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General Adult Flashcards

1
Q

Common commorbidities with depression

A

Alcohol >40%
Anxiety >40%
PD 30%

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2
Q

How many people with depression attempt suicide?

A

9%

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3
Q

Duration of depressive episodes

A

Untreated 6-13 months

Treated 1-3 months

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4
Q

How many people have only one episode of depression?

A

50%

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5
Q

How likely are you to have another episode of depression if you have had two episodes?

A

70%

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6
Q

How likely are you to have another episode of depression if you have had three episodes?

A

80-95%

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7
Q

When is depression considered to be in remission?

A

> 3m without symptoms

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8
Q

When is someone considered to be recovered from depression?

A

> 6m without symptoms

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9
Q

Treatment for mild depression

A

Watchful waiting for 2/52

CBT

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10
Q

Treatment for moderate depression

A

SSRIs, continue for at least 6m after remission

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11
Q

How long should people continue antidepressants if they have had >2 episodes already?

A

At least 2 years

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12
Q

Treatment for severe depression

A

SSRI + CBT together

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13
Q

What to consider if someone is not responding to medication for depression

A 
Adequate dosage
Lack of adherence
Axis 2 disorder (PD)
Alcoholism
Alternate diagnosis
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14
Q

Prevalence of bipolar

A

1.5%

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15
Q

Lifetime prevalence of depression

A

13%

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16
Q

1 year prevalence of depression

A

5.3%

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17
Q

Suicide rate in bipolar

A

15-18 times higher than general population

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18
Q

How many people with bipolar have another mental illness?

A

66%

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19
Q

Comorbid disorders common with bipolar

A

Anxiety - increases risk of relapse of depression
Substance misuse - increases risk of relapse of mania
Impulse disorders

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20
Q

How long does it take to recover from mania when treated?

A

4-5 weeks

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21
Q

What defines rapid cycling

A

4 or more episodes a year

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22
Q

What is ultra rapid cycling

A

4 or more episodes a month

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23
Q

Characteristics of rapid cycling bipolar

A 
80% women
Early onset of illness
More severe depression and mania
Lower global functioning
Poor response to Lithium
Hypothyroid
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24
Q

DSM duration criteria for hypomania

A

4 days

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25
Q

DSM duration criteria for mania

A

7 days

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26
Q

First line treatment for mania if untreated

A

Haloperidol
Olanzapine
Risperidone
Quetiapine

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27
Q

Treatment for mania if known bipolar and on treatment

A

Increase dose of mood stabiliser
Check serum Li levels
Consider adding antipsychotic to lithium or valproate - especially if incongruent psychotic sx
ECT

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28
Q

Treatment for Depression in bipolar

A

Psychological intervention
Moderate to severe: fluoxetine with olanzapine
Quetiapine
Lamotrigine (second line)

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29
Q

When to consider long term maintenance treatment in bipolar

A
  • after a manic episode involving significant risk and adverse consequences
  • bipolar I disorder with two or more acute episodes
  • Bipolar II disorder with significant functional impairment, or risk.
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30
Q

First line maintenance treatment for bipolar

A

Lithium

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31
Q

What can Lithium reduce risk of in bipolar?

A

Suicide
Mania
Depression

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32
Q

Other maintenance options in bipolar

A 
Valproate
Olanzapine
Quetiapine
Carbamazepine
Lamotrigine
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33
Q

Management of rapid cycling

A

R/o hypothyroid and substance use and medication non-compliance
Stop antidepressant
Lithium, valproate or lamotrigine

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34
Q

How long to continue medication for maintenance after episode of bipolar?

A

2 years

5 years if high risk factors for relapse

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35
Q

What can CBT offer in Bipolar

A

Psychoeducation
Self monitoring
Self regulation; action plans and modification
Compliance

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36
Q

How much is increase of SCZ increased in migrants?

A

3-5x more

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37
Q

How much is increase of SCZ increased in urban areas?

