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3a Psychiatry > Common Conditions > Flashcards

Common Conditions Flashcards

1
Q

What is generalised anxiety disorder (GAD)?

A

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

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2
Q

Name some secondary causes of anxiety

A
  • Substance use (e.g., caffeine, stimulants, bronchodilators and cocaine)
  • Substance withdrawal (e.g., alcohol or benzodiazepine withdrawal)
  • Hyperthyroidism
  • Phaeochromocytoma
  • Cushing’s disease
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3
Q

What is panic disorder?

A

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)

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4
Q

What are the emotional + cognitive symptoms of GAD?

A
  • Excessive worrying
  • Unable to control the worrying
  • Restlessness
  • Difficulty relaxing
  • Easily tired
  • Difficulty concentrating
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5
Q

What are the physical symptoms of GAD?

A

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
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6
Q

How do panic attacks present?

A

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

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7
Q

Define phobia

A

Phobia = extreme fear of certain situations or things → causing symtoms of anxiety + panic

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8
Q

Examples of common specific phobias

A
  • 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).

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9
Q

What questionnaire can assess the severity of generlalised anxiety disorder (GAD)?

A

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

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10
Q

Management for GAD

A

Mild anxiety:
* Active monitoring
* Self-help strategies (e.g. meditation), sleep, diet, exercise, avoiding alcohol, caffeine and drugs

Moderate-severe anxiety:
* CBT
* Medication

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11
Q

Medication management for GAD

A
  • 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.

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12
Q

Define depression

A

Depression = a disorder that causes persistent feeling of low mood + low energy + reduced enjoyment of activities

Affects everyone

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13
Q

Pathophysiology of depression

A

Mechanism not fully understood

Involves a disturbance in neurotransmitter activity in the central nervous system - particular serotonin AKA 5-hydroxytryptamine (5-HT)

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14
Q

Causes of depression

A

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

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15
Q

What are the core symptoms of depression?

A
  • Low mood
  • Anhedonia (lack of pleasure or interest in activities)
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16
Q

Emotional symptoms of depression?

A
  • Anxiety
  • Irritability
  • Low self-esteem
  • Guilt
  • Hopelessness about the future
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17
Q

Cognitive symptoms of depression

A
  • Poor concentration
  • Slow thoughts
  • Poor memory
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18
Q

Physical symptoms of depression

A
  • Low energy (tired all of the time)
  • Abnormal sleep (particularly early morning waking)
  • Poor appetite or overeating
  • Slow movements
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19
Q

Name some environmental factors that contribute to depression

A
  • 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)
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20
Q

What are some essential factors to explore when taking a history regarding depression?

A
  • Caring responsibilities (e.g., children or vulnerable adults)
  • Social support
  • Drug use
  • Alcohol use
  • Forensic history (e.g., violence or abuse)
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21
Q

Every encounter of depression should include a risk assessment. What does this involve?

A
  • Self-neglect
  • Self-harm
  • Harm to others (including neglect)
  • Suicide
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22
Q

What questionnaire is used to assess the severity of depression?

A

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

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23
Q

Management of depression

A
  • 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
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24
Q

Pyschotic depression involves the symptoms of psychosis. What 3 things does psychosis invole?

A
  • 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.

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25
Q

Treatment for psychotic depression

A

Combination of antipsychotics (e.g. olanzapine or quetiapine) + antidepressants

Other options: ECT

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26
Q

Name 3 postnatal mental health issues

These occur in a spectrum

A
  • 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)
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27
Q

When and how does baby blues occur?

A
  • 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

28
Q

How does postnatal depression present?

A
  • 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)

29
Q

How and when does puerperal psychosis present?

A

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

30
Q

What is the screening tool or postnatal depression?

A

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

31
Q

Define dementia

A

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.

32
Q

What is mild cognitive impairment?

A

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

33
Q

What is Alzheimers dementia?

A
  • Alzheimers disease = most common type
    Pathophysiology involves:
  • Brain atrophy
  • Amyloid plaques
  • Reduced cholinergic activity
  • Neuroinflammation
34
Q

What is vascular dementia?

A

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)
35
Q

What is Dementia with Lewy bodies?

A

Dementia with Lewy bodies = type of dementia associated with features of Parkisonism

Symptoms:
* Cognitive decline
* Visua hallucinations
* Delusions
* REM sleep disorders
* Fluctuating consciousness

36
Q

What is frontotemporal dementia?

