Psychiatry Flashcards
criteria for generalized anxiety disorder
excessive anxiety and worry occurring more days than not for at least 6 months
the individual finds it difficult to control the worry
1 or more out of 6 (TCHERS)
WATCHERS Worry Anxiety Tension in muscles Concentration difficulty Hyperarousal (or irritability) Energy loss Restlessness Sleep disturbance
Neuroleptic malignant syndrome
FEVER F- Fever E- Encephalopathy V- Vital sign instability E- Elevated WBC/CPK R- Rigidity (lead pipe rigidity)
Serotonin syndrome
HARMED H- hyperthermia, hyperreflexia A- Autonomic instability (Increased HR, RR and decreased BP) R- Restlessness M- Myoclonus E- Encephalopathy (decreased LOC) D- Diaphoresis *myoclonus is key
Major Depression
SIGECAPS
5 or more criteria out of 9 with depressed mood or loss of interest/pleasure for 2 week period
in children/adolescents mood can be irritable rather than depressed *
S- sleep I- interest G- guilt E- energy C- concentration A- appetite P- psychomotor changes (agitation or retardation) S- suicidal thoughts
Manic episode
DIGFAST
elevated mood with 3/7 one week or irritable mood with 4 of 7 one week
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
D- distractibility I- indiscretion (excessive involvement in pleasures) G- grandiosity F- flight of ideas A- activity increase S- sleep deficit (decreased need) T- talkativeness (pressured speech)
Post traumatic stress disorder criteria
Presence of one or more after event occurred
TRAUMA
T- traumatic event
R- re-experience (memories, nightmares, flashbacks)
A- avoidance
U- unable to function
M- month or more of symptoms
A- arousal increased (insomnia, hyper-vigilance)
Panic Attack
>or =4 of PANNICCCSSS Palpitations Abdominal distress Numbness, Nausea Intense fear of death Choking, chills, chest pain Sweating, shaking, shortness of breath
Panic disorder- recurrent unexpected panic attacks.
Tourette disorder
Multiple motor tics and at least one vocal tic
onset before 18
>12 months
not due to drugs or other medical condition
Tx: Haldol, pimozide (only 2 FDA approved)
alpha agonists (clonidine), risperidone
ADHD Inattention
6 or more of the symptoms that have persisted for at least 6 months, inappropriate for developmental level
present in 2 or more settings
age<12
impairing functioning
a. fails to give close attention to details or makes careless mistakes
b. difficulty sustaining attention
c. does not listen when spoken to directly
d. does not follow through on instructions and fails to finish school work, chores, or duties in the workplace
e. difficulty organizing tasks and activities
f. avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort
close attention/mistakes, sustaining attention, not listen, not follow through, poor organization, sustained mental effort, lose things, easily distracted, forgetful
ADHD hyperactivity
6 or more of the symptoms for at least 6 months
present in 2 or more settings, inappropriate for developmental level
age <12
impairing functioning
a. fidgets with or taps hands or feet
b. leaves seat in situations when remaining seated is expected
c. runs or climbs in situations where it is inappropriate
d. often unable to play or engage in leisure activities quietly
e. often “on the go” acting as if “driven by a motor”
f. talks excessively
g. blurts out an answer before a question has been completed
h. difficulty waiting his or her turn
i. often interrupts or intrudes on others
fidgets, leaves seat, runs/climbs, no quiet play, on the go/motor, talks excessively, blurts, not wait turn, interrupts/intrudes
side effects of SSRI’s
7 S's s- stomach upset s- sexual dysfunction s- serotonin syndrome s- sleep difficulties (insomnia and headaches) s- suicidal thoughts s- stress (Agitation, anxiety) s- size increase (weight gain)
stomach upset, headaches, dizziness, activation (Especially in younger children)
what is one risk associated with chronic administration of haloperidol
tardive dyskinesia
what are some side effects of atypical antipsychotics
weight gain metabolic syndrome diabetes extrapyramidal symptoms hyperlipidemia hyperprolactinemia hematologic adverse effects- leukopenia, neutropenia seizures hepatotoxicity NMS
what are some examples of atypical antipsychotics
risperidone
aripiprazole
olanzapine
quetiapine
what is an example of a typical antipsychotic
haloperidol
what are extrapyramidal symptoms
dystonia
rigidity
tremor
akathisia
what conditions are comorbid with depression?
anxiety * disruptive behavior disorders * substance use disorders * ADHD Eating disorder
*= most common Comorbidity conditons
what is required to diagnose Bipolar I disorder?
criteria must be met for at least 1 manic episode
lifetime risk of suicide in people with bipolar disorder is estimated to be at least 15 times that of the general population
what is required to diagnose Bipolar II disorder?
criteria for at least 1 hypomanic episode and at least 1 major depressive episode
hypomanic episode is shorter duration (4 days) and less severe (less functional impairment)
what is the treatment for bipolar disorder in kids?
