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Year 3 Psychiatry > Medically Unexplained Symptoms and Sleep Disorders > Flashcards

Medically Unexplained Symptoms and Sleep Disorders Flashcards

1
Q

What is the correlation between mental illness and physical health?

A

Ps with mental illness are more likely to experience physical illness and to have poor physical health outcomes.

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2
Q

What is it called when mental illness presents physically?

A

Somatisation

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3
Q

What illness / adverse effect do
- antipsychotics
- ADs
run the rusk of?

A

Antipsychotics = inc risk of diabetes, obesity and CVD

ADs = inc risk of hyponatremia

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4
Q

What psychological complications can arise from physical illness?

A
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5
Q
A
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6
Q

How do you need to tailor a psychiatric assessment when a patient is physically ill?

A
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7
Q

What are the physical health disparities for Ps with mental illness?

A
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8
Q

Which team provides mental health care to patients in physical health care settings?

A

The liaison psychiatry team

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9
Q

What are medically unexplained symptoms?

A

Physical symptoms without an obvious physical cause.

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10
Q

What are the problems of medically unexplained symptoms?

A
  • Often repeated investigations = £££
  • Risk of iatrogenic harm
  • Diagnosis and Tx delayed
  • Longer the duration of Sx, the poorer the prognosis.
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11
Q

Why is it important to give a thorough history, exam and investigations for patients with medically unexplained symptoms?

A

1) To organise if a physical disorder exists

2). The P is more likely to feel like their Sx have been taken seriously and are therefore more likely to accept their diagnosis of MUS

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12
Q

What do neurologists call medically unexplained symptoms?

A

Functional Neurological Disorder

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13
Q

What is the equivalent of functional neurological disorder under the ICD11?

A

Dissociative Neurological Symptom Disorder

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14
Q

What RF can predispose a P to developing MUS?

A
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15
Q

Which factors can act as perpetuating factors for MUS?

A
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16
Q

How can MUS be treated?

A

Sleep hygiene
Treat underlying psych disorders
Lifestyle factors
Relaxation techniques
CBT
ADs - can treat mood disorder and have a specific role in functional illness

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17
Q

How can you explain MUS to a patient?

A

Explain mind-body interactions - e.g. butterflies / inc HR with anxiety

Investigations can’t show everything - e.g. tension headache

Computer hardware / software correlation - attacking the hardware won’t solve a software / programme issue.

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18
Q

What are the 4 classifications of MUS under ICD 11?

A
  • Disorders of bodily distress / experience
  • Dissociative disorders
  • OCD or OCD related disorders
  • Factitious disorder
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19
Q

Which disorders are found under the heading of disorders of bodily distress?

A
  • Bodily Distress Disorder
  • Bodily Integrity Disorder
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20
Q

What is bodily distress disorder?

A

Characterised by
- Bodily Sx which are distressing and persistent
- Excessive attention directed towards the symptoms
- May manifest by repeated contact with healthcare providers

Opposite of hypochondriasis (based around Sx not the disorder itself)

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21
Q

Which disorder is associated with an intense, persistent desire to become physically disabled in a significant way?

A

Bodily Integrity Disorder

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22
Q

Which MUS disorder is classified as a dissociative disorder under ICD11?

A

Dissociative neurological symptom disorder (AKA Functional Neurological Disorder)

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23
Q

Which symptoms can arise in Dissociative Neurological Symptom Disorder?

A
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24
Q

What types of prognostic factors for dissociative neurological symptom disorder are the following:

A
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25
Q

Which MUS count as disorders under obsessive-compulsive disorders?

A

Hypochondraisis

Body Dysmorphic Disorder

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26
Q

Which disorder involves a persistent preoccupation or fear about the possibility of having one or more serious, progressive or life-threatening illness?

A

Hypochondrasis

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27
Q

Which disorder involves a persistent, inappropriate concern about the appearance of the body despite reassurance?

A
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28
Q

Which disorder involves intentionally feigning, falsifying, inducing or aggravating symptoms?

A

Can present with self-induced infections, ingestions of medicines or self-induced injury.

Ps can present with previous multiple procedures, lack of appropriate concern about their health problems and they are “unrealistically cooperative”

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29
Q

What types of factitious disorder are there?

A

Factitious disorder imposed on self

Factitious disorder imposted on another

30
Q

What is the term for a feigned, intentional production or significant exaggeration of physical or psychological symptoms which is MOTIVATED BY EXTERNAL INCENTIVES

A

Malingering

31
Q

How does sleep change with age?

