Disorders Flashcards
Treatment of anorexia nervosa in CAMHS community?
- family base treatment
- dietitian
- olanzapine
- SSRI
Risk with anorexia nervosa?
- refeeding syndrome
What risk assessment score is used in anorexia?
MARSIPAN risk assessment
What factor is used in anorexia scaling in adults and children?
- Adults = BMI <13
- children = <70% BMI for age
What is refeeding syndrome
- fatal metabolic response to too rapid re-feeding after a period of starvation
Treatment of refeeding syndrome
- low energy replacement with high phosphate content
- correct electrolyte imbalances
- daily monitoring of bloods
What is ARFID?
- Avoidant - restrictive food intake disorder
Explain Avoidant-restrictive food intake disorder (ARFID)
- Sensory based
- fear of consequences e.g. vomiting
- little interest in eating
Management of ARFID
- CBT
- SSRI
- Dietetic input
ARFID may be seen in what conditions?
- autism - sensory based avoidance of food
What is bulimia nervosa?
- episodes of binging followed by purging (vomiting or laxative)
Features of bulimia nervosa?
- dental erosions
- parotid gland swelling
- russell’s sign
Treatment of bulimia nervosa?
- CBT
- Fluoxetine (60mg)
- family therapy
Treatment of binge eating disorder?
- self-help guide
- group CBT
Consequences of eating disorders?
- bone health
- fertility
- dental health
- physical and mental health
Define personality
a cluster of relatively predictable patterns of thinking, feeling and behaving
Define personality disorder
- out with the individuals character
- pervasive
- stable, long duration
Symptoms of an anankastic personality?
- excessive doubt
- perfectionism
- conscientiousness
Trait vs disorders?
- disorder = pervasive, causes distress, impairment of functioning
What rating scales can be used for personality disorders
- zanarini rating scale
- personality assessment schedule
- personality disorders questionnaire
Cluster A DSM V categories
- paranoid
- schizoid
- schizotypal
Cluster B DSM V categories?
- antisocial
- bordeerline
- historonic
- narcissistic
Cluster C DSM V categories?
- avoidant
- dependent
- obsessive - compulsive
What is present in the DSM V but not in the ICD 10
- Schizotypal
- narcissistic
- avoidant
Cluster A PD are generally defined as?
- odd and eccentric
Explain paranoid PD
- Extreme sensitivity
- suspicion
- self-importance
- tendency to bear grudges
Explain schizoid PD
- Emotional coldness and detachment
- limited capacity to express emotions
- lack of close friendships
- insensitivity to social norms
Schizotypal PD
- pattern of extreme difficulty interacting socially
- inappropriate behaviour and strange speech
- odd beliefs or magical thinking
Antisocial PD
- Callous unconcern for the feelings of others
- tendency to blame others
- failure to obey laws
Borderline PD - aka. emotionally unstable
- Pattern of abrupt mood swings
- impulsive
- inability to control temper
Histrionic PD
- Attention seeking
- sexually inappropriate
- shallow
- relationships considered more intimate than they are
Narcissistic PD
- Pattern of grandiosity
- lack of empathy
- sense of entitlement
Avoidant pd
- Strong feelings of inadequacy and fear of social situations
- self-impose isolation
Dependant PD
- Intense psychological need to be cared for by other
- lack initiative and need others to make decisions
Anakastic PD?
- Preoccupied by rules
- perfectionist
- activities are pleasurable and desirable
Anxious PD
- tension/apprehension
- preoccupation
- restrictions in lifestyle for security
Treatment of disorders with impulse control?
- SSRI
- olanzapine
- sodium valporate
Treatment of affective dysregulation?
- SSRI
- Mirtazepine
Explain the pillars of dialectical behavioural therapy?
- mindfulness
- regulate emoptions
- distress tolerance
- interpersonal effectiveness
Treatment of emotionally unstable PD
- Dialectical behavioural therapy
- STEPPS - Systems training
Anorexia nervosa classified in children as?
- weight less than 85% expected for age and height
Anorexia nervosa classified as what in adults?
- BMI <17.5
2 Types of anorexia?
- restricting
- binge-purge
Signs of an eating disorder
- Difficulties eating in front of others
- Preoccupation with food
- Low confidence
- Negative body image
- Tiredness and difficulty concentrating
Physical examination in anorexia nervosa?
- BMI
- Physical examination
- Bloods
- ECG / BP
Why is a physical examination conducted in a patient with a suspected eating disorder?
