Targeted cards Flashcards
Aim of Primary Prevention?
Reduce incidence of disease by preventing development of new cases
Aim of secondary prevention
Reduce total number of existing cases by more rapid effective interventions that shortens duration of illness
Aim of tertiary intervention
For individuals to reach their highest level of functioning
Types of prevention under IOM
Universal Preventive Intervention
Selective Preventive Intervention
Indicated Preventive Intervention
Who does a selective preventive intervention target?
Members of population with higher than average risk factors.
Who does indicated preventive intervention target?
Members of population with subsyndromal symptoms of a disorder, or diagnosed with another associated disorder.
Who described the prevention paradox?
Geoffrey Rose, 1981
Who conducted the first ECT and when?
Lucio Cereletti
Ugo Bini
1938
Indications for ECT
Depressive illness Mania Schizophrenia Catatonia Parkinsons Neuroleptic Malignant Syndrome Intractable seizure disorders (raises seizure threshold)
When is ECT first line treatment for depressive illness?
Emergency treatment where rapid response is needed
Treatment resistant depression where a person has responded to ECT previously
Absolute CI of ECT?
None
Relative CI of ECT?
Acute respiratory infection MI in past 3 months Uncontrolled cardiac failure Cardiac arrhythmias CVE in past month Raised ICP Untreated cerebral aneurysm Untreated Pheochromocytoma Unstable major fracture DVT - until anticoagulation (to reduce risk of PE) Acute/impending retinal detachment High anaesthetic risk
Relapse rate of ECT
51% in 12 months
37% in 6 months
Which drugs raise seizure threshold?
Benzodiazepines
Barbituates
Anticonvulsants
Which drugs lower seizure thresholds?
Antipsychotics
Antidepressants
Lithium
Which drugs need to be stopped 24 hours pre-ECT?
Clozapine
Moclobemide
Difficulties with Lithium and ECT?
Best avoided as may increase cognitive side effects and increase likelihood of neurotoxic effects of Lithium.
Who developed TMS for brain stimulation?
Anthony Barker, 1985
Results for rTMS in depression
40% response rate that is sustained for 6 months
Who carried out the first pre-frontal leucotomy and when?
Moniz and Lima
1995
What key functions did Moss identify for multidisciplinary teams?
Continuing proactive care of those with long-term serious MH problems
Uninterrupted access to information and support, intervention and treatment before and during crises
An organised response to requests for help from primary care
What is Assertive Community Treatment (ACT) based on?
Stein & Test (1980) evaluated training in community living. Main issue was transfer of learning in social skills training in real life when patients move from inpatient units to community.
What did the UK 700 study report?
Caseload is the most important predictor of outcome of an ACT service.
What led to the introduction of the CPA?
Case of Sharon Campbell who killed her SW (DSHH, 1991)
What types of CPA are there?
Enhanced
Standard
Who are enhanced CPA for?
Those whose care needs are best served by regular MDT meetings
Who developed the filter model?
Goldberg
Huxley
What are the five levels of mental illness occurrence?
Community Primary Care Attendees Diagnosed primary care attendees Level of Psychiatrist Level of psychiatric inpatient care
What is used for the criteria of early intervention?
PACE-UHR (Personal assistance and Crisis Evaluation service)
What are the PACE-UHR criteria?
Uses ‘close in’ strategy
Specificity>sensitivity
Ages 14-30
Considers experiencing attenuated positive symptoms or episodes of frank psychosis (BLIPS - brief limited intermittent psychotic sx)
Having schizotypal personality or FHx of schizophrenia
What is used to assess prediction of sx from basic to schizophrenia?
Bonn Scale for Assessment of Basic Symptoms
How good is Bonn Scale for Assessment of Basic Symptoms?
Predicts conversion from basic symptom to schizophrenia in 78% of individuals
Which studies show that the initial gain from early intervention may not be sustained if it is discontinued after 2 years?
PEPP (London, Ontario)
TIPS (Norway)
What did the SOCRATES study show?
Compared CBT with supportive counselling for first or second-episode schizophrenia.
At 18 month follow-up, addition of both CBT + counselling showed significant improvement.
What did the PRIME study show?
Olanzapine at low dose prevents progression of psychosis.
What did EPPIC study from Melbourne (McGorry et al) show?
Combination of CBT and Risperidone reduced conversion rate at 6 months.
What did the Lambeth Early Onset (LEO) study show?
Compared specialised care (low dose antipsychotic, CBT, family counselling) based on assertive outreach with standard care and found relapse rates were lower with the former.
Who recognised ‘Duration of Untreated psychosis’ (DUP) as a prognostic marker?
Wyatt
What was the first study that challenged the pessimism about schizophrenia recovery?
Vermont Longitudinal study
Recovery rate of schizophrenia
38% at 15 and 25 years
Who identified internal and external conditions for recovery?
Jacobson and Greenley
Who reported on the treatment gap in MH?
Kohn 2004 in the WHO Bulletin
What is the treatment gap for psychosis?
32% worldwide untreated
18% in Europe
40% in Europe with Bipolar untreated
>50% with depression and anxiety untreated
Who reported that improving adherence can have a greater impact on population health than anything else?
Haynes in 2001 Cochrane Review
Who did a study on Psychiatry and Human Rights?
Drew et al. 2011
What did Drew et al. 2011 find re Human rights in MH?
The right to marry and hvae children is often denied on the grounds of mental illness.
What is Article 2?
Right to Life
What is Article 3?
Prohibition of torture
What is Article 5?
Right to liberty
What is Article 6?
Right to a fair hearing
What is Article 8?
Right to a private/family life
What is Article 9?
Freedom of thought & religion
What is Article 10?
Freedom of expression
What is Article 14?
Right not to be discriminated against
Rules for drivers with acute psychosis, mania/hypomania and schizophrenia re Group 1 for the DVLA?
Driving must cease during acute illness.
When can relicensing be considered for a Group 1 driver who had psychosis?
All must be fulfilled:
Patient has remained well and stable for at least 3 months
Compliant with treatment
Free from adverse effects of medication which could impair driving
Subject to specialist favourable report
Regained insight in case of bipolar mania or hypomania
Psychosis and Group 2 drivers?
Driving should cease pending outcome of medical enquiry.
When can Group 2 drivers with psychosis drive again?
Person must be well and stable for minimum of 3 years with insight into condition before driving can be resumed.
What study looked into the decision-making capacities of people in hospital with MI?
MacArthur Treatment Competence Study 1988
What tool did the MacArthur Treatment Competence Study create?
MacCAT:
Choosing: ability to state a choice
Understanding: understand relevant information
Appreciating: appreciate nature of ones own stiuation
Reasoning: reason with information
Who created the Traumagenic Dynamics Model?
Finkelhor (1988)
What is the Traumagenic Dynamics model?
Adverse effects of child sexual abuse depend on four factors: Powerlessness Betrayal Traumatic sexualisation Stigma
What is used to measure obstetric complications during childbirth?
Lewis-Murray scale
What plasma level of clozapine should be reached before patient can be considered non-respondent to clozapine?
350-450ng/ml
Non-pharmacological adjuvant to clozapine?
Fish omega oil - ethyl-eicoaspentanoate
What does CATIE stand for?
Clinical Antipsychotic Trials of Intervention Effectiveness
What type of study was CATIE?
Double-blind pragmatic RCT
Patients in CATIE?
1493 patients with chronic schizophrenia across 57 sites from 2001-2004
Medications used in CATIE?
Olanzapine Quetiapine Risperidone Ziprasidone (added later) Perphanazine
How many patients discontinued treatment in 18 months in CATIE?
74%
Which medication had lowest discontinuation rate in CATIE?
Clozapine - 10 months
Olanzapine - 64%
Which medication had highest SE burden in CATIE?
Olanzapine
Which medication caused most anticholinergic sx in CATIE?
Quetiapine
What is CUtLASS?
Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study
Primary outcome of CUtLASS?
QoL at 1 year
Participants in CUtLASS?
1,227 patients with schizophrenia assessed by their clinical team for medication review because of poor response or adverse effects were randomised
Results of CUtLASS?
No advantage of 2nd generation drugs
Those on 1st generation drugs did relatively better
Patients had no clear preference
Who did a meta analysis of 10 RCTs into psychotic depression?
Wijkstra et al.
What did Wijkstra et al. find re medication treatment for psychotic depression?
Combination of antidepressant and antipsychotic is no better than antidepressant monotherapy.
Which combination is superior for psychotic depression compared to monotherapy?
Antidepressant + antipsychotic compared to antipsychotic alone
Point prevalence estimate of depression?
7%
In how many patients does the initial diagnosis of depression change?
56%
What does the initial diagnosis of depression change to in patients?