A

Amount required decreases with age but plateaus after 60. Deep sleep decreases and REM also decreases

32
Q

Which is the most important cue for the SCN?

A

Photic input

33
Q

Which inputs to the SCN control the circadian rhythm?

A

Photo inputs (light)
Non-photic input (e.g. activity, food, body temp etc)

34
Q

Which gland secretes melatonin?

A

Pineal gland (following stimulus from the SCN)

35
Q

What is the central pacemaker of the circadian rhythm?

Where are peripheral clocks located?

A

Central pacemaner = SCN = suprachiasmatic nucleus

Peripheral clocks - located in organs in the body

36
Q

How do circadian rhythms vary with age?

A

Teenagers - circadian rhythm naturally wants to wake up later and stay up later.

Older people - have lower-amplitude rhythms - tend to shift to an earlier cycle - going to bed earlier and waking earlier.

37
Q

Why do we sleep?

A
  • Consolidation of learning and memory
  • Restorative functions - e.g. synthesis of proteins
  • Neural detoxification = glymphatic clearance

There is growing evidence that memory consolidation involves transfer of packets of information between the hippocampus and cortex in the form of sharp-wave ripples – if these ripples are disrupted during sleep, then learning and memory are impaired

38
Q

What stops us sleeping?

A

Lifestyle factors
Environment
Psychosocial
Sleep disorders
Health problems

39
Q

What are the short term consequences of lack of sleep?

A

Increased SS activation
- Mental illness, cognition, mood and stress problems

  • Somatic problems - e.g. headache, pain
  • Psychosocial problems e.g. emotional distress, irritability, cognitive impairment (poor judgment, slowing of reactions, reduced attention, impaired memory, mental illness, performance impairment, reduced QOL, burnout)
40
Q

What are the long term consequences of lack of sleep?

A

Inc CVD risk, obesity, T2DM, Cancer, Death

41
Q

What can be experienced in cases of extreme sleep deprivation?

A

Hallucinations
Disorientation
Persecutory ideas

42
Q

What are the following sleep disorders called
- Not enough sleep
- Too much sleep
- Abnormal episodes during sleep
- Disturbances of the timing of sleep

A
43
Q

Is insomnia more common in M or F?

A

F

44
Q

How is insomnia sometimes defined clinically?

A

Sleep continuity disturbance on 3 or more days of the week

45
Q

How is acute and chronic insomnia defined?

A

Acute (short-term) = <3m

Chronic (long-term) = >3m

46
Q

How is acute insomnia managed?

A
  • Identify cause & treat underlying cause (if any) - e.g. depression, anxiety
  • Explain to P what is happening
  • Promote good sleep hygiene & psychoeducation
  • Advise P not to drive if they feel sleepy
  • If likely to resolve soon, and sleep hygiene measures fail AND daytime impairment causing distress - consider hypnotic medications.
  • If NOT likely to resolve AND sleep hygiene measures fail AND daytime impairment causing distress = CBTi - CBT for insomnia
47
Q

How does management of long term insomnia differ from acute insomnia?

A

CBT = first line

Avoid medication - unless acute exacerbation

If over 55 - can think about modified-release melatonin

48
Q

What sleep hygiene advice can you give Ps?

A

Wind down/relax for ³1 hour before going to bed, with no electronic devices

Follow a nightly routine – following similar steps each night to reinforce that it’s bedtime (e.g. clean teeth, pyjamas on, shower)

Have a milky drink before bed (contains tryptophan)

Keep the lights dim before bedtime – bright lights suppress melatonin production

Keep bedtime and waking time as regular as possible

Avoid sleeping during the day. If you do nap, make it in the early afternoon.

Exercise regularly (but not late at night)

Eat a healthy diet, eat regularly, avoid a heavy meal close to bed

Make sure the bedroom is comfortable, dark and quiet and at a comfortable temperature

Use the bed only for sleeping and sex (e.g. avoid TV, phone scrolling, eating, work)

Avoid caffeine in the afternoon

Avoid smoking, especially in the hour before bed

Drink only moderate alcohol if at all

49
Q

How does CBT approach insomnia?

A

It aims to reduce hyperarousal underpinning insomnia and improve stress management.

Challenges unhelpful beliefs and attitudes around sleep.

Identifies intrusive thought patterns and cognitive biases.

50
Q

Which medications can be prescribed for insomnia?

