Recall Deck 3 (2022) Flashcards
- ANXIETY: Selective mutism
a. What are 4 core features of selective mutism?
i. Failure to speak in expected social situations despite speaking in other situations, present for 1 month, functional impairment, not a language or knowledge issue.
b. What is the treatment of selective mutism?
i. CBT (systematic desensitization, systematic reinforcement of speech behaviour).
ii. Limited evidence but some respond to fluoxetine.
- ANXIETY: Sunday night abdominal pain, gets better by Monday afternoon.
a. What is the differential?
i. Generalized anxiety disorder, social anxiety disorder, separation anxiety, somatic symptoms disorder, rule out medical condition
b. What are 2 non-DSM criteria of separation anxiety (or was it criteria… just learn both the criteria and the “associated features” section) ***may not have been a question, review anyway
i. Criteria: developmentally inappropriate persistent, excessive fear of separation from attachment figure, 3+ of distress w/separation, worry about separation, worry about harm/loss of attachment, refusal to leave home, refusal to be alone, refusal to sleep, nightmares of separation theme, physical symptoms
ii. Associated features: social withdrawal, apathy, sadness, difficulty concentrating on work or play; fear of specific situations that are perceived as dangerous to attachment figure (eg. burglars, car accidents); homesickness or extremely uncomfortable when away from home; school refusal; academic difficulties; social isolation; angry or aggression towards someone who may be forcing separation; described as demanding, intrusive, in need of constant attention as children; dependent and overprotective as adults.
c. 3 specific strategies you would employ to reduce absenteeism:
i. Planned exposures, collaboration with school and family (eg. teacher aware, classroom set up), designated break space at school, psychoeducation around accommodation for family, reward system if youth interested
ii. Rule out other contributing challenges or barriers to school (eg. specific learning disorders, ADHD, etc.)
- CL: Kid with epilepsy and presenting with neuroveg shift (low mood, suicidal ideation, concentration, appetite change, insomnia).
a. What is your diagnosis?
i. Major depressive disorder, current episode, mod-sev.
b. Name 3 mental health conditions associated with epilepsy.
i. Major depressive disorder, generalized anxiety, ADHD, autism spectrum disorder, psychosis
ii. Bidirectional
c. What is the interaction with carbamazepine and fluoxetine?
i. Fluoxetine, inhibitor of CYP2D6 and to a lesser degree inhibiting CYP2C19, causes significant elevations in the plasma levels of a number of antiepileptic drugs (eg. phenytoin and valproate).
ii. Some case report suggest significant elevations of carbamazepine plasma levels with fluoxetine. Fluoxetine may also elevate the concentration of the carbamazepine toxic metabolite. Some studies have not reported on any clinically significant interactions between carbamazepine and fluoxetine.
- CULTURE: 16F immigrated from Jordan, coming in for first psychiatric assessment. What 5 cultural things would you assess/explore?
a. Cultural identity of the individual, cultural concepts of distress, psychosocial stressors and cultural features of vulnerability and resilience, cultural features of the relationship between the individual and the clinician, treatment team and institution
b. DSM5-TR: Cultural Formulation Interview – Cultural Definition of the Problem (questions 1–3); Cultural Perceptions of Cause, Context, and Support (questions 4–10); Cultural Factors Affecting Self-Coping and Past Help Seeking (questions 11–13); and Cultural Factors Affecting Current Help Seeking (questions 14–15); Clinician-Patient Relationship (question 16).
- DEPRESSION: DMDD question
a. Per DSM what are 2 things that cannot be co-diagnosed with DMDD:
i. Bipolar disorder, IED, ODD.
b. Per DSM what are 2 things that CAN be co-diagnosed with DMDD:
i. ADHD, MDD, CD, SUD.
ii. Straight out of DSM5-TR: “This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders.”
c. What are kids with DMDD they at risk for as adults?
i. Unipolar depressive disorder or anxiety disorder
- DEPRESSION: What, other than substance use, impulsivity, and psychiatric comorbidities are risk factors for acute suicidal ideation in adolescents? 5 things.
a. Indigenous, family history, previous suicide attempts, agitation, male, older age (16+)
- DEPRESSION: Bullying
a. What are 3 individual patient factors that increase SI risk after bullying?
i. Depression, anxiety, sleeping difficulties, eating disorders, school absenteeism, running away, substance use, non-suicidal self-harming
Demographic Factors
Being male - Males who are bullied tend to have a higher risk of suicidal ideation compared to females.
Younger age - Bullying victimization during early adolescence (ages 11-13) is associated with increased suicide risk.
Mental Health Factors
Pre-existing depression or anxiety disorders
History of previous suicide attempts
Substance abuse issues
Emotional distress and poor coping skills
Social/Environmental Factors
Lack of social support from family and peers
Coming from a single-parent family
Low socioeconomic status
Experiencing other forms of abuse (physical, sexual, etc.)
