core conditions - 1 Flashcards

Question 1

Q

PSYCHOSIS

what is it?
three clusters of symptoms?

Answer

A

an umbrella term

—> Described as experience of being out of touch with reality, struggling to distinguish what is real from what is not.

There are THREE clusters of psychotic symptoms (may have one or a combination of these):

hallucinations
delusions
thought disorder.

Psychosis is an umbrella term for a group of symptoms. It is not a diagnosis in itself but a feature of many other diagnoses.

—> Presence of psychosis is not confined to mental illness.

Question 2

Q

Definition of delusion?

Answer

A

False, unshakeable belief, despite evidence to contrary, not held by others in the same culture and held with intense personal conviction and certainty.

Question 3

Q

List types of delusions? 8

nb 3 are arround thoughts, the rest are more general

nb don’t need definitions yet

Answer

A

nihilistic
grandiose
control
delusional perception
reference delusions
thought insertions
thought withdrawal
thought broadcast

nb the bottom four are delusions of thought interference

nb thought echo is an auditory halluciantion and thought blocking is a thought disorder

Question 4

Q

Definition of:

nihilistic delusions?
grandiose delusions?

Answer

A

Nihilistic delusions

Extremely negative delusions of being dead or part of the body decaying.

Grandiose delusions

Delusion of having of a higher status or significance, special powers or a secret mission.

Question 5

Q

Definition of delusion of control / passivity?

Answer

A

The subject believes their thoughts, feelings and/or actions are not their own but are being imposed/controlled by an outside force

Remember in passivity experiences the subject is ‘passive’ as they believe they are being controlled by another agent

nb this is not the same as auditory hallucinations where someone is telling them to do something/threatening them, in delusions of control the person believes they are being controlled and have no agency over their own thoughts/feelings/actions

Question 6

Q

Definition of:

delusional perceptions?
ideas/delusions of reference?

and what’s the difference?

Answer

A

Delusional perception

The subject receives a normal perception but it’s interpreted with delusional meaning and has immense significance (e.g. I know I’m the king as I saw the traffic light turn green)

ideas of reference

The belief that innocuous events have direct personal significance to the subject (e.g. believing something on the TV is a direct message to them). With ideas of reference they take special meanings from inanimate stimuli.

so teachnically a idea of reference is a type of delusional perception

Question 7

Q

Describe the 3 main delusions of thought interference?

Answer

A

Thought insertions

Thoughts which are not believed to be the subject’s own infiltrate their mind. They often have bizarre explanations of how it’s happened.

Thought withdrawal

The subject believes their thoughts have been removed from their mind by an external agency.

Thought broadcast

The belief that others can hear or are aware of an individual’s thoughts (e.g. a person may believe that other people can hear or read her thoughts)

Question 8

Q

Definition of hallucination?

Answer

A

A perceptual experience in the absence of an object or stimulus, that appears subjectively real but uncontrollable by the patient. To the person this has the impact of a real perception and is indistinguishable. It occurs externally (not in the mind).

Can be in any sensory modality:

Auditory
visual
olfactory
gustatory
sensory / tactile (touch)
—kinaesthetic (movement)
—somatic (sensation within the body)

nb visual halluciantions normally always have an organic cause

Question 9

Q

Definition of:

pseudo-hallucination?
illusion?

how are these different from a hallucination?

Answer

A

Pseudo-hallucination

A sensory experience vivid enough to be a hallucination but recognised by the subject not to be real.

Illusion:

False perception of a real stimulus. Three types: affect, completion and pareidolia.

An illusion is based on a real sensory stimulus that is interpreted incorrectly whereas a hallucination is created by the mind without any stimulus.

hallucinations occur without a stimulus and are peceived by the patient to be real

nb don’t put effort into learning these: types of illusion:
PAREIDOLIA
Seeing shapes in inanimate objects (e.g. faces in clouds)
COMPLETION
The mind completes partial images (e.g. seeing white triangle in > image)
AFFECT
Based on current affect (e.g. see a monster in the cupboard when scared)

Question 10

Q

Three main types of auditory hallucination?

Answer

A

2nd person auditory hallucination:

The subject hears voices which talk to them directly (e.g. “you’re going to die, you need to kill the baby”)

3rd person auditory hallucination:

The subject hears voices talking about them in the third person or commentating on their actions (e.g. ”he’s having a drink, now he’s going to the bathroom”)

Thought echo:

The subject experiences his own thoughts as if they were being spoken aloud. The repetition may be subtly or grossly changed.

Question 11

Q

definitions of:

depersonalisation?
derealisation?

when can they often occur acutely?

what diagnosed with if occur chronically?

Answer

A

Depersonalisation

A change in awareness of self, in which the individual feels they’re not real and are detached from the world. They are aware this is abnormal.

Derealisation

To the subject the external world appears unreal or artificial. They’re aware this is abnormal.

Though degrees of depersonalization and derealization can happen to anyone who is subject to temporary anxiety or stress (eg during a panic attack), chronic depersonalization is more related to individuals who have experienced a severe trauma or prolonged stress/anxiety (called a dissociative disorder).

nb depersonalisation and derealisation can occur in other psychiatric conditions but if this is the predominant symptom then diagnosed with a dissociative disorder

Question 12

Q

Definition of thought disorder?

Answer

A

Thought Disorder:

An abnormality in the mechanism of thinking
To the observer their speech doesn’t make sense

Question 13

Q

What thought disorder is being described:

Loss of structured thinking. The subject seems muddled and doesn’t become clearer with further questioning, things often seem more confusing the more you ask them.

Answer

A

Loosening of associations

Question 14

Q

What thought disorder is being described AND what condition often seen in?

Rapid flow of thought, manifested by accelerated speech with abrupt changes from topic to topic. There is often some form of link between topics.

Answer

A

flight of ideas

often seen in mania but can also be seen in psychosis

Question 15

Q

What thought disorder is being described AND what condition often seen in?

Give the same answer to different questions

The repetition of a particular response (phrase, word, or gesture) despite the absence or cessation of the stimulus.

Answer

A

perservation

Often seen in organic brain disorders eg dementia

Question 16

Q

What thought disorder is being described AND what conditions often seen in?

A new, made up word that has no real meaning

Answer

A

neologism

mania and psychosis - normally as part of a delusion

can occur in autism too though

BE CAREFUL - may not be a made up word - you just might not have heard it before - always ask!

Question 17

Q

Define circumstantiality and tangentality and the difference between them

Answer

A

Circumstantiality is the inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return the original point.

Tangentiality refers to wandering from a topic without returning to it.

Question 18

Q

What thought disorder is being described

when ideas are related to each other only by the fact they sound similar or rhyme

Answer

A

clang associations

Question 19

Q

What thought disorder is being described

completely incoherent speech where real words are strung together into nonsense sentences

Answer

A

Word salad

Question 20

Q

What thought disorder is being described AND what often a feature of?

there are unexpected and illogical leaps from one idea to another

Answer

A

Knight’s move thinking

severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another

a feature of schizophrenia

Question 21

Q

What thought disorder is being described

repetition of someone else’s speech, including the question that was asked.

Answer

A

Echolalia

Question 22

Q

Groups of differential diagnoses for psychosis? 5

Answer

A

1) ORGANIC
2) SUBSTANCE USE OR WITHDRAWAL
3) PSYCHOTIC CONDITIONS
4) OTHER MENTAL HEALTH CONDITIONS
5) OTHER

Question 23

Q

Differential diagnosis for psychosis:

organic disorders? 5
substance use or withdrawal? 4 (incl one medication)
psychotic conditions? 3
other mental health conditions? 2
other? 2

Answer

A

1) ORGANIC
- dementia
- delirium
- encephalitis
- post-partum
- metabolic disorders

2) SUBSTANCE USE OR WITHDRAWAL
- acute intoxication (drugs or alcohol)
- alcohol withdrawal (delirium tremens)
- cannabis-induced psychosis (or other psychosis from chronic drug use
- steroids! (also levodopa!)
(nb often get physical hallucinations with drugs)

3) PSYCHOTIC CONDITIONS
- schizophrenia
- shizo-affective disorder
- delusional disorders

4) OTHER MENTAL HEALTH CONDITIONS
- depression
- mania

5) OTHER
- sleep deprivation
- bereavement

Question 24

Q

definition of:

positive symptoms?
negative symptoms?

examples of negative symptoms? 7

way to remember negative symptoms?

Answer

A

POSITIVE SYMPTOMS

A cluster of psychotic symptoms including hallucinations and delusions.
A positive symptom is something added on to what most people experience (eg a hallucination)

NEGATIVE SYMPTOMS

A cluster of symptoms that often occur in chronic schizophrenia including poverty of speech, flat affect, poor motivation, poor attention and neglect.
negative symptoms are the lack of a normal experience (i.e. lacking concentration)

EXAMPLES OF NEGATIVE

marked apathy
paucity/poverty of speech
blunting or incongruent affect
social withdrawal
poor motivation
poor attention / concentration
neglect

THINK OF THE As
Avolition (lack of motivation)
Anhedonia
Alogia (poverty of speech)
Asociality 
Affect = blunt

negative symptoms often a late feature, less treatment responsive and have a poorer prognosis

Question 25

Q

SCHIZOPHRENIA

diagnostic criteria? (be specific)
incl how long symptoms go on for before give diagnosis? (what called if shorter than this?)

Answer

A

ONE OR MORE OF:
- delusion
- delusional perception
- 3rd person auditory hallucination
- thought insertion/ echo/ withdrawal/ broadcast
- delusion of control / passivity
^ie scheiner's first rank

OR

TWO OR MORE OF:

any other hallucination
negative symptoms
loosening of assciations
catatonia

lasting persistently for AT LEAST ONE MONTH (even with medication)
- AND not in acute intoxication or withdrawal OR evidence of overt brain disease (eg lewy body)

if <28 days then = acute psychotic disorder

nb often called undifferentiated psychosis for longer than a month in practice as some people recover and don’t want to give them that label

nb diagnosis of schizophrenia should not be made in the presence of extensive depressive or manic symptoms unless it is clear that schizophrenic symptoms antedated the affective disturbance

Question 26

Q

Definition of schizoaffective disorder?

how is it different to schizophrenia?