lithium- only mood stabilizer approved in kids
atypical antipsychotics have good response and considered 1st line
Criteria for ODD
at least 4 symptoms
lasting at least 6 months
angry/irritable mood:
- often loses temper
- often touchy or easily annoyed
- often angry or resentful
Argumentative/Defiant Behavior
- argues with authority figures
- defies or refuses to comply with requests from authority figures
- deliberately annoys others
- blames others for his or her mistakes or misbehavior
Vindictiveness
8. has been spiteful or vindictive at least twice in the past 6 months
Criteria for conduct disorder
3 of the following 14 criteria in the past 12 months
- bullies, threatens or intimates others
- initiates physical fights
- used a weapon that can cause serious physical harm to others
- physically cruel to people
- physically cruel to animals
- has stolen while confronting a victim
- has forced someone into sexual activity
- deliberately engaged in fire setting with the intention of causing serious damage
- deliberately destroyed others property
- broken into someone else house, building or car
- lies to obtain goods or favors or to avoid obligations
- has stolen items
- stays out at night despite parental inhibitions
- has run away from home overnight at least twice
- is often truant from school
what often precedes the development of conduct disorder?
ODD
what condition is often comorbid with ODD
ADHD
what conditions are often comorbid with CD
ADHD ODD anxiety depression learning disorder substance related disorder
what is the main treatment for patients with personality disorders?
psychotherapy
what is the most common method used to complete suicide?
firearms
suicide attempts are more common in females but completed suicide is more common in males
what treatment combination has the best response rate for anxiety symptoms?
CBT + SSRIs
what is the criteria for brief psychotic disorder?
presence of 1 (or more) of the following symptoms for <1 month
- delusions
- hallucinations
- disorganized speech
- grossly disorganized or catatonic behavior
duration at least 1 day but less than 1 month, with eventual return to pre morbid level of functioning
what is schizophreniform disorder
2 or more of the following for 1-6 months
- delusions
- hallucinations
- disorganized speech
- grossly disorganized or catatonic behavior
- negative symptoms (diminished emotional expression or avolition)
the episode lasts at least 1 month but less than 6 months
what is the criteria for schizophrenia
2 or more of the following for AT LEAST 6 months
- delusions
- hallucinations
- disorganized speech
- grossly disorganized or catatonic behavior
- negative symptoms (diminished emotional expression or avolition)
typically develops between the late teens and mis 30s
what is the treatment for schizophrenia?
1st or 2nd generation antipsychotics
what are some common obsessions?
contamination thoughts of harming loved ones/oneself washing/cleaning compulsions checking straightening
OCD can be associated with what type of infection?
Group A Strep
PANDAS
pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection
what is PANDAS
sudden onset or exacerbation of tic symptoms following a recent streptococcal infection
what is the treatment for OCD
CBT +/- SSRI
CBT is the first-line treatment for children with mild to moderate OCD symptoms; SSRI’s are used when CBT is insufficient to address OCD symptoms, or when CBT is not accessible or the symptoms are severe.
what is the definition of obsessions
Noelle’s- persistent thoughts that are distressing
recurrent and persistent thoughts, urges or images that are unwanted and that in most individuals cause marked anxiety or distress
the individual attempts to ignore or suppress such thoughts, urges or images or to neutralize them with some other thought or action (ie by performing a compulsion)
what is the definition of a compulsion
repetitive behaviours (hand washing ordering, checking) or mental acts (praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly
what is the diagnostic criteria for OCD
presence of obsessions, compulsions or both that are time consuming (>1h/day) or cause clinically significant distress/impairment
half experience remission by early adulthood
what are some co-morbidities with OCD
>50% HAVE A COMORBIDITY ADHD separation anxiety disorder specific phobias agroaphobia multiple anxiety disorders tics
what is the name of the rating scale for OCD
Children’s Yale-Brown Obsessive Compulsive scale
what is the rating scale for CD
Conners parent/teacher rating scale
what is the rating scale for ADHD
SNAP IV, Conners
What is the rating scale for anxiety?
MASC
multidimensional anxiety scale for children
what are 3 options for treatment for ADHD
- psychoeducation and support (for all)
- behavioral management (for most)
3, medications (for some)
what are the medications recommended for treating ADHD
Stimulants: methylphenidate, amphetamine
atomoxetine- norepinephrine uptake inhibitor (mono therapy)
alpha 2 agonists- clonidine, guanfacine (mono therapy or adjunct to stimulant)
atomoxetine is approved for what age group
age >6
takes weeks to months to see a response but will have a continuous response throughout the day
what are the 2 main side effects of atomoxetine
sedation
stomach upset
small increased risk of suicide related events!
others: decreased appetite weight loss insomnia irritable mood dizziness increased HR and BP dry mouth
why do you have to alter the dose of atomoxetine if a patient is on fluoxetine
CYP2D6 substrate
fluoxetine is a 2D6 inhibitor and will therefore increase the levels of atomoxetine
what are the 3 main side effects associated with alpha 2 agonists?
