Psych Flashcards
Patients ≤ 25 years who have been started on an SSRI should be reviewed when?
after 1 week
What is flight of ideas?
Jumping from idea to idea with links between these
What is Knights move?
Jumping from idea to idea with no links between these
What is the risk of SSRI in third trimester?
Persistent pulmonary HTN
What is a C/I to triptans for migraines?
Patients taking SSRI
Patients under 25 starting an SSRI should be reviewed when?
After 1 week
When do you get alcohol withdrawal symptoms, seizures and delirium?
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours
Management of OCD?
- SSRI
- Clomipramine
OCD vs OCPD?
OCD must have functional component/impact of daily life
Management of SSRIs before ECT?
Dose should be reduced but not stopped
When should lithium levels be checked after a change in dose?
One week after change and then weekly until levels are stable
Signs of alcohol addiction
Attempted and failure of abstinence, compulsion to drink, narrowing of drinking repertoire, increased tolerance to alcohol, alcohol is priority over oth e r aspects of life, physical withdrawal when alcohol is stopped
Why can antipsychotics cause elevated prolactin?
Prolactin release from lactotrophs is inhibited by dopamine released from the hypothalamus. Therefore, when this inhibition is lifted, prolactin release is increased
How can patients appeal against being sectioned?
Appeal must be applied for in writing to a mental health tribunal within 14 days o f detention
How does activated charcoal work?
Activated charcoal works by providing a large surface area to absorb a potential poison and stop it from being absorbed by the GI tract;
Lithium toxicity may be precipitated by what?
NSAIDs
Management of PTSD?
- Trauma focused CBT
- EMDR
- Venlafaxine/SSRI
Triggers for lithium toxicity
Dehydration
Infection
Renal failure
ACE/ARB
NSAID
Diuretic
How long should symptoms be present for with PTSD?
4 weeks
What is the management of lithium toxicity?
Mild/Moderate: IV Fluid resus
Severe: Haemodialysis
Bipolar I vs Bipolar II
Bipolar I - mania and depression
Bipolar II - hypomania and depression
Purposefully causing symptoms such as hypoglycaemia?
Munchausen syndrome
Hypomania in the community?
Routine referral to community mental health
How do you define chronic insomnia?
Trouble falling asleep/staying asleep for 3 months or longer
What are risk factors for insomnia?
- Increasing age
- Female gender
- Lower educational attainment
Which medications can cause insomnia?
Corticosteroids
OCD vs psychosis?
OCD will have a level of insight of their actions
What can be protective factors against completed suicide ideation?
- Social support
- Religious beliefs
- Having children at home
- Regretting an attempt
What are common PTSD symptoms?
- Flashbacks/nightmares
- Avoiding people or situations
- Hypervigilance/Sleep problems
Schizoid vs schizotypal PD?
Schizotypical will also have unusual beliefs/magical thinking
How should SSRI dose be stopped?
Over a 4 week period
What ophthalmic feature is associated with Charles Bonnet?
Age related MD
Flight of idea vs tangentiality?
In flight of ideas, they would answer the question then jump to another idea whereas in tangentiality, they would not answer the question
Sweating, tremor, confusion and hyperreflexia?
Serotonin syndrome
Which medications can cause serotonin syndrome?
- MAO
- SSRIs + Tramadol/St Johns Wort
- Ecstasy
- Amphetamines
Which medications can be used as mood stabilizers?
- Lithium
- Sodium valproate
- Carbamazepine
5 stages of grief
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
What is an hallucination?
Abnormal perception in the absence of external stimulus
Which deaths should be referred to coroner?
- Unknown cause of death
- Death was violent or suspicious
- Accidental death
- Death due to self neglect
- Death related to employment/industrial disease
- Death during operation
What are risk factors for NMS?
- Use of neuroleptic medication
- High dose medication
- Depot
- Previous NMS
Which receptor is blocked in NMS?
Dopamine
What are principles of the mental capacity act?
- Assume capacity
- Decisions made in best interests
- Help can be provided to make decision for themselves
- People with capacity can make unwise decisions
- Decisions made should be with the least restrictive option
Who can be a representative party for patients when no relatives during mental capacity discussions?
Independent Mental Capacity Advocates
What is an advanced decision?
Legally bound document allowing someone to state treatment they would not want in the future if they lack capacity to make the decision
What is panic disorder?
Regular, sudden or unexpected attacks of panic or fear
What questionnaires can be used for anxiety?
- Beck Anxiety Inventory
- Hamilton Anxiety scale
- General health questionnaire
Signs of anorexia on examination
- Bradycardia
- Lanugo hair
- Dry skin
- Evidence of self harm
- Acid erosion
- Hypotension
What is a community treatment order?
Service user has to meet certain supervised conditions in the community, if they fail to do this, they may be recalled to hospital
Risk of using antipsychotics in elderly?
- Stroke
- VTE
Recurrent vomiting can cause what?
- Russell sign
- Erosion of teeth
Clozapine S/E
- Agranulocytosis
- Reduced seizure threshold
- Constipation
- Dose must be adjusted if smoking if started/stopped
What assessment tools can be used for depression?
- HAD scale
- PHQ-9 scale
Section 2
- Admission for upto 28 days
- AMHP
Section 3
Treatment for 6 months
- 2 doctors and AMHP
Section 4
- 72 hours order
- GP and AMHP
Section 5(2)
Detained for 72 hours by doctor
Section 5(4)
Detained for 6 hours by nurse
Section 17(A)
Community treatment order
Section 135
Police order to retrieve someone from home to place of safety
Section 136
Police order to bring someone from public place to a place of safety
What is the most important prognostic indicator in paracetamol overdose?
Arterial PH
What is indication for liver transplant in paracetamol overdose?
pH < 7.3 more than 24 hours after transplant
What kind of reaction does N-acetylcysteine cause?
Anaphylactoid - non-IgE mediated mast cell release
What is high in anorexia?
