurate and corroborated longitudinal history decline in activities of daily living? Exclude and treat reversible factors Driving Neuroimaging, organic screening, neuropsychological assessment Repeat testing Take home message The presence of cognitive deficits does not automatically signify the presence of dementia Assessment of cognition is the easy part – Interpretation of your findings is hard Questions? Afternoon Tea Update on Psychopharmacology Professor Nicholas Keks Monash University, Delmont Private Hospital Competing interests statement • During my career I have received research support, and/or acted as consultant to, and/or received travel support and/or received honoraria from Astra Zeneca, Eli Lilly, Novartis, Wyeth, Bristol Myer Squibb, Janssen, Sanofi Aventis, Organon, Lundbeck, Servier and Pfizer • During my career I have been employed by Government services and acted as consultant to Governments • I am affiliated with Monash University, the Mental Health Research Institute of Victoria, Epworth Healthcare & Delmont Private Hospital Issues • • • • • Antidepressants: Agomelatine Antipsychotics: asenapine Diagnostic assessment of psychoses Mortality and antipsychotic treatment Polypharmacy in management of psychoses Antidepressants 1 • tricyclics : imipramine (Tofranil) amitriptyline (Tryptanol) dothiepin (Prothiaden) clomipramine (Anafranil) • MAOIs : phenelzine (Nardil) tranylcypromine (Parnate) • moclobemide (Aurorix) • reboxetine (Edronax) • mianserin (Tolvon) • mirtazepine (Avanza) Antidepressants 2 • SSRIs : fluoxetine (Prozac, Lovan) sertraline (Zoloft) fluvoxamine (Luvox) paroxetine (Aropax) citalopram (Cipramil) escitalopram (Lexapro) • SNRIs: venlafaxine (Efexor) duloxetine (Cymbalta) desvenlafaxine (Pristiq) Melatonin (McCord & Allen, 1917) O NH CH3 H3C O N H N-acetyl 5-methoxy tryptamine (Lerner, 1958) Melatonin • So called because bovine pineal extract made tadpoles pigmented (McCord & Allen 1917) • Chemically characterised by Lerner, 1958 • Not till 1980s discovered melatonin is a non‐ photic messenger for circadian and diurnal rhythms • Melatonin is the primary circadian synchronising hormone in brain • With motor and mood implications Melatonin • A key synthesizer of biological rhythms and sleep • Secretion from pineal gland • is tightly coupled to light‐dark and seasonal cycles • Controlled by suprachiasmatic nucleus (SCN) located above hypothalamus • SCN has input from retina and feedback from melatonin Melatonin, 5‐HT and the SCN • • • • SCN is the neuronal master clock Input from light at retina via GLU path Outputs include pineal gland Melatonin is a potent agonist at MT1 & MT2 receptors in SCN • SCN also gets input from 5‐HT pathway originating in brainstem Raphe nuclei through 5‐HT2c receptor (as well as other 5‐HT receptors) Melatonin receptors • • • • Cloned in 1990s MT1 & MT2 High density in suprachiasmatic nucleus Also in hippocampus, hypothalamus, frontal cortex, cerebellum, thalamus • Possibly much more extensive physiological role than currently known Chronorhythms in depression • • • • • • Alterations in mood: diurnal variation Changes in sleep e.g. EMW, delay in REM onset Cortisol secretion peak earlier Core body temperature alterations Mostly phase advances But seasonal affective disorder associated with phase delay • Atypical/bipolar depression Melatonin in depression • Nocturnal melatonin pulse blunted • Less melatonin is released in depression • Melatonin levels rise as antidepressants improve depression • Melatonin improves sleep in depression • But melatonin is not an effective antidepressant Chemical structures of agomelatine and melatonin O Melatonin NH Agomelatine NH CH3 CH3 H3C O H3C N H O O Agomelatine • • • • • • Naphthalene derivative of melatonin Potently binds MT1 & MT2 receptors Mimics action of melatonin Inhibits firing of SCN α dose Alters protein synthesis within SCN neurones Normalizes disturbance of circadian rhythms (resynchronization) • Antagonises 5‐HT2c receptor Resynchronising effect of agomelatine • In animals and humans, agomelatine reinstates normal circadian rhythms • effect is via SCN, not pineal • Works for both phase delay and phase advance • Needs only 1 hour of effect daily, maximal at light‐dark transition • Effect by initiating intraneuronal protein synthesis to alter SCN neuronal function Agomelatine and 5‐HT2c receptors • Modest but