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351 Cards in this Set
- Front
- Back
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response rate of melancholy depression sufferers to TCAs compared to SSRI's are...
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twice as high
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what is the comparative efficacy of TCAs and SSRIs for sufferers of non melancholic depression?
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roughly equivalent
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how do the onset of depression and anxiety differ?
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anxiety typically has an earlier onset
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how does therapy compare to AD's in;
- mild to moderate depression - severe depression |
- mild to moderate = similar efficacy
- severe = AD efficacy greater then that of therapy |
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what types of psychological therapy have level 1 evidence for efficacy in mild to moderate depression?
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- CBT
- interpersonal therapy - behavioural activation strategies - structured problem solving |
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for which type of depression does combination therapy have the strongest evidence?
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chronic AND moderate to severe depression
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major side effects of SSRIs are...
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- GI discomfort (diarrhoea, constipation, maybe GIT Bleeding)
- sexual dysfunction - CNS effects (sedation, fatigue) - headache, nausea and agitation - usually settle after a week |
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major side effects of TCAs are...
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- anticholinergic effects (M blockade: cant see, cant pee, cant poo, cant chew {dry mouth}, hearts racing, heads confused)
- sedation and increased appetite (H1 blockade) - orthostatic hypotension (alpha blockade) |
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the major side effects of SNRIs are...
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- activation (agitation, palpitations, hypertension, diaphoresis)
- sexual dysfunction - nausea, dry mouth S = same SD as SSRIs N = sympathetic system = activating features |
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the major neurotransmitters implicated in the following types of depression are;
- psychotic - melancholic - non melancholic |
- psychotic = dopamine
- melancholic = noradrenaline - non melancholic = serotonin |
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what area of the brain has been shown to have some level of atrophy in depression?
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hippocampus
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is bipolar more common in men or women?
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approximately equal
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what percentage of UNTREATED bipolar sufferers commit suicide?
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10-15%
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key feature of type I vs type II bipolar...
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type I = one manic episode +/- additional hypomanic or depressive episodes
type II = at least one hypomanic episode and one MDE |
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causes of secondary mood disorders include...
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V = vascular - MI, stroke
I = infectious - encephalitis, meningitis N = neoplastic - neuroendocrine tumour, brain tumour, any cancer D = degenerative - MS, huntingtons, alzhemiers I = intoxication/deficiency - recreational drugs, wernickes encephalopathy C = congenital A = autoimmune T = trauma E = endocrine/metabolic - hypothyroidism, diabetes, hypopituitarism |
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major depressive episode - major criteria and minor criteria include...
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depressed mood (MAJOR CRITERIA)
plus SIGECAPS s = sleep I = interest/pleasure deficit - other MAJOR CRITERIA g = guilt/worthlessness e = energy c = concentration a = appetite p = psychomotor retardation s = suicidal ideation |
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over what period must the symptoms be experienced for a major depressive episode to be dx?
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2 weeks, 5 + of the symptoms listed, 1 must be a major criteria
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what other caveats are there for a MDE to be dx?
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- episode must not be explained by bereavement
- episode must not meet criteria for a mixed episode - episode must cause functional impairment (e.g. social, occupational) |
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criteria for a manic episode are...
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FIDGETS = 3 or more + persistently elevated/irritiable mood for 1 week or more
- flight of ideas - insomnia - distractibility - grandiosity - energetic - talkativeness - socially inappropriate behaviour |
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for a mixed episode to be dx there must be...
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symptoms of both a manic and a MDE for each day of at least a week
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how many MDEs are required for MD to be diagnosed?
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1 or more
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lifetime prevalence of depression in australia is...
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10 - 20% (1/4 females, 1/6 males)
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psychosocial risk factors for major depression include...
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- recent adverse life event (relationship breakdown, bereavement)
- childhood events (neglect, abuse) - significant physical illness - post partum - social circumstances (isolation, unemployment) |
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what are the 2 types of melancholic depression
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structural = later onset, associated with microvascular disease (HTN, vasculitis)
functional = usually onset < 30, greater genetic predisposition |
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features suggestive of a secondary depression include...
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- rapid onset
- late initial onset - treatment refractory - neurological symptoms - associated major illness - atypical depression features (hallucinations, hypersomnia) |
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medications associated with secondary depression include...
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- beta blockers
- antihypertensives - PD treatments - corticosteroids |
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which anxiety disorder most commonly precedes MDD?
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GAD = GENERALISED ANXIETY DISORDER
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withdrawal symptoms can be seen commonly in which ADs?
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- TCAs = cholinergic rebound effects (hypersalivation, diarrhoea, abdo cramps, sleep disturbance)
- venlofaxine (SNRI), paroxetine, fluvoxamine = dizziness, headache, nausea, anxiety, insomnia, parasthesia |
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which 3 SSRIs cause CYP 2D6 inhibition and what does this put them at risk of?
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- paroxetine, fluoxetine and sertraline
- significant risk of drug interactions - especially a reduction in risperidone metabolism |
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which SSRI has the lowest risk of drug interactions?
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citalopram
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what classes are the following ADs;
- reboxetine - mirtazapine - duloxetine |
- NARI
- NaSSA (selective serotinin and alpha antagonist) - SNRI |
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what is the limitation of SNRIs compared to SSRIs
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typically a greater side effect profile
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which antidepressants present the biggest risk in OD?
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TCAs and MAOIs
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what is the mechanism of action of TCAs
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inhibition o f uptake of serotonin and noradrenaline by presynaptic nerve terminals
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what is the major risk of MAOIs to users?
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- hypertensive crisis
- caused by excessive build up of dietary consumed tyramine which is broken down by MAOa (therefore risk does not apply to MAOB-Is) - tyramine triggers monoamine release (noradrenaline, dopamine etc) |
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main side effect of ECT...
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- transient cognitive impariment
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features of atypical depression include...and when is it often seen?
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- hypersomnia, hyperphagia, impulsivity, irritability
- often in bipolar depressive episodes |
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people with 1st degree bipolar relatives are how much more likely to develop bipolar disorder themselves...
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7 times
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how many episodes an in what time frame must a person with BPD experience to be classified as in rapid cycling?
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3 episodes in the preceding 12 months (manic, hypomanic, depressive or mixed episodes)
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when assessing risk for a patient experiencing a manic episode, what must on consider?