- Growth hormone
- Glucose
- Salivary glands -> parotidomegaly
- Cortisol
- Cholesterol
- Carotenaemia
When can paracetamol overdose become high risk to develop liver failure?
- Chronic alcoholic
- HIV
- Anorexia
- Taking P450 inducers
Lead pipe rigidity is a sign of what?
Neuroleptic malignant syndrome
What is a Fregoli delusion?
Belief that everyone is the same person/strangers are familiar
What is a capgras delusion?
Relative/Friend has been replaced by an imposter
What are C/I to using anti-cholinesterase inhibitors?
- prolonged QT
- 2nd/3rd degree heart block
- Sinus bradycardia
Use Cognitive stimulation therapy instead
What is logoclonia?
Where the patient gets stuck on a particular word and repeats it
What is Ekbom syndrome?
Believe they are infested with parasites
What test is used to assess muscle wasting in patients with anorexia?
Sit-up-squad-stand test
Postpartum depression has to be within when?
12 months after birth
Stopping of voluntary movement or staying still in an unusual position
Catatonia
Serotonin syndrome vs NMS
Serotonin: faster onset, increased reflexes, dilated pupils
NMS: slower onset, decreased reflexes, normal pupils
Social phobia vs agoraphobia
Agoraphobia - fear of open spaces + crowds / difficulty of immediate easy escape to a safe place
Social Phobia - feat of scrutiny in small groups e.g. public speaking
Lithium can cause a benign what?
Leucocytosis - raised WCC
Antipsychotics can increase the risk of what?
Stroke
Symptoms of aspirin overdose?
- Hyperventilation
- Tinnitus
- Sweating
- N+V
- Seizures
- Causes respiratory alkalosis then metabolic acidosis
Conversion disorder?
Neuro symptoms without any underlying cause
Tahycardia, HTN, CNS stimulate, GI upset?
Think opioid withdrawal
What is agnosia?
Inability to recognise people, objects or places which were once known
Confusion screen bloods
FBC, U&E, LFTs, CRP/ESR, Ca2+, TFTs, B12, folate, syphilis, HIV
ophthalmoplegia, ataxia, and confusion
Wernickes
Personality disorders
Cluster A - Paranoid, schizoid, schizotypal
Cluster B - Antisocial, EUPD, Histrionic, Narcissistic
Cluster C - OCPD, Avoidant, Dependent
Fregoli delusion
Different people are the same person
How long should treatment for SSRI be continued before thinking about switching?
4 weeks - younger
6 weeks - elderly
What is schizoaffective disorder?
Schizophrenia with mood disturbance e.g. depression/mania
What should be considered in elderly patients with new onset psychosis?
Organic cause -> CT head
Acute stress disorder?
acute stress reaction that occurs in 1st 4w after person has been exposed to a traumatic event eg. threatened death, serious injury (road traffic accident, sexual assault ect)
PTSD vs acute stress disorder?
Acute stress disorder= occurs in 1st 4w after exposed to traumatic event
PTSD= diagnosed after 4w
Features of acute stress disorder?
intrusive thoughts e.g. flashbacks, nightmares
dissociation e.g. ‘being in a daze’, time slowing
negative mood
avoidance
arousal e.g. hypervigilance, sleep disturbance
Examples of intrusive thoughts in acute stress disorder?
flashbacks, nightmares
Examples of dissociation in acute stress disorder?
being ‘in a daze’, time slowing
Mx for acute stress disorder?
1st= trauma focused CBT
acute symptoms (eg. agitations, sleep disturbance)= benzodiazepines (should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation)
DSM-V defines ADHD as what?
condition incorporating features relating to inattention and/or hyperactivity/impulsivity that are persistent
has to be an element of developmental delay (like many paeds conditions)
=<16yrs= need 6 features
17yrs+= 5 features
Who is ADHD more common in?
males
most diagnosed 3-7yrs
possible genetic component
Diagnostic features of ADHD (need 6 features if =<16yrs or 5 if 17yrs+)?
Inattention:
- does not follow through on instructions
- reluctant to enage in mentally-intense tasks
- easily distracted
- finds it difficult to sustain tasks
- finds difficult to organise tasks/activities
- forgetful in daily activities
- often lose things
- often does not seem to listen when spoken to directly
Hyperactivity/Impulsivity:
- unable to play quietly
- talks XSly
- does not wait their turn easily
- will spontaneously leave their seat when expected to sit
- is often ‘on the go’
- interruptive or intrusive to others
- will answer prematurely before a question has been finished
- will run and climb in situations not appropriate
ADHD is a behavioural syndrome characterised by what?
hyperactivity, impulsivity and inattention
When does ADHD typically appear?
3-7yrs but may not be recognised until after 7yrs esp if hyperactivity not present
Assessing ADHD?
- core symptoms= hyperactivity, inattention and/or impulsivity present since childhood
- result in signif psycho, social and/or educational impairment
- symptoms present at least 6m
- symptoms at least in 2 settings eg. home, school, social situations
- other causes excluded
Suspect ADHD if at least 5 (6 in adults) inattention symptoms and/or 6 (5 in adults) hyperactivity-impulsivity symptoms that have….
- started <12yrs old
- occurred in 2+ setting
- present for at least 6m
- interfered with or reduced quality of social, academic or occupational functioning
- not explained by another disorder eg. oppositional defiant disorder or conduct disorder
Ix for ADHD?
- formal diagnosis and Tx carried out by specialist
- if only moderate impairment can be initially Mx in primary care with self-help, behavioural Mx or parent support programmes
What to do if ADHD is suspected in a child?
1) assess social and educational impact of their symptoms
2) if adverse effects on life then= watch and wait up to 10w with self help and behavioural Mx; parent support group
3) Refer children to CAMHS, specialist paeds or child psychiatrist if severe, watching not acceptable or problems persist
What to do if ADHD is suspected in a adult?
1) assess psych, social, educational or occupational impact of symptoms
2) refer pt without prior diagnosis for assessment by specialist
2) if previously Tx for ADHD then refer to general adult psych services for assessment
How to assess social and educational impact of ADHD in child?
