2. Psych [2] Flashcards
Describe 4 clinical features that PTSD may present with.
Hyperarousal; hypervigilance, sleep problems, irritability, difficulty concentrating, exaggerated startle response
Avoidance, of people and place related to event
Re-experience e.g. flashbacks, nightmares, intrusive memories
Emotional numbing
Complex PTSD is defined as PTSD but has 3 additional groups of symptoms. What are these?
Negative / unstable sense of self / self concept
Dysregulation of affect
Disturbance in relationships
What are the options for treatment of PTSD?
In mild cases, watching and waiting can be useful, with advice about sleep hygiene etc, and regular follow ups.
CBT
EMDR (eye movement desensitization and reprocessing); patient is asked to think about the trauma whilst attending to other sensory stimulus e.g. flashing lights
SSRI or venlafaxine can also be used
Severe / refractory; may be able to add in antipsychotic e.g. risperidone if severe hyperarousal / psychotic features and no response to other treatments.
Risk factors for PTSD can be split into person-factors and event factors. Give some of each.
Person:
Hx of previous trauma
Hx of previous mental health diagnosis
Lower socioeconomic status
Female
Younger age
Certain professions
Multiple other major stressors at time of event
Low social support
Refugees and asylum seekers
Event:
Increased severity of event
Longer duration of event/s e.g. years of child abuse or torture
Intentional > accidental
Physical injury included in traumatic event
What is the prognosis of PTSD?
50% self resolve in 3 months.
1/3 have moderate / severe symptoms lasting for years.
Can present straight after the event, but 15% may present years later.
Patients with PTSD are more likely to have other medical problems e.g. drug and alcohol abuse, GI symptoms, cardiorespiratory symptoms etc.
ASD involves impaired social interaction, social communication and behaviours. Give some clinical examples of how each of these areas may present in an individual with ASD.
Communication:
Delay / regression in language development.
Repetitive use of words or phrases.
Lack of eye contact / non-verbal communication.
Difficulty with imaginative play etc.
Interaction:
Cannot understand non-verbal social cues.
Avoids physical contact.
Doesn’t make eye contact.
Difficulty making friendships.
Behaviours:
Interest in objects / patterns / numbers over people.
Rigid routine and repetitive behaviours and anxiety and distress when this is disrupted.
Stimming / self stimulating e.g. hand flapping, rocking
Deep, intense interests.
Restricted food habits.
ASD is a highly heritable condition, with a heritability of around 80%. Substantial proportion of this risk arises from sporadic mutations, and the same genetic variants can increase risk of neurodevelopmental disorders. What other conditions are linked to the genes that have been linked to ASD?
Intellectual disability
Epilepsy
ADHD
Schizophrenia
3 areas that ASD affects:
Social communication
Social interaction
Behaviour
Describe briefly the heritability and risk factors for ADHD.
Highest heritability of all psychiatric disorders, ~80%.
First degree relative of someone with ADHD has 20% chance of having it also.
Prenatal, perinatal and postnatal environmental factors also increase risk: maternal smoking, alcohol and heroin use during pregnancy, very low birth weight, fetal hypoxia, perinatal birth injury, prolonged emotional neglect during infancy.
ADHD symptoms can be split into 2 groups, and individuals may display mainly one or the other, or both. What are the two groups and give examples.
Hyperactivity / Impulsivity:
Can’t sit still, fidgets, restless.
Talks excessively.
Difficulty taking turns.
Poor risk perception, reckless.
Inattention:
Difficulty focusing on tasks especially those that are mundane, doesn’t finish tasks, careless mistakes etc.
Easily distracted, seems like isn’t listening, frequently ‘daydreaming’.
Difficulty with organisation, e.g. day to day tasks, forgetful.
Give some differentials for attention deficit in adults.
ADHD
Secondary to substance use
Intellectual disability
Secondary to other psychiatric disorder e.g. schizophrenia, depression
Brain injury
Neurodegeneration e.g. depression
First line management of ADHD is always environmental modification and parenting skill support. Give some examples of these.
School age: seating plan arrangements, support of a teaching assistant.
Use of headphones to reduce distractions.
Regular movement breaks during tasks.
Reinforcing verbal instructions in writing.
If despite optimal environmental modifications the child is still experiencing significant impairment, medication can be offered. Outline the medication options and the order of which they may be tried.
Methylphenidate; CNS stimulant. Comes in short acting form of Ritalin and other modified release forms e.g. Concerta XL, Xaggitin XL etc. FIRST LINE IN CHILDREN.
Lisdexamfetamine 2nd line if 6 week trial of methyphenidate at adequate dose not working / side effects.
Atomoxetine and Guanfacine = 3rd line.
Describe when a diagnosis of ADHD should be considered.
At least 6 (5 in adults) symptoms of hyperactivity/impulsivity or inattention symptoms are present.
Present for >6 months and interfering with educational or occupational performance.
Symptoms started before age 12.
Present in 2 settings or more.
Cannot be explained by another disorder.
Name 3 drugs used to treat ADHD.
Methylphenidate
Lisdexamfetamine
Atomoxetine
Guanfacine
Describe the mechanism of lisdexamfetamine and prescribing notes.
It’s a pro-drug that is metabolised to dexamfetamine by an enzyme in red blood cells. This limits the rate at which dexamfetamine is generated, limiting its potential for abuse.
However, some patients benefit from the faster on-off times that dexamfetamine straight provides. Can try this as a second option after trial of lisdexamfetamine.
What associations with methylphenidate might a parent come to you with concerns about, and how is this monitored?
Growth suppression with prolonged use.
Regular weight and height monitoring is always indicated, every 6 months, and drug holidays can be used to allow for catch-up growth.
What is the MOA of methylphenidate? And give some side effects.
CNS stimulant; primarily acts as a dopamine and noradrenaline reuptake inhibitor.
Growth suppression, abdo pain, nausea, dyspepsia.
Stimulants are sympathomimetic, and can potentially suppress appetite.
What investigation must be done prior to starting ADHD medication and why?
Baseline ECG, as all of these drugs are potentially cardiotoxic.
What is recommended as first line treatment for bulimia nervosa, and what does it involve?
BN-GSH; bulimia nervosa guided self help.
Helps to:
Understand their eating disorder
Develop coping strategies for binge-purge cycles
Develop healthier attitudes towards food and body image
Monitor their own symptoms
When should CBT be considered for bulimia nervosa?
If BN-GSH has been trialled for 4 weeks with no improvement.
Bulimia nervosa is an eating disorder characterised by:
Binge eating episodes followed by purgative behaviours including intentional vomiting, use of laxative / diuretics and excessive exercise.
Describe the DSM-5’s diagnostic criteria for bulimia nervosa (6 bullet points).
Recurrent episodes of binge eating.
Lack of control during episodes.
Recurrent inappropriate compensatory mechanisms to prevent weight gain.
Episodes occur at least once a week for 3 months.
Self evaluation is unduly influenced by body shape.
Does not occur exclusively during periods of anorexia nervosa.
Give some complications of anorexia nervosa.
Cardiac arrhythmias due to electrolyte imbalance, hypotension, bradycardia.
Osteoporosis due to chronic malnutrition, amenorrhoea.
Gastroparesis and constipation.
Anaemia and leukopenia.
Lanugo hair growth and xerosis (dry skin).
Death due to multiorgan failure.
Give 3 points described in the DSM-5 for the diagnosis of anorexia nervosa (3).
- Restriction of eating leading to significantly low body weight in context of age, sex, developmental stage etc.
- Intense fear of gaining weight.
- Disturbance in body perception, unaware of own body weight or shape, undue weight on body image when considering sense of self.
