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Psychiatry > Bipolar, Depression & Anxiety > Flashcards

Bipolar, Depression & Anxiety Flashcards

1
Q

Define Delirium

A

An acute and fluctuating disturbance in level of consciousness, attention and global cognition

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2
Q

How is delirium investigated?

A 
Bloods: U&E, FBC, WCC, LFTs, TFTs, glucose
AMTS
Confusion Assessment Method
ECG
CXT
Urinalysis
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3
Q

What is the epidemiology of delirium?

A

Most common: Elderly & very young
50% of hip fractures & terminal illness
10% >65 on hospital admission
50% after hospital admission

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4
Q

What are the signs & symptoms of delirium?

A

Recent onset of fluctuating awareness!!
1) Inattention
2) Impaired global cognitive functions (inc memory-confabulation)
3) Disorganised thinking- Delusions (Dr is poisoning me)
4) Perceptual disturbances
5) Inc/dec psychomotor activity (Hyper/hypoactive)
6) Disturbed sleep wake cycle (insomnia, day sleeping, difficult to distinguish between dreams & reality)
Other:
Reduced level of consciousness
Disorientation (time/place/person)
Illusions/hallucinations
Altered personality
Mood disturbance
Speech disorders (slurred/aphasia/chaotic pattern)
Lack of insight

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5
Q

In delirium are the symptoms stable or changing?

A

Fluctuate over the course of the day and tend to be worse at night.
Patients may show signs of hyperactivity (typically in withdrawal states) or lethargy (common in hepatic encephalopathy).

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6
Q

What are the common causes of delirium?

A

S- Sepsis, Substrate (hyper/hypoG)
M- Meningitis, mental illness
A- Alcohol (toxic/withdrawal)
S- Seizure, STROKE
H- Hyper (thyroid, parathyroid, thermia, carbia), Hypo (thyroid, thermia, tension, hypoxia)
E- Encephalopathy, Electrolytes (hyper/hypoNa, hyperCa), Embolism
D- Drugs: anticholinergics, antiemetics, opiates, corticosteroids, digoxin, levodopa, benzos (intoxication & withdrawal)

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7
Q

What are the main differences between delirium & dementia?

A

Delirium: Sudden onset, fluctuating, days-weeks, varying level of consciousness, inattention, psychomotor changes, reversible
Dementia: Gradual onset, slowly progressive, months-years, consciousness unimpaired, attention preserved, psychomotor normal, degenerative

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8
Q

What are the main types of affective disorders?

A

Bipolar
Depression
Mania

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9
Q

How is bipolar diagnosed?

A

> 2 episodes of mood & activity disturbance

One episode MUST be mania or hypomania

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10
Q

What are the risk factors for bipolar?

A 
Early age of mood disorder <20
Family history
Prev Hx of depression
Stressful life events
Sunstance abuse
Comorbid anxiety
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11
Q

How is bipolar investigated?

A

Hx: If prev overactivity/disinhibited behaviour >4days referral for specialist mental health assessment considered
PHQ-9: Depression screen
PRIME-MD: Mental health screen
Self-rating scale= Mood disorder questionnaire: mania/hypomania
Bipolarity index

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12
Q

How is bipolar managed?

A

1) CBT or IPT
1st manic episode: Seen 1/w for 6w then every 4w for 3m,
ACUTE manic: Antipsychotic (Haloperidol, Olanzapine, Risperidone)
Ineffective inc dose/change drug
Ineffective add Lithium (CI = Valproate)
STOP antidepressants
ECT if all else fails
ACUTE depressive: mild= monitor, mod-severe= Fluoxetine w/Olanzapine +/- CBT
Ineffective Lamotrigine alone
Review = 4weeks of episode
ONGOING: Lithium (only if more than 1 episode)
(if ineffective +) Valproate
Long-term= 2years but may last 5

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13
Q

What are the complications of bipolar?

A 
Drug abuse
Suicide/Self-harm
Cognitive dysfunction
Lithium hypothyroid/nephrotoxicity
Rapid cycling - >4 cycles of depression &amp; mania a year, with no intervening asymptomatic episodes (10-20%)
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14
Q

Define depression

A

Persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive, physical, and behavioural symptoms.

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15
Q

What is the pathophysiology of depression?

What conditions can cause depression?

A 
Monoamine-deficiency theory= A depletion of neurotransmitters serotonin, norE or dopamine in the CNS
Chronic health conditions including pain
Hypothyroidism
Genetic predisposition
Female
Elderly
Substance abuse
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16
Q

What are the core symptoms of depression?

A

Anhedonia- loss of interest/pleasure
Low mood
Loss of energy/fatigue

Other: Loss of appetite
Poor conc/attention
Lack of emotional reactivity
Insomnia

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17
Q

What are symptoms of atypical depression?

A 
Reactive mood
Increased appetite
Weight gain
Excessive sleepiness
Sensitivity to rejection
Usually seen in SAD
18
Q

How does NICE diagnose depression?

A

Either 2 core symptoms present most days, most of the time for at least 2/52.
NOT: Secondary to effects of drugs/OH-, organic illness, bereavement
Ask about appetite, fatigue, energy, insomnia, suicide
MUST have 1 or more core condition & 5/9 of the other symptoms

19
Q

How is SAD diagnosed?

A

Episodes of depression occurring annually at the same time each year with remission in between

20
Q

How is depression investigated?

A 
Mental state Exam
PHQ-9: Self-report questionnaire  mild:5-9, Severe 20-27
Geriatric depression scale
Suicide &amp; self harm 
Rule out organic causes: Bloods, imaging
21
Q

What medications can be given to treat depression?