School-age children= extent of impairment should be judged in the context of self-care (for example, eating, or hygiene), travelling independently, making and keeping friends, achieving in school, forming positive relationships with other family members, developing a positive self-image, avoiding criminal activity, avoiding substance misuse, maintaining emotional states free of excessive anxiety and unhappiness, and understanding and avoiding common hazards.
For adolescents, difficulties may extend to cover occupational or educational underachievement, dangerous driving, and difficulties in carrying out daily activities (such as shopping and organizing household tasks), in making and keeping friends, and intimate relationships (for example, excessive disagreement).
Suspected ADHD= in addition to assessing social and educational impact of their symptoms in children, primary care practitioners with appropriate training/expertise may wish to augment this assessment using what?
Strengths and Difficulties questionnaire or the Conners’ rating scale.
Mx of ADHD is initiated and coordinated by who?
Specialists
Depending on locally-agreed shared care arrangements, drug treatments initiated and titrated by a specialist may be continued and monitored in primary care.
What should be documented in pts notes if they have ADHD and on treatment?
1) weight= every 3m if 10yrs and younger; 3m & 6m when starting Tx and every 6m after in children >10yrs; every 6m in adults (BMI)
2) height= every 6m
3) BP and HR= before and after each dose change and every 6m
When to seek specialist advice for pt who has ADHD and is managed in primary care using shared care arrangement?
if drug treatment results in sustained resting tachycardia (>120 bpm), arrhythmia, or systolic blood pressure greater than the 95th percentile (or a clinically significant increase) measured on two occasions, or other significant adverse effects develop.
Specialist advice should also be sought if a child or young person’s height over time is significantly affected by medication (that is, they have not met the height expected for their age), as a planned break in treatment over school holidays may be required to allow ‘catch-up’ growth.
ADHD: what to give advice on if adult is prescribed an amfetamine eg. dexamfetamine or lisdexamfetamine) for ADHD?
They should not drive if they feel drowsy, dizzy, unable to concentrate or make decisions, or if they have blurred or double vision.
It is now an offence to drive if they have more than a specified amount of amfetamines in their body, whether driving is impaired or not. It may be helpful for the person to keep evidence (such as the other half of their prescription) in the car to show that they are taking the amfetamine in accordance with medical advice.
Diet and exercise advise for pt with ADHD?
normal healthy diet and regular exercise
if appears to be a link between certain food/drink advise to keep food diary; ?refer to dietician before dietary elimination considered
if weight a problem= take ADHD meds with or after food not before; additional meals/snacks in morning or late evening when drugs worn off
Secondary care Mx for preschool children with ADHD?
1st line= ADHD focused group parent-training programme
- if still impairment after environmental modifications been implemented, advise from ADHD service specialist
Secondary care Mx for school aged children and young people with ADHD?
- group support to pt and parents= education and info; liaison with school/uni if consent
- individual parent-training programmes if can’t attend group or too complex for group
- Still not improved= methylphenidate
- if insomnia= melatonin 6-17yrs
- if medication effective but still impairment eg. social skills, self control= CBT
Secondary care Mx for adults with ADHD?
- environmental modifications
- no improved= medication
- meds effective but still impairment= structured supportive psychological intervention, regular follow up and/or CBT
Medication for ADHD?
methylphenidate
contraindicated/ineffective= Lisdexamfetamine, dexamfetamine or atomoxetine
Following presentation with suspected ADHD, immediate Mx?
watch and wait for 10w to observe if symptoms change or resolve
if persists then refer to secondary care= CAMHS or specialist paeds for tailored plan of action
holistic approach= parents attending education and training programmes; medication last resort if this fails or if severe
When is drug therapy used for ADHD?
last resort and only in pts aged 5yrs+
1st line drug for ADHD?
methylphenidate
initially 6w trial
MOA of methylphenidate for ADHD?
CNS stimulant which acts as a dopamine/norepinephrine reuptake inhibitor
Side effects of methylphenidate for ADHD?
abdo pain, nausea, dyspepsia, stunted growth in children, weight loss
What should be monitored every 6m if on methylphenidate for ADHD?
height and weight
What if methylphenidate not effective for ADHD Mx?
switch to lisdexamfetamine;
Dexamfetamine should be started in those who have benefited from lisdexamfetamine, but who can’t tolerate its side effects.
1st line ADHD meds in adults?
Methylphenidate or lisdexamfetamine are first-line options;
Switch between these drugs if no benefit is seen after a trial of the other.
What should be done before starting pt on ADHD drugs?
baseline ECG before starting treatment, and refer to a cardiologist if there is any significant past medical history or family history, or any doubt or ambiguity.
Why is baseline ECG done before starting ADHD drugs?
all ADHD drugs potentially cardiotoxic
Autism?
pattern of qualitative differences and impairments in reciprocal social interaction and social communication, combined with restricted interests and rigid and repetitive behaviours, often with lifelong impact
When do features of autism usually present?
in early childhood
persistent
may not become apparent until a change in the child or young person’s life eg. transition to school
Difficulties in autism can affect what?
personal, social, educational, occupational or other functioning
usually observable in all settings
Autism spectrum disorder?
broad, heterogeneous neurodevelopmental disorder which is behaviourally defined, with different levels of severity, that encompasses autism, Asperger’s syndrome, and atypical autism.
Cause of autism?
unknown
genetic, neurobiological and environmental factors
Autism may be associated with range of coexisting problems such as what?
neurodevelopmental= learning disability, severe visual & hearing impairments, motor or co-ordination disorders, speech & language disorders, epilepsy, ADHD
Mental health= anxiety, depression, conduct disorder, Tourettes
Functional= sleep, diet, nutrition, bladder and bowel
Other= social isolation, exclusion, bullying, child exploitation and maltreatment, carer stress
Assessment for suspected autism in child?