effective antagonist • SCN 5‐HT2c receptors mediate input to ‐VTA: Dopamine pathways ‐locus coeruleus: Noradrenergic pathway • 5‐HT2c receptors are overactive in depression and anxiety • Antagonism of SCN 5‐HT2c receptors enhances frontal NA and DA Noradrenergic and serotonergic pathways Dopaminergic pathways Agomelatine: mechanism of antidepressant activity • Neither agonism at MT1 & MT2 receptors nor antagonism at 5HT2C receptors can individually explain MOA • synergistic action at melatonin and 5HT2C receptors needed to explain antidepressant activity in models • Antidepressant properties of agomelatine result from actions at MT1, MT2 and 5HT2C receptors Antidepressant efficacy of agomelatine versus SSRIs and SNRI after 6/8 weeks HAM-D17 total score 0.92 CGI-I total score NS 1.49 P=0.024 NS 1.46 -1 0 Favours comparator 1 2 Favours Agomelatine 0.29 vs sertraline vs escitalopram 1.37 P<0.001 3 NS 0.18 vs fluoxetine P=0.031 1.68 0.19 -0.2 P=0.023 NS 0.24 P<0.001 META META ANALYSIS ANALYSIS 4 P=0.016 0.32 vs venlafaxine -0.1 Favours comparator 0.0 0.1 0.2 0.3 0.4 0.5 0.6 Favours Agomelatine Agomelatine 25-50 mg (N=630) sertraline 50 -100 mg, fluoxetine 20-40 mg, venlafaxine 75 -150 mg, escitalopram 10 -20 mg (N=642) (Kasper et al. Europ Neuropsychopharmacol 2010 Volume 20, Supplement 3, Page S348) Comments: agomelatine • not hypnotic, sleep benefit takes days/weeks • dose 25 to 50mg but tested to 100mg nocte • contraindicated in active liver disease/cirrhosis; hepatic metabolism therefore probably need wide dose range • do LFT at baseline, 6, 12, 24 weeks and as needed (1% elevation, higher at high doses eg 1.5% at 100mg) • nausea, dizziness and headache at same rate as placebo, no weight gain, sexual dysfunction, or cardiac issues Classification of psychoses Psychoses Medical cause • Drug intoxication • Drug withdrawal • Metabolic • Endocrine • Brain disease • Epilepsy • Infective, eg AIDS No identifiable medical cause Bipolar mood disorder Schizophrenia (including schizophreniform and schizoaffective) and other disorders, (delusional disorder/paranoid psychosis, psychotic depression, etc) Symptom dimensions in psychoses • Positive (delusions, hallucinations, positive formal thought disorder) • Negative (flat affect, poverty of thought, amotivation, withdrawal) • Cognitive (executive function, concentration, working memory) • Affective (elevated, depressed, mixed) • Anxiety/obsessive compulsive Typical antipsychotics • Low potency: – chlorpromazine (Largactil) • High potency: – – – – – – – – – – haloperidol (Serenace) haloperidol decanoate (Haldol) trifluoperazine (Stelazine) pericyazine (Neulactil) pimozide (Orap) droperidol fluphenazine decanoate (Modecate) zuclopenthixol acetate (Acuphase) zuclopenthixol dec (Clopixol) flupenthixol dec (Fluanxol) Novel/atypical antipsychotics • • • • • • • • • • risperidone (oral & injectable) olanzapine (oral & injectable) quetiapine (IR & XR) clozapine amisulpride aripiprazole ziprasidone paliperidone (oral & injectable) sertindole asenapine Asenapine Mirtazepine Asenapine • Asenapine belongs to dibenzo‐oxepino pyrrole family • The structure of asenapine is unlike other antipsychotics • still effectively a serotonin dopamine antagonist with noradrenergic and antihistaminic properties • non‐anticholinergic Clinical implications • • • • • Serotonin blockade: nausea, headache Noradrenergic: postural hypotension, dizziness Antihistaminic: sedation, weight gain Antidopaminergic: EPS, prolactin No anticholinergic effect (dry moth, blurred vision, urine difficulties, constipation, tachycardia, memory, delirium) Asenapine pharmacokinetics • Poor bioavailability unless taken sublingually and nil orally for 10 minutes afterwards • Biphasic elimination; terminal half life about 24 hours • Steady state in 3 days • Hepatic metabolism CYP1A2 (fluvoxamine) & CYP2D6 • Recommended to be taken BD (? to minimise EPS) but mostly used nocte in USA Asenapine: clinical effectiveness • RCTs in acute schizophrenia and relapse prevention indicate effectiveness of comparable level to risperidone • RCTs in bipolar disorder indicate effectiveness for mania and for manic and depressive symptoms in mixed states • Also effective long‐term in bipolar, equivalent to olanzapine Asenapine: clinical effectiveness • Real‐life clinical experience indicates asenapine is an effective antipsychotic • Useful in mood disorders • May have benefit for depression • Probably milligram equivalent to olanzapine. Asenapine: tolerability • • • • • • • Sedation (< olanzapine) Oral hypoaesthesia & bitter taste Akathisia and EPS (low but > nil risk) Dizziness and postural hypotension About half weight gain of risperidone Prolactin effect minor (similar to olanzapine) NO anticholinergic effects (very important if changing from cholinergic drug eg olanzapine or quetiapine) Cautions (all appear to be equivalent to class effects) • • • • • • CVA in elderly; use smaller dose Neuroleptic malignant syndrome Seizures Diabetes QTc prolongation Pregnancy and lactation Using asenapine • • • • Start 5mg nocte or 5mg BD Increase as needed to 10mg BD Most patients tolerate nocte dose eventually Instruct not to touch tablet but to remove cover and keep tablet in foil to apply to bottom of tongue • Always warn about 10 minute eat/drink rule, numbing of tongue and bitter taste Tiihonen et al, Lancet, 2009 • Long‐term antipsychotic use associated with lower mortality than no AP use • Clozapine associated with much lower mortality than other APs • Combination APs caused lower mortality than risperidone and quetiapine monotherapies (Tiihonen et al, 2009) Antipsychotic risk benefit evaluation • Enormous emphasis on risk e.g. metabolic syndrome • De‐emphasis of benefits, mixed up with dispute about whether SGAs are more effective than FGAs • Tiihonen study strongly suggests that undertreatment can, with adverse effects taken into account, increase mortality • Clear support for the benefit of treatment. Antipsychotic polypharmacy • Clinically, the use of two or more antipsychotics at the same time is very common • Meta‐analyses have suggested that antipsychotic combinations may be more effective than monotherapy • Tiihonen suggests polypharmacy causes less mortality than monotherapy • CPGs still advocate antipsychotic monotherapy (Correll et al, Schiz Bull, 2009) Polypharmacy: Tiihonen et al, 2012 • 7 year study in 2588 Finnish registry patients hospitalised with first episode schizophrenia • Use of antipsychotic combinations did not increase mortality • Benzodiazepine use was dissociated with a marked increase in mortality • Antidepressant use was dissociated with decrease in suicide (Archives Gen Psychiatry 69:476, 2012) Polypharmacy in psychoses • Generalisions about polypharmacy are none‐ sense • Some combinations are useful and safe • Dose optimisation is also essential for effective treatment • Personalised medicine Psychopharmacology masterclass • • • • • Saturday October 6 9.45am – 4pm Delmont Private Hospital 300 Warrigal Rd Glen Iris [email protected] Questions? Diagnosis and Formulation Dr. Ajit Selvendra Consultant Psychiatrist St. Vincent’s Mental Health 205 Topics Covered – The process of diagnosing psychiatric conditions – Review diagnostic classification systems and approaches used in psychiatry (including upcoming changes in DSM) – Use of a Multi-Axial Diagnostic system – Developing a Formulation of the person’s current presentation and context 206 What is a Diagnosis? Why Diagnose? 207 Diagnosis – definition Medicine a) The act or process of determining the nature and cause of a disease or injury – done through evaluation of patient history, examination, and review of laboratory data b) The opinion derived from such an evaluation 208 Why Diagnose? – A means of communication between healthcare staff, and between research and clinical practice – to assist in understanding the underlying aetiology of the patient’s clinical features – gives an indication of future prognosis and possible trajectory of a condition – allows the development of specific treatments – Allows research with inter-rater reliability and replicable clinical trials – (used by departments and government for funding and legal purposes) 209 Current Diagnostic Classification Systems – DSM IV TR (American Psychiatric Association, 2000) – Diagnostic and Statistical Manual of Mental Disorders (originally developed as DSM I in 1952) – ICD-10 (World Health Organisation, 1990) – International Classification of Diseases and related Health problems (ICD-6 first included Mental Health Disorders) Historical: – Some psychiatric terms and the criteria required to diagnose conditions have changed over time 210 – New conditions have been added Future DSM 5.0 May 2013 ICD-11 2014 Similar psychiatry