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Core Conditions > Mental Health > Flashcards

Mental Health Flashcards

1
Q

Depression definition

A

• Mental state characterised by persistent low mood, loss of interest and enjoyment in everyday activities, neurovegetaive disturbance and reduced energy causing varying levels of social and occupational dysfunctional

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2
Q

how common is depression

A

leading cause of disability worldwide

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3
Q

who does depression affect

A
  • Higher rates in older people
  • Mid 30s if recurrent, can occur at any age
  • F:M 2:1
  • Also people of low social class and unemployment
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4
Q

causes of depression

A

• Abnormal concentrations of neurotransmitters, dysregulation of the HPA acis and abnormalities of second messenger systems have all been identified as being possibly involved in the pathophysiology of depression

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5
Q

risk factors of depression

A
  • Age >65yrs
  • Postnatal status
  • Personal or family history of depressive disorder or suicide
  • Corticosteroids
  • Interferon
  • Propanolol
  • Oral contraceptives
  • Co-existing
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6
Q

symptoms / signs of depression

A
  • Presence of risk factors
  • Depressed mood
  • Anhedonia – diminished interest or pleasure in all or almost all activities most of the day
  • Functional impairment
  • Low energy
  • Libido changes
  • Sleep disturbance
  • Excessive guilt
  • Poor concentration
  • Suicidal ideation
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7
Q

DDx of depression

A
  • Adjustment disorder with depressed mood
  • Substance/medication or medical illness-associaed and other depressive disorders
  • Bipolar disorder
  • PMDD – premenstrual dysphoric disorder
  • Grief reaction
  • Dementia
  • Anxiety disorders
  • Alcohol abuse
  • Anorexia nervosa
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8
Q

Investigations of depression

A

• 1st LINE:

  • Major depression - >5 of the following symptoms have been present during the same 2-week period and represent a change from previous functioning
  • Metabolic panel – provides baseline and may reveal metabolic disturbance
  • FBC – other causes of fatigue such as anaemia should be ruled out
  • TFTs – an elevated serum TSH level suggests hypothyroidism
  • PHQ9 & PHQ2 – patient health questionnaire – positive result screens for depression in primary care
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9
Q

Management of depression

A

• 1st LINE:

  • SEVERE: psychiatric referral + hospitalisation + antidepressant e.g. citalopram (1st), agomelatine (2nd)
  • MODERATE: antidepressant e.g. citalopram (1st), agomelatine (2nd)
  • MILD: antidepressant e.g. citalopram (1st), agomelatine (2nd)
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10
Q

prognosis and complications of depression

A

prognosis:
• Complete remission of symptoms and return to normal functioning are the therapy goals
• Depression recurs in about one third of patients within 1 year of discontinuing treatment and in more than 50% of pts during their lifetime

complications:
• Sexual adverse effects of SSRIS and SNRIS
• Riskof self-injurious behaviour
• Undesired weight gain from antidepressants
• Unmasking mania
• Mania due to antidepressant withdrawal

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11
Q

Definition of Anxiety (Generalised Anxiety Disorder)

A

• Defined as at least 6 months of excessive worry about everyday issues that is disproportionate to any inherent risk, causing distress or impairment

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12
Q

How common is Anxiety (Generalised Anxiety Disorder)

A

• Usually occurs with other mental disorders – 76% of people who had more than 1 mental disorder for 12 months had GAD
- affects anyone of any age

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13
Q

Causes of Anxiety (Generalised Anxiety Disorder)

A
  • Pathophysiology is not clearly understood but biological studies have focused on abnormal responses to stress, multiple neurotransmitter involvement, neurohormone alterations, sleep disturbances and genetic factors
  • Abnormalities in brain corticotrophin-releasing factor secretion in the HPA axis appear to co-occur with anxiety episodes and may adversely affect neurotransmitters and arousal
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14
Q

Risk factors for Anxiety (Generalised Anxiety Disorder)

