Laz Psych Histories Flashcards
1
Q
differential diagnosis of normal bereavement
A
- depression
- adjustment disorder
- substance misuse
- BPAD
2
Q
Investigations for normal bereavement
A
- PHQ9 to assess baseline level of depression
- investigations for physical causes: FBC (anaemia), TFTs, cortisol
3
Q
management of normal bereavement
A
- assess risk
- grief counselling
- offer support helplines (e.g. Samaritans, Campaign Against Living Miserably (CALM - only for men)
- CBT
- Antidepressants (SSRIs e.g. sertraline)
- IAPT
4
Q
what are some features of abnormal grief?
A
- extreme/ intense (disabling)
- lasting >6 months
- delayed
5
Q
what are some physical causes of depression?
A
- Cushing’s syndrome
- Hypothyroidism
- Addison’s disease
- Dementia
- Head injury
- Stroke
- MS
6
Q
what are some cognitive symptoms of depression?
A
- selective memory for negative events
- pathological guilt
- feeling of guilt about being a burden on others
- pessimism
7
Q
what are the components of Beck’s cognitive triad?
A
- Negative views about the self (worthless)
- Negative views about the world (helpless)
- Negative views about the future (hopeless)
8
Q
Features of Lewy Body dementia
A
- confusion (mixing up names etc)
- falls
- hallucinations
- fluctuating
9
Q
potential other differentials for Lewy Body dementia
A
- vascular dementia
- Alzheimer’s disease
- derlirium
- pseudodementia
10
Q
investigations for Lewy Body Dementia
A
- physical exam: resting tremor, cogwheel rigidity in wrist
- AMTS: 5/10
- MMSE: 21/30
- FBC, U&Es, glucose, TFTs (NAD)
- CT/ MRI (mild atrophy)
11
Q
management of lewy body dementia
A
- adaptations for patient (with an OT): reality orientation, environmental modifications
- social support/ support carers
- optimising physical health (review meds)
- psychological therapies (e.g. reminiscence therapy)
- Acetylcholinesterase inhibitors may provide symptomatic relief
- Parkinsonian symptoms can be treated with Parkinson’s drugs but this can make hallucinatiosn worse
12
Q
reversible causes of dementia
A
- brain (subdural haematoma, SOL, NPH)
- endocrine (Addison’s, Cushing’s disease)
- Vitamin deficiency (B12, folate, thiamine (Wernicke’s), niacin (pellagra)
- Neurosyphilis
13
Q
key differences between between DLB, AD and VD
A
- VD has stepwise decline, DLB and AD has a more gradual decline
- AD has insidious onset, VD is sudden and DLB varies
- DLB causes parkinsonism, hallucinations and syncope
- short term memory is less affected than in VD and AD
14
Q
risk factors for VD
A
- vascular risk factors (CVD, HTN, high cholesterol, diabetes)
15
Q
CT changes in AD, VD and DLB
A
AD - gernealised atrophy
DLB - mild atrophy
VD - multiple lucencies
16
Q
name a congenital condition that increases the risk of developing AD
A
Down syndrome
17
Q
differential diagnoses for anorexia nervosa
A
- bulimia nervosa
- physical cause (e.g. hyperthyroidism, GI disease)
- depression
- eating disorder not otherwise specified
- body dysmorphic disorder
18
Q
investigations in anorexia nervosa
A
- physical exam: emaciated, lanugo hair, very thin
- height and weight, BMI
- squat test: difficulty standing from squatting without help
- TFTs (NAD)
- FBC: low Hb
19
Q
management of anorexia nervosa
A
- speak to child directly and figure out stressors
- explore the possibility of OCD
1st: Anorexia-focused family therapy
2nd: ED-CBT - other options: specialist supportive clinical management (SSCM), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
- treat co-morbid OCD if necessary: education and self help, ERP
20
Q
how do you counsel a patient with anorexia nervosa
A
- condition characterised by restriction of energy intake leading to low body weight, an intense fear of gaining weight and a disturbance in the way an individual perceived their body shape/weight
- this can lead to several physical health problems so want to help you get to a healthy weight
- involve attending anorexia-focused family therapy (involved showing you how you can support your daughter in returning to normal pattern of behaviour)
- also possible to have some features of OCD (obsessions and compulsions) which is something we’d like to explore further and see whether treatment is necessary
21
Q
difference between anorexia nervosa and bulimia nervosa
A
bulimia is characterised by periods of bingeing followed by purging (using laxatives, forced vomiting, diuretics)
22
Q
physical complications of anorexia nervosa?
