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phty2230 > L6: Organic Psychiatry > Flashcards

L6: Organic Psychiatry Flashcards

1
Q

What are 3 causes of organic mental disorders?

A
  1. Coarse brain disease
  2. Identifiable general medical conditions
  3. Intoxication and withdrawal from substances
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2
Q

What is dementia?

A

Syndrome characterised by an appreciable deterioration of cognition in an alert person

It results in impaired performance of daily activities

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3
Q

How common is dementia?

A

5% of persons

> 65 years have moderate or severe dementia 20% of persons

> 80 years have moderate or severe dementia

Prevalence doubles approximately every 5 years after the age of 60 years

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4
Q

What are 5 reasons why to investigate cognitive decline?

A
  1. 10-20% of patients with dementia have a potentially reversible condition e.g. hypothyroidism
  2. Intercurrent medical problems are common
  3. Benchmark for future comparison (CT head)
  4. Baseline normal values prior to treatment (haematology & biochemistry)
  5. * No correlation between cerebral atrophy on CT and cognitive function
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5
Q

What are 5 characteristics of hypothyroidism?

A
  1. Weight gain
  2. Bradycardia
  3. Ankle jerks
  4. Dry skin
  5. Cognitive decline
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6
Q

What are 4 causes of dementia?

A
  1. Alzheimer’s Disease 60 % of cases
  2. Cerebrovascular Disease 5-20% of cases
  3. Mixed AD & CVD
  4. Other e.g. Parkinson’s disease, brain tumor, HIV, head injury, hypothyroidism, neurosyphilis, hydrocephalus
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7
Q

What are 5 risk factors for AD?

A
  1. Old Age
  2. Family
  3. History of AD
  4. Down’s Syndrome
  5. Apolipoprotein E - allele 4
  6. Less education?
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8
Q

Alzheimer’s Disease focuses on _____, ______ and _____ lobes

A

frontal; temporal; parietal

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9
Q

What are 3 characteristics of the clinical picture of dementia?

A
  1. Gradual deterioration
    • Usually obvious in physios and other members of society compared to family members
  2. Disease is subtle
    • Occurs over a few months to a few years
  3. Gradual decline after one or more clinical events is common e.g. pneumonia, fractured hip
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10
Q

What are 3 changes in dementia?

A
  1. Cognition
  2. Level of functioning
  3. Personality and behaviour
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11
Q

What are 7 characteristics of decreased cognition in dementia?

A
  1. Loss of recent memory - progresses to involve more remote memories
  2. Overlearned tasks are preserved
  3. Language - difficulty with word-finding
  4. Calculation, handling money
  5. Comprehension of written material
  6. Recognition of people
  7. The capacity to reason, learn new information and solve problems is gradually lost
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12
Q

What are 3 characteristics of the level of functioning in dementia?

A
  1. Impaired ability to perform personal care tasks
  2. Reduced capacity to perform activities of daily living
  3. Reduced capacity to engage in social activities
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13
Q

What are 6 characteristics of personality and behaviour in dementia/

A
  1. Indifference or regression (filters out nasty comments)
  2. Unable to change behaviours
  3. Lack of insight Impaired planning and judgment
  4. Agitation, aggression, restlessness, wandering
  5. Hallucinations, delusions
  6. False unshaken belief
    • Eg. wife is having an affair (completely refractory) Disturbances of sleep
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14
Q

What are 12 characteristics of vascular dementia?

A
  1. Abrupt onset
  2. Stepwise deterioration
  3. Fluctuating course
  4. Nocturnal confusion
  5. Relative preservation of personality
  6. Depression and emotionality
  7. Somatic complaints
  8. History of hypertension
  9. History of strokes
  10. Evidence of associated atherosclerosis
  11. Focal CNS symptoms
  12. Focal CNS signs
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15
Q

What are 6 risk factors for vascular dementia?

A
  1. Old Age
  2. Family History of Dementia or Stroke
  3. High Blood Pressure
  4. Low levels of High Density Lipoprotein Cholesterol (HDLC)
  5. Tobacco Smoking
  6. Alcohol Abuse
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16
Q

What are 5 dementia-related behaviour problems?