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risk to self reputation, employment, finances, relationships, and others
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what should be avoided in acute treatment of BP depressive episode? what should be given in this scenario?
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- antidepressants - risk of precipitating a manic episode
- mood stabiliser monotherapy (lithium, valproate, carbamazepine) |
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what treatment should be given for someone suffering an acute manic episode?
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- mood stabiliser (lithium, valproate)
- add an atypical antipsychotic if severe/requiring hospitalisation (olanzipine, quetiapine) |
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what dose of lithium is advised in the treatment of acute mania? what is the target serum level for maintenance dosing?
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- 400 - 1200mg a day
- 0.6-0.8mmol/L |
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which combination bipolar mania therapy has the lowest tolerability difficulty?
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valproate + atypical antipsychotic > lithium + atypical antipsychotic
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which agents have the highest efficacy in the treatment (monotherapy) of bipolar depression?
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quetiapine > olanzipine > lithium/lamotrigine
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the three components of bipolar mania treatment are...
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acute mania = antimanic (lithium, valproate, atypical APs)
behavioural disturbance = benzodiazepines, AP cognitive disturbance/psychosis = AP |
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the AD class most responsible for CYP450 enzyme inhibition is... the specific member of this class most responsible is...
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SSRIs and fluvoxamine
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CYP 2D6 is responsible for the metabolism of which antipsychotic... which SSRIs inhibit this enzyme
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- risperidone = atypical/2G antipsychotic
- paroxetine, sertraline, fluoxetine 2-D-6 metabolises risperiDone |
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CYP 1A2 is responsible for the metabolism of which antipsychotics...what inhibits/induces this enzyme?
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- metabolism of clozapine and olanzapine (app. 30%+ of each)
- inhibited by fluvoxamine - induced by cigarette smoke do the 1-2 cough (CYP 1A2 - Cloz, Olan, Fluvox) |
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alcohol induces which CYP450 enzyme and what risk does this impose on users?
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- CYP2E1 = E for Ethanol
- this induction increases the risk of paracetamol OD |
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fluvoxamine inhibits many CYP450 enzymes. CYP 3A4 is one such example. Which psychotropic drugs rely on this enzyme for their metabolism?
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- amitriptyline (TCA)
- clomipramine (TCA) - carbamazepine |
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name as many SSRIs as you can
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- the prams - citalopram, escitalopram
- the ines - fluoxetine, paroxetine, fluvoxamine, sertraline dispensed like lollies, like pra'M'ines (as in praline) |
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what effect do SSRIs have in OD, on weight and when combined with alcohol?
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- minimal risk of cardiotoxicity in OD
- usually weight neutral - no risk when taken with alcohol |
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what class of drug is mirtazapine and what side effects is it associated with?
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- NaSSA (noradrenaline and specific serotonin antidepressant) - antagonises 5HT and alpha receptors
- sedation, weight gain, dyslipidemia - mediatd by H1 receptor binding |
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side effects of TCAs and the corresponding receptors are...
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- sedation and increased appetite (H1 antagonism - histamine regulates leptin function)
- anticholinergic effects (M antagonism - cant pee, cant see, cant poo, cant chew, my heart is raising and im confused) - postural hypotension (alpha antagonism) - bonus = relatively little sexual dysfunction |
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MAOI side effects include...
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- sexual dysfunction
- weight gain (strange as no H1 binding) - orthostatic hypotension (counterintuitive) M for Mixed Bag OF SEs |
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how long after ceasing MAOIs should dietary restrictions remain? what do the dietary restrictions encompass?
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- 2 weeks to allow new MAO enzymes to be synthesised
- no hard cheese, no vegemite, no banana skins, |
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what very important side effect to most mood stabilisers have?
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they are TERATOGENS
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common side effects of lithium...
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- tremor
- renal impairment/dehydration - hypothyroidism - psoriasis - increased WCC - dry skin - nausea |
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common side effects of sodium valproate...
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- nausea
- tremor - weight gain - sedation - hair loss - ankle swelling |
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what are the two types of cannabinoid receptor and their location in the body?
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- CB1 = brain and peripheral tissues
- CB2 = immune cells |
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how is the THC level of available marajuana changingg?
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increasing = marajuana is becoming more potent
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what are the medicinal uses of marajuana?
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- anti-emetic
- analgesia - appetite stimulation (e.g. in HIV patients) - anxiolytic |
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what are the physiological effects of marajuana?
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- vasodilation
- bronchodilation |
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is cannabis use in australia increasing or decreasing?
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stable - minor decline
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how does cannabis use effect risk taking behaviour?
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reduces risk taking behaviour - the opposite to alcohol
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which molecule and which receptor appear to be upregulated in the CSF/CNS of people wioth schizophrenia?
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- anandamide (endogenous cannabinoid)
- CB1 receptors |
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what percentage of daily users of cannabis are physiologically dependent?
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30-50%
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are cannabinoid antagonists effective in treating withdrawal?
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NO
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approximate prevalence of smoking in australia today?
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35%
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what percentage of smokers die from smoking related causes?
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50%
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which nicotinic cholinergic receptor is thought to mediate the dependence associated with nicotine use?
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a4B2a5
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what is observed in fast metablizers of nicotine?
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- they smoke more
- higher rates of addiction - increased risk of lung cancer - less success on NRT |
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which CYP450 enzyme metabolizes nicotine?
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CYP 2A6
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what effect does pregnancy have on nicotine metabolism?
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increases it
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which ethnicities are associated with being;
- efficient/fast CYP 2A6 metabolizers - slow CYP 2A6 metabolizers |
- fast = mediterranean, europeans
- slow = asian, japanese |
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how does smoking effect CYP 1A2? what drug metabolisms are effected by this?
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- induces
- increased metabolism of caffeine, insulin, analgesics, antipsychotics (olanzapine, clozapine), anticoagulants |
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what re the features of nicotine withdrawal?
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- anxiety
- increased appetite - reduced concentration - sleep disturbance - mouth ulcers - constipation |
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which enzyme metabolizes buproprion? what is the active metabolite that is formed? what is it used for
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- CYP 2B6
- HYDROXYBUPROPRION |
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which TCA is used in smoking cessation therapy?
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notriptyline
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what is the MOA of buproprion and what is it used in?
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- D and NAd reuptake inhibition
- smoking cessation, depression |
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the 3 C's of alcohol/drug dependence?
