CASC Stations 3 Flashcards

1
Q

Legal questions to ask in alcohol use

A
  • Have you actually had an accident or hurt yourself?
  • Have you ever been convicted of drink driving?
  • Have you ever been arrested because of your dinking?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is detox

A

Detoxification is a treatment designed to control both the medical
and psychological complications that may occur temporarily after
a period of sustained alcohol misuse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What does detox involve

A

• It usually involves chlordiazepoxide at diminishing doses over 7 to
10 days with thiamine supplementation
• The doses of medication should be titrated against withdrawal
symptoms.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Indications for prescribing a reducing regime of CPZ

A

– Clinical evidence of alcohol withdrawal features
– History of alcohol dependence syndrome
– Consumption of alcohol is greater than 10 units per day over the
last 10 days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Indications of inpatient detox

A

– Symptoms of Wernicke-Korsakoff syndrome
– Past history of seizures or delirium during withdrawals
– Acute confusional presentation
– High risk of suicide
– History of poly drug misuse
– Co-morbid mental health illness, e.g., depression, psychosis
– Lack of stable support in the community, e.g., homelessness
– Severe malnutrition/severe physical health conditions.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

SEs of disulfiram

A

Headache
Halitosis
Hepatotoxicity
Psychosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

How does disulfiram work

A

Irreversible inhibitor of acetaldehyde dehydrogenase

Acts as adjunct to therapy and prescribed once abstinence is achieved

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How does acamprosate work

A

Enhances GABA transmission in the brain

Diminishes alcohol craving

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

SEs of acamprosate

A

Pruritis
GI upset
Rash

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How does naltrexone work

A

Antagonizes effect of endorphins released by alcohol consumption
Reduces total alcohol consumed and number of drinking days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

SEs of acamprosate

A
Anxiety
Headache
Fatigue
Flu-likw sx
GI sx
Sleep disturbance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Describe supportive psychotherapy in alcohol use

A

Education
Advice and counselling on physical and psychosocial complications of alcohol use and problem solving approach to normal day-to-day difficulties

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Describe CBT in alcohol use

A

Education and improvement of social and interpersonal skills
Relapse prevention including identifying situational or interpersonal triggers than result in excessive drinking, suggestions to change social milieu to get away from drinking and developing new interests and planning and rehearsing new methods of coping
Adopting behavioural approaches - self-monitoring, diary keeping

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What does motivational interviewing involve

A

Feedback of personal risk or impairment
Emphasis on personal responsibility for change
Clear advice to change
Menu of alternative change options
Therapeutic empathy as a counselling style
Enhancement of patient self-efficacy or optimism

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Duration of alcohol hallucinosis

A

Begins 12-24 hours after last drink

Resolves after 24-48 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What makes alcohol hallucinosis different from DT

A

Develops and resolves rapidly
Limited set of hallucinations - auditory and visual, usually accusatory or threatening voices
No other physical sx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What increases risk of alcohol hallucinosis

A

Long-term heavy alcohol abuse

Use of other illicit drug use

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Questions to ask about needle usage in drug use

A

Where are they obtained?
Are they shared?
What sites are used for injection?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Risks to ask about in drug use

A

Sharing needles
Unsafe sex
Sex of drugs
Financing of drugs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Features of dependence syndrome in drug use

A

Compulsion
Tolerance
Withdrawal sx
Treatment and re-instatement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Timeframe of opioid withdrawal

A

Appear 6-24 hours after last dose
Last 5-7 days
Peak on 2nd or 3rd day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Pharmacological options for opioid use

A

Methadone
Buprenorphine
Lofexamine
Symptomatic treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is methadone

A

Long acting, synthetic opioid
Long half-life of 24 hours
Prescribed as a liquid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What happens in rapid reduction regime of methadone

