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Psych/MH Flashcards

1
Q

Psych general stats and RFs

A
  1. Statistics
    a. 14% of children between 4 and 17 years of age – have a diagnosable mental health condition
    i. ADHD most common; M > F
    ii. Anxiety disorder 2nd most common; M = F
    iii. Conduct disorder is around 2%
    b. Only 55% of those children and adolescents with mental disorders had used any services for emotional or behavioral problems in the previous 12 months
    c. Statistics from last year
    i. 17-37% overall
    ii. 11 year olds = 17.6%
    iii. 18 year old = 36%
    d. At 15 years old:
    i. Anxiety 1.7-12.8%
    ii. Conduct/ oppositional disorder 8-10%
    iii. Mood disorder 6.5-8%
    iv. Substance abuse 5.2-7.7%
    v. ADHD 2.8-4.8%
  2. Rik factors:
    a. Perinatal/ maternal depression
    i. Associated with lower cognitive performance, behavioural problems child psychiatric disorder
    ii. Decreased uptake of well child checks, decreased immunization
    b. Chronic disease
    i. Increases risk x2 alone
    ii. X3 if associated physical disability
    iii. 14% of children with mental illness have chronic disease
    c. Neuroepileptic disorders
    d. Environmental problems
    i. FHX of mental illness (esp maternal)
    ii. High maternal anxiety
    iii. Rigid parental beliefs
    iv. Disadvantaged minority
    v. Stressful life events
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2
Q

Psych conditions - most heritable

A

(most to least)

  1. Bipolar
  2. Schizophrenia
  3. Anorexia nervosa
  4. Major depression
  5. Generalised anxiety disorder
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3
Q

Psych conditions - most reliable informants (depression, ADHD, CD)

A

Depression – adolescent/child
ADHD – teacher
CD – parent or teacher

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4
Q

Oppositional defiant disorder - general

A

DSMV key criteria:

  • 6 months duration
  • angry/irritable
  • argumentative/defiant
  • vindictiveness
  1. Key points
    a. Recurrent pattern of negative, defiant, hostile behavior, can be normal but becomes an issue when impacts functioning
  2. Epidemiology
    a. 3% male, 1.5% female
    b. Usually emerges before 7 years
    c. First evident at home
  3. Comorbidities
    a. ADHD most common co-morbid condition with ODD
  4. Management
    a. Wider range of behavioral treatment have been investigated
    b. Most involve behavioral parent-training/education
    c. Two main approaches of behavioral and relationship but most feature aspects of both
    d. Pharmacotherapy NOT indicated
  5. Prognosis + relationship with CD
    a. ODD is always considered a potential precursor to CD
    b. Some see as spectrum as CD can have all features of ODD
    c. 30% proceed to CD, the risk is higher if they have comorbid ADHD
    d. 65% of children with ODD exit the diagnosis after 3 years
    e. Earlier Dx conveys a poorer prognosis and persistence to adulthood
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5
Q

Conduct disorder - general

A

DSMV key bits

  • 12 months
  • “repetitive and persistent pattern of behaviour in which the basic rights of others and/or major age appropriate societal norms/rules are violated
  • aggression to people/animals
  • destruction of property
  • deceitfulness or theft
  • serious violation of rules
  1. Key features
    a. Lying
    b. Being sadistic or cruel to animals and people
    c. Physically or sexually abusing others
    d. Law-breaking behaviours such as deliberately lighting fires, vandalism or stealing

b. Often preceded by ODD

  1. Comorbidities
    a. ADHD
    b. Depressive disorders
    c. Language based difficulties
  2. Natural history
    a. Usual onset late childhood or adolescence
    b. Majority remit by adulthood
    c. Substantial fraction develop antisocial PD
  3. Management
    a. Psychotherapy – implement approach over 4-6weeks, can take up to 6m to change
    i. Parent/ teacher management training
  4. Limit setting
  5. Increase positive interactions
  6. Planned ignoring of unwanted behaviours
    b. Medication (none evidence based)
    i. Include
  7. Risperidone
  8. Haloperidol
  9. Lithium
  10. Prognosis
    a. 30% develop antisocial personality disorder
    b. Factors that predict poor outcome
    i. Earlier onset of severe problems <8yrs (MOST)
    ii. Early onset <8years 50% persistence
    iii. Adolescent onset 15% persistence (environmental)
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6
Q

Common symptoms of anxiety disorders in children

A

a. Distress and agitation when separated from parents and home
b. School refusal
c. Pervasive worry and fearfulness
d. Restlessness and irritability
e. Timidity, shyness, social withdrawal
f. Terror of an object (eg. dog)
g. Associated headache, stomach pain
h. Restless sleep and nightmares
i. Poor concentration, distractibility, and learning problems
j. Reliving stressful event in repetitive play
k. Family factors
l. Parental anxiety, overprotection, separation difficulties
m. Parental (maternal) depression and agoraphobia
n. Family stress – marital conflict, parental illness, child abuse
o. Family history of anxiety

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7
Q

Common/general management of anxiety in children

A

a. CBT a key component = first line, treatment of choice
i. F (feelings) E (expectation) A (attitude/action) R (reward) – for generalised anxiety and systematic desensitization and modeling for specific phobias are highly recommended

b. Medication therapy
i. 2nd line treatment
ii. Fluoxetine, Sertraline and Paroxetine approved for children
iii. Evidence greatest for OCD

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8
Q

General anxiety disorder - general

A

Prevalence 2.5-5%
Puberty onset
Recovery 80%

Symptoms often related to school performance, sports, finances, friends, family, perfectionistic. Sleep issues common.

Features 
1.	Excessive anxiety and worry occurring most days for >6/12 about numerous events or activities
2.	Difficult to control worry
3.	Anxiety/worry associated with 3+ of the following
o	Restlessness
o	Easy fatigue
o	Difficulty concentrating
o	Irritability
o	Muscle tension
o	Sleep disturbance
4.	Significant impairment
5.	Not due to other condition
6.	Not due to drugs/GMC

Management
CBT*** – FEAR (feeling, expectation, attitude/action, result/reward)(most effective)
ii. Cognitive behavioural therapy = treatment of choice!
Education and skill building
SSRI
BZD – short term use, low dose
Busiprone – not first line

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9
Q

Separation anxiety disorder - general

A

Fear that something bad will happen to child/parent when apart, excessive fear before and at time of separation. Behavioral symptoms like crying, clinging. Physical symptoms like headache, abdominal pain, fainting. Nausea, cramps, palpitations.

2-5% children/adolescence
3x more likely to develop panic disorder in adolescence
Onset peak 7-9years
Separation anxiety considered normal <5years therefore must Dx after this age

Features
>4 weeks duration, onset<18yrs. Characterised by
1. Unrealistic & persistent worries of possible harm affecting child or primary caregivers
2. Reluctance to go to school or sleep without being near parents
3. Persistent avoidance of being alone
4. Nightmares involving themes of separation, numerous somatic symptoms, complaints of subjective distress
Impairment of functioning

Common times – going to school/day care, school bus, moving house, going to bed. Worsens with change of school, changing friends, suffering from bullying or medical illness.

Management
CBT involving the parents (most effective) +/- SSRI
CBT individual and group

Minimal evidence for efficacy
SSRI – Fluoxetine, Fluvoxamine
TCA – Imipramine (second line)

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10
Q

Social phobia - general

A

Prevalence 3-13%

Excessive anxiety in social settings leading to social isolation. Avoidance of speaking in front of others, meeting new children, being centre of attention.
• Family history common

Features

  1. Marked and persistent fear of 1+ social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others
  2. Exposure to feared social situation provokes anxiety
  3. Person recognizes that fear is excessive or unreasonable
  4. Feared social situations avoided/endured with anxiety or distress
  5. Avoidance interferes with relationships
  6. Duration > 6/12

Management
CBT + SSRI (most effective)
CBT specific
SSRI – Sertraline

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11
Q

Specific phobia - brief

A

Avoidance of specific situations of fear/
Prevalence 2% (F:M 2:1)

Types
o	Animal
o	Environment (storms, height, water)
o	Blood/injury
o	Situational (planes, elevators)

Rx: CBT +/- SSRI (most effective)

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12
Q

Panic disorder - general

A

Peak onset 15-19years
Prevalence 1-2%
30-40% genetic

Panic attack – fear in absence of threat. Recurrent, discrete episodes of fear or discomfort in which individuals experience abrupt onset of physical and psychologic symptoms

Features
1. Recurrent unexpected panic attacks AND 1+ attack followed by > 1/12 of > 1 of:
o Persistent concern of additional attacks
o Worry about implications of attack
o Change in behaviour related to attacks
1. Agoraphobia
2. Not due to drug/medication/ medical condition
3. Not due to other disorder

Panic attack >4 within 10minutes-
1. Physical symptoms
Palpitations, sweating, shaking, SOB, dizziness, chest pain, nausea, choking, chills/hot flushes, paresthesia, derealisation
2. Psychologic symptoms
Fear of death/impending doom/loss of control

Management
CBT – panic control treatment – relaxation training, cognitive restructuring (most effective)
SSRI – only case reports, low dose

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13
Q

Agoraphobia - brief

A

95% have concurrent panic disorder.
“Fear of the marketplace”

Subsequent fear that a panic attack may occur in a place where help or escape may be unavailable.
Avoidance of places like public transport, enclosed space, cinemas, heavy traffic.