classifications to DSM Australian hospitals use ICD coding systems 211 Commonly used DSM IV Adult Psychiatric Diagnoses and Groupings: Psychotic Disorders –Schizophrenia –Schizoaffective Disorder –Delusional Disorder Substance Abuse Disorders (Drug or alcohol-related) Anxiety Disorders –Generalised Anxiety Disorder –Obsessive Compulsive Disorder –Social Anxiety Disorder –Specific Phobia –Post-traumatic Stress Disorder –Panic Disorder Mood Disorders – Major Depressive Disorder – Bipolar Disorder - I and II – Cyclothymic Disorder – Dysthymic Disorder – Substance-Induced Mood Disorder – Mood Disorder due to a General Medical Condition – Substance-Induced Mood Disorder – Mood Disorder NOS Somatoform Disorders (Physical disorders which have a psychological component) Personality Disorders 212 Additional DSM IV Diagnostic Groupings – Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence – Delerium, Dementia, and Amnestic and Other Cognitive Disorders – Mental Disorders Due to a General Medical Condition – Factitious Disorders – Dissociative Disorders – Sexual and Gender Identity Disorders – Eating Disorders – Sleep Disorders – Impulse- Control Disorders Not Elsewhere Classified – Adjustment Disorders 213 Definitions and Concepts Syndrome – cluster of signs and symptoms that occur together and are characteristic for a specific disorder e.g. Major Depressive Episode – depressed mood, weight loss, insomnia, feelings of worthlessness or excessive guilt, suicidal ideation DSM-IV Approach Categorical approach – each diagnosis is separate Criteria-based diagnostic system Uses standard prototypes as “best examples” with vague or fuzzy boundaries But: –a) cases sometimes fit criteria for two disorders – b) sometimes need to distinguish the boundary between normal variants and pathology/illness –c) atypical presentations - there are variable presentations that are different from standard ‘prototype’ clinical case 214 DSM IV General Criteria and Concepts The disorder causes clinically significant distress or impairment in social, occupational or other important areas of functioning Diagnosing multiple conditions is possible except within certain rules: 1. Disorder is not due to the direct effect of a substance or a general medical condition (requires a substance or medical related diagnosis) 2. Precedence of Diagnoses: eg. pervasive disorder is more important (pervasive – how extensively symptoms permeate patient’s life in terms of their type, duration and intensity) –“has never met the criteria for…” –“does not occur exclusively during the course of” 3.Clinical judgement is necessary “not better accounted for by” eg. Specific phobia – “Not better accounted for by Panic Disorder with 215 agoraphobia” What are the psychotic disorders? What is Psychosis? – A condition which affect the mind, where there has been some loss of contact with reality. Features: – Hallucinations – Hallucinations involve sensing things while awake that appear to be real, but instead have been created by the mind. Can occur in any sensory modality Eg. hearing voices which no-one else can hear, or seeing things which aren’t there – Delusions – a fixed false belief which is held with absolute conviction, not amenable to reason, not culturally appropriate. E.g. from the way cars are parked outside my house the police are watching me. – Disorganisation of speech, thought or behaviour. Thought Disorder often includes deficits in higher 216 intellectual or executive functioning, eg, making plans Common Subtypes of Psychosis – – – – – – – – – Brief Psychotic Disorder /Schizophreniform Disorder Schizophrenia Schizoaffective Disorder Delusional Disorder Substance Induced Psychotic Disorder (specify substance) Psychotic Disorder due to General Medical Condition(specify condition) Psychotic Disorder Not Otherwise Specified Bipolar Disorder with psychotic features (manicdepressive psychosis) Major Depressive Disorder with Psychotic Features 217 Schizophrenia – DSM-IV 218 Schizophrenia A. Characteristic Symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): -delusions -hallucinations -disorganised speech -grossly disorganised or catatonic behaviour -negative symptoms i.e. Affective flattening, alogia or avolition 219 Schizophrenia ctd. – B: Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one of major areas of functioning such as work, interpersonal relations, or self