Symposium 4 - Child and Adolescent Flashcards
In CAHMS, what is the criteria for a child to be seen by a psychiatrist?
- Mental illness in presentation
2. Some kind of functional impairment OR risk
What are potential functional impairments in children associated with mental illness.
With school, relationships (family, friends), hobbies
What are potential risks for children and adolescents with mental health problems?
Self harm Suicide Drugs Abuse Alcohol Exploitation Grooming Running away
What are the three sections of investigating mental health in children and adolescents?
Presentation (recently)
Other background (previously)
Mental state examination (right now)
How do you investigate presentation?
Presenting complaint + History of presenting complaint
What are the 4 Ps in relation to formulation in psychiatry?
Predisposing
Precipitating
Protective
Perpetuating
In CAMHS, what are important factors to consider in the past psychiatric history?
Counselling
Therapy
In CAMHS, what are important physical factors to consider when taking a psychiatric history?
Seizures (temporal lobe epilepsy)
Head injuries
What sections do you consider in a psychiatric history when taking a history from a child or adolescent?
Past psychiatric Past medical Meds and allergies Social and habits FH (psychiatric and physical) Personal Developmental
List the sections of the mental state exam for children and adolescents.
Appearance Behaviour Speech Mood Thoughts Perception Cognition Risk Insight
What tool is used to understand the cognitive profile of children and young people?
WHISC test
What are “Hopes for change” ?
Ask about goals of child and parents
Ask about expectations
What are assessment principles of psychiatric history taking?
Biopsychological approach, multiple perspectives and relationships, communication
List biological factors that may contribute to a young persons mental health.
Genetics, neurodevelopment insults, illness
List psychological factors that may contribute to a young persons mental health.
Temperement, attachment style, psychological attributes e.g impulsivity, low self esteem, perfectionism
List social factors that may contribute to a young persons mental health.
Relationships, hobbies, interests, religious faith, school, neighbourhood, criminality, finances
What type of studies are increasingly being used to identify genetic risk factors for psychiatric disorders?
Genone Wide Association Studies
Twin studies
What are developmental influences on psychopathology?
Genetics
Family history
Intrauterine and perinatal factors
Environmental factors
List intra-uterine and perinatal factors of development of psychopathology.
Maternal health Substance misuse Toxins Drugs Endocrine environment immune environment premature birth twinning
What are signs of fetal alcohol syndrome/
Growth retardation
Neuro-developmental effects: sensorimotor, cognitive development, executive function, language, ADHD, DCD, LD
What is poor white matter connectivity associated with?
Cognitive instability
ADHD
Poor concentration
Distractibility
List common psychiatric problems in children.
Learning difficulties
Conduct disorders e.g ODD
Combined ADH or ADD or hip-lmp subtypes
Anxiety disorders
List environmental factors that can influence the psychiatry of a child.
Relationships Parenting skills Marital harmony Nutrition Poverty Abuse/neglect Discipline Day-care/schooling Life events Physical disability Attachment e.g lack of bonding
How does early life stress influence function of the brain?
Influences function of limbic circuit including amygdala
How does the brain adapt to a hostile environment?
Experience of adversity
List concepts in psychological development.
Reward-based Executive function Delay-aversion Sharing emotion and empathy Expressed emotion
What is the hypoactive reward response?
Application of reward deficiency model
“Addiction”
Increased delay aversion
What is operant conditioning?
Dopamine neurons fire when you associate and action with a subsequent reward
Give an example of a test used to look at delay-aversion.
Marshmallow test
What is the relationship between delay-aversion and ADHD.
Inability to wait and maintain attention in the absence of immediate reward
What is expressed emotion related to?
Increased rate of relapse from chronic illness
Schizophrenia, Depression, ADHD
Physical illness (epilepsy, CF, DM, Asthma)
What is the out-of-school matrix?
School refusal from fear of leaving home and fear of going to school
vs
Truancy from being unwilling to leave home and to go to school
Not going to school is associated with what mental health disorders?
Anxiety, conduct disorder, autism, depression, OCD
List effects of mental health problems on school attendance and learning.
Learning difficulties Poor attention Difficulty controlling emotions Lack of energy/motivation Difficulty joining in Sensory problems
Discuss the biological cause of anxiety in childhood.
Amygdala activity suppressed by right ventrolateral cortex when labelling emotions
What is separation anxiety?
Fear of leaving parents and home
What is social phobia?
