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GP > GP Psychiatry > Flashcards

GP Psychiatry Flashcards

1
Q

Explain the difference between pathological and normal anxiety?

A

• Anxiety disorders are pathological in EXTENT – i.e. the anxiety is more extreme than normal and/or pathological in CONTEXT – i.e. anxiety is present in situations that are not “normally” anxiety provoking
• Anxiety disorders cause significant distress and impairment of social/ occupational/ other function
• The stress response: exposure to stress results in instantaneous and concurrent biological responses
• The amygdala acts as the emotional filter of the brain for assessing whether sensory material via the thalamus requires a stress or fear response (ms), this is modified by the later received cortically processed signal (i.e. act first, think later)
• In pathological anxiety there is an initial response and then cognition kicks in to perpetuate the response

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2
Q

Define generalised anxiety disorder?

A

• Anxiety that is generalized and persistent but not restricted to, or even strongly predominating in any particular environmental circumstances
• Persistent and chronic (fluctuating course)
• The anxiety is not about a particular thing but many things

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3
Q

What are the dominant symptoms and feelings patients may have in GAD?

A

• Dominant symptoms are variable but include complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness and epigastric discomfort
• Typically associated with restlessness or feeling keyed up or on edge, easily fatigued, difficulty concentrating or mind goes blank, irritability, muscle tension, sleep disturbance

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4
Q

What is the criteria to diagnose GAD?

A

• It is NOT due to any other disorder (i.e. they don’t have GAD due to hyperthyroid because if hyperthyroid is treated the anxiety gets better)
• Needs to be severe enough to be long lasting (most days for at least 6 months), not controllable and causing significant distress/ impaired function

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5
Q

What is the typical age of onset for GAD?

A

• Typical age of onset = 20-40 (it is odd for someone to present with GAD later and other causes should be ruled out)

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6
Q

Step Management for GAD?

A

Step 1 (for everyone): education, self help, active monitoring
Step 2 (for those not improved by step 1): low intensity CBT, self help, self help groups
Step 3 (GAD causing functional impairment/ not responded to step 2): high intensity CBT and/or drug treatment
Step 4 (refractory/ risk of self harm/ marked functional impairment): refer for highly specialised help

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7
Q

Define panic disorder? Explain how it differs from GAD?

A

• Essential feature is recurrent attacks of severe anxiety (panic) which are not restricted to any particular situation or set of circumstances and are therefore unpredictable
• The anxiety is more severe than GAD but is short lasting, and the person feels fine after the episode (this is in contrast to GAD where there is a constant level of background anxiety)

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8
Q

What are the dominant symptoms of panic disorder?

A

• Dominant symptoms: sudden onset chest pain, palpitations, choking sensations, dizziness and feelings of unreality, also secondary feelings of fear of dying, losing control or going mad

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9
Q

What is the most common type of anxiety disorder?

A

GAD

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10
Q

Management of panic disorder?

A

• In mild offer self help and education, next step is CBT, next is SSRI (or other antidepressant but SSRI is first line), then refer to mental health services if still not improving

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11
Q

Define agoraphobia?

A

• A fairly well defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places or travelling alone in trains, buses or planes

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12
Q

Symptoms/ signs of agoraphobia?

A

• Avoidance of the phobic situation is often prominent and some people with agoraphobia experience little anxiety because they are able to avoid their phobic situations
• Often involves other people, alcohol or technology to avoid anxiety e.g. others do shopping, drink before going out to overcome panic, internet shopping

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13
Q

Management of agoraphobia?

A

• CBT and exposure therapy is first line
• SSRIS/ SNRIS if needed
• Benzodiazepines are used short term only

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14
Q

Define specific phobias?

A

• A marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation e.g. flying, heights, animals, insects, blood

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15
Q

Signs/ symptoms of specific phobias?

A

Even talking about the phobia can cause distress
Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response akin to a panic attack
AnticipatoryAnxiety
The person generally has good insight – they are aware that the fear is excessive and/ or unreasonable

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16
Q

Management of specific phobias?

A

• Treatment is with behavioural therapy and graded exposure, add in CBT if necessary, SSRIs/ SNIRs if required can be helpful to augment behavioural therapy

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17
Q

Define social phobia/ social anxiety disorder?

A

• A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others
• Typically occurs in small social settings (vs agoraphobia which occurs in large crowds)

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18
Q

Signs/ symptoms of social phobia/ social anxiety disorder?

