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FRCPC > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What is prognosis for trichotollomania?

A

Most self resolve

>6 months needs behavioural treatment +/- SSRI

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2
Q

DSM V Criteria for Somatic Symptom Disorder

A

A. Somatic symptoms:

One or more somatic symptoms that result in disruption of daily life

B. Excessive thoughts, feelings and behaviors related to these somatic symptoms or associated health concerns: At least two of the following are needed to meet this criterion:

1. High level of heath-related anxiety
2. Disproportionate and persistant concerns about the medical seriousness of one's symptoms
3. Excessive time and energy devoted to these symptoms or health concerns

C. Chronicity: the state of being somatic last > 6 months

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3
Q

DSM V Criteria for Functional Neurological Symptoms Disorder (used to be conversion disorder)

A

A. The patient has ≥1 symptoms of altered voluntary motor or sensory function.

B. Clinical findings provide evidence of incompatibility between the symptom and recognised neurological or medical conditions.

C. The symptom or deficit is not better explained by another medical or mental disorder.

D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

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4
Q

List 3 steps in the management of somatiform disorder

A

1) COMPLETE MEDICAL AND PSYCHIATRIC ASSESSMENTS
- Obtain histories, examinations, and studies
- Elicit risk factors for pediatric somatization
- Do these concurrently!

2) CONVENE AN INFORMING CONFERENCE WITH THE FAMILY
- Convey integrated medical and psychiatric findings to family
- Acknowledge the patient’s suffering and family’s concerns and emphasize that the symptoms are not feigned or under voluntary control
- Help reframe understanding of symptoms into a developmental biopsychosocial formulation

3) IMPLEMENT TREATMENT INTERVENTIONS IN BOTH MEDICAL AND PSYCHIATRIC DOMAINS
- Set up ongoing pediatric follow-up appointments
- Physical therapy may be added depending on symptoms
- Consider the following psychiatric interventions: CBT, pschyotherapy,

4) REGULAR FOLLOW UP
5) REHABILITATION WITH FOCUS ON RETURN TO NORMAL ADAPTIVE FUNCTIONING

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5
Q

DSM 5 criteria for Major Depression Disorder

A

At least FIVE depressive symptoms for > two weeks
One of the symptoms has to be dysphoria/anhedonia: (SIGECAPS)
●Depressed or irritable mood (dysphoria)
●Diminished interest or pleasure in almost all activities (anhedonia)
●Change in appetite or weight
●Insomnia or hypersomnia
●Psychomotor agitation or retardation
●Fatigue or loss of energy
●Feelings of worthlessness or guilt
●Impaired thinking or concentration, indecisiveness
●Suicidal ideation or behavior

Must cause significant distress/psychosocial impairment

Not the direct result of a substance or general medical condition

Bereavement does not exclude the diagnosis of a major depressive episode

A prior history of mania/hypomania indicates the diagnosis of bipolar depression

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6
Q

What is the likelihood of recurrence of depression on medications (past MCQ)?

A

50% relapse (40% recur in 2 yrs, 70% in 5 yrs)

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7
Q

Who is more likely to complete suicides, males or females?

A

MALES (4x more likely)

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8
Q

List 4 risk factors for suicide (past SAQ)

A

Greatest risk factor for suicide attempt=previous suicide attempt
Psychiatric illness (depression, conduct disorder)
Substance abuse
Sexual orientation/recent stressor
History of Px/Sx abuse
FHx of suicide

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9
Q

Components of suicide risk assessment

A
  • Ask about previous attempts
  • Ask about intent, plan, note
  • Assess mental status (?altered by depression, anxiety, substance, psychosis)
  • Assess supervision
  • Assess access to harmful material (firearms, medications, alcohol, drugs)
  • Make safety plan/contract
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10
Q

List 5 ways to keep a suicidal teen safe who is being discharged home before re-evaluation (past SAQ)