Schizophrenic spectrum - 16%
PD - 9%
Neurotic, stress-related and somatoform disorders - 8%
Bipolar - 8%
In the community, how many patients with a depressive episode go on to develop mania?
One in ten patients within ten years
Risk of suicide in patients with mood disorders compared to the general population
14 times greater
How many patients with depression will experience a recurrence in 5 years?
50%
What is the risk of a patient with 2 major depressive episodes having a third?
70%
How long should antidepressants be continued in those with moderate or severe depression?
For at least 6 months after remission
Which patients must continue antidepressants for 2 years?
Patients with >2 episodes in recent past or residual impairment
How long should treatment be continued for a single episode of depression?
At least 6-9 months after resolution of sx
What is NNT for antidepressant response?
4-5
What is NNT for antidepressants for remission?
6-7
What did Kirsch’s meta-analysis include
47 trials including 4-8 weeks RCTs of Nefazadone, Venlafaxine, Fluoxetine and Paroxetine.
Weighted mean improvement in Kirsch’s meta-analysis between treatment and placebo?
- 6 points on Hamilton in drug group
7. 8 in placebo
Did Kirsch’s meta-analysis show significance in findings for antidepressant treatment?
Statistical significance but not the three-point Hamilton criterion for NICE for clinical significance.
Magnitude of difference was a function of baseline of severity of depression.
What was Geddes research?
Pooled analysis of data from 31 randomised trials of 4,410 patients taking antidepressants
Average rate of relapse on antidepressant in Geddes research?
18%
Treatment effect duration of antidepressants in Geddes research?
36 months
What is STAR*D?
Sequenced treatment alternative for depression was a pragmatic RCT - 2/3 had comorbid physical disorder, 2/3 had co-morbird psychiatric diagnosis and 40% had onset of depression at <18 years of age - similar to the real world.
How many patients in the STAR*D study?
4041 patients at 25 sites in the USA
How did STAR*D study work?
4 steps of treatment.
Any patient who failed to meet remission criteria at each step was moved up to the next level.
What was Level 1 in the STAR*D study?
Citalopram for up to 12 weeks
What was Level 2 in the STAR*D study?
If after 12 weeks patient failed remission, they were randomized as per their preference to switch to either Bupropion, Sertraline or Venlafaxine, to cognitive therapy or to augment citalopram with Bupropion or Buspirone or to combine citalopram with cognitive therapy.
What was level 3 in the STAR*D study?
Participants who did not achieve remission after 12 weeks in level 2 were randomised to switch to mirtazapine, nortriptyline or augment level 2 treatment with lithium or thyroid medication.
What was level 4 in the STAR*D study?
Patients who did not achieve remission after 12 weeks in level 3 were switched to an MAOI, tranylcypromine or switch to a combination of venlafaxine XR and mirtazapine.
Cumulative remission rate after all 4 steps in STAR*D study?
67%
Cumulative non-response rate in STAR*D study?
33%
How many patients became symptom free after 2 levels in the STAR*D study?
Half of participants
What were the findings at level 3 of the STAR*D study?
No statistical difference between the different antidepressants or augmentation with Lithium or T3.
What were the results at level 4 in the STAR*D study?
No difference between MAOI and Mirtazapine/Venlafaxine XR combination although degree of symptom relief was better with the latter.
Who is at risk of suicidal behaviours when started on antidepressants?
<25 years of age
What did Hawton et al study in 2010?
Toxicity of antidepressants in OD
Which TCAs are more toxic in an OD?
Dosulepin
Doxepin
What are the 5As which can result in apparent resistance to antidepressant treatment?
Alcoholism Lack of adequate dosage Lack of adherence Axis 2 disorders (PD) Alternative diagnosis
Prevalence of Bipolar?
1.5%
What is NCS-replication?
Part of the World Mental Health survey initiative
Lifetime prevalence of bipolar in NCS-replication?
Bipolar 1 - 1%
Bipolar 2 - 1.1%
Suicide rate of Bipolar?
15-18x higher than the general population.
How many people with bipolar experience another MH disorder?
2/3
Who described an extension to bipolar 1 & 2 classification?
Akiskal and Pinto in 1999
How many patients with bipolar get misdiagnosed with depression?
40%
Median time to recover from mania with treatment?
4-5 weeks
Suicide rate in bipolar?
10-19%
15x greater than the general population
Risk of recurrence in people with bipolar?
50% in one year
>70% at 4 years
compared with other psychiatric disorders
What type of depression is suggestive of bipolar?
Psychotic depression in early adulthood
What is rapid cycling?
4 or more episodes in a year - both mania and depression
What % of rapid cyclers are women?
80%
Which medications are associated with mania?
L-Dopa
Steroids
When is ECT considered in mania?
Severely ill manic patients
Treatment-resistant mania
Those who prefer ECT
Severe mania during pregnancy
How long should maintenance treatment be continued for in bipolar?
2 years after episode
5 years if high-risk factors for relapse
Which study did research in adjunctive antidepressant use in bipolar?
STEP_BD
Male:female ratio of schizophrenia?
1.4:1
Median prevalence of schizophrenia?
4.6/1000 - point prevalence
Period prevalence of schizophrenia
3.3/1000
Lifetime prevalence for schizophrenia
4/1000
Lifetime morbid risk of schizophrenia
7.2/1000
Which study looked at schizophrenia in BME communites?
AESOP study
What did the AESOP study find?
All psychoses are more common in BME groups compared to white population in Bristol, SE london and Nottingham
What did ONS 2000 Psychiatric comorbidity survey of households find?
- 5% endorsed at least one psychosis item
- 2% endorsed hallucination item: of this, 4.2% said they heard/saw something others could’nt, 0.7% reported hearing voices
Who did a study into genetic risk of schizophrenia?
Johnstone et al. 2005
What did Johnstone et al. 2005’s study find re schizophrenia?
10% risk present in those with high risk FHx increases to nearly 50% in subgroup of those who have a high score on schizotypal cognition and social withdrawal.
What did the Australian PACE clinic sample show?
20 of 49 high-risk subjects (40.8%) developed a psychotic disorder within 12 months.
Incidence of delusional disorders
0.7-1.3 per 100,000
Prevalence of delusional disorders
24-30 per 100,000
Proportion of people with delusional disorder admitted to hospital
1-3%
Mean age of onset of delusional disorder
39 y/o
Sex ratio of delusional disorder
1.18:1 - M:F
What was the structure of the Iowa study show re outcomes for schizophrenia?
186 people with schizophrenia were followed-up for 35 years.
What did the Iowa study show re outcomes for schizophrenia?
46% of people improved or recovered.
What was the structure of the Bonn Hospital Study in Germany?
502 people with schizophrenia were followed up for 22.4 years.
Results of Bonn Hospital Study in Germany?
22% had complete remission of sx
43% had non-characteristic types of remission (non-psychotic)
35% experienced characteristic schizophrenia residual sx.
Structure of Chestnut Lodge study
446 patients with schizophrenia were followed-up for 15 years
What did the Chestnut Lodge study show re schizophrenia?
36% recovered or functioned adequately.
What did the Vermont longitudinal study show re outcomes of schizophrenia?
68% of patients who underwent a rehab programme had good functioning as per the GAF scale.
What was the International study of Schizophrenia (ISoS 1997)
Follow-up analysis of two major WHO incidence cohorts from 9 countries.
Results from ISoS 1997 study
52% of patients in developing countries were assessed to be in the ‘best’ outcome category (single episode followed by partial or full recovery) compared with 39% in developed countries
What did ISoS 1997 study show re follow-up of patients with schizophrenia?
At 5 years, 73% of those from developing countries were in the best outcome group compared with 52% in developed countries.
Risk of schizophrenia if both parents have schizophrenia
40-50%
Single nucleotide polymorphisms (SNPs) linked to schizophrenia
12p13.33
12q24.11
1q42.2
11q23.2
2q33-34
5q33.2
16p13
7q21
1p21
8p12
17p13
18q21
2q32
Copy Number Variations (CNVs) linked to schizophrenia
2p16.3 deletion
7q36.3 duplication
Hemi deletion of 22q11
Gene of 12p13.33
CACNA1C (L-type calcium channel)
What is CACNA1C important for?
Neuronal function
What do mutations of CACNA1C cause?
Timothy Syndrome
Brugada Syndrom
Gene of 12q24.11?
D-amino acid oxidase
What is D-amino acid oxidase important for?
Degrades d-serine (NMDA co-agonist)
Gene of 1q42.2?
DISC-1
What is DISC-1 seen in?
Scottish family with 1:11 translocation
Disrupted in schizophrenia
Gene of 11q23.2?
Dopamine D2 receptor
Importance of 11q23.2?