- developmental history and behaviour, speech, language and communication; social skills; sensory difficulties; severity and duration of features and presence in different settings; impact on the person and family/carers; family history; risk factors for autism; coexisting physical, mental health, and behavioural problems; educational history; safeguarding issues, any previous assessments and treatments.
Examination of general appearance, developmental stage, growth, eye contact, vocabulary and language skills, social interaction and communication, behaviour; neurological, vision and hearing assessment.
Ix/Mx for suspected autism?
- referral to local team/paeds/psych depending on age, RFs, level of concern
- if suspect genetic/chromosomal anomaly= refer to clinical genetics specialist
- review after watchful waiting and gathering info about development and behaviour from other health, social and educational professionals if uncertain
Mx of child with confirmed autism?
- liasise with allocated key worker and local autism team for ongoing care and support= social and communication skills, physical and mental health, behaviour that challenges, sleep, safeguarding concerns
- info and support
- advise about making reasonable adjustments or adaptations, structuring time and activities, carer support and future planning
When to suspect autism in preschool child? (features consistently present across different settings)
- language delay or regression, unusual characteristics of spoken language, reduced/infrequent use of language
- reduced or absent interaction with others
- reduced eye contact, pointing and other gestures
- reduced or absent imagination and variety of pretend play
- unusual or restricted interests and/or rigid and repetitive behaviours eg. hand flapping, body rocking while standings, spinning
- over or under reaction to sensory stimuli eg. sounds, smells, taste, textures; extreme food fads
When may diagnosing autism be challenging?
- <24m
- child developmental age of <18m
- child where lack of info about early life eg. adopted
- severe sensory impairment eg. hearing or vision or motor disorder eg. cerebral palsy
- milder symptoms and/or average or above intelligence
When to suspect autism in primary school/secondary school child? (features consistently present across different settings)
- unusual speech eg. limited, repetitive, monotonous
- reduced, absent or negative response to others eg. reduced/absent response to facial expressions; reduced/no response to name but normal hearing
- reduced or absent interaction with others
- reduced or absent eye contact, pointing or other gestures
- reduced or absent ideas and imagination
- unusual or restricted interests and/or rigid and repetitive behaviours eg. strong preference for for familiar routines and dislike of change
- over or under reaction to sensory stimuli
- unusual profile of skills or deficits eg. skills or knowledge advanced for chronological or mental age
- social development more immature eg. XS trusting
ASD?
autism spectrum disorder
Prognosis of autism?
no cure for ASD, early diagnosis and intensive educational and behavioural management may improve outcomes
Around 50% of children with ASD have what
intellectual disability
Autism: when may features present?
Social communication impairments and repetitive behaviours are present during early childhood (typically evident before 2-3 years of age), or maybe manifested later.
Clinical features of autism can be classified as what?
- impaired social communication and interaction
- repetitive behaviours, interests and activities
- often associated with intellectual impairment or language impairment
- may also have ADHD (35%) and epilepsy (18%)
- associated with higher head circumference to brain volume ratio
What conditions are associated with autism?
ADHD (35%) and epilepsy (18%)
Clinical features of autism= examples of impaired social communication and interaction?
Children frequently play alone (younger children may not play alongside other children) and maybe relatively uninterested in being with other children.
They may fail to regulate social interaction with nonverbal cues like eye gaze, facial expression, and gestures.
Fail to form and maintain appropriate relationships and become socially isolated.
Clinical features of autism= examples of repetitive behaviours, interests and activities?
Stereotyped and repetitive motor mannerisms, inflexible adherence to nonfunctional routines or rituals are often seen.
Children are noted to have particular ways of going about everyday activities.
Mx for autism should be what?
initiated early, involves educational and behavioural Mx, medical therapy and family counselling
Goal in the Mx of autism?
The goal is to increase functional independence and quality of life through:
- Learning and development, improved social skills, and improved communication
- Decreased disability and comorbidity
- Aid to families
Non-pharmacological therapy for autism?
Early educational and behavioural interventions:
- Applied behavioural analysis (ABA).
- ASD preschool program.
- Treatment and Education of Autistic and Communication related handicapped CHildren (TEACCH)/Structured Teaching method.
- Early Start Denver Model (ESDM).
- Joint Attention Symbolic Play Engagement and Regulation (JASPER).
Family support and counselling:
- Parental education on interaction with the child and acceptance of his/her behaviour.
Pharmacological interventions for autism?
no consistent evidence
may need methylphenidate if also have ADHD
self-injury, aggression= antipsychotic drugs
anxiety, aggression, repetitive behaviours= SSRIs
What was bipolar previously known as?
manic depression
Bipolar?
serious long term mental illness, characterised by episodic depressed and elated moods, and increased activity (hypomania or mania)
Manic episode in bipolar according to NICE?
period during which there is abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week, accompanied by at least three additional symptoms, and which is severe enough to cause marked impairment in social or occupational functioning or necessitate hospitalization, or which includes psychotic features.
Hypomanic episode in bipolar according to NICE?
similar to a manic episode except that a diagnosis only requires that symptoms have lasted for 4 days, is not severe enough to cause marked impairment in social or occupational functioning or necessitate hospitalization, and there are no psychotic features.
Depressive episode in bipolar according to NICE?
period of at least 2 weeks during which there is either depressed mood or loss of interest or pleasure in nearly all activities (or irritability in children and adolescents), accompanied by at least four additional depressive symptoms.
What is a mixed episode in bipolar according to NICE?
A mixture or rapid alternation of manic and depressive symptoms, or
A period of time (at least 1 week) in which the criteria are met for either a manic or hypomanic episode and at least three symptoms of depression are present during the majority of the days of the current or most recent episode of mania or hypomania, or
A period of time (at least 2 weeks) in which the criteria for a major depressive episode are met and at least three manic or hypomanic symptoms are present during the majority of days of the current or most recent episode of depression.
What is rapid-cycling bipolar disorder?
defined as the experience of at least four depressive, manic, hypomanic, or mixed episodes within a 12-month period.
