Psych Flashcards
What is the definition of ADHD?
Attention Deficit Hyperactivity Disorder
Is a neuro-developmental disorder characterised by features relating to inattention and/or hyperactivity/impulsivity that are persistent.
What is the epidemiology of ADHD?
- More common in Boys (M:F 4:1)
- Persists to adult hood in 30-50% of cases.
What are the causes/risk factors for ADHD?
Multifactorial
- Genetics 74% heritability
- 3-4x risk if siblings suffer
- Environment
- Pregnancy issues: Alcohol, Smoking, Prematurity, Infections, Low birth weight
What are the criteria on the ICD-11 for a diagnosis of ADHD?
- Symptoms of Inattention, Hyperactivity or impulsivity (DSM says 6/9 Sx)
- Present for at least 6 months
- Onset should occur during Childhood (typically before 12 years)
- Significant Functional impairment in personal, social, academic or occupational functioning
- Impairment present in 2 or more settings
- Not better explained by an alternative mental health or neurodevelopmental disorder
What are some differentials for ADHD?
Learning Disabilities:
Characterised by difficulties in reading, writing, mathematics or other learning skills, often with normal attention span.
Conduct Disorder:
Presents with persistent pattern of antisocial behaviour, such as aggression or destructiveness.
Autism Spectrum Disorder:
Mood Disorders:
E.g. depression and bipolar disorder, can cause concentration problems and impulsivity
What investigations are done for ADHD?
Diagnosis is done primarily done using the ICD-11/DSM-5 criteria. But the following can also help:
- Comprehensive history and physical examination (Clinical Interview)
- 10 week watch and wait Observation of the individual’s behaviour and see if Sx resolve
- Teacher and parent reports or rating scales
- Nurse observation in classrooms
- Neuropsychological testing
What is the management of ADHD?
What is first line
What referral may be made?
What medications can be used?
What monitoring is required for the medications?
Non-Pharmacological
- Watchful waiting for up to 10 weeks
- Healthy diet and exercise.
- Behaviour management - including reward charts, positive redirection.
- Behavioural Therapies - CBT, Psychoeducation, interpersonal therapy is first line for management
If symptoms persist
- Referral to CAMHS
Pharmacological: Stimulant Medications (Amphetamines/Methylphenidate)
- First Line in children in Severe/uncontrolled Sx: Methylphenidate on 6 week trial basis
- Second line in children: Dexamfetamine or Atomoxetine
- Cannot be given to children <5 years
- Children should have weight and height monitored every 6 months
- First Line in Adults: Either Methylphenidate/Lisdexamfetamine
- Second line: Lisdexamfetamine
What is the definition of Major Depressive Disorder?
Major Depressive Disorder
It’s a common mental health disorder typified by persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable
What is the epidemiology of depression?
- Lifetime risk is around 1 in 8 (12%)
- Increased prevalence in Females (F:M 2:1)
- Mean age of onset is 40 years (but becoming more present in younger people)
What causes/risk factors depression?
Genetics
- Family history of depression
- High concordance in twins
- Personal history of depression
Environmental:
- Stressful life events
- Childhood abuse
- Substance abuse
- Medical conditions
What is the Diasthesis-Stress Model?
A Stressful event in a person with pre-existing vulnerability has a greater likelihood of developing depression.
Therefore 2 people experiencing the same stressful event: one without pre-existing vulnerability may not develop depression whilst the other individual does.
What are the main differentials for depression?
Bipolar Disorder
Anxiety Disorders
Substance/Medication-Induced Mood Disorder
Mood disturbance associated with intoxication or withdrawal from substances or side effects of medications.
Adjustment Disorders
Development of emotional or behavioural symptoms in response to identifiable stressors.
Various organic causes also need to be considered:
Neurological disorders
E.g. Parkinson’s disease, dementia, and multiple sclerosis.
Endocrine disorders especially thyroid dysfunction and hypo/hyperadrenalism (e.g., Cushing’s and Addison’s disease).
Substance use or medication side effects
e.g. steroids, isotretinoin, alcohol, beta-blockers, benzodiazepines, and methyldopa.
Chronic conditions
like diabetes and obstructive sleep apnea.
Long-standing infections
Neoplasms and cancers
low mood can theoretically be a presenting complaint in any cancer, with pancreatic cancer being a notable example.