A

Reduce dose over 14-21 days using symptomatic drugs as adjuncts

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Slow reduction technique in methadone use
Reduce over 4-6 months by 5-10mg every 2 weeks
26
What is oral methadone effective in
``` – Reducing illicit drug use – Reduced injecting – Reduced criminal activity – Improved physical health – Improved social well-being -Reduced drug-related mortality ```
27
What is Buprenorphine
Partial opiate agonist | Reduces effects of additional opioid use because of its high receptor affinity
28
How does Buprenorphine titration occur
Dose increases made 2-4mg at a time | Maintenance should be achieved within 1-2 weeks
29
What is Lofexedine
Alpha-adrenergic agonist | Given as 7-10 day course with 2-4 day withdrawal
30
Risks with Lofexidine
Postural hypotension - BP should be monitored
31
Symptomatic meds used in opioid withdrawal
Metoclopramide - vomiting Loperamide - diarrhoea Ibuprofen - pain
32
What is Naltrexone used for in opioid use?
Relapse prevention in those who have completed detox | Can be used to facilitate rapid detox over 5-7 days
33
What is harm reduction
Reduce morbidity and mortality in drug users without necessarily insisting on abstinence
34
Examples of harm reduction
* Advice regarding safe sex * Advice directed at the use of safer drugs * Advice directed at safer routes of administration * Advice regarding safer injecting practice * Treatment of co-morbid mental or physical health problems * Engagement with other sources of help * Prescription of maintenance opiates or benzodiazepines.
35
Risks of heroin use in pregnancy
Provoke miscarriage or intrauterine death Can cross placenta resulting in neonatal abstinence syndrome, baby may need to be treated for withdrawal Baby more likely to be premature and small for dates
36
Impact of cocaine use on the baby
Impact development of GU system and bones of skull Risk of placental abruption Abstinence syndrome in baby Sudden infant death syndrome
37
What to do if woman is on high dose methadone when pregnant
Reduce slowly Fetal monitoring Dose may need to be increased in third trimester due to increased metabolism
38
Can women breast feed while on Methadone
Yes
39
When does opioid withdrawal syndrome start in babies
24-48 hours after birth depending on time of last dose | Signs may not appear for 3-4 days
40
Risk of congenital defects on Methadone
No increase
41
Is Buprenorphine licensed for use in pregnancy?
No
42
Sx of DT
Clouding of consciousness Disorientation to time and place Poor attention Visual hallucinations - vivid and frightening Tactile hallucinations - insects crawling over skin Autonomic disturbance - fever, sweating, tachycardia, hypertension, pupil dilation
43
Treatment of DT
Treat any underlying cause e.g. infection, dehydration • Ensure adequate fluid and electrolyte balance, providing adequate nutrition • Optimisation of environment- well lit quiet room with adequate lighting • Nursing support-Consistent nursing support to offer reassurance, reorientation and explanation. If possible, discuss about providing input from the psychiatric nursing team • Librium sliding scale (detoxification regime with Chlordiazepoxide (Librium) in a reducing dose). • Using parenteral benzodiazepines to achieve quick sedation. • Instituting parenteral, high potency vitamins (thiamine supplementation or multivitamins). • Avoiding use of phenothiazine antipsychotics (Haloperidol) due to risk of inducing seizures. • Warn about the risk of withdrawal seizures and Wernicke’s encephalopathy.
44
What is conversion disorder
A loss or disturbance of normal function, which initially appears to have a physical cause but is attributed to a psychological cause
45
Treatment of conversion disorder
• Obtain medical and psychiatric history from patient and informants • Physical causes should be ruled out by full examination and appropriate investigation • Supportive psychotherapy; Sympathetic explanation and reassurance that the patient is suffering from a temporary condition and does not have a permanent disabling disorder. • Treatment of psychiatric co morbidity like depression etc. Offer continuing assessment and treatment of psychiatric and social problems • Avoidance of reinforcement of disability.
46
Prognosis of conversion disorder
• The prognosis is generally good for those patients with a clear precipitant and if symptoms were of sudden onset and shorter duration. • Complete resolution of symptoms is possible and has been observed in 70-90% of cases at follow-up. • If the symptoms are longer lasting and well established, then the outcome is more likely to be poorer.
47
Risk factors for conversion disorder
``` Childhood experience of illness Negative life events Relationship conflict Modelling of others illnesses Physical illness such as epilepsy ```
48
Perpetuating factors of conversion disorder
Behavioural responses such as avoidance, disuse, reassurance seeking Cognitive responses such as fear of worsening, fear of serious disease
49
Diagnostic criteria of dissociative disorders