A
23
Q
physical complications of anorexia nervosa
A
- bradycardia and hypotension (risk of sudden death)
- GI upset (constipation, abdo pain, ulcers)
- amenorrhoea and infertility
- osteoporosis
- peripheral neuropathy
24
Q
medical causes of weight loss
A
- hyperthyroidism
- malignancy
- GI diseasse (e.g. coeliac disease)
- Addison’s
25
mortality rate of anorexia nervosa
10%
26
when might inpatient treatment of anorexia nervosa be needed?
- BMI < 13 or rapid weight loss
- serious physical complications
- high suicide risk
- MHA may be used to enforce compulsory feeding
27
Paranoid schizophrenia features to ask about
- auditory hallucinations
- visual hallucinations
- delusional beliefs and thought disorder
- risk
- insight
28
investigations to investigate paranoid schizophrenia
- physical exam: assess baseline, rule out organic causes
- FBC, TFTs, U&Es and glucose
- lipids: before starting anti-psychotics
- urine drugs screen
29
differential diagnosis of paranoid schizophrenia
- substance misuse
- FEP
- mood disorder
30
management of paranoid schizophrenia
- biopsychosocial model
- biological therapies: antipsychotics
- psychological therapies: CBT, family therapy, concordance therapy
- social interventions: admission, social skills training, education, mood disorder
31
how would you counsel a schizophrenic patient?
- voices you are hearing and feelings you have been feeling are due to an imbalance in the chemicals in your brain
- normally when you see something in life it will trigger a change in chemicals in your brain to help you understand what is going on
- if chemicals are unbalanced, it can cause you to see/ hear things that other people don't see and hear
- can give medication that can help balance these chemicals and make these symptoms go away
32
what is the MOA of atypical antipsychotics?
blocks dopamine receptors and serotonin receptors
33
side effects of anti-psychotics
- extra-pyramidal: dystonia, akathisia, parkinsonism, tardive dyskinesia, hyperprolactinaemia (galactorrhoea)
- weight gain
- sedation
- dyslipidaemia
34
what are Schneider's First-Rank Symptoms?
- delusional perception
- passivity
- delusions of thought interference (insertion, withdrawal, broadcasting)
- auditory hallucinations (thought echo, 3rd person voices, running commentary)
35
what is schizoid personality disorder?
- lack of interest in social or intimate relationships
- difficulty with expressing emotions
- prefer solitary lifestyle
36
differential diagnoses for delirium
- FEP
- intoxication
- dementia
- if taking steroids = steroid induced psychosis
37
management of delirium
- admit: delirium fluctuates so even if they are lucid right now, they could deteriorate if they go home
- identify source of infection (CXR, stool culture) or cause of delirium
- treat cause
38
define delirium
acute confusional state resulting from physical cause e.g. infection
39
name some drugs that can cause psychosis
- steroids
- ethambutol
- cannabis
- cocaine
40
Management of OCD
- 1st: CBT
| - 2nd: SSRI (usually at high dose)
41
how do you counsel someone with OCD?
the symptoms described are suggestive of OCD, have you heard much about this before?
it is a condition in which you have recurrent intrusive thoughts to do something and it can really disturb your life
This can be managed using something called CBT (explain CBT)
42
what are the key differences between an obsession and a delusional belief?