A
  1. Wandering
  2. Agitation
  3. Inappropriate sexual behaviour
  4. Delusions occur in 30-57% of patients with AD
  5. Hallucinations in 10-28% of patients
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17
Q

What are 5 causes of behaviour problems in dementia?

A
  1. 50% of dementia patients have at least one co-existing medical illness
  2. Sensory impairment
  3. Medication
  4. Psychiatric illness
  5. Environmental and social factors

Consider behaviour as communication

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18
Q

How does medication act as a behaviour problem?

A
  • Takes longer to excrete medication in an older person
  • Half life = amount of time taken to excrete half of drug
  • Half life in an adult = 24 hrs
  • Half life in an 80 year old = 80 hrs Eg. taking valium
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19
Q

What are 4 characteristics of “Acute Confusional State” in delirium?

A
  1. Usually transient (In end of life = can be permanent) disturbance of attention and cognition
  2. Abnormal psychomotor behaviour
  3. Altered sleep-wake cycle
  4. 16-35% of elderly inpatients have delirium on admission to hospital or develop delirium within three days
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20
Q

What are 7 clinical features of delirium?

A
  1. Clouding of consciousness
  2. Impairment of attention and memory
  3. Psychomotor agitation (1/3 of patients) or retardation ( 2/3 of patients)
  4. Abnormal affect or mood
  5. Hallucinations, delusions (Sometimes can be very lucid)
  6. Disorganised thinking
  7. “Sundown” effect
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21
Q

What are 6 reasons of why delirium has clinical significance?

A
  1. Common condition, but often misdiagnosed
  2. High mortality (~ 20%)
  3. Presenting clinical syndrome of serious physical illness
  4. May lead to self-harm or dangerous behaviour
  5. Recalled as a distressing experience by at least half of patients
  6. May be mistaken for other conditions
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22
Q

Delirium shows that the body is extremely ____. Everyone can have delirium but with a ____ (larger/smaller) brain in older people, there is ____(more/less) reserve. If a young person has delirium, they are very ____.

A

sick; smaller; less; sick

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23
Q

What are 8 causes of delirium?

A
  1. Brain disease or systemic disease affecting the brain
  2. Intoxication or withdrawal (esp. alcohol)
  3. Dehydration
  4. Drugs - prescribed or illicit (including withdrawal) Infection
  5. Electrolyte imbalance Na = 112g –> clouding of consciousness
  6. Malignancy (disease process and treatment)
  7. Endocrine
  8. Cerebral reserve
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24
Q

What are 7 features of management in delirium?

A
  1. Recognition and treatment of the cause
  2. Maintenance of intake, electrolyte balance etc.
  3. Ensure safety of patient and staff
  4. Consistent, low-stimulus environment with familiar staff, objects
  5. Night lighting
  6. Low-dose haloperidol or risperidone
  7. Alcohol Withdrawal Scale to titrate diazepam if alcohol withdrawal (plus thiamine)
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25
Q

What is a TBI?

A

“a blow or other force to the head which results in damage to the brain or alteration in brain function”

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26
Q

What is the CGS for a severe TBI criterion?

A

3-8

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27
Q

What are 3 characteristics of a severe TBI criterion (GCS 3-8)?

A
  1. Only opens eyes in response to a voice
  2. Cant talk coherently
  3. Flexes in response to pain
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28
Q

What are 3 most common causes of TBIs?

A
  1. Falls 42%:
    • Females > males
    • High mortality in older persons
  2. Transportation 29%:
    • Direct trauma
    • Shearing forces/deceleration
  3. Assault 14%:
    • Males: females = 5:1
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29
Q

How long is post traumatic amnesia in a very mild TBI?

A

Less than 5 minutes

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30
Q

How long is post traumatic amnesia in a mild TBI?

A

Between 5-60 minutes

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31
Q

How long is post traumatic amnesia in a moderateTBI?

A

Between 1-24 hours

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32
Q

How long is post traumatic amnesia in a severe TBI?

A

Between 1-7 days

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33
Q

> 90% of patients reach final level of functioning within _____ months of injury

A

6

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34
Q

If severely disabled at ______ months unlikely to have good recovery

A

3

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35
Q

What are 5 characteristics in early phase of delirium?