Answer

A

Combination of psychosis and an affective disorder (ie depression or mania)

if affective symptoms predominant then depression with psychosis, if psychosis predominant then schizophrenia - if equal impact of both AND start at the same time = schizoaffective disorder

diagnosis of schizophrenia should not be made in the presence of extensive depressive or manic symptoms unless it is clear that schizophrenic symptoms antedated the affective disturbance. If both schizophrenic and affective symptoms develop together and are evenly balanced, the diagnosis of schizoaffective disorder should be made, even if the schizophrenic symptoms by themselves would have justified the diagnosis of schizophrenia.

nb better prognosis in those with a predominant manic presentation

Question 27

Q

Epidemiology of Schizophrenia:

gender ratio?
peak age of onset?
% prevelence in UK?

Answer

A

M:F 1:1 - but men have earlier onset and often more severe
Peak onset: male = 20-28years. Female = 26-32 years

prevelence = 1%

Question 28

Q

Epidemiology of Schizophrenia:

biggest risk factor?
other risk factors? (2 peri-natal, 5 around life events, 2 substance misuse)

Answer

A

1) GENETIC (40% have FHx)

winter births
perinatal viral infection/trauma/hypoxia (or other pregnancy complications)
Social exclusion
Low SES
Childhood trauma or abuse
Migration
Urban environment
Cannabis (4x risk if regular use <15yo)
Amphetamines

nb although not causes, first episodes of psychosis are often triggered by a stressful life event (bereavement, unemployment, divorce etc) in people who are susceptible

Question 29

Q

Describe the dopamine theory of schizophrenia AND the 4 related brain pathways - which responsible for positive and negative symptoms and side effects of A/Ps

Answer

A

Dopamine Theory:
—> Schizophrenic patients show greater occupancy of DA receptors.
Thus, antipsychotics are all antagonists at dopamine post-synaptic receptors – mainly D2

MESOLIMBIC
= motivation, emotion, reward
- high levels in schizophrenia -> positive symptoms

MESOCORTICAL
= cognition + executive function
- low levels in schizophrenia -> negative symptoms

NIGROSTRIATAL
= stimulation of movements
- normal levels in schizophrenia (but A/Ps -> EPSEs)

TUBERINFUNDIBULAR
= dopamine acts as prolactin inhibitory hormone (PIH)
- normal levels in schizophrenia (but A/Ps -> elevated prolactin)

Question 30

Q

5 main types of schizophrenia?

describe each briefly

Answer

A

1) PARANOID
- eg a beautiful mind
- most common
- paranoid delusions usually with auditory hallucinations and perceptual disturbances

2) HEBEPHRENIC
- affective changes prominent (shallow + inappropriate mood)
- Irresponsible and unpredictable behaviour
- Delusions and hallucinations fleeting and fragmentary
- Thought and speech disorganised
- Tendency to social isolation
- Rapid development of negative symptoms

3) CATATONIC
- A state of immobile stupor with cardinal features such as posturing and waxy flexibility

4) SIMPLE
- Characterised by profound negative symptoms without any delusions or hallucinations.
- ie only have the negative symptoms

5) UNDIFFERENTIATED

Question 31

Q

what is the term for schizophrenia which intially presents over age 45?

Answer

A

paraphrenia

Question 32

Q

assessment of psychosis:

when do they need to be assessed by a psychiatrist? 2 (what’s the urgency of this?)
what should be done before referring to secondary care? 3
how is psychosis diagnosed? 2
what investigation can be done if suspect that psychosis is drug induced? 1

Answer

A

need to be seen by a psychiatrist

1st episode psychosis
decline in functioning / relapse in someone being managed in primary
review medication to check not iatrogenic
take hx to check for infective signs or other signs of an organic cause
RISK ASSESS! (if high risk, refer same day/section)

need to see URGENTLY - espeically if initial presentation as faster you treat, better the prognosis

full psych Hx
mental state exam

urine drug screen

ALSO always think about delirium if 1st presentation and acute onset - eg sepsis etc

Question 33

Q

Management of psychosis/schizophrenia:

short-term biological? (1 + route, 1 sometimes)
short-term psycho-social? 2
long-term biological (1 always, 2 possible)
long-term psycho-social? 5

Answer

A

SHORT-TERM BIO

antipsychotics (oral/IM)
(sedatives)

SHORT-TERM PSYCHO-SOCIAL

psychoeducation (CBT/family interventions)
care planning

LONG-TERM BIO

anti-psychotic (oral/monthly depot)
(mood stabilisers)
(antidepressants)

LONG-TERM PSYCHO-SOCIAL

CBT for psychosis
art therapy
family interventions
supported employment (always ask about finances)
care planning

FAMILY THERAPY
especially important in families where there is high expressed emotion as there is good evidence that lots of intense emotion in the household increases the risk of relapse

COGNITIVE BEHAVIOURAL THERAPY

Doesn’t reduce symptoms but can help manage the distress associated with these symptoms (e.g. derogatory hallucinations)
Helps with an individuals understanding of their disorder

ART THERAPY
Recommended by NICE for those with negative symptoms

Question 34

Q

First presentation of psychosis

objectives in the acute management? 4
what team will they be under and for how long?

Answer

A

1) therapuetic trial of A/P medication
2) monitoring of mental state + response to therapy until stable
3) formulation of a care plan, allocated a care coordinator (incl a crisis plan)
4) family intervention / psychoeducation

under early intervention in psychosis team (ASPIRE in leeds) for 3 years

nb in subsequent presentations they will remain under services until they’re stable enough to be transferred back to the care of their GP

Question 35

Q

Prognosis following a first psychotic episode? (ie outcomes and proportion of those outcomes)

Answer

A

1/3rd recover and never have another episode

1/3rd have relapse & remitting schizophrenia but can function between relapses

1/3rd have chronic schizophrenia

Question 36

Q

Risk factors for relapse in psychosis/schizophrenia? 5

Answer

A

On-going symptoms
Poor compliance
Lack of insight
Substance use
Stopping medication suddenly

Taking an antipsychotic reduces the risk of relapse by a third

Stopping an antipsychotic within 6 months increases risk of relapse by four times

Question 37

Q

poor prognostic factors for psychosis / schizophrenia?

FHx of schizophrenia?
FHx of affective disorder?
gender?
marital status?
pre-morbid intelligence + personality?
age of onset?
speed of symptom onset?
presence of negative symptoms?
response to treatment?
ongoing substance use?

Answer

A

FHx of schizophrenia = POOR
FHx of affective disorder = GOOD
gender MALE = poor
marital status SINGLE = poor
pre-morbid intelligence + personality = good = good, SCHIZOID = poor
age of onset EARLY = POOR
speed of symptom onset INSIDIOUS = POOR
presence of negative symptoms = POOR
response to treatment, poor = poor
ongoing substance use = POOR

Question 38

Q

SCHIZO-AFFECTIVE DISORDER

- two ways to differentiate between this and psychotic depression/mania?

Answer

A

1) TIMING OF SYMPTOMS
- in schizoaffective, psychotic symptoms start at same time as change in mood (in depression/mania, affective symptoms first, then psychosis)

2) INCONGRUENT DELUSIONS
- in depression or bipolar with psychosis, the delusions are congruent with mood (eg grandiose with mania, nilhilstic with depression) - in schizoaffective they are more likely to be incongruent

Question 39

Q

Biological management of schizo-affective disorder? 2

Answer

A

medication norm = mood stabiliser PLUS antipsychotic

nb psycho-social management is same as schizophrenia

Question 40

Q

DELUSIONAL DISORDERS

definition? (incl features + length of symptoms)
what type of delusions not compatible with?
gender more common in?

Answer

A

Delusions are the most prominent feature

typically well formed and long standing (they can be life-long!)
Hallucinations aren’t present or are only fleeting
no marked blunting of affect.
Symptoms >1 month.

Delusions of control/passivity experiences aren’t compatible with this diagnosis

more common in females.

Question 41

Q

sub-types of delusional disorder:

- describe PERSECUTORY

Answer

A

Belief that they, or someone close to them is being mistreated, or that someone is planning to harm them.

Question 42

Q

sub-types of delusional disorder:

- describe OTHELLO SYNDROME

Answer

A

Morbid jealousy
Delusional belief that partner is having affair
No evidence/ misinterprets minor evidence
Association with alcohol dependence/ sexual dysfunction
Risk of stalking/ violence

“always get jealous partners in shakespeare plays”

Question 43

Q

sub-types of delusional disorder:

- describe DE CLERAMBAULT’S SYNDROME (what aka?)

Answer

A

Aka erotomania

Delusional belief a famous person/ of higher social status, is in love with them.
- Cannot declare love, so communicate via secret signs.

“CLERAM = like CLAMBER - you clamber over all the other fans to get to the celebrity”

Question 44

Q

sub-types of delusional disorder:

- describe CAPGRAS SYNDROME

Answer

A

Delusional misidentification

Belief that relative/ spouse/ close friend has been replaced by identical looking double or impostor

“someone has taken loved one’s CAP and is trying to interpret them”

Question 45

Q

sub-types of delusional disorder:

- describe FREGOLI’S SYNDROME

Answer

A

Different people are a single person who changes appearance or is in disguise.

Often believe they are being persecuted by that person

“can’t be FREE of the person who is shape-shifting to continue persecuting you”

Question 46

Q

sub-types of delusional disorder:

- describe COTARD’S SYNDROME

Answer

A

A nihilistic delusion without other psychotic symptoms.

Delusion of being dead/ dying/ non-existent/ rotting

patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary.

Associated with severe depression and psychotic disorders

“COT-death - believe they are dead or dying”

Question 47

Q

sub-types of delusional disorder:

describe EKBOM’S SYNDROME
what associated with?

Answer

A

Delusional Parasitosis – infested with parasites

No evidence – only small marks/ freckles

Risk of self-harm through excoriation to get rid of parasites.

Often present to Derm.

Associated with Cocaine.

“tiny BOMBS of insects under their skin”

Question 48

Q

sub-types of delusional disorder:

describe FOLIE A DEUX
aka?

Answer

A

aka Induced delusional disorder – psychosis shared by two people.

The dominant partner has a delusional belief and then the dependent partner develops the same belief.

The dominant partner requires treatment but the dependent partner recovers upon separation.