sedation
hypotension
bradycardia
others: dizziness rebound tachycardia and hypertension headache dry mouth irritability and other emotional changes modest increase in QT (guanfacine)
should patients avoid taking guanfacine with a high fat meal?
yes!! because it increases its absorption considerably
how is guanfacine metabolized?
by CYP3A4
- inform patients of drug and food interactions (ex: grapefruit)
why do you have to taper a2 agonists gradually?
due to risk of
rebound tachycardia
hypertension
arrhythmias
what conditions are comorbid with ADHD
anxiety OCD Depression tic disorders learning disorders substance use disorders * almost 70% of children with ADHD had at least one comorbid condition
do stimulate cause exacerbation or new onset of tics?
on AVERAGE stimulants do not cause exacerbation or new onset of tics but they can do so in certain individuals
what psychosocial intervention is specific for conduct disorder?
multi systemic therapy
ODD often precedes what 3 conditions
CD
substance use disorder
severely delinquent behavior
what percentage of children will no longer meet the criteria for ODD after 3 years
2/3
most children with ODD do not go on to develop CD
youth with conduct disorder may go on to develop what personality disorder in adulthood
antisocial personality disorder
what percentage of youth with CD will experience improvement
> 50%
what are 3 risk factors for worse outcomes associated with CD
early are of onset
increased severity
increased pervasiveness
what is the first line treatment for children and adolescents with disruptive/aggressive behavior?
psychosocial interventions
when disruptive/aggressive behavior occurs with ADHD what should be used to treat?
medication for ADHD should be used first
what medication is supported for treating disruptive/aggressive behavior?
risperidone
what guidelines are used for a patient on an antipsychotic medication
CAMESA Guidelines
Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children
what are 3 treatment options for anxiety?
- psychoeducation and support (for all)
- psychotherapy (for most)- primarily CBT
- medication (for some)- primarily SSRIs
what is the basic model for CBT
Feelings
thoughts
behaviours (relaxation/exposure)
way to address feelings is by modifying dysfunctional thoughts
what is the CBT program for anxiety
Coping Cat
what type of psychotherapy is recommended for PTSD
Trauma focused CBT
exposure to memories of the trauma to get desensitized to the memories
what is the most effective psychotherapeutic approach in the treatment of pediatric OCD
exposure and response prevention
what are 3 treatment options for OCD
- psychoeducation and support (for all)
- psychotherapy (for most)
CBT with emphasis on exposure and response prevention (ERP) - medication (for some)- primarily SSRIs
up to what age have antidepressants been associated with an increased risk of suicide-related events
age 24
what is the risk of later bipolar disorder in children with MDD
20-40%
cautious when treating with antidepressants, especially if family history of bipolar disorder
what are some risk factors for suicide in children and adolescents?
older age male sex MDD substance abuse impulsivity/aggression history of suicide attempts presence of suicidal plan/intent stressful life events exposure to abuse/violence access to lethal means (ie firearms) family history of suicide
Name 4 treatment approaches for depression
- Risk assessment and safety planning (for all)
- psychoeducation and support (for all)
- psychotherapy (for most)- primarily CBT and IPT-A
- medication (for some)- primarily SSRIs but most evidence for fluoxetine
what is IPT-A
focus on >/= 1 of the following interpersonal areas: grief role transition role disputes interpersonal deficits
SSRIs are most efficacious for what condition? least efficacious?
most- anxiety
least- MDD (most evidence for fluoxetine)
escitalopram is approved for what ages and condition?
> 12 yo with MDD
fluoxetine is approved for what ages with MDD
> 8 yo
what is cannabinoid hyperemesis syndrome?
The cannabinoid hyperemesis syndrome is characterized by recurrent episodes of vomiting associated with abdominal pain and nausea; patients often find relief by taking a hot shower or bath. Cannabis use has been chronic (>1-2 yr) and frequent (multiple times per week). Treatment includes stopping marijuana use, antiemetics, and topical capsaicin.
what is cannabis withdrawal syndrome?
CWS is defined by experiencing at least two of five psychological symptoms—irritability, anxiety, depressed mood, sleep disturbance, appetite changes
AADIS
and at least one of six physical symptoms—abdominal pain, shaking, fever, chills, headache, diaphoresis—after cessation of heavy cannabis use.
ACDFHS
Heavy cannabis use is defined as daily or near daily use for at least a few months.
Withdrawal symptoms commonly occur 24 h to 72 h after last use and persist for 1 to 2 weeks. Sleep disturbance is often reported for up to 1 month.
Name 3 conditions associated with Tourettes
- OCD
- ODD
- ADHD
- LD
- ASD
- Anxiety
- Depression
Pt treated with prozac for 2 years. What is the chance of recurrence of depression once she is taken off this medication? 10% 20% 40% 75% 90%
40%
CUD
CUD is defined as a problematic pattern of cannabis use leading to clinically significant impairment in areas of function or distress within a 12-month period
Usually, adolescents experience the following functional impairments: reduced academic performance, truancy, reduced participation and interest in extracurricular activities, withdrawal from their usual peer groups and conflict with family.