care are markedly below the level achieved prior to the onset – C Duration: Continuous signs of the disturbance persist for at least 6 months including at least 1 month of active symptoms (or less if successfully treated) and may include periods of prodromal or residual features 220 Schizophrenia ctd. – D Schizoaffective disorder and mood disorder exclusion: Schizoaffective disorder and mood disorder with psychotic features have been ruled out – E Substance/general medical condition exclusion The disturbance is not due to the direct physiological effect of a substance (e.g. drug of abuse, a medication) or a general medical condition – F Relationship to a Pervasive Developmental Disorder: If there is a history of pervasive developmental disorder then diagnose only if prominent delusions or hallucinations are also present for at least a month 221 Process of Making a Diagnosis Case Example - Psychosis 222 Changes in Presentation and Diagnosis Over Time Level of Activity and Functioning Mr ZZ. 18 year old male and a first year university student. Has a few friends and doing reasonably at university. A C B 19 years 20 years 21 years Age 223 SITUATION A – Keeping to self the past few months, lot of time in his room, does not see friends – known to be smoking marijuana but not talking about it – Not going to university regularly, academic results down – Not very communicative, isolates himself, – He appears worried, anxious and upset – Some odd ideas which occur particularly after smoking marijuana 224 SITUATION A DIAGNOSES: – “At Risk Mental State” or Ultra-High Risk (prodrome) group – Major Depressive Disorder – Anxiety Disorder – Personality Disorder or personality traits – Drug or alcohol issues – No clear diagnosis but stressors such as social, family, work or study pressures – No specific condition 225 Case Example Level of Activity and Functioning A C B 19 years 20 years 21 years Age 226 SITUATION B – Deterioration over past 2-3 weeks – Has lots of plans and ideas, some are odd and not practical – Believes that his room is being invaded by groups of people, and there is surveillance happening in the house. Mr. ZZ feels people are communicating with him by special means – Mr. ZZ claims to have done things to protect himself and defend his room but will not reveal what they are. He stated once that he has special abilities – Very disorganised, sleep very poor, up at all hours of the night 227 SITUATION B DIAGNOSES: – “1st Episode Psychosis” – Substance Induced Psychosis(cannabis) – Schizophreniform Psychosis Schizoaffective Psychosis/ Manic phase of Bipolar Disorder with Psychotic Features – Psychotic disorder due to general medical condition (Organic Psychosis) 228 Case Example Level of Activity and Functioning A C B 19 years 20 years 21 years Age 229 SITUATION C – Increasing worry about surveillance over the past few days – Starting to keep to self again, states there are probably other people out to do something nasty. Not clear on details – Increasingly awake at night, less organised in activities, not getting things finished – Ongoing marijuana use – Parents concerned, bring him in for help, he is refusing help, stopped medications 230 Situation C Clearer Diagnosis – Schizophrenia – (Possibly additional diagnosis of Substance Abuse Disorder) Differential Diagnoses: – Bipolar Disorder with psychotic features – Schizoaffective Disorder 231 Diagnosis at First Presentation – 164 cases Diagnosis at 3 Months Considerations and Approach to Diagnosis: – Review Severity and Clinical Features – Rule out disorder due to direct effect of a general medical condition or substance use – Develop a Diagnosis and Differential Diagnosis – Determine specific primary disorder(s) • Multiple diagnoses • Some hierarchies in diagnoses (ie. not better accounted for by….) 