**_🤯Psychiatry🤯 - Mental Disorders & Physical Health

Question 1

What are the characteristic features of adjustment disorder?

Answer 1

Recent psychosocial stressors (risk factor)
Mood lability - preoccupation on stressors
Typically resolves after 6 months
Psychotic symptoms generally not seen

Question 2

What are psychosocial stressors?

Answer 2

Events that cause significant stress and affect a person’s psychological or mental wellbeing
e.g. having a stroke and moving into a care home

Question 3

What are the characteristic features of psychotic depression?

Answer 3

Recent psychosocial stressors (risk factor)
Older age and chronic medical conditions - both risk factors
Features same core symptoms as depression
Usually mood congruent psychosis seen(delusions of nihilism, guilt etc…) - not paranoid psychosis

Question 4

What are the features of behavioural ad psychological symptoms of dementia (BPSD)?

Answer 4

Known history of vascular insult to the brain (risk factor)
Delusions or hallucinations can be seen
Ongoing vascular risk factors and advancing age (risk factors)

Question 5

Richard is a 69 year old retired businessman. Referred due to mental health concerns
Been in care home for close to 2 years
PMH: Stroke and TIA, hypertension, hyperlipidaemia, appendicectomy, bilateral cataracts
Recently reviewed by GP: No acute concerns, normal bloods and urine dip
Normal mood, enjoys going to the pond, angry and sad about losing wife, stroke and now being in a care home
Believes wife may have been “kidnapped”, believes care home manager “drugs and rapes him at night”, reports seeing people coming out of his bathroom
Oriented to time, place, person, normal MoCA scores

How well does Richard fit adjustment disorder?

Answer 5

Has had recent psychosocial stressors (stroke and being moved into care)
Mood lability is present - preoccupied with his stressors
Typically resolves after 6 months - Richard’s symptoms have not
Psychotic symptoms are typically not seen in adjustment disorder

Fairly weak differential

Question 6

Richard is a 69 year old retired businessman. Referred due to mental health concerns
Been in care home for close to 2 years
PMH: Stroke and TIA, hypertension, hyperlipidaemia, appendicectomy, bilateral cataracts
Recently reviewed by GP: No acute concerns, normal bloods and urine dip
Normal mood, enjoys going to the pond, angry and sad about losing wife, stroke and now being in a care home
Believes wife may have been “kidnapped”, believes care home manager “drugs and rapes him at night”, reports seeing people coming out of his bathroom
Oriented to time, place, person, normal MoCA scores

How well does Richard fit psychotic depression?

Answer 6

Has had recent psychosocial stressors (stroke and being moved into care)
Older age and chronic medical conditions are present
Lacks other core features of depression (anhedonia, anergia) and no biological symptoms (sleep disturbances, loss of appetite etc…)
Paranoid psychosis rare in psychotic depression. Usually mood congruent psychosis (delusions of nihilism, guilt etc…)
Visual hallucinations uncommon

Very weak differential

Question 7

Richard is a 69 year old retired businessman. Referred due to mental health concerns
Been in care home for close to 2 years
PMH: Stroke and TIA, hypertension, hyperlipidaemia, appendicectomy, bilateral cataracts
Recently reviewed by GP: No acute concerns, normal bloods and urine dip
Normal mood, enjoys going to the pond, angry and sad about losing wife, stroke and now being in a care home
Believes wife may have been “kidnapped”, believes care home manager “drugs and rapes him at night”, reports seeing people coming out of his bathroom
Oriented to time, place, person, normal MoCA scores

How well does Richard fit BPSD?

Answer 7

Known history or recent vascular insult to the brain (TIA and stroke)
Delusions and hallucinations are seen in BPSD
Ongoing vascular risk factors (hyperlipidaemia) and advancing age
Normal score on MoCA - BPSD usually seen in advanced dementia - cognitive decline would be evident before BPSD arises

Fairly weak differential

Question 8

Richard is a 69 year old retired businessman. Referred due to mental health concerns
Been in care home for close to 2 years
PMH: Stroke and TIA, hypertension, hyperlipidaemia, appendicectomy, bilateral cataracts
Recently reviewed by GP: No acute concerns, normal bloods and urine dip
Normal mood, enjoys going to the pond, angry and sad about losing wife, stroke and now being in a care home
Believes wife may have been “kidnapped”, believes care home manager “drugs and rapes him at night”, reports seeing people coming out of his bathroom
Oriented to time, place, person, normal MoCA scores

How well does Richard fit psychotic post-stroke psychosis?

