Mental Health Flashcards
Characteristics of vascular dementia ?
Represents cumulative effect of many small strokes:
- sudden onset and stepwise deterioration
- evidence of vascular pathology (hypertension, past stroke, focal CNS signs)
Characteristic presentation of Lewy body dementia ?
- fluctuating cognitive impairment
- detailed visual hallucinations (e.g. Small animals or children)
- Parkinsonism
- histology= Lewy bodies in brainstem and neocortex
Characteristics of picks dementia ?
- frontal and temporal atrophy without Alzheimer’s histology
- linked to genes on chromosome 9
- executive impairment
- behaviour and personality change
- early preservation of episodic memory and spatial orientation
- disinhibition
- hyper orality
- emotional unconcern
What are the positive symptoms of dementia ?
- wandering
- aggression
- flight of ideas
- logorrhoea
Pathogenesis if Alzheimer’s disease
accumulation if beta amyloid peptide (degradation product of amyloid precursor protein) results in:
- progressive neuronal damage
- neurofibrillary tangles
- increased no. Amyloid plaques
- loss of acetylcholine
- defective clearance of beta amyloid plaques by macrophages
- selective neuronal loss
Which areas are vulnerable to neuronal loss in AD ?
- hippocampus
- amygdala
- temporal neocortex and subcortical nuclei
Risk factors for AD ?
- first degree relative with AD
- Down’s syndrome
- vascular risk factors
- depression and loneliness
Presentation of AD ?
Progressive and GLOBAL cognitive impairment (unlike any other dementia which affect certain domains)
- visuospatial skills (gets lost)
- memory
- verbal ability
- executive function
- ansognosia (lack of awareness)
Pharmacological treatment for cognitive decline in AD
- donepezil (acetylcholinesterase inhibitor)
- rivastigmine (parasympathomimetic) - also for Parkinson’s
- galantamine (cholinesterase inhibitor) - vascular origin
What is Huntington’s disease ?
Incurable, progressive, Neurodegenerative disorder presenting. Middle age
- often prodromal phase of mild symptoms (irritability, depression, incoordination)
- progresses to chorea, dementia +/- fits
- death ~15 years after diagnosis
Pathogenesis of huntingtons
- Atrophy and neuronal loss of striatum and cortex
- genetic basis: expansion of CAG repeat on chromosome 4
- no treatment prevents progression
Pathogenesis of CJD
- Prion protein (PrPSc), misfiled form of normal protein that can turn other proteins into prions
- increased PrPSc -> spongiform changes (tiny cavities) in brain
Signs of CJD
- progressive dementia
- focal CNS signs
- myoclonus
- depression
- eye signs: diplopia, supranuclear palsy, Hallucinations etc
What are the 8 signs of delirium ?
DELIRIUM: globally impaired cognition, awareness/consciousness
D- disordered thinking
E- euphoric, fearful, depressed or angry: labile mood
L- language impaired: reduced, repetitive, disruptive
I- illusions, delusions, hallucinations (tactile or visual)
R- reversal of sleep-wake cycle
I- inattention: distractable
U- unaware/disorientated
M- memory deficits
Causes of delirium
- systemic infection (pneumonia, UTI, malaria, wounds
- intracranial infection: encephalitis, meningitis
- drugs: opiates, sedatives, anticonvulsants, levodopa
- alcohol withdrawal
- metabolic: uraemic, liver failure etc
- hypoxia
- head injury
- epilsepsy
Investigations in delirium
- FBC, U&Es, LFT, blood glucose,
- ABG
- septic screen (urine dipstick, CXR, blood cultures)
- ECG
- malaria films
- LP
- CT/MRI
- EEG
What is somatisation
Multiple, recurrent and frequently changing physical symptoms usually present for several years with negative investigations
Which conditions is somatisation associated with ?
- IBS
- chronic pain
- post traumatic stress disorder
- antisocial personality disorder
Pathogenesis of somatisation ?
