psychiatry Flashcards
psych cards for MCCQE 1
DSM V criteria for Tourettes
A. Both multiple motor and one or more vocal tics have been present at some time during illness - not necessarily at the same time
B. The tics may wax and wane in frequency but have persistent for more than a year since first tic onset
C. Onset before 18 years
D. Disturbance is not attributable to to an organic cause (medication or medical condition)
what is echolalia
repeating phrases of others - a common symptom of tourettes
what is coprolalia
shouting of obscenities - can occur in tourettes
what is echopraxia
the repeating of gestures of others
what is palilalia
repetition of one’s own stated phrases
what is abulia
refers to an motivational state which can be seen in traumatic brain injury, post neurosurgery and in dementia
Tourettes treatment options
dopamine blockers, dopamine depletors, clonidine, clonazepam, DBS
post partum depression
10-15% general population
4 months to 1 year post partum
elements in mental status exam
General appearance Behaviour Speech Mood and affect Thought process/Form Thought content Perception Cognition Insight Judgement
what are clang associations
speech based on sound such as rhyming or punning
neologism
use of novel words or of existing words in a novel fashion
thought blocking
sudden cessation of flow of thought and speech
ideas of reference
similar to delusion of reference, but less fixed (the reality of the belief is questioned)
Persecutory delusion
belief that others are trying to
cause harm to you
Reference delusion:
interpreting publicly known
events/celebrities as having direct
reference to you
Erotomania delusion:
belief that another is in love
with you
Grandiose delusion:
belief that he or she has special
powers, talents or abilities
Religious delusion:
belief of receiving instructions/
powers from a higher being; of being a
higher being
Somatic delusion:
belief that you have a physical
disorder/defect
Nihilistic delusion:
belief that things do not exist; a
sense that everything is unreal
epidemiological risk factors to suicide
male 15-24 highest attempts over 65 more successful suicides native canadian and White widowed or divorced Alone / no children stressful life event access to firearms
psychological risk factors for suicide
■ mood disorders (15% lifetime risk in depression; higher in bipolar)
■ anxiety disorders (especially panic disorder)
■ schizophrenia (10-15% risk)
■ substance abuse (especially alcohol – 15% lifetime risk)
■ eating disorders (5% lifetime risk)
■ adjustment disorder
■ conduct disorder
■ personality disorders (borderline, antisocial)
management of low risk of suicide
not actively suicidal, with no plan or access to lethal means
■ discuss protective factors and supports in their life, remind them of what they live for, promote
survival skills that helped them through previous suicide attempts
■ make a safety plan that could include an agreement that they will:
◆ not harm themselves
◆ avoid alcohol, drugs, and situations that may trigger suicidal thoughts
◆ follow-up with you at a designated time
◆ contact a health care worker, call a crisis line, or go to an emergency department if they feel
unsafe or if their suicidal feelings return or intensify
management of high risk of suicide
(hospitalization needs to be strongly considered)
■ patients with a plan and intention to act on the plan, access to lethal means, recent social stressors,
and symptoms suggestive of a psychiatric disorder
■ do not leave patient alone; remove potentially dangerous objects from room
■ if patient refuses to be hospitalized, complete form for involuntary admission (Form 1)
diagnostic criteria for schizophrenia
DSM 5
A. two (or more) of the following, each present for a significant portion of time during a 1 mo 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 behaviour
5. negative symptoms (i.e. diminished emotional expression or avolition)
Good Prognostic Factors for schizophrenia
- Acute onset
- Shorter duration of prodrome
- Female gender
- Good cognitive functioning
- Good premorbid functioning
- No family history
- Presence of affective symptoms
- Absence of structural brain abnormalities
- Good response to drugs
- Good support system
Management of Schizophrenia
• biological / somatic
antipsychotics (haloperidol, risperidone, olanzipine,
paliperidone; clozapine if refractory); often regiments of IM q2-4 wk used in severe cases to ensure
compliance
■ adjunctive: ± mood stabilizers (for aggression/impulsiveness - lithium, valproate, carbamazepine) ±
anxiolytics ± ECT
■ treat for at least 1-2 years after the first episode, at least 5 years after multiple episodes (relapse
causes severe deterioration)
• psychosocial
■ psychotherapy (individual, family, group), supportive, CBT (see Table 14, PS41)
■ ACT (Assertive Community Treatment): mobile mental health teams that provide individualized
treatment in the community and help patients with medication adherence, basic living skills, social
support, job placements, resources
■ social skills training, employment programs, disability benefits
■ housing (group home, boarding home, transitional home)
Schizophreniform Disorder
acute onset of A,D,E criteria lasting 1 month but less than 6.