Most important Cx of bipolar?
suicide and deliberate self-harm
Cx of acute episodes in bipolar?
- suicide and self-harm
- Financial difficulties from overspending.
- Traumatic injuries and accidents.
- Sexually transmitted infections and unplanned pregnancy from disinhibition and increased libido.
- Damage to reputation, income and occupation, and relationships.
- Self-neglect, exhaustion, and dehydration.
- Exploitation by others.
- Alcohol and substance misuse.
- Harm to others.
When to suspect bipolar in someone?
present with symptoms suggestive of mania, hypomania, depression and a history of previous episodes of possible mania or hypomania, or a mixture of both manic and depressive symptoms.
What to do if suspect bipolar disorder?
- refer for specialist mental health assessment, Mx, follow up
- risk assessment to determine urgency of referral
- if considered a danger to themselves or other then arrange hospital admission
-Tx in secondary care but can be transferred to primary care for ongoing Mx once stabilised
Diagnostic criteria for bipolar disorder in children and young people state that…
- Mania must be present.
- Euphoria must be present on most days and for most of the time, for at least 7 days.
- Irritability is not a core diagnostic criterion.
Suspect bipolar if pt has or has had any symptoms of what?
- mania
- hypomania
- depression and history of previous episodes of mania or hypomania
- mixture of both manic and depressive symptoms
List symptoms of mania in bipolar?
- abnormally elevated mood, extreme irritability, aggression
- increased activity/energy, restlessness, decreased need for sleep eg. feel rested after 3hrs sleep
- pressure of speech or incomprehensible speech
- flight of ideas or racing thoughts
- distractibility, poor conc
- increased libido, disinhibition, sexual indiscretion
- extravagant or impractical plans eg. spending sprees
- psychotic symptoms eg. delusions (grandiose) or hallucinations (usually voices)
Diagnosis of manic episode in bipolar requires symptoms of mania lasting how long?
at least 7 days which usually begin abruptly
examples of psychotic symptoms in manic episode in bipolar?
delusions (usually grandiose) or hallucinations (usually voices)
What suggests hypomania in bipolar?
symptoms of mania that are not severe enough to cause marked impairment and the absence of psychotic features
- mild elevation of mood/irritability
- increased energy & activity which may lead to increased performance at work/socially
- feeling of well-being, physical and mental efficiency
- increased sociability, talkativeness and over familiarity
Diagnosis of hypomanic episode in bipolar requires what?
symptoms to last at least 4d
Mixed episode in bipolar?
mixture or rapid alternation (usually within few hrs) of manic/hypomanic and depressive symptoms
Are symptoms of depression required to diagnose bipolar?
no
but at onset, most people with bipolar disorder present with a depressive episode, and a proportion of people with a diagnosis of unipolar depression will actually have bipolar disorder.
Symptoms and signs that may help distinguish bipolar disorder from unipolar depression include:
Hypersomnia, lability, and weight instability (experienced by around 90% of people with bipolar disorder and around around 50% of people with unipolar depression).
Earlier age of onset (peak age 15 to 19 years), abrupt onset (possibly triggered by stressor).
More frequent episodes of shorter duration.
Comorbid substance misuse.
Higher post-partum risk.
Psychosis, psychomotor retardation, and catatonia.
Lower likelihood of somatic symptoms.
FHx bipolar
When diagnosing bipolar, what is it important to do?
be aware of differential diagnoses to determine whether TFTs, FBC, vit D or other bloods (incl. toxicology screen) are required
How is bipolar diagnosed in secondary care?
adults= refer to specialist mental health
children= made after intensive monitoring by specialist:
<14yrs= refer to CAMHS
14-18yrs= specialist early intervention in psychosis or CAMHS
Differential diagnosis for autism (may be misdiagnosed or comorbid also)?
- unipolar depression
- cyclothymia
- schizophrenia
- mood disorders due to stroke, thyroid disease or MS
- substance misuse
- organic brain disease
- iatrogenic= antidepressents, levodopa, corticosteroids, methylphenidate
- metabolic disorders= hyperthyroidism, Cushings, Addisions, vit B12 def, end-stage kidney disease
- personality disorders
- anxiety disorders
- OCD
- PTSD
- ADHD
- sexual, emotional or physical abuse
- learning difficulties
most common comorbidities in people with bipolar disorder include
anxiety disorders, alcohol and substance misuse, and personality disorders. Comorbidity occurs in two-thirds of people with bipolar disorder throughout their lifetimes.
Onset of mania in later life may be indicative of what?
underlying medical comorbidity
Mx of bipolar in the acute phase?
therapeutic trial of oral antipsychotic eg. haloperidol, olanzapine, quetiapine or risperidone
if 1st not effective, can add 2nd, if still not can add lithium
mixed episodes Tx same as mania
Tx of depression= Quetiapine alone, or
Fluoxetine combined with olanzapine
- 4w after acute episode resolved then secondary care Mx long term
Chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression
bipolar disorder
Epidemiology of bipolar?
typically develops in late teen years
2 types of bipolar disorder?
Type I= mania and depression (most common)
Type II= hypomania and depression
What is hypomania and mania?
both terms relate to abnormally elevated mood or irritability
with mania, there is severe functional impairment or psychotic symptoms for 7 days or more
hypomania describes decreased or increased function for 4 days or more
Hypomania vs mania?
psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) suggest mania
no psychotic symptoms= hypomania
Mx for bioplar?
- psychological interventions
- mood stabiliser= lithium; alternative is valproate
- Mx of mania/hypomania= consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol
- Mx of depression= talking therapies; fluoxetine antidepressant of choice
- adress co-morbidities= 2-3 times increased risk of diabetes, cardiovascular disease and COPD
Mx of mania/hypomania in bipolar?
consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol
Mx of depression in bipolar?
talking therapies; fluoxetine is the antidepressant of choice
Mood stabiliser of choice in bipolar?
lithium
valproate alternative
Primary care referral for bipolar?
if symptoms suggest hypomania then NICE recommend routine referral to the community mental health team (CMHT)
if there are features of mania or severe depression then an urgent referral to the CMHT should be made
Pts with bipolar may have what to help with Mx of relapse?
advanced care plan
Advice to pt with bipolar to prevent relapse?
