Psychiatry Flashcards
Which psych med causes sexual dysfunction:
Antidepressant (SSRI)
Risperidone with frequent syncopal episode. What is the cause?
Prolonged QT
List 3 AE of risperidone:
- **Metabolic syn (wt gain, DM, dyslipidemia)
- **Hyperprolactinemia (gynecomastia, sexual dysfunction)
- Anticholinergic (dry mouth, constipation)
- **Cardio (QTc)
- ** Agranulocytosis (neutropenia, leukopenia)
- Sedation
- ** Hepatotoxicity
Recurrence of depression once off:
50%
btwn 30-50% within first year and 50-70% in next 8yrs
Teen has change in behaviour. Drop in grades. Not interested in sport. Divorced 2 years ago. Picks on sister. Likely: - adjustment - substance - MDD - ADHD
MDD (mood dx)
Kid w/ in change w/ behaviour.
Psychology assessment, TSH or Tox?
Tox screen
If occasional smoke but no other drug use in hx- then think psych.
List DDX for Depression:
Medical
- **Neuro
- **Endo (DM, thyroid)
- ** Eating Dx
- Infection (**Mono)
- CA
- Anemia
- ** HIV
- Chronic pain
Meds
- Narcotics
- Chemo
- Beta blocker
- Steroid**
- ** Substance Abuse
Psychiatry
- **Anxiety
- ADHD
- ODD
- CD
- Adjustment Disorder
List the DSM criteria for Major Depressive Episode:
“SIGECAPS”
Depressed or anhedonia x 2 weeks + 4 of:
- sad
- no interested
- guilt or worthless
- energy low
- low concentration
- appetite/wt (up or down)
- psychomotor agitation or retardation
- insomnia or hypersomnia
- death or SI
+ cause distress or f’n issue
+ not due to substance or medical condition
How do you treat depression:
- psychoeducation
- CBT or interpersonal therapy
- Antidepressant if severe
Girl referred for possible ADHD. Agitated, irtaible, only sleep 4 hour a night. Mom bipolar. Likely:
- drug
- bipolar
- ADHD
Bipolar
HIGHLY HERITABLE
F irritable, low sleep, provocative clothing. FHX suicide. Likely tx:
- TCA
- Paroxetine
- Lithium
- Fluoxetine
Lithium or antipsychotic (risperidone, aripiprazole, olanzapine)
OR VPA or carbamazepine.
T or F: Medication is the only treatment of manic stage of bipolar.
True
What med do you use for bipolar depression?
Lamotrigine (mono therapy or adjunct)
Manic Episode DSM5 Criteria?
“DIGFAST”
Elation or irritable x 1 week \+ min. 3-4 symptoms D- distractibility I- Irresponsible (risk behaviour) G- grandiosity (high SE) F- flight of ideas A- activity goal directed or agitated Sleep down Talkative
+ cause impairment
+ not due to substance of medical condition
Versus hypomanic: last 4d instead
What is bipolar 1 versus 2 disorder?
Bipolar 1= Manic
Bipolar II= hypomanic + 1 major depressive
T or F: Homosexuality is NOT a RF for increased suicide?
False.
List RF for suicide in teens:
> Non Modifiable: *Male *Teens *Aboriginal *LGBQT History of Abuse FHX Suicide *Pre-exsting psych (esp depression) Chronic pain
>Modifiable *hopelessness/ (-) self attribution loss of reality severe agitation lack social support
What is the suicide pattern with M and F?
F= ideation M= completion
T or F: safety contract help avoid suicide.
False.
Safety planning helps
What can you recommend for suicidal teen in remote community over next two days.
- use coping skills
- (+) focus on leverage (Something to live for)
- recognize personal warning signs
- name people to support
- ID close friend or adult to resolve conflict
- know mental health to contact (helpline, local ED)
- ensure safe environment (fire arm, locked meds)
Attempting suicide teen. Troubled violent thoughts. Thoughts to hurt others. Likely psych dx?
Schizophrenia
(+ symptoms like hallucination, psychotic thought to harm others versus “I’m bad” psychosis in depression, high risk suicide (20%))
How does anxiety present in kids at school?
Non specific symptom (intermittent abdo pain, daily h/a in healthy pt, chest feel tight in morn)
What is the most common psychiatric disorder of childhood?
Anxiety Disorders
List the diagnostic criteria for GAD:
Excessive anxiety + worry most days x 6 month.
AND hard to control
AND associated w/ 1 of: BE SKIM
- Blank mind, [hard]
- Easy fatigue
- Sleep disturb (insomnia, wake from sleep)
- Keyed up or on edge
- Irritable
- Muscle tension
And cause impairment. And not due to drug. And not due to med condition.
