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Psychiatry > Symposium 4 - Child and Adolescent > Flashcards

Symposium 4 - Child and Adolescent Flashcards

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1
Q

In CAHMS, what is the criteria for a child to be seen by a psychiatrist?

A
  1. Mental illness in presentation

2. Some kind of functional impairment OR risk

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2
Q

What are potential functional impairments in children associated with mental illness.

A

With school, relationships (family, friends), hobbies

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3
Q

What are potential risks for children and adolescents with mental health problems?

A 
Self harm 
Suicide
Drugs 
Abuse 
Alcohol 
Exploitation 
Grooming 
Running away
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4
Q

What are the three sections of investigating mental health in children and adolescents?

A

Presentation (recently)
Other background (previously)
Mental state examination (right now)

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5
Q

How do you investigate presentation?

A

Presenting complaint + History of presenting complaint

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6
Q

What are the 4 Ps in relation to formulation in psychiatry?

A

Predisposing
Precipitating
Protective
Perpetuating

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7
Q

In CAMHS, what are important factors to consider in the past psychiatric history?

A

Counselling

Therapy

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8
Q

In CAMHS, what are important physical factors to consider when taking a psychiatric history?

A

Seizures (temporal lobe epilepsy)

Head injuries

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9
Q

What sections do you consider in a psychiatric history when taking a history from a child or adolescent?

A 
Past psychiatric 
Past medical 
Meds and allergies
Social and habits 
FH (psychiatric and physical)
Personal 
Developmental
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10
Q

List the sections of the mental state exam for children and adolescents.

A 
Appearance
Behaviour
Speech
Mood 
Thoughts 
Perception 
Cognition 
Risk 
Insight
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11
Q

What tool is used to understand the cognitive profile of children and young people?

A

WHISC test

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12
Q

What are “Hopes for change” ?

A

Ask about goals of child and parents

Ask about expectations

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13
Q

What are assessment principles of psychiatric history taking?

A

Biopsychological approach, multiple perspectives and relationships, communication

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14
Q

List biological factors that may contribute to a young persons mental health.

A

Genetics, neurodevelopment insults, illness

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15
Q

List psychological factors that may contribute to a young persons mental health.

A

Temperement, attachment style, psychological attributes e.g impulsivity, low self esteem, perfectionism

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16
Q

List social factors that may contribute to a young persons mental health.

A

Relationships, hobbies, interests, religious faith, school, neighbourhood, criminality, finances

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17
Q

What type of studies are increasingly being used to identify genetic risk factors for psychiatric disorders?

A

Genone Wide Association Studies

Twin studies

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18
Q

What are developmental influences on psychopathology?

A

Genetics
Family history
Intrauterine and perinatal factors
Environmental factors

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19
Q

List intra-uterine and perinatal factors of development of psychopathology.

A 
Maternal health 
Substance misuse
Toxins 
Drugs
Endocrine environment 
immune environment 
premature birth 
twinning
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20
Q

What are signs of fetal alcohol syndrome/

A

Growth retardation

Neuro-developmental effects: sensorimotor, cognitive development, executive function, language, ADHD, DCD, LD

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21
Q

What is poor white matter connectivity associated with?

A

Cognitive instability
ADHD
Poor concentration
Distractibility

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22
Q

List common psychiatric problems in children.

A

Learning difficulties
Conduct disorders e.g ODD
Combined ADH or ADD or hip-lmp subtypes
Anxiety disorders

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23
Q

List environmental factors that can influence the psychiatry of a child.

A 
Relationships 
Parenting skills 
Marital harmony 
Nutrition 
Poverty 
Abuse/neglect 
Discipline 
Day-care/schooling
Life events 
Physical disability 
Attachment e.g lack of bonding
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24
Q

How does early life stress influence function of the brain?