A
  1. Disorientation
  2. Memory disturbance
  3. Mis-identification of family, friends, health professionals
  4. Restlessness and agitation or aggression
  5. Hallucinations or delusions
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36
Q

In TBIs, Mobility not typically a problem for ___%

A

75

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37
Q

In TBIs, ____% had problems with cognition, communication, behaviour and emotions

A

60

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38
Q

In TBIs, up to 70% returned to driving by _____ years

A

5

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39
Q

In TBIs, ~40% required more _____ than before their injury

A

support

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40
Q

In TBIs, only half returned to previous _____ activities

A

leisure

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41
Q

In TBIs, fewer than _____% of those employed at the time of the injury were in work at 10 years

A

50

42
Q

What are 4 cognitive changes with a TBI?

A
  1. Capacity to concentrate
  2. Use of language
  3. Abstraction, calculation
  4. Reasoning, processing of information
    • May be subtle, but have a major impact on rehabilitation
43
Q

What are 7 personality changes with a TBI?

A
  1. Common but not inevitable
  2. A significant burden for families
  3. If marked, are almost always associated with cognitive changes
  4. Reduced capacity to engage in relationships
  5. Inflexibility
  6. Tiredness, lack of interest
  7. Specific changes e.g. frontal lobe syndrome/executive dysfunction This is what distresses family the most!
44
Q

What are 3 characteristics of executive dysfunction with TBI?

A
  1. Planning
  2. Self-correct
  3. Organise
45
Q

What are 3 characteristics of social behaviour with TBI?

A
  1. Lack of self-monitoring
  2. Insensitivity
  3. Unawareness of subtle social messages
46
Q

What are 3 characteristics of impaired control with TBI?

A
  1. Impatience
  2. Easily frustrated
  3. Sexual disinhibition
47
Q

What are 4 behavioural problems with TBI?

A
  1. Social behaviour
  2. Impaired control
  3. Irritability and/or aggression
  4. Dependency
48
Q

What are 4 emotional problems with TBI?

A
  1. Anxiety
  2. Loss of confidence, loss of control, status and dignity
  3. Depression
  4. Suspiciousness and paranoia - compounded by fear of rejection and sense of incompetence
49
Q

What is a catastrophic reaction?

A

Overwhelming reaction to being challenged beyond capacity

50
Q

What are 7 management strategies of a TBI?

A
  1. Routine and consistency
  2. Reduce stresses imposed
    • Reduce burden on a fragile brain (eg. if patient likes coffee not tea –> don’t ask which one –> make coffee)
  3. Clear simple instructions - repeat as necessary
  4. Convey honest expectations which are realistic
  5. Recognise lowered self-esteem - preserve dignity
  6. Role of medication
  7. Try not to take insults personally!
51
Q

What is pain?

A

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage Pain is not solely a biological thing, it has emotional consequences –> affects the patient’s reactions and able to deal with pain

52
Q

What are 3 external factors shaping chronicity and disability?

A
  1. Factors related to type of trauma or disease
  2. Social adversity - cumulative stressful life events depleting emotional reserves
  3. Compensation
53
Q

What are 7 factors relating to the individual shaping chronicity and disability?

A
  1. Vulnerability depends on personal and social context - what is the meaning of this pain for this individual?
  2. Personality style e.g. dependent
  3. Culture and family experiences
  4. Physical and sexual abuse
  5. Capacity to express feelings - controversial
  6. Relationships
  7. Fear and avoidance play a significant part in the maintenance of chronic pain
54
Q

What are 3 psychiatric aspects of pain?

A
  1. Those with chronic pain are often distressed and seeking an answer
  2. Appraisal by health professionals may fail to explore the extent of suffering and functional disability
  3. 30 - 40% of patients attending pain clinics have depression which can often be effectively treated
55
Q

What are 6 management issues for chronic pain?

A
  1. Pain is a subjective experience
  2. It may represent an expression of distress
  3. Chronic pain affects attitudes and beliefs
  4. Attitude of health professionals (our own fantasy of rescue vs. punishment)
  5. Beware co-morbidity e.g. alcohol, benzodiazepines, doctor-shopping
  6. Coping not cure - setting realistic goals
56
Q

What is negative reinforcement?

A
  • Had a dog in a box –> gave electric shock
  • Ring a bell before shock
  • Move to other side of box
57
Q

What is learned helplessness?

