Liaison Psychiatry 1.3 Flashcards
1
Q
Prevalence of CFS
A
0.5%
2
Q
M:F ratio of CFS
A
1:3
3
Q
Who is CFS more common in
A
Females
Lower occupational status
Lesser educational background
4
Q
Mean age of onset of CFS
A
29-35 years
5
Q
Mean illness duration of CFS
A
3-9 years
6
Q
CFS criteria
A
Persistent or relapsing unexplained chronic fatigue of new onset, lasting at least 6 months and not the result of organic disease or continuing exertion, not alleviated by rest.
7
Q
Which sx are required for CFS?
A
Four or more of the following, present for >6 months: Impaired memory/concentration Sore throat Tender cervical/axillary lymph nodes Muscle pain Pain in several joints New headaches Unrefreshing sleep Malaise after exterion
8
Q
Exclusion criteria for CFS
A
Major psychiatric disorders including psychotic depression, bipolar, schizophrenia, dementia, ED, alcohol or substance abuse.
Does not include non-psychotic disorders.
9
Q
Predictors of poor outcome of CFS
A
Claiming a disability related benefit Low sense of control Strong focus on physical sx Being passive with reduced activity Membership of self-help grous
10
Q
How many patients with CFS are unable to work?
A
33%
11
Q
Which sx of CFS may indicate another serious illness
A
Significant weight loss Clinically significant lymphadenopathy Localising neurological signs Features of inflammatory arthritis, connective tissue disease or cardiorespiratory disease Sleep apnoea
12
Q
When does onset of CFS typically occur?
A
After an episode of viral infection
13
Q
Predisposing factors of CFS
A
Neuroticism
Childhood inactivity
Childhood illness
14
Q
Precipitating factors of CFS
A
Infectious mononucleosis
Q fever
Lyme disease
Serious life events
15
Q
Perpetuating factors of CFS
A
Strong belief in physical cause Activity-avoidance Poor self-control Primary/secondary gains Low self-perception of cognitive ability
16
Q
Metabolic findings in patients with CFS
A
Abnormality in HPA-axis and serotonin pathway suggest altered physiological response to stress.
17
Q
How many patients with CFS have low cortisol?
A
33%
18
Q
What do family studies of CFS suggest?
A
Mutation of cortisol transporting globulin
19
Q
Effective treatment of CFS?
A
CBT
Graded exercise therapy
20
Q
Components of CBT for CFS
A
Explanation of aetiological model
Motivation for CBT
Challenging and changing of fatigue related cognition
Achievement and maintenance of basic amount of physical activity
Gradual increase in physical activity
Rehab e.g. rigorous self-monitoring
21
Q
How long can CBT last for in patients with CFS who initially respond?
A
5 years
22
Q
How is timing of treatment important in CFS?
A
Patients improve if medications are added to CBT but now when CBT is added to medication
23
Q
What is graded exercise therapy based on?
A
Physiological model of deconditioning
24
Q
What is affected by inactivity?
A
Muscle strength
Autonomic response
Perception of exercise related sensations
25
What is the aim of graded exercise therapy?
Gradually increase exercise and thus reduce unwanted consequences of inactivity.
26
Improvement rate of CBT for CFS
70%
27
Improvement rate of graded exercise therapy for CFS
55%
28
Antidepressant treatment for CFS
Should not be used
29
When should antidepressants be considered for CFS?
Depressive sx
30
What factors must be taken into account if antidepressants are used for CFS?
Polonged inactivity increases risk of autonomic side effects such as postural hypotension
Sedation may worse fatigue
31
What is pacing?
People with CFS are encouraged to achieve a balance between rest and activity
32
What is the aim of pacing?
Prevent vicious circle of overactivity and setbacks while setting realistic goals for increasing activity
33
Disadvantages of pacing
No evidence
| May prolong illness by encouraging avoidence
34
Prognosis of CFS
1-5 years
35
How many patients improve over 5 years with CFS?
17-65%
36
How many patients with CFF recover over 5 years?
<10%
37
How many patients with CFS worsen over 10 years>
10-20%
38
Mortality of CFS?
Not associated with increased mortality
39
How many patients with CFS have depression
23%
40
How many patients with CFS have a history of depression
50-75%
41
Impact of CFS on CNS
Upregulation of serotonin
42
What sx does CFS not have which depression does?
Absence of lack of motivation, guilt, anhedonia
43
HPA axis in CFS
Downregulation
44
HPA axis in depression
Upregulation
45
Sleep disturbance in depression
Reduced REM latency
| Increased REM density
46
Lifetime prevalence of panic disorder in those with CFS
17-25%
47
Lifetime prevalence of GAD in those with CFS
2-30%
48
Overlapping sx between anxiety and CFS
Decreased cerebral blood flow
Sympathetic overactivity
Sleep abnormalities
49
Rate of somatisation in CFS
28%
50
How does examination impact rate of somatisation of CFS?
If examiner attributes sx to physical cause, rate of somatisation decreases and vice versa.
51
How many patients with fibromyalgia meet criteria for CFS?