A

• Common anxiety symptoms are: blushing or shaking, fear of vomiting, urgency or fear of micturition or defaecation
• Tends to come on early in life resulting in poor school performance, school refusal and poor employment history

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19
Q

Management of social phobia/ social anxiety disorder?

A

• CBT is treatment of choice, may add SSRI/ SNRI, benzodiazepines short term only

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20
Q

Explain what OCD is?

A

• Recurrent obsessional thoughts and/ or compulsive acts
• Obsessional thoughts may be ideas, images or impulses entering themind in a stereotyped way, they are recognized as the patient’s own thoughts but are unpleasant, resistant and ego-dystonic (not in harmony with self)
• Involves repeated rituals, stereotyped behaviours, that are not enjoyable or functional and recognized as pointless

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21
Q

Criteria for OCD?

A

Obsessional symptoms or compulsive acts must be present most days for at least 2 weeks AND be a source of distress and interference with activities:
 Obsessions must be individuals own thoughts
 Resistance must be present
 Rituals are not pleasant
 Obsessional thoughts/ images/ impulses must be repetitive

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22
Q

Management of OCD?

A

CBT is the main treatment, then may add SSRIs

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23
Q

Explain why benzodiazepines should generally not be used in anxiety disorders?

A

• Benzodiazepines short term help with anxiety disorders but in general they should not be used as patients develop tolerance and they don’t help long term
• Most anxiety disorders are chronic conditions so patients will simply become reliant on them

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24
Q

What is depressive disorder? What groups tend to get it?

A

• Disorder where symptoms of unhappiness become qualitatively different and pervasive or interfere with normal functioning
• More than 50% of cases before age 30
• Onset is usually late 20s-30s

25
Q

Criteria for depressive disorder?

A

• The depressive episode should last at least 2 weeks
• There have been no hypomanic or manic episodes in the individual’s life
• At least 2 of the following 3 symptoms must be present:

1) Depressed mood
2) Loss of interest or pleasure
3) Decreased energy

• An additional symptom or symptoms from the following list should be present, to give a total of at least 4:

1) Loss of confidence
2) Guilt
3) Suicidal ideas or behaviours
4) Poor concentration
5) Agitation/ retardation
6) Sleep disturbance
7) Changes in appetite

26
Q

What is dysthymia?

A

• This is mild or moderate depressive illness that lasts intermittently for 2 years or more

27
Q

What is psychotic depression?

A

• This occurs in those with severe depression where thinking becomes psychotic (not everyone with severe depression will become psychotic though)
• Usually, hallucinations are within the theme of depression e.g. voices telling them they are a failure

28
Q

Mental State Exam in Depression?

A

• Appearance: slouching, tired, unkempt, disheveled
• Behaviour: upset or teary
• Speech: slowed down speech, monotonal, low volume, poverty of speech
• Mood: feeling low
• Affect: blunted, flattened, not responding much to what you are saying
• Thoughts: suicidal thoughts, thoughts of self harm, guilt, shame, thought blocking
• Perception: probably normal unless psychotic depression
• Cognition: poor concentration and memory, but most likely oriented in time place and person
• Insight: generally aware of how they are feeling

29
Q

What are the 2 screening questions for depression, that if answer yes prompts assessment for depressive illness?

A

During the last month, have you been bother by feeling down, depressed or hopeless? During the last month, have you been bothered by having little interest or pleasure in doing things?

30
Q

What are 2 depression scales?

A

PHQ-9 and Hospital anxiety and depression scale (HAD)

31
Q

Step wise management for depression?

A

1/ Education
2/ mild to moderate - talking therapy - CBT
3/ moderate and severe - medication and therapy - SSRI
4/ ECT for severe life and life threatening depression

32
Q

Do anti-depressants work instantly?

A

no - they need weeks of continuous administration to work so patients should be warned about this

33
Q

What is the first line antidepressant?

A

SSRIs
Escitalopram is probably the best all round SSRI but sertraline is also well established and has good cardiac safety profile and has easy dose titration
if patients do not feel effect from first antidepressant they should be switched to another SSRI

34
Q

How long should anti-depressants be continued after recovery in depression?

A

for first episode: antidepressant should be given for at least 6 months after full recovery without reducing the dose
for second episode: antidepressants should be continued for 1-2 years after complete recovery without reducing the dose

35
Q

What is dementia?