A
  1. Family to stay with the patient continuously
  2. Restrict access to all lethal means of suicide (firearms, medications, sharp objects)
  3. The acute crises that precipitated the event must be addressed and attempts made to resolve it.
  4. Warn about dangerous disinhibiting effects of alcohol/drugs
  5. Return to the emergency department if patients decompensate
  6. Have her sign a safety contract about what to do if she feels unsafe/suicidal
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11
Q

DSM V for Bipolar I disorder

A

Bipolar I disorder→ At least one manic episode, often alternating or concurrent with at least one major depressive episode

Mania is defined as:

Abnormally and persistently:
●Elevated, expansive, or irritable mood
●Increased energy or goal directed activity
AND
For >1 week (or any duration if hospitalization is necessary), nearly every day, for most of the day, at least three (if elated mood predominates) or four (if irritable mood predominates) of:
●Inflated self-esteem or grandiosity
●Decreased need for sleep (eg, feels rested after three or four hours of sleep)
●More talkative than usual or pressured speech
●Racing thoughts or flight of ideas (abrupt changes from one topic to another that are based upon understandable associations)
●Distractibility
●Increase in goal-directed activity or psychomotor agitation
●Excessive involvement in pleasurable activities that have a high potential for painful consequences (eg, buying sprees or sexual indiscretions)

Must Impair psychosocial functioning, necessitate hospitalization, or accompanied by psychotic features(delusions/hallucinations).

Not result of a substance or general medical condition

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12
Q

List 2 options for treatment of bipolar

A

Lithium

Valproate

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13
Q

How do you distinguish adjustment disorder from MDD?

A

Key in differentiating from depression=an identifiable stressor within three months of symptoms, usually resolves by 6 months, does not meet criteria for MDD

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14
Q

List 5 medical conditions that can mimic anxiety disorders

A 
Hyperthyroidism
Hypoglycemia
Pheochromocytoma
Delirium
Brain tumour
Asthma (panic attack)
Lead poisoning
Substances/meds-Caffeine, steroids, SSRIs (initiation), antipsychotics, diet pills, antihistamines, cold medicines
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15
Q

DSM V criteria for Generalized Anxiety Disorder

A

A. Excessive anxiety/worry (apprehensive expectation) about several events/activities, on more days than not, for ≥ 6 months
B. Difficult to control the worry
C. Anxiety/worry associated w/ ≥1/6 of (≥3/6 in adults):
CRIMES
1. Concentration difficulties or mind going blank
2. Restlessness
3. Irritability
4. Muscle tension
5. Easily fatigued
6. Sleep disturbance (difficulty falling/staying asleep, or restless/unsatisfying sleep)

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16
Q

DSM V for Panic attacks

A 
≥4/13 symptoms rapidly develop and peak within 10 min:
o	Sweating
o	Trembling/shaking
o	Unsteadiness, light-headedness
o	Depersonalization/derealization
o	Excessive HR (palpitations, tachycardia)
o	Nausea
o	Tingling/paraesthesias
o	SOB
o	Fear of dying
o	Fear of losing control or going crazy
o	Chills or hot flashes
o	Chest pain
o	Choking
17
Q

DSM V for Panic disorder

A
  • Recurrent unexpected panic attacks
  • At least 1 attack followed by ≥ 1 mo of either:
    (a) persistent fear of another panic attack or its consequences (e.g. heart attack, going craxy)
    (b) significant maladaptive ∆ behaviour related to attacks - which may include agoraphobia/avoidance
18
Q

DSM V criteria for Separation anxiety disorder

A

-Persistent and excessive anxiety beyond what’s expected for developmental level, lasting ≥4 weeks, related to separation from attachment figure, with ≥3 of recurrent/excessive:

  1. Distress re: separation
  2. Worry about losing/harm to attachment figures
  3. Worry about experiencing an event that causes separation from attachment figure (eg, getting lost, kidnapped,…)
  4. Reluctance/refusal to go out (e.g. to school, out of home) due to fear of separation
  5. Reluctance about being alone or without attachment figures
  6. Refusal to sleep out, or to go to sleep without being near attachment figure
  7. Nightmares involving theme of separation
  8. Complaints of physical symptoms (eg, HA, stomachaches, N/Vx) when separation occurs or is anticipated

Causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning

19
Q

List 4 steps in management of school refusal (past SAQ)

A
  • Counsel family that exam is normal, no serious cause, importance of going to school
  • Parents to calmly send child to school
  • Provide rewards/praise for completed days of school
  • Speak to school about refusal behavior and being supportive about anxiety w/ return to school
  • Parent management training and family therapy
  • If continues-referral to child psychiatrist for consideration of SSRIs
20
Q

Treatment for social anxiety

A

Social effectiveness therapy for children (SET-C), alone or with SSRIs

β-blockers used specifically for performance anxiety

21
Q

DSM V for PTSD (past SAQ)

A
  1. Life-threatening event (personal or indirect exposure) that posed harm to child or caregiver
  2. Symptoms from all 4 clusters , with persistence ≥1 mo:
    i) Intrusion:
    - Persistent re-experiencing of trauma through intrusive recollections
    - Nightmares
    - Dissociative reactions

ii) Avoidance :
- Persistent effortful avoidance of: related thoughts/feelings or related external reminders

iii) Persistent alterations in cognition and mood that began/worsened after trauma
- Amnesia
- Negative beliefs/expectations
- Distorted blame (self/others) for trauma
- ++ diminished interest in activities
- Constricted affect

iv) Alterations in arousal and reactivity:
- Irritable or aggressive behavio
- Hypervigilance
- Exaggerated startle response, -Sleep disturbance

22
Q

DSM V criteria for OCD

A

Presence of obsessions, compulsions, or both:

Obsessions must have BOTH:

  1. Recurrent and persistent thoughts, urges, or impulses that are intrusive/unwanted, and cause marked anxiety/distress
  2. Pt attempts to ignore/suppress these thoughts or to neutralize them with other thought or action (i.e. by performing a compulsion)

Compulsions must be BOTH

  1. Repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words) that Pt feels driven to perform in response to obsession or according to rules that must be applied rigidly
  2. Acts aimed at preventing/reducing anxiety/distress, or preventing dreaded event/situation - however in reality, acts not connected w/ what they are designed to neutralize/prevent, or are clearly excessive

Obsessions or compulsions are time-consuming (e.g., take > 1 hour per day) or cause clinically significant distress/impairment in functioning

23
Q

Treatment for OCD

A

SSRIs+CBT

24
Q

What is the most important aspect of history in differentiating selective mutism from communication disorder, neurologic disorder, or pervasive developmental disorder?

A

Normal language use in at least one situation

25
Q

What is the most important feature needed for diagnosis of OCD? (Past SAQ)

A

Obsessions or compulsions are time-consuming (e.g., take > 1 hour per day) or cause clinically significant distress/impairment in functioning

26
Q

What complication should you think about in a patient with trichotollomania and signs of bowel obstruction?

A

Trichobezoar (GROSS)

27
Q

DSM V for ODD

A

A. Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months with 4+ Sx. from any of the following categories and exhibited in interaction with 1+ individual not a sibling:

Angry/Irritable Mood

  1. Often loses temper.
  2. Is often touchy or easily annoyed.
  3. Is often angry and resentful.

Argumentative/Defiant Behavior
4. Often argues with authority figures or for children and adolescents with adults.
5. Often actively defies or refuses to comply with requests from authority figures or rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or misbehaviour.
Vindictiveness
8. Has been spiteful or vindictive 2+ within past 6 months.

B. Disturbance in behavior associated with distress in individual or others in immediate context or it impacts negatively on social, educational, or other important areas of functioning.

C. Behaviors do not occur exclusively in the course of a psychotic, substance use, depressive, or Bipolar Disorder. Also, criteria are not met for disruptive, mood dysregulation disorder.

