Psychiatry Flashcards
What is Autism Spectrum Disorder?
A neuro-developmental disorder characterised by abnormal social interaction, communication and restricted, repetitive behaviours. ASD is four times more prevalent in boys than girls.
Risk increased if a sibling has ASD and increases chance of having ADHD and/or learning difficulties
What is the aetiology of ASD?
Not completely understood but it is believed there are genetic factors due to risk increased in twins and siblings. Commonly associated with some genetic syndromes e.g. fragile X, tuberous sclerosis, Down’s etc
Others: increased maternal age, prenatal infections, obstetric complications, exposure to toxins or teratogens
What are the clinical features of ASD?
Presentation is highly variable
- Social:
Lack of response to other people’s emotions
Unable to interpret social cues
Inability to form social attachments - Communication:
Usually delayed or minimal expressive speech
Impairment in make-believe or fantasy play
Lack of social gestures
Conversational skills tend to be one-way (monologues, endless questions etc…) - Repetitive Restrictive Behaviours & Interests:
Resist change with a rigid daily routine
Preoccupations with specific interests like dates or timetables
Inability to adapt to new environments
How is ASD diagnosed?
Full developmental history
Screening tools - MCHAT, CARS, CAST etc
Diagnostic tools - ADI-R, DISCO, ADOS, etc
For a formal diagnosis, must impair daily function and be present in the early developmental period and can’t be better better explained by learning disability or global developmental delay.
What other Ix may be needed when a diagnosis of ASD is made?
Genetic testing
Metabolic testing
Neuroimaging (e.g. MRI brain)
Electroencephalogram
How is ASD managed?
Very individualised to achieve as much functional independence as possible and improve the quality of life for the patient.
- Early diagnosis + special educational programmes
- Occupational therapy
- Speech therapy
- Clinical psychology
- Sleep hygiene
- Family support
- Medications should not be used routinely to treat the core features of ASD. They may be used to treat concurrent medical or psychiatric co-morbidities but in conjunction with behavioural interventions
What is ADHD?
A neurodevelopmental condition characterised by an abnormally high activity level and an inability to concentrate.
More common in boys, usually presents before 7 but can be diagnosed at any age in 2 or more important settings
What are the RF for ADHD?
FHx
Prematurity
Low birth weight
Low paternal education
Prenatal smoking
Maternal depression
Maternal nicotine+alcohol
Psychosocial adversity
What are the clinical features of ADHD?
Inattention, Hyperactivity and Impulsivity having an adverse effect on QoL in 2 or more settings
e.g. short attention span, quickly losing interest in tasks, constantly fidgeting or unable to sit still, impulsive behaviour, described as disruptive, poor organisational skills, acting without thinking
Many patients will have co-morbidities like learning difficulties, dyspraxia, Tourette’s, mood disorders, anxiety etc
How is ADHD diagnosed?
Clinical diagnosis - Can use “strengths and difficulties questionnaire” or the “Conners’ rating scale”. In adults, assessment can be aided by the Diagnostic Interview for ADHD in Adults (DIVA) questionnaire. Can also use DSM-5 criteria (under 16= 6 or more in each, 17+= 5 or more in each. Categories = inattention + hyperactivity & impulsivity)
How is ADHD managed?
10 week watch and wait, if symptoms persist then refer
Management will depend on age and severity
1. Parent ADHD support programme
2. Methylphenidate + CBT
What are the RF for GAD?
Female sex
Family history
Childhood abuse and neglect
Environmental stress (e.g. redundancy, divorce)
Emotional trauma
Substance abuse
What is the DSM-V criteria for GAD?
- Excessive anxiety and worrying (more days than not for six months or longer)
- The worry and anxiety is difficult to control
- Three of the following have been present (more days than not for six months):
Restlessness
Easily fatigued
Sleep disturbance
Irritability
Muscle tension
Trouble concentrating
In addition, the following must be present:
Symptoms cause significant distress and impair normal function
Symptoms or episode not caused by another condition of substance
Episode not better explained by other mental health illnesses
What are the differentials for anxiety?