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- control impairment
- compulsion - inability to cut down |
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what are the timeframes for the following:
- EtOH withdrawal onset - peak - duration |
- 6-24 hrs
- 24-48hrs - 4-6 days |
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what are the features of alcohol withdrawal?
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- tachycardia
- delerium tremens - anxiety - sweating - GIT upset - insomnia - seizures |
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what is acamprosates MOA and what is it used for?
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- NMDA receptor antagonism
- GABA receptor agonism - alcohol withdrawal/abstinence maintenance |
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what are type A and type B alcoholics?
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- type A = later onset and with greater social stressors/burdens
type B = earlier onset with a larger suspected genetic component |
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in which group of abstinent alcoholics are SSRIs more risky for triggering relapse?
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type B
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is prescription opioid use increasing or decreasing in australia?
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INCREASING
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what is the biggest risk factor for prescription drug misuse?
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prior abuse/addiction (of illicit or legal drugs, activities etc)
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in what circumstances is an authority prescription required?
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- prescribing drugs of addiction to drug dependent patients
- prescribing >2months worth of drugs of addiction to non drug dependent people - prescribing dexamphetamine or methyl.... |
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a man presents with agitation, rhinorrhea, lacrimation and diarrhoea. What do you suspect is occurring in this gentleman?
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opioid withdrawal
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what is the health insurance commission definition of a prescription shopper?
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- greater then 6 doctors in a 3 month period
- use of 25 + target pharmaceutical benefits - use of 50 + total pharmaceutical benefits |
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what is the most highly prescribed opioid in australia?
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oxycodone
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how long does amphetamine induced psychosis typically take to resolve?
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- normally days
- 1 month max |
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what is buprenorphine?
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high affinity mu receptor partial agonist
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what are the 4 broad harm categories of heroin use?
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- OD
- injection related - psychological - social |
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what is clonidine used for? what is its moa?
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- relieve hypertension
- alpha 2 agonist (centrally acting, causing vasodilation and reducing CO) |
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approximately what amount is methadone is required to prevent adjunctive heroin use in opioid dependent patients?
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60mg + daily
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what are the advantages of buprenorphine compared to methadone opioid replacement?
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- less risk of OD
- less sedation - longer T 1/2 (fewer dosings) however not tolerated by more highly dependent individuals |
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approximately how long should an antipsychotic be trialled before change to another medication is made?
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6 weeks
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is clozapine a 1st line AP?
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NO - typically used in treatment refractory psychosis, following the trial of 2 other atypical AP's
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major side effects of risperidone?
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- EPSEs (especially akathisia = restlessness)
- elevated prolactin (galactorrhoea, amenorrhoea, sexual dysfunction, gynaecomastia) less sedating then other APs |
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with which APs is hyperprolactinemia more common?
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- atypicals = risperidone, amisulpride, paliperidone
- all typicals |
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major side effects of clozapine?
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- agranulocytosis
- neutropaenia - weight gain - sedation - anticholinergic side effects minimal effect on QT and prolactin |
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psychotropic drugs which have a significant effect on QT interval include?
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- haloperidol
- chlorpromazine - quetiapine - TCAs |
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which antipsychotic side effects should lead to the consideration of a switch to clozapine?
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- significant EPSEs (1st gen, risp, amisulpride, paliperidone)
- significant QT prolongation - hyperprolactinemia (1st gen, risp, amisulpride, paliperidone) |
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prolactin sparing antipsychotics include?
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- clozapine, olanzapine and quetiapine
- zisperidone - aripriprazole |
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what factors increase the risk of suicide in an indicidual?
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Sex = male
Age = elderly Depression Previous attempt Ethanol abuse Rational thought disturbance Social supports lacking Organised plan evident No spouse Sickness SAD PERSONS |
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what features of depression are associated with better AD response?
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- psychomotor agitation
- diurnal mood variation |
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what pattern of diurnal mood variation is seen in atypical depression?
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mood is better in the morning and worse in the evening
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what are the trade names for the following drugs?
- quetiapine - clozapine - olanzapine - risperidone - haloperidol - chlorpromazine |
- seroquel
- clopine/clozaril - zyprexa - ozidal/rispa/resdone/risperdal - seredace - largactil |
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What are the two most common symptoms of schizophrenia?
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- delusions (90%)
- hallucinations (auditory – 70%, visual – 15%) |
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the four negative symptoms of schizophrenia are (four A’s)?
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- alogia (poverty of speech)
- amotivation/avolition - affect (blunted) - asociality |
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the disorder that sits in the spectrum between schizophrenia and a mood disorder (e.g. biopolar) is…
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shizoaffective disorder
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which personality types are commonly associated with psychosis?
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cluster A personality disorders - the BAD
- schizoid - schizotypal - paranoid |
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DSM criteria for schizophrenia...
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2 or more of the following for the significant portion of a month
- delusions - hallucinations - disorganised speech - disorganised/catatonic behaviour (catatonic stupor of catatonic excitement) - negative symptoms PLUS - social/occupational dysfunction - six month history of disturbance - exclusion of mood, substance or developmental explanation |
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what investigations would you consider performing to exclude organic causes of a mood disturbance or psychosis presentation?
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- FBC/inflammatory markers
- EUC/BSL - head CT - EEG - TFTs - Toxicology screen - VitaminB12 level |
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which symptoms predict poorer patient outcome in schizophrenia?
|
negative symptoms
- alogia - affect (blunt) - asociality - amotivation |
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approximately what percentage of patients with schizophrenia will die by suicide?