A

Influences function of limbic circuit including amygdala

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25
How does the brain adapt to a hostile environment?
Experience of adversity
26
List concepts in psychological development.
``` Reward-based Executive function Delay-aversion Sharing emotion and empathy Expressed emotion ```
27
What is the hypoactive reward response?
Application of reward deficiency model "Addiction" Increased delay aversion
28
What is operant conditioning?
Dopamine neurons fire when you associate and action with a subsequent reward
29
Give an example of a test used to look at delay-aversion.
Marshmallow test
30
What is the relationship between delay-aversion and ADHD.
Inability to wait and maintain attention in the absence of immediate reward
31
What is expressed emotion related to?
Increased rate of relapse from chronic illness Schizophrenia, Depression, ADHD Physical illness (epilepsy, CF, DM, Asthma)
32
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
33
Not going to school is associated with what mental health disorders?
Anxiety, conduct disorder, autism, depression, OCD
34
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 ```
35
Discuss the biological cause of anxiety in childhood.
Amygdala activity suppressed by right ventrolateral cortex when labelling emotions
36
What is separation anxiety?
Fear of leaving parents and home
37
What is social phobia?
Fear of joining group
38
List the 3A's of anxiety.
Anxious thoughts and feelings Autonomic symptoms Avoidant behaviour
39
List factors that can affect school attendance.
``` learning difficulties bullying lack of friends lack of parental attention/concern maternal depression ```
40
Describe the emotional contagion in childhood anxiety.
Child fearful --> fearful parent --> fearful doctor
41
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
42
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
43
What medication can you give to children with anxiety?
Fluoxetine (SSRI)
44
What are autistic spectrum disorders?
Syndromes of persistent, pervasive and distinctive behavioural abnormalities
45
What is the etiological factors for autism?
M>F (3:1), Highly heritable, comorbid with congenital or genetic disorders e.g rubella
46
What are distinctive features of ASDs?
Reciprocity Language problems Obsessions
47
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
48
How do you manage ASD?
``` Recognition and description Establish needs Appreciate the can't and won't Reduce demands --> reduce stress --> increase coping Psychopharmacology ```
49
What conditions fall under Hard to manage children (H2M)?
Oppositional defiant disorder (ODD) | Attention deficit hyperactivity disorder (ADHD)
50
What are signs of ADHD?
Aggression is impulsive Poor cognition control and ability to sustain a goal Often remorseful Resistant to poor behavioural management
51
Does ADHD or ODD have the strongest genetic component?
ADHD
52
Discuss ODD.
Relates to temperament - irritable and headstrong Behaviour is learned More likely to result from impaired parenting
53
What are outcome risks of H2M children?
Antisocial behaviour, substance misuse, long-term mental health problems
54
How are H2M children managed?
``` Parent training Multi-systemic therapy Meds - stimulants (Rital/methylphenidate), atomoxetine, guanfacine School interventions Treat comorbidity Voluntary organisations ```
55
What are SEs of methylphenidate used for ADHD?
Appetite, weight and sleep disturbances
56
What is the ABCD of dementia?
ADLs Behavioural and psychiatric symptoms of dementia Cognitive impairment Decline
57
What re cognitive features of dementia?
Dysmnesia plus one or more of: dysphasia, dyspraxia, dygnosia, dysexecutive functioning Functional decline
58
List neuropsychiatric disturbances linked with dementia.
``` Psychosis Depression Agitation Anxiety Altered circadian rhythms ```
59
What re two types of dysphasia/
Expressive and receptive
60
What is dyspraxia?
Inability to carry out motor tasks
61
What is 'sundown' common in dementia patients?
Get more agitated late afternoon
62
What is the characteristic sign of vascular dementia?
Step-wise progression
63
What is the most common type of dementia?
Alzheimer's
64
What causes a dementia syndrome?
Different pathologies - e.g overlap between different types
65
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
66
What are differentials for dementia that need to be excluded?
Delirium and depression
67
What basic cognitive tests are carried out for dementia?
MMSE | MOCA
68
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
69
What imaging would you organise for suspected Alzheimer's?
CT or MRI or SPECT | MEDIAL TEMPORAL ATROPHY ON BOTH LOBES
70
What is dementia with Lewy bodies?
Dementia Amnesia not prominent Deficits of attention, frontal executive, visuospatial Fluctuation Visual hallucinations Parkinsonism Psychotic symptoms
71
What type of drugs do Lewy body Dementia patients have a sensitive to which complicates treatment?
Antipsychotics
72
What scan is used to determine Lewy body dementia?
DATScan
73
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
74
What scan will confirm frontotemporal dementia?