Fear of joining group
List the 3A’s of anxiety.
Anxious thoughts and feelings
Autonomic symptoms
Avoidant behaviour
List factors that can affect school attendance.
learning difficulties bullying lack of friends lack of parental attention/concern maternal depression
Describe the emotional contagion in childhood anxiety.
Child fearful –> fearful parent –> fearful doctor
How do you manage anxiety in children?
Behavioural e.g learning alternative patterns of behaviour, desensitisation, overcoming fear, managing feelings
Meds - SSRI e.g fluoxetine
What is the differences in CBT for children?
Don’t expect children to have cognitive awareness
Parents should be collaborators
Step-wise approach
Goal setting
What medication can you give to children with anxiety?
Fluoxetine (SSRI)
What are autistic spectrum disorders?
Syndromes of persistent, pervasive and distinctive behavioural abnormalities
What is the etiological factors for autism?
M>F (3:1), Highly heritable, comorbid with congenital or genetic disorders e.g rubella
What are distinctive features of ASDs?
Reciprocity
Language problems
Obsessions
What are common clinical problems associated with ASD?
Learning disability, disturbed sleep and eating habits, hyperactivity, increased anxiety and depression, OCD, school avoidance, aggression, tantrums, self-harm/injury, suicidal behaviour
How do you manage ASD?
Recognition and description Establish needs Appreciate the can't and won't Reduce demands --> reduce stress --> increase coping Psychopharmacology
What conditions fall under Hard to manage children (H2M)?
Oppositional defiant disorder (ODD)
Attention deficit hyperactivity disorder (ADHD)
What are signs of ADHD?
Aggression is impulsive
Poor cognition control and ability to sustain a goal
Often remorseful
Resistant to poor behavioural management
Does ADHD or ODD have the strongest genetic component?
ADHD
Discuss ODD.
Relates to temperament - irritable and headstrong
Behaviour is learned
More likely to result from impaired parenting
What are outcome risks of H2M children?
Antisocial behaviour, substance misuse, long-term mental health problems
How are H2M children managed?
Parent training Multi-systemic therapy Meds - stimulants (Rital/methylphenidate), atomoxetine, guanfacine School interventions Treat comorbidity Voluntary organisations
What are SEs of methylphenidate used for ADHD?
Appetite, weight and sleep disturbances
What is the ABCD of dementia?
ADLs
Behavioural and psychiatric symptoms of dementia
Cognitive impairment
Decline
What re cognitive features of dementia?
Dysmnesia plus one or more of: dysphasia, dyspraxia, dygnosia, dysexecutive functioning
Functional decline
List neuropsychiatric disturbances linked with dementia.
Psychosis Depression Agitation Anxiety Altered circadian rhythms
What re two types of dysphasia/
Expressive and receptive
What is dyspraxia?
Inability to carry out motor tasks
What is ‘sundown’ common in dementia patients?
Get more agitated late afternoon
What is the characteristic sign of vascular dementia?
Step-wise progression
What is the most common type of dementia?
Alzheimer’s
What causes a dementia syndrome?
Different pathologies - e.g overlap between different types
List difference between dementia and delirium.
Dementia - insidious onset, slow gradual progressive decline, irreversible, disorientated in late illness
Delirium - abrupt onset, acute illness lasting days to weeks, usually reversible, disorientated in early illness
What are differentials for dementia that need to be excluded?
Delirium and depression
What basic cognitive tests are carried out for dementia?
MMSE
MOCA
78 year old woman referred by GP with 3 year history of gradual and progressive deterioration in memory. Cognitive testing show dyskinesia and dysexecutive dysfunction. Reliant on daughter, no focal neurological signs, no h/o vascular disease or risk factors.
Most likely diagnosis?
Alzheimer’s
What imaging would you organise for suspected Alzheimer’s?
CT or MRI or SPECT
MEDIAL TEMPORAL ATROPHY ON BOTH LOBES
What is dementia with Lewy bodies?
Dementia
Amnesia not prominent
Deficits of attention, frontal executive, visuospatial
Fluctuation
Visual hallucinations
Parkinsonism
Psychotic symptoms
What type of drugs do Lewy body Dementia patients have a sensitive to which complicates treatment?
Antipsychotics
What scan is used to determine Lewy body dementia?