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10%
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what are some of the risks to self that can be posed by certain mental illnesses?
|
- suicide
- self harm - risk to reputation - risk to finances - self neglect - exploitation vulnerability |
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is high or low intelligence associated with increased risk of suicide
|
high IQ
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how does psychotic relapse effect treatment response?
|
it appears that relapsing psychosis leads to a reduction in response to treatment
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what percentage of schizophrenics remain significantly impaired throughout their life (e.g. cant return to work, have minimal periods of remission)
|
60%
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biological factors thought to predispose an individual to schizophrenia include?
|
- family history
- obstetric complications - maternal influenza/rubella - prenatal malnutrition - prenatal bereavement/stress - early cannabis use - male sex |
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social risk factors associated with increased risk of schizophrenia include?
|
- social isolation
- family dysfunction - unemployment - urban living - migration |
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on average what is the decrease in global brain volume in schizophrenia? which two regions of the brain show the greatest degree of volume reduction?
|
- 5-10%
- hippocampus and amygdala |
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which subtype of schizophrenia tends to resent later in life and have a better prognosis? which subtype tends to present earlier and have a worse prognosis?
|
- paranoid
- disorganised |
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major side effect of quetiapine...
|
sedation
|
|
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major side effect of risperidone...
|
EPSEs (tardive dyskinesia - greater risk then for other SGAs)
|
|
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psychological therapies for schizophrenia include?
|
- CBT or remediation
- case management (monitor community living, medication compliance) - social/vocational skills training - illness education (treatment side effects, help seeking) |
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the main receptor antagonised by both FDAs and SGAs is? which pathway is targeted to try and symptoms?
|
- D2
- mesolimbic |
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what are the important features of haloperidol's side effect profile?
|
- significant EPSEs
- low levels of sedation |
|
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what are the key features of pathological anxiety?
|
- increased intensity
- extended duration - loss of control over anxiety - false alarms = trigger anxiety - disabling/functionally impairing |
|
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what emotions are often felt concurrently with pathological anxiety?
|
- guilt
- shame - disgust - anger |
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what is the most common psychiatric disorders?
|
anxiety disorders
|
|
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what physical symptoms are associated with a panic attack?
|
- tachycardia
- chest tightness - palpitations - dizziness - SOB |
|
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what psychological symptoms are associated with PAs?
|
- derealisation = sensation of the external world as unreal (unreality of ones sense of the world)
- depersonalisation = sensation of being outside of ones self, without control over ones actions (unreality of ones sense of self) |
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what is the ratio of M:F suffering from panic disorder? including agoraphobia? when is its typical onset?
|
- 1:2
- 1:3/4 - 3rd decade |
|
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what is the most common anxiety disorder? M:F prevalence? typical onset?
|
- GAD
- 1:2 - 15-25 |
|
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in what types of situations can SAD cause fear?
|
- performance situations
- interactional situations |
|
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what is unique about the pathophysiological response seen to blood/injury/needles?
|
- it is a 2 phase response
- phase 1 = hyperactivity (tachycardia, palpitations, sweating etc) - phase 2 = vasovagal reaction (bradycardia, hypotension) |
|
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what is the M:F prevalence of specific phobias? OCD?
|
- specific phobias = 1:2
- OCD = 1:1 |
|
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what is the M:F prevalence of SAD?
|
- 1:1.5
- clinical presentations = 1:1 |
|
|
which therapies target anxiety symptoms? behaviours? maladaptive thinking?
|
- symptoms = pharmacotherapy's
- behaviours = behavioural therapy - maladaptive thinking = cognitive therapy |
|
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what are the advantages of psychotherapy > medications
|
- longer duration of efficacy
- lower risk of disorder relapse - absence of pharmacological SE's |
|
|
how long should symptoms be absent before you consider tapering a patient of anxiolytic medications?
|
6mth - 1 year
|
|
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what is the 1st line medication for anxiety disorders and for which disorders is it effective?
|
- SSRIs
- GAD, SAD, PD, OCD |
|
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In which ADs is venlefaxine effective? What class of drug is it?
|
- GAD, SAD, PD
- SNRI |
|
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For which ADs are benzodiazepines effective?
|
- GAD, SAD, PD
|
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which drug can be used in addition to SSRIs to treat OCD and what class of drug is it?
|
- clomipramine
- TCA |
|
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in which AD disorder/s are the following treatments potentially useful?
- beta blockers - imipramine - MAOIs |
- SAD and GAD
- GAD and PD - SAD |
|
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in PTSD loss of memory of parts of the traumatic episode is known as...
|
dissociative amnesia
|
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experience of somatic symptoms in PTSD is known as...
|
somatization
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a significant % of people with PTSD recover in time without treatment. T/F
|
true
|
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what % of people will develop PTSD following a traumatic event?
|
5-10%
|
|
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what are the most effective psychotherapies for PTSD?
|
- exposure based exercise
- arousal reduction training |
|
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what re the 3 main models of psychotherapy?
|
- CBT = altering maladaptive thinking patterns and teaching new associations
- psychodynamic therapy = unveiling unconscious thoughts and rectifying behaviours following insight - experiential/humanistic therapy |
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what is psychic determinism?
|
the belief that all mental phenomenon develop from preceding experiences and exposures
|
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|
what is the most common illness in indigenous women?
|
depression/anxiety
|
|
|
name some interventions recognised as cost effective means of improving indigenous health?
|
- early childhood intervention
- economic empowerment of women - violence reduction |
|
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how is the age of 1st use (drug related) changing in indigenous communities?
|
decreasing
|
|
|
the most widely abused illicit drug in indigenous communities is...
|
cannabis
|
|
|
at what age does petrol sniffing peak in indigenous communities?
|
12-14
|
|
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long term consequences of petrol sniffing include...
|
- impaired cognitive functioning
- ataxia - seizures - impaired growth - death |
|
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more indigenous adults abstain from alcohol use the non indigenous adults. T/F
|
true
|
|
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more indigenous adults have had no alcohol consumption in the past 12 months then non indigenous adults. T/F
|
true
|
|
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oral tranquilizers that can be considered in an acutely agitated patient?
|
- benzodiazepines - diazepam
- antipsychotics - olanzapine, quetiapine |
|
|
IM tranquilizers that can be considered in an acutely agitated patient?
|
- midazolam
- haloperidol |
|
|
what type of hallucinations are associated with increased risk of suicide?
|
- command hallucination
|
|
|
how is intellectual disability defined?
|
- IQ < 70
- impaired function (communication, self care, interpersonal skills, academic skills, occupational etc) - onset before 18 |
|
|
what % of the population have an ID?
|
- 3%
- 3/4 of these are only mild ID (IQ 50-70) |
|
|
what are the pre, peri and post natal causes of ID?
|
pre natal
- genetic - exogenous (infection, toxin, placental insufficiency) peri natal - infections - birth complications post natal - infections - trauma - malnutrition - toxins |
|
|
is autism classified as an ID?
|
NO
|
|
|
which stage of pregnancy is most commonly found to be the aetiology of ID ?
|
pre natal
|
|
|
the aetiology of ID can be found in approximately 80% of severely ID people. T/F
|
TRUE
|
|
|
people with an ID have a higher risk of developing a mental illness. T/F
|
true
|
|
|
what % of autistic children have an ID?