Answer 8

Most commonly seen in right sided middle cerebral artery lesions
Most common psychotic symptom is delusions - most of a jealous or persecutory type (Othello’s syndrome)
Perceptual abnormalities also seen

Strong differential

Question 9

What is the definition of a delusion?

Answer 9

A fixed, false belief not understandable within the person’s sociocultural setting

Question 10

What mental health disorders is cardiovascular disease a risk factor for?

Answer 10

3x increased risk of depression/anxiety

Question 11

What mental health disorders are MSK disorders a risk factor for?

Answer 11

2x increased risk of depression

Question 12

What mental health disorders is diabetes a risk factor for?

Answer 12

2x increased risk of depression

Question 13

What mental health disorders is COPD a risk factor for?

Answer 13

10x increased risk of panic disorder

Question 14

What is the first priority of a psychiatrist when a patient first presents to them with apparent neurological/psychological symptoms?

Answer 14

Exclude an organic cause for the patients presentation (e.g. an endocrine issue, infections etc…)

Question 15

What mental health presentations can Addison’s mimic?

Answer 15

Depression
Poor concentration
Irritability

Question 16

What mental health presentations can be mimicked by hypercalcaemia?

Answer 16

Depression
Anxiety

Question 17

What mental health presentations can be mimicked by hyperthyroidism?

Answer 17

Anxiety
Mania

Question 18

What mental health presentations can be mimicked by hypothyroidism?

Answer 18

Depression
Cognitive impairment

Question 19

What mental health presentations can be mimicked by Cushing’s?

Answer 19

Depression

Question 20

What mental health presentations can be mimicked by infections (syphilis, HIV etc…)?

Answer 20

Psychosis
Dementia

Question 21

What mental health presentations can be mimicked by SLE?

Answer 21

Depression

Question 22

What mental health presentations can be mimicked by cancer?

Answer 22

Depression

Question 23

What mental health presentations can be mimicked by Parkinson’s?

Answer 23

Depression
Anxiety
Dementia
Psychosis

Question 24

What mental health presentations can be mimicked by phaeochromocytoma?

Answer 24

Anxiety

Question 25

What mental health presentations can be mimicked by dementia?

Answer 25

Psychosis
Aggression/violence
Depression
Anxiety

Question 26

What mental health presentations can be mimicked by Huntington’s?

Answer 26

Psychosis
Aggression/violence
Cognitive impairment
Depression
Anxiety

Question 27

What are some examples of organic causes of depression?

Answer 27

Addison’s, Cushing’s
Hypercalcaemia, hypothyroidism
Parkinson’s, dementia, Huntington’s
Cancer, SLE
Huge range of conditions can cause depressive symptoms

Question 28

Which medications can lead to psychosis as an adverse effect?

Answer 28

Dopamine agonists
L-dopa
Steroids (prednisolone)
Isoniazid
Anticholinergics
Digoxin
INF-alpha
Lots of medications

Question 29

What is the relationship between mental illness and physical health?

Answer 29

People with chronic mental illness are at greater risk of all cause mortality; the so called “mortality gap”

Question 30

How does mental illness lead to physical health problems?

Answer 30

Multifactorial Cause
Medication adverse effects (e.g. weight gain, dyslipidaemia, insulin insensitivity, hypertension, sedation)
Increased rates of smoking, illicit substance use and alcohol intake
Poor diet, dental hygiene and low levels of exercise
Chaotic lifestyles and low socioeconomic status

Question 31

How can the effect of mental illness on physical health me managed/minimised?

Answer 31

Choose medication that minimises impact on physical health
(e.g. weight gain sparing antidepressants and antipsychotics in those already with increased BMI)
Monitoring of cardiometabolic factors (BMI, HbA1C, lipid profile, blood pressure)
Ensure registered with a GP and dental practice
Dietary advice and smoking cessation
Drug and alcohol support services

Question 32

What would you expect to see in an MRI of someone’s brain with Alzheimer’s disease?

Answer 32

Temporo-parietal cortical atrophy
Mesial temporal lobe atrophy
Possibly mild small vessel disease

Question 33

An elderly gentleman undergoes a fall with a long lie. After surgery to fix an intracapsular neck of femur fracture (total hip arthroplasty in this case), he suddenly presents with strange behaviour
Disoriented, shouting in the night
Reporting “seeing devils” coming into the bay at night
Irritability and aggression at times (punched a nurse)
Stuporous and quiet at other times, sleeping in the day
ACE III – Repeated and score drops from 81/100 to 34/100 (incredibly abnormal)
What is the diagnosis?