Target for antipsychotic action
Gene for 2q33-34?
Receptor tyrosine kinase erbB4
Importance of 2q33-34?
Neuregulin 1 receptor
Gene for 5q22.3?
AMPA receptor subunit 1
Importance of 5q33.2?
Affects synaptic plasticity
Gene for 16p13?
NMDA receptor subunit 2A
Importance of 16p13?
Influences channel conductance and synaptic localisation
Gene of 7q21?
Metabotropic glutamate receptor 3
Importance of 7q21?
Inhibitory autoreceptor
Gene of 1p21?
Micro RNA 137
Importance of 1p21?
Regulates transcription
Gene of 8p12?
Neuregulin 1
Importance of 8p12
Growth factor
Gene of 17p13?
Serine racemase
Importance of serine racemase?
Synthesizes d-serine from l-serine
Gene of 18q21?
Transcription factor 4
Importance of transcription factor 4?
Deletion causes Pitt-Hopkins syndrome
Gene of 2q32?
Zinc finger 804A
Importance of zinc finger 804A?
Affects gene regulation especially in cortical pyramidal neurons
Gene of 2p16.3 deletion?
Neurexin 1
Importance of Neurexin 1?
Involved in synaptic structure
Gene at 7q36.3 duplication?
Vasoactive intestinal peptide receptor 2
Importance of VIP receptor 2?
Regulates synaptic transmission in hippocampus and development of neural progenitor cells in dentate gyrus
Gene at 22q11
COMT coding genes
What does hemi deletion of 22q11 cause?
Velocardiofacial syndrome
Which anxiety disorder is most common in boys?
OCD
Which anxiety disorder has equal distribution between men and women?
OCD
Point prevalence of OCD in adults
1-3%
Point prevalence of OCD in children
1-2%
Lifetime prevalence of OCD
2-3%
Most commonly prevalent psychiatric disorders?
Phobias Alcohol misuse Depression OCD (in that order)
Gender ratio of OCD in community
1.5:1 female:male
What can OCD spectrum disorders be classified into?
Somatic preoccupation e.g. anorexia
Neurological disorders e.g. Tourettes
Impulse control disorders e.g. paraphilias
Anankastic PD
What does PANDAS stand for?
Paediatric autoimmune neuropsychiatric disorders associated with strep infection
What sx does PANDAS produce?
Tics
Fluctuating OCD sx
Anxiety
NIMH diagnostic criteria for PANDAS
Presence of OCD or a tic disorder
Onset between 3 years of age and beginning of puberty
Abrupt onset of sx or a course characterised by dramatic exacerbations of sx
Onset of exacerbation of sx temporally related to infection with GABHS
Abnormal neuro exam during exacerbation
What is found to be elevated in those with PANDAS?
AntiDNAseB or Antistreptolysin O titres
Some may have autoantibodies to neurons in basal ganglia; called basal ganglia antibodies
Treatment for mild-moderate OCD (first line)
Self-help
2nd line treatment for mild-moderate OCD
CBT with ERP (Exposure and response prevention)
3rd line treatment for mild-moderate OCD
SSRIs +/- CBT
1st line treatment for severe OCD
SSRIs+/-CBT
How long do people with severe OCD need to continue SSRIs if they respond well?
1-2 years +/- booster CBT
2nd line treatment for severe OCD
Switch to different SSRI or clomipramine
How many patients with OCD show some sort of improvement to SSRI?
60-70%
NNT for SSRI for OCD?
6-12
When is antipsychotic augmentation with SSRI considered for OCD?
If no response after 3 month trial of maximal dose of SSRI.
Particularly useful if tics.
Point prevalence of PTSD
1%
Lifetime prevalence of PTSD in America for adults?
6.8%
Lifetime prevalence of PTSD in men vs women
Men: 3.6%
Women: 9.7%
How many people exposed to trauma will develop PTSD?
30%
Who did research into factors associated with PTSD?
Bisson 2007
NICE guidelines for initial management of PTSD in primary care
Watchful waiting if sx are mild and present for <4 weeks after trauma
When does NICE recommend px of non-benzo sleeping tablet for PTSD in primary care?
After 4 consecutive nights sleep disturbance
NICE Guidelines for PTSD in secondary care
Psychological treatment regularly and continuously (once a week) by the same person
What does NICE specifically not recommend for PTSD management in secondary care?
Non-trauma focused interventions such as relaxation/non-directive therapy
NICE guidelines for PTSD management in secondary care if sx present within 3 months of trauma
Trauma-focused CBT
When should trauma-focused CBT be offered?
Those with severe PTSD
Those with severe PTSD in first month after traumatic event
Those with PTSD within 3 months of event
How is trauma-focused CBT delivered?
OP; 8-12 sessions (5 if treatment starts within 1 month of event)
NICE guidelines for PTSD if sx present for more than 3 months after trauma
Trauma-focused CBT or EMDR
How many sessions of trauma-focused CBT or EMDR are offered for PTSD sx >3 months after trauma?
12 sessions
Pharmacological treatment for general use for PTSD
Paroxetine
Mirtazapine
Pharmacological treatment for specialist use for PTSD
Amitriptyline
Phenelzine
Which medication is licensed for females only with PTSD?
Sertraline
Who discovered EMDR and how?
Shapiro; used it on herself
Which sx is not needed for GAD which is usually needed for other anxiety disorders?
Avoidance
Lifetime prevalence of GAD
5%
Point prevalence of GAD
2-3%
MZ vs DZ concordance of GAD?
41% vs 4% (MZ vs DZ)
Risk factors for GAD?
Exposure to civilian trauma Bullying Higher number of life events Being first-degree relative of GAD patient Female
What is Hamilton anxiety scale?
14-item scale
Emphasises somatic sx
Definition of clinical recovery of GAD
<7 on Hamilton anxiety scale
Which SSRIs can be used for GAD?
Escitalopram
Paroxetine
Sertraline
Which TCAs can be used for GAD?
Imipramine
Which medications can the herb Valerian interact with?
Loperamide and fluoxetine, causing delirium
Which medications can evening primrose oil interact with?
Phenothiazides, causing epileptic seizures
Point prevalence of social phobia?
2.8%
Duration of medication for social phobia (first line)
12 weeks
How long should drug treatment continue if good response for social phone?
6-12 months
2nd line treatment for social phobia?
Phenelzine
Point prevalence of panic disorder
0.9%
Lifetime prevalence of panic attacks
28%
Lifetime prevalence of panic disorder
4.7%
Mean age of onset of any panic attack
22 years
How does ICD 10 classify panic disorder?
Recurrent, unpredictable panic attacks with sudden onset of palpitations, CP, choking sensation, dizziness and feelings of unreality, often associated with fear of dying/losing control but w/o requirement for sx to have persisted >1 month.
First line treatment for panic disorder
7-14 weeks of CBT (weekly 1-2 hours) completed within 4 months
SSRI
Bibliotherapy
How long do SSRIs need to be continued for panic disorder to assess efficacy?
12 weeks
2nd line drug treatment for long term treatment of panic disorder
Imipramine
Recommendations if initial therapy fails for panic disorder
Add Paroxetine or Buspirone to psychological treatment if partial response
Add Paroxetine while continuing CBT if no response
Prevalence of Hypochondriasis
0.8-4.5%
Treatment for Hypochondriasis
CBT
Group CBT
SSRIs
What can BDD be divided into?
Psychotic
Non-psychotic
Treatment for treatment-resistant BDD?
Fluoxetine with CBT
Prevalence rate of somatisation disorder
1-2%
Gender ratio of somatisation disorder
2:1 female:male
What did Rohricht and Elanjithara (2009) find re MUS?
42% of patients with MUS have primary diagnosis of somatoform disorder
36% had depression medicated by effect of somatic sx
What does ICD 10 classify conversion dsorder as?
Dissociative disorder
Prevalence of dissociative disorder in adults
10%
Recommendation for treatment of dissociative disorder?
Individual psychotherapy; especially structured therapy such as Acceptance and Commitment therapy & DBT
What types of ED are recognised in ICD 10?
Anorexia
Bulimia
EDNOS
How many patients with bulimia have a hx of anorexia?
1/4 - 1/3
Which criteria for anorexia has been eliminated in DSM V?
Amenorrhoea
Prevalence of anorexia in teenage girls
0.5-1%
Prevalence of bulimia in 16-35?
1-2%
Prevalence of anorexia in females per year
19/100,000
Prevalence of bulimia in females per year
29/100,000
Comorbid psychiatric disorders in patients with anorexia?
65% have depression
34% have social phobia
26% have OCD
MZ vs DZ rates of anorexia
55% MZ
5% DZ
MZ vs DZ rates of bulimia
33% MZ
30% DZ
Heritablility of ED?