“DEUX = two, delusion shared by 2 people”

Question 49

Q

DELUSIONAL DISORDER:

biological management?
psycho-social management?
prognosis?

Answer

A

anti-psychotics

psych-social = same as schizophrenia

Is particularly difficult to treat - even with intensive treatment

People often retain some aspect of the delusion or continue to hold the belief but are less preoccupied with it

Question 50

Q

Acute psychotic disorder:

- definition?

Answer

A

person has psychosis for LESS THAN 28 DAYS

ie too short in duration to diagnosis schizophrenia, delusional disorder, schizoaffective disorder

Question 51

Q

Depression:

porportion of people who will have an episode in their lifetime?
gender more common in?

Answer

A

1/5th

more common in female (2:1)

Question 52

Q

DDx for depression:

psych? 10
if been present for ‘all their life’? 2
organic? 8

what should always be reviewed before giving a diagnosis of depression?

Answer

A

PSYCH

seasonal affective disorder
adjustment disorder (eg grief)
drug-induced affective disorders (eg alcohol, cannabis)
dementia (incl parkinsons)
anxiety (may be co-morbid)
OCD
eating disorders
bipolar
schizo-affective
schiophrenia (esp if negative symptoms)

ALL LIFE

dysthymia
emotionally unstable personality disorder

ORGANIC

hypothyroidism
cushings (incl med-induced)
anaemia
cancer
IBD
EBV
chronic fatigue (>6mo)
MS (or stroke or other CNS disorder)

ALWAYS REVIEW MEDICATION LIST (as some medications can mimic depression)

Question 53

Q

Common groups of medications that can mimic / cause depression? 7

Answer

A

anti-psychotics
anti-convulsants (incl gabapentin)
beta-blockers
PPIs + H2 blockers
corticosteroids
contraceptives
retinoids (for severe acne)

Question 54

Q

What proportion of pts with depression will also meet criteria for another psychiatric disorder?

what other co-morbid psych conditions should be screened for when doing a psych hx? 4 (incl example of how would ask about each)

Answer

A

2/3rds

1) MANIA
- ‘have you ever had a period when you’ve had a lot of energy and managed to do a lot of things, despite having very little sleep?’

2) PSYCHOSIS
- ‘sometimes when people are feeling really low they can hear voices or see things that others can’t hear or see - has that ever happened to you? do you have any beliefs that you don’t think are shared by others?’

3) ANXIETY
- ‘many people who feel low in mood also experience feelings of anxiety and feel anxious, nervous or on edge about things - do you feel like this? have you ever had any panic attacks?’ (get them to describe the latter)

4) ALCOHOL/SUBSTANCE MISUSE
- ‘sometimes when people are feeling very low, they find that they start drinking more alcohol or using other medications to escape from those feelings, is that something you experience? how much alcohol do you drink? do you use any recreational drugs?’

Question 55

Q

RISK FACTORS FOR DEPRESSION

biggest risk factor for an episode of depression?
bio? 5
psycho? 3
social? 7

Answer

A

BIGGEST = previous depressive episode

BIO

genetic / FHx
female
chronic disease eg stroke (esp ones causing disability or pain)
post-partum
heavy alcohol or illicit substance use

PSYCHO

adverse childhood experience (parental bereavement, neglect, parental alcoholism, childhood sexual abuse)
personality traits (anxiety, obsessive, impulsive)
low self-esteem

SOCIAL

unemployment
low socio-economic status
seperation or divorce
bereavement (seperate from normal adjustment reaction)
adverse life event
migration
LGBT+

Question 56

Q

What are the 4 Ps for causes of a psychiatric illness

Answer

A

BIO, PSYCH and SOCIAL for:

1) PREDISPOSING
2) PRECIPITATING
3) PERPETUATING
4) PROTECTIVE

Question 57

Q

SYMPTOMS OF DEPRESSION:

core? 3
psychological? 10
biological / somatic? 6
social? 3

duration of symptoms to make a diagnosis?

Answer

A

CORE

1) anhedonia
2) low mood (often diurnal variation)
3) low energy / fatigue

PSYCHOLOGICAL

worthlessness
low self-esteem
tearful
guilt
irritable / intolerant of other
low motivation
struggle to make decisions
poor concentration
hopelessness + helplessness
suicidal thoughts

BIOLOGICAL

Change in APPETITE (decrease is typical, increase is atypical)
SLEEP disturbance (early morning waking is typical - but can get hypersomnia = atypical)
low SEX drive
PSYCHOMOTOR retardation (moving or speaking slowly)
CONSTIPATION
ACHES and PAINS

SOCIAL

avoiding friends
neglecting hobbies/interests
having difficulties in home, work or family life

symptoms must be present for at least TWO WEEKS
- (not secondary to effects of drug/ alcohol misuse, organic illness, or bereavement (before 6 months)

nb pt w bipolar more likely to have atypical sleep and apetite compared to unipolar depression

Question 58

Q

How assess severity of depression?

what additional group of symptoms can occur in severe depression?

Answer

A

mild depression – has some impact on your daily life

moderate depression – has a significant impact on your daily life

severe depression – makes it almost impossible to get through daily life; a few people with severe depression may have psychotic symptoms

nb can do based on symptom count, PHQ-9 etc - but in reality do based on level of functioning

Question 59

Q

Two key differentiators between grief and depression?

Answer

A

People who are grieving find their feelings of sadness and loss come and go, but they’re still able to enjoy things and look forward to the future.

In contrast, people who are depressed constantly feel sad. They find it difficult to enjoy anything or be positive about the future

Question 60

Q

Patients over 55 may present differently with depression - some symptoms / features that are more likely in this age group? 6

Answer

A

Psychomotor retardation
Pseudodementia
Hypochondriacal overvalued/delusions
Obsessive-compulsive symptoms
Agitated depression
Apathy

Question 61

Q

PSEUDODEMENTIA:

what is it?
how differ from dementia?

Answer

A

depression in older people (ie depression can often present very similar to dementia)

symptoms incl:

memory loss
imparied executive functioning

ONSET

fast in pseudodementia
insidious in dementia

MEMORY LOSS

global in pseudodementia
short-term initially in dementia

COGNITIVE TESTS

say ‘i don’t know’ in peudodementia
try to answer Qs but fail in dementia

depressed mood in pseudodementia, incongruity of affect in dementia

Question 62

Q

How to screen for 3 core symptoms of depression? (ie what Qs to ask)

Answer

A

MOOD
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’

ANHEDONIA
‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’

FATIGUE
‘during the last month, have you often felt very fatigued or that you had no energy?’

Question 63

Q

INVESTIGATION OF LOW MOOD / SUSPECTED DEPRESSION

hx + exam to do? (what assessment should this include)
bedside investigation? 1
other investigations to consider to rule out organic causes?

Answer

A

full psych hx (and systems review)
including FULL risk assessment (to self, to others incl safeguarding, from others)
MSE
PHQ-9

if suspect organic cause:

physical exam
review meds
bloods (esp TFTs + FBC)
(imaging if neuro signs)

Question 64

Q

possible effects of despression on physical health? 4

what % of depression in general hospital patients goes undetected?

Answer

A

pain can be harder to control
may have less motivation to engage in treatment or take medication
self-neglect (incl not attending appts etc)
doubles risk of getting type 2 DM

50% of depression in general hospital pts goes undetected

Answer 65

A

LIFESTYLE

reduce alcohol intake
sleep hygiene
regular exercise

MILD-MODERATE
- low-intensity psychological interventions (eg via IAPT)
(ie not medication)

MODERATE-SEVERE

high-intensity psychological intervention
antidepressant (SSRI 1st line)

plus SOCIAL management (see other flashcard)

NICE CKS on initial management of depression is very good! - incl leaflets etc

Answer 66

A

OTHER MEDICAL CONDITIONS
- get these under control, incl pain etc

ADLs

‘take me through a typical day’
address holes eg older people may need additional support
also CARERs need support too!

HOUSING

isolated?
issues?

EMPLOYMENT

working? problems at work?
can provide letters/reports of support

FINANCES

any debts?
citizen’s advice re debt management plans
referral to food banks

ACTIVITIES

if lonely/isolated/bored
gardening? social group?
social prescribing!

“if easier to remember can go through ASD OHA DOT”

Answer 67

A

individual guided self-help (norm CBT-based)
CCBT
group-based CBT
structured group-based physical activity programme

Answer 68

A

individual CBT
interpersonal therapy (IPT)
behavioural activation
couple therapy (although not commonly used)

nb each of the above norm 16-20 sessions over 3-4 months

Counselling and short-term psychodynamic therapy — these can be considered for people who decline antidepressants and high-intensity psychological interventions
- but counsel patients on the uncertainty of effectiveness of these interventions

Answer 69

A

type of talking therapy
structured and practical
involves problem and goal definition
use diaries to monitor and identify problematic thoughts, or other problems and monitoring progress
help you learn to think in more helpful ways, includes behavioural experiments
based on the here and now (not exploring past)
based on the cognitive model (how we think affects how we feel, behave and our biology)

nb see my notes for more infor on CBT

Answer 70

A

structured talking therapy that typically works intensely on established interpersonal issues. The underlying belief of interpersonal therapy is that psychological symptoms (such as depression) are often a response to difficulties we have interacting with others. The resulting symptoms can then also affect the quality of these interactions, causing a cycle. The thought process behind the therapy is that once a person is capable of interacting more effectively with those around them, the psychological symptoms can improve.