|
80%
|
|
|
what is the triad of impairment seen in autism?
|
- social impairment
- behavioural impairment - language/communication impairment |
|
|
risk factors for mental illness too which the ID are more commonly exposed include?
|
- stigma and social isolation
- poverty - abuse - neglect |
|
|
people under the mental health act do not require consent fro treatment. T/F
|
true
|
|
|
what are the 3 broad categories of child psychiatric disorder?
|
- emotional/mood = internalising
- behaviour = externalising - developmental |
|
|
at what age do autistic spectrum disorders usually emerge?
|
3-5
|
|
|
in which sex are externalising disorders more common? internalising disorders?
|
- males = externalising (ADHD, CD, ODD)
- females = internalising (anxiety, depression) |
|
|
what disorders are classified as internalising disorders?
|
depression, anxiety, psychosomatic disorders
|
|
|
what disorders are classified as externalising disorders?
|
ADHD, CD, oppositional DD
|
|
|
what is the key component of CBT?
|
graded exposure therapy/behaviour modification through gradual response adjustment
|
|
|
what are the medications indicated for OCD?
|
- clomipramine (TCA)
- SSRIs |
|
|
key differences between child/adolescent and adult depression include...
|
- depressed children more likely to exhibit anger, irritability and mood lability
- impacts on different life areas (school, peers, family) - often somatic symptoms (headaches, tummy aches) |
|
|
the gold standard pharmacotherapy for child/adolescent depression is...
|
SSRI (fluoxetine) + CBT
|
|
|
at what dose should fluoxetine be started for child/adolescent depression and to what should it be increased?
|
- 5/10mg once daily
- 20mg once daily |
|
|
what are the 3 childhood externalising disorders?
|
- ADHD
- oppositional defiant disorder - conduct disorder |
|
|
what re the 3 key features of ADHD?
|
- hyperactivity
- inattention - impulsivity |
|
|
someone with ADHD can still demonstrate the capacity to concentrate on certain stimuli (e.g. video games). T/F
|
TRUE
|
|
|
the NTs implicated in ADHD are?
|
NAd and dopamine
|
|
|
what is the ratio of M:F ADHD?
|
4:1
|
|
|
features of oppositional defiant disorder include...
|
- disobedience and defiance
- negativity - hostility - persistence of symptoms (6+ months) - disruptive to the home and/or school environment |
|
|
ODD can manifest with sufferers often...
|
- being argumentative
- blaming others for mistakes - throwing tantrums - failing to follow orders - being irritable, angry and struggling to make friends |
|
|
what is the prevalence of ADHD in australian children?
|
3-5/100
|
|
|
are ADHD sufferers receiving stimulant medications at an increased risk of developing substance abuse disorders?
|
no
|
|
|
what is conduct disorder?
|
- persistent patterns of behaviour that violate the rights of others
- sufferers are deceitful, aggressive, destructive and violate rules |
|
|
side effects of stimulant medication include?
|
- insomnia
- appetite suppression/weight loss - nausea - anxiety/depression/irritability - tics/tremors - hypertension |
|
|
what i the suspected MoA of dexamphetamine and methylphenidate (ritalin)?
|
enhancement of dopamine and noradrenaline neurotransmission
|
|
|
how does atomoxetine work?
|
inhibits presynaptic reuptake of noradrenaline
|
|
|
what percentage of new mothers experience PN depression? how long does it take to develop following birth?
|
- 10-15%
- 3-6 months |
|
|
the 3 major post natal psychiatric disorders are? their typical onset...
|
- post natal blues = 3-5 days following birth
- puerperal psychosis = 3 weeks - post natal depression = 3-6 months |
|
|
subsequent bipolar occurs in what % of women with puerperal psychosis?
|
80%
|
|
|
PND can cause poor mother-infant interaction which can result in...
|
- cognitive impairment
- behavioural problems - attachment difficulties |
|
|
features of puerperal psychosis include?
|
- hallucinations
- delusions - indecisiveness, confusion - symptoms can fluctuate in severity |
|
|
what type of pre morbid personality is associated with an increased risk of developing PP?
|
obsessional personality
|
|
|
which drugs pose a significant risk of foetal malformation?
|
- anticonvulsants and lithium
|
|
|
by what factor do SSRIs increase the risk of foetal heart malformation?
|
2x
|
|
|
SSRIs increase the risk of gestational diabetes and pre eclampsia. T/F
|
true
|
|
|
when are mood stabilisers the most harmful to the foetus?
|
1st trimester
|
|
|
If lithium is initiated again following the 1st trimester, why should it be decreased in the final third of the third trimester?
|
to reduce the risk of neonatal lithium toxicty
|
|
|
what serum level of lithium should be targeted in the closing stages of the third trimester ?
|
0.2-0.6 mmol/L
|
|
|
define a personality disorder?
|
a persisting pattern of behaviour that deviates markedly from social/cultural norms, develops in adolescence or early adulthood, is stable and pervasive and causes distress/impariment
|
|
|
personality comprises of..
|
emergent feelings, thoughts and behaviours of an individual
|
|
|
what are the cluster A personality types and their features
|
cluster A = MAD group
- paranoid = distrust, suspicion - MOE - schizoid = social detachment, emotionally cold - COMIC BOOK GUY - schizotypal = uncomfortable with intimacy, eccentric/odd beliefs - TIME TRAVEL DUDE |
|
|
what are the cluster C personality types and their features?
|
cluster C = SAD
- avoidant = overly sensitive, inferiority complex, social avoidance - GILL - dependant = submissive, clingy/needy - GOLLUM - obsessional = perfectionism, likes control, orderliness preoccupation - NED FLANDERS |
|
|
what are the cluster B personality types and their features?
|
cluster B = BAD
- narcissistic = exhibitionist, low empathy, grandiose/arrogant - PARIS HILTON - histrionic = drama queen, emotion lability - VERUKA SALT - antisocial = disregards rules, callous, lacks guilt - BRONSON - borderline = intense relationships, impulsive and moody, self harming, chronic emptiness - CABLE GUY |
|
|
axis I as opposed to axis II...
|
axis I = ego dystonic, episodic
axis II = ego syntonic, ingrained traits |
|
|
high potency typical antipsychotics include...