What are keys to separation anxiety versus social anxiety.
Separation: worry about self or caregiver (avoid school, nightmare)
Social: diffuse nature + 1 other complaint
Separation Anxiety Disorder DSM 5 Criteria:
Name 3…
Developmentally inappropriate + excessive anxiety re: separate with min. 3 of x 4 week:
- ++ distress if separated
- excessive worry about event that could lead to separation
- refusal to go to school
- fear to be alone
- refusal to sleep without attachment near by
- nightmare about separation
- physical (h/a, abdo pain, N/V)
T or F: separation anxiety commonly present with somatic symptom like stomachaches, h/a to avoid leaving home. School refusal common
True.
3/4 show school avoidance.
What is the most common childhood anxiety disorder?
Separation anxiety
5%
What is separation anxiety associated with:
Tics
Panic disorder
Best Tx for separation anxiety?
CBT +/- SSRI
7 y.o. w/ separation anxiety refusing to go to school? What to do?
- Send back asap
- Send back to school gradual
- SSRI and back to school
Send back to school immediately
7 y.o. w/ separation anxiety. Refuse to go to school. Four things in management:
- ** Psychoeducation (ID signs of fright)
- ***Psychotherapy= CBT, coping, (+) reinforcement)
- **Immediate return to school (graded exposure doesn’t work)
- ***Pharma (SSRI if severe)
- Screen for comorbid (tic, panic, anxiety)
- R/O medical (thyroid, meds, substance abuse)
- Referral to psych
Panic Attack Disorder:
“Students Fear the 3 C’s”
Abrupt intense fear within 1 mon. and include min. 4 of:
Sweating Trembling/shake Unsteady/Dizzy Derealization Excess HR Nausea Tingling/Paresthesia SOB/smothering Fear of Death
Choking (feeling)
Chills/Flush
Chest Pain
Panic Disorder:
Recurrent panic attack
followed by 1 mon of:
- worry about more
- change behaviour related to attack (avoid unfamiliar situation)
Not due to psych or med dx
What helps with panic attacks:
- CBT
- SSRI
- Short term benzo
Teen. Violent thoughts overwhelm him. Frequent and not hurt anyone yet but fears will. Likely dx:
- behav issue
- OCD
- schizo
- antisocial
OCD
schizophrenia usually lack insight into dx
Antisocial min. 18 y.o.
6 y.o. with 2 week new onset OCD. What infectious agent we worry about?
Controversial= Group A Strep
= PANDAS
Tx:
- If (+)= Abx (penicillin)
- Behavioural therapy
- SSRI for OCD +/- clonidine for tics
***Unproven theory= routine lab GAS, ASOT, long term Abx, IVIG NOT recommended.
OCD DSM5 Criteria:
Obsession and/or compulsion
+ Time consuming/distress
+ Not due to substance
+ not due to Psych dx
Common comorbidities with OCD:
Tic
LD or DD
Depression
How to treat OCD
CBT (including desensitization) +/- SSRI
Tourette Criteria
2 motor + 1 vocal
x 1 year
< 18 y.o.
Tx: Clonidine
Tourette comorbidies
ADHD
OCD
LD
Give two traits of “obsession” in OCD Criteria
- **recurrent + persistent thoughts, urge, image
- **intrusive and unwanted
- cause **distress
- try to **neutralize (compulsion) or ignore
Given two traits of “Compulsions” in OCD criteria
- **Repetitive behave or mental act
- **To respond to obsession
- Goal to reduce anxiety but **not logically connected to obsession
- **Time consuming
Which is true about trichotillomania:
- assoc. w/ OCD
- self-limiting
- rare
Associated with OCD
Trichotillomania = visible hair loss due to recurrent pull - common cause of alopecia - usually teen - associated w/ OCD in older kids - irregular area of incomplete hair loss; often crown - behavioural -> SSRI (fluoxetine) - often remit
List 4 traits of PTSD:
TTRAUMA
Traumatic event= Exposed to actual or life threatening dead, injury, sexual violence.
- (-) Thought/ feeling of trauma
(amnesia, self-image, blame) - Re-experiences (intrusive thought, nightmare, flashback)
- Arousal (Hyperarousal- irritable, aggression, self-destructive)
- Unable to Function
- Month (min.)
- Avoidance
(of trauma related stimuli)
5 y.o. with single mom. Hyperactive, hoarding food, not remorseful for inappropriate behaviour. No contact w/ mom but runs and hugs you. Likely dx?
- ADHD
- Autism
- Attachment Disorder
Attachment Disorder
What is diecenphalic syndrome?
Severe FTT or emaciation
DESPITE norm/ or ++ appetite
Preserved Ht.
Association w/ hypothal neoplasm
What are the DSM5 ADHD criteria
Symptom prior to 12 y.o.