Significant heritability for anorexia
Not for bulimia
Physical sx of ED
Increased sensitivity to cold GI sx - constipation, bloating Dizziness and syncope Amenorrhoea, low sexual appetite, infertility Poor sleep with early morning wakening
Physical signs of ED
Emaciation, stunted growth and failure of breast development if pre-pubertal
Lanugo on back, forearms and side of face
Russels sign
Swelling of parotid and submandibular glands in bulimia
Perimylolysis
Hypothermia
Bradycardia, orthostatic hypotension, cardiac arrhythmias
Dependent oedema
Week proximal muscles
Endocrinel abnormalities in ED
Low LH, FSH and oestradiol Low T3, T4, Normal TSH Increase in plasma cortisol Raised GH Hypoglycaemia Low leptim
Haematological abnormalities in ED
Moderate normocytic normochomric anaemia
Mild leucopenia with relative lymphocytosis
Thrombocytopenia
Metabolic abnormalities in ED
Hypercholesterolaemia
Raised seum carotene
Low phosphate (refreeding)
Dehydration
Most effective treatment for bulimia?
CBT
Recovery rate for bulimia with CBT
33-50% make full recovery
Therapeutic goals for anorexia?
Engagement
Weight restoration
Psychological therapy - cognitive restructuring
If needed, use of compulsion
What therapies should be considered for anorexia?
CBT/CAT
Interpersonal psychotherapy
Focal dynamic therapy
Family interventions focused on ED
First line SSRI for bulimia
Fluoxetine 60mg OD
Prevalence of PD?
5-13%
Most prevalent PD in psychiatric settings
BPD
Prevalence of any PD in prison?
78% for male on remand
64% for male sentenced
50% for females
Prevalence of PD in prisons
53% of male remand
49% of sentenced
31% of female prisoners
Prevalence of antisocial PD in UK
0.6%
Median prevalence rate per 1000 of paranoid PD
6
Median prevalence rate per 1000 of schizoid PD
4
Median prevalence rate per 1000 of schizotypal
6
Median prevalence rate per 1000 of antisocial
19
Median prevalence rate per 1000 of BPD
16
Median prevalence rate per 1000 of histrionic
20
Median prevalence rate per 1000 of narcissistic
2
Median prevalence rate per 1000 of anankastic
17
Median prevalence rate per 1000 of avoidant
7
Median prevalence rate per 1000 of dependent
7
Median prevalence rate per 1000 of passive aggressive
17
Female:male ratio of BPD?
3:1
What did McLean Study of Adult Development show re BPD?
Prevalence of five core BPD sx declines with rapidity; quasi-psychotic thought, self-mutilation, help-seeking suicide efforts, treatment regressions and countertransference problems
What was Seivewright & Tyrer’s study into PD?
12 year follow-up where 178 out of 202 patients were reassessed for their personality status.
What did Seivewright & Tyrer’s study show?
Personality traits of patients with Cluster B PD became significantly less pronounced after 12 years.
Those with Cluster A and C became more pronounced.
Cluster A PDs?
Paranoid
Schizoid
Schizotypal (in DSM)
Cluster B PDs
Antisocial
BPD
Histrionic
Narcissistic
Cluster C PDs
Avoidant
Dependent
OCD
Risk of psychiatric episode postpartum?
Significant increase in first three months; 80% are mood disorder
Risk of depression during pregnancy
7-15%
Risk of depression in women outside perinatal period?
7%
Relapse rate of depression in patients with a history who are pregnant?
50%
Risk of postpartum psychosis
0.1-0.25%
Risk of postpartum psychosis in bipolar
50%
Risk of postpartum psychosis in patients with a hx of postpartum psychosis
50-90%
Incidence of puerperal psychosis
One per 1000 births
Most used antipsychotic in pregnancy?
Olanzapine
Which antipsychotics are commonly used in pregnancy?
Chlorpromazine Trifluoperazine Haloperidol Olanzapine Clozapine
Treatment of depression in pregnancy
Explore possibility of delaying treatment until 2nd-3rd trimester e.g. CBT
Which antidepressant must be avoided in pregnancy
Paroxetine
Recommended antidepressants in pregnancy?
Nortriptyline
Amitriptyline
Impramine
Fluoxetine
Which patients with bipolar should continue medication?
Severe illness and high risk of relapse
When should discontinuation of mood stabilisers be considered in the pregnant woman with bipolar?
Only if absolutely necessary and followed by frequent monitoring
Which mood stabilisers should be avoided in pregnancy?
Valproate
Combination of mood stabilisers
What should be done if a pregnant women is on Valproate or Carbamazepine?
Folic Acid 5mg OD from at least a month before conception should be px
Vitamin K should be given to mum and neonate after delivery
Risk of SSRIs in pregnancy
13.3% increase in spontaneous abortion
Risk of decreased gestational age and low birth weight
Which drugs increase risk of spontaneous abortion
SSRIs
Mirtazapine
Bupropion
Which antidepressant has least placental exposure?
Sertraline
Risk of malformation if Lithium used in first trimester?
1 in 10
What is Lithium associated with if used in first trimester?
All types of malformation risk increased three-fold
Cardiac malformations risk increased 8-fold
Relative risk of Ebsteins anomaly if on Lithium
10-20 times higher
Risk of relapse if a women stops lithium when pregnancy
70% within 6 months
Faster discontinuation = higher risk of relapse
Risk of any birth defect while on Sodium Valproate?
7.2%
Findings of IQ of children in mothers who took valproate during pregnancy
42% had verbal IQ <80
30% needed special educational support compared to 3-6% of those exposed to other antiepileptic drugs
Which malformation is Lamotrigine associated with?
Cleft palate
Risk of benzo use during first trimester
0.6% risk of cleft palate & CNS & urinary tract malformations
How much lithium is exreted into breast milk?
40-50% of maternal serum level
How much can infant serum level of lithium rise up to?
200% of maternal serum conc (5-200%)
Which benzos are safe during breastfeeding
Low doses of Temazepam and Oxazepam (short acting)
Which benzos should be avoided during breastfeeding?
Diazepam
Alprazolam
Which sedative is safe during breast feeding?
Zolpidem
What did SADHART show re impact of Sertraline on depression?
Little difference in depression status after 24 weeks treatment
Effect of Sertraline greater in patients with severe and recurrent depression
Prevalence of depression in CCF patients
21.5% (2-3 times higher than general population)
Relative risk of mortality in patients with CCF who are depressed
2:1 compared to risk in non-depressed CCF patients
M:F ratio of hypothyroidism
1:6
Rates of depression in patients with Diabetes
2-3 times more common compared to general population
How many patients with erythema migrans develop neuroborreliases?
15%
What is neuoborreliases?
Lyme disease where CNS is affected
Sx of Lyme disease
Back pain worse at night
Facial numbness
Facial palsy
Psychiatric sx of SLE
Depression
Anxiety
Psychosis (Rare)
Physical sx of SLE
Chronic, remitting-relapsing course of febrile illness, butterfly rash, inflammation of joints, kidney and serosa
Lifetime prevalence of depressive sx in MS
40-50% - 3x higher than general population
Suicide rates of people with MS
3% over 6 year period
15% over 16 years
How many patients with MS on steroids develop mild to moderate mania?
33%
Prevalence of post-stroke depression?
35%
What type of stroke has high incidence of anxiety?
Cortical
Prevalence of post-stroke anxiety?
25%
Treatment for mild-moderate post-stroke depression
Increase social interaction
Exercise
Psychosocial intervention
Which antidepressants have good evidence for post-stroke depression?
Fluoxetine
Citalopram
Frequency of depression in epilepsy
30-50%
Frequency of panic disorder in epilepsy
20%
Which type of epilepsy is depression most common in?
TLE
Risk of suicide in patients with epilepsy
10-15%
Mortality rate if epilepsy and depressed
25x higher than general population
Which psychotropic can cause psychosis?
Vigabatrin
Which antipsychotics are less epileptogenic?
Sulpride
Haloperidol
Prevalence of depression in Parkinsons
40-50%
Prevalence of hypomania/euphoria in Parkinsons
2%/10%
Prevalence of anxiety in Parkinsons
50-65%
Prevalence of Psychosis in Parkinsons
40% - drug-related
Prevalence of cognitive impairment in Parkinsons
19% if no dementia
25-40% if dementia
Prevalence of psychiatric sx in Huntingtons at first presentation?
30%
Suicide rates in patients with Huntingtons
4x higher than general population
How many patients with Huntingtons first present with schizophreniform psychosis?
3-6%
When can OCD-like sx occur in Huntingtons?
If basal ganglia involvement
Where is gene for Huntington Disease?