20-70%
52
How many patients with CFS meet criteria for fibromyalgia?
35-70%
53
Which conditions do sx of CFS overlap with?
Fibromyalgia
Multiple chemical sensitivity
IBS
Temporomandibular joint disorder
54
What has replaced the diagnostic criteria for pain disorder in DSM IV in DSM V?
Somatic Symptom and Related Disorders (SSD)
55
What is SSD diagnosis made on?
The basis of positive sx and signs rather than absence of a medical explanation for somatic complaints.
56
What are the positive sx and signs of SSD?
Distressing somatic sx plus abnormal thoughts, feelings and behaviours in response to these sx
57
Which DSM IV disorders have been removed?
Somatization disorder
Hypochondriasis
Pain disorder
Undifferentiated somatoform disorder
58
How do psychiatric illnesses increase pain intensity?
Via shared mehcnaism through central pain modulating system
59
What is the most common presenting somatic sx in medial OP?
Pain
60
What is the most common mental disorder in patients suffering from pain disorders?
Depression - 10-15%
61
How many depressed adults complain of pain?
43%
62
When is CBT effective for chronic pain?
Cognitive restructuring
Relaxation training
Time-based activity pacing
Graded homework assignments to decrease avoidance and encourage more active lifestyle
63
Who first introduced the term atypical facial pain?
Frazier and Russell in 1924
64
What is atypical facial pain?
Atypical in distribution, unilateral, poorly localised, lasts most of the day and described as severe ache, crushing or burning.
65
What is the definition of persistent idiopathic facial pain?
Facial pain that is present daily and persists most of the day.
Pain is confined at onset to limited area on one side of the face, deep ache, poorly localised.
66
Exclusion criteria for persistent idiopathic facial pain?
Associated sensory loss or physical signs
| Abnormalities in lab or imaging studies
67
BAP guidelines on use of antidepressants in pain management
Lack of evidence that SNRIs are more effective than SSRIs for pain sx associated with depression.
68
What are primary organic neuropsychiatric disorders due to in HIV?
Viral CNS damage
69
What are secondary organic neuropsychiatric disorders due to in HIV?
Opportunistic infections
| Drugs
70
What are reactive neuropsychiatric disorders in HIV due to?
HIV-associated acute stress reaction
71
Prevalence of any mental disorder in the lifetime of HIV positive patients?
38-73%
72
When does HIV associated acute stress reaction occur?
When informing someone of seropositivity of when a transition to full clinical AIDs occurs from state of infection.
73
Sx of HIV associated acute stress reaction?
```
Brooding about the future
Panic attacks
Social isolation
Rage
Feelings of isolation
```
74
Duration of HIV associated acute stress reaction
Appear within minutes of hours of patient being informed
| Remit within 2-3 days
75
How many patients with HIV show adjustment disorder?
5-20%
76
How many patients with HIV show anxiety disorder?
11-25%
77
Which psychiatric disorder is most common in HIV patients?
Depression
78
How many patients with HIV report being depressed at some point?
40%
79
M:F ratio of depression in HIV patients
More common in women
80
Reasons for high incidence of depression in HIV patients
```
Psychological impact
Neuripathological deficits
Homosexuals
Lower socioeconomic groups
Some sx of depression also occur in HIV e.g. weight loss, sleep disorder
```
81
Risk factors of suicide in patients with HIV
Having friends who died from AIDS
Recent notification of HIV seropositivity
Difficult social issues due to homosexuality
Inadequate social and financial support
Presence of dementia or delirium
82
Treatment of depression in HIV patients
SSRIs or TCAs
83
Dosing of SSRIs for depression in HIV
25% of usual recommended dosage when starting
84
Which TCAs to use in depression in HIV?
Secondary amines
85
Risk of TCAs used in patients with AIDS
May suffer severe anticholinergic effects
86
What therapy is helpful for depression in HIV
Interpersonal psychotherapy
87
What might cause psychosis during late stages of HIV?
Direct neurotoxicity
Iatrogenic
Substance misuse
88
Difficulties in px antipsychotics to patients with AIDs
Prone to EPSEs and NMS
89
What is the most frequent reason for psychiatric hospitalisation of patients with HIV?
Mania
Depression
Psychosis (in that order)
90
Causes of mania in HIV
Illicit drug use
| Iatrogenic
91
What iatrogenic things can cause mania in HIV?
```
Didanosine
Ganciclovir
Procarbazine
Estavudine
Steroids
Zidovudine
```
92
What is mania in advanced HIV associated with?
Cognitive impairment
| Reduced survival
93
Difficulties in treating mania in HIV patients
Lithium and Valproate can induce neurological reactions and toxicity
94
What needs to occur if a patient with HIV is started on Carbamazepine?
Control of patients haemopoietic function as other medications can trigger toxic effects in bone marrow
95
Which organic mental disorder is most frequently observed in patients with HIV?
Delirium
96
What is 'mild cognitive/motor disorder' in HIV?
AIDs dementia where ADLs are intact
97
How many patients with AIDs have dementia?
3%
98
Incidence of dementia syndrome within first 2 years of diagnosis of AIDs?