Encouraging compliance with treatment.
Maintaining an adequate amount of sleep.
Avoidance, if possible, of shift work, night flying and flying across time zones, or routinely working excessively long hours.
Establishing a regular routine in the morning.
Structuring the day with some activity and social contact.
Self-monitoring of symptoms (including triggers and early warning signs) and coping strategies.
Avoiding caffeinated drinks such as tea, coffee, or cola.
Smoking — advise the person to stop, or if this is not possible cut down (nicotine is a stimulant).
Avoiding alcohol and drug misuse.
Lithium?
mood stabilising drug used most commonly prophylactically in bipolar disorder but also as an adjunct in refractory depression
Therapeutic range and half life for lithium?
very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys.
MOA of lithium?
not fully understood, two theories:
- interferes with inositol triphosphate formation
- interferes with cAMP formation
Adverse effects of lithium?
nausea/vomiting, diarrhoea
fine tremor
nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
weight gain
idiopathic intracranial hypertension
leucocytosis
hyperparathyroidism and resultant hypercalcaemia
Lithium ECG changes?
T wave flattening/inversion
When to check lithium levels to monitor, when should the sample be taken?
12hrs post dose
When should lithium be monitored when starting?
after starting, levels should be performed weekly and after each dose change until concentrations are stable
When should lithium blood levels be monitored?
every 3m
When should lithium levels be checked after a change in dose?
1w after changing and weekly until levels are stable
Monitoring lithium= what should be checked every 6m?
thyroid and renal function
What should pts with bipolar be given when started on lithium?
info booklet, alert card and record book
Monitoring of lithium in bipolar?
- when checking levels, take sample 12hrs post dose
- check weekly after starting until concentrations are stable
- check levels weekly after change in dose
- once levels stable check levels every 3m
- every 6m check thyroid and renal function
How is depression classified?
less severe and more severe depresson
‘Less severe’ depression?
PHQ-9 score <16
previously termed subthreshold and mild depression
‘More severe’ depression?
PHQ-9 score >=16
previously termed moderate and severe depression
Mx of less severe depression (in order of preference)?
1) guided self-help
2) group CBT
3) group behavioural activation (BA)
4) Individual CBT
5) Individual BA
6) group exercise
7) group mindfulness and meditation
8) interpersonal psychotherapy (IPT)
9) SSRIs
10) counselling
11) short-term psychodynamic psychotherapy (STPP)
(order of preference)
Are antidepressants offered 1st line for less severe depression?
no, unless that is the pts preference
How is Tx approached in less severe depression?
discuss Tx options with pts to reach shared decision; least intrusive and least resource intensive Tx 1st
Mx for more severe depression (in order of preference)?
1) combined CBT and antidepressant
2) individual CBT
3) Individual behavioural activation
4) Antidepressants= SSRI or SNRI or other
- individual problem-solving
counselling
- short-term psychodynamic psychotherapy (STPP)
- interpersonal psychotherapy (IPT)
- guided self-help
- group exercise
What 2 questions can be used to screen for depression?
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
if yes to either then more depth assessment needed
Name 2 tools to assess degree of depression?
Hospital Anxiety and Depression (HAD) scale
and
Patient Health Questionnaire (PHQ-9)
Assessing depression: Hospital Anxiety and Depression (HAD) scale?
consists of 14 questions, 7 for anxiety and 7 for depression
each item is scored from 0-3
produces a score out of 21 for both anxiety and depression
severity: 0-7 normal, 8-10 borderline, 11+ case
patients should be encouraged to answer the questions quickly
Assessing depression: Patient Health Questionnaire (PHQ-9)?
asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
9 items which can then be scored 0-3
includes items asking about thoughts of self-harm
How is severity of depression grouped?
2 groups= less severe and more severe
used to be subthreshold, mild, moderate and severe
Score <16 on PHQ-9?
less severe depression
Score of 16 or more on PHQ-9?
more severe depression
What provides a criteria for diagnosing major depressive disorder (MDD) aka depression?
DSM-5
How many symptoms needed to diagnose depression (major depressive disorder) according to DSM-5 criteria?
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Symptoms in the DSM-5 criteria to diagnose depression include what?
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
- Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Depression meds= can you switch from from citalopram, escitalopram, sertraline, or paroxetine to another SSRI?
direct switch possible
Depression meds= switching between fluoxetine to another SSRI?
withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low dose of the alternative SSRI
Depression meds: switching from SSRI to tricyclic antidepressant (TCA)?
cross-tapering is recommended (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
- an exception is fluoxetine which should be withdrawn, the leave a gap of 4-7 days prior to TCAs being started at a low dose
Depression meds: switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine?
direct switch is possible (caution if paroxetine used)
Depression meds: switching from fluoxetine to venlafaxine?
withdraw and then start venlafaxine at a low dose 4–7 days later
SSRI stands for?
selective serotonin reuptake inhibitors
1st line medical Mx for depression?
SSRIs
Examples of SSRIs?
- citalopram
- sertraline
- fluoxetine
What SSRI is useful post MI?
sertraline
SSRIs should be used in caution in what population?
children and adolescents
SSRI of choice when indicated in a child or adolescent with depression?
fluoxetine
Adverse effects of SSRIs?
- GI symptoms (most common)
- increased risk GI bleeding so PPI if also taking NSAIDs
- increased anxiety after starting
- fluoxetine and paroxetine have a higher propensity for drug interactions
When first starting SSRI, what should you warn pts?
anxiety and agitation may increase at first
SSRIs: citalopram and escitalopram are associated with what? So do not use in who?
dose-dependent QT interval prolongation
those with= congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval
Citalopram max daily dose (due to dose-dependent QT interval prolongation)?
40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment
Interactions with SSRIs?