Rx: SSRI (most effective)

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14
Q

Types of anxiety disorders - list

A

a. Generalised anxiety disorder
b. Social anxiety disorder
c. Panic disorder with or without agoraphobia
d. Agoraphobia without a history of panic disorder
e. Specific phobia
f. Separation anxiety disorder
g. Selective mutism

h. OCD REMOVED

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15
Q

Anxiety based school refusal

A
  1. Key points
    a. School refusal is often an indicator of separation difficulties, where the child/adolescent is frightened to leave their parent or home
    b. Children refusing to attend school often present with somatic complaints such as abdominal pain
    c. Ascertain the basis of the child’s/adolescents anxiety – these may be related to factors at home such as parents physical or mental health, difficulties with parental or peer relationships, or school factors (such as bullying or academic performance)
  2. Management
    a. Physical assessment if present with somatic symptoms
    b. Assess the source of anxiety and consider whether further management required (eg. school counsellor, family therapy)
    c. Returning to school is a high priority – if necessary this can be done by gradually increasing duration of time at school
    d. Evidence supports CBT in group settings or educational support therapy
    i. The latter involves having a nominated teacher or aide to support the child through participation in the therapeutic intervention and then assisting them practice the learnt strategies at school
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16
Q

Post traumatic stress disorder - general

A
  1. Precipitating event (threatened death, serious injury, violence)
  2. > 1 of: presence of intrusive memories, distressing dreams, dissociative reactions (flashbacks), reaction to reminders of event
  3. > 1 of: persistent avoidance of things that remind of event, negative cognitions (fear, guilt, shame, withdrawal)
  4. Alterations in arousal/reactivity, >2 of: irritability/angry outbursts, hypervigilance, startle, concentration problems, sleep disturbance

b. PTSD can only be diagnosed when the traumatic event precedes the symptoms, and the symptoms are present for >1 month

  1. Management
    a. Trauma-focused CBT – shown to be effective
    i. Techniques include graded exposure, cognitive processing, psychoeducation, training in stress reduction, relaxation and positive self-talk
    b. Medication is NOT first line unless comorbid conditions such as depression are present
    i. In such circumstances – propranolol, clonidine, risperidone and citalopram (SSRI) can be used
    ii. Reactivity - Clonidine and propranolol
    iii. Depression – SSRI (Citalopram), TCA for adolescents
    iv. Self harm/aggression – atypical antipsychotics (Risperidone)
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17
Q

Obsessive compulsive disorder - general

A

A. Presence of obsessions/compulsions/both
B. These are time consuming and impair function
C. Not due to another disorder

  1. Key points
    a. One of the more severe forms of anxiety disorders
    b. Relatively rare – 1-2% of children and adolescents
    c. Onset relatively early in life – usually before 6 years of age
    d. More common in males
    e. Note: in paediatrics, children will NOT report that a thought is irrational
    f. > 50% have a comorbid psychiatric disorder
  2. Features in children
    a. Peak symptoms usually ~ 10 years
    b. Compulsions often precede obsessions
  3. Comorbidities
    a. Tic disorders 20-60% high if early age of onset
    b. Anxiety disorders
    c. Mood disorder
    d. Learning/Behavioral – ADHD, ODD, CD, specific learning disorder 75%
    e. Eating disorders
  4. Management
    a. Non-pharmacological
    i. CBT is first line – psychoeducation, cognitive training, graded exposure and response
  5. Thought stopping
  6. Exposure response prevention – systematic desensisation + Graded exposure
  7. Flooding – can be very effective
    b. Medication therapy
    i. Indicated if disease is severe/ CBT fail
    ii. Always need high doses!!!
    iii. Approved 1st line = sertraline + fluvoxamine
    iv. Do NOT Provide BDZ
  8. Prognosis
    a. 70% chronic course
    b. 12-50% remit 1-7years
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18
Q

Attention deficit hyperactivity disorder - background

A
  1. Key points
    a. Most common neurodevelopmental disorder in childhood
    b. Younger children with ADHD often exhibit motor hyperactivity
  2. Classification
    a. Combined type = 75%
    b. Predominantly inattentive = 25%
  3. Epidemiology
    a. 5% of children/ adolescents
    i. No evidence of increase over the last 30 years
    ii. Most with significant childhood symptoms continue to have symptoms into adult life
    b. All countries, all ethnic groups
    c. Twice as more common in boys than girls
    d. Mean age at diagnosis 9 years (boys > girls)
  4. Pathophysiology
    Prefrontal dysfunction/ abnormal development (MRI studies show underdevelopment of prefrontal cortex
    a. and basal ganglia) – with more evidence know more parts of the brain are involved
    b. Hypoactivity of dopamine/ noradrenaline - modulate front-striato-cerebellar circuitry

iii. Heritability 70-80%

d. SUMMARY: Risk factors
i. Family history
ii. Prematurity, VLBW
iv. In utero exposure to neurotoxins
v. Environmental deprivation in infancy
vi. Syndromes: Fragile X, 22q11, tuberous sclerosis

  1. Comorbidities
    a. Comorbidities = present in 80% or more
    b. Include
    i. ODD 40-70%/ CD 20% (overall 50%)
    ii. Learning disability – 20-60%
    iii. Autism
  2. 50% of those on autism spectrum have ADHD
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19
Q

Attention deficit hyperactivity disorder - sx/ix/dx

A

Summary of features (more extensive in DSMV)

  • inattention: 6 or more symptoms for 6+ months and inappropriate for developmental level
  • hyperactivity/impulsivity: 6+ syptoms 6+ months
  • inattentive/hyperactive symptoms begin before 12 years of age
  • present in two or more settings (social, academic, occupational, home, school)
  • interfere with function
  • not due to something else
  1. Assessment
    a. Examination – cardiac disease  need to rule out syndromes or cardiac problems prior to starting stimulant medications
    b. Behaviour rating scales
    i. Broad band eg. Achenbach
    ii. ADHD specific eg. Conners
  2. Investigations – RARELY DONE
    a. Neuropsychological tests
    b. EEG
    d. fMRI
    e. PET, SPECT scanning
  3. DDx
    a. Developmental disorders
    i. Fetal alcohol syndrome
    ii. Down’s syndrome
    iii. Fragile X
    b. Medical conditions
    i. Acquired brain injury (traits in 20%)
    ii. Post encephalitis
    iii. Neurodegenerative disorders
    iv. Hearing/vision loss
    v. Substance abuse, poisoning
    vi. Side effects of medications
    vii. Thyroid disorders
    viii. OSA/sleep disorders
    c. Psychosocial
    i. Response to inappropriate parenting, parental psychopathology
    ii. Physical or sexual abuse
    iii. Response to acculturation, inappropriate classroom setting
    d. Psychiatric
    i. OCD
    ii. Tic disorders and Tourette’s
    iii. Anxiety disorders
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20
Q

Attention deficit hyperactivity disorder - rx

A
  1. Management summary
    a. Always
    i. Behavior modification
    ii. Educational strategies
    iii. ‘Housekeeping’
    b. Often
    i. Medication – 80% of children who see a paediatrician are commenced on medication
    ii. Talking therapies – individual, group, family
  2. Non-Pharmacological
    a. Should be initial management for preschool children, adjunctive in older children
    b. Includes
    i. Parent child behavioural therapy – improves disruptive behaviours
    ii. Intensive clinical based intervention - reduces oppositional / aggressive behaviour
    c. Two key strategies
    i. Behavioral modification
    ii. Educational strategies
    d. Other ‘housekeeping’
    i. Sleep
    ii. Family stressors/dynamics/parenting
    iii. School – fit, learning disorder, bullying
    iv. Nutrition
    v. General heath
  3. Pharmacological
    a. Positive early response in 70%
    b. Classes of medications
    i. Stimulant
  4. Methylphenidate
  5. Dexamphetamine
    ii. Atomoxetine
    iii. Clonidine
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21
Q

ADHD - prog/outcomes

A
  1. Long-term outcome
    a. Increased risk
    i. ADHD – persistent/ partial remission (65%)
    ii. Academic failure/ school drop-out
    iii. Smoking, alcohol, substance
    iv. Mental health problems
    v. Unemployment/ low occupational status
    vi. Injuries
    vii. Delinquency
    viii. Relationship difficulties
    ix. Obesity
    x. Early parenthood/ problems with parenting
  2. Prognosis
    a. Most children continue to have difficulties through adolescence and into adulthood
    i. 60-80% persist to adolescence
    ii. 40-60% persist to adulthood
    b. Although many develop compensating strategies and function well – a significant minority have adverse long-term outcomes including academic underachievement, delinquency, vocational disadvantage, relationship difficulties, substance abuse, mental health disorders and motor vehicle accidents
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22
Q