What investigations are done for Depression?
Depression is primarily a clinical diagnosis using DSM-5 or ICD-11, with patients fulfilling the diagnostic criteria outlined above. Other investigations that are done can be:
- Patient Health Questionaire - 9 (PHQ-9)
- Hospital Anxiety and Depression Scale (HAD)
- FBC
- TFTs
- U+Es
- LFTs
- Blood glucose
- B12/Folate Levels
- Cortisol levels
- Toxicology Screen
- CNS Imaging
What is the Non-Pharmacological Management of Depression?
Lifestyle Changes:
- Exercise and Diet changes
- Reduce alcohol and stop smoking
- Stop drug use
- Regular Schedule
Psychotherapies:
Less severe depression:
- Guided self-help
- Group Cognitive Behavioural Therapy (CBT)
- Interpersonal Therapy
More severe depression:
- Individual CBT (with medication)
- individual behavioural activation
What is the Pharmacological management of depression?
First-line pharmacological treatment:
- Selective Serotonin Reuptake Inhibitor (SSRI): Sertraline, Citalopram, Fluoxetine
- Fluoxetine is first line in children
- Selective Noradrenaline Reuptake Inhibitors (SNRI): Duloxetine, Venlafaxine (Work well in patients with associated pain disorders)
2nd line pharmacological treatment
- Atypical Anti-depressants: Mirtazapine
- Tricyclic Antidepressants (TCAs): Amitriptyline
- Monoamine Oxidase Inhibitors: Selegiline
What is the definition of Refractory Depression?
Its defined as a failure to demonstrate an adequate response to an adequate treatment trial
How is Refractory Depression Managed?
- Antipsychotics: Olanzepine, Quetiapine
- Lithium
Electroconvulsive Therapy (ECT) (After all other approaches have been tried). is safe and effected for Severe medication resistant and psychotic depression
- Requires a GA
- Electrodes trigger a short generalised seizure
- Side effects include: Headache, Muscle Ache, Memory loss (short term)
What is the definition of Austistic Spectrum Disorders (ASDs)?
ASDs are a set of complex neuro-developmental disorders, characterised by a spectrum of impaired social, communication, and behavioural deficits. and restrictive or repetitive patterns or interests
What is the epidemiology of Autistic Spectrum Disorders?
- Higher prevalence in Males (M:F 3/4:1)
- Prevalence of 1-2%
- Features normally present by age 3
- Around 50% of children with ASD have intellectual disability
What are some risk factors for developing an ASD?
Genetics:
- Male sex
- Advanced parental age at the time of conception
- Certain genetic mutations
- Maternal exposure to specific drugs or infections during pregnancy
Environment:
- No current clear risk factors
What deficits in social interaction might someone with Autism show?
- Lack of eye contact
- Delay in smiling
- Avoids physical contact
- Unable to read non-verbal cues
- Difficulty establishing friendships
- Not displaying a desire to share attention (i.e. not playing with others)
What deficits in communication might someone with Autism show?
- Delay, absence or regression in language development
- Lack of appropriate non-verbal communication such as smiling, eye contact, responding to others and sharing interest
- Difficulty with imaginative or imitative behaviour
- Repetitive use of words or phrases
What behavioural traits may someone with Autism show?
- Greater interest in objects, numbers or patterns than people
- Stereotypical repetitive movements. There may be self-stimulating movements that are used to comfort
themselves, such as hand-flapping or rocking. - Intensive and deep interests that are persistent and rigid
- Repetitive behaviour and fixed routines
- Anxiety and distress with experiences outside their normal routine
- Extremely restricted food preferences
What are some differentials for ASDs?
Intellectual Disability
Characterised by generalised deficits in intellectual functioning and adaptive behaviour, typically lacking the social deficits seen in ASD.
Attention Deficit Hyperactivity Disorder (ADHD)
Exhibits symptoms of inattention, hyperactivity, and impulsivity, but does not exhibit significant social or language communication deficits as seen in ASD.
Specific Language Impairment
Characterised by difficulties in language acquisition in the absence of cognitive impairment. Unlike ASD, social interaction is not typically affected.
Childhood Schizophrenia
Characterised by hallucinations, delusions, and disorganised speech or behaviour, which are not typical in ASD.