- thoughts are identified as your own
- thoughts are repetitive and intrusive
- evidence of resistance by the patient (as least in early stages)
- signs of avoidance
43
co-morbidities associated with OCD
- depression
| - eating disorders
44
investigations for OCD
physical exam (get idea of baseline state and rule out organic causes)
PHQ9 and GAD7 to assess baseline
admit pt if think they are at high risk of suicide
45
management of depression
Biopsychosocial
Biological: SSRI - follow up closely and explain that they take time to work
Psychological: CBT or psychodynamic therapy
Social: recommend taking part in more activities day day, occupy time with stimulating activities
46
main symptoms of depression
- anergia
- anhedonia
- low mood
- sleep change
- appetite change
- concentration change
- memory deficits
47
list 3 classes of anti-depressants and give an example of each
- SSRI: sertraline, citalopram, escitalopram, fluoxetine
- SNRI: duloxetine, venlafaxine
- NaSSA: mirtazapine
- TCA: imipramine, amitriptyline
48
how might the treatment be different if the patient has psychotic depression?
- start anti-psychotic (e.g. quetiapine) alongside anti-depressant
49
how is psychosis in depression different from psychosis in schizophrenia?
- psychosis is mood congruent in psychotic depression
| - psychosis tends not to be mood congruent in schizophrenia as patients have blunted affect
50
investigations in GAD
- GAD7 questionnaire to assess baseline state
51
differential diagnosis for GAD
- substance misuse (caffeine)
- depression
- anxious personality disorder
- hyperthyroidism
52
management of GAD
1st: CBT + self help methods, encourage reliance on supportive contacts, problem-solving (to help identify and deal with stressors)
Propranolol is CONTRAINDICATED (because of asthma) but relaxation techniques and breathing exercises may be helpful
53
pharmacological treatment for GAD
1st: SSRI (e.g. sertraline) - usually required higher doses (200mg), takes longer to act (6-8 weeks)
2nd: taper SSRI and switch to SNRI (e.g. venlafaxine)
3rd: add pregabalin
4th: quetiapine (off label)
54
support charity for GAD
mind.co.uk
55
how long do SSRIs take to act in GAD?
6-8 weeks
56
what's the difference between GAD and panic disorder?
- GAD is not triggered by specific stimulus, it is continuous and generalised
- Panic disorder is characterised by sudden attacks of extreme anxiety lasting <30 minutes and relatively free of anxiety in between attacks
57
what is agoraphobia?
fear of being unable to easily escape to a safe place (usually home)
58
fear of social phobia
fear of being scrutinized or criticized by other people
59
what is the prognosis of anxiety disorders?
1/3 recover completely
1/3 improve partially
1/3 fare poorly and suffer considerable disability
60
differential diagnoses of PTSD
- anxiety disorder
- depression
- adjustment disorder
61
management of PTSD
1st: Trauma focused CBT (trauma can shatter previous belief systems, these new beliefs can be examined and tested, helps pt to understand link between current feelings and trauma)
Adjunct: SSRI (helps with sleep and low mood)
2nd line: EMDR
62
how you counsel a patient with PTSD
PTSD is a condition that occurs after someone has gone through a major traumatic event
it is characterised by episodes where you feel like you are vividly reliving the trauma as well as times when you feel like you're particularly anxious/ high alert
can affect your behaviour e.g. avoid anything that may trigger you to feel all these emotions again
63
cardinal features of PTSD
- flashback and reliving
- hyperarousal
- avoidance
64
what is adjustment disorder?