Short arm of chromosome 4, associated with expanded trinucleotide repeat.
When is Huntingtons fully penetrant?
CAG repeats reach 41 or more
When does Huntingtons show incomplete penetrance?
36-40 repeats
How many patients present with Wilsons disease via psychiatric presentations?
20%
Most common psychiatric sx of Wilsons?
Personality disturbance
Mood abnormalities
Cognitive dysfunction
How many patients with Wilsons have cognitive impairment?
25%
What type of dementia occurs in Wilsons?
Frontosubcortial pattern of dementia
How many patients with Wilsons have depression?
30%
What does MRI show in patients with Wilsons?
Intense hyperintensity of midbrain with relative sparing of red nucleus, superior colliculus and part of pars reticulata of substantia nigra
Hypointensity of aqueduct - called Giant Panda sign
Diagnostic criteria of transient global amnesia
Witnessed attacks with information available from observer
Clear-cut anterograde amnesia during attack
Absence of clouding of consciousness & loss of personal identity
Cognitive impairment limited to amnesia only
No accompanying focal neurological symptoms during attack and no signs afterwards
Absence of epileptic features
Attack resolves within 24 hours
Exclusino of patients with HI or active epilepsy
Rate of transient global amnesia
5-10/100,000 per year
Rate of transient global amnesia in those >50 years of age
30/1000,000 per year
Characteristics of transient global amnesia
Abrupt onset of anterograde amnesia characterised by significant new learning deficit.
Mild confusion and lack of insight into problem but intact sensorium.
Episode length of transient global amnesia
6-24 hours
What happens in Fahrs disease?
Idiopathic progressive calcium deposition in basal ganglia
Onset of Fahrs disease
20-40 years
40-60 years
Sx of Kluver-Bucy syndrome?
Emotional blunting
Hyperphagia
Visual agnosia
Inappropriate sexual behaviour
What causes sx of Kluver-Bucy Syndrome?
Bilateral temporal lobe damage
What can be used to control sx in Kluver-Bucy Syndrome?
Carbamazepine
Who described Meige Syndrome?
Henri Meidge in 1904
What characterisis Meige syndrome?
Repetitive blinking, chin thrusting, lip pursing or tongue movements.
What causes secondary Meige’s syndrome?
Antipsychotics
Levodopa
Lewy Body Dementia
Classification of mild HI
PTA <60 minutes
Classification of moderate HI
PTA between 1-24 hours
Classification of severe HI
PTA 1-7 days
What predicts depression in patients with HI?
Proximity of lesion to left frontal lobe
In which type of HI might there by schizophrenia-like psychosis with prominent paranoia?
Left temporal injury
In which type of HI might there by affective psychoses?
Right temporal or orbitofrontal injury
What are dyssomnias divided into?
Primar insomnia Primary hypersomnia Circadian sleep disorders Narcolepsy Breathing related sleep disorders Sleep state misperception
What are parasomnias divided into?
Arousal disorders (NREM sleep) Sleep-wake transition REM sleep parasomnias Sleep bruxism Sleep enuresis
Prevalence of narcolepsy
0.025%
How many patients with narcolepsy have cataplexy?
75%
How many patients with narcolepsy have sleep paralysis?
30%
How many patients with narcolepsy have all 4 sx: narcolepsy, cataplexy, sleep paralysis and hypnagogic hallucinations?
10%
How many patients with narcolepsy have automatic behaviours?
33%
What is strongly associated with narcolepsy?
HLA-DQB1*0602
Low concentration of hypocretin-1 in CSF
Treatment for Cataplexy
Imipramine
Prevalence of OSA
Men 4%
Women 2.5%
What is sleepwalking?
Partial arousal during slow-wave stages 3 and 4.
When do night terrors occur?
During first third of night
During stages 3-4 of NREM sleep
When do REM sleep behavioural episodes occur?
Middle to latter third of night during REM sleep
Diagnostic criteria for REM behavioural sleep disorder?
Movements of body or limbs associated with dreams and at least one of:
potentially harmful sleep behaviour
Dreams that appear to be acted out
Sleep behaviour that disrupts sleep continuity
Diagnostic criteria for restless leg syndrome in patients >12 y/o
Akathisia usually accompanied by paresthesia (core feature)
Motor restlessness
Sx worse at rest
Sx worse at night
Prevalence of restless leg syndrome
3-15%
M:F ratio of restless leg syndrome
1:2
First licensed drug for restless leg syndrome
Ropinirole
Which dopaminergic agents can be used for restless legs?
Nonergot D2 agonists: ropinrole, pramipexole
Bromocriptine and dopaminergic precursors: levodopa/carbidopa
Which anticonvulsants can be used for restless legs?
Gabapentin
CBZ
What is Periodic Limb Movement Disorder?
Periodic episodes of repetitive and stereotyped limb movements during sleep.
Can cause clinical sleep disturbance.
How many patients with PLMS also have Narcolepsy?
45-65%
How many patients with PLMS also have REM sleep behavioural disorder?
70%
What pathology has been linked to PLMS?
Dopaminergic impairment
Fe deficiency
Prevalence of CFS
0.5%
M:F ratio of CFS
1:3
Mean age of onset of CFS
29-35 years
Mean illness duration of CFS
3-9 years
CFS criteria
Persistent or relapsing unexplained chronic fatigue of new onset, lasting at least 6 months and not the result of organic disease or continuing exertion, not alleviated by rest.
Which sx are required for CFS?
Four or more of the following, present for >6 months: Impaired memory/concentration Sore throat Tender cervical/axillary lymph nodes Muscle pain Pain in several joints New headaches Unrefreshing sleep Malaise after exterion
How many patients with CFS have low cortisol?
33%
What do family studies of CFS suggest?
Mutation of cortisol transporting globulin
Effective treatment of CFS?
CBT
Graded exercise therapy
What sx does CFS not have which depression does?
Absence of lack of motivation, guilt, anhedonia
HPA axis in CFS
Downregulation
HPA axis in depression
Upregulation
Lifetime prevalence of panic disorder in those with CFS
17-25%
Lifetime prevalence of GAD in those with CFS
2-30%
What has replaced the diagnostic criteria for pain disorder in DSM IV in DSM V?
Somatic Symptom and Related Disorders (SSD)
What is SSD diagnosis made on?
The basis of positive sx and signs rather than absence of a medical explanation for somatic complaints.
What are the positive sx and signs of SSD?
Distressing somatic sx plus abnormal thoughts, feelings and behaviours in response to these sx
Which DSM IV disorders have been removed?
Somatization disorder
Hypochondriasis
Pain disorder
Undifferentiated somatoform disorder
Who first introduced the term atypical facial pain?
Frazier and Russell in 1924
What is atypical facial pain?
Atypical in distribution, unilateral, poorly localised, lasts most of the day and described as severe ache, crushing or burning.
What is the definition of persistent idiopathic facial pain?
Facial pain that is present daily and persists most of the day.
Pain is confined at onset to limited area on one side of the face, deep ache, poorly localised.
Predictive markers for HIV Dementia
B2-microglobulin and neopterin levels in CSF
CD41 cell counts
Side effects of Zidovudine
Confusion Agitation Insomnia Mania Depression
Side effects of Stavudine and Zalcitabine
Peripheral neuropathy
Side effects of Efavirenz
Neuropsychiatric side effects:
33% depression, 2% psychosis
How many patients on Efavirenz develop neuropsychiatric side effects?
46%
What makes one suspect psychotropic induced catatonia such as NMS?
Rapid onset
Marked rigidity
Autonomic instability without posturing
Total global mortality from suicide
1-2%
How many deaths in England and Wales are from suicide?
1%
Rate of suicide in England and Wales
8 per 100,000 per year
Most common suicide method in men
Hanging
How many deaths by men are from hanging?
40%
Second most common cause of death by men
OD
How many deaths from OD are caused by men?
20%
Third most common cause of death by men
Poisoning by car exhaust fumes
How many men die by poisoning from car exhaust fumes?
10%
Most common method of suicide by women
OD
Second most common method of suicide by women
Hanging
Third most common method of suicide by women
Drowning
How many women die by OD
46%
How many women die by hanging?
27%
How many women die by drowning?
7%
In most countries which age group has the highest rate of suicide?
> 75
Predictors of suicide in the elderly
Depression
Social isolation
Impaired physical health
Personality traits - anxious, obsessive
Suicide due to depression
36-90%
Suicide due to alcohol abuse
43-54%
Suicide due to drug abuse
4-45%
Suicide due to schizophrenia
3-10%
Suicide due to organic mental disorder
2-7%
Suicide due to PD
5-44$
How many patients with a mood disorder will die by suicide?
6-10%
Which patients with depression are at highest risk?