Social phobia
Panic disorder
Obsessive-compulsive disorder
Post-traumatic stress disorder
Acute stress disorder
Thyroid/endocrine
AF
Pheochromocytoma
Alcohol and drugs
What tool is used to assess the severity of GAD?
GAD-7 is a self-reported questionnaire that can act as a screening tool and measure of severity for GAD.
What are the processes thought to drive the spiral of anxiety?
Avoidance, anxious rumination and attentional + cognitive biases are all linked to evolution
Low self worth and poor sleep also feed into it.
Avoidance - perpetuates anxiety because it makes it hard to unlearn your fear of stimulus
Ruminations - Keep thinking through catastrophic outcomes so may propogate anxiety
Attentional and cognitive bias - primes you to pay attention to threats which is useful in flight or fight but not in situations where you can’t escape your fear e.g. school
What is GAD?
Persistent “free-floating” anxiety (not restricted to/predominant in any specific circumstances), or excessive worry focused on multiple everyday events.
Common features of generalised anxiety disorder include:
Subjective experience of nervousness
Difficulty maintaining concentration
Muscular tension or motor restlessness
Sympathetic autonomic over-activity
Irritability
Sleep disturbance.
What are phobic anxiety disorders?
Abnormal state anxiety evoked only/predominantly by a specific external situation/object which is not currently dangerous. The key feature is the avoidance of that situation.
Types of phobic anxiety disorders include:
Agoraphobia (crowds, public places, leaving home ♀>♂)
Social phobia (associated with low self-esteem and fear of criticism. ♂=♀)
Specific phobias (e.g. claustrophobia, animal phobias, etc.)
Characteristic features include:
Anticipatory anxiety (about exposure to precipitant, and about anxiety itself)
Somatic symptoms (e.g. palpitations, sweating, trembling, dyspnoea, chest pain, dizziness, chills, hot flushes)
What is panic disorder?
Recurrent unpredictable episodes of severe acute anxiety, which are not restricted to particular stimuli or situations.
Characteristic features include:
A crescendo of anxiety, usually resulting in exit from the situation
Somatic symptoms (e.g. palpitations, sweating, trembling, dyspnoea, chest pain, dizziness, chills, hot flushes)
Secondary fear of dying/losing control (often related to the somatic symptoms)
How is GAD managed?
- Psychoeducation, sleep hygiene, and self-guided cognitive-based therapy (CBT)/ relaxation techniques.
- CBT - may use exposure therapy and applied relaxation.
- Pharmacological (equal 1st line with CBT). SSRI, SNRI or atypical antidepressant depending on side-effect profile.
Also, Busipirone (5HT1A agonist) is suitable for short term management (Delayed onset of action, diminished efficacy in previous benzo users, SE = dizziness, headache and nausea, minimal sedation)
B-blockers effective in patients with somatic anxiety symptoms
Low-dose antipsychotics or Pregabalin may also be of use
Which drug should be avoided in chronic anxiety?
Avoid benzodiazepines (e.g. diazepam) for chronic anxiety. because they have such an immediate effect, this group of drugs is highly addictive. Tolerance develops rapidly, so after a month or two of benzodiazepines, your patient will be back to the same level of anxiety but also addicted to benzodiazepines.
They can be used for transient causes of anxiety (ie. fear of flying) or in crisis only, maximum of 2 weeks prescription advised.
What is depression?
Depression is a mood (affective) disorder characterised by persistent low mood, low energy and loss of interest/enjoyment in everyday activities (anhedonia). It can be unipolar (first occurrence or recurrent) or bipolar (with occurrences of mania and depression).
What are the RF for depression?
