CASC Stations 3 Flashcards
Legal questions to ask in alcohol use
- 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?
What is detox
Detoxification is a treatment designed to control both the medical
and psychological complications that may occur temporarily after
a period of sustained alcohol misuse
What does detox involve
• 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.
Indications for prescribing a reducing regime of CPZ
– 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
Indications of inpatient detox
– 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.
SEs of disulfiram
Headache
Halitosis
Hepatotoxicity
Psychosis
How does disulfiram work
Irreversible inhibitor of acetaldehyde dehydrogenase
Acts as adjunct to therapy and prescribed once abstinence is achieved
How does acamprosate work
Enhances GABA transmission in the brain
Diminishes alcohol craving
SEs of acamprosate
Pruritis
GI upset
Rash
How does naltrexone work
Antagonizes effect of endorphins released by alcohol consumption
Reduces total alcohol consumed and number of drinking days
SEs of acamprosate
Anxiety Headache Fatigue Flu-likw sx GI sx Sleep disturbance
Describe supportive psychotherapy in alcohol use
Education
Advice and counselling on physical and psychosocial complications of alcohol use and problem solving approach to normal day-to-day difficulties
Describe CBT in alcohol use
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
What does motivational interviewing involve
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
Duration of alcohol hallucinosis
Begins 12-24 hours after last drink
Resolves after 24-48 hours
What makes alcohol hallucinosis different from DT
Develops and resolves rapidly
Limited set of hallucinations - auditory and visual, usually accusatory or threatening voices
No other physical sx
What increases risk of alcohol hallucinosis
Long-term heavy alcohol abuse
Use of other illicit drug use
Questions to ask about needle usage in drug use
Where are they obtained?
Are they shared?
What sites are used for injection?
Risks to ask about in drug use
Sharing needles
Unsafe sex
Sex of drugs
Financing of drugs
Features of dependence syndrome in drug use
Compulsion
Tolerance
Withdrawal sx
Treatment and re-instatement
Timeframe of opioid withdrawal
Appear 6-24 hours after last dose
Last 5-7 days
Peak on 2nd or 3rd day
Pharmacological options for opioid use
Methadone
Buprenorphine
Lofexamine
Symptomatic treatment
What is methadone
Long acting, synthetic opioid
Long half-life of 24 hours
Prescribed as a liquid
What happens in rapid reduction regime of methadone
Reduce dose over 14-21 days using symptomatic drugs as adjuncts
Slow reduction technique in methadone use
Reduce over 4-6 months by 5-10mg every 2 weeks
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
What is Buprenorphine
Partial opiate agonist
Reduces effects of additional opioid use because of its high receptor affinity
How does Buprenorphine titration occur
Dose increases made 2-4mg at a time
Maintenance should be achieved within 1-2 weeks
What is Lofexedine
Alpha-adrenergic agonist
Given as 7-10 day course with 2-4 day withdrawal
Risks with Lofexidine
Postural hypotension - BP should be monitored
Symptomatic meds used in opioid withdrawal
Metoclopramide - vomiting
Loperamide - diarrhoea
Ibuprofen - pain
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
What is harm reduction
Reduce morbidity and mortality in drug users without necessarily insisting on abstinence
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.
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
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
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
Can women breast feed while on Methadone
Yes
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
Risk of congenital defects on Methadone
No increase
Is Buprenorphine licensed for use in pregnancy?
No
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
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.
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
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.
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.
Risk factors for conversion disorder
Childhood experience of illness Negative life events Relationship conflict Modelling of others illnesses Physical illness such as epilepsy
Perpetuating factors of conversion disorder
Behavioural responses such as avoidance, disuse, reassurance
seeking
Cognitive responses such as fear of worsening, fear of serious disease
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.
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
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
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
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
Prevalence of BDD
1-2%
11.9% in those who receive derm care
Age of onset of BDD
Late adolescence
Chronic with fluctuations over time
Comorbidity of BDD
Mood disorders
OCD
Social phobia
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
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.
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.
Comorbidity of hypochondriasis
50% have GAD
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.
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
First line treatment of Hypochondriasis
CBT
Second line treatment of Hypochondriasis
SSRIs - many sx are secondary to depression
What does CBT cover in Hypochondriasis
- Identify and challenge misinterpretations.
- Substitution of realistic interpretation.
- Graded exposure to illness-related situations with response
prevention should be undertaken. - Modification of core illness-beliefs.
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
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
How long does a grief reaction normally last
Up to 12 months
Average duration of 6 months
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).
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.