- to assess risk
What guideline is used in the diagnoses of anorexia?
- MARSIPAN
What does the SCOFF questionnaire include
- Sick
- Control
- One stone loss
- Fat feeling
- Food dominates life
Define psychosis
- mental disorder
- interferes with thoughts, affective response of ability to recognise reality
Characteristics of psychosis (3 examples)
- hallucinations
- delusions
- disorder of form of thought
Define delusion
- Fixed, strange or irrational belief
Define hallucination
- A sensory perception without a stimulus o Auditory o Visual o Touch o Smell
Types of delusions?
- Delusions of grandeur (exaggerated ideas of importance)
- Paranoia (belied in a plot against them)
- Somatic (belied they have a terrible incurable illness)
What causes hallucinations?
- aberrant brain processing
Difference between hallucinations and illusions?
- illusions can be “switched off”
- hallucinations are not under conscious controls
What is ideas of reference?
- Innocuous or coincidental events will be ascribed significant meaning by the person
- Thinking there is a message in the newspaper about them, seeing meaning in other’s gestures
A fixed, falsely held belief is known as?
- a delusion
List some thought disorders?
- clanging
- loosening of associations
- neologism
- word salad
Examples of thought intereference
- Thought insertion
- Thought withdrawal
- Thought broadcasting
- Thought blocking
What is loss of insight
- Reality testing is lost
- To you everything seems as real as they always did
Passivity of volition
- made actions
Passivity of affect?
- made feeling
Passivity of impulse?
- made urges
Causes of primary psychosis?
- schizophrenia
- schizophreniform
- schizoaffective disorder
- delusional disorder
- substance induced
Causes of secondary psychosis?
- thyroid
- adrenal
- Wilson’s
- huntington’s
- stroke
What is delirium?
- acute transient disturbance from the persons’ normal cognitive function
- due to insult to the brain
Symptoms of delirium
- acute symptoms, previously normal
- clouding of consciousness (worse at night)
- impaired concentration and memory
- visual hallucinations
Drug induced psychosis?
not the same as intoxication
tends to improve with removal of substance
Symptoms of depressive psychosis
- depressive symptoms
- delusions of worthlessness
- hallucinations
- threatening voices (usually 2nd person)
What is Cottard’s syndrome
- believe they have already died
Symptoms of mania with psychosis?
- mood congruent
- hallucinations tend to be 2nd person
- flight of ideas
Positive symptoms of schizophrenia?
- psychotic symptoms
- acute onset
- delusions
- hallucinations
- thought disorder
- disorganised speech and behaviour
Negative symptoms of schizophrenia?
- insidious, slow onset
- weight change
- sleep problems
- social withdrawl
- reduced speech
For a diagnosis of schizophrenia at least 2 of 5 symptoms need to be present. What are these 5?
- delusions
- hallucinations
- disorganised speech
- disorganised behaviour
- negative symptoms
What is schizotypal?
- magical thinking
- eccentric behaviour
schizoaffective disorder differs from schizophrenia how?
- more effect on mood
Schizophrenia treatment?
- anti-psychotic
- psychological
name some first generation of antipsychotics?
- chlorpromazine
- halopreidol
- zuclopenthixol
what is the target of 1sr generation anti-psychotics
- D2 receptor blockers
What is the mode of action of anti-psychotics?
- dopamine therapy (block D2 receptor) within the mesolimbic pathway
name some 2nd generation anti-psychotics and what they target?
- clozapine
- olanzapine
- risperidone
- d2 and 5ht receptor blocker
dopaminergic side effects?
- extrapyramidal (acute dystonic reaction, parkinsons, tardive dyskinesia)
- neuroleptic malignant syndrome
- hyperprolactinema
- akathisia
treatment of the extra-pyramidal side effects associated with anti-psychotics?
- anticholinergics
- change anti-psychiotic
Explain acute dystonic reactions
- extrapyramidal side effect of dopaminergics
- increased muscle tone, energetic
What is neuroleptic malignant syndrome
- fatal if untreated (rhabdomylsis)
- side effect of anti-psychiotics
- slowly increased dystonia, increased tone, fluctuation pulse
- CK >1,000
Treatment of neuroleptic malignant syndrome
- stop anti-psychotic
- rapid cooling
- renal support
- skeletal muscle relaxants (dantrolene)
Another name for akathisia?