- NSAIDs (do not offer SSRIs but if do then give PPI too)
- warfarin and heparin= consider mirtazapine not SSRI
- aspirin
- triptans
- monoamine oxidase inhibitors (MAOIs)
Why to avoid SSRIs in pts taking triptans or MAOIs?
increased risk of serotonin syndrome
When to review pt by a doctor after starting antidepressant therapy?
after 2w
but if <25yrs or at risk of suicide then review after 1w
How long should pt be on antidepressants?
if good response then be on at least 6m after remission (symptoms better) to reduce risk of relapse
(don’t stop as soon as feel better)
How to stop SSRI antidepressants?
the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
SSRI discontinuation symptoms?
increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia
SSRIs and pregnancy?
- weigh up benefits and risk when deciding whether to use in pregnancy.
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
Risk of SSRIs in 1st trimester of pregnancy?
small increased risk of congenital heart defects
Use of SSRIs during 3rd trimester of pregnancy?
can result in persistent pulmonary HTN of the newborn
Paroxetine (SSRI) and pregnancy?
increased risk of congenital malformations, esp in 1st trimester
Features of beta-blocker overdose?
bradycardia
hypotension
heart failure
syncope
Mx of beta blocker overdose?
- bradycardic= atropine
- resistant then give glucagon
haemodialysis NOT effective
Drugs that can be cleared with haemodialysis in overdose?
BLAST
Barbiturate
Lithium
Alcohol (inc methanol, ethylene glycol)
Salicylates
Theophyllines (charcoal haemoperfusion is preferable)
Drugs that cannot be cleared with haemodialysis in overdose?
tricyclics
benzodiazepines
dextropropoxyphene (Co-proxamol)
digoxin
beta-blockers
Cx of iron overdose?
- metabolic acidosis
- erosion of gastric mucosa= GI bleeding
- shock
- hepatotoxicity and coagulopathy
Iron overdose= Mx is guided by what?
total amount of iron ingested (elemental iron/kg) and the presence/absence of symptoms (abdominal pain, diarrhoea, vomiting, lethargy)
Mx of iron overdose= ingested <40mg/kg elemental iron and are symptomatic?
observed at home
Mx of iron overdose= ingested >40mg/kg iron or symptomatic?
medical assessment with serum iron levels measured 2-4 hours post-ingestion and abdominal x-ray
Iron overdose= Mx for all patients presenting within 4 hours who have ingested > 60mg/kg elemental iron or have undissolved tablets on abdominal x-ray?
Whole bowel irrigation
if not effective or iron is adhered to gastric wall then endoscopy or surgery
Can you use activated charcoal in iron poisoning?
no
Drug used in iron overdose?
Desferrioxamine
When is desferrioxamine indicated in iron overdose?
Patients with serum iron level > 90umol/l,
Patients with serum iron level 60-90umol/l, who are symptomatic or have persistent iron on abdominal x-ray despite whole bowel irrigation
Any patient with shock, coma or metabolic acidosis
When is lithium used?
prophylactically in bipolar disorder but also as an adjunct in refractory depression
Half-life of lithium?
long plasma half-life
excreted by kidneys
Lithium toxicity generally occurs following concentrations of what?
> 1.5mmol/L
Lithium toxicity may be precipitated by what?
dehydration
renal failure
drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.
Features of lithium toxicity?
coarse tremor (a fine tremor is seen in therapeutic levels)
hyperreflexia
acute confusion
polyuria
seizure
coma
Mx of lithium toxicity?
mild-moderate= may respond to volume resuscitation with normal saline:
- IV fluids with isotonic saline, until euvolemic, then typically twice maintenance rate
- monitor serum sodium closely (every 4 hours with serial lithium concentrations) if there is a concern about lithium-induced nephrogenic diabetes insipidus
haemodialysis may be needed in severe toxicity
sodium bicarbonate is sometimes used but there is limited evidence to support this (by increasing the alkalinity of the urine it promotes lithium excretion)
Paracetamol overdose= minority of pts that present within 1hr may benefit from what?
activated charcoal to reduce absorption of the drug
Drug for the Mx of paracetamol overdose?
N-Acetylcysteine
When should acetylcysteine be given in paracetamol overdose?
the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity
there is a staggered overdose or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration
patients who present 8-24 hours after ingestion of an acute overdose of more than 150 mg/kg of paracetamol even if the plasma-paracetamol concentration is not yet available
patients who present > 24 hours if they are clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal
- acetylcysteine should be continued if the paracetamol concentration or ALT remains elevated whilst seeking specialist advice
What rate is aceytlcysteine infused over in paracetamol overdose?
1hr (used to be 15mins)
Why in paracetamol overdose, is acetylcysteine infused over 1hr and not 15mins?
reduce the number of adverse effects.
Acetylcysteine commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release).
Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate.
Anaphylactoid reactions to IV acetylcysteine are generally treated by
stopping the infusion, then restarting at a slower rate.
Paracetamol overdose= King’s College Hospital criteria for liver transplantation (paracetamol liver failure)?
Arterial pH < 7.3, 24 hours after ingestion
or all of the following:
- prothrombin time > 100 seconds
- creatinine > 300 µmol/l
- grade III or IV encephalopathy
When is an overdose considered as staggered?
if all the tablets were not taken within 1hr
Pathophysiology behind paracetamol overdose?
The liver normally conjugates paracetamol with glucuronic acid/sulphate. During an overdose the conjugation system becomes saturated leading to oxidation by P450 mixed function oxidases*. This produces a toxic metabolite (N-acetyl-B-benzoquinone imine)
Normally glutathione acts as a defence mechanism by conjugating with the toxin forming the non-toxic mercapturic acid. If glutathione stores run-out, the toxin forms covalent bonds with cell proteins, denaturing them and leading to cell death. This occurs not only in hepatocytes but also in the renal tubules
*this explains why there is a lower threshold for treating patients who take P450 inducing medications e.g. phenytoin or rifampicin
Pathophysiology behind paracetamol overdose= why is N-acetyl cysteine used?
as it is a precursor of glutathione and hence can increase hepatic glutathione production
The following groups of patients are at an increased risk of developing hepatotoxicity following a paracetamol overdose:
1) patients taking liver enzyme-inducing drugs (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St John’s Wort)
2) malnourished patients (e.g. anorexia nervosa) or patients who have not eaten for a few days
Acute alcohol intake, as opposed to chronic alcohol excess, is not associated with an increased risk of developing hepatotoxicity and may actually be protective.