Axial MRI - cerebral atrophy in frontal and temporal regions
75
What are drug treatments prescribed for dementia?
Acetylcholinesterase inhibitors e.g donepezilm rivastigmine, galantamine ``` Antipsychotics (risperidone, quetiapine, amisulpride) antidepressants Anxiolytics Hypnotics Anticonvulsants ```
76
What drug is prescribed for Alzheimers?
Memantine
77
What is the benefit of cholinesterase inhibitors for dementia?
Improve cognitive function and non-cognitive symptoms e.g ADL, longer at home
78
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
79
What are abnormal symptoms from grief/bereavement?
``` Persistent beyond 2 months Guilt Thoughts of death Worthlessness Psychomotor retardation Psychosis Prolonged and marked functional impairment ```
80
What is the rate of suicide in elderly?
Same as for under 25 | M>F
81
What are common triggers for suicide in elderly/
``` Loneliness Widowed Ill health Chronic pain Recent life events ```
82
How do you manage schizophrenia in elderly/
Neuroleptics Increased social contact Compulsory admission
83
What are risk factors for schizophrenia in elderly/
Social isolation Genetic Sensory loss
84
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?
85
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
86
At what BMI is considered anorexic?
15% below ideal body weight/ B,MI 17.5 or less
87
What suggests anorexia nervosa in relation to menstrual cycles?
Absence of menstrual cycle or amenorrhoea (greater than 3 cycles)
88
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 ```
89
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
90
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 ```
91
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
92
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
93
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 ```
94
What medications can be abused to try get rid of calories?
Excessive caffeine, stimulant consumption - laxatives, ipecac, pain killers
95
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
96
What are psychological consequences of eating disorders?
Depression Anxiety Obsessionalitu Loss of concentration on anything but food
97
What are social consequences of eating disorders?
Forced to lie and cheat or steal Withdraw from friendships and lose interest in sexual relationships
98
What are potential physical consequences of eating disorders?
``` Prolonged QTc --> arrhythmia Seizures Infections Anaemia Bone loss Fertility problems Hypokalaemia Disruption of growth and development ```
99
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
100
What psychiatric disorder has the highest mortality rate?
Anorexia nervosa
101
What is the average time for recovery from anorexia nervosa?
6-7 years
102
How can anorexia nervosa patients be helped?
``` Re-feeding CBT Mantra SSCM IPT Fluoxetine Olanzapine (antipsychotic) Specialist family work ```
103
What is the only evidence based medication for eating disorders.
Olanzapine - feel less anxious, helps sleep, blocks intrusive thoughts
104
What are organic mental disorders?
Due to common demonstrable aetiology in cerebral disease, brain injury or other insult leading to cerebral dysfunction
105
What is the difference between primary and secondary organic mental illness?
Primary - direct effect on brain Secondary - systemic disease that affects the brain
106
List psychiatric disorders that have an organic basis?
Schizophrenia BAD Melancholia
107
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
108
When can organic mental illness occur?
Any age - most start in adult or later life
109
List acute/subacute organic mental disorders.
Delirium Organic mood disorder Organic psychotic disorder
110
List chronic organic mental disorders.
Dementia Amnesic syndrome Organic personality change
111
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
112
What are physical signs of delirium?
``` Tachycardia Hypertension Diaphoresis Dilated pupils Fever ```
113
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 ```
114
What medications can be given for delirium?
Avoid sedation unless required for safety
115
What is the difference between delirium and encephalopathy/
``` Delirium = psychiatric presentation Encephalopathy = description of underlying process ```
116
Give examples of encephalopathies?
Hepatic, Wernicke's, HIV
117
What are signs of hepatic encephalopathy?
General psychomotor retardation Drowsiness Fluctuating confusion Asterixis
118
List examples of organic mental disorders.
Delirium Encephalopathies Dementia Amnesic syndrome
119
What is amnesic syndrome?
Syndrome of impairment of recent and remote memory
120
What are signs of amnesic syndrome/
``` Immediate recall preserved New learning reduced Anterograde amnesia Disorientation retrograde amnesia Confabulation Perception and other cognitive functions preserved ```
121
What are the most common causes of amnesic syndrome?
Alcohol | Poor nutrition
122
How do you treat amnesic syndrome?
Depends on cause Prevent alcohol amnesic syndrome
123
How do you prevent alcohol amnesic syndrome?
``` Months - years Pabrinex (vitB1) Oral thaimine Abstinence form alcohol MDT rehab ```
124
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