A
  • Fx of anxiety
  • Physical or emotional stress
  • Hx of physical or emotional trauma
  • Other anxiety disorder
  • Female
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15
Q

Symptoms/signs for Anxiety (Generalised Anxiety Disorder)

A
  • Presence of risk factors
  • Excessive worry for at least 6 months
  • Anxiety not confined to another mental disorder
  • Anxiety not due to medication or substance
  • Muscle tension
  • Sleep disturbance
  • Fatigue
  • Restlessness
  • Irritability
  • Poor concentration
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16
Q

DDx for Anxiety (Generalised Anxiety Disorder)

A
  • OCD
  • Panic disorder
  • Social phobia
  • PTSD
  • Somatoform disorders
  • Depression
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17
Q

Investigations for Anxiety (Generalised Anxiety Disorder)

A

• 1st LINE:
- CLINICAL DIAGNOSIS: DSM-5 criteria for GAD are defined as at least 6 months of excesive worry about everyday issues that is disproportionate to any inherent risk, causing distress or impairment, worry is not confined to features of another mental disorder or as a result of substance abuse or a general medical condition
o At lest 3 of the following symptoms are present most of the time: restlessness, nervousness, being easily fatigued, poor concentration, irritability, muscle tension or sleep disturbance

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18
Q

management for Anxiety (Generalised Anxiety Disorder)

A

• 1st LINE:
- CBT - significant depression not responding to CBT or CT warrants a trial of an antidepressant if tolerated by the pt – suitable first-line option to pharmacotherapy
- SSRIs – e.g. citalopram
• 2nd LINE:
- Tricyclic antidepressant – e.g. imipramine or diazepam or pregablin
• With pregnant pts  CBT (1st line), pharmacotherapy (2nd line) – be cautious with pharmacotherapy particularly for patients in their second or third trimester  consult psychiatrist with experience in treating pregnant women or obstetrician when selecting the most appropriate drug to use in these pts

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19
Q

Prognosis and complications for Anxiety (Generalised Anxiety Disorder)

A

Prognosis - Depression co-occurs in 30 to 60% of pts and increases the risk for suicidality

Complications - Comorbid depression, substance abuse, dependence or anxiety disorder

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20
Q

Alcohol Dependance Definitions

A

• Alcohol use disorder is a term used to refer to the misuse of alcohol

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21
Q

how common is Alcohol dependance

A
  • Common psychiatric disorder with lifetime prevalence estimates of 7% to 10% in most western countries
  • Greatest in resource-poor countries, mainly adults
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22
Q

Causes of alcohol dependance

A

• Confirm the diagnosis using ICD-10 criteria for alcohol dependence. According to this, dependence is diagnosed if three or more of the following have been present together during the previous year:

  • A strong desire or sense of compulsion to drink alcohol
  • Difficulty in controlling drinking in terms of its onset, termination, or level of use
  • A physiological withdrawal state when drinking has ceased or reduced, or drinking to relieve or avoid such a withdrawal state
  • These symptoms include tremor, sweating, tachycardia, anxiety, insomnia, and less commonly seizures, disorientation and hallucinations
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23
Q

risk factors for alcohol dependance

A
  • Fx of alcoholism
  • Antisocial behaviour (pre-morbid)
  • High trait anxiety level
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24
Q

symptoms/signs for alcohol dependance

A
  • Presence of risk factors
  • Withdrawal
  • Tolerance
  • Increased/decreased liver size, jaundice, ascites
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25
Q

DDx for alcohol dependance

A
  • Other psychiatric disorders

* Other substance use disorders (especially sedatives)

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26
Q

Investigations for alcohol dependance

A

• 1st LINE:

  • Diagnostic interview: uses the DMS-5 or ICD-20 cirteria to make a diagnosis of alcohol-use disorder  presence of at least 2 of the 11 DSM-5 criteria over the same 12-month period indicates an alcohol use disorder
  • Alcohol level (breath and blood)
  • Clinical institute withdrawal assessment for alchol-revised (CIWA-Ar)
  • CDT (carbohydrate-deficient transferrin) – increased concentrations found in serum after regular, excessive alcohol intake
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27
Q

Management for alcohol dependance

A

• 1ST LINE:

  • SIGNIFICANT ALCOHOL WITHDRAWAL: detoxification + supportive care e.g. diazepam and thiamine (both IV)
  • PROBLEM/MILD ALCOHOL DEPENDENCE: physician advice + brief interventions
28
Q

prognosis and complications for alcohol dependance

A

prognosis - minority of patients will continue to progress in their use of alcohol when interventions are used

complications - dependant on cause

29
Q

self harm definition

A

• Self-inflicted injury that is not associated with an implicit or explicit intent to die

30
Q

how common is self harm

A

• Prevalence of approximately 0.5%, but may be an underestimate as it relies on self-reporting

31
Q

who does self harm affect

A
  • More common in adolescents and young adults – incidence peaks between the ages of 15-19 years in females and 20-24 years in males
  • A national survey in the UK of 15-16 year olds estimate that more than 10% of girls and 3% of boys self-harmed in the previous year
  • This is consistent with the fact that women are more likely to self-harm then men
  • A UK survey of self-reported data found that 5.6% of people reported lifetime suicide attempts (6.9% of women and 4.3% of men), and 4.9% of people reported a lifetime history of self-harm without lethal intent (5.4% F, 4.4% M)
32
Q

causes of self harm

A
  • Poorly understood
  • Genetic, social, persona, behavioural, situational and environmental factors are involved in incressing a person’s suicide risk
33
Q

risk factors for self harm

A
  • Current suicidal plan
  • Self-harm
  • Hx of mental illness, including substance misuse
  • Availability of lethal means
  • Hx of childhood abuse or neglect
  • Fx of death by suicide
  • Male sex
  • Prison inmate
34
Q

symptoms/ symptoms of self harm

A
  • Previous suicide attempt or self-harm episodes
  • Current suicide plan
  • Access to lethal means
  • Hx of psychiatric disease, including substance misuse
  • Fx of suicide or mental illness
35
Q

DDx of self-harm

A
  • Depression
  • GAD
  • Schizophrenia
36
Q

Investigations of self harm

A

• 1ST LINE:
- CLINICAL DIAGNOSIS: detailed history with risk assessment  assess the physical risk, psychological harm and the risk of further self-harm or suicide by exploring the persons feelings e.g. what are these feelings, understanding of self-harm, level of emotional distress, mental state, possible presence of an associated mental health disorder e.g. depression or schizophrenia

37
Q

management of self harm

A

1ST LINE:

  • FOLLOW UP: follow-up needed within 48hrs if not sooner
  • MANAGE PSYCHOSOCIAL NEEDS: remove access to any means of self-harm where possible, offer written and verbal information to the person and their family, carers or significant others about local and national sources of support, groups and voluntary organisations  arrange for follow up and review
38
Q

Somatisation definition

A

• Group of psychiatric conditions that fall under the somatic symptoms and related disorders category of the DSM-5

39
Q

how common is somatisation

A
  • Strong female predominance
  • 10-15% of primary care pts have multiple unexplained symptoms that are present >2 yrs
  • Prevalence of somatic symptom disorder is not known but may be around 5-7%
40
Q

causes of somatisation

A
  • May arise from generalised sensory amplifications of bodily symptoms involving the insula – preliminary neuroimaging evidence suggests increased activity of limbc regions in response to painful stimuli
  • Somatic amplification may occur when previously sensitised brain cytoine systems are reactivated by infectious or non-infectious trauma
  • Cytokines acting on the brain are likely to be involved in a variety of sickness behaviours – chronic activation of the immune system in response to stress may sensitise the cytokine response
  • Central sensitisation may play an important role in symptom production and may be a useful pathophysiological model for how symptoms develop
41
Q