Inpatients
Hx of impulsive and aggressive behaviour
Alcohol and drug misuse
Cluster B PD
How much does the risk of suicide increase if there is a history of a suicide attempt?
40x increase
Lifetime risk of suicide in alcohol dependence
7%
Suicide rate in heavy drinks
3.5x higher than general population
Suicide rate in alcohol use disorders
15x higher than general population
Suicide rate in drug dependence
15x higher than general population
Suicide rate in Anorexia
20-fold higher than general population
When do majority of schizophrenia patients commit suicide?
Active phase of disorder after suffering depressive sx
Global annual suicide rate
1 in 6000/year
Male:female ratio of suicide
2-4:1
Most common age of suicide
15-24 females
25-34 males
Mental disorders without much increase in suicide rate
Mental retardation
Dementia
OCD - if no depression
Risk of suicide within one year of DSH
0.7%
Males: 1.1%
Females: 0.5%
66x more than general population
Diagnosis of those who complete suicide
Major psychiatric disorders
Substance use
Diagnosis of those who attempt suicide
Mental distress
Reactive depression
Cognitive precipitants of those who complete suicide
Guilt
Hopelessness
Cognitive precipitants of those who attempt suicide
Identity difficulties
Emotional distress
How many people who DSH will repeat the act in the next year
20%
How many people who DSH will eventually complete suicide?
10%
Psychosocial factors suggestive of high suicidal intent
Hopelessness Impulsiveness Low self-esteem Recent stressful life event Relationship instability Lack of social support
What scales can be used to assess suicide risk?
SAD PERSONS
Beck Hopelessness
Beck Scale for Suicidal Ideation
Outline the SAD PERSONS score
Sex - 1 if male, 0 if female
Age - 1 if <20 or >44
Depression - 1 if depression present
Previous attempt - 1
Ethanol abuse - 1
Rational thinking loss - 1
Social support lacking - 1
Organized plan - 1 if plan is made and lethal
No spouse - 1 if divorced, widowed, separated of single
Sickness - 1 if chronic, debilitating and severe
What is Beck Hopelessness Scale?
20 T/F statements focused on pessimism about the future.
Scores of Beck Hopelessness Scale
0-3 - minimal risk
4-8 - mild risk
9-14 - moderate risk
15-20 - severe risk
Factors associated with dangerousness
Younger age Males Past hx of criminality and violence Childhood physical or sexual abuse Childhood conduct disturbances Psychiatric diagnosis Conducive environment Specific sx Unemployment
Which specific sx are linked to dangerousness?
Command hallucinations
Agitation
Hostile suspiciousness
Triad of sx of normal prssure hydrocephalus?
Dementia
Gait ataxia
Urinary incontinence
Population prevalence of NPH in the elderly
0.4%
Common features of SDH
Headache
Drowsiness
Altered consciousness
Confusion - fluctuating severity
When might CT not show a SDH?
First 3 weeks as clot is isodense during early phase
Complications of surgical treatment of SDH
Seizures
Re-bleeding
Where is Prion protein coded?
PRNP gene on Chromosome 20
What are the four forms of prion dementia?
Kuru
CJD
Fatal familial insomnia
Gerstmann Straussler Syndrome
Which sign becomes prominent as CJD progresses?
Myoclonus
How many CJD cases are sporadic?
85%
What does MRI show in CJD?
Non-specific basal ganglia hyperintensities
CSF findings in CJD
14-3-3 protein elevated.
Characteristics of vCJD?
Anxiety and depressive sx
Personality changes
Progressive dementia
Ataxia and myoclonus
What is diagnostic of vCJD?
Pulvinar sign; symmetric high-signal-intensity changes affecting pulvinar and medial areas of thalamus and tectal plate on FLAR sequence in MRI
Predicted risk of developing Alzheimers in first-degree relatives
15-19%
5% in controls
Relative risk of Alzheimers if you have a first-degree relative with the disease?
3-4 times relative to the risk in controls
Which genes are associated with early onset Alzheimers?
Presenilin 2 gene
Presenilin 1 gene
Beta amyloid precursor protein gene
Which chromosome is Presenilin 2 gene on?
1
Which chromosome is Presenilin 1 gene on?
14
Which chromosome is beta amyloid precursor protein gene on?
21
Where on chromosome 21 is beta amyloid precurser protein gene found?
Long arm
Describe structure of the beta amyloid protein
42 amino acid peptide that is a breakdown product of amyloid precursor protein
What increases risk of late onset Alzheimers?
Apolipoprotein allele 4
Where can Apolipoprotein allele 4 be found?
Chromosome 19
Risk of Alzheimers if you have one copy of the Apolipoprotein allele 4 gene?
3x
Risk of Alzheimers if you have two copies of the Apolipoprotein allele 4 gene?
8x
Cut-off for MMSE?
24/30
What scale is commonly used to assess severity and stage of Alzheimers?
DRS
What does NPI do?
Rates frequency and severity of a range of neuropsychiatric sx.
What does NPI-NH measure?
Rates of occupational disruptiveness, a measure of caregiver distress.
How long does CAMCOG take to complete?
40 minutes
What does CAMCOG give a score out of?
104
Cognitive areas of assessment tested by CAMCOG?
Orientation Comprehension Perception Memory Abstract Thinking
What does Clock drawing test .. test?
Praxis
Higher executive function
Starting dose of Rivastigmine for Alzheimers?
1.5mg BD
Treatment dose of Rivastigmine for Alzheimers?
6mg BD
Starting dose of Galantamine for Alzheimers?
4mg BD
Treatment dose of Galantamine for alzheimers?
12mg BD
Starting dose of Memantine for Alzheimers?
5mg OD
Treatment dose of Memantine for Alzheimers?
10mg OD
Recommendations from Committee on Safety of Medicines re use of Olanzapine and Risperidone for Dementia?
Each associated with 2x increase in risk of stroke and therefore should not be used
What is the NINCDS-AIREN criteria for vascular dementia?
Evidence of CVD both on examination and brain imaging
Relationship between onset of dementia and CVD
What type of dementia is Binswangers disease?
Subcortical
Characteristics of Binswangers disease?
Slow intellectual decline Slowness of thought Decreased STM Disorientation Motor problems; gait, dysarthria
What does CADASIL stand for?
Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy
Where is CADASIL gene?
Long arm of chromosome 19
How do patients with CADASIL gene present?
Recurrent stroke at age of 40-50
Hx of migraine
How many cases of dementia are lewy body dementia (LBD)?
15-20%
Associated features of LBD pathologically
Lewy-related neuritis Plaques Neurofibrillary tangles Regional neuronal-loss in brainstem Synapse loss Microvacuolation
Where is regional neuronal loss common in LBS?
Brainstem - locus cereleus and substantia nigra
Nucleus basalis of Meynert
How many patients with Parkinsons go on to develop dementia?
10%
What type of deficits are more severe in LBD and Parkinsons vs Alzheimers?
Executive dysfunction:
planning, reasoning, sequencing
FTD accounts for how many cases of presenile dementia?
20%
Which chromosome is linked to FTD?
17
What does SPECT show in FTD?
Disproportionate decrease in blood flow, radio tracer uptake and glucose metabolism in frontal lobe
What causes Picks?
AD
Mutation in Tau gene with complete penetration
Where is the tau gene?
Chromosome 17q 21-22
Which conditions are rarely seen in senile patients?
Progressive supranuclear Palsy
Corticobasal degeneration
Frontotemporal degeneration
Which genes have been identified in familial Alzheimers with early onset?
Amyoid precursor gene - APP
Genes encoding PSEN1 and 2
Characteristic sx of PSP
Supranuclear opthalmoplegia
Pseudobulbar palsy
Axial dystonia
Vertical gaze palsy
Prevalence of delirium on admission to hospital
10-15% of elderly
Point prevalence of delirium in the general population
0.4%
Major pathway implicated in delirium?
Dosral tegmental pathway which projects from mesenchephalic reticular formation to tectum and thalamus
Name the rating scales for delirium
Delirium rating scale - DRS
MMSE
CTD - cognitive test for delirium
CAM - confusion assessment method
Most widely used scale for delirium?
DRS
Advantage of DRS?
Distinguishes delirium from dementia
What is required for DRS use?
Interpretation by skilled clinician
Information from multiple clinical sources
Which delirium rating scale has high sensitivity and specificity?
CAM
What does CAM allow?
Diagnosis of delirium
Incorporated into routine clinical settings
Prevalence of depression in >65 age group
10-15%
How much more common is depression in nursing homes?
2-3 times more common
How many people with dementia have depression?
25%
SPECT findings in late onset depression
Reduced cerebral blood flow, sparing the posterior parietal cortex
NNT for antidepressant use in elderly
4 - similar to other age groups
Depression scales for the elderly
Geriatric depression scale BASDEC Hamilton MADRS Depressive sign scale CSDD PHQ 9
How many items in Geriatric depression scale?