ADHD pharmacotherapy - stimulant medications

A

a. Key points
i. 80% of children who see paediatrician are prescribed stimulant medication – average duration 2 years
ii. Psychostimulant medication is the single most effective intervention for children with ADHD
iii. First line treatment
iv. Provides effective symptom reduction in 80%  improved impulse control and sustained attention
v. Secondary benefits = academic progress, peer status, family functioning and self esteem

b. Types of stimulant
i. Short acting (BD/TDS)= methylphenidate, dexamphetamine
ii. Long acting (OD) = LA-methylphenidate (Concerta) , lisdexamphetamine

c. Action
i. Sympathomimetic (block re-uptake, increase pre-synaptic release, inhibit MAO)
2. Increase dopamine (key NT) and noradrenaline in the synaptic cleft
ii. Increase arousal and alertness

d. Adverse effects
i. Short-term
1. Anorexia = MAJOR side effect 70-80%
2. Anxiety
3. Tics
4. Mood lability
5. Initial insomnia
6. Depression, psychosis, mania
ii. Long-term
1. Growth - does have an effect on growth (1-2cm overall)
iii. Risk of cardiovascular events

e. Contraindications
i. Anxiety, tension states (sometimes still used with anxiety)
ii. Tics, FHX of Tourettes
iii. Hyperthyroidism
iv. Glaucoma
v. CVS disease

f. Overdose = delirium, sweating, tremor, twitching, vomiting

g. Practical tips
i. Start low and titrate weekly
ii. Start 7 days – some children may be able to reduce to only school days
iii. Tight titration and monitoring may improve adherence, effectiveness

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23
Q

ADHD pharmacotherapy - atomoxetine

A

i. Key points
1. Smaller effect than stimulants
2. Used in ADHD > 6 year olds (second line)
3. Takes up to 8 weeks for full effect
4. Long acting, daily dosing
5. Usually given in the morning

ii. Mechanism = selective noradrenaline reuptake inhibitor

iii. Benefits
1. Anti-anxiety
2. Anti-tics (not really)

iv. Side effects
1. Sedating
2. GI upset
3. Insomnia
4. Hostility – can cause aggression, oppositional behavior, mood changes
5. Rarely cause hepatotoxicity , priapism
6. Potentially increases risk of suicidal ideation

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24
Q

ADHD pharmacotherapy - alpha 2 adrenergic agonists

A

= clonidine

i. Key points
1. Moderate positive effect size (variable)
2. Added to stimulants – reduce ODD/CD symptoms
3. Some decrease in tics

ii. Mechanism = alpha adrenergic agonist
1. Widely distributed in the brain
2. Implicated in pathophysiology of disruptive behaviour disorders

iii. Indications
1. Sleep onset
2. Explosive behaviour
3. Tics – if tics are a major problem can be used first line before stimulants
4. Anxiolytic

iv. Side effects
1. Sedation
2. Hypotension – must be stored safely

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25
Q

Autism spectrum disorder - bg

A
  1. Key points
    a. Defined by difficulties in 2 areas
    i. Social communication
    ii. Repetitive behaviour and restricted infants
    b. Wide spectrum that includes
    i. A range of intellectual abilities
    ii. A range of severity of social impairments
    iii. Widely different symptomatology and prognosis
    c. Other describers
    i. High functioning – IQ >70
    ii. Low functioning – not high functioning, often used for children who are non-verbal
    iii. ‘On the spectrum’ – refers to having some ASD traits
    iv. ‘Asperger’ – no formal language impairment
    v. Pervasive developmental disorder-NOS – do not fit criteria
    vi. Broader autistic phenotype – some but not all characteristics of ASD
  2. Epidemiology
    a. Prevalence 1%
    b. Now considered a high prevalence disorder
    c. Much debate about whether increase in incidence reflects an ‘Autism epidemic’
    d. M> F 4: 1
    e. Associated syndromes: Fragile X, Prader Willi, Smith-Lemli Opitz, Rets, Angelman’s, fetal alcohol syndrome, tuberous sclerosis, neurofibromatosis, rubella, PKU
    - TS most common associated syndrome***
  3. Aetiology
    a. Genetics – variable
    i. Strongly genetic
  4. 70-90% identical twin concordance rates
  5. 50% heritability in community studies
    b. Known genetic syndromes
    i. Tuberos Sclerosis  MOST COMMON
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26
Q

Autism spectrum disorder - DSM criteria

A

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative,
not exhaustive; see text):
1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures: to a total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive):

  1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic
    phrases) .
  2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
  3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
  4. Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by
learned strategies in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual developmental
disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum
disorder and intellectual disability, social communication should be below that expected for general developmental level.

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27
Q

Autism spectrum disorder - symptoms

A
  1. Presenting features
    a. Lack of communication skills at 2 years
    b. ¼ -1/3 achieve early language milestones but then have regression
    c. Average age of diagnosis at 6 years
  2. Early indicators
    a. Lack of social smile and responsive facial expression
    b. Limited social language/ babble
    c. Preference for solitude
    d. Lack of pointing to items of interest (rather than need)
    e. Not turning to name
    f. Delayed pretend play
    g. Sensory hyper/ hyposensitivity
  3. Developmental courses
    a. Unusual development in first year of life with that becomes more unusual as child get older
    b. Near normal development in 1 year to 18 months with regression, usually in language, and social interaction
    c. Quirky preschooler who struggles with social interaction more in second half of years
    d. Challenging child who presents to mental health services and is found to have rigid thinking and social difficulties
  4. Comorbidities
    a. ID 30-70%
    b. ADHD, anxiety and mood disorders 70%
    c. Macrocephlay 20%
    d. Learning difficulties (independent of ID) – common
    e. Hearing and visual impairment
    f. Epilepsy 17%
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28
Q

Autism spectrum disorder - ix, ddx

A
  1. Investigations
    a. Hearing and vision
    b. Speech therapy review
    c. Chromosomal studies – fragile X, other genetic studies as indicated
    d. TORCH screen
    e. Metabolic disorders – PKU
    f. MRI / CTB – tuberous sclerosis
    g. EEG – unhelpful as often nonspecific abnormalities even without seizures
  2. Differential diagnoses
    a. Language disorders
    i. Social functioning and understanding of others is preserved
    ii. Children compensate with non-verbal communication
    b. Intellectual disability = look for level of appropriate social communication (verbal and non-verbal)
    c. Selective mutism and anxiety-related social avoidance disorders = lack repetitive behaviours and rigid thinking
    d. Reactive attachment disorder = improves with change in environment; abuse must be severe
    e. Tourette’s syndrome
    f. ADHD may co-exist
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29
Q

Autism spectrum disorder - rx

A

a. Early speech and language therapy
b. Applied behavioural analysis
c. Sensory management
d. Family support and community agency support

e. Limited role for medication:
i. SSRIs – for obsessive compulsive symptoms, repetitive behaviours and anxiety
ii. Low dose risperidone and haloperidol for aggression + stereotypies (risperidone has evidence)
iii. Sleep dysfunction – melatonin, alpha 2 agonist, Mirtazepine

f. Behavioural/ educational strategies (supported by evidence)
i. Educational interventions = most longstanding
- many options, focus on developing joint attention, communication and social skills
- intensity unclear ?>20hrs/week
5. Special education settings
a. Autism specific schools
b. Special schools – all children with ID
c. Mainstream schools with integration aide
6. Children with normal IQ rarely get funding as language scores are too high

ii. Manage challenging behaviour
1. Understand reason for behaviour
2. Avoid triggers
3. Do not talk to child
4. Natural consequences

iii. Environmental ‘treatment’
1. Reduce language environment to the child’s comfort level
2. Add in visual communication
3. Reduce stimuli to which the child is hypersensitive

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30
Q

Autism spectrum disorder - prognosis

A

j. Long-term needs
i. Specific training in social skills
ii. Mental health support for comorbid problems such as depression + anxiety
iii. Specific psychological support in sexual development
iv. Specialised employment and training supports
v. Treatment team – Child Psychiatrist, Psychologist, Speech Pathologist, Occupational Therapist
vi. Support or family

  1. Prognosis
    a. Best predictors of outcome are IQ and speech by 5 years old
    b. Poor prognostic factors = lack of language development, delay in diagnosis or therapy
    c. Good prognostic factors = lack of bizarre behaviour, higher IQ, better language skill
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31
Q