The somatising patient seems to seek the sick role, which affords relief from stressful or impossible interpersonal expectations (‘Primary gain’)
- in most societies this provides attention, caring and sometimes monetary reward (‘secondary gain’)
- this is not malingering as patient is unaware of process through which symptoms arise, cannot will them away and genuinely suffers from the symptoms
Presenting features of somatisation
- patients feelings and behaviours about symptoms are disproportionate or excessive
- life long history of ‘sickliness’
- combo if symptoms with and without organic causes
- stress worsens symptoms
- cardiac: palpitations, sob, chest pain
- GI: abdo pain, bloating, diarrhoea, vomiting
- MSK: back and joint pain
- neuro: headaches, dizziness, vision changes, headaches
- urogenital: low libido, dysmenorrhea, dysuria
Typical features pointing to somatisation for diagnosis
- multiple symptoms often in different organ systems
- vague symptoms exceeding objective findings
- chronic course
- psychiatric disorder e.g. depression, anxiety
- history of extensive diagnostic testing
- rejection of previous physicians
What emotional responses of practitioner to patient should point them. To considering somatisation
- frustration and anger at number and complexity of symptoms snd the time required to evaluate them in an apparently well person
- a sense of being overwhelmed by a patient who has had numerous evaluations by other physicians
What questions should you ask someone you suspect has a somatoform disorder ?.
BATHE:
B- background - what is going on in their life
A- affect- how do you feel about that
T- trouble- what troubles you most about the situation
H- handle- what helps you handle that
E- empathy- understand it is a tough situation to be in, your reaction makes sense to me
Management of somatisation
- stress relief
- coping methods
- psychotherapy e.g. CBT
- antidepressants if anxiety or depression present
Investigations in dementia
- FBC, ESR , U&Es, Ca, LFT, TSH, autoantibodies, B12/folate,
- syphilis serology
- CT/MRI For vascular damage , structural path etc
Diagnostic criteria for major depression
At least one core symptom:
- persistent sad or low mood almost every day
- loss of interests or pleasure in most activities
Plus some of the followng:
- fatigue or loss of energy
- worthlessness, excessive or inappropriate guilt
- recurrent thoughts of death, suicidal thoughts, suicide attempts
- diminished ability to concentrate
- psychomotor agitation /retardation
- insomnia/hyper insomnia
- changes in appetite and/or weight loss
*5 required to make diagnosis, present for at least 2 weeks causing significant distress
Risk factors for depression
- female sex
- past history of depression
- chronic illness
- other mental health problems e.g. Dementia
What percentage of depressed patients present with somatisation ?
~2/3
Which medications may cause depression ?
- centrally acting antihypertensives e.g. Methyldopa
- lipid soluble beta blocker (e.g. Propanolol)
- benzodiazepines or other CNS depressants
- progesterone contraceptives esp. Injection
What conditions are associated with depression ?
- eating disorders
- substance misuse
- other psych e.g. Anxiety, panic, OCD
- Parkinson’s
- chronic disease e.g. DM, Stroke, cancer, autoimmune
First line antidepressant in children and young people ?
Fluoxetine (SSRI)
First line antidepressant in adults ?
SSRI as same effectiveness as tricyclics but less side effects and less toxic in overdose
- citalopram, paroxetine, Sertraline
Risk factors for generalised anxiety disorder
- aged 35-54
- being divorced or separated
- living alone or a line parent
Diagnostic criteria for generalised anxiety disorder ?
Excessive anxiety or worry occurring more days than not about wide range of events. Difficult to control worry. Associated with 3+ of:
- restlessness/on edge
- easily fatigued
- difficulty concentrating/mind blank
- irritability
- muscle tension
- sleep Disturbance
PLUS 4 of following, 1 from first group:
- autonomic arousal: palpitations, sweating, shaking
- chest & abdo: difficulty breathing, choking feeling, chest pain discomfort, abdominal distress
- mental state: dizzy, derealisation/depersonalisation, going crazy, fear of dying
- general: hot flushes, numbness, tingling, muscle tension aches and pains
- non-specific: being startled, persistent irritability, difficulty getting to sleep
First line drug treatment for generalised anxiety disorder
Sertraline
Define self harm
An act with nonfatal outcome in which an individual did 1+ of:
- a behaviour intended to cause harm (e.g. Cutting)
- ingesting a substance in excess e.g. Prescribed drug or illicit drug
- ingesting a non-ingestible substance or liquid
Which conditions are associated with self harm?