IPT focusses on:

conflicts
life changes
grief and loss
relationship problems

Answer 71

A

Focuses on addressing behaviour:

When we are depressed we stop doing the things that usually give us pleasure which makes us even more depressed.
We isolate ourselves and avoid interactions with others as this might be difficult e.g. going back to work after time off sick
We wait until we feel better before doing things - unfortunately we never feel better so never do things

Treatment involves getting people to act according to a plan rather than how they feel and involves doing things!
- Simple goals to start e.g. walk dog every day and build up

Answer 72

A

life-threatening depression
moderate-severe depression that has responded to ECT in the past
prolonged or severe mania
catatonia

2 x weekly treatment - approx 12 in total

unilateral vs bilateral

short GA and muscle relaxant - then short induced controlled seizure

nb 70-80% response in depression

Answer 73

A

short-term memory loss
headache
nausea
muscle pain

Answer 74

A

try for at least 4-6 weeks
effects will take a few weeks and energy improve first, then mood (also get SEs before therapeutic effect)
warn about suicide risk (give crisis numbers)
different ones work for different people, try this one first and can try another if this doesn’t work
not addictive but don’t stop suddenly as may get discontinuation symptoms

FOLLOW UP after 2 weeks, 1 week if under 30 (as higher suicide risk)

continue for 6-9 months AFTER resolution of symptoms

to reduce risk of relapse
reduce dose gradually (to avoid discontinuation symptoms)

nb if multiple episodes, consider for at least 2 years

Answer 75

A

restlessness
problems sleeping
unsteadiness
sweating
abdominal symptoms
altered sensations (for example electric shock sensations in the head)
altered feelings (irritability, anxiety, confusion)

1/3rd pt experience these when coming off treatment

Answer 76

A

REVIEW

Review DIAGNOSIS
Check COMPLIANCE
(they may not but be too embarrassed to say that they forget)
Check taking correct DOSE
Review ALCOHOL intake
(will stop antidepressants being effective)
Check for OTHER DRUGS
Address PSYCHOLOGICAL and SOCIAL factors

ONLY THEN:

1) INCREASE dose
2) SWITCH drugs
3) AUGMENT with lithium or A/Ps
4) ECT if severe and not responsive

Answer 77

A

EMERGENCY

1) significant risk of self-harm
2) danger to others
3) psychotic symptoms
4) severe agitation

ROUTINE

1) significant depression with functional impairment persisting despite adequate treatment in primary care
2) when additional community support from community mental health team or day hospital staff is required
3) indication for specialist psychological treatment (eg ECT, lithium)

Answer 78

A

—> Average length of depressive episode = 6 months

after a first episode of depression, 50% chance of having another one

chance of recurrence increases if have second episode

Median is 4 episodes in lifetime

10 % go on to have manic episode

Answer 79

A

MOOD =

abnormally ELEVATED
extreme IRRITABILITY
sometimes AGGRESSION

ACTIVITY

INCREASED energy / activity
RESTLESSNESS
decreased need for SLEEP
DISTRACTIBILITY / poor concentration
IMPULSIVITY
increased LIBIDO / sexual indiscretions
DISINHIBITION

THOUGHTS

extravagant or impractical PLANS (eg business investments, spending sprees)
PSYCHOTIC symptoms (norm grandiose delusions, auditory hallucinations) - these are CONGRUENT with mood

nb if ingongruent with mood then suspect schizoaffective

MSE (all of the above plus:)

pressured or incomprihensible speech
flight of ideas or racing thoughts

Answer 80

A

MANIA

at least 7 days
may have psychotic symptoms
severe enough to cause marked impairment in social or occupational functioning
may need hospitalisation

HYPOMANIA

at least 4 days
no psychotic symptoms
not severe enough to cause marked impairment in social or occupational functioning
no hospitalisation

so as soon as an episode has ANY of the below things, it is, by default a manic episode:

lasts 7 days
psychotic symptoms
has severe impact on functioning
requires hospitalisation

Answer 81

A

A mixed episode is:

1) A mixture or rapid alternation of manic and depressive symptoms, or
2) A period of time (at least 1 week) in which the criteria are met for either a manic or hypomanic episode and at least three symptoms of depression are present during the majority of the days of the current or most recent episode of mania or hypomania, or
3) A period of time (at least 2 weeks) in which the criteria for a major depressive episode are met and at least three manic or hypomanic symptoms are present during the majority of days of the current or most recent episode of depression.
basically: what it suggests - is a mix of manic and depressive symptoms

Answer 82

A

Mild elevation of mood, or irritability.
Increased energy and activity, which may lead to increased performance at work or socially.
Feelings of well-being, or physical and mental efficiency.
Increased sociability, talkativeness, and over-familiarity.

Answer 83

A

Mood disorders in which pts experience bouts of mania, hypomania, depression and mixed states
- may be long periods (years) of recovery between

DEFINITION:

after at least 2 episodes of disturbed mood
one of which should be manic or hypomanic

NB usually complete recovery between episodes

depression (2 weeks)
mania (7 days)
hypomania (4 days)
mixed (7-14 days - depends)
50% start with depressive episode - don’t give them diagnosis of bipolar until have a manic episode (always screen for past mania if depression)

nb in DSM-5 have type 1 and 2 (2 is hypomanic, don’t need manic episodes - type 1 must have manic episodes - this is the main difference between them)
- but in ICD-10 (use in UK) don’t distinguish between type 1 and 2

Answer 84

A

1% prevelence

M=F

21 mean age of onset

“both men & women go on a spending spree for their 21st”

Answer 85

A

MONOAMINE THEORY
- mania results from INCREASED levels of noradrenaline, serotonin + dopamine

GENETICS / FHx = biggest risk factor
(largest heritability of any

COMMON INITIAL TRIGGERS

severe stress / disruption
drugs (eg cocaine, amphetamines)

Answer 86

A

features of depression that make bipolar more likely

FHx of bipolar
hypersomina
hyperphagia

Answer 87

A

FHx of BAD

BD = yes
UD = no

Hx of Mania

BD = yes
UD = no

sex ratio

BD = M=F
UD = F>M

Age of onset

BD = early
UD = 30-50 (can be earlier)

Onset

BD = abrupt
UD = insidious

Psychosis

BD = more common
UD = less common

activity

BD = retardation
UD = agitation

sleeo
- BD = hypersomnia
- UD = insomnia
(same w appetite)

Answer 88

A

PSYCH

BAD
schizoaffective disorder
schizophrenia
ADHD

MEDS/SUBSTANCES

stimulants
alcohol
steroids
dopamine agonists

ORGANIC

hyperthyroidism
cushings
epilepsy (ask re focal features)
frontal lobe disease
multiple sclerosis
huntington’s disease
HIV
sleep deprivation

Answer 89

A

full psych hx
MSE
ECG
Urine drug screen

BLOODS

FBC
U+E
LFT
Calcium (high or low can trigger)
LITHIUM LEVELS (if on, to assess compliance)

consider CT head if first presentation or any focal or abnormal signs

Answer 90

A

BIOLOGICAL
- atypical antipsychotic (if psychotic)
OR
- benzos

to manage initial hyperactivity

then TITRATE up lithium (or other mood stabiliser)

consider short-term hypnotics (z drugs) if sleep deprived

1) ADMIT pt while tirating up mood stabiliser for own safety
2) risk assessment before discharge
3) stop driving (if relevant) - also consider restricting access to finances

Answer 91

A

BIOLOGICAL

mood stabilisers, lithium 1st line
(antipsychotics)

length of treatment depends on sevrity and frequency of episodes, need regular follow up to manage, can consider weaning off if been symptom-free for mnay years but this may provoke a relapse

nb can use antidepressants in some pts but tend to avoid as can trigger mania/hypomania

PSYCHOLOGICAL

psycho education to pt + family (incl compliance aids, recognising triggers + symptoms etc)
BAD-specific psychotherapies (eg CBTetc)

SOCIAL

crisis management plan / care coordinator
avoid recreational drugs
address financial, employmert etc issues

ECT for intractible / severe mania (but rarely used)

Answer 92

A

TO SELF
= self-harm
= suicide

financial difficulties (overspending)
damage to reputation/occupation/relationships
traumatic injuries/accidents
STIs/unplanned pregnancy
self-neglect / exhaustion / dehydration
alcohol and substance misuse

TO OTHERS

reckless driving / injuries
neglect of children/dependants

FROM OTHERS
- exploitation (dt lack of insight)

nb much higher risk of suicide than in unipolar depression! - risk is highest in post-manic depressive phase

nb hypomanic patients are at risk too but this often goes unnoticed

life charts and symptom diaries may also be helpful for some people

Answer 93

A

PHOBIC ANXIETY

agoraphobia
social phobia
specific phobias

OTHER ANXIETY

panic disorder
generalised anxiety disorder

OTHER
- obsessive compulsive disorder

REACTIONS TO SEVERE STRESS

acute stress reaction
post-traumatic stress disorder
adjustment disorders

DISSOCIATIVE / CONVERSION DISORDERS
- Amnesia
- fugue
- stupor
- motor
- convulsions
- trance &amp; possession states
- anaesthesia and sensory loss 
(this include depersonalisation, derealisation, conversion disorders)

SOMATOFORM DISORDERS

somatisation disorder
hypochondrial disorder

Answer 94

A

The essential feature is anxiety, which is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. it is
“free-floating”).

As in other anxiety disorders the dominant symptoms are highly variable, but complaints of continuous feelings of nervousness, trembling, muscular tension, sweating,
lightheadedness, palpitations, dizziness, and epigastric discomfort are common.

Fears that the sufferer or a relative will shortly become ill or have an accident are often expressed, together with a variety of other worries and forebodings.

ICD-10: The sufferer must have primary symptoms of anxiety MOST DAYS for at least SEVERAL WEEKS at a time, and usually for several months (DSM IV says 6 mo).

These symptoms should usually involve elements of:

1) APPREHENSION (worries about future misfortunes, feeling “on edge”, difficulty in concentrating, etc.);
2) MOTOR TENSION (restless fidgeting, tension headaches, trembling, inability to relax); and

3) AUTONOMIC OVERACTIVITY (lightheadedness, sweating, tachycardia or tachypnoea, epigastric
discomfort, dizziness, dry mouth, etc.).

could also split into 4 groups:

psychological
arousal
motor
autonomic

Answer 95

A

Worry/ Apprehension/ Fear
Persistent nervousness
Poor Concentration
Irritability

Answer 96

A

hypervigilance
increased startle response
restlessness
insomnia (struggle geting to sleep)

Answer 97

A

musle tension
headaches
trembling
purposeless activity

Answer 98

A

CVS

palpitations
chest tightness
chest pain

RESP

difficulty inhaling
hyperventilation

GI

dry mouth
loss of appetite (or craving food)
nausea
‘butterflies’
epigastric pain
loose stools

URINARY
- frequent micturation

NEURO

blurred vision
light headedness
pins and needle

OTHER

sweating
depersonalisation
derealisation

Answer 99

A

more common in female

PREDISPOSING

FHx of anxiety
Hx of physical or emotional trauma
Hx of other anxiety disorders (panic, social phobia, specific phobias)
Hx of substance abuse

PRECIPITATING

current physical or emotional trauma
Chronic pain or physical illness (such as arthritis, cancer, coronary heart disease, cerebrovascular accident, or COPD).