DATScan
50 year old man presents with gradual change in behaviour over last 2 years, stopped taking care of his appearance and e personal hygiene, clear personality change, apathetic, withdrawn. What is the likely diagnosis?
Frontotemporal dementia
What scan will confirm frontotemporal dementia?
Axial MRI - cerebral atrophy in frontal and temporal regions
What are drug treatments prescribed for dementia?
Acetylcholinesterase inhibitors e.g donepezilm rivastigmine, galantamine
Antipsychotics (risperidone, quetiapine, amisulpride) antidepressants Anxiolytics Hypnotics Anticonvulsants
What drug is prescribed for Alzheimers?
Memantine
What is the benefit of cholinesterase inhibitors for dementia?
Improve cognitive function and non-cognitive symptoms e.g ADL, longer at home
What are common mental health problems in old age?
Dementia
Depression Anxiety disorders - GAD, panic disorder, agoraphobia, PTSD
Affective disorders - mania, schizophrenia, alcohol problems
Grief, mourning and bereavement
What are abnormal symptoms from grief/bereavement?
Persistent beyond 2 months Guilt Thoughts of death Worthlessness Psychomotor retardation Psychosis Prolonged and marked functional impairment
What is the rate of suicide in elderly?
Same as for under 25
M>F
What are common triggers for suicide in elderly/
Loneliness Widowed Ill health Chronic pain Recent life events
How do you manage schizophrenia in elderly/
Neuroleptics
Increased social contact
Compulsory admission
What are risk factors for schizophrenia in elderly/
Social isolation
Genetic
Sensory loss
What questionnaire can be used as a screening tool for eating disorders?
SCOFF Questionnaire - 2 or more then likely
Do you make yourself Sick because you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you recently lost more than One stone in a three month period?
Do you believe yourself to be Fat when others say you are too thin?
Would you say Food dominates your life?
What are signs of anorexia nervosa?
Restriction of intake to reduce weight
Relies on compulsive compensatory behaviours when food cannot be avoided, self induced vomiting, laxative abuse, excessive exercise
At what BMI is considered anorexic?
15% below ideal body weight/ B,MI 17.5 or less
What suggests anorexia nervosa in relation to menstrual cycles?
Absence of menstrual cycle or amenorrhoea (greater than 3 cycles)
what are signs of anorexia nervosa?
Cold intolerance Blue hands and feet Constipation Bloating Delayed puberty Primary or secondary amenorrhea Dry skin Fainting Hypotension Lanugo hair Scalp hair loss Early satiety Weakness, fatigue short stature Osteopenia and osteoporosis
What are signs of bulimia nervosa?
Episodes of binge eating with a sense of loss of control
Binge eating followed by compensatory behaviour of the purging type
Binges and compensatory behaviour must occur a minimum of two times per week for three months
Dissatisfaction with body shape and weight
What are signs and symptoms of bulimia nervosa?
Mouth sores Pharyngeal trauma Dental caries Heartburn/chest pain Oesophageal rupture Impulsivity Muscle cramps Weakness Bloody diarrhoea Irregular periods Fainting Swollen parotid glands Hypotension
What is binge eating disorder?
Similar to bulimia but absence of purging behaviours
Ongoing and/or repetitive cycles often include - eating quickly, alone, unusually large amounts, embarrassment, shame, guilt and depression afterwards
Give examples of avoidance behaviours seen in eating disorders.
Not touching food
Developing dislikes, pickiness
Avoiding parties and social occasions, spoiling or messing of food
How do patients with eating disorders try to get rid of calories?
Self-induced vomiting Chewing and spitting out Overexercuse Overactivity Cooling Blood letting Medication abuse
What medications can be abused to try get rid of calories?
Excessive caffeine, stimulant consumption - laxatives, ipecac, pain killers
What is diabulimia?
Patient enjoys carb rich diet but then omits insulin so as to “effectively purge” calories and insulin omission in diabetic patients
May omit to reduce insulin after meals
What are psychological consequences of eating disorders?
Depression
Anxiety
Obsessionalitu
Loss of concentration on anything but food
What are social consequences of eating disorders?
Forced to lie and cheat or steal
Withdraw from friendships and lose interest in sexual relationships
What are potential physical consequences of eating disorders?
Prolonged QTc --> arrhythmia Seizures Infections Anaemia Bone loss Fertility problems Hypokalaemia Disruption of growth and development
What are causes of eating disorders?