Asperger’s syndrome - general

A
  1. Key points
    a. Separate diagnosis under ICD-10, combined on Autism spectrum in DSMV
    b. Previous characterization = autism features WITHOUT significant delay in language or cognitive ability, only impaired in non-verbal language and communication
  2. Features
    a. NORMAL speech and language development
    b. NORMAL/elevated IQ
    c. Qualitative impairment of reciprocal social interaction
    d. Deficits in facial expressions, gestures
    e. Limited empathy
    f. Repetitive behaviours
    g. Strange interests
  3. Treatment
    a. Psychotherapy
    i. Group social skill training is an effective intervention
    ii. CBT in patients with associated anxiety
    b. Pharmacology
    i. Risperidone can help negative symptoms
  4. Comorbidities
    a. Mood and anxiety
    b. 30% comorbid
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32
Q

Affective disorders - overview/list

A
  1. Epidemiology
    a. Major depression
    i. Preschoolers 0.3% (community), 0.9% (clinc)
    ii. School age 2% boys > girls
    iii. Adolescent: 5% *community< 20-40% (patients in psych hospital)
    iv. MZ = 50% concordance, DZ 20%
    b. 4th Most heritable psychiatric disorder schizophrenia, autism, bipolar, depression
  2. DSMV – Classification
    a. Childhood depression
    b. Major depressive disorder
    c. Persistent depressive disorder (dysthymia)
    i. Do not reach the level of ‘major depression’ but do have a long length of depression
    ii. Double depression – major depression on TOP of dysthamia (common in teenagers)
    d. Disruptive mood dysregulation disorder - new
    e. Bipolar affective disorder
    i. Mainly depressive
    ii. Mainly hypomanic
    iii. Mixed
    f. Mood disorders complicating other psychiatric disorders
  3. Pathophysiology
    a. Fronto and fronto-temporal lobes
    d. Serotonin is the most important NT involved in mood – noradrenaline
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33
Q

Bereavement - general

A

a. Has gone into DSMV
b. Pathological bereavement
i. Occurs in first 2 months
ii. Cannot have major depression at the same time (but can precipitate major depression)
iii. Do NOT treat with medications – do not work

34
Q

Major depressive disorder - DSM

A

A. 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.
1. 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.)
2. 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).
3. 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.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. 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.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

35
Q

Major depressive disorder - background

A
  1. Key points
    a. 2% incidence in children, with a cumulative incidence of 20% by age of 18 years of age
    b. Twice as common in females during adolescence, no gender difference in children
    c. Chronic, highly relapsing, recurrent and debilitating disorder
    d. DEPRESSED MOOD + APATHY = 2 key symptoms

e. Comorbidities
i. 28% anxiety disorder
ii. 7% ADHD

f. Incidence of comorbidities
i. In patients with anxiety disorder 10-20% have comorbid depression
ii. IN patients with depressive disorders >50% have comorbid anxiety
iii. IN patients with disruptive behavioral disorders 15-30% have comorbid anxiety

  1. Risk factors
    a. Depressed parent: 1x parent = 2x risk, 2x parent = 4x risk
    b. Likely heritable – 4x monozygotic, 30-40% heritability
    c. Boys whose fathers pass away
36
Q

Major depressive disorder - rx, prog

A

a. Phases of treatment
i. Acute phase lasting 6-12 weeks (stage 1 and 2 of treatment)
ii. Continuation phase lasting 6-12 months (stage 3 of treatment)
iii. Maintenance phase for 1 year or more

b. Based on severity (mild can be managed without pharmacotherapy)

a. Non-pharmacological
i. Psychoeducation
1. 50% improved with psychoeducation
2. Involves teaching what depression is
ii. CBT has the best evidence***
iii. Interpersonal therapy – some, not as good as CBT
iv. Limited evidence for family therapy

a. Pharmacological = antidepressants
i. Always helpful in moderate-severe depression – do not work in mild depression
ii. ALWAYS try non-pharm first
iii. Fluoxetine – most studied, no evidence of difference between SSRIs
1. Lowest NNT
iv. Fluoxetine – approved for the treatment of childhood depression
v. Fluoxetine and escitalopram – approved for adolescent depression
vi. Take 6 week to full effect
vii. 50% chance of efficacy with different SSRI if first does not work (preferred to alternative medication e.g. SNRI)
viii. Side effects: Irritability, GI symptoms, sleep disturbance, diaphoresis, headache

  1. Prognosis
    a. Median course 8 months duration, 40% recurrence in 2years
    b. 10% have chronic course into adulthood
    c. Earlier onset and co-morbidities (especially conduct disorder) associated with poorer outcome
    d. 60% have suicidal ideation, 30% attempt suicide
37
Q

SSRIs and suicidality

A

a. Risk of self-harm highest in the first 2-4 weeks of starting an SSRI
i. Paroxetine – higher suicide rates than others

b. Guidelines for starting an SSRI
i. Start with a low dose and increase slowly – side effects are dose dependent but efficacy is not, always use the lowest effective dose
ii. Only use as an adjunct to psychotherapy
iii. Explain to parents (if relevant children) about possible AE – discuss the issues of deliberate self-harm and suicidality and the need for close monitoring, especially in the first 2-4 weeks
iv. Explain the discontinuation syndrome, which occurs when an SSRI is stopped abruptly – irritability, mood lability, insomnia, anxiety, vivid dreams, nausea, vomiting, headache dizziness, tremor, dystonia, fatigue, myalgia, rhinorrhoea and chills
v. Monitor closely for AE in the first 4 weeks

38
Q

Suicidality - background

A
  1. Epidemiology
    a. Suicide is the third leading cause of death in adolescents
    b. Suicide rare before puberty
    c. Thoughts very common, 1/6 girls, 1/10 boys
    d. 8% high school students attempt
    e. 2% requiring medical attention
    f. 10% attempted will complete suicide
    g. M:F ratio for completed suicide 4:1
  2. Risk factors
    a. Overview
    i. Males = firearms
  3. Risk factors conduct disorder, substance abuse
    ii. Females = poisoning
  4. Risk factors chronic anxiety, panic disorder
    b. Demographics
    i. Post-pubertal
    ii. Male
    c. Suicidality
    i. Previous attempts – 50% will reattempt within 2 years, 20x risk compared with others (STRONGEST)
    d. Psychiatric illness - 80-90% who suicide have psychiatric illness
    i. MDD - Depression - 60% consider suicide, 30% attempt suicide
    e. Family
    i. Family history of depression/suicide
    ii. Recent contact with suicide (friends/family)
    f. Life
    i. Physical or sexual abuse
    ii. Dealing with homosexual feelings in unsupportive family/community
    iii. Lack of support network, poor relationship with peers, social isolation
39
Q

Suicidality - assessment and rx

A
  1. Assessment
    a. Risk factors
    b. Protective factors
    c. Ideation
    d. Intention
    e. Plan and steps
    f. Lethality
  2. Management
    a. Therapeutic relationship
    b. Systematic assessment
    c. Where possible, neutralize precipitants
    d. Try to delay suicidal impulses, offer strategies – E.g. distraction
    e. Remove obvious means of self harm
    f. Ensure supervision
    g. Try and make contract to keep themselves safe
    h. Ensure immediate 24hour access to suitable clinical care
    i. Identify supportive people or services who can be contacted
    j. Engage in consultation with colleagues – discuss difficult cases with others, ensure treatment plan appropriate, therapeutic
  3. Therapy
    a. Cognitive analytic therapy (CAT)
    b. CBT for suicide (CBTS)
    c. DBT
40
Q

Disruptive mood dysregulation disorder - general

A
  1. New disorder
    a. Previous ‘paediatric bipolar’
    b. Irritability with or without depression
    c. Not classic depression
    d. 25-40% of children with ADHD  ODD
    e. 50% of children with ODD  CD
    f. Mood and irritability persistent = disruptive mood dysregulation disorder
    g. Aggression may occur in clusters; 3-4 times per week
    h. INDEPENDENT to mood – persistently irritable, bad violent episodes
  2. Criteria
    a. Severe verbal and physical aggression
    b. Inconsistent with developmental level
    c. 3 or more/week
    d. Mood between outbursts obviously irritable
    e. Present for 12 or more months, not absent for over 3 months
    f. Two settings (home school, peers)
    g. 6-18 years
    h. No mania/hypomania/MDE/ASD/PTSD/Other mood disorder/separation anxiety
    i. Not due to substance/ neurological condition
  3. Epidemiology
    a. 2-5%
    b. Males > females
    c. Children > adolescents
41
Q

Persistent depressive disorder (dysthymia) - general

A
  1. Diagnostic criteria
    a. Depressed mood for 1 year (2 years in adults)
    b. 2 or more
    i. Poor or over appetite
    ii. Insomnia/hypersomnia
    iii. Low energy
    iv. Low self-esteem
    v. Poor concentration/ decision making
    vi. Hopelessness
  2. Difference
    a. EPISODES of depression - vs gradual onset and persistent
    b. SEVERE – vs not as severe
  3. Other points
    a. Higher rates of persistent depressive disorder than major depression
  4. Specifiers
    a. With anxious distress
    b. Mixed
    c. Melancholia
    d. Mood congruent/ incongruent psychotic features
    e. Atypical
    f. Postpartum
    g. Partial remission/ full remission
42
Q

Major depression versus persistent depressive disorder/dysthymia

A

PDD and MDD are two forms of depression that have similar symptoms and treatment methods. The main difference concerns the duration of symptoms. PDD symptoms last for at least 2 years (in adults, 1 year in kids) while people with MDD experience depressive episodes that are separated by at least 2 months.