a person's reaction to life changes that require adaptation to cope (e.g. moving to uni) is greater than usually expected
not severe enough to diagnose disorder or depression
65
physical manifestations of anxiety
tremor
palpitations
sweating
hyperventilation
66
differential diagnosis of acute mania
- BPAD type 1
- drug induced state
- FEP
- schizophrenia (grandiose)
- delusional disorder
- schizoaffective disorder
67
management of acute mania
Biological: pharmacological management of acute mania and BPAD
Psychological: CBT (identify relapse indicators, relapse prevention strategies)
Social: family support, aiding return to work, deal with financial issues resulting from overspending
Risk: admit if risky
68
Pharm management of acute mania
- atypical antipsychotic (e.g. aripiprazole, quetiapine, olanzapine, risperidone)
if fails, add mood stabiliser
- mood stabiliser (e.g. lithium, carbamazepine, sodium valproate)
69
Long term management of mania
- mood stabiliser is mainstay
| - Lithium and monitoring
70
how do you counsel a patient with mania
- we believe you are experiencing mania
- get a chemical change in your brain and can lead to very increased mood
- may not seem like a bad thing but it can actually be very damaging in long run
- can lead you to make risky decisions that you wouldn't otherwise make
- can cause you serious harm (financial, physical, emotional)
- we would like to keep you in hospital to give you some treatment that can normalise chemicals in your brain and help you think clearer
- when you are feeling back to normal, we can discuss how we can help you get back to regular work
71
what are 2 types of bipolar affective disorder?
1: characterized by episodes of main interspersed with depressive episodes
2: mainly recurrent depressive episodes with less prominent hypomanic episodes
72
what are some features of lithium toxicity?
- GI disturbance (D&V)
- sluggishness
- giddiness
- ataxia
- gross tremor
- fits
- renal failure
73
what are some long term consequences of lithium use?
- hypothyroidism
| - renal impairment
74
what are the teratogenic effects of mood stabilisers in pregnancy?
- Lithium: Ebstein's anomaly
| - Valproate and carbamazepine: spina bifida
75
if this patient was in depressive phase of BPAD, how would you manage him?
- anti-depressant (e.g. SSRI) with an atypical antipsychotic (e.g. arirprazole, quetiapine) to prevent triggering mania
76
potential differential diagnoses for puerperal psychosis
- BPAD with psychosis
- schizophrenia
- FEP
- psychotic depression
- substance misuse
77
management of puerperal psychosis
- admit to a mother and baby unit for treatment
- take collateral history from husband
- treat psychosis with atypical antipsychotic (e.g. quetiapine)
- other agents used for treatment: antidepressants, mood stabilisers
- investigate possibility of underlying BPAD
- severe cases: ECT may ne requried
- most pt require in 6-12 weeks
78
risk factors for puerperal psychosis
- personal or FH of puerperal psychosis or BPAD
- puerperal infection
- obstetric complications
79
what is incidence of puerperal psychosis?
1 in 1000 births
80
how is puerperal psychosis different from postnatal depression and baby blues?
- postnatal depression does not tend to have psychotic symptoms or if it does they tend to be mood congruent
- baby blues tend to occur within few days of birth. Characterized by tearfulness and low mood which swiftly recover
81
describe Dialectical Behavioural Therapy (DBT)
- focuses on factors contributing to emotional instability (being emotionally vulnerable and sensitive to stress, growing up where emotions were dismissed by those around)
- there factors lead to viscous cycle where you experience intense and upsetting emotions
- make you feel guilty and worthless
- leads to actions that can make you feel upset again
- DBT aims to introduce 2 important concepts (Validation and Dialectics)
- Validation: accepting that your emotions are acceptable
- Dialectics: showing you that things in life are rarely black or white, help you be open to ideas/ opinions that contradict your own
82
what is mentalisation-based therapy?
- mentalisation is ability to think about thinking
- examining your own thoughts and assessing them based on reality
- teaches you how to take a step back and scrutinise your thoughts and impulses
- teaches you how to recognise other people's thought patterns and accept your interpretation may not be correct
83
what other therapies can be used in personality disorder?
- therapeutic communities: teaching social skills to groups of people with complex psychological conditions, inc tasks that improve social skills and self confidence
- art therapies if pt suffer to express feelings verbally
84
when treating a crisis, what useful contact numbers should be given?
