4.9 - Psychiatry across the lifecourse

Question 1

What kind of approach does the biopsychosocial model allow?

Answer 1

Systemic approach (focus on relationships and social context e.g. school, family)

Question 2

What are the four Ps of formulation in the biopsychosocial model?

Answer 2

• predisposing factors (firewood)
• precipitating factors (the spark - triggers)
• perpetuating factors (someone adding in firewood)
• protective factors (someone putting out fire - support, treatment)

Question 3

What % of global burden of disease and injury in people aged 10-19 years do mental health conditions account for?

Answer 3

16%

Question 4

What age do mental health conditions generally start?

Answer 4

Half of all mental health conditions start by 14 years of age but most cases are undetected and untreated

Question 5

What are Erikson’s Stages of Psychosocial Development? (approximate age - psychosocial crisis/task - virtue developed)

Answer 5

• infant to 18 months - trust vs mistrust - hope
• 18 months to 3 years - autonomy vs shame/doubt - will
• 3 to 5 - initiative vs guilt - purpose
• 5 to 13 - industry vs inferiority - competency
• 13 to 21 - identity vs confusion - fidelity
• 21 to 39 - intimacy vs isolation - love
• 40-65 - generativity vs stagnation - care
• 65+ - integrity vs despair - wisdom

Question 6

What is it important to know about the adolescent brain?

Answer 6

• the prefrontal cortex matures later than the cortical areas associated with sensory and motor tasks
• adolescence is a period of neural imbalance caused by early maturation of subcortical brain areas and delayed maturation of prefrontal control areas

Question 7

What is the peak age of onset for attention deficit hyperactivity disorder (ADHD)?

Answer 7

12

Question 8

What is the peak age of onset for autism spectrum disorder (ASD)?

Answer 8

9

Question 9

What is the peak age of onset for eating disorders?

Answer 9

17

Question 10

What is the proportion of individuals with onset of any mental disorders before the age of 18?

Answer 10

48.4%

Question 11

Match the condition with the case description:
10yo girl, does not want to sleep in the room alone, gets raised heart rate, sweating and difficulty breathing in crowded places and does not like doing presentations in class

Answer 11

Anxiety disorder

Question 12

Match the condition with the case description:
10yo boy, several attendances to GP and emergency department with recurrent abdominal pain, no physical cause found so far

Answer 12

Somatisation disorder (bodily distress disorder)

Question 13

Match the condition with the case description:
15yo young woman with tiredness, sleeping 12h/day, irritability and reduced enjoyment from her hobbies

Answer 13

Depressive disorder

Question 14

Match the condition with the case description:
4yo boy, language is behind peers in class, does not interact much with others, prefers watching buses/trains to playing in playground

Answer 14

Autism spectrum disorder

Question 15

Match the condition with the case description:
8yo boy who has been fidgeting in lessons, speaking out of turn and struggling to stay focused on homework tasks

And what is this treated with?

Answer 15

ADHD (treated with amphetamines)

Question 16

Match the condition with the case description:
9yo boy, has been using increasing amounts of alcohol hand gel, wearing rubber gloves when going outdoors and lining up the toys in his room before going to sleep

Answer 16

Obsessive compulsive disorder (OCD)

Question 17

Match the condition with the case description:
10yo boy with involuntary movements in the face, neck and arms as well as making sounds which are not context-appropriate

Answer 17

Tic disorder / Tourette’s syndrome (if severe enough)

Question 18

Match the condition with the case description:
15yo young man with conduct disorder has been truanting from school and stealing mother’s credit cards; he was found smelling of cannabis, and more recently has been smoking it in his bedroom

Answer 18

Substance misuse

Question 19

Match the condition with the case description:
16yo young woman who has been cutting herself with a razor when feeling distressed, and recently has bough several packets of paracetamol

Answer 19

Self-harm

Question 20

Match the condition with the case description:
14yo girl who has been spending a lot of time thinking about her weight, has cut out carbohydrates from her diet, has been skipping breakfast and is using grandfather’s laxatives to lose weight

Answer 20

Eating disorder (anorexia nervosa)

Question 21

What are the basic similarities/differences between anorexia nervosa and bulimia?