A
  • Has a fence
  • Ring the bell –> tries to move but fence in the way
  • Has an electric shock
  • Removes fence
  • Rings bell
  • Dog no longer moves to the other side despite not having a fence This can be the same with people
  • Meet people who haven’t succeed in life –> why bother? Given up
58
Q

What is pain, disparity, chronic pain, setting goals?

A
  • Pain
    • Performance drops
  • Disparity
    • Determinant of happiness
  • Chronic pain
    • Trying to get back to normal through smaller and more achievable short term goals
  • Setting goals
  • About patient and physio
    • Let go of what you would do and think of what they can achieve (eg. be more empathetic)
59
Q

What are 6 clinician barriers to comprehensive care with chronic pain?

A
  1. Concern about inadequate skills to explore psychosocial issues
  2. Concern about “opening a Pandora’s box”
  3. Comparing patient responses to adversity (unfavourably) with one’s own, and considering them to be “not coping” vs. depressed
  4. Too close to home
  5. Belief that “just listening” is not a valid role that has any benefit
  6. Being more interested in “urgent” or more “interesting” cases
60
Q

What are 8 ways to identify anxiety and depression?

A
  1. Tendency to disregard distress as an “understandable” reaction to illness or disability
  2. Reluctance to explore emotional adjustment
  3. Patient grief resonates with personal grief about our own past losses
  4. Major health problems in ourselves or loved ones
  5. Fear of being overwhelmed
  6. Unrealistic expectations of performance
  7. Lack of self-awareness, knowledge or training about psychological issues
  8. “Compassion fatigue”
61
Q

What are 3 characteristics of reluctance to explore emotional adjustment?

A
  1. Listening is a difficult task for health professionals who are primarily inclined to act
  2. Fear of making things worse
  3. Belief that nothing can be done
62
Q

What are 4 characteristics of an adjustment disorder before it is depression?

A
  1. An emotional reaction with depressed or anxious mood (not severe)
  2. In relation to a defined event
  3. Does not cause major disruption to social and occupational functioning and relationships
  4. Expectation of resolution with time to a new level of functioning Emergence of suicidal ideation means depression until proven otherwise
63
Q

What are 4 characteristics of depression?

A
  1. Depressed mood - note persistence and severity of depressed mood
  2. Impaired capacity for pleasure
  3. Cognitions - negative view of oneself, the environment and one’s future (“What’s the point, nothing will make a difference”)
  4. Associated disturbances in sleep, appetite, energy, motivation, attention and concentration, libido
64
Q

What are 9 clinical features of depression? (5/9)

A
  1. Depressed mood most of the day
  2. Diminished interest or pleasure
  3. Significant weight loss or gain
  4. Insomnia or hypersomnia every day
  5. Psychomotor agitation or retardation
  6. Fatigue or loss of energy every day
  7. Feelings of worthlessness, guilt
  8. Impaired concentration Thoughts of death
65
Q

What are 5 characteristics to distinguishing depression from adjustment disorder?

A
  1. Weigh up risk factors for depression
  2. Look at quality and severity of mood disturbance - pervasively impaired capacity for pleasure suggestive of depression
  3. Look at persistence of symptoms
  4. Emergence of guilt, worthlessness, helplessness and hopelessness typical of depression
  5. Diurnal mood variation and early morning waking more typical of depression
66
Q

What are 10 factors for depression relating to the person?

A
  1. Younger
  2. Female
  3. Single, separated, divorced or widowed
  4. Living alone
  5. Lack of social support
  6. Having dependent children
  7. Economic adversity
  8. Poor marital or family functioning
  9. History of psychiatric illness
  10. Cumulative stressful life events
  11. History of alcohol or other drug abuse
67
Q

What are 8 factors relating to the disease (depression)?

A
  1. At the time of diagnosis or recurrence
  2. During advanced stage of disease
  3. Poorer prognosis
  4. More treatment side-effects
  5. Greater functional impairment and disease burden
  6. Experiencing lymphoedema
  7. Experiencing chronic pain
  8. Fatigue
68
Q

What is the pathway to depression in medical illness?

A
69
Q

What are the 4 characteristics of depression?

A
  1. Biological
  2. Cognitive
  3. Dynamic
  4. Psychosocial
70
Q

What are 3 observations (emotional cues) for depression?