|
- haloperidol (depot form available)
- droperidol - fluphenazine (depot form available) - zuclopenthixol (clopixol - depot available) |
|
|
which sex has a higher lifetime risk of developing schizophrenia?
|
equal for males and females
|
|
|
which sex has an earlier average age of onset for schizophrenia? better prognosis?
|
- males have an earlier average onset
- females have a better px |
|
|
what is concordance between monozygotic twins for the following illnesses;
- major depression - schizphrenia |
- MD = 70%
- Schizophrenia = 40% |
|
|
major depression is frequently a manifestation of carcinoma of which organ
|
pancreas
|
|
|
effexor =
largactil = |
E = sertraline
L = chlorpromazine |
|
|
which antidepressant has a slightly lower risk of inducing mania when used to treat bipolar depression?
|
buproprion - atypical AD (dopamine reuptake inhibitor)
|
|
|
when does panic disorder typically develop?
|
late teens - early twenties
|
|
|
common physiological effects experienced during panic attacks include...
|
- tachycardia/palpitations
- tachypnoea/dyspnoea - chest tightness - dysphagia/feeling of choking - fear of dying |
|
|
DSM criteria for panic disorder...
|
- recurrent unexpected panic attacks
- persistent concern of another PA, concern about consequences of attack and behavioural change following attack for 1+ months following a PA - not accounted for by another anxiety disorder, drugs or a medical condition |
|
|
what constitutes agoraphobia?
|
- anxiety toward being in certain situations and experiencing a PA (where there is no help, no escape or its embarrassing)
- situation avoidance/or endurance with significant distress |
|
|
what psychological therapies can be used to treat PD?
|
- education about symptoms (not actually harmful)
- CBT (exposure therapy, maladaptive thinking identification) |
|
|
pharmacotherapies for PD...
|
- SSRIs (fluoxetine)
- TCA (clomipramine, imipramine) |
|
|
people with social phobia feel their anxieties/fears are reasonable. T/F
|
FALSE. SAD sufferers appreciate that their anxieties are unreasonable/unfounded
|
|
|
for the dx of SAD or SP to be made in someone <18 how long do the symptoms need to be present for?
|
6+ months
|
|
|
describe the following;
- social phobia - specific phobia |
- anxiety relating to social or performance based situations, where an individual fears negative evaluation or embarrassment and so avoids or endures feared situations with great anxiety
- anxiety or fear of specific stimuli leading to avoidance or endurance with great fear - individuals with both recognise that fears are unreasonable - the anxiety must lead to functional impairment |
|
|
what personality disorders may be DDX's for anxiety disorders?
|
- avoidant = overly sensitive, inferiority complex, social avoidance - GILL
- schizoid = social detachment, emotionally cold - COMIC BOOK GUY |
|
|
what psychotherapies are of use in treating SAD/phobias?
|
CBT = systematic desensitization and graded exposure
|
|
|
what specific therapy can help with symptom control during graded exposure therapy?
|
beta blockers
|
|
|
first line pharmcotherapy for SAD and phobic disorders?
|
SSRIs or venlafaxine (SNRI)
|
|
|
neurotransmitters implicated in the pathophysiology of anxiety disorders include...
|
- NAd
- GABA - 5HT |
|
|
RECAP - only anxiety disorder with the same prevalence between males and females...
|
OCD
|
|
|
an obsession is...
a compulsion is... |
obsession = mental event, repetitive thoughts or ideas
compulsion = a behaviour OR mental response/activity, attempted attenuation of obsessions |
|
|
the 4 features of PTSD are...
|
- re experiencing of the event
- avoidance of event related stimuli - arousal - emotional numbing/detachment |
|
|
what is best evidence therapy for PTSD?
|
psychotherapy > pharmacotherapy
|
|
|
mechanism of action of buspirone?
|
partial 5HT1 agonist = inhibitory serotonin receptor
|
|
|
what percentage of children/adolescents with a mental health issue seek professional help?
|
app. 25%
|
|
|
describe erikson's 6 developmental stages with regards to;
- age - basic conflict (outcomes of success vs. failure in this stage) - key events |
1 = infancy - 18 months; trust/mistrust; feeding
2 = early childhood (2-3 yrs); autonomy/self doubt; toilet training 3 = preschool (3-5 yrs); initiative/disapproval & guilt; environmental exploration and control 4 = school (6-11 yrs); competence/inferiority; school attendance 5 = adolescence (12-18 yrs); self identity/role confusion; social relationships 6 = young adulthood (19-40 yrs); intimacy/isolation; intimate relationships |
|
|
the three basic developmental stages are...
|
- infancy + early childhood = 0-5
- primary school = 6-12 - adolescence = 13-18 |
|
|
disorders in infancy are usually the result of...
|
- developmental problems (autism, ID)
- organic problems - disturbed parent-child relationship therefore when assessment must look at infants health, developmental milestones AND parent-child relationship (also parental mental health) |
|
|
what are the 4 attachment types and the parenting styles with which they are associated?
|
secure = sensitive, appropriate parenting (providing support and allowing exploration
avoidant = the result of rejection by the caregiver (i.e. little interaction resistant-ambivalent = caregivers interactions provide little affection disorganised = unpredictable caregiving, with caregiver viewed as frightening OR frightened |
|
|
which attachment type is thought to be the best predictor of subsequent mental problems?
|
disorganised attachment
|
|
|
what are the two attachment disorders?
|
- separation anxiety disorder - anxious during actual or anticipated separation from parent, often school refusal occurs
- reactive attachment disorder - avoidant toward parent OR overly familiar with strangers (disinhibited subtype), associated with non organic failure to thrive |
|
|
features commonly leading to parental presentation of an undiagnosed autistic child...
|
- lack of responsiveness (poor eye contact, poor reciprocity)
- poor school performance (both academically and in interacting with other children) |
|
|
M:F for autism estimated prevalence...
|
- 3:1
- 5-10/1000 |
|
|
autism is more common in low SES children. T/F
|
false
|
|
|
what is aspergers...
|
- impaired socialfunction
- absence of impaired language development - normal IQ |
|
|
how is functional enuresis diagnosed?
|
bed or clothing wetting 2+ weekly, for 1+ months, in children >5, in the absence of medical condition (e.g. diabetes, UTI, epilepsy)
|
|
|
what is secondary enuresis?