v Dissociative disorders are presumed to be “psychogenic” in origin, being associated closely in time with traumatic events, insoluble and intolerable problems, or disturbed relationships. v The onset and termination of dissociative states are often reported as being sudden and the symptoms usually develop in close relationship to psychological stress. v In these disorders there is a loss of or interference with movements or loss of sensations (usually cutaneous). The patient therefore presents as having a physical disorder, although none can be found that would explain the symptoms. v The commonest varieties are loss of ability to move the whole of part of a limb or limbs. Paralysis may be partial, with movements being weak or slow, or complete. Various forms and variable degrees of incoordination (ataxia) may be evident, particularly in the legs, resulting in bizarre gait or inability to stand unaided (astasia-abasia). There may also be exaggerated trembling or shaking of one or more extremities or the whole body. v The symptoms can often be seen to represent the patient’s concept of physical disorder, which may be a variance with physiological or anatomical principles. v In addition, assessment of the patient’s mental state and social situation usually suggests that the disability resulting from the loss of functions is helping the patient to escape from an unpleasant conflict, or to express dependency or resentment indirectly v Individuals with dissociative disorders often show a striking denial of problems or difficulties that may be obvious to others. v A variable amount of attention-seeking behaviour may be present in addition to a central and unvarying core of loss of movement or sensation which is not under voluntary control. v Premorbid abnormalities of personal relationships and personality are usually found, and close relatives and friends may have suffered from physical illness with symptoms resembling those of the patient.
50
Management of dissociative disorders
v Thorough neurological and medical evaluation is absolutely crucial v Timely diagnosis v Treatment of any co-morbid depression and other psychiatric disorder v Combined treatment that uses a medical model approach and psychological modalities to best address any physical needs and that invites the patient to engage in treatment without feeling humiliated (Addressing psychological factors and reactions to the presented deficits is combined, if appropriate, with progressive physical therapy). v Some form of physical therapies or rehabilitation such as physiotherapy for a patient with paralysis and speech therapy for a patient with aphonia. v Working through patient’s defences and helping him/her to develop more mature and adaptive defense mechanisms to prevent future development of conversion episodes. v The ultimate goal is development of an appropriate level of control and mastery, through psychotherapeutic modalities, that may be used to help to manage their conversion symptoms v When a specific psychological factor is identified, clinical experience suggests that addressing the stressors that may have led to the onset of conversion symptoms, including any identified trauma is paramount for an effective intervention. Helping patients make the connection between recent or current stressors and earlier conflicts may allow them to understand the significance and reasons for conversion symptoms. After this is accomplished, the patients themselves may recognise the need to address the areas of conflict, which may dramatically ameliorate the severity or frequency of symptoms
51
Prognosis of dissociative disorder
v There is no good estimates of average duration of symptoms or time to symptom resolution v Sometimes, simply removing the acute stressors or placing the patient in a protective environment like a medical or inpatient psychiatric ward may lead to resolution in a matter of hours or days v Sometimes reassurance about absence of a medical cause along with supportive psychotherapy achieves the same quick resolution of symptoms v Adjunctive use of relaxation techniques, with or without formal hypnosis training may be beneficial, often accelerating the course of progress in therapy v If symptoms do not improve/resolve with these approaches, a more intensive intervention may be needed v A number of techniques used alone/jointly have been found useful, including pharmacologically facilitated interview (Narco-analysis), CBT approach and hypnotically facilitated psychotherapy v Data have suggested that a quicker resolution of symptoms have been associated with a better prognosis (Ford & Folks 1985). Thus it makes sense to consider approaches relatively in the early course of treatment v In many cases, the symptoms may remit dramatically with a variety of symptoms such as physiotherapy, psychotherapy, hypnotism, electrical stimulation, persuasions, explanation, reassurance or no treatment at all
52
What is BDD
ü Body dysmorphic disorder also called as Dysmorphophobia, is described as a ‘subjective description of ugliness and physical defect which the patient feels is noticeable to others’ ü It is characterized by a preoccupation with an imagined defect in appearance, or if there is a slight physical anomaly and the concern is out of proportion to the anomaly ü It is an excessive concern (overvalued idea) about trivial or non-existent physical abnormalities, which are perceived to be deformities. Here the patient is constantly pre-occupied, convinced and tormented by abnormal belief that some part oh his/her body is too large, too small or misshapen, which to other people, the appearance is normal or there is a trivial abnormality
