Psychiatry Flashcards
1
Q
Treatment of OCD?
A
CBT
2
Q
Treatment of severe conduct disorder?
A
Multisystemic therapy.
MST recognises that in order to best deal with a youth in trouble, treatment must target the many “systems” that impact the youth, including the family, school environment, friendships, and peer pressures.
3
Q
Which condition is most commonly co-morbid with ADHD in primary school children?
A
Specific learning disability - around 50%
Conduct disorder - 30%
Depression - 30%
Generalised anxiety disorder - 20-30%
Tic disorder - not usually associated but can be a side effect of medication.
4
Q
Early onset (before age 10) conduct disorder most strongly predicts which adult mental health problem?
A
Antisocial personality disorder in 30-50%
5
Q
What are the side effects of methylphenidate?
A
- Decreased appetite 80%
- Sleep disturbance 3-85%
- Weight loss 10-15%
- Transient motor tics 15 to 30%
- Tachycardia, hypertension nervousness, irritability, moodiness, deceleration of linear growth may occur, but adult height is not affected.
6
Q
What is the mechanism of action of methylphenidate?
A
Inhibition of noradrenaline and dopamine reuptake
7
Q
What are the most common mental health disroders by age 15?
A
- Anxiety (10%)
- Mood disorders (7%)
- Conduct/oppositional disorders (8-10%)
- ADHD (3-4%)
- Substance abuse (5-7%)
- > 95% not seen by mental health services
8
Q
Risks for developing mental health issues?
A
- Long term physical conditions
- Physical disability
- Epilepsy
- Parents with mental illness and addiction
9
Q
What are the multiaxial diagnosis steps?
A
- Axis I - primary psych
- Axis II - personality, cognitive impairment
- Axis III - medical conditions
- Axis IV - acute and chronic stressors, strengths/resilience
- Axis V - global assessment of function
10
Q
Risk factors for attachment disorder
A
- History of prolonged separation from primary caregivers, multiple placements
- Neglect or FTT
- Abuse
- Parental psychopathology
- Parental substance abuse
11
Q
What are the two main domains for diagnosis of ASD?
A
- Persistent deficits in social communication and social interaction across contexts (social-emotional reciprocity, nonverbal communication, developing and maintaining relationships)
- Restricted, repetitive patterns of behaviour, interests, or activities (stereotyped or repetitive speech, motor movements, routines, excessive resistance to change, restricted and fixated interests, hypo or hyper-reactivity to sensory input)
- Must be present in early childhood
- Must limit and impair everyday functioning
12
Q
Describe ASD incidence, recurrence rate, associated syndromes
A
- 1%, 4:1 M>F
- Average age diagnosis 6-7 years
- Increasing awareness and change in classification causing rising incidence
- Siblings 2-8% chance autism
- Associated with fragile X and tuberous sclerosis, raised serum lead
13
Q
What are the comorbidities with ASD?
A
- Intellectual disability 75% have IQ less than 70
- Epilepsy 7-14%
- ADHD 50%
- Anxiety disorders 50% (girls often present later with anxiety, eating disorders, when teenager)
14
Q
What is the most commonly used assessment for ASD?
A
ADOS-G
15
Q
What is the treatment of ASD?
A
- Early SLT
- Applied behavioural analysis
- Sensory management
- Early start Denver model
- Limited role for meds: fluoxetine if excessive anxiety, low-dose risperidone and haloperidol for aggression and sterotypies
16
Q
What are the outcomes of ASD?
A
- 25% develop seizures
- 10% adolescents lose skills/speech
- Best predictors of outcome are IQ and speech by 5 uears (50% have good social outcome)
17
Q
What is the definition of ADHD?
A
- Inattention, hyperactivity, impulsivity
- Symptoms before age 7
- Two or more settings
- Causes dysfunction
- Subtypes: inattentive, hyperactive, or combined
18
Q
What are the comorbidities for ADHD?
A
- ODD, CD 50%
- Depression 6%
- Anxiety 33%
- Learning problems up to 90%
19
Q
Risk factors for developing ADHD?
A
- Heritability 80%
- Fragile X, velocardiofacial, tuberous sclerosis
- Antenatal ETOH, possibly smoking
- Extreme adversity, poor mother-child relationship
20
Q
What is the most commonly used assesment for ADHD?
A
Connors
21
Q
What are the treatments for ADHD?
A
- Psycho-eduction
- Stimulants: methylphenidate, dexamphetamine (speed up frontal cortex to help regulate child’s behaviour)
- Family focused - parent management training
- School based interventions
- Comorbid disorders may require other treatments
- As get older, usually don’t need meds: caffeine, self-regulation, routines, diaries
22
Q
Side effects of stimulants?
A
- Loss of appetite, weight loss (0-5kg)
- Abdo pain, headache
- Sleep disturbance
- Irritability, crying, mood changes
- Decreased growth - normal end height. Take medication breaks eg over holidays. Reduction 1-2.5cm.
- Tachycardia, inc BP
- Can worsen or unmask tics or steroetyped behaviour, but don’t cause them. Avoid high doses in Tourettes
- Rare: thrombocytopenia, SJS
23
Q
What is the mechanism of action of amphetamine?
A
Increases dopamine release, blocks reuptake of dopamine
24
Q
What is the usual dose and duration of methylphenidate?
A
- 0.3-0.5mg/kg/dose
- Short acting (3-4 hours)
25
Children with ADHD and conduct disorder have a high risk of developing..?
Antisocial personality disorder (+ suicide attempts, more social isolation, lower self esteem)
26
What is the definition of oppositional defiant disorder?
- >6m of losing temper, argues with adults, refuses to comply with requests/rules, annoys people, blames others, easily annoyed, angry/resentful, spiteful/vindictive
27
Children with ODD are at risk of developing?