- borderline personality disorder
- depression
- bipolar
- schizophrenia
- drug or alcohol abuse
Risk factors for self harm
- socioeconomic disadvantage
- bullying, physcial/mental abuse
- mental health conditions
- eating disorders
- South Asian women
What symptoms of depression are most likely to present first ?
- chronic fatigue
- headache
What is dysthymia?
Chronic low grade unipolar depressive illness that lasts for 2 years or more and is characterised by tiredness and low mood
What abnormal blood results may point to alcoholism ?
- Abnormal LFTs
- macrocytosis
- raised MCV and deceased platelets
- gamma-GT best indicator of excessive alcohol consumption
What are the two main aspects of alcohol assessment ?
- is their alcohol a problem
- do they have any illnesses relating to alcohol intake - physical, psychological and social
What are the aspects of alcohol use needed to ask about in order to determine dependence ?
- strong desire to drink
- difficulty controlling alcohol
- physiological withdrawal when intake reduced
- tolerance e.g. Increasing amount to get same effect
- harm from alcohol use e.g. Work, relationships
What are the symptoms of alcohol withdrawal?
- hyperactivity, anxiety and coarse peripheral tremor
- mild Pyrexia, tachycardia, hypertension
- sweating, nausea and retching
- seizures
- auditory and visual hallucinations
- delirium tremens= severe form of above symptoms + circulatory collapse and ketoacidosis
What signs of disease due to alcoholism should be looked for ?
- malnourishment
- signs of acute withdrawal e.g. Coarse tremor, tachycardia
- liver disease: palmar erythema, gynaecomastia, spider naevi, jaundice
- hepatomegaly ( in chronic alcoholic liver disease= shrunken)
- Ascites
- AF
- Wernicke’s-korsakoff syndrome
What is Wernicke’s-Kirsakoff syndrome ?
Encephalopathy resulting from thiamine deficiency, usually due to alcoholism
Pathogenesis of Wernicke’s-Korsakoffs syndrome ?
Chronic alcohol consumption can result in thiamine deficiency by causing:
- inadequate nutritional thiamine intake
- decreased absorption of thiamine from GI tract
- impaired imagine utilisation in cells
Thiamine is required as cofactors in enzymatic processes and lack results in:
- neuronal loss
- interference with cellular function
Symptoms of Wernicke’s-Korsakoffs?
- vision changes: diplopia, eye palsy, ptosis
- loss of muscle coordination
- profound loss of memory
- inability to form new memory’s
- hallucinations
Signs of Wernicke’s-Korsakoffs syndrome ?
Usually mentally alert with vocab, comprehension, motor skills, social habits and naming ability maintained:
- polyneuropathy on nervous system exam
- abnormal reflexes
- gait and coordination abnormalities
- nystagmus, bilat lat rectus palsy
- low BP and body temp
- high pulse
Cognitive features of Wernicke’s-Korsakoffs
- confabulation: falsification on memory in clear consciousness, can answer questions promptly with inaccurate and bizarre answers
- memory loss: anterograde amnesia, disorientated in time and place
When should patients in alcohol withdrawal be sent for inpatient detox ?
- Disorientation, agitation or seizures occur
- suicide risk
- those without social support
- history of severe withdrawal symptoms
Drugs used to treat acute alcohol withdrawal
- benzodiazepines: long term (e.g. Diazepam) to reduce tremor and agitation, short acting (e.g. Lorazepam)for seizures
- vit B complex: IV pabrinex For few days then oral thiamine and multivitamins (pabrinex used to treat W-K)
- beta blockers- reduce autonomic hyperactivity (not used often)
Treatment for maintenance of abstinence from alcohol
- Calcium acetyl-homotaurinate (acamprosate): blocks GABA and reduces NMDA receptor glutamate-related excitation, neuro protective, reduces cravings, doesn’t interact with alcohol
- Naltrexone: reduces pleasure effects of alcohol by competitively binding to opioid receptor (preventing endogenous opioid from binding)
*all treatment in conjunction with psychosocial interventions