53
Sx of BDD
They would get involved in time consuming behaviours such as re- examining, repeated checking, mirror-gazing, excessive camouflage, comparison of features, skin-pricking, reassurance seeking, avoidance of social situation. etc
54
Prevalence of BDD
1-2% | 11.9% in those who receive derm care
55
Age of onset of BDD
Late adolescence | Chronic with fluctuations over time
56
Comorbidity of BDD
Mood disorders OCD Social phobia
57
Management of BDD
Liaison with GP and cosmetic surgeons as these interventions unnecessary. Joint appts can be helpful to ensure consistent advice. Help-seeking behaviour may also be contained as they may repeatedly consult other plastic surgeons etc. Reassurance and practical support Serotonergic antidepressants at high doses for long periods - helpful for depressive sx. CBT
58
What is somatoform pain disorder
Patients with chronic pain not caused by physical sx | Pain is main focus of presentation. Psychological factors have role in onset, severity and exacerbation.
59
What is hypochondriasis?
Hypochondriasis is the preoccupation with the fear of having a serious disease, usually one which will lead to death or serious disability and this constant preoccupation persists despite negative investigations. In this condition, minor ailments will be interpreted as signs of serious disease. • There is a persistent refusal to accept the advice and reassurance of doctors that no such physical illness exists. • It could cause significant distress, impaired function and severe disability. • The form of the belief is that of an over-valued idea. Here the patient may be able to accept that his/her worries are groundless but nonetheless be unable to stop dwelling or worrying and acting on them.
60
Comorbidity of hypochondriasis
50% have GAD
61
Aetiology of hypochondriasis
Previous experience of organic illness, especially in childhood in oneself or family member Excess medical seeking in parents • Childhood motional abuse or neglect, childhood sexual abuse are associated. • Psychological model: Individuals with combination of anxiety symptoms and predisposition to misattribute psychical symptoms, seek medical advice. The resulting medical reassurance provides temporary relief of anxiety, which acts as a ‘reward’ and makes further medical attention seeking more likely. • Precipitating factors are usually significant psychosocial stressors. The condition is often perpetuated by persistence of such stresses and advantages of sick role.
62
Management of Hypochondriasis
• Allow patient time to ventilate their illness anxieties. • Organic disease should be excluded. • Primary psychiatric disorder such as depression and anxiety should be treated vigorously. • Explain negative tests and avoid further unnecessary tests. • Specific medical interventions should be kept to a minimum. • It is important to establish continuing relationships and review patients regularly and attention should be given to nay social and personal factors from which the complaints are considered to arise. • Emphasize aim to improve function. Education on role of psychological factors in development of sx and how to cope with sx Break cycle of reassurance and repeat presentations - family support and education CBT
63
First line treatment of Hypochondriasis
CBT
64
Second line treatment of Hypochondriasis
SSRIs - many sx are secondary to depression
65
What does CBT cover in Hypochondriasis
1. Identify and challenge misinterpretations. 2. Substitution of realistic interpretation. 3. Graded exposure to illness-related situations with response prevention should be undertaken. 4. Modification of core illness-beliefs.
66
Prognosis of Hypochonriasis
• Prognosis of often poor, with indivuduals having chronic mild disbility for most of their adult life. • Hypochondriasis often is refractory to treatment and improvement involved better coping methods rather than cure. • Role functioning may improve as a functional outcome. • Reduced distress associated with beliefs rather than eradication of beliefs is the primary outcome expected
67
Stages of normal grief
v Shock or denial- lasts from minutes to days v Pining or searching- feels sad, angry, guilty, urge to search for the deceased person. Important features may include tearfulness, loss of appetite, loss of weight, poor concentration and poor short-term memory. v Disorganization/despair: Feel like life has no meaning. Tend to relive events. It is often common to experience hallucinations of the deceased person, when falling asleep. It resolves as adjust to the new reality without the deceased person v Reorganization: Begin to look forward and explore a new life v Recurrence: Grief may recur on anniversaries, birthdays etc
68
How long does a grief reaction normally last
Up to 12 months | Average duration of 6 months
69
What is abnormal grief