15
Scoring in geriatric depression scale?
> 5 suggests depressive illness
Advantage of geriatric depression scale?
Avoids somatic sx
What does BASDEC stand for?
Brief assessment schedule depression cards
What is BASDEC?
Series of statements in large print on cards which are shown to patients; answer T/F
Why is Hamilton not as appropriate for the elderly?
Somatic items
Advantages of MADRS
Sensitive to change in depression
Disadvantages of MADRS
Not reliably answered by patients with dementia
What does Depressive sign scale consist of?
9 items
Advantage of depressive sign scale?
Helps detect depression in people with dementia
What does CSDD stand for?
Cornell scale for depression in dementia
What is the best validated scale for detecting depression in dementia patients?
CSDD
How does CSDD work?
Interviewer-administered
Using info from both patient and an informant
Factors involved in CSDD
General depression
Biologic rhythm disturbances
Agitation/psychosis
Negative sx
How many items in PHQ 9?
9
Self-report
Advantages of PHQ 9
Easy to use
Sensitive to change
Cognitive impairment in late onset depression
Specific deficits in attention and executive function, consistent with frontal lobe dysfunction
Cognitive deficits in early onset depression
Deficits in episodic memory - consistent with temporal lobe dysfunction
How many patients with pseudodementia develop true dementia within 3 years?
40%
What did Simpson et al’s study show?
Poor response to antidepressants in patients with vascular depression
Drugs used for prevention of CVD might reduce risk of vascular depression
Which antidepressants promote ischaemic recovery?
Dopamine or norepinephrine enhancing agents
What % of mood disorders in the elderly are due to mania?
5-10%
One year prevalence of bipolar among adults >65?
0.4%
Who coined the term paraphrenia?
Kraepelin in 1913
What is late onset psychosis divided into?
Late onset >40 years
Very late onset >60 years
Prevalence of late onset psychosis in the community
0.1-4%
Incidence of late onset psychosis
10-26 per 100,000 per year
Point prevalence of paranoid ideation in the elderly population?
4-6%
How many patients with late onset psychosis present with delusions only?
10-20%
ICD diagnosis of paraphrenia?
No such diagnosis
Patients must be diagnosed either with schizophrenia or delusional disorder
Prevalence of schizophrenia in siblings
7%
Prevalence of schizophrenia in parents
3%
Most prevalent anxiety disorder in the elderly?
Phobic disorders
Least common anxiety disorder in the elderly?
Panic disorder
Lifetime prevalence of drug misuse in the elderly
1.6%
Most common drugs used in OD in the elderly
Benzos
Analgesics
Antidepressants
Psychiatric disorders in elderly who DSH
Depression - half
Alcohol abuse - one third
What did the Monroe County sample find re the elderly and suicide (>50 years)?
Suicide was associated with higher levels or Neuroticism and lower scores on openness to experience
What did Harwood and colleagues found in patients >60 who committed suicide?
Anankastic and anxious traits were associated with both depression and suicidality in the elderly
Prevalence of PDs in the elderly
5-10%
Which PD has the highest prevalence in the elderly?
OCD
Prevalence of OCD PD in the elderly?
3.3%
What medications reduce REM sleep?
TCAs
Impact of SSRIs on sleep
Increase SWS
Reduce REM
What can REM sleep behaviour disorder be an early clinical marker for?
Synucleopathies
Name the syncucleopathies
LBD
MSA
Parkinsons
Prevalence of REM behaviour disorder in Parkinsons?
15-34%
Prevalence of REM behaviour disorder in MSA?
90%
How many men >70 have impotence?
10-20%
What is phase 1 of grief?
Shock and Protest
What does phase 1 of grief involve?
Numbness
Disbelief
Acute dysphoria
What is phase 2 of grief?
Preoccupation
What does phase 2 of grief involve?
Yearning
Searching
Anger
What is phase 3 of grief?
Disorganization
What does phase 3 of grief involve?
Despair
Acceptance of loss
What is phase 4 of grief?
Resolution
When is improvement expected in normal grief?
2-6 months
Percentage of general population who drank alcohol in last week in UK
67% men
53% women
Percentage of adults who drank above recommended limits
55% men
53% women
Percentage of children 11-15 who had drunk alcohol at least once
43%
Percentage of patients who present to primary care that consume alcohol at a harmful level
20%
Annual prevalence of hazardous drinking in UK households
38% men 15% women 27% white adults 18% black adults 8% south asian asults
Peak age of hazardous drinking?
16-19 (women)
20-24 (men)
Number of all hospital admissions that all alcohol related
1 in 16 hospital admissions
1 in 6 ED attencees
Age of death of people who are alcohol dependent
60
Alcohol use during pregnancy
1 in 10
% of adults in the UK 16-59 who took an illicit drug in the last year
8.3%
Popular recreational drugs in the UK
Cannabis 6.4%
Cocaine 1.9%
Ecstacy 1.3%
Percentage of adults 16-24 taking any drug in last year in the UK
16.3%
Percentage of adults 16-59 who had taken a Class A drug in last year
2.6%
Percentage of school pupils who took an illicit drug in last year in UK
12%
Percentage of drug users in last year who use multiple substances
61% if EtOH included
7% if not included
Most commonly reported age of first taking drugs
Cannabis - 16
Cocaine and Ecstacy - 18
Average duration of drug use
Cannabis - 6 years
Cocaine - 4.4 years
Ecstacy - 3.9 years
Which law classifies recreational drugs?
1971 Misuse of Drugs Act UK
Name the Class A drugs
Ecstasy LSD Heroin Cocaine Crack Magic mushrooms Methamphetamine Other amphetamines if prepared for injection
Name the Class B drugs
Amphetamines
Methylphenidate
Pholcodine
Name the Class C drugs
Cannabis Tranquilisers Some painkillers GHB Ketamine
ICD-10 alcohol dependence criteria
At least 3 of the following in last 12 months:
Intense desire to drink alcohol
Difficulty in controlling onset, termination and level of drinking
Withdrawal sx if alcohol not taken
Use of alcohol to relieve withdrawal sx
Tolerance as evidenced by need to escalate dose over time to achieve same effect
Salience
Narrowing personal repertoire of alcohol use
What is salience?
Neglecting alternate forms of leisure or pleasure in life
Criteria for DSM IV alcohol dependence
At least 3 of the following lasting for a month
Consuming alcohol for longer period and in larger amounts than intended
Unsuccessful attempts to cut down
Experiencing withdrawal sx if alcohol not taken
Use of alcohol to relieve withdrawal sx
Tolerance - 50% increase from start
Salience
Failure in role obligations and physical health
Giving up alternate pleasures
Continued use despite knowing harm caused
Changes in alcohol & substance dependence criteria in DSM V
Combines DSM IV categories of substance abuse and dependence into Substance Use Disorder that is measured from mild (abuse) to severe (dependence).
Who created the criteria for alcohol dependence
Edwards & Gross in 1976
What are the criteria for alcohol dependence?
Narrowed repertoire Salience of alcohol-seeking behaviour Increased tolerance Repeated withdrawals Drinking to prevent or relieve withdrawals Subjective awareness of compulsion Reinstatement after abstinence
When do features of alcohol withdrawal start?
Within 12 hours of last drink
Onset of shakes in alcohol withdrawal?
4-12 hours
Onset of perceptual disturbances in alcohol withdrawal?
8-12 hours
Seizure onset in alcohol withdrawal
12-24 hours
Peak of seizure onset in alcohol withdrawal
48 hours
Delirium onset in alcohol withdrawal
72 hours
Prominent sx of alcohol withdrawal
Tremor Diaphoresis Sleeplessness Anxiety GI distress Increased urge and craving for alcohol
How many patients with alcohol withdrawal will get delirium tremens?
5%
Incidence of seizures in untreated alcohol-dependent patients
8%
Risk of seizures in alcohol withdrawal if treated
3%
How many patients with withdrawal seizures go on to develop delirium tremens?
30%
Prevalence of heroin use in the UK
1%
M:F ratio of heroin use
2:1
Age of most treatment seekers of heroin misuse?
20s
Oral bioavailability or morphine
30%
How many patients on benzos for 1-5 months will develop dependence?
15%
How many patients on benzos for a year will develop dependence?
40%
How many 16-29 year olds in the UK have used amphetamines at least once?
22%
Features of withdrawal from cocaine
Intense craving with lack of physical withdrawal sx Dysphoria Anhedonia Irritability Hypersomnolence
When do withdrawal of cocaine sx peak in heavy use?
3 days
How many schedules in the Misuse of Drug Regulations 2001?