Have high level of suspision for GAD in patients who make repeated visits with the same physical symptoms which do not respond to treatment (for example insomnia, headache, or fatigue)

Answer 100

A

depression
panic disorder
agoraphobia
social phobia
specific phobias
health anxiety
OCD
alcohol (and other substance, incl cannabis) misuse

Answer 101

A

PRESCRIBED

salbutamol
theophylline
beta-blockers
steroids
some antidepressants (esp initially)

NOT-PRESCRIBED

alcohol use or withdrawal
other illicit substances (use or withdrawal)
caffeine
herbal medicines (including ma huang, St. John’s wort, ginseng, guarana, belladonna)

Answer 102

A

psych hx
MSE
physical exam (to exclude DDx)

possible findings on physical exam:

increased HR
SOB
trembling
exaggerated startle response

GAD-7 questionnaire

ALWAYS risk assess (to self, to others, from others)

Answer 103

A

PSYCH

SITUATIONAL anxiety (controllable anxiety that is not generally associated with pathological symptoms and relates to a particular life event, such as an upcoming exam)
ADJUSTMENT disorder (temporary anxiety that has occurred in response to a life stressor and persists for no longer than 6 months after the stressor ends)
DEPRESSION (can be co-morbid)
PANIC disorder (recurrent episodes of sudden onset anxiety, in the absence of multi-themed worry - can be co-morbid)
SOCIAL phobia (anxiety or persistent fear that is limited to social situations and fear of social scrutiny or embarrassment. Avoidance behaviour is commonly present.)
OCD (anxiety due to compulsions or obsessions)
PTSD (anxiety that is caused by exposure to reminders of past trauma)
SOMATOFORM disorders (anxiety related to specific physical complaints, which have no medical basis)
ANOREXIA NERVOSA (axiety related to fear of gaining weight)
SUBSTANCE and ALCOHOL misuse / withdrawal (frequently associated with anxiety, especially among men)
MEDICATION-INDUCED anxiety (anxiety triggered by exposure to medications including salbutamol, theophylline, corticosteroids, antidepressants, and some herbal medicines. Caffeine may also be a trigger. Withdrawal from CNS depressants can also trigger anxiety)

Answer 104

A

CARDIAC DISEASE

symptoms such as palpitations, sensation of rapid or skipped heartbeat, dizziness, dyspnoea and chest pain on exertion, and numbness
Examination may reveal hypertension, hypotension, tachycardia or bradycardia, or S3 or S4 gallops

RESP DISEASE

suggested by a hx of lung conditions such as asthma or COPD, the person being a current or previous smoker, and signs/symptoms such as wheezing, cough, respiratory distress, or sputum production, and a feeling of suffocation.
Pulse oximetry may reveal low oxygen sats

HYPERTHYROIDISM
- weight loss, warm moist skin, heat intolerance, ophthalmopathy, or goitre

ANAEMIA
- fatigue, dyspnoea, and palpitations

INFECTION
- anxiety and additional symptoms of fever, night sweats, or cough, which resolve following successful treatment

IRRITABLE BOWEL
- alteration of bowel habit associated with pain, and abdominal discomfort, bloating, or distention

PHAEOCHROMOCYTOMA
- anxiety that co-exists with hypertension and/or tachycardia

Answer 105

A

BIO

SSRIs
(benzos - short term only!)

PSYCH
- CBT (group, CCBT, 1-to-1)

SOCIAL

address substance misuse
regular exercise
sleep hygiene
practically address stressors (financial, relationships, work)

(also make sure any co-morbid medical conditions are managed)

do:

1) social
2) psych
3) meds

(although can do meds + psych simultaneously)

nb people w GAD are particularly prone to ADR - so tend to start with lower doses and rise slower than, eg for depression
- expect result in 6-12 wks

monitor for:

increased anxiety or akasthesia
suicidal ideation

NICE suggest a step-wise approach:
step 1: education about GAD + active monitoring
step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment (sertraline 1st line)
step 4: highly specialist input e.g. Multi agency teams

Answer 106

A

PANIC ATTACK = discrete episode of intense fear or discomfort.

which are not restricted to any particular situation or set of circumstances, and which are therefore unpredictable

Starts abruptly, reaches maximum with few minutes.

Features at least 4 specific symptoms of anxiety.

dominant symptoms vary from person to person, but sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality
(depersonalization or derealization) are common.

There is also, almost invariably, a secondary fear of dying, losing control, or going mad.

frequent and unpredictable panic attacks produce fear of being alone or going into public places. A panic attack is often followed by a persistent fear of having another attack.

nb one panic attack doesn’t mean you have a disorder

Answer 107

A

several (norm 4) severe attacks of autonomic anxiety should have occurred within a
period of about 1 month:

(a) in circumstances where there is no objective danger;
(b) without being confined to known or predictable situations; and
(c) with comparative freedom from anxiety symptoms between attacks (although anticipatory anxiety is common).

ie differentiate from GAD and specific phobias

Panic disorder should not be given as main diagnosis if the patient has depressive disorder at the time the attacks start (panic attacks are probably secondary to depression)

can occur with or without agoraphobia

Answer 108

A

FHx of panic or other anxiety disorder
stress
life changes / traumatic event
smoking
excess caffeine

Answer 109

A

LIFE THREATENING

anaphylaxis (or other airway obstruction)
asthma attack
PE
ACS
arrythmia / SVT

OTHER ORGANIC

CARDIOvascular diseases (incl angina, heart failure)
PULMonary diseases (incl asthma)
NEUROlogical diseases (incl epilepsy, TIA, huntingtons)
ENDOCRINE diseases (addisons, thyroid, menopause, hypoglycaemia)
drug INTOXICATION (amphetamines, hallucinogens, cocaine)
drug WITHDRAWAL (alcohol, opiates, sedatives)

PSYCH

GAD
agoraphobia
specific phobia
PTSD
depression

Answer 110

A

psych hx
MSE
physical exam (esp heart and lungs)

try and identify any triggers (may lead to specific phobia instead of panic disorder)

Panic disorder should not be given as main diagnosis if pt has depressive disorder

Answer 111

A

SSRIs (may increase panic initially)
propranolol (‘pill in pocket’ - not sure how often used)
CBT (go through IAPT)
psychoeducation (what to do during a panic attack)
reduce alcohol and caffeine intake

1) social
2) psych
3) bio

Answer 112

A

–> Anxiety that is situational – initiated by experience or anticipation of phobic stimulus.

Anxiety is restricted to a specific situation or object

Anxiety out of proportion to a specific stimulus

Fear cannot be reasoned or explained away.

ANTICIPATORY behaviour: People tend to worry leading up to the situation: anticipatory anxiety

AVOIDANCE behaviour: Avoidance of stimulus/ situations where it may arise

Patients present when causing loss of function

nb can have panic attacks but not panic disorder as in reaction to a specific stimulus

Answer 113

A

SPECIFIC PHOBIAS

F=M
childhood

SOCIAL PHOBIA

F>M
adolescence

AGORAPHOBIA

F>M
20-35 years

nb specific phobias are ‘simple’ phobias, whereas social and agoraphobia are ‘complex’ phobias

Answer 114

A

Anxiety provoked by open spaces or large crowds where escape is difficult

“fear of the marketplace”
Fear of space (open or closed)

Usually involve fears of:

leaving home / being away from home
entering shops, queues
crowds and public places, being trapped
travelling alone in trains, buses or planes

Avoidance of the phobic situation is often prominent
- Some people with agoraphobia experience little anxiety because they are able to avoid their phobic situations.

Concerns with fainting, dying, not able to escape etc.

Answer 115

A

Better if:

way out
accompanied e.g. pets

Often occur with panic attacks = panic disorder with agoraphobia

Depressive and obsessional symptoms, and social phobias are also commonly present as subsidiary features

Answer 116

A

The fear is of being judged or “scrutinised” by others in a negative way
- can lead to avoidance

This is on a spectrum with normality as everyone has this to a certain extent
- Is only problematic if it interferes with your life and causes you distress

May present as a complaint of blushing, hand tremor, nausea, or urgency of micturition
- Symptoms may progress to panic attacks.

usually associated with low self-esteem and fear of criticism.

May have triggering incident e.g. embarrassing event

ADVERSE OUTCOMES

Withdrawal from society
Alcohol abuse common to overcome phobia

Answer 117

A

Specific or simple phobias centre around a particular object, animal, situation or activity

They often develop during childhood or adolescence and may become less severe as you get older.

RISK FACTORS

triggering / traumatic event
learned phobia from parents/siblings

animal phobias – such as dogs, spiders, snakes or rodents

environmental phobias – such as heights, deep water and germs

situational phobias – such as visiting the dentist or flying

bodily phobias – such as blood, vomit or having injections

sexual phobias – such as performance anxiety or the fear of getting an STI

Answer 118

A

Phobias are not usually formally diagnosed. Most people with a phobia are fully aware of the problem.

A person will sometimes choose to live with a phobia, taking great care to avoid the object or situation they’re afraid of.

But if you have a phobia, continually trying to avoid what you’re afraid of will make the situation worse.

Answer 119

A

any triggering/precipitating factors? when did it start?
any anticipatory behaviour / anxiety?
any avoidance behaviour (or coping, like alcohol)?
severity - how severe is it now?
psych comorbidities - any GAD, depression, OCD, PTSD etc

Answer 120

A

PTSD

(also OCD)

(also panic disorder if no trigger, GAD if all the time etc)

Answer 121

A

BIOLOGICAL

SSRIs (social + agor)
propranolol (pill in pocket)
benzos (short term - eg if flying)

bio options are just to manage symptoms - real treatment is psych!

PSYCH

graded exposure (specific)
CBT (complex)

SOCIAL MANAGEMENT

psychoeducation: avoidance reinforces the phobia, can use self-help to do own graded exposure
reduce alcohol use (esp social phobia)

PROGNOSIS is really good if psychotherapy!

