Psychiatry Flashcards
Hospital admission criteria for eating disorders
- Significant electrolyte disturbance (K < 3.0)
HR ≤ 50bpm
Postural HR increase ≥ 30bpm
Resting systolic BP ≤ 80mmHg
Postural systolic drop ≥ 20mmHg
Hypothermia < 35.5C
Dehydration
Arrhythmia or prolonged QTc > 0.45s
Weight <75% of their expected body weight or rapid weight loss (>10-15% in 3-6 months is significant)
Out of control ED compensatory behaviours e.g. prolonged fasting/ inability to eat at home/ uncontrolled purging and exercising
Admission may be appropriate in rare circumstances where community management is not effective
1st line treatment for anorexia nervosa
1st line treatment for bulimia nervosa
Does medication alter the outcome in anorexia nervosa
Definition of somatisation
- Tendency to experience and communicate somatic distress
- Psychological distress manifested in the form for physical symptoms
- Seeks medical help
What condition is selective mutism MOST associated with?
Social phobia
What style of attachment is the highest risk for developing a psychopathology?
- Disorganised attachment highest risk
- Avoidant + resistant attachment are risk factors for psychopathology BUT low predictive value
What is the criteria for autism spectrum disorder?
- Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays and manifests by ALL 3 of the following:
- Deficits in social-emotional reciprocity
- Deficits in nonverbal communication
- Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers)
- Restricted, repetitive patterns of behaviour, interests or activities as manifested by at least 2 of the following:
- Stereotyped or repetitive speech, motor movements, or use of objects
- Excessive adherence to routines, ritualised patterns of verbal or nonverbal behaviour, or excessive resistance to change
- Highly restricted, fixated interests that are abnormal in intensity or focus
- Hyper or hypo reactivitiy to sensory input or unusual interest in sensory aspects of environment
- Symptoms must be present in early childhood (but may not become fully manifest until social demans exceed limited capacities)
- Symptoms together limit and impair everyday functioning
What is the average age at diagnosis for autism spectrum disorder?
7-8yrs
10% for each sibling (x50 increased risk)
Monozygotic twin = 60% risk
Serum lead above normal in 44%- related to pica/ oral-motor stage
What are co-morbidities in autism spectrum disorder?
Who get picked up earlier with autism girls or boys?
Boys: usually noticed as they get in trouble
Girls: usually are better at masking their symptoms
Screening + assessment tools for autism?
What are the best predictors for outcome in autism?
What % of patients with autism develop seizures?
25% by 11-14yrs
What are the diagnostic criteria for ADHD?
- Inattention
- Hyperactivity
- Impulsivity
- Symptoms must be before 7yrs of age + in TWO settings or more (e.g. home + school)
- Causes dysfunction
- Subtypes:
- Inattentive
- Hyperactive
- Combined (most common)
What is the prevalence of ADHD?
What are the common comorbidities in ADHD?
- ODD / CD 50%
- Learning problems 10-90%
- Anxiety 33%
- Depression 6%
What are the risk factors for ADHD?
What is the treatment for ADHD?
- Stimulant medication alone is as good or better than other treatment alone or in combination
- Medications
- Stimulants:
- Methylphenidate
- Dexamphetamine
- Uncommonly used: atomoxetine (takes 1-2 weeks to work, may be more beneficial in families with history of substance use), clonidine (sleep difficult), imipramine, risperidone (used if behavioural concerns)
- Not helpful for ADHD but can be used for comorbid anxiety: SSRI’s
- Stimulants:
- Comorbid disorders may determine other treatment (in addition to stimulants)
- Medication + behavioural treatment for comorbid anxiety
- Parent management training if comorbid ODD/CD
- Tourettes doesn’t preclude stimulants, but avoid high doses
What is the mechanism of action of:
- Methylpenidate
- Amphetamine
- Atomoxetine
- Methylpenidate (short acting 3-4hrs), slow release forms available
- Block reuptake of dopamine
- Amphetamine
- Block reuptake of dopamine + increases dopamine release
- Atomoxetine
- Blocks transporter and blocks reuptake of noradrenaline
Efficacy of stimulants + positive effects of stimulants in ADHD
Efficacy
Improvements in core symptoms range from 50-95%
60-70% of school age children respond to 1st agent, 80% to 2nd
Positive side effects
- Improved sustained attention
- Improved performance on memory, vigilance, attention
- Improved academic productivity
- Improved social interation
- Reduced aggressive behaviour
Negative effects of stimulants
Extremely rare: hypersensitivity, SJS, thromobocytopenia, alopecia, toxic psychosis
What is the association between stimulant use + growth?
- Associated with reductions in height of 1-2.5cm after 2-3.5 years of treatment
- Weight 0-5kg less than expected
- To overcome this:
- Give medication morning + lunch
- Give large dinner
- Off medication on the weekends + feed
- To overcome this:
- Height and weight growth rates increase after medication stopped
What are the outcomes in ADHD?