Risk factors of somatisation

A
  • Hx of sexual or physical abuse, unstable childhood, trauma-related disorders
  • Female
  • Alexithymia – difficulty identifying and describing feelings
  • Neuroticism
42
Q

symptoms of somatisation

A
  • Unconventional behaviour during Hx
  • Emotional processing problems
  • Recent or remote life stressors
  • Multiple illness behaviours
  • Give-way weakness
  • Inconsistent examination findings
  • False sensory findings
  • Distractible symptoms
  • Inconsistent paralysis
  • Bizarre movements
  • Gait disorders
43
Q

signs of somatisation

A
  • Hoover;’s sign – involuntary extension of the pseudoparalysed leg when the unaffected leg is flexing against resistance can indicate functional (psychogenic) aetiologies
  • Speech and swallowing disturbance
44
Q

DDx of somatisation

A
  • Bipolar disorder
  • Schizoaffective disorder
  • Panic disorder
  • GAD
  • Schizophrenia
45
Q

Investigations of somatisation

A

• 1ST LINE:

  • LABORATORY TESTING: all patients should have laboratory testing to rule out potential medical or neurological conditions
  • EEG: continuous video-EEG monitoring can be useful in establishing a psychogenic non-epileptic seizures diagnosis when typical spells are captured
46
Q

management of somatisation

A

• 1st LINE:
- ECLECTIC PSYCHOTHERAPY: combo of CBT, interpersonal psychotherapy and general psychotherapy
• 2nd LINE:
- ANTIDEPRESSANT: duloxetine (1st), sertraline (2nd)
• 3rd LINE:
- FURTHER PSYCHOTHERAPY

47
Q

prognosis and complications of somatisation

A

prognosis - remission rates are low

complications - depression, anxiety, suicidal ideation, substance use/abuse

48
Q

Delirium definition

A

• Acute, fluctuating change in mental status with inattention, disorganised thinking and altered levels of consciousness

49
Q

how common is delirium

A

• The prevalence in the general population is about 0.4%.

50
Q

who does delirium affect

A

• The prevalence of delirium among people aged 65 years and over living in long term care is 10-40%. It is also thought to affect up to 50% of older people in hospital and occur in 30% of older people in emergency departments. Complicates 17-61% of major surgery.

51
Q

causes of delirium

A

• Usually multifactorial
• In people with predisposing factors, a relatively benign additional factor e.g. a single dose of hypnotic medication may precipitate it
• The exact mechanism is not understood
• PREDISPOSING FACTORS INCLUDE:
- Infection e.g. UTI, infected pressure sore or pneumonia
- Metabolic disturbance e.g. hypoglucaemia, hyperglycaemia, or electrolyte abnormalities (including due to dehydration)
- Cardiovascular disorders e.g. MI or HF
- Respiratory disorders e.g. PE or COPD exacerbation
- Medication e.g. opioids, benzodiazepines and others

52
Q

risk factors for delirium

A
  • > 65
  • Cognitive impairment e.g. dementia – one of the main ones
  • Frailty/multiple comorbidities e.g. stroke/HF
  • Iatrogenic events e.g. bladder catheterisation, polypharmacy or surgery
53
Q

symptoms of delirium

A

• Behaviour changes develop acutely (hours to days)
• Clinical evidence underlying precipitating factor such as infection or an adverse drug reaction
• Symptoms typically fluctuate
• Lucid intervals usually occur during the day with worst disturbances at night
• Behavioural changes may include:
- Altered cognitive function
- Inattention
- Disorganised thinking
- Altered perception
- Altered social behaviour and level of consciousness
- Falling and loss of appetite
• Hyperactive delirium: increased sensitivity to their surroundings, agitation + restlessness
• Hypoactive delirium (more common): clouding of consciousness + reduced awareness, lethargic, moonlighting (awake at night and sleeping during the day)