Family dysfunction or conflict
Unsafe school environment
Bullying-Related Factors
Being a bully-victim (both a bully and a victim)
Experiencing more severe or frequent bullying
Being cyberbullied in addition to traditional bullying
Feeling hopeless about the bullying situation
Other Risk Factors
Poor academic performance
Low self-esteem
Impulsivity or aggression
Belonging to a sexual minority group
b. Name 2 reasons you would call police for internet bullying
i. Exploitative content (eg. photos, written information)
ii. Sexually-inappropriate content (eg. age, consent)
iii. Threatening content to self or others (eg. individual, groups)
- DISRUPTIVE: Kid with ADHD and teacher gave a screening/rating scale and says has ODD. At home, okay except upset when doing homework. Plays competitive hockey and swimming.
a. What specific 3 questions do you ask hockey coach to figure out if they have ODD?
i. Affective (easily annoyed, loses temper, resentful), defiance (argues w/authority, refuses to comply, deliberately annoys others, blames others), vindictive/spiteful
b. Assuming collateral rules out ODD, what are 2 most likely diagnoses?
i. ADHD, specific learning disorder(s), parent-child relationship problem
- EATING: Eating disorders: bulimia
a. Name 3 risk factors for bulimia?
i. Family history, history of trauma, decreased self-esteem, social anxiety, depressive symptoms, childhood obesity/weight concerns, overanxious temperament.
b. Name 2 most common triggers for binge/ purge?
i. Negative affect, interpersonal stressors, boredom, body weight, dietary restraint.
*stress
*poor body image
- ECT:
a. 2 reasons o/s of Dx for ECT:
i. Acute SI, depression with psychotic features, treatment resistant depression; catatonia, multiple medication intolerances, prior favourable response to ECT, rapidly deteriorating physical status, or any of the above in pregnancy; pt preference; refractory mania, resistant psychosis, refractory OCD, Parkinson’s, refractory status epilepticus, NMS
b. 3 things you would do on assessment/prior to initiation of ECT
i. Psychiatric evaluation – interview, collateral, rating scales, Dx, severity, past treatments
ii. Physical exam & labwork – Eeg. CBC, TSH, LFTs, U/A, tox screen, +/- ECG, EEG, CT or MRI. F pts should get pregnancy testing.
iii. Cognitive assessment for memory (pre-treatment, post-treatment and 3-6 mo post-treatment)
iv. Informed consent
v. Second opinion
vi. Concurrent treatment – therapy, medications
- ELIMINATION: Enuresis in a 6-year-old who is having bed wetting at home 4x per week. Nervous about going to sleepover. No hx of not having enuresis.
a. What is one possible pathophysiology mechanism of enuresis?
i. No arousal to bladder distension.
ii. Uninhibited bladder contractions prior to enuresis
iii. Dysfxnal arousal system during sleep
iv. OSA assoc’d w/enuresis
v. Developmental immaturity including motor & language
vi. Excessive volume + detrusor muscle contraction; or retention + detrusor muscle contraction
b. What are 2 non Pharm treatments for eneuresis?
Psychoeducation & reassurance. ∅ punshiment, ∅ humiliation. Bathroom before bed, avoid drinking fluids or caffeine before bed. Assure access to toilet. Include child in morning or diaper clean up non-punitively. Reward for good behaviour (if sensitive child, be careful that failure could ↓ self-esteem).
Behavioural strategies better longer term – motivational Tx for 5-7yo who are not wetting the bed every night but >1/wk. Enuresis alarms (effective in Rx <50%, preventing relapse & LT, good for motivated older kids) – use if 14 consecutive dry nights; bell and pad, night alarms, routine/hygiene before bedtime; consider overlearning by drinking excessive fluids.
c. What are 2 Pharm treatments for eneuresis?
If going to sleepovers, needing rapid, short-term response (high relapse rate however) or behavioural Tx not effective, can use DDAVP (>5yo).
3rd line: TCAs (eg. imipramine) ↓ amount of time spent in REM sleep, stimulate vasopressin secretion, relaxes detrusor muscle).
