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Psych misc 3

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imo132's version from 2016-11-23 01:24

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Question Answer
Child anxiety epidem3% boys, 5% girls, 15-20% risk in adolescence
Child depression10%, more females, mood more irritable than low, use DASS scale in 14-18, CDI in younger
Suicide in kids25% of all deaths in 15-19 year olds, females higher than males
Child depression RxFluoxetine, fluvoxamine, paroxetine, need expert opinion for SNRI or TCA (SE & low efficacy)
ADHDIn 5% kids, 3% adults, inattention, impulsive behvaiour, difficulty regulating self, commence <12 years, impairment in >2 settings, with combined, inattentive (in girls), hyperactive/impulsive types
ADHD SxMotor tics, sleep disturbance, mood swings, aggression, unpopularity with peers, temper tantrums, clumsiness, learning problems, immature language
ODDIn 4%, angry, irritable mood, defiant, vindictiveness, >6 months, Sx every day if <5, at least once a week if >5 years
Conduct disorder (CD)In 3%, persistent violation of others’ rights, preceded by ODD if onset in childhood or onset in adolescence, deceitful, destructive, aggressive
Externalising disorders epidemADHD 5%, others 4%, M>F, ADD & ODD decline with age, CD has 2 peaks & becomes antisocial personality disorder, ODD often with ADHD
ADHD causeGenetics (75%), perinatal hypoxia/smoking/alcohol/heroin, lead, brain injury, neurofibromatosis type 1, delayed cortical maturation (thinning)
ODD/CD causeGenetics (MAO), perinatal smoking/heroin/alcohol, lead, parenting style, social adversity
ODD/CD RxPsychosocial management (parent-behaviour training for children, strategic family therapy for adolescents), not as effective in ADHD, risperidone, clonidine, fluoxetine
ADHD RxMethylphenidate, dexamphetamine first line, atomoxetine second line (longer onset)
Intellectual disabilityIQ <70, impairment in >2 of communication, self-care etc, onset before 18, profound if IQ <20, 3% population
Guardianship actFor intellectual disability, special Rx needs tribunal's consent (if refusing), urgent Rx no consent, anyone under MHA does not need consent, can refuse Rx if capacity present
Anorexia0.5% girls 15-19, 20% chronic
Bulimia prev5%
EDNOS prev10%
Binge eating prev10%
Eating disorder prev20% (total)
ED in youngerDehydration, ketosis, hypoglycemia, growth retardation, osteoporosis, delayed puberty, stunting, sudden death
ED child presentationFood refusal, dehydration, ketosis, halitosis, hypoTN, standing BP >20, standing HR >20, ST/T wave changes, long QT, bradycardia, delayed puberty, stunting
ED adult presentationMenstrual disturbance, PCOS, infertility, low libido, dyspareunia, atrophic vaginitis, cold, fatigue, Raynauds, sleep disturbance, fractures
ED complHypoK/Na, hypothermia/glycemia/thyroid, arrhythmias, pancytopenia, dental decay, periph neurop, sialadenosis, rectal prolapse, renal failure, hyperaldosteronism, body odour, oedema, SIADH
ED prognosis80% better & 50% fully recovered (anorexia), 70% asymptomatic (bulimia), 10-20% mortality
Anorexia BMI17.5
RefeedingNeed 130% REE + exercise, CHO 50% energy, protein 25%, fat 25%, B1, PO4, Mg, Zn, Ca, Fe, fluid 30 ml/kg/day, avoid 5% dextrose for hypoglycemia, use saline then milk
Refeeding SxCCF, chest pain, QT >47O, delirium, Wernicke’s, beri beri, periph oedema, hypophosphatemia, prophylactically supplement electrolytes
Delirium SxOnset hours-days, with hallucinations, reversed sleep-wake cycle, affective lability, delusions (paranoid)
Intersecting pentagonsAssesses construction apraxia
Clock drawingAssesses frontal lobe for executive function, parietal lobe for spatial awareness, occipital lobes for sight
Delirium dxConcentration (months backwards), temporal sequencing of history, orientation to time/day, memory registration, memory recall
Psychosis in deliriumVisual hallucinations, persecutory delusions from poor memory & disorientation, poverty of thought, illogicity
Delirium time courseBest early in morning, worst at night
Delirium typesHypoactive (risk dehydration, PE, bedsores, undetected), hyperactive (risk injury from aggression, oversedation), mixed
Delirium epidem1-2% community, <50% hospital, >70% ICU
Delirium pathLow ACh (from anticholinergics), high dopamine (haloperidol treats, anti-parkinsons causes)
Delirium mortalityHigh (<60%), do not go back to baseline
Illness & depressCancer, stroke, hypothyroid, SLE, hepatitis, Parkinsons, oestrogen withdrawal
Meds & depressSteroids, IFN, indomethacin, levodopa, cimetidine, propranolol, narcotics, procarbazine, amphotericin, amphetamines or cocaine (chronic or withdrawal)
Illness & depress DxExclusive diagnostic criteria used (only use physical Sx if out of proportion to disease), cognitive Sx, anhedonia, use trial Rx if in doubt
MMSEImpacted by age, education, language