43
Q

Bipolar disorder - manic episode (and hypomanic)

A

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization
is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investments).

C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.

Hypomania is the same as the above, but :

  • lasts at least 4 days rather than at least 1 week
  • is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization
  • does not have psychotic features
44
Q

Bipolar disorder - background

A
  1. Classification
    a. Bipolar I = one or more periods of mania
    b. Bipolar II = one or more periods of depression, alternating hypomania
  2. Variants
    a. Cyclothymic disorder
    i. At least 1 year of hypomania + sub syndromal depression
    ii. Causes clinically significant distress
    iii. Not better accounted for by other psychiatric disorders/ medications/medical conditions
    b. BPAD NOS when symptoms are present but not enough to meet full diagnostic criteria
    c. Mixed episode needs 1 week of symptoms from both manic and major depressive episode
  3. Epidemiology
    a. Prevalence 0.6%, M= F
    b. FHx = increased risk
  4. Heritability
    a. First degree relatives of pt with bipolar I have a 4-6 fold increase risk of bipolar or depression (Nelsons says 10 x risk)
    b. Strongest heritability of any mental illness***
    i. 70% monozygotic twins
    ii. 20% with FHx
    c. Linked to underdevelopment of subcortical (amygdala) and prefrontal regions
45
Q

Bipolar disorder - dx, sx

A

See DSM cards for details on mania/hypomania/depression

  1. Differentials
    a. ADHD, oppositional defiant disorder, post-traumatic stress, substance abuse, borderline personality disorders
    b. Premorbid symptoms common (mood + behavioural regulation)
  2. Clinical features
    a. Usually depressive episode first, 20-40% of those with RF (psychotic features, FHx BPAD, mania with SSRI) develop BPAD, 10% in those without risk factors (higher than adults)
    b. Usual trigger – sleep deprivation, substance abuse, antidepressants
    c. Rapid cycling between mania, depression and euthymia
    d. Giggly, laughing, to the annoyance of others
    e. Defy usual social rules – e.g will tell adults what to do and how to do it
    f. Lack of sleep
    g. Temper tantrums
    h. Paediatric specific things:
    A. Increased activity/ silliness above developmental age
    B. Decreased need for sleep
    C. Inappropriate sexual behaviours
    ii. Tends to have more variable course with recurrent episodes
    iii. High rates of comorbid disorder
    iv. Diagnosis on average occurs 10 years post first manifestation
  3. Comorbidities
    a. 60-90% ADHD
    b. 30-70% Anxiety
    c. Substance abuse
    d. 30-70% Disruptive behavior disorders – e.g. CD
46
Q

Bipolar disorder - rx, prog

A
  1. Management
    a. Treat comorbidities
    i. Eg. ADHD
    b. Non-pharmacological = Psychotherapy
    i. Education, addressing family issues
    c. Mood stabilisers (< 50% response rate)
    i. Lithium, valproate, atypical antipsychotic
    ii. Continue medical therapy for 12-24 months at least (lifelong therapy often required)
    d. Anti-depressive therapy for bipolar II
    i. Lamotrigine can be helpful for bipolar depression
  2. Prognosis
    a. 25-33% of children and 50% adolescence attempt suicide
    b. Earlier onset predicts persistence, severity, and likelihood of children having BPAD
    c. Poor prognostic features – long duration, mixed mania, psychosis, rapid cycling
    d. 70-100% recovery from initial mood derangement, but >80% recurrence
    e. Completed suicide occurs in 10-15% of children with bipolar I
47
Q

Psychosis - terminology

A

a. Psychosis = general term for states in which mental function is grossly impaired
i. Must be oriented to time, place and person
ii. No ‘clouding of consciousness’

b. Symptoms
i. Hallucinations = sensory experience when there is no stimuli
ii. Delusions
1. Belief held with total conviction
2. Great personal significance
3. Not amenable to reason or modification by experience
4. Less systemized in children
5. CF. magical thinking but concern if fixed/pervasive/child acts on them/ poor reality testing
iii. Thought disorder
1. Illogical thinking, loose associations, incoherence
2. Poverty of speech (normal < 7 years)
3. DDX = SCZ, organic, expressive language disorders
iv. Negative symptoms
v. Disorganisation

c. Classification of symptoms
i. Positive = reality testing and insight are lacking; delusions, hallucinations, incoherence, and thought disorder and disorganised behavior
ii. Negative = inexpressive faces, blank looks, monotone, reduced and monosyllabic speech, few gestures, seeming lack of interest in the world, inability of feel pleasure or act spontaneously
1. Negative symptoms are much more pervasive and have a much greater effect on a patient’s QOL
d. 25% of patients with schizophrenia psychosis have the deficit syndrome – defined by severe and persistent negative symptoms

48
Q

Psychosis - differentials

A

a. If ‘psychosis’ is present
i. ‘psychotic symptoms’
ii. Schizophrenia
iii. Schizophreniform = lasts <6 months
iv. Schizoaffective
v. Mood disorder
vi. Brief psychotic disorder = occurs in the context of stress
vii. Organic = younger is more likely to be organic pathology

b. Other DDx
i. Pseudohallucination
ii. Dissociative states = occurs with acute stress
iii. OCD = children classically describe a voice but it is their own thought
iv. Transient psychotic symptoms with BPD
v. Schizotypal personality disorder
vi. Drug intoxication
vii. Factitious disorder

c. Organic DDx
i. Drugs – particularly hallucinogenics (LSD, ice, amphetamines)
ii. Temporal lobe epilepsy – can have post seizure psychotic symptoms
iii. Encephalitis – viral, anti-NMDA, teratoma associated
iv. SLE
v. Other organic brain disorders
vi. Delirium

49
Q

Hallucinations in children - ddx

A

i. Note that hallucinations are common in children
1. Key is in direct observation  are they responding to external stimuli?
ii. Parahallucinations are common in children
1. Hypnopompic (awaking) and hypnogogic hallucination (going to sleep)
2. Eidetic imagery/imaginary

iii. DDx
1. Anxiety states
2. Transient situational
3. Deprived with PD
4. Schizophrenia
5. Organic

50
Q

Schizophrenia - DSM

A

A. Two (or more) of the following, each present for a significant portion of time during a 1 -month period (or less if successfully treated). At least one of these must be (1 ), (2), or (3):

  1. Delusions.
  2. Hallucinations.
  3. Disorganized speech (e.g., frequent derailment or incoherence).
  4. Grossly disorganized or catatonic behavior.
  5. Negative symptoms (i.e., diminished emotional expression or avolition).

B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).

C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion
A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1 ) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

51
Q

Schizphrenia - bg

A
  1. Epidemiology
    a. 1% prevalence world wide
    b. Incidence 0.1%
    c. ‘Typical’ males 15-25, females 20-30
    d. 20% <20 years, 5%< 15
    e. 30-50% of cases of childhood schizophrenia are preceded by pervasive developmental disorder
    f. VERY rare <13 year old
  2. Classification
    a. Early onset schizophrenia >13
    b. Very early onset schizophrenia <13
    c. Youngest report <3 years; extremely rare <11 years
    d. Earlier the onset the larger the abnormality of personality and function – therefore very pronounced presentation
52
Q

Schizophrenia - sx, ix

A
  1. Phases
    a. Prodrome
    i. Subthreshold psychotic symptoms = perceptual abnormality, changes in thought pattern, suspiciousness, odd beliefs
    ii. Non-specific symptoms = sleep changes, anxiety, anger, depression, poor concentration
    iii. Behavioural changes = social withdrawal, deterioration in school performance
    b. Reactive – psychotic symptoms emerge and diagnosis made
    c. Residual – often period of negative symptoms following reactive phase
  2. Clinical presentation
    a. Deterioration in performance
    b. Deterioration in personality – irritable and difficult
    c. Paranoia (delusional self reference “centre of attention”, not persecutory)
    d. Auditory hallucinations
    e. Delusions paranoid “everyone talking about me”
  3. Investigations – first presentation psychosis
    a. Bloods = FB, UEC, LFT, TFT, blood glucose, prolactin
    b. Urine drug screen
    c. MRI brain – rule out space occupying lesion or temporal lobe epilepsy
    d. +/- EEG
    e. +/- other eg. NMDA receptor antibodies
53
Q

Schizophrenia - rx, prognosis

A

Uptodate: First-line treatment for children and adolescents with schizophrenia is antipsychotic medication with adjunctive psychosocial treatment. Multiple randomized trials have found individual antipsychotics to be efficacious in treating schizophrenia in youth. Clinical trials comparing antipsychotic efficacy have found them to have similar effectiveness with the exception of clozapine, which is consistently superior; however, the side effect profile of clozapine limits its use to patients who do not respond to other antipsychotics.
•We start with a second-generation antipsychotic due to their lower rates of extrapyramidal symptoms and tardive dyskinesia compared with first-generation antipsychotics. We typically use risperidone, but choose an alternative for patients with any gynecomastia or elevated prolactin, and in late-adolescence boys.