A

2x more

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38
Q

M:F ratio of SCZ

A

1.4:1

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39
Q

Lifetime prevalence of SCZ

A

4 in 1000

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40
Q

M:F ratio of delusional disorders

A

1.18:1

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41
Q

Incidence of delusional disorders

A

0.7-1.3 per 100,000

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42
Q

Psychosocial treatments in SCZ

A 
Psychoeducation
CBT 
Family therapy if high EE
Social skills training
Vocational rehab
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43
Q

How many patients with FEP relapse if not treated

A

61%

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44
Q

How many patients with FEP relapse if treated

A

27%

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45
Q

Lifetime suicide prevalence in those with SCZ

A

5.6%

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46
Q

Good prognostic factors for SCZ

A 
Late onset
Obvious precipitating factors
Acute onset
Good premorbid adjustment
Affective symptoms (esp. depression)
Being married
Family history of affective disorders
Good social support
Positive symptoms only
Good initial response to treatment (best
predictor)
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47
Q

Poor prognostic factors for SCZ

A 
Early onset* (not strong)
No precipitating factors**
Insidious onset**
Poor premorbid adjustment
Social withdrawal
Single, divorced, or widowed
Family history of schizophrenia* (weak, controversial)
Poor social network, High EE families
Negative symptoms
Poor compliance
Neurological signs and symptoms
History of perinatal trauma
No remissions in 3 years
Many relapses
History of violence
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48
Q

Negative sx if SCZ

A 
Anhedonia
Avolition
Apathy
Amotivation 
Restricted affect.
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49
Q

Prevalence of negative symptoms in patients with SCZ

A

20-30%

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50
Q

First line treatment for SCZ

A

4-6 weeks of PO atypical - amisulpride, aripiprazole, olanzapine, quetiapine, risperidone

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51
Q

Risk of relapse following FEP in next 5 years

A

4-5x chance

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52
Q

Duration of maintenance treatment following FEP and remission

A

1-2 years

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53
Q

Duration of maintenance treatment following multiple episodes of SCZ and in remission

A

At least 5 years

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54
Q

NICE definition of treatment resistant SCZ

A

Lack of
satisfactory clinical response to sequential use of at least two antipsychotics for a period of 6 to 8
weeks: at least one of the agents must be from atypical (non-clozapine) group.

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55
Q

Mean age of onset of GAD

A

30

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56
Q

Mean age of onset of panic disorder

A

22-25

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57
Q

Mean age of onset of OCD

A

20

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58
Q

Mean age of onset of social phobia

A

15

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59
Q

Treatment of anxiety disorders

A

Rule out comorbidities and previous response to treatment
Psychological therapy first line
SSRIs
Combination in complex disorders refractory to treatment

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60
Q

Lifetime prevalence of OCD

A

2-3%

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61
Q

M:F ratio of OCD

A

1.5:1

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62
Q

Characteristics of OCD in men

A

Earlier onset
More severe
Tics
Poorer outcome

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63
Q

Four categories of OCD sx

A

• Aggressive, sexual, and religious obsessions, and checking compulsions;
• Symmetry and ordering obsessions and compulsions; (often chronic and treatment resistant)
• Contamination obsessions and cleaning compulsions;
• Hoarding obsessions and compulsions (may be neurobiologically distinct and often treatment
resistant)

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64
Q

Treatment of mild to moderate OCD

A

First line: self-help
Second: CBT with ERP
Third: SSRIs +/- CBT

65
Q

Treatment of severe OCD

A

SSRIs and CBT

If no response, switch to another SSRI or Clomipramine

66
Q

How many patients with OCD improve on SSRIs/Clomipramine?

67
Q

Lifetime prevalence of PTSD

A
  1. 6% men

9. 7% women

68
Q

M:F ratio PTSD

69
Q

How many people exposed to trauma develop PTSD?

70
Q

Who is PTSD more common in?