Five
Examples of drugs in Schedule 1
Coca leaf
Cannabis
LSD
Mescaline
Regulations of Schedule 1 drugs
No medicinal use.
Supply limited to research or special purposes judged to be in public interest.
Requires Home Office license to possess.
Examples of drugs in Schedule 2
Diamorphine Dipipanone Morphine Remifentanil Pethidine Secobarbital Glutethimide Amphetamine Cocaine
Regulations of Schedule 2 drugs
Special px requirements and safe custody requirements - except for secobarbital.
Stock drugs must be recorded in a register that meets regulations of the 2001 Regulations
Drug stock must only be destroyed in presence of an appropriately authorized person
Schedule 3 drugs?
Barbituates except secobarbital Buprenorphine Diethylpropion Mazindol Meprobamate Pentazocine Phentermine Temazepam
Regulations of Schedule 3 drugs
Subject to special px requirements except for temazepam.
Not subject to safe custody requirements except for buprenorphine, diethylpropion, flunitrazepam and temazepam.
No need to keep register.
Requirement for retention of invoices for 2 years.
Schedule 4 Part 1 drugs
Benzos except temazepam
Zolpidem
Schedule 4 Part 2 drugs
Androgenic and anabolic steroids Clenbuterol HCG Non-human chorionic gonadotrophin Somatotropin Somatrem Somatropin
Regulations of Schedule 4 drugs
Not subject to special px or safe custody requirements.
No need for register.
Requirement for retention of invoices for 2 years.
Schedule 5 drugs
Weak preparations of drugs in other schedules e.g. codeine
Regulations of Schedule 5 drugs
Exempt from all CD regulations except need to keep invoices for at least 2 years
What should all CD px have?
Patients full name, address and age
Name and form of drug written
Dose written
Total quantity of preparation or number of dose units to be supplied in both words and figures
Patient identifier number (NHS)
Signed by prescriber along with GMC number - must be handwritten
How long are px of Schedule 1-4 drugs valid?
28 days
Which drugs cannot be px on repeat prescriptions?
Schedule 2 & 3 drugs
What is Varenicline?
Partial agonist at alpha4beta2 subunit of nicotinic acetylcholine receptor
Who first described central pontine myelinolysis?
Adams et al in 1959
What happens in central pontine myelinolysis?
Demyelination of central portion of base of pons
Sx of central pontine myelinolysis?
Pain sensation in limbs Bulbar palsy Quadriplegia Disordered eye movements VOmiting Confusion COma/locked-in syndrome
Which non-alcoholic diseases can result in central pontine myelinolysis?
Wilsons Malnutrition Anorexia Burns Cancer Addisons Severe hyponatraemia
Heritability of alcohol use disorders
0.51-0.66
Risk of alcohol dependence in individuals with both first and 2nd degree relative
4x increase
Risk of alcohol dependence in those with affected first degree relative
2x increase
Genetic loci linked to alcohol misuse
Chromosomes 4p13-12 (GABRB1) Chromosome 5q33-34 Chromosome 11q23.1 Chromosome 12q24.2 Chromosome 4q22 cluster
Role of chromosome 12q24.2
Aldehyde dehydrogenase variants
Role of chromosome 4q22
Alcohol dehydrogenase polymorphism
Screening tools used for alcohol disorders
AUDIT
CAGE
MAST
What setting is AUDIT made for?
GP
Sensitivity of AUDIT
83% males
65% females
How can AUDIT be carried out?
Brief structured interview or
self-report questionnaire
What subtype of AUDIT can be used in ED?
FAST - fast alcohol screening test
What is the most widely used alcohol screening tool?
CAGE
Disadvantages of CAGE
Does not include frequency of alcohol use, levels of consumption or episodes of heavy drinking - all of which identify patients in early stages of alcohol misuse.
Who conducted a study into use of CAGE in GP?
Aertgeerts et al. 2001
Sensitivity of CAGE in primary care
62% males
54% females
What does MAST stand for
Michigan Alcohol Screening test?
Who was MAST developed for?
Detecting dependent drinkers
Structure of MAST
25 questions related to respondents self-appraisal of problems associated with excessive drinking
Sensitivity of MAST
86-98%
Specificity of MAST
81-95%
Drawbacks of MAST
Focus is on lifetime rather than current occurrence of alcohol problems.
Can therefore miss early stages of alcohol misuse
How long is amphetamine present in urine?
Up to 48 hours
How long are benzos present in urine?
Up to 3 days
How long is cannabis present in urine if occasional use?
Up to 3 days
How long is cannabis present in urine if heavy use?
Up to 4 weeks
How long is cocaine present in urine?
6-8 hours
How long is cocaine metabolite present in urine?
2-4 days
How long is codeine present in urine?
48 hours
How long is methadone present in urine?
3 days or more
How long is heroin present in urine?
1-3 days
How long is morphine present in urine?
2-3 days
How long is PCP present in urine?
3-8 days
How long is LSD present in urine?
<24 hours
False positive test producer of PCP
Dextromethorphan
False positive test producer of marijuana metabolites
Ibuprofen
False positive test producer of opiates?
Tonic water
False positive test producer of amphetamines
Phenylephrine decongestants
What are successive episodes of alcohol withdrawal associated with?
Increasing severity and complications
What drugs other than benzos can be used in alcohol detox?
Chlormethiazole
Carbamazepine
Anticonvulsants
Haloperidol
Why should Chlormethiazole be avoided?
Risk of respiratory depression, especially when alcohol is consumed during detox
First-line alternative to benzos in alcohol detox?
Carbamazepine
What is Acamprosate?
Taurine derivative
Inhibits glutamatergic NMDA receptor function
Balances GABA-glutamate imbalance seen in alcohol dependence
Odds ratio for abstinence with acamprosate vs placebo
1.73
NNT for acamprosate
11
What is naltrexone licensed for in the UK?
Ralapse prevention in alcohol dependence
What has naltrexone been shown to be superior that placebo in?
Maintaining abstinence Relapse rates Time to first drink Reduction in number of drinking days Reduction in craving Improvement in GGT
NNT of naltrexone
9-11
How does Nalmefene work?
Opioid receptor modulator
Anatagonist at mu and delta receptors
Partial agonist at kappa receptors
When is Nalmefene recommended?
To reduce alcohol consumption in dependent individuals with high drinking level risk after 2 weeks of initial assessment and without physical withdrawal sx and who do not require immediate detox
What is the definition of high drinking risk level as per WHO?
> 60grams/day in men
>40grams/day in women
How long should Disulfiram be continued if initial beneficial effects?
3-6 months
In whom can SSRIs be helpful for alcohol misuse?
Improve drinking outcomes in Type 1 alcoholism
In whom can SSRIs be harmful for alcohol misuse?
Worsen outcomes in Type 2 Alcoholism
What was project MATCH?
Multisite (9) USA based RCT of 1726 patients testing the hypothesis that matching patient characteristics to specific treatments would improve alcohol dependence.
What did project MATCH find?
Patients with low support for drinking derived more benefit from motivational enhancement therapy.
Readiness to change and self-efficacy were the strongest predictors of long-term drinking outcomes.
What was the UKATT?
Multicentre (7) pragmatic effectiveness RCT of 742 patients comparing MET and Social Behaviour and Network therapy.
Who did a meta-analysis into therapies for alcohol dependence
Slattery et al 2003
What is the FRAMES approach to alcohol?
Feedback of risks Responsibility highlighted Advised to abstain or cut down Menu of alternative options Empathic interviewing Self-efficacy enhanced
Which drugs should be used in opioid withdrawal if short duration is desirable
Alpha 2 adrenergic agonists
Buprenorphine
Relapse rates of smoking after 6 months?
8%
How many smokers quit without assistance?
5-10%
How long is nicotine replacement therapy (NRT) given for?
2 weeks
How many patients are compliant with patch NRT?
82%
Who is Bupropion not licensed for in smoking cessation?
Adolescents
Pregnant women
Contraindications for Bupropion?
Hx of seizures or ED
What was pathological gambling classified as in DSM IV?
Impulse Control disorder
Prevalence of compulsive buying
2-8%
Gender ratio of compulsive buying
> 80% are females
How many fitness users use anabolic steroids?
13%
How many young people in Europe have taken legal highs in the past year?
5-10%
When should detox for opioid use be used in pregnant women?
Middle trimester
If done in first trimester - abortion risk
Laster trimester - possible premature birth
What needs to be done if a woman starts pregnancy while on methadone
Reduce 1mg every 3 days
Fetal monitoring
What dose of methadone is advocated during maintenance while pregnant
15mg
Calculation for odds
Probability / 1 - probability
Calculation for probability
Odds / 1 + odds