28
Q

List 5 parenting recommendations for treatment of ODD (past SAQ)

A

Parent Management Training:

  1. Supervise, provide good behavioural models, set consistent rules
  2. Allow child to have increased autonomy in small decisions
  3. Use praise and approval liberally but not excessively; motivators as necessary
  4. Withdrawal or delay of privileges are acceptable
  5. Consequences and time-outs are also still acceptable
29
Q

List 4 behaviours suggestive of conduct disorder (past SAQ)

A

(1) Aggression to people or animals (i.e. killing the cat)
(2) Deceitfulness or theft (i.e. Shoplifting)
(3) Destruction of Property (i.e. Fire setting)
(4) Violation of rules (i.e. Truant from school or running away from home repeatedly)

30
Q

Treatment of conduct disorder

A

‘Multisystemic Therapy’
-Treatment involves extensive contact between the therapist and the multiple life contexts of the patient, especially the family, school, and peer group, with the goal of developing competencies and rewarding adaptive behavior

31
Q

List 2 comorbidities of ODD (past SAQ)

A

ADHD

Depression

32
Q

What is the difference between brief psychotic disorder, schizophreniform and schizophrenia?

A
  • Brief Psychotic disorder - < 1mo
  • Schizophreniform – 1-6 mos
  • Schizophrenia - >6 mos
33
Q

Differential diagnosis of psychosis

A

-Psychotic diosrder (schizophrenia, brief psychotic disorder, schizophreniform)
-Mood disorder with psychotic features
-Manic episode with psychotic features
-Substance-induced
-Medical conditions:
Brain tumour, TBI, CNS infection, temporal lobe epilepsy, thyroid disease, uremia, metabolic disorder (UCDs, porphyria, Wilson’s), electrolyte disturbance

34
Q

DSM V for schizophrenia

A

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

  1. Delusions
  2. Hallucinations
  3. Disorganized speech
  4. Grossly disorganized or catatonic behavior
  5. Negative symptoms

B.Social/occupational dysfunction: Failure to achieve expected level of interpersonal, academic, or occupational achievement).

C. Duration: 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

D. Schizoaffective and mood disorder exclusion

E. Substance/general medical condition exclusion

F. Relationship to a pervasive developmental disorder: If there is a history of autistic disorder or another pervasive developmental disorder, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

35
Q

List 5 side effects of atypical antipsychotics

A
  • Extrapyramidal symptoms (e.g., restlessness and dyskinesias)
  • Weight gain
  • Metabolic syndrome and DM
  • Hyperprolactinemia
  • Hematologic adverse effects (e.g., leukopenia or neutropenia)
  • Seizures
  • Hepatotoxicity
  • Neuroleptic malignant syndrome
  • Prolonged QTc Interval
36
Q

Management of delirium

A

Environmental:

  • Well-lit room – preferably private, near nursing station
  • Minimize excessive stimulation
  • Sensory aids
  • Try to restore normal sleep/wake cycle
  • Lights on during the day; sufficient nighttime illumination
  • Familiar objects – photos, toys, people
  • Re-orient – use clock, calender

Support, reassure patient, family (& team)

Constant observation due to safety risk →risk of self-harm, aggression, falls, wandering

Restraints may be necessary →Chemical better than physical restraints

37
Q

List 3 serious side effects of risperidone (past SAQ)

A
  1. Prolong QT
  2. Agranulocytosis
  3. Tardive dyskinesia
38
Q

Define Munchausen by proxy and describe 3 typical features (past SAQ)

A

Definition: Where a parent or caregiver falsely presents their child for medical attention, either by fabricating a false medical history or by inducing illness

3 features:

  1. Parent is operating with the need to fulfill a sick role by proxy, not for external rewards
  2. Illness typically improves with separation of parent
  3. The illness is often recurrent, unusual, or prolonged and does not respond to treatment
39
Q

List 5 steps in transition to adult care (past SAQ)

A
  1. Start discussing transition early on (as early as 10-12 yrs)
  2. Collaboration with the family physician who will provide ongoing care
  3. Educate the teen about their condition and provide resources
  4. See teen without parents for part of the appointment to give an opportunity to learn how to present a history, ask and answer questions, and advocate for themselves
  5. Refer to peer support groups for teen and parents

FRCPC (27 decks)

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