Psych/adolescents Flashcards
DSM criteria AN
- Low body weight/loss of weight (restrictive eating)
- intense fear of gaining weight/getting fat or behaviours that interfere with weight gain
- Body image disturbance despite weight loss
+/- restrictive/binge eating or purging subtypes
DSM Bulimia
- Recurrent episodes of binge eating (large amounts/lack of control)
- Inappropriate compensative behaviours
at least 1 per week for 3 month - Self-evaluation is unduly influenced by body shape/weight
DSM binge eating disorder
- recurrent episodes of binge eating
- > NO COMPENSATORY behaviours
At least 3 of the following eating fast uncomfortably full when not hungry eating alone because embarassed feeling disgusted afterwards Distressed about it At least 1 per week for 3 months
Atypical AN
Starts off overweight but develops all the cognitions and behaviours of AN and loses weight, but at time of being seen is NOT underweight
Will progress to typical AN if not stopped
Avoidant/restrictive food intake disorder (ARFID)
Decr eating/LOW due to severe anxiety
- > phobia (fear of being sick or choking)
- > somatising (feel full/bloated secondary to feeling stressed/anxious all the time)
- > ASD (chronic history of being fussy, picky eaters and triggering event causes them to eat even less and become critically underweight)
AN cx
Haemodynamic - postural hypotension and tachycardia Osteoporosis Growth Fertility Brain pseudoatrophy teeth blood cells electrolytes
Treatment of BN
CBT
+/- meds (SSRIs, specifically fluoxetine)
+/- family based treatment
Treatment of AN
Family based treatment +/- CBT
NO evidence that medications change the course of the illness
HOWEVER
- Can use SSRIs for comorbid depression or OCD (need higher doses than normal)
- Antipsychotics (olanzapine/quetiapine) can help to lesses distress/mood/anxiet at meal time
Treatment of ARFID
Family based treatment
Address the underlying anxiety
Somatising disorders
Psychological distress manifested in the way of PHYSICAL sx
-> no physical cause found for Sx
Patient AND parent attribute physical sx to medical cause and seek MEDICAL treatment
Conversion disorder
Functional neurological disorder
- > voluntary motor or sensory function symptoms unexplained by medical/neurological diagnosis
- > significant distress or impairment
There does NOT need to be a triggering/identifiable psychological cause
Factitious disorder
Falsifiction of physical or psychological signs or sx (medically unexplained) assoc w IDENTIFIED DECEPTION
(by proxy if parent is driving it)
Complex Somatic symptom disorder
Somatic sx causing significant distress or dysfunction in which psychosocial factors may initiate, agravate or maintain the sx
High levels of excessive concern/preoccuptation w sx
Incr pattern of health service utilisation
At least 6 months duration
Aetology of somatoform disorders
Biopsychosocial aetiology
Biol:
- Autonomic NS mediated (unconscious and automated physical response triggered by stress/anxiety)
Psycho:
- Dissociation from the feelings of anxiety leads to unconscious presentation w neurological/somatic sx
- patients state they ‘don’t get stressed’ and seem to avoid anxiety
Social:
- Temperament related
- -> ‘Alexithymia’ - unable to identify and describe emotions felt by oneself. dysfunctional emotional intelligence (lack thereof).