|
a relapse of bed/clothing wetting following a 12 month dry period
|
|
|
what % of children with functional enuresis have a family hx?
|
75%
|
|
|
what is delirium?
|
an acute, fluctuating, confusional state presenting with;
- disturbed consciouness - disturbed cognition and perception (e.g. visual hallucinations) |
|
|
what are the suggested pathophysiological pathways of delirium?
|
- hypoxemia = cerebral metabolic dysfunction in turn reducing NT production
- inflammation = cytokine accumulation |
|
|
what is the cholinergic system responsible for in regards to controlling consciousness?
|
- arousal
- memory - attention - REM sleep |
|
|
predisposing factors for delirium...
|
- age > 65
- dementia - previous delirium - sensory impairment - nursing home living - poor education |
|
|
precipitating factors for delirium...
|
- drug intoxication
- polypharmacy - illness (e.g. cancer, endocrinopathy) - dehydration - malnutrition - constipation, urinary retention - sleep disturbance - disorientation - pain - immobility |
|
|
the addition of how many medications in hospital is associated with an increased risk of delirium?
|
4+
|
|
|
multiple bed moves is associated with an increased risk of delirium in hospital. T/F
|
true
|
|
|
what are the two types of delirium, their features and their prevalence?
|
- hyperactive; aggression, agitation, wandering, hallucinations - 30%
- hypoactive; withdrawal, quiet, psychomotor retardation, sleepiness - 70% |
|
|
the earliest apparent deficits in acute delirium are...
|
- inattention
- comprehension impairment (more prominent then disorientation) |
|
|
what effect has haloperidol been shown to have when given as delirium prophylaxis in post operative patients?
|
- reduction in duration and severity of delirium
- no effect on delirium incidence |
|
|
what is the only context in which benzos are useful in the treatment of delirium?
|
when delirium is induced by EtOH or benzo withdrawal
|
|
|
what are the short and long term effects on delirium on sufferers?
|
- short term = increased length of hospitalization and increased mortality
- long term = reduced ADL function and reduced reduced cognitive capacity |
|
|
approximately what percentage of patients in hospital have a diagnosable psychiatric disorder?
|
50%
|
|
|
medical illnesses commonly associated with depression...
|
- cancer (esp. pancreatic, bowel and lymphoma)
- stroke - PD - endocrinopathies - viral illnesses - CT disorders |
|
|
medications associated with depression...
|
- levodopa
- beta blockers - corticosteroids - indamethacin (NSAID) - interferon - narcotics |
|
|
what is the safest antidepressant (SSRI) to use in the context of concurrent medical illness?
|
citalopram
|
|
|
what is abnormal illness behaviour?
|
maladaptive behaviour in relation to the state of ones health despite receiving appropriate medical examination and advice - can be both denial ('im not sick') or refusal to accept absence of pathology ('i want another opinion, i know something is wrong with me')
|
|
|
what is somatization?
|
the tendency to experience and communicate psychiatric disorders in the form of somatic symptoms
|
|
|
how are somatization and abnormal illness behaviour related?
|
AIB is a subset of somatization
|
|
|
what is the most common form of depression in the elderly? what symptoms are more prominent?
|
- melancholic
- physical complaints (general pain, GI upset) |
|
|
in which depressed patients is the suicide rate highest?
|
elderly men
|
|
|
what % of stroke sufferers have depression in the months following the event?
|
25%
|
|
|
what are the 1st rank symptoms of schizophrenia?
|
- hallucinations (2st and 3rd person auditory)
- delusions - thought broadcast - thought insertion and withdrawal - thought passivity - thought echo |
|
|
is an individuals consciousness typically clouded in dementia?
|
NO
|
|
|
features of agitation in dementia include...
|
- wandering
- aggression - purposeless activity - sexual disinhibition |
|
|
common mood symptoms in dementia?
|
- lability of mood
- apathy |
|
|
which BPSD have a tendency to resolve over time?
|
- hallucinations
- mild depression |
|
|
which BPDS have a tendency to persist?
|
- agitation
- severe depression |
|
|
which infections pose a high risk of associated delirium developing?
|
- UTIs
- pulmonary infections always consider constipation, urinary retention and pain |
|
|
medications with a high risk of causing delirium?
|
- benzos
- anticholinergics (TCAs, some antihistamines, antimuscarinics) - antiparkinsonian drugs |
|
|
what medications might be of use in treating mild-moderate BPSD? severe BPSD? are they 1st line?
|
- SSRIs or cholinesterase inhibitors
- antipsychotics - non pharmaceutical management is 1st line |
|
|
what is major risk for patients receiving antipsychotics for BPSD in the first few weeks of treatment?
|
CV events
|
|
|
group most likely to suffer from an eating disorder?
|
females 13-30
|
|
|
criteria for anorexia nervosa...
|
- BMI < 17.5
- BODY IMAGE disturbance (want to lose weight OR think they are overweight when very thin) - PATHOLOGICAL FEAR of gaining weight and associated behaviours (starvation, vomiting, exercise) no longer amenorrhoea |
|
|
menarche is often a trigger for eating disorders. T/F
|
true
|
|
|
at what period following menarche is there the biggest difference between females actual and desired weights?
|
7-12 months
|
|
|
criteria for bulimia nervosa...
|
- 1+ binge eating episodes weekly for 1+ months
- loss of control during eating episodes - employs subsequent methods of weight loss (starvation, vomiting, exercise) - over concern with body weight/shape |
|
|
prognosis for eating disorders...
|
- 40% complete recovery
- 40% recovery + preoccupation - 20% chronic |
|
|
a pregnant woman with an eating disorder is at increased risk of...
|
- miscarriage
- hyperemesis gravidarum - postnatal depression |
|
|
3 features of delirium...
|
- reduced consciousness
- disturbed cognition - acute onset and fluctuating course |
|
|
what is the 1 year mortality of delirious patients?
|
50%
|
|
|
the 2 pathological features of alzheimers disease are...
|
- beta amyloid plaques
- nuerofibrillary tangles (tau protein collections) |
|
|
mutations in which genes are associated with early onset familial AD?
|
- amyloid precursor protein (APP)
- presinilin 1 and 2 |
|
|
what is the biggest RF for AD? which sex is at higher risk of AD?
|
- age
- women |
|
|
what is the best medication for behavioural symptoms of AD?
|
galantamine
|
|
|
which gender has a higher risk of vascular dementia?