- community mental health nurse
- out of hours social worker
- local crisis resolution team
85
what are the 3 clusters of personality disorder?
A: odd, eccentric = schizoid, schizotypal, paranoid
B: dramatic = histrionic, narcissistic, antisocial, emotionally unstable
C: anxious = avoidant, dependent, anakastic
86
what distinguishes a personality disorder from a personality trait?
- pervasive: all/ most areas of life
- persistent: evident in adolescence and continues into adult life
- pathological: causes distress to self or others
87
what is the difference between schizoid and schizotypal personality disorder?
- Schizoid: odd, loner, little interest in forming relationships, no interest in sexual experiences, cold affect
- Schizotypal: bizarre beliefs, magical thinking, strange behaviour
88
what are the big 5 personality traits?
- openness
- conscientiousness
- extraversion
- agreeableness
- neuroticism
89
things to ask about in alcohol history
- CAGE
- dependence symptoms
- mood
- psychotic symptoms (to exclude delirium tremens)
- safeguarding issues
- driving
90
rating scales in alcohol dependence
- AUDIT to identify use disorder
- SADQ to determine severity of dependence
- APQ to assess nature of problems arising from alcohol
91
management of alcohol dependence - BIO
- motivational interviewing and encourage abstinence
- advise healthy diet/lifestyle
BIO: assisted withdrawal. if community based = Drug and Alcohol Service
- chlordiazepoxide or diazpam, after successful withdrawal = acamprosate or naltrexone with psychological intervention
- thiamine supplementation
EXPLANATIONS: withdrawal symptoms worst within first 48 hours, takes about 3-7 days after last drink to disappear
92
management of alcohol dependence - PSYCH
- CBT, behavioural, social network and environment based
- focus on alcohol-related cognitions (weekly 1 hour sessions for 12 weeks)
- refer to self help resources and support groups (AA, SMART recovery)
93
management of alcohol dependence - SOCIAL
- direct to relevant services regarding legal/ financial support
- direct to services that can help find new job
- Driving: DVLA will need to be informed, can't drive during treatment
- arrange follow up for any time after you finish withdrawal
94
what are some risks associated with excessive drinking?
- liver disease
- CV disease
- malnutrition
95
what are the symptoms of delirium tremens?
- nightmares
- agitation
- confusion
- disorientation
- visual and auditory hallucinations
- tactile hallucinations
- fever
- high BP
- sweating
96
what drugs are used for alcohol detox?
- chlordiazepoxide or diazepam
| lorazepam if liver failure
97
what is the rout of admin of drugs used for opiate withdrawal?
- methadone (oral liquid)
| - buprenorphine (sublingual tablet)
98
MoA of methadone and buprenorphine
Methadone: full mu receptor agonist
Buprenorphine: partial mu receptor agonist
99
which medications can be given for prevention of relapse?
- naltrexone
- acamprosate
- disulfiram
100
how would you counsel a somatoform disorder to a patient?
- validate the pain is real
| - explain the root cause is psychological
101
management of a somatoform disorder?
- Bio: SSRI, counsel mood may get worse before it gets better, follow up in 1 week
- Psycho: CBT
- Social: if stress caused by work, can offer a note
102
what is somatisation?
manifestation of multiple, recurrent and frequently changing physical symptoms
>2 years duration
results from psychological distress
103
how is somatisation different from hypochondrial disorder?
- Hypochondriasis is characterised by a persistent preoccupation with the possibility of having one or more serious and progressive physical disorder
- focused on one disease rather than cluster of symptoms
104
give some examples of medically-explained symptoms
- stomach pains
- conversion disorder
- chronic fatigue syndrome
- fibromyalgia
105
what are some side effects of SSRIs?
- N&V
- appetite change and weight change
- anxiety/agitation
- headache
- sweating
- hyponatraemia
106
which medications should not be used in patients who are on SSRIs?
- NSAIDs and aspirin
- Triptans
- Warfarin/heparin