- Conscientiousness
- Poor coping/catastrophising
- Parental behaviour attributes (pushing for medical diagnosis/treatment makes things worse)
Mx of Somatoform disorders
Adequate medical investigation and exclusion of physical ddx
CBT
Family based treatments to support family
Manage the ‘dilemma’ - what stressor is being avoided by the sx -> manage the cause
Disruptive mood disregulation disorder
3 or more outbursts (verbal, physical aggression) per week
Irritably mood between outbursts
Present for 2 or more month most of the time
Present in >1 setting
6-18yo
Persistent depressive disorder
Depressed mood for >/= 1 year
Previously known as dysthymic disorder
Premenstrual dysphoric disorder
Up to a week before period and improves within days of onset of period
Total of 5 of the below sx (can be from category A and or B)
A) One or more of: Affective lability Irritability, anger Depressed mood Anxiety, tension, on edge
B) One or more of:
Decr interest, concentration, lethargy; appetite, sleep changes; sense of feeling overwhelmed; physical sx
Depressive sx in children
Irritability Agressive/oppositional behaviour Somatic sx Lots of anxiety/worries Reduced weight gain rather than weight loss
Management of depression
Mod-Severe
- Initial crisis intervention
- CBT or interpersonal therapy (good response 55%)
- -> if no response (15%), start SSRI (fluoxetine or escitalopram)
- -> if partial response (15%), continue CBT/IPT
first line antidepressants for children vs adolescents
SSRIs for all:
Fluoxetine - childhood depression
Escitalopram - adolescent depression
Duloxetine is second line for both children and adolescents if no response to first line agents
3 phases of psychosis
- Prodrome: Changes in feeling/thoughts/behaviours. reduction in concentration, sleep disturbance, social withdrawal, suspiciousnesss, depressed mood
- Acute phase:
Positive sx - hallucinations, paranoia, delusions, disorganised thought and behaviour
Negative sx - reduced function, amotivation, anhedonia, drepression, suicidal thoughts
Affect flattening - Recovery phase
Brain parts implicated in depression and schizophrenia
Frontal and prefrontal cortex
Limbic system
Schizoaffective disorder
Mania OR depression
along with schizophrenia
SE of antipsychotic medications
Weight gain (atypical > typical) Pyramidal SE (typical > atypical) Anticholinergic (antiSLUD) SE
Puberty blockers - MOA
GnRH analogues
Stops the production of GnRH hormones (LH and FSH)
red flags for amenorrhoea - when is it abnormal?
amenorrhea at 16
no menstruation within 4 years of onset of breast development
or cessation of period >6mo (Secondary amenorrhoea)
aetiologies of primary amenorrhoea
Gonadal dysgenesis due to chromosomal abnormalities (ovarian failure due to premature depletion of eggs and follicles) eg Turners XO
Hypothalamic hypogonadism
Mullerian (uterus, cervix, vagina) absence
Pituitary disease
Transverse vaginal septum or imperforate hymen
Give an example of an androgen blocker and indications for use
Spironolactone or cyproterone
For:
PCOS
Medical transition (trans female)
Biochemical changes with refeeding syndrome
- Hallmark is hypophosphataemia, hypokalaemia, hypoMg
- Metabolic alkalosis
- Thiamine deficiency
- Water and sodium retention
- MOA: Increased serum insulin levels leads to intracellular shift of glucose, K, Mg, Ph
o Note can be associated with hyperglycaemia if inadequate insulin supply at initial feeding
o Postprandial hypoglycaemia occurs due to depleted liver glycogen reserves and gluconeogenesis substrates despite high levels of insulin
Fertility counselling for children transitioning
Young people assigned female at birth but identifying as male
- Testosterone reduces fertility but pregnancy remains possible in future if ceased
- Storage of eggs or ovarian tissue can be offered but not necessarily recommended as possibility of future pregnancy without intervention, the invasiveness of the retrieval procedure and the requirement for estrogen stimulation
Young people assigned male at birth but identifying as female
- Infertility occurs following use of estrogen
- Storage of sperm if patient is post pubertal is recommended
- Storage of testicular tissue via biopsy is recommended + offered if patient is pre-pubertal or in early puberty
Stages of transition
Stage 1 treatment
- Puberty blockers
a. Reversible
b. GnRH analogues – Lucrin or zolodex
- > Stops development of secondary sexual characteristics whilst continue to grow physically, emotionally and cognitively
Stage 2 treatment: hormones
- Estrogen
- Testosterone
Stage 3 treatment
- Surgery and ongoing hormones
- Top surgery in men = therapeutic
- Bottom surgery not recommended – impact on sexual function and reproduction
Medical complications of AN
Facial - parotid enlargement
CV - Bradycardia, palpitations, postural hypotension, decr CO, pericardial effusions and MV prolapse
Renal - incr urea (if dehdyration and decr GFR), low urea if malnutrition; proteinuria, renal calculi
Bones - decr bone mineral density (osteopenia/osteoporosis)
Endo
- High cortisol
- High GH
- Decr GnRH
- Decr sex hormones (estradiol, FSH, LH, testosterone)
- sick euthyroid (decr T3/4, normal or low TSH)
GIT - constipation, gastro paresis, esophagitis, elevated LFTs, low albumin (protein, correlates w degree of starvation)
Metabolic - low Na, K, Mg, Ph, glucose, temperature, high cholesterol
Haem - iron def anaemia
Derm - acne, lanugo, hair loss, lived reticular
RF for eating disorders
i. Familial = eating behaviour, weight concerns, communication
ii. Ballet, gymnastics, modelling
iii. Sociocultural norms
iv. Dieting = the biggest risk factor for eating disorder (Around 2/3 of eating disorders arise in girls who have been moderate dieters in the past)
How is schizophreniform disorder different from schizophrenia?