Chronic conditions
History of depression or other mental health illness
FHx
Substance misuse
Female sex
Medication (e.g. corticosteroids)
Older age
Recent childbirth
Psychosocial issues (e.g. unemployment, homelessness)
Separated/Divorced
Grief
History of childhood abuse
History of head trauma
What is the DSM-V criteria for depression?
defined by DSM-V as the presence of five of the following symptoms, for at least two weeks, one of which should be low mood or loss of interest/pleasure:
Low mood
Loss of interest or pleasure
Significant weight change
Insomnia or hypersomnia (sleep disturbance)
Psychomotor agitation or retardation
Fatigue
Feelings of worthlessness
Diminished concentration
Recurrent thoughts of death or suicide
In addition, the following must be present:
Symptoms cause significant distress and impair normal function
Symptoms or episode not caused by another condition of substance
Episode no better explained by other mental health illnesses
No episodes of mania or hypomania
What are the 3 core symptoms of depression?
Low mood
Anhedonia: low interest or pleasure in most activities of the day
Lack of energy (anergia)
What are the other symptoms of depression other than the core 3?
Weight change: exclusion of intentional dieting
Disturbed sleep: insomnia or hypersomnia
Psychomotor retardation (slowed down actions) or psychomotor agitation (increased restlessness)
Reduced libido
Worthlessness or guilt feelings
Decreased concentration
Recurring thoughts of harm, death or suicide: nihilistic thoughts
What are the somatic symptoms of depression?
Anhedonia
Loss of emotional reactivity
Diurnal mood changes: mood often worse in the morning
Early morning wakening: typically 2-3 hours earlier than usual
Psychomotor retardation or psychomotor agitation
Appetite loss
Weight loss
What are the psychotic symptoms of depression?
if present, these are usually mood-congruent and may include:
Delusions: often revolving around guilt and personal inadequacy
Hallucinations: can be auditory, olfactory or visual
What are DDx for depression?
Substance/medication use
Bipolar affective disorder
Premenstrual dysphoric disorder
Bereavement
Anxiety disorders
Alcohol-use disorder
Physical health illness or organic illness differentials include:
- Hypothyroidism
- Cushing’s disease or syndrome
- Vitamin B12 deficiency
What are the Ix for depression?
Screening tool = PHQ-9
Risk assessment to self, others and from others
Exclude organic causes if indicated:
- Full blood count: anaemia
- Thyroid function test: hypothyroidism (elevated thyroid stimulating hormone)
- Vitamin B12: vitamin b12 deficiency
- Imaging and other investigations (e.g. a CT head) may be performed in patients with atypical features and signs indicative of an organic pathology
What is the short term management for mild depression?
First-line management should involve initiating primarily low-intensity psychosocial interventions.
Antidepressants should not be routinely offered unless that is the patient’s preference. Exceptional cases to consider starting on biological therapy (i.e. antidepressants) include:
Past history of moderate or severe depression
Presence of mild depression that has been present for at least 2 years
Presence of mild depressive symptoms after other interventions
What is the long term management of mild depression?
Risk assessment
Ongoing review: response to low-intensity psychosocial intervention, compliance and symptoms. An SSRI antidepressant should provide benefit within 4-6 weeks.
Measurement scales to assess response to treatment and quality of life
Relapse prevention plan
Assess for social support, and review previous issues flagged up during consultations
If taking antidepressant therapy review compliance, side effects and adjust doses if appropriate
What is the short term management of moderate or severe depression?
may include a combination of antidepressant therapy (biological treatment) and high-intensity psychosocial interventions.
Combination of individual CBT and an antidepressant (e.g. SSRI)
Individual CBT
Individual behavioural activation
Antidepressants (e.g. SSRI) alone
Individual problem-solving
Counselling
Short-term psychodynamic psychotherapy
Interpersonal psychotherapy
Guided self-help
Group exercise
In severe depression what additional treatments may be considered?
If presenting with psychotic symptoms, then treatment should be augmented with an antipsychotic (quetiapine or olanzapine).
Electroconvulsive therapy (ECT) should be considered in severe cases of depression where:
The patient has a strong preference for ECT: this usually applies when patients have responded to ECT well before
Rapid treatment of the patient is needed: cases of life-threatening depression where the patient is not eating or drinking
Multiple other treatments have been trialled unsuccessfully
Generally which antidepressant medications are offered as first line?