|
males (think CV risk - HTN, smoking, diabetes, lipidemia)
|
|
|
what signs present in progressing vascular dementia?
|
focal neurological signs
- ataxia - hemiplegia - hyper-reflexia - + babinski |
|
|
what is the typical course of VD?
|
fluctuating/step-wise, with progressive decline during each episode and periods of modest improvement in between
|
|
|
VD is associated with higher rates of depression then other dementias. T/F
|
true
|
|
|
the classic triad of SS of NPH?
|
- urinary incontinence (WET)
- dementia (WACKY) - ataxia (WOBBLY) |
|
|
does NPH respond to CSF drainage?
|
yes
|
|
|
which sign is usually the first to appear in NPH?
|
gait disturbance/ataxia
|
|
|
main risk factors for NPH?
|
- >65
- vascular disease |
|
|
what therapeutic approach can be used to differentiate between NPH and PD (can have very similar physical signs - shuffling, freezing)?
|
- levodopa trial - unresponsive excludes PD
- LP and CSF drainage (30-60ml) - should improve symptoms in NPH |
|
|
management of NPH? (consider both surgically fit and unfit patients)
|
- control of CV risk factors (lipids, HTN, smoking, BSL)
- ventriculoperitoneal shunt (surgically fit) - repeated CSF drainage (surgically unfit) |
|
|
classical features of Wernicke's encephalopathy?
|
- confusion
- opthalmoplegia - ataxia |
|
|
what signs and symptoms are associated with korsakoffs syndrome?
|
- amnesia (retro and antero)
- confabulation - apathy - absence of insight |
|
|
is KS always preceded by WS?
|
not always - in app. 80% of cases
|
|
|
what would cause the following clinical picture;
- <24hrs of total loss of anterograde memory - preservation of identity - preservation of procedural memory (no cognitive deficits) |
transient global amnesia
|
|
|
what is post traumatic amnesia?
|
the inability to remember events surrounding the injury OR form new memories following the injury - both retrograde and anterograde amnesia
|
|
|
when is PTA considered to be finished?
|
when there is a return of continuous memory (specifically scoring a required level on 3 consecutive days in the galveston orientation and amnesia test)
|
|
|
GCS and not PTA is the best prognostic factor following TBI. T/F
|
FALSE
|
|
|
what changes are most commonly seen in individuals following TBI?
|
- personality change (irritability, aggression, impulsivity, disinhibition)
- emotional changes (depression, lability, anxiety) patient from community mental health is the perfect example - irritable, apathetic, anxious/OCD, inflexible |
|
|
what are the processes of executive function?
|
- goal formation
- planning - behaviour/emotional inhibition/monitoring - cognitive/motor coordination - goal directed behaviour - attention |
|
|
what pathological changes are seen in the brains of people with chronic traumatic encephalopathy?
|
- reduced cortical, SN and cerebellum volume
- NFTs and amyloid plaques (as seen in AD) |
|
|
an 8 yo presents with purposeless, repetitive, jerky movements of the face and neck. What is the most likely dx?
|
tic syndrome
|
|
|
what is the lifetime risk of depression in sufferers of MS?
|
50% - highest of any neurological disorder
|
|
|
cognitive impairment is an early feature of MS. T/F
|
false
|
|
|
What changes in consciousness would you associate with a subdural hematoma?
|
fluctuating consciousness and possibly delayed onset of symptoms (weeks)
|
|
|
subdural hematomas are confined by suture lines of the skull. T/F
|
false - extradural hematomas are confined by the sutures of the skull
|
|
|
what infection can present many years after contraction with neuropsychiatric signs and symptoms (personality change, emotional disturbances, psychosis, motor signs)?
|
syphilis - neurosyphilis in tertiary stage of infection
|
|
|
what are the 4 traits and 3 characters of cloninger's personality inventory?
|
temperaments
- harm avoidance - novelty seeking - persistence - reward dependence characters - self directedness - transference - self transcendence |
|
|
what are the big 5 personality traits?
|
- introversion/extroversion
- agreeableness/antagonism - conscientiousness - openness - neuroticism |
|
|
what are the 4 key stages of management in personality disorder
|
- crisis management
- stabilisation - change - understanding |
|
|
what is the biggest risk factor for LBD?
|
- parkinsons disease
|
|
|
which dementia other then LBD can also have lewy bodies?
|
alzheimers disease
|
|
|
what % of fronto-temporal dementia is inherited?
|
50%
|
|
|
what areas of functioning are pirmarily effected by FTD?
|
language OR behaviour
|
|
|
which dementia is associated with motor neurone disease
|
FTD - when there is a TDP 43 mutation
|
|
|
risk factors for bulimia include...
|
- childhood abuse
- female - poor body image - impulsive personality - family hx alcoholism/depression/ED - overweight as child |
|
|
some physical signs of bulimia include...
|
- tooth erosion
- oesophagitis - russel's sign (calloused knuckles) - parotid gland hypertrophy |
|
|
what are the features of bulimia nervosa?
|
- recurrent binge eating (1+ weekly for 1+ months)
- recurrent compensatory behaviour (exercise, starvation, vomiting, laxative use etc) - preoccupation with body weight/image |
|
|
what is the management for BN?
|
- CBT or IPT
- SSRI or SNRI for concurrent anxiety/depression |
|
|
what is binge eating disorder?
|
- recurrent episodes of binge eating
- eating episodes associated with 3+ eating beyond feeling full eating alone due to embarrassment eating wen not hungry eating rapidly post eating depression, shame |
|
|
treatments for BED include...
|
- CBT or IPT
- weight loss (dietary advice, exercise) - adjunctive antidepressants |
|
|
what electrolyte disturbance may be seen in BN?
|
- hypokalemia
- hypomagnesemia |
|
|
low SES is a risk factor for anorexia. T/F
|
false
|
|
|
what is the prevalence of co-morbid OCD and dysthymia in AN?
|
OCD = 25%
AN = 50-70% |
|
|
treatment for AN?
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- structured eating plan (initially may need to be parenteral)
- CBT/IPT - K supplementation |
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what is the 1st line therapy advised for children and adolescents?
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- family based treatment = the maudsley method
- initially the family feeds the patient - as weight is gained responsibility of feeding is shifted to the patient - focus shifts to interfamily relationships and adolescent issues as the patient improves |
