Common Conditions Flashcards
What is generalised anxiety disorder (GAD)?
GAD = causes excessive + disproportional anxiety and worry that negatively impacts the person’s everyday activity.
Symptoms = should be persistent, occurring most days for at least 6 months - and not caused by substance use or other condition
Name some secondary causes of anxiety
- Substance use (e.g., caffeine, stimulants, bronchodilators and cocaine)
- Substance withdrawal (e.g., alcohol or benzodiazepine withdrawal)
- Hyperthyroidism
- Phaeochromocytoma
- Cushing’s disease
What is panic disorder?
Panic disorder = involves recurrent panic attacks
* Panic attacks = unexpected (appear randomly, often without trigger) → result in worry about further attacks + maladaptive behaviour changes relating to the attacks (e.g. avoiding activities)
What are the emotional + cognitive symptoms of GAD?
- Excessive worrying
- Unable to control the worrying
- Restlessness
- Difficulty relaxing
- Easily tired
- Difficulty concentrating
What are the physical symptoms of GAD?
Physical symptoms = caused by the overactivity of the sympathetic nervous system
- Muscle tension
- Palpitations (e.g., a feeling of their heart racing)
- Sweating
- Tremor
- Gastrointestinal symptoms (e.g., abdominal pain and diarrhoea)
- Headaches
- Sleep disturbance
How do panic attacks present?
Sudden onset of intense phsyical + emotional symptoms of anxiety
* They come on quickly (within minutes) and last a short time (e.g., 10 minutes) before the symptoms gradually fade.
Physical symptoms:
* Tension
* Palpitations
* Tremors
* Sweating
* Dr mouth
* Chest pain
* Shortness of breath
* Dizziness
* Nausea
Emotional symptoms:
* Feelings of panic, fear, danger
* Depersonalisation (feeling separated or detached)
* Feeling of loss of control
Define phobia
Phobia = extreme fear of certain situations or things → causing symtoms of anxiety + panic
Examples of common specific phobias
- Claustrophobia (fear of closed spaces)
- Acrophobia (fear of heights)
- Arachnophobia (fear of spiders)
- Glossophobia (fear of public speaking)
- Trypanophobia (fear of needles)
Agoraphobia = a fear of situations in which they may be unable to escape if something goes wrong. E.g. this could be a fear of busy places, public transport, or anywhere outside their home.
Social phobia involves a fear of social situations (also called social anxiety disorder).
What questionnaire can assess the severity of generlalised anxiety disorder (GAD)?
Generalised Anxiety Disorder Questionnaire (GAD-7)
* It consists of 7 questions
The total score indicates the severity:
* 5-9 indicates mild anxiety
* 10-14 indicates moderate anxiety
* 15-21 indicates severe anxiety
Literally just the condition name with 7 on the end
Management for GAD
Mild anxiety:
* Active monitoring
* Self-help strategies (e.g. meditation), sleep, diet, exercise, avoiding alcohol, caffeine and drugs
Moderate-severe anxiety:
* CBT
* Medication
Medication management for GAD
- First line: SSRIs (particularly sertraline) (for GAD + panic disorder)
- Other options: SNRIs (e.g. venlafaxine), pregabalin
- Propanolol = a non-selective beta-blocker - used to treat phsycial symptoms → reduce sympathetic nervous system overactivity → improves palpitations, tremors, sweating. Only has short-term effect. Main contraindication = asthma (can cause bronchoconstriction in asthmatic patients)
- Benzodiazepines (e.g. diazepam) - only in crisis → stimulating GABA receptors (similar effects to alcohol) → relaxing effect on brain. Prolonged use = quickly results in down-regulated GABA receptors → leading to tolerance (reduced effects at same dose) + dependence (significant withdrawal symptoms on stopping)
The NICE guidelines (2020) recommend not offering benzodiazepines for GAD. The exception is using them for a short duration during a crisis, stopping them as soon as possible.
Define depression
Depression = a disorder that causes persistent feeling of low mood + low energy + reduced enjoyment of activities
Affects everyone
Pathophysiology of depression
Mechanism not fully understood
Involves a disturbance in neurotransmitter activity in the central nervous system - particular serotonin AKA 5-hydroxytryptamine (5-HT)
Causes of depression
Can occur with:
* No apparent triggers
* Life events (e.g. loss of loved one)
* Physical health conditions (e.g stroke, MI, MS, and Parkinson’s)
Consider:
* Genetic
* Psychological
* Biological
* Environmental
What are the core symptoms of depression?