234 Considerations in Diagnosis: – Establishing boundary with no mental disorder i.e. clinically significant/ culturally appropriate behaviour – Distinguish Adjustment Disorder (response to a stressor) and Not Otherwise Specified (NOS) – Add subtypes/specifiers : severity (mild moderate, severe – with or without psychotic features) treatment relevant (psychosis – subytypes, depression -melancholic, atypical, etc.) longitudinal course (with/without full inter235 episode recovery, depression -seasonal pattern) Challenges in Diagnosis Diagnostic Uncertainty and Role of Clinical Judgement Natural variance – occurs normally in natural world, varies individual to individual Information variance – the amount and type of clinical information collected varies, due to sources and patient’s different reports Observation and interpretation variance – different clinicians focus on different parts, attach different significance to a feature. Especially difference between normal/pathological – behaviour, mood, thought Criterion variance – different criteria systems 236 Initial Assessment Requirements – – – – – – Complexity of initial presentation Risk assessment Location of treatment Consider medium term treatment requirements More comprehensive history Initiation of treatment, review likelihood of compliance/treatment – Comorbidity - assessment 237 Approaches Depression in Medically ill –Inclusive –Exclusive –Aetiological –Substitutive Investigations used in Psychiatry 238 Brain Changes in Schizophrenia, Established by Systematic Reviews – – – – – – Enlargement of lateral and third ventricles (+25-40%) Smaller brain volumes (-3%) Smaller cortical volume (-4%) Smaller Grey matter volume (-6%) Relatively smaller medial temporal lobe volume (*-5%) Relatively smaller thalamic volume (-4%) Other replicated findings: – Decrease or loss of cerebral asymmetries Adapted from Harrison PJ, 2000 239 Course of Schizophrenia Inter-rater reliability (Francis, 2012) 241 DSM-III Changes - Descriptive Non-etiologic focus Diagnostic criteria Multiaxial system Multiple diagnoses Splitting Reliability 242 Diagnostic Systems DSM 5 Challenges: –Diagnoses reified –Dimensional vs Categorical –Inter-rater reliability –Over-medicalisation and stigmatisation 243 Unintended consequences – Financial and legal uses – Media and public perception – Diagnosis used as entry requirement into accommodation, social security and other benefits Oversimplification Eg. Brief consultations and less skilled clinicians 244 What is in DSM-IV – Systematic framework for diagnosis (including Multiaxial system) – Diagnostic criteria – Detailed explanatory text – Names and codes (from ICD-9) – Appendices to expand educational/practical utility 245 Multi-Axial System of Diagnosis Axis I - Clinical Disorders Axis II – Personality Disorders and Mental Retardation Axis III – General Medical Conditions Axis IV – Psychosocial and Environmental Problems Axis V – Global Assessment of Functioning (GAF) 246 Axis II – Disorders Arising in the Developmental Period Personality Disorders: –An Enduring pattern of inner experience and behaviour that deviate markedly from expectations of the individual’s culture. Pattern is manifested in two(or more ) of the following areas: 1. Cognition 2. Affectivity 3. Interpersonal Functioning 4. Impulse Control –Enduring pattern is: inflexible and pervasive –leads to clinically significant distress or impairment in functioning –stable , long duration and onset traced to adolescence or early adulthood 247 DSM IV Types of Personality Disorders Cluster A – “odd, eccentric, isolative or suspicious behaviour” –* Paranoid Personality Disorder –Schizoid Personality Disorder –* Schizoptypal Personality Disorder Cluster B - “dramatic, emotional, erratic or impulsive behaviour or a reduced capacity for empathy” –* Antisocial Personality Disorder –* Borderline Personality Disorder –Histrionic Personality Disorder –Narcissistic Personality Disorder Cluster C – “anxious, fearful or perfectionistic behaviour” –Avoidant Personality Disorder –Dependent Personality Disorder –Obsessive Compulsive Personality Disorder 248 Axis V – Global Assessment of Functioning Numerical scale (0 through 100) to subjectively rate the social, occupational, and psychological functioning of adults, e.g., how well or adaptively one is meeting various problems-in-living: –81 - 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members) –51-60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). –41 - 50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). –11 - 20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute 249 Sample DSM Diagnosis Case of ZZ , after treatment of Stage B: Axis I Schizophrenia – (Single Episode, in Partial Remission) Cannabis Abuse Disorder Axis II Diagnosis Deferred Axis III Nil Axis IV Problems with primary support group (disruption of family) Educational problems (difficulties at university) Axis V GAF Score During episode 25 