Answer 21

• both can involve binging and purging (e.g. using laxatives and exercise)
• anorexia nervosa involves weight loss
• bulimia is normal/increased weight

Question 22

What are the core features and diagnostic criteria for ADHD according to the DSM-V? (7)

Answer 22

• persistent pattern of inattention and/or hyperactivity-impulsivity
• present for at least 6 months
• inappropriate for their developmental level
• interferes with functioning or development
• several symptoms present before age 12
• several symptoms present in two or more settings
• the symptoms are not better explained by another mental disorder

Acronym: ADHD MEMO

Attention, Duration (>6mth), Hyperactivity, Developmentally inappropriate
Multiple settings, Early onset (<12y), functional iMpairment, Other conditions ruled out

Question 23

What are the genetic risk factors for ADHD? (4)

Answer 23

• no isolated gene for ADHD, there are likely multiple genes conferring vulnerability for developing it
• twin studies have shown a significant heritability for ADHD - as high as 76%
• first degree relatives of children with ADHD have an ADHD diagnostic probability 4-5x higher than the general population
• boys are more vulnerable than girls (3:1)

Question 24

What is the prevalence of ADHD?

Answer 24

3-4%

Question 25

What are the subtypes of ADHD? (3)

Answer 25

• 20-30% inattentive
• 15% hyperactive
• 50-75% combined

Question 26

What are the environmental risk factors for ADHD? (3)

Answer 26

• premature birth
• low birth weight
• prenatal smoking exposure (maternal)

Question 27

What is the prognosis like for ADHD?

Answer 27

70% of children who have ADHD will have this disorder as teenagers, and about 40-60% will still have it as adults

Question 28

What is dementia?

Answer 28

• degenerative disease of the brain with:
  
  • irreversible and progressive changes
  • global cognitive and behavioural impairment
  • sufficiently severe to interfere significantly with social and occupational function
  • an umbrella term that has many underlying causes
  • can be conceptualised as chronic brain failure

Question 29

What are some causes of dementia, in order of most to least common? (7)

Answer 29

• Alzheimer’s disease
• vascular dementia
• mixed
• dementia with Lewy bodies
• other
• Parkinson’s dementia
• frontotemporal dementia

Question 30

What are some reversible causes of dementia? (9)

Answer 30

• normal pressure hydrocephalus
• intracranial tumours
• subdural haematoma
• depression
• B1, B6, B12 deficiency
• folate deficiency
• hypothyroidism
• neurosyphilis
• delirium
• (always think to exclude - surgical, metabolic, infective and psychiatric reversible causes for cognitive impairment)

Question 31

What are the features of normal pressure hydrocephalus?

Answer 31

• dilated ventricles
• clinically presents with the Hakim-Adams triad:
  
  • cognitive impairment/confusion
  • urinary frequency/incontinence
  • gait disturbance (magnetic/stuck to the floor gait)

Question 32

What is the Hakim-Adams triad? (3)

Feature of normal pressure hydrocephalus (reversible cause of dementia)

Answer 32

• cognitive impairment/confusion
• urinary frequency/incontinence
• gait disturbance (magnetic/stuck to the floor gait)

Question 33

What are some epidemiology facts of dementia?

Answer 33

• 47.5 million worldwide have dementia
• leading cause of death in women and second to heart disease in men in UK
• most common form is Alzheimer’s (70%)
• risk of Alzheimer’s increases with age - doubles every 5 years after 60y and is 40% at 85

Question 34

What are the clinical features of mild dementia? (5)

Answer 34

• living independently but some supervision/support often needed
• can participate in community activities and can appear unimpaired to those who do not know them
• judgement and problem solving typically impaired
• social judgement may be preserved
• difficulty making complex plans/decisions and handling finances

Question 35

What are the clinical features of moderate dementia? (7)

Answer 35

• require support to function outside the home and only simple household tasks are maintained
• difficulties with basic activities of daily living (ADLs) e.g. dressing and personal hygiene
• significant memory loss
• judgement and problem solving are typically significantly impaired, and social judgement is often compromised
• may have difficulty communicating with individuals outside the home without caregiver assistance
• socialising is increasingly difficult as the individual may behave inappropriately (e.g. in disinhibited or aggressive ways), with associated behaviour changes (e.g. calling out, clinging, wandering, disturbed sleep, or hallucinations)
• difficulties are often obvious to most individuals who have contact with the individual

Question 36

What are the clinical features of severe dementia? (6)

Answer 36

• severe memory impairment
• often disoriented to time and place
• often unable to make judgements or solve problems
• may have difficulty understanding what is happening around them (situational awareness)
• dependent on others for basic personal care (bathing, toileting and feeding)
• urinary and faecal incontinence may emerge

Question 37

What are behavioural and psychological symptoms in dementia (BPSD)?

Answer 37

• common in dementia
• includes apathy, mood disturbances, hallucinations, delusions, irritability, agitation, aggression, sleep changes
• typically, these symptoms are more frequent and impairing in moderate and severe forms of dementia