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FRACP > Psych/adolescents > Flashcards

Psych/adolescents Flashcards

1
Q

DSM criteria AN

A
  1. Low body weight/loss of weight (restrictive eating)
  2. intense fear of gaining weight/getting fat or behaviours that interfere with weight gain
  3. Body image disturbance despite weight loss

+/- restrictive/binge eating or purging subtypes

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2
Q

DSM Bulimia

A
  1. Recurrent episodes of binge eating (large amounts/lack of control)
  2. Inappropriate compensative behaviours
    at least 1 per week for 3 month
  3. Self-evaluation is unduly influenced by body shape/weight
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3
Q

DSM binge eating disorder

A
  1. 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
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4
Q

Atypical AN

A

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

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5
Q

Avoidant/restrictive food intake disorder (ARFID)

A

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)
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6
Q

AN cx

A 
Haemodynamic - postural hypotension and tachycardia 
Osteoporosis
Growth
Fertility
Brain pseudoatrophy
teeth
blood cells
electrolytes
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7
Q

Treatment of BN

A

CBT
+/- meds (SSRIs, specifically fluoxetine)
+/- family based treatment

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8
Q

Treatment of AN

A

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

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9
Q

Treatment of ARFID

A

Family based treatment

Address the underlying anxiety

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10
Q

Somatising disorders

A

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

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11
Q

Conversion disorder

A

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

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12
Q

Factitious disorder

A

Falsifiction of physical or psychological signs or sx (medically unexplained) assoc w IDENTIFIED DECEPTION
(by proxy if parent is driving it)

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13
Q

Complex Somatic symptom disorder

A

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

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14
Q

Aetology of somatoform disorders

A

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)
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15
Q

Mx of Somatoform disorders

A

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

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16
Q

Disruptive mood disregulation disorder

A

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

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17
Q

Persistent depressive disorder

A

Depressed mood for >/= 1 year

Previously known as dysthymic disorder

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18
Q

Premenstrual dysphoric disorder

A

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

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19
Q

Depressive sx in children

A 
Irritability
Agressive/oppositional behaviour
Somatic sx
Lots of anxiety/worries
Reduced weight gain rather than weight loss
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20
Q

Management of depression

A

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
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21
Q

first line antidepressants for children vs adolescents

A

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

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22
Q

3 phases of psychosis

A
  1. Prodrome: Changes in feeling/thoughts/behaviours. reduction in concentration, sleep disturbance, social withdrawal, suspiciousnesss, depressed mood
  2. Acute phase:
    Positive sx - hallucinations, paranoia, delusions, disorganised thought and behaviour
    Negative sx - reduced function, amotivation, anhedonia, drepression, suicidal thoughts
    Affect flattening
  3. Recovery phase
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23
Q

Brain parts implicated in depression and schizophrenia

A

Frontal and prefrontal cortex

Limbic system

24
Q

Schizoaffective disorder

A

Mania OR depression

along with schizophrenia

25
Q

SE of antipsychotic medications

A 
Weight gain (atypical > typical)
Pyramidal SE (typical > atypical)
Anticholinergic (antiSLUD) SE
26
Q

Puberty blockers - MOA

A

GnRH analogues

Stops the production of GnRH hormones (LH and FSH)

27
Q

red flags for amenorrhoea - when is it abnormal?

A

amenorrhea at 16
no menstruation within 4 years of onset of breast development
or cessation of period >6mo (Secondary amenorrhoea)

28
Q

aetiologies of primary amenorrhoea

A

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

29
Q

Give an example of an androgen blocker and indications for use

A

Spironolactone or cyproterone

For:
PCOS
Medical transition (trans female)

30
Q

Biochemical changes with refeeding syndrome

A
  • 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
31
Q

Fertility counselling for children transitioning

A

Young people assigned female at birth but identifying as male

  1. Testosterone reduces fertility but pregnancy remains possible in future if ceased
  2. 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

  1. Infertility occurs following use of estrogen
  2. Storage of sperm if patient is post pubertal is recommended
  3. Storage of testicular tissue via biopsy is recommended + offered if patient is pre-pubertal or in early puberty
32
Q

Stages of transition

A

Stage 1 treatment

  1. 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

  1. Estrogen
  2. Testosterone

Stage 3 treatment

  1. Surgery and ongoing hormones
    - Top surgery in men = therapeutic
    - Bottom surgery not recommended – impact on sexual function and reproduction
33
Q

Medical complications of AN

A

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

34
Q

RF for eating disorders

A

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)

35
Q

How is schizophreniform disorder different from schizophrenia?

A

Schizophreniform disorder is characterized by symptoms identical to those of schizophrenia but that last ≥ 1 month but < 6 months.

36
Q

Conduct disorder DSM V criteria

A

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.

37
Q

comorbid conditions with tourettes

A
  1. ADHD
  2. OCD
  3. ODD
38
Q

Treatment of tourettes syndrome

A
  1. Education and reassurance
  2. CBIT for tics
  3. Pharmacological
    - > alpha adrenergic antagonists (clonidine, ganficine)
    - > antipsychotics (risperidone, haloperidol, aripiprazole)
  4. Methylphenidate if concurrent ADHD sx
  5. Deep brain stimulation
  6. Botolinum toxin
39
Q

Which ATYPICAL antipsychotics have highest risk of weight gain?

A
  1. Clozapine (for treatment of resistant schizophrenia)

2. Olanzapine

40
Q

DSMV criteria for depression

A

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

40
Q

Treatment of depression

A

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.
41
Q

Antidote for dystonic SE of antipsychotics

A

Dystonic reactions usually occur early in therapy and can be treated with IV benztropine.

42
Q

‘Stages of change’ - addiction

A

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.

43
Q

3 most common conversion disorder presentations

A

Weakness
Ataxia
Non-epileptic seizures

> 50% have multiple presenting neurological sx
~50% have concomitant chronic pain

44
Q

What is the main life threatening complication of typical antipsychotics? and how does this present?

A

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)

45
Q

What is a life threatening complication of SSRIs and how does it present?

A

Serotonin Syndrome (excessive SSRIs so Sx result from excess serotonin) - Fever, tachycardia, hypertension, Clonus (hyperreflexia), diarrhoea, vomiting, sweating, dilated pupils

46
Q

Atomoxotine

  • MOA
  • What is it used to treat?
A

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

47
Q

What most increases an adolescent girl’s risk of developing bulimia nervosa?

A

In up to 60% of cases, patients with bulimia nervosa report prior histories of anorexia nervosa.

48
Q

Indications for use of atypical antipsychotics (risperidone) in ASD

A

Disruptive behaviours: aggression, explosive outbursts (tantrums), and self-injury.

49
Q

DSM V criteria diagnosis of Bipolar disorder

Treatment

A

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

50
Q

Predictors of poor outcome in AN

A

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

51
Q

Typical vs atypical antipsychotics
MOA
Main SE of each
Examples of each

A

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
53
Q

MOA spironolactone

Indications and SE

A

Aldosterone antagonist/Potassium sparing diuretic/

  1. Acts primarily through competitive binding of receptors at the aldosterone-dependent sodium-potassium exchange site in the distal convoluted renal tubule.
  2. 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
54
Q

Treatment of GAD, social phobia, OCD

A

GAD - fluoxetine
Social phobia - Sertraline
OCD - SSRI - either fluoxetine or sertraline

55
Q

Which antipsychotic has the SE of agranulocytosis?

A

Clozapine - typical/first gen antipsychotic. also weight gain +

FRACP (21 decks)

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