- restless legs
treatment of akathisia?
- b blockers (propanolol)
- benzodiazepine (clonazepam)
What is clozapine used for?
- 2nd gen anti-psychiotic
- good for non-respodant anti-psychiotic treatment
- good for negative psychotic symptoms
Side effects of clozapine
- agranulocytosis (neutropenic sepsis)
- myocarditis
- weight gain
Monitoring of clozapine?
- weekly WCC for first 6months
- fortnightly for 6-12months
- then monthly
- due to risk of agranulocytosis
First line anti-psychotics?
- 2nd generation
- then 1st or 2nd
- consider depot
- consider clozapine
what are the 4 dopamine pathways in schizophrenia?
- increased mesolimbic (hallucinations)
- decreased mesocortical (social withdrawal)
- nigrostriatal
- tuberoinfundibular (hyperprolactinaemia)
Anti-psychotics aim to target which dopamine pathway in schizophrenia?
- mesolimbic pathway increased
- aim to reduce by binding of dopamine blockers to d2 receptors
What is puerperium psychosis?
- psychiatry emergency (due to safe guarding of child)
- 1 in 1,000 births
- 2-4wks post delivery
What is post-natal depression?
- 1 in 10 women
- 1 - 4 weeks post delivery
Personality disorders are diagnosed after what age?
- after the age of 18
- first present to services around 14yrs
Conduct disorder is diagnosed over what age?
- over the age of 12
Oppositional defiant disorder is diagnosed at what age?
- under 12
What is pseudo-dementia?
- remains good insight
- fluctuating symptoms
- not progressive
- good drug and ect response
Late onset depression is more likely to present with __expressive/somatic__ symptoms
- late onset = somatic
- early onset = expressive
Treatment of anxiety disorder in young?
- CBT
- SSRI
- Benzodiazepines
Treatment of depression in young?
- CBT
- Group IP
- First line = fluoxetine
- sertraline
Management of self-harm in adolescents?
- suicidal vs non-suicidal
- education
- specialist referral
Licensed drug treatment for depression in those aged under 18?
- fluoxetine
Heretability of schizophrenia
- 78% heritability
- if 2 parents have, 45% risk to child
Pathology of schizophrenia on the brain?
- enlarged ventricles
- reduced frontal lobe volume
- reduced grey matter
Risk factors for developing schizophrenia?
- 2nd trimester viral illness
- pre-eclampsia
- fetal hypoxia
- childhood CNS infection
3 modified genes associated with schizophrenia?
- neuregulin
- dysbindin
- DISC-1
What hypothesis is suggested for the development of schizophrenia?
- dopamine hypothesis
- excess dopamine
First rank symptoms with schizophrenia?
- auditory hallucinations
- disorders of thoughts
- delusional perception
- passivity phenomena
Definition of a learning disability
- reduced intellectual ability and difficulty with everyday activities
What IQ defines intellectual disability?
- iq <70
What is the average IQ in the general population?
- IQ = 100
Name learning disability assessments?
- wechsler adult intelligence scale
- wechsler scale for children
What is the Flynn effect?
- increase in IQ over generations
- slowing down, especially in developed countries
Diagnosing an adult with a learning disability?
- must be acquired in childhood
- although a new diagnosis can be made in adulthood, it will have been present since childhood
- wechsler adult intelligence scale
Learning difficulty and disability are the same?
False
- they are different
What is a borderline ID?
- IQ 70-84
- mental age 12-15
Mild ID?
- IQ range 50-69
- mental age 9-12
Moderate ID?
- IQ 35-49
- Mental age 6-9
Severe ID?
- IQ range 20-34
- mental age 3-6yrs
Profound ID?
- IQ <20
- Mental age < 3yrs
Co-morbidities in ID?
- Epilepsy
- mental illness
- dementia
- hypothyroidism
- diabetes
- obesity
What is type 1 trauma?
- sudden incident
- sudden
- unexpected
What is type 2 trauma and its risks?
- repetitive trauma
- ongoing abuse
- 3 x more likely to get PTSD compared to type 1
What percentage of people with bipolar have a childhood history of abuse or neglect?
- 50%
Where does the emotions associated with anxiety arise?
- Periaqueductal grey (PAG)
- Ventral tegmental area
Explain tonic immobility?
- freeze response in response to inescapable danger
- involuntary
Distant dread is processed where in the brain and where does it move?