Conduct disorder, depression
28
Management of ODD?
- Parent management training
- Incredible years, triple P, PCIT
- Key: increasing positive interaction with child, planned ignoring of unwanted behaivours, setting limits, modelling behaviours, time-out 1 minute/year of age
29
What is conduct disorder?
- Cruelty to people and animals
- Destruction of property
- Deceitfulness or theft
- Serious violations of rules
- Present >12m
- Childhood (<10) or adolescent onset (>10)
- Repetitive and persistent pattern
30
What are the differences between childhood and adolescent conduct disorder?
- Childhood: <10, more likely male and aggressive, likely have ODD, ADH, likely develop antisocial personality disorder
- Adolescent: >10, F=M, less aggression, less likely to develop ASPD
31
What is the prevalence of conduct disorder?
3-5%, one of the commonest disorders, increased prevalence after age 12
32
What is the treatment for conduct disorder?
- Intervene as early as possible
- Multi-systemic therapy, functional family therapy, treatment foster care, parents management training
- Treat comorbidities (ADHD, depression, substance abuse, anxiety)
- Meds rarely: stimulants if ADHD (but risk misuse), low dose risperidone, haloperidol, lithium in aggression - might be used to get control/calm while applying behavioural techniques
33
40% of patients with Tourettes are diagnosed with what by the time of adulthood?
OCD
34
Mangement of Tourettes
- CBT - habit reversal therapy
- haloperidol, risperidone, clonidine
- if have ADHD then methylphenidate + clonidine +/- antipsychotic
35
Treatment of dystonic reactions?
Benztropine
36
How do typical antipsychotics affect prolactin, and what does high prolacitn cause?
- Typical antipsychotics block dopamine inhibition of the pituitary, therefore causing a prolactin rise (normally dopamin inhibits prolactin)
- Males: gynaecomastia, females: galactorrhea, ammenorrhea
- Note: Opiates can stimulate prolactin release.
37
Which antipsychotic medications have the highest and lowest risk of weight gain?
- Highest: clozapine, olanzapine, quetiapine
| - Lowest: risperidone
38
What is the treatment for panic attacks caused by separation anxiety disorder?
- 1st line: CBT, relaxation, graduated exposure
| - 2nd line: SSRI eg fluoxetine
39
What is the treatment of generalised anxiety disorder?
- CBT
- Family work
- Medication if severe e.g. fluoxetine. Do not use tricyclics e.g. amitryptilline as risk in overdose
40
What are the components of CBT?
- Cognitive restructuring
- Avitivty scheduling
- Problem solving
- Relaxation training
- If anxiety: identification of stimuli, exposure, reducing avoidance
41
PTSD vs. acute stress disorder?
PTDS needs symptoms weeks to >3m. ASD has shorter timeframe
42
What are the criteria for PTSD?
- Experienced or witnesses event involving actual or threatened death or serious injury
- Re-experiencing - flashbacks, dreams
- Avoidance - places, people, thoughts
- Hyper-arousal - hyper-vigilance, poor concentration, poor sleep
43
What is the treatment of PTSD?
- Re-establish sense of safety and control
- Trauma-focused CBT
- No RCT evidence for SSRI, clonidine, B-blocker, but can be used short term
- EMDR = eye movement desensitisation relaxation therapy, not as much evidence as CBT
44
What are the criteria for OCD?
- Obsessions: ideas, images, impulses. Cause marked anxiety and distress and take significant time
- Compulsions: reptitive behaviours, goal of which is to reduce symptoms of anxiety
45
What are the comorbidities of OCD?
- ADHD
- Depression
- Tics
- ODD
- Developmental
- Other anxiety
46
What is the treatment of OCD?
- CBT (exposure and response prevention)
| - Meds: SSRIs, often require higher doses (c.f. lower doses in anxiety)
47
Describe social phobia
- Marked and persistent fear of social or performance situations, leading to avoidance e.g. school refusal
- Can lead to substance abuse when older
- Tx: CBT, SSRIs
48
Describe panic disorder
- Recurrent panic attacks
- Worry about implications/ consequences or significant behavioural change
- Affects function at school
- Tx: controlled breathing, relaxation, CBT, SSRIs
49
What are the criteria for Tourette's disorder?
- Multiple motor tics and one or more vocal tics
- Multiple per day, >1 year
- Onset before age 18
50
What are the types of tics?
- Simple - e.g. repetitive muscle twitch
- Complex - e.g. touching, throwing, retracing steps
- Vocal - grunts, yelps, clearing throat
- Coprolalia - obscenities (10%)
51
Medication for chronic pain/somatiform disorders
- Low dose amitryptilline 10-20mg nocte
- Neuropathic pain - gabapentin
- Clonidine dermal patches
- Avoid opiates
52
What is conversion disorder?
- Symptoms or deficits affecting voluntary motor or sensory function that suggest a neuro or other medical condition
- Not intentional
- Causes distress and impairment
- Not limited to pain
- Motor impairment most common presentation of conversion disorder in children
53
Treatment of enuresis?
- After age 7
- Behavioural/alarm - 70% success, 30% relapse with bed alarm
- DDAP - 24% remission but high relapse
- Address social issues
54
Discuss avoidant/restrictive food intake disorder (AFRID)
- Previously known as selective eating disorder
- Inability to eat certain foods (e.g. colour, taste, texture,
sometimes entire food groups – i.e. fruit or vegetables)
resulting in inability to maintain weight, or growth faltering
- Dependence on supplements or enteral feeding
- Typical onset in childhood
- Does not occur in context of anorexia nervosa or bulimia
nervosa, and no other medical explanation
55
Discuss borderline personality disorder
- Borderline personality disorder is defined as a pervasive of instability of interpersonal relationships, self image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts.