A. two (or more) of the following, each present for a significant portion of time during a 1 mo 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 behaviour
5. negative symptoms (i.e. diminished emotional expression or avolition)
D. rule out schizoaffective disorder and depressive or bipolar disorder with psychotic features 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. rule out other causes: GMC, substances (e.g. drug of abuse, medication)
Brief psychotic disorder
meets criteria A,D,E for schizophrenia but symptoms last longer than a day but less than a month
Schizoaffective Disorder criteria DSM 5
A. concurrent psychosis (criterion A of schizophrenia) and major mood episode - uninterrupted period of
illness
B. delusions or hallucinations for 2 or more wk in the absence of a major mood episode during the
lifetime duration of the illness
C. major mood episode symptoms are present for the majority of the total duration of the active and
residual periods of the illness
D. the disturbance is not attributable to the effects of a substance or another medical condition
• specifiers: bipolar type, depressive type, with catatonia, type of episode, severity
Delusional disorder
DSM 5
A. the presence of one (or more) delusions with a duration of 1 mo or longer
B. criterion A for schizophrenia has never been met
Note: hallucinations, if present, are not prominent and are related to the delusional theme
C. apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and
behaviour is not obviously bizarre or odd
D. if manic or major depressive episodes have occurred, these have been brief relative to the duration of
the delusional periods
E. the disturbance is not attributable to the physiological effects of a substance or another medical
condition and is not better explained by another mental disorder
• subtypes: erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified
• further specify: bizarre content, type of episode (e.g. first episode, multiple episode), severity
criteria for depression
MSIGECAPS at least 5: Mood: depressed Sleep: increased/decreased Interest: decreased Guilt Energy: decreased Concentration: decreased Appetite: increased/decreased Psychomotor: agitation/retardation Suicidal ideation
criteria for mania
GST PAID at least 3? Grandiosity Sleep (decreased need) Talkative Pleasurable activities, Painful consequences Activity Ideas (flight of) Distractible
hypomania
• criterion of a manic episode is met, but duration is ≥4 d
• episode associated with an uncharacteristic change in functioning that is observable by others but not severe
enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization
• absence of psychotic features (if these are present the episode is, by definition, manic)
treatment of depression
lifestyle: increased aerobic exercise, mindfulness based stress reduction, zinc supplementation,
medications: SSRI’s SNRI’s
postpartum blues
• transient period of mild depression, mood instability, anxiety, decreased concentration; considered to
be normal changes in response to fluctuating hormonal levels, the stress of childbirth, and the increased
responsibilities of motherhood
• occurs in 50-80% of mothers; begins 2-4 d postpartum, usually lasts 48 h, can last up to 10 d
• does not require psychotropic medication
• usually mild or absent: feelings of inadequacy, anhedonia, thoughts of harming baby, suicidal thoughts
Post partum depression
- MDD with onset during pregnancy or within 4 wk following delivery
- typically lasts 2-6 mo; residual symptoms can last up to 1 yr
- may present with psychosis (rare, 0.2%), usually associated with mania, but also with MDE
- severe symptoms include extreme disinterest in baby, suicidal and infanticidal ideation
Risk factors for post partum depression
Risk Factors
• previous history of a mood disorder (postpartum or otherwise), family history of mood disorder
• psychosocial factors: stressful life events, unemployment, marital conflict, lack of social support,
unwanted pregnancy, colicky or sick infant
treatment of post partum depression
- psychotherapy (CBT or IPT)
- short-term safety of maternal SSRIs for breastfeeding infants established; long-term effects unknown
- if depression severe or psychotic symptoms present, consider ECT
prognosis postpartum depression
Prognosis
• impact on child development: increased risk of cognitive delay, insecure attachment, behavioural disorders
• treatment of mother improves outcome for child at 8 mo through increased mother-child interaction
Indicators of sexual abuse
allegations by the child allegations by an adult injuries to genitalia or anus genital infection recurrent urinary tract infections unexplained behavioural changes psychological disorders
indications for long term treatment of depression
2 depressive episodes within 5 years
three prior episodes
long term treatment should be continued for at least 3-5 years
subsyndromal depressions
doesn’t quite meet the DSM V criteria but has higher associations with major depression, physical disability, medical illness and high use of medical services
treating depression in patients who have had MI
Depression increases risk of IHD in Men but not women
Sertraline improves mood with lowest amount of cardiovascular side effects
if no effect 50% will respond to a change in SSRI
ADHD
Attention deficit hyperactivity disorder
A syndrome of inattention, hyperactivity, and impulsivity.
classified as a developmental disorder
DSM 5 criteria ADHD
9 signs and symptoms of inattention
6 of hyperactivity
3 of impulsivity
must occur in at least 2 situations and manifest before the age of 12
DSM 5 inattention symptoms of ADHD
does not pay attention to details
has difficulty sustaining attention at school
does not seem to listen when spoken to
does not follow through on instructions or finish tasks
has difficulty organising tasks and activities
avoids, dislikes or is reluctant to engage in tasks that require mental effort
often lose things
easily distracted
easily forgetful
DSM 5 hyperactivity criteria for ADHD
often fidgets with hands or feet or squirms often leaves seat in class or elsewhere often runs about or climbs excessively has difficulty playing quietly often on the go as if driven by a motor often talk excessively
DSM 5 criteria for impulsivity of ADHD
often blurts out answers before questions are finished
has difficulty awaiting their turn
interrupts or intrudes on others
negative symptoms of schizophrenia
blunting of affect
poverty of speech
anhedonia - diminished capacity to experience pleasure
Asociality - lack of interest in relationships with others
DSM V criteria for panic attack
chest pain or discomfort chills or heat sensation derealisation or depersonalization fear of dying fear of losing control or going crazy feeling dizzy, light headed, unsteady or faint feelings of choking nausea or abdominal distress palpitation or pounding heart or accelerated heart rate paresthesias sensations of Shortness of breath or smothering sweating trembling or shaking
treatments for panic attacks
MEDICAL: antidepressants Benzodiazepines work faster but high risk of dependance PSYCHOTHERAPY: cognitive behaviour therapy exposure therapy supportive psychotherapy
major depressive disorder
characterised by 1 or more episodes of depression lasting for at least 2 weeks without a past history of manic or hypomanic episodes
selective mutism
affects children entering school age and characterised by the persistent inability to speak in certain situations such as at school. But will happily talk at home.