  1. Management

a. Antipsychotics
i. Minimise side effects
ii. Start low go slow, increase gradually
iii. Shift if no change in 8 weeks
iv. Trial further atypical
v. If no improvement think – compliance, drug abuse, stress, clozapine, treatment resistant illness, comorbid illness (eg. depression), comorbid substance abuse, ongoing stress (eg. high EE family)

b. Improvement of compliance - Insight (psychoeducation), Side effects (tailor to suit patient), Engagement/therapeutic alliance, Family support/monitoring

c. Summary of side effects
i. Sedation
ii. Akathisia – increases risk of suicide (more likely with risperidone)
iii. EPS
iv. Weight gain and metabolic
v. Hyperprolacintaemia – prolactin is always elevated
vi. Sexual
vii. Anticholinergic

d. Types of antipsychotics
i. ‘Typical’ antipsychotics = haloperidol, stelazine, chlorpromazine, thiordazine, pimozide
ii. ‘Atypical’ antipsychotics = risperidone, olanzapine, quetiapine, amisulpride, aripirazole, ziprasidone, lurasidone, clozapine
1. Risperidone – weight gain and EPS
2. Olanzapine – weight gain is a huge issue
3. Quetiapine – sedation and weight gain
4. Clozapine – weight gain, myocarditis, neutropenia; needs to be monitored, if develop neutropenia it is reversible

e. Psychosocial intervention
i. Engagement
ii. CBT - no great evidence
iii. Stress management
iv. Vocational rehab
v. Drug and alcohol
vi. Family intervention

  1. Prognostic factors
    a. Poor prognosis if – early age onset <14years, poor pre-morbid functioning, negative symptoms, family history of schizophrenia, male gender, substance abuse
    b. 20% only have one episode
54
Q

Tic disorder - bg

A
  1. Key points
    a. Tic = sudden, rapid, involuntary, non—rhythmic movements or vocalisations that occur repeatedly
    b. Patients usually have some degree of voluntary control over tics – can suppress them for minutes or hours, at the cost of a buildup of tension
    c. Tend to be less severe when the child is engaging in a task requiring concentration
    d. Tourette’s = motor and vocal tics present for at least 12 months***
    e. Transient if <12 months, Chronic if >12months
  2. Classification
    a. Motor tics = commonest type, where one muscle group twitches repeatedly eg. eye blinking, limb jerking
    i. Complex motor tics = stereotypic movement involving multiple groups or limbs
    ii. Can be difficult to differentiate from stereotypies or seizures
    b. Vocal tics = common, including sniffling, throat clearing and various vocalisations
    i. Complex vocal tics = less common, involve repeating ones’ own sounds or the last heard words or phrase, or rarely socially unacceptable words or insults
  3. Epidemiology
    a. 4-12% of children suffer from tics at some point
    b. 3-4% affected by chronic tics
    c. 1% have Tourette’s syndrome
    d. Common in childhood – peak age of onset 6-8 years (range 2- 15 years)
    e. Affect boys 4x more than girls
    f. More common in children with neurodevelopment disorders – ADHD, autism
  4. Genetics
    a. Strong family predisposition – heritability 50%
55
Q

Tics - hx, comorbidities

A
  1. Natural history
    a. Onset typically in preschool or early PS years
    b. Most cases are transient
    c. Start in face – E.g. blinking or grimacing, spread to shoulders, extremities, torso, vocal tics later
    d. Fluctuations in symptoms
    e. Natural history of tics is to wax and wane, usually disappearing in adolescence
    f. Only a small proportion persist into adulthood
    g. Tourette’s specifically:
    i. Usually 5-8 years
    ii. Tics increase when stressed or tired
    iii. Tics decrease when concentrating, distracted or sleeping
    iv. No interference with purposeful motor activity – E.g. cycling
  2. Comorbid conditions with Tics
    a. ADHD = 40-60% (considered most common)
    b. OCD = 40-70%
    c. Anxiety = 25-40%
    d. Depression = 50%
    e. Sleeping disorder = 12-44%
56
Q

Tic disorder - rx, prog

A
  1. Treatment
    a. Most children do not require treatment
    b. Indication for treatment
    i. Embarrassment and social exclusion
    ii. Emotional disturbance
    iii. Muscle pain
    iv. Interference with function
    c. Treatment = pharmacological
    i. Antipsychotics – haloperidol, risperidone, olanzapine
    (Haloperidol and clonidine listed in MRCPCH book)
  2. Significant side effects
    ii. Anti-anxiety medications – if anxiety is a significant factor
    iii. Other medications
  3. Clonidine
  4. Clonazepam
  5. Terbenazine
  6. Botulinum toxin – for disabling motor tics
  7. Transcranial magnetic stimulation DBS
    d. Treat comorbid conditions
  8. Prognosis
    a. Spontaneous remission in 50-70% cases, 3-40% Tourette’s syndrome
    b. Poor prognosis = Fhx, vocal/complex tics, OCD symptoms, co-morbid hyperkinetic disorder, aggression
57
Q

Somatoform disorders - bg

A
  1. Key points
    a. Somatic response to stressful situations are common
    b. Somatic complaints in children are also believed to be relatively common and appear as physical sensations related to affective disease
    c. Psychosomatic or somatoform disorders = refer to the presence of physical symptoms suggesting an underlying medical condition without such a condition being found (medical or psychiatric), or where a medical problem cannot adequately account for the level of functional impairment
    d. Not associated with emotional distress or stressors
    e. May be present in a child whose families have a history of illnesses or psychosomatic disorder
  2. Epidemiology
    a. 25% of children/adolescents experience somatic complaints regularly
    b. 2% ‘somatisers’’
    c. Overall minimal research in area of SDs in children/adolescents
    d. Increased risk of being classified as somatiser as get older
    e. Conversion disorders more likely to remit
  3. Somatoform disorders in children
    a. Complex somatic symptom disorder – encompasses pain disorder
    b. Illness anxiety disorder – encompasses hypochondriasis
    c. Conversion disorder
    d. Factitious disorder
    e. Somatoform disorder not otherwise specified
58
Q

Somatic symptom disorder - DSM

A

A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.

B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

  1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
  2. Persistently high level of anxiety about health or symptoms.
  3. Excessive time and energy devoted to these symptoms or health concerns.

C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

59
Q

Somatoform disorders - sx

A
  1. Common symptoms
    a. Headache
    b. Abdominal pain
    c. Limb pain
    d. Fatigue
    e. Pain/soreness
    f. Disturbance of vision
    g. Symptoms suggestive of neurological disorders
  2. Risk factors
    a. Female sex
    b. Fewer years of education
    c. Lower socioeconomic status
    d. History of childhood chronic illness
    e. History of sexual abuse or other childhood and other adult trauma
    f. Concurrent general medical disorders (especially older patients)
    g. Family history chronic illness
    h. Comorbid psych illness = depressive and anxiety disorders
60
Q

Somatoform disorders - rx

A

a. Principles
i. Treat symptoms seriously
ii. Investigate appropriately
iii. Have ‘somatising’ on list of differentials from the beginning and discuss openly when appropriate

b. Steps
i. Assess the symptoms to determine a lack of clear ‘medical pattern’
ii. Validate the symptoms as a real issue for the patient
iii. Assess how the symptoms affect the life of the child and family
iv. If medical tests normal bring up the possibility of a somatoform problem not in exclusion to medical causes but alongside it
v. Assess the patient’s awareness of the psychological nature of the symptoms
vi. Give the child and parents an explanation
vii. Explain that stress results in an ‘organic’ bodily response – use examples such as tachycardia when stressed
viii. Explain treatment is psychotherapy

c. Psychotherapies
i. CBT
ii. Individual psychotherapy
iii. Family therapy
iv. Psychological advice

d. Treat underlying anxiety/depression

61
Q

Illness anxiety disorder - DSM

A

A type of somatoform disorder

a. Preoccupation with having or acquiring a serious illness
b. Somatic symptoms are not present or if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate
c. High level of anxiety about health, and the individual is easily alarmed about personal health status
d. The individual performs excessive health-related behaviours (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g, avoids doctor appointments and hospitals)
e. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time
f. The illness-related preoccupation is not better explained by another mental disorder
g. Specifier = seek or avoid medical care