125
What IQ suggests intellectual impairment?
Less than 70
126
What is the gold standard scale used to measure intelligence and indicate intellectual impairment/
Weschler
127
Discuss the Weschler classification scale used to classify ld.
Mild 50-69 Moderate 35-49 Severe 20-34 Profound <20
128
Discuss aetiology of learning difficulties.
Genetics - single gene (Fragile x), micro deletion (DiGeorge), chromosomal (Down syndrome) Infective Toxic Trauma Idiopathic
129
Give examples of infective causes of learning disability.
Ante-natal e.g rubella Post-natal e.g meningitis
130
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 ```
131
What is the commonest aetiology of learning difficulties?
Unknown
132
What is the link for psychiatric disorders and learning difficulties?
More severe LD has higher prevalence of psychiatric disorders
133
What are psychiatric assessment areas for learning difficulties?
Aetiology of LD Associated biomedical conditions Severity of LD Consequences e.g forensic history
134
What are common mental health problems associated with LD?
OCD Autism Over-activity syndromes Self-harm
135
What questionnaire can be given to patient if considering depression in general practice?
PHQ-9 Depression
136
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
137
In primary care, what would be the first line medications prescribed for depression?
SSRI - e.g fluoxetine, citalopram
138
What are Med-3 forms?
Fit for work forms
139
What are main side effects from SSRI?
Gastric - dyspepsia, diarrhoea, N&V
140
What is the normal follow-up in primary care for antidepressants?
2 weeks after starting, intervals of every 2-4 weeks for 3 months
141
How long do you recommend patients to remain on antidepressants after remission?
6 months - up to 2 years
142
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
143
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
144
What should you do if you suspect bipolar disorder in primary care?
Refer/ discuss with secondary care
145
In primary care, what would you offer to a patient with a generalised anxiety disorder?
Active monitoring GAD-7 scoring SSRI Psyhchoeducational groups
146
What should you not prescribe for GAD?
Benzodiazepines, antipsychotics
147
What do you prescribe for management of panic disorders?
Psychological therapy - CBT Self-help SSRI - sertraline
148
What should you NOT prescribe for panic disorders?
Fluoxetine Avoid benzodiazepines/sedating antihistamines/antipsychotics
149
How do you treat social anxiety disorder/
CBT | Medication - sertraline or escitalopram
150
What is prolonged grief disorder?
MARKED DISTRESS AND DISABILITY CAUSED BY THE GRIEF REACTION and PERSISTENCE FOR MORE THAN 6 MONTHS
151
What are treatment options for grief disorder?
Counselling | Antidepressants for co-morbid depression
152
What is the criteria for diagnosis of OCD?
Obsessions and compulsions must be time consuming >1 hour, or cause significant distress or functional impairment
153
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
154
List parasomnias.
Restkess legs, sleep walking/talking/terrors/teeth grinding
155
How do you treat insomnias?
Sleep hygiene CBT-I Melatonin For >55Y, <13 weeks use
156
What monitoring do you need to do for lithium?
TFTs, kidney function - 6 monthly 3 monthly checks
157
What are common side effects of lithium?
``` Fine tremor Dry mouth altered taste Increased thrust Urinary frequency Mild nausea Weight gain ```
158
What are signs of lithium toxicity?
``` Confusion Ataxia Coarse tremor Slurred speech Blurred vision Seizures D&V Muscle weakness Lethargy ```
159
List reasons for increased prevalence of mental health disorders in general hospitals?
Challenges of physical illness | Treatment of physical illness
160
What mental health problems are less commonly seen in general hospitals?
Schizophrenia BAD Severe depression
161
What illnesses is depression common in?
Chronic illness | Neurological diseases
162
With regards to self-harm, what percentage of patients will repeat within one year?
15-20%
163
What is the most common drug taken in overdose?
Paracetamol
164
What are functional mental health disorders?
Medically unexplained symptoms
165
What mental disorders are classed as functional disorders?
Dissociative disorders | Somatoformin disorders
166
What are symptoms of functional disorders?
Present in all specialities e.g IBS, fibromyalgia, chronic fatigue syndrome FND presents more with psychological symptoms
167
What causes rebound mania in association with lithium use?
Dose to low
168
Doe lithium have a large or narrow therapeutic index?
Narrow
169
When does postpartum psychosis occur?
within days to 6 weeks
170
When does postnatal depression occur?
Within 6 months
171
Define Agraphia
inability to write
172
Define Alexithymia
sub clinical emotional blindness
173
Define Cyclothymia
relatively mild mood fluctuations
174
Define Dyscalculia
difficulty dealing with numbers
175
Define Anhedonia
lack of pleasure/interest
176
Define Catatonia
immobility, stupor
177
Define Dysarthia
difficulty articulating speech
178
Define Dystonia
involuntary muscle spasms/contractions

Psychiatry (5 decks)

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