A

A clinical syndrome with multiple causes defined by:
- An acquired loss of higher mental function affecting 2 or more cognitive domains
- Being of sufficient severity to cause significant social or occupational impairment
- Being chronic and stable (different from delirium which is acute and fluctuating)

36
Q

What is the most common form of dementia?

A

Alzheimers

37
Q

What are the pathological hallmarks of Alzheimers?

A

amyloid beta protein plaques, intracellular neurofibrillary tangles, amyloid angiopathy, loss of neurons and synapses

38
Q

What groups tend to get alzheimers?

A

• Cause still isn’t known
• Thought to be both genetic and environmental influences
• Family history increases risk
• Presenilin 1 gene is associated with early onset

39
Q

Clinical features of Alzheimers?

A

• There is memory loss in early stages, initial symptoms are forgetfulness, progressive loss of ability to learn, retain and process new information
• Patients tend to lack insight into their disease
• As the disease progresses language becomes impaired, patients may suffer from apraxia (difficulty in carrying out skilled motor activities), agnosia (difficulty in recognising objects or people), loss of frontal executive function
• In contrast to other forms of dementia basic personality and social behaviour remain intact in Alzheimer’s disease until relatively late on

40
Q

Investigations for Alzheimers disease?

A

• Imaging can be normal in early stages
• MRI typically shows atrophy of temporal and parietal lobes
• SPECT shows temporoparietal decreased metabolism

41
Q

Management for Alzheimers disease?

A

• Should address vascular risk factors as AD and VD are closely interlinked
• Rivastigmine, galantamine or other cholinesterase inhibitors increase acetylcholine levels by inhibiting acetylcholinesterase. Patients with AD have a central cholinergic deficit. There is usually a small but significant improvement
• NMDA antagonist memantine is another drug option (NMDA receptors have some role in brain function)

42
Q

Prognosis of Alzheimers disease?

A

• Insidious onset with gradual progression over a decade sometimes longer

43
Q

Is FTD early or late onset?

A

early onset (before 65)

44
Q

Compare atrophy of lobes in AD vs FTD?

A

AD: temporoparietal
FTD: frontotemporal

45
Q

What disease is FTD related to?

A

MND and the C9ORF gene

46
Q

Clinical features of FTD?

A

• Frontal behavioural presentation: personality change, apathy, disinhibition, carelessness, stereotyped or compulsive behaviours
• There is an early loss of insight

47
Q

Difference in presentation of AD vs FTD?

A

FTD has behaviour changes as an initial presentation whereas AD behaviour changes are a late manifestation of disease

48
Q

Investigations for FTD?

A

• MRI shows atrophy of frontotemporal lobes and SPECT shows decreased frontotemporal metabolism

49
Q

Management of FTD?

A

• Mainly involves ensuring patient safety, occasionally antipsychotics are given to help with behavioural changes

50
Q

Is vascular dementia early or late onset?

A

late onset after 65yo

51
Q

Diagnostic criteria for vascular dementia?

A

presence of cerebrovascular disease plus a clear temporal relationship between the onset of dementia and cerebrovascular disease

52
Q

What dementia has a step wise progression?

A

vascular

53
Q

Clinical features of vascular dementia?

A

• There tends to be step wise progression
• Symptoms depend on the area affected

54
Q

Management of vascular dementia?

A

• Manage vascular risk factors, if there are AD features can give a cholinesterase inhibitor

55
Q

What are the pathological features of lewy body dementia?

A

• Dementia where pathology shows widespread neuronal loss and surviving neurons contain lewy bodies, known components of lewy bodies include alpha synuclein aggregates and ubiquitin

56
Q

What groups tend to get dementia with lewy bodies?

A

• This is related to Parkinsons disease, where it is Lewy Body dementia if dementia appears within 1 year of diagnosis or is the initial presentation
• There is a lot of overlap

57
Q

Clinical features of dementia with lewy bodies?

A

• It is characterised by the early feature of visual hallucinations, fluctuating cognition with variation in attention and alertness, sleep disorders, autonomic dysfunction and parkinsonism

58
Q

Investigations for dementia with lewy bodies?

A

• It is largely a clinical diagnosis but some people do get a DaT (type of SPECT scan that looks at dopamine)

59
Q

Management of dementia with lewy bodies?

A

• Treatment is similar to that of parkinsons
• Note: Parkinsons disease dementia refers to those who develop dementia > 1 year after PD diagnosis. DLB is dementia as presenting complaint or within a year of PD diagnosis.

GP (9 decks)

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