ADHD

Question 1

What is ADHD?

Answer 1

Attention deficit hyperactivity disorder (ADHD) is at the extreme end of “hyperactivity” and inability to concentrate (“attention deficit“). It affects the person’s ability to carry out everyday tasks, develop normal skills and perform well in school.

Features should be consistent across various settings. When a child displays these features only at school but is calm and well behaved at home, this is suggestive of an environmental problem rather than an underlying diagnosis.

Question 2

What are the features of ADHD?

Answer 2

All the features of ADHD can be part of a normal spectrum of childhood behaviour. When many of these features are present and it is adversely affecting the child, ADHD can be considered:

Very short attention span
Quickly moving from one activity to another
Quickly losing interest in a task and not being able to persist with challenging tasks
Constantly moving or fidgeting
Impulsive behaviour
Disruptive or rule breaking

Question 3

What is the management for ADHD?

Answer 3

A detailed assessment should be carried out by a specialist in childhood behavioural problems before a diagnosis is made. Management should be coordinated by a specialist in ADHD. Parental and child education is essential. This includes education about parental strategies to manage the child.

Establishing a healthy diet and exercise can offer significant improvement in symptoms. Keeping a food diary may suggest a link between certain foods, such as food colourings, and behaviour. Elimination of these triggers should be done with the assistance of a dietician

Medication is an option after conservative management has failed or in severe cases. This should be coordinated by a specialist. Contrary to what you might think, they are central nervous system stimulants. Examples are:

Methylphenidate (“Ritalin“)
Dexamfetamine
Atomoxetine

Question 4

What is depression?

Answer 4

Depression is a disorder that causes persistent feelings of low mood, low energy and reduced interest. It can affect people of all ages, including children and adolescents. It is often triggered by life events, although it can happen without any apparent triggers.

Question 5

What are the typical symptoms of depression?

Answer 5

Low mood
Anhedonia, a lack of pleasure in activities
Low energy
Anxiety and worry
Clinginess
Irritability
Avoiding social situations (e.g. school)
Hopelessness about the future
Poor sleep, particularly early morning waking
Poor appetite or over eating
Poor concentration
Physical symptoms such as abdominal pain

Question 6

What are the potential triggers of depression?

Answer 6

Potential triggers (e.g. loss of a family member)
Home environment
Family relationships
Relationship with friends
Sexual relationships
School situations and pressures
Bullying
Drugs and alcohol
History of self harm
Thoughts of self harm or suicide
Family history
Parental depression
Parental drug and alcohol use
History of abuse or neglect

Question 7

How should mild depression be managed?

Answer 7

Mild depression or low mood associated with a single negative event (e.g. loss of a family member) can be managed with watchful waiting and advice about healthy habits, such as healthy diet, exercise and avoiding alcohol and cannabis. Follow up within 2 weeks is advised.

Question 8

How should moderate to severe depression be managed?

Answer 8

NICE recommend referral to CAMHS for children with moderate to severe depression. CAMHS can then initiate:

Full assessment to establish a diagnosis
Psychological therapy as the first line treatment with cognitive behavioural therapy, non-directive supportive therapy, interpersonal therapy and family therapy
Fluoxetine is the first line antidepressant in children, starting at 10mg and increasing to a maximum of 20mg
Sertraline and citalopram are second line antidepressants
When the child responds to medical treatment, it should continue 6 months after remission is achieved
When they do not respond to medical treatment they may require intensive psychological therapy
Where there is follow up monitoring in secondary care, the mood and feelings questionnaire (MFQ) may be used to assess progress.

Question 9

When should a patient be admitted with depression?

Answer 9

Admission may be required where there is high risk of self harm, suicide or self-neglect or where they may be an immediate safeguarding issue.

Question 10

What is autistic spectrum disorder?

Answer 10

Autistic spectrum disorder refers to the full range of people affected by a deficit in social interaction, communication and flexible behaviour.

The classification of autistic spectrum disorder was introduced in the diagnostic and statistical manual of mental disorders fifth edition (DSM-5), introduced in 2013.

Question 11

What are the different categories of autism?

Answer 11

Features vary greatly between individuals along the autistic spectrum. They can be categorised as deficits in social interaction, communication and behaviour. Features are usually observable before the age of 3 years.

Question 12

What are the features of social interaction autism?

Answer 12

Lack of eye contact
Delay in smiling
Avoids physical contact
Unable to read non-verbal cues
Difficulty establishing friendships
Not displaying a desire to share attention (i.e. not playing with others)

Question 13

What are the features of communication autism?

Answer 13

Delay, absence or regression in language development
Lack of appropriate non-verbal communication such as smiling, eye contact, responding to others and sharing interest
Difficulty with imaginative or imitative behaviour
Repetitive use of words or phrases

Question 14

What are the features of behaviour autism?

Answer 14

Greater interest in objects, numbers or patterns than people
Stereotypical repetitive movements. There may be self-stimulating movements that are used to comfort themselves, such as hand-flapping or rocking.
Intensive and deep interests that are persistent and rigid
Repetitive behaviour and fixed routines
Anxiety and distress with experiences outside their normal routine
Extremely restricted food preferences

Question 15

How is autism diagnosed?

Answer 15

Diagnosis should be made by a specialist in autism. This may be a paediatric psychiatrist or paediatrician with an interest in development and behaviour. A diagnosis can be made before the age of 3 years. It involves a detailed history and assessment of the child’s behaviour and communication.

Question 16

How should autism be managed?