SSRIs like citalopram will be offered first line. Sertraline may be used in co-morbid patients as it has fewer drug-drug interactions
Fluoxetine is first line in kids
General rule is that antidepressants should be continued for 6 months minimum unless there are adverse effects. When stopping, they need to be tapered off.
Which medications need to be avoided in patients with high suicide risk or a history of overdose?
avoid certain antidepressants in patients with suicide risk or a history of overdose (e.g. tricyclics, venlafaxine).
What is bipolar disorder?
Bipolar disorder is a cyclical mood disorder that fluctuates between episodes of mania/hypomania and depression.
Bimodal incidence, peaks from 15-24 and 45-54. Same incidence in men and women. Likely to be comorbid with other mental health issues and increases risk of physical conditions such as CV disease.
What are the etiological factors of bipolar?
Genetic - Having a 1st degree relative with bipolar increases your risk of depression, bipolar and schizoaffective disorders. Heritability is around 60% in monozygotic twins and around 20% in dizygotic twins.
Environmental - nothing specific just the same predisposers of all mental health conditions. Negative life events can trigger an episode in someone with bipolar.
Neurobiological - Increased dopaminergic signalling, disturbance of the HPA axis leading to higher cortisol and corticosteroid use all linked to mania
What are some risk factors for bipolar?
Genetic factors
Prenatal exposure to Toxoplasma gondii (the parasite that causes toxoplasmosis)
Premature birth <32 weeks gestation
Childhood maltreatment
Postpartum period
Cannabis use
What are bipolar I and II?
In bipolar I, the person has experienced at least one episode of mania
In bipolar II, the person has experienced at least one episode of hypomania, but never an episode of mania. They must have also experienced at least one episode of major depression.
What are the clinical features of mania?
Elevated mood
Increased energy resulting in overactivity, pressure of speech, and a decreased need for sleep
Inability to maintain attention, often with marked distractibility
Self-esteem which is often inflated with grandiosity and increased confidence
Loss of normal social inhibitions
Mood congruent psychotic symptoms
The manic episode should last for at least seven days and have a significant negative functional effect on work and social activities
What are the clinical features of hypomania?
Persistent, mild elevation of mood
Increased energy and activity, usually with marked feelings of wellbeing
Increased sociability, talkativeness, over-familiarly, increased sexual energy and a decreased need for sleep
Irritability may be present
Absence of psychotic features
Should last for at least 4 days
What is cyclothmyia?
Refers to chronic mood disturbance with depression and hypomania symptoms that do not meet the criteria for a full episode
What are the DDx for bipolar?
- Mental health disorders: schizophrenia, unipolar depression, personality disorder or anxiety disorder.
- Substance misuse: cocaine, ecstasy or amphetamines
- ‘Organic’ causes: thyroid disorder, multiple sclerosis, Cushing’s, Addison’s, cerebrovascular disease, dementia, epilepsy, SLE, encephalitis.
- Iatrogenic causes: antidepressants, corticosteroids, levodopa or dopamine agonists.
What is the acute management for mania?
Trial of oral antipsychotics:
Haloperidol
Olanzapine
Quetiapine
Risperidone
If on antidepressant medication, this should be tapered off and discontinued.
Benzodiazepines may be used as an adjunct to manage symptoms of increased activity and allow for better sleep.
What is the management of depression in bipolar?
Antidepressants can induce mania or rapid cycling so different to the manangement in unipolar derpression.
Fluoxetine + olanzapine
Quetiapine alone
Olanzapine alone
Lamotrigine alone
After an acute episode of bipolar has passed, what is the long term management?
Mood stabilising medication such as lithium. If lithium is not effective, sodium valproate may be added but this is highly teratogenic.
Structured psychotherapy is also important.
What is OCD?
Obsessive compulsive disorder is characterised by the presence of obsessions and/or compulsions.
Obsessions: intrusive thoughts, urges and images that cause anxiety and distress.
Compulsions: repetitive behaviours that one feels compelled to perform, these may be observable or occur in the mind (e.g. repeating a phrase).
How can OCD present?