- 2/3 of ADHD children continue to have one or more initial core symptoms of the syndrome later in life
- 1/3 have full diagnosis at 18 yrs of age
- ADHD + CD kids are at higher risk of antisocial personality disorder
What is ODD
Oppositional defiant disorder
- Pattern of negativisitic, hostile and defiant behaviour lasting at least 6 months during which at least 4 of OFTEN;
- Loses temper
- Argues with adults
- Actively defies or refuses to comply with requests/ rules
- Deliberately annoys eople
- Blames others
- Touchy, easily annoyed
- Angry / resentful
- Spiteful/ vindictive
At risk of developing CD, depression + other psychiatric illnesses
What are effective interventions for ODD in 3-12yr olds?
Parent management training
- Increase positive interactions with your child
- Planned ignoring of unwanted behaviours
- Limit setting
Conduct disorder key features
- Childhood onset VS
- Adolescent onset
Childhood onset
- One symptom present before 10yrs old
- More likely male, aggressive, disturved peer relationships
- Likely have ODD, ADHD
- Likely develop antisocial personality disorder
Adolescent onset
- No symptoms before 10yrs
- F=M
- Less aggression
- Less likely to develop antisocial personality disorder
What is the prevalence of conduct disorder?
3-5%
Increase in prevalence after age 12yrs
What are the anxiety disorders?
- Separation anxiety
- Generalised anxiety disorder
- Specific phobia
- Obsessive compulsive disorder
- Post traumatic stress disorder
- Social phobia
- Panic disorder
What is separation anxiety?
Developmentally inappropriate and excessibe anxiety concerning separation from parents and home
- School refusal common
- Often demanding, intrusive and in need of constant attention, especially when anxious
- Often have somatic complaints especially on school days or when facing separation e.g. bed-time
Separation anxiety
- Prevalence
- Long term
- Management
- Prevalence 4% of children / young adolescents
- Increased symptoms after a stressor (e.g. death of pet, family member, changing school)
- Long term: most children do not have ongoing anxiety disorders at end of extended follow up. Higher risk if family history of anxiety disorders.
- Family history of anxiety, mood disorders and alcohol abuse common
- Management:
- Behavioural and cognitive strategies
- Relaxation
- Graduated exposure
When do you use SSRI’s in anxiety?
SSRI’s useful if NOT responding to CBT alone
- Fluoxetine (mainstay)
DO NOT use TCA’s: high risk in overdose
What are the 3 key features of PTSD?
- Re-experiencing: flashbacks, dreams, repetitive play
- Avoidance: places, activities, people, thoughts
- Hyper-arousal: hypervigilance, poor concentration, poor sleep
What is the main treatment of PTSD?
- Trauma focussed CBT
- Relaxation + breathing, cognitive reframing
- Traume narrative, mastery via play, talking, drawing
- Group / individual therapy
- Pharmacotherapy
- No RCT evidence for SSRI’s clonidine or B blockers
What is the definition of OCD?
-
Obsessions
- Persistent ideas, thoughts, images or impulses that are experienced as intrusive and inappropriate and that cause marked anxiety and distress
-
Compusions
- Repetitive behaviours or mental acts (praying, counting) the goal of which is to prevent or reduce the symptoms of anxiety
What is the prevalence of OCD?
1%
Generlly gradual onset / progression
Most have a waxing / waning course
15% have progressive deterioration
Remember to think about PANDAS (Paed autoimmune neuropsychiatric disorder associated with strep infection) usually quicker onset
What are the comorbid conditions in OCD?
80% have another comorbid disorder
- ADHD 35-50%
- Depression 33-40%
- Tics 26%
- ODD 17-51%
- Developmental 24%
- Other anxiety 16%
What is the treatment for OCD?
- 1st line = CBT exposure and response prevention
- Medication: SSRI’s often require higher doses
Social phobia
- Key characteristics
- Outcome
- Treatment
- Marked and persistent fear of social or performance situations leading to avoidance
- May present as school refusal
- May lead to substance abuse
- Treatment: CBT, SSRI’s
Difference between a panic attack + panic disorder:
What sort of tics can you have?
When is the peak onset?
When do you outgrow them usually?
- Motor, vocal or combined
- Peak age of onset - primary school
- Most outgrow them by - high school
What are the features of Tourettes disorder?
- Multiple motor tics, and one or more vocal tics
- Occur multiple times / day, through a period of > 1 year
- Onset BEFORE 18yrs
- Simple tics- muscle twitch like eye blinking
- Complex tics- touching, throwing movement, retracing steps
- Vocal tics- grunts, yelps, snorts, clearing throat
- Coprolalia- uttering obscenitis
What are comorbid disorders in Tourette’s?
ADHD + OCD
Usually worse when stressed
M:F 3:1
What is the treament of Tourette’s?
- Psychoeducation, support, family work
- CBT- habit reversal therapy
- Medication: antipsychotics at low doses
- Haloperidol + risperidone
- Clonidine less effective
- MOST patients with ADHD and Tourettes able to take methylphenidate, if problems can trial clonidine +/- antipsychotic
What is the most common presentation of conversion disorder in children?
Motor impairment