``` It is a grief reaction that is very intense, prolonged, delayed (or absent), or where symptoms outside the normal range are seen: e.g. preoccupation with feelings of worthlessness, thoughts of self-harm or suicide, excessive guilt, marked slowing of thoughts and movements, a prolonged period of lack of ability to function, hallucinatory experiences (other than the image or voice of the deceased). ```
70
Criteria for abnormal grief
The criterion for abnormal intensity is that the symptoms meet the criteria for a depressive disorder. The criterion for abnormal duration is that the response lasts more than 12 months.
71
Risk factors for abnormal grief
1. Sudden and unexpected death of the deceased 2. Insecure survivor, Dependent or ambivalent relationship with the deceased 3. Presence of dependent children and so cannot show grief easily 4. Presence of previous psychiatric disorder in the survivor (especially depression) 5. Los self esteem 6. Low social support 7. Multiple prior bereavements
72
Risk factors for atypical grief
1. Prolonged duration and severity of symptoms- Lack of ability to function 2. Thoughts of self-harm or suicide 3. Mummification 4. Other Hallucinatory experiences apart from hallucinations of widowhood.
73
What is post post-concussional syndrome
Psych disorder following HI, usually sufficiently severe to cause LoC
74
Sx of post-concussional syndrome
ü The symptoms would include headache, fatigue, dizziness, irritability, increased sensitivity to noise, anxiety, depression, mild cognitive impairment leading to impairment of memory, insomnia, sleep disturbance, reduced tolerance to stress and possibly sexual dysfunction ü It is also accompanied by feelings of anxiety or depression, resulting from loss of self-esteem and fear of permanent brain damage and Hypochondriacal symptoms are not uncommon. ü Some of them embark on a search for diagnosis and cure and may adopt a permanent sick role
75
Symptoms and signs of frontal lobe injury
``` Personality changes Behavioural changes Cognitive changes Mood sx Errors of judgement ```
76
Personality changes in frontal lobe injury
a. Disinhibition with reduced social awareness and control | b. Loss of finer feelings and sexual indiscretions.
77
Behavioural changes in frontal lobe injury
a. Loss of spontaneity, b. Loss of drive and motivation, c. Deterioration in general ability to function d. Catastrophic response (inability to adapt to the unexpected) leading to agitation and aggression
78
Mood sx of frontal lobe injury
a. Apathy b. Periods of irritability c. Elevated mood (fatuous, childishness making jokes and performing pranks)
79
Errors of judgement in frontal lobe injury
a. Decreased abstracting ability, b. Impaired attention & concentration, c. Difficulties in planning and problem solving.
80
Language difficulties in frontal lobe injury
Perseveration of speech and movements, repetition of phrase and sentences, Decreased articulation, sparse speech and decreased verbal fluency
81
Questions to ask about inattention in ADHD
v Have you noticed your child having trouble paying attention to tasks v Does your child make careless mistakes frequently? v Does your child struggle with tasks that require a lot of concentration v Does your child have trouble following verbal instructions? v Does your child easily distracted by other things going on? v Have you noticed your child having trouble getting organized? v Does your child starts things but does not finish them
82
Questions to ask about hyperactivity in ADHD
v Have you noticed your child being fidgety with hands or feet v Have they got trouble sitting still and appear to be restless most of the time v Have you noticed your child having trouble doing things quietly v Does your child talk too much and also interrupt other people’s conversations? v Is your child impatient and gets frustrated when having to wait for things v Do you think your child act before thinking things through most of the time?
83
Treatment of conduct disorder
``` Behavioural programme Parent management training programme Teachers Anger management Family therapy Multi-systemic therapy Meds Social services for family assessment and increased support to parents Referral to youth clubs ```
84
What are behavioural programmes for conduct disorder
Functional behaviour analysis to analyse ABC with help with parents. Parents taught how childs antisocial behaviour may be reinforced unintentionally by paying attention to it and taught how to reinforce normal behaviour by praise or rewards and measures to eliminate unwanted behaviour by removing the childs privileges Focus on issues such as damage to property, non-compliance with house or school rules, physical and verbal abuse
85
What are parent management training programmes
Parents provided written information and videotapes showing other parents applying behavioural principles. Involves teaching good parenting skills such as promoting positive relationship with child, good parenting skills including rewards for sociable behaviour, clear setting of rules and commands, consistent and calm consequences for unwanted behaviour
86
What happens in multi systemic therapy
Problem behaviours are conceptualised as being linked with individual characteristics and with various aspects of the multiple systems in which the adolescent is embedded, including the family, peers, schools and neighbourhood. Treatment goals developed with family and family strengths used for therapeutic change.