Answer 122

A

OBSESSION:
- ideas, images, or impulses that enter the patient’s mind again and again in a stereotyped form
- almost invariably
distressing (because they are violent or obscene, or simply because they are perceived as senseless) and the sufferer often tries, unsuccessfully, to resist them.
- They are, however,
recognized as the individual’s own thoughts, even though they are involuntary and often
repugnant.
- This causes anxiety and distress and leads to an attempt to neutralise ie the compulsion.

Obsessions may include:

Fear of getting disease
Fear of coming to harm
Fear of causing harm to others

nb 90% popn experience obs, difference is that people with OCD can’t dismiss these thoughts as insignificant - they view them as significant and meaningful - eg “Having this thought means that it will come true”

COMPULSION:

strong urges to repeatedly perform an action, even though it is unnecessary.
stereotyped behaviours that are repeated again and again.
not inherently enjoyable, nor do they result in the completion of inherently useful tasks.
function is to prevent some objectively unlikely event, often involving harm or danger to or caused by the patient, which they fear might otherwise occur. (ie cancel out the obsessional thought)
recognised by the patient as symbolic, pointless or ineffectual
Anxiety is almost invariably present.
Repeated attempts are made to resist but if acts are resisted the anxiety gets worse

Compulsions can involve:

Cleaning/handwashing
repeated checking (to ensure that a potentially dangerous situation has not been allowed to develop e.g. turning off electrical switches)
orderliness and tidiness.

Answer 123

A

obsessional symptoms or compulsive acts, or both, must be present on MOST DAYS for at least TWO successive WEEKS and be a source of distress or interference with activities.

The obsessive-compulsive symptoms should have the following characteristics:

(a)they must be recognized as the individual’s own thoughts or impulses;

(b)there must be at least one thought or act that is still resisted unsuccessfully, even though others
may be present which the sufferer no longer resists;

(c)the thought of carrying out the act must not in itself be pleasurable (simple relief of tension or
anxiety is not regarded as pleasure in this sense);

(d)the thoughts, images, or impulses must be unpleasantly repetitive

close relationship between
obsessive + compulsive symptoms, particularly obsessional thoughts, and DEPRESSION.

Individuals with
OCD often have depressive symptoms, and patients suffering from recurrent depressive disorder may develop obsessional thoughts during their episodes
of depression. In either situation, increases or decreases in the severity of the depressive symptoms are generally accompanied by parallel changes in the severity of the obsessional symptoms.

Differentiating between OCD and a depressive
disorder may be difficult because these two types of symptoms so frequently occur together.

In an acute episode of disorder, precedence should be given to the symptoms that developed first; when both types are present but neither predominates, it is usually best to regard the depression as primary. In chronic disorders the symptoms that most frequently persist in the absence of the other should be given priority

Answer 124

A

M=F

often prominent
ANANKASTIC (ie OCD) features in the underlying personality

‘anankastic’ is derived from the Greek word meaning ‘compulsion’.

Onset is usually in childhood or early adult
life.

The course is variable and more likely to be chronic in the absence of significant
depressive symptoms.
- compulsions are more easily treatable than the obsessions

nb can subcategorise by if obsessions or compulsions are more prominent or if is mixed

Answer 125

A

1) INSIGHT
- People with OCD are typically distressed by the nature of their behaviors or thoughts, however much they are unable to control them (ie have insight).
- People with OCPD believe that their actions have an aim and purpose. (ie don’t have insight)

2) ADDITIONAL BEHAVIOUR
- OCPD tend to think their way of doing things is the “right and best way,” and they are fixated with following set procedures or routines in their work or daily living, even when these routines are inefficient.
- they tend to be overly controlling of their environments or relationships, wanting others to conform to the strict rules they set.
- maladaptive traits and behaviors, including perfectionism that interferes with completing tasks, rigid following of moral or ethical codes, hoarding behaviors, and an excessive fixation with lists and rules

3) PERVASIVENESS
- OCPD is pervasive in all areas of life (not just with one type of thought or behaviour)

Answer 126

A

BIOLOGICAL

SSRIs (fluoxetine, sertraline)
TCA (clomipramine)

PSYCH

CBT sometimes
exposure and repeated prevention

eg:

stimulus control: patient given specific time of day where allowed to think about obsessional thoughts
Apps eg NOCD: pts can watch videos e.g. hand washing, which reduces anxiety and compulsion

Combined psychotherapy AND drug treatment generally better than each alone

Answer 127

A

= Delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone

e.g. RTA, severe assault, military violence, rape

Symptoms develop in aftermath –> Approx. 1-6 months after event

(see other flashcard for exactly which type of symptoms needed for diagnosis)

lifetime prevelence = 1-10%

Answer 128

A

PREDISPOSING

personality traits (compulsive, asthenic)
previous history of neurotic illness
genetic: sensitive amygdala & hippocampus – decreased hippocampus size on MRI

nb predisposing factors may lower the threshold for the development of the syndrome or aggravate its course (but they are neither necessary nor sufficient to explain its occurrence)

HIGH RISK GROUPS

Traumatic occupation: soldiers, doctors, police
disaster victims
rape, torture and assault victims = ASK about forensic Hx

RISK FACTORS SURROUNDING EVENT

scale of trauma
pt’s previous experience
low level of social support available

Answer 129

A

1) RE-EXPERIENCE (flashbacks, nightmares, intrusive memories)
2) HYPERAROUSAL / anxiety with hypervigilance and increased startle reaction (ie jumpy)
3) NUMBNESS
4) EMOTIONAL BLUNTING / detachment from others
5) AVOIDANCE of activities associated with trauma

(scroll down for comorbidities)

In addition to
evidence of trauma, there must be a repetitive, intrusive recollection or re-enactment of the event in memories, daytime imagery, or dreams.

Conspicuous emotional detachment, numbing of feeling, and avoidance of stimuli that might arouse recollection of the trauma are often present but are not essential for the diagnosis. The autonomic disturbances, mood
disorder, and behavioural abnormalities all contribute to the diagnosis but are not of prime importance.

PSYCH CO-MORBIDITIES

depression + suicidal ideation
substance misuse

Answer 130

A

Hx of traumatic event
when onset of symptoms
what symptoms present
screen for depression
screen for substance misuse
RISK ASSESS (esp for suicide!)

Answer 131

A

BIO
- antidepressants, esp PAROXETINE

PSYCH
- trauma-focused CBT (multiple sessions, repeated graded exposure)

OTHER

EMDR (eye movement desensitisation + repreocessing)
move eyes side to side whilst thinking of event

SOCIAL

treat substance abuse
crisis management plan

65% recover in 18 months

Answer 132

A

States of subjective DISTRESS and emotional disturbance, usually interfering with social functioning and
performance, and arising in the period of adaptation to a SIGNIFICANT LIFE CHANGE or to the
consequences of a STRESSFUL LIFE EVENT (including the presence or possibility of serious physical illness).

The stressor may have affected the integrity of an individual’s social network
(through bereavement or separation experiences) or the wider system of social supports and values (migration or refugee status). The stressor may involve only the individual or also his or her group or community.

manifestations vary, and include:
- depressed mood
- anxiety
- worry (or a mixture of these)
- poor concentration
- avoidance / denial
- feeling of inability to cope, plan ahead, or continue in the present situation
- some degree
of disability in the performance of daily routine.
- irritability
- dramatic behaviour or outbursts of violence, but these rarely occur.
- autonommic arousal (eg palpitations and sweating)

However, conduct disorders (e.g.
aggressive or dissocial behaviour) may be an associated feature, particularly in adolescents.

None of the symptoms is of sufficient severity or prominence in its own right to justify a more
specific diagnosis.

In children, regressive phenomena such as return to bed-wetting, babyish
speech, or thumb-sucking are frequently part of the symptom pattern.

The onset is usually within ONE MONTH of the occurrence of the stressful event or life change, and the
duration of symptoms does not usually exceed SIX MONTHS

includes NORMAL GRIEF REACTION

Answer 133

A

what was the stressful event and when did it happen (ie how long ago)
how does it continue to affect life now (incl level of functioning)

SCREEN FOR

depression
anxiety
substance misuse

nb if no stressful event, situation or life change has occured then seek alternative diagnosis - by definition, adjustment disorder requires an event/change to ‘adjust’ to

Answer 134

A

Treatment aims to accelerate the natural process of adjustment.

Working through the life-change reduces anxiety and allows denial and avoidance to decline.

Anxiolytics are rarely required.

PSYCHO

problem solving psychotherapy
crisis intervention

SOCIAL

address any ongoing social issues (eg finances, housing, other relationships etc)
address substace misuse

make sure to keep following up

Answer 135

A

1) SEVERITY
- increased distress and disability (ie functioning - eg meets criteria for depression)

2) LENGTH
- more than 6 months (can also be delayed in onset)

SYMPTOMS OF GRIEF:

longing for deceased
emotional pain
preoccupation with deceased (incl pseudohallucinations)
difficulty accepting death
disbelief/denial
bitterness/anger
blame/guilt
feeling one has lost a part of oneself
difficulties engaging with acitivities or making plans for the future
sadness
emotional numbness
inability to experience positive mood
impairment in important areas of functioning (family, personal, educational, occupational)

nb these symptoms often occur transiently in many bereaved individuals, but it is only when these reactions are experienced on more days than not, causing severe distress and impairment in important areas of functioning more than six months after loss that a PGD diagnosis is applicable

Answer 136

A

PREDISPOSING

female
low educational level
insecure attachment + neurotic personalities
PMHx of psych conditions

PRECIPITATING

very close to deceased (esp partner or child)
unnatural / violent death
unexpected death

Answer 137

A

depression

- PTSD (esp if they witnessed death)

Answer 138

A

BIO
- consider antidepressants (but not always)

PSYCHO

CBT
other psychological therapies

SOCIAL

social prescribing etc to increase engagement in social activities
address social issues, eg finances, occupation etc
specialist grief charities or support groups

nb not a lot of research has been done about this so use clinical judgement

Answer 139

A

One of the most popular models of grief divides it into 5 stages.

1) DENIAL: this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
2) ANGER: this is commonly directed against other family members and medical professionals
3) BARGAINING
4) DEPRESSION
5) ACCEPTANCE

It should be noted that many patients will not go through all 5 stages.

The GRIEF TASK MODEL proposes that normal grief is the successful achievement of certain “grief tasks,” whereas complications in managing these tasks might indicate disturbed grief. There is no recommended or specific order in which to achieve these tasks.