A 
Younger
Higher anxiety response to initial event
External locus of control
Previous mental illness
Female
Low socioeconomic and educational status
Ethnic minority
Cluster B PD
Perceived threat to life
Peritraumatic dissociation
Severity of trauma
Lack of social support
Subsequent life stressors
Physical illness - chronic pain
71
Q

Protective factors of PTSD

A

High IQ
Higher social class
Opportunity to grieve for loss

72
Q

Initial management of PTSD if symptoms mild

A

Watchful waiting if <4 weeks after trauma

73
Q

Treatment for PTSD

A

Psychological treatment

74
Q

Who should be offered trauma-focused CBT in PTSD?

A

Severe PTSD in first month after traumatic event

PTSD within first 3 months of trauma

75
Q

What does trauma-focused CBT involve?

A

Exposure therapy, cognitive therapy and stress management

76
Q

Treatment for PTSD sx after 3 months of trauma

A

Trauma-focused CBT or
EMDR
Up to 12 sessions

77
Q

When should medication be considered for PTSD?

A

If limited improvement from psychological therapy

78
Q

Medications used in PTSD

A

Paroxetine
Mirtazapine
Amitriptyline
Phenelzine

79
Q

What is exposure therapy in in trauma focused CBT?

A

Repeated confrontation of traumatic memories and repeated exposure to avoided situations with relaxation and anxiety reduction

80
Q

How long should trauma-focused treatment for PTSD continue for?

A

Weekly for 8-12 sessions

81
Q

What is the cognitive component of trauma focused CBT?

A

Modification of misinterpretations that lead to overestimation of current threat and modification of other beliefs related to traumatic experiences and behaviour during trauma via cognitive restructuring

82
Q

Theory of EMDR

A

Allows processing of traumatic memories in the form of eye movements

83
Q

What happens in EMDR

A

While the patient focuses on specific
images, negative sensations and associated cognitions, bilateral stimulation is applied to desensitize the
individual to these memories and more positive sensations and cognitions are introduced.

84
Q

Duration of sx in acute stress disorder

85
Q

Lifetime prevalence of GAD

86
Q

Risk factors for GAD

A 
Exposure to trauma
Bullying
Life events
First degree relative of GAD
Female
87
Q

First line treatment of GAD

88
Q

Other meds for GAD

A

SNRI

Pregabalin

89
Q

What does CBT involve for GAD

A

Education
Relaxation training
Exposure and cognitive restructuring

90
Q

SSRIs for acute treatment in GAD

A

Escitalopram
Paroxetine
Sertraline

91
Q

Non-SSRIs for acute treatment of GAD

A

Imipramine
Venlafaxine
Duloxetine
Buspirone

92
Q

Long-term meds for GAD for relapse prevention

A

Paroxetine
Escitalopram
Venlafaxine
Pregabalin

93
Q

Adjuncts with antidepressants for GAD where limited response

A

Olanzapine or Risperidone in low doses

94
Q

Prognosis of GAD

A

42% patients recover in 12 months

Poorer outcome if another anxiety disorder

95
Q

Types of social phobia

A

Generalised - fear occurs in most social situations

Situational - fear of public speaking or performance anxiety

96
Q

Medications for social phobia

A

SSRI first line

Venlafaxine

97
Q

Which SSRIs to use in social phobia

A

Fluoxetine
Sertraline
Escitalopram
Fluvoxamine

98
Q

How long to continue medication in social phobia after remission?