A

For v short period only - Zopiclone, Zolpidem
Benzos

If over 55s - modified release melatonin

Don’t recommend OTC (antihistamines, Nytol) - can have severe anticholinergic side effects inc hallucinations. NICE guidance says they shouldn’t be recommended.

51
Q

Which sleepiness scale is used to measure hypersomnia?

A

Epworth sleepiness scale

52
Q

What is the epidemiology of narcolepsy?

A

Rare = 0.2-0.5/1k
M=F

53
Q

What disease makes a P feel sleepy every day, worsens until uncontrollable and refreshing period of sleep - that may occur at inappropriate times which the P cannot prevent?

A

Narcolepsy

54
Q

How is narcolepsy managed?

A

Practical support
Scheduled naps
Modafinil (Stimulant)

55
Q

Which screening tool is used to assess sleep apnoea?

A

STOP-BANG

56
Q

What disease is this?

Pauses in breathing during sleep
Oxygen desaturation
Frequent awakenings (patient may not be aware)
Unrefreshing sleep, ”muzzy head”
Cognitive impairment, low mood, anxiety
Increased cardiovascular risk and mortality

A

Obstructive Sleep Apnoea

57
Q

Why does obstructive sleep apnoea occur?

A

As the oropharyngeal muscles relax during sleep, the airway can be blocked – the risk of this happening is increased when there is excessive soft tissue around the airway – hence obesity and large neck circumference are important risk factors

Sleep apnoea can be central (i.e. due to control of sleep by brain) but this is rare, whilst obstructive sleep apnoea is very common,

58
Q

How is Obstructive sleep apnoea managed?

A

CPAP

59
Q

What are unusual physical, emotional, perceptual or behavioural events during sleep termed?

A

Parasomnias

60
Q

Which disorder is this?

Wakes up confused and disorientated after night time sleep or daytime nap

A

Confusional arousal

61
Q

What is sleepwalking known as?

What is the usual age of onset?

A

Somnambulism

62
Q

What disorder is this?

Person suddenly wakes up and screams with marked autonomic activation (fight/flight – sweaty, dilated pupils, tachycardia, fast breathing etc). Can last 10-15 minutes but often shorter, then goes back to sleep. Person does not remember in the morning.

A

Sleep terrors

63
Q

Which REM parasomnia is more common in student populations and Ps with mental illness, that is a deeply unpleasant experience of paralysis that is present on waking and often associate with hypnopompic hallucinations. It is thought to be due to an extension of the paralysis of REM sleep on waking.

A

Sleep paralysis

64
Q

Which REM parasomnia is the opposite of sleep paralysis - I.e. the loss o normal paralysis of REM sleep? It is associated with neurological conditions - especially Parkinsons.

A

REM Sleep Behaviour Disorder

The person will effectively “act out” their dreams, often leading to injury of their bed partner. It has been used as a defense for murder (successfully). It is often associated with neurological conditions, and can start many years before the onset of Parkinson’s disease or dementia with Lewy bodies, as well as other conditions.

65
Q

What is the management for
- Sleep Paralysis
- REM Sleep Behaviour Disorder
- Nightmares
- Restless leg syndrome

A

Sleep paralysis = No specific management

REM Sleep Behaviour Disorder = Clonazepam

Nightmares - sleep hygiene, avoid triggers and poss low dose AD (v occasionally)

RLS - sleep hygiene, treat iron deficiency, can have meds if severe (rotigotine or gabapentin)

66
Q

What causes is restless leg syndrome associated with?

A

FHx
Pregnancy
Anaemia
Renal Failure
DM
Medications
Caffeine, Alcohol, Sleep Deprivation and Stress

67
Q

What are hallucinations experienced when falling asleep called?

A

Hypnagogic hallucinations

(Go to sleep)

are not an indicator of psychosis - are common!

68
Q

What are hallucinations that are experienced when waking up called?

A

Hypnopompic hallucinations

(Pompeii - wakes up)

69
Q

What is the medical term for bedwetting?

What age is it diagnosed from?

How is managed?

A

Nocturnal enuresis

Diagnosed from age 5

Management usually involves non-pharmacological strategies including fluid and diet restriction and bladder training

70
Q

Which circadian rhythm disorder is common in AD?

A

Irregular sleep-wake pattern

71
Q

How are circadian rhythm disorders managed?

A
72
Q
A

Year 3 Psychiatry (11 decks)

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