54
Q

DDx of delirium

A
  • Dementia
  • Pain
  • Stroke/Cerebrovascular accident and TIA
  • MI and Thyroid disease
55
Q

Investigations of delirium

A

• 1st LINE:

  • CLINICAL DIAGNOSIS: take a detailed Hx from someone that knows the pt well so you can assess how they have changed and over what time frame
  • 4AT: set of questions, score over 4 = diagnosis of delirium – name, DOB, hospital they’re in, current year
  • Blood tests: LFTs, FBC, PSA, WCC, CRP/ESR, calcium/vit d, TFTs
56
Q

management of delirium

A

• 1st LINE:
- Tx UNDERLYING CONDITION
• ONLY USED IF NECESSARY: Low dose haloperidol can be used short-term (<7/7) or low dose lorazepam – overall not very effective

57
Q

Alzheimer’s Dementia definition

A

• Chronic neurodegenerative disease with an insidious onset and progressive but slow decline

58
Q

how common is Alzheimer’s Dementia

A
  • Most common form of dementia worldwide

* 29 million people with dementia

59
Q

causes of Alzheimer’s Dementia

A
  • Cortical atrophy is apparent in the temporal, frontal and parietal areas whereas the thalamus and brainstem, cerebellar hemispheres ad basal ganglia appear normal in seize and weight
  • Senile plaques and neurofibrillary tangles are the characteristic histopathological features post-mortem
  • Plaques are made up of beta-amyloid and are extracellular, wehereas neurofibrillary tangles are intracellular and composed of cytoskeletal filamaents of hyperphosphorylated tau
60
Q

risk factors of Alzheimer’s Dementia

A
  • Advanced age
  • Fx
  • Genetics
  • Downs syndrome
  • Cerebrovascular disease
  • Hyperlipidaemia
  • Lifestyle
  • Less than secondary school education
61
Q

symptoms/signs of Alzheimer’s Dementia

A
  • Presence of risk factors
  • Memory loss
  • Disorientation
  • Normal dysphagia
  • Misplacing items/getting lost
  • Apathy
  • Decline in activities of daily living and instrumental activities of daily living
  • Personality change
  • Unremarkable intial physical examination
62
Q

DDx of Alzheimer’s Dementia

A
  • Delirium
  • Depression
  • Vascular dementia – tend to have problems with gait
  • Dementia with Lewy bodies – sleep disorders associated
  • CJD, parkinsons dementia, frontotemporal dementia
63
Q

Investigations of Alzheimer’s Dementia

A

• 1ST LINE:

  • BEDSIDE COGNITIVE TESTING: mini-mental state exam and the blessed dementia scale  impaired recall, nominal dysphagia, disorientation, constructional dysphagia and impaired executive functioning
  • TFTs - rule out hypothyroidism
  • FBC – rule out anaemia
  • METABOLIC PANEL – exclude abnormal sodium, calcium, glucose levels
  • SERUM TSH – rule out hyper or hypothyroid associated dementia
  • SERUM B12 – rule out vit B12 deficiency-induced dementia
  • CT – rule out tumours, haematoma, normal pressure hydrocephalus
  • MRI – generalised atrophy with medial temporal lobe and later parietal predominance
64
Q

Management of Alzheimer’s Dementia

A

• 1st LINE:

  • SUPPORTIVE TREATMENT
  • CHOLINESTERASE INHIBITOR: e.g. donepezil or galantamine
  • ANTIDEPRESSANT: e.g. sertraline
  • ANTIPSYCHOTICS: e.g. risperidone (1st), haloperidol (2nd)
  • If cholinesterase inhibitors not tolerated or severe disease  SWITCH OR ADD MEMANTINE
65
Q

Prognosis and complications of Alzheimer’s Dementia

A

prognosis - Chronic illness with progressive course

complications - Pneumonia, UTI, falls, weight loss

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