7% per year
99
How many patients with AIDs develop dementia?
15%
100
Risk factors for developing HIV-associated dementia
Older age
Decreased body mass
Decrements in haematocrit
History of IV drug abuse
101
Early cognitive sx of HIV-dementia
Forgetfulness
Loss of concentration
Mental slowing
Reduced performance on sequential mental activities
Apathy
Reduced spontaneity and emotional responsivity
Social withdrawal
102
Early emotional sx of HIV-dementia
Depression
Emotional lability
Agitation
Psychotic sx
103
Early motor sx of HIV dementia
```
Loss of balance and coordination
Clumsiness
Leg weakness
Postural tremor
Hyperreflexia
Ataxia
Slowing of rapid alternating movements
Frontal release signs
Dysarthria
Saccades
```
104
Cognitive tests in early HIV dementia
Slowing in verbal or motor responses or difficulty in recalling a series of objects after >5 mins
105
Sx in late HIV dementia
```
Global deterioration of cognitive function
Severe psychomotor retardation
Mutism
Paraparesis
Bowel/bladder incontinence
Myclonus
Seizues
Pedal parasthesias and hypersensitivities due to concurrent sensory neuropathy
```
106
Predictive markers for HIV Dementia
B2-microglobulin and neopterin levels in CSF
| CD41 cell counts
107
Indirect factors leading to HIV dementia
Cytokines - TNF
Parts of HIV itself - gp41, gp120, Tat, Rev, Nef
Excitatory aminoacids - quinolinic acid
108
What can be used to differentiate HIV Dementia from depression?
Neuropsychological tests
| Brain imaging
109
What cognitive functions are preserved in HIV dementia?
Naming
| Vocab
110
What does brain imaging show in HIV dementia?
Cerebral atrophy, widened cortical sulci, enlarged ventricles
High intensity T2 signal abnormalities in periventricular white matter and centrum semiovale
111
What in brain imaging would suggest primary CNS lymphoma?
Contrast-enhancing mass lesions
112
What in brain imaging would suggest cerebral toxoplasmosis?
Multiple bilateral ring-enhancing lesions
113
What can CSF help to exclude in HIV?
Cryptococcal meningitis
CNS TB
CMV encephalitis
Neurosyphilis
114
What does CSF show in HIV dementia?
Increase of total proteins
Increase of IgG fraction and mononuclear pleocytosis index
HIV core antigen p24 or HIV RNA
115
What does HIV RNA in CSF correlate with?
Severity of dementia
116
What can help diagnosis of cryptoccocal meningitis?
CSF indian ink staining, cryptococcal antigen tires and fungal cultures
117
Treatment of HIV infection
Zidovudine
118
What is Zidovudine?
Reverse transcriptase inhibitor
119
What medication has been found to improve cognitive sx in patients with AIDs?
Methykphenidate 10-90mg/day
120
What secondary organic brain diseases can occur in HIV?
Progressive multifocal leucoencephalopathy
Cerebral toxoplasmosis
Cryptococcal meningitis
Primary CNS lymphoma
121
What is progressive multifocal leucoencephalopathy?
Papovavirus infection affecting white matter diffusely.
122
Sx of progressive multifocal leucoencephalopathy?
Rapid dementia
Blindness
Ataxia
Hemiparesis
123
Treatment of progressive multifocal leucoencephalopathy?
None
124
What is cerebral toxoplasmosis?
Reactivation of latent cerebral infection by Toxoplasma gondii
125
What is Toxoplasma gondii?
Opportunistic intracellular protozoan
126
Sx of cerebral toxoplasmosis?
Rapid development of marked alteration in mental state
127
Where do lesions tend to be in cerebral toxoplasmosis?
Basal ganglia
128
How is diagnosis of cerebral toxoplasmosis made>
Structural neuroimaging tests
129
Treatment of cerebral toxoplasmosis?
Pyrimethamine and Sulphadiazine
130
What is cryptococcal meningitis?
Caused by yeast-like fungus cryptococcus neoformans
131
Sx of cryptococcal meningitis?
```
Headache
Meningism
Photophobia
Nausea
Fever
Deirium
```
132
Treatment of cryptococcal meningitis?
Amphotericin B IV
133
What is primary CNS lymphoma?
Late complication of HIV
| EBV-assocaited
134
How many patients with HIV develop primary CNS lymphoma?
10%
135
Sx of primary CNs lymphoma?
```
Epileptic seizures
Personality change
Changes in attention
Headache
Focal deficits without fever
```
136
Name some antiretrovirals used in HIV
```
Zidovudine
Stavudine
Didanosine
Zalcitabine
Efavirenz
```
137
Side effects of Zidovudine
```
Confusion
Agitation
Insomnia
Mania
Depression
```
138
Side effects of Stavudine and Zalcitabine
Peripheral neuropathy
139
Side effects of Didanosine
Peripheral Neuropathy
| Mania
140
Side effects of Efavirenz
Neuropsychiatric side effects:
| 33% depression, 2% psychosis
141
How many patients on Efavirenz develop neuropsychiatric side effects?
46%