87
Pharmacological management of conduct disorder
Only if comorbid conductions like ADHD or depression | Risperidone can be considered for aggression but note risk of EPSEs
88
Prognosis of conduct disorder
50% show ongoing antisocial behaviour in adulthood
89
How many people with autism have normal IQ
30%
90
Examples of difficulty social relationships in autism
• Absent social smile • Lack of eye-to-eye contact • Lack of attachment to parents • Absence of separation anxiety • Persistent aloofness or awkward interaction with peers • No or abnormal social play; prefers solitary games • Difficulty in making friends, few or no sustained relationships • Limited empathy or sensitivity • Usually egocentric with little concern for others; treats people as furniture
91
Examples of problems in communication in autism
• Absent or delayed speech • Absence of communicative sounds like babbling • Lack of verbal or facial responses to sounds or voices (might be thought as deaf initially) • Language is superficially good but too formal, stilted or pedantic • Odd voice, monotonous and perhaps at an unusual volume talking at you with little awareness of your response • Difficulty in catching any meaning other than the literal • Awkward or odd posture and body language
92
Examples in narrowed interests
• A set approach to everyday life that may include unusual routines or rituals; change is often upsetting • Resistance to even the slightest change in environment • Obsessively pursued and unusually circumscribed interests • Attachment may develop to inanimate objects • Stereotyped behaviours like head banging, body spinning, rocking, lining up objects etc.
93
Investigations for diagnosis of autism
1. Psychologist to be involved to perform psychometric assessment to determine IQ assessment and rule out Learning disability 2. Educational psychologist assessment 3. ADI with trained assessor, ADI – R (autism diagnostic interview – revised) 4. ADOS assessment (trained assessor), (ADOS-G Autism diagnostic observation schedule – generic) 5. Speech and language assessment
94
Management of autism
Educate parents about diagnosis, prognosis and treatment Behavioural management Educate child in mainstream school in more intensive support. If functioning is low, special schooling can be considered Social services for comprehensive assessment of social care needs, arrange special care Vocational training in adolescents
95
What is behavioural management in autism
Functional analysis of target behaviour and the formulated plan should focus on promoting desired behaviour and reduce unwanted ones. If the child is behaving inappropriately view this as needing to be clearer about the rules and state the rules of expected behaviour very clearly.
96
Medications for autism
Only for specific problems - SSRIs for aggressive and repetitive behaviour Risperidone in hyperactivity, aggression and repetitive behaviour
97
Psychological treatment of tic disorder
1. Advice for parents to ignore tics as commenting on them makes no difference and may affect the child’s self-esteem 2. Education about the condition. Liaise with the schools, ‘Tic Breaks’ at school 3. Groups with affected young persons 4. Reduction of external stressors.
98
Medical management of tic disorder
ü Mild forms may not require specific treatment. ü If tics are disabling and non responsive to other therapies, then use medications such as low dose Haloperidol or Risperidone (Other medications which could be tried include sulpiride and clonidine) ü Treat the co morbid condition like OCD and ADHD accordingly. ü Treatment of Co-morbid psychiatric disorder such as OCD and ADHD may be clinically more important than treatment of the core features of the syndrome
99
Comorbidities in tic disorder
1. ADHD-Hyperactivity and behavioural problems (25-50%) 2. OCD (30-60%) 3. Behavioural problems 4. Emotional disorders such as anxiety and depression
100
Prognosis of tic disorder
Many tics occurring in childhood last only a few weeks. Others last longer but 80-90% of cases improve within 5 years. A few cases become chronic and may be life-long.
101
What is tourettes
Multiple motor tics and one or more vocal tics | Wax and wane, less prominent after adolescence
102
Medical treatment of tourettes
• Risperidone and Sulpiride have been shown to be effective and well tolerated. • Other drugs that could be used are Clonidine, Haloperidol and Pimozide
103
What is primary enuresis?
In a child who has never attained significant continence
104
Management of enuresis
``` Restrict fluid at night Simple star chart Bell and pad Mattress alarm, night alarm Imipramine Desmopressin Reboxetine ```
105
What is bell and pad?
This involves putting a pad underneath the child’s sheet, which is connected to an electrical buzzer. The buzzer goes off as soon as the child starts to wet the bed. The child then gets up and will use the toilet. The child will gradually learn to wake and use the toilet by itself. The child should be praised and rewarded for their dry nights. It takes many weeks for this training to become effective.