Grief tasks include:

to accept the reality of the loss
to process the associated pain
to adjust to a world without the deceased
to find an enduring connection with the deceased in the midst of embarking on a new life.

Answer 140

A

transient disorder
develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress

Symptoms mixed but could include being in a daze, disorientation, panic, amnesia

Initial state of shock +/- symptoms of anxiety and depression

Symptoms usually appear within MINUTES of the impact of the stressful stimulus /event
- usually subsides within HOURS or DAYS (2-3).

Answer 141

A

SOMATISATION DISORDER

multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
“S for symptoms”

HYPOCONDRIAL DISORDER

persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
“C for cancer”

CONVERSION DISORDER
- typically involves loss of motor or sensory function
the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
- patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies

DISSOCIATIVE DISORDER

dissociation is a process of ‘separating off’ certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder

FACTITIOUS DISORDER

aka Munchausen’s syndrome
the intentional production of physical or psychological symptoms

MALINGERING
- fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain (eg to get drugs)

Answer 142

A

SOMATISATION DISORDERS ARE PSYCHOLOGICAL DISORDERS THAT EXHIBIT PHYSICAL SYMPTOMS OR TAKE THE FORM OF PHYSICAL DISORDERS

There will be no discernable physical or organic reason for these symptoms and this leads to the presumption that they are caused by a psychological disorder

FEATURES OF SOMATISATION
- These physical symptoms do NOT HAPPEN VOLUNTARILY and are completely beyond the individuals control

FORMS OF SOMATISATION
- The two most common forms of somatisation are SOMATISATION DISORDER and HYPOCHONDRIAL DISORDER. The two have distinct psychologies…

In SOMATISATION DISORDER (AKA Briquet’s Syndrome) people have specific symptoms that they complain of
- You can remember this because it’s S for Somatisation and S for symptoms

In HYPOCHONDRIAL DISORDER people are convinced of having a specific disease
- E.g. they think they’ve got cancer or HIV
HYPOCHONDRIACAL DISORDER
- This disorder is distinct form somatisation disorder but it is quite subtly different

In hypochondriacal disorder patients misinterpret normal bodily sensations and think that they mean that they’ve got a serious medical disease.

A key difference from somatisation disorder is:
- Often patients with somatisation disorder will ask for TREATMENT for their symptoms whereas patients with hypochondriacal disorder will become fixated on the diagnosis and so they will often be demanding INVESTIGATIONS to confirm this diagnosis

Again, patients with hypochondriacal disorder will refuse to accept information an reassurance from doctors that there is not organic cause or disease process.

BODY DYSMORPHIC SYNDROME is a specific type of hypochondriacal disorder where people become concerned/preoccupied with a specific defect or deformity e.g. crooked nose or ugly hands.

Answer 143

A

GI:

Nausea
vomiting
diarrhoea
food intolerance
belching
regurgitation
abdo pain
constipation

Skin:

itching
burning
numbness

Sexual:

loss of libido
ejaculatory or erectile dysfunction
irregular menses
dysmenorrhoea

Urinary:

dysuria
frequency
urinary retention

Neurological:

paralysis
sensory loss
hearing or vision loss
double vision
seizures
difficulty swallowing
impaired coordination

***patients should have numerous symptoms from more than one of these groups not just one symptom in isolation

Answer 144

A

Patients with somatisation disorders are highly at risk of having iatrogenic complications - a key example is a patient with multiple abdominal adhesions from having multiple explorative laparoscopies.

Answer 145

A

In order for somatisation disorder to be diagnosed the ICD-10 suggests all of the following should be present:

At least 2 years of symptoms with no organic explanation found
Persistent refusal by the patient to accept reassurance from several doctors that there is no physical cause
Some degree of functional impairment due to the symptoms and resulting behaviour

Answer 146

A

This is when there is a perceived loss of motor or sensory function - describes the situation whereby psychological pain is converted into the somatic or physical form.

Often neurological symptoms (paralysis, blindness, sensory loss)

It is distinct from factitious disorder where the patient purposefully feigns symptoms.

In conversion disorder the motor and sensory loss are involuntarily experienced

A common thing that patients seem to experience is profound loss of peripheral visions. They state that is is ‘like looking down a tube’. Again patients might seem indifferent (see below)

Patients might be experiencing La belle Indifference - they might be completely indifferent to their symptoms but this is not well backed up by research

Answer 147

A

manage by GP

see same dr every time to build rapport
Schedule frequent visits (e.g. 15 minute visit/month)

This has the effect of:

Replaces emergency visits and telephone calls
Allows patient attention without a new symptom
Not contingent on new complaints
Not focused on symptoms

GENERAL PRINCIPLES:

Do not suggest “it’s all in your head”
Encourage patient to assume active role in their care
Focus on function (not symptoms)
Manage comorbid psychiatric conditions
Provider reassurance that serious conditions have been ruled out (avoid additional lab testing and subspecialist referral)
Spend most of the encounter listening (aknowledge that what they are feeling is real, allow the “sick role”)

SOCIAL (focus on stress reduction)

exercise
manage financial / relationship stress
social gatherings / pleasurable activities (incl social prescribing)
relaxation (nature walks, yoga)

PSYCH
- CBT (but need to encourage them to come to this idea - eg suggesting pts own strategies haven’t been working - is ‘worth a try’)

BIO
- SSRIs have shown some benefit!

Can also do ‘benign’ management, eg:

Hot and cold packs
Bandages
Canes
Lotions
Vitamins or Nutritional
Supplements
Acupuncture
Chiropractic massage therapy
Biofeedback

Answer 148

A

= A ‘binge’ is the consumption of a large number of calories in a relatively short space of time- can be up to 6000 calories in 1-2 hours - with a sense of a ‘loss of control’ while doing this - binge will only end when can find no more food in house or feel in so much pain from all food that have to purge - then get huge guilt and regret and try to purge

Subjective over eating is different!

An episode of binge eating is characterized by
both:
1. Eating in a discrete period of time (e.g. within any 2 hour period), an
amount of food that is definitely larger than what most individuals would
eat in a similar period of time under similar circumstances;
2. A sense of lack of control over eating during the episodes (e.g. a feeling
that one cannot stop eating or control what or how much one is eating).

Binge eating episodes are associated with three or more of the following:

Eating much more rapidly than normal.
Eating until feeling uncomfortably full.
Eating large amounts of food when not feeling physically hungry.
Eating alone because of feeling embarrassed by how much one is eating.
Feeling disgusted with oneself, depressed, or very guilty afterwards.

Answer 149

A

1) FEAR of fatness
2) PURSUIT of thinness

3) Body DISSATISAFACTION
4) Body image DISTORTION

5) SELF-EVALUATION based on weight and shape

‘imagine facing your worst fear 3x a day, every day’

Answer 150

A

when human body is starved, direct effect on psychology:

Fixation on food – starvation, restriction
Depression
Anxiety, social phobia
Suicidal ideation
OCD symptoms
rigidity

Rumination about food, incl:

bizarre beliefs about good and bad food, calories, fat etc
beliefs around miasmatic calories (thinks can absorb calories through skin or breath them in)

Answer 151

A

ANOREXIA NERVOSA

1) BMI <18.5 (or 17.5?)
2) weight loss is self-induced by food-avoidance etc behaviour
3) presence of core psychopathology

BULIMIA NERVOSA

1) BMI >18.5 (or 17.5?)
2) presence of at least one episode of binging and purging per week for at least 3 months
3) presence of core pathology

BINGE EATING DISORDER

1) At least one binge eating episode per week for 3 months
2) marked distress regarding binge eating
3) binge eating is not associated with recurrent use of compensatory/purging behaviours
4) presence of core psychopathology

nb see other flash card for definition of a ‘binge’

ie the presence of CORE PSYCHOPATHOLOGY is present in all eating disorders!!!

Answer 152

A

Symptoms characteristic of a feeing or eating disorder that cause clinical distress or impairment in social, occupational, or other important areas of functioning predominate.

However DO NOT meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class

ATYPICAL ANOREXIA NERVOSA:
all of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range.

BULIMIA NERVOSA (of LOW FREQUENCY and/or LIMITED DURATION):
all of the criteria for
bulimia nervosa are met, except that the binge eating and inappropriate
compensatory behaviors occur, on average, less than once a week and/ or for less than 3 months.

BINGE-EATING DISORDER (of LOW FREQUENCY and/or LIMITED DURATION):
all of the criteria for binge-eating disorder are met, except that the binge occurs, on average,
less than once a week and/ or for less than 3 months.

PURGING DISORDER: recurrent purging behavior to influence weight or shape (e.g. self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating.

NIGHT EATING SYNDROME:
Recurrent episodes of night eating, as manifested by
eating after awakening from sleep or by excessive food consumption after the
evening meal. There is awareness of recall of the eating. The night eating causes significant distress
and/or impairment in functioning.

EXCESSIVE COMPULSIVE EXERCISE
- significant amount of time dedicated to physical activity to detriment of other factors in goal of achieving an unrealistic desired weight

nb don’t need to learn these by heart but just be aware

Answer 153

A

CVS
AN - Bradycardia
AN - Hypotension
BN - arrythmias
BN - heart failure
BOTH = Sudden death (in AN norm dt QTc prolongation, in BN norm dt arrythmias)

RENAL (all BOTH)
= Oedema (severe in BN)
= Electrolyte abnormalities
= Renal calculi
= Renal failure

GASTROINTESTINAL
AN - Delayed gastric emptying
AN - Nutritional hepatitis
BN - Dental erosion
BN - Oesophageal erosion / perforation
BOTH = Parotid swelling
BOTH = Constipation

SKELETAL
AN - Short stature
BOTH = Osteoporosis
BOTH = Pathological fractures

ENDOCRINE
AN - Amenorrhoea
AN - Infertility
AN - Hypothyroidism
BN - oligo / amenorrhoea

HAEM
AN - Anaemia
AN - Thrombocytopenia
BOTH = Leukopenia (sometimes lymphocytosis in BN)

NEURO (all BOTH)
= Generalised seizures
= Confusional states

METABOLIC (all BOTH)
= Impaired temperature regulation
= Hypoglycaemia

DERM
AN - lanugo
AN - brittle hair and nails
BN - Calluses on dorsum of hands (Russell’s sign)

Answer 154

A

SCOFF Screening:

S = SICK:

do you ever make yourself SICK because you feel uncomfortably full?