62
Q

Conversion disorder - general

A

a. DSMV Criteria
i. One or more symptoms of altered voluntary motor or sensory function
ii. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions
iii. The symptom or deficit is not better explained by another medical or mental disorder.
iv. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation
v. Symptom type = weakness or paralysis, abnormal movement, swallowing symptoms, speech symptom, attacks or seizures, anaesthesia or symptom loss, sensory symptom
vi. Specify acute episode (<6 months), with or without psychological stressor

b. Common presentations
i. Gait disturbance
ii. Paraesthesia
iii. Paralysis
iv. Pseudoseizures

c. Key points
i. More common in adolescence than childhood
ii. Onset of symptoms usually closely associated to a psychological stressor
iii. Generally short lived
iv. Often alleviated by identification and management of the stressor(s) and in some instances, symptomatic treatment of the physical problem

63
Q

Factitious disorder - imposed on self

A

i. DSMV criteria
1. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception
2. The individual presents himself or herself to others as ill, impaired, or injured
3. The deceptive behavior is evident even in the absence of obvious external rewards
4. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder
5. Specifiers = single episode, recurrent episodes, imposed on another

ii. Risk factors
1. Female
2. Unmarried
3. HCW

64
Q

Factitious disorder - imposed on another

A

Previously Factitious Disorder by Proxy

i. DSMV criteria
1. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception
2. The individual presents another individual (victim) to others as ill, impaired, or injured
3. The deceptive behavior is evident even in the absence of obvious external rewards
4. The behavior is not better explained by another mental disorder

ii. Key points
1. The child suffers from the falsification either through iatrogenic harm from unnecessary medical testing or procedures or direct injury cause by perpetrator
2. Adult perpetrator who is mentally ill and carries the diagnosis of factitious disorder imposed on another

iii. Risk factors
1. Female, mostly mother or primary caregiver
2. History of factitious or somatoform disorders
3. History of unfortunate childhood disorders

iv. Warning signs
1. Unexplainable, persistent, or recurrent illnesses
2. Discrepancies among the history, clinical findings, and child’s general health
3. A working diagnosis of a rare disorder
4. Symptoms and signs that occur only in the mother’s presence
5. A mother who is extremely attentive and always in the hospital
6. A child who is frequently intolerant of treatment
7. A mother who appears less worried about her child’s illness than about the medical staff
8. Seizures that do not respond to appropriate therapy
9. Families in which unexplained sudden infant death syndrome (SIDS) occurs
10. A mother with previous medical or nursing experience or an extensive history of illness

v. Methods
1. Fabricated illness
2. Induced illness
a. Medications to induce vomiting
b. Comas from medications
c. Salt poisoning
d. Bacteriological abuse
e. Seizures from medications/suffocation

65
Q

Antidepressants - classes, indications, efficacy

A
  1. Classes
    a. Tricyclic antidepressants (TCAs)
    b. Monoamine oxidase inhibitors (MAOIs)
    c. Selective serotonin reuptake inhibitors (SSRIs)
    d. Serotonergic and noradrenergic reuptake inhibitors (SNRIs)
    e. Selective noradrenaline reuptake inhibitors (NRIs)
    f. Other agents
    i. Alpha2 antagonists (NaSSa)
    ii. 5HT2C antagonist/ melatonin agonist
  2. Indications
    a. Major depressive disorder
    b. Anxiety disorder
    i. Panic disorder
    ii. OCD (SSRIs)
    iii. Generalised anxiety disorder (venlafaxine, dual acting drugs)
    iv. PTSD
    c. Other – neuropathic pain (TCAs)
  3. Efficacy
    a. Depression
    i. Relatively slow onset of action = 2-4 weeks before marked improvement
    ii. Some improvement of symptoms in the first week; usually due to improvement in sleep
    iii. Full recovery rare in under 6 weeks
    b. Anxiety
    i. Slower response than for depressive disorders (3-4 weeks)
    ii. Require higher doses
    iii. Concurrent use of BDZ may be useful due to delayed onset of action
66
Q

Antidepressants - general side effects

A
  1. Antidepressants + suicide
    a. The risk of suicide increases around the time of presentation for treatment and in the early stages of treatment for depression or psychosis with ANY treatment
    b. The highest risk occurs in the week BEFORE treatment
    c. Some antidepressants may INCREASE the risk of suicidal behavior by enhancing impulsivity and aggression in the first 2 weeks of treatment, particularly in children and adolescents
  2. Important side effects
    a. Bleeding = SSRIs
    i. Block the uptake of serotonin into platelets
    ii. ↑ risk of GI bleeding – risk increased by concurrent NSAIDs, anticoagulant drugs and antiplatelet drugs
    b. Hyponatraemia = TCAs, SSRIs, SNRIs, MAOIs
    i. May be asymptomatic or accompanied by general malaise and nausea
    ii. Routine monitoring of serum sodium is not indicated, but measurement of serum sodium may be considered in patients at high risk of hyponatreamia approximately 3-4 weeks after initiating Tx
    c. Psychomotor impairment and sedation
    i. Sedating antidepressants
    ii. Impair psychomotor skills, although some tolerance to this develops over a period of days
    iii. Avoid concurrent sue of other CNS depressants (eg. alcohol, BDZ)

Fluoxetine first line SSRI treatment of depression in children/adolescents >8years.

67
Q

SSRIs - general

A
  1. Pharmacology
    a. Inhibit of cytochrome P450 – can interact with other drugs
    b. Low lethality in OD
  2. Side effects
    a. Discontinuation rate due to SEs 5-10%
    b. Physical
    i. GIT = nausea, abdominal pain, anorexia
    ii. Headache, dry mouth
    iii. Sleep disturbance = delayed onset, waking, vivid dreams
    iv. Sexual = erectile dysfunction, anorgasmia, decreased libido
    v. ? Growth suppression
    vi. Discontinuation
    c. Psychiatric
    i. Agitation/ irritability
    ii. Manic switching – (hypo)mania 2%
    iii. Suicidal thoughts/ behaviours – small increase
  3. Usually happens in first few weeks
  4. Paroxetine had particularly increased risk
  5. Indications
    a. Anxiety disorders – GAD, OCD
    b. Obsessionality in ASDs
    c. Adolescent depression - NOT used in pre-adolescent depression
  6. Safe use
    a. Start low
    b. Warn of possible activation
    c. Monitor growth
    d. Avoid sudden cessation
  7. Precautions
    a. Epilepsy, reduces seizure threshold
    b. Bipolar disorder – all antidepressants may provoke manic episode
    c. People at risk of bleeding, eg age >80 years, previous upper GI bleeding
  8. Withdrawal/discontinuation
    a. Physical = dizziness, nausea, vomiting, lethargy, flu-like (chills, aches), light headedness, insomnia
    b. Psychological = irritability, anxiety, crying spells
    c. Worse with paroxetine and sertraline d/t shorter half life – should be tapered over several weeks
    d. Fluoxetine can be stopped without problems due to its long half life
    e. Symptoms 1-3 days after last dose
68
Q

TCAs - general

A
  1. Examples = amitriptyline, dothiepin, doxepin, imipramine, nortriptyline, trimipramine, clomipramine
  2. Side effects
    a. Sedation, dry mouth, constipation, urinary retention (anticholinergic)
    b. Blurry vision and urinary retention, at high doses
    c. OTHER = weight gain, postural hypotension, sinus tachycardia, anticholinergic delirium (elderly + PD), loss of libido
  3. Important = lethal in overdose due to cardiac arrhythmia (impaired ventricular conduction)
    a. Avoid prescribing to people with suicidal ideation
    b. TCA toxicity = three C’s
    i. Convulsions
    ii. Coma
    iii. Cardiac arrhythmia – prolonged conduction through the AV node and long QRS
  4. Must be closely monitored
  5. Precautions
    a. Risk factor for acute angle closure glaucoma
    b. Epilepsy – lowers seizure threshold
    c. CV – exacerbate heart block, exacerbate angina, increase risk of arrhythmia
69
Q

SNRI - general

A

Serotonin and NA reuptake inhibitor

Not generally used in children due to increase risk side effects.