- Low mood
- Anhedonia (lack of pleasure or interest in activities)
Emotional symptoms of depression?
- Anxiety
- Irritability
- Low self-esteem
- Guilt
- Hopelessness about the future
Cognitive symptoms of depression
- Poor concentration
- Slow thoughts
- Poor memory
Physical symptoms of depression
- Low energy (tired all of the time)
- Abnormal sleep (particularly early morning waking)
- Poor appetite or overeating
- Slow movements
Name some environmental factors that contribute to depression
- Potential triggers (e.g. stress, grief or relationship breakdown)
- Home environment (e.g., housing situation, who they live with and their neighbourhood)
- Relationships with family, friends, partners, colleagues and others
- Work (e.g., work-related stress or unemployment)
- Financial difficulties (e.g., poverty and debt)
- Safeguarding issues (e.g., abuse)
What are some essential factors to explore when taking a history regarding depression?
- Caring responsibilities (e.g., children or vulnerable adults)
- Social support
- Drug use
- Alcohol use
- Forensic history (e.g., violence or abuse)
Every encounter of depression should include a risk assessment. What does this involve?
- Self-neglect
- Self-harm
- Harm to others (including neglect)
- Suicide
What questionnaire is used to assess the severity of depression?
PHQ-9 Questionnaire
There are nine questions about how often the patient is experiencing symptoms in the past two weeks.
- 5-9 indicates mild depression
- 10-14 indicates moderate depression
- 15-19 indicates moderately severe depression
- 20-27 indicates severe depression
Like anxiety, below 10 then mild. below 15 then moderate, above then severe
Management of depression
- Active monitiring and self-help
- Address lifestyle factors (exercise, diet, stress, alcohol)
- Therapy (CBT, counselling, psychotherapy)
- Antidepressants (SSRIs = first-line)
NICE recommends: NOT offerring antidepressants first-line to patients with less severe depression (less than 16 on the PHQ-9) - unless they have a preference for taking them
- Severe or psychotic depression → urgent specialist unput → Crisis resolution + home treatment team (no admission)
- High risk of self-harm, suicide, self-neglect, immediate safeguarding issue → admission
- Unresponsive or severe depression: antipsychotic medications (e.g. onlazapine or quetiapine), lithium, ECT
Pyschotic depression involves the symptoms of psychosis. What 3 things does psychosis invole?
- Delusions (beliefs that are strongly held and clearly untrue)
- Hallucinations (hearing or seeing things that are not real)
- Thought disorder (disorganised thoughts causing abnormal communication and behaviour)
When psychosis accompanies depression, it generally indicates severe depression, although psychosis can occur with mild or moderate depression.
Treatment for psychotic depression
Combination of antipsychotics (e.g. olanzapine or quetiapine) + antidepressants
Other options: ECT
Name 3 postnatal mental health issues
These occur in a spectrum
- Baby blues (seen in the majority of women in the first week or so after birth)
- Postnatal depression (1 in 10 peak around 3 months after birth)
- Puerperal psychosis (1 in 1000, starts a few weeks after birth)
When and how does baby blues occur?
- Onset: Affects more than 50% of women in the first week or so after birth
Presentation - usually mild, last a few days - will resolve within 2 weeks of delivery:
* Mood swings
* Low mood
* Anxiety
* Irritability
* Tearfulness
No treatment required
Baby blues = results from:
* Significant hormonal changes
* Recovery from birth
* Sleep deprivation
* Increased responsibility
* Difficulty with feeding
How does postnatal depression present?
- Onset: 3 months after birth
Similar to depression out of pregnancy:
* Low mood
* Anhedonia
* Low energy
- Symptoms should last at least 2 weeks before diagnosis
Treatment = similar to depression (depending on severity)
How and when does puerperal psychosis present?
Rare
* Onset = 2-3 weeks after delivery
Presentation - psychosis:
* Delusions
* Hallucinations
* Depression
* Mania
* Confusion
* Thought disorder
Treatment: Urgent assessment + possible admission to mother + baby unit, medications, ECT
What is the screening tool or postnatal depression?
Edinburgh postnatal depression scale
* Assesses how the mother has felt over the past week
* 10 questions, score out of 30.
* More than 10 points = suggests postnatal depression
Define dementia
Dementia = causes progressive + irreversible impairment in memory, cognition, personailty and communication.