A

6-12 months

99
Q

Second line treatment for social phobia

A

Phenelzine

100
Q

Third line treatment for social phobia

A

SSRI and clonazepam
Gabapentin
Pregabalin

101
Q

Mean age of onset of any panic attack

102
Q

Treatment for panic disorder

A

CBT - 7-14 hours, weekly 1 hour sessions, complete within 4 months
Self-help
SSRIs

103
Q

Medications to consider if no response to SSRIs for panic disorder

A

Imipramine

Clomipramine

104
Q

Longer term treatment/prevention of panic disorder

A

Cognitive therapy with exposure

Continue meds for 6 months

105
Q

Prevalence of hypochondriasis

106
Q

Point prevalence of panic disorder

107
Q

Point prevalence of social phobia

108
Q

Point prevalence of GAD

109
Q

Treatment for hypochondriasis

A

CBT including group CBT

SSRIs

110
Q

Predisposing factors for BDD

A

Low self-esteem
Critical parents and significant others
Early childhood trauma
Unconscious displacement of emotional conflict

111
Q

Co-morbidities of BDD

A

Depression 26%
Social phobia 16%
OCD 6%

112
Q

How many patients with BDD seek cosmetic surgery

113
Q

Treatment of BDD

A

High dose SSRIs for longer duration than as antidepressant - Fluoxetine
CBT combination in treatment resistance case

114
Q

Outcome of BDD

A

Poor - waxing and waning course

Preserved psychosocial functioning

115
Q

Prevalence of somatisation disorder

116
Q

M:F ratio of somatisation disorder

117
Q

Treatment for Somatisation disorder

A

CBT

Antidepressant medications

118
Q

Aetiology of dissociative disorder

A

Childhood psychological abuse - 57-90%

119
Q

Aim of treatment for dissociative disorder

A

Integrate feelings, perceptions, thoughts and memories

120
Q

Treatment of dissociative disorder

A

Individual structured psychotherapy such as Acceptance and Commitment Therapy and DBT

121
Q

Prevalence of anorexia

A

0.5-1% in teenage girls

122
Q

Prevalence of bulimia

A

1-2% in 16-35 age group

123
Q

Co-morbidities in anorexia

A

65% have depression
34% have social phobia
26% have OCD

124
Q

Risk factors for ED

A

FHx of ED for anorexia
FHx of substance misuse and obesity for bulimia
Females, adolescence and early adulthood
Adverse parenting - low contact and high expectations and parental discord
Critical comments about eating, shape and weight from others
Childhood sexual abuse
Occupational and recreational pressure to be slim
Low self-esteem and perfectionism
History of obesity in bulimia

125
Q

What characterises binge eating disorder?

A

Recurrent episodes of binge eating without extreme weight-control behaviour

126
Q

Treatment of BED

A

Self help - first line
Behavioural weight loss programmes
CBT and IP

127
Q

Treatment of bulimia

A

CBT - 20 sessions over 5 months

128
Q

Prognosis of bulimia

A

33-50% make complete and lasting recovery

Antidepressants can decline frequency of binge eating and purging but effect not sustained

129
Q

Good prognostic factors for anorexia

A

Illness present for <6 months
No bingeing or vomiting
Cooperative parents willing to participate in family therapy

130
Q

Treatment for anorexia

A

CAT or CBT
IPT
Family interventions

131
Q

Meds for bulimia

A

SSRI - fluoxetine up to 60mg OD

132
Q

Prevalence of PD

133
Q

M:F ratio of dissocial PD

134
Q

Prevalence of dissocial PD in prisons

A

63% male remand
49% sentenced
31% female prisoners

135
Q

Prevalence of EUPD

A

2% in general population

136
Q

M:F ratio of EUPD

137
Q

How common is EUPD in patients with first degree relatives of EUPD?

A

5x more common

138
Q

What sx of EUPD decline rapidly with time?

A 
Quasi-psychotic thoughts
Self-harm
Help-seeking suicide efforts
Treatment regressions
Countertransference problems
139
Q

Which sx of EUPD are more stable over time?