Answer 16

Autism cannot be cured. Management depends on the severity of the child’s condition. Management involves a multidisciplinary team to provide the best environment and support for the child and parent:

Child psychology and child and adolescent psychiatry (CAMHS)
Speech and language specialists
Dietician
Paediatrician
Social workers
Specially trained educators and special school environments
Charities such as the national autistic society

Question 17

What is bipolar affective disorder?

Answer 17

Bipolar disorder is a mental disorder characterised by periods of depression and periods of elevated mood (mania).

Question 18

What is the epidemiology of Bipolar affective disorder?

Answer 18

It affects around 1-3% of the general population.

Question 19

What is the aetiology of bipolar affective disorder?

Answer 19

The aetiology of Bipolar Affective Disorder is not fully understood, but there is clear evidence to suggest that there is a genetic component and it can be inherited. Triggers for manic episodes can include stressful life events, physical illness or illicit substance misuse. A ‘manic switch’ can sometimes be induced by someone with Bipolar Affective Disorder taking antidepressants to treat a depressive episode.

Question 20

What are the clinical features of bipolar affective disorder?

Answer 20

During periods of depression the patient may become withdrawn and tearful, with low mood, poor sleep and anhedonia. They may experience suicidal thoughts or make attempts.

Manic episodes are characterised by elevated mood or irritability. They may make impulsive and dangerous decisions with little thought for consequences. The need for sleep is often reduced. Mood congruent delusions may be present. They often have pressured speech and exhibit flight of ideas.

Question 21

How is Bipolar affective disorder diagnosed?

Answer 21

The full DSM criteria for the diagnosis of bipolar disorder are as follows:

Bipolar disorder is diagnosed when a person has at least one episode of a manic or a hypomanic state, and one major depressive episode.

Mania

The DSM defines mania as a “distinct period of abnormally and persistently elevated, expansive, or irritable mood.” The episode must last at least a week. The mood must have at least three of the following symptoms:

Elevated self-esteem
Reduced need for sleep
Increased rate of speech
Flight of ideas
Easily distracted
An increased interest in goals or activities
Psychomotor agitation (pacing, hand wringing etc.)
Increased pursuit of activities with a high risk of danger
Hypomania

Additionally, the DSM states that in hypomania “the episode (should not be) severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalisation, and there are no psychotic features”

Depression

The DSM states that a major depressive episode must have at least four of the following symptoms. They should be new or suddenly worse, and must last for at least two weeks:

Changes in appetite or weight, sleep, or psychomotor activity
Decreased energy
Feelings of worthlessness or guilt
Trouble thinking, concentrating, or making decisions
Thoughts of death or suicidal plans or attempts

Question 22

What is the acute management of bipolar disorder?

Answer 22

Bipolar disorder may be seen as an acute presentation of either mania or depression. The management of these are as follows:

Acute mania with agitation: patients will typically require IM therapy, either a neuroleptic or a benzodiazepine. They may need urgent admission to a secure unit.

Acute mania without agitation: oral monotherapy can be attempted with an antipsychotic. Sedation and a mood stabilizer such as lithium can be added if necessary.

Acute depression: mood stabilizer and/or atypical antipsychotic and/or antidepressant with appropriate psychosocial support.

All of these patients will require long-term follow up and maintenance therapy.

Question 23

What is the chronic management for patients with bipolar disorder?

Answer 23

Patients with bipolar disorder are at high risk of relapse into either depression or mania. As such, they require careful follow-up and ongoing maintenance treatment.

Lithium is the gold standard medication for bipolar disorder and acts as a mood stabiliser. Valproate is a suitable second line alternative. Anti-psychotics and anti-convulsants may also be used in treatment resistant cases.

Additionally, NICE recommends that all patients with bipolar disorder have access to psychological therapies. These should be targeted towards bipolar disorder specifically, and should be high intensity in nature. This can include CBT, interpersonal therapy or couples/family therapy.

Question 24

In Bipolar what are the main classes of drugs you want to give in an acute presentation?

Answer 24

Anti-psychotics

Question 25

In Bipolar what drugs do you want to give in a chronic presentation?

Answer 25

Lithium - first line
Sodium valporate - second line

Question 26

What is a manic switch in BPAD?

Answer 26

manic switch is defined as a report of mania, hypomania, or mixed episodes within the first 12 weeks of treatment with an antidepressant. This definition entirely excludes patients without any antidepressant treatment

Question 27

What are anxiety disorders?

Answer 27

Anxiety disorders include Generalized Anxiety disorder, phobias, panic disorder, Obsessive Compulsive Disorder and Post-traumatic Stress Disorder

Question 28

What is the concept of neuroses in anxiety disorders?

Answer 28

Symptoms that are both understandable and with which one can empathize
Insight is maintained
This is as opposed to delusions which are not understandable or cannot be empathised with
Neuroses are quantitively but not qualitatively different from normal
Neuroses different to ‘neurotic’ individuals who often suffer from lifelong personality difficulties

Question 29

What is the epidemiology of anxiety?

Answer 29

Most predominantly female
Affects up to 10% of all individuals
Comorbidity with depression, substance misuse and personality disorder is common
If individual presents after age 35-40 years, it is more likely due to depressive disorder or organic disease
Associated Factors: Lower social class, unemployment, divorced, renting rather than owning, no educational qualifications, urban living Aetiology
Genetics: family history often seen, people with high neuroticism scores more likely
Early experiences and life events:
Childhood adversity predispose
Life events (WW1 trenches most extreme example)