Schizophreniform disorder is characterized by symptoms identical to those of schizophrenia but that last ≥ 1 month but < 6 months.
Conduct disorder DSM V criteria
A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age- appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:
Aggression to People and Animals
1. Often bullies, threatens, or intimidates others.
2. Often initiates physical fights.
3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
4. Has been physically cruel to people.
5. Has been physically cruel to animals.
6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
7. Has forced someone into sexual activity.
Destruction of Property
8. Has deliberately engaged in fire setting with the intention of causing serious damage.
9. Has deliberately destroyed others’ property (other than by fire setting).
Deceitfulness or Theft
10. Has broken into someone else’s house, building, or car.
11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).
Serious Violations of Rules
13. Often stays out at night despite parental prohibitions, beginning before age 13 years.
14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period.
15. Is often truant from school, beginning before age 13 years.
B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.
comorbid conditions with tourettes
- ADHD
- OCD
- ODD
Treatment of tourettes syndrome
- Education and reassurance
- CBIT for tics
- Pharmacological
- > alpha adrenergic antagonists (clonidine, ganficine)
- > antipsychotics (risperidone, haloperidol, aripiprazole) - Methylphenidate if concurrent ADHD sx
- Deep brain stimulation
- Botolinum toxin
Which ATYPICAL antipsychotics have highest risk of weight gain?
- Clozapine (for treatment of resistant schizophrenia)
2. Olanzapine
DSMV criteria for depression
According to criteria published in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), diagnosis of depression requires that a child experience five of the following nine criteria for at least 2 weeks:
a) Depressed or irritable mood nearly every day for most of the day
b) Markedly diminished interest or pleasure in previously enjoyed activities
c) Weight loss or weight gain
d) Changes in pattern of sleep (increases or decreases in amount of time spent sleeping)
e) Psychomotor agitation or retardation
f) Fatigue or loss of energy
g) Feelings of worthlessness or excessive or inappropriate guilt
h) Indecisiveness or diminished ability to concentrate
i) Recurrent thoughts of death
Treatment of depression
Both psychotherapy and pharmacotherapy are effective in treating depression in childhood and adolescence.
- Cognitive-behavioural therapy (12-16 weeks) is effective in approximately 40-50% of cases of adolescent depression.
- Combination therapy with fluoxetine and CBT results in significant clinical improvement in 71% of moderate to severely depressed adolescent patients.
- This improvement rate exceeds that of other approaches, such as treatment with fluoxetine alone (61%) or CBT alone (43%).
- The best treatment is SSRIs as monotherapy or ideally combination therapy as shown above.
Antidote for dystonic SE of antipsychotics
Dystonic reactions usually occur early in therapy and can be treated with IV benztropine.
‘Stages of change’ - addiction
PCP in the AM
Pre-contemplation – people are not intending to take action in the foreseeable future, and are most likely unaware that their behaviour is problematic.
Contemplation – people are beginning to recognize that their behaviour is problematic, and start to look at the pros and cons of their continued actions.
Preparation – people are intending to take action in the immediate future, and may begin taking small steps towards change.
Action – people have made specific overt modifications in their life style, and positive change has occurred.
Maintenance – people are working to prevent relapse, a stage which can last indefinitely.
3 most common conversion disorder presentations
Weakness
Ataxia
Non-epileptic seizures
> 50% have multiple presenting neurological sx
~50% have concomitant chronic pain
What is the main life threatening complication of typical antipsychotics? and how does this present?
Neuroleptic malignant syndrome:
- Toxicity from antipsychotic medications (Typical or 1st gen antipsychotic)
Restlessness -> metabolism of muscles -> fever, tachycardia, HYPERtension
Myoglobulinaemia/elevated CK and WBC
Confusion/encephalopathy
RIGIDITY (lead pipe-parkinsonian like)
What is a life threatening complication of SSRIs and how does it present?
Serotonin Syndrome (excessive SSRIs so Sx result from excess serotonin) - Fever, tachycardia, hypertension, Clonus (hyperreflexia), diarrhoea, vomiting, sweating, dilated pupils
Atomoxotine
- MOA
- What is it used to treat?