- intrusive unwanted anxiogenic thoughts
- patients typically recognise these are irrational thoughts
- repetitive behavioural or mental acts to neutralise anxiety caused by obsessions
- compulsions give brief relief and are self-enforcing
- higher frequency of compulsions related to treatment resistance
- concomitant schizotypal personality disorder and Tic disorder related to worse outcomes
Which disorders are related to OCD?
Body dysmorphic disorder (BDD)
Body-focused repetitive behaviour disorders (ie. trichotillomania, dermatillomania)
Hypochondriasis (health anxiety disorder)
Hoarding disorder
What questions can you ask when diagnosing someone with OCD?
Do you wash or clean a lot?
Do you check things a lot?
Is there any thought that keeps bothering you that you would like to get rid of, but cannot?
Do your daily activities take a long time to finish? Interference of over an hour a day
Are you concerned about putting things in a special order, or are you upset by mess?
Do these problems trouble you?
How is OCD managed?
Do risk assessment and screen for other MHx
Mild - refer for low-intensity CBT with Exposure and Response Prevention (ERP) is commonly offered.
Moderate - offer intensive CBT with ERP or an SSRI. Clomipramine may be used as second-line therapy.
Severe - refer for specialist input. Consider an SSRI (e.g escitalopram) combined with CBT in the interim. Clomipramine may be used as second-line therapy.
What is the most commonly used measure of OCD?
Yale Brown Obsessive Compulsive Scale
Should be used on patients about to start treatment for OCD and then every 6 months after that to track
What is PTSD?
A disorder that may develop following exposure to a stressful event or a situation of exceptionally threatening or catastrophic nature. It is thought to result from impaired memory consolidation of experiences too traumatic to be processed normally, which leads to a chronic hyperarousal of fear circuits.
What are RF for developing PTSD?
Traumatic events, DV, bullying, natural disaster, torture, terrorism, combat, traumatic brain injury, sudden death of loved one, sexual assault, multiple major stressors, lack of social support, history of substance abuse or mental health disorders
How does PTSD present?
HARD:
- Hyperarousal: persistently heightened perception of current threat (may include enhanced startle reaction)
- Avoidance of situations/activities reminiscent of the events, or of thoughts/memories of the events
- Re-experiencing the traumatic events (vivid intrusive memories, flashbacks, or nightmares).
- Distress: strong/overwhelming fear and physical sensations when re-experiencing
Also, impaired memory of event, anhedonia, detachment from others, irritable/outbursts, reckless behaviour, exaggerated startle response, depression and anxiety, substance misuse
What differentiates PTSD from an acute stress reaction?
ASR is usually less than a month after an event
How is PTSD diagnosed?
PTSD checklist DSM-V, there are military, civillian or specific ones
How is PTSD managed?
Mild/moderate = ACS active monitoring
Severe =
1) Trauma-focused CBT OR Eye-Movement Desensitization and Reprocessing (EMDR) therapy with SSRI OR venlafaxine (possible adjunctive antipsychotic)
Plus psychoeducation/sleep hygiene/ relaxation etc. as above.
What is personality disorder?
Personality disorder (PD) is an umbrella term that covers a number of variations of maladaptive personality traits that are lifelong, persistent, deeply ingrained maladaptive behaviours that characterises an individual, deviate markedly from culturally expected or accepted ‘normal’ range and have an onset in late childhood or early adolescence
What are the subtypes of personality disorders?
Cluster A - Odd/Eccentric
Cluster B - Dramatic/Emotional
Cluster C - Fearful/Anxious
Which personality disorders are in Class A?
Odd and Eccentric
- Paranoid
- Schizoid
- Schizotypal
How does paranoid personality disorder present?
Suspicious of others
Unforgiving
Spouse Infidelity
Perceives attack
Envious
Cold affect/Criticism poorly taken
Trust in others reduced
How does schizoid personality disorder present?
Characterised by a lack of interest in others, apathy and a lack emotional breadth.
They tend to have few friends and do not form relationships, preferring solitary activities.
Flattened affect, indifferent, low sex drive, little pleasure taken in activities