- distant = frontal cortex
- close threat = midbrain and PAG
What neuroanatomy changes are seen in PTSD?
- Hippocampal atrophy
- hyperactivity of the amygdala
- deactivation of broca’s area
- adult = right side of brain
- children = left side of brain
What is neuroception?
- safe, dangerous or life-threatening processing
- primitive regions of the brain
- without conscious awareness
Periacedutal grey is associated with what in PTSD?
- Emotional response
- close threat
Symptom criteria for PTSD?
- Minimum of 4 weeks
- intrusive phenomena (>1)
- avoidance (>1)
- negative alterations (>1)
- increased arousal and reactivity (>2)
Explain intrusive phenomena?
- recurrent distressing recollections
- nightmares
- flashbacks
- distress accompanying reminders
- physiological reactions
Explain avoidance in PTSD?
- avoidance of thoughts or feelings of the event
- avoidance of external reminders
Negative alterations in PTSD?
- amnesia
- loss of interest
- Negative affect
- negative thoughts
- exaggerated blame
- feeling isolated
- difficulty experiencing positive emotion
1st line treatment in PTSD?
- CBT
- EMDR
Increased arousal and reactivity in PTSD?
- Sleep disturbances
- irritability
- concentration difficulties
- hypervigilance
- exaggerated startle response
- risky and destructive behaviour
What drug can be given for sleep associated symptoms in PTSD?
- Prazosin
What region of the brain acts as the emotional filter?
- amygdala
During acute stress what is released?
- cortisol
- catecholamines
Explain generalised anxiety disorder
- free floating
- generalised and persistent
- physical symptoms
Treatment of GAD
- CBT
- SSRI
- SNRI
- benzodiazepines (short term)
Explain panic disorders?
- recurrent
- severe
- anxiety attacks
Symptoms of an panic disorder?
- palpitations
- chest pain
- fear of dying
What do 50% of panic disorder suffered also suffer from?
- agoraphobia
What are the 3 terms of phobia?
- agoraphobia (big busy spaces)
- specific
- social
What is obsessive compulsive disorder?
- recurrent obsessional thoughts or acts
- ego-dystic (causes distress to the person) - they don’t enjoy doing
- present most days for at least 2 weeks
How do benzodiazepines work in anxiety?
- gaba A receptor
- modulate gaba affect (allosteric effect)
- membrane hyperpolarisation (Cl- enters)
- less likely for an action potential
Chronic use of benzodiazepines may cause?
- sedation and psychomotor impairment
- withdrawal problems
- dependency and abuse
What is a functional disorder?
- cannot easily associate the symptoms with a classically identifiable organic disease
- soft ware problem rather than hardware
Define dissociation
- detachment from reality
Define depersonalisation
- a feeling your body doesn’t quite belong
Define derealisation
A feeling that you are disconnected from the world around you
What is hazardous drinking?
- pattern of alcohol consumption that increases someones risk of harm
- anyone drinking more than 14 units per week
What screening questionnaire can be done for alcohol consumption?
- Alcohol screening questionnaire (AUDIT)
What screening tool for alcohol dependence?
- CAGE
- tried to Cut down
- people Annoyed at your drinking
- feel Guilty
- need an Eye opener (drinking first thing)
What score on the alcohol screening questionnaire leads to brief intervention?
- score = 6-20
- brief intervention
Brief intervention for alcohol consumption, FRAMES mnemonic
Feedback Responsibility Advice Menu Empathy Self-efficacy
3 or more criteria for alcohol dependance
o Strong desire or sense of compulsion to take drug
o Difficulty in controlling use of substance
o Physiological withdrawal state
o Evidence of tolerance
o Progressive neglect of other pleasures
o Persistence with use despite clear evidence of harmful consequences
Pathology of alcohol withdrawal?
- alcohol is a CNS depressant
- up regulation of glutamate for excitation
- sudden withdrawal leads to unapossed excitation
- toxic to nerve cells
Symptoms of alcohol withdrawal?
- restlessness
- tremor
- sweating
- tachycardia
- quick onset
- peak 24-48hrs
- resolved in 5-7days
Treatment of alcohol withdrawal
- General support
- Benzodiazepines (diazepam)
- Vitamin supplementation (Pabrinex)
- Thiamine as prophylaxis for Wernicke’s encephalopathy
Relapse prevention in alcohol dependence - psychosocial
Psychosocial interventions
- CBT
- Motivational enhancement
- 12 steps (AA)
Pharmacological management of relapse prevention in alcohol dependence?