Current 60 250 FORMULATION - Why does this patient suffer from these problems at this particular time? – An integrated understanding of this unique individual, describing his/her vulnerabilities and resources and how he/she comes to be in the current predicament – Highlight possible linkages between factors and this presentation – A hypothesis – General types of Contributory Factors: – Biological – Psychological – Social – Also provide a broad description of the mechanism of contribution: Predisposing Precipitating Perpetuating Protective 251 Formulation ctd. – Identify key contributing factors for the presentation – Attempt to suggest a clearer mechanism of contribution i.e. how each factor may have contributed – this may require knowledge of various theories and concepts: biological (genetic, physical illness etc.) psychological (psychodynamic and cognitive behavioural) social (family systems theory etc.) – Advanced: develop skills in various styles of formulation & tailor approach to the type of case e.g. diagnostic dilemma, predominant biological focus, or psychological focus 252 Grid of Contributing Factors Biological Psychological Social Predisposing “vulnerable to this condition because of…..” Underlying medical conditions, Genetics, childbirth issues Early attachment & relationships, personality traits (eg. obsessional) Social avoidance, Social isolation, Unemployment, Family history of illness Precipitating “This Episode was triggered by….” Cannabis use Lack friendships, Academic pressures and trying to keep up Perpetuating “He remains vulnerable to this due to….” Ongoing cannabis Poor insight and use acceptance of condition Decision to continue at University Difficult family environment Protective “On the other hand his strengths are….” Maturity of personality Supportive parents Reasonable engagement with Mental Health Service 253 Variety of Trajectories and phases 254 Genetics of Schizophrenia – CNV's (Copy Number variants) - deletion or duplication of nucleotide pairs – Relatively rare, explain small amount of variance of schizophrenia – Usually also associated with other conditions - intellectual disability, autistic spectrum disorders and epilepsy (Levinson, AJP 2011) – risk alleles – Endophentypes – Associated with disorder, present whether ill or active – found in non-affected family members>general population (Gottesman and Gould 2003) 255 Potential Mechanisms (Stefanis, 2012) Genes Cells Systems Behaviour multiple susceptibility alleles each of small effect subtle molecular abnormalities abnormal information processing complex functional interactions and emergent phenomena Cognition behavioural phenotypes temperament 256 The Stress Vulnerability Model Genetic Vulnerability Early trauma Substance use Death of a loved one Work stress Relationship break-up Psychosis Protective Factors Medication Coping Skills Social Network 257 Formulation Presentation – Paragraph 1: Brief introduction of case and context – few lines – Paragraph 2: Highlight important factors which explain this case “Vulnerable to….because….” – Exercise judgement in which factors to choose – Paragraph 3: Make links between vulnerabilities and current presentation: (suggest a mechanism in some cases). Utilise theories if appropriate Eg. his childhood conflict with parents resulted in noncompliance and conflict with authority figures Eg. Childhood abuse resulted in guilt/lower selfesteem/poor self-image later contributed to depression 258 Summary – DSM diagnosis is categorical and criteria based, but it is important to understand the broader clinical scenario – Explored benefits and limitations of systems – Explored skills required to make a clear diagnosis and differential diagnosis, and to be able to discuss pros and cons of each diagnosis – Broader case presentation skills include: Multi-Axial Diagnosis Case Formulation 259 Comments ? Additional Reading / References –American Psychiatric Association, Diagnostic and statistical manual of mental disorders (4th ed.) ,1994, Washington, DC –Fauman M, Study Guide to DSM-IV American Psychiatric Press, 1994, Washington DC –American Psychiatric Association - DSM V website –Royal Australian and New Zealand College of Psychiatrists RANZCP Formulation Guidelines for Candidates, Trainee Clinical Examination 01/11/2004 260 Questions? Panel Discussion Psychiatric Essentials 31 August 2012 Thank you