Risk factors for abnormal grief
- Sudden and unexpected death of the deceased
- Insecure survivor, Dependent or ambivalent relationship
with the deceased - Presence of dependent children and so cannot show grief
easily - Presence of previous psychiatric disorder in the survivor
(especially depression) - Los self esteem
- Low social support
- Multiple prior bereavements
Risk factors for atypical grief
- Prolonged duration and severity of symptoms- Lack of ability to
function - Thoughts of self-harm or suicide
- Mummification
- Other Hallucinatory experiences apart from hallucinations of
widowhood.
What is post post-concussional syndrome
Psych disorder following HI, usually sufficiently severe to cause LoC
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
Symptoms and signs of frontal lobe injury
Personality changes Behavioural changes Cognitive changes Mood sx Errors of judgement
Personality changes in frontal lobe injury
a. Disinhibition with reduced social awareness and control
b. Loss of finer feelings and sexual indiscretions.
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
Mood sx of frontal lobe injury
a. Apathy
b. Periods of irritability
c. Elevated mood (fatuous, childishness making jokes and
performing pranks)
Errors of judgement in frontal lobe injury
a. Decreased abstracting ability,
b. Impaired attention & concentration,
c. Difficulties in planning and problem solving.
Language difficulties in frontal lobe injury
Perseveration of speech and movements, repetition of phrase and
sentences,
Decreased articulation, sparse speech and decreased verbal fluency
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
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?
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
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
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
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.
Pharmacological management of conduct disorder
Only if comorbid conductions like ADHD or depression
Risperidone can be considered for aggression but note risk of EPSEs
Prognosis of conduct disorder
50% show ongoing antisocial behaviour in adulthood
How many people with autism have normal IQ
30%
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
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
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.
Investigations for diagnosis of autism
- Psychologist to be involved to perform psychometric assessment
to determine IQ assessment and rule out Learning disability - Educational psychologist assessment
- ADI with trained assessor, ADI – R (autism diagnostic interview –
revised) - ADOS assessment (trained assessor), (ADOS-G Autism diagnostic
observation schedule – generic) - Speech and language assessment
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
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.
Medications for autism
Only for specific problems - SSRIs for aggressive and repetitive behaviour
Risperidone in hyperactivity, aggression and repetitive behaviour
Psychological treatment of tic disorder
- Advice for parents to ignore tics as commenting on them makes
no difference and may affect the child’s self-esteem - Education about the condition. Liaise with the schools, ‘Tic
Breaks’ at school - Groups with affected young persons
- Reduction of external stressors.
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
Comorbidities in tic disorder
- ADHD-Hyperactivity and behavioural problems (25-50%)
- OCD (30-60%)
- Behavioural problems
- Emotional disorders such as anxiety and depression
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.
What is tourettes
Multiple motor tics and one or more vocal tics
Wax and wane, less prominent after adolescence
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
What is primary enuresis?
In a child who has never attained significant continence
Management of enuresis
Restrict fluid at night Simple star chart Bell and pad Mattress alarm, night alarm Imipramine Desmopressin Reboxetine
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.
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.
Efficacy of imipramine for enuresis
80%
Management of mutism
Speech therapy assessment
Behavioural modification - work with school to decrease social anxiety, rewarding positive behaviour
Encourage school activities, joining local grups
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
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.
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.
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.
Duration of multisystemic therapy
3 months
Progress monitored weekly; parents and child fill weekly questionnaires on whether they are receiving therapy as planned
Aim of multisystemic therapy
Reduce rates of antisocial behaviour
Reduce out of home placements
Most common causes of sex offences in LD
Lack of sexual knowledge
Poor social skills
Inability to express a normal sex drive appropriately
Prevalence of LD
1%
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
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
Incidence of Autism in UK
1%
M:F ratio of Autism
4:1
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
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
Three components of complex partial seizures
Aura
Altered consciousness
Automatism
What are auras equivalent to
Simple partial seizures
Types of auras
Motor
Somatosensory
Autonomic - nausea, tachycardia, salivation
Psychic manifestations - deja vu, depersonalisation, fear, anxiety, confusion
Dysphasic sx, cognitive and affective sx
Most common aura in TLE
Epigastric followed by autonomic and visceral sensations
What happens during altered consciousness of TLE
Patient may be motionless and inaccessible with wide eyed stare and unresponsive to questions or command
What are automatisms
Involuntary motor actions
Duration of most 3As in TLE
1-2 minutes
What happens in absence epilepsy
No auras, last <30 seconds, no post-ictal phase
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
What is an uncinate crisis?
Hallucinations of taste and smell associated with dream like reminiscence and altered consciousness
