Psychiatry Flashcards
Treatment of OCD?
CBT
Treatment of severe conduct disorder?
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.
Which condition is most commonly co-morbid with ADHD in primary school children?
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.
Early onset (before age 10) conduct disorder most strongly predicts which adult mental health problem?
Antisocial personality disorder in 30-50%
What are the side effects of methylphenidate?
- 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.
What is the mechanism of action of methylphenidate?
Inhibition of noradrenaline and dopamine reuptake
What are the most common mental health disroders by age 15?
- Anxiety (10%)
- Mood disorders (7%)
- Conduct/oppositional disorders (8-10%)
- ADHD (3-4%)
- Substance abuse (5-7%)
- > 95% not seen by mental health services
Risks for developing mental health issues?
- Long term physical conditions
- Physical disability
- Epilepsy
- Parents with mental illness and addiction
What are the multiaxial diagnosis steps?
- 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
Risk factors for attachment disorder
- History of prolonged separation from primary caregivers, multiple placements
- Neglect or FTT
- Abuse
- Parental psychopathology
- Parental substance abuse
What are the two main domains for diagnosis of ASD?
- 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
Describe ASD incidence, recurrence rate, associated syndromes
- 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
What are the comorbidities with ASD?
- 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)
What is the most commonly used assessment for ASD?
ADOS-G
What is the treatment of ASD?
- 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
What are the outcomes of ASD?
- 25% develop seizures
- 10% adolescents lose skills/speech
- Best predictors of outcome are IQ and speech by 5 uears (50% have good social outcome)
What is the definition of ADHD?
- Inattention, hyperactivity, impulsivity
- Symptoms before age 7
- Two or more settings
- Causes dysfunction
- Subtypes: inattentive, hyperactive, or combined
What are the comorbidities for ADHD?
- ODD, CD 50%
- Depression 6%
- Anxiety 33%
- Learning problems up to 90%
Risk factors for developing ADHD?
- Heritability 80%
- Fragile X, velocardiofacial, tuberous sclerosis
- Antenatal ETOH, possibly smoking
- Extreme adversity, poor mother-child relationship
What is the most commonly used assesment for ADHD?
Connors
What are the treatments for ADHD?
- 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
Side effects of stimulants?
- 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
What is the mechanism of action of amphetamine?
Increases dopamine release, blocks reuptake of dopamine
What is the usual dose and duration of methylphenidate?
- 0.3-0.5mg/kg/dose
- Short acting (3-4 hours)
Children with ADHD and conduct disorder have a high risk of developing..?
Antisocial personality disorder (+ suicide attempts, more social isolation, lower self esteem)
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
Children with ODD are at risk of developing?
Conduct disorder, depression
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
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
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
What is the prevalence of conduct disorder?
3-5%, one of the commonest disorders, increased prevalence after age 12
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
40% of patients with Tourettes are diagnosed with what by the time of adulthood?
OCD
Mangement of Tourettes
- CBT - habit reversal therapy
- haloperidol, risperidone, clonidine
- if have ADHD then methylphenidate + clonidine +/- antipsychotic
Treatment of dystonic reactions?
Benztropine
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.
Which antipsychotic medications have the highest and lowest risk of weight gain?
- Highest: clozapine, olanzapine, quetiapine
- Lowest: risperidone
What is the treatment for panic attacks caused by separation anxiety disorder?
- 1st line: CBT, relaxation, graduated exposure
- 2nd line: SSRI eg fluoxetine
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
What are the components of CBT?
- Cognitive restructuring
- Avitivty scheduling
- Problem solving
- Relaxation training
- If anxiety: identification of stimuli, exposure, reducing avoidance
PTSD vs. acute stress disorder?
PTDS needs symptoms weeks to >3m. ASD has shorter timeframe
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
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
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
What are the comorbidities of OCD?
- ADHD
- Depression
- Tics
- ODD
- Developmental
- Other anxiety
What is the treatment of OCD?
- CBT (exposure and response prevention)
- Meds: SSRIs, often require higher doses (c.f. lower doses in anxiety)
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
Describe panic disorder
- Recurrent panic attacks
- Worry about implications/ consequences or significant behavioural change
- Affects function at school
- Tx: controlled breathing, relaxation, CBT, SSRIs
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
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%)
Medication for chronic pain/somatiform disorders
- Low dose amitryptilline 10-20mg nocte
- Neuropathic pain - gabapentin
- Clonidine dermal patches
- Avoid opiates
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
Treatment of enuresis?
- After age 7
- Behavioural/alarm - 70% success, 30% relapse with bed alarm
- DDAP - 24% remission but high relapse
- Address social issues
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
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.