Predisposing - genetics, OCD, anxiety, perfectionism, perinatal, life events
Perpetuating - consequences of starvation and of avoidance, delayed gastric emptying, narrowing focus, obsessionality
Precipitating factors - puberty, dieting, increased exercise, stressful life events
What psychiatric disorder has the highest mortality rate?
Anorexia nervosa
What is the average time for recovery from anorexia nervosa?
6-7 years
How can anorexia nervosa patients be helped?
Re-feeding CBT Mantra SSCM IPT Fluoxetine Olanzapine (antipsychotic) Specialist family work
What is the only evidence based medication for eating disorders.
Olanzapine - feel less anxious, helps sleep, blocks intrusive thoughts
What are organic mental disorders?
Due to common demonstrable aetiology in cerebral disease, brain injury or other insult leading to cerebral dysfunction
What is the difference between primary and secondary organic mental illness?
Primary - direct effect on brain
Secondary - systemic disease that affects the brain
List psychiatric disorders that have an organic basis?
Schizophrenia
BAD
Melancholia
What are common features of organic mental illness?
Cognitive - memory, intellect, learning
Sensorium - consciousness, attention
Mood - depression, elation, anxiety
Psychotic - hallucinations, delusions
Personality and behaviour disturbance
When can organic mental illness occur?
Any age - most start in adult or later life
List acute/subacute organic mental disorders.
Delirium
Organic mood disorder
Organic psychotic disorder
List chronic organic mental disorders.
Dementia
Amnesic syndrome
Organic personality change
List presenting features of delirium.
Impairment of consciousness and attention Global disturbance of cognition Psychomotor disturbances Disturbance in sleep-wake cycle Emotional disturbance
Rapid onset, diurnal variation, duration less than 6 months
What are physical signs of delirium?
Tachycardia Hypertension Diaphoresis Dilated pupils Fever
List causes of delirium.
Medications Drug abuse Withdrawal symptoms Metabolic Vitamin deficiencies Endocrinopathies Infections Neurological causes Toxins and industrial exposures SLE Cerebral vasculitis Paraneoplastic syndromes
What medications can be given for delirium?
Avoid sedation unless required for safety
What is the difference between delirium and encephalopathy/
Delirium = psychiatric presentation Encephalopathy = description of underlying process
Give examples of encephalopathies?
Hepatic, Wernicke’s, HIV
What are signs of hepatic encephalopathy?
General psychomotor retardation
Drowsiness
Fluctuating confusion
Asterixis
List examples of organic mental disorders.
Delirium
Encephalopathies
Dementia
Amnesic syndrome
What is amnesic syndrome?
Syndrome of impairment of recent and remote memory
What are signs of amnesic syndrome/
Immediate recall preserved New learning reduced Anterograde amnesia Disorientation retrograde amnesia Confabulation Perception and other cognitive functions preserved
What are the most common causes of amnesic syndrome?
Alcohol
Poor nutrition
How do you treat amnesic syndrome?
Depends on cause
Prevent alcohol amnesic syndrome
How do you prevent alcohol amnesic syndrome?
Months - years Pabrinex (vitB1) Oral thaimine Abstinence form alcohol MDT rehab
What is the definition of learning disability?
Condition of arrested or incomplete development of mind which is characterised by impairment of skills manifested during DEVELOPMENT period
What IQ suggests intellectual impairment?
Less than 70
What is the gold standard scale used to measure intelligence and indicate intellectual impairment/
Weschler
Discuss the Weschler classification scale used to classify ld.
Mild 50-69
Moderate 35-49
Severe 20-34
Profound <20
Discuss aetiology of learning difficulties.
Genetics - single gene (Fragile x), micro deletion (DiGeorge), chromosomal (Down syndrome)
Infective
Toxic
Trauma
Idiopathic
Give examples of infective causes of learning disability.
Ante-natal e.g rubella
Post-natal e.g meningitis
Give examples of common and/or important physical conditions associated with LD.
Epilepsy Sensory impairment Obesity GI issues Resp problems e.g aspiration pneumonia Cerebral palsy Orthopaedic problems e.g osteoporosis Dermatological or dental
What is the commonest aetiology of learning difficulties?
Unknown
What is the link for psychiatric disorders and learning difficulties?
More severe LD has higher prevalence of psychiatric disorders
What are psychiatric assessment areas for learning difficulties?
Aetiology of LD
Associated biomedical conditions
Severity of LD
Consequences e.g forensic history
What are common mental health problems associated with LD?