A

Mild-mod: Consider watch & wait & review in 2weeks, exercise, low intensity psychological interventions (self-help CBT) NOT meds
Mod-severe: Combined SSRI (consider PPI) & HIPT/CBT
Life-threatening: ECT
REVIEW: Suicidal/<30 =1week, no suicide= 2weeks

22
Q

What are the core symptoms in the ICD-10 assessment for diagnosis of depression?

A 
Low/depressed mood
Loss of interest &amp; enjoyment
Lack of energy
Sleep disturbance
Change in appetite
Reduced concentration
Reduced sex drive
Loss of confidence
Guilt feelings
Suicidal thoughts
23
Q

What are the levels of severity of depression according to the ICD 10 criteria?

A 
Mild= 2core + 2other
Mod= 2core + 3other
Severe= 3core + 4other
24
Q

How is a manic episode in Bipolar classed by ICD 10?

A 
Elated/irritable/labile mood
Increased energy/overactive
Distractibility/ reduced conc/ constant change of plans
Reduced need for sleep
Inflated self esteem/ grandiosity
Overfamiliarity/ disinhibition
Reckless behaviour/ overspending
Inc sex drive
Psychotic symptoms
Racing thoughts/ flight of ideas
25
Q

What is anxiety?

A

Evolutionary response to a threatening situation
Associated ↑ HR, ↑BP, ↑RR, nausea, muscle tingling
Fight or flight response

26
Q

When does anxiety become problematic?

A

Out of proportion to threat
More prolonged
Occurs without a threat
Interferes with daily life

27
Q

What is a panic attack?

A

Discrete episode(s) of intense fear or discomfort
Starts abruptly/unpredictable
Reaches max within mins & lasts mins
4 symptoms of anxiety: Palpitations, chest pain, feelings of unreality, choking sensation, dizziness

28
Q

What are the signs & symptoms of anxiety?

A 
Headaches/ lightheaded
Tiredness
Choking sensation
SOB
Tension
Dry mouth
Sweating
Nausea
Flushing/chills
Stomach pains
Chest pain/palpitations
Butterflies
Jelly legs/ shakiness/trembling
Loss of appetite
29
Q

What are the different types of anxiety disorders?

A

Phobic
Other: Panic, GAD
OCD
Dissociative/conversion: Amnesia, stupor, motor, sensory loss, trance & possession states
Somatoform: Hypochondriacal, somatisation
Reactions to s. stress: PTSD, acute stress reaction, adjustment disorder

30
Q

What is an adjustment disorder? What are the signs?

A

Abnormal and excessive reaction to an identifiable life stressor. The reaction is more severe than normally expected and can result in signif impairment in social or occupational
Signs: Depression, anxiety, inability to cope, physical complaints, withdrawal, conduct disturbance (truancy)

31
Q

How is delirium diagnosed?

A

DSM-IV Criteria:

  • Disturbance of consciousness: Poor attention, focus, lack of awareness
  • Change in cognition: disorientated, memory deficit, language/visual disturbance
  • Develops over a short time period: Fluctuating over course of the day
32
Q

How is delirium managed?

A

Conservative: Orientate the patient, clear communication, hearing aids/glasses
Treat underlying cause
Aggression & Agitation: Haloperidol 0.5-1mg PO/IM

33
Q

What are the signs & symptoms of Bipolar disorder?

A

Manic: Pressure of speech, Grandiose ideas, Excessive energy, Overactivity, Flight of ideas, Needing little sleep, easily distracted, Inc sex drive, Inc spending, unusual clothing +/- delusions & hallucinations
Hypomanic: Persistent mild elevation of mood, energy, without delusions or hallucinations no significant effect on functional ability
Depressive: Low mood-worse am, reduced energy, anhedonia, guilt, despair, low self-esteem, reduced appetite, altered sleep
Psychosocial functioning: Difficulties with work/ relationships

34
Q

What symptoms are indicative of mania? How many symptoms are needed for a diagnosis?

A 
3 of the following:
Grandiosity/inflated self-esteem.
Decreased sleep.
Pressured speech.
Flight of ideas
Distractibility.
Psychomotor agitation.
Excessive involvement in pleasurable activities without thought for consequences (spending spree resulting in excessive debts).
35
Q

What are the abnormal signs of bereavement?

A

Prolonged grieving
Severe reactive depression with/without suicidal ideation
Excessive feelings of guilt
Converting emotional conflicts into psychosomatic symptoms.
Searching for the deceased
Sometimes mild auditory/visual hallucinations (e.g seeing the deceased face in a crowd)
Self-neglect
Impulse of radical changes (suddenly moving house)
Denial of the death

36
Q

What medications can increase someone’s risk of depression?

A 
Beta blockers
Steroids
Anticonvulsants
Benzos
Opiates
Antipsychotics
NSAIDs
37
Q

What are the risk factors for delirium?

A 
Age
Cognitive impairement
Prev delirium
Depression
Sensory impairment
Falls
38
Q

What is inattention?

A

Unable to generate, sustain or shift attention, easily distracted
Disorientated: Time/place
Bedside test: Serial 7’s, months backwards

39
Q

What are the signs of psychomotor disorder in delirium?

A

Hyper: Restless, Pressured speech, Laughing/crying, Repetitive movements
Hypo: Lethargy and sedation, respond slowly to questioning, and show little spontaneous movement.

40
Q

In what condition is caution needed with Haloperidol?

A

Parkinson’s
Haloperidol: Can worsen parkinsonian symptoms
Use Lorazepam instead

Psychiatry (19 decks)

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