Examples:
Venlafaxine *suicidal ideation 4%
Desvenlafaxine
Duloxetine

70
Q

Antipsychotics - general bg and SEs

A
  1. Classification
    a. First generation/ typical (FGAs)
    b. Second generation/ atypical (SGAs)

Examples:
Typical
- Chlorpromazine
- Haloperidol

Atypical

  • Aripiprazole
  • Clozapine**
  • Olanzapine**
  • Quetiapine**
  • Risperidone**
  1. Mode of action
    a. Inhibit dopamine 2 receptors
    b. Typical = bind tightly to these (and other) dopamine receptors
    c. Atypical = bind to dopamine 2 receptors + others throughout the brain
  2. Efficacy
    a. Typical = do not benefit negative + cognitive features
    b. Atypical = beneficial effects upon negative features of psychosis + cognitive features
    i. Olanzapine + clozapine particularly good for negative symptoms
71
Q

Antipsychotics - general SEs

A

a. Adverse effects traditionally associated with older agents appear to be less common or less severe with some of the newer antipsychotics
b. Typical = higher risk of EPS (dystonia, Parkinsonian features, akathisia), hyperprolactinaemia (impotence, amenorrhoea, gynaecomastia), and tardive dyskinesia
c. Atypical side effects
i. Weight gain + metabolic syndrome (T2DM) [clozapine, olanzapine, quietiapine]
1. Consider switch to risperidone, aripiprazole
ii. Sedation
iii. Insomnia
iv. Agitation
v. Constipation, dry mouth (anticholinergic)
vi. Cardiological effects
1. QTc prolongation [haloperidol, quietiapine, ziprasidone, sertindole]
2. Myocarditis, cardiomyopathy for some)[clozapine]

MECHANISMS
“Extrapyramidal” effects (EPS) ie. drug induced – parkinsonism: Central D2 blockade
Gynacomastia/ amenorrhea: Central D2 blockade
Sedation: H1 blockade
Postural hypotension: α1 blockade
Dry moth/blurred vision/ constipation (anti-SLUD): Muscarinic blockade
Weight gain: 5HT2C blockade

72
Q

Antipsychotics - extrapyramidal side effects

A 
	Dystonic reaction = hours-days
	Parkinsonism = days-weeks
	Akathisia = days-weeks
	Tardive dyskinesia = years
	NMS = any time

i. Mechanism = inhibition of dopamine 2 receptors in SN and basal ganglia -> imbalance of dopaminergic and cholinergic activity -> signs and symptoms associated with Parkinson’s disease and BG disease
ii. Particularly associated with FGAs, much less with SGAs

iii. Incidence is dose-related and is
1. Highest with haloperidol, fluphenazine and trifluoperazine
2. Lower with chlorpromazine, pericyazine
3. Lowest with some of the newer agents
4. Much less common with atypical antipsychotics (more common with risperidone; aripiprazole has greater tendency to akathisia)
iv. Aggravated by anxiety

v. Acute forms
1. Tremor = worst at rest
2. Dystonias = involuntary sustained muscle contractions, particularly of the head and neck; very unpleasant and can be painful, may include facial muscles including tongue
3. Oculogyric crisis = dystonia which affects external ocular muscles
4. Laryngeal stridor = dystonia which affects laryngeal muscles; can be very serious
5. Parkinsonism = mask-like facial expression; muscle rigidity with tremor (cog wheel rigidity); shuffling gait; retropulsion; reduced spontaneous arm swing
6. Akathisia = subjective sensation of very uncomfortable restlessness which is not relieved by movement (cf. restless legs); manifests with pacing, shifting position + constant leg movement

vi. Management
1. Reduce dose of medication as much as possible
2. Switch to alternate antipsychotic if possible
3. Acute dystonias
a. IV or IM benztropine (muscarinic antagonist)
b. Switch to oral benztropine in lowest effective dose; discontinued within several weeks at the most
4. Parkinsonism
a. Oral benztropine or benzhexol
b. After several weeks should be ceased
5. Akathisia
a. Propranolol (1st line)
b. Diazepam

vii. Tardive forms (delayed)
1. Movement disorder of face + tongue (primarily)
2. TD may appear after medium- to long-term treatment, or even after stopping the antipsychotic (particularly after suddenly stopping)
4. Up to a third of people treated for 10 years with older antipsychotics will develop TD
5. No known effective treatment
a. BDZ may give some relief and change to atypical antipsychotic medication, particularly clozapine, can be helpful
b. Withdrawal or change to an atypical antipsychotic early in the appearance of tardive side effects can promote reversal of the movement disorder
i. Switch to clozapine if possible
c. May resolve spontaneously

73
Q

Antipsychotics - precautions

A

a. Parkinson’s disease + Lewy body dementia
b. Epilepsy – antipsychotics may alter EEG or lower seizure threshold
c. Respiratory failure
d. Hyperthyroidism – increases risk of acute dystonia
e. Risk factor for prolonged QT interval – amisulpride, Droperidol, haloperidol and ziprasidone are most likely to have this effect
f. Increased intra-ocular pressure, GI obstruction, bladder outlet obstruction, urinary retention – may be exacerbated by anticholinergic effects of some antipsychotics
g. Low white cell count or previous blood dyscrasia
h. Diabetes – antipsychotics (clozapine, olanzapine, quietiapine)

74
Q

Antipsychotics, second generation - indications, SEs

A
  1. Indications
    a. Aggressive/ self-injurious behaviour in autism/ ID
    b. Tourette
    c. Sleep disturbance unresponsive to melatonin
    d. ? Aggression in conduct disordered with normal IQ
  2. Side effects

a. Metabolic
i. Weight gain
1. Olanzapine > risperidone > quetiapine > aripiprazole
ii. Dyslipidaemia - Increased total cholesterol, LDL, TG; decreased HDL - Monitoring recommended
iii. Insulin resistance

b. Hyperprolactinaemia
i. Dopamine inhibits prolactin
ii. Dose-dependent
iii. Level weakly correlates with symptoms – mostly no symptoms
1. Not recommended to check levels
iv. Symptoms
1. Gynaecomastia, galactorrhoea
2. Hirsutism
3. Oligo/amenorrhoea, erectile dysfunction, decreased libido

c. Extrapyramidal symptoms
i. Risk acute dystonia lower than traditional antipsychotics
ii. Akathisia relatively high
iii. Tardive dyskinesia relatively low (and some reversible)

d. QT prolongation = risk relatively low
e. Sedation = dose related, tolerance usually develops

f. Other
i. Neutropenia
ii. Hepatotoxicity
iii. Thyroid dysfunction
iv. NMS
v. Seizures

75
Q

Mood stabilisers - examples/list

A

a. Valproate
b. Carbamazepine
c. Lamotrigine
d. Topiramate
e. (Lithium)

76
Q

Valproate - AE, monitoring

A

a. Adverse effects
i. Tremor
ii. Weight gain (+ increased appetite)
iii. Alopecia
iv. Blurry vision
v. Thrombocytopenia
vi. Hepatotoxicity
vii. Menstrual irregularities, PCOS, hyperandrogenism in females, lipid dysregulation
viii. OTHER = N+V, paraesthesia, drowsiness, dizziness, memory impairment
ix. Danger in pregnancy -> results in NEURAL TUBE DEFECT***

b. Monitoring
i. FBE – before starting treatment
ii. LFTs
iii. Blood monitoring for toxicity - there is poor correlation between therapeutic efficacy and plasma concentration but concentrations may be useful to confirm toxicity or compliance
iv. Bone mineral density – for long term treatment

77
Q

Carbamazepine - AEs, contraindications

A

a. Adverse effects
i. Skin rash, SJS***
ii. Dizziness
iii. Sedation, ataxia, dysarthria
iv. Thrombocytopenia, agranulocytosis
v. Elevated LFTs
vi. Other = blurred vision, diplopia, headache, dry mouth, abdo pain, N+V, anorexia, constipation

b. Contraindications
i. AV conduction abnormalities
ii. History of bone marrow depression
iii. Porphyria
iv. Treatment with clozapine – increases risk of serious haematological affects
v. Severe hepatic impairment

78
Q

Lamotrigine - indications, AEs, contraindications

A

a. Indications
i. Partial (focal) and generalised seizures (adjunctive treatment or monotherapy)
ii. Bipolar disorder (prevention of depressive episodes)

b. Adverse effects
i. Diplopia, blurred vision, dizziness, ataxia, headache, somnolence, hyperkinesia, nausea, vomiting, maculopapular rash
ii. SJS*** – increase dose slowly to monitor for rashes

c. Contraindications
i. Hypersensitivity
ii. Treatment with valproate
iii. Allergy or rash with other anti-epileptics

79
Q

Lithium - general

A

Unknown mechanism

Baseline tests:
UEC and BUN
Urinalysis
Thyroid function
FBE
CMP, albumin
Weight 
Lithium level for monitoring (0.8-1.2)

Indications:
First line mood stabilizer in BPAD
Been approved for longest time by FDA

Side Effects:

Polyuria/Polydipsia
Nausea/diarrhoea
Tremor
Sedation
Weight gain
Hypothyroidism 
Leukocytosis
Acne/psoriasis/hair loss
Bradycardia, ECG changes (TW flat)
80
Q

Anticonvulsant hypersensitivity syndrome - general

A

Reported with carbamazepine and lamotrigine (valproate structurally different and not associated, considered alternative if hypersensitivity occurs).

Occurs 1-4 weeks after starting therapy, with: fever, rash, systemic organ involvement (lymphadenopathy, hepatitis, myositis, myocarditis, pneumonitis).

Rash is variable, can be as severe as SJS/TEN.

Rx: discontinue offending agent. Valproate as alternative.

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