106
What is a mattress alarm, night alarm?
This is based on the principles of classical conditioning model. Night alarms are devices with a sensor to detect a few drops of urine. They serve as unconditioned stimulus and are generally placed in the child’s underwear at nighttime. It works like a pager with either sound or vibration to awaken the child. In this phase of unconditioned stimulus, the child wakes, holds the rest of the urine volume until getting to the toilet and then completes voiding. After several weeks of practice, the conditioned response to the alarm develops and the physiologic sensations associated with the initiation of voiding cause the child to awaken before actual voiding begins. The main drawback is that it takes many weeks for this training to become effective and it is also not helpful for diurnal cases.
107
Efficacy of imipramine for enuresis
80%
108
Management of mutism
Speech therapy assessment Behavioural modification - work with school to decrease social anxiety, rewarding positive behaviour Encourage school activities, joining local grups
109
Management of school refusal
First step: functional analysis of school refusal, organise meeting with school and parents Anxiety management and relaxation training Family therapy - explore issues like overprotective parents. May change family dynamics and empower the parents to aid childs return to school. If chronic, for graded return Graded behavioural plan
110
Describe graded behavioural plan to manage school refusal
• Establishing a good therapeutic relationship with the child and the family. • Identification of triggering factors/situation which gives rise to anxiety at home/(or)school. • Selection of appropriate method of desensitizing the boy to the feared situation. • Challenge & confront the feared situation. • Review of progress at appropriate intervals and identifying high-risk situation for relapse.
111
Impact of ongoing school refusal
v Worsening of current situation v Social relationships may be affected and possibility of impairment of adequate social skills v Deterioration in self-confidence, mood and self-esteem v Long-term education may be affected.
112
Aims of parent management training
• Promoting a positive relationship with the child • Using praise and rewards to increase desirable sociable behaviour • Setting of clear rules and directions • Using consistent and calmly executed consequences for unwanted behaviour. • Reorganising the child’s play to prevent problems.
113
Duration of multisystemic therapy
3 months | Progress monitored weekly; parents and child fill weekly questionnaires on whether they are receiving therapy as planned
114
Aim of multisystemic therapy
Reduce rates of antisocial behaviour | Reduce out of home placements
115
Most common causes of sex offences in LD
Lack of sexual knowledge Poor social skills Inability to express a normal sex drive appropriately
116
Prevalence of LD
1%
117
Reasons for challenging behaviour
To communicate a need Express frustration or boredom Avoid demands Psychiatric illness Physical - pain, infection, constipation, epilepsy Medication SEs Environment - change in environment or carers Sensory deficit like visual or hearing Psychosocial - bereavement, disrupted family, recent stressful situation
118
Management of challenging behaviour in LD
Behaviour analysis to understand behaviour and modification of behaviour Management of underlying cause Antipsychotic as last resort if treatment of underlying cause has not helped and associated risks
119
Incidence of Autism in UK
1%
120
M:F ratio of Autism
4:1
121
Causes of self injurious behaviour in LD
Physical - epilepsy, pain Psychiatric - depression, anxiety, psychosis Communication difficulties Sensory impairment Environment - lack of stimulation, adverse life events Genetic causes - Lesch-Nyhan
122
What is TLE
Complex partial seizure which may begin with impairment of consciousness or be precede by a simple partial seizure Arise from temporal lobe in 60% of cases, 30% in frontal lobe cases
123
Three components of complex partial seizures
Aura Altered consciousness Automatism
124
What are auras equivalent to
Simple partial seizures
125
Types of auras
Motor Somatosensory Autonomic - nausea, tachycardia, salivation Psychic manifestations - deja vu, depersonalisation, fear, anxiety, confusion Dysphasic sx, cognitive and affective sx
126
Most common aura in TLE
Epigastric followed by autonomic and visceral sensations
127
What happens during altered consciousness of TLE
Patient may be motionless and inaccessible with wide eyed stare and unresponsive to questions or command
128
What are automatisms
Involuntary motor actions
129
Duration of most 3As in TLE
1-2 minutes
130
What happens in absence epilepsy
No auras, last <30 seconds, no post-ictal phase
131
Common sx in TLE
``` Autonomic sensations Forced thinking Evocation of thought - intrusion of stereotyped words or thoughts Sudden obstruction to thought flow Panoramic memory Psychic seizures - hallucinations, depersonalisation Uncinate crises Affective experiences- fear and anxiety ```
132
What is an uncinate crisis?
Hallucinations of taste and smell associated with dream like reminiscence and altered consciousness