@ 2 settings
W/ functional impairment
6 symp x 6 month
Inattention:
- *lack attn/ careless mistake
- can’t sustain attain
- *no listening
- d.n. follow through
- *poor organization
- *avoid task if need effort
- *lose imp things
- *easily distracted
- *forgetful
H/I:
- *fidget
- *leaves seat
- run/climbs
- can’t play quietly
- *“on the go”
- talks +++
- *blurt answer
- *can’t wait turn
- interrupt other
What are 4 things you must investigate for ADHD
- Symptoms
> Report Cards
> SNAP scales (parents + teacher) - Hx and P/E to R/O medical dx and consider BW (thyroid, lead level, CBC anemia)
- Vision and Hearing
- Psycho educational testing (LD)
- +/- OT evaluation for sensory impairments
- if concerns for genetics (Fragile X)
T or F: ADHD is highly heritable.
True.
60-80%
State two RF for ADHD:
Male
BW < 1500g
In utero smoke
FHX
List DDX for ADHD
Med/Neuro
- Thyroid
- Hearing or vision deficit
- Auditory or visual processing disorder
- Absence sz
- Migraine H/a
- OSA
- Lead poisoning
Psychosocial
- poor parenting
- LD/ Intellectual disability
- Mood disorder (depression)
- Bipolar dx (OCD)
- ASD
- Substance Abuse
- child abuse or neglect
- *Dx Associated
- Fragile X
- FASD
- Tourette
- Attachment Dx
What are common co-existing dx with ADHD:
- Learning Dx
- ODD
- CD
- Depression
- Anxiety
List ADHD stimulant AE:
- h/a
- reduced appetite
- delayed sleep phase
- wt loss
- tachycardia
- HTN
- “rebound effect”
- psychotic (e.g. halluincation) effect
When is straterra particularly helpful:
ADHD + tic or anxiety or resistance or high AE to stimulants
Name two meds in dextroamphetamine and methylphenidate group.
Dextroamphetamine: = DAV - Dexedrine - Adderall - Vyvanse
Methylphenidate = RBC - Ritalin - Biphentin - Concerta
Name two non stimulant medication for ADHD:
> Atomoxetine (Straterra)
- (+): tics, anxiety, AE from stimulant
(-) may increase SI
> Guanfacine (Intuniv)
- (+): tics, aggression
- (-): somnolence, sedation
- rebound tachy HR and BP if stop abruptly
Contraindication to Stimulants:
- symptomatic cardiac dx
- mod/severe HTN
- hyperthyroidism
- fhx long QT
T or F: you must do routine ECG prior to stimulant
FALSE.
Unless hx of palpitation, pre-syncope, or syncope, or strong fhx cardiac dx.
7 y.o. with normal IQ. Can’t read out-loud and doesn’t understand material but can learn when read to. Likely dx:
- ADHD
- Expressive aphasia
- Global delay
- Reading Disorder
Reading disorder
- expressive aphasia = oral and can’t understand when read to
Global delay= < 5 y.o., developmental delay + IQ issue
ADHD= not skill performance but LEARNING
List 3 RF for learning disability:
- IUGR
- HIE
- FAS
- Meningitis
- Traumatic brain injury
Math LD called
Dyscalculia
Written expression disorder called
Dysgraphia
Reading disorder called
Dyslexia
T or F: in LD IQ is fine.
True.
How can you tell ADHD versus LD
ADHD= issue performing academic skill NOT learning it.
How do you treat LD
- demystify (highlight strength, educate)
- accommodate
- remediate skill
- curriculum modify
List three things if loss of language skills:
< 3 y.o.
= Autism Spectrum Disorder
= Landau-Kleffner syn
> 3 y.o.
= Sz
How many kids with initial speech delay “catch up” by 3?
50%
T or F: isolated expressive speech delay more common in F.
False.
MALE more common.
T or F: early language disorder strongly related to reading disorder.
True (50%)
4 y.o. M with trouble expressing lang. Receptive fine. Development fine. At risk for:
- DD
- Reading difficulty
- ASD
- ADHD
Reading difficulty
10 y.o. steal, kills pet, lights fire. Dx?
Conduct disorder
Two treatment modality for ODD
- Anger management for youth
- Parent and family skills(Triple P = (+) parenting program)
- Medications:
> stimulants
> risperidone
List 4 behaviours in Conduct disorder
- Aggression to ppl or animal
- Destruction of property
- Deceitful or theft
- Serious violation of rules
List ODD DSM 5 criteria:
min. 6 mon
4 of following:
> angry (lose temper, annoyed easily, resentful)
defiant (argue, won’t comply w/ rule, annoy, blame others)
vindictive (x 2 within last 6 mo.)