- NEURODEVELOPMENTAL: Adolescent Kid with ID that behaves at baseline at a level of a 4 year old, history of not doing well at school. Presents with 4 day hx of fluctuating mood, lability, not sleeping well, and randomly screams. Given ativan and got worse.
a. What are 3 psychiatric differentials you’re considering apart from ID.
i. Substance use
ii. Catatonia
iii. Mood disorder – depression, bipolar
iv. Psychosis – brief psychotic disorder, schizophreniform disorder
v. Trauma – adjustment disorder, acute stress disorder
vi. More LT – specific learning disorder, language disorder, sleep disorder
- NEURODEVELOPMENTAL: Adolescent Kid with ID that behaves at baseline at a level of a 4 year old, history of not doing well at school. Presents with 4 day hx of fluctuating mood, lability, not sleeping well, and randomly screams. Given ativan and got worse.
b. Name 2 medical conditions that you would consider
i. Neurological – Seizures/epilepsy, encephalitis
ii. Pain syndromes
- NEURODEVELOPMENTAL: Person with winking/shrugging. Hx adhd + odd. On a stimulant. Had a grandpa with unknown neurological condition that recently passed away.
a. What are 3 differentials?
i. Tic disorder – provisional tic disorder, chronic motor tic disorder
ii. Stereotypic movement disorder
iii. Medication side effect
iv. Substance-induced
- NEURODEVELOPMENTAL: Person with winking/shrugging. Hx adhd + odd. On a stimulant. Had a grandpa with unknown neurological condition that recently passed away.
b. What is one investigation or strategy (both words were used) to figure out what it is?
i. Stop the stimulant (?unmasking of tics)
ii. Consider ruling out partial seizures w/EEG
- NEURODEVELOPMENTAL: Person with winking/shrugging. Hx adhd + odd. On a stimulant. Had a grandpa with unknown neurological condition that recently passed away.
c. What is one Pharm treatment you would use?
i. 1st line pharm: Guanfacine, clonidine
ii. 2nd line pharm: Risperidone, aripiprazole
- NEURODEVELOPMENTAL: Person coming in with math difficulties. What are 5 things on a psychoed that would suggest a learning disorder in math?
a. Not sure why this is a question on this exam… lemme just get my PhD in my spare time, see below for articles.
b. General answer probably: Deficits could be in basic mathematical computational skills, concepts, problem-solving, logical reasoning, fluency, mental calculation, visuospatial working memory
c. Calculation, fact retrieval, quantity processing, quantity-number linking, numerical relations, and visual-spatial short-term storage.
i. Haberstroh S, Schulte-Körne G. The cognitive profile of math difficulties: A meta-analysis based on clinical criteria. Frontiers in Psychology. 2022 Mar 11;13:842391.
e. Deficits in visuospatial and verbal WM deficits, deficits in cognitive control (problem-solving, decision-making), logical reasoning
i. Menon V, Padmanabhan A, Schwartz F. Cognitive neuroscience of dyscalculia and math learning disabilities.
- NEURODEVELOPMENTAL: Kid with refractory ADHD, not responding to meds. Recurrent episodes of falling asleep (actually teacher observed “sleepiness”) in class, daily.
a. Name 2 sleep disorders that could explain these symptoms
i. Obstructive sleep apnea
ii. Hypersomnolence disorder
iii. Narcolepsy
iv. Circadian-related
v. Medication-related
- NEURODEVELOPMENTAL: Kid with refractory ADHD, not responding to meds. Recurrent episodes of falling asleep (actually teacher observed “sleepiness”) in class, daily.
b. Name 3 symptoms that would connect the issues to the sleep disorders
i. Morning headaches, weight gain, snoring, snorting/gasping, pauses in breath, daytime sleepiness, unrefreshing sleep, tonsillar issues, large neck size, abnormal maxillary-mandibular anatomy
ii. Recurrent lapses into sleep within the same day, non-restorative night time sleep, prolonged main sleep episode >9h
iii. Cataplexy, lapsing into sleep or napping during the day,
- NEURODEVELOPMENTAL: 4 year old ADHD, really severe (climbing on things, running away from group, dysregulated and hits other kids). All over the place. Name 5 first line treatments.
a. Non-pharmacological 1st line – parent training, behavioural management, psychoeducation, environmental/educational accommodations, skills-based, mindfulness, relaxation techniques, individual therapy, family therapy, couples/marital therapy
- NEURODEVELOPMENTAL: ADHD 5 things that impact the interpretation of long term studies of psychostimulants in ADHD
a. Question not clearly defined – long term effect of being treated with ADHD medication OR cumulative effect of being treated for longer periods of time.
b. Confounding time-factors (eg. life events, episodes of disease) for starting or stopping treatment which can change risk of outcomes.
c. Time-to-event outcomes (eg. injuries, suicide attempts) measured with duration of treatment is dependent on length of follow-up.
d. Use of ADHD medication measured by filled prescriptions, only applies to patients who choose to fill prescriptions (misclassification of exposure and bias results, drug holidays).
e. Treatment assignment not masked for either patients or clinicians.
f. Data from one country/state/region, which may not be generalizable to other settings. Differences in diagnostic and treatment practices of ADHD.
b. 3 other evidence based skills for developing social emotional reciprocity and language skills in ASD kids/youth?
c. What 3 interventions would you suggest for addressing pragmatic language, social reciprocity?