MMSE limitationsMild cognitive impairment, frontal/subcortical pathology
RUDAS scaleNot impacted by language or education, addresses executive function (unlike MMSE), <23 shows cognitive imparment
Major treatmentConsent needed, for CNS medications, injectables, castration, HIV testing, dental treatment
Minor treatmentNo consent if for health & wellbeing, gas for surgery, endscopies, sedation, PRN meds
Special treatmentsNeed NCAT guardianship, for sterilization, TOP, addictive drugs, androgens for behavior
OA pharmaIncreased tardive dyskinesia, delirium with anticholinergics, postural hypoTN, CVA with dementia & APs, oral absorption affected, increased fat mass, lithium affected by renal impairment
OA psychosisPersecutory delusions, visual hallucinations
BPSD40% Alzheimer’s, more lewy body, Sx fluctuate, with sundowning or ADL help, hallucinations and mild depression resolve, agitation & severe depression persists
BPSD RxAvoid changes, exclude delirium, use structure, planned positive activities, reminiscence, exercise, meds if high risk, distress, severe depression, non-drug failed
BPSD drug RxSSRI or cholinesterase inhibitor if mild-moderate, AP or mood stabilizer if severe, screaming & shouting, hoarding, spitting will not be fixed
SSRIs for BPSDSertraline best in severe depression, Citalopram = Risperidone for agitation (but QT prolongation), SE hypoNa, GIT, akathisia, sleep disturbance, falls
Chol inh in BPSDBest effect on anxiety, apathy, depression/dysphoria, need several weeks for effect
APs for BPSDHaloperidol & risperidone, discontinue after 3 months, continue if severe withdrawal or no alternative Rx
CVA in BPSDFrom APs, in first 8-12 weeks, RF >80, obesity, DM, HTN, smoking
Death in BPSDFor first 6 months, from CHF, infection
Paranoia in OAMost have dementia, F>M, social isolation RF, those with hallucinations likely to develop dementia in 3 years
Psychosis in OA causeDementia (40%), delirium, drug-induced (benzos & withdrawal), depression/bipolar/schizophrenia, myxedema, hyperPTH, CVA, metabolic abnormality
Paranoid psychosisIn chronic schizophrenics or late-onset (rare)
Partition delusionsThings passing through impermeable barrier, in most late-onset schizophrenics
Late-onset schizMore females, depots more effective
Vascular depressionFrom cerebral ischemic damage to fronto-striatal circuits
Depression & illnessCommon with brain & vascular disease, arthritis, DM
OA depression RxECT common (melancholic, parkinson’s), TCA>SSRI, SNRI, hypoNa & falls with SSRI, confusion with TCAs, anxiolytics not indicated
OA bipolar10% after 50, high morbidity, with mixed mania, use lower lithium dose
Secondary maniaFrom dementia, CVA, head injury, hyperthyroid, hypercortisol, HIV, syphilis, encephalitis
AD switchingMust have 3 week washout (no drugs for 3 weeks to avoid combination)
Serotonin syndromeTremor, fever, altered mental state, withdraw Rx to fix, can be caused from no washout
SSRIsFor typical depression (eat & sleep less)
MirtazapineSNRI, weight gain
VenlafaxineSNRI, diastolic HTN
ImipramineTCA, causes convulsions, cardiac complications, coma, long QT, anti-Ach SE
MAO-ISelegiline, phenylzine
LithiumTeratogenic, nephrogenic DI
Valproate effectsSpina bifida, pancreatitis, thrombocytopenia, agranulocytosis
Carbamazepine2nd line for mood, treats trigeminal neuralgia, causes cleft palate, AV block
Lamotrigine2nd line for mood, causes blurry vision
BenzosFor panic attacks & alcohol withdrawal (Rx tachycardia, HTN & seizures)
Benzo half-livesLoraz short, diaz med, clonaz long
Anxiety RxSSRI for OCD, PTSD, GAD chronically, benzos acutely, beta blockers for speaking
Public speaking RxBeta blockers, SE bradycardia
Agitation RxIM lorazepam, haloperidol, Benadryl
Positive schiz RxMesolibmic D2c activation, typicals & atypicals
Typical APsNonspecific, very potent, cause hyperprolactin (tuberoinfundibular), EPSE (nigrostriatal), sedation & anti-ACh SE
Negative schiz Rx5HT1 activation, atypicals only
Typical AP potencyHaloperidol (strongest, more SE) > chlorpromazine (weakest)
NMSFever, lead-pipe rigidity, AMS, destroy muscle (high CK)
NMS RxDantrolene (uncouple ECC), don’t restart AP
Atypical APsLower potency, higher specificity, D2c for pos, 5HT1 for neg, no depot
Atypical AP SEDM & weight gain (olanzapine), prolonged QT
ClozapineAtypical AP, specific for D2c & 5HT1, best for pos & neg Sx, low EPSE & NMS but agran
DystoniaAcute, torticollis (head to side), hand-wringing, spastic, oculogyric, Rx anticholinergics
AkathisiaRestlessness, Rx decrease dose
Acute dyskinesiaParkinsonism, Rx anticholinergics
Tardive dyskinesiaFacial tics, irreversible, from upregulated D2 receptors in response to blockade by APs, Rx by stopping drug (not by blocking DA)
Noncompliant schiz RxUse depot typical (monthly), everyone else start PO atypical
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