A

Depression, anger, loneliness and feelings of emptiness

General impulsivity

140
Q

Prognosis of EUPD

A

40% remit after 2 years

88% no longer meet criteria in 10 years

141
Q

Things to cover in OCD history taking

A
  • Obsessional thoughts-ideas, images or impulses, own thought, unpleasurable, repetitive, resistance & response
  • Compulsive acts/rituals-washing, cleaning, checking, counting, The anxiety symptoms associated with it.
  • Resistance and avoidance
  • Duration, effects and coping
  • Avoidance and anticipatory anxiety
  • Rule out co-morbidity-depression, anxiety
142
Q

What to ask about obsessional thoughts

A 
Own thought,
Unpleasurable, 
Repetitive, 
Resistance 
Response
143
Q

Structure of PTSD hx station

A
  1. Details of the traumatic incident itself
  2. Look for core features of post-traumatic stress disorder (PTSD) that includes
    hyperarousal, intrusions and avoidance
  3. Assess the mode of onset, duration, progression of current symptoms and
    impairment in different areas of functioning (Social and occupational
    functioning)
  4. Rule out co-morbidity.
144
Q

PTSD sx of hyperarousal

A
  1. Persistent anxiety and Irritability or outbursts of anger
  2. Insomnia
  3. Poor concentration and exaggerated startle response
145
Q

PTSD sx of instrusions

A
  1. Intensive intrusive imagery (flashbacks)
  2. Vivid memories
  3. Recurrent distressing dreams and nightmares
146
Q

PTSD sx of avoidance

A
  1. Actual or preferred avoidance of circumstances resembling or associated
    with the stressor
  2. Emotional detachment and inability to feel emotions
  3. Diminished interest in activities.
147
Q

Questions to explore traumatic incident in PTSD hx

A

Explore the details of the accident, in particular the perceived severity and
establish the level of distress and fear at the time of the event.
• Could you describe the accident please? (Here approach the patient
empathetically as it is difficult to talk about traumatic incidents, and
acknowledge the patients distress.)
• Find out about when it happened, how (terrifying) it was?
• Ask about any injuries in particular head injury, loss of consciousness,
whether any other person was injured etc.
• Inquire about any blame, litigation, court cases and their outcome.

148
Q

Questions about intrusions in PTSD

A
  • How often do you think about the accident?
  • Do you sometimes feel as if the accident is happening again?
  • Do you get flashbacks?
  • Have you revisited the scene?
  • Do you get any distressing dreams/nightmares of the event?
  • What would happen if you hear about an accident?
  • Do you have any difficulties remembering parts of the accident?
149
Q

Questions about hyperarousal in PTSD

A
  • Have you had the feeling that you are always on the edge?
  • Do you tend to worry a lot about things going wrong? (Feeling anxious)
  • Do you startle easily? (Enhanced startle response)
  • Tell me about your sleep please. (Explore for sleep disturbance)
  • Are you sometimes afraid to go to sleep?
  • How has your concentration been recently?
  • How has your memory been lately?
  • Do you loose your temper more often that you used to? (Irritability)
150
Q

Questions about avoidance in PTSD

A

• How hard is it for you to talk about the accident?
• Do you deliberately try to avoid thinking about accidents?
• Have you been to the place where the accident happened?
• Do you make any effort to avoid the thoughts or conversations associated
with the trauma? How would you do that?
• Do you make any effort to avoid activities, places or people that arouse
recollection of the trauma?

151
Q

Construct of PTSD hx taking

A

Obtain details of the traumatic accident- nature and extent of the problem,
severity of symptoms and impairment on current functioning
Hyper arousal Symptoms (Persistent Anxiety, irritability,
Poor concentration, insomnia, enhanced startled response etc)
Intrusions (flashbacks, nightmares, Recurrent distressing Day dreams)
Avoidance of reminders of the events
(Place, person and activities), emotional detachment, numbness
Rule out co-morbidity, coping strategies
(Depression, anxiety, substance misuse etc)

152
Q

Areas to cover in dementia history taking

A 
• Mode of onset, duration and progression of the symptoms
• Ask in detail about cognitive, behavioural, psychological, physical and -
biological symptoms
• Risk assessment
• Past medical history
• Past psychiatric history
• Relevant personal history
• Relevant family history.
153
Q