SNRI
Treatment of ADHD in children > 6 years, adolescents, and adults.
-> Particularly useful for patients at risk of substance abuse, as well as those who have co-morbid anxiety or tics, or those with significant sleep disruption/insomnia from stimulants.
Side effects: decreased appetite, dizziness, drowsiness, dyspepsia
Rare - mood swings/suicidal ideation, hepatotoxicity, VTE, HTN
What most increases an adolescent girl’s risk of developing bulimia nervosa?
In up to 60% of cases, patients with bulimia nervosa report prior histories of anorexia nervosa.
Indications for use of atypical antipsychotics (risperidone) in ASD
Disruptive behaviours: aggression, explosive outbursts (tantrums), and self-injury.
DSM V criteria diagnosis of Bipolar disorder
Treatment
To be diagnosed with bipolar disorder, a person must have experienced at least one episode of mania or hypomania.
To be considered mania, the elevated, expansive, or irritable mood must last for AT LEAST 1 WEEK and be present most of the day, nearly every day. To be considered hypomania, the mood must last at least four consecutive days and be present most of the day, almost every day.
During this period, three or more of the following symptoms must be present and represent a significant change from usual behaviour:
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- Increased talkativeness
- Racing thoughts
- Distracted easily
- Increase in goal-directed activity or psychomotor agitation
- Engaging in activities that hold the potential for painful consequences, e.g., unrestrained buying sprees
- The depressive side of bipolar disorder is characterized by a major depressive episode resulting in depressed mood or loss of interest or pleasure in life.
The DSM-5 states that a person must experience five or more of the following symptoms in two weeks to be diagnosed with a major depressive episode:
Depressed mood most of the day, nearly every day
- Loss of interest or pleasure in all, or almost all, activities
- Significant weight loss or decrease or increase in appetite
- Engaging in purposeless movements, such as pacing the room
- Fatigue or loss of energy
- Feelings of worthlessness or guilt
- Diminished ability to think or concentrate, or indecisiveness
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt
Tx: lithium, anticonvulsants (carbemazepine, Na valproate, lamotrigine) - mood stabilisers
Predictors of poor outcome in AN
Length of time from diagnosis to treatment (long duration of illness)
Later onset
- Onset of anorexia nervosa before adulthood carries a more favourable outcome.
- However, onset at an age younger than 11 years is a poor prognostic factor.
Low minimum weight (lowest weight achieved)
Duration of inpatient admission
Number of readmissions
Binge/purge behaviour (bulimic behaviours)
Personality difficulties (such as obsessionality and impulsivity – i.e. poor premorbid functioning)
Poor family relationships
Typical vs atypical antipsychotics
MOA
Main SE of each
Examples of each
First gen antipsychotic = Typical
- Act on the dopaminergic system, blocking the dopamine type 2 (D2) receptors.
- higher risk of extra pyramidal side effects and neuroleptic malignant syndrome
- ex: haloperidol and chlorpromazine
Second gen antipsychotic = atypical
- Lower affinity and occupancy for the dopaminergic receptors, and a high degree of occupancy of the serotoninergic receptors 5-HT2A.
- Higher risk of metabolic side effects (obesity, dislipidaemia, diabetes, CV disease etc) and withdrawal sx
- ex: Risperidone, olanzapine, quetiapine, clozapine, paliperidone
MOA spironolactone
Indications and SE
Aldosterone antagonist/Potassium sparing diuretic/
- Acts primarily through competitive binding of receptors at the aldosterone-dependent sodium-potassium exchange site in the distal convoluted renal tubule.
- Is a nonselective antagonist that can bind to androgen and progesterone receptors.
Indications for use:
- HTN
- Heart failure
- Oedema secondary to nephritic syndrome and cirrhosis
- Primary hyperaldosteronism
- Used as androgen blocker in transiting M->F
- Acne
- Hirsutism
SE:
- Men experience gynecomastia, loss of libido, and general feminization
- Hyperkalaemia
Treatment of GAD, social phobia, OCD
GAD - fluoxetine
Social phobia - Sertraline
OCD - SSRI - either fluoxetine or sertraline
Which antipsychotic has the SE of agranulocytosis?
Clozapine - typical/first gen antipsychotic. also weight gain +