OCD
Autism
Over-activity syndromes
Self-harm
What questionnaire can be given to patient if considering depression in general practice?
PHQ-9 Depression
If recognised depression with persistent sub threshold symptoms or mild to moderate depression, what would you suggest in GP?
Advice on sleep hygiene
Active monitoring
Low-level CBT, mindfulness
DON’T rountinely use antidepressants
In primary care, what would be the first line medications prescribed for depression?
SSRI - e.g fluoxetine, citalopram
What are Med-3 forms?
Fit for work forms
What are main side effects from SSRI?
Gastric - dyspepsia, diarrhoea, N&V
What is the normal follow-up in primary care for antidepressants?
2 weeks after starting, intervals of every 2-4 weeks for 3 months
How long do you recommend patients to remain on antidepressants after remission?
6 months - up to 2 years
What should you do if patient does not respond to antidepressants after 3-4 weeks at therapeutic dose?
Increase level of support or switch to another SSRI, then another class e.g TCA, MAOI, can combine or augment, or augment with lithium
In primary care, what should you do for severe and complex depression with risk to life, psychotic symptoms or severe self-neglect?
Refer to MDT and possible inpatient care
What should you do if you suspect bipolar disorder in primary care?
Refer/ discuss with secondary care
In primary care, what would you offer to a patient with a generalised anxiety disorder?
Active monitoring
GAD-7 scoring
SSRI
Psyhchoeducational groups
What should you not prescribe for GAD?
Benzodiazepines, antipsychotics
What do you prescribe for management of panic disorders?
Psychological therapy - CBT
Self-help
SSRI - sertraline
What should you NOT prescribe for panic disorders?
Fluoxetine
Avoid benzodiazepines/sedating antihistamines/antipsychotics
How do you treat social anxiety disorder/
CBT
Medication - sertraline or escitalopram
What is prolonged grief disorder?
MARKED DISTRESS AND DISABILITY CAUSED BY THE GRIEF REACTION and PERSISTENCE FOR MORE THAN 6 MONTHS
What are treatment options for grief disorder?
Counselling
Antidepressants for co-morbid depression
What is the criteria for diagnosis of OCD?
Obsessions and compulsions must be time consuming >1 hour, or cause significant distress or functional impairment
What should you do in primary care who presents with insomnia?
Screen for secondary causes e.g anxiety/depression, physical problems, sleep apnoea, excess alcohol/drugs
List parasomnias.
Restkess legs, sleep walking/talking/terrors/teeth grinding
How do you treat insomnias?
Sleep hygiene
CBT-I
Melatonin
For >55Y, <13 weeks use
What monitoring do you need to do for lithium?
TFTs, kidney function - 6 monthly
3 monthly checks
What are common side effects of lithium?
Fine tremor Dry mouth altered taste Increased thrust Urinary frequency Mild nausea Weight gain
What are signs of lithium toxicity?
Confusion Ataxia Coarse tremor Slurred speech Blurred vision Seizures D&V Muscle weakness Lethargy
List reasons for increased prevalence of mental health disorders in general hospitals?
Challenges of physical illness
Treatment of physical illness
What mental health problems are less commonly seen in general hospitals?
Schizophrenia
BAD
Severe depression
What illnesses is depression common in?
Chronic illness
Neurological diseases
With regards to self-harm, what percentage of patients will repeat within one year?
15-20%
What is the most common drug taken in overdose?
Paracetamol
What are functional mental health disorders?
Medically unexplained symptoms
What mental disorders are classed as functional disorders?
Dissociative disorders
Somatoformin disorders
What are symptoms of functional disorders?
Present in all specialities e.g IBS, fibromyalgia, chronic fatigue syndrome
FND presents more with psychological symptoms
What causes rebound mania in association with lithium use?
Dose to low
Doe lithium have a large or narrow therapeutic index?
Narrow
When does postpartum psychosis occur?
within days to 6 weeks
When does postnatal depression occur?
Within 6 months
Define Agraphia
inability to write
Define Alexithymia
sub clinical emotional blindness
Define Cyclothymia
relatively mild mood fluctuations
Define Dyscalculia
difficulty dealing with numbers
Define Anhedonia
lack of pleasure/interest
Define Catatonia
immobility, stupor
Define Dysarthia
difficulty articulating speech
Define Dystonia
involuntary muscle spasms/contractions