C = CONTROL:

do you worry you have lost CONTROL over how much you eat?

O = ONE:

have you lost more than ONE stone in a 3-month period?

F = FAT:

Do you believe yourself to be FAT when others say you are too thin?

F – FOOD:

would you say that FOOD dominates your life?

primary care screening tool (if 2 or more positive, refer for more detailed assessment)

Answer 155

A

1) cardiac arrest / sudden death
2) suicide (20-40% of deaths)

so manage risk of both

anorexia nervosa has highest mortality of any psych condition

Answer 156

A

1) Clinical Hx and physical examination
2) BMI
3) ECG
4) Bloods (see other flashcards for which ones)

can’t do a valid risk assessment if haven’t got all of these 4 components
- ie don’t base risk on BMI alone!!!

Answer 157

A

PSYCH:

ANOREXIA NERVOSA
FOOD AVOIDANCE EMOTIONAL DISORDER (an ED that affects children which involves a fear of eating which is not accompanied by a fear of weight gain)
PHAGOPHOBIA (anxiety disorder characterized by a fear of eating, it is usually initiated by an adverse experience while eating such as choking or vomiting, Individuals with this disorder may present with complaints of pain while swallowing)
eg Pt saw with liaison with NG tube - had never been good eater then struggled with constipation and was so scared that she’d have it again - scared of the pain
DEPRESSION - stop eating and drinking, form of self-neglect
ANXIETY - if really anxious - trigger fight or flight, don’t want to eat (similar to post-intensive exercise)
Somali pt saw with liaison - never eaten much but anxiety just caused her to stop eating- hated how skinny her arms looked (also access to food - dad just having takeaways, didn’t like rice, didn’t know how to eat healthily)
PSYCHOSIS / DELUSIONAL BELIEFS - paranoid beliefs of being poisoned

ORGANIC CAUSES:

MALIGNANCY - anorexia is a core feature partially due to nausea (also comorbid anxiety or depression)
IBD / COELIAC - eat sufficient amounts but not put on weight so may be a clinical suspicion that not eating
INFECTIONS - make nauseous - eg flu can shed weight off very healthy people - also TB
METABOLIC CONDITIONS - diabetes type 1, hypo/hyperthyroidism, addisons

OTHER

PAST TRAUMA
Pt in becklin who kept throwing up - but because he ate food so quickly, parents had berated him about eating (also parental pressure may -> ED)

AUTISM SPECTRUM DISORDER
Man just ate kidney beans boiled in oil - struggled to put on weight - his autism, restrictive and repetitive behaviour

DRUG ABUSE
Long term cannabis use can suppress appetite (saw on medical show - always take drugs hx - pt didn’t realise this was the reason so didn’t tell staff as thought irrelevant)

Answer 158

A

GROUPS OF BEHAVIOURS TO ASK ABOUT:

restricting food intake
increasing calorie burning
suppressing appetite
behaviours around obsession over body
binge/purge behaviours
other social / self harm

(list examples of all of the above on a different flashcard)

OTHER THINGS

explore core psychopathology
screen for other mental health conditions (eg depression, social anxiety)
ask about CVS symptoms (CP, dizziness, palpitations, blackouts)
rule out organic DDx (will have other symptoms, and not have core psychopathology)
risk assess (physical and DSH/suicide)

also any physical comorbidities - esp insulin-dependent diabetes or pregnancy = very high risk!

Answer 159

A

RESTRICTING FOOD INTAKE

Dieting
Fasting
Calorie counting
chewing and spitting
other culinary behaviour (bizarre combinations of food, spoiling food)

INCREASING CALORIE BURNING

Excessive exercise
over-activity (fidgeting, twitching, pacing, fetching one thing at a time)
Thyroxine
Diet pills
ritalin
cooling (wearing less clothes)

SUPPRESSING APPETITE

Water loading
Appetite suppressants (gum, cigarettes)

OBSESSION OVER BODY

Excessive weighing
body checking
mirror gazing or avoidance

BINGE / PURGE BEHAVIOUR

binging
purging
starve-bing-purge cycle
misuse of insulin
laxatives

SOCIAL

Avoidance
Isolation
deliberate self-harm (DSH)
Substance misuse.

Answer 160

A

OBS

bradycardia
hypotension
hypothermia

OTHER

irregular pulse
postural hypotension
enlarged salivary glands
dentition
skin on knuckles
test for proximal myopathy

basically do a full examination but look out for these specific things

Answer 161

A

SQUAT TEST

get them to squat right down and then stand up (without using arms)

if can’t do, concerned about protein malnutrition

Answer 162

A

BMI = wt(kg)/ht(m)2

<18.5 = AN (?changed to 17.5)

<15 = moderate risk

<13 = high risk (start seeing organ failure)

Proxy measure of physical risk with clear limitations
- can be manipulated, eg water loading, so don’t use in isolation

Answer 163

A

Bradycardia (<40bpm)
t wave changes (hypokalaemia)
QTc prolongation (>450ms)

only way to reverse these abnormalities is adequate nutrition, don’t need cardiac drugs

most deaths due to cardiac arrest.
- nb Cardiac abnormalities in up to 85% of anorexia pts.

Answer 164

A

standard

FBC
U+E
LFT
glucose

more specialist

CK
phos, Mg, Ca
TFTs
Zn

(^get all of these, just split them up so easier to remember)

also in anorexia:
- low FSH, LH, oestrogens, testosterone
- raised cortisol + growth hormones
- imppaired glucose tolerance
- hypercholestoraemia
- hypercarotenaemia (raised beta-carotene)
low T3 (if not taking thyroxine)

“in ANOREXIA = most things low BUT G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, CK, carotinaemia”

Answer 165

A

bloods can show what behaviours patients have been doing - even if they don’t admit it

Starvation
= Hypoglycaemia

Vomiting
= Hypokalaemia

Water-loading
= Hyponatraemia

Laxative misuse
= Hyperkalaemia + Hyponatraemia

Diuretics misuse
= Hypokalaemia, hyponatraemia

Thyroxine misuse
= ↑T3/T4, ↓TSH

Bone marrow hypoplasia
= Normocytic anaemia + Leucopenia

Proximal myopathy
= ↑ CK, ↑ LFTs

Answer 166

A

Re-feeding syndrome

Hypophosphataemia
Hypomagnesaemia
Hypocalcaemia
Hypokalaemia

so low of all the positive ions (except sodium)

Answer 167

A

Usually managed as outpatient

Most AN require specialist Rx
BN + OSFED/EDNOS will mainly be treated either in primary care or secondary services

SPECIALIST ED UNIT (yorkshire)

moderate/severe AN (bmi <17)
severe BN (daily bingeing + purging)
OSFED/EDNOS with comorbid IDDM or pregnancy

OTHER WARDS:

Gastro-enterology ward (for initial refeeding)
Acute medical ward (if electrolyte disturbances)
General psychiatric ward (avoid if possible!!!)

Match needs to appropriate setting

clinical state, level of risk
local resources
capacity to consent to treatment
motivation to change
patient and family’s views

Answer 168

A

MARSIPAN = Management of really sick patients with anorexia nervosa

MARSIPAN group:

Physician with special interest in ED
ED/Liaison Psychiatrist +/- CMHT
Dietician and nutrition support team
Nursing team

Have regular MARSIPAN meetings
- coordinated care

Answer 169

A

1) nutrition (if super low)
2) motivational enhancement
3) formal psychological support

Answer 170

A

because when low weight, psychology is more rigid, need to increase nutrition first before can manage psychopathology

use dieticians a lot

EDUCATION on what body needs, eg:

carbs at every meal to stabilise blood sugar
dairy 2-3x a day for clcium, vit D and phosphate
protein 2-3x a day for growth + repair (incl immune systm, skin integrity, tissue restoration)

explaining the binge-purge cycle
- explain to BN that need regular meals to avoid purging (typically binges happen later in the day)

NG feed as last resort

Answer 171

A

before any in-depth psychotherapy
most pts are initially not distressed - it’s their relative who are
At point of referral they don’t realise that they have a problem

AIM

to understand the psychological functions of the ED
weigh up how the individual feels about change
to increase motivation to change (lots of motivational interviewing techniques)
to make an informed decision about whether this is the right time to change

TECHNIQUES / Qs:
= Affirmations
= Reflective listening
= Open ended questions
--- Why Change?
--- Advantages/Disadvantages?
--- What do you like about your ED?
--- What do you dislike about your ED?
--- Write a list of all the things you have stopped doing because of your ED
--- Barriers to change – What would stop me giving up your ED?
= Summaries
= Elicit change talk

Brief therapy, usually lasting 4-6 sessions
- Beneficial in the initial phase of treatment with promotion of responsibility and a commitment to change

Answer 172

A

1) PRE-CONTEMPLATION
- unwilling to change

2) CONTEMPLATION
- considering change

3) DETERMINATION
- preparing to change

4) ACTION
- implementing change

5) MAINTENANCE
- maintaining change

6) either PERMANENT EXIT or RELAPSE

At point of referral they don’t realise that they have a problem (<50% referred to specialist ED are in action phase)

Answer 173

A

ANOREXIA NERVOSA

MANTRA (maudsley approach to treating anorexia)
CBT
SSCM (specialist supportive counselling)

nb all of equal efficacy, try others if don’t work

BULIMIA NERVOSA

CBT
IPT

nb both of equal efficacy, try others if don’t work

nb BN much easier to treat than AN

ALSO can use FLUOXETINE 60mg daily in BN (not in AN, nb dose is higher than for depression)

OSFED = mainly GUIDED SELF-HELP

Education (e.g. physical and psychological risks of disordered eating)
Increased awareness and responsibility (e.g. food/thought diaries)
Structured eating
Identify and challenge beliefs
Promote self-management skills

Answer 174

A

Develop therapeutic alliance
Diagnosis & screening
Risk assessment and coordinate medical monitoring (BMI, bloods, ECG)
Medication review
Use motivational enhancement techniques
Knowledge of local care pathways and MARSIPAN
Guided self help and support groups
Encourage self-monitoring (e.g. diaries) and structured eating

*see my full psych notes for additional resources for GPs

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core conditions - 1 Flashcards

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