A
  1. Low, flat, sad mood
  2. Slow movements / expressionless face
  3. Tearfulness
71
Q

What are 7 aspects of history (emotional cues) for depression?

A
  1. Loss of interest and pleasure
  2. Social withdrawal
  3. Loss of motivation; feelings of futility about treatment
  4. Feelings of hopelessness
  5. Feelings of guilt or worthlessness
  6. Sense of being a burden on others
  7. Suicidal thoughts /wish to hasten death
72
Q

Context : Discussing psychosocial issues with a patient with known depression

Verbal Cue : “I just don’t see the point in going out anymore. I’m tired, and I just don’t have anything to say to my friends.”

Non -Verbal Cue : Dejected voice. Little eye contact.

What are 2 blocking responses?

A

Trying to fix/jolly the patient along:

“It’s really important you keep yourself busy. You really should try to get out more. It’ll be good for you.”

“Well of course you won’t beat the cancer unless you have a positive attitude.”

73
Q

Context : Discussing psychosocial issues with a patient with known depression

Verbal Cue : “I just don’t see the point in going out anymore. I’m tired, and I just don’t have anything to say to my friends.”

Non -Verbal Cue : Dejected voice. Little eye contact.

What are 2 facilitating responses?

A

Open questions. Expression of concern. Discussion of referral:

“I’m concerned about you. This depression is really hard and it might be useful if we can talk with the doctor about how we can help.”

“I know you feel stuck right now, but I am confident that treatment will help you get beyond this awful feeling.”

74
Q

What are 6 responses to depression?

A
  1. Explore emotions/symptoms
  2. Ask about thoughts of self-harm/suicide
  3. Emphasise that depression is treatable
  4. Suggest that the patient be referred to a specialist in psychosocial matters
  5. Arrange referral
  6. Continue to monitor
75
Q

What are 6 features of making a referral for depression?

A
  1. Normalise emotions - they’re not going crazy!
    • “A lot of people in your situation describe feeling like this”
  2. Discuss value of support:
    • “It can really help to talk to a professional who understands”
  3. Check their understanding of psychological support services and how they feel about the referral:
    • “To make sure that I have explained everything clearly, can you tell me what you have understood about the role of the psychologist?”
  4. Emphasise that multi-disciplinary support is commonplace / normal practice:
    • “We work as a team, and your emotional well- being is an important part of your care”
  5. Focus on enhancing well-being
  6. Emphasise benefits to patient and family:
    • “You and your family don’t have to go through this on your own. We’re here to support you.”
76
Q

What are 5 reasons for treating depression?

A
  1. Reduce the suffering of the patient
  2. Reduce the risk of suicide - 2/3 of all suicides committed by people who are depressed
  3. Suicide risk compounded by comorbid anxiety
  4. Improve coping with disease burden
  5. Improve outcome for children - a depressed parent one of the strongest predictors for depression
77
Q

What are 5 characteristics of depression and medical outcomes?

A
  1. Increased mortality
  2. Morbidity
  3. Depression appears to be a more common pathway to alcohol abuse for women:
    • Note lower rates of detection of alcohol abuse in women
  4. Past or current depression associated with decreased bone density in women
  5. Reduced ability to cope with burden of disease
78
Q

What are 4 predictors of time at full depression?

A
  1. Female
  2. Greater index severity
  3. Greater index anxiety
  4. Prior episodes of depression
79
Q

______ is conceptualised as a relapsing/chronic illness

A

Depression

80
Q

What is treatment adherence?

A

 Odds are 3 times greater that depressed patients will be noncompliant with medical treatment recommendations DiMatteo et al 2  Patients who are depressed are less likely to accept adjuvant chemotherapy

81
Q

What are 8 static suicide risk factors?

A
  1. Male
  2. Age (15-29 and >75 years)
  3. Living alone
  4. Single, widowed, separated
  5. Past self-harm
  6. Family history of suicide
  7. Alcohol or substance abuse
  8. Chronic medical illness
82
Q

What are 5 dynamic suicide risk factors?

A
  1. Current depression (esp. guilt)
  2. Access to means
  3. Hope for the future
  4. Recent experience of loss or grief
  5. Shame/humilliation
83
Q

What are static and dynamic risk factors?

A
84
Q

What are 4 treatment of depression?