A

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

37
Q

Name some medications with an anticholinergic effect that could cause cognitive impairment, memory impairment, personality changes?
(Differential diagnosis for dementia)

A

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)

38
Q

Name some psyhiatric conditions that are differential diagnosis for dementia

A
  • Depression
  • Psychosis
  • Delirium (e.g. secondary to infection)

(DPD) - delivering mems

39
Q

Name some neurological conditions that are differential diagnosis for dementia

A
  • Brain tumours (particularly affecting the frontal lobes)
  • Parkinson’s disease
  • Huntington’s disease
  • Progressive supranuclear palsy
40
Q

Name some endocrine conditions that are differential diagnosis for dementia

A
  • Hypothyroidism
  • Adrenal insufficiency
  • Cushing’s syndrome
  • Hyperparathyroidism (causing hypercalcaemia)
41
Q

What nutritional deficiencies that are differential diagnosis for dementia?

A
  • Vitamin B12 deficiency
  • Thiamine deficiency (causing Wernicke-Korsakoff syndrome)
42
Q

Name some modifiable risk factors for dementia

A
  • 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)
43
Q

Info: Dementia

A
  • Symptoms = tend to have a slow + insidious onset
  • Having a collateral history from a close contact such as family member is helpful
44
Q

Name some early symptoms of dementia

A
  • Forgetting events
  • Forgetting names
  • Difficult remembering words
  • Repeatedly asking the same questions
  • Impaired decision making
  • Reduced flexibility
45
Q

Name some advanced features of dementia

A

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
46
Q

Name some screening tests for memory + cognition

A
  • Six Item Cognitive Impairment Test (6CIT)
  • 10-point Cognitive Screener (10-CS)
  • Mini-Cog
  • General Practitioner Assessment of Cognition (GPCOG)
  • Montreal Cognition Assessment (MoCA)
47
Q

What are some investigations that are required to exclude a physical cause before you refer to the memory clinic, when you suspect dementia?

A

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)

48
Q

What are the 5 domains that are tested in the ACE-III (comprehensive assessment tool for memory impairment)?

A
  • Attention
  • Memory
  • Language
  • Visuospatial function
  • Verbal fluency
  • Less than 88/10 → indicates possible dementia
  • Even lower → severe impairment
49
Q

What can be put into place in the early stages of dementia to support the patients and carers?

A
  • 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)
50
Q

What are the 2 medication options for Alzheimer’s disease to help improve symptoms?

A
  • Acetylcholinesterase inhibitors (e.g. donepezil, rivastigime, galantamine)
  • Memantine (blocks NMDA receptors)
51
Q

Name some behavioural and psychological symptoms of dementia (BPSD)

A
  • Depression
  • Anxiety
  • Agitation
  • Aggression
  • Disinhibition (e.g., sexually inappropriate behaviour)
  • Hallucinations
  • Delusions
  • Sleep disturbance
52
Q

Name some of the initial steps to manage BPSD

A
  • 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
53
Q

Name some medication options for managing BPSD

A
  • ** SSRI antidepressants** for depressive symptoms
  • Antipsychotic drugs (typically risperidone = first-line)
  • Benzodiazepines (only for crisis management)
54
Q

Define delirium

A

Delirium = an acute + fluctuating disturbance in level of consciousness, attention, global cognition

55
Q

Why is delirium so important?

A
  • Prompt treatment = required to avoid potential brain damage
  • The underlying mechanism = poorly understood - but believed to involve neurotransmitter abnormalities + inflammation
56
Q

Who does delirium occur in?

A

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.

57
Q

Signs + symptoms of delirium

A

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).

58
Q

Causes of delirium

A

P - Pain.
I - Infection.
N - Nutrition.
C - Constipation.
H - Hydration.
E - Endocrine + Electrolyte.
S - Stroke.

M - Medication and Alcohol.
E - Environmental.

59
Q

Causes of delirium

A
  • 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
60
Q

Delirium vs dementia

A

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

61
Q

Diagnosis of delirium

A
  • 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)
62
Q

Diagnostic features of delirium

A
  • Acute change in cognition - which fluctuates during the day
  • Inattention
  • Disturbance of consciousness
  • Disorganised thinking
63
Q

What 2 things you should examine in a patient that presents with delirium?

A
  • Potential sites of infection
  • Focal neurological signs (suggesting a strutural CNS disorder)
64
Q

Treatment of delirium

A
  • 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.
65
Q

Name some symptoms of SSRI withdrawal

A
  • GI symptoms
  • Restlessness
  • Mood changes
  • Insomnia

3a Psychiatry (9 decks)

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