How can you tell ODD versus CD
ODD = NO PHYSICAL aggression
List Conduct disorder DSM5 criteria.
Min. 3 of x 12 month and 1 for 6 mo.:
“TV AD”
- Theft/ deceitfulness
- Violation of rules (run away, stay out)
- Aggression (people and animal)
- Destruction of property (fire setting, damage property)
17 y.o. teen with persistent issue with (-) evaluation, fear of social situation. Likely?
- avoidant PD
- social phobia
- depression
Avoidant personality disorder
*feel inadequate, avoid work that could be criticized, *hypersensitive to (-) eval, *social inhibition w/ new relationships
T or F: FHX of tics would support dx of Tourette’s in pt with facial tics.
True. Usually (+) FHX.
List 3 things on Chorea ddx:
- *Genetic (rare juvenile Huntington)
- Rare structural (vascular chorea in stroke or mass)
- Parainfectious and AI (*Sydenham Chorea, *SLE)
- Infectious (HIV)
- metabolic or Toxic (acute porphyria, Na)
List the most common acquired chorea
Sydenham chorea
- neuro manifestation due to rheumatic fever (GAS)
- long term Abx for rheumatic heart dx
- if chorea impairing= VPA
- resolve on own within 6-9 mo.
What are the hallmark of Sydenham chorea:
Chorea
+ Emotional Lability
+ Hypotonia
List for things on ddx for teen with weird statements and personality change.
> Medical
- Brain tumour
- Head trauma
- antiNMDA
- Low BG
- high thyroid
- adrenal dysfunction
- Wilson’s
- IEM
- Seizures
> Drugs
- steroid, stimulant
- hallucinogen, LSD
> Mood Disorder
- depression w/ psychotic features
> Psychotic Disorder
List the psychotic disorder and how to tell the diff
- Brief psychotic (<1 mo.)
- Delusional Dx (1 mo.; nothing odd)
- Schizo phreniform (< 6 mo.)
- Schizophrenia (6 mo. x 2 symptoms) (2 of- delusion, halluincation, disorganized speech and behav, (-) symp)
- Schizoaffective (mood + symp but ALSO delusion/ halluincation for min. 2 wk w/out mood)
List 4 non -psychiatric dx for psychosis/delirium:
DIMS (extended)
> Drugs
- withdrawal: alcohol, benzo
- substance use
- steroids AE
- heavy metal (lead)
> Infection
- encephalitis
- meningitis
> Metabolic
- acute: BG, lyte
- low B12
- thyroid
- adrenal HTN crisis
> Structural/ Sz/ Syncope
- trauma: injury, bleed
- brain tumour
- sz disorder
What is the difference between sleep terror and nightmares:
Nightmare
- child to young adult
- REM
- last 1/3 of night
- no autonomic or confusion
Sleep terror:
- preschool
- FHX (+)
- slow wave sleep (early in)
- agitation w/ comforting
- amnesia
- educate
- sched awakening 30 min. prior to expected episode
5 things to tell boy to improve sleep hygiene
- increase physical activity in day but not within 2h of bed
- quiet, dark, comfortable
- consistent wake and sleep time
- avoid screen
- read until fatigued
Divorcing parents. Best for kids?
- joint custody asap
- see both parent even if fighting
- parents settle differences and not fight in front of kids
Settle differences and not fight in front of kids.
T or F: best predictor of child’s response is post-separation parental conflict and depression rather than custody issue.
True.
List key 3 factors for child morbidity after family going through divorce.
- Degree of inter parental conflict
- Quality of parenting (love + discipline)
- Parent-child interaction (supportive, communicate, low conflict)
List 3 protective factors for child is parents divorcing
- quality authoritative parenting
- healthy parent-child relationship
- protection from conflict
- psychologically well child
- household stability
- economic stability
T or F: best adjusted kids after divorce have one parent.
False.
Best if 2 psychologically healthy parents who minimize conflict and have sibling and other who are support network.
What is adjustment disorder
Emotional or behav symp within 3 month of stressor that are:
- distress > than what is expected
and/or cause significant impairment
List 3 reasons you can breach confidentiality
- Self Risk (form)
- Risk to other (police report)
- Risk to other kids (CYPT)
- Reportable infection (public health)
Depression RF (increases with):
- FHX depression
- Hx of lang disorder, ADHD
- (-) life events
- Family conflict
Poor prognostic factors for mood dx:
- long duration or severe episodes
- psychotic features
- EtOH/ substance use
- anxiety dx
- > 1 previous episode
- poor premorbid functioning
Indication for hospitalization if mood dx:
- threat to self/ others
- severe symptom without support
- failed output management
- significant co-morbidities needing intervention