A
  1. Combination of supportive psychotherapy, cognitive and behavioural techniques and antidepressant medication
  2. Selection of medication according to symptoms, medical status and potential for drug interactions
  3. SSRIs and TCAs superior to placebo for treatment of depression in medically ill
  4. No consistent evidence that SSRIs associated with increased risk of suicide
85
Q

What are 6 characteristics of psychotherapy?

A
  1. Opportunity to talk about concerns and be offered support and information
  2. Being able to talk about grief, fear and anger
  3. Relaxation techniques, guided imagery
  4. Help with problem-solving
  5. Learning not to look at things in black and white
  6. Opportunity to reflect on priorities and values
86
Q

What are 6 alternative treatments for depression?

A
  1. St John’s Wort
  2. Folate
  3. Relaxation
  4. Fish oil
  5. Acupuncture
  6. Exercise
87
Q

What are 7 characteristics of St John’s Wort?

A
  1. Hypericum perforatum - 300 species
  2. Inhibits uptake of serotonin, noradrenaline and dopamine
  3. Has high concentrations of melatonin
  4. More effective than placebo for mild to moderate depression
  5. Most trials lasted 4-8 weeks
  6. Comparisons with antidepressants failed to use appropriate doses of antidepressants
  7. Low incidence of side-effects
88
Q

What is folate?

A

Some evidence that may be a helpful addition to antidepressant treatment

89
Q

What is relaxation?

A

Better than no treatment or minimal treatment but not as effective as treatments such as CBT

90
Q

What is fish oil?

A

Insufficient evidence currently to advocate benefit

91
Q

What is acupuncture?

A

Insufficient evidence of effectiveness

92
Q

What are 3 characteristics of exercise?

A
  1. Some evidence of effectiveness in reducing depressed mood in women with breast cancer
  2. Cochrane Review:
    • Analysis of 25 trials demonstrated benefit of exercise
    • More rigorous methodology reveals a moderate, non-significant effect
    • Insufficient detail about the amount or type of exercise required
  3. Mechanism by which exercise might improve mood is unclear - emerging suggestions of reduction in inflammation and oxidation via cellular and humoral neuroimmunological changes
93
Q

What are the risk of recurrence/

A

 50% for one episode  70% for two episodes  90% for three episodes

94
Q

For those with residual symptoms - risk that the lowered mood is seen by patients, their family and health professionals as “______” and patient fails to seek treatment

A

normal

95
Q

What are 4 key messages about depression?

A
  1. It is too important to miss
  2. You don’t have to fix it - refer to someone who does this for a living!
  3. You need to have a defined referral pathway, including what to do if you feel really stuck
  4. You need to have a repertoire of things you can say to patients to encourage them to accept referral
96
Q

How do we improve the detection of depression?

A

Include attention to psychosocial issues in routine clinical practice so that patients see it as part of comprehensive care

97
Q

What are 3 ways to the patient know important things?

A
  1. The emotional impact of medical illness is often significant
  2. Feeling stressed at times is normal
  3. If this is affecting the person on a daily basis, affecting relationships or interfering with social or occupational functioning, something needs to be done
    • “You don’t have to suffer in silence”
    • “I can imagine that things might be pretty tough for you emotionally with all of this going on”
    • “Gosh you look worn out! Come and tell me about how you are” “I might be wrong, but I thought you looked hassled”
98
Q

What are 2 specific questions to ask about mood?

A
  1. “During the past month have you often been bothered by feeling down, depressed or hopeless?”
  2. “During the past month have you often been bothered by little interest or pleasure in doing things?”
99
Q

What are 7 atypical presentations of depression?

A
  1. Poor capacity to tolerate symptoms
  2. Irritability
  3. Increased complaints of pain
  4. Alcohol or other substance abuse
  5. Non-compliance with treatment recommendations
  6. Difficulty making decisions
  7. Negative cognitions: “Why bother?”
100
Q

What are 3 roles of the physiotherapist?

A
  1. Recognition of the multiple factors which influence outcome
  2. Awareness that the presentation, clinical course and outcome of few conditions are unaffected by emotional factors
  3. Understanding of the functioning of multidisciplinary teams and the role of members working collaboratively to help patients achieve the best possible outcome

phty2230 (24 decks)

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