Cognitive sx to explore in dementia history taking

A

Short term vs long term memory
Attention and concentration
Temporal and spatial - time of day, wandering, losing way home
Visuospatial/agnosia - recognising places and familiar faces
Nominal dysphagia - names of people
Language difficulties - way they speak, word-finding difficulties, understanding others
ADLs
Handling money
Planning and making decisions, everyday problems

154
Q

Behavioural sx to explore in dementia history taking

A

• Has there been any change in his behaviour like being more irritable than usual?
• Have you noticed any change in personality that seems to have occurred recently?
• Ask about becoming aggressive frequently, episodes of violent and anger outbursts
• Also enquire about behaving inappropriately, socially withdrawn, wandering at
nighttime, disinhibited behaviour, repetitive behaviours etc.

155
Q

Construct of dementia hx taking

A

Presenting problems: Onset, duration, severity and
progression
Impact on normal functioning
Memory & confusion- Short term and long term
memory impairment with examples
Orientation to time & place
Attention & concentration, Visuospatial
dysfunction
Language/communication difficulties, Recognition,
naming difficulties, Reading, writing etc
Functional abilities- simple ADLs (Personal ADLs )
Complex ADLs- Domestic ADLs & Community ADLs

Risk assessment-
self-neglect, wandering, aggression, non

compliance etc

156
Q

Risks in dementia station

A 
Self-neglect
Falls
Wandering
Self-harm
Non-compliance
Fires
Financial abuse
Aggression/others
Driving
Carer burnout
157
Q

Exploring wandering in dementia station construct

A

Identify specific behavioural problems- Nature, Mode of
onset, duration and progression of symptoms, Identify
triggers
Explore Psychiatric symptoms that could be causing these
problems – Depression/psychosis, dementia.
Rule out Physical problems- constipation, UTI, pain,
infection
Assess environmental factors and Change in social
environment

  1. New resident disturbing the patient
  2. Lack of stimulation and Regular visitors
    Other factors- Loss of mobility + loss of gardening activity,
    Lack of routines
    Structured activities at home to overcome boredom
    (Music, art, activity nurse, pet animals, bingo, games
    etc)
    Psychosocial interventions to improve quality of life
    (Reminiscence therapy/reality orientation)
158
Q

Construct for vascular dementia history taking

A 
Mode of onset, duration and progression of
symptoms
Further exploration of presenting
symptoms
(H/O Major strokes and TIAs)
Cognitive symptoms (Short term; long term
memory, Orientation, Intermittent
confusion)- Seek examples
Other areas of cognitive domains- Language
difficulties, Visuospatial difficulties,
recognition, reading, writing etc
Assess Functional abilities- ADL skills
Mood and Psychological Symptoms
(Depression, anxiety, paranoia, delusions,
hallucinations)
Physical Symptoms-
(Incontinence, gait disturbance, sensory &
Motor deficits, aphasia, Parkinsonian
movements)
Medical History (Diabetes, Hypertension,
Heart disease, high cholesterol etc) &
Medications
Personal and family history
Risk assessment (Falls, aggression,
wandering, Non-compliance, carer’ stress)
159
Q

Testamentary capacity criteria

A

It refers to the capacity to make a valid will.
The will may be legally valid if the testator is of “Sound disposing
mind” at the time of making it.
This depends on four legal criteria.
ü Whether the testator understands what a will is and what the
consequences are (Is ware of what a will constitutes)
ü Basic understanding of the nature and extent of the property.
(Knows the general extent of their assets)
ü He/she must be aware of the people who might reasonably
expect to benefit from the assets (should know the name of
close relatives and can assess their claims to the property)
ü He/She should be free from an abnormal state of mind and
must be free of delusional beliefs that might affect the
distribution of assets and must not be under the influence of
any drugs that tend to distort the patient’s mental capacity as
far as making a will is concerned.

CASC (16 decks)

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