- 1st line = Naltrexone (opioid antagonist)
- disulfiram (antabuse)
- acamprosate
What is Korsakoff’s and wernickes?
- result of excessive alcohol and dependance
- thiamine (vitamin b1) deficiency
- memory problems and damage to brain
- prophylaxis - thiamine
- wernickes = acute
- korsakoffs= chronic
What is the CAGE screening tool?
- cut down
- annoyed
- guilty
- eye opener
Initial stages of an addictive substance can be described as?
- positive reinforcement
- substance taken for the pleasure
Later, chronic stages of a substance addiction can be described as?
- negative reinforcement
- substance taken to remove the negative symptoms
What pathway in the brain is involved in the “wanting”
- mesolimbic
- dopamine neurotransmitter
Explain tolerance to reward?
- repeated dopamine release
- down regulation of dopamine receptors
- more substance required for same effect
What is the role of the pre-frontal cortex in addicition
- responsible for the intention of guided behaviours
- can suppress mesolimbic pathway
- addicts have reduced pre frontal cortex usage
What is the role of the hippocampus and amygdala in addiction?
- involved in learned drug associations
- cue craving
What is the role of the orbit-frontal cortex?
- motivation to act
- addicts have increased activation of ofc
Explain the effect of stress on addiction?
- acute stress triggers dopamine in neural pathways
- chronic stress = downregulation of dopamine receptors
- encouragement to be exposed to highly rewarding behaviours
What is a safety bundle?
- needed for treatment of opioid misuse
- includes: drug diaries, drug screens, opioid withdrawal scale, recovery care plan, risk assessment
What is a treatment for opioid misuse?
- ORT
- opioid replacement therapy
What is ORT and what are the phases?
- opioid replacement therapy
- induction
- optimisation
- maintenance
- reduction
What is methadone?
- Mu receptor agonist
- long half life
- peak plasma conc 4hrs
Where is methadone metabolised
- Hepatic (liver)
A substitute of methadone?
- buprenorphine
Explain buprenorphine?
- ORT
- Mu receptor partial agonist
- low intrinsic activity
- high affinity
- sublingual tablets
Side effects of methadone
- long QT
- sedation
- drug interaction
Life saving opioid antagonist?
- naloxone
What is delirium?
- impaired consciousness with intrusive abnormalities of perception and affect
How is the diagnosis of delirium made?
- impaired consciousness
- disturbance of cognition
- psychomotor distrubances
- disruption of sleep wake cycle
- emotional disturbance
General features of delirium (3)
- rapid onset
- transient and fluctuating
- lasts days to months
Causes of delirium?
PINCH ME
- Pain
- Infection
- Nutrition
- Constipation
- hydration
- medications
- electrolytes
Risk factors for delirium?
- elderly
- cognitive deficit
- long stay in hospital
- emergency surgery
- stress
What cognitive assessment is conducted for delirium?
- 4AT
- alertness
- AMT 4 ( Age, place, year, DOB)
- Attention
- acute and fluctuating
Management of delirium?
- identify underlying cause and treat
- manage environment
- ? haloperidol
- if alcohol withdrawal? benzodiazepines
Subtypes of delirium?
- hyperactive
- hypoactive
- mixed
Symptoms of hyperactive delirium?
- confusion, agitation, restlessness
- fine during day, overactive at night
- disruptive
- delusions
Symptoms of hypoactive delirium?
- unmotivated
- suddenly quiet, withdrawn sleepy
- often misdiagnosed as depression
Symptoms of mixed delirium?
- sleep all day awake all night
What is the cause of limbic encephalitis?
- potassium channel antibody
Symptoms of limbic encephalitis?
- middle aged
- subacute memory loss
- panic attacks
- partial seizures
What is delirium tremens?
- delirium after acute withdrawal of alcohol
- confusion, hallucinations, sweating, hypertension
Tx = chlordiazeproxide (benzodiazepine), fluids, parbrinex
Triad of wernicke’s encephalopathy?
- ophthalmoplegia
- ataxia
- confusion
Lesions in Korsakoff syndrome are located where?
- mammillary bodies
5Ps of the formulation model?
- predisposing
- precipitating
- presenting problem
- protective factors
- perpetuating factors
3 types of frontotemporal dementia?
- behaviour
- primary progressive aphasia
- semantic