* Associated with older age
* Early-onset dementia = refers to when the symptoms start before 65 y/o.
What is mild cognitive impairment?
MCI = a deficit in cognition + memory - that is greater than expected with age, but not significant enough for a dementia diagnosis
People with MCI = can usually live independently
What is Alzheimers dementia?
- Alzheimers disease = most common type
Pathophysiology involves: - Brain atrophy
- Amyloid plaques
- Reduced cholinergic activity
- Neuroinflammation
What is vascular dementia?
Vascular dementia = second most common type
* Vascular dementia = caused by vascular damage + impaired blood supply to brain
- Risk factors = are the same as other cardiovascular diseases (e.g. hypertension, diabetes, smoking)
What is Dementia with Lewy bodies?
Dementia with Lewy bodies = type of dementia associated with features of Parkisonism
Symptoms:
* Cognitive decline
* Visua hallucinations
* Delusions
* REM sleep disorders
* Fluctuating consciousness
What is frontotemporal dementia?
Frontotemporal dementia = affects people at a younger age (40-60)
* Mainly affects the frontal + temporal lobes
Initial presentation = involves:
* Behaviour
* Speach
* Language
Frontotemporal dementia = can be familial
Name some medications with an anticholinergic effect that could cause cognitive impairment, memory impairment, personality changes?
(Differential diagnosis for dementia)
Medications with an anticholinergic effect:
* Anticholinergic urological drugs (e.g., oxybutynin, solifenacin and tolterodine)
* Antihistamines (e.g., chlorphenamine and promethazine)
* Tricyclic antidepressants (e.g., amitriptyline)
Name some psyhiatric conditions that are differential diagnosis for dementia
- Depression
- Psychosis
- Delirium (e.g. secondary to infection)
(DPD) - delivering mems
Name some neurological conditions that are differential diagnosis for dementia
- Brain tumours (particularly affecting the frontal lobes)
- Parkinson’s disease
- Huntington’s disease
- Progressive supranuclear palsy
Name some endocrine conditions that are differential diagnosis for dementia
- Hypothyroidism
- Adrenal insufficiency
- Cushing’s syndrome
- Hyperparathyroidism (causing hypercalcaemia)
What nutritional deficiencies that are differential diagnosis for dementia?
- Vitamin B12 deficiency
- Thiamine deficiency (causing Wernicke-Korsakoff syndrome)
Name some modifiable risk factors for dementia
- Exercise
- Mental stimulation (e.g., a more mentally challenging job)
- Maintaining a healthy weight (obesity increases the risk)
- Blood pressure control (hypertension increases the risk)
- Blood glucose control (diabetes increase the risk)
Info: Dementia
- Symptoms = tend to have a slow + insidious onset
- Having a collateral history from a close contact such as family member is helpful
Name some early symptoms of dementia
- Forgetting events
- Forgetting names
- Difficult remembering words
- Repeatedly asking the same questions
- Impaired decision making
- Reduced flexibility
Name some advanced features of dementia
As the condition progresses, memory and cognitive impairment worsen. Eventually, patients lose the ability to complete self-care tasks such as cooking, cleaning, and dressing themselves.
- Inability to speak or understand speech (aphasia)
- Swallowing difficulties (dysphagia) → lead to aspiration + pneumonia
- Appetite + weight loss
- Incontinence
Name some screening tests for memory + cognition
- Six Item Cognitive Impairment Test (6CIT)
- 10-point Cognitive Screener (10-CS)
- Mini-Cog
- General Practitioner Assessment of Cognition (GPCOG)
- Montreal Cognition Assessment (MoCA)
What are some investigations that are required to exclude a physical cause before you refer to the memory clinic, when you suspect dementia?
Blood tests:
* Full blood count
* Urea and electrolytes
* Liver function tests
* Inflammatory markers (e.g., CRP and ESR)
* Thyroid profile
* Calcium
* HbA1c
* B12 and folate
Additional tests:
* Mid-stream urine (MSU) if infection is suspected
* Chest x-ray (if lung cancer is suspected) (+?pneumonia)
Structural pathology:
* Imaging (e.g. MRI brain)
What are the 5 domains that are tested in the ACE-III (comprehensive assessment tool for memory impairment)?
- Attention
- Memory
- Language
- Visuospatial function
- Verbal fluency
- Less than 88/10 → indicates possible dementia
- Even lower → severe impairment
What can be put into place in the early stages of dementia to support the patients and carers?