Answer 33

Delirium

Question 34

What is the definition of delirium?

Answer 34

Delirium is characterized by a disturbance of attention, orientation, and awareness that develops within a short period of time, typically presenting as significant confusion or global neurocognitive impairment, with transient symptoms that may fluctuate depending on the underlying causal condition or etiology. Delirium often includes disturbance of behaviour and emotion, and may include impairment in multiple cognitive domains. A disturbance of the sleep-wake cycle, including reduced arousal of acute onset or total sleep loss with reversal of the sleep-wake cycle, may also be present. Delirium may be caused by the direct physiological effects of a medical condition not classified under mental, behavioural or neurodevelopmental disorders, by the direct physiological effects of a substance or medication, including withdrawal, or by multiple or unknown etiological factors

Question 35

What is a more concise definition of delirium?

Answer 35

An acute confusional state and a neuropsychiatric manifestation of physical illness/injury/interventions
Can be considered as “acute brain failure” compared to “chronic brain failure” (dementia)

Question 36

How can delirium arise?

Answer 36

An insult, such as an infection or new medication, to someone with an already “vulnerable” brain (e.g. Alzheimer sufferers etc…)

Question 37

How can delirium be categorised?

Answer 37

Hyperactive
Hypoactive
Mixed

Question 38

What are the features of hyperactive delirium?

Answer 38

Agitation
Hallucinations
Inappropriate behaviour

Question 39

What are the features of hypoactive delirium

Answer 39

Lethargy
Reduced concentration
Reduced alertness
Reduced oral intake

Question 40

What are the features of mixed delirium?

Answer 40

A combination of hyperactive and hypoactive features

Question 41

What is the epidemiology of delirium?

Answer 41

Affects 50% of those in hospital aged >65
Complicates 80% of ITU admissions
May affect 14% of those >85 in the community
Leads to increased mortality and delays in discharge

Question 42

What are the main (not exhaustive list) risk factors for delirium?

Answer 42

Advancing age
Cognitive impairment (e.g. dementia), sensory impairment
Poor nutrition
Polypharmacy/alcohol misuse
Frailty

Question 43

What is the pathophysiology of delirium?

(not essential knowledge - poorly understood so these are just theories)

Answer 43

A critical illness leads to increased cortisol levels and cerebral hypoxia (older adults predisposed) which leads to↓acetylcholine synthesis and dysfunction of hippocampal and neocortical areas (↑500 times dopamine and↑adrenergic output)

Likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, neurovascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity

Question 44

What are the main management strategies of delirium?

Answer 44

Anticipate and address any modifiable risk factors (e.g. reducing polypharmacy, visual and hearing aids)
Optimise treatment of underlying co-morbidities
Treat any underlying cause (e.g. UTI, constipation, physical injury, electrolyte disturbance, dehydration)
Re-orientation strategies (familiar environments, use of clocks, reminding of name and current location)
Normalise sleep-wake cycle (encourage uninterrupted sleep, use of appropriate lighting, discourage daytime napping)
Maintain safe mobility to avoid falls

Question 45

How can challenging behaviour be managed in delirium?

Answer 45

Address underlying unmet needs (thirst, need for toilet, discomfort/pain)
Safe and low stimulation environments
Verbal and non-verbal de-escalation techniques
In extremis – Short term pharmacological interventions (e.g. low dose Haloperidol [0.5mg] for <7 days)

Question 46

What are the issues surrounding mental health stigma?

Answer 46

3 in 4 people with mental illness experience stigma (highest in ethnic minority groups)
Stigma acts as a barrier to accessing all aspects of care - don’t want to admit/acknowledge they have a mental health issue
Stigma can also be a risk factor for people experiencing abuse, rejection and isolation
Stigma contributes to difficulties in employment

Question 47

What factors affect the efficient diagnosis of physical disorders in people with mental illness?

Answer 47

Illness behaviour (e.g. poor insight, mistrust of others, chaotic lifestyle)
Diagnostic overshadowing (misattribution of physical symptoms to psychiatric symptoms)
Lack of resources/lack of access to services (low socio-economic status is a risk factor for the development of mental disorders)