Salicylate overdose leads to what results on ABG?
mixed respiratory alkalosis and metabolic acidosis.
Early stimulation of the respiratory centre leads to a respiratory alkalosis whilst later the direct acid effects of salicylates (combined with acute renal failure) may lead to an acidosis. In children metabolic acidosis tends to predominate.
Features of salicylate overdose?
hyperventilation (centrally stimulates respiration)
tinnitus
lethargy
sweating, pyrexia
nausea/vomiting
hyperglycaemia and hypoglycaemia
seizures
coma
Why may pt get pyrexia with salicylate overdose?
salicylates cause the uncoupling of oxidative phosphorylation leading to decreased adenosine triphosphate production, increased oxygen consumption and increased carbon dioxide and heat production
Tx for salicylate overdose?
general (ABC, charcoal)
urinary alkalinization with intravenous sodium bicarbonate - enhances elimination of aspirin in the urine
haemodialysis
Indications for haemodialysis in salicylate overdose?
serum concentration > 700mg/L
metabolic acidosis resistant to treatment
acute renal failure
pulmonary oedema
seizures
coma
Causes of serotonin syndrome?
monoamine oxidase inhibitors
SSRIs
- St John’s Wort, often taken over the counter for depression, can interact with SSRIs to cause serotonin syndrome
- tramadol may also interact with SSRIs
ecstasy
amphetamines
Features of serotonin syndrome?
neuromuscular excitation= hyperreflexia, myoclonus, rigidity
autonomic nervous system excitation= hyperthermia, sweating
altered mental state= confusion
Mx of serotonin syndrome?
supportive including IV fluids
benzodiazepines
more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine
Serotonin syndrome vs Neuroleptic maligant syndrome?
SS= caused by SSRIs, MAOIs, ecstasy/novel psychoactive stimulants; faster onset (hrs); increased reflexes, clonus, dilated pupils; Mx of severe= cyproheptadine, chlorpromazine
NMS= caused by antipsychotics; slower onset (hrs-d); decreased reflexes, ‘lead pipe’ rigidity, normal pupils; Mx of severe= dantrolene
Both= drug reactions often in young pts; tachycardia, HTN; pyrexia, diaphoresis; rigidity; increased CK (more in NMS); IV fluids, benzodiazepines
Serotonin syndrome or neuromalignant syndrome= increased reflexes, clonus , rigidity and dilated pupils?
Serotonin syndrome
NMS= decreased reflexes, lead pipe rigidity, normal pupils
What tricyclics are particularly dangerous in overdose?
amitriptyline and dosulepin (dothiepin)
Early features of tricyclic overdose?
anticholingeric= dry mouth, dilated pupils, agitation, sinus tachy and blurred vision
Features of severe tricyclic overdose?
arrhythmias
seizures
metabolic acidosis
coma
ECG changes in tricyclic overdose?
sinus tachycardia
widening of QRS
prolongation of QT interval
Tricyclic overdose= widening of QRS and prolonged QT means what?
Widening of QRS > 100ms is associated with an increased risk of seizures whilst QRS > 160ms is associated with ventricular arrhythmias
Mx for tricyclic overdose?
- IV bicarbonate= first-line therapy for hypotension or arrhythmias; indications include widening of the QRS interval >100 msec or a ventricular arrhythmia
- other drugs for arrhythmias
- correction of acidosis is the first line in the management of tricyclic-induced arrhythmias
- intravenous lipid emulsion is increasingly used to bind free drug and reduce toxicity
What is ineffective in tricyclic overdose?
dialysis
What is contraindicated in tricyclic overdose?
+ class 1a (e.g. quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are contraindicated as they prolong depolarisation
class III drugs such as amiodarone should also be avoided as they prolong the QT interval
response to lignocaine is variable and it should be emphasized that correction of acidosis is the first line in the management of tricyclic-induced arrhythmias
Antidotes can be given in overdose why?
to prevent the poison from working or reverse the effects of the poison
Antidote for paracetamol overdose?
acetylcysteine
Antidote for digoxin overdose?
Digoxin-specific antibody fragments
Antidote for benzodiazepine overdose?
Flumazenil injection
reverses the central nervous system and respiratory depression.
if the person has also taken a tricyclic antidepressant or has epilepsy, there must be caution, as flumazenil can cause seizures and arrhythmias.
Antidote for insulin, BB or CCB overdose?
Glucagon injection
Antidote for morphine, heroin or opiate overdose?
naloxone injection
In people with reduced consciousness due to suspected opioid poisoning, administration which leads to significant improvement in the person’s condition within 1-2 minutes is highly suggestive of opioid poisoning.
Antidote for iron overdose?
Desferrioxamine mesilate
Antidote for ethylene glycol or methanol overdose?
fomepizole
Most common cause of admission to child and adolescent psychiatric wards?
anorexia nervosa
Epidemiology of anorexia nervosa?
90% female
teens and young-adults mainly
Diagnosis of anorexia nervosa based on what criteria?
DSM-5 (BMI and amenorrhoea no longer specifically mentioned)
DSM-5 criteria for diagnosis of anorexia nervosa?
- Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
- Intense fear of gaining weight or becoming fat, even though underweight.
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
Mx of anorexia nervosa?
one of:
individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
specialist supportive clinical management (SSCM).
1st line Mx of anorexia nervosa in children and young people?
‘anorexia focused family therapy’
The second-line treatment is cognitive behavioural therapy.