- Lasting power of attorney (nominating a person to make decisions on their behalf when they are no longer able)
- Advanced decisions (around treatments they would want or not want)
- Planning future care (including places and end-of-life care)
What are the 2 medication options for Alzheimer’s disease to help improve symptoms?
- Acetylcholinesterase inhibitors (e.g. donepezil, rivastigime, galantamine)
- Memantine (blocks NMDA receptors)
Name some behavioural and psychological symptoms of dementia (BPSD)
- Depression
- Anxiety
- Agitation
- Aggression
- Disinhibition (e.g., sexually inappropriate behaviour)
- Hallucinations
- Delusions
- Sleep disturbance
Name some of the initial steps to manage BPSD
- Treating underlying causes (e.g., pain, constipation or urinary retention)
- Environmental factors (e.g., providing a calming setting and removing triggers)
- Appropriately trained carers
- Appropriate supervision (one-to-one observation may be required)
- Music therapy
Name some medication options for managing BPSD
- ** SSRI antidepressants** for depressive symptoms
- Antipsychotic drugs (typically risperidone = first-line)
- Benzodiazepines (only for crisis management)
Define delirium
Delirium = an acute + fluctuating disturbance in level of consciousness, attention, global cognition
Why is delirium so important?
- Prompt treatment = required to avoid potential brain damage
- The underlying mechanism = poorly understood - but believed to involve neurotransmitter abnormalities + inflammation
Who does delirium occur in?
Mostly in the elderly + very young
* It is predicted that 10% of patients over 65 show signs of delirium on admission to hospital.
* Affects 15% of in-patients.
Signs + symptoms of delirium
Reduced level of consciousness
Psychiatric symptoms:
* Disorientation (time/place/person)
* Inattention
* Illusions/hallucinations
* Altered personality
* Mood disorders
* Speech disorders (slurred speech/aphasic error/chaotic pattern)
Lacking insight
Symptoms = fluctuate over the course of the day + tend to be worse at night
Patients may show signs of hyperactivity (typically in withdrawal states) or lethargy (common in hepatic encephalopathy).
Causes of delirium
P - Pain.
I - Infection.
N - Nutrition.
C - Constipation.
H - Hydration.
E - Endocrine + Electrolyte.
S - Stroke.
M - Medication and Alcohol.
E - Environmental.
Causes of delirium
- CNS: Stroke, abscess, tumour, subdural haematoma
- Drugs/withdrawal: Anticholinergics, antiemetics, antipsychotics, corticosteroids, digoxin, opioids, alcohol
- Endocrine: Hyperparathyrodism, hyper/hypothyroidism
- Infection/injury: Encephalitis, meningitis, pneumonia, sepsis, UTI, burns, hypothermia
- Metabolic: Acid-base disturbance, hepatic encephalopathy, uraemia, hypo/hyperglycaemia, electrolyte abnormalities, thiamine/vitamin B12 deficiency
- Other: Post-operative states, other mental disorders, sleep depravation
Delirium vs dementia
Delirium:
* Sudden onset + fluctuating course over days - weeks
* Variation in level of consciousness
* Impaired attention
* Psychomotor changes
Dementia:
* Gradual onset, slowly progressive over months - years
* Consciousness unimpaired
* Attention preserved
Diagnosis of delirium
- Collateral history: determine if the changes in mental status are recent and the patients normal level of functioning.
- Drug + aclcohol history: consider any with CNS effects or new additions as a potential cause
- Mini-mental state examination: Likely to show deficits in attention (e.g. immediate repitation of 3 objects)
Diagnostic features of delirium
- Acute change in cognition - which fluctuates during the day
- Inattention
- Disturbance of consciousness
- Disorganised thinking
What 2 things you should examine in a patient that presents with delirium?
- Potential sites of infection
- Focal neurological signs (suggesting a strutural CNS disorder)
Treatment of delirium
- Treating the underlying cause or removing aggravating drugs = principle treatment
- Environmental management: nurse patients in a quiet and well-lit room.
- Minimise sensory deficits: check hearing aids/glasses etc
- Agitation can be managed with haloperidol (0.5-1.0mg PO) or lorazepam (0.5-1.0mg PO), however, they should be AVOIDED as they may worsen or prolong delirium.
Name some symptoms of SSRI withdrawal
- GI symptoms
- Restlessness
- Mood changes
- Insomnia
